Patients' First Encounter Can Color Schizophrenia's Course

A patient's first episode of psychosis offers a unique opportunity for clinicians to impact the individual's entire lifetime course of schizophrenia, said Nina Schooler, Ph.D., at APA's Institute on Psychiatric Services last month in New Orleans.

Schooler said longitudinal data regarding the effect of first-episode treatment on long-term course of disease has been exceedingly difficult to come by, yet she asserted that there are ample clinical and scientific reasons for believing that the first episode is a crucial window of opportunity to get patients started on the right foot.

She is a professor of psychiatry at the State University of New York Downstate Medical Center.

Especially crucial, she said, is the need for patients and family members to understand the long-term nature of schizophrenia, and she outlined a staged strategy for transitioning first-episode patients from the hospital to community care and into maintenance treatment.

“It is a belief I hold very strongly, though the data have been hard to assemble, that the quality of experience the patient has in the first encounter with us is going to color the rest of [the patient's] experience with the disorder” and his or her prognosis, she said.

“When you are treating chronic patients, you are dealing with an entire history of experience with the disease,” Schooler told psychiatrists at the institute. “So the first episode represents a unique window of opportunity to start treatment and to start to do it right.”

How to Define First Episode?

But Schooler acknowledged that defining when a patient is experiencing the“ first episode” of psychosis can be difficult, since many patients are likely to have had anomalous perceptual experiences for years and to have received any number of diagnoses before becoming acutely psychotic.

“If you work with first-episode patients, you often find when they come to the clinic that they have had a variety of diagnoses along the way,” she said. “Some of these diagnoses are legitimate, and some represent a tendency I have seen over the years, a wish on the part of both patients and clinicians not to have schizophrenia and so to try treatment with other medications—antidepressants being the most common.”

Retrospective case reports indicate that when a patient first comes to the attention of the mental health system, clinicians should not assume that the patient is experiencing the symptoms “de novo,” that is, for the first time.

“We have found that if you ask how long they have been experiencing symptoms, at the time they first come to the clinic they will give you a shorter duration than they will when you inquire a year later after you build up a relationship of trust,” Schooler said. “At that time, many patients will tell you, 'Oh, I've been hearing those voices since I was in junior high school.' But when you initially ask, they will tell you a much shorter duration.”

For research purposes, Schooler described criteria for defining first-episode psychosis that she used in a report comparing first-episode treatment with risperidone and haloperidol published in the American Journal of Psychiatry in 2005.

In that study, patients were deemed to be in first episode if they had a diagnosis of schizophrenia, schizoaffective disorder, or schizophreniform disorder for no longer than one year; had been treated with antipsychotic medication for no longer than 12 weeks; had no more than two hospitalizations during the index year; and were between the ages of 16 and 45.

Schooler said that study and many others have confirmed the remarkably rapid efficacy of medication in resolving the positive symptoms of schizophrenia in most first-episode patients. That success is typically greeted ecstatically by patients and family members, who are apt to present initially in a highly fearful and confused state of mind.

This is in marked contrast to chronic patients, for whom response to antipsychotic medication may not be so quick, and who have developed strategies of adaptation over many years of experiencing symptoms.

“When chronic patients experience a recurrence they are liable to think, 'Oh, yes, here are those symptoms again,'” she said. “It may be frightening, but parts of the experience are familiar.

“In contrast, first-episode patients have a real inability to distinguish their symptoms from reality,” Schooler said. “The degree of conviction with which the delusions and hallucinatory experiences are accepted as real is profound.

“And family members usually are extremely fearful. They say, 'This is not my son; I don't know what to make of it,'” she added.“ Everyone is inexperienced, and they don't where to go. So the idea that this is an illness can be very difficult to convey.”

Success Has a Downside

But the typically rapid success of antipsychotic medication in resolving positive symptoms in first-episode patients can have a downside.

“The experience most people have had with medicating other illnesses is that when they get better, they stop taking the medication and are done with it,” Schooler said.

So a crucial issue in psychosocial education of patients and families is helping them to understand that this is an illness they are likely to be dealing with for years. Also, the vast majority of patients who discontinue medication will experience recurrence of symptoms, Schooler strongly believes.

“The question is when they will invariably relapse,” she said.

Schooler said the “stress diathesis” model—in which schizophrenia is conceptualized as a biological and genetic disorder brought to the fore by environmental stressors—is generally one that patients and families accept and understand. It can be a useful clinical tool in introducing them to the need to avoid returning immediately to pre-illness situations that are liable to be stressful and to exacerbate symptoms.

Schooler also described a model for introducing patients and families to the need for long-term treatment built on a foundation of therapeutic trust in which clinicians, patients, and family members are involved together in evaluating progress in the hospital and monitoring the transition from the hospital to the community and into a program of maintenance therapy.

The model was used for research purposes as part of the Prevent First-Episode Relapse (PREFER) study, which was designed by Schooler and principal investigator Peter Weiden, M.D., a professor of psychiatry and director of the psychotic disorders program at the University of Illinois at Chicago. But Schooler said she believes the model translates well into a clinical setting.

In that study, patients were randomized to receive a recommendation for oral treatment or long-term injectable risperidone microspheres. Patients could refuse the long-acting injectable medication, and those who did were treated with an appropriate oral antipsychotic.

Schooler said the benefit of injectable medication is the much improved ability to monitor compliance. “You know the minute a patient is nonadherent because he or she doesn't show up for the injection,” she said.

But she said preliminary results from the PREFER study confirm the generally sobering picture for long-term treatment of schizophrenia—a substantial percentage of patients in both treatment arms ceased to take medication for at least two weeks within a 12-week period.

She noted that even with antipsychotic medication, there tends to be an“ inexorable course of relapse.” Moreover, studies of outcome using criteria for “recovery” are equally disquieting; few patients are likely to return to normal social and occupational functioning five years after first treatment, she said.

For these reasons, Schooler said she believes the future of psychiatric treatment for first-episode patients with schizophrenia lies in facilitating and improving long-term maintenance care.

“I would argue that we know how to treat the disorder acutely,” she said. “The real issue is how to go on to long-term pharmacologic treatment.”

“Risperidone and Haloperidol in First-Episode Psychosis: A Long-Term Randomized Trial” is posted at<http://ajp.psychiatryonline.org/cgi/content/abstract/162/5/947>.▪