How to manage the first episode of schizophrenia

The lifetime prevalence of schizophrenia is about 1%, but the associated social disability and cost are disproportionately large. According to the World Health Organization, schizophrenia is among the leading causes of disability worldwide. Representative measures have estimated the annual cost of schizophrenia in England to be £2.6bn and in Canada to be $C2.35bn (£1.06bn).^1–3 A growing body of evidence suggests that the early stages of schizophrenia are critical in forming and predicting the course and outcome of the disorder.⁴ Accordingly, clinical and research interest is now focused on the early stages of the illness because early detection and treatment may result in a better prognosis and functional outcome.

The first episode of schizophrenia typically occurs in the late teenage years or the early 20s.⁵ However, the illness can remain undetected for about 2-3 years after the onset of clearly diagnosable symptoms.⁴ Early recognition is hindered by the often insidious nature of the onset of schizophrenia, which occurs against a background of premorbid problems in language, cognitive ability, and behaviour.⁵,⁶ Frequently, neurotic features (social anxiety, panic attacks, and obsessional ideas), antisocial behaviour, or substance misuse dominate the clinical picture and obscure the underlying psychosis.⁵ Functional deficits such as emotional flattening, social withdrawal, and a lack of motivation and pleasure are usually prominent. The most commonly reported psychotic features are auditory hallucinations and delusions.

Once schizophrenia is diagnosed, the primary aim of treatment is to bring about rapid remission of the acute psychotic episode using the most effective and best tolerated drugs. A number of randomised clinical trials and cohort studies have suggested that patients are more responsive to treatment during their first episode regardless of the antipsychotic drug used but are more sensitive to extrapyramidal side effects, such as acute dystonia and parkinsonism.⁷ In this respect, treatment strategies that minimise the risk of side effects, such as the use of low dose typical neuroleptics or atypical antipsychotic drugs, may be a rational choice for the first episode.⁷

Although nearly 80% of patients with a first episode of schizophrenia will eventually recover, most (up to 70%) will have a second psychotic episode within five to seven years.⁸ Early withdrawal of drugs is therefore not advisable. If drugs are to be discontinued, this must be done gradually, and plans should be made to enable the early detection and treatment of an impending relapse.⁷ The emergence of a lack of response to treatment should also be addressed promptly. At present, clozapine is the only antipsychotic drug licensed in the United Kingdom for treating patients who have responded poorly to standard antipsychotic treatment.⁷

Even after clinical recovery, most patients have difficulty reintegrating into the community. They tend to underachieve in terms of education and employment and experience problems in forming relationships.⁵ Intensive rehabilitation helps to minimise these social disadvantages at all stages of schizophrenia but may be particularly relevant in the early phase of the illness.⁹ It is also important to work with the family to improve their knowledge of the condition and to nurture emotional relationships and communication between patients and their carers.¹⁰ Cognitive behavioural therapy is useful in reducing persistent delusions and hallucinations, and cognitive remediation, a rehabilitation programme that targets cognitive impairment by teaching patients thinking skills, may provide the basis for improvement in social functioning.¹¹,¹²

During their first episode of schizophrenia patients need specific services that provide rapid and easy access to specialist assessments, swift initiation of treatment in a setting which does not have stigma attached to it, and comprehensive psychosocial interventions and support. The development of close links between psychiatrists, primary care professionals, services for those who misuse substances, and educational and vocational services will help patients to be diagnosed early and allow them to benefit from continuing treatment and rehabilitation.

Focusing on early detection and intervention in schizophrenia offers the opportunity to make a real difference to the lives of our patients and their families. We cannot afford to miss it.