By Asiya K. Kazi, MSPH 
March 24, 2023

U.S. Army National Guard photo by Staff Sgt. Tawny Schmit

What is First Episode Psychosis?

First Episode Psychosis is a condition in which thoughts, feelings, and behaviors do not necessarily reflect reality.¹ Psychosis, whether FEP or subsequent episodes, is a symptom rather than an illness (though it often occurs as part of an illness, such as schizophrenia, a mood disorder like postpartum psychosis, or a host of other disorders).² Signs that may indicate FEP can be grouped into cognitive, behavioral, and emotional categories.¹ Cognitive signs associated with FEP may include atypical thinking patterns, persistent and unusual beliefs, and difficulties with concentration or focus.¹ Behavioral signs may include trouble with self-care, social withdrawal, and subpar work performance.^1,2 Emotional signs may include intense emotional responses to environmental triggers and feeling uncomfortable around others.^1,2

Most experiences of psychosis consist of hallucinations or delusions.² Hallucinations involve sensing things that are not present, such as hearing voices or seeing distorted images no one else can hear or see.² Delusions occur when individuals have strong beliefs which are not rooted in reality nor do they reflect their cultural norms.² For example, someone with psychosis might erroneously believe they are the target of a massive conspiracy or an external entity is controlling them.

What risk factors are associated with FEP?

Approximately three out of 100 people develop psychosis during their lives.² While some instances of FEP mark the beginning of a chronic illness (e.g. schizophrenia or bipolar disorder with psychotic features), many episodes are relatively brief (less than one month) and isolated events (e.g. acute trauma-induced psychosis).^3–5 Risk factors that may lead to brief or chronic psychotic disorders include genetics, environmental stressors, and traumatic experiences.⁵ Substance or prescription drug use may also induce a brief episode of psychosis.⁵

The beginning months of military service tend to have the highest risk of FEP for service members. Genetic factors along with stress associated with adjustment to military service and customs can contribute to the expression of FEP symptoms.^6–8 Moreover, younger people (whether civilians or service members), particularly those under age 30, are at higher risk of experiencing psychotic disorders.^5,6,9–11 Prior or current marital status decreases the risk of developing schizophrenia, in particular.¹⁰ Overall incidence of FEP is similar between males and females.^10,11

How can military line leaders support service members with FEP?

First, line leaders can help reduce the stigma around FEP by speaking openly about mental health. Line leaders should encourage service members experiencing mental or behavioral difficulties to seek help as early as possible.

Second, line leaders should receive education on the warning signs of potential FEP among service members, including poor performance, subpar personal hygiene, social withdrawal, and difficulties with emotional regulation or concentration. Line leaders can encourage service members who may be experiencing FEP to schedule an appointment with the Military Health System for evaluation by a primary care or mental health professional.

Finally, leaders can take advantage of their supervisory role to reduce the Duration of Untreated Psychosis  for service members with FEP.¹² A short DUP, ideally within 12 weeks of symptom onset, is crucial to optimize symptomatic and functional recovery for individuals experiencing FEP.^1,13 Early treatment of FEP for service members is also likely to be more cost effective for the military.¹⁴ Fortunately, the military structure, particularly its expectations of accountability, close interactions between line leaders and service members, and easy access to covered health care, lends itself to shortening DUP for service members experiencing FEP.¹²

What does treatment look like?

Service members who may be experiencing FEP should receive medical care from a primary care or mental health provider as soon as possible. Treatment for FEP typically consists of medication, psychotherapy, and social and employment supports.⁵ A treatment model called Coordinated Specialty Care has demonstrated particular effectiveness in alleviating FEP symptoms.¹ In CSC, mental health care providers combine medication management, psychotherapy, family support and education, and education and employment support to curate a personalized, multimodal treatment for patients.¹  

Medical providers tailor FEP treatment plans to individual patients based on their medication tolerability, symptoms, functional impairment, and other unique circumstances.^5,15 Clinical guidelines recommend patients with FEP continue to take prescribed medication consistently for the duration directed by their medical provider even if it seems as if symptoms are improving.¹⁵ Patients should ask questions about their medications and discuss any concerns about side effects with their provider before they stop taking their medications as prescribed.

What is the prognosis for FEP?

Early and proactive treatment improves medical providers’ ability to assess the impact of risk factors on symptom onset and identify any associated diagnoses. Brief episodes of psychosis, such as those triggered by acute environmental stress or trauma, may never recur; however, affected individuals may be at higher risk for experiencing future episodes of psychosis in reaction to extreme stress.^3,4 Other first episodes of psychosis denote the beginning of a chronic illness such as schizophrenia, schizoaffective disorder, or bipolar disorder.⁵

For chronic mental illnesses, a combination of medication, psychotherapy, and psychosocial support can enhance resiliency, improve daily functioning, and manage symptoms.⁵ While persistent illnesses like schizophrenia and bipolar disorder may not be entirely cured, they can be effectively managed in concert with a health care team and social support system, thereby enabling affected service members to live full, functional lives.⁵

Helpful Resources

Military OneSource

Substance Abuse and Mental Health Services Administration (SAMHSA) Factsheet on FEP in Young Adults

Recovery After an Initial Schizophrenia Episode (RAISE)

References

1. Pennsylvania Department of Human Service. (n.d.). First-episode psychosis. Commonwealth of Pennsylvania. Retrieved January 10, 2023, https://www.dhs.pa.gov/Services/Mental-Health-In-PA/Pages/First-Episode-Psychosis.aspx
2. NAMI- National Alliance on Mental Illness; (n.d.). Psychosis. Retrieved January 10, 2022, https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Psychosis
3. Stephen, A., & Lui, F. (2022). Brief Psychotic Disorder. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK539912/
4. MedlinePlus. (2022). Brief psychotic disorder. National Library of Medicine. National Institutes of Health, U.S. Department of Health and Human Services. https://medlineplus.gov/ency/article/001529.htm
5. Substance Abuse and Mental Health Services Administration. (n.d.). Understanding A First Episode of Psychosis (HHS Publication No. (SMA) 16-5006). U.S. Department of Health and Human Services. Retrieved January 10, 2023, https://store.samhsa.gov/sites/default/files/d7/priv/sma16-5006.pdf
6. Stahlman, S. & Oetting, A. A. (2021). Update: Mental health disorders and mental health problems, active component, U.S. Armed Forces, 2016-2020. MSMR, 28(8), 2–9. http://www.ncbi.nlm.nih.gov/pubmed/34622649
7. Chasiropoulou, C., Siouti, N., Mougiakos, T., & Dimitrakopoulos, S. (2019). The diathesis-stress model in the emergence of major psychiatric disorders during military service. Psychiatriki. 30(4), 291–298. https://doi.org/10.22365/JPSYCH.2019.304.291
8. Dimitrakopoulos, S., Vitoratou, S., Mougiakos, T., Bogeas, N., Giotakos, O., Van Os, J., & Stefanis, N. C. (2018). Steinberg and Durell (1968) revisited: increased rates of First Episode Psychosis following military induction in Greek Army Recruits. Psychological medicine. 48(5), 728–736. https://doi.org/10.1017/S0033291717002276
9. Stahlman, S., & Oetting, A. A. (2018). Mental health disorders and mental health problems, active component, U.S. Armed Forces, 2007-2016. MSMR. 25(3), 2–11. https://pubmed.ncbi.nlm.nih.gov/29578729/
10. Costello, A. (2012). Mental health diagnoses during the year prior to schizophrenia, U.S. Armed Forces, 2001-2010. MSMR. 19(3), 10–13. https://pubmed.ncbi.nlm.nih.gov/22452716/
11. Cowan, D. N., Weber, N. S., Fisher, J. A., Bedno, S. A., & Niebuhr, D. W. (2011). Incidence of adult onset schizophrenic disorders in the US Military: Patterns by sex, race and age. Schizophrenia Research. 127(1–3), 235–240. https://doi.org/10.1016/J.SCHRES.2010.12.005
12. Hann, M. C., Caporaso, E., Loeffler, G., Cuellar, A., Herrington, L., Marrone, L., & Yoon, J. (2018). Early interventions in a US military FIRST episode psychosis program. Early Intervention in Psychiatry. 12(6), 1243–1249. https://doi.org/10.1111/EIP.12709
13. Horvitz-Lennon, M., Predmore, Z., Orr, P., Hanson, M., Hillestad, R., Durkin, M., El Khoury, A. C., & Mattke, S. (2020). The Predicted Long-Term Benefits of Ensuring Timely Treatment and Medication Adherence in Early Schizophrenia. Administration and Policy in Mental Health and Mental Health Services Research. 47(3), 357–365. https://pubmed.ncbi.nlm.nih.gov/31745735/
14. Aceituno, D., Vera, N., Prina, A. M., & McCrone, P. (2019). Cost-effectiveness of early intervention in psychosis: systematic review. The British Journal of Psychiatry. 215(1), 388–394. https://doi.org/10.1192/BJP.2018.298
15. Kikkert, M. J., Veling, W., de Haan, L., Begemann, M. J. H., de Koning, M., Consortium, H. and O., Sommer, I., de Haan, L., Veling, W., & van Os, J. (2022). Medication strategies in first episode psychosis patients: A survey among psychiatrists. Early Intervention in Psychiatry. 16(2), 139–146.https://pubmed.ncbi.nlm.nih.gov/33754470/

Asiya K. Kazi, MSPH is a contracted Senior Program Analyst in the Research Adoption section at the Psychological Health Center of Excellence. She has experience conducting research and evaluation for serious mental illnesses and substance use disorders, equitable mental healthcare delivery, and trauma-informed programs.