First Episode Psychosis
First episode psychosis represents the initial presentation of psychotic symptoms. Early intervention within 2 weeks via EIP services significantly improves long-term outcomes.
Key Facts
Duration of untreated psychosis (DUP) is the strongest modifiable prognostic factor — shorter DUP = better outcomes NICE mandates referral to EIP services within 2 weeks; EIP provides care for 3 years, ages 14-65 Prodromal symptoms may precede FEP by 1-5 years: social withdrawal, declining function, unusual ideas First-line: Low-dose oral atypical antipsychotic + CBTp + family intervention Cannabis is the most important modifiable risk factor — high-potency use in adolescence doubles risk Up to 25% may have underlying organic cause — thorough investigation is mandatory Incidence ~32 per 100,000/year; peak age 18-24; Black Caribbean populations have 5-10× higher rates in UK 75% of psychotic disorders begin before age 25
Overview
Key Facts
FEP is a critical period where early comprehensive intervention has the greatest impact on long-term outcomes. NHS mandates access to EIP services for all cases.
Epidemiology
Incidence approximately 32 per 100,000/year in the UK. Peak onset 18-24 years. Males have earlier onset. Significant health inequalities — Black Caribbean and Black African populations have 5-10× higher rates.
Aetiology
Genetic predisposition + neurodevelopmental factors + environmental stressors (cannabis, social adversity, urban environment) → dopaminergic dysregulation → psychosis (stress-vulnerability model).
Pathophysiology
- Prodromal phase (1-5 years before FEP): Progressive neurobiological change before threshold symptoms
- Critical period hypothesis: First 2-5 years after FEP are a window of neuroplasticity where intervention has maximal impact
- Mesolimbic dopamine overactivity drives positive symptoms
- Excessive synaptic pruning in adolescence may contribute (C4 gene association)
Clinical Presentation
Prodromal Features
- Declining academic/occupational performance
- Social withdrawal, suspiciousness, irritability
- Unusual/magical thinking, sub-threshold psychotic experiences
- Sleep disturbance, reduced motivation
Psychotic Episode
- Positive symptoms: Delusions, hallucinations, thought disorder
- Behavioural change: Bizarre behaviour, agitation, self-neglect
- Cognitive decline, negative symptoms may be present from outset
Red Flags
- Organic features (confusion, visual hallucinations, seizures, focal neurology) — investigate urgently
- Catatonia (immobility, mutism, posturing) — medical emergency
- High suicide risk: ~5% die by suicide within first 5 years
- Command hallucinations to harm self/others
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Substance-induced psychosis | Temporal relationship to drug use, resolves with abstinence | Urine drug screen |
| Bipolar mania | Elevated mood, episodic course | Mood assessment, collateral |
| Autoimmune encephalitis | Young woman, movement disorder, seizures, psychiatric symptoms | NMDA receptor antibodies, MRI, EEG |
| Delirium | Fluctuating consciousness, acute onset, medical cause | Septic screen, bloods |
| Temporal lobe epilepsy | Brief episodes, automatisms, déjà vu | EEG |
| Psychotic depression | Mood-congruent delusions during severe depression | PHQ-9 |
Diagnosis / Investigation
Bedside
- Full MSE and neurological examination
- Risk assessment: Suicide, violence, self-neglect, vulnerability
- Collateral history: Essential
Bloods
- FBC, U&Es, LFTs, TFTs, fasting glucose, HbA1c, lipids: Baseline and organic screen
- Calcium, B12, folate, CRP: Metabolic/inflammatory causes
- HIV, syphilis serology: Infective causes
- Urine drug screen: Cannabis, amphetamines, cocaine
- NMDA receptor antibodies: If encephalitis suspected
Imaging
- MRI brain: Recommended in all FEP to exclude organic pathology
Special Tests
- ECG: Baseline before antipsychotic
- EEG: If seizures suspected
- Neuropsychological assessment: Baseline cognitive profile
Management
Non-pharmacological
- EIP team: Comprehensive care package for 3 years
- CBTp: ≥16 sessions
- Family intervention: ≥10 sessions — reduces relapse by ~50%
- Supported employment/education: IPS model
- Physical health monitoring: Annual metabolic screening
Pharmacological
- Low-dose atypical antipsychotic: Aripiprazole 5-15mg, risperidone 1-4mg, or olanzapine 5-15mg
- Start lowest dose, titrate slowly; trial 4-6 weeks before switching
- Continue ≥1-2 years after FEP
- Clozapine if failed 2 adequate trials
Referral Criteria
- All suspected FEP — EIP team within 2 weeks (NHS standard)
- Organic features — neurology
- Under 14 — CAMHS
- Postpartum psychosis — perinatal team
Prognosis
- ~25% single episode with full recovery
- ~50% relapsing-remitting course
- ~25% chronic, treatment-resistant illness
- DUP >3 months associated with significantly worse outcomes
- Suicide: ~5% in first 5 years
- EIP services reduce hospitalisation by 50% and improve employment
- Cannabis cessation after FEP significantly improves outcomes
Other Relevant Information
EIP Core Components (NICE CG178)
| Component | Details |
|---|---|
| Antipsychotic medication | Low-dose atypical, shared decision-making |
| CBTp | ≥16 sessions |
| Family intervention | ≥10 sessions |
| Supported employment | IPS model |
| Physical health | Metabolic monitoring |
| Substance misuse support | Integrated approach |
| Carer support | Assessment and support |