Abstract
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.
Method: 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.
ACKNOWLEDGMENTS
The authors acknowledge the NHMRC Program Grant (510135) for essential financial support.
DISCLOSURES
Gin Malhi has served on a number of international and national pharmaceutical advisory boards, received funding for research and has been in receipt of honoraria for talks at sponsored meetings worldwide involving the following companies: AstraZeneca, Eli Lilly, Jansen-Cilag, Organon, Pfizer, and Wyeth. Garry Walter has received educational grants from Eli Lilly, Janssen-Cilag and Pfizer, and travel assistance and an honorarium for a talk from Eli Lilly. Danielle Adams has received honoraria from Eli Lilly for a speaking engagement. Beverley Moss has no declaration of interest.