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First Episode Schizophrenia-Spectrum Disorders: Wh ...
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Hello, and welcome. I'm Amy Cohen, the Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, first episode, Schizophrenia and Spectrum Disorders, What Clinicians Need to Know. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Delbert Robinson. Dr. Delbert Robinson is a professor of psychiatry and molecular medicine at the Donald and Barbara Zucker School of Medicine at Hofstra-Northwell in New York. He has led NIMH-funded studies focused upon first-episode schizophrenia, tools to enhance antipsychotic medication adherence, and obsessive-compulsive disorder. For the RAISE ETP study, he chaired the Psychopharmacological Treatment Committee and has served as a member of the Psychopharmacological Drugs Advisory Committee of the Food and Drug Administration and on multiple NIH review committees. Dr. Robinson, thank you for leading today's webinar. Thank you very much, and thanks, everyone, for taking the time to learn about treatment advances for first-episode schizophrenia spectrum disorders. These are my disclosures. Also, I should mention that many of the schizophrenia spectrum disorders, for example, schizophrenia-informed disorders, have no FDA-approved treatment, even though, obviously, clinically, the same medications are often used. But you will need to know that some of these are off-label because of that. So, today, we're going to talk about the major findings from first-episode treatment studies. We're going to focus first on symptom outcomes, but then we're also going to talk a lot about side effects that we've learned from the treatment studies, which are very crucial for all patients, but also especially for young patients with schizophrenia spectrum disorders. And we're also going to talk about some of the major health risks that our patients have and talk about how to minimize some of these risks. So, that's our overall goals. And exactly what we'll be doing this afternoon is the first thing is to review what science has told us about the treatment of first episode. Then the next part, we'll talk about how to take those treatment insights from research findings and try to put them into clinical practice. And then we will talk a little bit about choosing proper medications and dosing, which is, again, we're applying the research evidence to what we prescribe. Now, one question that is a fundamental question is, well, does really better first-episode treatment make a difference? And there have been developed a lot of different models for first-episode treatment. And one of the real questions has always been, well, are those models really better than standard care? Now, one of the things we'll talk a little bit at the beginning to show you that by applying some of these specialized treatment paradigms, you actually can improve outcomes for your patients. Now, one of the studies, just briefly to go over, it was called RAISE-ETP. It was funded by the National Institutes of Mental Health. And it compared a specialized treatment model called NAVIGATE with clinician's choice treatment. And what clinician's choice treatment consisted of was the clinicians treating those particular study participants gave the participant whatever treatments they thought were the best for them. So there was absolutely no restrictions on what they did. And then patients were treated for two years at a minimum. And we'll talk a little bit about the two-year outcomes. Now, as we would expect, standard care works. That's why we all are clinicians. So of course, people got better with standard care or obviously what's called clinician's choice. But what you will see in the next few slides is that with some of these first-episode treatment principles, the patients stayed in treatment longer. And they had more improvement in overall symptoms, also in depression and quality of life, than people who were getting standard care. OK. OK. This is the distribution of the different clinics that were part of the RAISE-ETP study. As she mentioned, all of these clinics were community facilities. And none of them had specialized first-episode programs before they started the project. And as you can see, we covered most of the country. Now, one of the most fundamental things, obviously, about any treatment, and especially with first-episode patients, is do patients actually find it useful and stay around? Now, one of the things that we saw was that people given more specialized first-episode treatment compared to standard care, they stayed in treatment much longer than people in community care. This is the graph of people who, how many stayed in community care. And here is the graph of, sorry, of people in Navigate. So obviously, there was a retention difference. Now, unfortunately, even with best-of-care, you still have patients who will leave treatment. But you can minimize that by using some of these specialty care models. Now, this is what happened in terms of symptoms. This is the Heinrichs-Carpenter quality of life scale. And it's a scale that starts off asking questions about social relationships with family, friends, romantic partners. Then it goes into questions about job performance, job satisfaction. And then it goes into a whole set of questions that globally you can think of are activities of daily living. And on the Heinrichs-Carpenter scale, a higher score is a better score. And what you see is people in community care, they started off with a 55. They ended up at 65. Again, what we'd expect, standard treatment works. But, and again, people are improving because higher is better. But here's what happened in Navigate. Navigate, the people actually started off just, it was a random assignment study. But it just happened that people in Navigate ended up starting off with slightly worse quality of life than people in community care. And by the end of the two years, they actually had better. So again, what you're getting is people in standard care improve. But if you're in a specialized treatment model or applying some of their evidence-based practices for first episode treatment, people will have more improvement than they would with just standard care. Now, the PANS, which is on this part of the panel, is, as many of you are aware, a standard severity assessment measure for people with psychotic disorders. It covers positive symptoms, negative symptoms, and also some general symptoms that are often associated with psychotic disorders. And as many of you are aware, the PANS has a scaling so that higher scores mean more severe illness. So again, what you see is that people in community care started off here, ended up here. So again, their symptoms severity went down over time. Again, what you would expect. But again, people in Navigate had a differential improvement. And they actually had experienced less severity of symptoms over time than people who were in community care. And this is the Calgary Depression Scale for Schizophrenia. It's a depression severity measure that was specifically designed to measure depression in people who have schizophrenia or other psychotic disorders. And on the Calgary, higher score is worse because it says the higher your score is, the more depressed you are. And again, by now, you've caught the pattern. People in community care started off here, they ended here, which meant over time they had less severe depressive symptoms. But again, in Navigate, you ended up having even less depressive symptoms than you did if you were getting standard treatment. Now, today, we're going to talk a lot about medication treatment. So I'll talk to you a little bit about the prescription outcomes. Again, using this specialized first episode care model called Navigate versus clinicians' choice. Again, clinicians making the best determination that they could. What we saw here is that this is the average number of medication visits patients had per month. And over time, patients in Navigate had about twice as many medication visits as people in community care. And again, it's showing that these special care models are acceptable to patients because literally they come, and they come more often than people in community care. Now, in terms of the actual medicines prescribed, people in Navigate were more likely to be prescribed an antipsychotic. Again, all the patients in Navigate had a first episode of a schizophrenia spectrum disorder. So all of them met clinical indications for having an antipsychotic medication. They were also more likely to get an antipsychotic that conforms to what we think of as best clinical practice for first episode treatment. Later today, we'll talk about in terms of choosing medicines and how particular ones may be better than another. And it was more likely that patients were getting some of the better antipsychotics for them. If they were in Navigate. Now, one of the things is also Navigate patients were less likely to be prescribed an antidepressant. People often wonder, well, wait, you just said a few minutes ago that people had less depression if they were in Navigate, but they got antidepressants less. And how can that be? Well, there are two big factors. One is Navigate and other coordinated specialty care models. That's the name for the group of different treatment models that have been developed for first episode. They are team-based and patients do not just get medication treatment. They get individual therapy. They get support education employment. They get family psycho-ed and they often get case management, depending on the model. So one of the things is in these coordinated care models, people are getting individual therapy and in part of the individual therapy, there are modules about managing depression and symptoms. So one thing is people's mood got better often, sometimes due to the psychotherapy that we're getting or the support education employment would lead to people either doing well in school or at work. And obviously that helps people's mood. The other thing is, as we'll talk about later, often first episodes, some of the mood symptoms, depressive symptoms really can be treated with antipsychotics alone. And that was another thing that may have contributed to even people got less depressed, even though we were prescribing less antidepressants. And on top of that, we were able to demonstrate that with very careful monitoring that patients in Navigate treatment experienced less side effects than people who are being treated in community care. And this is very amazing on some level, because again, we just talked about people in Navigate were getting antipsychotics more frequently than people in community care. But despite that, they actually were experiencing antipsychotic side effects less. And we'll talk later today about how that was achieved. OK. Now, so I'm hoping that after this, we've convinced you that delving into some of these first episode treatment programs and learning some of those principles is a good thing, because your patients will get a differential improvement than you would with standard care. So the next step is, if we've convinced you that these are things worth exploring, we'll go and talk a little bit about what we know about first episode medication treatments from controlled research studies. Now, this is a summary of the major first episode treatment studies that compare different antipsychotics, and they had a defined response criterion. Some of you are very familiar with the first episode treatment literature. One of those things like studies like UFAST is not here, because UFAST had an all-cause discontinuation as its primary outcome versus a really response rate. But there are several things that are very critical about this slide in terms of deciding about first episode medication treatment. The first thing is, these are the response rates in each of the studies. And one of the things that has been shown is that in each of these studies, there was no difference in terms of symptom response rates from one medicine to another. So within a first episode context, one antipsychotic will work pretty much as well as another if you're thinking about positive symptoms. The next thing is that these response rates are much greater than we are able to obtain with patients who have multi-episode schizophrenia. Unfortunately, often we don't have the technology to get our patients with multi-episode schizophrenia as much symptom control as you do with patients with first episode. Sometimes people ask me, well, in some of these studies which are reporting, the response rates are half or two thirds. The important thing about these studies was that the response criterion was that people could not have active hallucinations and delusions at all. So this was really people who didn't have delusions, didn't have thought disorder, and didn't have hallucinations anymore. So again, that's a pretty high bar. We wish that all of our patients could achieve that, but again, unfortunately, a lot of multi-episode patients sometimes can't. Now, the other thing about that is that these very high response rates, again, in comparison to what you typically get with people with multi-episode schizophrenia, is that the doses, you'll notice, the doses of the medicine are relatively low. So for example, three milligrams of risperidone in most studies turns out to be quite an effective dose, 15 milligrams of aripiprazole, et cetera. So you're able to achieve a very robust response for most patients with a low to moderate dose strategy. And again, this is just a slide that summarizes the points that we've just been talking about. Now, one of the areas also where first episode treatment differs from treatment with people with multi-episode schizophrenia is how long we give each medication trial to work. Now, one of the things is we talked about is globally people with first episodes tend to respond quite well to treatment, at least in terms of positive symptoms. So they often really do okay with actually a trial of monotherapy with just a single antipsychotic. And because they tend to be rather treatment responsive, essentially what happens is you don't need to keep switching constantly, which sometimes people do with multi-episodes, and give things a trial for a week or two if they're not working, change, because that's not necessary in first episode. And one of the data we have for that was a study that NIMH funded, which was called Preventing Morbidity. And essentially in that study, people were randomly assigned to an antipsychotic and they were followed for 16 weeks for the first trial. And basically what you saw is by two months of treatment, 40% of the people had absolutely no positive symptoms anymore. But if you kept people on the same antipsychotic, by week 16, 65% of them didn't have any positive symptoms anymore. So again, it's a situation where often with first episodes, the strategy is to start with sort of a low moderate dose and give the medicine more time than you're usually used to with working with multi-episode patients. Also, one of the things that doesn't hold in first episode, that does hold with treatment of multi-episode is we know with multi-episode patients, if you start them on an antipsychotic and they haven't had some degree of response within a week or two, then they're unlikely to respond if you just continue the same drug. Whereas in Preventing Morbidity, we showed very much that that doesn't hold. There were a lot of patients who didn't seem to improve enormously at first, but just would eventually respond. Subsequent to the Preventing Morbidity trial, there's been a trial reported, it's called Optimize, where they looked at people, they gave them an antipsychotic for four weeks. If they weren't actually free of positive symptoms, then they randomly assigned people to either stay on the original drug for a longer period of time, or go to another antipsychotic. And what they showed in that trial is both groups ended up having exactly the same outcomes. So again, the idea is not to keep switching very quickly when you're treating your first episode patients. And we're gonna get to why you shouldn't be doing that in the next few slides. Because we talked about that patients have very high response rates to their positive symptoms. We can do that with relatively low doses of antipsychotics. But the difficulty, and we're gonna show you the data, is about side effects. The side effects are very, unfortunately, are very frequent with first episode patients, even using this low to moderate dose strategy. The drugs, so you often sort of are choosing medicines based on side effect profile, not nearly as much as efficacy, because most of them are gonna work quite well for the efficacy. Now, unlike the situation where all the drugs seem to be quite effective with positive symptoms, the side effect profiles of the antipsychotics do differ with first episode patients. And one of the key clinical points that we'll talk about in a minute from the data is that even when you choose a medicine that you think of has, quote unquote, a good side effect profile, you still have to constantly monitor for side effects if you're going to actually achieve what we did in the RAISE-ETP study and actually have patients have less side effects. Now, this is a slide from the CAFE trial, which was led by Joe McEvoy, who was at Duke at the time. And this is a study where they randomly assigned first episode patients to either take olanzapine, quetiapine, or risperidone. Now, the important thing about this slide is not to try to look at each and every data point. The important thing about this slide, which shows the percentages of patients who had a particular side effect, is you know, the numbers are quite high. So basically, a lot of the patients were experiencing side effects. And that's why monitoring for side effects is so crucial. Now, you will note here is an example of why monitoring is so crucial. This was the percentage of female participants who had menstrual irregularities. And there is a difference between the medicines in terms of causing that. And for those of you who are very familiar with the pharmacology of olanzapine, quetiapine, and risperidone, you will not be surprised that risperidone caused that had a higher rate than people who were assigned to either quetiapine or olanzapine. And that just comes out of the straight pharmacology and effects of risperidone on prolactin levels. But even on olanzapine, quetiapine, a lot of the patients were experiencing menstrual irregularities. So again, the idea is when you're choosing medicines for your patients, you certainly can choose one based on a side effect profile that you particularly or the patient or the family particularly want to avoid, but you're gonna constantly have to monitor for side effects. Again, even if you think, okay, I've given the medicine that would cause that the least. This is some data about weight gain. This is after only 12 weeks of treatment. And one of the things is that the weight gain can be phenomenal. And this is why it's so critical to take vital signs every visit. A lot of clinics talk about, well, we take them, but we separate how frequently do it by months. The reality is the weight gain can be very rapid with first episode patients and you don't have time to wait to find out. So for example, in the CAFE trial we just talked about, people randomly assigned to a lens beam had already gained 35 pounds after 12 weeks of treatment. So again, you have to be very diligent about monitoring for weight gain and other vital sign changes. You have to do it frequently and you have to do it systematically or you're gonna miss things. And this is a wonderful example of the sort of overall idea that for all side effects you have to constantly monitor, even if you're using a medicine that's sort of quote unquote good about that side effect. Because this was a study funded by NIMH that randomly assigned patients to either aripiprazole or risperidone. And as you know, aripiprazole among the second generation antipsychotics actually has a much more favorable weight gain profile than many other antipsychotics. But even with aripiprazole patients on average gained 11 pounds in 12 weeks. So again, if you're concerned about metabolic side effects, et cetera, you certainly would choose aripiprazole over lanzapine. But even if you're giving people aripiprazole, you still have to monitor and actually often initiate healthy lifestyle, et cetera, education, because again, patients tend to be incredibly side effect. Now, we talked about that the response rates to the initial psychotic episode are quite high. The bad news, of course, was that there was a big side effect, liability among the patients. And the other big challenge is that responses, even though the response rate's very high, the relapse rate is very, very high. This is from an NIMH study where we followed first episode patients for five years. And this is the number of patients who after their initial episode were totally remitted, had no positive symptoms essentially. What happens is you follow them over five years. And by five years, essentially 82% of them had had another psychotic episode. It's not on this slide, but the sad part is that people who had one episode, if you followed them again for this five year period, about 80 some percent of them went on to have a second episode. And also people who had a second episode, the majority of them went on to have a third. So what you have is an illness that in terms of the positive psychotic symptoms is very treatment responsive at the beginning, but then patients go unfortunately into this cycle of repeated relapse. And the relapse is overwhelmingly due to medication non-adherence. From that same study, we analyzed every week of the five years that people are in the study, whether they were on an antipsychotic or they were not. And every time they went off, essentially their relapse risk went up by five times compared to what it was if they, for the months that they had stayed on their antipsychotic. So this is a big challenge. We have tools to help our patients in terms of getting out of a psychotic episode. The real challenge for most patients is to keep them well and keep them from going into this repeated relapse pattern. Now, another opportunity for first episode treatment is that one of the very bad aspects of schizophrenia is that not only does it cause a lot of emotional problems, social vocational problems, but also unfortunately people with schizophrenia die on average, depending on the study, between two decades and three decades earlier than the general population. So literally schizophrenia is not only an impairing disease, but often it's a deadly disease. And we know, and again, this is from study after study, this is a wonderful example, one of the studies by Mark Olson, again, but there are many, many showing the same thing. And they all end up either showing that people with schizophrenia die either two decades or three decades earlier. And also all of them talk about that the major causes of the excess mortality are cardiovascular disease and pulmonary disease. Our patients with schizophrenia do have higher suicide rates, for example, than the general population. But the overwhelming cause of the premature mortality is not that, but it's the cardiovascular and the pulmonary disease. Now, we've talked about some of the issues. So one of the things is we always want better medicines, et cetera, but part of the thing is sometimes while you're waiting for those, what we should try to do is really take what we already have and sort of use it better. So what we know is there are some targets for improvement. This is from the RAISE ETP study where, because these were all community facilities, they were all outpatient facilities. And so the vast majority of community outpatient facilities in the country, the way they get first episode patients is unfortunately the patients get admitted at the hospital. And then the hospital refers them for ongoing care after they've been stabilized in the hospital. The patients on average in RAISE had taken antipsychotics for around a month and a half in their whole lifetime before they got into the trial because they had to first go to their outpatient facility and then they had to consent to the study. And so what we knew is we knew the medicines that they were getting, which was essentially the medicines they were taking when they came for their intake appointment on the whole at their community facility. And what we saw is about 40% of them had some prescriptions that really didn't conform with good first episode medication practices. So we have some things that we might wanna try to improve. The other thing which we found was even though first episode patients are young and raised, the mean age was 23, that a lot of them already have medical comorbidities that weren't getting treated. For example, over half the patients had abnormal lipids but only less than 1 percent of them were getting any lipid-lowering medications. Now, why is that so important? Obviously, we just talked about that our patients are going to die on average two decades to three decades prematurely. Cardiovascular disease is the major cause of the premature death. The patients, even when they're first coming to mental health centers, they have some of the things that are eventually going to lead to excess mortality. One of the things is they have it, but they're not getting treated for it. The same thing, we had 40 percent of the people who had elevated blood pressure not quite reaching hypertension criteria yet, but 10 percent of the patients walked in with full hypertension and only about 4 percent of them were getting any treatment for that. We found people had pre-diabetes, and again, they were rarely getting treatment for that. Also, over half the patients were using tobacco products and none of them were getting any nicotine replacement or other medications for tobacco cessation. Again, we know over the long-term, if those things aren't treated, they're going to end up with our patients dying prematurely. The nice thing about first episode is if we intervene and get people the appropriate medical care early, we may actually be able to add decades to their lifespan. That's the promise. That's the research background. Talk a little bit about how you put those things into clinical practice. All of the specialized first episode care models use a shared decision-making model. In that, essentially what you do is you present patients with medication choices based on the evidence base, which we've talked about. Basically, in shared decision-making, if a group of medicines have the simplest equivalent effectiveness, then the choice within that group is really based on patient preferences. For example, a patient or their family may say, well, I don't want this medicine because I don't like the fact that it has a worse side effect that I'm concerned about than others. That's fine as long as they're choosing within the evidence, but choice is always constrained by the evidence base. Because why would people get treated with things that haven't been studied if there's things that have been studied, and we know a lot more about them that have shown efficacy? Now, within these first episode specially care models, patients often will refuse evidence-based treatment. In that case, then the staff works with them, tries to give them more education about the evidence base, and continue to try to follow them and help them. With the goal, hopefully, eventually, they will agree to something that's more evidence-based. The typical thing is somebody comes in and they say, well, they don't want to take any antipsychotic medication, even though obviously, all of the patients with schizophrenia spectrum illness that they have the indication for it. But if that happens, then we continue to follow them, monitor them for symptom levels. If they do start to have more exacerbations, hopefully, we can intervene early. We continue to work with them and give them education and also with their families. In terms of thinking about treatment goals, again, your treatment goal for a first episode patient should be that you want to get them so that they don't have symptoms. It's not just that they still have voices, but they're better. You're really looking for trying to get rid of the positive symptoms. Also, you have to always be prepared for non-adherence. First episode patients and their families have a slightly different background than our multi-episode patients. Because the families or the patients, they've never experienced themselves any of the negative consequences of treatment discontinuation. By that, I mean many multi-episode patients and their families have, unfortunately, had the bitter experience of when they've stopped their maintenance treatment in the past, they often get an exacerbation and have to go back to the hospital. But again, with first episodes, that is something you can talk to them about, but they haven't personally experienced that. Again, that makes it easier in some ways to stop treatment because you've never experienced the bad outcomes that can happen if you do that. Also, patients and their family, because they haven't had that experience, they often interpret if a patient gets better, returns to good function, returns to school or work, that means that the illness is over and they don't need treatment anymore. Again, that's because they haven't had those experiences. Our model is to try to give them the education that they understand the need for. Once you're better, the next goal is we have to really work in trying to keep you better. But that often, especially for a young person who's 20 years old, that is a difficult concept to integrate into their world view. Also, you have to always think about other risk factors for non-adherence because unfortunately, around half of all first episode patients do have a comorbid substance misuse problem. Again, as we all know, substance misuse is actually a risk factor in and of itself for medication non-adherence. One of the things is when you're treating patients, always think about the possibility of non-adherence. One is, again, continually making sure that patients and their families understand the risks of discontinuing treatment. Again, going over the maintenance treatment studies showing, again, that maintenance treatment is so important in terms of preventing relapse. Also, you have to assess adherence at all contexts. Clinicians often say, well, I only ask people about adherence if they're not doing well or things have changed. But the reality is, is because non-adherence is so common, you really have to do it all the time. In terms of non-adherence, for first episodes, family members will sometimes monitor or supervise medication intake. You have to be very aware that over the long term, sometimes that does lead to some power struggles within the family. If family is going to be doing that, you have to be very careful and very aware that over the long term, sometimes that leads to some really conflict. You have to monitor that part of it very carefully. Again, helping people understand that we know that half of all patients in medicine, not talking about people with psychotic disorders, but just in medicine in general, if they have to take a medication every day, for example, an antihypertensive, only about half the patients are able to do that on a consistent basis. So part of the thing is with our first episode patients, again, the idea is to convey to them, almost everybody has some problems over the long term. Let's talk about ways we can support your adherence. And one of the things is obviously long-acting formulations of medications. There is also lots of things in terms of smart pill containers, et cetera. So for all the patients, you should really talk to them about adherence supports. And there's a variety of them, again, long-acting being one of them. Also, try always to maintain engagement because a lot of the patients, even if you present all the evidence, are going to want to, for example, they will stop medication treatment. And in that case, what you're going to try to do is try to continue them in treatment, at least in terms of coming in for monitoring. And most first episodes and their families will agree to that because obviously you're trying to keep them engaged enough that if they do start to have an exacerbation of symptoms, hopefully you can intervene quickly enough that things do not spiral into a horrific episode. And again, most first episodes will agree to this sort of monitoring plan. In terms of, we've talked a lot about how important it is that we detect if people are having dyslipidemias and other medical problems. So what we at Navigate had done was we followed the guidelines of the American Psychiatric Association and American Diabetes Association in terms of getting chem screens when patients start an anti-psychotic three months afterwards and then annually. If people don't have abnormalities, unfortunately, we talked about a lot of the patients will. And in that case, the laboratory testing schedule gets determined by the particular medical problem the person has. So for example, if they have diabetes, you're obviously not going to be following this schedule. You're going to be following a much more rigorous monitoring schedule. But this is the minimum recommended for patients, again, who are not otherwise having any sort of medical issues. In terms of depression, we talked about a little bit that exactly the depression rate required for depressive symptoms in the first episode of schizophrenia, that there's a number of people who will remit just with an anti-psychotic. For example, they may be depressed because they believe that their mother is not, the person who says that their mother really isn't their mother anymore. It's a substitute. They will be unhappy about that. So sometimes the depressive symptoms go away just with anti-psychotic monotherapy. That's not always the case. So one of the things is when you're treating the first episode, you have to carefully think, is this somebody that would do OK with just an anti-psychotic? Is this somebody who would do OK with an anti-psychotic and individual therapy? Or is this somebody who will need the addition of an antidepressant? There will be some people who do need that. It's just you have to carefully think about that. What we see often is sometimes if somebody just says they're unhappy or sad, prescribers just automatically give them an antidepressant. They're a very side effect-prone population, and an antidepressant adds a whole other level of side effects. So again, the idea is that it's not that you never give an antidepressant. You just carefully think about what are the different treatment options you have for that particular patient, and which one would be more appropriate for them. We do know that the first episode of psychosis is a period of increased suicide risk. So for each visit, you really have to assess people for suicidality. Again, the typical things you look for, you know, hopelessness, ruminations about falling behind, et cetera. There are a whole bunch of variety of different assessment schedules you can use. This is just one of them, which was from the RAISE study, which is available at this website for free because it was paid for by NIMH. But again, the important thing is you can choose different scales because there are different assessment instruments. The important thing is that you just make an assessment, and you make it routinely. So the overall advice is, again, always be watchful. I live in New York City, and this is a hawk family that lives in a park that's a few blocks from me. And again, the idea is for our patients, you have to sort of constantly be watchful in terms of making sure that first you get them out of the episode, which, again, for most patients, that's quite feasible. But again, thinking about long-term supporting them to keep out of that repeated relapse pattern. So just in summary of what we've been talking about today, you first need to get a very good assessment of patient symptoms, but also you need to know about their medical status, their side effect status, et cetera. Then use a shared decision-making process to come up with the best decisions. You're going to aim for symptom remission, not just improvement, but actually remission. Choose an antipsychotic with a favorable side effect profile. Give it in sort of a low to moderate dose strategy. And again, often you can give it for several months because there will be some people that it takes that long for them to really get better. Again, you're going to be using around doses around half of what you use with multi-episode. Again, the important thing is to monitor closely for side effects. Once you know about them, you can do something about them, which is often dose reduction. And or for some patients, you still have to add a side effect medication. Again, they're very prone to these. And if you don't do the constant monitoring, you won't know about them. And you always have to think about with this very young patient population, you have to always consider non-adherence.
Video Summary
In this video, Amy Cohen, the Associate Director for SMI Advisor and a clinical psychologist, introduces the SMI Advisor webinar on schizophrenia and spectrum disorders. The webinar aims to provide clinicians with information about evidence-based care for those living with serious mental illness. Dr. Delbert Robinson, a professor of psychiatry and molecular medicine at the Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, leads the webinar. He discusses the major findings from first-episode treatment studies, focusing on symptom outcomes and side effects in patients with schizophrenia spectrum disorders. The webinar also addresses the health risks associated with these disorders and strategies to minimize them. Dr. Robinson emphasizes the importance of early intervention and adherence to medication for first-episode patients. He highlights the benefits of specialized treatment models and shares data from the RAISE-ETP study that shows improved outcomes for patients who received specialized care. The webinar also emphasizes the need for ongoing monitoring and assessment of side effects and provides guidance on medication choices and dosing. Dr. Robinson concludes by discussing the high relapse rate among first-episode patients and the importance of engagement and adherence to long-term treatment.
Keywords
Amy Cohen
SMI Advisor
schizophrenia
spectrum disorders
evidence-based care
Dr. Delbert Robinson
first-episode treatment studies
specialized treatment models
RAISE-ETP study
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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