First episode psychosis

Editor—Lester's article on first episode psychosis is welcome,1 given that general practitioners have a low index of suspicion for the presence of psychosis and little confidence in diagnosing it.2 But the article omitted two essential considerations—namely, the need to ask about hallucinations and about the risk of self harm and of harm to others; these may be closely related when command hallucinations instruct the person to commit self harm or harm others. Exploration of suicidal ideation (which may be independent of depression) is essential. Suicide is the chief cause of premature death among people with schizophrenia, with 4-13% of such people committing suicide and 25-50% making a suicide attempt. The risks may be further compounded by misuse of alcohol and drugs, precipitating impulsive self harm or harm to others. Identification of comorbid substance misuse may be crucial in managing this group, given the increased attendant risks and the strong association between first episode schizophrenia and substance misuse.3 Substance misuse is likely to be related to suicidal ideation and warrants early attention.4,5 Regrettably, little systematic study has been done of people with first episode psychosis, but the development of a positive trusting relationship with a single mental health key worker as early as possible is advisable. Probably the best results come when the person with schizophrenia and the key worker search for common ground. The key worker should avoid a premature confrontation about the explanatory model of the illness and deliver treatment in as flexible a manner as possible.