The first episode of schizophrenia usually occurs in the late teenage years or the early 20s.

Initial symptoms include:

 

• A period of gradual social withdrawal
• Feelings of suspiciousness
• Paranoia
• Unusual behaviour

• Emotional flattening
• Lack of motivation and pleasure 

Due to insidious nature of the onset of schizophrenia, attention is only raised when significant psychotic symptoms that impair everyday functioning have developed. The most common psychotic symptoms reported are delusions and auditory hallucinations.

A first episode of schizophrenia should be treated urgently as a greater duration of untreated schizophrenia is associated with an increased risk for severely greater psychotic and negative symptoms and a weak response to antipsychotic treatment.

Patients that present with psychotic symptoms in primary care should be referred to local community- based secondary mental health services such as early intervention service, community mental health team, crisis resolution and home treatment team, or other similar community based services. If a person refuses necessary admission to hospital, compulsory admission can be arranged under sections 2, 3, or 4 of the Mental Health Act.

These mental health services provide a thorough assessment and develop a care plan which consists of a crisis plan. The crisis plan aims to recognise the responsibilities of primary and secondary healthcare, and to identify important clinical contacts, which may be beneficial in an emergency or impending crisis, such as a relapse.

Pharmacological intervention is offered to the patient which includes an oral typical or atypical antipsychotic drug. The choice of antipsychotic medication is made together with the patient, whilst taking into consideration the side effect profile for each agent (Figure 9).

Studies have shown that the response to antipsychotic medication at a lower dose is greater for those patients experiencing a first episode, than for those patients with chronic schizophrenia.

Antipsychotic treatment is usually continued for at least one year after a reduction in symptoms and the patient has remained stable. Considerations can then be made to withdraw from antipsychotic therapy, making sure this is achieved in a cautious and controlled manner. However, antipsychotic drug withdrawal is associated with a relapse rate of approximately 80% within 5 years from initial response to therapy.