First episode schizophrenia: Considerations on the timing, selection, and duration of antipsychotic therapies

In recent years, there has been an encouraging and accelerated growth in research in First Episode Psychosis (FEP). The growth in FEP research results from a confluence of findings pointing to the early (even in-utero) origins of schizophrenia. There is also a broadening appreciation that while it is not yet possible to “spot” schizophrenia from a variety of nonspecific and subtle “impairments” in social, linguistic, and cognitive performance, it is nevertheless evident that people later diagnosed with schizophrenia have been “ill” for (in many instances) several years before they actually present for care (1). Moreover, there is now intriguing and provocative information from several high risk studies which suggests that effective, early intervention might (at least) forestall the onset of FEP (2, 3). Such a perspective is important because it offers a glimpse of the potential for primary prevention of schizophrenia. Heretofore this was largely considered an unrealistic proposition. There is evidence now of early cognitive and structural brain neurodegenerative changes even at (or close to) the onset of FEP (4, 5). Thus, appropriate (and even “aggressive”) management of schizophrenia at its first presentation might result in a more favorable trajectory over the course of subsequent care. While both of these suppositions are just that-suppositions-nevertheless they form an important and heuristic “backdrop” when considering the pharmacologic management of FEP.