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Providing care to young people with emerging risk of psychosis: balancing potential risks and benefits

Patrick D McGorry*, Barnaby Nelson and Sherilyn Goldstone

Early detection and treatment of those demonstrating emerging risk of developing a psychotic disorder has the potential to considerably ameliorate the negative psychological and social consequences of these serious mental illnesses or, possibly, even prevent their development. Psychosis does not usually suddenly appear in people who have been perfectly well, although conversely it is now known that isolated psychotic-like symptoms are relatively common in nonhelp-seeking people, particularly children and adolescents. Over the last two decades, clinical and epidemiological studies have enabled the characterization of a persistent subthreshold or prepsychotic clinical stage of illness in which help-seeking often occurs, driven by distress and functional decline and which manifests a greatly increased risk for worsening of the psychotic dimension of symptoms, such that the threshold for diagnosis of the first-episode psychosis is reached. This advance and careful clinical research has allowed the development of evidence-based interventions designed to minimize the impact of the illness, which have now been tested in a series of clinical trials. It appears that there are real benefits in engaging people in care prior to the onset of frank psychosis; however, the type and sequence of interventions must be carefully followed so that the benefits always outweigh the risks. Specifically, antipsychotic medications should not be offered as a first-line therapy for such patients, since cognitive behavioral therapy and supportive needs-based case management, perhaps combined with omega‑3 fatty acids, represents a much safer initial approach.