The first episode of schizophrenia is a field of great interest from both clinical and research perspectives. Most clinical and psychosocial deterioration in schizophrenia occurs within the first 5 years of the onset of the illness, suggesting that this is a critical period for treatment initiation. Therefore, early detection and subsequent effective therapeutic intervention are vital for the patient, as they significantly determine the course and the long term outcome of the disease. Pharmacotherapy is the cornerstone of the whole therapeutic approach. Patients with first-episode psychosis are comparatively more treatment responsive than patients with multiple episodes. They need lower doses of antipsychotic medication but at the same time are quite sensitive to side effects mainly to extrapyramidal symptoms and signs. All current guidelines consider second generation antipsychotics as first choice drug for first episode schizophrenics. Data from few double blind randomized clinical trials indicate that the newer agents show equal or even better efficacy than the neuroleptics and to a certain extend fewer side effects, mainly extrapyramidal symptoms. Despite initial symptom reduction, achievement of full remission -particularly if it is defined according to strict criteria- and even more, achievement of full recovery remains unsatisfactory. Predictors of poor short term and long term outcome include male gender, low educational level, "soft" neurological signs, severe positive symptoms at baseline, cognitive deficits at intake, poor premorbid functioning especially during adolescence, prefrontal neuronal dysfunction, extrapyramidal symptoms and tardive dyskinesia early in treatment, long duration of untreated psychosis or untreated illness. Although published guidelines do not make definitive recommendations about the duration of maintenance treatment after the first episode, recent data suggest that 1 or 2 years might not be adequate. Medication adherence is problematic in first episode schizophrenics even within the first six months. Poor adherence is predicted by male gender, younger age, poor insight after discharge, severe positive symptoms at baseline, alcohol and drug abuse, inadequate family involvement, lower occupational status, not positive relationship with the psychiatrist, bad admission experience and medication side effects. Adjunctive psychosocial interventions may be beneficial across a variety of domains and can assist with symptomatic and functional recovery. Cognitive-behavior therapy has shown modest efficacy in reducing symptoms and assisting patients in adjusting to their illness but has shown minimal efficacy in reducing relapse. Some reports support the benefits of family interventions, while there is a paucity of data evaluating group inter ventions. Comprehensive (i.e. multi element) treatment approaches show promise in reducing symptoms and hospital readmissions as well as improving functional outcomes. More randomized controlled trials are needed to evaluate the ef fectiveness of psychosocial interventions, in general, in first-episode psychosis patients.
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