2. This is the first study to provide meta-analytic evidence for the effectiveness of specialist FEP programs in reducing relapse rates as well as hospital days in the first 2 years after psychosis onset. 5. There was no evidence of inconsistency across subgroups (I2 = 11.0%, P = .29) or overall estimates (I2 = 0.0%, P = .53). Well-conducted trials of all interventions are needed. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Scottish Schizophrenia Research Group, Maintenance treatment with risperidone or low-dose haloperidol in first-episode schizophrenia: 1-year results of a randomized controlled trial within the German Research Network on Schizophrenia, Atypical and conventional antipsychotic drugs in treatment-naive first-episode schizophrenia: a 52-week randomized trial of clozapine vs chlorpromazine, Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial [see comment], The Scottish First Episode Schizophrenia Study V. One-year follow-up. This study aimed to evaluate the effectiveness of a psychosocial treatment designed to prevent the second episode of psychosis compared with standardized early psychosis care. Two-year outcome in first-episode psychosis treated according to an integrated model. … Psychosocial interventions included specialist FEP programs vs treatment as usual (TAU),39–41 cognitive-behavioral therapy (CBT),42–44 and individual and family cognitive-based relapse prevention therapy45 and family therapy vs TAU.46,47 Trials of pharmacological interventions included those comparing antipsychotic medication with placebo,48–50 second-generation antipsychotics (SGAs) with first-generation antipsychotics (FGAs),3,51–53 FGAs with FGAs,54 and treatment maintenance with discontinuation therapy.55. Summing Up: The Science of Reviewing Research, A controlled trial of cognitively oriented psychotherapy for early psychosis (COPE) with four-year follow-up readmission data, Long-acting injectable risperidone in the treatment of subjects with recent-onset psychosis: a preliminary study, Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial, A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis, An RCT of early intervention in psychosis: Croydon Outreach and Assertive Support Team (COAST), Treatment, expressed emotion and relapse in recent onset schizophrenic disorders, Randomized comparison of olanzapine versus risperidone for the treatment of first-episode schizophrenia: 4-month outcomes, Dosing quetiapine in drug-naive first-episode psychosis: a controlled, double-blind, randomized, single-center study investigating efficacy, tolerability, and safety of 200 mg/day vs. 400 mg/day of quetiapine fumarate in 141 patients aged 15 to 25 years, Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the treatment of early-onset schizophrenia spectrum disorders (TEOSS) study, Comparative effect of atypical and conventional antipsychotic drugs on neurocognition in first-episode psychosis: a randomized, double-blind trial of olanzapine versus low doses of haloperidol, Efficacy and tolerability of olanzapine, quetiapine, and risperidone in the treatment of early psychosis: a randomized, double-blind 52-week comparison, The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis, Two years of continued early treatment for recent-onset schizophrenia: a randomised controlled study, A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness, Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus befriending for first-episode psychosis: the ACE project, Cognitive-behavioural therapy in first-episode and early schizophrenia. and S.E.H.) To reduce the risk of relapse, it is very important to continue medication and other treatments as recom-mended by the physician and clinical team. However, with the exception of family interventions and FGAs vs placebo, pooling treatment effects in the diverse comparisons showed that all estimates were in the same direction with no evidence of statistical heterogeneity. What Is Psychosis? Broad definitions of a FEP were considered including the following diagnostic categories: schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, substance-induced psychotic disorder, and psychotic disorder not otherwise specified. Clinical manifestations, differential diagnosis, and initial management of psychosis in adults are reviewed separately. All statistically significant differences in outcomes estimated via ORs remained significant when outcomes were pooled using relative risk measures. ", Journal of Women’s Health: “A Review of Postpartum Psychosis.”, Annals of General Psychiatry: "Postictal Psychosis: Presymptomatic Risk Factors and the Need for Further Investigation of Genetics and Pharmacotherapy. Three reviewers (M.Á.-J., S.E.H., and A.P.) 1 However, using the term “first” could imply that a second episode of psychosis is likely. This suggests that the subgroups of RCTs (ie, specialist FEP programs vs both TAU and individual generic CBT and FGAs vs SGAs) were clinically meaningful, and comparisons were sufficiently homogeneous to obtain summary effect estimates across subgroups.20 Regardless, research on relapse prevention would clearly benefit from consensus regarding the relapse and clinical remission criteria employed.73 Most definitions of relapse included either significant worsening of psychotic symptoms or hospital readmission. VII. Heterogeneity of intervention estimates was assessed by visually inspecting the overlap of CIs on the forest plots and by the I2 statistic. Only 3 small studies compared first-generation antipsychotics (FGAs) with placebo with no significant differences regarding relapse prevention although all individual estimates favored FGAs (OR = 2.82, 95% CI = 0.54–14.75; P = .22). I'm going through my second psychotic episode, this one is not as bad as the first one for which I had to sign myself into a mental hospital. February 25, 2015 March 8, 2015 brief reactive psychosis brief reactive psychosis, mental illness, shame. Regarding publication bias, there was no clear evidence of funnel plot asymmetry (trial effect vs trial size) in any analysis (Supplementary Data). Analyses were performed using both relative risks and OR as measures of effect size. The pilot project ‘Soteria Berne'. I have borderline personality disorder with comorbid schizotypal personality disorder (and I have complex post traumatic stress disorder). The recovery process—how long it takes and how much improve-ment there is—varies from person to person. Finally, given that some potentially eligible pharmacological trials did not report on relapse/readmission rates,37,38 the possibility of reporting bias cannot be discarded. A psychotic episode can be an awful experience for anyone to have.If a loved one has experienced symptoms of psychosis, get medical help sooner rather than later, as timeliness is a vital factor in treating psychosis.Medical professionals can help you and your loved one understand the causes of psychosis and how treatment can help them cope with, and even prevent, future episodes. Who Stays in Treatment? The pooled OR showed no statistically significant advantage in favor of FGAs (OR = 2.82, 95% CI = 0.54–14.75; P = .22; figure 3) with some evidence of statistical heterogeneity (I2 = 50.0%, P = .14). independently extracted relevant data from included trials, including the characteristics and nature of the intervention and comparison groups, definition of relapse and method of assessment, the clinical remission criteria employed, and information regarding the outcome parameters. Finally, interventions in this phase are crucial for the secondary prevention of illness progression to clinical stage 3, in particular to prevent relapse into a second episode of psychosis (3a). Furthermore, no clinical trial has been conducted to test the effectiveness of SGAs vs placebo in preventing relapse in FEP. This population clearly differs from clinically stable patients included in earlier psychosocial studies of relapse prevention for whom positive findings have been demonstrated.64 Thirdly, Edwards et al65 tested a CBT intervention aimed at reducing substance abuse in FEP psychosis. Sometimes you can lose touch with reality even when you don’t have a primary psychotic illness such as schizophrenia or bipolar disorder. First-episode psychosis represents a critical juncture in the treatment of schizophrenia. Other symptoms may include incoherent speech and behavior that is inappropriate for the situation. Electronic searches were supplemented by hand searching reference lists of retrieved trials, previous reviews, and abstracts from meetings. This is the stage when characteristic psychotic symptoms – such as hallucinations, delusions and very odd or disorganized speech … Mario Álvarez-Jiménez, Alexandra G. Parker, Sarah E. Hetrick, Patrick D. McGorry, John F. Gleeson, Preventing the Second Episode: A Systematic Review and Meta-analysis of Psychosocial and Pharmacological Trials in First-Episode psychosis, Schizophrenia Bulletin, Volume 37, Issue 3, May 2011, Pages 619–630, https://doi.org/10.1093/schbul/sbp129. However, given the clinical and social relevance of preventing relapse early in the course of psychosis, it is somewhat surprising—the modest controlled evidence on relapse prevention strategies for FEP patients. The second phase of treatment is the longest as it can last for over a year. Based on the data presented, the trial methods appear feasible. Differences in Risk of Relapse in FEP Patients in Studies Comparing Antipsychotic Medications With Placebo. Such trials should include consensual and prospective relapse and remission criteria and should be properly randomized and powered. While most trials included follow-ups of 12–18 months, studies varied in the timing of baseline assessment in relation to the initiation of pharmacological treatment, which may have influenced the rates of relapse obtained. Future relapse criteria should also include objective measurement of functional consequences of relapse. A psychotic episode occurs in three phases, with the length of each varying from person to person.Phase 1: ProdomeThe early signs may be vague and hardly noticeable. Differences in Risk of Relapse in FEP Patients in Studies Comparing SGAs With FGAs. 2011;37:619-630. These episodes stem from something else, like drug use or a medical condition. Clinical experiences and results, Schizophrenia and obesity: impact of antipsychotic medications, Remission in schizophrenia: applying recent consensus criteria to refine the concept, Systematic reviews in health care: assessing the quality of controlled clinical trials. If you are in the grips of a psychotic break or episode, you may not be able to understand that that’s what’s occurring. Current Psychiatry. A description of the conduct of the trials included in the meta-analysis and assessment of the risk of bias are presented in Supplementary Data. Nonetheless, only FGAs were tested, and these trials had design aspects that could limit the generalizability of the findings to clinical practice. FEP, first-episode psychosis; FGAs, first-generation antipsychotics; SGAs, second-generation antipsychotics; M-H random, Mantel-Haenszel method random effects; CI, confidence interval. Trials were excluded if they had a follow-up period shorter than 6 months, as these were not considered to be adequate for an assessment of relapse prevention.17 Two reviewers (M.Á.-J. Usually, a person has gradual, non-specific changes in thoughts and perceptions, but doesn't understand what's going on. Specifically, 2 of the 3 relevant trials reported a small sample size and did not specify the criteria used to determine clinical remission.49,50 In addition, the trial by McCreadie et al50 included patients who took part in a previous study and had not experienced relapse. The primary outcome was the number of relapses, with secondary outcome measures including mean hospital days, time to relapse, duration of second episode, and discontinuation of treatment due to adverse events. The epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis of schizophrenia in adults and children are also … Note: event = number of relapses; weight = it is indicated by the size of the square on each graph line and is related to the number of participants and events in the study. First episode psychosis is typically preceded by subtle premorbid signs in childhood and subsyndromal prodromal symptoms. Note: event = number of relapses; weight = it is indicated by the size of the square on each graph line and is related to the number of participants and events in the study. Both drugs that depress the nervous system, like cannabis (marijuana), and stimulant drugs, like cocaine and amphetamines, can affect your brain activity in dramatic ways so that what seems real to you doesn't match with the world. FEP, first-episode psychosis; CBT, cognitive-behavioral therapy; RPT, relapse prevention therapy; TAU, treatment as usual; M-H random, Mantel-Haenszel method random effects; CI, confidence interval. Early Intervention (EI) for psychosis services have been established internationally for individuals experiencing a first episode of psychosis (FEP). But there’s a strong link between all these drugs and primary psychosis. Given the robust evidence for relapse prevention for family interventions in the later phases of schizophrenia66,67 and the theoretical potential of these interventions to prevent psychotic relapse,68 it is surprising that there is such a small number of RCTs evaluating their effectiveness in FEP patients. ... Hetrick SE, et al. This study sought to undertake a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the effectiveness of pharmacological and non-pharmacological interventions to prevent relapse in FEP patients. Given the small number of relevant trials comparing SGAs with FGAs, results for the newer generation of antipsychotics were pooled in an exploratory manner. The number needed to treat (NNT) statistic, calculated as the reciprocal of the risk difference in relapse between 2 groups, was estimated in the case of significant results. Eight trials included clinically remitted FEP patients,40,44,45,47,49–51,55 and 10 followed responders from acute phase trials.3,39,41–43,46,48,52–54 Ten trials reported follow-up periods ranging from 7 months to 1 year,2,42,44–46,49–51,53,54 and 8 trials included follow-up periods of 18 months to 2 years.3,39–41,43,47,48,55 Regarding the assessment of relapse, 11 trials used prespecified relapse criteria (ie, relapse defined as stated by the authors),3,39,40,43,45,48–51,54,55 and 7 trials assessed relapse defined as the number of rehospitalizations due to an exacerbation of psychotic symptoms.41,42,44,46,47,52,53 Of those that included specific relapse criteria, 3 trials employed previously proposed criteria3,40,45 and 8 established their own criteria,39,43,48–51,54,55 although a significant exacerbation of positive symptoms and a marked social impairment were included in most definitions of relapse (Supplementary Data and Supplementary Data). The intervention aimed at correcting delays in cerebral inhibition that may develop perinatally, as indexed by electrophysiological bio- markers. Longer clinical trials are clearly needed to determine the long-term effectiveness of these interventions. Finally, further research should make efforts to identify those FEP patients who will only experience one psychotic episode and therefore may not need antipsychotic medication to prevent psychotic relapses. Although it's extremely rare, some women have menstrual psychosis. Antipsychotic drugs like olanzapine and risperidone can stop symptoms and may help prevent future episodes. Trial authors were contacted for the provision of missing data for the meta-analysis if necessary. I mostly feel out of my body, and have delusions of reference and persecution, not suicidal. But psychosis from cocaine, PCP (aka angel dust), and amphetamines could last for weeks. Finally, only one trial examined the effectiveness of a guided discontinuation strategy vs maintenance treatment in young patients with psychosis. Moreover, given that previous research has found relapse rates increase over longer periods of time,4 findings from the present meta-analysis can only be generalized to the first 2 years after treatment initiation. Three trials, including 166 participants, examined the effectiveness of antipsychotic medication compared with placebo to prevent relapse, as defined by the authors.48–50 The 3 trials used different FGAs (see Supplementary Data), and, given the small number of trials, the effects of FGAs were analyzed as a group. Schizophr Bull. Preventing the Second Episode: A Systematic Review and Meta-analysis of Psychosocial and Pharmacological Trials in First-Episode psychosis Mario Álvarez-Jiménez, Mario Álvarez-Jiménez 1. As a result, these programs are likely to include a substantial proportion of therapeutic components usually offered in CBT interventions, thus making it difficult to find significant differences between treatment groups. © 2005 - 2019 WebMD LLC. While one trial with positive findings included male participants and tested an intervention consisting of group and individual counseling sessions for 18 months,47 the other trial, which showed no difference between treatment conditions, evaluated a brief individual intervention comprising 7 sessions of psychoeducation.46 Similarly, the extant literature consistently shows that longer term family programs produce stronger clinical effects than shorter interventions in multiepisode patients.66 Taken together, these results indicate that longer family interventions may be needed in order to obtain clinical benefits in FEP patients. Random-effects models are, in general, more conservative than fixed-effects models because they take heterogeneity among studies into account.23 With decreasing heterogeneity, the random-effects approach moves asymptotically toward a fixed-effects model. During the episodes, you may be confused about what's real, hallucinate, and believe things that aren't true. Subsequently, the number of hospital days for both the specialist FEP programs and TAU groups was analyzed. Recent evidence suggests that the reduction of hospital days associated with specialist FEP programs may be maintained over 5 years of follow-up.63 Thus, the duration of FEP programs as well as the duration of the follow-up are equally important aspects to consider in future research. Conclusions: Specialist FEP programs are effective in preventing relapse. 2011;37(3):619-630. Three trials including 283 participants investigated the effectiveness of individual CBT vs other forms of therapy.42–44 One trial compared CBT with both supportive counseling and TAU,43 one examined the effectiveness of CBT compared with befriending plus specialist FEP program,42 and one trial evaluated a cannabis-focused intervention in addition to specialist FEP care compared with a specialist FEP program alone.42,44 One trial provided data on relapse as defined by the authors,43 whereas 2 evaluated relapse defined as admission to hospital.42,44 When those trials evaluating the effectiveness of CBT plus specialist FEP care vs an FEP specialist program were combined, the resulting pooled OR demonstrated no statistically significant advantages in favor of CBT (OR = 1.95, 95% CI = 0.76–5.00; P = .17) with no evidence of statistical heterogeneity (I2 = 0%, P = .48; figure 2). ", The Primary Care Companion to the Journal of Clinical Psychiatry: "Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited. Current American Psychiatric Association guidelines recommend brain imaging in first-episode psychosis (FEP), favoring MRI or CT 1 ; however, other national guidelines do not make similar recommendations. The available evidence suggests that intensive psychosocial interventions together with low-dose medication strategies—in accordance with early psychosis treatment guidelines—are effective in reducing relapse rates in young patients with FEP psychosis. Copyright © 2020 Maryland Psychiatric Research Center and Oxford University Press. While the funnel plot of all trials showed no evidence of publication bias, it was not possible to formally assess such bias because of the small number of trials for each comparison. ", Psychotherapy and Psychosomatics: "Antipsychotic-Induced Dopamine Supersensitivity Psychosis: Pharmacology, Criteria, and Therapy. Differences in Risk of Relapse in FEP Patients in Studies Comparing Specialist FEP Programs With TAU, Individual CBT, and Individual and Family RPT. The authors acknowledge Sara Gook of ORYGEN Research Centre-University of Melbourne and Dr César González-Blanch of University Hospital “Marqués de Valdecilla” for helpful comments on an earlier draft of this article. The present study sought to undertake a systematic review and meta-analysis of all relevant randomized controlled trials (RCTs) of pharmacological and nonpharmacological interventions to prevent relapse in FEP patients. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. In comparison, almost all patients with first-episode schizophrenia experienced future psychosis. There may be changes in the way some people describe their feelings, thoughts and perceptions, which … Cannabis is involved in roughly half of all cases. The I2 test of heterogeneity describes the proportion of total variation in study estimates that is due to heterogeneity.22 Given the heterogeneity of trials, random-effects meta-analysis was fitted. Taken together, these data lend support to the contention that multimodal CBT interventions specifically designed to prevent relapse offered to remitted FEP patients may improve further upon relapse rates achieved by specialist FEP services. Relapse was defined according to the criteria used in the individual studies. The authors also thank authors who provided additional information including Dr Susy Harrigan, Dr Jane Edwards, Dr. Lex Wunderink, Dr Lone Petersen, Dr Gerard Leavey, Dr Nina Schooler, Dr Wolfgang Gaebel, Dr Hans-Jürgen Möller, Dr Jeffrey A. Lieberman, Dr Joseph P. McEvoy, and Dr John R. Bola. This time it was triggered by extreme guilt of having my employees caught in a blizzard and comments from my boss which made me doubt my value as an employee and, worse, a human being. When taken together, findings from this and previous studies indicate that there is the need to evaluate, in a controlled fashion, the effectiveness of antipsychotic medication plus TAU vs a specialist FEP program with no use of antipsychotic medication in preventing relapse in young patients with an FEP. Three trials involving 679 patients demonstrated specialist FEP programs to be effective in preventing relapse in relation to TAU. I just fell stupid right now for going back to weed, and overstraining myself again, because people have warned me not to do that, I just feel very stupid, I know someday life will … independently assessed all potentially relevant articles for inclusion. More than 25% of those who are diagnosed with amphetamine-induced psychosis later have psychotic disorders. One trial that involved 128 FEP patients evaluated maintenance vs guided discontinuation of pharmacological therapy (SGAs including risperidone, olanzapine, quetiapine, clozapine, and zuclopenthixol) in the prevention of relapse, as defined by the authors.55 This trial found that maintenance of treatment was statistically significantly superior compared with guided discontinuation for relapse prevention (OR = 2.91, 95% CI = 1.33–6.37; P < .01).
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