An international response to improving outcomes for first‐episode psychosis is warranted, but more needs to be done to make it happen
Authors: Sudipto Chatterjee
Journal: World Psychiatry (2017)

Fusar-Poli et al1 propose a staging model for first episode of non-affective psychosis and put together an impressive summary of the current state of evidence in relation to interventions matched to these stages. They also highlight the effectiveness and limitations of current prevention strategies for people at risk of developing psychosis, outline some of key issues in relation to improving interventions for people with an overt episode of psychosis, and flag important risk factors that influence their outcomes. Finally, they stress upon the need to develop coordinated specialty programs globally that are integrated within national health systems. However, as they point out, the current evidence does not suggest that primary prevention strategies have any reliable impact on attenuating the longer-term course of the illness, even though they positively impact some important treatment-related outcomes. What is even more concerning is the limited uptake of screening, detection and referral to specialist services of people with emergent psychosis (stage 1c) in existing secondary services, where such strategies might be the most effective. On the other hand, the evidence base around the effectiveness of early engagement and treatment with people with an overt psychotic episode (stage 2) through multi-component interventions is more robust in terms of reducing the duration of untreated psychosis and improving treatment-related variables and functional outcome for both the person and caregivers. However, these interventions again do not seem to reduce the chance of relapse and thus a progression into stage 3. While strategies like early initiation of long-acting injectable antipsychotics, reduction of illicit substance abuse and a longer duration of engagement with specialist services can potentially improve outcomes, their impact on the longer-term course of the illness continues to be limited. Any disease staging process is based on the assumption that the defining variable(s) chosen to measure progression of the illness are closely linked to the underlying pathophysiology and strongly predictive of outcomes. As the authors point out, neither of these conditions is satisfied in the case of first-episode psychosis, where heterogeneity between and within the stages is common. The absence of reliable neurobiological measures of psychosis is a critical gap in developing targeted stage-specific interventions and, till these are available, the staging outlined in Fusar-Poli et al's paper should be considered as provisional in nature. In the short term, the staging process can be progressively refined by future research that specifically examines potential neurobiological mechanisms underlying the functional outcomes, an explicit focus on the elucidation of more robust moderating and mediating variables, and efforts to include population-based cohorts to reduce selection bias that limit the generalizability of findings. It needs to be emphasized that the evidence presented in support of the staging process and matched interventions is derived from selected cohorts receiving dedicated treatments in high-income settings, where substantial investments have been made to make specialist first-episode psychosis services available. Thus, the essential precondition in making comprehensive, stage-specific, matched interventions more widely available is the presence of a well-functioning health system that can provide accessible, affordable, comprehensive and continued care. Globally, the overwhelming majority of people who experience a first episode of psychosis live in low- and middle-income countries and, in many of them, community-based mental health systems are either non-existent or rudimentary2. Thus, the majority of such persons are unlikely to receive any treatments; for example, the recent national mental health survey in India has estimated that the treatment gap for people with a current diagnosis of psychosis is more than 75%3. In such situations, it is extremely unlikely that rolling out resource intensive and specialist driven interventions for people at clinical high risk for psychosis will be feasible or become a national health priority in the face of scarce human and financial resources. A more realistic option might be to develop locally feasible and culturally appropriate methods for the early identification and treatment of people with a first episode of psychosis (stage 2 onwards) through a combination of wide community engagement methods and task sharing with other trained and supervised non-specialist health workers and community volunteers. There is no doubt that, given the enormous unmet need and therapeutic potential of services for people with a first episode of psychosis, there is an urgent need to develop and evaluate adaptations and innovations that are feasible, acceptable and cost-effective in low- and middle-income country settings. The ongoing Jan Man Swasth (People's Mental Health) program in India shows that early intervention is feasible in rural Indian settings by adopting a three pronged approach: firstly, through intensive community engagement using culturally adapted methods; secondly, through the availability of trained accredited social health activists who are embedded in the local community as the first point of contact; and third, through effective linkages with community-based treatment teams which provide need-based comprehensive treatments. Making services for first-episode psychosis more widely available beyond high-income country settings is necessary but challenging, and an area where dedicated research attention is warranted as a matter of priority. Sudipto Chatterjee National Institute of Advanced Studies, Bangalore, India