Early Intervention in Psychosis (EIP) services have demonstrated that timely, comprehensive and evidence-based care in the early stages of psychosis can improve long-term outcomes, reduce hospitalisations and enhance functional recovery. Despite widespread implementation of these services, the specific components that drive improved outcomes remain poorly understood.
To address this, Williams et al Reference Williams, Penington, Gupta, Quirk, Tsiachristas and Rickett1 conducted a national retrospective cohort study of 14 874 individuals receiving EIP care in England, examining which specific service components most strongly influenced clinical outcomes (primarily time to psychotic relapse, as indicated by in-patient admission or referral to a crisis-resolution and home-treatment team) over 3 years. The study identified several features associated with improved outcomes. Reduced care coordinator caseloads and the use of clozapine in those eligible were associated with reduced relapse risk. Moreover, physical health interventions were associated with lower mortality compared with individuals who required these interventions but did not receive them. These findings highlight the active ingredients of EIP care that contribute most meaningfully to improved recovery and reduced morbidity.
Applying these findings to psychosis prevention
The lessons learned from EIP can also inform best practice for specialist preventive early-detection services. Approximately 80% of first-episode psychosis patients experience a prodromal stage prior to disorder onset. Reference Benrimoh, Dlugunovych, Wright, Phalen, Funaro and Ferrara2 This is characterised by subtle, attenuated psychotic symptoms and functional impairment, which are associated with help-seeking behaviour, known as the clinical high risk for psychosis (CHR-P) phase. Around 20% of CHR-P individuals will develop psychosis within 2 years, Reference Fusar-Poli, Correll, Arango, Berk, Patel and Ioannidis3 making this a key period for ‘targeted’ preventive intervention. Reference Fusar-Poli, Correll, Arango, Berk, Patel and Ioannidis3 CHR-P services aim to detect individuals during this earlier stage through semi-structured clinical assessments, and provide evidence-based preventive care. There are currently no validated biomarkers to facilitate prevention in the CHR-P phase. Those who transition to psychosis can be quickly referred to EIP for initiation of antipsychotic treatment. As a result, implementation of CHR-P services is one of the few effective ways to reduce the duration of untreated psychosis, which is a key determinant of outcomes. Furthermore, first-episode patients who present to CHR-P services spend fewer days in hospital and have a shorter referral to diagnosis time, lower frequency of hospital admissions and lower likelihood of compulsory hospital admission compared with patients who present to EIP services first. Reference Fusar-Poli, Correll, Arango, Berk, Patel and Ioannidis3
Despite this, the most recent clinical audits of CHR-P services in England demonstrates that these remain unevenly implemented and inconsistently resourced. Reference Spencer, De Micheli, Murguia-Asensio, Provenzani and McGuire4 Translating the key elements of effective EIP care into CHR-P frameworks could strengthen preventive psychiatry and reduce the burden of psychotic disorders at a population level.
Reduced care coordinator caseloads stand out as a particularly robust predictor of positive outcomes. In EIP settings, they facilitate more personalised care, assertive engagement and timely responses to early signs of relapse. The same principle applies to CHR-P services, where therapeutic alliance, flexible engagement and rapid response to clinical changes are essential for effective care within these services and for facilitating engagement with EIP services for those who develop psychosis. High caseloads risk reducing clinician capacity for relational and preventive work, undermining the very purpose of early detection. Healthcare workers cannot be asked to take care of EIP and CHR-P patients simultaneously because those in EIP are more unwell and, rightly so, will be prioritised. However, this would lead to limited care for CHR-P individuals. Only CHR-P services with dedicated staff and independent funding tend to have moderate care coordinator caseloads. Reference Spencer, De Micheli, Murguia-Asensio, Provenzani and McGuire4 This is in part due to the complexity of CHR-P assessments, which requires training and protected time. Ensuring manageable care coordinator caseloads in CHR-P services would allow clinicians to deliver genuinely personalised care that is tailored to individual needs.
Similarly, early identification of people requiring higher-intensity care was shown to improve outcomes within EIP, particularly through the appropriate use of clozapine. In CHR-P settings, this can be represented through effective detection of individuals at risk. Despite established CHR-P services, only a small minority of individuals who later develop psychosis are detected during the CHR-P phase; this limited reach of CHR-P services reflects a structural bottleneck in efficient detection. One opportunity to address this is by expanding access to CHR-P services through community outreach. Embedding services within local community infrastructures, and increasing the accessibility and knowledge of services, can help increase the number of people self-referring. However, due to the suboptimal specificity of CHR-P instruments, increasing the number of referrals can translate into more false positives (i.e. providing care to people who would not develop psychosis without care). Online screening approaches (e.g. the E-detection tool for emerging mental disorders Reference Wallman, Estrade, Azis, Haining, Liang and Spencer5 ) can help expand access without diluting risk, through the use of pre-screening measures. Similarly, digital tools that passively estimate risk through routinely collected information (e.g. transdiagnostic risk calculator for psychosis Reference Oliver, Arribas, Perry, Whiting, Blackman and Krakowski6 ) can help detect people at risk in populations with higher underlying psychosis risk, and circumvent the requirement for help-seeking specifically for attenuated psychotic symptoms. These approaches could be further supported through digital assessment tools (e.g. the mini Comprehensive Assessment of At-Risk Mental States Reference Stefana, Oliver, Estradé, Azis, Damiani and Fusar-Poli7 ), which can reduce the burden on services associated with higher numbers of referrals. Together, data-driven tools like these can increase the efficiency of the screening and assessment pathway, enabling greater focus on the provision of preventive care. Similarly, individuals who transition to psychosis require rapid referral to EIP services to ensure that the duration of untreated psychosis is short, which aids better long-term outcomes.
Finally, the association between physical health interventions and reduced mortality has direct implications for the earlier stages of care. Metabolic vulnerability, sedentary behaviour and poor diet are apparent during the CHR-P phase. Reference Provenzani, De Micheli, Damiani, Oliver, Brondino and Fusar-Poli8 CHR-P individuals are more likely to be tobacco smokers, engage in hazardous drinking, have a poor diet and lower engagement in physical activity compared with young adults in the general population. Reference Provenzani, De Micheli, Damiani, Oliver, Brondino and Fusar-Poli8 These lifestyle factors increase the risk of future physical health problems, as well as the onset of a broad range of mental disorders. Reference Fusar-Poli, Correll, Arango, Berk, Patel and Ioannidis3 Integrating physical health interventions (e.g. lifestyle counselling, physical activity programmes and metabolic monitoring) into CHR-P services could reduce future morbidity and mortality. In this way, preventive psychiatry can adopt a truly holistic preventive approach to care, addressing risk factors for poor physical and mental health outcomes.
Resourcing and structural requirements for effective CHR-P services
Effective implementation of these initiatives is dependent on system configuration and resource allocation. CHR-P care cannot simply be absorbed within existing EIP teams without independent funding and dedicated staff. Currently only 17% of CHR-P services are standalone, with the remainder embedded within EIP services. Reference Spencer, De Micheli, Murguia-Asensio, Provenzani and McGuire4 When CHR-P responsibilities are delegated to EIP clinicians already managing individuals with established psychosis, prevention becomes a secondary task rather than a primary focus. This is compounded by the complexity of CHR-P assessments, requiring extensive training in addition to their long administration time (∼2 h). The result is predictable: diluted attention to CHR-P service provision, delayed responses and, ultimately, ineffective prevention.
To succeed, CHR-P services require dedicated staff, dedicated funding and clear integration within the EIP care pathway. Services with staff funded independently of EIP have the largest care coordinator caseloads in the UK. Although this independence is important, these services must not be purely standalone: they must be integrated with EIP services to be truly effective. In this way, dedicated CHR-P clinicians can specialise in assessing the CHR-P state, psychoeducation and preventive interventions while shared governance and care pathways with EIP ensure smooth transitions for those who do develop psychosis. By maintaining the independence of CHR-P services while aligning with EIP, both services can retain focus and identity: CHR-P on prevention, EIP on treatment and recovery. This also promotes continuity of care for service users as they progress through different stages of the disorder.
Towards a harmonised model of early detection and early intervention
The implications of these points extend beyond psychosis, because there is growing interest in expanding the CHR-P construct to other disorders. These critical components similarly apply when considering such expanded services. Care coordinators must have small caseloads to enhance engagement; detection strategies need to be more efficient, through the use of new digital tools; individuals who develop psychosis must be quickly referred to EIP services to reduce the duration of untreated psychosis; and physical health should be proactively managed early in the service pathway. Coordinated, prevention-oriented services could form a unified architecture for early mental healthcare, bridging the traditional divide between prevention and treatment. There is growing momentum worldwide for transdiagnostic prevention services, in line with a clinical staging model, considering attenuated, subclinical symptoms as disorder-agnostic with the potential for individuals to transition to any of a range of mental disorders. For this to be effective, early detection services need EIP-equivalent services to which people can be referred if they do experience a first episode of the corresponding mental disorder. At present there are no equivalent EIP services for most mental disorders. Moreover, because of current funding constraints in the UK National Health Service (NHS), severe mental disorders have greater priority and, as a result, preventive services for bipolar disorder are being prioritised in the UK. The clinical high risk for bipolar disorder (CHR-B) state has the highest available evidence for existent prodromal symptoms and their assessment, Reference Fusar-Poli, De Micheli, Rocchetti, Cappucciati, Ramella-Cravaro and Rutigliano9 as well as substantial overlap with psychosis for considered referral to EIP services.
A harmonised approach to early detection and early intervention spanning CHR-P, CHR-B and EIP could strengthen both risk reduction and acute care at the system level. Such integration would enable stepped prevention, where risk is detected, monitored and mitigated before illness onset within CHR-P and CHR-B settings, but with rapid escalation to specialist care in EIP if required.
To achieve this, policy and commissioning frameworks must support preventive psychiatry with the resourcing to establish and maintain independent preventive services that can support EIP services by reducing incident cases. In addition, prioritisation of training of staff to ensure high-quality assessment of the CHR-P state, and outreach to educate potential referrers, can further improve their effectiveness. This can be facilitated. The findings of the national EIP study provide an empirical foundation for how this potential can be realised.
The success of EIP services demonstrates that reduced care coordinator caseloads, evidence-based interventions and attention to physical health are core determinants of outcomes. Extending these lessons to CHR-P services can close the gap between detection and intervention, reducing the incidence and impact of psychosis. For this to be effective, dedicated CHR-P teams need to be integrated with EIP pathways and we can then move towards a coherent continuum of care: one that intervenes early, prevents earlier and promotes recovery across the lifespan.
Acknowledgements
D.O. is supported by the National Institute for Health and Care Research (NIHR) Oxford Health Biomedical Research Centre. P.F.-P. is supported by the NIHR Maudsley Biomedical Research Centre, NEXTGENERATIONEU, funded by the Ministry of University and Research, National Recovery and Resilience Plan, project MNESYS (no. PE0000006) – a multi-scale, integrated approach to the study of the nervous system in health and disease (no. DN. 1553 11.10.2022). The views expressed are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health and Social Care.
Author contributions
D.O. and P.F.-P. drafted the manuscript and revised the content.
Declaration of interest
P.F.-P. has received research funds or personal fees from Lundbeck, Angelini, Menarini, Sunovion, Boehringer Ingelheim, Mindstrong and Proxymm Science, outside the current study. D.O. reports no conflicts of interest.
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