Management of First-Episode Psychosis and Schizophrenia: Guidelines From the VA/DoD

First-episode psychosis commonly presents in males in their early to mid-20s and females in their late 20s and is often triggered by stress. First-episode psychosis can appear as a prodrome to schizophrenia, and management can improve the severity of psychiatric illness later in life. Schizophrenia is a neurodevelopmental disorder that impacts approximately 1% of the U.S. population. Schizophrenia presents with positive symptoms including perceptual distortions, such as hallucinations and delusions, and motor deficits and negative symptoms including diminished emotional expression and significant reduction in goal-directed activities. Negative symptoms are the most important predictor of poor long-term functioning. People with schizophrenia die an average of 15 years earlier than unaffected individuals. The U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) published new recommendations for diagnosing and managing schizophrenia and first-episode psychosis.

There are numerous screening and assessment instruments for predicting if a patient with suspected psychosis will transition to psychosis; however, they have low specificity and are recommended only for use in a specialty mental health care environment. There is insufficient evidence to recommend using biomarker screening tools. Although magnetic resonance imaging appears reasonably accurate in small studies of high-risk patients, standardized criteria are not yet available.

Patients with a first episode of psychosis should receive early intervention services. Early interventions include 32 evidence-based components, including family interventions and supported employment. Family interventions improve symptoms and functionality and reduce hospitalization length and future relapses compared with individual care. Individual placement and supported employment should be considered, with the goal of participation in employment or education. Use of an antipsychotic other than clozapine for initial treatment based on patient characteristics and adverse effect profiles is recommended. About five patients need to be treated with an antipsychotic for one additional response vs. placebo.

Treatment with early intervention services for 2 years improves the severity of positive and negative symptoms more than usual treatment. Although early intervention services can be extended up to 5 years, there is little evidence to support this prolonged treatment. Nearly two-thirds of people with significant psychiatric illness desire employment, but only 15% are employed. Supported employment programs for people with first-episode psychosis increase employment at 6 months or longer vs. usual treatment.

For patients with comorbid substance use disorders, family therapy reduces the severity of substance use.

Treatment should be provided through assertive community care models, which include shared caseload among teams with low patient-to-staff ratios, high frequency of patient contact, direct service provision, and community outreach. This treatment can reduce hospitalizations and rates of relapse. Aerobic exercise can be considered in addition to usual treatment to reduce negative symptoms and improve functioning, and yoga may reduce positive and negative symptoms.