Disrupting the status quo: is bolder action needed to tackle the complexity of psychosis risk and prevention?

Professor Kelleher's editorial raises important questions about the existing clinical high risk (CHR) model.^{Reference Kelleher1} Concluding, he rightly emphasises the need to build on the ‘bold’ ambition of the CHR model, which has helped transform the landscape of early intervention and prevention. But we question whether our allied fields in clinical and public mental health are being ‘bold’ enough in our efforts to tackle the complexity of psychosis risk and prevention.

There is a growing recognition that CHR services are not sufficiently identifying and engaging the breadth of young people most at risk of developing psychosis. One major limiting factor is that access to these services is typically predicated on help-seeking behaviours, disadvantaging many minoritised and marginalised groups, who are often less likely to seek help from services. These individuals are already exposed to many psychosis risk factors, including socioeconomic deprivation, childhood adversity, social exclusion, lower educational attainment, discrimination and racism.^{Reference Jongsma, Gayer-Anderson, Tarricone, Velthorst, van der Ven and Quattrone2} Indeed, several of the social determinants of psychosis (and other psychopathologies) are also likely to be the social determinants of mental health help-seeking.

Kelleher and colleagues recently demonstrated that 50% of eventual psychosis cases in a Finnish population had previously been in contact with child and adolescent mental health services (CAMHS), which, as argued, holds enormous potential for the future of psychosis prediction and prevention.^{Reference Lång, Ramsay, Yates, Veijola, Gyllenberg and Clarke3} Although we concur with this view, particularly given this advance over the dismal comparable figures for CHR approaches (between 4% and 14%),^{Reference Kelleher1} there is also a risk of overlooking the inherent problem of equitable access and engagement. Early positive engagement with services is essential for improved outcomes, but repeatedly we see more coercive, involuntary detentions in care pathways, or lack of sustained engagement with minoritised and marginalised groups. These stark inequalities are mirrored across our mental health services, not just in access to early intervention in psychosis services,^{Reference Morgan, Mallett, Hutchinson, Bagalkote, Morgan and Fearon4} but also for Black, Asian and other ethnic minority children entering CAMHS.^{Reference Edbrooke-Childs, Newman, Fleming, Deighton and Wolpert5} Unsurprisingly, these experiences are described as disempowering and, added to wider forms of psychosocial disempowerment, are likely to perpetuate a cycle of mistrust and disengagement with services.

To build on Desmond Tutu's influential quote, perhaps now is the time to stop pulling people from the river; we need to go upstream and find out why they are falling in. This will entail identifying and removing the structural, systemic and cultural barriers to equitable, timely access to mental health services – prioritising children and young people – and will require clinical and population-based interventions which disrupt the status quo.

Neither people nor psychosis develop in a vacuum, but little attention is given to the role of wider societal systems in the delivery of preventive interventions for psychosis. Schools, social care, and religious, community and charity organisations are often overlooked, despite their apparent advantages in being more accessible and more attuned to the needs of local communities. A cross-sector, integrated care systems approach, fostering engagement and collaboration with the wider community and partner organisations, could enhance equitable, early and more comprehensive risk identification, in turn maximising the preventive utility and value of the services we deliver.

In the UK, where the poverty gap is widening and services are struggling to meet demand, amid ever-tighter financial constraints, this ‘bold’ action is required more than ever. But, first, we need to instil trust in our communities to promote access and inclusion to better serve our young people and provide psychosis care and prevention that is equitable for all.