Expert: First-Episode Psychosis Is 'Brain Attack,' and LAIs Should Become Standard to Prevent Recurrence

By McKnight, Whitney | Clinical Psychiatry News, August 2017 | Go to article overview

Expert: First-Episode Psychosis Is 'Brain Attack,' and LAIs Should Become Standard to Prevent Recurrence


McKnight, Whitney, Clinical Psychiatry News


WASHINGTON -- As data mount confirming the neurodegenerative effects of psychotic episodes in schizophrenia, one expert urges psychiatrists to think of psychosis as a "brain attack" which, like heart attacks, must be prevented from recurring.

"Schizophrenia doesn't have to be progressive neurodegenerative unless patients relapse again and again, but that happens all the time because we give our patients pills they don't take as prescribed," Henry A. Nasrallah, MD, said at the meeting held by Global Academy for Medical Education.

The solution is for the field to update its treatment standards so that giving long-acting injectable atypical antipsychotics (LAIs) directly after the first episode of psychosis becomes standard treatment, according to Dr. Nasrallah.

In a presentation dedicated to the emerging science reshaping views on schizophrenia, Dr. Nasrallah emphasized that there now exist enough data to show that timely intervention with LAIs reliably prevents relapse in most patients, averting progressive neurodegeneration and subsequent disability.

"The additional damaging effects of the second episode are what lead to clinical deterioration and can start the process of treatment resistance. But if no psychotic episodes are allowed to recur after the first episode, many patients can return to their baseline functioning," Dr. Nasrallah, the Sydney W. Souers Endowed Chair and professor of psychiatry and behavioral neuroscience at Saint Louis University, told his audience.

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The field still is clarifying the neurodevelopmental aspects of schizophrenia, including genetic and in utero adverse events that disrupt brain development. However, Dr. Nasrallah said, science already has demonstrated how the neurotoxic effects of psychosis in the brain of a person with schizophrenia lead to brain tissue degradation with every psychotic episode. The result is a progressive decline in social and vocational functioning.

Psychosis is associated with activation of microglia, which are monocytic cells that cross the blood-brain barrier during fetal life, settling in the brain and ultimately comprising 10%-15% of all brain cells. Once activated, they trigger an immune response, leading to neuroinflammation and oxidative stress (free radicals). However, Dr. Nasrallah said, rather than protect the brain, these processes destroy gray and white matter--particularly in the cortical region--degrading the brain and leaving it more compromised. …

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