Early detection and intervention for people with psychosis: getting to the bottom line.

T he development of new medications, the availability of community-based treatment, and an attitudinal shift toward recovery have improved services for people with schizophrenia and other psychotic disorders. But these disorders remain pervasive conditions, often affecting many aspects, if not the whole fabric, of a person’s life. And because the disorders are widely prevalent and typically persist for decades, their global burden of disease is high (Whiteford et al., 2015). Unfortunately, knowledge about the etiopathology of schizophrenia and other psychotic disorders has unfolded only slowly. It was widely assumed that the application of recently developed molecular techniques would result in an increased understanding of the disease process and the identification of major genes that would inform diagnosis and treatment. Instead, a recent study found that there are more than 100 genetic variants of small effect that contribute to a portion of disease risk and that none has been shown to be specific to schizophrenia (Schizophrenia Working Group, 2014). In addition, psychological theories of schizophrenia etiology have been debunked, and environmental factors have not yet led to treatments that can be put into routine clinical practice. But we cannot wait to develop new approaches and to improve the lives of persons living with schizophrenia and other psychotic disorders. There is now a consensus that if we can identify people early in the course of the illness, or even before the illness starts, there will be a better chance to improve outcomes. If we can identify people who are going to become psychotic in the future, we can offer treatment that will forestall, if not prevent, illness and disability. If we can discover etiological pathways that contribute to disease risk, we will be able to develop novel treatment approaches that complement existing medications. If we cannot cure schizophrenia, at least we can improve the quality of life and lower the rate of premature deaths. There is now an imperative to do so. The articles in this special issue bring together some recent developments in the field of early detection and intervention for people with psychosis. The issue includes 13 articles by some of the preeminent researchers in this rapidly evolving field. In the US, research on the topic has taken its cue from investigators in Australia, Canada, England, Denmark, and other countries, some of whose work is represented here. The issue includes five articles focused primarily on the prodrome or the prediction of psychosis, seven that are focused on the treatment or outcome of first-episode psychosis, and one on immunologic-based medication treatments. Among the contributions are original research reports, review articles, and personal commentaries. McGorry, a pioneer in early intervention research and practice, provides a personal account of the field's history over the past 30 years (McGorry, 2015). McGorry is critical of most current treatment for serious mental illness, noting “the soft bigotry of low expectations” and the “palliative mindset of traditional mental health care. ” Motivated to improve the system, McGorry describes how his work progressed from the initiation of a specialized first-episode unit in 1984 to a worldwide movement and to his current vision for the wider application of early intervention beyond psychosis to all mental disorders. There has been much cross-fertilization between McGorry and other leading researchers, including McGlashan, who also has an article in this issue (McGlashan, 2015). Additional contributions are focused on the prodrome or prediction of psychosis. The article by Weber and colleagues presents intriguing findings from a unique data set, persons in the US military who developed schizophrenia and bipolar disorder during their military enlistment (Weber et al., 2015). What makes these data so extraordinary is the availability of archived blood samples that were obtained months or years before the onset of psychosis and the availability of a carefully matched comparison group. These samples are a unique resource toward the goal of identifying pre-onset biomarkers of serious mental illness. The investigators found that levels of pentraxin 3, a marker of innate immunity, were lower in the individuals who went on to develop schizophrenia than in the matched controls. This finding adds to the growing evidence identifying innate immunity and other