Prompt diagnosis and treatment

Recently there has been a growing awareness of the association between a longer duration of untreated psychosis and worse outcomes in the medium term and the long term.[20 21] Obviously, there will be a greater impact on the psychosocial networks (including those of work, family, education, and friends) of people who are psychotic and who remain untreated; one school of thought suggests that prolonged, untreated psychosis can result in a poorer long term prognosis because of altered neurobiological mechanisms.[1] Just as prolonged coma and lengthy periods of post-traumatic amnesia are associated with poorer clinical outcomes, so is prolonged psychosis.

As a consequence, many agencies providing mental health services are attempting to reduce the duration of untreated psychosis. For example, health education programmes can teach the general public about psychosis and the need for prompt self referral and the prompt referral of potential patients by caregivers. Close ties need to be developed between key agencies in contact with adolescents and young adults (for example, teachers and healthcare workers) to facilitate the pathway to care for those experiencing psychosis of recent onset. In particular, general practitioners have an important role in the prompt identification of psychosis. General practitioners should monitor closely patients who are at risk to identify the onset or evolution of frank psychosis. Prodromal features of psychosis may include depression, anxiety, suspiciousness, social isolation, and bizarre behaviour. Those with a family history of psychosis or with a schizoid or schizotypal personality are at an increased risk of psychosis. Specialised services for patients with recent onset psychoses have been developed by many centres (see box for information).[22]

Conclusions

The introduction of new antipsychotic drugs has alleviated many of the problems of side effects for people with psychoses and resulted in obvious improvements in their quality of life. Hopefully, use of the new antipsychotics in combination with optimal education and community support, will improve compliance with treatment and reduce the chance of relapse. It is necessary for those involved in planning the delivery of services to devise ways to reduce the duration of untreated psychosis. Evaluations carried out over the next few years will determine whether these interventions are associated with improvements in clinical outcomes in the medium term and the long term.

The optimal goal of treatment must be the immediate, complete, and sustained remission of all symptoms of psychosis in all individuals being treated. Although we are still a long way from achieving this goal, the new antipsychotic drugs have narrowed the gap between current and optimal practice.

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