CLINICAL HANDBOOK OF SCHIZOPHRENIA

372 VI. SPECIAL POPULATIONS AND PROBLEMSthe psychosis, medications can be started before the physical examination and symptominvestigations have been undertaken. The potential risks and benefits of the proposedmedications should be discussed with the young person and his or her family. Initiating amedication regimen needs to be integrated into the process of engaging the patient andfamily into treatment. This involves developing meaningful and realistic pharmacologicaltreatment goals for the patient. For one patient, eliminating distressing hallucinationsmight be the primary target. For another, improved sleep and reduced anxiety may bemost salient. Negative early experiences with pharmacotherapy can have a long-term impacton adherence. Adherence is more likely when families have been involved in educationand support.First-episode patients are more sensitive than multiepisode patients to extrapyramidalside effects and are more likely to respond to lower doses. As a result, startingdoses may be lower than those recommended for the general treatment of schizophrenia,and the dose may be titrated upward at weekly intervals, depending on the positive symptomresponse and the side effects experienced. It is important to explain such a “start low,go slow” strategy to patients and families and to ensure that safety is appropriately addressed.For the 20% of patients who cannot achieve a remission of positive symptomswith an adequate dose of antipsychotic for an adequate duration of time, clozapineshould be offered as a second-line treatment.Most clinical practice guidelines have recommended second-generation antipsychoticmedications as the first-choice treatment of first-episode schizophrenia. The main benefitappears to be the lack of extrapyramidal side effects. The main drawbacks have been theincreased costs compared with first-generation antipsychotics and the potential for metabolicside effects, especially weight gain. The results of recent large-scale “realistic” orpragmatic clinical trials in the United States and Europe have generally demonstrated alack of meaningful differences in major clinical outcomes, such as time to treatment discontinuation,symptoms, and quality of life. None of these studies was conducted in firstepisodepatients, but randomized controlled studies in first-episode patients have notdemonstrated consistent and significant differences in efficacy and safety with secondgenerationantipsychotics.Psychosocial InterventionsPsychosocial interventions in schizophrenia are supported by a growing body of evidence,as summarized in recent clinical practice guidelines, and some useful general guidelineshave been articulated. Such interventions should be seen as necessary, complementarytreatments to improve clinical symptoms, functional outcome, and quality of life, and toprovide support for patients, their families, and caregivers. Common comorbid conditions,such as substance abuse, anxiety disorders, and depression, are also appropriatetargets for psychosocial interventions. Psychosocial interventions are best implementedwhen acute symptomatology has been reduced to the extent that the patient can successfullyengage in treatment. They should be adjusted to the stage of the illness and the needsof patients and their families. Listening and attending to the patient’s concerns not onlydevelops empathy, rapport, and a good therapeutic relationship but it can also improveengagement and adherence to treatment. Several studies support the effectiveness ofpsychosocial treatments for psychotic illnesses; however, not all of these studies have beenreplicated in patients with first-episode psychosis, indicating a clear need for increasedstudies. Psychosocial interventions for schizophrenia can target broad or narrow outcomes.They can provide emotional support, enhance skills for functional recovery, or alterillness processes such as symptoms, addictions, or relapse.