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CLINICAL REVIEW: Peter Byrne Managing the acute psychotic episode BMJ 2007; 334: 686-692 [Full text]

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Complexities in managing psychosis and its acute nature

Kishen Neelam   (1 April 2007)

Catch them early for best outcome

Saddichha Sahoo   (5 April 2007)

Complexities in managing psychosis and its acute nature 1 April 2007
Kishen Neelam, Staff Grade Psychiatrist Lancashire Early Intervention Services, 1 Ashfield Road, Chorley, PR7 1LH Send response to journal: Re: Complexities in managing psychosis and its acute nature	It was interesting to read Peter Byrne’s review “Managing the acute psychotic episode”,1 despite raising many questions it served as a good review on the management of the acute psychotic episode. I want to put forward some of my views on the different aspects of acute psychotic episode. It is true early intervention teams embrace diagnostic uncertainty, however it is important to realise the fact that co- morbidity/dual diagnosis is lot more common in this group of people. It can occur at all stages right from pre-morbid to the recovery phase, considering co-morbidity more as an expectation than the exception will help in managing acute psychotic episodes more effectively. Some of the important co-morbidities or differentials to be considered in acute psychotic episode in addition to those already mentioned in the review are eating disorders, childhood abuse or trauma2, borderline and anti-social personality disorders3;4 these co-morbidities can consume all the range of resources available in Early intervention services. With growing evidence of worse prospective outcomes in psychosis with comorbidities5 management of acute psychotic episode can be clinically challenging and highlights the need for early detection and effective management of not only psychosis but also its co-morbidities. When talking of early detection I always wonder whether psychosis needs to be “acute” for us to detect it early. Despite evidence for shorter duration of untreated psychosis as being a strongest predictor of remission6 and of better occupational outcomes7 not all psychiatrists are in a position to acknowledge the importance of early detection. We have been waiting for the “perfect” antipsychotic over the last few decades and it is unlikely for us to find one in the coming decades. However if we can work towards prevention of psychosis by fostering early detection I hope we would be able to reduce the complexities in the management of psychosis and improve the long-term outcomes in this disabling condition. Reference List (1) Byrne P. Managing the acute psychotic episode BMJ 2007; 334(7595):686-692. (2) Shevlin M, Dorahy MJ, Adamson G. Trauma and psychosis: an analysis of the National Comorbidity Survey Am J Psychiatry 2007; 164(1):166-169. (3) Oldham JM, Skodol AE, Kellman HD, Hyler SE, Doidge N, Rosnick L et al. Comorbidity of axis I and axis II disorders The American journal of psychiatry 1995; 152(4):571-578. (4) Moran P, Hodgins S. The correlates of comorbid antisocial personality disorder in schizophrenia SCHIZOPHR BULL 2004; 30(4):791-802. (5) Sim K, Chua TH, Chan YH, Mahendran R, Chong SA. Psychiatric comorbidity in first episode schizophrenia: A 2 year, longitudinal outcome study. J PSYCHIATR RES 2006; 40(7):656-663. (6) Emsley R, Rabinowitz J, Medori R. Remission in early psychosis: Rates, predictors, and clinical and functional outcome correlates Schizophr Res 2007; 89(1-3):129-139. (7) Norman RM, Mallal AK, Manchanda R, Windell D, Harricharan R, Takhar J et al. Does treatment delay predict occupational functioning in first-episode psychosis? Schizophr Res 2007; 91(1-3):259-262. Competing interests: None declared
Catch them early for best outcome 5 April 2007
Saddichha Sahoo, Resident in Psychiatry Central Institute of Psychiatry, Ranchi, India-834006 Send response to journal: Re: Catch them early for best outcome	I read the article “Managing the acute psychotic episode” by Peter Byrne [1] with interest. It presents a very lucid and easily-understandable approach to the complex question of management of acute psychosis. As such, it will be of tremendous benefit to all non-psychiatric clinicians who regularly face challenges, both in diagnosis and management of acute psychosis. It is also true that this group of patients has the best prognosis if intervention is done early. However there are a few things that I would like to contribute to this very informative review: (a) Although catatonic symptoms are rarely seen in Western societies, it is a common phenomenon in the Indian subcontinent [2]. The recognition of this is important since it is often co-existing with metabolic and biochemical abnormalities, which are reversible [3]. (b) The presence of altered consciousness is very rare indeed, however the disorientation of patients to time and place often raises doubts and it is essential to rule out contributing medical illnesses. (c) Suicide is very common in this population with up to 15% completing suicide successfully [4], especially as they start to regain insight into their illness, making it imperative to keep a close watch during the first few days of treatment. (d) The diagnosis of Post traumatic Stress disorder, one of the differential diagnoses of acute psychosis, has the best prognosis. However, in my experience, most of these patients often require antipsychotics in low dosages for complete remission [5]. (e) In the case of first episode mania, mood stabilizers also need to be prescribed if there is a family history of affective illness [6]. (f) Metabolic syndrome in these patients cannot be ascribed to unhealthy lifestyles, with certainty, as several reviews have described the role of antipsychotics, especially atypical ones, in causing it [7]. (g) Psychosocial interventions are very useful treatment approaches for management of psychosis, but only as adjuncts to pharmacotherapy. 1. Byrne P. Managing the acute psychotic episode BMJ 2007; 334(7595):686-692 2. Stompe T, Ortwein-Swoboda G, Ritter K, Schanda H, Friedmann A. Are we witnessing the disappearance of catatonic schizophrenia? Compr Psychiatry. 2002; 43(3):167-74. 3. Pommepuy N, Januel D. Catatonia: resurgence of a concept. A review of the international literature. Encephale. 2002;28(6):481-92 4. Auquier P, Lancon C, Rouillon F, Lader M, Holmes C. Mortality in schizophrenia. Pharmacoepidemiol Drug Saf. 2006; 15(12):873-9 5. Opler LA, Grennan MS, Opler MG. Pharmacotherapy of post-traumatic stress disorder. Drugs Today (Barc). 2006;42(12):803-9 6. Sachs GS. Decision tree for the treatment of bipolar disorder. J Clin Psychiatry. 2003;64 (S8):35-40 7. Newcomer JW. Metabolic considerations in the use of antipsychotic medications: a review of recent evidence. J Clin Psychiatry. 2007;68 (S1):20-7 Competing interests: None declared