Predictors of Favorable Outcomes in First-Episode Psychosis Without Medication

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Cognitive behavior therapy reduced symptom severity in patients with schizophrenia who refused medication.
Cognitive behavior therapy reduced symptom severity in patients with schizophrenia who refused medication.

Researchers from several international universities recently investigated predictors of favorable outcomes among patients with first-episode psychosis (FEP) who forego medication. Their findings were reported online in Schizophrenia Research.1

Clinical guidelines recommend treatment with antipsychotic medication for patients with a full-threshold first episode of psychosis, which, despite their effectiveness, are associated with a range of serious adverse effects. The authors of the present study note that, considering advances in early psychosis intervention and alternate effective interventions, it may be time to consider whether young patients with FEP can achieve recovery from psychosis without antipsychotic drugs.

"The earlier stage of a mental health disorder is an ideal opportunity to provide safer, more acceptable, affordable and effective interventions," they wrote. Certain psychological and psychosocial approaches have been found to reduce symptom severity and relapse rates when used together with antipsychotic medication, and one randomized trial showed that cognitive behavioral therapy reduced symptom severity in patients with schizophrenia who refused medication.2,3

Although previous findings indicate that some patients with FEP may recover without antipsychotic drugs, there is no established way to differentiate such individuals.4,5 In an earlier study by the authors of the present research, patients with FEP who refused medication were generally found to have worse premorbid functioning and outcomes, less insight, and increased rates of substance abuse, although a subset of these patients demonstrated favorable outcomes.6

The current study explored potential predictors of such favorable short-term outcomes among patients with FEP admitted to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. Of the 108 patients who refused medication, the researchers compared those who experienced favorable outcomes in terms of symptoms and functioning with those who had poor outcomes.

The results show that 41% of medication refusers achieved symptomatic remission, predictors of which included higher baseline education, employment status, and premorbid functioning. Predictors of functional recovery, which was achieved by 33% of the sample, included a shorter prodromal phase, lower cannabis use, and less severe baseline psychopathology.

These findings offer a "clear signal that some individuals could do well without medication, provided they receive a consistent treatment, based on assertive case management as well as on a specific and intensive psychosocial approach," according to the authors.

The results further suggest that young patients with "a rapid onset of psychosis, low intensity of symptoms at presentation, absence of cannabis abuse and good pre-morbid level of functioning may be a good target population to explore alternatives to antipsychotic medications as first line treatment." Two clinical trials are now underway to investigate the use of psychological approaches as sole first-line interventions for early psychosis.

References

  1. Conus P, Cotton SM, Francey SM, et al. Predictors of favourable outcome in young people with a first episode psychosis without antipsychotic medication [published online January 5, 2017]. Schizophr Res. doi: 10.1016/j.schres.2016.12.029
  2. Lloyd-Evans B, Crosby M, Stockton S, et al. Initiatives to shorten duration of untreated psychosis: systematic review. Br J Psychiatry. 2011;198:256-263. doi: 10.1192/bjp.bp.109.075622
  3. Morrison, AP, Turkington D, Pyle M, et al. Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a singleblind randomised controlled trial. Lancet. 2014;383:1395-1403. doi: 10.1016/S0140-6736(13)62246-1
  4. Bola JR, Mosher LR. At issue: predicting drug-free treatment response in acute psychosis from the Soteria project. Schizoph Bull. 2002;28:55975.
  5. Bola JR, Mosher LR. Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria project. J Nerv Ment Dis. 2003;191:219-229. doi: 10.1097/01.NMD.0000061148.84257.F9
  6. Lambert M, Conus P, Cotton S, Robinson J, McGorry PD, Schimmelmann BG. Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. J Clin Psychopharmacol. 2010;30:565-572. doi: 10.1097/JCP.0b013e3181f058a0
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