Advances and challenges in early intervention in psychosis
Authors: Ashok Malla, Jai Shah, Shalini Lal
Journal: World Psychiatry (2017)

Fusar-Poli et al1 offer a "state of the art" account of what is possible to do for prevention and early intervention in psychotic disorders. As they correctly point out, "indicated prevention" directed at individuals at an elevated clinical high risk for developing a psychotic disorder is at present the closest we can get to any level of prevention. However, the specificity of the clinical high risk state for psychotic disorders may depend partly on the service context within which such cases are defined and followed. While it may hold for clinical high risk patients in specialty clinics, the same may not be true in services for general psychiatric populations. This is suggested by two streams of evidence: first, childhood psychotic symptoms are not associated exclusively with the later onset of psychotic disorders2; second, the relationship between psychotic experiences and a variety of mental disorders has been shown to be bidirectional in a large international population based study3. Thus, psychotic disorders may not be the only consequence of early psychotic experiences, while clinical high risk for psychosis may be something other than a "diluted" form of psychosis4. An equally, if not more, important consideration is the inverse question that remains unaddressed: whether most first-episode psychosis cases emerge via a clinical high risk state. Initial reports suggest that less than half of cases have gone through such a state prior to onset of psychosis5, leaving a substantial proportion who may have experienced only non-psychotic symptoms. There are different lenses through which a staging model of psychosis is viewed: one that considers a first episode of psychosis as a progressive enrichment of an earlier "psychosis-like" state; and the other as a transdiagnostic model in which early stages have pluripotential outcomes6. Further, a staging model that relies almost exclusively on symptoms may miss some earlier stages where the presenting problems may be more social and functional7. The difficulties associated with identifying all or even the majority of individuals with clinical high risk for psychosis are well recognized. However, this challenge may be better addressed by structuring services around a transdiagnostic staging model. To facilitate a higher rate of penetration into the true prevalence across all clinical high risk states, the entrance point for mental health services needs to be made more easily accessible rather than being embedded in the current multi-layered systems. An enhanced primary care system with direct connection to speciality programs, such as early intervention services for psychosis, is more likely to achieve a higher yield of cases at both at-risk as well as first-episode psychosis stages, aided by the use of digital and mobile technologies favoured by young people. As the authors suggest, selective intervention for clinical high risk subjects may promote better outcome for first-episode psychosis, beyond delaying or preventing psychosis through better service engagement. On the other hand, there is some evidence that individuals with clinical high risk states who develop psychosis despite interventions known to reduce conversion to psychosis may, in fact, have a worse course and outcome8. Such variation in outcome will also depend on whether the clinical high risk state is ultimately found to be a common phase en route to a first episode psychosis: if not, then interventions aimed at those states, however effective at the individual level, will ultimately have limited ability to improve outcomes for the first-episode psychosis population as a whole. The authors also quite correctly emphasize the importance of preventing further decline following treatment of first-episode psychosis. However, an exclusive emphasis on relapse to gauge clinical outcomes may not be adequate, for several reasons, including variation in the definition of what constitutes a relapse, reliance on hospitalization as a proxy for relapse and, most importantly, variation in the length of a relapse. It may be better to monitor and sustain longer periods of remission of both positive and negative symptoms, given the consensus on an operational definition of remission9 and the very high proportion of variance in functional outcome explained by the length of remission10. While earlier use of long-acting injectable antipsychotic medications, as suggested by the authors, may improve chances of symptom remission, their use within the context of multi-component psychosocial interventions provided in early intervention services may add further benefits. Despite this, nearly half of fully remitted patients may not achieve a satisfactory functional outcome11, due to several reasons, including persistent negative symptoms, untreated comorbidity (e.g., social phobia), substance abuse, unstable housing and self-stigmatization. These impeding factors are likely to require targeted psychological interventions. For example, for negative symptoms, pharmacological interventions are likely to have limited effect, while several specific psychological and psychosocial interventions are likely to be more effective12. Two other considerations may facilitate improvement of outcomes in first-episode psychosis and in clinical high risk states. A greater emphasis on patient and family perspectives and processes involved in facilitating recovery is needed to improve outcome. Further, in the current environment, digital technologies are being increasingly investigated for additional benefits to promote recovery and prevent relapse following treatment of a first episode of psychosis. Last, but not least, the enormous global burden of psychosis, that the authors quite rightly refer to, will need a global effort that involves understanding of suitable models of care for populations that differ on culture, economy, geography and politics. To summarize, early interventions for psychosis may be best conceptualized as comprising two components, one attached closer to an enhanced primary care mental health service designed for this age group and a second of more specialized care for both at-risk states and full fledged serious mental disorders, such as psychoses. The former would provide an entry point for those at risk for not only psychosis but also other moderate to severe mental disorders, while the latter would assure a state-of-the-art multiple component treatment framework with established evidence of effectiveness. Further research is needed to identify methods that would assist in matching patients to appropriate intensity and length of service based on the stage of illness. Ashok Malla1, Jai Shah1,2, Shalini Lal3 1Department of Psychiatry, McGill University, Montreal, QC, Canada; 2Douglas Mental Health University Institute, Montreal, QC, Canada; 3School of Rehabilitation, University of Montreal and University of Montreal's Hospital Research Center, Montreal, QC, Canada