Introduction and aims
This essay will discuss the importance of recognising and utilising evidence-based interventions
in the treatment of first episode psychosis, with a focus on anti-psychotic medication and cognitive
behavioural therapy. Additionally, this essay will consider the extent to which positive symptoms (e.g.
hallucinations and delusions) and second relapse can be prevented by these two treatment methods,
and the issues surrounding collaborating with patients with first episode psychosis. Psychosis is a mental
health problem whereby an individual may interpret or perceive their world differently from other
people, to the extent that they experience hallucinations or delusions (National Health Service, 2016)
(NHS). Specifically, first episode psychosis (FEP) is an episode of psychosis which is being experienced for
the first time and is unfamiliar (Centre for Addiction and Mental Health, 2015) (CAMH).
Evidence-based practice in nursing is extremely important as it can inform and enhance a
clinician’s traditional skills when diagnosing, treating and preventing illness through utilising relevant
systematic and answerable questions, using mathematical estimates about probability and riskiness
(Greenhalgh, 2003). Furthermore, evidence-based practice can provide findings which help to support or
oppose psychological theories which inform best nursing practice. Craig and Smyth (2011) highlight that
it is important that a nurse has the skills and ability to recognise and distinguish between low quality and
high quality evidence-based research. For example a low quality piece of research may have used an
inappropriately small sample size, or may have significant methodological flaws.
Research has previously shown little evidence which indicates significant differences in anti-
psychotic medication in reducing positive symptoms, although some of anti-psychotic medications are
more effective than others but present differing side effects. Anti-psychotic medication for psychosis
attempts to block the effects of the neurotransmitter dopamine in the brain (NHS, 2016). One anti-
psychotic medication which has shown efficacious findings in reducing positive symptoms is that of
clozapine. The National Institute for Health and Care Excellence (NICE) (NICE, 2014) advocate that
clozapine should be prescribed to patients whose condition has not responded to other treatments. The
NICE emphasise that clozapine should be offered to a patient with schizophrenia when two different
anti-psychotics (where at least one was not clozapine based) did not treat their condition. Furthermore
the NICE (2014) highlight that where conditions have not responded to clozapine at an optimised
dosage, healthcare professionals should consider a patient’s therapeutic drug levels prior to adding a
second anti-psychotic medication to augment treatment with clozapine. Any anti-psychotic added should
be chosen wisely as to not compound side effects associated with clozapine.
As well as being offered anti-psychotic medications, patients with schizophrenia and FEP are also
offered cognitive behavioural therapy (CBT) (NICE, 2014). CBT occurs between a patient and a therapist
where the therapist helps the patient to understand and make sense of their experiences and problems,
and to achieve personal goals (NHS, 2016). The NICE encourages that patients use anti-psychotic
medications and CBT in conjunction with each other as a form of combined treatment, as CBT has been
found to be effective in long-term treatment but not in the short/medium term (Jones, Hacker, Cormac,
Meaden & Irving, 2012), however it has also been shown to have little treatment success (Lynch, Laws &
McKenna, 2010). As previous research does not provide a majority consensus about the effects of anti-
psychotic medication versus CBT in treating FEP, this essay therefore aims to review the literature
surrounding the success of anti-psychotic medication and CBT in the treatment of positive symptoms and
second relapse in patients with FEP.
The NICE (2014) also discuss the importance of offering early intervention treatment to patients
presenting with psychosis without any delay. This is because the earlier a patient can receive an
intervention, the better the benefits (e.g. reduced suicidal risk and severity of illness) (Melle et al., 2006;
Larsen et al., 2006). McGorry, Killackey and Yung (2008) argue that withholding treatment from a FEP
patient until their symptoms are more severe and less reversible represents a failure of care and
therefore advocates the importance of early interventions. In addition, the CAMH (2015) list several
benefits associated with early interventions for FEP which include: reduced secondary problems (e.g.
disruption to work), retention of social skills and support, less hospitalisation, faster recovery and better
prognosis, reduced family distress, reduced resistance to treatments and reduced risk of relapse. Gumley
et al. (2003) found that patients who experienced early intervention CBT (N=72) compared to treatment
as usual (N=72) had fewer experiences of relapse (hazard ration= 0.47, p< .05) and showed significant
improvements in the occurrence of positive symptoms. Likewise, Robinson et al. (1999) found that
patients who had an early intervention of anti-psychotic medication were less likely to relapse than
those who did not, and the discontinuation of anti-psychotics increased the risk of relapse by five times
(hazard ratio= 4.89). Therefore, early intervention treatments hold significant value and should be
incorporated into all mental health services.
Collaboration
When treating patients for their FEP and any subsequent diagnosed mental health conditions, it is
imperative that healthcare professionals build a care and treatment plan in collaboration with the
patient and their family (NICE, 2014). The NICE (2014) stress that healthcare professionals must foster a
collaborative approach which supports the patient and their carers (e.g. family) which respects their
needs and interdependence. However, this is sometimes difficult due to the nature of the patient’s
psychosis. For example, the psychosis can result in a patient having distorted views of reality (NHS, 2016)
and so their input into their treatment and care plan may not be suitable or beneficial. Furthermore,
communication can be difficult between healthcare professionals and psychosis patients and can lead to
avoidance, confrontation and disagreement resulting in potential disengagement (McCabe & Priebe,
2008). Subsequently, this creates a challenge for nurses and healthcare staff who must work
collaboratively with patients.
Anti-psychotic medication
The NICE (2014) advocate’s anti-psychotic medications as a first-line treatment for FEP, but the guidelines
do not suggest one single anti-psychotic medication for patients with FEP, and instead recommend
various drugs. The NICE also do not advocate one anti-psychotic in particular as there is little evidence-
based research to suggest one anti-psychotic works significantly better than another (Lally & MacCabe,
2015). Furthermore, a patient’s circumstances must be taken into consideration when prescribing anti-
psychotics through a collaborative approach. For example, when collaborating with a patient about
treatment options, it would be wise to opt for an anti-psychotic which did not have fatigue as a side
effect if the patient is still in employment and has parental responsibility.
Clozapine is a well-known anti-psychotic used in the treatment of FEP, usually when other anti-psychotics
have been unsuccessful (NICE, 2014). The National Alliance on Mental Illness (NAMI) describe that
clozapine operates by rebalancing levels of the neurotransmitters of dopamine and serotonin in the
brain to improve mood, thinking and behaviour associated with psychosis. This is because it is believed
that the dopamine hypothesis plays a role in psychosis (Ayano, 2016). Ayano (2016) writes that drugs
which blocked dopamine function in the brains of psychotic patients reduced psychotic symptoms, and
drugs which increase dopamine release can induce psychotic symptoms. Therefore, it is believed that
psychosis is partly caused by having high levels of dopamine in the brain.
In order to assess which anti-psychotics are best for treating FEP, systematic reviews and meta-analyses
are the most effective way to do so as they assemble together relevant research evidence and present
conclusive findings (Egger, Davey-Smith & Altman, 2008). An example of a poor quality meta-analysis
assessing the efficacy and tolerability of pharmacological anti-psychotic medications in preventing
relapse amongst first episode psychosis patients was conducted by Alvarez-Jiménez, Parker, Hetrick,
McGorry and Gleeson (2009). The meta-analysis compared first (FGA) and second generation anti-
psychotics (SGA) with psychosocial treatments. FGAs tend to be drugs that have been used since the
1950s and have more side effects, whereas SGAs are drugs which have been used since the 1990s
(Rethink Mental Illness, 2017). The meta-analysis included eighteen studies and revealed that when
FGAs were compared to placebos, they were non-significant as they did not prevent relapse (p= .22),
however in comparison to FGAs, SGAs were able to significantly reduce relapse (p< .02). Unfortunately,
this meta-analysis does not give information about the effects of medication on positive symptoms.
Additionally, this meta-analysis had several limitations including the studies not having similar designs or
relapse and remission criteria, therefore making them difficult to compare with accuracy.
On the other hand, a good quality meta-analysis was conducted by Leucht et al. (2009), which compared
nine SGAs with FGAs to assess the efficacy and tolerability of the anti-psychotics in relation to positive
symptoms, relapse and extrapyramidal side-effects amongst schizophrenic and FEP patients. Although
the sample of FEP patients was smaller. The authors found four SGA drugs were more efficacious than
FGAs, however the other SGAs were not more efficacious. SGAs did reduce extrapyramidal symptoms
and some reduced relapse (olanzapine, risperidone and sertindole), whilst clozapine showed no
significant difference in relapse rates. There was little difference between the reduction in positive
symptoms between FGAs and SGAs. Leucht et al. (2009) concluded that anti-psychotics whether FGAs or
SGAs have many differing properties and should form part of an individualised treatment basis based on
efficacy, side-effects and cost. Consequently, the focus should be based on what works best for each
patients rather than generalising which anti-psychotic is most effective (Leucht et al., 2013). This meta-
analysis was of a good quality because it analysed a large number of studies and investigated many
aspects of anti-psychotic medication treatment (e.g. negative and depressive symptoms, quality of life,
weight gain and sedation). Additionally, the research provided clinicians with data that can be used for
an individualised treatment approach, to achieve the best efficacy, least side-effects and reduced
financial cost.
Cognitive Behavioural Therapy
CBT is advocated by the NICE (2014) and NHS (2016) for the treatment of FEP and schizophrenia
in the situation where psychotic symptoms persist regardless of anti-psychotic medication treatment,
when there is no compliance with medication and when a patient is in full conviction of their delusions
and hallucinations. CBT allows patients to identify and build coping skills, reduce distress and the
intensity of symptoms and to improve social functioning impaired by their condition (NICE, 2014). A
recent meta-analysis by Bighelli et al. (2018) investigated the efficacy, acceptability and tolerability of
CBT in relation to other psychosocial interventions in reducing positive symptoms. CBT studies accounted
for forty of the fifty-three randomised control trials assessed and were consistently found to be the most
successful treatment for reducing positive symptoms, when patients were on anti-psychotic medication
also. However, the limitations of this research are that effect sizes were only small to medium, therefore
questioning the true significance of findings, and also there was little discussion of CBTs effect on
relapse. CBT appears to be suitable for treating the positive symptoms relating to psychosis, however the
study did find that CBT has high drop-out rates, making adherence poor.
Additionally, CBT requires a patient to do ‘homework’ whereby they practice what they have
learned in their sessions with their therapist outside of this time, and if not practiced, CBT will be less
successful (Sanders, 2011). Furthermore, CBT requires motivation and concentration which can be
difficult for patients with psychosis (NHS, 2016).
Conclusion
In conclusion, the NICE (2014) advocate anti-psychotic medication as a first-line treatment for
FEP, however they also advocate the use of CBT to create a combined treatment approach. Additionally,
the NICE (2014) highlight the importance of early intervention treatments for FEP and emphasise the
importance of healthcare professionals working collaboratively with patients regarding creating their
care plan and treatment, where appropriate. Collaboration can however be difficult as patients suffering
from psychosis often have a distorted reality and poor concentration (NHS, 2016). Additionally,
communication can be poor due to patient avoidance, confrontation and disagreement, which can lead
to disengagement with treatments (McCabe & Priebe, 2008).
Anti-psychotic medications present several benefits regarding symptom reduction and ease of
use, however medication is not to be considered a ‘quick fix’, and has many side-effects including;
relapse, sedation, weight-gain, restlessness, dizziness, dry mouth and loss of libido to name a few.
Alternatively, the psychosocial treatment of CBT presents benefits regarding its success when psychosis is
unresponsive to medication, allowing patients to identify and build coping skills, reduce distress and the
intensity of symptoms and to improve social functioning (NICE, 2014). Nevertheless, CBT does have
disadvantages including requiring motivation and concentration from patients, where this may be
difficult due to the nature of psychosis symptoms.
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