CLINICAL HANDBOOK OF SCHIZOPHRENIA

36. First-Episode Psychosis 377Supported employment facilitates competitive work in integrated work settings forindividuals with the most severe disabilities, for whom competitive employment has nottraditionally occurred, and for those who, because of the nature and severity of their disability,need ongoing support services to perform their job. Supported employment providesassistance such as job coaches, transportation, specialized job training, and individuallytailored supervision. Recent studies indicate that the provision of ongoing supportservices for people with severe disabilities significantly increases their rates of employmentretention.Return to education is best achieved through a graduated process at an initially lessintense level than that prior to the psychosis. Different jurisdictions provide varying degreesof support or accommodation for persons with disabilities, including disabilitiesthat result from mental disorders. It is important for case managers to be familiar withthe resources available within the local educational institutions and to work collaborativelywith them.Suicide PreventionStudies of pathways to care indicate that many patients attempt suicide in the early stagesof psychosis, prior to diagnosis and treatment. Indeed for a proportion of patients the suicideattempt is the presenting problem that identifies the underlying disorder. An inconsistentfinding in studies is that patients in the early years of the illness have an increasedrisk of suicide and attempted suicide. However, both prior depression and suicide attemptsare robust predictors of suicide and attempted suicide. Furthermore, depression, acommon early sign of psychosis, is a greater problem during recovery from first-episodethan from multiepisode psychosis. Results from an RCT and real-world services supportthe contention that early-psychosis programs reduce the rate of attempted suicide.Recovery from psychosis has received more attention recently, because it is apparentthat remission of positive symptoms often is not accompanied by a full functional recovery.It is appropriate that this should be considered an important issue for the treatmentof early psychosis. There are two approaches in thinking about the term recovery: Thefirst is a pragmatic, research-based approach that seeks to establish criteria for level offunctioning and absence of symptoms. The second use of the term does not include symptomaticand functional recovery, but it does include concepts such as awareness of the tollthe illness takes, recognition of the need to change, insight as to how this change can begin,and the determination it takes to recover. Both are valid uses of the term, and a fewstudies have demonstrated that these concepts appear to be mutually reinforcing. Attentionto both the biomedical and the psychosocial aspects of treatment are required forboth approaches.DELIVERING SERVICES TO PATIENTS WITH EARLY PSYCHOSISEarly-psychosis treatment services are provided wherever patients present with first-episodepsychosis. Such services may be easy or difficult to access, coordinated or fragmented,and sensitive or insensitive to the specific needs of these patients and the families whosupport them. There is a debate as to whether such services should be provided by specializedteams or as part of routine mental health services. Specialized programs existaround the world and have been mandated in the United Kingdom and in Ontario, Canada’slargest province. Most of these services deliver some or all of the evidence-base ser-