Can we prevent relapse of psychosis?

Question 1

What is treatment resistance?

Answer 1

No responce to at least 2 different type of antipsychotics after being given an adequate dose for an adequate time (6-weeks)

-> Clozapine is the only approved drug which works for treatment resistance group

Question 2

What is relapse?

Answer 2

Its definitions vary based on a study, generally can be described only in the presence of remission. Can be viewed as hospitalization, re-emergence of symptoms (similar mechanisms can underline FEP and relapse)

Around 80% of people with psychosis will relapse in first 5 years after FEP

Question 3

Why is relapse prevention important?

Answer 3

1. Many people (80%) relapse in first 5 years
2. Relapse is often associated with hospitalization which cause social and personal financial burden (you cannot work in a hospital)

Question 4

How to prevent relapse?

Answer 4

1. Ensure medication continuation (anything that stops D2 seems to work for psychosis)
   Both stopping the drugs or taking them at random linked with risk of relapse
2. LAI ensure taking meds = linked with less relapse than orals
   BUT ppl still relapse on LAI so some will always do
3. Switch to Clozapine early (no response at 12 weeks predicts resistance)–> responders and control often have similar brain structures –> possible cause (biomarker) on poor response + possible subtype of psychosis?
4. Decrease EE in house= stress over
5. Not smoking cannabis

Question 5

What is EE ?

Answer 5

Expressed Emotion
Can be high or low

• Critical comments
• Hostility
• Emotional over-involvement

Question 6

What is the effect on antipsychotics on the brain?

Answer 6

Antipsychotics increase brain metabolism, use more glucose in brain areas involved at frontal level

The meds need to maintain brain activity level to be effective

It can be so that the brian cannot handle the levels of activity and relapse– relapse on medication

Study of drug taking in healthy controls : 1 dose of Haloperidol vs Aripiprazole vs placebo
=> Massive increase in blood flow in basal ganglia
=> Shows that just giving the antipsychotics increases the demand on the brain

Question 7

Why are people with psychosis not taking medication?

Answer 7

• Risk of side effects (unpleasant)
• Stigma
• Want to believe first episode was a one off event
• Lack of organised lifestyle
• Some clinical staff are ambivalent about / ideologically
  opposed to treatment with medication

Question 8

What is the ‘getting better’ paradox?

Answer 8

1. In many first episode patients, symptoms rapidly improve with antipsychotic medication
2. Patient (and even clinical staff) may conclude that medication is no longer necessary
3. This substantially increases the risk of relapse

Question 9

Can we predict relapse?

Answer 9

At this moment we cennor predict a relapse in an individual patient

If it was possible then we could target those who are at most risk for relapsig->prsonalising care

Key goal of current research