To medicate or not to medicate, when diagnosis is in question: decision-making in first episode psychosis.
OBJECTIVE
This paper reports on a brief survey of clinicians' judgements when making treatment decisions in the context of diagnostic uncertainty. Specifically, attitudes and opinions were sought from practising consultant psychiatrists regarding two key areas of clinical decision-making in first episode psychosis (FEP), namely, when to initiate medication and, how long to continue treatment.


METHODS
Interviews were conducted with consultant psychiatrists using a combination of structured and semi-structured questions that examined and explored pharmacological treatment decisions in FEP.


RESULTS
Twenty-three consultant psychiatrists participated in the interviews. The threshold to initiate pharmacological treatment was lower when a risk to self or others is present, when symptoms are primarily positive, when the patient is in distress, or where there is a family history of mental illness. Atypical antipsychotics are routinely used as front-line medication in FEP and the choice of medication is determined largely by their likely side effect profile. However, the greater the perceived efficacy, the greater the anticipated tolerability burden. The ideal duration of treatment is considered to be 1-2 years in instances of full remission, and 5 years where only a partial response has been achieved or where recovery has not been sustained.


CONCLUSIONS
The 'first episode' represents a unique period in the management of psychosis where by definition there is no history of pattern of illness, diagnostic certainty is rare, and the patient usually does not have any prior exposure to medications. Therefore, each management decision needs to be considered following a risk benefit analysis which takes into account the context of the individual.
Department of Academic Psychiatry, CADE Clinic, Royal North Shore Hospital, NSW, Australia. gmalhi@med.usyd.edu.au
Gin
G
Malhi
Danielle
D
Adams
Beverley
B
Moss
Garry
G
Walter
D014150:Antipsychotic Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D003617:Dangerous Behavior; D003663:Decision Trees; D020022:Genetic Predisposition to Disease; D006801:Humans; D007406:Interview, Psychological; D007600:Judgment; D008297:Male; D002189:Marijuana Abuse / Q000150:complications / Q000523:psychology; D010147:Pain Measurement; D011605:Psychoses, Substance-Induced / Q000175:diagnosis / Q000188:drug therapy / Q000523:psychology; D011618:Psychotic Disorders / Q000175:diagnosis* / Q000188:drug therapy* / Q000235:genetics / Q000523:psychology; D012017:Referral and Consultation; D018570:Risk Assessment; D055815:Young Adult
D014150:Antipsychotic Agents