Pharmacotherapy challenges in patients with first-episode psychosis

The first episode of a psychotic disorder typically occurs in late adolescence or young adulthood, a critical time of development with respect to personality, social role, education, and vocation. The first few years of psychosis appear to be a critical period during which intervention needs to be initiated before the consequences of psychosis become more severe. Early intervention is therefore crucial in maximizing outcomes. Although response rates to antipsychotic medication in first-episode psychosis (FEP) are good, there is a relatively high risk of relapse. The greatest challenges that physicians face in treating FEP and preventing relapse are engaging patients in treatment and preventing non-adherence to therapy. Overall rates of non-adherence to antipsychotic medications for FEP patients are estimated to be at or higher than 50% within the first year of treatment, suggesting that malleable factors linked to non-adherence need to be targeted in interventions provided. Factors influencing adherence can be categorized into four groups: (1) environment-related, (2) patient-related, (3) medication-related, and (4) illness-related. This paper will review the factors associated with adherence and discuss solutions to optimize engagement, adherence to medication, and treatment in order to prevent relapse. Factors like social and family support, therapeutic alliance, attitudes and beliefs toward illness and medication, insight, substance use disorders, medication efficacy, tolerability, and accessibility will be discussed. Solutions, such as early psychosis specialized services integrating psychosocial therapies and careful selection of appropriate antipsychotic medication, will be proposed.