Psychosocial treatment, antipsychotic postponement, and low‐dose medication strategies in first‐episode psychosis: A review of the literature

The Association of Antipsychotic Postponement With 5-Year Outcomes of Adolescent First-Episode Psychosis

Background and Hypothesis

Based on the need-adapted approach, delaying antipsychotics could help identify first-episode psychosis (FEP) adolescents who might not require them. However, some individuals might need antipsychotics, and postponing could harm their prognosis. This nationwide register-based follow-up aimed to test these two hypotheses.

Study Design

All adolescents aged 13-20 with a psychotic disorder (ICD-10 codes: F20-F29) in Finland between 2003 and 2013 were identified (n = 6354) from national registers. For each case, a fixed 1825-day follow-up period was established from the onset of psychosis or until death. The outcome was considered "good" if adolescents did not die and had not received psychiatric treatment and/or disability allowances during the final year of follow-up. Testing the first hypothesis involved all antipsychotic treatment-naïve adolescents with FEP (n = 3714). The second hypothesis was tested with a sub-sample of only those who had received antipsychotics during follow-up (n = 3258). To account for baseline confounders, hypotheses were tested via a stabilized inverse probability of treatment weighted generalized linear models with logit link function.

Study Results

Immediate antipsychotic treatment after the onset of psychosis was associated with poor 5-year outcome (adjusted odds ratio [aOR]: 1.8, 95% CI: 1.6-2.1). There was no statistically significant association between antipsychotic postponement and treatment outcome in those who eventually received antipsychotic treatment (aOR: 1.02, 95% CI: 0.7-1.2, P: .8), thus not providing support for second hypothesis.

Conclusions

There is a significant subgroup of adolescent with psychosis who do not require immediate antipsychotic treatment. A more robust design is needed to evaluate the causality of the observed association.

Postpartum Psychosis: The Role of Women's Health Care Providers and the Health Care System

Importance

The postpartum period is a time of high risk for serious psychiatric symptoms and hospitalization. Postpartum psychosis (PPP) is the most severe disorder that emerges during this time, with significant and wide-ranging consequences that can include suicide and infanticide.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about PPP, including subtopics (eg, infanticide, maternal suicide). Citations in these articles were also reviewed for relevant references.

Results

Although it is clear that the triggering event for PPP is childbirth, the processes by which this occurs are not fully understood, which is a critical need for being able to predict, prevent, and manage PPP. There are risk factors that contribute to PPP, and specific groups of women may be at increased risk (eg, women with bipolar disorder). Many questions and challenges remain related to the phenomenology, nosology, prevention, and treatment of PPP. However, there are changes that women's health care providers and systems can take to improve the care of women at risk of and experiencing PPP.

Results

Of the 1382 articles reviewed, 8 met eligibility criteria, representing 6 distinct cohorts and 726 subjects. Synthetic slings available for review were either tension-free vaginal tape (TVT) or minisling. The vast majority of studies demonstrated similar short- and long-term success rates of AFS and SS procedures utilizing a range of outcome measures. Both AFS and TVT sling had low recurrence rates in short- and long-term follow-up. However, AFS had significantly longer operative time, and longer hospital stay. Bladder perforation, on the other hand, occurred more commonly in TVT sling. Health-related quality-of-life scores, including sexual function, were similar between groups.

Conclusions and Relevance

Postpartum psychosis is a rare but serious condition. However, recovery is possible. Women's health care providers and systems can improve the care by better understanding the needs of women and families, offering patient-centered discussions and options for care, particularly those that promote recovery, minimize risk, and limit the interruption of the maternal-infant bond. Improving the prevention and treatment of PPP can have a broad impact for women, children, and families.

How important are informed consent, informed choice, and patient-doctor relationships, when prescribing antipsychotic medication?

BACKGROUND

Antipsychotic medications (APs) are used for people with psychosis diagnoses and, increasingly for other problems and groups.

AIMS

This study examines how APs are prescribed, from the perspective of recipients.

METHODS

757 people, from 30 countries, responded to questions about their experiences with APs, in an online survey.

RESULTS

Most (70%) were told nothing about adverse effects. Fewer than 2% recalled being told about the risks of diabetes, suicidality, sexual dysfunction, or reduced life span. None recalled being told about reduced brain volume or withdrawal effects. Only 28% recalled being offered other treatments; with only 14% offered talking therapies. 46% were not told how long to take the APs; and, of those who were told something, 48% were told to take them forever. Most respondents (76%) were not told how APs work. Only 19% were satisfied with the prescribing process, and only 25% reported a good, or very good, relationship with the prescriber. Information, satisfaction with the process, and the prescriber relationship were all positively related to three self-reported outcomes: reduction of problems the drugs were prescribed for, general helpfulness, and quality of life.

CONCLUSIONS

Steps need to be taken to ensure people prescribed antipsychotics are fully informed, especially about adverse effects and alternatives.

Psychological intervention, antipsychotic medication or a combined treatment for adolescents with a first episode of psychosis: the MAPS feasibility three-arm RCT

BACKGROUND

When psychosis emerges in young people there is a risk of poorer outcomes, and access to evidence-based treatments is paramount. The current evidence base is limited. Antipsychotic medications show only a small benefit over placebo, but young people experience more side effects than adults. There is sparse evidence for psychological intervention. Research is needed to determine the clinical effectiveness and cost-effectiveness of psychological intervention versus antipsychotic medication versus a combined treatment for adolescents with psychosis.

OBJECTIVES

The objective of Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) was to determine the feasibility of conducting a definitive trial to answer the question of clinical effectiveness and cost-effectiveness of these three treatment options.

DESIGN

This was a prospective, randomised, open-blinded, evaluation feasibility trial with a single blind. Participants were allocated 1 : 1 : 1 to receive antipsychotic medication, psychological intervention or a combination of both. A thematic qualitative study explored the acceptability and feasibility of the trial.

SETTING

Early intervention in psychosis services and child and adolescent mental health services in Manchester, Oxford, Lancashire, Sussex, Birmingham, Norfolk and Suffolk, and Northumberland, Tyne and Wear.

PARTICIPANTS

People aged 14-18 years experiencing a first episode of psychosis either with an International Classification of Diseases, Tenth Revision, schizophrenia spectrum diagnosis or meeting the entry criteria for early intervention in psychosis who had not received antipsychotic medication or psychological intervention within the last 3 months.

INTERVENTIONS

Psychological intervention involved up to 26 hours of cognitive-behavioural therapy and six family intervention sessions over 6 months, with up to four booster sessions. Antipsychotic medication was prescribed by the participant's psychiatrist in line with usual practice. Combined treatment was a combination of psychological intervention and antipsychotic medication.

MAIN OUTCOME MEASURES

The primary outcome was feasibility (recruitment, treatment adherence and retention). We used a three-stage progression criterion to determine feasibility. Secondary outcomes were psychosis symptoms, recovery, anxiety and depression, social and educational/occupational functioning, drug and alcohol use, health economics, adverse/metabolic side effects and adverse/serious adverse events.

RESULTS

We recruited 61 out of 90 (67.8%; amber zone) potential participants (psychological intervention, n = 18; antipsychotic medication, n = 22; combined treatment, n = 21). Retention to follow-up was 51 out of 61 participants (83.6%; green zone). In the psychological intervention arm and the combined treatment arm, 32 out of 39 (82.1%) participants received six or more sessions of cognitive-behavioural therapy (green zone). In the combined treatment arm and the antipsychotic medication arm, 28 out of 43 (65.1%) participants received antipsychotic medication for 6 consecutive weeks (amber zone). There were no serious adverse events related to the trial and one related adverse event. Overall, the number of completed secondary outcome measures, including health economics, was small.

LIMITATIONS

Medication adherence was determined by clinician report, which can be biased. The response to secondary outcomes was low, including health economics. The small sample size obtained means that the study lacked statistical power and there will be considerable uncertainty regarding estimates of treatment effects.

CONCLUSIONS

It is feasible to conduct a trial comparing psychological intervention with antipsychotic medication and a combination treatment in young people with psychosis with some adaptations to the design, including adaptations to collection of health economic data to determine cost-effectiveness.

FUTURE WORK

An adequately powered definitive trial is required to provide robust evidence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80567433.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 4. See the NIHR Journals Library website for further project information.

The beliefs of non-psychiatric doctors about the causes, treatments, and prognosis of schizophrenia

OBJECTIVES

To examine the causal beliefs about schizophrenia of non-psychiatric doctors and whether differential belief in biogenetic vs. psychosocial causes influences doctors' views about treatments and prognosis.

DESIGN AND METHODS

Three hundred and five non-psychiatric doctors working in outpatient community centres completed the 'Opinions on mental disorders Questionnaire' after reading a clinical description of people with schizophrenia.

RESULTS

The factors most frequently reported as causes of schizophrenia were heredity (65.2%) and use of street drugs (54.1%). Seventy-five per cent of participants endorsed both one or more biological causal factors and one or more psychosocial causal factors. Of the 264 participants who expressed their opinion about the most important cause of schizophrenia, 53.8% indicated a biogenetic cause. Fifty-two per cent of respondents thought it 'completely true' that drugs are useful in schizophrenia, and 33.9% thought it 'completely true' that people with schizophrenia must take drugs all their life. Participants stating that the most important cause was biogenetic more frequently recommended a psychiatrist and less frequently a psychologist. Compared to doctors who indicated a psychosocial cause as the most important one, those who indicated a biogenetic cause were more sceptical about recovery, more confident in the usefulness of drugs, and more convinced of the need of lifelong pharmacological treatments in schizophrenia.

CONCLUSIONS

These findings suggest the need to provide some doctors with training on the multiple, interacting causes of schizophrenia and the efficacy of the broad range of available treatments. The education of health professionals regarding stigma and its effects on clinical practice is also needed.

PRACTITIONER POINTS

Viewing schizophrenia as mainly due to a biological cause is associated with greater confidence in the usefulness of drugs, higher belief in the need for lifelong pharmacological treatments, and greater prognostic pessimism. Belief in a biologically oriented model of schizophrenia may lead doctors to underestimate the value of psychologists. Prognostic pessimism among doctors may negatively influence clinical decisions, the information doctors provide to their clients, and clients' own beliefs about their chances of recovery. Belief in the need for lifelong pharmacological treatments in schizophrenia may lead doctors to resist drug withdrawal in case of severe side effects.

Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review

Antipsychotics are the first-line treatment for people with schizophrenia or psychosis. There is evidence that they can reduce the symptoms of psychosis and risk of relapse. However many people do not respond to these drugs, or experience adverse effects and stop taking them. In the UK, clinical guidelines have stressed the need for research into psychosocial interventions without antipsychotics. This systematic review examines the effects of psychosocial interventions for people with schizophrenia or psychosis who are on no/minimal antipsychotics. Databases were searched for empirical studies investigating a psychosocial intervention in people with a schizophrenia spectrum disorder who were not taking antipsychotics or had received an antipsychotic minimisation strategy. We identified nine interventions tested in 17 studies (N = 2250), including eight randomised controlled trials. Outcomes were generally equal to or in a small number of cases better than the control group (antipsychotics/treatment as usual) for Cognitive Behavioural Therapy (CBT), Need Adapted Treatment and Soteria. The remaining interventions provided some encouraging, but overall inconsistent findings and were Psychosocial Outpatient Treatment, Open Dialogue, Psychosocial Inpatient Treatment, Psychoanalysis/Psychodynamic Psychotherapy, Major Role Therapy, and Milieu Treatment. Study quality was generally low with little recent research. In conclusion, nine psychosocial interventions have been studied for patients on no/minimal antipsychotics. The majority of studies reported outcomes for the intervention which were the same as the control group, however, study quality was problematic. Given the adverse effects of antipsychotics and that many people do not want to take them, high quality trials of psychosocial treatments for people on minimal/no antipsychotics are needed.

Five-Year Cumulative Exposure to Antipsychotic Medication After First-Episode Psychosis and its Association With 19-Year Outcomes

Background

The long-term effectiveness of antipsychotic maintenance treatment after first-episode psychosis (FEP) is contested. In this real-world observational study, we examined how cumulative exposure to antipsychotics within the first 5 years from FEP was associated with the 19-year outcome.

Methods

Finnish national registers were used to detect all patients who were hospitalized due to non-affective psychosis in the mid-1990s, and who were treatment naïve prior to the inclusion period (N = 1318). Generalized linear models with logit link function were used to estimate how cumulative exposure to antipsychotics within the first 5 years from onset was associated with mortality, work capability, and the use of psychiatric services at the end of the 19-year follow-up. To adjust for confounding by indication, the primary outcome analyses implemented stabilized inverse probability of treatment weighting using propensity scores.

Results

Persons with a higher cumulative exposure to antipsychotics within the first 5 years from FEP were more likely to still be receiving antipsychotics (adjusted odds ratio [OR] = 2.1; 95% CI: 1.5−2.8), psychiatric treatment (OR = 1.4; 95% CI: 1.1−1.7), and disability allowances (OR = 1.3; 95% CI: 1.01−1.6) at the end of the 19-year follow-up, as compared to low/zero-exposure. Higher cumulative exposure was also associated with higher mortality (OR = 1.5; 95% CI: 1.1–2.1).

Conclusions

After adjustment for confounders, moderate and high cumulative exposure to antipsychotics within the first 5 years from FEP was consistently associated with a higher risk of adverse outcomes during the 19-year follow-up, as compared to low or zero exposure. Due to potential unmeasured confounding, controlled trials are needed.

Using Open Questions to Understand 650 People's Experiences With Antipsychotic Drugs

Studies of antipsychotic medication, which are increasingly prescribed for a broad range of problems and circumstances, rarely ask the people who take them to describe their experiences with the drugs. In this study, 650 people, from 29 countries, responded, in an online survey, to "Overall in my life antipsychotic medications have been _____?" and "Is there anything else you would like to say, or emphasise, about your experiences with antipsychotic drugs?" Of the total participants, 14.3% were categorized as reporting purely positive experiences, 27.9% had mixed experiences, and 57.7% reported only negative ones. Negative experiences were positively correlated with age. Thematic analysis identified 749 negative, 180 positive, and 53 mixed statements. The 2 positive themes were "symptom reduction" (14) and "sleep" (14), with the majority (153) unspecified. The 4 negative themes (besides "unspecified"-191) were: "adverse effects" (316), "interactions with prescriber" (169), "withdrawal/difficult to get off them" (62), and "ineffective" (11). The adverse effects included: weight gain, emotional numbing, cognitive dysfunction, sedation, akathisia, effects on relationships, and suicidality. "Interactions with prescriber" included lack of information about withdrawal effects, support, or discussion of alternatives. The only mixed theme was "short-term good, long-term bad" (28). Open questions can add to findings from methodologies focused on symptom reduction. Clinicians should pay more attention to the need for respectful and collaborative patient-prescriber relationships. At the point of prescription, this must include providing the full range of information about antipsychotics, including potential benefits and harms, difficulties withdrawing, and information on alternatives treatments such as psychological therapies.

Positive and Negative Effects of Antipsychotic Medication: An International Online Survey of 832 Recipients

Background:

Antipsychotic medication is currently the treatment of choice for psychosis, but few studies directly survey the first-hand experience of recipients.

Objective:

To ascertain the experiences and opinions of an international sample of users of antipsychotic drugs, regarding positive and negative effects.

Methods:

An online direct-to-consumer questionnaire was completed by 832 users of antipsychotics, from 30 countries – predominantly USA, UK and Australia. This is the largest such sample to date.

Results:

Over half (56%) thought, the drugs reduced the problems they were prescribed for, but 27% thought they made them worse. Slightly less people found the drugs generally ‘helpful’ (41%) than found them ‘unhelpful’ (43%). While 35% reported that their ‘quality of life’ was ‘improved’, 54% reported that it was made ‘worse’. The average number of adverse effects reported was 11, with an average of five at the ‘severe’ level. Fourteen effects were reported by 57% or more participants, most commonly: ‘Drowsiness, feeling tired, sedation’ (92%), ‘Loss of motivation’ (86%), ‘Slowed thoughts’ (86%), and ‘Emotional numbing’ (85%). Suicidality was reported to be a side effect by 58%. Older people reported particularly poor outcomes and high levels of adverse effects. Duration of treatment was unrelated to positive outcomes but significantly related to negative outcomes. Most respondents (70%) had tried to stop taking the drugs. The most common reasons people wanted to stop were the side effects (64%) and worries about long-term physical health (52%). Most (70%) did not recall being told anything at all about side effects.

Conclusion:

Clinical implications are discussed, with a particular focus on the principles of informed consent, and involving patients in decision making about their own lives.

Supportive psychodynamic psychotherapy for psychosis

The UK National Institute for Health and Care Excellence guidance suggests that psychodynamic principles may be used to understand the experiences of people with psychosis. In this article we consider the application of psychodynamic principles in psychotherapy for psychosis, focusing on one particular model: supportive psychodynamic psychotherapy (SPP). We describe this approach with a detailed fictitious case example and discuss how SPP has developed through significant modifications of classical psychoanalytic therapy and the evidence base for it. We consider its overlap with cognitive–behavioural therapy, its advantages and disadvantages, and the arguments for making SPP available as a treatment option in services for psychosis.

A 20-Year multi-followup longitudinal study assessing whether antipsychotic medications contribute to work functioning in schizophrenia

To assess the long-term effectiveness of antipsychotic medications in facilitating work functioning in patients with schizophrenia we conducted longitudinal multifollowup research on 139 initially psychotic patients. The 70 patients with schizophrenia and 69 initially psychotic mood disordered control patients were followed up 6 times over 20 years. We compared the influence on work functioning of patients with schizophrenia continuously prescribed antipsychotics with patients with schizophrenia not prescribed antipsychotics, using statistical controls for inter-subject differences. While antipsychotics reduce or eliminate flagrant psychosis for most patients with schizophrenia at acute hospitalizations, four years later and continually until the 20 year followups, patients with schizophrenia not prescribed antipsychotics had significantly better work functioning. The work performance of the patients who were continuously prescribed antipsychotics was at a low rate and did not improve over time. Multiple other factors also interfere with work functioning. The data suggest that some patients with schizophrenia not prescribed antipsychotics for prolonged periods can function relatively well. Multiple other factors are associated with poor post-hospital work performance. The longitudinal data raise questions about prolonged treatment of schizophrenia with antipsychotic medications.

[Frontal brain volume reduction due to antipsychotic drugs?]

This article reviews the results of longitudinal studies on frontal brain volume reduction in patients with schizophrenia spectrum disorders and focuses on the relationship with antipsychotic treatment. Based on a systematic literature search all studies were included in which results on changes of brain volumes over a longer period of time were correlated with antipsychotic treatment dose and disease severity. The findings indicate that there is evidence for grey and white matter volume changes of the frontal brain, which cannot be explained by the severity of the disease alone but are also very likely a manifestation of long-term effects of antipsychotics. Whether second generation antipsychotics have an advantage compared to first generation antipsychotics is currently unclear. Considering the contribution of antipsychotics to the changes in brain structure, which seem to depend on cumulative dosage and can exert adverse effects on neurocognition, negative and positive symptoms and psychosocial functioning, the guidelines for antipsychotic long-term drug treatment should be reconsidered. This is the reason why we and others recommend prescribing the lowest dose necessary to control symptoms. In non-schizophrenic psychiatric disorders, antipsychotics should be used only with great caution after a careful risk-benefit assessment. Moreover, treatment approaches which can help to minimize antipsychotic medication or even administer them only selectively are of increasing importance.

Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study

BACKGROUND

This research assesses whether multi-year treatment with antipsychotic medications reduces or eliminates psychosis in schizophrenia. It provides 20 years of longitudinal data on the frequency and severity of psychotic activity in samples of schizophrenia patients (SZ) treated versus those not treated with antipsychotic medications.

METHOD

A total of 139 early young schizophrenia and mood-disordered patients were assessed at index hospitalization and then reassessed six times over 20 years for psychosis and other major variables.

RESULTS

At each follow-up assessment over the 20 years, a surprisingly high percentage of SZ treated with antipsychotics longitudinally had psychotic activity. More than 70% of SZ continuously prescribed antipsychotics experienced psychotic activity at four or more of six follow-up assessments over 20 years. Longitudinally, SZ not prescribed antipsychotics showed significantly less psychotic activity than those prescribed antipsychotics (p < 0.05).

CONCLUSIONS

The 20-year data indicate that, longitudinally, after the first few years, antipsychotic medications do not eliminate or reduce the frequency of psychosis in schizophrenia, or reduce the severity of post-acute psychosis, although it is difficult to reach unambiguous conclusions about the efficacy of treatment in purely naturalistic or observational research. Longitudinally, on the basis of their psychotic activity and the disruption of functioning, the condition of the majority of SZ prescribed antipsychotics for multiple years would raise questions as to how many of them are truly in remission.

Diagnostic stability of first-episode psychosis and predictors of diagnostic shift from non-affective psychosis to bipolar disorder: a retrospective evaluation after recurrence

Diagnostic changes during follow-up are not uncommon with a first-episode psychosis (FEP). This study aimed to evaluate the diagnostic stability of the FEP and to identify factors associated with a diagnostic shift from non-affective psychosis to bipolar disorder. Considering that the diagnosis of FEP is frequently more definite after recurrence in many clinical settings, a retrospective evaluation after recurrence was preformed. Subjects were 150 patients with psychotic disorders who had been admitted to a psychiatric ward both for first episode and recurrence of their psychosis. Consensus diagnosis was made for each episode through a review of hospital records. Patients diagnosed with non-affective psychoses at the first episode were included in the analysis of predictive factors of a diagnostic shift to bipolar disorder. First-episode diagnoses were revised upon recurrence in 20.7% of patients. The most common change was to bipolar disorder accounting for more than half of all diagnostic changes. Schizophrenia exhibited the highest prospective and retrospective diagnostic consistencies. Female gender, short duration of untreated psychosis, high level of premorbid functioning, and several symptoms including lability, mood elation, hyperactivity, and delusions with religious or grandiose nature were identified as predictive factors for a diagnostic shift from non-affective psychosis to bipolar disorder. Clinical features of psychoses seem to evolve during the disease course resulting in diagnostic changes upon recurrence in a significant portion of FEP. Special consideration on a diagnostic shift to bipolar disorder is required in patients exhibiting the predictive factors identified in the current study.

Time to abandon the bio-bio-bio model of psychosis: Exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms

Mental health services and research have been dominated for several decades by a rather simplistic, reductionistic focus on biological phenomena, with minimal consideration of the social context within which genes and brains inevitably operate. This ‘medical model’ ideology, enthusiastically supported by the pharmaceutical industry, has been particularly powerful in the field of psychosis, where it has led to unjustified and damaging pessimism about recovery. The failure to find robust evidence of a genetic predisposition for psychosis in general, or ‘schizophrenia’ in particular, can be understood in terms of recently developed knowledge about how epigenetic processes turn gene transcription on and off through mechanisms that are highly influenced by the individual's socio-environmental experiences. To understand the emerging evidence of the relationship between adverse childhood events and subsequent psychosis, it is necessary to integrate these epigenetic processes, especially those involving the stress regulating functions of the HPA axis, with research about the psychological mechanisms by which specific types of childhood trauma can lead to specific types of psychotic experiences. The implications, for research, mental health services and primary prevention, are profound.

Declaration of Interest: None of the authors have any conflicts of interest in relation to this paper.

Childhood trauma and increased stress sensitivity in psychosis

OBJECTIVE

The notion that traumatic experiences in childhood may predict later psychotic outcomes would be strengthened if a plausible mechanism could be demonstrated. Because increased stress sensitivity is part of the behavioural expression of psychosis liability, the possible mediating role of childhood trauma was investigated.

METHOD

Fifty patients with psychosis were studied with the experience sampling method to assess stress reactivity in daily life, defined as emotional and psychotic reactivity to stress. Traumatic experiences in childhood were assessed with the Childhood Trauma Questionnaire.

RESULTS

A significant interaction was found between stress and CT on both negative affect (event stress: β = 0.04, P < 0.04; activity stress: β = 0.12, P < 0.001) and psychotic intensity (event stress: β = 0.06, P < 0.001; activity stress: β = 0.11, P < 0.001), showing that a history of CT is associated with increased sensitivity to stress.

CONCLUSION

A history of childhood trauma in patients with psychosis is associated with increased stress reactivity later in life, suggestive for an underlying process of behavioural sensitization.

Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ethics in the era of early intervention

In recent years, early intervention services have attempted to identify people with a first episode of psychosis as early as possible, reducing the duration of untreated psychosis and changing the timing of delivery of interventions. The logic of early intervention is based partly on accessing people in a more treatment responsive stage of illness in which psychosocial damage is less extensive, and partly on remediating a putatively active process of neuroprogression that leads to pathophysiological, symptomatic and structural changes, hence improving symptomatic and functional outcomes. However, as in other areas of health care, earlier identification of new patients may mean that different treatment approaches are indicated. The corollary of early detection is that the sequence and complexion of treatment strategies for first episode psychosis has been revaluated. Examples include the minimal effective dosage of antipsychotic medication and the content of psychosocial interventions. With the substantial reductions of DUP now seen in many early psychosis services, based on clinical staging and stepped care principles, it is even possible that the immediate introduction of antipsychotic medication may not be necessary for all first episode psychosis cases, but that potentially safer interventions, which may be more acceptable to many patients, such as comprehensive psychosocial intervention, may constitute effective treatment at least for a subgroup of patients. In this paper, we review this theoretical background and describe a randomised controlled trial currently underway at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne designed to test outcomes for first episode psychosis patients in response to two different treatments: intensive psychosocial intervention plus antipsychotic medication versus intensive psychosocial intervention plus placebo. This is a theoretically and pragmatically novel study in that it will provide evidence as to whether intensive psychosocial intervention alone is sufficient for a subgroup of first episode psychosis patients in a specialised early intervention service, and provide a test of the heuristic clinical staging model. By experimentally manipulating duration of untreated psychosis, the study will also provide a methodologically strong test of the effect of delaying the introduction of antipsychotic medication, as well as helping to disentangle the effects of antipsychotic medications and the putative neurobiological processes associated with brain changes and symptom profiles in the early phase of psychotic disorders. The study has been carefully crafted to satisfy critical ethical demands in this challenging research domain.