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Prevention and early intervention in psychotic disorders

This chapter considers treatment approaches in early psychosis and the possibility of prevention prior to the development of illness. The chapter first considers the various definitions of the pre-psychotic state, including prodrome, and the concept of clinical high-risk (CHR) groups. The CHR groups, including the ultra-high-risk (UHR) and basic symptoms (BS) groups aim to identify individuals at imminent risk of transitioning to full-blown psychosis. Further, the chapter summarizes the notion of a staging model for psychosis, which incorporates these earliest pre-psychosis stages, and considers the onset and progression of the illness to chronicity, with differing intervention options for each stage. The relevance of interventions targeting non-specific risk factors, such as trauma, stress, bullying, drug abuse, and migration, in the early years is considered. The chapter discusses possible interventions to prevent or delay psychosis onset or progression (for example, prenatal choline or vitamin D), and public health measures at the population level. It also explores the issues relating to drug prescribing in the pre-psychosis stage and outlines controversies regarding the risk–benefit ratio and ethics of these pre-emptive strategies. Models of care aimed to reduce the duration of untreated psychosis may prove useful. Integrative treatment in early psychosis has been more successful than ‘treatment as usual’ in reducing symptoms, relapse rates, and improving engagement. Early detection and intervention services and public awareness campaigns are key to primary prevention. Studies that investigate trajectories of symptom development and emergence of psychosis are needed, in order to evaluate the effectiveness of pre-emptive and later interventions.