First-episode psychosis refers to a clinical psychotic phenomenon occurring for the first time in an individual and can have a varied presentation with multiple risk and protective factors 2. Although the vast majority of individuals presenting with their first psychotic episode will not have any identifiable organic cause, in a minority a causative abnormality will be detected using various imaging modalities such as a brain CT or MRI 1. Whether or not this justifies routine imaging of all patients presenting with first-episode psychosis remains an area of debate 1,6.
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Epidemiology
First-episode psychosis is usually diagnosed in the age group of 15-25 years and most patients present as a case of emergency 2.
The prevalence of a clinically relevant radiological abnormality in patients with first-episode psychosis is 6%, which is higher than that in healthy controls 1.
Diagnosis
Clinical staging of first-episode psychosis 2:
stage 1: prepsychotic stage
stage 2: first acute episode
stage 3: phase of relapses and remissions
stage 4: refractory stage requiring longer treatment
Diagnosis in first-episode psychosis requires a multidimensional approach and patients must be monitored in specialized units with careful and thorough inpatient examination 4,5.
The differentiation between schizophrenia and mood disorders can only be reliably made on long term monitoring 5.
Autoimmune encephalitis needs to be ruled out by conducting investigations such as brain MRI, EEG and testing for anti-NMDA antibodies, especially in young patients presenting with early- onset schizophrenia 5.
Testing for substance use is also essential to rule out first-episode psychosis related to substance use or withdrawal symptoms 5.
Clinical presentation
The two major symptoms of first-episode psychosis include hallucinations and delusions. Hallucinations may include auditory or visual hallucinations. Other symptoms include disorganized speech and thoughts, heightened anxiety, withdrawing from social interactions, decline in personal hygiene and work performance and abnormal sleep pattern 2-4.
Complications
Complications of first-episode psychosis include 3,4:
relapse
anxiety
suicidal thoughts and self harm
injury to others
Radiographic features
Brain imaging will be structurally normal in the three-quarters of individuals presenting with first-episode psychosis 1.
Of the quarter of patients who have radiological abnormalities most do not affect the treatment plan. Depending on definitions of "clinically relevant" between 0% and 6% of all individual who present with first-episode psychosis an abnormality that affects the clinical approach and prognosis will be detected 1,6.
These range widely from white matter abnormalities, vascular abnormalities, cysts, tumors etc. 1. It is important to note that many of these have uncertain etiological relevance to psychosis, but may nonetheless affect treatment.
Of interest, small white matter hyperintensities are commonly associated with first-episode psychosis and are clinically relevant. They may be an indicator of neuronal inflammation and increased risk of cognitive decline 1.
Treatment and prognosis
Patients with first-episode psychosis have a better prognosis and response to treatment when compared to patients with multiple psychotic episodes 4,5.
Additionally, multiple factors have been identified that influence the clinical course and outcome of patients presenting with first-episode psychosis. Some are positive (better outcomes) and some are negative.
Positive modifiers include 2:
short duration of untreated psychosis
female gender
social contact
older age of onset
good intelligence quotient
Negative modifiers include 2:
substance use
poor physical health
unemployment
negative symptoms
decreased global function at the time of diagnosis
non-compliance with treatment
Pharmacological treatment includes use of antipsychotic drugs. Second and third generation antipsychotic drugs are preferred, such as risperidone, ziprasidone, and aripiprazole 5. Haloperidol and clozapine can be used as second-line drugs in management 5. These drugs are often prescribed for at least one year to minimize relapses and various psychosocial therapies are also considered for this purpose 5.
Electroconvulsive therapy (ECT) may be used when there is risk of injury to self or others 5.
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