Abstract
Treatment resistance is prevalent in early intervention in psychosis services, and causes a significant burden for the individual. A wide range of variables are shown to contribute to treatment resistance in first episode psychosis (FEP). Heterogeneity in illness course and the complex, multidimensional nature of the concept of recovery calls for an evidence base to better inform practice at an individual level. Current gold standard treatments, adopting a ‘one-size fits all’ approach, may not be addressing the needs of many individuals. This following review will provide an update and critical appraisal of current clinical practices and methodological approaches for understanding, identifying, and managing early treatment resistance in early psychosis. Potential new treatments along with new avenues for research will be discussed. Finally, we will discuss and critique the application and translation of machine learning approaches to aid progression in this area. The move towards ‘big data’ and machine learning holds some prospect for stratifying intervention-based subgroups of individuals. Moving forward, better recognition of early treatment resistance is needed, along with greater sophistication and precision in predicting outcomes, so that effective evidence-based treatments can be appropriately tailored to the individual. Understanding the antecedents and the early trajectory of one’s illness may also be key to understanding the factors that drive illness course.
Highlights
Treatment resistance in psychosis has traditionally been dominated by the Kraepelinian view of chronic disorder associated with enduring impairment [1]
The outlook is positive for many individuals with first episode psychosis (FEP; please see Table 1 for a list of abbreviations, but there remains a subgroup of individuals who do not achieve a symptomatic and/or functional recovery, despite receiving specialised care under an early intervention service (EIS) [2,3]
It is established that depression in psychosis is associated with a range of poor outcomes, but yet there is a lack of large-scale controlled trials investigating the effectiveness of adjunctive antidepressants, or cognitive behavioural therapy (CBT), to target depression within psychosis [26,47,48]
Summary
Treatment resistance in psychosis has traditionally been dominated by the Kraepelinian view of chronic disorder associated with enduring impairment [1]. Two longitudinal studies have shown that of individuals who were identified as treatment resistant, over 70% were treatment resistant from illness onset [4,5]. Initial response to treatment is one of the strongest predictors of longer-term outcomes in those with early psychosis [6,7]. It is imperative that these individuals are identified as early as possible in their illness trajectory and given appropriate stratified interventions to improve outcomes and prevent further decline.
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