Early Onset Psychosis

Abstract

Early Psychosis by definition emerges in late adolescence or early adulthood with a peak at the age of between 18 and 25 years of age and comprises of conditions such as Schizophrenia and Bipolar Disorder. Only 20% of people have a single episode of psychosis and for those who develop schizophrenia, the outlook is quite pessimistic with less than 20% of being employed after 5 years, 20% being homeless at 1 year follow up, and the rates of contact with criminal justice system 3 times higher than expected. Naturally, any strategy that would enhance the early detection and treatment of people who were having prodromal symptoms would be paramount. Early intervention with medication or supportive therapy was believed to be vital in stopping roughly 40% of those with such sub-syndromal symptoms to develop a full-blown psychosis within a year. However, over time, it has become apparent that only between 15 and 20% of such people transition to psychosis. Furthermore, a recent study has indicated that the majority of prodromal subjects do not convert to psychosis over 2 years of follow up in the absence of medication. In fact, they improve and have better overall functioning. These findings have two important ramifications. Firstly, we do not need to use antipsychotics in this young cohort and secondly, the validity of including the prodrome as a separate diagnostic category in DSM-5 is being questioned. Those that they do develop a full-blown psychotic episode need antipsychotic treatment. Second generation antipsychotics such as, aripiprazole, olanzapine and risperidone are effective in early psychosis. Clozapine should be used for treatment resistant schizophrenia. However, the use of such drugs may come at a price. Studies are showing that within a year, changes in prolactin, weight and other metabolic parameters are evident. Yet, debate still continues as to what the differential liabilities of medication versus the illness are in terms of fat distribution, liability to develop type 2 diabetes, cardiac disease and whether the use of any medication can have a beneficial effect on all-cause mortality. Therefore, the monitoring of physical health in patients with early psychosis is vital irrespective of what actual medication they are prescribed. Yet this essential and pragmatic suggestion, raises the thorny issues of what should be done, how often and most importantly by whom.