Academic journal article Current Psychiatry

For First-Episode Psychosis, Psychiatrists Should Behave like Cardiologists: Starting a Long-Acting Injectable Antipsychotic Soon after a First Psychotic Episode Can Prevent a More Destructive Second Episode

Academic journal article Current Psychiatry

For First-Episode Psychosis, Psychiatrists Should Behave like Cardiologists: Starting a Long-Acting Injectable Antipsychotic Soon after a First Psychotic Episode Can Prevent a More Destructive Second Episode

Article excerpt

Schizophrenia has been declared 'arguably the worst disease affecting mankind.' (1)

Myocardial infarction (MI) is the leading cause of death in the United States, and schizophrenia is the leading cause of disability. But while cardiologists manage the first heart attack very aggressively to prevent a second MI, we psychiatrists generally do not manage first-episode psychosis (FEP) as aggressively to prevent the more malignant second psychotic episode. Yet abundant evidence indicates that psychiatrists must behave like cardiologists at the onset of schizophrenia and other serious psychosis.

Individuals who survive the first heart attack, which permanently destroys part of the myocardium, are at high risk for a second MI, which may lead to death or weaken the heart so much that heart transplantation becomes necessary. Only implementation of aggressive medical intervention will prevent the likelihood of death due to a second MI in a person who has already suffered a first MI.

Similarly, the FEP of schizophrenia destroys brain tissue, about 10 to 12 cc containing millions of glial cells and billions of synapses. (2) This neurotoxicity of psychosis is mediated by neuroinflammation and oxidative stress. (3) In most FEP patients, the risk of a second psychotic episode is high, and the tissue destruction of the brain's gray and white matter infrastructure is even more extensive, leading to clinical deterioration, treatment resistance, and functional disability. That is the grim turning point in the trajectory of schizophrenia.

Although most FEP patients respond well to antipsychotic medications and often return to their baseline social and vocational functioning, after a second episode, they are much more likely to become disabled. Unlike physical death, the mental, cognitive, social, and vocational death of chronic schizophrenia goes on for decades with much suffering, misery, and inability to have love and work, which is what life is all about (according to Freud).

MI patients have healthy brains and minds, and they wholeheartedly agree with their cardiologists' recommendations and religiously adhere to their cardiologists' instructions, such as drastic lifestyle changes and a slew of medications intended to lower the risks of a second MI (Table 1).

But what is the most common psychiatric practice for a patient who suffers a FEP after he (she) is admitted to an acute inpatient ward? The patient is started on an oral antipsychotic but a long-acting injectable (LAI) antipsychotic, which is the best protection against future episodes, is never considered, let alone recommended. The patient is given a prescription for an oral antipsychotic at discharge and the family is told to find a private psychiatrist or a community mental health center for follow-up. This practice pattern will likely guarantee a relapse into a second psychotic episode for the following reasons:

* patients' lack of insight (anosognosia) and refusal to believe they are sick or need medications

* adverse effects, especially extrapyramidal symptoms, to which FEP patients are particularly vulnerable unless they are started on small doses

* apathy and lack of motivation to take medication due to negative symptoms, which impair ability to initiate actions (avolition)

* severe memory impairment that leads to forgetting medications

* substance use, such as marijuana, stimulants, and hallucinogens, as well as alcohol, interferes with adherence.

Most patients and families are ignorant about FEP of schizophrenia and its recurrence and devastating effects.

Thus, because of the almost ubiquitous inability to adhere fully to antipsychotic medications after discharge, FEP patients are essentially destined (ie, doomed) to experience a destructive second psychotic episode, whose neurotoxicity starts the patient on a downhill journey of lifetime disability. …

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