International Journal of Mental Health Nursing (2008) 17, 85–91 doi: 10.1111/j.1447-0349.2008.00515.

Feature Article
First-episode psychosis: A literature review
Simone I. Reed
School of Nursing, Deakin University, Burwood, Victoria, Australia

ABSTRACT: This paper reports on a literature review of the impacts of first-episode psychosis on
both the patient and their family and carers. The discussion focuses on the effects on the patient
experiencing psychotic symptoms for the first time, including disruption to their environment, social
connectedness, and future plans. Patients experiencing these symptoms can experience fear, distress,
and isolation. Many of these patients are also at greater risk to themselves and others. The family and
carers witnessing this psychosis may experience fear, guilt, and often carry the emotional and physical
burden of care. Early intervention and treatment are crucial to potentially achieving better clinical
outcomes, and to alleviating the psychological impact on patients and their families. The nurse’s role
in the treatment of the patient experiencing first-episode psychosis is to facilitate early intervention
through recognition of symptoms and ongoing assessment, work to reduce a patient’s risks, manage
treatments, and work with the patient to reduce the risk of relapse.
KEY WORDS: family, first-episode psychosis, impact, literature review, nursing.

INTRODUCTION Early intervention in FEP is important in alleviating

the distress and anxiety associated with psychotic symp-
First-episode psychosis (FEP), the first presentation of
toms, as well as reducing the risk of suicide (Johannessen
psychotic symptoms, usually occurs in adolescence, a time
et al. 2007; Payne et al. 2006). The delays in gaining treat-
of great change and upheaval (Harris et al. 2005; Mackrell
ment can be either the failure of individuals to seek help,
& Lavender 2004). The effect on the sufferer (‘the
or the failure of health professionals to recognize psy-
patient’) and their family and carers can be immense, with
chotic symptoms (Norman et al. 2004). Both health-care
patients often confused, scared, depressed, socially iso-
professionals and the community need to be educated
lated, and devastated by the disruption to their lives and
in early detection of symptoms, appropriate avenues of
goals (Kilkku et al. 2003; Sanbrook et al. 2003). Patients
referral, and to support individuals in accessing this help
typically suffer trauma from their disturbing symptoms,
(Welch & Garland 2000).
from treatment itself, and have increased physical and
The nurse’s role is to alleviate suffering, aid recovery,
psychological risks, including that of suicide (Jackson
and minimize the risk of relapse. They do this through the
et al. 2004; Payne et al. 2006). Family and carers typically
therapeutic relationship, and use the skills of assessment
suffer distress, fear, and confusion to the patient’s erratic
and risk identification in order to maximize patient out-
and often aggressive behaviour, while holding the physical
comes (Keks & Blashki 2006). Nurses manage the symp-
and emotional burden of care, and dealing with the stigma
toms and issues of psychotic illness in adolescents,
and guilt associated with mental illness (Addington et al.
including family interventions, education, and medication
2003; Barker et al. 2001).
management (Keks & Blashki 2006; Kilkku et al. 2003).
Nurses prepare patients to then re-enter their own envi-
Correspondence: Simone Ingeborg Reed, School of Nursing, ronment with skills and knowledge, and aim to reduce the
Deakin University, 221 Burwood Highway, Burwood, Vic. 3125, Aus- risk of relapse (Gleeson 2005).
tralia. Email: simireed@gmail.com
Simone I. Reed, B Fin Admin, RN, BN.
This paper reports on a review of the literature on the
Accepted July 2007. impacts of FEP, on both the patient, their family and

© 2008 The Author

Journal compilation © 2008 Australian College of Mental Health Nurses Inc.
86
carers, the issues related to early intervention, and dis-
cusses the nurse’s role in their care.
FIRST-EPISODE PSYCHOSIS
Psychosis is a condition in which people suffer from
symptoms such as delusions, hallucinations, erratic
behaviours, and disordered thoughts (Keks & Blashki
2006). When people first present with the symptoms of
a FEP, they may display some or all of these symptoms,
appear agitated or depressed, may be aware of what is
happening, or may have no insight at all (Keks & Blashki
2006).
Although anyone can be affected, patients with FEP
are most likely to be adolescents or young adults, more
often male, and frequently living with their parents
(Harris et al. 2005; Malla et al. 2005; Mullen et al. 2002).
Often these patients are relatively unskilled or unem-
ployed, having left school because of their symptoms, and
are usually socially isolated (Harris et al. 2005).
People experiencing FEP often present to the Emer-
gency Department of a hospital, with multiple problems,
such as aggressive behaviour, suicidal tendencies, and
histories of substance misuse, and frequently then
become involuntary patients (Malla et al. 2005; Payne
et al. 2006).
IMPACT ON THE PATIENT
Adolescence, the phase when many first experience psy-
chosis, is a time that people are forming peer networks,
beginning the transition from family to independence,
and exploring their role in the world (Mackrell & Laven-
der 2004). Psychosis at this time makes this time even
more uncertain, and disrupts the process of developing
social networks (MacDonald et al. 2005; Mullen et al.
2002).
During the acute stage of the illness, the patient often
has difficulty making sense of the experience, and this
leads to confusion, fear, and a sense of ‘losing control of
himself/herself and the environment’ (Kilkku et al. 2003;
p. 60). This ‘disruption’ often threatens their own self-
concept, and disrupts or removes their plans for the
future, their career, and social goals (Sanbrook et al.
2003).
There is a high need for social support during this time,
but often peer groups are limited after a person has expe-
rienced a psychosis. The stigma of mental illness and a
patient’s erratic or aggressive behaviour may lead friends
to withdraw from the patient (Barker et al. 2001; Mackrell
& Lavender 2004). Patients themselves may isolate them-
Journal compilation © 2008 Australian College of Mental Health Nurses Inc.
S. I. REED
selves from their peer group, their illness making it harder
for them to maintain intimate or close relationships (Mac-
Donald et al. 2005).
This social dysfunction leads to feelings of loneliness,
isolation, being stigmatized, and a general reduction in
social activity (Barker et al. 2001; Kilkku et al. 2003; Mac-
Donald et al. 2005; Sanbrook et al. 2003). The longer the
psychosis goes untreated, the greater the feelings of iso-
lation and social dysfunction the patient may experience
(Chen et al. 2005).
The patient with FEP is often distressed, not only with
the changes to their social patterns, but also through their
symptoms. Hallucinations and delusions can cause con-
siderable distress and anxiety, mixed with feelings of
hopelessness, shame, entrapment, and a feeling of being
‘out of control’ (Hanssen et al. 2005; Iqbal et al. 2004).
Patients often suffer depression, feel hopeless, and
have feelings of loss related to both their immediate expe-
rience and their thoughts of the future (Harris et al. 2005;
Kilkku et al. 2003; Power et al. 2003). Levels of depres-
sion also seem to increase with the increase in a patient’s
insight into their illness (Iqbal et al. 2004).
Researchers now argue that patients who suffer a psy-
chotic episode actually suffer a trauma, especially when
their symptoms include paranoid or persecutory themes
(Jackson et al. 2004; Mueser & Rosenberg 2003). The
patient has often suffered traumatic events before their
illness, and are vulnerable to further trauma, including
violence. The treatment for psychosis can be distressing for
patients, especially the use of seclusion and restraints, with
the most common traumatic event being involuntary
admission into a mental health facility (Gorrell et al. 2004).
First-episode psychosis also puts patients at risk, or is
associated with risk-taking behaviours. Adolescence, the
time when FEP usually occurs, is a time of exploration of
sexual behaviour, and an increase of risk of sexually trans-
mitted disease and unwanted pregnancy (Shield et al.
2005). Shield et al. (2005; p. 150) report that psychotic
adolescents are ‘twice as likely to be sexually active, report
intercourse without condoms, and use intravenous drugs’.
Cognitive dysfunction also leads to vulnerability, including
that of sexual victimization (Mueser & Rosenberg 2003).
Psychosis is also linked to substance use disorders
(SUDs), with an estimated 20–60% of patients having a
SUD at some stage in their life (Lambert et al. 2005;
Wade et al. 2005). It is thought that substance abuse,
especially of cannabis, can lead to psychosis, is related to
poorer medication compliance and a poorer treatment
response (Lambert et al. 2005). Psychotic patients are also
more likely to use tobacco, another major health risk
(Wade et al. 2005).
© 2008 The Author
FIRST-EPISODE PSYCHOSIS
The most significant physical threat to patients with
FEP is that of suicide, the leading cause of death among
patients with schizophrenia (Payne et al. 2006). It is esti-
mated that two-thirds of these suicides happen within
6 years of the first symptoms appearing (O’Toole et al.
2004).
The psychotic patient can also pose a threat to people,
animals, and property due to aggressive behaviour, with
aggression being seen in many patients during their first
admission (Payne et al. 2006). This aggression, usually
related to delusions, can make the patient anxious, agi-
tated, and hostile, and can lead to legal consequence
which can delay or hinder treatment (Keks & Blashki
2006; Payne et al. 2006).
AFFECT ON FAMILY/CARERS
Psychosis has an enormous impact on the sufferer’s family
and carers, especially in the first episode (Addington et al.
2003; Chong et al. 2005). Families are often distressed,
anxious, and confused, mostly because of the patient’s
disturbed and difficult behaviour, and negative symptoms
(Addington et al. 2003; Barker et al. 2001; Jeppesen et al.
2005).
Families can also be fearful, of the patient’s behaviour,
and of what the future might hold (Barker et al. 2001).
The family might have feelings of loss, for goals that might
now not be reached, and to the change in relationship
with the patient (Patterson et al. 2005).
The physical and emotional burden of care often falls
on the family, which can add to stress and anxiety, as they
care for the patient and try to deal with their own negative
feelings (Patterson et al. 2005; Raune et al. 2004). With
more treatment now happening in the community, caring
for an individual who has suffered FEP can also lead to an
increase to the financial burden on family and carers
(Chen et al. 2005; Sanbrook & Harris 2003).
Families also ‘deal’ with the stigma of mental illness, in
a society that has focused on the hereditability of mental
illness (Sanbrook & Harris 2003). Families and carers can
experience feelings of guilt associated with potential bio-
logical causes of the illness, as well as guilt for not having
recognized the symptoms sooner (Barker et al. 2001;
Sanbrook & Harris 2003). Unfortunately, some families
attribute the early changes in behaviour of patients to
normal adolescent behaviour, and as they ‘adapt’ to these
changes, it increases the time it takes to seek help, and can
then add to the burden of guilt they experience (Barker
et al. 2001; Chen et al. 2005).
Expressed emotion (EE) in families is characterized by
hostility and criticism towards the patient (Sanbrook &
© 2008 The Author
Journal compilation © 2008 Australian College of Mental Health Nurses Inc.
87
Harris 2003). Raune et al. (2004) found that more than half
of the patient–carer relationships in FEP are characterized
by high EE. Families/carers in high EE relationships
report higher subjective stress and greater rates of emo-
tional burden (Patterson et al. 2005; Raune et al. 2004).
They often perceive the client as demonstrating disturbing
behaviour deliberately, are less empathetic to the patient,
perceive greater threat, and feel they have less control over
the situation than other families (Patterson et al. 2005).
EARLY INTERVENTION
It is known that there are often significant delays between
the onset of psychotic symptoms and the commencement
of treatment. Research has shown that it may take up to
2 years for individuals to begin to receive the interven-
tions needed to alleviate psychotic symptoms (Shiers &
Lester 2004). This delay is twofold in nature, with delays
occurring due to individuals not seeking help, and when
they do often treatment is delayed by health-care profes-
sionals (Norman et al. 2004).
Individuals often do not seek treatment as they do not
understand the nature of their psychotic symptoms, espe-
cially in the prodromal phase (Berger et al. 2006; Norman
et al. 2004). Delays in seeking assistance can also be due
to fear of stigmatization, psychological factors such as
denial, and lack of support or motivation (Johannessen
et al. 2007; Jorm et al. 2007). Access to relevant services
may also impair an individual’s ability to access treatment.
Individuals in rural areas face greater barriers to treat-
ment, with less psychiatry services available, poorer socio-
economic status, and generally a lack of critical mass of
patients in these areas (Payne et al. 2006; Welch &
Garland 2000).
Disturbingly the initiation of treatment can often be
delayed when individuals are actively in the care of their
general practitioner (GP) or other health-care profession-
als (Norman et al. 2004). With approximately 30–40% of
individuals using their GP as their first contact after devel-
oping symptoms, and 50% contacting their GP at some
stage during the course of their illness, GPs are best
situated to recognizing symptoms and initiating treatment
(Berger et al. 2006; Norman et al. 2004). GPs and other
health professionals often though fail to realize the signs
of FEP, even when individuals have been in their care for
some time. One reason for this is that early symptoms of
psychosis, such as sleep disturbances, depression, and
withdrawal, may be attributable to a variety of other con-
ditions or even normal adolescent behaviour (Norman
et al. 2004; Shiers & Lester 2004). In addition, even when
presented with florid psychotic symptoms, GPs may fail to
88
adequately assess patients as they may be unfamiliar with
the condition, seeing only one or two cases of FEP per
year (Berger et al. 2006; Shiers et al. 2004).
There is considerable debate in the literature as to
whether early intervention leads to better clinical out-
comes. Some studies show no difference in outcomes for
patients with longer or shorter duration of untreated psy-
chosis (DUP) (Friis et al. 2004; Shiers et al. 2004). Others,
however, show a longer course of illness with more severe
symptoms in those individuals with longer DUP (Johan-
nessen et al. 2007). Shiers et al. (2004) argue that the
early stage of psychotic illness is a crucial time for inter-
vention, with outcomes at 2 years after symptom onset
predictive of illness severity 15 years later. Berger et al.
(2006) state that early intervention is imperative, as func-
tional and structural brain changes seen in schizophrenia
may actually occur at the onset of psychotic symptoms.
Research suggests that deterioration is most rapid in the
2–3 years after onset of psychotic illness, so early inter-
vention may halt this decline (Payne et al. 2006).
Even though the debate remains, early intervention is
essential when we look at the psychological impacts on
both patient and their family as discussed earlier (Johan-
nessen et al. 2007). Delays in treatment prolong anxiety
and distress for patients and their families, and can lead to
an increased risk of relapse (Hopkins 2002; Norman et al.
2004). Importantly, it is vital to alleviate psychotic symp-
toms as it is known that they increase the risk of suicide
and suicidal behaviour (Payne et al. 2006).
In order to facilitate early intervention, education
related to early detection needs to be given to both
health-care professionals and the community (Norman
et al. 2004; Welch & Garland 2000). GPs, nurses, and
other health-care workers need to be educated as to the
early identification of psychotic symptoms and their
assessment, and then be encouraged to either begin treat-
ment or refer patients to appropriate specialist services
(Berger et al. 2006; Norman et al. 2004).
Second, community stakeholders and carers of young
people also need to be aware of early symptoms. Teach-
ers, counsellors, the police, and others who may have
ongoing contact with youth in the community need to be
taught about the symptoms of psychosis, be encouraged
to seek help for young people of whom they are con-
cerned, and be shown where that help may be found
(Jorm et al. 2007; Welch & Garland 2000). Individuals
themselves also need to be supported to change their
help-seeking behaviour, with information and access to
services being readily available (Johannessen et al. 2007).
In order to combat the barriers to early treatment, a
number of early intervention services have emerged
Journal compilation © 2008 Australian College of Mental Health Nurses Inc.
S. I. REED
(Payne et al. 2006). In Victoria, Australia, for example, the
Early Psychosis Prevention and Intervention Centre
(EPPIC) has a mobile assessment team which takes refer-
rals from GPs, the police, and concerned relatives and
friends to respond in a timely manner when individuals
display potentially psychotic symptoms (Berger et al.
2006). The EPPIC is part of Orygen Youth Health which
targets youth aged 13–25 years, attempting to bridge the
gap between child and adult mental health services
(McGorry 2005).
NURSE’S ROLE
Early intervention
Early intervention in FEP includes the early detection of
psychotic symptoms, reducing the time before first treat-
ment, and ongoing interventions in the 3–5 years after
onset (Joseph & Birchwood 2005). As shown previously,
early intervention potentially can lead to better clinical
outcomes and can also reduce the impacts of anxiety,
confusion, and distress of both family and patient (Kilkku
et al. 2003; Malla et al. 2005).
The nurse’s role, therefore, as with other health pro-
fessionals, is to facilitate early intervention through rec-
ognition of symptoms and ongoing assessment (Etheridge
et al. 2004; Keks & Blashki 2006). Nurses can often be the
first point of contact for a patient displaying prodromal or
psychotic symptoms, and they need to recognize them
wherever they occur (Etheridge et al. 2004).
Assessment and risk reduction
Nurses also must be involved with physical, mental health
and risk assessment, as these factors all influence clinical
outcomes. Physical assessment includes comorbid factors,
such as other illnesses and substance use, and the side-
effects of antipsychotic medication (Gorrell et al. 2004;
Harris et al. 2005). Side-effects may include extrapyrami-
dal, anticholinergic, and other autonomic symptoms. It is
important for nurses to assess patients for these symp-
toms, and to assist patients in their medication manage-
ment (Walker & MacAulay 2005).
Mental health assessment includes symptoms, charac-
teristics, and psychological state, as well as the psycho-
social factors applicable to the patient (Keks & Blashki
2006). Nurses help to establish baseline data for a patient,
as well as being involved in the ongoing assessment of
patients. This will include talking to both patients and
their family (Gorrell et al. 2004; Keks & Blashki 2006).
As discussed earlier, a patient suffering from FEP is at
greater risk of harm to themselves and others. The nurse
is responsible, with other members of the treatment team,
© 2008 The Author
FIRST-EPISODE PSYCHOSIS
to identify the nature and extent of a patient’s suicide risk,
risk to others, and risk to themselves, and to plan inter-
ventions that reduce that risk, for example, helping to
rapidly reduce psychotic symptoms (O’Toole et al. 2004;
Power et al. 2003).
A nurse must also assess for substance use/abuse, as
SUD can lead to poorer treatment response, can be
related to poor medication compliance, has physical
health risks such as cancer, and can increase the risk of
suicide (Lambert et al. 2005; Wade et al. 2005). Research
has also shown that substance abuse has been associated
with aggression and violence towards others (Milton et al.
2001). Nurses need to be involved in assessment of sub-
stance abuse, as well as education and interventions that
can reduce the disorder, or the risks associated with it
(Lambert et al. 2005).
In order to combat the increased risk of pregnancy,
sexually transmitted infections, and HIV, the nurse needs
to be involved in assessing patient’s risk and providing
education (Shield et al. 2005). Shield et al. (2005) stress
the importance of behavioural education among patients
suffering from psychosis, as well as providing access to
additional support groups.
Therapeutic relationship
The therapeutic relationship, the basis of care in mental
health nursing, must be built on good rapport, trust, genu-
ineness, and patient-centred goals if it is to be effective
(Keks & Blashki 2006). Trust is the key element in the
therapeutic relationship, but can be particularly hard to
establish with adolescents (Ramjan 2004). Nurses need to
understand the unique characteristics of the adolescent
phase, and the process of young people’s social support
and development (MacDonald et al. 2005).
Effective therapeutic relationships help to alleviate
anxiety and confusion, and enable the patient to feel more
in control (Hanssen et al. 2005; O’Toole et al. 2004).
Nurses also need to understand the trauma associated
with hospitalization and treatment, that this trauma may
lead to patients avoiding treatment, and longer treatment
times. Nurses should ensure they are treating patients in
the least traumatic and restrictive manner (Gorrell et al.
2004; Mueser & Rosenberg 2003).
Integrated treatment
As discussed previously, FEP affects and is affected by
the family and carers of the patient. It is not surprising
that research has shown that integrated treatment that
involves family/carers leads to better patient outcomes,
including reduction in symptoms and reduced treatment
time (Jeppesen et al. 2005). Nurses are involved in inte-
© 2008 The Author
Journal compilation © 2008 Australian College of Mental Health Nurses Inc.
89
grated approaches to treatment including psychoeduca-
tion, which provide patients and their families/carers with
clear and understandable information and education to
increase understanding of mental illness and the issues
which relate to it (Kilkku et al. 2003; Mullen et al. 2002).
Nursing care can also be aimed at supporting families and
patients to use their own resources and skills in living with
mental illness, as well as ‘teaching them crisis manage-
ment, communication and problem-solving skills’ (Kilkku
et al. 2003; p. 58).
Integrated treatment has also been shown to decrease
levels of EE by families and carers, leading to not only a
reduction in subjective levels of family burden, but also
better patient outcomes (Raune et al. 2004). It is the
nurse’s role then, to support and be involved in integrated
treatment, and perhaps to help target those families
which would most benefit from it (Raune et al. 2004).
Medication
Nurses are also responsible for the management of medi-
cation treatment. Nurses not only administer medication,
but must be aware of the indications, contraindications,
and side-effects of medication prescribed (Zipursky et al.
2005). Medication side-effects need to be managed col-
laboratively with the patient, and nurses need to under-
stand the reasons patients do not take medication, and
have skills to lessen the effects of these barriers (Barker
et al. 2001; Keks & Blashki 2006).
Discharge planning
Nurses must also be involved in the discharge planning
for their patients. This may include ending the therapeu-
tic relationship in a positive manner, education for
ongoing issues that patients will face, preparing patients
for a return to social activity, and connecting patients
to services that are available (Etheridge et al. 2004;
Lendrum 2004; O’Toole et al. 2004; Sanbrook et al.
2003). An important role of effective discharge planning is
giving patients the best possible chance of avoiding
relapse (Gleeson 2005).
CONCLUSION
First-episode psychosis typically causes confusion,
depression, and fear in sufferers who are often also trying
to cope with the uncertainties of adolescence. Patients
can suffer isolation through the disruption of social net-
works and the challenges of disturbing behaviour. They
are at greater risk of harm, both physical and emotional.
The families and carers of these young people can suffer
from confusion, fear, and uncertainty as they cope with
90
the loss of relationships as they knew them, as well as the
physical, emotional, and financial burden of care.
Early intervention can possibly make a difference to
the course and severity of an individual’s illness. It can
definitely make a difference to the distress that patients
and those close to them suffer. With delays in treatment
of up to 2 years after psychotic symptoms present, health-
care professionals need to be more vigilant in correctly
assessing symptoms, and either beginning treatment, or
referring patients to specialist services. Community stake-
holders who spend time with those at greatest risk, such as
teachers, counsellors, and those in the justice system,
need information and education about how symptoms
may present, and how to obtain help for those in their
care.
Nurses are in a position to make a real difference in the
care of patients with FEP and their families. Effective
therapeutic relationships, coupled with highly refined
assessment and education skills, can reduce the impacts of
distress, confusion, and the risks associated with mental
illness. Nurses who can promote or assist early interven-
tion and integrated treatment gain for their patient’s
better clinical outcomes, reduction in distressing symp-
toms, and help to reduce the risk of relapse. Lastly,
nurse’s discharge planning helps support patients to
return to their environments and relationships.
ACKNOWLEDGEMENT
I would like to acknowledge the help of Dr Alicia Evans,
Senior Lecturer, School of Nursing, Deakin University,
for reviewing the drafts of this paper.
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