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First Episode Psychosis: Information for Primary Care

Summary: Psychosis is a brain disorder in which there is a loss of contact with reality, with problems with thinking, feeling, perception and action. Many communities will have first episode psychosis programs or mental health services where a patient with first episode psychosis can be referred to. Antipsychotic medications are the first-line treatment for first episode psychosis. Primary care physicians play a key role, as early identification and treatment makes an important difference in outcome. Many patients with first episode psychosis will eventually be diagnosed as later having schizophrenia, but a significant proportion will also resolve and not have any future problems with psychosis.
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Epidemiology

  • Approximately 3 out of every 100 people will experience at least one psychotic episode in their lifetime
  • Approximately 1 in 100 will be diagnosed with schizophrenia
  • First episode of psychosis usually occurs in adolescence or early adulthood

Case

  • Suzy is a 17-year-old female who lives with her parents and attends high school
  • She has always been somewhat withdrawn and quiet
  • Over the past few months however, she has been mumbling to herself, and has been more irritable, and lost interest in school and extracurricular activities
  • Her parents and teachers are concerned about her consistently ‘bizarre’ behaviour

Signs and Symptoms

Early signs/symptoms in childhood:

  • Language delays
  • Motor problems such as late or unusual crawling; late walking

Early signs/symptoms in youth:

  • Withdrawal from friends and family
  • A drop in performance at school
  • Trouble sleeping
  • Irritability or depressed mood
  • Lack of motivation
  • Strange behavior
  • Compared with adults, teens may be less likely to have delusions and more likely to have visual hallucinations

Early signs/symptoms in adults:

  • "Positive" symptoms
    • Hallucinations. Hallucinations can involve any of the senses, but these usually involve seeing or hearing things that don't exist. Yet for the person with schizophrenia, they have the full force and impact of a normal experience.
    • Delusions. These are false beliefs that are not based in reality. For example, you believe that you're being harmed or harassed; certain gestures or comments are directed at you; you have exceptional ability or fame; another person is in love with you; a major catastrophe is about to occur; or your body is not functioning properly.
    • Disorganized thinking (speech). Disorganized thinking is inferred from disorganized speech. Effective communication can be impaired, and answers to questions may be partially or completely unrelated. Rarely, speech may include putting together meaningless words that can't be understood, sometimes known as word salad.
    • Disorganized or abnormal motor behavior. This may show in a number of ways. Behavior is not focused on a goal, which makes it hard to perform tasks. Abnormal motor behavior can include resistance to instructions, inappropriate and bizarre posture, a complete lack of response, or useless and excessive movement (catatonia).
       
  • "Negative" symptoms
    • Lack of or reduced ability to function normally
    • E.g. Patient lacks emotion, patient does not making eye contact, not changing facial expressions, or speaking without inflection. Also, the person may talk less, neglect personal hygiene, lose interest in everyday activities or socially withdraw. 

Hx/Interviewing Questions

For the parents

  • Hallucinations
    • Visual: Does s/he see any things that others can’t see?
    • Auditory: Does s/he hear any things that others can’t, e.g. voices?
  • Delusions
    • Does s/he have any strong beliefs that seem a bit extreme? E.g. paranoia, a worry that others are out to get him/her?
  • Has s/he had troubles functioning?
    • Troubles with relationships?
    • Troubles at school?
    • Troubles at work

For the youth

  • Hallucinations:
    • General
      • Do you think that your senses may be playing tricks on you? Do you think that your senses may be playing tricks on you?
    • Visual:
      • Do you see any things that others can’t? E.g. Do you ever see things out of the corner of your eye, shadows, shapes or people whom others don’t appear to see? 
    • Auditory
      • Do you hear any things that others can’t? E.g. Hear any voices talking to you or about you when no one was there? 
    • Tactile:
      • Any unusual sensations on your skin?
    • Olfactory
      • Any unusual smells or tastes?
  • Delusions:
    • Normalizing statement: Everyone has beliefs in certain things. Some people are religious. Some people believe in UFOs.
    • General: Any ideas ideas that you just can’t get out of your mind?
    • Paranoia: Are you worried that there might be people out to get you? Do you ever fear for your safety?
    • Hyperreligiousity: Are you religious? How religious? Do you feel a special connection with (your religion, e.g. God) that goes beyond what others have?
    • Grandiosity: Any special abilities that you have? Tell me more…
    • Thought broadcasting: At times does it feel as though people know, and can hear all of your thoughts?
    • Ideas of reference: Do you ever feel that the radio, or TV are talking about you?
    • Somatic delusions: Any worries about your health?

DDx of Psychotic Disorder

Mental health diagnoses

  • Schizophrenia:
    • Signs of illness for > 6 months; psychotic symptoms (two or more of a) delusions, b) hallucinations, c) disorganized speech, d) disorganized or catatonic behavior, e) negative symptoms) for > 1 month; social/occupational dysfunction.
  • Schizophreniform:
    • Similar to schizophrenia except duration of psychosis < 6 months.
  • Schizoaffective disorder:
    • Symptoms of schizophrenia and mood disorder occur at the same time together, and > 2 weeks of delusions or hallucinations in absence of prominent mood symptoms.
  • Delusional disorder:
    • Non-bizarre (i.e. within the realm of possibility) delusions for > 1 month and does not meet criteria for schizophrenia.
  • Brief psychotic disorder:
    • Psychotic symptoms that last anywhere between 1-30 days, and may or may not be related to a marked stress. Resolves, with the patient eventually returning to premorbid level of functioning.
  • Substance induced disorder:
    • Delusions or hallucinations that are triggered by substance use, which starts within 1-month of substance use (or withdrawal)
    • Common examples include
      • Cocaine, amphetamines, ecstasy, LSD, PCP, anabolic steroids
      • Alcohol, benzodiazepine, barbiturate, GHB withdrawal
      • Prescription medications: L-dopa, steroids, anti-retrovirals, anti-tubercular agents
  • Psychotic disorder due to general medical condition:
    • Delusions or hallucinations are the direct physiologic due to a general consequence of a medical condition, and occur in the medical condition absence of delirium.
  • Psychotic disorder not otherwise specified:
    • Psychotic symptoms present but criteria for a specific otherwise specified disorder is not met, or there is insufficient or contradictory information.
  • Major depression with psychotic features:
    • Major depressive episode with mood congruent psychotic features (most common), or mood incongruent psychotic symptoms.
  • Bipolar disorder:
    • Manic episode with mood congruent (most common, where psychosis symptoms are in keeping with the mood state, e.g. in manic, euphoric mood, patient may have delusions of grandeur), or mood incongruent psychotic symptoms (where patient’s delusions are not in keeping with the mood).

General Medical Conditions

Physical Exam (Px)

  • Physical with full neurological exam
  • Involuntary movements, particularly if patients on older generation antipsychotic medications

Investigations

  • CBC, electrolytes, BUN, Cr, AST, ALT, Ca, PO4, TSH, B12, folate, fasting glucose and lipid profile
  • Urinalysis
  • Toxicology/Drug screen in order to rule out possible substance intoxication/withdrawal 
  • EKG
  • EEG
  • CT/MRI may be indicated if structural brain problems are suspected 

Management in Primary Care

  • Rule out psychosis due to general medical conditions 
  • Discontinue any medications that can cause or contribute to psychosis such as:
    • Stimulants (e.g. ADHD medications, or caffeine)
    • Dopamine agonists
    • Steroids
    • Recreational drugs (e.g. marijuana, stimulants)
  • Prior to recommending treatment such as medications, focus first on building a  therapeutic alliance
    • Physician: "I'm concerned about you. I'm worried about ______. What do you think?"
    • If the patient agrees with the physician regarding goals, then try to find an agreement about medications
    • If the patient disagrees with the physician, then try to find some other goal that you can agree on with the patient 
  • Psychoeducation
    • Educating the patient and family about psychosis
  • Relapse planning
    • Teach patient/family about signs of psychosis; where to go and what to do if psychosis worsens
  • Lifestyle interventions
    • Have a regular bedtime and get enough sleep 
    • Have regular exercise 
    • Eat a healthy diet 
    • Avoid recreational drugs especially marijuana, stimulants, and hallucinogens
    • Be careful with stimulants such as too much caffeine, nicotine 

Management in Primary Care: Medications

  • The earlier that medications are started, the better the eventual outcome
  • Thus, even if a patient has been referred to specialized services, since waitlists may be very long, it is reasonable to start antipsychotic medication treatment in the interim
  • Medications are the same as used for schizophrenia, however usually lower dosages are used because patients are medication-naive
  • Start with a low dose of an atypical antipsychotic chosen on the basis of potential side effects and target symptoms
    • E.g. Olanzapine for patients with comorbid mood/bipolar symptoms
    • E.g. Quetiapine for people with insomnia/anxiety
    • E.g. Aripiprazole/ziprasidone for over weight individuals or those with a diabetes history. 
  • Increase dosage as needed with the expectation of evidence of clinical improvement in 6-8 weeks. 
  • Duration of treatment usually at least 12-months following first episode
  • Monitoring of patient on antipsychotic medications
  • Baseline monitoring
    • BMI, personal/family history, waist circumference
    • Symptoms of hyperglycemia (advise patients of hyperglycemia symptoms)
    • At week 4,8, and 12-weeks
    • Reassess weight change at 4, 8, and 12 weeks after initiation or change in antipsychotic therapy and quarterly thereafter
    • At 3-months and annually
    • Reassess fasting plasma glucose, lipids, and blood pressure at 3 months and annually thereafter
  • Adapted from American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27:596-601.

Dosing information for common antipsychotic medications

 

Risperidone (Risperdal™)

Start at 0.25-0.5 mg daily

Target 0.25-10 mg/kg/day or 1-4 mg daily

Doses of less than 3 mg have been shown optimal in first-episode cases

Dosing is typically bid or tid; available in oral solution and orally disintegrating tablets

Olanzapine (Zyprexa™)

Start 2.5 mg daily

Target 5-20 mg daily

Available in orally disintegrating tablets (Zydis)

Compared to Risperidone, lower risk of motor side effects and elevated prolactin but higher risk of sedation and weight gain

Quetiapine (Seroquel™)

Start 25 mg daily

Target 25-800 mg daily

Ophthalmologic monitoring for cataracts no longer felt necessary in most cases

Ziprasidone (Geodon™)

 

Start 20 mg daily

Target 20-160 mg daily

Monitor for QTc prolongation

Aripiprazole* (Abilify™)

Start 5-10 mg daily

Target 5-30 mg daily   

Favorable side-effect profile in adults                

Clozapine (Clozaril™)

Start at 12.5 mg daily

Target 25-800 mg daily

For treatment resistant psychosis when other options have failed

Required weekly blood count for first six months and then every other week, reporting to the National Clozapine Registry

 

For major depressive or anxiety symptoms

  • Use antidepressant medication such as SSRI

 

Fluoxetine (Prozac)

Child: Start 5 mg daily; target 10-20 mg daily

Youth: Start 5-10 mg daily; target 10-60 mg daily; max 60-80 mg daily

Escitalopram (Cipralex or generic)

Child: Start 5-10 mg daily; target 10-40 mg daily

Youth: Start 10 mg daily; target 10-40 mg daily for most; maximum 60 mg daily

Sertraline (Zoloft or generic)

Child: Start 25 mg daily; target 50-200 mg daily
Youth: Start 50 mg daily; increase by 50 mg/day every 2-weeks until satisfactory clinical response or maximal dosage; target 50-200 mg daily

Maximum 200 mg daily

Fluvoxamine (Luvox or generic)

 

Child: Start 25 mg daily; target 25-200 mg daily

Youth: Start 25-50 mg daily; target 50-300 mg daily 

Paroxetine (Paxil or generic)

Child: Start 5 mg daily; target 5-40 mg daily

Youth: Start 10 mg daily; target 25-200 mg daily

Not usually used in children/youth due to having short half-life            

When to Refer

  • All patients presenting with first episode psychosis should be:
    • Referred to the specialized mental health services (e.g. the local early intervention service or first episode clinic)
    • Treated for any underlying medical conditions that are contributing to the psychosis 
    • Referred to specialty services or even emergency department depending on what underlying medical causes might be suspected
      • E.g. urgent neurological consult if NMDA receptor encephalitis suspected
  • In patients that already have a diagnosis of psychosis
    • Consider a referral if there is poor response to treatment; poor nonadherence to treatment; intolerable side effects with current medication treatment; comorbid substance use problems; risk to self or others.

Where to Refer

  • Local psychosis early intervention service, e.g. First Episode Clinic 
  • Other services
    • Day hospital or therapeutic school environment as needed
    • Private practice psychiatrists for ongoing follow-up
  • Psychologist
    • Psychoeducational and neuropsychological testing to look for cognitive deficits, learning styles, strengths and weaknesses to be repeated once stabilized and used for school/work planning.
    • Psychological testing to clarify diagnosis if needed: if substances, pervasive developmental disorders, OCD, mood disorders, personality disorders also suspected
  • Allied health referrals
    • Occupational therapy (OT):  Can help with scholastic/vocational re-entry
    • Social work (SW): Can help with family support, housing, financial disability supports, liason with schools/work
    • Dietician: Can help if there are problems with appetite increase or weight gain, common with antipsychotic medications
  • Local Support Groups for Psychosis/Schizophrenia
    • In Canada, there is the Schizophrenia Society of Canada, which has branch societies throughout all provinces and many cities

References

Nasrallah H: Recognizing and managing psychotic and mood disorders in primary care, J. Family Practice, 2008.

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Date Posted: Sep 28, 2012
Date of Last Revision: Jun 7, 2017

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