搜索结果：Early intervention in psychiatry

Psychotic disorders and particularly schizophrenia are serious and sometimes fatal illnesses which typically emerge during the sensitive developmental period of adolescence and emerging adulthood 1. For over a century, a corrosive blend of pessimism, stigma and neglect have confined therapeutic efforts to delayed and inconsistent palliative care. Much of this can be attributed to the conceptual error underpinning the concept of schizophrenia, namely that a true disorder could be validly defined by its (poor) outcome. This error was, in turn, a legacy of the 19th century degeneration theory, which has been allowed to influence the field well beyond its use-by date 2. Although Kraepelin himself and some of his contemporaries ultimately recognized the fallacy, his dichotomy (between dementia praecox and manic depressive insanity) has withstood several challenges and has been strongly reinforced with the advent of operational diagnostic systems. This has not only hampered neurobiological research, but has caused widespread iatrogenic harm and inhibited early diagnosis because of an exaggerated fear of the expected outcome. Until recently, apart from transient and illusory optimism generated by the mental hygiene movement in the 1920s, early intervention for psychotic disorders has been the furthest thing from the minds of clinicians and researchers. Ironically, however, since the early 1990s, this hitherto barren landscape has seen the growth of an increasingly rich harvest of evidence, and widespread national and international efforts for reform in services and treatment approaches, setting the scene for more serious efforts in early intervention in other mental disorders 3–5. Building on seminal research on first episode psychosis from the 1980s 6–8, frontline early psychosis clinical services were established, first in Melbourne 9 and soon after in many key locations in the UK, Europe, North America and Asia 10. There are now hundreds of early intervention programs worldwide, of varying intensity and duration, which focus on the special needs of young people and their families. International clinical practice guidelines and a consensus statement have been published 11 and clinical practice guidelines for the treatment of schizophrenia now typically have a major section on early psychosis 12,13. The International Early Psychosis Association (www.iepa.org.au), an international organization which seeks to improve knowledge, clinical care and service reform in early psychosis, has been in existence for over ten years, led by a highly collegial leadership group of clinicians and researchers. This association has over 3000 members from over 60 different countries, and by 2008 will have held six international conferences, stimulating and capturing a large volume of research and experience. In recent months, responding to the widespread international momentum, the US National Institute of Mental Health has announced a large new funding initiative to study and promote the development of better services for patients with first episode psychosis (www.nimh.nih.gov). The advent of preventive thinking has required a shift in the way schizophrenia and other psychotic disorders are viewed. Rather than seeing them as having inevitably poor prognoses with deterioration in social and functional outcome as the norm, more recent thinking backed up by evidence from large international studies 14–25 views the course of these disorders as much more fluid and malleable. Examination of risk factors which can influence outcome has revealed that many of these may be reversible. For example, disruption of peer and family networks and vocational drop-out commonly occur around and even before the onset of a first psychotic episode. Attention to these areas as part of treatment has the potential to limit or repair the damage. Comorbid depression, substance use, personality dysfunction and post-traumatic stress disorder (PTSD) are all factors which may influence outcome in a person with first episode psychosis. Again, early and vigorous management of these problems can result in better outcomes 26. Early intervention is a potentially confusing term. Because there is no aetiopathological basis for diagnosing psychotic disorders, they can only be diagnosed by symptoms or combinations of symptoms. In addition, we have no known malleable causal risk factors which predict onset of psychotic disorder with any specificity. Thus, it seems that primary prevention is currently out of our reach. Early intervention, therefore, means early secondary prevention. In keeping with the clinical staging model 27 articulated below, early intervention in psychosis can be defined as comprising three foci or stages: ultra-high risk, first episode, and the recovery or critical period. The principal reason for making such distinctions relates to the underlying risk of chronicity, and specifically the timing and duration of prescription of antipsychotic medication, since psychosocial interventions are needed at all stages, though these interventions too vary by stage. Clinicians and researchers have debated whether to focus on the preventive target of schizophrenia or of psychotic disorders more broadly. There are several reasons for stepping out of the current diagnostic silos and preferring a relatively broad target. As described above, schizophrenia is conceived and defined in part as an outcome as much as a diagnosis. While it is very stable once applied 28–31, it is intrinsically difficult to apply until the patient has been ill for a prolonged period of time. Within a sample of ultra-high risk cases (already defined in order to preferentially predict transition to non-affective psychosis), only 75% of those who go on to develop a first episode psychosis will progress to a schizophrenia diagnosis 32. So, the false positive rate is higher for schizophrenia than for first episode psychosis. Even within a first episode psychosis sample, only 30–40% will meet criteria for schizophrenia, and this percentage will increase over time with additional diagnostic flux. Thus, some cases of first episode psychosis which do not meet criteria for schizophrenia can be seen as being at risk for this in the future 33. Schizophrenia, therefore, is to some extent a more distal target than psychosis, which is a better and broader initial waystation for critical treatment decisions. An even earlier and broader point for intervention is the ultra-high risk clinical stage, where there is a need for care prior to the positive psychotic symptoms having become severe and sustained. In addition, due to fear and stigma derived from the notion of intrinsic poor prognosis, clinicians are reluctant to use the label “schizophrenia” early on anyway, justifiably concerned about iatrogenic effects on hope and the potential for recovery 34. This has led some countries, such as Japan, to change their diagnostic terminology and eschew the word “schizophrenia” 35. Our preferred alternative is to retain it for the time being, as one subtype of psychotic disorder outcome, admittedly a major one, among a small range of distal targets. Psychosis itself is a variable syndrome, defined by the presence of positive psychotic symptoms, especially delusions and hallucinations, and typically features one or many comorbidities, including negative symptoms, mood syndromes, personality disorders, substance use disorders, medical diseases and PTSD. The relative prominence of the positive symptoms and comorbidities varies, and this leads to a more hetero-geneous group of patients. As a consequence of this, a broader range of clinical skills will be required in early psychosis programs than in narrower schizophrenia programs. Some have argued that the schizophrenia focus allows the other psychotic disorders, especially psychotic mood disorders and psychoses associated with certain personality disorders and PTSD, to be treated in more appropriate settings. However, provided there is a flexible attitude and a broad range of clinical expertise available, both groups of patients benefit more from this broad, early, and inclusive focus on the spectrum of psychosis. It provides a good balance between specialization and addressing common needs, and also facilitates both clinical and aetiological research, which increasingly needs to transcend traditional diagnostic barriers. Many of the problems of categorical diagnosis flow from a telescoping of syndromes and stages of illness which conceals and distorts the natural ebb and flow of illness, remission and progression. In addition to augmenting categorical approaches with symptom dimensions, consideration needs to be given to the dimensions of time, severity, persistence and recurrence. The notion of staging can be borrowed and adapted from mainstream medicine to assist us here. A clinical staging model provides a heuristic framework allowing the development and evaluation of broad and specific interventions as well as the study of the variables and processes underlying the evolution of psychiatric disorder 27,36. Clinical staging is simply a more refined form of diagnosis 37,38. Its value is recognized in the treatment of malignancies, where quality of life and survival rely on the earliest possible delivery of effective interventions. However, it also has applicability in a diverse range of diseases. Clinical staging differs from conventional diagnostic practice in that it defines the extent of progression of disease at a particular point in time, and where a person lies currently along the continuum of the course of illness 36. The differentiation of early and milder clinical phenomena from those that accompany illness extension, progression and chronicity lies at the heart of the concept. It enables the clinician to select treatments relevant to earlier stages, and assumes that such interventions will be both more effective and less harmful than treatments delivered later in the course. While staging links treatment selection and prediction, its role in the former is more crucial than in the latter, particularly since early successful treatment may change the prognosis and thus prevent progression to subsequent stages. In addition to guiding treatment selection, a staging framework, which moves beyond the current diagnostic silos to encompass a broader range of clinical phenotypes, and which at the same time introduces subtypes along a longitudinal dimension, has the potential to organize endophenotypic data in a more coherent and 36. In other medical clinical stages are defined by the of progression and of illness in the which in with This a to as well as the or extent of the disease In clinical this could not only a clinical but a of extent or progression. in addition to the severity, persistence and of symptoms, volume and the social of the disorder the social and could also be the a model could the clinical stages to progression of disease a framework for the evaluation of interventions. The key positive outcomes are prevention of progression to more stages, or to an earlier stage. This an of those broad and risk and factors which influence progression from one to the we need to the relative of these risk factors and which of them may be to current interventions. While some factors may several or all may be for substance or stress may be especially harmful in onset of the first episode of illness, be less and these where variables such as substance psychosocial and social may with and other risk factors an aetiological over a century of research with traditional diagnostic of psychosis and severe mood disorders has to these to any A clinical staging which allows the of to of illness to be may to the of current or defined clinical processes from and and to be better and In psychotic disorders, an early is known to one in which much of the psychosocial is known to occur This earliest in be the the of the psychotic stage. However, since we can only apply the with the psychotic such as the or have been to that psychosis is not and that false positive cases also This is the earliest point at which preventive interventions for psychosis can be conceived The in such a is to the clinical for earliest intervention and for which the between and a of clinical and other need to be defined which a at risk for psychotic This is a and the key have been in many recent to the diagnosis of schizophrenia in the in the century in and though their that they on A operational of a or mental which could be to a risk of psychosis within a and in the early This has the of the field and has been the focus of much subsequent research, on prediction, treatment and neurobiological criteria do predict an group for early transition to psychosis to a relative risk of to the rate of psychotic disorders in the However, there is a false positive rate of though they typically are or out to be true for other disorders, and While the for psychosis can be by the use of key variables such as risk, depression, functional and substance use this is of due to the This means that the positive value the and percentage of cases that can So, the sample is one is on but cases who do go on to develop the disorder are due to the narrower focus that cases of first episode psychosis are by There have been a of clinical of relatively small sample both as preventive treatment for ultra-high risk patients that and may prevent or at the onset of psychotic disorder and A of clinical has been with for a range of psychosocial and including and However, young people in the some that patients be to and potentially harmful This has in the US in particular around this of This in has led to being preferred the traditional the that this thinking have allowed the same treatments that could not be of within a to be label in a widespread and in these the a since the natural course may be by studies that use of antipsychotic seems to be common in clinical in the by with delayed and treatment of first episode and psychotic disorders Clinical data is crucial to the and of of treatment in a new clinical focus and for an This is the to on widespread and potentially harmful and use of antipsychotic in The or ultra-high risk field in clinical since we do not which treatments will be and to and in which or or data can be in the and in the of a large clinical with an than and a intervention to which to can be can that and and such as and are to be but their use in research be within study In the the international clinical practice guidelines on early psychosis which a to the use of antipsychotic and more use of psychosocial be This to treatment of ultra-high risk is even more as it has been that the of early transition to first episode psychosis have been in the more with a much higher rate of being these This may be due to earlier of ultra-high risk or of interventions provided This in transition rate and over treatment in the ultra-high risk group has led to about of and intervention with these patients defined by the ultra-high risk criteria for first episode psychosis are at risk not only for schizophrenia or psychosis but for other mental outcomes may need to an even broader initial clinical with a range of possible or target we have our clinical and research with the development of a broader and more of clinical care for those in the of risk for all of mental disorders and with the of a clinical staging model for mood and disorders This enables a to to that the transition in ultra-high risk and the false positive rate can be in future clinical and that other syndromes and remission and can be us to beyond some of the to early diagnosis and namely the potential problems with the of and of specificity. As we this the problems with our and the need to the more The a therapeutic focus on the period after the onset of psychosis known as episode This is the period before psychosis is and the period after the or can be even in even psychosis is the of effective treatment may be The is to this duration of psychosis the intervention are and of and psychosocial interventions at and functional recovery and the prevention of are delivered during the early and of The the of and treatment in first episode psychosis seems to have been the of some key and recent longitudinal studies have now that is both a and risk for poor outcome. The Early and of Psychosis study in has the possible that leads to early in risk and of illness at initial treatment and in of negative symptoms and social The between and outcome is being over many of However, these studies do though being a malleable risk for a relatively of outcome the of treatment and quality during the early of There is an to the of care of the first psychotic episode. This is in the International Clinical for Early Psychosis published in the growth in research in this has This has led to the of the The large has that in the treatment of first episode and disorders, or have some While patients well to both and with no and were for This true even with very While the and were the of the of the with those of the Clinical of study in schizophrenia, where no were for outcome The data the of the International Clinical in Early Psychosis which the use of as first because of better crucial in first episode and risk for However, some have a particularly risk of and and these need to be and A recent however, that is a in the first of for first episode patients on both and with the key being the rate at which it treatments in early psychosis have been and there are positive to the value of in and and functional recovery there has been to the that in do by to a to This has led to an focus on the need to social recovery especially and vocational the of effective psychosocial interventions with There is also an focus on to limit the of that is as illness has in the of evidence but also the of early diagnosis. we we have effective interventions in psychosis, it is to that delayed treatment is being a is In the the key of intervention are and are as the data from and other studies have both are in it is possible to very of of a also result in a less and of care and patients to be a of positive symptoms or being required to or highly service systems. be in all and a of all mental systems. In of the specific of first episode psychosis intervention, a of have that in are for first episode patients where and are at a though some may be out on these in many patients. The recent study is especially The of new and needs to be as well as that of such as and and vocational are the key psychosocial interventions in early psychosis and need to be much more and treatment for the of patients is interventions are also an of even though the evidence is not This the critical early beyond the first episode, which can be as the critical period in this are the management of effective and the use of effective psychosocial interventions to the development of and of concept is now for these However, there a large in between and is available, even in and in the and the first episode, we that the first are crucial in setting the for recovery and outcome. This is the period of risk for and as well as with the major developmental challenges of a stable peer vocational and It that a of care on young people and on this of illness is required to the of of appropriate to family and vocational recovery and the evidence from and studies strongly the value of early psychosis programs in outcome in the these programs are only provided for years, there is also evidence that some of the are for a at early psychosis care needs to be provided for a up to in many cases The evidence that care provides outcomes in the to to care While this may be to meet the such evidence, with and has been to mental and service in hundreds of locations to and this The have only of this with a treatment model being the Even the are positive for the first of care. It seems for a at these are to be the early psychosis model be for up to this illness and may be in a much percentage of needs may be well by more traditional mental services for This may be a much better point to care. The of reform is typically in care. While early intervention in psychosis has progress in recent years, in many Many and have no progress at and even those which have have only have on this and some of the reasons for it can be seen as a blend of care and in which evidence is only one of a range of from a and the as and to flow of evidence This has been as since and and the of change and reform are other key on is a as well as a of reform and the by setting and by the once evidence is can be as a to and reform in a that be in other of medicine In better this it is to on and reform in care of is a major in all from to The study of of has a in the social Many have and to and promote this in care There are many factors but there are also of and care which influence the we of the There be the be with the and needs of those It be or of in the of it is that be adapted and in to there are several groups of in the of The are the group and the and are who form national and international networks or and they in these may be of as in a The early are a group of who on the and with one are to a range of new and have the and risk to new they are by the the early who are more in their focus and more risk The early to the early for about is to The the are even more and to the early an only it to be the new we have the members of a point of is the be this their since they point to the need to retain some of current and prior However, they are also the and and of evidence before the evidence for are applied to the which in mental at is typically less than the new This is and by the of to and after of the progress in early intervention, the have been in the early intervention While medicine is by the for and potentially and in of change have been to the to change which is and in the of the There is about where the of lies in such and other than evidence influence especially where have such as care and early it is that the relative value of early diagnosis and palliative which is where has out that the of has a point around once the early have in an the are to to as This is a that can be by several by example, and early with and time, making the of early highly and as a form of than of Many of the to early intervention are the same which progress in mental more as in the on Mental Health pessimism, the that the and a to and need to the of and treated mental A key which is to be recognized is that mental disorders are the diseases of the young mental disorders substance use and personality disorders have their onset and in adolescence and early A broader focus for early intervention many of the order by the early psychosis reform such as diagnostic a need for stigma and and be more effective in for and reform in mental This is in and and is in a of other countries, along the of the described It currently a and for early in to

Family members play an important role in supporting their loved ones with first episode psychosis (FEP), but few have access to interventions demonstrated to support them in this endeavour. Psychosis REACH (Recovery by Enabling Adult Carers at Home; p-REACH) is a family intervention for psychosis (FIp), delivered directly to families by clinicians and peers, that provides both psychoeducation and Cognitive Behavioural Therapy for psychosis (CBT-p) informed skills to family carers. This study aimed to qualitatively explore family participants' experiences of receiving the p-REACH intervention and assess its feasibility and acceptability within an early psychosis service. Following the p-REACH intervention, all participants were invited to partake in qualitative interviews and analysed using a Reflexive Thematic Analysis approach. Family carers reported positive experiences with the intervention. Key themes indicated that it helped build (1) internal resources, as participants valued increasing their knowledge and understanding of psychosis and learning skills to support themselves and their loved ones-leading to greater confidence and (2) external resources, as the group-based, peer-supported format enhanced their sense of connection with their loved ones and with other families. This study demonstrates that the intervention was both feasible and acceptable to participants in an early psychosis setting. It contributes to the growing body of evidence supporting the positive impact of family interventions in psychosis, specifically the teaching of CBTp skills to caregivers of those with early psychosis.

This study aimed to evaluate the quality of GPT-4-generated responses to commonly asked psychosis-related psychoeducational questions from patients, caregivers and relatives in a first-episode psychosis programme. Evaluation focused on accuracy, clarity, inclusivity, completeness, clinical utility and overall quality. This cross-sectional study employed a qualitative evaluation design. GPT-4, accessed via the ChatGPT interface, generated responses to 20 psychosis-related psychoeducational questions. These questions were developed through iterative discussion and consensus among clinicians working in a first-episode psychosis treatment programme, informed by commonly encountered questions from patients, caregivers and relatives in clinical practice and are provided in Appendix A. The generated responses were subsequently evaluated for their potential clinical applicability. ChatGPT was presented with 20 psychoeducational questions derived from real-world clinical interactions with patients, caregivers and relatives. Two experts in psychosis independently assessed the responses using a structured six-domain rubric: accuracy (1-3), clarity (1-3), inclusivity (1-3), completeness (0-1), clinical utility (1-5) and overall quality (1-4), where lower scores indicate poorer performance and higher scores indicate stronger performance across domains. Discrepancies in ratings were resolved through discussion and consensus. Using a structured evaluation rubric, LLM-generated responses were assessed across accuracy, clarity, inclusivity, completeness, clinical utility and overall quality. Responses were generally coherent, well-organized and readable across all 20 psychoeducational questions. Performance was strongest in accuracy (M ± SD = 2.88 ± 0.22), clarity (2.93 ± 0.18), completeness (0.93 ± 0.18) and clinical utility (4.35 ± 0.52), indicating that responses were largely correct, understandable and clinically relevant. Inclusivity scores were comparatively lower (2.30 ± 0.41). A descriptive linguistic analysis showed that responses were written at a relatively high Flesch-Kincaid Grade Level (FKGL) (mean = 15.59 ± 1.59), indicating increased reading complexity. Although responses addressed core aspects of the questions, some lacked sufficient nuance for complex or individualized clinical scenarios. GPT-4, as an example of a large language model (LLM), may have a limited adjunctive role in supporting psychoeducation for psychosis when used within structured and clinician-guided contexts. Although responses were generally readable and clinically relevant, their complexity and variability in inclusivity highlight potential limitations in accessibility for diverse patient populations, and cautious use is warranted given the ongoing concerns regarding accuracy, safety and real-world implementation. Further research is needed before broader clinical integration can be recommended.

Despite the efficacy of antipsychotics, medication non-adherence remains common among individuals with a First Episode of Psychosis (FEP). A systematic review was conducted in accordance with the PRISMA 2020 guidelines to summarise the existing evidence base regarding the reasons, attitudes, and beliefs underlying both medication non-adherence and adherence in FEP, as well as psychosocial interventions designed to promote medication adherence in psychosis. Seventy-six studies were eligible for inclusion. Nineteen reasons for medication non-adherence in FEP were identified, which were synthesised into 10 overarching themes: Insight and Perceived Need, Autonomy and Control, Trust and the Therapeutic Relationship, Cultural and Spiritual Factors, Side Effects and Perceived Inefficacy, Social and Family Influences, Stigma, Practical Barriers, Substance Use and Symptom-Driven Factors. Facilitators of adherence included illness insight, motivation to recover and fear of relapse, trust in clinicians, acceptance of the bio-psychosocial model, experiencing positive treatment outcomes, use of digital reminders and social support. A range of psychosocial interventions demonstrated effectiveness for enhancing medication adherence in psychosis. This included Cognitive Behaviour Therapy, psychoeducation, motivational interviewing, adherence therapy, assertive community treatment, and adherence-focused psychosocial skills training, particularly when delivered in combination. Medication non-adherence in FEP is shaped by a complex interplay of personal, relational, cognitive, cultural and systemic influences. Addressing these factors in the design and delivery of psychosocial interventions may serve to improve medication adherence outcomes in early psychosis. To support clinical application, this review also provides a fictitious clinician-client transcript along with Socratic questions and CBT strategies to assist clinicians in assessing and promoting medication adherence in FEP.

Despite the high prevalence of comorbid cannabis use at first onset of psychotic symptoms, high transition rates from cannabis-induced psychosis to schizophreniform psychoses and bipolar disorder, and evidence of cannabis use as a risk factor in developing primary psychosis, only a few studies have addressed the difficulties in differential diagnosis focusing on the early stages of the disease. The present study is the first to date to examine clinical and sociodemographic characteristics of individuals with early psychosis, comparing cannabis-induced psychotic disorder (CIPD), non-substance-induced psychotic disorder with concurrent cannabis use (NSIPD+C), and non-substance-induced psychotic disorder (NSIPD). A retrospective chart review of patients aged 18-35 with early psychosis who received inpatient treatment at FRITZ Early Intervention Center between December 2016 and September 2021 was conducted. Sociodemographic characteristics included age, biological sex, family history of psychiatric illness, migration background, living status, education/work status. Clinical characteristics included insight into illness, duration of untreated psychosis (DUP), social functioning, pathway to treatment, treatment motivation, treatment recommendation, and type of discharge. Of 509 participants, 42.6% had a diagnosis of NSIPD, 33.3% of CIPD, 7% of NSIPD+C. NSIPD had a significantly longer treatment duration compared to CIPD, a higher treatment motivation, and a higher discharge in accordance with clinicians' recommendation compared to both CIPD and NSIPD+C. No significant group differences were found in sociodemographic characteristics, DUP, and functioning scores. The examined sociodemographic parameters as well as level of functioning and DUP do not aid in the differential diagnostic classification when cannabis use and psychotic symptoms occur simultaneously. The absence of differences in DUP across diagnoses may reflect the efficacy of low-threshold access provided by FRITZ and further supports the need for comprehensive implementation of early intervention services.

Psychosis is increasingly recognised as a systemic disorder characterised by interrelated metabolic dysfunction, chronic low-grade inflammation and sedentary lifestyles. Physical exercise is a promising intervention to address this triad. This pilot study investigated the feasibility and systemic impact of a pragmatic exercise intervention within a first-episode psychosis (FEP) service. We conducted a parallel-group randomised controlled trial involving people with FEP, comparing an 8-week structured aerobic and resistance training programme to Treatment As Usual. We assessed feasibility of the intervention and assessments by measuring recruitment, attendance, retention, and engagement with assessments. Exploratory outcome measures spanned physical fitness, metabolic health, psychometric scales and the Cambridge Neuropsychological Test Automated Battery (CANTAB) cognitive battery. The study recruited 40 participants, 19 in the intervention and 21 in the control group. At baseline assessment, 23 of 38 had an elevated BMI and 24 of 35 had elevated cholesterol. Study retention was adequate, with only four participants (10%) lost to follow up. However, the assessment battery was poorly completed, highlighting its infeasibility. Fitness outcomes proved especially challenging, with between 11 and 13 participants (27.5% to 32.5%) completing both baseline and endpoint assessments. Of the 19 people recruited to the intervention arm, 7 (36.8%) attended less than half of the 8 sessions. Outcome data were limited by substantial missingness, with no consistent pattern of benefit or harm observed across domains. Implementing exercise within real-world FEP services is challenging as indicated by the attrition observed in our study. Future research should individualise exercise prescription and minimise participant assessment burden to mitigate attrition.

The staging model in psychiatry is heuristic and evolving, provoking debate and stimulating alternative views. This paper reviews major controversies in the field of staging and prevention of psychosis. We review the literature on the classification model, the continuum model and the dynamic systems model applied to psychiatry. Other controversies are stigmatisation of early detection, the prevention paradox and the interpretation of data on prevention of transition to psychosis. DSM classifications still lack validity. The continuum model supports preclinical stages but has no discrete conversions to different stages of illness. The emerging dynamic systems model builds on the interaction of symptoms eliciting networks of symptoms, while at the same time it explains sudden catastrophic shifts (transitions) between different states of equilibrium. Stigmatisation of early psychosis can be balanced against the benefits of early interventions. The prevention paradox states that only a minority of first episode cases arises from the high-risk group. However, there are many reasons to combine indicated prevention with population-based preventive interventions. A long-lasting controversy is on the interpretation of the research data. Several meta-analyses are reviewed on methodological issues. The staging model is adequate to conceptualise psychiatric disorders and the progress over time in more chronic stages. No one is suggesting that help-seeking patients with an ARMS should be denied access to psychosocial treatment and it is recommended and necessary to continue building age and stage specific services to treat them and continue with research into risk factors and helpful interventions.

Established standards and guidelines for early psychosis intervention (EPI) in British Columbia (BC) and across Canada define the intent and scope of individual EPI programs. EPI programs are a critical mental health service both in BC and internationally, providing a range of pharmacological, psychological, and social supports under one service. If EPI principles and practices are applied, positive outcomes are expected, including greater reduction of psychotic symptoms compared to standard treatment, improved treatment adherence, fewer recurrent episodes of psychosis, and greater client satisfaction. Low fidelity, or difficulty adhering to the principles associated with the EPI model, may jeopardize attaining these positive outcomes. Evaluation of program fidelity to established EPI practice standards and guidelines was conducted at 16 mental health service sites in BC that provide care to young adults with early psychosis. Fidelity assessment was performed via utilization of the EPI Fidelity Scale (EPI-FS). Based on the EPI-FS, two sites (12.5%) met criteria for high fidelity, nine (56.3%) attained moderate fidelity, three (18.8%) attained low fidelity, and two (12.5%) attained very low fidelity. Specialized EPI programs were linked to higher fidelity, while many generic mental health and substance use centres had difficulty following the EPI model. Identified weaknesses included provision of psychological therapy, family education, ongoing program evaluation, and supervision and mentorship for clinicians. Sites with sufficient resources and staff development opportunities had higher overall fidelity. These findings underscore the importance of equitable resource allocation and the need for specialized EPI services, especially in underserved areas in BC.

BACKGROUND: Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007. OBJECTIVES: To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption. MAIN RESULTS: We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment. AUTHORS' CONCLUSIONS: We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.

Substance use is common and developmentally normative among transition-age youth and linked to poor outcomes among individuals with early psychosis. Peer Support Specialists (PSSs) are increasingly part of early psychosis Coordinated Specialty Care (CSC). CSC team substance use-specific practices are lacking despite the prevalence of CSC client substance use. This study describes the development of a substance use practice approach for CSC PSSs. This study occurred within the 'Advancing Early Psychosis Intervention Network in Texas' (EPINET-TX), a university-affiliated Learning Health System with 15 community mental health providers and 29 CSC teams. A research team composed of a study coordinator with PSS experience, community mental health intervention researchers and a current CSC PSS leveraged EPINET-TX research findings, a literature review and expert consultation to design 'Peer Approaches to Substances for Early Psychosis Programs' (PAS-EPP). The team developed a conceptual model, practice principles and core practices and training materials. PAS-EPP has eight practice principles and four core practice domains. The PAS-EPP toolkit provides an adaptable, accessible harm reduction approach to substances for CSC PSSs intended to promote self-exploration of personal beliefs and biases, intentional sharing and team collaboration strategies and confidence building in capacity to explore and share information about substance use that is relevant to young people. PAS-EPP is a promising practice approach for CSC PSSs. Future evaluation of PAS-EPP will provide insight into its feasibility and impact.

Detection of psychiatric comorbidity is essential given its high burden and frequent under-recognition. The DSM-5 Level 1 Cross-Cutting Symptom Measure (DSM-XC) is a multidimensional screener designed to capture relevant psychopathological domains, yet its ability to detect comorbid conditions remains unclear. In this study, we evaluated the DSM-XC's capacity to screen additional psychiatric comorbidity in individuals with an existing psychiatric diagnosis. Cross-sectional data from 796 individuals aged 22 years (60.8% female) from the 1993 Pelotas birth cohort in Brazil were analysed. Participants were included if they met criteria for at least one of seven psychiatric diagnoses based on structured clinical interviews. Screening accuracy metrics were calculated for targeted DSM-XC domains in identifying secondary diagnoses (e.g., depression domain for major depressive disorder [MDD]), using standard and Youden-optimized thresholds. Non-targeted performance assessments (e.g., anxiety domain for MDD) were also performed. Additionally, all 13 domains and the total score were evaluated for detecting any comorbidity. For the targeted domain assessment, high sensitivity and negative predictive values were observed using original thresholds, supporting rule-out utility, but specificity and positive likelihood ratios were low. The application of optimized thresholds increased specificity, with positive likelihood ratios reaching ~2 across domains. Non-targeted domains frequently outperformed targeted domains. Good discrimination for detecting any comorbidity was achieved using the DSM-XC total score (AUC = 0.75), with a cutoff of ≥ 21 providing the best balance between sensitivity (0.71) and specificity (0.69) and acceptable likelihood ratios. DSM-XC domains are useful for excluding comorbidities but have limited confirmatory value. The total score provides a global indicator of comorbidity. These findings support the DSM-XC primarily as a rule-out transdiagnostic triage tool for improving comorbidity detection in community settings.

Early Intervention in Psychosis (EIP) services in England are commissioned to provide up to 3 years' support to people experiencing first episode psychosis, but the optimal duration remains debated. This qualitative study aimed to explore how decisions about EIP duration are made and experienced by multiple stakeholders. Qualitative longitudinal study comprising semi-structured interviews with EIP Service Users (SUs), carers, EIP practitioners, GPs, and mental health service commissioners; follow-up interviews with SUs 6-11 months later. Data were collected between September 2022 and September 2024 and informed by information power. Data were thematically analysed by a multidisciplinary team. Patient and carer involvement and engagement were integral to the study. The 3-year time limit of contact with EIP teams was thought to work well when SUs felt supported and ready for discharge, but constrained shared decision making when they did not. Some participants described early discharge before 3 years, either as a negotiated decision based on wellness and readiness to move on or as a consequence of poor engagement. Others reported extended care beyond 3 years in response to individual needs or delays in transfer to Community Mental Health Teams (CMHTs). This flexibility in duration varied across teams and trusts. Well-managed, relational care was viewed as key to effective discharge. Flexible, person-centred episodes of care and collaborative discharge planning, supported by effective coordination between EIP, primary care, and CMHTs, are essential to sustaining relational practice and ensuring smoother transitions.

Psychosis is a debilitating condition and prompt treatment is a key prognostic factor. Early intervention services aim to provide timely care, but co-occurring substance use disorders (SUDs) complicate treatment, leading to poorer outcomes. This study examined the clinical journey of individuals with SUD who were subsequently diagnosed with a psychotic disorder, focusing on the interval between diagnoses to understand this issue. Patient pathways were constructed using linked health data (2005-2022) from Western Australia for individuals aged ≥ 18 years with a diagnosis of SUD followed by a primary psychotic disorder. Service events across emergency departments (EDs), inpatient and community mental health services were analysed. Descriptive statistics and subgroup analyses examined variations based on the time between diagnoses, sex, remoteness and socioeconomic status. Analysis of 7568 patient pathways revealed a median diagnostic interval of 1.9 years. Initial SUD diagnoses occurred most frequently in inpatient settings (62%), whilst psychoses diagnoses were most common in EDs (46%). Common diagnostic pathways included inpatient to ED (28%) and inpatient to inpatient (24%). Subgroup analyses showed women had a 7-month longer diagnostic interval and six more mental health service events than men. Remoteness and socioeconomic disadvantage correlated with increased diagnosis in inpatient settings and decreased diagnosis in EDs. A significant delay between diagnoses is likely associated with poorer outcomes. Integrated service delivery, particularly between EDs and specialised mental health services, is important for early intervention. Patient demographics and geographic location influence diagnostic pathways, suggesting targeted interventions to improve access to prompt, appropriate care.

Experience-Based Co-design (EBCD) is a participatory action research technique aimed at enhancing the experiences of both service users and service providers within healthcare services. Hence, the aim was to develop strategies to improve the engagement of youth with mental health services being delivered in Chennai, India. We adopted a modified EBCD method involving three phases (data collection, designing strategies and implementation) spread across six stages. Starting from stage-1 interviews with service users and providers to identify factors that may lead young service users to disengage from treatment, followed by group interactions undertaken separately with service providers and users to pinpoint key areas for improvement. This also included a co-design process with all stakeholders, where solutions were refined using SMART criteria and rated on a scale of 1-5, with 1 being less prioritised and 5 being highly prioritised. The final stage involved a meeting with institution management to deliberate and decide on the plan for implementation of the generated solutions. Service users, providers, and stakeholders found key areas such as outpatient department (OPD) timings, continuity in MHP-client associations, awareness about medication and treatment processes, and the facilities, including the physical environment and refreshments provided for service users, were major reasons why patients disengaged from the treatment. In this study, service users, providers, and stakeholders prioritised touch points grouped under three major themes: (1) appointments, (2) facilities and (3) awareness. Despite some challenges, EBCD was successfully implemented at the Schizophrenia Research Foundation (SCARF) in the Youth Mental Health Department, Chennai, India. EBCD was a promising methodology for service improvement and empowering service users. It identified crucial areas for enhancement and empowered the service users by involving them in the decision-making process, ultimately contributing to improved engagement and satisfaction with mental health services.

CBT for psychosis (CBTp) is an evidence-based care standard and a core element of Canadian and United States (US) early intervention for psychosis (EIP) programs. Outside of early intervention programs, fewer than 1% of Canadian and US individuals experiencing psychosis have access to this intervention. However, no empirical investigations of CBTp availability in EIP programs exist in the peer-reviewed literature. We investigated CBTp availability and quality among Canadian and US EIP programs using a structured questionnaire distributed to team leaders via listservs. Across program respondents (Canada N = 28; US N = 48), all endorsed offering CBTp in some form (low-intensity, group-based and/or high intensity), yet few endorsed quality monitoring or ongoing supervision specific to CBTp. We report EIP program characteristics and determinants of clients being offered CBTp. Efforts and resources to enhance CBTp delivery, including quality assurance, are a vital part of enhancing access to CBTp in EIP programs.

Early-onset psychosis and anorexia nervosa, while traditionally conceptualised as distinct disorders, demonstrate significant clinical overlap, particularly during adolescence. This period of profound bodily and identity transformation is a critical window where both conditions can emerge, sometimes with complex, overlapping symptoms. However, existing explanatory frameworks often fail to account for this comorbidity, leaving a conceptual gap. This hypothesis paper proposes that anorexia nervosa, when emerging in the context of adolescent psychosis, functions as a 'negative delusion'. This is not a pathological belief involving the distortion of the symbolic body, but rather its erasure. Drawing on Lacanian psychoanalytic theory, we argue that this erasure stems from a shared structural failure in symbolic integration common to both psychosis and this form of anorexia. The hypothesis is built upon a Lacanian theoretical framework, utilising concepts such as the mirror stage, the paternal function (Name-of-the-Father), the symbolic body and jouissance. The argument is further elucidated through clinical vignettes that illustrate how self-starvation can serve as a defence against psychotic threats by negating the body's symbolic dimension within social and intersubjective meaning. This framework has significant implications for early diagnosis and intervention. Rather than proposing a new diagnostic subtype, it identifies a structural configuration-anorexia functioning as a 'negative delusion'-that may be operative in a subset of presentations at the intersection of psychosis and eating restriction. By reframing the comorbidity, this paper provides an original perspective on the intertwined failure of symbolic embodiment and its clinical consequences, outlining future research directions in phenomenology and neurobiology.

Early intervention in psychosis is associated with improved outcomes, yet prolonged duration of untreated psychosis remains a major barrier globally. Public health campaigns offer a promising strategy for promoting early detection and help-seeking, although findings on their effectiveness remain mixed. This scoping review examines the characteristics, strategies, and outcomes of psychosis public health campaigns published between 2008 and 2025, with particular attention to metrics that are used to evaluate campaign success. Six databases were searched for peer-reviewed studies reporting outcomes of psychosis public health campaigns. Studies were included if they reported on campaign effectiveness and used a comparison condition. Data extraction focused on campaign characteristics, strategies, messages, target audiences, and outcomes. Nineteen studies describing 14 distinct campaigns met inclusion criteria. Campaigns varied widely in geographic scope, target audiences, duration, and messaging strategies. There was substantial heterogeneity in how duration of untreated psychosis was defined. Although some campaigns demonstrated significant reductions in overall duration of untreated psychosis, most showed mixed effects or improvements in subcomponents only. Campaigns employing multi-modal and sustained engagement strategies were more likely to report positive outcomes. Recent digital campaigns offered targeted outreach but showed inconsistent effects. Findings highlight the need for standardized definitions of the duration of untreated psychosis construct and consideration of more proximal outcomes for a public health intervention. Future campaigns should incorporate digital strategies, stakeholder-informed messaging, and alternative success metrics-such as referral volume and service engagement-to more accurately capture impact and guide implementation efforts in diverse settings.