Most patients presenting to health services with an 'at risk mental state' will not develop psychosis. In the original Yung and McGorry study, transition rates were 40% over 12 months, but more recent studies found rates more in the vicinity of 15-30%. This still represents a level of risk increased a thousand-fold over the general population...
These early trials raise the possibility of primary or at least secondary prevention of psychotic disorders, although many questions remain. There are ethical issues in treating a group of people of whom 80% will not in any case progress to psychosis in the short term. Also, the base-rates, specificity and sensitivity of these at risk mental states in predicting psychosis may still mean this approach is of limited value at a population level...
Recovery rates from the first episode are high, with 85% achieving remission over a mean time of 3 months. Individuals in the first episode are sensitive both to the therapeutic effects and the adverse effects of antipsychotic drugs. This means they are more likely to respond to lower doses than in later episodes, but also are more susceptible to motor side effects. Most expert opinion advocates second generation antipsychotics as first line treatment (e.g. initially 0.5-2 mg risperidone or 2.5-7.5 mg olanzapine per day). Benzodiazepines are often used as adjuncts for agitation or catatonic symptoms. Poor adherence with treatment is if anything more problematic than at later stages of illness, since placebo controlled trials show a greater benefit of antipsychotics in first episode treatment and first relapse prevention yet up to 50% of individuals will be non-adherent in the first year. Cognitive behaviour therapy in addition to drug treatment is indicated.
Early Detection of Schizophrenia: Post-Detection: Early Treatments in the First Episode
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