Dose reduction,relapse and functional recovery in first episode psychosis

The article by Catts and O’Toole (2016) directly addresses important areas in which there is debate. An additional area that arises from their paper is whose version of recovery should take primacy.

Catts and O’Toole suggest that early intervention guidelines encourage delayed diagnosis and thus delay the onset of effective treatment. This is not so. The section of the 2010 Australian Early Psychosis Guidelines (AEPG) they quote when read in its full context does not make this implication. The guidelines in fact recommend a 24–48 hour anti-psychotic free assessment phase and then the commencement of anti-psychotic medication to treat psychotic symptoms. In addition, they recommend maintaining an open mind on diagnosis because as McGorry and Nelson (2016) have recently commented, ‘The dynamics of early psychopathology are complex and emerging microphenotypes ebb, flow, and evolve in many patterns, which do not follow rigid train tracks to discrete macrophenotypes such as schizophrenia or bipolar disorder’. The early commencement of anti-psychotic treatment is crucial as it is well known that prolonging the duration of untreated psychosis when psychotic symptoms are present – even if for the purpose of greater syndromal clarity – is likely associated with poorer outcome (McGorry and Nelson, 2016).

In terms of duration of anti-psychotic treatment the AEPG, along with other guidelines recommends 24 months maintenance treatment after remission to prevent relapse. The AEPG however also adds that ‘for some clients, a conservative approach of maintenance treatment over the 3-5 year period of vulnerability to suicide and relapse may be appropriate’(ORYGEN Youth Health, 2010: 60).

There is, however, genuine debate about the balance of benefits and risk of prolonged anti-psychotic use (Sohler et al., 2016), and a lack of good data to guide practice (Sohler et al., 2016). The follow-up to the original Wunderink et al. (2013) study further challenged the orthodox view with its findings of better long-term outcomes in a dose reduction/discontinuation group. There has been a tendency in some places to dismiss the findings of Wunderink in preference for discussion of the study’s methodological value. One can’t help but feel that this is in part driven by the challenge that Wunderink’s results pose to the status quo. The more appropriate scientific response when a challenging finding arises should surely be to seek to test the hypothesis that the challenging results present through replication. This is precisely what my co-investigators and I are commencing to do in an National Health and Medical Research Council (NHMRC)-funded randomised controlled trial examining if functional recovery in first episode psychosis can be improved in the context of guided anti-psychotic dose reduction. The rationale for this study that will begin recruiting in 2017 was first to see if the results obtained by Wunderink could be replicated or brought forward. Second, to prospectively examine within a randomised controlled trial (RCT) design the impact of medication dose on brain changes in first episode psychosis. Finally, to examine the impact on physical health of reduced anti-psychotic medication in first episode psychosis.

It is to be hoped that our study, and at least two similar others internationally that we are aware of that are also commencing, will address more definitively some of the issues raised by Catts and O’Toole. However, there is another important issue implicit in the article of Catts and O’Toole that deserves to be made explicit. This is the issue of whose version of recovery should take primacy in the approach to treatment.

The avoidance of relapse as a prime focus of treatment of psychosis congruent with a strictly medical aim of minimising pathology. However, when asked what they want of treatment, young people with psychosis list, in order, employment, education, relationships, housing and health. If a recovery oriented, client-centred model is the basis for mental health care, then these aims cannot be ignored. The fact that functional recovery is not being attained suggests something needs to change in the treatment approach. It is not sufficient to say that people with psychosis are not being prescribed anti-psychotic medication, or that when they are, they are not taking it. The Survey of High Impact Psychosis (SHIP) found that 82% were prescribed antipsychotic medication and that of that group 88% were adherent. Despite this 90% of the sample in the SHIP study reported deterioration in social and vocational functioning.

The purpose of first episode psychosis treatment extends beyond the clinical aim of resolving the acute episode. Treatment must align with the goals of young people with psychosis. If the findings of Wunderink and others lead to the questioning of current approaches, and the exploration of new ways to achieve the optimal balance between symptomatic and functional recovery, then this is to be welcomed. Clinging to the practices of the past can only guarantee the persistence of the results of the past.