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Challenges in diagnosing and managing psychosis

Early identification and timely intervention of first episode psychosis is critical for both short and long-term prognosis as research tells us that delayed diagnosis and a longer duration of untreated psychosis may lead to challenges in functional and clinical outcomes. When first-episode psychosis (FEP) is diagnosed, it is critical to ensure that patients are provided with effective and timely interventions to improve their quality of life, psychopathology, involvement in work and school, and prognosis. Challenges associated with both diagnosing and intervening in early psychosis coupled with programs which have successfully helped those at-risk or those who have already experienced a FEP were discussed by a panel of psychiatrists to provide guidance for community psychiatrists at APA 2018.

For many individuals who experience a first-episode psychosis (FEP), the psychotic symptoms have been present for some time, perhaps years, before diagnosis.

Diagnosis of a primary psychotic disorder in the presence of psychiatric comorbidities

Caitlin Rose Costello, psychiatry specialist, San Francisco, CA, presented cases which discussed the challenges associated with diagnosing a primary psychotic disorder in the setting of comorbidities which – in severe cases – can share a number of similarities to psychosis, such as obsessive-compulsive disorder (OCD).

The panel – chaired by Gabrielle Shapiro, Professor of Child and Adolescent Psychiatry, Mount Sinai Hospital, NY and psychiatrist Tresha Gibbs, NYC Health and Hospitals/Coney Island, NY, with discussants Ragy Girgis, Assistant Professor of Psychiatry, Columbia University, NY, and psychiatrist Ilana Nossel, Columbia University, NY – concluded that disorders such as OCD can be differentiated from psychosis as follows:

  • in OCD, the obsessions are normal; if the obsessions are abnormal the diagnosis is not OCD
  • a family history of psychosis favors psychosis
  • accompanying negative symptoms favor psychosis
  • in some cases, early onset OCD increases the risk of psychosis

Pathway towards a positive outcome

In the OnTrackNY treatment programs, the term “psychosis” is avoided to minimize stigma and encourage enrollment and participation

The panel highlighted that the Recovery After an Initial Schizophrenia Episode (RAISE)* program has shown that coordinated specialty care (CSC) improves functional and clinical outcomes after FEP, particularly for those with a shorter DUP and can be implemented in community clinics.1,2

CSC promotes shared decision-making and involves specialists working with the patient to create a personal treatment plan.

The panel also highlighted the innovative OnTrackNY treatment programs located throughout the State of New York. 3 The programs aim to help “…with unusual thoughts and behaviors, or those who have started hearing or seeing things that others don’t achieve their goals for school, work, and relationships.” The term ‘psychosis’ is purposefully avoided to minimize stigma and encourage enrollment and participation.

The challenges associated with substance abuse in psychosis

The Panel noted that a population of vulnerable individuals develop psychosis after substance abuse, and that the management of these patients can be challenging, especially if they refuse to cooperate with a treatment program.

Coordinated specialty care improves functional and clinical outcomes after first-episode psychosis and can be implemented in community clinics

If particular challenge in these cases are:

  • how to assess and treat patients with a history of acute substance abuse
  • following FEP, deciding how best to involve and educate the family

They emphasized the importance of engaging family members, and the beneficial role that can be played by programs, such as OnTrackNY. Other agencies and programs that provide valuable advice and support include:

  • PEPPNET (Prodrome and Early Psychosis Program Network),4 which has a national steering committee of clinicians, educators, policy leaders, government agencies and researchers, and is leading community implementation efforts for early psychosis and psychosis risk programs
  • the Prodromal Clinic (Center of Prevention and Evaluation: COPE), University of Columbia, NY5
  • the Substance Abuse and Mental Health Services Administration (SAMHSA) within the US Department of Health and Human Services, which works to reduce the impact of substance abuse and mental illness on America's communities6

*For further information about the RAISE study, click here.

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