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The rationale behind the importance of detecting early psychosis is that the longer the duration of untreated psychosis, the worse the prognosis of the psychotic condition.

Obviously persistent auditory hallucinations and delusions need investigation and possible treatment, but prior to these developing people may describe less clear psychotic phenomenology, for example hearing poorly-defined mumblings, whisperings or ill-defined noises.

Similarly, prior to delusions fully developing people may describe increasing preoccupations such as peculiar quasi-religious thoughts. The presence of substance misuse complicates matters, but if symptoms persist treatment should be considered as some studies now suggest cannabis can induce schizophrenia.

Other signs that should alert the GP to possible psychosis would be a period of declining function for several months prior to the onset of symptoms and signs of thought disorder. The threshold of concern should be lowered in those with a family history of psychotic illness.

Regarding investigations, I would suggest full blood count, liver function tests, renal function, serum calcium, thyroid function and an ESR; investigations such as a CT head scan or MRI can usually wait until secondary care unless there are obvious indications of organic cerebral pathology.

Most services should respond to a referral of possible early psychosis quickly, so initiation with antipsychotic medication in primary care should not be routinely required. Early intervention services should be established in most areas in the relative near future.

In these services the first screening assessment may well be by a community psychiatric nurse. However, if an assessment is not quickly available the GP may wish to start atypical antipsychotic medication.

Certainly the atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole) should be used rather than the typical antipsychotics (haloperidol, chlorpromazine).

Within the atypical antipsychotic group, differences between the medications are emerging. If a GP did wish to start atypical antipsychotics it would be advisable to use a low dose. The atypicals are much less likely to produce acute dystonic reactions and other extra pyramidal symptoms than the older typical drugs.

Starting doses such as olanzapine 5mg, quetiapine 25mg or risperidone 0.5 to 1mg daily would be appropriate.

My first line of advice would be to involve the CMHT by contacting the patient's care co-ordinator. Certainly the addition of older drugs such as chlorpromazine is not advisable.

Short-term increases in the dose of the atypical, while remaining within the BNF limits, would be the second best step to contacting the CMHT. Patients on enhanced levels of Care Programme Approach should have details of what steps should be taken should early signs of relapse occur.

Schizophrenia is a complex disorder both in terms of the associated neurochemical disturbances and the psychosocial adaptations that are required to live with the condition.

Depression is common in schizophrenia; probably more so than other chronic conditions that give a similar level of debility. The depression in schizophrenia may be due to direct affective associated neurochemical disturbances in the aetiology of schizophrenia; therefore, antidepressant medication such as SSRIs or other antidepressants is appropriate.

A step to care approach to treatment, as described in the NICE guidelines for depression, depending on the severity of the depressive episode, would be the most appropriate to treat depression and schizophrenia.

For a long time it was accepted that patients with schizophrenia smoke ­ some theories suggest nicotine helps some of the negative symptoms. But most of the increased mortality in patients with schizophrenia is due to physical health problems so increased efforts are being made in helping people with schizophrenia to stop smoking. Quitting is unlikely to have any adverse effects on mental health in schizophrenia and certainly should be encouraged. My experience with patients who have managed to stop is that it certainly helps their self-esteem.

The majority of increased mortality in patients with schizophrenia is due to physical health problems. So patients should really have yearly health checks including checking for hypertension and giving anti-smoking advice. Monitoring of body mass index and screening for metabolic syndrome is also advisable in patients, especially those on atypical antipsychotics.

If the antipsychotics are not causing any problems (eg extrapyramidal or tardive dyskinesia) patients should keep using them. I well remember a patient of mine who relapsed after I stopped the small dose of Modecate that had kept her well for the last 40 years. Her age at relapse was 94!

NICE guidelines for schizophrenia have been helpful in this regard. They recommend atypical antipsychotics in all patients with newly diagnosed schizophrenia as first -line and that atypical antipsychotics should be used first-line in those who are incapable of consent. So the costs are justifiable, and although higher than typical antipsychotics, the costs are low if one compares with the cost of inpatient care.

Local arrangements about the sharing of information should be arranged to avoid duplication. Clear agreements about which service is responsible for which aspects of the annual review should be drawn up.

For this to be effective it requires close working relationships between PCTs and mental health trusts, and interested clinicians can often make quite a difference in pushing them up the agenda!

Most family members need educational as well as emotional support. Close family members are likely to be shocked by the diagnosis of schizophrenia and hold many misconceptions.

It is important to be clear with families that schizophrenia is an illness, caused by an overproduction of one of the chemical messengers in the brain, and that the illness is treatable. It may be useful for the GP to ask what the family member understands by the term schizophrenia, a question such as this is bound to unearth a myriad of misconceptions!

Family members offering significant support should be offered a carer's assess-

ment by the mental health services.

There are a number of useful resources for families on the Sane and Rethink websites (www.sane.org.uk and www.rethink.org)

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