Improving outcomes of first-episode psychosis: an overview

Paolo Fusar-Poli; Patrick D McGorry; John M Kane

doi:10.1002/wps.20446

Improving outcomes of first-episode psychosis: an overview

World Psychiatry. 2017 Oct;16(3):251-265. doi: 10.1002/wps.20446.

Authors

Paolo Fusar-Poli^{1

2}, Patrick D McGorry³, John M Kane⁴

Affiliations

¹ Early Psychosis: Interventions and Clinical Detection Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
² OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK.
³ Orygen, the National Centre of Excellence in Youth Mental Health, Parkville, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
⁴ Zucker Hillside Hospital, Glen Oaks, NY, USA; Departments of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA.

Abstract

Outcomes of psychotic disorders are associated with high personal, familiar, societal and clinical burden. There is thus an urgent clinical and societal need for improving those outcomes. Recent advances in research knowledge have opened new opportunities for ameliorating outcomes of psychosis during its early clinical stages. This paper critically reviews these opportunities, summarizing the state-of-the-art knowledge and focusing on recent discoveries and future avenues for first episode research and clinical interventions. Candidate targets for primary universal prevention of psychosis at the population level are discussed. Potentials offered by primary selective prevention in asymptomatic subgroups (stage 0) are presented. Achievements of primary selected prevention in individuals at clinical high risk for psychosis (stage 1) are summarized, along with challenges and limitations of its implementation in clinical practice. Early intervention and secondary prevention strategies at the time of a first episode of psychosis (stage 2) are critically discussed, with a particular focus on minimizing the duration of untreated psychosis, improving treatment response, increasing patients' satisfaction with treatment, reducing illicit substance abuse and preventing relapses. Early intervention and tertiary prevention strategies at the time of an incomplete recovery (stage 3) are further discussed, in particular with respect to addressing treatment resistance, improving well-being and social skills with reduction of burden on the family, treatment of comorbid substance use, and prevention of multiple relapses and disease progression. In conclusion, to improve outcomes of a complex, heterogeneous syndrome such as psychosis, it is necessary to globally adopt complex models integrating a clinical staging framework and coordinated specialty care programmes that offer pre-emptive interventions to high-risk groups identified across the early stages of the disorder. Only a systematic implementation of these models of care in the national health care systems will render these strategies accessible to the 23 million people worldwide suffering from the most severe psychiatric disorders.

Keywords: Psychosis; clinical high risk; clinical staging; first episode psychosis; indicated prevention; outcomes; psychosis risk; schizophrenia; selective prevention; universal prevention.