Psychiatrist Challenges Usual Care for First Psychosis Episode

Can some patients experiencing a first psychotic episode be treated without neuroleptics and hospitalization? Yes, according to psychiatrist Peter Stastny, M.D., who challenged the prevailing wisdom that all first-episode patients require inpatient hospitalization and antipsychotic medication at APA's Institute on Psychiatric Services in New York last month. He presented the lecture “Starting From Scratch: How to Promote Recovery From Early Psychotic Episodes.”

Stastny, whose views are at variance with much of mainstream psychiatric research and thinking, cited a body of data from experimental programs in the United Kingdom, continental Europe, and North America showing successful treatment of psychosis using alternative approaches.

These alternatives included outpatient and in-home services; small, highly staffed, and unlocked residential programs designed specifically for patients with first-episode psychosis; and/or acute day services. Clinical management in these alternative settings included supportive crisis planning, emotional support and information for the family, regular and liberal doses of anxiolytics, and a focus on avoiding extrapyramidal symptoms associated with antipsychotic medication.

“Emergency rooms and acute hospital units weren't developed to treat first-episode psychosis,” Stastny told Psychiatric News. “They basically exist for their own reasons and over time, like a force of nature, have magnetically attracted individuals with all kinds of needs. Going back to the 1960s, community mental health centers never developed the capacity, as they were supposed to, to include crisis and family interventions. So if you look around the country, crisis intervention is not an integrated element of community services and has largely been replaced by crisis management and triage in emergency departments attached to hospitals.”

Stastny is a senior psychiatrist at South Beach Psychiatric Center in Staten Island, N.Y., and consults with several community-based residential programs. Known as a critic of main-stream approaches to treatment, he has written and spoken widely about psychosocial treatments, recovery, self-help and empowerment, and subjective experiences of mental illness.

He is also a member of the planning committee for the conference “Rethinking Psychiatric Crisis: Alternatives to ‘First Breaks,’ ” sponsored by the International Network Toward Alternatives and Recovery, the Center to Study Recovery in Social Contexts, and Community Access Inc. The conference will be held November 23 at the Kimmel Center at New York University. More information is posted at <www.intar.org>.

Poor Outcomes From Standard Treatment

In his lecture, Stastny challenged the conventional wisdom that insists that all patients presenting with an acute psychosis be hospitalized and treated quickly with antipsychotic medication.

He presented data showing the poor outcomes and high rates of patient dissatisfaction associated with conventional treatment. For instance, a research report in the March 2004 American Journal of Psychiatry titled “Symptomatic and Functional Recovery From a First Episode of Schizophrenia or Schizoaffective Disorder” showed that after five years only 13.7 percent of subjects met full recovery criteria for two years or longer.

(Recovery measures in that study were derived from the University of California at Los Angeles recovery criteria, as published in the International Review of Psychiatry in November 2002, in the article “Operational Criteria and Factors Related to Recovery From Schizophrenia.” Full recovery required that subject ratings covering the same period fulfill criteria for both symptom remission and adequate social/vocational functioning.)

Treatment May Compound Trauma

Moreover, Stastny said that patients experience trauma associated with standard treatment that compounds the trauma often accompanying a first psychotic episode. He presented data from a report in the January 2007 Social Psychiatry and Psychiatric Epidemiology by Nicholas Tarrier and colleagues showing that 80 percent of first-episode patients felt they had been traumatized by their treatment and 38 percent were diagnosed with symptomatic PTSD as a consequence.

Stastny also presented data from three projects—the Swedish Parachute Project, the Finnish Open Dialogues Program, and the Soteria Programs in North America and Europe—showing that first-episode patients can be treated successfully without hospitalization and neuroleptics.

For instance, the Parachute project is based on the following principles:

A follow-up study of outcomes published in the October 2002 Acta Psychiatrica Scandinavica showed that Global Assessment of Functioning values were significantly higher for patients in the program than for those in a historical comparison group but similar to those for the prospective group.

Psychiatric inpatient care was lower, as was prescription of neuroleptic medications. Satisfaction with care was generally high in the Parachute group, according to the report.

Doctors Would Rather Be ‘Safe Than Sorry’

Stastny underscored his belief that what is now considered the standard of treatment for first-episode psychosis is largely an artifact of imperatives created by the fragmentation of services in the United States.

In addition, Stastny said he believes an increasingly biological approach in American psychiatry combined with fears of liability has resulted in an overreliance on antipsychotic medication.

Because of the legal standard of dangerousness to self and others, doctors would “rather be safe than sorry,” Stastny said, and hospitalization has become the reflexive fallback. “I've personally seen many patients who had been admitted but who obviously didn't need hospitalization,” he said.

Stastny also addressed the issue of “duration of untreated psychosis” (DUP) and the considerable body of research showing that a longer DUP—typically interpreted as duration of time before treatment with antipsychotic medication—is associated with poorer outcomes.

He said he believes that the assumption is based largely on observations of those patients who typically have had a long, insidious onset of psychosis with prodromal symptoms existing for many years prior to what is designated as the first break. Such patients might be vulnerable to a more severe form of psychosis and tend to develop the overt disorder in ways that lead to later identification and treatment, and hence to poorer outcomes.

Many other patients presenting with a more acute first-episode psychosis, not properly reflected in studies of DUP, will not be so predisposed and may not require coercive inpatient treatment and treatment with neuroleptics, Stastny said.

Neuroleptic-Free Period Beneficial

He cited a summary of five studies of psychosocial treatment for first-episode psychosis in the March Psychosis showing that a neuroleptic-free period of two to three weeks in the early phases of a first psychotic episode along with the use of anxiolytics appears safe and likely to help distinguish those individuals who might need ongoing or intermittent low-dose neuroleptics from those who can recover without them altogether.

“All persons experiencing a first psychotic episode should be given the opportunity to recover without neuroleptics within the context of an intensive psychosocial intervention in the community that involves team work, short-term residential alternatives, continuity of care, and family support,” Stastny told Psychiatric News. “This is not only a prudent course of action, but it is likely to help us further differentiate patient groups and their needs while preventing avoidable long-term damages, such as metabolic syndrome and foreshortened lives.”

“Symptomatic and Functional Recovery From a First-Episode Schizophrenia or Schizoaffective Disorder” is posted at <http://ajp.psychiatryonline.org/cgi/content/full/161/3/473?ck=nck>. An abstract of “The Subjective Consequences of Suffering a First-Episode Psychosis: Trauma and Suicide Behavior” is posted at <www.springerlink.com/content/l8261p7w84581871/?p=4bb2c3080a774ad48c6b98b90a1087bf&pi=4>.

An abstract of “One-Year Outcome in First-Episode Psychosis Patients in the Swedish Parachutes Project” is posted at <www3.interscience.wiley.com/journal/120697858/abstract>. An abstract of “Operational Criteria and Factors Related to Recovery From Schizophrenia” is posted at <www.informaworld.com/smpp/content~db=all?content=10.1080/0954026021000016905>. “Psychosocial Treatment, Antipsychotic Postponement, and Low-Dose Medication Strategies in First-Episode Psychosis” is posted at <http://psychrights.org/Research/Digest/Effective/PsychoSocialMoreEffective2009Psychosis.pdf>.