CLINICAL HANDBOOK OF SCHIZOPHRENIA

36. First-Episode Psychosis 371have to be assessed. The wide range of available structured and semistructured measuresis an excellent way to ensure that all the domains are not only assessed initially but alsomonitored over time for change.It is well known that people with schizophrenia have a reduced lifespan, and morerecently, there is great concern about the metabolic side effects of pharmacotherapy. Attendingto the physical needs of individuals with a first episode of schizophrenia by earlyassessment and ongoing monitoring during treatment should be routine. This allows foradjustment of the treatment in response to emerging problems.PharmacotherapyPharmacotherapy with antipsychotic medications continues to be central to the treatmentof first-episode psychosis. The goals of pharmacotherapy have expanded and are synergisticwith the goals of psychosocial treatments (to be discussed later). The main goals ofpharmacotherapy include remission of positive symptoms and relapse prevention. Secondarygoals include the reduction of negative and depressive symptoms, and improvementsin neurocognition and quality of life.Antipsychotics are most effective in the reduction of the positive symptoms of psychosis,and are more effective in first-episode than in multiepisode cases, with responserates in the range of 50–90% of patients achieving a positive symptom remission, dependingupon the criteria used. Maintenance studies designed to establish the benefit ofantipsychotics in relapse prevention show consistent and strong differences between medicationtreatment and placebo over 2 years, which is the longest outcome published. Naturalisticstudies show relapse rates from 50 to 80% over 5 years and a five times higherrate of relapse in those who stop pharmacotherapy.Adherence to pharmacotherapy is generally less than 50% over 1 year. This adherenceis not simply due to lack of insight, although insight is a factor. Recent clinical trialsin which time to medication discontinuation has been the primary outcome indicate thatmedications are discontinued by both clinicians and patients. Reasons include lack of efficacyand side effects. It is helpful to encourage openness about the issue and provide educationabout specific risks and signs of pending relapse when there is nonadherence. Thegoal is to maintain a good therapeutic relationship and to resume pharmacotherapy assoon as possible when the patient’s psychotic symptoms return.The issue of advising patients and families on the optimal duration of maintenancepharmacotherapy following the first psychotic episode is addressed in a number of clinicalpractice guidelines for the treatment of schizophrenia. Recommendations are for 1 or2 years of pharmacotherapy after a remission of positive symptoms following a first episodeof psychosis. Risk of relapse is increased by earlier onset and comorbid substanceabuse.Depression in the first episode tends to improve, along with a reduction in positivesymptoms, but at a slower rate than in multiepisode patients or those with a morechronic course of illness. Insight also increases with time, which is important, becauseincreased insight is related to adherence. As with multiepisode patients, those with negativesymptoms respond poorly to pharmacotherapy. The neurocognitive deficits ofschizophrenia tend to be present from the first episode. Although patients experience usefulimprovements in neurocognition with pharmacotherapy over the first year, they arestill significantly impaired in comparison to normal control groups.Initiating antipsychotic pharmacotherapy should begin as soon as possible and doesnot need to be initiated in a hospital unless safety issues require inpatient care. Providedthat a medical history has been taken and there are no concerns about an organic cause of