[Therapeutic strategies in the first psychotic episode]

A first psychotic episode includes a wide range of disorders with different outcomes: schizophrenia, bipolar disorder, schizophreniform disorder, schizoaffective disorder, drug-induced psychosis, brief reactive psychosis, organic psychoses and delusional disorder. The course and outcome of a first psychotic episode is greatly dependent on its initial management. Major clinical, etiopathogenic and therapeutic advances have been achieved in this field and have allowed specific management strategies to be adopted. The primary task of therapists involved in the management of patients who have experienced a first episode of psychosis is promotion of recovery and prevention of secondary morbidity, relapse and persistent disability. The main guidelines of an early psychosis management are:--to keep in mind that early psychosis is not early schizophrenia. Thus, clinicians and therapists should avoid an early diagnosis of schizophrenia. Diagnosis in early psychosis can be highly unstable. A diagnosis of schizophrenia, with its implications of pessimism, relapse and disability, does not contribute anything positive in terms of guiding treatment. On the contrary, such a diagnosis may damage the patient and family by stigmatizing them and affecting the way they are viewed and managed by healthcare professionals.--To integrate biological, psychological and social interventions: effective medications is useful in reducing the risk of relapse, but is not a guarantee against it. Psychological and social interventions can greatly help promote recovery.--To tailor the various strategies to met the needs of an individual: as an example, it is important to formulate appropriate strategies for the different stages of the illness (prodromal phase, acute phase, early recovery phase and late recovery phase) because patients have different therapeutic needs at each stage.--In the acute treatment, not to concentrate on short-term goals in indicating antipsychotic treatment: prescribing principles for first-episode psychosis are to maximise benefit and minimise side effects because the first experience of medication may influence a patient's future attitudes of therapy of all types. Effective strategies which may reduce long-term morbidity and improve recovery are currently available but their implementation is too often delayed. The time lag between the onset of symptoms and the start of treatment can be many months or years and this delay can have serious consequences. The critical period of the first 2-5 years after the first psychotic episode is a time of maximum vulnerability and of maximum opportunity. Consequently, actions should be undertaken to promote early recognition and assistance in psychotic disorders: understanding of the factors that may cause delay in treatment can help minimise this problem and lead to the initiation of appropriate treatment at the earliest opportunity. Training the general practitioners who have an important part to play in the early recognition is also of crucial importance.