Early Intervention In First-episode Psychosis Research Articles

GAPi: A description of the initiative for early psychosis intervention in Latin America and the short- to medium-term outcomes in early psychosis patients

IntroductionSchizophrenia is a debilitating disorder that affects a significant proportion of the population and leads to impaired functionality and long-term challenges. The first episode of psychosis (FEP) is a critical intervention stage for improving long-term outcomes. The GAPi program was established in São Paulo, Brazil to provide early intervention services and evaluate biomarkers in individuals with FEP. This article delineates the objectives of the GAPi program, detailing its innovative research protocol, examining the clinical outcomes achieved, and discussing the operational challenges encountered during its initial decade of operation. MethodsThe study comprised a prospective cohort of antipsychotic-naïve individuals with first-episode psychosis aged between 16 and 35 years. Participants were recruited from a public psychiatric facility in São Paulo. Emphasizing the initiative's commitment to early intervention, clinical assessments were systematically conducted at baseline and at two months, one year, two years, and five years of treatment to capture both short- and medium-term outcomes. Various assessment tools were utilized, including structured interviews, symptom scales, the Addiction Severity Index, and functional assessments. ResultsA total of 232 patients were enrolled in the cohort. Among them, 65.95 % completed the 2-month follow-up. Most patients presented with schizophrenia spectrum disorders, followed by bipolar disorder and major depressive disorder with psychotic features. Treatment response rates and remission rates were evaluated at different time points, with promising outcomes observed. The program also assessed socio-demographic factors, substance use, family history, and genetic and biomarker profiles, providing valuable data for research. DiscussionThe GAPi program has emerged as the largest ongoing cohort of antipsychotic-naïve first-episode psychosis in Latin America, contributing to the understanding of early psychosis in low- and middle-income countries. Despite operational challenges, the program has demonstrated efficacy in reducing the duration of untreated psychosis and in improving clinical outcomes. A multidisciplinary approach, including pharmacological treatment, psychosocial interventions, and family involvement, has been instrumental in enhancing treatment adherence and long-term prognosis. ConclusionThe GAPi program represents a valuable model for early intervention in first-episode psychosis and provides insights into the pathophysiology, treatment, and long-term outcomes of individuals with schizophrenia and related disorders. Continued research and resource allocation are essential for addressing operational challenges and expanding early intervention services in low- and middle-income countries.

What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future.

Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs. FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP. Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.

M244. PENNSYLVANIA FIRST-EPISODE PROGRAM EVALUATION OF COORDINATED SPECIALTY CARE: SIX- AND 12-MONTH OUTCOMES

BackgroundInterest in early intervention for first-episode psychosis (FEP) has increased globally in recent decades in response to evidence that multi-component programs may reduce individual and societal burden of psychotic disorders. In 2016, the Pennsylvania (PA) Office of Mental Health and Substance Abuse Services (OMHSAS) provided funding to develop a statewide Program Evaluation (PE) initiative. PA-FEP-PE assesses benefits of nine PA coordinated specialty care (CSC) programs both individually and in aggregate. We previously (SIRS 2019) presented preliminary data from initial participants. We now present data from 598 participants enrolled across PA.MethodsOur CSC programs serve youth age 12–34 experiencing early psychosis onset between 12–24 months before admission. Services, including pharmacotherapy, CBT-based psychotherapy, case management, supported employment and education, peer support, and multi-family groups and psychoeducation, are offered for >=2 years. Participant characteristics at referral, admission, follow-up and discharge are collected via standardized computerized (REDCap) forms. The computerized clinical battery, administered at admission and at 6-month follow-up intervals, is composed of measures selected for domain coverage, clinical utility, reliability/validity (from the PhenX toolkit), practical utility, low burden, and high utility to multiple stakeholders. Domains include symptoms and diagnosis (Brief Psychiatric Rating Scale, Beck Depression Inventory-7, Hopelessness Scale, Self-Esteem-Scale-Revised, Loneliness Scale, Defeatist Beliefs Scale, Post-Traumatic Stress Disorder Symptom Scale), psychosocial functioning and recovery (Global Function Role and Social Scales, Psychosis Recovery Assessment Questionnaire, Quality of Life Functional Assessment, Systematic Clinical Outcome Routine Evaluation), medication side effect monitoring (Extrapyramidal Symptom Rating Scale, Glasgow Antipsychotic Side Effect Scale), and service quality and satisfaction (Youth Services Survey).ResultsBetween 1/1/17-7/1/19, 1,917 referrals were received, of whom 598 participants (mean age=21.1 SD=4.5; 35% female; 45% Caucasian, 41% African-American) were enrolled. Unspecified/other psychotic disorder was the most common diagnosis at admission (48%). Mean age at psychosis onset was 20.2 years (SD=4.6). An average 13.7 (SD=21.8) months lapsed between symptom onset and admission. The majority (78%) of participants had prior hospitalizations. At admission, participants showed moderate severity of psychiatric symptoms, serious impairment in global role and social functioning, and 72% reported experiencing >=1 traumatic events. At 6-month follow-up, participants (n=142) exhibited several significant improvements, including decreased hospitalizations and hospitalization days, suicidal ideation, substance use, overall psychopathology, and positive psychosis symptoms, and increased employment and school enrollment, global role and social function, self-rated quality of life, medication side effects, and satisfaction with mental health services. Individuals who engaged for 12 months (n=60) continued to maintain significant improvement in clinical features.DiscussionPA-FEP-PA is a comprehensive model yielding clinical and functional improvements after 6 and 12 months of CSC participation. Continued data collection will enable increased power to analyze population and site differences to illuminate mediators and moderators underlying individual variations and improve personalized prediction of salient outcomes. Further, the PA-FEP-PE model offers PA CSC programs a collaborative learning network for ongoing quality improvement.

PROFIP: A Portuguese early intervention programme for first-episode psychosis in Lisbon.

There is currently no national plan for early intervention in first-episode psychosis in Portugal. Consequently, there is some heterogeneity in the evaluation and treatment of first-episode psychosis across the country. The aim of this article is to provide a complete description of the early intervention programme Programa de Intervenção nas Fases Iniciais da Psicose (PROFIP) in Lisbon, a pioneering team in Portugal for treating first-episode psychosis (FEP) patients. We also describe the baseline socio-demographic and clinical data obtained from new patients over a 1-year period. PROFIP programme accepts all cases of FEP, taking a transdiagnostic approach. Description of PROFIP programme and baseline socio-demographic and clinical data obtained from new patients over a 1-year period. The team was constituted to provide early detection, treatment and support to people aged 16 to 35 years with affective and non-affective FEP. Over a 1-year period, 39 patients were included in the PROFIP programme. The majority of patients were young male patients with a diagnosis of non-affective psychosis, and with 56% of patients reporting cannabis use. Patients received pharmacological and psychosocial interventions based on evidence and individual needs. Our team allowed young people with early psychosis to receive effective care. We do need improvements, namely in referrals and the education of health professionals. More teams in our country should be constituted, allowing larger numbers of patients with early psychosis to be treated by specialized teams.

First-episode psychosis research in India: A review

Background: With the growth of early intervention services for psychosis worldwide, it is imperative to understand the current knowledge on first-episode psychosis (FEP) from Indian context. Hence, the purpose of this review is to comprehensively examine the research studies on FEP from India. This would help to compare and contrast with other countries, develop specialist early intervention services and enlist research priorities pertaining to FEP. Methods: A Boolean search of articles published from January 1990 to March 2018 in electronic database of PubMed and Google Scholar was carried out and original research studies done on first-episode psychosis in India were incorporated in the current review. Case reports and review articles were excluded. Results: A total of 31 research studies were included for the review and classified into different subheadings of convenience. Conclusion: Even though the number of studies in Indian context pertaining to FEP is comparatively less than other western literature, the available results indicate certain characteristic similarities and differences in FEP from other parts of the world. We have also discussed on the importance of early intervention in FEP and the necessity for the creation of specialist early intervention services for mental health disorders.

First-episode psychosis research in India: A review

Background: With the growth of early intervention services for psychosis worldwide, it is imperative to understand the current knowledge on first-episode psychosis (FEP) from Indian context. Hence, the purpose of this review is to comprehensively examine the research studies on FEP from India. This would help to compare and contrast with other countries, develop specialist early intervention services and enlist research priorities pertaining to FEP. Methods: A Boolean search of articles published from January 1990 to March 2018 in electronic database of PubMed and Google Scholar was carried out and original research studies done on first-episode psychosis in India were incorporated in the current review. Case reports and review articles were excluded. Results: A total of 31 research studies were included for the review and classified into different subheadings of convenience. Conclusion: Even though the number of studies in Indian context pertaining to FEP is comparatively less than other western literature, the available results indicate certain characteristic similarities and differences in FEP from other parts of the world. We have also discussed on the importance of early intervention in FEP and the necessity for the creation of specialist early intervention services for mental health disorders.

Prediction of motivational impairment: 12-month follow-up of the randomized-controlled trial on extended early intervention for first-episode psychosis

BackgroundAmotivation is prevalent in first-episode psychosis (FEP) patients and is a major determinant of functional outcome. Prediction of amotivation in the early stage of psychosis, however, is under-studied. We aimed to prospectively examine predictors of amotivation in FEP patients in a randomized-controlled trial comparing a 1-year extension of early intervention (Extended EI, 3-year EI) with step-down psychiatric care (SC, 2-year EI). MethodsOne hundred sixty Chinese patents were recruited from a specialized EI program for FEP in Hong Kong after they have completed this 2-year EI service, randomly allocated to Extended EI or SC, and followed up for 12 months. Assessments on premorbid adjustment, onset profiles, baseline symptom severity and treatment characteristics were conducted. Data analysis was based on 156 subjects who completed follow-up assessments. ResultsAmotivation at 12-month follow-up was associated with premorbid adjustment, allocated treatment condition, and levels of positive symptoms, disorganization, amotivation, diminished expression (DE) and depression at study intake. Hierarchical multiple regression analysis revealed that Extended EI and lower levels of DE independently predicted better outcome on 12-month amotivation. ConclusionOur findings indicate a potentially critical therapeutic role of an extended specialized EI on alleviating motivational impairment in FEP patients. The longer-term effect of Extended EI on amotivation merits further investigation.

Preventive strategies for severe mental disorders

Since the 1990s, there has been a tremendous upsurge in research on early intervention in psychotic disorders. The neurodevelopmental hypothesis enabled the development of clinical staging models of schizophrenia, which in turn demonstrated that early intervention is possible before the onset of psychosis. Such intervention relied on early detection using prodromal vulnerability indicators and on targeted and stage-specific treatments. Initial efforts were focused on reducing the duration of untreated psychosis to improve outcome. As these efforts were not always successful, research moved on to the examination of prodromes and high-risk states. The “at-risk mental state” strategy based on principles of indicated prevention consisted of the “ultra-high risk” and the “basic symptoms” approaches. A large body of evidence indicated that about 30% of the patients who met criteria for either approach went on to develop full-blown psychosis in the next 2–3 years. Several early psychosis detection programs have been set up worldwide, and controlled trials have shown efficacy of early intervention in first-episode psychosis as well as prodromal or at-risk states. However, several issues regarding identifying and managing such patients still need to be sorted out before prevention of severe mental disorders becomes a reality.

McLean OnTrack: a transdiagnostic program for early intervention in first-episode psychosis.

Most programs specializing in the treatment of first-episode psychosis in the United States focus on schizophrenia. However, many early psychosis patients do not fit into this diagnostic category. Here we describe McLean OnTrack, an intensive outpatient treatment program that accepts all comers with first-episode psychosis. We assessed baseline characteristics of patients in the 2.5 years since program initiation. We examined how initial referral diagnoses compare with current diagnoses, calculating the proportion of diagnostic changes. At 2.5 years, patients in McLean OnTrack consist of 30 (33.0%) individuals with primary psychotic disorder, 40 (44.0%) with affective psychosis, 19 (20.9%) with psychotic disorder not otherwise specified (NOS) who do not meet full criteria for either category and two (2.2%) individuals with no psychosis. Although patients with affective psychosis had higher pre-morbid functioning, all three categories of psychosis had similar rates of prior hospitalizations and substance use. The retention rate in the psychotic disorder NOS group was lower than that in affective and primary psychotic disorders. Finally, diagnoses changed over the course of treatment in 50.5% of patients. Diagnostic heterogeneity appears to be the norm among patients with first-episode psychosis, and diagnoses commonly evolve over the illness course. Baseline indices of illness severity were similar across categories and suggest the need for early intervention, irrespective of specific diagnosis. We discuss the benefits and challenges of a transdiagnostic approach to early intervention in first-episode psychosis, treating patients who share many but not all characteristics.

Early intervention for first-episode psychosis: broadening the scope of economic estimates.

To explore the economic impacts of early intervention in England on outcomes and costs for people with first-episode psychosis. Three decision analytical models were constructed to compare treatment by early intervention for first-episode psychosis with standard care in relation to employment, education, homicide and suicide. Data on effectiveness and costs were taken from previous studies and expert opinion. Sensitivity analyses tested the robustness of assumptions. Our models indicate that early intervention demonstrates savings of £2087 per person over 3 years from improved employment and education outcomes. In addition, the annual costs over 10 years related to homicide after early intervention were £80 lower than for standard care. There were also annual savings of £957 per person for early intervention over 4 years compared to standard care as a result of suicides averted. Not only can investment in early intervention help reduce some of the long-term costs and consequences of mental disorders to the health-care system. In addition, there are broader economic benefits that strengthen the potential cost savings to society.

What needs to follow early intervention? Predictors of relapse and functional recovery following first‐episode psychosis

As a foundation for considering how gains may be maintained following early intervention in first-episode psychosis (FEP), this study aimed to describe and investigate factors predicting post-discharge relapse and longer term functioning. An evaluation via case-note review obtained quantitative data on 163 patients sequentially discharged from Birmingham Early Intervention Service (EIS) followed up for a median of 3.6 years. Time to relapse was calculated and hierarchical regression was used to determine predictors of relapse and functioning. Patients likely to relapse do so within the first year post-discharge; however, over 40% did not relapse during the follow-up period. The number of relapses occurring during EIS care predicted time-to-relapse post-discharge. At discharge from the EIS and study end-point, the proportion with low social and vocational functioning remained high. Predictors of positive 'Not in Education Employment or Training' status at end-point include being in a minority ethnic group, substance misuse and number of relapses. Increased emphasis on relapse prevention and early post-discharge monitoring may be needed, especially in the first year, for those who have experienced previous relapse. To maintain early outcomes in FEP, targeted interventions to address substance misuse and functional recovery need to be sustained in the long term. EISs should aim to make the first episode of psychosis the last. Services providing care for patients with psychosis post EIS should be designed to deliver care for ongoing need, with continued emphasis on relapse prevention and social recovery.

Premiers épisodes psychotiques : actualités cliniques et épidémiologiques

In the context of the development of early intervention for first-episode psychosis, this manuscript reviews new data with respect to its incidence, risk factors and evolution. Annual incidence of non-affective psychosis appeared to be between 14 and 30/100,000 in people aged 18-64. Incidence decreases with age and is twice higher in men than in women. There is an interaction between age and gender; the risk of psychosis decreases with age faster in men than in women. Thus, for schizophrenia, incidence rate is twice higher in men under 45 year-old and similar in both genders after. There is evidence that genetic and environmental factors may cause enduring liability to psychotic disorder, and, in addition, that genes and environment may interact synergistically. Some environmental factors have been identified; they concern foetal life, childhood or adolescence and may be conceptualized at the individual or the contextual level. The definition of recent onset psychosis may be based on duration of psychosis, between two and five years. Its development is identified through the occurrence of major psychotic symptoms, such as positive, negative symptomatology or disorganization, and impairment of social functioning. The types and patterns of occurrence and of evolution of psychotic symptoms have a prognostic impact. A long duration of untreated psychosis impacts symptomatology. It is associated with less severe positive symptoms at baseline and more severe after three years, insidious onset, male gender, early onset, and diagnosis of schizophrenia. Recent onset psychosis is often associated with comorbidities, such as depression, anxiety disorders, suicidal behaviours, and addiction. Symptomatic remission rates are found between 25 and 60%. Symptomatic and functional remissions favour each other. A third to half of patients is active, employed or students. Symptoms and evolution are various in studies, probably corresponding to various patho-physiological mechanisms.

Enjeu de la réinsertion sociale après un premier épisode psychotique

One of the main issues of early intervention in first-episode psychosis is to prevent social exclusion, or at least to seek to reduce it as soon as possible. The aim is not only symptom remission and relapse prevention, it is also to optimize the social and functional outcome of the illness. Social exclusion is not only one the disabling consequences of the illness, it is also, due to a negative circularity, an aggravating factor. Therefore, alongside the healthcare strategy aiming at the remission and relapse prevention, it will be useful to set up, at an early stage, a strategy aiming at maintaining or restoring social inclusion, and more generally to support the social recovery. We will specify the factors conditioning such prospects for recovery, and the variety of measures to support this strategy.

Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study)

Information about the cost-effectiveness of early intervention programmes for first-episode psychosis is limited. To evaluate the cost-effectiveness of an intensive early-intervention programme (called OPUS) (trial registration NCT00157313) consisting of enriched assertive community treatment, psychoeducational family treatment and social skills training for individuals with first-episode psychosis compared with standard treatment. An incremental cost-effectiveness analysis of a randomised controlled trial, adopting a public sector perspective was undertaken. The mean total costs of OPUS over 5 years (€123,683, s.e. = 8970) were not significantly different from that of standard treatment (€148,751, s.e. = 13073). At 2-year follow-up the mean Global Assessment of Functioning (GAF) score in the OPUS group (55.16, s.d. = 15.15) was significantly higher than in standard treatment group (51.13, s.d. = 15.92). However, the mean GAF did not differ significantly between the groups at 5-year follow-up (55.35 (s.d. = 18.28) and 54.16 (s.d. = 18.41), respectively). Cost-effectiveness planes based on non-parametric bootstrapping showed that OPUS was less costly and more effective in 70% of the replications. For a willingness-to-pay up to €50,000 the probability that OPUS was cost-effective was more than 80%. The incremental cost-effectiveness analysis showed that there was a high probability of OPUS being cost-effective compared with standard treatment.

Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis

Although there have been numerous studies on pathways to care in first-episode psychosis (FEP), few have examined the determinants of the pathway to care and its impact on subsequent engagement with mental health services. Using a sample of 324 FEP patients from a catchment area-based early intervention (EI) program in Montréal, we estimated the association of several socio-demographic, clinical, and service-level factors with negative pathways to care and treatment delay. We also assessed the impact of the pathway to care on time to disengagement from EI services. Few socio-demographic or clinical factors were predictive of negative pathways to care. Rather, service-level factors, such as contact with primary care providers, have a stronger impact on patterns of health service use across multiple indicators. Patients who were in contact with primary care had a reduced likelihood of negative pathways to care, but also had longer referral delays to EI services. Socio-demographic and clinical factors were more relevant for predicting subsequent engagement with EI services, and indicators of negative pathways to care were not associated with service disengagement. Primary care providers may be an efficacious target for interventions aimed at reducing overall treatment delay. Increasing the uptake of primary care services may also reduce the likelihood of negative pathways to care. Our findings draw attention to the need for further investigations of the role that the primary care system plays in early intervention for FEP, and strategies for supporting service providers in this role.

Three-year outcome of phase-specific early intervention for first-episode psychosis: a cohort study in Hong Kong

Although phase-specific early intervention for first-episode psychosis has been implemented in many different parts of the world, limited medium-term outcome data are available in non-Western populations with relatively low mental health resources. The study aimed to determine the effectiveness of phase-specific early intervention in first-episode psychosis. In this cohort study, we compared the 3-year outcome of 700 first-episode psychosis patients who received phase-specific early intervention with that of 700 patients matched for age, sex and diagnosis who received standard psychiatric care prior to early intervention. Using a structured data acquisition procedure, we determined functional outcome, symptom levels, relapse, recovery, suicidal behaviour and service utilization from clinical records. Patients in the early intervention group had longer full-time employment or study (P<0.001), fewer days of hospitalization (P<0.001), less severe positive symptoms (P=0.006), less severe negative symptoms (P =0.001), fewer suicides (P=0.009) and fewer disengagements (P=0.002) than the historical control group. Additionally, more patients in the early intervention group experienced a period of recovery (P=0.001), but the two groups had similar rates of relapse (P=0.08) and durations of untreated psychosis (P=0.72). The 3-year outcome in phase-specific early intervention compared favourably with that of standard psychiatric care, particularly with respect to functional outcome and reduction in hospitalizations, suicides and disengagements. However, intervention did not appear to reduce the rate of relapse.

Multiple economic evaluation of Early Intervention (EI) for young people with first-episode psychosis

Background/Objectives: Participation in employment tends to be low in people with mental disorders. Recent studies show the potential for Early Intervention (EI) in young people aged 15 to 35 with first episode psychosis to help prevent suicide and some of the long term burdens of psychosis to the health care system. Moreover, preventing some of these adverse events may help to facilitate return to workplace and school. However, the cost-effectiveness of EI, including its wider social and economic implications has so far not been explored. Methods: Three decision analytical models were constructed to compare investment in a community-based multidisciplinary team for EI in first episode psychosis with standard care. Costs and benefits in terms of vocational, educational and criminal justice system related outcomes over a two year period, as well as suicide over a five year period, were modelled. Data on the effectiveness and costs of the intervention were taken from an empirical study in an area of high socio-economic deprivation in South London, as well as from a supplementary review of the literature. Sensitivity analyses were performed to test the robustness of different assumptions in the model, for instance on the cost of interventions including the intangible costs associated with physical and emotional impacts of poor mental health, and the likelihood of return to education or employment. Results: EI was found to be more cost-effective than standard care as EI was less costly due to significantly reduced costs for employment lost due to early psychosis, given higher rates of employment and returns to education, compared with standard care. Using a minimum wage rate the average savings are £ 2,087 in addition to health care savings. Although the cost of homicide is low for both EI and standard care, the lifetime costs with EI are £ 2,729 lower than for standard care. The annual saving in suicide costs with EI is £ 975 for men and £ 884 for women given a gender difference in suicide rates with lower rates of suicide after EI. The long-term economic impact of EI depends on what happens to readmission rates after a patient is discharged from the EI team. If the readmission rates remain constant, then the expected savings over eight years are £ 36,632. If rates converge immediately after EI team discharge, the figure is £ 17,427. Finally, if the rates converge gradually, the expected savings are £ 27,029. Discussion/Conclusions: Multidisciplinary team approaches to EI can help prevent some of the long term consequences of mental disorders, including the risk of suicide. This can also have positive economic benefits in terms of decreased homicide. The investment in EI can provide significant benefits of helping young people return to work and education, and actively engage in a normal healthy lifestyle.

Early intervention in first-episode psychosis

Substantial delays in providing access to treatment in first-episode psychosis have been well documented. The present study examines the impact of strategies aimed at improving access and reducing delays. A pilot community education campaign was conducted with the aim of reducing the duration of untreated psychosis (DUP) in a geographically defined intervention sector located in the northwestern region of Melbourne, Australia. Utilising a quasi-experimental design, a comparison sector with similar demographics was selected from another part of the north-western region. A mobile early detection team and the same treatment system served both sectors. While there was no significant difference between the mean DUP for intervention and comparison sectors, the distributional features of DUP between the two regions were significantly different. In the intervention sector, disproportionately more cases with very long DUP were detected. When a small number of outliers were removed, the mean and median DUP in the intervention sector was reduced. These findings highlight the complexity of treatment access and delay and suggest that efforts to reduce DUP may have two effects, not one. Firstly, a different sample of cases is treated through the detection of hidden "long DUP" cases that otherwise may have remained untreated. Secondly, the DUP for the remainder may indeed be reduced. More research with larger samples and more potent campaign strategies is clearly required. It may also be worth considering whether there is a safe and ethical way to undertake a RCT of early versus delayed antipsychotic treatment to perhaps settle the DUP debate once and for all.

A specialist early intervention for first-episode psychosis.

A specialist early intervention for first-episode psychosis.

Origins of Early Intervention in First-Episode Psychosis

Objective: To outline reasons contributing to the delayed introduction of early intervention strategies for first-episode psychosis, followed by a discussion of recent factors that have supported the increased use of these strategies. Conclusions: The reasons for this delay include pessimistic beliefs carried over from early in the 20th century about the prognosis of schizophrenia, the central role of the institution in psychiatric history, and the need for a working neurobiological model for psychosis. The discovery of the antipsychotic drugs, the process of deinstitutionalization, and new conceptualizations of schizophrenia have been necessary precursors to current best practice treatments. In recent years these factors have been complemented by the increasing influence of consumer and family advocacy groups, and government policy initiatives.