Australian Clinical Guidelines For Early Psychosis PDF

Australian Clinical Guidelines
for Early Psychosis
Second edition
updated June 2016
Australian Clinical Guidelines
for Early Psychosis
Second edition
updated June 2016
© Orygen, The National Centre of Excellence Acknowledgements
in Youth Mental Health, 2016
Update to the Second Edition
This publication is copyright. Apart from use permitted
Many people have contributed to the development of this
under the Copyright Act 1968 and subsequent
update to the second edition of the Australian Clinical
amendments, no part may be reproduced, stored or
Guidelines for Early Psychosis, and a list of contributors
transmitted by any means without prior written permission
appears in the appendices. The specific team of writers
of Orygen.
responsible for the update were:
Anthony Couroupis
ISBN: 978-1-920718-38-1
Dr Shona Francey
Sarah Fraser
Disclaimer Krista Gregory
This information is provided for general educational and Heather Stavely
information purposes only. It is current as at the date of
publication and is intended to be relevant for all Australian From the Second Edition
states and territories (unless stated otherwise) and may The second edition of these guidelines has been long in
not be applicable in other jurisdictions. Any diagnosis and/ the making and a large number of people have assisted
or treatment decisions in respect of an individual patient in their development, review, editing and writing. A list
should be made based on your professional investigations of contributors is in the Appendices and we would like to
and opinions in the context of the clinical circumstances thank all our colleagues for their assistance in this task.
of the patient. To the extent permitted by law, Orygen,
The National Centre of Excellence in Youth Mental Health We specifically thank the project writers without whom
will not be liable for any loss or damage arising from your this project would not have been possible:
use of or reliance on this information. You rely on your Dr Catharine McNab (2009-2010)
own professional skill and judgement in conducting your Dr Darryl Wade (2004)
own health care practice. Orygen, The National Centre of Dr Helen Krstev (2000-2002)
Excellence in Youth Mental Health does not endorse or
recommend any products, treatments or services referred The editorial group
to in this information.
Professor Patrick McGorry
Simon Dodd
Suggested citation Associate Professor Rosemary Purcell
Early Psychosis Guidelines Writing Group and EPPIC Professor Alison Yung
National Support Program, Australian Clinical Guidelines Dr Andrew Thompson
for Early Psychosis, 2nd edition update, 2016, Orygen, The Dr Sherilyn Goldstone
National Centre of Excellence in Youth Mental Health, Associate Professor Eoin Killackey
Melbourne.
We would also like to acknowledge and thank
our clients and their families.
Orygen, The National Centre of Excellence
in Youth Mental Health
From the First Edition
Locked Bag 10 We would specifically like to acknowledge the support of
Parkville Vic 3052 the Mental Health Branch, Commonwealth Department
Australia of Health and Family Services through the National
Mental Health Strategy; particularly the efforts of Katy
orygen.org.au
Robinson and the late Charles Curran, in the completion
of these guidelines; and the support of each of the health
departments of the participating state and territory
governments.
The National Early Psychosis Project is indebted to the

many individuals and organisations who have provided
advice, assistance and comments which have enabled the
document to be developed to this point. These individuals,
groups and organisations are listed in the appendices. The
National Early Psychosis Project would also like to thank
Amanda Price for writing the Guidelines and Dominic Miller
and Jenny Mercer for their invaluable assistance in the
preparation of this manuscript.
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AUSTRALIAN CLINICAL GUIDELINES
FOR EARLY PSYCHOSIS
Contents Diversity and

specific populations 13
Aboriginal and Torres Strait Islander
List of recommendations 6 communities 13
Access to care 6 Culturally and linguistically
diverse communities 13
Assessment 6
Rural and remote populations 14
Treatment for early psychosis 7 LGBTIQ 14
Recommendations for the UHR phase 7 Homelessness 14
Recommendations for treatment
Abbreviations 15
of FEP: the acute phase 7
Recommendations for FEP treatment
in the early recovery phase 8
Recommendations for treatment Section 1.
of FEP relapse 8 Introduction 17
of FEP: incomplete recovery, medication What are clinical practice guidelines? 17
discontinuation and discharge 9
The initial guidelines and the rationale
Recommendations for early psychosis
for early intervention in psychotic disorders 17
treatment across all phases 9
Engagement 9 The need for the second edition 17
Physical health 9 Update to the Second Edition 18
Sexual health 10
Case management 10 The process, structure, and scope
Functional recovery 10
of the revised guidelines 19
Trauma 10 Process of guideline development 19
Integrated specialist treatment 10 Process of the update 19
Least restrictive treatment 11
Structure of the second edition 19
Family involvement 11
Structure of the update to the second edition 20
Goals to guide treatment 11
Group programs 11 Scope of the guidelines 20
Psychoeducation 12 Limitations of the Update to the
Suicide prevention 12 second edition guidelines 20
Substance use 12
Comorbidities 12
Miscellaneous therapies 13
Youth participation 13
Family participation 13
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FOR EARLY PSYCHOSIS
The nature of psychosis 20 Guideline 3. Treatment 49

Definitions 20 Guideline 3.1. Treatment guidelines
for the UHR phase 49
Aetiology 21
Background 49
Epidemiology 22
Psychological therapies for UHR 49
Course of illness 23 Medication 51
The clinical staging model 23 Integrated treatment 51
Stage 0: the premorbid phase 25 Recommendations 52
Stages 1a and 1b: the possible prodrome 26
Guideline 3.2. Treatment guidelines
Stage 2: the acute phase, recovery and for first episode psychosis 53
the ‘critical period’ 31
Guideline 3.2.1. The acute phase 53
Stage 3: late/incomplete recovery, relapse
Recommendations 65
with poor outcome, and the ‘critical period’. 32
Guideline 3.2.2. Early recovery 66
Stage 4: prolonged/treatment
refractory illness 34 Recommendations 69
Summary 34 Guideline 3.2.3. Relapse 69
Recommendations 70
Guideline 3.2.4. Late/incomplete recovery,
medication discontinuation, and discharge 70
Section 2. Recommendations 75
Clinical practice guidelines 37
Guideline 3.3. Early psychosis treatment
across all phases 75
Guideline 1. Access 37
Guideline 3.3.1. The importance
Background 37 of engagement 76
Recommendations 39 Recommendation 76
Guideline 3.3.2. Physical Health 76
Guideline 2. Assessment 40 Recommendations 79
Background 40 Guideline 3.3.3. Sexual health 79
Rapport and the timing of assessment 40 Recommendations 80
Guideline 3.3.4. Case management 80
Domains of psychiatric assessment
in early psychosis 40 Recommendations 83
Clinical and personal history 40 Guideline 3.3.5. Functional Recovery 83
Mental state examination 40 Recommendations 85
Biological assessment 41 Guideline 3.3.6. Trauma 85
Cognitive assessment 43 Recommendations 87
Assessment of comorbid disorders: Guideline 3.3.7. Integrated specialised
treatment in FEP 87
substance use 43
Recommendation 88
Assessment of other psychiatric disorders 43
Guideline 3.3.8. Use least restrictive
Risk assessment 44 treatment possible 89
Use of informants during assessment 46 Recommendations 89
Communication of rights and responsibilities 47 Guideline 3.3.9. Family involvement 90
Recommendations 48 Recommendations 92
Guideline 3.3.10. Goals as guides
to treatment 92
Recommendations 92
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FOR EARLY PSYCHOSIS
Guideline 3.3.11. Group programs 93 Appendices 109

Recommendations 93
Glossary of terms 109
Guideline 3.3.12. Psychoeducation 94
Recommendations 95 Contributors to the Second Edition Update 111
Guideline 3.3.13. Suicide prevention 95 Contributors to the Second Edition 111
Recommendations 96 Contributors to the First Edition 112
Guideline 3.3.14. Substance use
(including cigarette use) 96 References 113
Recommendations 98
Guideline 3.3.15. Treatment of
psychiatric comorbidity 98
Recommendations 99
Guideline 3.3.16. Miscellaneous
psychological therapies 99
Recommendations 100
Guideline 3.3.17. Youth participation
and peer support 100
Recommendations 101
Guideline 3.3.18. Family participation
and family peer support 101
Recommendations 102
Guideline 4. Diversity and specific

populations 102
Guideline 4.1. Aboriginal and Torres Strait
Islander communities 102
Background 102
Recommendations 103
Guideline 4.2. Culturally and linguistically
diverse communities 103
Background 103
Recommendations 104
Guideline 4.3. Rural and
remote populations 105
Background 105
Recommendations 105
Guideline 4.4. LGBTIQ – Same-sex
attracted and gender diverse 106
Background 106
Recommendations 107
Guideline 4.5. Young people experiencing
homelessness 107
Background 107
Recommendations 108
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FOR EARLY PSYCHOSIS
List of recommendations
Access to care 1.3.3 Undergraduate and postgraduate medical

education should be developed to allow for better
1.1 Mental health services should be accessible training in assessment and treatment of emerging
and provide a timely assessment for people mental illness.
experiencing their first episode of psychosis.
1.3.4 Close links should be developed between
1.2 Enhancing help seeking: primary and specialist mental health services to
facilitate assessment and treatment of emerging
1.2.1 Mental health services should provide mental illness.
education about early intervention to families and
the wider community. The community needs to 1.4 Enhance connection to appropriate services:
be well informed about psychotic disorders and
1.4.1 Specialist early detection teams should be set
how to obtain effective help. Community-wide
up to enable timely access to care.
initiatives to increase knowledge and reduce
the stigma associated with psychosis should be 1.4.2 The means to access the service and the
implemented. hours of operation should be promoted and
advertised to the community.
1.3 Enhance professional identification of
psychotic symptoms: 1.4.3 The mental health service should be
accessible 24 hours/day, 7 days/week.
1.3.1 Primary health care professionals should be
competent in eliciting and recognising the early 1.4.4 The service should accept potential new
clinical features of psychotic disorders referrals from a wide range of individuals, family
and friends, and primary care services. A low
1.3.2 Primary care professionals should be trained
threshold for expert assessment should be set for
in identifying psychosis and given information
any person suspected of developing a psychotic
about how to refer to specialist services.
disorder for the first time.
Assessment 2.4.1 Assessment of the personal context of illness

should include: developing an understanding of
2.1 Assessment begins therapeutic engagement the longitudinal course of symptoms and how
and treatment, so establishing rapport should be they are regarded by the young person; and the
a priority. young person’s strengths, resources (including
family resources), and skills in managing these
2.2 Assessment is an ongoing process, not just symptoms specifically and other stressors more
restricted to initial entry into service. broadly.
2.3 Assessments should occur as soon as 2.4.2 Mental state examination, assessing
practicable after referral, and within 48 hours in signs, symptoms, and insight, is aided by an
the case of suspected FEP. antipsychotic-free period of assessment.
2.4 All young people presenting with possible 2.4.3 Physical examination, including baseline
psychosis should have a comprehensive assessment of metabolic functioning (see
biopsychosocial assessment by an acute Guideline 3.3.2) and related lifestyle factors
treating team. This should include: developing (such as diet and exercise) should occur to rule
an understanding of the personal context of out an organic basis to illness, guide appropriate
illness and developing a case formulation; mental treatment, and enable monitoring of side effects.
state examination; physical examination and Basic metabolic monitoring should be ongoing and
investigations; cognitive assessment; assessment include regular weight and waist circumference
for comorbid disorders; and risk assessment. measurement.
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FOR EARLY PSYCHOSIS
2.4.4 Assessment for comorbid disorders should 2.5 Where possible, informants (particularly
include thorough and regular assessment of referrers, but also other key members of the
substance use (including cigarette use) and other young person’s social networks) should be drawn
psychiatric disorders. upon as valuable sources of information about
the trajectory and nature of the young person’s
2.4.5 Risk assessment
difficulties. Assessment should also consider
2.4.5.1 Risk assessment should be undertaken needs of the family, their knowledge of psychosis,
and documented at each visit, and should include the impact of psychosis on the family, and their
routine assessment of depressive symptoms, strengths and coping resources.
hopelessness, suicidal intent, the effect of
2.6 Feedback regarding assessment (particularly
returning insight, and the role of psychotic
provisional diagnoses and possible formulation of
features on mood.
the young person’s difficulties) should be provided
2.4.5.2 Risk assessment should take into account to the young person, and to referrers and GPs,
the fluctuating nature of suicidality in young and, where appropriate, to other key supports of
people. the young person.
2.4.5.3 Risk assessment should also include 2.7 Rights, responsibilities and information about
assessment of risk to others, risk attributable the treatments and services available within the
to neglect and victimisation by others, and service should be communicated to young people
risk of non-adherence to treatment (including and their key supports within 48 hours of entry to
absconding). the service.
Treatment for early psychosis 3.1.7 Supportive counselling alone may improve
social functioning in the pre-onset phase.
Recommendations for the UHR phase 3.1.8 Antipsychotic medications should not
3.1.1 The possibility of psychotic disorder should normally be prescribed unless at least 1 week
be considered for anyone who is experiencing of frank positive psychotic symptoms have
unexplained functional decline. been sustained. The exception may be where
briefer or milder positive symptoms are directly
3.1.2 If subthreshold psychotic features combined associated with risk of self-harm or aggression.
with the onset of disability indicating ultra high E.g. in substance-related psychotic disorder, or
risk are present, the individual and their relatives when subthreshold positive psychotic symptoms
should be assessed and mental state and safety persist in the face of CBT and other psychosocial
monitored regularly (every 2–4 weeks) in a treatments and are causing distress and or
context of ongoing support. CBT is the preferred disability.
intervention.
3.1.9 Omega-3 fatty acids may delay or prevent
3.1.3 Information about the level of risk should transitions to psychosis.
be carefully provided taking into account social,
educational and cultural factors. Recommendations for treatment of
3.1.4 Syndromes such as depression and FEP: the acute phase
substance use, and problem areas such as 3.2.1.1 All young people with first episode
interpersonal, vocational and family stress, should psychosis should be seen by a doctor within 48
be appropriately managed. hours after entry into the early psychosis service.
3.1.5 CBT may reduce psychotic symptomatology 3.2.1.2 All young people should be seen by a
and prevent or delay transition to psychosis in the consultant psychiatrist within one week after
pre-onset phase. entry to service.
3.1.6 CBT may improve social functioning in the
pre-onset phase.
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FOR EARLY PSYCHOSIS
3.2.1.3. All young people should be seen at least 3.2.1.15 With the exception of the above situations,
twice-weekly in the acute phase by the acute polypharmacy should be avoided, specifically the
treating team, or case manager, and a doctor. use of multiple antipsychotics.
3.2.1.4 All families should be seen or contacted 3.2.1.16 CBT, supportive therapy, or befriending
at least weekly in the acute phase by the acute should be provided during the acute phase, with
treating team or case manager. CBT having the most immediate benefit.
3.2.1.5 Antipsychotic medication should not be

Recommendations for FEP treatment
used during the first 24–48 hours of treatment in
young people with first episode of psychosis, to
in the early recovery phase
facilitate assessment. 3.2.2.1 Treatment response and adherence should
be regularly reviewed. All young people with early
3.2.1.6 SGAs should be used in preference to
psychosis should be seen at least weekly by a case
FGAs.
manager, and at least fortnightly by a doctor, in
3.2.1.7 Side effect profile should guide choice of the early recovery phase.
SGA.
3.2.2.2 All families should be seen or contacted at
3.2.1.8 Potential side effects (including metabolic least fortnightly during the early recovery phase.
side effects, weight gain, extrapyramidal motor
3.2.2.3 Early response to antipsychotic medication
symptoms, and sexual side effects) should be
should be considered as a prognostic sign.
noted and discussed with young people within
a shared decision making approach, prior to 3.2.2.4 CBT interventions may be indicated in this
pharmacotherapy commencement, and then group, as it may speed up recovery, reduce period
monitored, managed and addressed early, with of hospitalisation, enhance short-term adaptation
a prevention model if possible (e.g., weight to illness, reduce positive symptoms, and improve
management strategies implemented prior to personal goal attainment.
treatment initiation).
3.2.2.5 The possibility of relapse should be
3.2.1.9 Affective and non-affective psychosis discussed with young people and their families,
should be distinguished to enable appropriate along with education regarding early warning
treatment (i.e., appropriateness of use of a mood signs and the development of a ‘relapse action’
stabiliser). plan.
3.2.1.10 Pharmacological treatment should
proceed with a ‘start low, go slow’ approach.
of FEP relapse
3.2.1.11 Adherence should be monitored and
explicitly addressed where necessary. 3.2.3.1 Medication should be recommenced or
increased at early signs of relapse.
3.2.1.12 Long-acting injectable antipsychotic
medications may be offered as an alternative to 3.2.3.2 The advantages of maintenance
oral medication within a shared decision making antipsychotic therapy in relapse prevention should
approach in which young people are fully informed be weighed against any impact of side effects on
about, and collaborate in treatment decisions. functioning.
3.2.1.13 Benzodiazepines may be a useful adjunct 3.2.3.3 Relapse prevention strategies (including
in florid psychosis for sedation. more regular review and provision of information
about rapid access to care) are particularly
3.2.1.14 Treatment of the primary psychotic indicated if medication dosages are decreased or
disorder should be prioritised unless comorbidity medication ceased.
leads to high levels of risk to self or others or
clinical judgement considers that the comorbidity 3.2.3.4 Specialised FEP interventions and
has a major impact on the primary psychotic combined family and individual CBT specifically
disorder (e.g., cannabis dependence). focusing on preventing relapse should be used.
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FOR EARLY PSYCHOSIS
Recommendations for treatment of 3.2.4.6 CBT should be considered as an adjunctive

FEP: incomplete recovery, medication therapy during late/problematic recovery.
discontinuation and discharge 3.2.4.7 Families of young people with a slow or
difficult recovery or frequent relapses may benefit
3.2.4.1 All young people being treated should be
from more intensive and structured interventions,
seen at least fortnightly by a case manager, and at
emphasising problem solving and communication
least monthly by a doctor, during the late recovery
skills.
phase.
3.2.4.8 Young people with early psychosis should
3.2.4.2 All families should be seen or contacted at
have their risk regularly reviewed by clinicians,
least 2-monthly by the treating team during the
particularly during transitions from acute care and
late recovery phase.
at discharge from the service.
3.2.4.3 People with persisting positive or negative
3.2.4.9 Clinicians should clearly communicate and
symptoms should be identified early.
document a discharge plan that is shared with
3.2.4.4 Clozapine should be considered for those the young person, their family, their GP and the
who have not responded to adequate trials of two new service provider at least 3 months prior to
antipsychotic medications, of which one is a SGA. discharge.
3.2.4.5 After resolution of positive psychotic 3.2.4.10 Clinicians should assist young people in
symptoms, antipsychotic medication may be their care with orientation and engagement with
continued for 12 months or more. A shared future treatment providers, including a visit and
decision making approach and a comprehensive clinical handover to the designated clinician, such
evaluation of the risks and benefits of ongoing as a GP, or other mental health service clinician.
medication in each particular case should inform
treatment decisions.
Recommendations for early motor symptoms, and sexual side effects) should
be noted and discussed with people prior to their
psychosis treatment across all commencing pharmacotherapy. Such effects
phases should be monitored, managed and addressed
early, with a prevention model if possible (e.g.,
Engagement weight management strategies implemented prior
to treatment initiation) .
3.3.1.1 Engagement should be prioritised as the
foundation of early psychosis treatment. 3.3.2.4 Structured behavioural lifestyle
interventions should be implemented to improve
Physical health physical health outcomes for people with early
psychosis.
3.3.2.1 Routine metabolic screening should
guide intervention, and prevention of physical 3.3.2.5 Tobacco cessation should be offered
ill-health must be prioritised as part of routine routinely to young people with early psychosis.
early psychosis treatment (see http://www.heti. 3.3.2.6 Oral health assessment should form a part
nsw.gov.au for adolescent cardiometabolic health of routine assessment using standard checklists
screening protocol) that can be completed by non-dental personnel.
3.3.2.2 Cardiometabolic screening should occur 3.3.2.7 Where lifestyle interventions prove
on entry into service, after medication changes, ineffective after at least 3 months, consider
repeated at 1-month and monitored at least every specific pharmacological interventions (e.g.,
3 months. Initial screening points should be metformin, antihypertensive treatment, statins)
repeated after any medication changes.
3.3.2.3 Potential physical side effects (including

metabolic side effects, weight gain, extrapyramidal
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FOR EARLY PSYCHOSIS
Sexual health 3.3.5.2 Clinicians should promote functional

recovery by directly implementing interventions
3.3.3.1 Clinicians need to be aware and informed and coordinating care in services.
of sexual health issues and potential dysfunction
in early psychosis populations. 3.3.5.3 Clinicians should facilitate access to
educational and vocational services to the FEP and
3.3.3.2 Clinicians should inform young people pre-onset groups
experiencing sexual dysfunction that sexual
difficulties are also common in the general 3.3.5.4 Employment and educational consultants
population. should be integrated within FEP services as much
as possible.
3.3.3.3 Clinicians should assess baseline sexual
functioning to monitor sexual related side effects 3.3.5.5 Employment services for people with FEP
of antipsychotic treatment. should be consistent with an individual placement
and support model.
3.3.3.4 Clinicians should be aware that use
a standardised assessment instrument may 3.3.5.6 Vocational goals should be formulated in
facilitate open communication about sexual collaboration with the individual being treated,
functioning. be developmentally appropriate and may include
education and training.
3.3.3.5 Clinicians should focus on risk-reduction
interventions such as condom use 3.3.5.7 Cognitive remediation programs and/or
cognitive adaptation strategies should be offered
Case management to young people who have cognitive deficits that
interfere with functional recovery.
3.3.4.1 The case manager or treating clinician
coordinates each individual’s treatment and care Trauma
throughout their episode of care.
3.3.6.1 Early psychosis clinicians should develop
3.3.4.2 The case manager should be present at a rapport with young people with early psychosis
medical appointments to ensure continuity of and then sensitively assess their current trauma
care. and trauma history. This includes the experience
3.3.4.3 A case formulation, including provisional of having a psychotic episode. This assessment
diagnosis and management plan, should be should be incorporated into psychological
completed by case managers and/or treating team treatment plans.
within 6 weeks of discharge from acute treatment. 3.3.6.2 Early psychosis services should have
3.3.4.4 Case managers should facilitate a policies in place to deal with reports or situations
person’s access to the necessary accommodation, of ongoing trauma.
vocational, recreational, welfare and primary 3.3.6.3 Clinicians should seek training, support
health services. and supervision as required for this work.
3.3.4.5 Case managers should regularly consult 3.3.6.4 Clinicians should be mindful of the
with individuals’ GPs, at least every 6 months. increased likelihood of depression and anxiety that
3.3.4.6 Case managers should utilise shared accompanies exposure to trauma, and treat these
decision making, a strengths-based and recovery accordingly.
approach to case management. 3.3.6.5 Trauma-focused psychological
interventions may be effective in reducing PTSD
Functional recovery and psychotic symptoms in young people with
3.3.5.1 Treatment of early psychosis should give psychosis.
equal weight to both symptomatic and functional
recovery. Clinicians should focus on remission of Integrated specialist treatment
symptoms and also prioritise functional recovery 3.3.7.1 Integrated specialist services are more
assessment of a young person’s functional effective than standard services in the treatment
capacities, performance and needs. of people with FEP.
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FOR EARLY PSYCHOSIS
Least restrictive treatment by helping the family, where necessary, develop

skills in problem solving and enhanced coping
3.3.8.1 People with early psychosis should receive strategies.
treatment in the least restrictive manner possible.
Whenever possible, the location of the initial 3.3.9.5 The treating clinician should maximise
assessment should be community-based and at the responsiveness of the family to early warning
a place that is convenient to the person and their signs in order to facilitate relapse prevention.
family.
3.3.9.6 Where necessary, the clinician should
3.3.8.2 A range of treatment settings should prepare the family to deal with crises.
be available to people, including home-based
3.3.9.7 Family peer support workers may be a
support, supported accommodation, rooming in,
useful resource for information and emotional
outpatient services, and inpatient care.
support, particularly in situations when an
3.3.8.3 The levels of risk (to self and others), individual being treated does not support the
the available resources (including community involvement of the family.
support) and the needs of the individual and their
3.3.9.8 Families with more complex needs, such as
family should be assessed to determine whether
those with a history of sexual and/or other abuse
the individual can be managed at home.
or long-standing emotional conflict, may need to
3.3.8.4 Where hospitalisation is required, people be referred to specialist agencies.
should be admitted to a facility that can cater
3.3.9.9 Early psychosis services should endeavour
for, and is appropriate to, their age and stage of
to establish a family peer support component
illness. Where streaming is not possible, a special
within their service.
section may be created in a general acute unit for
young people with recent-onset psychosis.
Goals to guide treatment
3.3.8.5 Community treatment orders should be
3.3.10.1 Both the case manager and treating doctor
used for the minimum duration required to meet
should meet with the individual being treated
specified treatment goals.
and, where possible, their family, and develop an
3.3.8.6 Involvement of police to enforce treatment individual service plan within 4–6 weeks after
should be kept to a minimum and used as a last entry to a service.
resort in the case of immediate risk.
3.3.10.2 The case manager should regularly review
3.3.8.7 The use of seclusion (if used at all) should the individual service plan with the individual.
be kept to the minimum frequency and duration to
meet the treatment aims when managing people Group programs
who are high-risk.
3.3.11.1 Group programs should be offered to those
with FEP and at UHR.
Family involvement
3.3.11.2 Group programs should be available in a
3.3.9.1 The needs of individual family members
range of clinical and community settings.
should be recognised and addressed (where
appropriate, within clinical services, or 3.3.11.3 Group programs should be tailored to the
alternatively, by referral to external agencies) at all different needs of people at different phases of
stages of a person’s recovery. illness.
3.3.9.2 The case manager should have frequent 3.3.11.4 Decisions about participation in any group
contact relevant to the phase of illness and the program should be made collaboratively with
needs of the individual and their family. the individual, based on an understanding of the
potential benefits for that person.
3.3.9.3 Family attendance and involvement should
be reviewed as part of the clinical review process. 3.3.11.5 Goals should be set collaboratively and
progress of participants towards these goals
3.3.9.4 The treating clinician should assist the
should be regularly reviewed.
family by providing information about psychotic
disorders (including the recovery process) and
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FOR EARLY PSYCHOSIS
3.3.11.6 The development of group programs 3.3.14.2 Treatment of psychosis and comorbid
should be based on a thorough planning process substance use (including tobacco use) should be
which includes needs assessment, the setting integrated.
of objectives, development of content areas and
3.3.14.3 Acceptance policies should be inclusive of
establishment of evaluation strategies.
individuals with comorbid substance use.
3.3.11.7 Where appropriate, group program
3.3.14.4 Policies and procedures should be
staff should assist people to find meaningful
developed regarding substance use and its
psychosocial activities (such as other groups/
behavioural consequences, including the
activities) external to clinical services.
possibility of substance use while within the
3.3.11.8 There should be an effective clinical service.
interface between the group program and the case
3.3.14.5 Services should develop minimum
manager (or treating clinician) or multidisciplinary
standards for clinicians regarding their knowledge
team.
about the assessment and integrated treatment of
substance use.
Psychoeducation
3.3.14.6 Where appropriate, clinicians should
3.3.12.1 Psychoeducation should be provided for
have access to specialist consultation to
people with early psychosis and their families.
provide assessment, supervision, advice or co-
3.3.12.2 The case manager and the treating management for comorbid substance misuse
doctor are responsible for ensuring access to (including tobacco use).
psychoeducation.
3.3.14.7 Where people are receiving treatment
3.3.12.3 Psychoeducational material should within a drug treatment service, clinicians should
be appropriate for young people and for early actively collaborate and communicate about the
psychosis. individual treatment plan.
3.3.12.4 Psychoeducation and support should be 3.3.14.8 Individual treatment plans should
provided to the individual and their family on an routinely include additional treatment goals
initial, continuing and ‘as needed’ basis through relevant to substance use.
individual work, group programs and a consumer
3.3.14.9 Support should be offered to family and
support groups or a family participation program.
friends, including psychoeducation on comorbid
3.3.12.5 People and families of a culturally or mental illness and substance use.
linguistically diverse background should have
3.3.14.10 Discharge planning should include
access to information in their own language, using
attention to ongoing treatment of substance use.
interpreters where appropriate.
Suicide prevention Comorbidities

3.3.15.1 All people with early psychosis, regardless
3.3.13.1 Intensive treatment should be provided
of comorbidities should receive treatment from
during high-risk phases of illness.
early psychosis services.
3.3.13.2 Services should develop and implement
3.3.15.2 Clinicians should conduct comprehensive
appropriate, evidence-based interventions for
assessment of comorbidities and consider the
deliberate self-harm. The LifeSPAN program is
impact of these, and adapt early psychosis
likely to be of some benefit for suicidal individuals.
treatment as appropriate.
3.3.13.3 SGAs, especially clozapine may be useful
3.3.15.3 Treatment of psychiatric comorbidity
for suicidality.
should be conducted in a consistent manner with
available clinical guidelines.
Substance use
3.3.15.4 Although treatment of psychosis often
3.3.14.1 Psychoeducation and CBT may help
remains paramount, the sequencing of treatment
reduce substance use in those in the pre-onset
of comorbid conditions should be driven by the
phase and with FEP.
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FOR EARLY PSYCHOSIS
symptoms/disorder that is most distressing/ outset, and based on the needs and interests of
disabling and whether it poses further risks to the young people.
person being treated or others.
to establish a peer support component within
Miscellaneous therapies
their service.
3.3.16 Milieu therapy, supportive psychodynamic
therapy, and cognitive remediation therapy may Family participation
be useful in treating symptoms and/or improving
functioning in FEP.
within their service.
Youth participation
3.3.18.2 Families participating in the service
3.3.17.1 The culture of an early psychosis
should receive some payment, and funding should
organisation should respect young people and
be available to allow family peer support workers
encourage their input.
to acquire any specialist skills that they may need
3.3.17.2 All youth participation initiatives should in their role. Family peers support workers should
be jointly planned with young people from the also receive training, ongoing supervision and
support from a clinical mentor.
Diversity and Culturally and linguistically

specific populations diverse communities
4.2.1 People with early psychosis or family
Aboriginal and Torres Strait Islander members who cannot speak English, or who
communities speak limited English, should be able to access
professional interpreting and translating services.
4.1.1 Clinicians should be especially alert to the
side effects of antipsychotics when working with 4.2.2 Clinicians should refer to appropriate
people from Aboriginal and Torres Strait Islander guidelines when working with interpreters and
communities. have training and support for this work.
4.1.2 Indigenous health or mental health 4.2.3 Clinicians should seek education and advice
practitioners should be involved in the assessment about the cultures of the young people and
and treatment of Indigenous people with emerging families that they work with in order to practice
psychosis to facilitate engagement and reduce in culturally-sensitive ways. They should seek
stigma. training, and supervision for this work and be
supported in this by their early psychosis service.
4.1.3 Clinicians should practice in a manner
consistent with relevant guidelines on working
with people from Aboriginal and Torres Strait
Islander communities (e.g., Aboriginal Mental
Health First Aid Training and Research Program,
2008).
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FOR EARLY PSYCHOSIS
Rural and remote populations Homelessness

4.3.1 Early psychosis prevention and intervention 4.5.1 Early psychosis clinicians should recognise
information should be readily available at key that stable, secure and appropriate housing is
locations in rural and remote areas, for example in essential to recovery from mental illness and the
GPs’ waiting rooms and community centres. maintenance of wellness.
4.3.2 Mental health services should provide 4.5.2 Early psychosis clinicians should recognise
tertiary consultation and education services to risk factors for homelessness in people with early
health practitioners in rural and remote areas. psychosis in order to intervene early.
4.3.3 Telepsychiatry and other technological 4.5.3 Early psychosis services should partner and
facilities should be made available to mental collaborate with youth homelessness services
health practitioners in rural and remote areas to in order to facilitate access to services and
facilitate links with early psychosis services. These co‑ordinated care.
should not, however, be seen as a replacement for
4.5.4 Early psychosis clinicians should focus on
visiting specialists.
the development of independent living skills in
their young people with early psychosis.
LGBTIQ
4.5.5 Early psychosis clinicians should work on
4.4.1 Clinicians should avoid assuming what
maintaining and improving familial relationships
a young person’s gender identity or sexual
even if a young person is homeless.
attraction is. This should be ascertained as part of
a comprehensive mental health assessment.
4.4.2 Clinicians should pay careful attention to

risk and its assessment in LGBTIQ people.
4.4.3 Clinicians should identify and address

stressors that LGBTIQ young people have that
also comprise risk factors for psychosis (i.e., by
referring to specialised LGBTIQ services, building
coping strategies and resilience in response to
potential bullying, discrimination, and trauma).
4.4.4 LGBTIQ young people should be linked

with supportive communities, and group support
networks.
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FOR EARLY PSYCHOSIS
Abbreviations
Abbreviation Definition Abbreviation Definition
ARMS At risk mental state of psychosis IMI Intramuscular injection
BLIPS Brief limited intermittent psychotic LEO Lambeth Early Onset
symptoms
CAARMS Comprehensive Assessment of At LGBTIQ Lesbian, Gay, Bisexual, Transgender,
Risk Mental State Intersex, Queer
CALD Culturally and linguistically diverse MHS Mental health services
CAT Cognitive analytic therapy MSE Mental state examination
CBT Cognitive–behavioural therapy NEPP National Early Psychosis Project
COPE Cognitively oriented psychotherapy NESB Non-English speaking background
in early psychosis
CPT Cognitive processing therapy OCD Obsessive compulsive disorder
CRT Cognitive remediation therapy PACE Personal Assessment and Crisis
Evaluation
DSM-IV Diagnostic and Statistical Manual of PE Prolonged exposure
Mental Disorders – 4th Edition
DSM 5 Diagnostic and Statistical Manual of PTSD Post-traumatic stress disorder
Mental Disorders – 5th Edition
DUI Duration of untreated illness RAISE Recovery after initial schizophrenia
episode
DUP Duration of untreated psychosis RCT Randomised controlled trial
ECT Electroconvulsive therapy SD Sexual dysfunction
EE Expressed emotion SGA Second-generation antipsychotics
EMDR Eye-movement desensitisation SoCRATES Study of cognitive realignment
reprocessing therapy in early schizophrenia
EPPIC Early Psychosis Prevention and SOS Start over and survive
Intervention Centre Melbourne
EPS Extrapyramidal side effects STI Sexually transmitted infection
EPMS Extrapyramidal motor symptoms STOPP Systematic Treatment of Persistent
Psychosis
FEP First episode psychosis TAU Treatment as usual
FGA First-generation antipsychotics TFCBT Treatment-focused CBT
GRIP Graduated recovery intervention UHR Ultra high risk of psychosis
program
ICD10 International Classification of
Diseases – 10th Edition
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FOR EARLY PSYCHOSIS
Section 1.
Introduction
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FOR EARLY PSYCHOSIS
Section 1.
Introduction
What are clinical practice • it was thought that early intervention would
reduce the duration of untreated psychosis
guidelines? (DUP), one of the few obviously malleable
Clinical practice guidelines are defined as candidate risk factors for poor outcome
systematically developed statements, based on • it was proposed to be associated with better
the best available evidence, to assist practitioners outcome in the short-term, perhaps because of
and clients to make decisions about appropriate an effect it may have on DUP
health care. They form part of the larger model • it was believed to be cost-effective, and
of evidence-based practice, which integrates the • in the case of the putative prodrome, it was
best available evidence, clinician expertise, and thought early intervention might prevent onset
client preferences. of psychotic disorder.
The initial guidelines and the The need for the second edition
rationale for early intervention in
psychotic disorders Significant changes have occurred since the
development of the initial guidelines. There
The initial guidelines were developed in response is increasing evidence demonstrating the
to growing research and clinical interest in a effectiveness of early intervention in psychotic
model of psychosis that challenged the pessimism disorders. Now, many of the proposals of the early
prevailing at the time regarding the prognosis proponents of early intervention are supported by
of people with psychosis. This earlier model a more substantial evidence base. For example,
developed from the Kraepelinian concept that it is now clear that DUP is related to outcome in
true psychotic disorder was degenerative, and first episode psychosis, with longer DUP being
therefore could only be validly characterised by related to short-term factors such as slower
poor outcome [12, 15]. The alternative model and less complete recovery, poorer response
advocates that young people should receive timely to antipsychotics, interference with social and
and comprehensive intervention during the critical psychological development, and an increased
years following onset, and that ‘withholding risk of relapse [16-21] and likely medium-term
treatment until severe and less reversible outcome [22, 23]. Early intervention does reduce
symptomatic and functional impairment have DUP [24], is associated with better short-term
become entrenched represents a failure of care’ outcome, and appears to be more cost-effective
(McGorry et al., 2008, p. 148 [15]). Specifically, than standard services [23, 25, 26]. Additionally,
the model proposed in the first edition of the empirical evidence now suggests that intervention
guidelines suggested that intervening early in the during the putative prodrome may prevent or
course of acute psychosis is crucial for a number delay transition to psychosis [27-29]. New
of reasons: guidelines are therefore required that reflect these
• it enables timely reduction of distressing developments.
experiences This additional evidence has prompted
widespread national and international efforts for
reform in services and treatment approaches for
early psychosis [30, 31]. There are now close to
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FOR EARLY PSYCHOSIS
200 early intervention centres worldwide, which reviews of the available evidence from randomised
focus on the special needs of young people and controlled trials for treating individuals with
their families [32, 33]. Clinical practice guidelines early psychosis (i.e., level I evidence). Where
relating to assessment and treatment of early such systematic evidence is not available, lower
psychosis now exist in a number of countries (e.g., order evidence has been used. We are aware that
Canada, the UK, the US), and international clinical evidence does not exist regarding all domains of
practice guidelines and a consensus statement treatment in early psychosis, and the absence
have been published [33, 34]. The International of this evidence does not necessarily mean
Early Psychosis Association (IEPA) reflects practices or interventions are ineffective. In partial
this groundswell of support for the continued recognition of this, in the absence of any evidence
exploration of an evidence-based adoption base, guidelines that reflect good practice
of principles of early intervention. Given the according to expert consensus (as reflected in
increasing interest in early intervention models, other guidelines, such as the previous edition of
further services are likely to develop, rendering it these guidelines or the WHO/IEPA consensus
appropriate to provide guidelines for best clinical statement [34]) are given the designation ‘GPP’
practice and service development based on the (good practice point).
experiences of existing services.
The National Health and Medical Research Update to the second edition
Council (NHMRC) have also, since the last
guidelines, updated their designation of levels of Early psychosis services and the evidence base
evidence, as outlined in Table 1. More broadly, the supporting the early intervention approach have
NHMRC has created ‘grades’ of recommendations continued to grow since the second edition of
which take into account not only the evidence the Australian Clinical Guidelines for Early Psychosis
base (quantity and quality), but also the was published in 2010. With further expansion
consistency of the findings that constitute the of early psychosis services both nationally
evidence base, the clinical impact of findings, the and internationally and the development of
generalisability of findings to all those to whom educational resources to support this, it is timely
the guidelines are likely to be applied, and their to update the second edition of the guidelines. The
applicability to the Australian health care context development of these resources and the needs
[35]. This edition of the guidelines therefore of new services identified some new areas for
makes reference to these grades (as outlined in guideline development and some areas in need of
Table 2) when making any recommendations. updating. This update has been produced as an
interim measure prior to the expected release of a
The following recommendations are based,
complete new third edition.
where possible, on meta-analyses or systematic
Table 1. Levels of evidence ratings (NHMRC, 1998)
NHMRC Level Basis of evidence
I Evidence obtained from a systematic review of all relevant randomised controlled trials
II Evidence obtained from at least one properly designed randomised controlled trial
III – 1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate

allocation or some other method)
III – 2 Evidence obtained from comparative studies (including systematic reviews of such
studies) with concurrent controls and allocation not randomised, cohort studies, case-
control studies, or interrupted time series with a control group
III – 3 Evidence obtained from comparative studies with historical control, two or more single arm
studies, or interrupted time series without a parallel group
IV Evidence obtained from case series, either post-test or pre-test/post-test

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FOR EARLY PSYCHOSIS
Table 2. NHMRC grades of recommendation
Grade of recommendation Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provided some support for recommendation but care should
be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
The process, structure, Process of the update

and scope of the revised Many experts (see ‘List of Contributors’ on page
guidelines 111) have been consulted and extensive literature
reviews have been completed in the development
Process of guideline development of material included in this update to the second
edition. However, systematic reviews of the
The original guidelines were developed to literature have not been undertaken and it is
address clinical ‘best practice’ in early psychosis possible that recent evidence in some areas has
prevention and intervention. A working group not been included. Systematic reviews of relevant
comprising the state and territory coordinators of databases will be conducted in the preparation
the National Early Psychosis Project (NEPP), the of the third edition of the Australian Clinical
national project manager and the project director, Guidelines for Early Psychosis, for which planning
convened to determine the content of the clinical has commenced.
practice guidelines.
The development process involved:

Structure of the second edition
1. initial drafting of the guidelines. This was
performed by a consultant in conjunction The format of the guidelines follows the access,
with the NEPP Working Group, a number of assessment, and treatment phases of service
expert consultants with clinical and research engagement. Guidelines relating to access and
experience, state-based steering committees engagement are broadly similar across the ultra
and individuals in the field high risk (UHR) and first-episode stages. However,
2. development and dissemination of the draft some treatment guidelines are specific to the
for national consultation. State and territory UHR stage and others to the period after the
coordinators were responsible for distributing onset of psychosis. Treatment guidelines may
the document to key stakeholders in mental also be specific to the various stages after the
health and early psychosis onset of frank psychosis. Other issues are likely to
3. integration of reviewers’ comments into the be relevant regardless of whether someone is at
document and the preparation of the final draft. risk of developing psychosis or has experienced
frank psychosis. For these reasons, treatment
The first phase of the revision process ensured guidelines are first presented with respect to the
that the Australian guidelines were consistent ultra high risk period, and then guidelines relating
with the International Clinical Practice Guidelines to the various stages of illness post-onset are
for Early Psychosis [33]. The second phase of the outlined. The final treatment guidelines are those
revision process involved a literature review, that apply across all stages of illness, including the
focusing on publications since 1998. This literature UHR stage.
review used the following databases: Medline,
PsychINFO, and the Cochrane Library. Searches Issues relevant to specific populations (e.g.,
were restricted to publications in English. culturally and linguistically diverse groups, rural
and remote communities) are addressed in their
own sections. Each section has introductory
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FOR EARLY PSYCHOSIS
information, and then specific recommendations, fast rules, and should be used together with the
accompanied by the level of evidence on which preferences of the person receiving treatment
they are based. and the clinical judgement of the clinician.
Structure of the update to the Limitations of the update to the

second edition second edition guidelines
The update to the second edition largely These guidelines are limited primarily
retains the structure of the second edition and by a focus on English-language evidence
introduces new sections. Guidelines 3.3 (‘General published prior to April 2016. It is possible
principles regardless of FEP stage’) and 3.4 that incorporating unpublished evidence or
(‘General principles related to treatment in early evidence in other languages may have altered our
intervention for psychotic disorders’) have been recommendations.
collapsed into one Guideline 3.3, titled, ‘Early
psychosis treatment across all phases’.
Guideline 4, ‘Specific populations’, now contains The nature of psychosis

two additional guidelines: ‘LGBTIQ – same sex-
attracted and gender diverse’ and ‘Young people
Definitions
experiencing homelessness’. A comprehensive
Psychosis refers to symptoms in which there
review of the existing sections of Guideline 4 was
is misinterpretation and misapprehension of
considered beyond the scope of this update and
the nature of reality, for example disturbances
will be conducted for the next edition.
in perception (hallucinations), disturbances of
Other new guidelines included in the update belief and interpretation of the environment
are: ‘Physical health’, ‘Sexual health’, ‘Functional (delusions), and disorganised speech patterns
recovery’, ‘Discharge planning’ and ‘Shared (thought disorder). Psychotic symptoms need to be
decision making’. Other sections have been distinguished from psychotic disorder, as outlined
updated as required. below. Diagnostic classification systems (e.g., the
American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, or DSM-5
Scope of the guidelines [36]; International Statistical Classification of
Diseases and Related Health Problems, or ICD
These guidelines have been developed as an [37]) generally list specific psychotic disorders
evidence-based resource for mental health rather than psychosis or psychotic disorder more
practitioners who treat people experiencing early broadly. The DSM, for example, identifies the
psychosis. It may also be used as a reference psychoses as schizophrenia, schizophreniform
for individuals outside specialist mental health disorder, schizoaffective disorder, schizotypal
services, particularly in the primary health care personality disorder, delusional disorder, brief
sector. The authors recognise that the structure psychotic disorder, substance/medication-
and resources of mental health services vary induced psychotic disorder, psychotic disorder
considerably among the states and territories, due to another medical condition, catatonia,
but this should not be viewed as an impediment catatonia associated with another mental disorder,
to implementing an appropriate early psychosis catatonic disorder due to another medical
prevention and intervention strategy. The condition, unspecified catatonia, other specified
fundamental principle is that all Australians with and unspecified schizophrenia spectrum and other
emerging psychotic disorders have a right to early psychotic disorder. Meeting diagnostic criteria for
diagnosis and quality treatment. Therefore, the any one of these disorders is generally regarded
guidelines have been framed in terms of optimal as the threshold for treatment. Such diagnoses,
service provision, while also providing a real- however, require both clear symptom profiles, and
world focus. The recommendations operate as a specified duration of these symptoms, which
evidence-based guidelines rather than hard-and- appears more appropriate in the context
of chronicity.
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FOR EARLY PSYCHOSIS
Making the distinction between diagnostic The aetiology of psychosis is generally accepted
categories early in the course of psychosis may as resulting from the impact of stress and other
be difficult. This may be because of fluidity of risk factors upon a biological predisposition:
acute symptoms, or the vagaries of nosologies the ‘stress–vulnerability’ interaction [45, 46].
themselves [38]. Initial diagnoses of first Stress–vulnerability models have been applied to
episode brief psychotic disorder, unspecified schizophrenia, but are equally applicable to early
schizophrenia spectrum and other psychotic psychosis, and emphasise genetic, neuronal, life
disorder, substance/medication-induced stress and physical vulnerabilities [45, 47]. The
psychosis, and schizophreniform disorder are greater the person’s vulnerability, the less stress
particularly likely to change over follow-up periods is required to trigger an episode of psychosis [48-
[39-43]. Additionally, the traditional pessimism 50].
associated with the diagnosis of schizophrenia
Factors that may influence levels of vulnerability
has permeated professional and popular culture to
and/or stress, and therefore predict onset of
some extent [44]. Making rigid and too-specific
psychosis, are outlined in Table 3.
diagnoses may therefore not only be unreliable
but have iatrogenic effects on the optimism of
both clinicians and people receiving care and
on the potential for recovery. For these reasons,
these guidelines refer to the psychoses broadly,
as shorthand for psychotic disorders, rather than
being limited to a specific psychotic disorder.
‘Early psychosis’ refers to the early course of

psychotic disorder, and in these guidelines
specifically refers to the prodrome and the period
up to five years from first entry into treatment for
a psychotic episode (i.e., first episode psychosis,
or FEP).
Aetiology
Many factors may be causally linked to the
development of psychiatric disorders, but they can
generally be categorised into three main groups:
biological, psychological and social. Biological factors
arise from physiology, biochemistry, genetics and
physical constitution, and may be present from
birth. The young person’s upbringing, emotional
experiences and interaction with other people
constitute psychological factors. Social factors
are associated with the young person’s present
life situation and sociocultural background. The
biopsychosocial model acknowledges the role of
these biological, psychological, and social factors
in the onset and course of psychiatric disorder and
forms a framework within which more specific
models may be developed.
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FOR EARLY PSYCHOSIS
Table 3. Risk factors for psychosis onset
Distal (premorbid) risk factors Proximal risk factors
Foetal life: Late childhood/adolescence:

• Maternal pregnancy complications/perinatal • Age [61]
trauma, (especially foetal hypoxia)[51] • Urbanicity [62]
• Family history of psychotic disorder (for a review, • Substance (especially cannabis) use [63]
see Olin & Mednick, 1996 [52]) • Traumatic head injury
• Candidate genes (DTNBP1, NRG1, DAOA, RGS4, (for a review, see Kim et al., 2007 [64])
COMT, DISC1, DISC2, BDNF; for a review, see • Stressful life events
Weinberger & Berger, 2009 [53]) (for a review, see Phillips et al., 2007 [65])
• Subtle impairments in cognition
• Developmental delay (for a review, see Rustin et
(for a review, see Pantelis et al., 2009 [66])
al., 1997 [54])
• Poor functioning [67, 68]
• Season of birth (late winter/early spring[55, 56])
• Cognitive, affective, and social disturbances
• Ethnic minority group membership [57] subjectively experienced by the individual
Early life: (‘basic symptoms’)[69]
• Quality of early rearing environment • Migration [70]
• Trauma (abuse or neglect) [58]
• Vulnerable personality (e.g., schizoid personality
[59, 60])
Epidemiology Experiencing psychotic symptoms does not,

however, necessarily indicate the presence of a
Psychotic disorders usually emerge during disorder. Psychotic symptoms seem to be part
adolescence or early adulthood. They tend to of the continuum of normal experiences, with a
be characterised initially by impaired social median prevalence of 5% and incidence of 3%
functioning and nonspecific ’neurotic’ symptoms, in the general population; between 75% and
which are then followed by attenuated or 90% of psychotic experiences are transitory
subthreshold forms of psychotic symptoms and and disappear with time [77]. The continuum of
which emerge just prior to the development psychosis is outlined in Figure 1.
of frank psychosis [71]. For example, in one
study, the prodromes of major depression and
schizophrenia were found to be indistinguishable
[72].
Estimates of the incidence of early psychosis

vary widely [73]. An Australian study of low-
prevalence psychiatric disorders found the
prevalence of individuals with psychosis engaging
in treatment in a 1-month period was 4.7 per 1000
adults [74]. This is likely to be an underestimate
of the true prevalence of psychotic disorders, as it
did not include people in the community who were
not receiving treatment [75]. Schizophrenia is the
third leading cause of burden and injury in young
men aged 15–24 years, and the fifth in young
women of the same age [76].
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Figure 1. Example of the continuum of psychotic-like experiences
Exaggerated self-consciousness
Believes being observed Delusions of persecution
and hypervigilance
Mental Mental Mental

health health illness
difficulties
Course of illness be selected by consumers and clinicians on the

basis of defined risk/benefit criteria which are
The previous edition of these guidelines focused likely to differ across different stages of illness.
on a ‘stage’ model of psychosis, comprising four Such models are widely used in mainstream
stages: (i) prodrome, (ii) acute onset of psychotic medicine; their application to psychiatry appears
disorder, (iii) early recovery, and (iv) late/ both appropriate and, given increasing interest in
problematic recovery. There has been a recent models of early intervention in psychiatry, timely.
argument, however, to shift the lens through which Such a model can guide the logic and timing of
early intervention specifically, and psychiatric interventions in psychosis and psychiatry more
nosology in general, is viewed [78], with a focus broadly, enabling the use of practical, preventive
on the concept of the clinical staging model. strategies routinely embraced in other types
of mainstream health care [15]. The clinical
This section defines the clinical staging model and staging model of psychosis can also provide a
reviews its different stages, with a particular focus clinically meaningful framework for disseminating
on the putative prodrome. knowledge and research findings. Table 4 outlines
the clinical staging model in its application to
The clinical staging model psychotic disorders.
The clinical staging model differs from
conventional diagnostic practice by defining the
course of illness as a continuum [78]. Clinical
staging models assume that treatments that are
offered earlier in the course of an illness have
the potential to be safer, more acceptable and
more effective, as well as more affordable than
those offered later in the course of disorder.
Interventions can then be evaluated in terms
of their ability to prevent or delay progression
from earlier to later stages of illness, and can
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FOR EARLY PSYCHOSIS
Table 4. Clinical staging model for psychotic disorders
Clinical Definition Definition in the Target populations Potential interventions

stage ‘phase’ model for recruitment
0 Increased risk of Premorbid First-degree teenage Indicated prevention of

psychosis relatives of the FEP, e.g:
No symptoms person with the • Improved mental
currently disorder health literacy
• Family education
• Drug education
• Brief cognitive skills
training
1a Mild or non-specific Possible prodrome Screening of teenage Indicated secondary

symptoms of populations prevention of FEP, e.g:
psychosis, including Referral by: • Formal mental health
neurocognitive literacy
• primary care
deficits. • Family
physicians
Mild functional • school counsellors psychoeducation
change or decline • CBT
• Actively reduce
substance use
1b Ultra high risk of Possible prodrome Referral by: Indicated secondary

psychosis: Moderate • educational prevention of FEP, e.g:
but subthreshold agencies • Psychoeducation
symptoms, • primary care • CBT
with moderate physicians • Substance use work
neurocognitive • emergency (cessation or harm-
changes and departments reduction)
functional decline to • welfare agencies • Omega-3 fatty acids
caseness or chronic
• school and • Antidepressant agents
poor functioning university or mood stabilisers
(≥ 30% drop in counsellors
SOFAS in previous 12
months OR < 50 for
previous 12 months)
2 First episode of Acute and early Referral by: Early intervention for
psychotic disorder: recovery • primary care FEP, e.g:
Full threshold physicians • Psychoeducation
disorder with • emergency • CBT
moderate–severe departments • Substance use work
symptoms, • welfare agencies • SGA medication
neurocognitive • specialist care • Antidepressant agents
deficits and agencies or mood stabilisers
functional decline
• drug and alcohol • Vocational
(GAF 30–50) services rehabilitation
Includes acute
and early recovery
periods
3a Incomplete Late/incomplete Primary and Early intervention for FEP

remission from first recovery specialist care As for stage 2, but with
episode of care services additional emphasis
on medical and
psychosocial strategies
to achieve remission
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FOR EARLY PSYCHOSIS
Clinical Definition Definition in the Target populations Potential interventions

stage ‘phase’ model for recruitment
3b Recurrence or Late/incomplete Primary and Early intervention for FEP

relapse of psychotic recovery specialist care As for stage 3a, but with
disorder which services additional emphasis on
stabilises with relapse prevention and
treatment, but ‘early warning signs’
at a level of GAF, strategies
residual symptoms,
or neurocognition
below the best level
achieved following
remission from first
episode
3c Multiple relapses, Late/incomplete Specialist care Early intervention for FEP

with objective recovery services As for stage 3b, but with
worsening in clinical emphasis on long-term
extent and impact of stabilisation
illness
4 Severe, persistent Chronicity Specialist care As for stage 3c, but with
OR unremitting services emphasis on clozapine,
illness as judged other tertiary treatments,
by symptoms, and social participation
neurocognition and despite ongoing disability
disability criteria
CBT, cognitive–behavioural therapy; FEP, first episode psychosis; GAF, Global Assessment of Functioning scale; SGA, second-
generation antipsychotic; SOFAS, Social and Occupational Functioning Assessment Scale.
Adapted from McGorry et al. 2006 [79].
Stage 0: the premorbid phase genetic high-risk never claimed early intervention
as a goal, focusing instead on investigating causal
The traditional approach to identifying individuals pathways into schizophrenia and other psychotic
who are at risk of developing schizophrenia is illnesses.
to study family members of individuals already
diagnosed with the disorder [80, 81]. This is Mednick et al. [82] modified the genetic high-risk
known as the ‘high-risk’ approach. Assessments approach by focusing on adolescent offspring who
usually begin when subjects are children, with were entering the peak age of risk (i.e., they added
follow-up continuing over many years, with the in the risk factor of age). This modification made
aim of detecting the development of psychotic the high-risk approach more practical. However,
disorder at some stage in the person’s life span. the number of people from this cohort who
Researchers using the high-risk family history develop a psychotic disorder is still not expected
approach acknowledge that the transition rate to to be large, and the number of false positives are
a psychotic disorder is not likely to be large and too high to make any intervention practical.
findings may well not be generalisable beyond the
Similarly, the Edinburgh High Risk Project [83-
genetically defined high-risk group [80, 81]. Those
85] studies individuals with presumed high
who have an increased genetic risk may be at
genetic liability for schizophrenia, including both
stage 0 of psychotic disorder, but given the lack of
first- and second-degree relatives of people with
sensitivity of a solely genetic model of risk, they of
schizophrenia. Like the Mednick approach, this
course may not. Furthermore, intervention in these
study recruits young adults (aged 16–25) who
‘at-risk’ individuals is neither practical nor ethical,
will pass through the period of maximum risk
as the degree of risk is low, those possibly ‘at-risk’
of developing schizophrenia during the planned
are not symptomatic, and the timing of onset of
10 years of the study. Data reported in 2002
psychotic disorder not known. Indeed, studies into
revealed that 13 out of 162 subjects (about 8%)
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FOR EARLY PSYCHOSIS
had developed schizophrenia to date, 6 years after Table 5. Common problems of young people with
study commencement [86]. Although this rate of an at-risk mental state
onset of schizophrenia is well above the expected
community rates, recruitment of large numbers Neurotic symptoms Anxiety
is needed in order to clarify other risk factors for Restlessness
development of schizophrenia and to eventually Anger, irritability
identify a group for whom preventive treatment is
justified. Mood-related Depression
symptoms Anhedonia
Stages 1a and 1b: the possible Guilt
prodrome Suicidal ideas
Mood swings
The ‘prodromal’ phase, or symptomatic ‘at-
risk mental state’ is usually characterised by a Changes in volition Apathy, loss of drive
sustained and clinically significant deviation from Boredom, loss of
the premorbid level of experience and behaviour interest
[71, 87, 88]. The clinical staging model conceives Fatigue, reduced
of two forms of this possible prodrome: a period energy
of mild or nonspecific psychotic symptoms, and a
period of increased symptom activity which still Cognitive changes Disturbance of
attention and
does not meet criteria for a psychotic episode.
concentration
Identifying the prodrome Preoccupation,
The definition of ‘at-risk’ status (i.e., the mental daydreaming
state that is thought to place the individual Thought blocking
at incipient or ultra high risk of developing a Reduced abstraction
psychotic disorder) varies across research groups,
and includes the ‘psychosis proneness’ research Physical symptoms Somatic complaints
of Chapman and Chapman et al. [89-91], the Loss of weight
basic symptoms method [92, 93], and the Ultra Poor appetite
High Risk method [67, 94, 95]. Common to Sleep disturbance
these groups is the idea that a constellation of
Attenuated or Perceptual
identifiable difficulties emerge in the psychosis
subthreshold abnormalities
prodrome. This enables clinicians to implement
versions of psychotic Suspiciousness
strategies that may prevent, or delay the onset
symptoms
of psychosis. Examples of such difficulties are Change in sense of self,
outlined in Table 5. others or the world
Other symptoms Obsessive compulsive

phenomena
Dissociative
phenomena
Increased interpersonal
sensitivity
Behavioural changes Deterioration in role

functioning
Social withdrawal
Impulsivity
Odd behaviour
Aggressive, disruptive
behaviour
Adapted from Yung, Phillips and McGorry, 2004 [95].

27
FOR EARLY PSYCHOSIS
Chapman et al. [89-91] attempted to identify Symptoms (B-SABS [96]) and, more recently,
individuals at risk of psychosis, or those they the Schizophrenia Prediction Instrument, Adult
called ‘hypothetically psychosis-prone’, by version (SPI-A [97]). Basic symptoms in the
focusing on attenuated and isolated psychotic absence of other symptoms would likely qualify
symptoms. In addition to these ‘positive’ psychotic an individual for stage 1a rather than stage 1b
phenomena, they also theorised that people membership.
who displayed physical and social anhedonia
In contrast to genetic high-risk studies, which
and impulsive non-conformity were also at risk.
focus purely on genetic risk for psychosis, Bell
Chapman et al. [91] also noted the need to
[98] proposed a ‘multiple gate screening’ or
focus on people at or near the age of greatest
‘close-in’ approach of combining risk factors
risk for schizophrenia, that is, late adolescence
beyond symptoms (for example, genetic factors)
and early adulthood, and thus studied college
to optimise prediction of those at high risk for
students. A sample of college students with high
disorder. Yung and McGorry, 1996 [71] describe
levels of self-reported ‘psychotic-like’ symptoms
the application of this model to define at-risk
were followed longitudinally over time and
mental states for psychotic disorder. As noted
compared with a group of controls. At 10–15-
earlier, most frequently occurring prodromal
year follow-up, students who scored highly on
features are non-specific and could be the
scales of perceptual abnormalities and magical
result of a number of conditions (e.g., major
thinking were more likely to have developed a
depression, substance abuse). Further, both
psychotic disorder than comparison subjects.
attenuated and frank psychotic symptoms are
Social anhedonia, physical anhedonia and
relatively common in the general community.
impulsive non-conformity were not predictive of
This model of identification of the at-risk group
psychotic disorder at follow-up, although high
therefore requires the presence of a number of
scores on the Social Anhedonia scale correlated
risk factors beyond symptoms or genetics alone
with high levels of psychotic-like experiences
(see Box 1). The primary ‘state’ criteria identified
at follow-up. However, the actual number of
to date to define the at-risk group are age (falling
students who developed a psychotic disorder
with the peak age range of onset of psychotic
after 10–15 years was low: 11 out of 375, or 2.9%.
disorder, i.e., adolescence and young adulthood),
Students with subthreshold forms of delusions
combined with either attenuated positive
and hallucinations seemed to be more at risk of
psychotic symptoms (i.e., positive symptoms that
subsequent full-blown psychotic disorder than
occur below psychotic threshold with respect
those without these symptoms. However, many
to frequency and/or intensity), or a brief period
students with high levels of magical thinking
of supra-threshold frank psychotic symptoms
and perceptual abnormalities did not develop a
that resolve spontaneously. The criteria then
psychotic disorder. To date, because of the low
invoke a ‘trait’ factor – presence of a first-degree
numbers developing a psychotic disorder, the
relative with a psychotic illness. However, both
high number of false positives and the long time
this group and the ‘mildly symptomatic’ groups
frame of the follow-up, the psychosis-proneness
also superimpose an additional state factor of
research has not been able to be used as the basis
either functional decline or long-standing poor
for any preventive intervention.
functioning. There is also an assumption that
The two other approaches – the basic symptoms people who meet the criteria are help seeking
and ultra high risk methods – focus on identifying or distressed by their symptoms, even if these
people at risk of psychosis using clinical, rather symptoms are not those which qualify the
than population, samples. The basic symptoms individual as at ultra high risk. This, then, excludes
approach, used primarily in German-speaking people who have psychotic-like experiences but
countries, shares with the psychosis proneness are functioning adequately with their symptoms.
approach a focus on symptoms as markers of Those who meet these criteria would qualify for
risk. Basic symptoms are subjectively experienced stage 1b membership.
abnormalities in the realms of cognition, attention,
perception and movement. They have also been
described as ‘self-experienced neuropsychological
deficits’ [93]. Basic symptoms are assessed
by the Bonn Scale for the Assessment of Basic
28
FOR EARLY PSYCHOSIS
Box 1. Criteria for identification of ultra high Box 2. CAARMS domains

risk (UHR) or at-risk mental state
1: Positive symptoms
• Young people between 15 and 25 years of 1.1 Unusual thought content
age.
1.2 Non-bizarre ideas
• A change in subjective experience and
1.3 Perceptual abnormalities
behaviour in recent months or within the
past five years (which may fluctuate but is 1.4 Disorganised speech
progressive) 2: Cognitive change attention/concentration
Plus either 2.1 Subjective experience
• Subthreshold positive symptoms not 2.2 Observed cognitive change
severe or persistent enough to be regarded 3: Emotional disturbance
as evidence of sustained frank psychosis
3.1 Subjective emotional disturbance
sufficient for a diagnosis of a psychotic
disorder 3.2 Observed blunted affect
or 3.3 Observed inappropriate affect
• history of brief self-limited psychotic 4: Negative symptoms

symptoms (frank psychotic symptoms that 4.1 Alogia
resolve within seven days) 4.2 Avolition/apathy
or 4.3 Anhedonia
• a genetic vulnerability, operationalised as 5: Behavioural change
either the presence of schizotypal disorder,
5.1 Social isolation
or a first-degree relative with a history of
5.2 Impaired role function
any psychotic disorder
5.3 Disorganising/odd/stigmatising
Plus
behaviour
• functional decline to caseness (≥ 30%
5.4 Aggression/dangerous behaviour
drop at any time in the previous 12 months
in scores on the Social and Occupational 6: Motor/physical changes
Functioning Assessment Scale (SOFAS) 6.1 Subjective complaints of impaired motor
[99]) or longstanding poor functioning functioning
(SOFAS < 50 for previous 12 months) 6.2 Informant reported or observed changes
in motor functioning
The dominant method of assessing the at-risk 6.3 Subjective complaints of impaired bodily
mental state is through semi-structured interview, sensation
using the Comprehensive Assessment of At Risk 6.4 Subjective complaints of impaired
Mental States (CAARMS) [100] or the Structured autonomic functioning
Interview for Prodromal States (SIPS) and related
7: General psychopathology
instruments [101, 102]. The CAARMS has two
functions: to provide a comprehensive assessment 7.1 Mania
of psychopathology thought to indicate imminent 7.2 Depression
development of a first episode psychotic disorder; 7.3 Suicidality and self harm
and to determine if an individual meets UHR 7.4 Mood swings/lability
status or has crossed the threshold for a psychotic
7.5 Anxiety
disorder. It is a semi-structured interview which
includes scales for assessing in detail threshold 7.6 Ocd symptoms
and subthreshold psychotic phenomena and other 7.7 Dissociative symptoms
symptoms and signs which occur in the psychotic 7.8 Impaired tolerance to normal stress
prodrome, including negative, dissociative and
‘basic’ symptoms. Its domains and subscales are
outlined in Box 2. The CAARMS shows good to
excellent reliability, and both overall scores and
negative symptoms in particular are predictive of
psychosis onset [100].
29
FOR EARLY PSYCHOSIS
The ‘clinical high risk’ approach adds further Rates of conversion to psychosis are influenced
criteria to the ‘ultra high risk’ method of by inclusion criteria, the population sampled
identifying the prodrome by focusing not only and the treatment provided. As such, transition
on attenuated positive psychotic symptoms to psychosis within 12 months of being initially
(the clinical high risk-positive group), but deemed at-risk has varied considerably [106].
also on enduring specific combinations of Initial studies applying the UHR criteria yielded
cognitive, academic, and social impairments and transition rates of approximately 40% within
disorganisation/odd behaviour which represent 12–30 months of assessment [107]. However,
possible attenuated negative psychotic symptoms there has been a steady decline in transition rates
(the clinical high risk-negative group [103]). across continents and clinics in recent years, with
These two groups are proposed to characterise a recent meta-analysis comprising 27 studies
the progression of the prodrome, with the clinical (n = 2502) reporting an overall transition rate
high risk-negative group representing the earliest of 22%, 12 months after assessment [108]. This
possible stage of identification of the prodrome reduction may be due to earlier detection and
(stage 1a membership), which may then progress improved treatment strategies in young people
into the ‘late prodrome’ clinical high risk-positive at risk of psychosis [109]. Thus, the syndrome
group identified by the CAARMS and the SIPS. which seems like, or could be, a prodrome should
Without effective preventive intervention, this not be thought of as a disease entity, but rather
group may develop ‘schizophrenia-like psychosis’ as a state risk factor for a full-blown psychotic
(full-blown psychotic symptoms of brief duration, disorder. That is, the presence of the syndrome
not yet meeting criteria for schizophrenia), a implies that the affected person is at that time
group that those adopting the model of Cornblatt more likely to develop psychosis in the near future,
et al. [104] regard as still being within the than someone without the syndrome. Instead of
prodrome, given their focus on prediction and being labelled as ‘prodromal’, the person should
prevention of schizophrenia rather than psychotic be thought of as having an ‘at-risk mental state’
disorders more generally. (or ‘at risk mental state for psychosis’, ARMS-P)
[67]. This terminology highlights the risk factor
The degree to which these measures accurately
approach, suggesting that the syndrome is a risk
identify the prodrome can only be retrospectively
factor for incipient onset of full-blown psychosis
determined, by exploring the proportion of this
[67, 94, 95].
‘at-risk’, or putatively prodromal group who go
on to develop psychosis. For this reason, stages
1a and 1b represent a possible prodrome. Figures
2 and 3 provide a graphical representation of
the distinction between the prospective and
retrospective identification of the prodrome.
Figure 2 identifies the challenge of identifying
the prodrome prospectively, given that the term
‘prodrome’ can only apply when there is certainty
that the full-blown disorder has emerged. Figure
3 demonstrates the appropriate retrospective
identification of a prodrome. Focusing on
individuals with apparently prodromal symptoms
and signs and identifying them as those likely
to develop a psychotic disorder will lead to the
problem of a large number of false positives: most
people with these features would not make the
transition to a full-blown psychotic disorder.
30
FOR EARLY PSYCHOSIS
Figure 2. Prospective identification of a possible prodrome
UHR
PREMORBID ARMS-P PSYCHOSIS
Figure 3. Retrospective identification of the prodrome
PREMORBID PRODROME PSYCHOSIS
Potential advantages of identification and this early phase of illness might facilitate more
intervention at stages 1a and 1b include: timely and effective treatment than among
• identifying people during a phase in which those with entrenched psychotic symptoms
subtle yet tenacious disability is possibly laid [95, 110]. Additionally, should progression
down. Much of the psychosocial disability to frank psychosis occur, this pre-existing
observed in first episode psychosis is engagement with mental health services
difficult to reverse in the absence of targeted may enhance medication compliance and
interventions such as vocational recovery, engagement with outpatient care [110]
even when the core symptoms remit with • reducing the severity of psychosis, and
effective antipsychotic treatment (as they therefore the burden of trauma, stigma, acute
do in up to 90% of cases). Intervention in or embarrassing behaviour, and the need for
the pre-psychotic stages may prevent the hospitalisation, by enabling early intervention if
entrenchment of such psychosocial disability symptoms do progress
• facilitating engagement with services by • potentially preventing or delaying transition to
managing current difficulties, before the person psychosis in a subset of people.
is too ‘out of touch’. Engaging young people in
31
FOR EARLY PSYCHOSIS
Preventive intervention strategies for the possible regarding treatment in these stages can be made.
prodrome currently include early recognition The development of psychotic disorder from
and access to services through increasing the premorbid and prodromal mental states needs to
awareness of specific groups (e.g., parents, be better understood. Further research is needed
teachers, school counsellors, general practitioners to determine which treatment strategies are
(GPs) and health professionals). Most research, effective in reducing symptoms and disability and
however, has centred on the more active and the risk of progression to stage 2, acute onset of
specific interventions of psychological therapies FEP. Such research must meet the highest ethical
and medication trials in the at-risk group. Evidence standards, and potential participants must give
from trials conducted in clinics in Australia, the genuine informed consent and be free to withdraw
US, UK and Europe demonstrates that specific from the research at any time. Non-participation
interventions can ameliorate, delay and even in research must not affect access to appropriate
prevent the onset of first episode psychosis in clinical care. Finally, research should be led by
some people. These interventions have included local clinicians and researchers so that culturally
cognitive–behavioural therapy (CBT) combined normal experiences and behaviours are not
with a second-generation antipsychotic (SGA) misconstrued as signs and symptoms of illness.
[28], CBT alone [29, 111], or antipsychotics alone
[27], and are outlined in more detail in Section 2. Stage 2: the acute phase, recovery and
There are, however, risks in attempting to identify,
the ‘critical period’
and intervene in, the pre-psychotic phase. These Stage 2 encompasses the initial acute treatment
include: phase and the early recovery phase of the first 3-6
• the ‘false positive’ scenario, where individuals months following the onset of psychosis [115].
are identified as at risk of developing a
psychotic illness who were not in fact at risk.
The acute phase
The acute phase can be characterised by the
There is a potential risk of self-stigmatisation
presence of psychotic features such as delusions,
for those who do not develop a persistent
hallucinations, and formal thought disorder. It
psychotic illness [112-114]
is usually during this phase that someone first
• side effects of any intervention, particularly comes into contact with mental health services.
antipsychotic medication, used to treat An individual’s presentation, which frequently
psychotic symptoms during this stage; includes symptoms of other comorbid conditions,
especially given these treatments may be will determine the setting in which they receive
unnecessary in the case of ‘false positives’. treatment and the urgency with which they are
These concerns have led to a preference in assessed.
some countries for ‘naturalistic designs’ over Goals of treatment in the acute phase include
randomised trials of intervention (including the resolution of positive psychotic symptoms,
use of antipsychotics) in the at-risk group. This preventing or treating comorbid conditions and
in turn, paradoxically, has led to widespread beginning psychosocial and functional recovery
and uncontrolled use of off-label medication for work
which there is currently no evidence of efficacy in
treating psychotic symptoms in the at-risk group Recovery
and/or preventing transition to psychosis [15]. It The focus of management during the initial
must be emphasised that use of antipsychotics in recovery phase is to help people who have
the UHR group is not recommended. There are, experienced psychosis to understand the disorder
however, a small number of situations in which and to develop skills that will enable them to
the introduction of an antipsychotic in someone achieve their goals in the future.
considered UHR may be justified. These situations
Predictors of short-term (2–5 year) recovery in
are outlined in guideline 3.1.
first episode psychosis include:
Given the risks of intervention in the pre- • earlier intervention/shorter DUP [17, 19, 20,
psychotic stages, and the limited (although 116-120]
consistent) research to date, more evidence is
• female sex [121-123]
required before definitive recommendations
• older age at onset [124, 125]
32
FOR EARLY PSYCHOSIS
• better premorbid functioning [117, 119, 120, 126] Late or incomplete recovery is generally defined
• severity of psychopathology, particularly by the persistence of positive symptoms.
negative symptoms [119, 127-129] However, it is likely to be better operationalised
in a multidimensional manner that focuses on
• a subjective sense of hope [130]
key predictors of disability, such as symptom
• absence of substance use [131-133] domains, behaviour, function, suicidality, and
• adherence to treatment [119, 134] ability to work. Other factors that may be markers
• social and family contacts [130, 135]. of incomplete recovery include ongoing negative
symptoms, depression and anxiety, social deficits
Some of these factors are more clearly malleable (especially difficulties in age-appropriate social
than others, with DUP, adherence to treatment, and vocational functioning), and cognitive deficits.
comorbid substance use, and a subjective sense of Incomplete recovery can be identified as early as
hope being the clearest malleable factors. A goal three months after the onset of the acute episode
of treatments during stage 2 is not only to manage [115].
current symptoms, disability, and distress, but also
to prevent further deterioration and progression to The staging model envisages three forms of
stage 3 or stage 4. incomplete recovery – one in which premorbid
levels of functioning or symptom status are
Stage 3: late/incomplete recovery, not reached after onset of FEP; another where
relapse with poor outcome, and the premorbid levels of functioning or symptom
status are initially reached in recovery from FEP,
‘critical period’.
but subsequent relapse leads to less positive
In contrast to Kraepelin’s model of progressive outcomes; and a third in which multiple relapses
psychopathology in the psychoses, Bleuler occur with associated ongoing deterioration.
[136] noted that psychopathology and disability These forms of incomplete recovery can
emerged rapidly early in the course of illness, be distinguished from stage 4, in which no
plateauing thereafter. This suggests a relatively significant recovery seems to have taken place
brief, active phase of deterioration, with a and symptoms or functioning appear to have
subsequent level of diminished functioning that progressed into a chronic course of illness.
stays stable for some years [137]. This has been
coined the ‘critical period’ [138], a period of up Stage 3a: incomplete recovery
to 5 years after the onset of psychosis, after without relapse
which the level of functioning attained endures Addington et al. [115] identify factors relevant in
for the long term. Intervening during this phase establishing and perpetuating incomplete recovery
of aggressive deterioration post-onset of acute in psychosis, as listed in Table 6. Intervening
psychotic symptoms may halt its progression during this phase requires targeting those factors
and hence reduce the likelihood of incomplete that are potentially modifiable, including treating
recovery. Interventions may include providing comorbidity, providing appropriate psychosocial
effective treatment of psychotic symptoms and services (such as vocational rehabilitation),
associated sequelae in as timely a fashion as facilitating psychological adjustment to
possible throughout this 5-year period (i.e., by psychosis, and enhancing adherence. The
reducing DUP, preventing relapse, and managing possibility of treatment-resistant illness can
psychosocial and psychological comorbidities of be entertained after these avenues have been
psychosis). Stage 3 includes this ‘critical period’ exhausted. Between 10 and 50% of people with
phase. FEP experience treatment resistance [144-146].
Treatment during stage 3a focuses on marshalling
Early evidence backed up Bleuler’s proposal additional pharmacological and psychotherapeutic
[139-141], although there has been more recent strategies to manage the potentially modifiable
suggestions that the critical period should include factors outlined in Table 6 and hence achieve full
the prodrome [142, 143]. The implication of the remission.
critical period is that intervention provided during
late/incomplete recovery may not only halt
deterioration and improve functioning in the short
term, but be a positive prognostic factor into the
medium and long term.
33
FOR EARLY PSYCHOSIS
Table 6. Factors relevant to establishing and perpetuating incomplete recovery in psychosis
Domain Unmodifiable factors Potentially modifiable factors
Factors related to the Poor prognosis factors: males, single, Comorbidity: substance-use disorders,
person being treated intellectual disability depression
Diagnosis of schizophrenia Psychological adjustment: sealing over
versus integration recovery style
Psychosocial milieu, including family
Factors related to the Poor premorbid adjustment Severity of psychopathology

illness Marked cognitive impairment Negative symptoms at first admission
Early and/or insidious onset +/- poor functioning
Longer duration of prodrome, delays Unawareness of negative symptoms
in treatment initiation, and/or longer Poor cognitive function at stabilisation
duration of untreated psychosis
Organic factors: abnormal brain
features, indicated by computed
tomography, magnetic resonance
imaging, baseline abnormal
electroencephalograph; poor integrity of
the dorsolateral prefrontal cortex
Factors related to Pharmacokinetics: incorrect dose, Impaired adherence: psychosocial

treatment drug–drug interactions, bioavailability treatments, medical treatments
problems, therapeutic windows Inadequate rehabilitation program or
lack of services and resources
Side effects (e.g., extrapyramidal
symptoms, metabolic, cognitive)
From Addington et al. [115], based in part on Pantelis and Lambert [147].
Stages 3b and 3c: single or multiple relapse [146], as well as other challenges inherent in the
with poor outcome ‘re-recovery’ process, such as post-psychotic
Ninety percent of people with FEP experience depression and suicide [152, 153] and broader
full or partial remission of positive psychotic psychosocial complications such as disruptions
symptoms within 12 months of treatment to vocational, educational, and social networks
commencement [148]. Relapse is, however, [154]. Relapse can also increase burden for family
common – naturalistic studies suggest 70–82% members and carers [155].
of people with FEP relapse within 5 years [149-
Risk factors for relapse in many ways mirror those
151]. Each relapse increases the risk of persistent,
for onset, and are outlined in Table 7.
particularly negative, symptoms developing
34
FOR EARLY PSYCHOSIS
Table 7. Summary of risk factors for psychotic relapse following FEP
Domain Risk factor
Factors related to the individual Poorer premorbid adjustment

Antisocial personality (positive); agreeableness (negative)
Cannabis use
Non-adherence to medication
Cognitive flexibility (negative)
Factors related to the environment Stressful life events

Expressed emotion
Adapted from The recognition and management of early psychosis: a preventive approach, 2nd Edition, Henry J. Jackson, Patrick
D. McGorry, Editors. 2009, Cambridge University Press: Cambridge P 352.[156]
Treatment in stages 3b and 3c focuses on ongoing General medical care also becomes a priority at
relapse prevention, continuing pharmacological this stage, given the high physical morbidity and
and psychosocial interventions for long-term premature mortality in this group, as in many
stabilisation, and intervening in functional highly disadvantaged groups in society [158,
domains such as vocational recovery to prevent 159]. This period may also include revisiting
disability. the degree to which medication side effects
outweigh benefits, given the medical and social
Stage 4: prolonged/treatment consequences of some medications, including
refractory illness obesity, lipid abnormalities, cardiac abnormalities
and impaired glucose tolerance. The preventive
Individuals may enter stage 4 at first presentation focus in stage 4 therefore includes prevention of
(i.e., from stage 2) by meeting the specific clinical mortality.
and functional criteria of this stage, as reflected in
symptoms, neurocognition, and disability criteria. Summary
They could also progress to stage 4 by failure to
respond to treatment, as indicated in stage 3a. The application of the clinical staging model
to psychiatry is in its early phases. Given this,
Even in the presence of ongoing disability, health these guidelines by and large use more familiar
and good quality of life can emerge. The primary concepts, such as putative prodrome/acute onset/
issues during this stage of psychosis include recovery/relapse/problematic recovery. However,
managing the illness itself, its physical and mental the staging model shows significant promise in
sequelae, and psychosocial correlates such as providing a heuristic around which timely and
strained relationships with family members, effective interventions in psychiatric illness can be
social isolation, and unemployment [157]. understood and delivered.
Clinical strategies include continuing relapse
prevention and psychological treatment for
the consequences of persistent illness, such as
demoralisation, depression and suicide. Contrary
to the therapeutic nihilism often seen at this stage,
some interventions may be of benefit, including
clozapine and CBT.
36
FOR EARLY PSYCHOSIS
Section 2.
Clinical practice guidelines
37
FOR EARLY PSYCHOSIS
Section 2.
Clinical practice guidelines
The previous section serves as background maintained at 3-month follow up, and at 1 year,
and rationale to the clinical practice guidelines the level of negative psychotic symptoms was
themselves, which provide principles (and the significantly less in the early detected sample
evidence for these) for the care of people with [163]. While replication studies in other countries
early psychosis. Regardless of stage of illness, will be valuable to confirm the evidence for early
some elements of care for those with psychosis detection, the Norwegian research program makes
are universal. These include timely access to care a compelling case for establishing early detection
and a comprehensive assessment processes. and engagement strategies to reduce treatment
Guidelines 1 and 2 outline recommendations delays.
relevant to access and assessment in the pre-
onset and FEP domains. Guideline 3, ‘Treatment’,
The two key components of intervention for
reducing DUP, as demonstrated by the TIPS study,
covers principles specific to particular phases of
are community awareness and mobile detection
illness, as well as those that apply generally to the
services. When both are in place, it is possible to
treatment of people with early psychosis.
achieve very low levels of DUP (a median of only
a few weeks). These strategies also result in a
less traumatic or ‘crisis-driven’ mode of entry into
Guideline 1. Access care and enable people to be engaged without a
surge of florid psychotic symptoms or disturbed
Background behaviour being necessary in order to gain entry
into service systems.
The importance of DUP in FEP has been
established following the publication of three The relationship between DUP and outcome is
systematic reviews [17, 20, 160]. These reviews robust, and has been demonstrated over long
indicate that longer DUP is both a marker and an follow-up periods (e.g., 8 years [168] and 15
independent risk factor for poor outcome. The years [169]). However, these studies show that,
Scandinavian Early Treatment and Identification of although it is a malleable risk factor, DUP accounts
Psychosis – or TIPS study [161] – is a Norwegian for a relatively modest amount of outcome
study that has demonstrated that reducing DUP variance, suggesting the importance of treatment
leads to both early and sustained benefits in access and quality during the early stages of
reducing the severity of illness and improving illness.
social functioning [162]. Comparing two regions
with an early psychosis detection program to A critical implication of the DUP literature is that
two areas without, this study found that DUP better outcomes will result from earlier detection
could be substantially reduced via community and treatment of psychotic disorder. Despite
education and the use of mobile detection teams the severity of frank psychosis, the mean time
[19]. The early detection program included between onset of symptoms and treatment is
targeted campaigns for GPs, social workers, generally in the range of 1–2 years, with median
and school welfare workers, as well as provision values being around 4–6 months and including
of information from the early detection teams. delays of 15 years or more [164]. Even those
Patients who subsequently entered care in who seek help (and many may do so even prior
the early detection sectors were also in better to the onset of psychotic symptoms [87, 165])
clinical condition and at less risk of suicide [18, may not do so for psychotic symptoms, but
19]. These positive clinical differences were rather nonspecific symptoms such as depression,
38
FOR EARLY PSYCHOSIS
anxiety, or concerns about decline in functioning Norman and Malla [164] outline that delays in
[166], making it particularly important that accessing appropriate care may be influenced by
clinicians be skilled in identifying signs of early two distinct factors: the period of time between
psychotic disorder (see Box 3 for what may onset of symptoms and seeking help from a
constitute timely access to care). Additionally, professional health provider; and the time between
regardless of the impact of DUP on outcome, ease this help seeking and the commencement of
of access to care is important because it provides appropriate treatment. Table 8 outlines different
relief from the distress that psychotic and non- sources of delay and interventions that may affect
psychotic symptoms can cause [32]. these. It is difficult to disentangle the relative
effectiveness of these strategies to reduce DUP by
promoting help seeking and accurate identification
Box 3. Service principles to facilitate timely of early psychosis, as in most studies a number of
access to care interventions have been combined. Community-
wide initiatives to increase knowledge and reduce
• Assessment occurs within 48 hours of stigma associated with psychosis appear to be
referral to a service effective in reducing delay in help seeking [19,
• Consultant psychiatrist review occurs 167-170]. Training primary care practitioners (such
within 1 week of service entry as GPs) has also demonstrated some success in
• A case manager is assigned within 5 days reducing DUP, although data is less consistent
of assessment [161, 168, 169, 171, 172].
Table 8. Sources of delay in accessing services, correlates, and ways to manage these
Stage of Help seeking by Identification Connection to Commencement of

possible delay patient and/or family of psychotic appropriate treatment
symptoms by services
generic services
Influenced by Stigma [173] Training of provider Presence of early Patient insight and
Nature and extent of to whom first detection teams engagement with
social network presents (36–43% [161] services
of the time, this Practitioner
Nature of onset:
will be a GP [164]; awareness of nature
precipitous/
see also Bechard- of appropriate
insidious;
Evans et al., 2007 treatment, importance
characterised by
[174]) of prompt treatment,
negative symptoms
[174] Age at onset and methods of
effectively engaging
Younger age [174]
patients
Intervention Mental health Training service Implementation

literacy e.g., mental providers (e.g., of early detection
health first aid for support agencies, teams
general public schools, GPs,
emergency
departments[161,
166]) to recognise
psychotic
symptoms
Some evidence that these two strategies

combined may be effective in reducing
DUP [169]
Some evidence that these three strategies combined may be

effective in reducing DUP [161, 168]; but may also detect those
with very long DUP [172].
39
FOR EARLY PSYCHOSIS
Recommendations 1.3.3 Undergraduate and postgraduate medical

education should be developed to allow for better
1.1 Mental health services should be accessible training in assessment and treatment of emerging
and provide a timely assessment for people mental illness.GPP
experiencing their first episode of psychosis.GPP 1.3.4 Close links should be developed between
1.2 Enhancing help seeking: primary and specialist mental health services to
facilitate assessment and treatment of emerging
1.2.1 Mental health services should provide mental illness.GPP
education about early intervention to families and
the wider community. The community needs to 1.4 Enhance connection to appropriate services:
be well informed about psychotic disorders and 1.4.1 Specialist early detection teams should be set
how to obtain effective help. Community-wide up to enable timely access to care.C
initiatives to increase knowledge and reduce
the stigma associated with psychosis should be 1.4.2 The means to access the service and the
implemented.C hours of operation should be promoted and
advertised to the community.GPP
1.3 Enhance professional identification of
psychotic symptoms: 1.4.3 The mental health service should be
accessible 24 hours/day, 7 days/week.GPP
1.3.1 Primary health care professionals should be
competent in eliciting and recognising the early 1.4.4 The service should accept potential new
clinical features of psychotic disorders.GPP referrals from a wide range of individuals, family
and friends, and primary care services. A low
1.3.2 Primary care professionals should be trained threshold for expert assessment should be set for
in identifying psychosis and given information any person suspected of developing a psychotic
about how to refer to specialist services.C disorder for the first time.GPP
40
FOR EARLY PSYCHOSIS
Guideline 2. Assessment Domains of psychiatric

assessment in early psychosis
Background
The purposes of assessment include engaging the
Clinical and personal history
young person and enabling the development of a The personal context of illness is a useful place
therapeutic alliance; and gaining information to to start an assessment. By focusing initially
enable diagnosis and formulation of the person’s on understanding the experience of the young
difficulties, including understanding personal person being assessed and his or her family, a
context. These factors both inform treatment context is provided for signs and symptoms, and
planning and are a vital foundation for further engagement is enhanced. As noted in Power &
successful treatment. Although it is placed in McGorry [175], important questions to answer in
its own section in these guidelines, it is clear establishing this context include:
that assessment must be an ongoing process. In • How, and how rapidly, did the psychosis and
practice, assessment and treatment often merge prodrome evolve?
[175]. Good assessment can not only enable
• To what degree are symptoms ego-syntonic or
treatment but can be a form of early treatment in
attributed to something other than illness?
its own right.
• Who is being affected by psychosis and how
Rapport and the timing of assessment are they coping with it?
• What is the young person’s premorbid
Assessment procedures for people experiencing
personality structure, self-concept, and phase
FEP should incorporate strategies to promote
of development?
engagement [176]. First contact with mental
health services is likely to occur in the context • What are his/her coping and problem-solving
of crisis or personal disaster for young people skills, current conflicts, social strengths
and/or their families [177], with some possible and resources, including issues such as
trauma involved in referral to mental health accommodation, financial issues, occupation,
services [178]. Therefore, although it is important and cultural factors?
that an assessment thoroughly cover the • How do these influence how the young person
domains detailed below, this should not occur is relating to his or her symptoms?
at the expense of the developing therapeutic • What family supports exist and how does the
relationship. A range of factors may increase the family respond to illness?
likelihood of the first contact serving as a solid
foundation for ongoing rapport, including: Mental state examination
• well-trained and experienced staff
Following (and during) the taking of a clinical
• an individually adapted interview situation and personal history, assessment of signs and
(calm, friendly, safe, and sufficient time) symptoms, via a mental state examination,
• consistency of care throughout assessment and including assessment of the presence, severity,
into treatment as far as possible and duration of difficulties, can occur. Insight
• an appropriate interview technique (listening is particularly important and should also be
carefully, taking the individual’s concerns assessed, bearing in mind that it has both a
seriously, dispelling their fears, establishing state and trait component and may be culturally
trust, trying to identify common ground, specific [179-182]. Elements of insight to assess
optimistic and supportive atmosphere, using include whether the person recognises that
open-ended questions where possible. see they have an illness, that the illness is a mental
Power & McGorry [175]). disorder, and that treatment is required. This
assessment is aided by having a neuroleptic-free
Reducing DUP requires not only enabling assessment period [175].Where practicable, a
access to mental health services, but initiating 48-hour antipsychotic-free observation period is
treatment as soon as possible. This suggests that recommended prior to commencing antipsychotic
assessment should occur as quickly as practicable, medication to confirm the diagnosis of psychosis
for both the UHR and FEP groups, but particularly and exclude organic causes [183-185].
the latter.
41
FOR EARLY PSYCHOSIS
Biological assessment
Although only 3% of FEP has an organic origin, the
initial assessment is the most appropriate time for
this to be examined [186]. Biological examination
can also serve other useful purposes, including:
• detection of medical comorbidities
• identification of risk factors for future medical
disorders
• identification of risk factors for incomplete
remission or treatment resistance
• identification of a baseline against which
pharmacological complications and side effects
can be assessed [187].
Biological assessment in UHR has received

less attention. There is no consistent standard
battery of physical tests employed by UHR clinics
worldwide. Often assessment of biomedical
problems begins in earnest when an individual
makes a ‘transition’ to a frank psychotic disorder.
However, screening for the following would be
advisable in this population:
• underlying pathology that may be responsible
for the psychotic or psychiatric phenomenon
• general medical morbidity
• a medical baseline for those starting
psychotropic medications.
For these reasons, good practice suggests a

general medical assessment in the UHR phase
that mirrors that in FEP (see Box 4). However, one
should bear in mind that the possibility of medical
problems unrelated, incidental or not causative
of psychotic phenomena might be higher in this
population.
42
FOR EARLY PSYCHOSIS
Box 4. Recommendations for biological assessments in early psychosis
The following are recommended for all people admitted to an early psychosis service (UHR and FEP)
Physical status
• Neurological examination
• Weight, waist circumference, waist/hip ratio and BMI
Vital signs
• Blood pressure, pulse, temperature
Medical history
• Family history, notably of cardiac or lipid abnormalities and diabetes
• Smoking history
• History of alcohol and other drug use
• Physical activity levels
• Menstrual history and possibility of pregnancy
• ECG (if cardiac risk)
Laboratory tests
• Haematology
• Electrolytes, including calcium
• Liver function test
• Renal function (blood, urea, nitrogen:creatinine ratio)
• Erythrocyte sedimentation rate (ESR)
• Antinuclear antibodies (ANA)
• Fasting glucose
• Lipid profile
• Prolactin level
• Consider hepatitis C if risk factors present
• Urine drug screen
The following are recommended only for those young people with suspected FEP.
Laboratory tests
• Tests for other treatable disorders
• Thyroid function tests (basal thyroid-stimulating hormone, total and free trilodothyronine/
thyroxine)
• Serum copper and ceruloplasmin for Wilson’s disease
• Fluorescent treponemal antibody absorbed (FTA-ABS) for neurosyphilis
• Vitamin B12/folate
• HIV
Neuroimaging
• MRI
Other Tests
Expand aetiological search if indicated, for example:
• EEG, chest x-ray, lumbar puncture, karyotyping, heavy metal testing
• Expand medical monitoring if indicated (e.g., eye exam if risk factors for cataracts)
Adapted from Freudenreich et al.[186]
43
FOR EARLY PSYCHOSIS
Cognitive assessment accessing treatment for psychosis because

symptoms are mistakenly attributed to substance
Cognitive deficits are present at the first episode use.
and show little alteration thereafter [188,
189]. They also seem to predate onset [190], Substance misuse is common in FEP. Individuals
with UHR groups generally demonstrating with FEP have significantly higher levels of
neuropsychological impairment [191-194], substance misuse than non-psychotic peers [215],
sometimes despite normal intelligence [192, 195], with most studies in Australia suggesting 60–70%
although generally to a lesser extent than FEP and of people with FEP report substance misuse at
established schizophrenia samples [192, 193]. some stage in their life prior to presentation.
Cognitive deficits predict functional outcome in Cannabis and alcohol are the most frequently
FEP, and may be linked to other clinical variables misused substances [133, 216], with use of
such as insight, medication adherence, substance opioids, cocaine, inhalants, and sedatives being
use and likely participation in therapy [196-198]. relatively rare. As well as being related to onset
in the UHR group, substance misuse, particularly
Social cognition (the way that people think about cannabis use, is also a frequently identified
themselves and others) has been demonstrated poor prognostic factor in FEP, including more
to be poorer in schizophrenia than control severe positive psychotic symptoms [133, 217],
groups (for a review, see Couture et al., 2006 disengagement with services [218, 219], increased
[199]) FEP (e.g., Edwards et al., 2001 [200]), rates of relapse in positive symptoms [133, 220],
first episode schizophrenia [201], and people at increased rate of inpatient admission [133, 217]
risk of developing psychosis [202-204]. Social and suicidal ideation and behaviour [221]. For
cognitive deficits also seem particularly related further discussion of alcohol and tobacco use
to psychosocial functioning in first episode in this population, see Guideline 3.3.2, ‘Physical
schizophrenia [201]. health’, on page 76.
Cognitive assessment can therefore allow
interventions, particularly psychological Assessment of other psychiatric
interventions, to be appropriately tailored to each disorders
person’s cognitive function; for example, by taking
Other psychiatric disorders are common in both
cognitive deficits into account in the delivery
the UHR and first-episode phases. In a study by
of therapy (such as poor working memory), or
Phillips et al. [222], 87% of their UHR sample met
making cognitive deficits a focus of intervention
criteria for at least one Axis I disorder, with the
(e.g., emotion recognition).
most common being major depression. Myles-
Worsley et al. [223] suggest that depression is
Assessment of comorbid disorders: a key component of the psychotic prodrome,
substance use reporting that 84% of their sample reported
Assessing substance use enables clinicians to ‘abnormal’ depressive symptoms, and that
implement interventions that improve a person’s positive and depressive symptoms build in parallel
outcome and accurately identify their prognosis. to onset. Similarly, Yung et al. [224] suggest that
Levels of substance use in the UHR group range low mood increases the likelihood that psychotic
from 7 to 40% [205-210]. Although substance like experiences will develop into psychotic
use typically precedes psychosis onset, the disorder, and that treating depressive symptoms
direction of any causal relationship between the may prevent onset of psychosis (see also
two remains unclear. One possibility is that the Cornblatt et al. [225]). Svirskis et al. [226] noted
onset of psychosis is due solely to substance that mood and anxiety disorders are particularly
abuse [211]. Alternatively, the onset of symptoms common in the UHR group, with higher levels of
may lead to the use of alcohol or drugs to modify psychotic symptomatology associated with more
distressing symptoms [206]. Cannabis use Axis I diagnoses. More broadly, Woods et al.
specifically is likely to be a contributing factor to [227] reported that comorbidities were common
psychosis onset [212, 213], especially in those in their UHR sample, with 69% having one or
with other vulnerabilities, such as functional more mood/anxiety diagnoses, and 44% with
polymorphism of particular genes [48, 214]. one or more Axis II diagnoses. Other psychiatric
Substance use may also result in delays in disorders are also seen in approximately half of
44
FOR EARLY PSYCHOSIS
people with FEP [228-231] and schizophrenia Risk factors: Risk factors for suicide and suicide
[232], and may be associated with poorer attempt in psychosis include being younger,
symptomatic and functional outcome [233-236]. male, single, having experienced a recent loss
Given that comorbid psychiatric disorders are event and having high levels of premorbid
associated with onset of psychosis in the UHR functioning plus anxiety regarding current mental
group and poorer outcome in the FEP group, deterioration [153, 246-248]. Greater insight,
assessment and treatment of these disorders is longer DUP and substance misuse have also
vital. been cited as risk factors, along with depression
and hopelessness [249, 250], yet depression
Risk assessment is often under-diagnosed, possibly due to a
focus on psychotic symptoms which may mask
Identifying whether there is significant risk of
depressive features [251]. Poor adherence to
adverse outcomes is likely to enhance attempts
treatment has been shown to be associated with
to prevent them. Although the most commonly
risk, in particular with regard to failure to attend
canvassed risk is that of suicide, other risks that
follow-up appointments and poor medication
can affect mortality and morbidity include risk of
compliance [246]. Suicide risk may be reduced in
violence, neglect and victimisation, and non-
the presence of psychotic features and negative
adherence to treatment or service disengagement.
symptoms [238, 252]; however, there is debate
Risk of suicide in the literature about this [246], and a small
The 1- to 2-year incidence rates for suicide number of people experiencing psychosis commit
range from 0.3% to 2.9% in the FEP population suicide in response to command hallucinations
[237-239]. Two studies have reported suicide [253]. In the only UHR study to date, a family
rates over a longer follow-up period: Clarke et al. history of psychiatric illness and problematic
[240] report a 4-year incidence rate of 3%, whist substance use predicted suicide attempts [245].
Bertelsen and colleagues [241] report a 5-year Known periods of risk include the early stages of
rate of approximately 1%. Suicide attempt is more illness, often following an acute psychotic episode
common and is the single greatest predictor of [175, 243, 248] and during the post-psychotic
future suicide [238]. Between 10% and 25% of early recovery phase [250]. This may reflect
people with FEP report either deliberate self- the distinction between the initial influence of
harm or a suicide attempt prior to presentation psychotic features on self-harm behaviours, which
for treatment [237, 238], and 50–65% will have may then be followed by a more prolonged rise
experienced recent thoughts of suicide [238- in suicidality in response to the struggles of the
240, 242, 243]. Rates remain high following recovery process [254], as well as developing
the commencement of treatment. One-year insight, hopelessness and depression, which are
prevalence rates of suicide attempt range from associated with suicidal ideation and suicide
2.9% to 11% [237-239]. Longer term follow-up attempt [255-257]. The period immediately
studies have reported a 2-year prevalence rate of following discharge from hospital is also known
11.3% [221] and a 4-year prevalence rate of 18.2% to be a period where risk is elevated [258, 259],
[240]. as is the time of transition from prodrome to
There is considerably less information available psychosis, and the occurrence of a relapse [175]
on rates of suicide, suicidal ideation, suicide Suicidality can change rapidly. A system of routine
attempt, and deliberate self-harm in the UHR assessment of suicide risk, including suicidal
group. Data suggests that 25–92% of people ideation and the presence or absence of known
identified as UHR experience suicidal ideation risk factors, is likely to reduce such risk. See Box 5
[244], and 10–24% have attempted suicide prior for indicated suicide risk assessment periods.
to identification [244, 245], with no difference
in rates of suicide attempt between the UHR
and FEP groups. Yung and McGorry [87] found
that 14.3% of their small UHR sample reported a
history of deliberate self-harm, while in a larger
study Phillips et al. [222] found that 64.8% of
their UHR sample reported at least one incident of
deliberate self-harm in their lives.
45
FOR EARLY PSYCHOSIS
Box 5. Periods where suicide risk violence to others should be regarded as part of
assessment is particularly indicated the comprehensive package of routine clinical
and recommended service responses care in early psychosis services. Where there
are concerns regarding someone’s potential
Transition from prodrome to psychosis
risk of violence or offending, structured clinical
Early phase of recovery assessment using tools, such as the HCR-20
Early relapse [264] are recommended, rather than unstructured
During rapid fluctuations of mental state clinical interview. This is due to greater accuracy
Prior to granting hospital leave of structured risk assessment, and its facilitation
of transparency in guiding decision making, which
On discharge from the service
may be especially relevant in the event of external
Following any incident of deliberate self-ham scrutiny [265]. Structured clinical assessment
Following loss events tools such as the HCR-20 assess both static
(unchanging) and dynamic (modifiable) risk
Recommended service responses when
factors for violence. These tools provide guidance
someone is identified as high risk
as to a person’s level of risk (e.g., low, moderate or
• Informing consultant psychiatrist high), but more importantly provide opportunities
• Discussing with clinical supervisor for interventions to manage relevant dynamic
• Development and documentation of risk factors, such as active symptoms, substance
immediate risk management plan in abuse, medication non-compliance, or lack of
conjunction with the individual, carers, personal support. Assessing the risk of violence
consultant psychiatrist, and other (or any risk) is futile if identified risks are not
members of the treating team managed.
For a thorough discussion of violence risk

assessment and management in mental health,
Risk of violence see Maden [265].
The majority of people with severe mental
illness are not violent. Nonetheless, there is an Risk of neglect and victimisation
established association between schizophrenia A history of neglect and victimisation is related to
and increased rates of violence and criminal psychotic disorder, both cross-sectionally [266],
offending [260]. For example, compared with the and in predicting onset in people identified as
general population, individuals with schizophrenia UHR [267, 268]. A recent study suggested that
are 4 times more likely to have been convicted of 34% of people with FEP have experienced sexual
a violent offence and 10 times more likely to have or physical abuse [269]; another study reported
been convicted of homicide [261]. These rates that 30% of people with FEP experienced child
increase substantially when substance abuse, sexual abuse and another 14% experienced
personality disorder and social disadvantage are physical abuse [270]. In psychosis broadly, the
included. A systematic review and meta-analysis British National Survey of Psychiatric Morbidity
[262] reported that the pooled estimates of the found that victimisation in almost all its forms
proportion of participants with FEP committing (i.e., sexual abuse, bullying, being taken into
any violence, serious violence and severe violence care, experiencing violence in the home, running
were 34.5%, 16.6% and 0.6%, respectively. There away from home, spending time in a children’s
is a significant association between DUP and institution, being homeless, being a victim of
homicide, such that people who experience a serious injury, or experiencing violence at work)
longer period of untreated illness are more likely was more frequent in people with psychosis than
to have committed homicide [263]. As early those with other psychiatric disorders and the
intervention reduces the delay in treating mental general population [271]. A recent systematic
illness, it has been suggested that this approach review found that criminal victimisation was
may be critical to reducing forensic outcomes up to 140 times greater among people with
such as violence [263]. psychosis than the general population [272].
Recent studies suggested that 16–25% of people
Given the association that exists between with schizophrenia are reported to be victims of
psychosis – particularly early psychosis – and violence at some time in their lives [273, 274].
offending, assessment of the risk of harm or
46
FOR EARLY PSYCHOSIS
Men with schizophrenia have an increased risk of factor identified in psychosis broadly is a good
dying by homicide than the general population, relationships with clinicians [286].
especially when involved in alcohol and drug
use [275]. Rates of sexual and physical abuse in Summary
women with serious mental illness are twice those Risk assessment includes suicide risk
for women in the general population [276-278]. assessment, but also a broad range of other risks,
This history of neglect and victimisation may including violence, neglect/victimisation, and
influence the way psychosis presents [270]; for disengagement from treatment. All should be
example, Thompson et al. [279] found that people assessed on a regular basis, to ensure treatment
identified as UHR who had experienced sexual is appropriate to the individual’s needs and to
trauma were more likely to report attenuated prevent clinical collusion in any ongoing risk the
psychotic symptoms with sexual overtones. individual experiences.
A number of factors could be responsible for

these links: psychosis may cause neglect and Use of informants during
victimisation; neglect and victimisation may assessment
cause psychosis; or some third variable may be
responsible for both psychosis and neglect and During the assessment process, as much
victimisation. There is limited data to suggest information as possible should be gathered
the first option, although some authors (e.g., from referring sources and other key people in
Goodman et al.[277]) suggest that cognitive and the individual’s network. This not only assists
behavioural symptoms of schizophrenia, such in gaining an understanding about how best to
as impaired judgement, planning difficulties, conduct an assessment and engage the individual,
and difficulties with social relationships, result but also provides some preliminary information
in greater vulnerability to abuse. There are also about their difficulties. However, accessing
instances in which treatment for psychosis services may be anxiety-provoking and possibly
becomes associated with neglect and abuse (such traumatic for the individual’s social network, as
as abuse on psychiatric inpatient units, [280]). well as for the individual themselves. Engagement
Iatrogenic neglect may also occur if clinicians are with families and other relevant social networks
not assiduous in detecting and treating comorbid should be a priority at this time, not only for their
physical conditions that can affect mortality, such own sake but as partners in care [175].
as HIV and pulmonary illness [281]. Maltreatment
An assessment should therefore consider the
may lead to psychotic disorder. On the other hand,
immediate needs of the family and address:
other factors (such as premorbid cognitive deficits
or problems with interpersonal functioning, with • family members’ understanding of psychosis,
associated poor social supports and disadvantage its treatment and prognosis
such as homelessness) may be associated with • the family’s previous experience with
both psychosis and risk of maltreatment [271]. psychosis, and their explanatory model(s) of
the psychosis
Risk of non-adherence to treatment
• the practical, cognitive and emotional impact of
and service disengagement
the psychosis on individual family members
The risk of non-adherence and service
disengagement may be substantially greater in • the family’s strengths and coping resources,
FEP than in more chronic samples [149, 282], including members’ perceptions of their
reflecting a normative denial process [175] as well strengths and coping resources
as other factors that contribute to non-adherence • the family’s experience in dealing with stress
in more chronic samples, such as substance • the family’s appraisal of the resources available
use and poor therapeutic alliance [283, 284]. to support them
Particular risk factors for disengagement from
• the patterns of communication within
FEP services include past forensic history, lower
the family (how the family relates to and
severity of illness at baseline, living without family
communicates with the person with the illness)
at discharge, and persistence of substance use
[175].
throughout treatment [218, 285]. A protective
47
FOR EARLY PSYCHOSIS
In some instances, however, people may be It is both ethically sound and good practice to
reluctant to allow communication between provide the person being assessed, and, where
services and their family. An early step is to appropriate, their support networks, with feedback
explain that the involvement of families is routine regarding the assessment process. This includes
and a useful part of someone’s overall care. If an diagnosis and any formulation that the assessor
individual continues to decline family involvement may be considering in relation to the individual’s
in assessment and/or treatment, careful difficulties (see Box 7). Feedback should be
exploration of their reasons is warranted. In rare provided to the referrer and where possible to the
cases, such as severe estrangement or abuse, individual’s GP.
involvement of the family may be inappropriate.
In the case of the UHR group, information about
Further discussion of issues of family involvement
the nature of symptoms and the risk of transition
in care and confidentiality is in Guideline 3.3.10,
should be carefully provided within a framework
‘Family involvement’.
of therapeutic optimism. It is important to confirm
that current problems can be alleviated, that
Communication of rights and progression to psychosis is not predetermined,
and that effective and well-tolerated treatments
responsibilities are readily available. The person can be reassured
Rights and responsibilities of mental health that if a more severe disorder were to develop,
service users and providers are outlined in the treatment would be available immediately.
federal Mental Health Statement on Rights
and Responsibilities [287] and various state
documents (e.g., Victoria: Charter of Human
Rights and Responsibilities; NSW: Department of
Health Charter for Mental Health Care in NSW),
as well as the United Nations Principles for the
Protection of Persons with Mental Illness and for
the Improvement of Mental Health Care. Although
these rights and responsibilities should be
canvassed throughout service engagement with
individuals and their families and other networks,
assessment is the most appropriate time to
initially communicate them in user-friendly ways
(see Box 6).
Box 6. Communication of rights and

responsibilities should occur in a timely
fashion (ideally within 48 hours of
assessment) This includes:
• Information packs about treatments and

services available
• Written and verbal information regarding
rights (especially privacy rights) and
responsibilities after entry to the service,
particularly with respect to involuntary
admissions and treatment
• Ways to access complaints procedures
Provision of feedback and diagnosis
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FOR EARLY PSYCHOSIS
Recommendations 2.4.4 Assessment for comorbid disorders should

include thorough and regular assessment of
2.1 Assessment begins therapeutic engagement substance use (including cigarette use) and other
and treatment, so establishing rapport should be psychiatric disorders.GPP
a priority.GPP 2.4.5 Risk assessment
2.2 Assessment is an ongoing process, not just 2.4.5.1 Risk assessment should be undertaken
restricted to initial entry into service.GPP and documented at each visit, and should include
2.3 Assessments should occur as soon as routine assessment of depressive symptoms,
practicable after referral, and within 48 hours in hopelessness, suicidal intent, the effect of
the case of suspected FEP.GPP returning insight, and the role of psychotic
features on mood.GPP
2.4 All young people presenting with possible
psychosis should have a comprehensive 2.4.5.2 Risk assessment should take into account
biopsychosocial assessment by an acute the fluctuating nature of suicidality in young
treating team. This should include: developing people.GPP
an understanding of the personal context of 2.4.5.3 Risk assessment should also include
illness and developing a case formulation; mental assessment of risk to others, risk attributable
state examination; physical examination and to neglect and victimisation by others, and
investigations; cognitive assessment; assessment risk of non-adherence to treatment (including
for comorbid disorders; and risk assessment.GPP absconding).GPP
2.4.1 Assessment of the personal context of illness 2.5 Where possible, informants (particularly
should include: developing an understanding of referrers, but also other key members of the
the longitudinal course of symptoms and how young person’s social networks) should be drawn
they are regarded by the young person; and the upon as valuable sources of information about
young person’s strengths, resources (including the trajectory and nature of the young person’s
family resources), and skills in managing these difficulties. Assessment should also consider
symptoms specifically and other stressors more needs of the family, their knowledge of psychosis,
broadly.GPP the impact of psychosis on the family, and their
2.4.2 Mental state examination, assessing strengths and coping resources.GPP
signs, symptoms, and insight, is aided by an 2.6 Feedback regarding assessment (particularly
antipsychotic-free period of assessment.GPP provisional diagnoses and possible formulation of
2.4.3 Physical examination, including baseline the young person’s difficulties) should be provided
assessment of metabolic functioning (see to the young person, and to referrers and GPs,
Guideline 3.3.2) and related lifestyle factors and, where appropriate, to other key supports of
(such as diet and exercise) should occur to rule the young person.GPP
out an organic basis to illness, guide appropriate 2.7 Rights, responsibilities and information about
treatment, and enable monitoring of side effects. the treatments and services available within the
Basic metabolic monitoring should be ongoing and service should be communicated to young people
include regular weight and waist circumference and their key supports within 48 hours of entry to
measurement.GPP the service.GPP
49
FOR EARLY PSYCHOSIS
Guideline 3. Treatment Psychological therapies for UHR

‘Detecting an illness early is of value only if There have been considerable advances in the
effective treatment is readily available’ (Falloon et use of psychological therapies as treatment
al, p. 33[288]). Some principles apply regardless components for psychosis (see Box 7 for CBT
of phase of illness, and in many ways reflect good intervention in the UHR phase). They can be
practice points in working with young people helpful to target specific treatment needs,
broadly. The pre-onset and first-episode periods for example addressing the distress caused by
do however have their own specific treatment hallucinations, and more generally in areas such
issues. Further, different approaches are likely to as engagement with treatment. CBT has been the
be indicated across the different phases of acuity primary stand-alone psychological intervention
in the FEP group (acute phase, early recovery, explored in empirical research in the UHR phase,
relapse, and late recovery/discharge). This section with a particular focus on reducing psychotic
outlines: symptoms and/or delaying or preventing
• principles specific to the UHR group transition to psychosis. CBT is an intervention
which challenges patterns of thought and the
• principles specific to the FEP group, including behaviour associated with these thoughts [291,
general principles for FEP and principles for the
292]. An overarching paradigm within the CBT
different phases of acuity (i.e., the acute phase,
model of psychosis is the stress–vulnerability
early recovery, relapse, and late/problematic
framework.
recovery)
• principles related to discharge from the clinical
service
• principles that operate regardless of illness
phase.
Guideline 3.1. Treatment

guidelines for the UHR phase
Background
One meta-analysis reports that various
interventions at the UHR stage reduce the risk
of transition to a first episode of psychosis by
54% (at 12 months [289]). A number of review
articles and books are available on psychological
intervention in the pre-psychotic phase that
provide more detailed information than these
guidelines can outline (e.g., Addington et al.
[290]; McGorry et al. [15]; Yung et al. [3]).
Information is much more limited regarding
medical management of this phase. A summary of
relevant issues is offered here. Case management
is clearly an intervention in its own right; however,
the principles of case management in both
UHR and FEP are reviewed in Guideline 3.3.4.
This section focuses on the evidence surveying
specific interventions implemented in a stand-
alone manner. Evidence concerning both CBT and
supportive therapy when combined with other
interventions in the UHR period is also discussed.
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FOR EARLY PSYCHOSIS
Box 7. The focus of CBT in the To date, four studies support the efficacy of CBT
UHR phase is to: as a stand-alone intervention in preventing or
delaying transition to a first episode of psychosis,
Enhance understanding of symptoms being
and/or treating symptoms in the UHR period.
experienced (including psychotic and
nonpsychotic symptoms) and target the Morrison et al. [29] reported that cognitive
symptoms through strategies such as: therapy (CT) alone (up to a maximum of 26
• psychoeducation and normalisation of sessions over 6 months, with an average number
anomalous experiences by provision of a of 12 sessions) significantly reduced the likelihood
general biopsychosocial model of these of transition to psychosis (as operationalised
by either scores on the Positive and Negative
• challenging and ‘reality testing’ delusional
Symptom Scale or meeting criteria for a DSM-
thoughts and hallucinations
IV psychotic disorder) and prescription of
• enhancing coping strategies regarding antipsychotic medication by an independent
positive symptoms (such as distraction and medical practitioner at 12-month follow-up. CT
withdrawal, as well as more general coping also predicted prescription of antipsychotics
strategies outlined below) and transition to psychosis (but on the PANSS
• encouraging self-monitoring of symptoms only, and only when controlling for baseline
to establish any relationship between cognitive factors such as metacognitive beliefs)
symptoms and stress at 3-year follow-up [293]. Social functioning and
• with respect to negative/depressive distress were, however, unaffected by CT. In brief,
symptoms, encouraging scheduling and treatment included the development of a case
monitoring of mastery and pleasure formulation and shared goals, with treatment
activities and cognitive restructuring of techniques such as examining the pros and cons
negative and self-defeating cognitions of particular ways of thinking and behaving,
• strengthening coping resources to considering evidence and alternative explanations
ameliorate the impact of stressors and, for beliefs, and behavioural experiments to
hence, vulnerability to developing further evaluate beliefs [294].
or more severe symptoms, via strategies More recently, Van der Gaag and colleagues [295]
including: found that 26 weekly sessions (6 months) of CBT
–– psychoeducation about the nature of significantly reduced transition to psychosis at
stress and anxiety treatment end and 18 month follow-up (relative
–– monitoring of stress to treatment as usual) in help seeking UHR
participants. Moreover, participants receiving CBT
–– introduction of stress management
intervention had a significantly higher remission
techniques
rate (from ‘at-risk’ status) at follow-up. The CBT
–– identification of maladaptive coping intervention targeted cognitive biases typical
techniques and promotion of more for UHR young people. This included increasing
adaptive responses to stress the participants’ awareness of cognitive biases,
–– identification and restructuring of and correcting for them (i.e., selective attention
cognitions associated with stress or to threatening stimuli, confirmation bias,
anxiety, and replacement of these with negative expectation bias, causal reasoning over
more positive coping statements coincidences).
–– goal-setting, time management,
Another recent study by Bechdolf and colleagues
assertiveness training and problem-
[296] described a CBT intervention for those in
solving skills [2-4].
the ‘early initial prodromal state’ (i.e., experiencing
basic symptoms or experiencing functional decline
plus other risk factors such as family history of
psychotic disorder, rather than meeting UHR
criteria). This CBT intervention used a stress–
vulnerability model, focusing on shared problems
and goals, guided discovery as the engine for
change, skills training, cognitive remediation, and
51
FOR EARLY PSYCHOSIS
psychoeducation for family and carers. Only 2/63 pharmacological treatment of comorbid disorders;
(3.2%) participants receiving CBT transitioned to and the fact that pharmacological interventions
a first episode of psychosis, compared with 11/65 for psychotic symptoms in the UHR group may
(16.9%) who received supportive counselling. be less acceptable to consumers, given drop-out
This effect was sustained at 24-month follow-up: rates in trials using pharmacological interventions
individuals who received supportive counselling [222]. These are particularly salient in the UHR
were 3.7 times more likely to transition to a first group because of the false-positive phenomenon
episode of psychosis, relative to participants noted earlier – individuals may be prescribed
receiving CBT intervention (p = 0.019). antipsychotic medication and experience all of
these adverse events when they were not at risk of
Whilst some studies investigating CBT
psychosis in the first place.
intervention in at-risk cohorts have shown no
benefit [297-299], two recent meta-analyses Preliminary naturalistic data also suggests that
conclude that CBT may be beneficial in delaying or antidepressant medication may be associated
preventing onset of psychosis in UHR individuals with lower rates of transition to psychosis than
[300, 301]. These are supported by a systematic antipsychotics [225, 306]. Additionally, long-
review reporting that CBT reduces subthreshold chain omega-3 polyunsaturated fatty acids
symptoms at 12 months and reduces the risk of (PUFAs) reduced the rate of progression to
transition to psychosis at 6, 12 and 18–24 months psychosis in comparison with placebo in one
[302]. CBT is a benign intervention that may randomised controlled trial [307]. A longer-
achieve a balance of safe and effective treatment, term follow-up of this study at a median of 6.7
which is important given the high rate of false years, again showed positive effects of omega-3
positives in UHR cohorts. PUFAs reducing both the risk of progression to
psychotic disorder and psychiatric morbidity
Medication in general [308], while a recent multi-centre
replication omega-3 trial reported inconclusive
Information to date suggests that medication,
results [739]. Thus, medical treatments that
particularly low-dose antipsychotic medication,
are more benign than antipsychotics may be
may be effective in preventing or delaying
effective [15]. For these reasons, further research
transition to psychosis in the short-term when
is required before antipsychotic medication can
combined with CBT [28, 303]. Antipsychotic
be recommended for treatment of the UHR group
medication may also be helpful in ameliorating
[309].
symptoms and preventing transition to psychosis
when used alone. The PRIME study was a However, in exceptional circumstances a low-
randomised double-blind trial of comparing the dose SGA medication may be indicated. One
efficacy of 5–15 mg olanzapine with placebo. Eight- example would be if there were rapid worsening
week follow-up suggested that olanzapine was of psychotic symptoms, significant deterioration
associated with significantly greater improvement in functioning related to these symptoms and
in psychotic symptoms than placebo [304], and elevated risk to self or others. In this case
there was a trend for those in the olanzapine antipsychotics would be used not only to
group to be less likely to transition to psychosis at prevent onset of psychotic disorder but also to
1-year follow-up. However, there was no difference ameliorate distress and the deteriorating social
approaching significance at 2-year follow-up functioning associated with this state. This is not
[305]. justified in the majority of such situations (see
recommendation 3.1.8).
Although these data suggest a possible role of
antipsychotic medication in preventing or delaying These data should not, however, preclude
transition to psychosis, there are a number the pharmacological treatment of comorbid
of concerns about prescribing antipsychotic psychiatric disorders, notably depression, in
medication to the UHR group. These include: the accordance with relevant treatment guidelines.
potentially serious side effects of antipsychotic
medications, which may be particularly Integrated treatment
distressing to young people (e.g., weight gain,
While there has been growing research focused
sexual dysfunction, extra-pyramidal side effects);
on the individual components of treatment in early
self-stigmatisation; the need to prioritise
52
FOR EARLY PSYCHOSIS
psychosis, a key issue is the role of specialised based case management, and pharmacological
or streamed systems to deliver mental health treatment of comorbid disorders if necessary.
care. Integrated treatment refers to packages The authors found that those in the supportive
that combine psychological and pharmacological therapy control group (n=28) were more likely
interventions, together with needs-based case to transition to frank psychosis than those in the
management. The Early Psychosis Prevention intervention group (n=31), but this difference was
and Intervention Centre (EPPIC) in Victoria no longer significant at 1-year follow-up, 6 months
pioneered the development of such systems and after treatment had ended [28] or at 3–4 year
showed that they were superior to historical and follow-up [303]. These findings suggest that the
generic models of care [310]. Many of the trials combination of antipsychotic medication and CBT
in this group compare an active intervention may delay but not always prevent transition to
with treatment as usual within this specialist psychosis in the UHR group.
paradigm; fewer studies have examined the
The Danish study (OPUS [311]) evaluated
difference between treatment as usual within a
an intervention package including assertive
specialist integrative service and less broad-based
community treatment (with a focus on symptom
approaches.
monitoring and treating comorbid substance use),
In the pre-onset group, results of trials social skills treatment, and psychoeducation for
implementing integrated therapy have emerged participants and their families in multi-family
from two countries, Australia and Denmark. groups. Results suggested that there was a lower
The Australian study examined the influence of transition rate from schizotypal to psychotic
CBT, combined with either low-dose risperidone disorder for those receiving the integrated
or placebo, and supportive therapy (aimed at treatment than those receiving treatment as usual
helping people to cope with current problems, at 12-month follow-up. These data suggest that
primarily social relationships and vocational this integrated intervention at the least postponed
and family issues, without CBT) plus placebo, and possibly prevented transition to psychosis.
in the UHR group. All groups received needs-
Recommendations 3.1.5 CBT may reduce psychotic symptomatology

and prevent or delay transition to psychosis in the
3.1.1 The possibility of psychotic disorder should pre-onset phase.
be considered for anyone who is experiencing
3.1.6 CBT may improve social functioning in the
unexplained functional decline.A
pre-onset phase.
3.1.2 If subthreshold psychotic features combined
3.1.7 Supportive counselling alone may improve
with the onset of disability indicating ultra high
social functioning in the pre-onset phase.
risk are present, the individual and their relatives
should be assessed and mental state and safety 3.1.8 Antipsychotic medications should not
monitored regularly (every 2–4 weeks) in a normally be prescribed unless at least 1 week
context of ongoing support. CBT is the preferred of frank positive psychotic symptoms have
intervention.C been sustained. The exception may be where
briefer or milder positive symptoms are directly
3.1.3 Information about the level of risk should
associated with risk of self-harm or aggression.
be carefully provided taking into account social,
E.g. in substance-related psychotic disorder, or
educational and cultural factors.C
when subthreshold positive psychotic symptoms
3.1.4 Syndromes such as depression and persist in the face of CBT and other psychosocial
substance use, and problem areas such as treatments and are causing distress and or
interpersonal, vocational and family stress, should disability.
be appropriately managed.
3.1.9 Omega-3 fatty acids may delay or prevent
transitions to psychosis.c
53
FOR EARLY PSYCHOSIS
Guideline 3.2. Treatment Medication in the acute phase

Pharmacotherapy is a first-line treatment
guidelines for first episode for psychotic disorders and therefore a
psychosis medical practitioner must be involved at the
commencement of treatment for FEP. There
Most empirical research in early psychosis, are a number of differences between young
particularly in psychological therapies, tailors people with FEP and people with established
treatment to the specific phase of psychotic schizophrenia that should be considered when
illness. Guidelines relevant to the acute, early prescribing pharmacological treatments for FEP.
recovery, relapse, and late/problematic recovery A summary of the issues particular to this group
and discharge phases are outlined in turn below. is presented in Box 8. The safety and efficacy of
antipsychotic and mood-stabilising medications
Guideline 3.2.1. The acute phase have not been systematically evaluated in young
Background people, and extrapolation from adult studies,
It is usually during the acute phase that someone clinical experience and expert opinion governs
first contacts mental health services. The their off-label use in this population [312, 313].
presentation will determine the initial setting Little information is available about the long-
for treatment (i.e., inpatient or outpatient care). term effects of antipsychotic medications on the
This first presentation of suspected psychosis development of the central nervous system [313].
is considered a psychiatric emergency requiring
immediate treatment, in order to reduce both
DUP and distressed caused to the individual and Box 8. Particular considerations for
caregivers. pharmacotherapy in the FEP group
The overall aims of treatment during the acute • Young people with FEP are often
phase are to: antipsychotic-naïve.
• monitor the individual’s mental state • A young person’s first experience of
• gain a thorough understanding of the person antipsychotic medication (response
and their situation as quickly as possible and side effects) will influence their
engagement and adherence [5].
• ensure the safety of the individual and others
• People with FEP often respond to much
• reduce delay in effective treatment by treating
lower antipsychotic doses than those with
or preventing:
established illness [7, 8].
–– positive symptoms of psychosis and
• People with FEP generally show a more
disturbed behaviour
rapid improvement in symptoms than
–– negative symptoms and coexisting problems people with established schizophrenia [7].
such as depression, mania, anxiety or panic
• Positive symptoms in people with FEP are
attacks and substance abuse
generally responsive to treatment in terms
• build a sustainable therapeutic and supportive of overall response rate and degree of
relationship with the individual and carers symptom reduction [12].
• develop a management plan to aid recovery • People with FEP and young people may
from the acute episode, reduce risk of relapse be particularly sensitive to antipsychotic-
and promote long-term well-being associated extrapyramidal side effects [8,
• minimise trauma 12-14].
• instil realistic hope • People with FEP are more susceptible to
• provide an acceptable explanatory model, with antipsychotic-associated weight gain and
education about psychosis and its treatment metabolic side effects than those with more
• inform and support the family to relieve chronic illness, due to their younger age and
their distress and to promote optimal family often being antipsychotic-naïve[14].
functioning. Diagnostic instability in FEP may require
ongoing adaptation of pharmacological
interventions [7].
54
FOR EARLY PSYCHOSIS
Figure 4. Pharmacological treatment for first episode non-affective psychosis
Add benzodiazepine Psychiatric and Psychiatric emergency

• agitation/aggression, physical assessment
e.g. diazepam Allow antipsychotic drug-free
• anxiety, e.g. lorazepam assessment phase
• sleep disturbance,
e.g. temazepam
Long acting injectable antipsychotic Start antipsychotic treatment Differential diagnoses

medications can be administered as a (start low, go slow) If manic or depressive symptoms
first-line treatment within a shared- evident, consider other disorders
decision making framework which involve psychosis:
• bipolar I disorder with
psychotic features
• schizoaffective disorder
• major depressive disorder
with psychotic features
Amisulpride Aripiprazole Quetiapine Risperidone Ziprasidone

Start with: Start with: Start with: Start with: Start with:
50–100 mg/day 5–10 mg/day 25–50 mg/day 0.5–1 mg/day 20–40 mg/day
Initial target dose: Initial target dose: Initial target dose: Initial target dose: Initial target dose:
300–400 mg/day 15–20 mg/day 300–400 mg/day 2–3 mg/day 80–120 mg/day
Highest dose: Highest dose: Highest dose: Highest dose: Highest dose:
up to 800 mg/day up to 30 mg/day up to 750 mg/day up to 6 mg/day up to 160 mg/day
Rapid dose
adaptation from
starting dose
recommended
Non-adherence Start low dose Response

• Discuss with patient and carers, then slowly increase according • Continue treatment for at least
analyse reasons and optimise to efficacy and tolerability 2–5 years
treatment, give compliance to inital target dose • If incomplete remission or treatment
therapy resistance, consider long‑term
• For non-adherence because of side treatment
effects: try another antipsychotic • If discontinuing, stop gradually
drug If insufficient response over at least 3–6 months with close
• Consider trial of depot medication after 3 weeks follow-up
(e.g. atypical depot agents Increase dose over next 2–3 weeks and
or low-dose typical drugs) optimisepsychosocial interventions
• Improved adherence: go on
withtreatment or switch to other If non-response after 6–8 weeks
antipsychotic if no response Cross-over switch to another SGA
If non-response to second
antipsychotic trial:
review reasons for failure, e.g.
adherence, substance use, family
stresses etc
Consider olanzapine
(use with caution, see box 9)
Start with: 2.5–5 mg/day
Initial target dose: 10 mg/day
Highest dose:up to 20 mg/day
Consider switch to clozapine

Start with: 25mg/day
Initial target dose: 300mg/day
Highest dose: 900mg/day
If not possible, consider add-on
or trial of low dose typical
antipsychotic or mood stabiliser
or (other) antipsychotic combination
therapy
55
FOR EARLY PSYCHOSIS
Figure 5. Pharmacological treatment for first episode affective psychosis
Benzodiazepine Psychiatric and Psychiatric emergency

• agitation/agression physical assessments High severity of illness with agitation:
e.g., diazepam consider short-term parenteral
• anxiety, e.g., lorazepam medication
Manic episode with mixed factors Psychotic depression
Mood stabiliser + Second-generation

antipsychotic drugs
Titrate dosage as necessary,
see Figure 4.
Lithium carbonate Risperidone + Benzodiazepine Risperidone + Major depression Bipolar depression

Start: low dose Start with: Early add-on Start with: Antidepressant Mood stabiliser
of approximately 0.5–1 mg/day therapy: short 0.5–1 mg/day plus low-dose (preferably
400–500 mg/day. or term use or SGA lithium carbonate
Assess lithium acceptable or lamotrigine)
serum e very 5–7 Quetiapine Quetiapine or quetiapine
days till s teady Start with: Start with: 25–50
state is reached: 25–50 mg/day mg/day
• antimanic use: Rapid dose Rapid dose
1–1.2 mmol/L adaptation from adaptation from
• prophylactic starting dose starting dose
mood- recommended recommended
stabilising: or or
0.6–0.8 mmol/L
Ziprasidone Amisulpride
Recheck serum
lithium every Start with: Start with: 50–100
2–3 months. 20–40 mg/day mg/day
Discuss pros or or
and cons of slow Aripiprazole Ziprasidone
release form
Start: Start with: 20–40
5–10 mg/day mg/day
or
Aripiprazole
Non-response
Start with:
5–10 mg/day
Switch to
Sodium valproate
Initial dose:
500–1000 mg/
day in 2 to 4
single doses Non-response Non-response Non-response Non-response
Antimanic use:
serum level
50–100 µg/L Switch to another atypical antipsychotic. Switch to Switch to another Add another
Monitor serum Increase dose over next 2–3 weeks and another atypical antidepressant; mood stabiliser
level closely optimise psychosocial interventions. If antipsychotic, consider mood or consider
non-response after 6–8 weeks crossover including stabiliser (e.g. combination
switch to another SGA including: Olanzapine lithium carbonate, of an SGA and
Non-response Olanzapine (use with caution, see box 9) lamotrigine); fluoxetine;
Start with: consider ECT consider ECT
Start with: 2.5–5 mg/day. Consider trial 2.5–5 mg/day
of or add-on with low-dose conventional
Switch to other antipsychotic
mood-stabiliser
or treatment
options Non-response
• carbamazepine
• oxacarbazepine
• combinations of
mood stabilisers ECT: 3 sessions/week, maximum Note: Guidelines are not a substitute for clinical knowledge.
of 14 sessions The range of treatment doses and d ose increases should take
into account clinical p
resentation.
Quetiapine (quetiapine fumarate) in this algorithm r efers to
Caution: Sodium valproate in women
non-extended release formulation.
Caution: Concurrent adminstration of lithium
or anticonvulsive mood stabilisers with ECT
56
FOR EARLY PSYCHOSIS
Atypical, or second-generation, antipsychotics Box 9. Caution re Olanzapine as treatment

(SGAs) are preferred over typical, or first- for young people with FEP: the evidence
generation, antipsychotics (FGAs) for initiation of
Olanzapine-elicited weight gain is equivalent
antipsychotic treatment in young people, due to
to clozapine, and greater than other SGAs
better tolerability (see Principle 1 on page 57). It
[318]. This effect is pronounced in early
is also possible that SGAs may have better effects
psychosis cohorts: clinically significant
on cognition, although the evidence is currently
weight gain occurs far more frequently with
equivocal.
olanzapine than with alternative first-line
Algorithms for medication prescribing in non- treatment options[319-321].
affective and affective FEP are presented in Figures Multiple short-term studies in healthy
4 and 5, and principles of pharmacotherapy in FEP volunteers have found evidence that
are listed in Box 10 and elaborated below. Recent olanzapine causes significant metabolic
studies report newer antipsychotic medications changes within hours or days of commencing
(i.e., lurasidone and asenapine) improve treatment. Changes include:
psychopathology in schizophrenia populations
• impaired insulin action on glucose [322]
[314-317]. However, further studies with early
psychosis cohorts are required to confirm their • elevated fasting plasma leptin and
suitability, and as such, these agents are not triglycerides [323]
currently included in the algorithms. • elevated post-prandial insulin and
accompanying insulin resistance [324]
• decreased glucose effectiveness and raised
fasting glucose [325]
• increased food intake [13, 326].
These studies, in over 90 healthy volunteers,
are not confounded by participants’
experiencing psychotic symptoms, or
underlying genetic risk for metabolic disease.
Given the greater propensity of olanzapine
to elicit weight gain and other metabolic
complications (relative to other SGAs), we
strongly recommend that olanzapine use in
first episode psychosis is limited to those
young people in whom a trial of at least one
other SGA has demonstrated inadequate
control of psychotic symptoms.
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FOR EARLY PSYCHOSIS
Box 10. Principles of Principles of pharmacotherapy in FEP

pharmacotherapy in FEP
Principle 1. Take side effect profiles into
Principle 1. Take side effect profiles into consideration
consideration Young people appear to have a higher risk than
adults for antipsychotic-associated weight gain,
Principle 2. Prevent and treat psychiatric
hyperprolactinaemia, extrapyramidal side effects
emergencies
(EPSEs) and sedation, and associated metabolic
Principle 3. Distinguish between affective abnormalities [327]. At a time when young people
and non-affective psychosis are experiencing psychological and physical
Principle 4. ‘Start low, go slow’ maturation, the impact of these side effects may
Principle 5. Avoid antipsychotic be different from that in adults.
polypharmacy
A Cochrane review of the efficacy of SGAs in
Principle 6. Monitor adherence and address adolescents reported that there was insufficient
non-adherence evidence to suggest that SGAs have superior
• Factors affecting adherence efficacy to FGAs, with the exception of clozapine
• Shared decision making to facilitate in treatment-refractory schizophrenia [328].
treatment adherence However, an open randomised clinical trial in 498
people with first-episode schizophrenia has shown
• Managing non-adherence
higher response and remission rates for SGAs
• Long-acting injectable (depot) medications compared with the FGA haloperidol [329].
to address non-adherence
Principle 7. Monitor and manage adverse Regardless, the tolerability of SGAs appears to
events and side effects be greater in the early psychosis population, with
fewer side effects seen in the short term [328].
Principle 8. Treat comorbidities
While there is little evidence to suggest that
Principle 9. Identify failure to respond but one SGA is preferable to another in this context,
provide a sufficient period for treatment side effect profiles of SGAs vary markedly, and
response and remission these should be taken into consideration when
Principle 10. Use special care when prescribing antipsychotics to young people [328].
prescribing for specific populations For example, SGAs with a known propensity
• Children to cause weight gain, such as olanzapine
[328, 330, 331] should be avoided as first-line
• Women of child-bearing age, and
pharmacotherapy, while those with the lowest risk
pregnancy
of weight gain (e.g., aripiprazole and ziprasidone)
• Breastfeeding mothers should be preferred. See Table 9 for a summary
• Young people with diabetes of side effects of antipsychotic therapy. The main
considerations when selecting an antipsychotic for
FEP in young people should be their response to a
trial of this medication and the most relevant side
effects for the each person [328].
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FOR EARLY PSYCHOSIS
Table 9. Side effect profiles of commonly used antipsychotics

Adapted from The recognition and management of early psychosis: a preventive approach, 2nd Edition Henry J. Jackson, Patrick D.
McGorry, Editors. 2009, Cambridge University Press: Cambridge p.194
SGA Severe side effects Commonly EPMS liability Most common

reported side EPMS reported
effects*
Amisulpride Elevated prolactin Insomnia, anxiety Low Akathisia

levels; can cause EPMS (at low dosage)
at higher dosage
Asenapine Moderate weight gain, Somnolence, oral Low Akathisia,

EPMS at higher dosage hypoesthesia (at low dosage) sedation
Aripiprazole Can cause EPSEs at Restlessness, Low Tremor, akathisia

higher dosage sleep disturbance, (at low dosage)
anxiety
Clozapine Weight gain, metabolic Hypersalivation, Extremely low Bradykinesia,

syndrome with sedation, cognitive akathisia
possible diabetic deficits
complications,
cardiovascular/
respiratory arrest
Lurasidone EPMS at higher dosage Nausea, insomnia, Low Akathisia

vomiting, (at low dosage)
somnolence,
Olanzapine Weight gain, metabolic Cognitive deficits, Very low Tremor, subjective
syndrome with insomnia, anxiety akathisia
possible diabetic
complications
Quetiapine Moderate weight gain Somnolence, Extremely low Tremor, akathisia

dizziness,
orthostatic
hypotension
Risperidone Elevated prolactin Headaches, Low Acute dystonia,

levels; can cause EPSEs insomnia, anxiety, (=4 mg/day) Parkinsonism, few
at higher dosage; sexual dysfunction cases of tardive
moderate weight gain dyskinesia
Ziprasidone Prolongs QT interval Somnolence, Very low Tremor, akathisia

dizziness
Zotepine Can cause Nausea, Low Acute dystonia,

electrocardiographic somnolence, (at low dosage) Parkinsonism
changes; moderate dizziness
weight gain
EPMS, extrapyramidal motor symptoms.

*
All antipsychotic drugs are associated with hyperglycaemia and possible diabetes mellitus
59
FOR EARLY PSYCHOSIS
It is imperative to address the physical and sexual health issues of

young people receiving treatment for psychosis. These areas are
elaborated in guidelines 3.3.2 and 3.3.3.
Principle 2. Prevent and treat psychiatric IM antipsychotic medication is occasionally

emergencies necessary [336] [340], and as with general
The immediate goals of emergency management medication principles in this group, the lowest
of aggression or agitation are to assure the possible dose to treat the symptoms should
safety of the young person who is experiencing be used; the use of multiple antipsychotics is
these symptoms, their family and friends, and discouraged [336]. The young person should have
health care providers, and to help the young close, regular medical and nursing monitoring for
person manage their emotions and distress and several hours following an IM injection [336].
control their behaviour, while minimising the
A recent meta-analysis [340] concluded that
psychological and physiological impact on them
IM SGAs were as efficacious as IM FGAs, and
[332, 333].
in some studies showed a superior and more
Non-coercive psychological and practical rapid response. Furthermore, SGAs were better
attempts at ‘de-escalation’ of an aggressive or tolerated with respect to EPSEs. FGAs should
agitated person are strongly encouraged as first- therefore now not be used in FEP psychiatric
line management [332, 334]. If such strategies emergencies.
are not successful within a safe timeframe, then
medication should be offered with the aim of Principle 3. Distinguish between affective and
achieving a state of calm [335]. Oral medication non-affective psychosis
should be offered in the first instance [336]. While differentiation between specific diagnostic
entities may be difficult at initial presentation,
Antipsychotics or benzodiazepines are used to it is important to consider whether affective
quickly alleviate distress [337]. Both FGA and symptoms are present. This is because there are
SGA medications appear to be effective, but different treatment recommendations, especially
benzodiazepines and SGAs have better tolerability the utility of adding a mood stabiliser to the
[338]. Furthermore, the observed efficacy of SGAs pharmacotherapeutic regimen, during the acute
may be dose-dependent [339]. phase. This key early distinction between affective
Despite being commonly used in clinical practice, and non-affective presentation must be made
the available data comparing the efficacy of [341]. Identifying if delusions or hallucinations
benzodiazepines and antipsychotics in controlling occur exclusively during a major depressive or
psychosis-induced symptoms of aggression and manic episode and the severity of the depressive
agitation are limited and of poor quality (for a or manic symptoms helps to distinguish between
meta-analysis, see Gillies et al. 2013 [337]). affective and non-affective psychosis [36].
Based on this information, benzodiazepines
Principle 4. ‘Start low, go slow’
appear to be as effective as antipsychotics alone,
Evidence suggests that there is a biological
but with fewer side effects such as EPSEs [337].
sensitivity to antipsychotics during the first onset
The combination of a benzodiazepine and an
of psychosis. People with FEP respond more
antipsychotic does not convey any advantage over
rapidly to antipsychotic medication. They generally
either drug alone.
require lower doses to achieve a greater response
If it is safe to do so, short-acting intramuscular than people with more established illness [7].
(IM) benzodiazepines such as midazolam may In addition, side effects of antipsychotics can
be used in emergency situations where oral occur at substantially lower doses in the first-
medication is not accepted or suitable. These have exposure population than in people re-exposed
been used either alone or in combination with to antipsychotics [7]. Rapid titration may also
an antipsychotic. The antidote, flumazenil, and increase the incidence of side effects [33].
resuscitation equipment must be at hand. Accordingly, a ‘start low, go slow’ prescribing
approach is absolutely essential, using the lowest
possible dose to control symptoms [342].
60
FOR EARLY PSYCHOSIS
Box 11. Use benzodiazepines Box 12. Factors that affect medication
for sedation [343] adherence in young people with FEP
The principle of ‘start low, go slow’ for the The young person’s environment, including
initiation of antipsychotic medication is the level of social support they receive [5]
extremely important. Doses of antipsychotic Family attitude to mental illness medication
medication should commence at the lowest and the young person’s relationship with
effective dose for the treatment of psychotic family members [5-7]
symptoms. Although clinicians often increase
Sensitivity to medication side effects [11]
doses of antipsychotic medication to produce
a sedative effect, there is no reason to do Limited insight or acceptance of the illness
this, and it is recommended that clinicians (particularly important in young people with
use benzodiazepines for sedative purposes. FEP, who have no previous experience of
Antipsychotic dose escalation should be psychotic illness) [5, 8]
done slowly in a series of careful ‘steps’, over A belief that treatment is unnecessary [11]
many weeks, and only if required. Substance use [5]
Homelessness or housing instability [5, 8]
Principle 5. Avoid antipsychotic polypharmacy
Although relatively common in clinical practice Shared decision making to facilitate treatment
[344, 345], there is little empirical evidence to adherence
suggest that combining antipsychotic medications Shared decision-making is well established in
has superior efficacy to monotherapy in the general medicine as a way to include patient
treatment of psychosis [344, 345]. Furthermore, preferences in decisions about their treatment
combining antipsychotic medications is [14]. Including the young person and their
associated with an increased risk of side effects, family in treatment decisions is likely to increase
non-adherence and drug interactions [344]. concordance (i.e. the degree to which the young
The majority of international guidelines for person’s behaviour agrees with clinical advice),
schizophrenia recommend against the use of which may in turn, improve adherence. Indeed,
more than one antipsychotic [342, 345, 346], an effective collaborative working alliance, with
except when changing medications [342, 346] or agreement between the clinician and young
during augmentation with clozapine in treatment- person regarding the goals of treatment and the
resistant cases [344]. Although there have tasks to achieve these goals has been shown
been no direct randomised controlled trials of to increase medication adherence in FEP [351].
antipsychotic polypharmacy in FEP populations, The decision-making process for antipsychotic
the increased propensity for side effects in this medication should include psychoeducation about
population would not support this practice. why treatment is necessary and why medications
must be continued after the young person’s
Principle 6. Monitor adherence and address
symptoms have responded to treatment. It should
non-adherence
also include an open and honest discussion about
Non-adherence to medication is particularly
the possible side effects of medication. The
prevalent in young people [347], and people with
young person should be informed that switching
FEP who are non-adherent tend to be younger
medications is an option if they experience
[348]. One study found that during the first 6
intolerable side effects with their initial treatment,
months of treatment, 45% of people with FEP
as side effects are a common reason for non-
were non-adherent to antipsychotic therapy
adherence.
[349], and Hill et al (2010) found that 26% of
their FEP sample were non-adherent at 4 years Managing non-adherence
[350]. There are a multitude of factors that are A non-judgemental reaction to non-adherence
particularly relevant to young people with FEP that will encourage honesty and ongoing engagement.
can affect medication adherence, some of which The young person’s reasons for non-adherence
are presented in Box 12. should be discussed, as they may suggest a
strategy to address this issue. For example, if
cognitive difficulties and/or memory impairment
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FOR EARLY PSYCHOSIS
have contributed to non-adherence, strategies effective and acceptable [354]. For example,
that help the young person remember to take their a young person might prefer an LAI over oral
medication should be tried, such as involving a treatment as it does not serve as a constant
family member or significant other in reminding reminder of their illness, or because it is more
the young person to take their medication as convenient, particularly for those who forget to
prescribed. A motivational interviewing approach take regular medication or have cognitive or social
could also be effective. barriers to regular medication adherence [356]. If
the treating team thinks it may be of benefit, LAIs
Side effects such as weight gain, sedation,
should be presented to a young person as one of
cognitive dulling and others are strongly related
many early treatment options. It is important that
to non-adherence [352]. Clinicians should try
the young person is also provided with appropriate
to anticipate and address side effects to reduce
information about LAI medication to ensure a
the chance of non-adherence (e.g., clinicians can
collaborative decision is made. Premature coercive
anticipate weight gain by providing education
use of LAIs must be avoided.
about diet and exercise as soon as a young
person is commenced on an antipsychotic. See Principle 7. Monitor and manage adverse
also ‘Physical health management’ on page 76). events and side effects
Persistent endocrine and sexual side effects may Antipsychotic medication may cause side
warrant a switch of medication. effects that are distressing or disabling for young
Although compliance therapy has been proposed people [8]. Side effects of current antipsychotic
as a way to promote adherence with a range of medications are shown in Table 9.
interventions, there is insufficient evidence to date There are consistently strong correlations
that it improves adherence with pharmacological between patients’ assessment of the impact of
treatment [353]. Other strategies for managing side effects and non-adherence [352]. In addition
non-adherence have been shown to be effective in to actively enquiring about side effects and
people with established schizophrenia, and may discussing their concerns, a validated self-rating
also be useful in FEP. These include training for tool to measure the young person’s perception of
case managers in medication management and the side effects they are experiencing (e.g., the
person-specific tailoring strategies and programs Liverpool University Neuroleptic Side Effect Rating
to compensate for cognitive deficits in people with Scale [357]) may provide additional information
schizophrenia, such as telephone intervention and on the tolerability of their treatment regimen.
cognitive adaptation training [353]. Intervention
strategies that span a longer period of time are It is imperative to address the physical and sexual
beneficial, particularly in FEP [353]. health issues of young people receiving treatment
for psychosis. These areas are elaborated in
Long-acting injectable (depot) medications to guidelines 3.3.2 and 3.3.3.
address non-adherence
Long-acting injectable (LAI), or depot, Principle 8. Treat comorbidities
medications may be considered in FEP if Psychiatric comorbidities are common in people
adherence to oral antipsychotic treatment is with FEP, and are often present before the first
known or suspected to be a problem. [5] LAIs episode of psychosis occurs [230]. In addition,
may be particularly useful to address covert people with schizophrenia have a higher risk of
non-adherence, as a clinician is involved in the anxiety or depressive disorders than the general
administration of the medication [353, 354]. population [232]. As many as 80–90% of people
Assured administration of medication delivers with FEP fulfil the diagnostic criteria for at least
a reasonably constant dose of antipsychotic one comorbid psychiatric disorder [8]. Major
and may minimise side effects and the risk of depression, anxiety disorders (including social
overdose [355]. Avoiding the peaks and troughs phobia and post-traumatic stress disorders)
in blood levels of antipsychotic medications that and obsessive-compulsive disorder can occur
occur with oral formulations may also improve concurrently with FEP [8].
tolerability [11].
Depression and anxiety in people with psychosis
Despite their perceived reluctance to accept LAIs, are often associated with poorer outcomes such
young people with FEP may in fact find them as increased hospitalisation rates and subjective
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FOR EARLY PSYCHOSIS
assessment of psychosis-related difficulties [358]. level of schooling ≤ year 10; a current GAF score
Anxiety and depression levels are also related to ≤ 30; male gender; and meeting friends no more
rates of suicide and self-harm [14, 358, 359]. than 2–3 times per month [366].
Comorbid substance use, including nicotine and Principle 10. Use special care when prescribing
alcohol, is common in people experiencing a for specific populations
first episode of psychosis [7], and may increase Children
risk factors for relapse even in people who are
There are no dosing recommendations for
adherent to their medication. Comorbid substance
amisulpride, aripiprazole, olanzapine and
use is also associated with a worse prognosis in
ziprasidone in people aged under 18 years, for
general, including more severe positive symptoms,
clozapine in people aged under 16 years or for
longer periods of hospitalisation and poorer
risperidone in people aged under 15 years [367-
adherence to medication [7].
372]. Quetiapine is indicated for bipolar disorder
Defining the boundaries of comorbid conditions in young people from the age of 10 years, and
may be difficult due to the interaction between in schizophrenia from the age of 13 years [373].
the symptoms of the primary disorder and Amisulpride is contraindicated in pre-pubertal
those of comorbid conditions [8, 14, 232]. children[367].
Periodic reassessment in people with FEP is
Children and adolescents are thought to be more
often required [8, 14]. Therapeutic interventions
susceptible than adults to EPSEs caused by FGAs
are recommended when the presence of
and metabolic abnormalities associated with
comorbidities impacts on the effective
SGAs, especially weight gain [374]. Obesity in
management of the primary psychotic disorder [8,
young people appears to carry a greater risk of
358]. Pharmacological treatment of psychosis also
future adverse cardiovascular outcomes than
has side effects that can affect a young person’s
adult-onset obesity [375]. For this reason,
health or pre-existing medical comorbidities, as
olanzapine, which is associated with the highest
discussed in Guideline 3.3.2, ‘Physical health’.
risk of weight gain of the SGAs [376], is not
Principle 9. Identify failure to respond but considered a first-line antipsychotic medication
provide a sufficient period for treatment in children and adolescents [374]. Increased
response and remission prolactin levels in this population should also be
Symptom response and remission can be defined considered in the light of physical growth and
in a number of ways, including via symptoms bone mineralisation [374].
themselves (total score reduction of ≥ 20% on the Less information is available on the use of mood
PANSS or a reduction of ≥ 2 on the Clinical Global stabilisers in children [375]. The mood stabiliser
Impression Severity scale) or subjective wellbeing lamotrigine is associated, in both adults and
(≥ 20% increase in the Subjective Wellbeing children, with the development of potentially
Under Neuroleptic treatment Scale: Lambert et al. life-threatening rashes, such as Stevens-Johnson
2006, 2007 [360, 361]). Some research shows syndrome (SJS) and toxic epidermal necrolysis, in
that symptoms will generally respond to treatment both adults and children [377]. However, the risk
within 6–8 weeks [362] and that 10–15% of of serious skin rashes is higher in children than in
people with FEP require 7–10 weeks for symptom adults [377]. Lamotrigine is used off-label to treat
response or remission [363-365]. However, bipolar disorder in children and adolescents aged
Lambert et al. [361] suggest that incomplete under 18 years [377].
response within 4 weeks of treatment predicts
non-response at 3 months, which in turn predicts Treatment with antidepressants is associated
incomplete remission at 24 months [360]. with an increased risk of suicidal thinking and
behaviour in children and adolescents with
Given the difference between these suggestions, major depressive disorder and other psychiatric
we propose that treatment non-response 4 weeks disorders [378]. Close observation for any signs
after commencement should be an alert for of increased risk of suicide should be maintained
possible longer-term non-response, especially in in children and adolescents with depression [378].
combination with other factors that predict poor
response. Predictors of poor response include: a
GAF score ≤ 70 in the year prior to onset; highest
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FOR EARLY PSYCHOSIS
Women of child-bearing age and during associated with the highest rate of malformations,
pregnancy particularly at doses above 1000 mg/day [379].
In young women of child-bearing age, special Mood stabilisers are also associated with neonatal
consideration must be given to the risk to the complications, necessitating careful assessment
foetus from exposure to psychotropic medication, and monitoring of newborns exposed to these
balanced with the risk to the mother and child medications [383].
from deterioration or relapse of psychosis
SGA medications have an Australian pregnancy
if treatment is discontinued [379]. This is
category C classification, and their use during
particularly relevant to women with psychotic
pregnancy is recommended only if the anticipated
disorders, as they have an increased risk of
benefit outweighs the risk; the administered dose
unplanned pregnancy compared with the general
and duration of treatment should be as low and
population [380, 381].
as short as possible. Although there are limited
The risk of foetal malformation is greatest in data on their safety, the risk of teratogenicity with
the first trimester, and it is possible that the SGAs does not appear to be increased over the
pregnancy may not be recognised until after this background rate [383]. Exposure to FGAs and
time [379]. The risks associated with the use SGAs during the third trimester of pregnancy has
of psychotropic medications during pregnancy been associated with extrapyramidal neurological
should therefore be discussed with all young disturbances and/or withdrawal symptoms in the
women of child-bearing age and a collaborative newborn following delivery [367-373, 383].
plan developed [379]. Sodium valproate is not
Breastfeeding mothers
recommended for use in women of child-bearing
potential unless alternative therapeutic options Antipsychotics and mood stabilisers are excreted
are ineffective or not tolerated [382]. in human breast milk and there is limited
information on potential long-term effects on
Hormonal contraceptives have been shown to the infant [384]. Women should therefore be
increase the clearance of lamotrigine [377]. In counselled about the benefits of breastfeeding
women currently taking oral contraceptives who versus the risk of exposure to the infant [384].
are starting lamotrigine, no adjustments are While in many cases the concentrations of drug in
required to the recommended dose escalation human breast milk are low, levels which approach
guidelines [377]. However, in women on clinical significance have been reported for some
maintenance doses of lamotrigine who are drugs [384]. Accordingly, manufacturers of these
starting oral contraceptives, the maintenance medications do not recommend their use while
dose of lamotrigine will need to be increased breastfeeding [367-373, 377, 382]. Clozapine
by as much as two-fold [377]. Similarly, when is not recommended due to an association with
discontinuing oral contraceptives that have been infant agranulocytosis, decreased suckling,
used concurrently with lamotrigine, it may be seizures and cardiovascular instability [385].
necessary to halve the maintenance dose of Ziprasidone may have adrenergic effects [385].
lamotrigine [377]. While any antipsychotic should be used with
caution, olanzapine and FGAs, such as haloperidol,
Mood stabilisers are assigned to Australian
may carry lower risk [385]. Sodium valproate and
pregnancy category D, and should not be used
carbamazepine appear to be relatively low-risk
during pregnancy unless there is no other
during breastfeeding [385]. Infants exposed to
suitable therapeutic option, with the risk to
lamotrigine should be monitored for Stevens-
the foetus from exposure balanced against the
Johnson syndrome (see use in children and
risks associated with untreated or undertreated
adolescents) [385]. Lithium is associated with
major mental illness during pregnancy
risks of neonatal toxicity and thyroid or renal
[379]. In a recent systematic review of mood
dysfunctions and is not recommended for use in
stabilisers (carbamazepine, sodium valproate,
breastfeeding women [385].
lamotrigine and lithium) during pregnancy, all
were associated with increased risk of foetal Young people with diabetes
malformation [379]. These were predominantly Hyperglycaemia, in some cases is extreme and
structural malformations, most commonly neural associated with ketoacidosis or hyperosmolar
tube defects, but also including cardiac and coma or death, and has been reported in people
craniofacial defects [379]. Sodium valproate was
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FOR EARLY PSYCHOSIS
taking SGAs [367-373]. The relationship between Two studies have examined the role of CBT in the
SGA medications and blood glucose abnormalities acute phase: the Study of Cognitive Realignment
is not fully understood, and is confounded by an Therapy in Early Schizophrenia, or SoCRATES,
increased background risk of diabetes mellitus study [390, 391], and the Active Cognitive
in people with schizophrenia [367-373]. People Therapy for Early Psychosis, or ACE, project [392].
with an existing diagnosis of diabetes mellitus
The model of the therapy used in SoCRATES is
should be closely monitored for worsening of
described elsewhere [393], but in summary, it
glucose control when prescribed SGAs [367-
aimed for intense treatment during the acute
373]. Similarly, people with risk factors for
phase (15–20 hours within a 5-week treatment
the development of diabetes should undergo
period, with booster sessions at 2 weeks, and 1, 2,
fasting blood glucose measurement and periodic
and 3 months). The stages of this therapy were:
monitoring during treatment [367-373]. People
who develop symptoms of hyperglycaemia during • engagement and detailed assessment of
treatment with SGAs should also undergo fasting mental state and symptom dimensions,
blood glucose testing [367-373]. See Guideline to enable a cognitive–behavioural case
3.3.2, ‘Physical health’, on page 76 for more formulation. Engagement was facilitated by
information. using the paradigm of the stress–vulnerability
model to explain links between biological and
Psychological therapies: CBT, supportive psychological features of illness
therapy, and ‘befriending’ • development of a problem list and prioritising
CBT is the most widely-examined of this according to associated distress
psychotherapeutic intervention for FEP. As in
• intervention (especially for positive symptoms,
the UHR phase, CBT practitioners working with
by generating alternative hypotheses for
people with psychosis encourage them to learn
abnormal beliefs and hallucinations, alleviating
alternative ways of thinking about particular
precipitating factors, and attempting to reduce
situations or experiences and to develop
distress associated with symptoms), and
adaptive strategies for dealing with stressors
[386, 387]. Coping strategies for voices or • monitoring.
distressing beliefs are not qualitatively different An initial study examined the impact of this
from coping strategies that may be used for any intervention over the very short term, in a
kind of distress related to low mood, anxiety, or sample of 315 people with FEP (83% of the
feelings of shame. These interventions are most sample) or second-episode psychotic disorder
useful if the clinician has a good understanding randomised to either the intervention plus routine
of the meaning and distress-causing appraisals care, supportive counselling plus routine care,
that the person holds in relation to their or routine care alone [391]. The nature of the
symptoms. One way to identify these appraisals supportive therapy was unclear, but appears to
is to use a cognitive–behavioural framework, have followed similar guidelines to those used in
which identifies triggers, appraisals, emotional, Haddock et al. (1999) [390]. Supportive therapy
behavioural and physiological responses. There in that study was non-directive and unstructured,
is no clear consensus as to what constitutes the with primary goals to provide clients with
most ‘adaptive’ coping strategy for psychotic positive regard, emotional support, and social
symptoms, although there is some indication contact. These data found that those receiving
that active acceptance and passive coping may the cognitive–behavioural intervention scored
reduce distress more than resistance coping lower than those receiving routine care alone, on
[388]. New coping strategies may be required to positive and negative symptoms in general and
attenuate psychotic symptoms. In this case, the positive symptoms and delusions in particular,
Hearing Voices Network (http://hvna.net.au/) and lower on auditory hallucinations than those
have a number of free resources available. Other receiving supportive counselling plus usual care.
strategies clinicians can develop with the young These effects were noted at 4-week follow-
person include normalising, distraction, reality up but not at 6-week follow-up. At 18-month
testing, self-talk, relaxation, acceptance, getting follow-up, there were significant advantages for
active, and singing or humming [389]. CBT and supportive counselling over usual care
on symptom measures, but not on relapse or
rehospitalisation; there were no differences in the
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FOR EARLY PSYCHOSIS
effectiveness of CBT and supportive counselling Guideline 3.2.2), and relapse prevention. Further
[394]. It seems, therefore, that provision of either information is available in the ACE manual [395].
supportive counselling or CBT during the acute The control condition was ‘befriending’, an
phase can have immediate and long-term effects intervention that allowed for social contact but
on symptoms, with CBT having additional effects not emotional support, with a focus on ‘pleasant
in the immediate term. chat’ about neutral topics [392]. Published data
from this trial suggest that, at mid-treatment,
The ACE project entailed the provision of cognitive
ACE outperformed the control condition of
therapy to young people in the acute phase of
befriending with respect to functioning, but not
illness (within 4 weeks of acceptance into a first-
symptomatology; however, at 12-month follow-up,
episode service) in the form of a maximum of 20
there was no significant difference between the
sessions of therapy over 14 weeks. The therapy
ACE and befriending groups, with the befriending
focused on a hierarchy of presenting problems
group ‘catching up’ with respect to functioning.
such as risk, positive psychotic symptoms (if
As in the SoCRATES trial, this data suggests that
present and distressing), comorbidities, negative
CBT may lead to better early recovery, but that
symptoms, issues of identity (using modules
other interventions (e.g., supportive therapy/
from the Cognitively Oriented Psychotherapy for
befriending) may be of similar benefit later in the
Early Psychosis [COPE] intervention outlined in
recovery process.
Recommendations management strategies implemented prior to

treatment initiation).GPP
3.2.1.1 All young people with first episode psychosis 3.2.1.9 Affective and non-affective psychosis
should be seen by a doctor within 48 hours after should be distinguished to enable appropriate
entry into the early psychosis service.GPP treatment (i.e., appropriateness of use of a mood
3.2.1.2 All young people should be seen by a stabiliser).GPP
consultant psychiatrist within one week after 3.2.1.10 Pharmacological treatment should
entry to service.GPP proceed with a ‘start low, go slow’ approach.GPP
3.2.1.3. All young people should be seen at least 3.2.1.11 Adherence should be monitored and
twice-weekly in the acute phase by the acute explicitly addressed where necessary.GPP
treating team, or case manager, and a doctor.GPP
3.2.1.12 Long-acting injectable antipsychotic
3.2.1.4 All families should be seen or contacted
medications may be offered as an alternative to
at least weekly in the acute phase by the acute
oral medication within a shared decision making
treating team or case manager.GPP
approach in which young people are fully informed
3.2.1.5 Antipsychotic medication should not be about, and collaborate in treatment decisions.GPP
used during the first 24–48 hours of treatment in 3.2.1.13 Benzodiazepines may be a useful adjunct
young people with first episode of psychosis, to in florid psychosis for sedation. GPP
facilitate assessment.GPP
3.2.1.14 Treatment of the primary psychotic
3.2.1.6 SGAs should be used in preference to FGAs.GPP disorder should be prioritised unless comorbidity
3.2.1.7 Side effect profile should guide choice of leads to high levels of risk to self or others or
SGA.GPP clinical judgement considers that the comorbidity
has a major impact on the primary psychotic
3.2.1.8 Potential side effects (including metabolic disorder (e.g., cannabis dependence).GPP
side effects, weight gain, extrapyramidal motor
symptoms, and sexual side effects) should be 3.2.1.15 With the exception of the above situations,
noted and discussed with young people within polypharmacy should be avoided, specifically the
a shared decision making approach, prior to use of multiple antipsychotics.GPP
pharmacotherapy commencement, and then 3.2.1.16 CBTA, supportive therapyB, or befriendingB
monitored, managed and addressed early, with should be provided during the acute phase, with
a prevention model if possible (e.g., weight CBT having the most immediate benefit.
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FOR EARLY PSYCHOSIS
Guideline 3.2.2. Early recovery Box 13. Essential features of the recovery
process [32]
Background
The focus of management during the recovery Psychotic symptoms can subside relatively
period (features outlined in Box 13) is not only rapidly with medication, but in some cases
to treat symptoms (a necessary but insufficient this may take several months. The concept of
criteria for recovery [396]), but also to: ‘relapse’ is categorical (that is, relapse either
• manage comorbidity, including occurs or does not occur) and is a poor way
substance abuse of describing the fluctuations in symptoms
• engage the person in their own treatment that can occur during recovery.
• increase adherence to treatment Recovery is a convalescent period of

recuperation and readjustment.
• help the person understand their experience
of illness Recovery is an active process for young
people with psychosis and their families.
• assist the person in reconstructing and
reorienting their lives (including helping As part of recovery, people with psychosis
them re-engage with educational or should develop an understanding of what
vocational activities) has happened to them, integrate the
experience and restore self-esteem.
• provide the person with a sense of
empowerment, rather than passive acceptance There may be a plateau in recovery when
of a withdrawn and disabled role [397] little appears to be happening. This may
reflect a period when the young person is
• prevent relapse
struggling with subtle psychotic symptoms
• assist the young person to develop or has been depressed or ‘shut down’.
resources for the future.
For some young people, a rapid return to
For some people, a paced approach is appropriate, their normal environment and responsibilities
with one stressor or step tackled at a time in is helpful and may minimise stigma and
working towards realistic and achievable goals. inappropriate illness behaviour. For others,
Contact with the treating team may be less there is a risk of precipitating a second
frequent than during the acute phase, but still episode of psychosis if reintegration is
needs to be regular. too rapid. Predicting the best approach is
difficult. An insidious onset of illness and a
long duration of untreated psychosis with
a slow remission may suggest that a gentle
reintegration is preferable. It is important to
support the young person in pursuing their
goals and not to take a patronising attitude
of ‘clinician knows best’.
Families and friends need to understand that
this plateau is part of recovery; they need to
keep the environment calm, positive and free
of distress. Continuing their usual activities
may help to alleviate pressure on the person.
Families and friends may also need support
with this from the clinical team.
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FOR EARLY PSYCHOSIS
Box 14. Ensuring adequate response to others with a relapse. Monotherapy is the gold
treatment standard for maintenance treatments, with mood
stabilisers considered first [399].
Adequate response to treatment is enabled
by adopting principles regarding frequency For people with a first episode of psychosis who
and type of contact during early recovery, present with severe depression with psychotic
such as: features, the continuation phase is conceptualised
• People are seen by a case manager weekly to continue until the person achieves symptom
during the early recovery phase recovery to the premorbid state [400] and
maintenance therapy after this point for relapse
• People are seen fortnightly by a doctor
prevention. The role of antipsychotic medications
during the early recovery phase
beyond the continuation phase is unclear.
• Families are seen or contacted at least Maintenance treatments are often considered
fortnightly during the early recovery phase based on similar considerations as for bipolar
• Families are seen with the case manager disorders/first episode mania. The availability of,
and person being treated to ensure and response to, psychological interventions for
consensus regarding action plans major depression may also influence the decision
regarding use of medications in the maintenance
treatment phase. For treatment resistance in acute
Medication
and maintenance phases of bipolar or depressive
Many principles of medication management are
disorders, escalating treatment options should be
outlined in Guideline 3.2.1, ‘The acute phase’.
considered [400].
During the early recovery phase, frequent
progress reviews are likely to assist in early Psychological therapies
identification and management of poor efficacy, At least three psychological interventions
poor tolerability, and problems with adherence. If have been developed specifically examining
adherence difficulties are pronounced during this recovery from FEP. The first, COPE, focuses on
phase, these should be addressed (see Principle 6 psychological impact of the psychotic disorder
on page 60). LAIs may be considered, consistent on the sense of self rather than symptom profile
with the general preference in FEP for SGAs. In (c.f. studies focusing on positive symptoms and
this instance, frequent risk–benefit monitoring is distress associated therewith, e.g. [401]). COPE
required. There is no consensus on the optimal consists of four phases, outlined in Box 15; further
duration of maintenance antipsychotic treatment information on COPE is available in the COPE
following the remission of psychotic symptoms manual [402].
[183]. Guidelines for treatment of young people
with FEP note that duration of maintenance An RCT of this intervention (n=80) found that
therapy in current clinical practice ranges from the COPE group scored better on adaptation
1 year to an indefinite period, and recommend to illness, quality of life, and insight, with lower
that consideration be given to the severity of the scores for negative symptoms. However, medium-
initial episode and the response to treatment term advantages seem fairly circumscribed (at
when deciding how long to continue antipsychotic 12-month follow-up, limited to the degree to which
maintenance [13, 183]. the young person has integrated the psychotic
experience or is using a ‘sealing over’ coping style
Among people with first episode mania, after the [403]) and there are no clear advantages over
acute treatment phase, a continuation phase of the provision of a specialist service only at 4-year
2 to 6 months may be necessary using the same follow-up [404].
medications as was used in the acute phase, but
in more tolerable doses [398]. A decision about
maintenance treatment that involves the person
being treated and their family may be considered
after this phase, and should consider factors
such as the risk of relapse, family history of major
mood or psychotic disorders, side effects related
to medications, including their impact on the
persons’ quality of life, and the risks to them or
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FOR EARLY PSYCHOSIS
Box 15. Phases of COPE 1. engagement and wellness management

(including psychoeducation, goal-setting,
Engagement symptom management and relapse prevention,
Develop a therapeutic relationship using strategies such as motivational
Assessment interviewing and behavioural tailoring and
Develop an understanding of the young identification of relapse signatures and triggers,
person being treated’s explanation of with the development of coping strategies)
disorder and of psychosis in general 2. substance use (using motivational interviewing
Adaptation strategies)
Promote an adaptive style of recovery from 3. persistent symptoms (covered in further detail
psychosis, with a focus on helping the young in ‘Late recovery’)
person comprehend the stress–vulnerability
4. functional recovery (including social skills and
model, reducing distress associated with
social support, role functioning, recreational
altered self-perception post-psychosis and
activity, and self-esteem/stigma, using external
the possibility of ongoing vulnerability
support agencies, social skills training, and
Prevention and treatment activity scheduling, focusing on positive
of secondary morbidity qualities).
Prevention and management of secondary
issues such as depression, anxiety, and All participants receive the first two phases of
stigma [405, 406] treatment (across 12 sessions), regarded as
the ‘minimal effective dose’ given they cover
critical illness management issues. Clinicians
A second intervention is described in Jolley et collaboratively determine with the person being
al. [407]. This intervention, focusing on the treated whether additional treatment is necessary
adjustment process rather than the acute phase of and further treatment is then individually tailored
illness, includes emphasis on: to the person.
• processing experiences of psychosis
Only one randomised study to date has explored
• making sense of these experiences with
GRIP’s effectiveness [409]. Results suggest some
reference to a personal formulation of illness
clinical and psychosocial benefits, especially with
that is as non-stigmatising as possible
respect to levels of positive symptoms and quality
• coming to terms with loss and change as a of life comparing pre- and post-intervention for
function of illness, and generating realistic treatment completers. Moreover, the intervention
plans for the future that are also imbued with was well-tolerated, as evidenced by good
hope and optimism attendance and low attrition. However, the small
• preserving social, occupational, and education sample-size (n=46) and the lack of rater blindness
functioning or rapid re-engagement with these. for two functional outcome measures militate
against any conclusions regarding effectiveness.
A very small RCT (n = 21) found at 6-month
follow-up that those receiving this intervention There is mounting evidence supporting the
spent less time in hospital than those receiving efficacy of psychological therapies that target
treatment as usual [407]. recovery from a first episode psychosis. Initial
studies report cognitive remediation therapy
More recently, Waldheter et al. [408] developed
improves global and social cognition [410], social
the Graduated Recovery Intervention Program
functioning [411] and positive symptoms [412],
(GRIP), an intervention that focuses specifically
while other studies suggest vocational recovery
on three domains of recovery in FEP: symptom
is achieved through supported employment
improvement; optimism and self-efficacy with
programs for individuals with FEP [413]. It seems
respect to illness; and functional recovery
particularly appropriate to consider offering
(including meaningful relationships and academic/
treatments that recognise the impact of illness
occupational functioning). With an overall focus
on the sense of self, and consider the possibility
on identifying and working towards personal
of relapse and plans for this (see the following
goals to engender a sense of hope and optimism,
section for further information on relapse).
and recruiting external supports to maximise
engagement, GRIP comprises four phases:
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FOR EARLY PSYCHOSIS
Recommendations 3.2.2.4 CBT interventions may be indicated in

this group, as it may speed up recovery, reduce
3.2.2.1 Treatment response and adherence should period of hospitalisationD, enhance short-term
be regularly reviewed. All young people with early adaptation to illnessB, reduce positive symptomsD,
psychosis should be seen at least weekly by a case and improve personal goal attainment.D
manager, and at least fortnightly by a doctor, in 3.2.2.5 The possibility of relapse should be
the early recovery phase.GPP discussed with young people and their families,
3.2.2.2 All families should be seen or contacted at along with education regarding early warning signs
least fortnightly during the early recovery phase.GPP and the development of a ‘relapse action’ plan.GPP
3.2.2.3 Early response to antipsychotic medication

should be considered as a prognostic sign.GPP
Guideline 3.2.3. Relapse versus placebo in relapse prevention. Two meta-

analyses involving 1055 FEP participants [417] and
Background
4504 schizophrenia remitted participants [418]
Psychotic symptoms will remit in most young
suggest that SGAs as a class (but not individual
people with a first episode of psychosis, but there
SGAs to date) may be more effective than FGAs
is a high rate of subsequent relapse. A systematic
in preventing relapse. Conversely, Leucht and
review and meta-analysis [414] reported the
colleagues [419] reported no difference in relapse
pooled prevalence of relapse rates (positive
rates in schizophrenia participants between
symptoms) were 28% at 1-year follow-up, 43% at
FGAs and SGAs. However, the pooled analysis by
2 years, and 54% at 3 years [414]. A young person
Alvarez-Jimenez and colleagues [417] is exclusive
may experience a number of ‘early warning signs’
to FEP cohorts and thus more relevant here. The
1–4 weeks preceding a relapse [415]. Relapse can
authors conclude that further studies comprising
range from mild to severe, and the severity of
heterogeneous trials with larger samples are
symptoms can fluctuate. Given these high rates
required to establish the superiority of SGAs over
of relapse in FEP, it is important to avoid the risk
FGAs to prevent relapse in FEP.
of providing unrealistic reassurance regarding
prognosis for fear of being pessimistic or affecting Psychological interventions
young people’s hopes for recovery. Instead, the Relapse is almost always preceded by non-
young person and their family should be prepared psychotic symptoms such as anxiety and
for risks ahead and levels of anxiety, hopelessness, depression and low-level psychotic symptoms
or denial of risk monitored [156]. (see Gumley et al. 2003 [420] for a review).
A number of factors may increase the risk of a The modal period in which changes in cognition,
young person experiencing a relapse of psychosis emotion and perception transform into psychotic
[156], including non-adherence to medication, symptoms is 4 weeks [421]. Approximately
substance use, poor premorbid adjustment and 60–80% of young people with psychosis will
‘critical’ comments from family or supports [414]. experience an acute relapse, while 20–30%
Assessment of such factors and a formulation of will experience recurrent symptoms [414, 422].
relapse risk can guide future treatment. There are Families as well as young people may assist in
benefits in educating the young person, family early identification of risk factors for relapse.
and friends to recognise early warnings signs of A meta-analysis and systematic review of three
relapse and develop strategies to respond [257]. RCTs comparing specialist FEP programs with
treatment as usual (n=679) reported specialised
Medication
FEP intervention was significantly more likely
A recent meta-analysis outlines the evidence
to prevent relapse. Specialised FEP intervention
for pharmacological strategies in preventing and
programs routinely incorporate psychological
treating relapse in FEP [416]. Some limited data
interventions to enhance coping and recovery. In
suggests that FGAs may be more effective than
addition, specialised FEP interventions achieved
placebo in preventing relapse in FEP. There have
lower attrition, less likelihood of hospital
been no studies testing the effectiveness of SGAs
readmission [16] and improved psychopathology
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FOR EARLY PSYCHOSIS
[423, 424]. The specialised interventions were Recommendations

delivered by multidisciplinary teams, based
on assertive outreach principles and included 3.2.3.1 Medication should be recommenced or
cognitive behavioural therapy, family counselling, increased at early signs of relapse.GPP
and vocational strategies tailored to the needs
of the people with early psychosis. Another 3.2.3.2 The advantages of maintenance
study [425] combined individual and family antipsychotic therapy in relapse prevention should
interventions (the former implemented fortnightly be weighed against any impact of side effects on
over a 7-month period and including intervention functioning.GPP
strategies listed in Box 16). This study reported 3.2.3.3 Relapse prevention strategies (including
that, at the cessation of the intervention, relapse more regular review and provision of information
rates were lower and time to relapse was longer about rapid access to care) are particularly
for those receiving the intervention compared indicated if medication dosages are decreased or
with those receiving treatment as usual. However, medication ceased.GPP
these differences were not maintained at 18, 24
or 30 month follow-up [426]. More studies are 3.2.3.4 Specialised FEP interventions and
required to ascertain whether longer treatment combined family and individual CBT specifically
duration will result in sustained, longer-term focusing on preventing relapse should be used.B
relapse prevention. Similarly, a 2010 Cochrane
review[427] showed that interventions with
families of people with schizophrenia may
Guideline 3.2.4. Late/incomplete
decrease their frequency of relapse, reduce
hospital admissions and encourage adherence to
recovery, medication discontinuation,
medication, although the authors conclude more and discharge
research is required in this area. Background
‘Incomplete recovery’ refers to young people who
despite having access to adequate treatment
Box 16. Psychological relapse prevention have not recovered from the onset of a psychotic
strategies may include: episode [147]. This includes young people who are
‘treatment resistant’ (not responding to evidence-
• Developing a shared, written formulation
based treatments) and ‘resistant to treatment’
regarding relapse risk
(treatment non-adherent individuals), with regard
• Developing an awareness of risk factors for to positive and negative symptoms [429]. The
relapse and how to minimise or manage prevalence of incomplete recovery ranges from 10
them to 50% [430]. Those likely to have a problematic
• Identifying a relapse signature of early recovery can often be identified as early as 3–6
warning signs for relapse (with the months after an acute episode [32] (see Box
individual and their family) and developing 17 for ways to identify incomplete recovery).
a relapse plan Predictors of incomplete recovery include a long
• Treatment of comorbid substance use and DUP [431, 432], a diagnosis of schizophrenia
psychiatric disorders and managing non- [433], and poor premorbid psychosocial
adherence to treatment functioning in childhood and adolescence [434].
This group must be distinguished from those who
• Parallel individual and family intervention
have not been adequately treated with first-line
focused on relapse prevention (given links
pharmacological and psychosocial interventions.
in people with more chronic illness between
A key implication of the DUP literature is that
expressed emotion and outcomes) [427]
problematic or incomplete recovery should be
• Supervision specifically focusing on relapse identified and managed early.
issues (see Gleeson et al. [428] for further
details)
• Family interventions
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FOR EARLY PSYCHOSIS
Box 17. Early identification of incomplete There is limited empirical evidence beyond case
recovery and relapse can be facilitated by: reports on pharmacological strategies should
clozapine be unsuccessful in managing incomplete
• Comprehensive case review by the treating
recovery in FEP [283]. Low-dose (100–300mg)
team every 3 months after entry to the
amisulpride may be beneficial for negative
service
symptoms [441, 442]. In clozapine-resistant
• Fortnightly contact between the case individuals with schizophrenia, augmentation
manager and the young person during late with a second antipsychotic is common. However,
recovery two reviews conclude there is little evidence
• Monthly contact between the doctor and supporting this practice, and that it can result in
young person during late recovery an increased risk of side effects [443].
• Monthly contact between the case Electroconvulsive (ECT) therapy has been
manager and family during late recovery investigated as an augmentation strategy for
clozapine, and despite methodological limitations,
Medication for incomplete recovery limited clinical studies in young people suggest
There is a subset of people with FEP who do not that ECT may be an option for medication-
respond to first- or second-line antipsychotic resistant schizophrenia [444]. A combination of
treatment. The guidelines for incomplete antipsychotic medication and ECT significantly
recovery in schizophrenia (including the Texas reduced the length of hospital stay compared
Medication Algorithm Project [435] and the with antipsychotic medication alone [445],
PORT group [436]) have received widespread and improved psychopathology and functioning
acceptance. A more recent, four-stage treatment [446] in young people with treatment-resistant
model for pharmacological intervention is also FEP. ECT also appears to be safe, with one study
outlined in Lambert and colleagues’ [437] report. reporting no differences in neuropsychological
Broadly, the four stages comprise: 1) identify the variables at a 2-year follow-up in adolescents with
domain of treatment resistance; 2) implement schizophrenia undergoing ECT (relative to those
the best-treatment option based on affected who did not receive ECT) [447]. However, given
domain; 3) consider clozapine maintenance that the long-term efficacy is unknown and the
treatment (discussed below); and 4) antipsychotic stigma attached to ECT, it should only be used (in
combination strategies. combination with antipsychotics) as a last-resort
for resolving acute psychosis, within a shared-
One pilot study investigated the relative and decision making framework.
combined efficacy of a 12-week course of
clozapine and CBT treatment for reducing Psychological interventions
persistent psychotic symptoms following a first A recent meta-analysis [448] comprising
episode of psychosis [438]. The CBT treatment, 12 RCTs reported CBT improved general and
‘STOPP’[439], was designed to target enduring positive symptoms in individuals who had not
positive symptoms. A significantly greater responded to medical treatment. Heterogeneity
proportion of individuals receiving clozapine in CBT techniques makes identifying the ‘active
achieved symptomatic remission (52%), relative ingredients’ difficult. Despite this, common focus
to those receiving thioridazine (35%) at 3 areas include psychoeducation, normalising
month follow-up. A Cochrane Collaboration psychotic symptoms, cognitive restructuring
review concluded clozapine is the most effective of activating events and subsequent beliefs,
antipsychotic medication for treatment-resistant and developing coping strategies to facilitate
psychosis [440]. Clozapine may therefore be relapse prevention [448]. Few interventions have
considered when remission does not occur despite been specifically designed for those with FEP
the sequential use (with good adherence) of two who experience prolonged recovery. Edwards
antipsychotic medications. Although response and colleagues have developed an intervention
to clozapine should emerge within 8 weeks of (Systematic Treatment of Persistent Psychosis, or
reaching a therapeutic dose, a trial of 6 months is STOPP therapy) to address prolonged recovery in
recommended [283]. the FEP group [449].
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FOR EARLY PSYCHOSIS
This intervention includes four phases: Box 18. Possible interventions for persistent
1. developing a collaborative working relationship symptoms: the GRIP approach [428]
2. exploring and coping with psychosis (including Delusions

discussing the person’s subjective response • Increasing cognitive flexibility through
to psychosis and increasing their knowledge, generating alternative explanations
considering and implementing strategies to
• Engaging in behavioural experiments to
manage and treat symptoms, and learning
evaluate the veracity of one’s beliefs
to tolerate the emotionality associated with
managing psychotic phenomena) • Examining the internal consistent of beliefs
3. strengthening the capacity to relate to others Auditory hallucinations
(with themes of increasing the person’s sense • Enhancing coping strategies (e.g., managing
of integration by developing awareness of antecedents differently)
personal strengths, their capacity to interact • Modifying interpretations of voices
with others by questioning psychotic beliefs of
• Behavioural experiments
others), and
Negative symptoms
4. finishing and moving on.
• Targeting consequences of these, such as
Results for a pilot RCT examining the efficacy of low activity and social withdrawal, through
STOPP and clozapine [438] suggested that both behavioural activation and cognitive
clozapine and STOPP may have an early beneficial restructuring
effect on both positive and negative symptoms,
which appears to be sustained for at least 3
months after the end of therapy. Thus emerging evidence suggest psychological
interventions may improve psychopathology
The GRIP intervention outlined above also has for medication-resistant individuals with
a phase focusing on persistent symptoms, with schizophrenia [452-454] and early psychosis
the goal to reduce distress or impairment caused [455]. Although research investigating
by these. The specific interventions employed psychological interventions for incomplete
depend on the symptom domain, as outlined in recovery in early psychosis is embryonic,
Box 18. These interventions draw on interventions it constitutes good clinical care to provide
developed for people with more chronic psychotic intervention at this stage.
disorder [386, 387, 394, 450, 451]. Again,
however, there are limited empirical data on the Withdrawal of medication
effectiveness of these interventions in the FEP The process of withdrawing medication must be
group. carried out slowly (over a number of months)
and with careful monitoring that extends for
several months after medication ceases. The
majority of treatment guidelines in early psychosis
advocate continuous treatment with antipsychotic
medication for 12 months following a psychotic
episode to minimise the risk of relapse, and
this approach is supported by existing research
evidence. Poor medication adherence is the
strongest predictor of relapse, followed by
substance use and a critical family environment
[456]. In traditional mental health services,
discontinuation of antipsychotic medication has
resulted in relapse rates of 80–100% [457-459].
However, the focus on preventing relapse as the
primary treatment target in FEP is beginning to be
questioned [460]. Recently, functional recovery
has begun to be viewed as the best treatment
goal for early psychosis services, as it enables
young people to live physically healthy and
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FOR EARLY PSYCHOSIS
meaningful lives. Evidence is now emerging that Transitioning strategies

very low-dose antipsychotic medication following Linking young people with the case management
a remission in psychotic symptoms is associated service in a structured way can increase the
with better functional capacity [461]. The onus is likelihood of their engaging with outpatient
on the treating team, including medical staff, to try community care during the transition phase.
to find the lowest possible dose of antipsychotic Effective strategies include: [464, 465]
medication to achieve a remission in symptoms • a crossover period of care where the young
and carefully consider the merits of maintenance person begins or visits the outpatient service
medication or medication withdrawal. Initial before they are discharged from inpatient care
response to treatment, diagnosis (affective/non or where the case manager meets with the
affective psychosis), the impact of antipsychotic person on the inpatient unit
side effects on functioning, and good and bad
• treatment within the inpatient unit is planned
prognostic factors (such as long DUP and poor
in collaboration with the outpatient community
premorbid functioning) should guide decision-
team at the commencement and at regular
making about medication continuation or
intervals, at a minimum of weekly clinical case
withdrawal.
reviews and particularly prior to discharge
Transitions in care and discharge planning • clear communication channels, for example
Transitions in care can represent a period of between inpatient and outpatient staff, about
increased risk for young people with early the plans for discharging the young person
psychosis, including increased risk of suicide,
• a dedicated clinician who acts as a liaison
disengagement, relapse and further decline in
between acute and non-acute services.
functioning [243, 462]. Discharge from the
service in particular can be a time of heightened There is a risk that services and clinicians perceive
risk. a young person who is out of the acute phase to
be no longer in crisis and therefore no longer at
Transition planning: inpatient to community high risk. This may result in a lessening of clinical
Having a clear transition plan for each person who support or attention [466]. It is therefore crucial
is discharged from inpatient care has been shown that services remain vigilant of suicide risk at this
to [462, 463]: point in a young person’s care. Reviews of their
• reduce the risk of readmission risk assessment and mental state examination
• increase the probability of adherence to are paramount. See Box 19 for factors related to
medication discharge from acute care that increase risk of
suicide.
• improve mental health outcomes.
Elements of transition planning that are effective

include: prompts to young people to engage with
the new service (letters or telephone follow-
ups); assigning a case manager while the young
person is still an inpatient; compiling a pharmacy
discharge plan; and offering peer support to the
young person [462]. Providing information to the
family as agreed with the young person is also
vital.
74
FOR EARLY PSYCHOSIS
Box 19. Suicide risk following discharge from Box 20. Community care discharge minimum
acute care standards
Up to 75% of people with FEP who • Discuss discharge from the commencement
commit suicide do so in the early recovery of treatment.
phase, usually with a few months of being • Develop a specific discharge plan in
discharged from an inpatient unit [466]. collaboration with the person receiving
The increased risk of suicide at this time may treatment and their family at least 3 months
be a result of [466]: prior to discharge.
• someone having newly gained insight into • Share this plan with the person’s identified
their condition supports, such as family members, their GP
• feelings of hopelessness or stigma or private psychiatrist or psychologist or
other mental health service.
• significant losses (e.g., of employment or
relationships) as a result of symptoms of • Advise the person, family, and any relevant
psychosis service providers about how to re-access
mental health services if necessary in the
• persistent distressing symptoms of
future, and provide with emergency contact
psychosis
numbers.
• the presence of post-psychotic depression
• Contact new treating team at least 3
• negative symptoms months prior to discharge to plan the
• the effects of treatment or service discharge process.
interactions (e.g., traumatic pathway to • Conduct a period of transition and
care, side effects of medication, poor handover to the new service provider.
continuity of care)
• remission of symptoms that in the acute
phase prevented a person from acting
on suicidal thoughts (e.g., acute mania,
thought disorder and negative symptoms)
• hospitalisation due to a relapse, which may
mean a person is particularly despairing.
Discharge from a service

Discharge and closure planning are integral
components of the late recovery phase. Timing
of the cessation of treatment will be influenced
by factors including the level of remission, DUP,
whether positive symptoms are persisting,
comorbid substance use, ongoing stressful life
circumstances, and the level of functioning in a
normal living situation [32]. Linkages should be
established for a person being discharged with a
local GP, private psychiatrist or area mental health
service, and social and vocational services. Box 20
outlines minimum standards relating to referral to
new treating teams following discharge.
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FOR EARLY PSYCHOSIS
Recommendations 3.2.4.6 CBT should be considered as an adjunctive

therapy during late/problematic recovery.GPP
3.2.4.1 All young people being treated should be 3.2.4.7 Families of young people with a slow or
seen at least fortnightly by a case manager, and at difficult recovery or frequent relapses may benefit
least monthly by a doctor, during the late recovery from more intensive and structured interventions,
phase.GPP emphasising problem solving and communication
3.2.4.2 All families should be seen or contacted at skills.GPP
least 2-monthly by the treating team during the 3.2.4.8 Young people with early psychosis should
late recovery phase.GPP have their risk regularly reviewed by clinicians,
3.2.4.3 People with persisting positive or negative particularly during transitions from acute care and
symptoms should be identified early.GPP at discharge from the service.GPP
3.2.4.4 Clozapine should be considered for those 3.2.4.9 Clinicians should clearly communicate and
who have not responded to adequate trials of document a discharge plan that is shared with
two antipsychotic medications, of which one is a the young person, their family, their GP and the
SGA.A new service provider at least 3 months prior to
discharge. GPP
3.2.4.5 After resolution of positive psychotic
symptoms, antipsychotic medication may be 3.2.4.10 Clinicians should assist young people in
continued for 12 months or more. A shared their care with orientation and engagement with
decision making approach and a comprehensive future treatment providers, including a visit and
evaluation of the risks and benefits of ongoing clinical handover to the designated clinician, such
medication in each particular case should inform as a GP, or other mental health service clinician. GPP
treatment decisions.GPP
Box 21. Key features and components of

Guideline 3.3. Early psychosis early psychosis treatment across all phases
treatment across all phases
Engagement
Many key features or components of early Physical health
psychosis treatment apply regardless of phase Sexual health
of psychotic illness. Many of these reflect Case management
good clinical practice with clients of mental
Functional recovery
health services generally or young people more
Trauma
particularly. These features and components are
listed in Box 21 and described in the following Integrated treatment
guidelines. Least restrictive treatment
Family involvement
Goals as guides to treatment
Group programs
Psychoeducation
Suicide prevention
Substance use
Treatment of psychiatric comorbidity
Miscellaneous psychological therapies
Youth participation and peer support
Family participation and family peer support
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FOR EARLY PSYCHOSIS
Guideline 3.3.1. The importance of cardiometabolic health is prevalent among people

engagement with schizophrenia, and is a result of a mixture
of factors, including antipsychotic medication-
Engagement is crucial in all forms of psychiatric induced weight gain and lifestyle-related factors
treatment, with the strength of the therapeutic such as poor diet, high smoking rates and reduced
alliance a moderate-to-strong predictor of physical activity [470-473]. In 2010, the second
outcome, regardless of therapeutic approach Australian national survey of psychosis, which
[467], including with young people [468]. examined adults with a diagnosed psychotic
Effective engagement at the time of the initial disorder, found that 72% of participants were
assessment can expedite the formation of a overweight or obese, approximately 55% met
therapeutic alliance. General psychotherapeutic the criteria for the metabolic syndrome (see Box
skills enable clinicians to gain a better 23) and 96% reported low physical activity levels
understanding of a young person and, in [474], far lower than the general population [475].
conjunction with medication, form the foundation There is also evidence that people with psychosis
for more specific recoverypromoting strategies. are at greater risk of developing diabetes [476].
Techniques for enhancing engagement are listed
in Box 22.
Box 23. The metabolic syndrome
Recommendation The metabolic syndrome is defined by the

International Diabetes Federation as a cluster
3.3.1.1 Engagement should be prioritised as the of risk factors that are associated with the
foundation of early psychosis treatment.GPP development of cardiovascular disease.
These risk factors are diabetes and raised
fasting plasma glucose, abdominal obesity,
raised cholesterol and raised blood pressure.
Box 22. 10 Techniques to enhance The full diagnostic criteria and further
engagement information about the metabolic syndrome
can be found on the International Diabetes
• Communicate to people that they are being Federation website (http://www.idf.org/
listened to and treated seriously metabolic-syndrome).
• Offer practical help
• Prioritise working with the person’s primary
Weight gain and obesity
worry and source of distress
Weight gain is a well-known side effect of almost all
• Be flexible with timing and location of antipsychotic drugs, with clozapine and olanzapine
treatment as far as possible showing the greatest risk [477] (see Table 10 for
• Explain the process of treatment antipsychotic-elicited weight gain potential). The
• Provide information and education about maximal increase in body weight normally occurs
symptoms during the first couple of months after initiation
of treatment [6], with some data suggesting this
• Work with family members if indicated
plateaus over a time period between a few months
• Set goals collaboratively
and up to 4 years [478, 479]. Early identification
(Phillips & Francey, 2004 [2]) and intervention in weight gain is important,
including considering change of pharmacotherapy.
A systematic review and meta-analysis suggests
Guideline 3.3.2. Physical Health that a range of psychosocial interventions –
including group and individual treatment, CBT and
Background
nutritional counselling – are effective in reducing or
People with psychosis can face a reduction in
attenuating weight gain compared with treatment
life expectancy of up to 20 years compared
as usual [480].
with the general population. This reduction is
accounted for in part by poor physical health,
such as cardiovascular disease [469]. Poor
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FOR EARLY PSYCHOSIS
Table 10. Comparative potential of antipsychotics • height

to cause weight gain [481] • BMI
Antipsychotic Potential for weight gain • blood pressure
• level of physical activity
Amisulpride +
• smoking (cigarettes per day)
Aripiprazole +
• fasting pathology (lipid profile, glucose,
Clozapine +++ liver function tests, vitamin D)
Haloperidol ++ • diet.
Olanzapine +++ An algorithm for metabolic screening and

intervention for young people who have been
Paliperidone ++ prescribed antipsychotic medication is available
Quetiapine ++ on the iphYs website (www.iphys.org.au).
Risperidone ++ Interventions
Evidence suggests that structured behavioural
Ziprasidone +
and lifestyle interventions are effective in reducing
Risk of weight gain rated as: + low, ++ medium, +++ high antipsychotic induced weight gain [480, 485,
Extrapyramidal motor symptoms (EPMS) 486], and are acceptable to young people
and tardive dyskinesia receiving care [485]. A recent study by Curtis and
The risk of EPMS and tardive dyskinesia is colleagues (2015) evaluated a 12-week lifestyle
generally low in the therapeutic dose range for and life skills program to prevent antipsychotic-
SGA medication [482, 483], relative to FGAs induced weight gain in FEP [485]. Only 13% of
[362]. Use of SGAs is therefore a key preventive participants receiving the program experienced
strategy, as is early identification of motor side clinically significant weight gain, relative to 75% in
effects by weekly assessment of acute EPMS the standard care group.
and akathisia until medication dose is stabilised.
Lifestyle interventions
Regular assessment of tardive dyskinesia is
recommended (6-monthly in the case of FGAs Physical activity
and yearly in the case of SGAs) [159]. Physical exercise can help prevent or address
weight gain and metabolic problems in people
Sexual side effects of medications with schizophrenia [487]. Guidelines and
See Guideline 3.3.3, ‘Sexual health’, on page 79. information sheets for recommended physical
activity can be downloaded from the Australian
Screening
Government Department of Health: http://
The routine cardiometabolic health screening of
www.health.gov.au/internet/main/publishing.
all people with early psychosis is recommended to
nsf/Content/health-pubhlth-strateg-phys-act-
guide detection, prevention and early intervention
guidelines#apa1317.
of physical health issues [484]. Initial screening
should occur upon someone’s entry to a service Diet
to gather baseline information about their Individuals with psychosis tend to have poorer
cardiometabolic health. This should be repeated at 1 diets than the general population [488-490].
month, and should continue at least every 3 months Helping people with early psychosis and their
for the duration of their treatment. The monitoring families understand nutrition labels, create
cycle should begin again whenever there is a shopping lists and develop healthy cooking skills
change in medication. A careful record of all improves diet quality and prevents weight gain.
medications and side effects should be maintained Weight management education (food quality and
and regularly shared with the person’s GP. portion control) may also minimise weight gain
At a minimum, cardiometabolic health screening [485].
should incorporate: For a healthy diet, see the Australian dietary
• waist circumference guidelines www.eatforhealth.gov.au.
• weight
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FOR EARLY PSYCHOSIS
Oral health Studies in populations with chronic schizophrenia

Despite being an important part of physical health suggest that people may ‘self-medicate’ with
[491], oral health has received little attention tobacco to reduce negative symptoms [503],
in early psychosis. Dental disease is linked with which probably acts through the effect of nicotine
coronary heart-disease, stroke, diabetes [492- on dopamine release in the brain. Smoking may
494] and it affects eating, speech and other social also attenuate some side effects of antipsychotic
and psychological domains of life [491]. People medication including drowsiness [504]. However,
with severe and enduring mental health problems in addition to adverse physical effects, smokers
are 3.4 times more likely to lose all their teeth with psychosis have higher levels of positive
compared with the general population [495]. They symptoms [505], which increase further on
are also significantly more likely to have decayed or tobacco withdrawal [506]. The half-life of
missing teeth and plaque sores [496]. Contributing antipsychotic medication is significantly shorter
factors can be lifestyle choices, amotivation, in smokers than non-smokers [507], probably
dental costs, difficulty accessing health care, and because smoking increases the metabolic
psychotropic medication [497, 498]. clearance of the drugs [508]. Smoking may also
increase the risk of tardive dyskinesia [509].
Clinicians can conduct brief oral hygiene
assessments that do not require any dental To help quit smoking, the UK’s National Institute
training. Evidence based oral health promotion for Health and Care Excellence (NICE) guidelines
resources which summarise the most effective for psychosis recommend considering nicotine
health promotion strategies for the prevention replacement therapy (NRT), bupropion or
of oral health problems are available from varenicline,[510]. Success rates for smoking
government websites (e.g., https://www2.health. cessation are often increased when psychological
vic.gov.au) and can be utilised by clinicians. and behavioural therapies are combined with
Specifically, clinicians can provide infomation pharmacotherapy [511, 512].
about oral hygiene (i.e. morning and evening
brushing, avoidance of sugars, smoking cessation, Medication interventions
encourage regular dental check-ups and address Specific medication may be indicated where
dental anxiety, if present). lifestyle interventions have been trialled for at
least 3 months and targets for weight, lipids and
Tobacco and alcohol use glucose have not been achieved.
Heavy alcohol use is more common in people
with psychosis than in the general population Metformin
[475]. Rates of alcohol misuse in FEP varies Metformin has been shown to be effective in
between 10 and 33%, but studies have not reducing or attenuating antipsychotic-induced
found any correlation between alcohol use and weight gain and is considered to be relatively safe
positive symptoms [499] or outcome [217]. To and effective in young people [513, 514]. It might
date, no studies have investigated treatment for also be considered if a young person presents
alcohol dependence or abuse in early psychosis. with increased blood glucose, especially when
However, one study [500] reported that routine accompanied by central obesity, hypertension
care integrated with motivational interviewing, and dyslipidaemia and where active lifestyle
CBT, and family intervention was an effective interventions have not succeeded.[515]
intervention (relative to routine care) for
Antihypertensive medication
individuals with comorbid schizophrenia and
Antihypertensive medication may also be
alcohol abuse or dependence.
considered in people who present with
Tobacco use is given far less attention in the persistent high blood pressure and where
literature than other substances, but is both lifestyle interventions targeting exercise and diet
prevalent and problematic in the early psychosis (including salt reduction) have not succeeded.
population. Tobacco is the most commonly
For people who present with persistently elevated
used substance by people with mental illness. In
blood lipid levels despite lifestyle interventions,
Australia, the rate of smoking among young people
statins may be prescribed to reduce future
experiencing a first episode of psychosis has been
cardiovascular risk. Fibrates might be considered
reported to be as high as 72% [501] – nearly three
for elevated triglycerides [516].
times that of the general population [502].
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FOR EARLY PSYCHOSIS
Recommendations should be monitored, managed and addressed

early, with a prevention model if possible (e.g.,
3.3.2.1 Routine metabolic screening should weight management strategies implemented prior
guide intervention, and prevention of physical to treatment initiation) GPP.
ill-health must be prioritised as part of routine 3.3.2.4 Structured behavioural lifestyle
early psychosis treatment (see http://www.heti. interventions should be implemented to improve
nsw.gov.au for adolescent cardiometabolic health physical health outcomes for people with early
screening protocol) GPP psychosis. GPP
3.3.2.2 Cardiometabolic screening should occur 3.3.2.5 Tobacco cessation should be offered
on entry into service, after medication changes, routinely to young people with early psychosis.GPP
repeated at 1-month and monitored at least every
3 months. Initial screening points should be 3.3.2.6 Oral health assessment should form a part
repeated after any medication changes. GPP of routine assessment using standard checklists
that can be completed by non-dental personnel. GPP
3.3.2.3 Potential physical side effects (including
metabolic side effects, weight gain, extrapyramidal 3.3.2.7 Where lifestyle interventions prove
motor symptoms, and sexual side effects) should ineffective after at least 3 months, consider
be noted and discussed with people prior to their specific pharmacological interventions (e.g.,
commencing pharmacotherapy. Such effects metformin, antihypertensive treatment, statins).GPP
Guideline 3.3.3. Sexual health was evident in 50% of individuals deemed UHR
and 65% of first-episode participants (compared
with 21% of non-clinical respondents). UHR
Box 24. Definitions in sexual health individuals who converted to FEP experienced
significantly greater sexual dysfunction than
Sexual health includes physical, emotional, the non-transitioning UHR subgroup. Another
mental and social wellbeing in relation to large-scale study comprising 498 FEP participants
sexuality[1]. It is not merely the absence of reported a positive relationship between
dysfunction, but encompasses a meaningful, (psychotic) symptom severity and severity of
respectful and positive experience of sexual dysfunction [520]. In combination, these
sexuality. results suggest young people in early psychosis
Sexual function is determined by are at elevated risk of sexual dysfunction, and the
psychological, social and physiological risk and severity of sexual dysfunction increases
factors and comprises sexual interest or with illness progression.
libido, arousal, orgasm, ejaculation and
The association between sexual dysfunction
resolution.
and early psychosis may be due to psychotropic
Sexual dysfunction refers to disruption in medication [521, 522], psychosocial factors
one of the areas (or processes) of sexual [523], somatic health [524] and psychotic
functioning (e.g., erectile dysfunction or symptoms [520, 525]. Crucially, sexual health is
premature ejaculation in males and orgasmic related to functional recovery [523] whilst sexual
dysfunction in females [9, 10]). dysfunction is associated with poorer quality of
life [526, 527] and non-adherence to treatment
[528]. Sexual dysfunction therefore represents
Background
a key focus area within the treatment of early
Sexuality is a fundamental aspect of everyday life.
psychosis.
As early psychosis typically emerges in young
adulthood, it can disrupt the crucial period when Clinical evidence
people start to form romantic relationships and More research is needed to understand the higher
explore their sexuality [517, 518]. The prevalence rate of sexual dysfunction in early psychosis
of sexual dysfunction in early psychosis is far groups, particularly with regard to interventions.
greater than in non-clinical populations. Marques Schizophrenia studies suggest sexual dysfunction
and colleagues [519] found sexual dysfunction is a greater imposition on quality of life than
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FOR EARLY PSYCHOSIS
extrapyramidal, sedative and vegetative side Recommendations

effects of antipsychotics [527, 529]. Despite this,
young adults rarely report sexual dysfunction. 3.3.3.1 Clinicians need to be aware and informed
One study [521] found only 37% of psychotic of sexual health issues and potential dysfunction
participants reported their sexual dysfunction in early psychosis populations. GPP
spontaneously. As such, therapists underestimate
the presence and impact of sexual dysfunction 3.3.3.2 Clinicians should inform young people
on the people they treat [530, 531]. This may experiencing sexual dysfunction that sexual
explain one study finding that clinicians are often difficulties are also common in the general
unaware that treatment non-adherence is often population. GPP
related to sexual dysfunction [524]. Importantly, 3.3.3.3 Clinicians should assess baseline sexual
people experiencing schizophrenia [532] and functioning to monitor sexual related side effects
young people at UHR of psychosis [523] are able of antipsychotic treatment. GPP
and willing to discuss sexual and relationship
concerns when prompted. However, clinicians 3.3.3.4 Clinicians should be aware that use
can be reticent to discuss sexuality issues [533]. a standardised assessment instrument may
Using structured interviews and self-report facilitate open communication about sexual
questionnaires have been found to increase functioning. GPP
sensitivity to reports of sexual dysfunction [534].
3.3.3.5 Clinicians should focus on risk-reduction
Thus, routine inquiry into sexual health as part of
interventions such as condom use. GPP
ongoing assessment is crucial to wellbeing and
increasing treatment adherence.
Sexually transmitted infections Guideline 3.3.4. Case management

Young people are overrepresented in the
population with regard to prevalence of sexually Background
transmitted infection (STI) [535]. Shield et al. Case management aims to assist people with
[536] and Brown et al. [537] determined STI mental ill-health navigate the complex elements
knowledge, attitudes, and beliefs were comparable of their psychiatric care. This extends beyond
across FEP, UHR and non-clinical cohorts. ‘formal’ psychiatric treatment to address other
However, young people with a first episode of needs, such as basic needs (e.g., accommodation,
psychosis are less likely to use condoms when food and employment), physical health
compared with young people with no clinical issues, broader needs (e.g., family and social
diagnosis [538]. This suggests young people relationships, leisure activities) and spiritual
with early psychosis have greater needs for STI needs [541]. Assertive community treatment,
prevention. typified by, amongst other things, low caseloads,
team caseworking, in vivo treatment, assertive
Antipsychotic medication engagement, and frequent contact, is the model of
In cases where someone is prescribed case management with the best evidence. It has
antipsychotic medication, clinicians should been shown to reduce lengths of admission and
discuss the potential for antipsychotic-induced improve engagement with services, independent
sexual dysfunction. Baseline sexual functioning living skills, compliance with medication and
should be ascertained to assess potential impact satisfaction with services and treatment [542-
of antipsychotic treatment. Reducing dosage, or 544]). There is some evidence to suggest that
switching to an SGA or an antipsychotic with a assertive case management may benefit people
neutral effect on prolactin levels (i.e., aripiprazole, with early psychosis more than those with long-
quetiapine [539]) may avoid negative impact term schizophrenia, although methodological
on sexual functioning[10]. However, more problems with this research mean it needs to be
well-designed studies are required for robust replicated before firm recommendations can be
inferences [540]. made [545].
The goal of the case manager or treating clinician

in early psychosis in particular is to promote
recovery and to prevent relapse and ongoing
disability. This can be achieved through assisting
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FOR EARLY PSYCHOSIS
the young person with early psychosis and their truly collaborative and respectful relationship
family to understand psychosis and to develop with people and families is the cornerstone
resources that will assist them in the future. The of the approach. This may include a degree of
case manager is expected to have a thorough therapeutic risk-taking and allowing people to be
knowledge of psychopathology and to have the drivers of their own recovery plans [546]. The
psychotherapeutic expertise; the case manager young person is the director of the interventions,
is the key psychotherapeutic contact and should and the relationship between the young person
use a case formulation, developed in concert and their case manager is highly influential [547].
with the rest of the treating team, to guide
treatment. The case manager provides a point of
service accountability, and works in partnership Box 25. Key elements of recovery-oriented
with the treating psychiatrist, who has key practice [549]
clinical accountability. Case managers are also
Connectedness
responsible for continuity of care. They should
also have links with other specialist providers, as Young people who experience early
well as existing mental health and community psychosis often lose connections with peers
services, being able to utilise them as needed in or momentum in developing important
response to the needs of the young person being relationships. It is an important part of
treated. recovery to establish social connections and
relationships.
Strengths-based and recovery approaches Hope and optimism
to case management
A pervasive sense of hope for the future
A strengths-based approach to early psychosis
and an optimistic outlook for recovery are
care and intervention emphasises the future
important for the treating team to discuss
ambitions and goals of the young person
and promote with the young person and their
receiving care and their personal resources and
family.
achievements [546, 547]. This is a different
approach to the traditional problem- (or deficit-) Establishing and consolidating sense
based approach, where the focus is on assessment of identity
and treatment of symptoms and impairments It is easy for young people to become defined
[546]. The strengths-based approach by their illness experience. Encouraging the
concentrates on what individual resources the development of identity that incorporates
young person brings. It acknowledges that each roles as a friend, partner, worker or volunteer,
person brings unique and individual strengths and sibling or team-mate is important.
difficulties regardless of illness. The approach has Meaning and purpose in life
an intentional focus on what the young person can
It is important to help people to develop roles
do, rather than on deficits or difficulties [548].
and engage in activities that are in line with
The strengths-based approach also aims to their beliefs and values, and develop a sense
develop independence and agency rather of purpose and meaning for the future.
than dependence on supports, simultaneously Empowerment
acknowledging that all people are interdependent Helping young people to understand what
and rely on each other [547]. The community is they need or want in their own recovery, and
viewed as an oasis of resources and is the primary develop the skills or resources needed to gain
setting for all psychosocial interventions [547]. this is important.
Strengths-based approaches should be
incorporated as part of the usual way in which Recovery refers to the individual’s personal process
clinicians work with young people with early of recovery and is not the same as rehabilitation
psychosis and their families. For example, or symptomatic wellness. It refers to the personal,
using a strengths-focused assessment when self-defined and non-linear journey towards
developing goals for intervention encourages wellbeing. This is not the same as a reduction in
the young person and their family to talk about physical and psychological symptoms, but may be
their aspirations and needs rather than just associated with it [550]. This model shares many
perceived difficulties [546]. Development of a
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FOR EARLY PSYCHOSIS
of the principles of a strengths-based approach, Much of the evidence for the efficacy of shared
but also emphasises encouraging and supporting decision making with regard to outcomes comes
the individual’s focus on their personal recovery from studies in physical health areas. The
journey, rather than a diagnosis. evidence base in mental health is still small, and
more research is needed [552], particularly into
Using a ‘recovery’ model with young people
the use of shared decision making where young
has been criticised on the basis that recovery
people are the active decision makers (i.e., rather
means returning to a previous state. Given the
than parents making decisions for their children).
characteristic flux in young people’s development,
this would be undesirable. Some terminology However, the evidence that is available (from adult
used in the recovery literature is based on the studies) indicates that shared decision making in
experiences of adults with mental illness and does mental health may improve:
not apply in the same way to young people. It is • how involved people feel in treatment decisions
important that clinicians understand the concept of [553, 554]
recovery and recovery-oriented practice and embed
• decisional conflict [555]
this in their work with young people. Though the
language may differ, the principles can be adapted • clinicians’ awareness of the preferences of the
to suit the needs and developmental stage of young people in their care [556]
people. The emphasis should be on helping them • satisfaction with treatment decisions, among
develop a meaningful and fulfilling life, rather than both individuals and treating clinicians [557-
treating a return to previous activities as a marker 559]
of their recovery (see Box 25). • individuals’ understanding of their own values
[555]
Shared decision making in case
management • attitudes towards recovery [560]
Shared decision making is a process that • knowledge about conditions and treatment
promotes the selection of treatments that is based [553, 557]
on both relevant evidence and the preferences • levels of concern about medications [553, 558]
of the young person being treated. At its core is • adherence to medication in the short term [558]
the principle that self-determination (i.e. that the
• severity of substance use and psychiatric
young person is able, willing and allowed to make
problems in people with substance use disorder
their own decisions) is a desirable clinical goal,
[561]
and one that young people should be supported to
achieve [551]. • paranoid ideation in people with psychosis
[560]
Shared decision making involves a clinician and
• uptake of psychoeducation and social
the young person being treated working together
interventions [553].
in a deliberate way to make decisions about the
person’s treatment. Multiple health professionals,
family members and other supports may also be
involved. One of the common misperceptions
held by mental health professionals is that shared
decision making is simply ‘collaboration’, and that
this is something that is already done in day-to-
day practice. Although shared decision making
is a collaborative approach, and engagement and
psychoeducation are all used in shared decision
making, these practices alone are not enough to
be classified as shared decision making. Shared
decision making is a conscious, semi-structured
approach to helping young people make decisions
about their treatment, based on the most relevant
evidence and their unique needs, preferences and
values.
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FOR EARLY PSYCHOSIS
Recommendations completed by case managers and/or treating team

within 6 weeks of discharge from acute treatment.GPP
3.3.4.1 The case manager or treating clinician 3.3.4.4 Case managers should facilitate a
coordinates each individual’s treatment and care person’s access to the necessary accommodation,
throughout their episode of care.GPP vocational, recreational, welfare and primary
3.3.4.2 The case manager should be present at health services.GPP
medical appointments to ensure continuity of 3.3.4.5 Case managers should regularly consult
care.GPP with individuals’ GPs, at least every 6 months.GPP
3.3.4.3 A case formulation, including provisional 3.3.4.6 Case managers should utilise shared
diagnosis and management plan, should be decision making, a strengths-based and recovery
approach to case management.GPP
Guideline 3.3.5. Functional Recovery recovery does not focus on symptoms. It focuses
on what the person is doing, how satisfied they
Background
feel with their life and to what degree they are
The social functioning of people with psychotic
functioning in a meaningful way [150]. Functional
illness is poorer than the general population.
recovery also incorporates the journey of personal
Most social, academic, and occupational role
recovery, during which a young person is able
functioning loss associated with psychotic illness
to make sense of their experience and move
occurs during the prodromal phase of illness
forward in their life. For young people, this means
and during the first few years following the first
developing roles, returning to activities that are
episode, after which it tends to reach a plateau
developmentally appropriate, and developing
[562, 563]. Premorbid social functioning, rather
interests in new or previously valued activities
than improvement in symptoms, predicts later
[569].
social functioning [564]. Pointing specifically to
vocational functioning, Killackey et al. [565] note
that:
Box 26. Core principles of functional
‘‘
recovery in early psychosis
The majority of people who develop
Principle 1: Functional recovery is an equal
psychosis do so at a time in their lives primary goal of someone’s treatment as
when they are just beginning to develop symptomatic recovery
vocational interests and directions. Not Principle 2: Functional recovery interventions
surprisingly, the experience of psychosis are guided by understanding the hopes,
derails this aspect of their development aspirations and goals of the young person.
and either leads, or contributes significantly Principle 3: The individual needs to be
to, a rapid decrease in their likelihood of empowered to drive their own recovery.
employment.” (p. 333) Principle 4: Functional recovery interventions
should commence as early as possible.
A lack of employment leads to other losses such Principle 5: Functional recovery interventions
as income, social contact, and external structure should aim at restoring or maintaining
[566, 567], and less directly to losses of quality normal developmental trajectory.
of life, community participation, and a sense
Principle 6: Functional recovery interventions
of productivity [568]. Functional recovery can
should take into account the young person’s
be understood as a reintegration and return to
phase of illness and clinical recovery.
previous roles, habits and meaningful activities.
It also includes the development of new skills, Principle 7: The multidisciplinary team
roles and interests that are in keeping with a should work collaboratively with the young
young person’s developmental trajectory and person young and their family to plan and
that support their goals for the future. Functional deliver functional interventions
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FOR EARLY PSYCHOSIS
Box 27. Defining features of Individual Research shows that the main goal for people
Placement Support (IPS) [570, 571] with severe mental illness is employment
[576]. More recently, studies have shown that
Focused on competitive employment
employment is among the highest priorities for
or education rather than sheltered or
young people recovering from FEP, and their
transitional employment
families [577, 578]. People employed or enrolled
Service open to any person with mental in training or education are more likely to have
illness who chooses to look for work or social connections, stable accommodation and be
education, so that acceptance into the socially and economically engaged [579]. Early
programme is not determined by measures functional recovery, including work and education,
of work readiness or illness variables is a more important predictor of long-term health
Job searching commences directly on entry and functioning than early symptomatic recovery
into the program [429].
The IPS program is integrated with the
Neurocognitive interventions
mental health treatment team, rather
Disturbances in cognitive functioning, such as
than constituting a separate vocational
poor concentration and memory, reduced speed of
rehabilitation service
information processing, or difficulties organising
Potential jobs are chosen based on consumer one’s thinking, are commonly experienced during
preference an acute phase of psychosis. Extensive research
The support provided in the program indicates that widespread stable impairments
continues after employment is gained, rather are also frequently present in early psychosis
than termination at a set point, as needed by [580]. These impairments are usually evident
the individual during the UHR phase. In this case by the time
The IPS services are provided in the FEP is diagnosed the impairments are of similar
community, rather than at the mental health severity to those seen in individuals with chronic
or rehabilitation facility schizophrenia.
Cognitive impairments are strongly associated

Specialist vocational and educational services, with poorer functional outcomes and disability
provided early in the course of illness or in (independent of symptomatic state [581]). There
the putative prodrome, may serve to halt or is also evidence that they may limit the benefit
reverse deterioration in functioning. Individual young people might gain from psychosocial
placement and support (IPS) is a vocational interventions like IPS, outlined earlier [582].
recovery intervention described in Box 27 that Cognitive remediation
has demonstrated positive outcomes in FEP Cognitive remediation therapy (CRT) is a
[548, 572-574]. Recent data suggest that people behavioural training-based intervention. It aims
with FEP with access to specialist vocational to directly improve or restore neurocognitive
interventions following the IPS model have odds processes (e.g., information processing speed,
of achieving vocational recovery 3.53 times that of attention, memory, executive function) [583].
those not receiving the intervention [572]. CRT usually involves computerised drill and
There is no current empirical evidence exploring practice exercises undertaken at high frequency
appropriate vocational functioning or vocational and intensity (e.g., for 40 minutes, 2–4 times
interventions for the pre-onset phase, but similar per week). CRT may also involve coaching in
principles are likely to be relevant, particularly strategies for improving neurocognitive functions.
given functioning deteriorates during the pre- Wykes et al. [584] found in a single-blind RCT
onset period. For this reason, provision of IPS in in a group of young people with ‘recent onset
the pre-onset period should be regarded as good schizophrenia’ that CRT delivered over 3 months,
clinical care. with at least three sessions per week, was
associated with improved cognitive flexibility to a
Further principles and processes to achieve them are greater extent than treatment as usual; improved
outlined in the international consensus statement cognitive flexibility was associated with better
on supporting young people with psychosis in clinical and functional outcome.
education, training, and employment [575].
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FOR EARLY PSYCHOSIS
Three other RCTs have also shown favourable Recommendations

effects for CRT, conferring benefit to learning
and memory [585], functional outcome 1 year 3.3.5.1 Treatment of early psychosis should give
post-treatment [586], executive functioning and equal weight to both symptomatic and functional
neurobiological protection [587] in key regions recovery. Clinicians should focus on remission of
implicated in social and non-social cognitive symptoms and also prioritise functional recovery
impairment in first episode cohorts. Whilst assessment of a young person’s functional
some methodological limitations undermine capacities, performance and needs.GPP
these results (raters not blinded to participants
treatment condition), a recent review [588] and 3.3.5.2 Clinicians should promote functional
meta-analysis and systematic review (2015; n recovery by directly implementing interventions
= 615) reports that CRT significantly reduces and coordinating care in services GPP,
symptoms and improves verbal learning and 3.3.5.3 Clinicians should facilitate access to
memory and functioning [589]. The authors educational and vocational services to the FEP and
conclude more research is required to consolidate pre-onset groups GPP
these preliminary results supporting the efficacy
of CRT treatment for individuals recovering from a 3.3.5.4 Employment and educational consultants
first episode of psychosis. should be integrated within FEP services as much
as possible.GPP
Cognitive adaptation
Applying compensatory strategies and 3.3.5.5 Employment services for people with FEP
environmental supports can help an individual should be consistent with an individual placement
‘work around’ their cognitive difficulties. An and support model.A
example of this is teaching an individual to
3.3.5.6 Vocational goals should be formulated in
use a calendar to aid memory, planning and
collaboration with the individual being treated,
organisation. The main focus of compensatory
be developmentally appropriate and may include
interventions is improving daily functioning.
education and training.GPP
A prime example of this approach is cognitive
adaptation training (CAT) [590, 591]. 3.3.5.7 Cognitive remediation programs and/or
Compensatory approaches directly improve cognitive adaptation strategies should be offered
functional outcomes: activities of daily living, to young people who have cognitive deficits that
vocational functioning and behaviours important interfere with functional recovery.GPP
for functioning, such as remembering to take
medication and motivation [592, 593].
Guideline 3.3.6. Trauma
Background
There is considerable evidence of a link between
prior exposure to trauma and psychosis. A
substantial body of research suggests that
exposure to potentially traumatic events (PTEs),
particularly in childhood, may increase the risk
of subsequent psychosis [594-596]. There is
also evidence of a cumulative, ‘dose-response’
relationship: the more exposures, the greater the
risk of subsequent psychosis [596]. Of particular
importance in FEP, a history of sexual trauma
significantly increases the risk of conversion to
psychosis in young people considered UHR of
psychosis [597].
Previous experience of trauma in both childhood

and adulthood is a strong predictor of later post-
traumatic stress disorder (PTSD) in the general
population [598]. Consistent with this, not only
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FOR EARLY PSYCHOSIS
does a history of trauma increase the risk of Australian Guidelines for the Treatment of Acute
developing a psychosis, but it also increases the Stress Disorder and Posttraumatic Stress Disorder
risk that a first episode of psychosis will result [607] and the UK’s NICE PTSD guidelines [608].
in PTSD. Bendall et al. [599] found that people
Preliminary research suggests that these trauma-
with a history of childhood trauma had 27 times
focused interventions are also useful for the
the risk of developing PTSD in response to a first
treatment of PTSD in people with psychosis. A
episode of psychosis. Rates of PTSD in early
2012 Dutch study [609] reported an open trial of
psychosis are high: around 39% of people with
27 people with diagnoses of both psychosis and
FEP also have PTSD triggered by their psychotic
PTSD who were provided with 6 sessions of EMDR
experiences [600-603]. Given the high levels of
therapy. Over 75% of participants who completed
distress and functional impairment associated
the study no longer met criteria for PTSD after
with PTSD, this result highlights the importance of
treatment. PTSD symptoms, auditory verbal
identifying and effectively managing the condition
hallucinations, delusions, anxiety, depression,
in people with FEP.
and self-esteem all improved significantly. A
There is good evidence that a history of trauma later study, also from the Netherlands [610],
may influence the clinical presentation in FEP, with randomly assigned 10 people with diagnoses of
certain types of childhood adversity more likely to both PTSD and psychosis to PE or EMDR. The
be associated with particular psychotic symptoms. two interventions were equally effective, with
Large epidemiological studies from the UK [604] 70% of participants no longer meeting criteria for
and the US [605] suggest that childhood sexual PTSD at follow-up. Importantly, no adverse events
abuse tends to be associated with increased risk occurred in either study and no participants
of hallucinations. Childhood physical abuse and showed any worsening of psychotic symptoms,
neglect, on the other hand, are more likely to general psychopathology or social functioning.
be associated with paranoid delusions. Clinical This latter finding is supported by a more recent
experience suggests that the actual content of larger study [611] of 155 people with both PTSD
these hallucinations and delusions (e.g., whose and psychosis who were randomly allocated to
voice is heard or which people feature in the either trauma-focused treatment (PE or EMDR;
delusion) often relates directly or indirectly to the n=108) or a waitlist control (n=47). Adverse
earlier trauma [606]. events and symptom exacerbation were rare but,
when they did occur, this was predominantly in
The impact of comorbid PTSD on the clinical
the waitlist condition.
presentations is predictable, with consistent
relationships found between the presence of PTSD
and the severity of depression and anxiety in FEP
[600]. There is also evidence that a comorbid
diagnosis of PTSD may increase the risk of suicide
in FEP [603]. The presence of comorbid PTSD
also affects clinical presentation in FEP, increasing
complexity and potentially influencing the content
of hallucinations and delusions. Since it plays such
an important role, it is reasonable to assume that
actively addressing trauma history is important in
a comprehensive treatment approach to FEP and
is part of good clinical care.
Systematic literature reviews and clinical

practice guidelines consistently nominate
trauma-focused psychological treatment as
the first line intervention for PTSD. This term
covers various trauma-focused CBT (TFCBT)
approaches including prolonged exposure (PE)
and cognitive processing therapy (CPT), as well as
Eye Movement Desensitisation and Reprocessing
(EMDR). Further details can be found in the
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FOR EARLY PSYCHOSIS
Recommendations 3.3.6.3 Clinicians should seek training, support

and supervision as required for this work. GPP
3.3.6.1 Early psychosis clinicians should develop 3.3.6.4 Clinicians should be mindful of the
a rapport with young people with early psychosis increased likelihood of depression and anxiety that
and then sensitively assess their current trauma accompanies exposure to trauma, and treat these
and trauma history. This includes the experience accordingly. GPP
of having a psychotic episode. This assessment
should be incorporated into psychological 3.3.6.5 Trauma-focused psychological
treatment plans. GPP interventions may be effective in reducing PTSD
and psychotic symptoms in young people with
3.3.6.2 Early psychosis services should have psychosis. GPP
policies in place to deal with reports or situations
of ongoing trauma. GPP
Guideline 3.3.7. Integrated specialised Another larger study compared an integrated

treatment in FEP multi-element psychosocial intervention (CBT,
family intervention and case management) for FEP
Background
patients and their families, with treatment as usual
As noted, integrated interventions refer to
[615]. The study comprised an epidemiologically
the collaborative provision of biological and
derived cohort (n=392) and the experimental
psychological interventions, along with assertive
treatment was delivered in routine mental health
case management and other psychosocial
services that adopted early intervention treatment
interventions (such as vocational or group
principles. Patients receiving the integrated
interventions). The Recovery After an Initial
treatment showed greater reductions in overall
Schizophrenia Episode (RAISE) study is a large-
symptom severity, global functioning, emotional
scale evaluation of 34 specialised integrated
wellbeing and subjective burden of delusions.
intervention FEP clinics in the USA. The clinics
Findings from this study suggest FEP integrated
combine pharmacological and psychosocial
services are effective and can be embedded within
treatments and are delivered by multidisciplinary
existing mental health services.
teams. The primary goal is to ‘promote
symptomatic recovery, minimise disability, Six European centres have conducted RCTs
maximise social academic and vocational to evaluate the effectiveness of specialist FEP
functioning and be capable of delivering in a real services. In addition to the pre-onset study, the
world setting’ (p.240) [612]. The collaborative OPUS trial in Denmark randomly assigned 547
and coordinated treatment implemented at the FEP participants to either an integrated treatment
clinics is titled ‘Navigate’. Broadly, it includes four in which they were provided with 2 years of
core components: 1) personalised medication enhanced service, or to standard treatment [616].
management; 2) family psychoeducation; 3) The integrated treatment was more intense and
resilience-focused individual therapy; and assertive (caseload 1:10) and covered additional
4) supported employment and education. domains such as family therapy and social skills
These components are conducted within a training. The more assertive nature of the early
shared decision-making, patient-preference intervention model is seen in the fact that people
framework [613] with small staff-to-client ratios. in the integrated treatment had an average of
Initial results are positive, with a recent study 77 contacts over the 2-year study, compared
(2016) reporting 223 participants receiving with 27 in the standard treatment group, which
‘Navigate’ remained in treatment for longer, additionally had a higher caseload (1:25). The
had greater improvement in quality of life and results indicate that the integrated treatment had
psychopathology, and greater involvement in work beneficial effects on symptomatic and functional
and school (relative to community care) [614]. outcome at 1- and 2-year follow-up [423, 616],
Importantly, the efficacy of the Navigate program as well as a perceived reduction in family burden
was greatest when implemented soon after initial [617]. At 5-year follow-up, those receiving the
psychosis onset, suggesting a critical period for intervention package were less likely to be living in
effective intervention in FEP. supported housing and had been hospitalised for
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FOR EARLY PSYCHOSIS
fewer days, but otherwise there was no difference In a study based in Bedfordshire, Agius et al.
between integrated and standard treatment [22]. [622] reported that an integrated treatment
This trajectory continued at 10-year follow-up, approach (including an assertive follow-up
with most of the positive short-term effects of the model, structured psychoeducation, relapse
OPUS intervention no longer significant [618]. prevention and other psychosocial interventions,
This suggests that early intervention may need to and use of SGAs at the lowest dose possible)
be sustained to be effective long-term. was associated with, among other things, higher
functioning, lower levels of depression and lower
The Lambeth Early Onset (LEO) trial in England
rates of involuntary treatment, relapse and
[16], randomised FEP participants (or people
rehospitalisation than those receiving standard
experiencing a second episode of psychosis where
care. Data were, however, based only on clinical
there had been failure to engage previously) to
notes, mitigating the empirical validity of the
receive either treatment from standard services,
study.
or from an early intervention service. The
results demonstrated a beneficial effect of early In contrast to these findings, Kuipers et al. [623]
intervention on hospital re-admissions, relapses evaluated a South London early intervention
and drop-outs. The early intervention group were service which offered an integrated treatment
also more adherent to medication, spent more including SGAs, psychological interventions
time engaged in educational or vocational pursuits, (individual CBT and, if appropriate, family
and established or re-established relationships intervention), and vocational and other assistance
better than those receiving standard treatment as needed. They reported that the integrated
[619]. In other words, the LEO trial showed that treatment had no demonstrably greater effect on
early psychosis intervention systems can produce participant outcome than standard treatment.
gains in clinical, functional and social recovery,
As it stands, therefore, integrated treatment
although there are some difficulties in drawing firm
approaches appear to be more effective than
conclusions given the relatively modest sample
standard care in the short-term treatment of early
size. More substantial improvement in vocational
psychosis, although their efficacy in the medium
recovery however remains a critical frontier in early
term is less settled.
psychosis intervention.
There are at least two ways of implementing
In Norway, Grawe et al. [620] reported
integrated early intervention services: as a
on an integrated treatment that included
specialist, stand-alone model, or as a partial
pharmacotherapy, case management, structured
model, in which early intervention specialists are
family psychoeducation, family communication
situated within existing service structures. The
and problem-solving skills within a CBT framework,
relative advantages and disadvantages of each
home-based intensive crisis management,
model have not been explored in any significant
and individual CBT for residual symptoms and
detail. Recent British data using historical
disability. This integrated care demonstrated
control as comparison suggests an advantage
a greater impact than standard treatment on
of the stand-alone model over a partial model
negative symptoms, ‘minor’ psychotic episodes,
with respect to days admitted to hospital and
and positive symptoms, but not on hospital
functional recovery over both 1- and 2-year follow-
admissions or ‘major’ psychotic episodes.
up, with the partial model demonstrating some
In Sweden, the Parachute Project [621] compared superiority with respect to functional gains to a
an integrated treatment approach (including generic approach in which there was no specialist
structured crisis intervention, lowest optimal early intervention involvement [624].
doses of neuroleptics, recurrent family meetings,
cognitive therapy, and access to low-stimulus
overnight care) with a historical and a prospective
control group. The intervention group used fewer Recommendation
inpatient bed days than both control groups
and received lower neuroleptic doses than the 3.3.7.1 Integrated specialist services are more
historical control group, and functioning was effective than standard services in the treatment
higher at 12-month follow-up in the intervention of people with FEP.A
group compared with the historical control group.
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FOR EARLY PSYCHOSIS
Guideline 3.3.8. Use least restrictive hinder recovery by inhibiting the degree to which
treatment possible skills learned during treatment are generalisable
to the individual’s normal environment.
Background
Choice of treatment setting is an important For all of these reasons, treatment at home is
element in the management of people with optimal. The choice of setting should be based on
psychiatric illness. This is particularly salient in the the severity of presentation, the assessed level of
instance of early psychosis, given that restrictive risk, and the extent and quality of social and family
treatment mechanisms may imperil engagement support. Home treatment is likely to be most
with services for some time to come, with the appropriate for those with social support and, in
likely outcome being a poorer prognosis. Further, the case of FEP, a shorter DUP [628]. Specialist
involuntary treatment and hospitalisation may be teams, rather than generic crisis teams, may be in
appraised as a particularly powerful stressor, and the best position to prevent admission [629].
serve as a catalyst for the development of post-
When hospital admission is necessary, clinical
traumatic stress symptoms [178, 625], although
experience suggests it is not appropriate to admit
psychotic symptoms themselves are likely to be
younger adolescents to adult facilities that are
more traumatic than the treatment for these [626,
dominated by people with long-term mental
627]. Minimising the trauma of both symptoms
illness. When hospital admission is necessary,
and the way in which these are treated should
but the facility is not considered appropriate, an
be an important consideration. Additionally,
adolescent or youth specialist should be involved
treatment in an unfamiliar environment may
in the person’s care.
Recommendations 3.3.8.4 Where hospitalisation is required, people

should be admitted to a facility that can cater
3.3.8.1 People with early psychosis should receive for, and is appropriate to, their age and stage of
treatment in the least restrictive manner possible. illness. Where streaming is not possible, a special
Whenever possible, the location of the initial section may be created in a general acute unit for
assessment should be community-based and at young people with recent-onset psychosis.GPP
a place that is convenient to the person and their 3.3.8.5 Community treatment orders should be
family.GPP used for the minimum duration required to meet
3.3.8.2 A range of treatment settings should specified treatment goals.GPP
be available to people, including home-based 3.3.8.6 Involvement of police to enforce treatment
support, supported accommodation, rooming in, should be kept to a minimum and used as a last
outpatient services, and inpatient care.GPP resort in the case of immediate risk.GPP
3.3.8.3 The levels of risk (to self and others), 3.3.8.7 The use of seclusion (if used at all) should
the available resources (including community be kept to the minimum frequency and duration to
support) and the needs of the individual and their meet the treatment aims when managing people
family should be assessed to determine whether who are high-risk.GPP
the individual can be managed at home.GPP
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Guideline 3.3.9. Family involvement in treatment, thereby minimising lengths of

hospitalisation [637] and possibly preventing first
Background
psychotic relapse [425]. The combined aims of
For the purposes of these guidelines, ‘family’ is
alleviating distress in families and maximising the
used in a broad sense to include parents, siblings,
individual’s prognosis suggests the importance of
partners, carers, extended family members and
the provision of support to families (refer to Box
close friends. This section refers specifically to
29 for general principles in working with families)
family involvement in an individual’s treatment
and the provision of supportive and other Family work should be developed within a
interventions to families; families’ contribution collaborative framework, in which the clinician
to service development is outlined in Guideline works in partnership with the family. The family
3.3.18, ‘Family participation and family peer should be promoted as active members of the
support’. treatment team. The aims of family interventions
are to minimise the disruption to the life of the
family and the risk of acute stress, high levels of
Box 28. Specific issues for families in early burden and long-term grief, and to maximise the
psychosis adaptive functioning of the family. Family work
should be flexible and tailored to the needs of
The heightened emotional impact of a young
each individual family. It should empower the
person experiencing mental health difficulties
family to cope and adjust to the crisis of the
for the first time, possibly maximised
psychotic illness. The underlying assumption
if the family’s pathway to receiving
should be that the family is no different to any
appropriate psychiatric assistance was not
other in their response to crisis and their ability to
straightforward, requires sensitive responses
solve problems. Interventions are therefore aimed
from services and clinicians.
at promoting coping skills, support and education
There are special needs for information and rather than addressing ‘dysfunction’. Given the
education as families: equivocal evidence to date linking expressed
• Deal with possibly severe psychiatric illness emotion (EE; an interactional style characterised
for the first time by criticism, hostility, and/or emotional over
• Cope with diagnostic ambiguity and involvement) and outcome in early psychosis, and
variable outcome the absence of any demonstrated link between
EE and outcome in the UHR group [638, 639], it
• Are faced with unfamiliar and often
is not clear that family interventions in this group
bewildering symptoms
should include an EE component.
A range of interventions have been employed

Psychosis (both emergent and established) can
with families in the FEP empirical literature,
have an enormous impact on the family system,
including therapies with an emphasis on
as it can lead to bewilderment, fear, grief and
psychoeducation alone (offered individually or
suffering for both the person with the illness and
in multifamily groups), to broader interventions
their families [630-632]. This may particularly
including a focus on early warning signs, stress
be the case with early psychosis, as most young
management, problem solving skills, affect
people are living with their families at the time of
regulation, attributing maladaptive behaviour
onset of psychosis [630, 633]. Family members
to illness, communication skills training, and
can experience stigma, embarrassment, isolation,
reduction of high EE (see McNab & Linszen [638],
loss of mastery and control, decreased self-worth,
for further details on empirically-explored family
and disruption to educational and/or vocational
interventions in FEP). It is therefore difficult to
trajectories [634]. Very few studies have
identify which components of family interventions
evaluated the emotional impact of early psychosis
are key. Further, these interventions sometimes
on families, but some studies suggest onset of
have little impact on client outcome [640] or
psychosis is a particularly distressing time for
paradoxically appear to be associated with worse
them [635, 636]. Specific issues for families in
client outcome [641]. Additional methodological
early psychosis are outlined in Box 28.
problems with this evidence preclude any firm
Families may play a vital role in supporting people conclusions being made about the efficacy of
with early psychosis and facilitating engagement these interventions. There is no evidence to date
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FOR EARLY PSYCHOSIS
exploring the efficacy of family interventions in Box 29. General principles for working with
the UHR phase. The evidence base for family families with an early psychosis member
intervention in the pre-onset and FEP stages is
Recognise the phase nature of the individual’s
therefore not established; however, there are
illness, and that family work needs to be
compelling reasons for this to be regarded as good
adaptable and flexible in approach.
clinical care, including the need to support those
who are supporting people with early psychosis, Recognise that families will have a range of
and the likelihood that, consistent with the stress- different feelings, worries and questions.
vulnerability model more broadly, at least some Recognise that families need time and
part of the family environment (although perhaps an opportunity to deal with the crisis and
not yet examined empirically) will influence a ensuing stressors.
young person’s progress. Recognise that the explanations that families
On a more general level, the initial stages of family have for what has happened to them need to
intervention may need to deal with feelings of be heard and understood.
guilt, anger, sadness and loss, and the first contact Recognise that families need a framework for
with the family often functions as a debriefing understanding.
session. It also provides an opportunity to explain Recognise that families also need a recovery
mental health services and the benefits of the time and may go through particular stages.
family’s support. Targets of intervention include Recognise that the family work may change
the impact on the family system, the impact on over time, ranging from a maintenance role
the family members, and the interaction between to dealing with longer-term, ongoing issues.
the family and the course of the psychosis.
Recognise that family work is a preventive
Emotional and practical support can assist this
intervention. It is aimed at addressing levels
process. Responses to pre-existing problems
of distress, burden, coping, social functioning
within the family should be guided by general
and general health for all family members.
crisis intervention principles.
Adapted from Gleeson, J., et al., Family intervention in

early psychosis, in The recognition and management of
early psychosis: a preventive approach, P.D. McGorry and
H.J Jackson, Editors. 1999, Cambridge University Press:
Supporting families requires Cambridge. P. 376-406[642]
having regular contact with them. In implementing the following recommendations,

Needs for contact are likely to it is important to respect individuals’ right to
confidentiality while providing support and
vary across phase of illness. information to family members. This can be a
Suggestions about frequency particularly fraught area with young people:
of contact according to phase their rights to confidentiality may not be well
of illness are outlined in each understood by family, and the limits of this right
may not be well understood by young people and
specific phase. clinicians. Guidelines written by Rethink (http://
www.rethink.org/resources/) and ReachOut
(au.reachout.com/confidentiality) regarding
confidentiality may be useful to provide to young
people, carers and clinicians. Although empirical
evidence is lacking, anecdotally it is in these
instances that family peer support workers –
family members of people who have been through
a clinical service before – may be particularly
helpful. These workers can provide assistance
and reassurance to families, having experienced
the process of caring for someone with emerging
psychotic illness. This approach may be more
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FOR EARLY PSYCHOSIS
acceptable to young people than clinicians’ Guideline 3.3.10. Goals as guides

having contact with family, given concerns about to treatment
possible confidentiality breach. Such workers
are not part of the clinical team, so do not have
Background
Treatment goals are key reference points for
access to confidential information. For further
assessing an individual’s progress and treatment
details about how such a scheme might operate,
effectiveness [643], and have been found to
see Leggatt [632]; for example, EPPIC guidelines
have positive effects on both client motivation
propose that all families should have access to a
and outcome [644, 645]. More recent policy
family peer support worker, perhaps even despite
initiatives have placed a greater emphasis
a young person’s objection, except in exceptional
on collaborative goal-setting, increasing the
circumstances (such as the unawareness of the
active participation of people in the planning
family of the young person’s involvement with
and implementation of their own treatment. In
services, or longstanding familial abuse).
contrast to the model of the clinician as ‘expert’
and the person being treated as a ‘passive
recipient’, collaborative treatment planning aims
to empower people in their own recovery [646].
Recommendations
The most frequent operationalisation of
3.3.9.1 The needs of individual family members collaborative treatment planning is the Individual
should be recognised and addressed (where Service Plan, an agreement between an individual
appropriate, within clinical services, or and their case manager (as a representative of the
alternatively, by referral to external agencies) at all service) about diagnosis, goals for treatment and
stages of a person’s recovery.GPP how these might be achieved. It may detail:
3.3.9.2 The case manager should have frequent • the major problems
contact relevant to the phase of illness and the • treatment goals
needs of the individual and their family.GPP • strategies to achieve goals
3.3.9.3 Family attendance and involvement should • people involved and their responsibilities
be reviewed as part of the clinical review process.GPP • time frames for achieving or reviewing goals.
3.3.9.4 The treating clinician should assist the family Individual service plans should be documented
by providing information about psychotic disorders early in the course of treatment and regularly
(including the recovery process) and by helping the reviewed to ensure progress is being made
family, where necessary, develop skills in problem towards treatment goals and that all parties,
solving and enhanced coping strategies.GPP including clinicians and the individual, are
satisfying key requirements and responsibilities.
3.3.9.5 The treating clinician should maximise
the responsiveness of the family to early warning The Office of the Chief Psychiatrist (Vic)
signs in order to facilitate relapse prevention.GPP has published helpful guidelines as to what
a treatment plan should include: (http://
3.3.9.6 Where necessary, the clinician should
www.health.vic.gov.au/chiefpsychiatrist/
prepare the family to deal with crises.GPP
treatmentplan/forum-feedback.pdf).
3.3.9.7 Family peer support workers may be a
useful resource for information and emotional
support, particularly in situations when an
individual being treated does not support the Recommendations
involvement of the family.GPP
3.3.10.1 Both the case manager and treating doctor
3.3.9.8 Families with more complex needs, such as
should meet with the individual being treated
those with a history of sexual and/or other abuse
and, where possible, their family, and develop an
or long-standing emotional conflict, may need to
individual service plan within 4–6 weeks after
be referred to specialist agencies.GPP
entry to a service.GPP
3.3.10.2 The case manager should regularly review
the individual service plan with the individual.GPP
within their service.C
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FOR EARLY PSYCHOSIS
Guideline 3.3.11. Group programs management program designed for people

with FEP has recently been found to reduce
Background
hospitalisation rates over and above standard FEP
Psychosis disrupts social networks, which in turn
services [650]. One very small open trial (n=5)
can worsen the outcomes of illness [135, 154].
found that participants were very satisfied with
Group work can meet a number of needs in early
CBT delivered in group format and reported a
psychosis, including reducing social isolation
reduction in psychotic symptoms after the group
and experiences of stigma and providing specific
intervention [651]. Qualitative data also suggests
content that may assist in recovering from
that young people appreciate groups as valuable
psychotic experiences. Group programs provide an
sources of information, therapy, and support
opportunity to reduce isolation, build self-esteem,
[652]. There is no evidence to date exploring the
and provide peer support [647]. Interacting
efficacy of group programs for people considered
with people who share similar experiences and
to be UHR; intuitively, however, the above
understand the impact of psychosis is highly
principles would seem to apply to that group as
valued by group participants.
much as FEP, with the exception of the ‘recovery’
Group work may provide a medium for therapeutic paradigm. Sound clinical practice also requires
change beyond this ‘normalising’ element, using effective liaison between the treating team and
a diverse range of theoretical frameworks and the group program, to ensure clinicians are
approaches including experiential learning, working together in meeting participants’ needs.
CBT, psychotherapy, psychoeducation, systems
theory and occupational science. Areas of
focus include coping and stress management
skills, psychoeducation, therapeutic groups for Recommendations
specific comorbid disorders such as anxiety and
depression, vocational and educational planning 3.3.11.1 Group programs should be offered to those
and training, social and recreational skills, health with FEPB and at UHR.GPP
promotion, lifestyle issues such as drug use
3.3.11.2 Group programs should be available in a
and safe sex practices, and creative expression
range of clinical and community settings.GPP
and personal development. A non-directive,
supportive, and encouraging attitude on the part 3.3.11.3 Group programs should be tailored to the
of staff is likely to optimise treatment gains in the different needs of people at different phases of
group setting [648]. illness.GPP
Malla et al. [128] suggest that a relatively short 3.3.11.4 Decisions about participation in any group
course of group treatment is more likely to retain program should be made collaboratively with
interest and engagement in younger people. The the individual, based on an understanding of the
group context may also differ in the early onset potential benefits for that person.GPP
population from those with more established
3.3.11.5 Goals should be set collaboratively and
illness because people with early psychosis may
progress of participants towards these goals
be more naïve regarding the mental health system,
should be regularly reviewed.GPP
more willing to exercise control over treatment
and their future, and may have a higher potential 3.3.11.6 The development of group programs
for substance use problems and impulsivity. Group should be based on a thorough planning process
interventions for early psychosis should take these which includes needs assessment, the setting
factors into account, for example by incorporating of objectives, development of content areas and
specific substance use interventions, or providing establishment of evaluation strategies.GPP
ample opportunity for participants to guide group 3.3.11.7 Where appropriate, group program
program development and evaluation. staff should assist people to find meaningful
There has been limited empirical examination of psychosocial activities (such as other groups/
the effectiveness of group interventions in people activities) external to clinical services.GPP
with FEP. Data suggests that those referred to 3.3.11.8 There should be an effective clinical interface
group programs may have poorer functioning between the group program and the case manager
prior to referral, which involvement in groups (or treating clinician) or multidisciplinary team.GPP
may effectively remediate [649]. A group stress
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FOR EARLY PSYCHOSIS
Guideline 3.3.12. Psychoeducation Qualitative research suggests a distinction

between information for the purpose of settling
Background
and reassurance, and information provided to
Psychoeducation aims to develop a shared and
educate the young person or family. These data
increased understanding of the illness for both
also reinforce the need to make psychoeducation
people with psychosis and their families [653]. In
an ongoing and individualised approach; young
the broader medical literature, it is clear that access
people who had experienced FEP noted that they
to quality information facilitates individual and
felt insignificant and not worthy of information
family decision-making and encourages people and
if needs for information were not recognised
their families to take a more active role in managing
and met during treatment, and were more likely
their own health [654, 655]. Data in established
to disengage from treatment [659]. Needs for
schizophrenia suggest that psychoeducation
information are, however, likely to differ from
significantly reduces relapse and re-admission
person to person, as are the most appropriate
rates and length of stay when re-hospitalised
media through which to deliver information.
[656]. It is also possible that psychoeducation
Peer-to-peer psychoeducational approaches,
improves compliance with medication and has
for example, have been shown to be effective in
a positive effect on wellbeing [656]. One study
adults with psychosis, and may be particularly
has examined the role of a ‘psychoeducational
palatable to adolescents [660].
treatment program’ in adolescents with psychosis,
but it is difficult to draw conclusions from this study Family psychoeducation may also reduce relapse
regarding psychoeducation specifically, as the rates [661-663]. However, as noted previously,
‘psychoeducational program’ included educational it is unclear whether psychoeducation alone in
seminars for parents, problem-solving sessions, the FEP or UHR groups shows positive effects,
and engagement with social networks (including given that most family interventions used in the
schools and vocational support [657]. To date only FEP literature include psychoeducation as one
one study has investigated the impact of seven amongst many interventions.
sessions of specific psychoeducational strategies
for people who are UHR and reported significant Psychoeducation can be delivered in a variety
reduction in psychopathology and as well as an of modes, including one-to-one interactions,
improvement in knowledge, global functioning and group sessions, peer support sessions, and
quality of life [658]. However, the uncontrolled family work. This information should be specific
nature of this study, and its small sample size to early psychosis. Psychoeducation in the first
(n=16), significantly limit its generalisability. Further episode field needs to be particularly aware
research is required before psychoeducation of healthy resistance to the psychological
alone can be said to have an empirical evidence threat of self-stigmatisation with associated
base as an intervention in the UHR or FEP groups. poorer insight and reluctance to engage in the
Despite this, however, and particularly given its psychoeducation process [664]. Psychoeducation
impact in established psychotic illness, provision of is also not a standalone intervention, but should
psychoeducation is good clinical care. be seen in the broader context of the overall
therapeutic task with several overall objectives,
including enhancing the individual’s sense of
Box 30. Psychoeducation can include meaning, mastery, and self-esteem. Timing of
explanation of: psychoeducation is also important – during acute
exacerbation of mental state abnormalities,
• The nature of illness/es (in the case basic practical information is essential, but more
of comorbidity) (including the stress- detailed and comprehensive psychoeducation
vulnerability model) should be deferred until this has settled
• The range of treatment options available [664]. Group programs may be a particularly
• The patterns and variable nature of effective way to provide psychoeducation, using
recovery facilitating techniques such as paired discussions,
• The prospects for the future and how these ‘brainstorming’ and role-playing. Regardless of
can be influenced the format, frequent checks that individuals and
their families understand psychoeducational
• Agencies and personnel involved in
material may be appropriate, as the emotional
treatment
impact of psychosis can make it difficult to
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FOR EARLY PSYCHOSIS
absorb new information. Information should Guideline 3.3.13. Suicide prevention

be provided at an appropriate pace, taking into
Background
account individual and family factors and the
Evidence suggests that suicide rates are lower
stage of illness, remembering that the emotional
in early intervention services than in previous
impact of psychosis can make it difficult to absorb
cohorts of young people with FEP treated in
information in the very early stages. It should also
generalist services [19, 237, 241]. However, the
take into account how the person usually learns or
‘active ingredients’ of the model in reducing risk
absorbs new information.
are unclear, and once treatment has terminated
There are likely to be some similarities between this effect seems to diminish [241, 243, 665].
psychoeducation for FEP and for those at UHR, Whilst the efficacy of early intervention services
particularly the stress-vulnerability model and the remain the focus of significant debate, evidence
experience of psychotic symptoms. There are key suggests that extending this model of care beyond
differences, however, given the UHR group is yet the initial 18-month to 2-year period could reduce
to experience psychosis onset. Psychoeducation suicide risk over time for this population.
in this group may also include an awareness of
A number of strategies can be employed to
the possibly stigmatising effect of an ‘at-risk’
prevent suicide. Universal service-wide suicide
diagnosis, a discussion of the risk of false positives
prevention strategies involve training staff and
in identifying those at UHR and in particular to
carers in order to increase confidence and skills
address fatalism about psychosis onset (see Yung
in detecting, assessing, and managing suicide
et al., 2004, for further details). In both the UHR
risk. Selective strategies to reduce suicide risk
and FEP phases, psychoeducation should not be
include screening and monitoring via routine
limited to psychotic symptoms and should extend
risk assessment and the development of
to any substance or psychiatric comorbidities that
risk management systems, and are generally
the individual is experiencing.
appropriate across all individuals presenting with
suicide risk factors. Indicated interventions, or
specific treatments for those identified as at high
risk at the screening stage, include acute suicide
Recommendations risk containment (including increasing frequency
of contact and support or hospitalisation),
3.3.12.1 Psychoeducation should be provided for pharmacological and physical treatments
people with early psychosis and their families.GPP specifically for suicide risk, psychological
3.3.12.2 The case manager and the treating interventions, psychosocial interventions, and
doctor are responsible for ensuring access to self-help. However, the additional benefit of these
psychoeducation.GPP interventions is generally small [666, 667], with
data suggesting that the key risk factor to address
3.3.12.3 Psychoeducational material should in reducing suicide is appropriate pharmacological
be appropriate for young people and for early treatment of psychotic and other psychiatric
psychosis.GPP disorders, and adherence to this treatment [246].
As with all therapies, these interventions must
3.3.12.4 Psychoeducation and support should be
be tailored to the individual, taking into account
provided to the individual and their family on an
the range of factors that could be contributing to
initial, continuing and ‘as needed’ basis through
suicide risk, including acute psychotic symptoms,
individual work, group programs and a consumer
comorbid mood disorder, other comorbidities such
support groups or a family participation program.GPP
as personality disorder, psychological reactions
3.3.12.5 People and families of a culturally or to psychotic illness, external factors such as
linguistically diverse background should have reactions of significant others and losses, and
access to information in their own language, using reactions to suicidality in others, including post-
interpreters where appropriate. GPP traumatic reactions and suicide pacts between
clients [239].
Pharmacological and physical treatments include,

for the FEP group, the use of SGAs rather than
FGAs [668] and clozapine [669]. Empirical
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FOR EARLY PSYCHOSIS
evidence outside the FEP field suggests other Guideline 3.3.14. Substance use
interventions. For example, the affective psychosis (including cigarette use)
literature suggests ECT can be helpful for
suicidality [670], and those with more established
Background
Interventions provided to young people to treat
illness have shown improvements in suicidality
substance use issues should recognise the
when treated with antidepressants (c.f., in the
features of this population including their young
absence of this [671]), and possibly lithium[672].
age, the circumstances that brought them into
Psychological interventions in early psychosis treatment, widespread substance use among
are rarely designed specifically to reduce suicide peers, and cognitive difficulties arising from
risk. The only specific intervention for suicidality substance use [675]. Integrated treatment is likely
in people with FEP, LifeSPAN, is a 10-session to have best effect, and can be provided either
individual CBT program creating a formulation within a single service or in collaboration with a
of short- and long-term factors contributing drug treatment service [676].
to suicidality and treating short-term factors.
Provision of feedback about assessment may
Evidence to date suggests LifeSPAN is associated
be therapeutic in its own right, providing an
with significant reductions in hopelessness and
opportunity to give psychoeducation about risks
suicidal ideation, but not in suicide attempts
to mental and physical health associated with
[152]. CBT for psychosis (c.f. suicidality in
substance use, especially links between regular
FEP) alone does not appear to reduce risk of
substance use and poor clinical outcomes [677,
suicidal behaviour in people with FEP over and
678]. Harm minimisation strategies may also be
above supportive counselling or treatment as
helpful to reduce harmful effects associated with
usual [673]. Psychosocial interventions such as
substance use and build motivation to change.
provision of support, encouragement of daily
activity, and supporting peer relationships and Psychological treatments can be successful in
work and vocational involvements may reduce reducing substance use, in particular cannabis
suicide risk [249, 674], although this has not been use. For example, motivational interviewing aims
explored in the FEP field specifically. Self-help to move the person from the pre-contemplative
resources may also be useful, although again their stage to the contemplation or action stage
impact in early psychosis has not been examined. in changing their substance use, usually by
increasing their awareness that substance use
Adequate and appropriate pharmacological
may thwart their pursuit of personal goals [676].
treatment of depression would also likely reduce
CBT can also be used to challenge the beliefs
suicide risk, given the relationship between
that individuals hold about their ability to change
depressive disorder and risk in the FEP group [22,
and their need to use substances. It focuses on
242]. Similarly, improving adherence to treatment
developing skills such as refusal rehearsal, stress
would likely reduce risk [246], as would working
management and problem solving to assist in
with young people around deliberate self-harm,
changing behaviour and preventing relapse.
given its relationship to suicide.
Particular strategies are outlined in Box 31.
CBT has been effective in the general population

in improving abstinence and reducing drug-related
Recommendations problems [679]. There have been no empirically-
evaluated interventions targeting substance
3.3.13.1 Intensive treatment should be provided use in the pre-onset phase. The Cannabis And
during high-risk phases of illness.GPP Psychosis (CAP) therapy project is the only
trial of a psychological intervention specifically
3.3.13.2 Services should develop and implement
designed to address cannabis use in those
appropriate, evidence-based interventions for
with early psychosis (specifically FEP [680]).
deliberate self-harm.GPP The LifeSPAN program
Implemented during the early recovery phase (10
is likely to be of some benefit for suicidal
weeks post-clinical stabilisation), this intervention
individuals.B
is delivered over 3 months, ideally with 10 weekly
3.3.13.3 SGAsB, especially clozapineA may be sessions and a ‘booster’ session via telephone 3
useful for suicidality. months post-completion. Using a motivational
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FOR EARLY PSYCHOSIS
interviewing paradigm, CAP starts with Box 31. Strategies for substance reduction
engagement and detailed assessment, followed (from Wade et al. 2009 [677]):
by education about links between cannabis and
Setting realistic, achievable and short-term
psychotic symptoms and addressing motivation to
goals that are clearly defined in behavioural
change. Subsequent therapy sessions are guided
terms.
by the individual’s motivation to change, and may
include additional education about cannabis and Providing regular monitoring of attempts to
psychosis, motivational interviewing strategies, achieve goals
goal setting and achievement strategies, and Engaging supportive others to assist with
relapse prevention (see Hinton et al 2007[678], plan to reduce substance use
for further details). No differences were detected Encouraging the individual to keep list of
between CAP and psychoeducation in a sample reasons of wanting to change substance use
of 47 young people with FEP, with both groups to help maintain motivation
reporting significantly lower level of cannabis
Teaching individual to challenge cognitions
use at 6-month follow-up. This suggests that
associated with substance use (e.g., positive
psychoeducation alone may be of significant
drug expectancies) and/or negative affective
benefit in reducing cannabis use in people with
states and to use problem solving to address
FEP.
high risk situations
Another CBT intervention has been designed to Providing personalised handouts of plans to
treat substance use more generally in psychosis, reduce substance use
the Start Over and Survive (SOS) program, which Identifying high risk situations for substance
is a 3-hour intervention offered over 6–9 sessions use
and usually completed within 7–10 days. The
Practising refusal skills for use in high-risk
program initially focused on engagement while
situations
participants are acutely symptomatic, progressing
to motivation enhancement and selection of goals Providing education about cravings and
for change. If participants identified these goals, withdrawal symptoms and practicing coping
specific plans were made within therapy and strategies to manage these difficulties
problem-solving strategies applied to expected Developing a plan to deal with lapse of
high-risk situations (including avoiding high-risk problematic substance use
situations, increasing enjoyable alternatives to
substance use, and engaging supportive others).
Clinical practice suggests that acute withdrawal
Social skills strategies (such as modelling and
raises its own issues. Withdrawal management
rehearsal) were used to practise drug refusal. SOS
may include education on the symptoms of
was associated with lower levels of substance
withdrawal and relaxation and coping skills to
use at 6 and 12 months, in contrast to standard
manage symptoms, detoxification (either home-
care. However, those receiving SOS also had more
based or inpatient, depending on the individual’s
support from families, so it is difficult to determine
needs), pharmacotherapy (especially for opiate
whether the intervention or family support was
and alcohol dependence), and specialist drug
responsible for these findings [681]. To date there
treatment services to advise on or manage
have been no studies in early psychosis focusing
detoxification or pharmacological interventions.
on treatment for alcohol dependence or abuse.
Pharmacological interventions may also be
appropriate in managing various phases of the
substance use reduction process, such as acute
detoxification, craving reduction, and treatment of
protracted withdrawal symptoms (see Tsuang et
al 2005 [682] for a review of the pharmacological
treatment of substance use disorders in
schizophrenia).
Although no links have been detected between

family burden and presence of comorbid
substance use in FEP [631], data exists suggesting
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FOR EARLY PSYCHOSIS
a relationship between the two in chronic Guideline 3.3.15. Treatment of

schizophrenia [683]. Good clinical care therefore psychiatric comorbidity
requires an awareness that families of those
with comorbid substance use and FEP may be
Comorbidity
Psychiatric comorbidities are common in people
particularly distressed and burdened, and require
with early psychosis, and are often present before
additional assistance.
the first episode of psychosis occurs [230]. In
addition, people with schizophrenia have a higher
risk of anxiety and depressive disorders than the
general population [232]. As many as 80–90%
Recommendations of people with FEP fulfil the diagnostic criteria for
at least one comorbid psychiatric disorder [8].
3.3.14.1 Psychoeducation and CBT may help
Major depression, anxiety disorders (including
reduce substance use in those in the pre-onset
social phobia and post-traumatic stress disorders)
phaseGPP and with FEPB.
and obsessive-compulsive disorder can occur
3.3.14.2 Treatment of psychosis and comorbid concurrently with FEP [8]. Comorbidity is also
substance use (including tobacco use) should be common in the UHR phase [684].
integrated.GPP
Depression and anxiety in people with psychosis
3.3.14.3 Acceptance policies should be inclusive of are often associated with poorer outcomes such
individuals with comorbid substance use.GPP as increased hospitalisation rates and subjective
assessment of psychosis-related difficulties [358].
3.3.14.4 Policies and procedures should be Anxiety and depression levels are also related to
developed regarding substance use and its rates of suicide and self-harm [14, 358, 359].
behavioural consequences, including the
possibility of substance use while within the Comorbid substance use, including nicotine
service.GPP and alcohol, is common in people experiencing
a first episode of psychosis [7], and may
3.3.14.5 Services should develop minimum increase risk factors for relapse even in
standards for clinicians regarding their knowledge people who are adherent to their medication.
about the assessment and integrated treatment of Comorbid substance use is also associated
substance use.GPP with a worse prognosis in general, including
3.3.14.6 Where appropriate, clinicians should more severe positive symptoms, longer periods
have access to specialist consultation to of hospitalisation and poorer adherence to
provide assessment, supervision, advice or co- medication [7]. Defining the boundaries of
management for comorbid substance misuse comorbid conditions may be difficult due to the
(including tobacco use).GPP interaction between the symptoms of the primary
disorder and those of comorbid conditions
3.3.14.7 Where people are receiving treatment [8, 14, 232]. Periodic reassessment in people
within a drug treatment service, clinicians should with FEP is often required [8, 14]. Therapeutic
actively collaborate and communicate about the interventions are recommended when the
individual treatment plan.GPP presence of comorbidities impacts on the effective
management of the primary psychotic disorder
3.3.14.8 Individual treatment plans should
[8, 358]. Applying the stress–vulnerability model
routinely include additional treatment goals
of psychosis would suggest that any source of
relevant to substance use.GPP
stress should be addressed in assisting people
3.3.14.9 Support should be offered to family and to recover from early psychosis, and thus
friends, including psychoeducation on comorbid guideline-concordant treatment of any psychiatric
mental illness and substance use.GPP comorbidities is recommended. Although it is
beyond the scope of these guidelines to provide
3.3.14.10 Discharge planning should include
details of treatments for comorbidities, clinical
attention to ongoing treatment of substance use.GPP
guidelines are available and should be consulted in
choosing treatments for comorbid conditions:
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FOR EARLY PSYCHOSIS
Royal Australian and New Zealand Guideline 3.3.16. Miscellaneous

College of Psychiatrists psychological therapies
https://www.ranzcp.org
There has been less specificity with respect to
The National Institute for Health phase of intervention in other psychological
and Care Excellence in the UK therapies than in CBT. Other psychological
https://www.nice.org.uk interventions have included milieu therapy,
Phoenix Australia psychodynamic therapy and family therapy. The
http://phoenixaustralia.org latter is outlined in a previous section about family
involvement and therapy (Guideline 3.3.9), while
NHMRC the former two are discussed below.
https://www.nhmrc.gov.au
Milieu therapy
There is no empirical evidence relating to issues Milieu therapy [686] focuses on therapeutically
of sequencing in treatment of comorbidities in designing everyday interactions and events in
UHR and FEP, (i.e., whether it is more effective inpatient therapeutic communities to build social
to sequentially treat, either pharmacologically skills and confidence, generally in the absence of
or psychologically, psychotic symptoms medication. Bola and Mosher [687] examined
and comorbid disorders or to treat them the impact of milieu therapy on a group of young
simultaneously as far as possible). There is people newly diagnosed with schizophrenia, and
mounting evidence that SGAs may have a direct found that completing milieu therapy conferred
antidepressant effect, as well as an indirect effect greater advantages at 2-year follow-up than
via improvement in psychotic symptoms[685]; engaging in treatment as usual with respect
this requires exploration in the emergent to psychopathology, and those in the milieu
psychoses. Clinical experience suggests that therapy condition were less likely to be prescribed
treatment for acute psychosis would usually be antipsychotic medication. Given the extended
prioritised with comorbid conditions becoming inpatient context of this model, however, its
the focus of treatment after some recovery form practical applicability is likely questionable.
psychosis has been achieved.
Psychodynamic therapy
There is some evidence for the effectiveness of
supportive psychodynamic therapy in treating FEP.
A prospective, longitudinal, multicentre study in
Recommendations
Denmark randomised 269 FEP participants into
3.3.15.1 All people with early psychosis, regardless either 2 years of ‘treatment as usual’ or supportive
of comorbidities should receive treatment from psychodynamic psychotherapy (SPP). Broadly,
early psychosis services. GPP SPP intervention focused on realistic cognition
of psychosocial events, maintaining adaptive
3.3.15.2 Clinicians should conduct comprehensive daily-living habits and interpersonal relationships
assessment of comorbidities and consider the and dealing with emotional experiences (i.e.,
impact of these, and adapt early psychosis ‘support’), within a traditional psychodynamic
treatment as appropriate. GPP framework – comprising a focus on working
alliance, transference/countertransference,
3.3.15.3 Treatment of psychiatric comorbidity
unconscious processes. The SPP group improved
should be conducted in a consistent manner with
significantly on measure of both PANSS and
available clinical guidelines. GPP
GAF scores with large effect sizes at 2-year
3.3.15.4 Although treatment of psychosis often follow-up. Between groups analyses also
remains paramount, the sequencing of treatment showed improvement in global functioning and
of comorbid conditions should be driven by the symptom reduction were significantly superior
symptoms/disorder that is most distressing/ in the intervention group, relative to treatment
disabling and whether it poses further risks to the as usual. However, these effects were not
person being treated or others. GPP sustained at 5-year follow-up [688]. Additionally,
methodological flaws and other considerations
mean that this model may not, however, be
feasible or justified in the Australian context.
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FOR EARLY PSYCHOSIS
Recommendations each other. A peer support program allows young

people to use their experience of treatment, care,
3.3.16 Milieu therapyC, supportive psychodynamic diagnosis, common challenges and recovery to
therapyC, and cognitive remediation therapyD may provide a message of hope to other young people
be useful in treating symptoms and/or improving and their families.
functioning in FEP. A meta-synthesis of qualitative research that
examined 27 published studies of peer support
in mental health services in the United States,
Guideline 3.3.17. Youth participation United Kingdom, Canada and Australia found that
and peer support recipients experienced increased social networks
and wellness [694]. Repper and Carter conducted
Background a review of both published and grey literature of
Consumer participation is an established right for
peer support in mental health services in 2011.
users of the mental health system, and is endorsed
They found that peer support was associated
in the National Standards for Mental Health
with a reduction in hospital admission rates and
Services [689]. Empirical research suggests that
length of admission. Additionally, it was shown
individuals who understand their health conditions
that peer support improved social empowerment
and are actively involved in decisions about their
and increased independence. Other studies that
own care value treatment programs more and
were reviewed found that peer support resulted in
have better health outcomes [690]. Participation
improvements in self-esteem and confidence, and
provides an avenue for consumers to process their
social support and social functioning [695].
experiences and apply their experience to help the
community, and it can have a positive effect on Peer support also challenges self-stigma and
consumer health outcomes [690]. Participation fosters hope in the individuals who are recipients
should be genuine and valued. For example, in of peer support [695, 696]. Furthermore, some
early psychosis services, young people should be studies reported that peer support promotes hope
invited to participate in relevant decision-making and belief in recovery, empowerment, increase
processes rather than participating after decisions self-efficacy and social networks better than
have been made. The Consumer and Carer professional staff within mental health services
Participation Policy [691] of the National Mental [695].
Health Consumer and Carer Forum provides
In addition to helping the people receiving peer
guidelines for all mental health organisations to
support services, peer support can also benefit
develop and implement consumer participation.
the individuals who are providing the peer support
Early psychosis services should involve young service, as this can increase self-esteem and
people in the planning, implementation and help with their ongoing recovery, as peer support
evaluation of their service, for the sake of both workers identify value in gaining skills, which can
young people and the services themselves [692]. help develop their personal growth [696, 697].
Early psychosis services should ensure that their
Peer support programs are run in Canada, the
processes are ‘youth-friendly’ and that sufficient
United States, the United Kingdom, New Zealand
support, training and resources are provided to
and Australia, and each program is run differently.
facilitate the participation processes. A range of
Early psychosis services are encouraged to base
processes can be used to account for the differing
their peer support program on the identified needs
abilities, interests and commitment of young
of the people using their service and their service
people. Examples are outlined Box 32.
goals.
Peer support is considered an important part of
youth participation. Peer support is described as
‘a system of giving and receiving help founded on
key principles of respect, shared responsibility and
mutual agreement of what is helpful’ [693]. The
fundamental principle of peer support assumes
that individuals with similar lived experiences can
provide genuine empathy, support and hope to
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FOR EARLY PSYCHOSIS
Box 32. Ways to encourage youth Guideline 3.3.18. Family participation

participation:
and family peer support
• Ensure a clear and accessible feedback Background
and complaints system with transparent The National Standards for Mental Health Services
resolution processes state that carer participation is an established
• Develop a youth advisory group right for people who have a relative receiving
• Facilitate youth representatives on boards services from the mental health system [689].
and committees ‘Family’ refers to all family members, relatives,
friends, and other people considered to be
• Facilitate youth involvement in staff
significant others by the person receiving care.
selection
• Facilitate youth involvement in education Early psychosis services should involve families
programs in the planning, implementation and evaluation
• Develop a peer support program that could of their service. Families’ expertise gained
include training peer workers to staff a ‘drop through their ‘lived experiences’ provides novel
in’ support room or to visit inpatient units perspectives and skills about the treatment and
care of people with early psychosis. Participation
• Staff support and a dedicated position to
by families is likely to enable them to better
co-ordinate youth participation activities is
manage their own circumstances, and provides
required.
an avenue for them to share their experiences
with other families and clinicians, and to further
develop the service.
Box 33. Youth participation should be Family participation can be developed in many
recognised for its contribution to the ways to suit the different skills and interests
service, including: displayed by families. Participation could include:
• Payment for time contributed • a family working group comprised of staff and
• Provision of travel subsidies family for the purpose of developing services to
families
• Provision of childcare if required
• attendance at service planning meetings
• Provision for other supports to encourage
involvement • a family resource room managed by family peer
• Provision of funding for training to facilitate support workers
participation (e.g., meeting procedure) • selection of family peer support workers to be
• Enabling development into more advanced trained to help and support other families
roles • family representation on boards and
committees
• providing training to staff about family
concerns
• family involvement in staff selection
Recommendations • family participation in advocacy for better
mental health services through the media and
3.3.17.1 The culture of an early psychosis
approaches to politicians.
organisation should respect young people and
encourage their input.GPP Services can adopt a model of employing family
peer support workers [698] with a primary
3.3.17.2 All youth participation initiatives should
function of supporting families. These workers can
be jointly planned with young people from the
provide assistance and reassurance to families,
outset, and based on the needs and interests of
having experienced the process of caring for a
young people.GPP
young person with emerging psychotic illness.
3.3.17.3 Early psychosis services should endeavour This approach may be more acceptable to the
to establish a peer support component within person being treated than clinicians having
their service.GPP contact with their family, given concerns about
possible confidentiality breach. Commonly
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FOR EARLY PSYCHOSIS
identified needs of families include information Recommendations

and support [632]. Services need to ensure that
sufficient support, training and resources are 3.3.18.1 Early psychosis services should endeavour
provided to family peer support workers to fulfil to establish a family peer support component
their roles. Clinicians should understand that within their service.GPP
family peer support workers are there to help
other families, as well as to support clinicians 3.3.18.2 Families participating in the service
in their interactions with families. Appropriate should receive some payment, and funding should
remuneration, training and support should be be available to allow family peer support workers
provided to family peer support workers. Leggatt to acquire any specialist skills that they may need
[632] provides a detailed description of a family in their role. Family peers support workers should
peer support program. also receive training, ongoing supervision and
support from a clinical mentor.GPP
Box 34. Family peer support worker training
Training for family peer support workers may

include: Guideline 4. Diversity and
• Ways to use ‘lived experiences of specific populations
psychosis’ to help other families. This
involves comparing the differences between
mental and physical illnesses and between Guideline 4.1. Aboriginal
experiential and professional knowledge. and Torres Strait Islander
• Telephone and face-to-face support. Active communities
listening for telephone and face-to-face
support, working with culturally diverse Background
families and reducing emotional tension
through active support. There is no conclusive national data relating to
the prevalence of psychiatric disorders broadly, or
• Helping family carers cope in first-episode
psychotic disorders specifically, among Aboriginal
mental illness.
and Torres Strait Islander peoples. The data
• Management of illness behaviour. Learning which exists is limited to hospitalisation and
to manage difficult behaviours; finding mortality, and it suggests that Aboriginal and
the fine dividing line between under- and Torres Strait Islander people have a 3–5 times
overstimulation of the young person; greater risk of being admitted involuntarily than
developing a calm response; reaching non-Aboriginal people, that Aboriginal people are
mutual agreements. admitted to hospital for ‘mental and behavioural
• Ways to help families understand the disorders’ at a higher rate than non-Aboriginal
mental health system. people, and that the rate of hospitalisation for
• Managing boundary issues. Understanding ‘mental and behavioural disorders’ secondary
the relationship between family peer to psychoactive substance use is 4–5 times
support workers and the family being higher than in the general population [699, 700].
supported; working alongside clinicians; Death rates from suicide in Indigenous people
self-care and supervision. are around twice the rate of the non-Indigenous
community, with the young adult years being a
• Facilitating a support group [677].
period of particularly high risk [701]. Individual
and community experiences that may in part
account for these figures include social exclusion
and marginalisation, stress/trauma (including
historically and currently, leading to increased
exposure to psychosocial stressors and violence),
and substance use.
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FOR EARLY PSYCHOSIS
Many initiatives have been developed for Recommendations

Aboriginal and Torres Strait Islander communities
through state and territory mental health 4.1.1 Clinicians should be especially alert to the
programs, but few have specifically addressed side effects of antipsychotics when working with
early psychosis. Until clinical expertise is better people from Aboriginal and Torres Strait Islander
developed in this area, it is recommended that communities.GPP
early psychosis services consult with local
Aboriginal mental health professionals. 4.1.2 Indigenous health or mental health
practitioners should be involved in the assessment
A useful resource on providing mental health and treatment of Indigenous people with emerging
services to Aboriginal and Torres Strait Islander psychosis to facilitate engagement and reduce
people is the Aboriginal Mental Health First Aid stigma.GPP
Training and Research Program’s guidelines on
cultural considerations and communications 4.1.3 Clinicians should practice in a manner
techniques. The key points of these guidelines are consistent with relevant guidelines on working
outlined in Box 35. with people from Aboriginal and Torres Strait
Islander communities (e.g., Aboriginal Mental
Health First Aid Training and Research Program,
Box 35. Key principles in working with 2008).GPP
Aboriginal and Torres Strait Islander
communities
• Learn about the other person’s culture and

their concept of mental illness
Guideline 4.2. Culturally
• Know what is normal, and what is not, in and linguistically diverse
the person’s culture communities
• Know what is culturally appropriate
communication Background
• Do not shame the person, their family, or People from non-English speaking backgrounds
their community (NESB) are less likely to be consumers of mental
• Use community and family supports health services (both inpatient and outpatient)
than the Australian-born population, but are
more likely to be admitted involuntarily in the
Of particular relevance in treatment of psychotic context of mental health treatment [703]. A key
symptoms in Aboriginal and Torres Strait Islander element of providing psychiatric care is facilitating
people is the need to be aware of the physical side communication, a process which can become
effects of antipsychotics; failure to monitor these more complicated when working with people from
appropriately could be particularly problematic NESB, whose English proficiency can be more
for these individuals given higher rates of medical limited. If not sufficiently addressed, this can lead
difficulties in general and specifically disorders to misdiagnosis and inappropriate treatment. This
that can also emerge consequent to antipsychotic requires not only working with interpreters when
medication (such as cardiovascular disease, appropriate (see standard 1.7, National Standards
diabetes, and obesity). for Mental Health Services [689]: ‘The mental
The CAARMS may also require some modification health service upholds the right of the consumer
in order for its use to be valid in Aboriginal and their carers to have access to accredited
peoples, given recent data suggesting its use leads interpreters’), but also working with them
to greater ‘false positives’ in Aboriginal than non- effectively. Relevant guidelines offer suggestions
Aboriginal people [702]. about key principles in this area (e.g., see the
Victorian Transcultural Mental Health website:
http://www.vtmh.org.au/resources/interpreter-
resources-1) and are summarised in Box 36.
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FOR EARLY PSYCHOSIS
Box 36. Good practice in working with interpreters in mental health settings
• Ensure that you know which language (and dialect) the consumer speaks:
do not assume the language spoken from the consumer’s country of birth.
• Check whether there may be an ethno-political divide between consumer and interpreter.
• Check whether the gender of the interpreter is important to the interview.
• Ensure that the interpreter knows the purpose of the interview.
• Be aware of the needs of the interpreter (particularly in stressful and difficult circumstances)
and keep in mind the complexity of the interpreter’s task.
• Introduce all people present to one another and explain the role of each person.
• Explain to the consumer and carers/family members that the interpreter is bound by a code
of ethics and is required to observe confidentiality.
• Speak to the consumer directly: do not say to the interpreter “Ask her if...”
• Use short simple sentences and speak in plain English, avoiding the use of jargon, slang,
and colloquialisms.
• Allow enough time for questions and answers to be interpreted - this may extend the
time needed for the interview.
• Do not ask for a ‘literal translation’ as mental health terms may not have a direct translation
in the consumer’s language. The interpreter’s role is to convey an equivalent meaning.
• Be aware that the interpreter is not a mental health expert and should not be asked about
the mental state of the consumer.
• Although the interpreter may be asked about cultural background issues, he/she is not
a cultural consultant, and may be from a different class or culture to the consumer.
• Review the session with the interpreter after the interview, and ask whether there were
any interpreting difficulties.
• Include the interpreter in any debriefings necessitated by incidents or occurrences that
he or she was party to.
Adapted from: Miletic et al. [704]
It is important to bear in mind that issues in Recommendations

accessing services, assessment, and treatment
may still emerge if someone is proficient in 4.2.1 People with early psychosis or family members
English, but they or their family are overseas-born. who cannot speak English, or who speak limited
These include challenges of resettlement and English, should be able to access professional
acculturation for young people and/or their families, interpreting and translating services. GPP
such as contending with any history of trauma
experienced in a country of origin, ‘parentification’ 4.2.2 Clinicians should refer to appropriate
of children if they are the key nexus of interaction guidelines when working with interpreters and
between their family and the dominant society, have training and support for this work. GPP
cross-generational conflict that may at times 4.2.3 Clinicians should seek education and advice
represent conflict between the original and new about the cultures of the young people and
cultures, and racism and media stereotypes [705]. families that they work with in order to practice in
Principles of working with people from Aboriginal culturally-sensitive ways. They should seek training,
and Torres Strait Islander communities also apply and supervision for this work and be supported in
to people not born in Australia. Various state this by their early psychosis service. GPP
bodies provide useful resources covering practical
strategies to address common challenges in
working with people from NESB (e.g., Victorian
Transcultural Mental Health Unit).
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FOR EARLY PSYCHOSIS
Guideline 4.3. Rural and Regardless of availability of services, what may

be suitable for a densely populated urban area
remote populations may not be appropriate for rural areas that do
not have a critical mass of incidence of early
Background psychosis [710]. In reviewing the three studies
There is limited data comparing the prevalence that have detailed provision of early psychosis
of early psychosis in urban and regional/remote services in rural/remote communities, two in
areas. However, young people who do not live Australia [711, 712] and another in Canada [713],
in major population centres may experience Welch and Welch [709] noted some common
considerable difficulties in accessing specialised features between the services, outlined in Box 37.
mental health care. This may be because of lack of Further exploration is necessary to establish what
service providers, fear of stigma, stoicism or travel constitutes the most effective service delivery for
and financial barriers [706-708]. Some progress early psychosis in rural/remote areas, including an
has been made towards remedying this situation examination of the prevalence and context of early
in Australia with federal funding for psychological psychosis in rural/remote communities, to ensure
services (Access to Allied Psychological Services early psychosis services are appropriately tailored
projects, funded under the Better Outcomes in to this group.
Mental Health Care initiative); the uptake of these
services has been proportionally greater in rural/
remote than urban areas (Morley et al., 2007).
Recommendations
Box 37. Features of early psychosis services 4.3.1 Early psychosis prevention and intervention
in rural/remote communities [709] information should be readily available at key
locations in rural and remote areas, for example in
• Community education campaigns to raise
GPs’ waiting rooms and community centres. GPP
awareness of early psychosis and support
early intervention 4.3.2 Mental health services should provide
• Strong GP liaison and primary care tertiary consultation and education services to
structures health practitioners in rural and remote areas. GPP
• Accessible expert consultation, such as via 4.3.3 Telepsychiatry and other technological
telepsychiatry facilities should be made available to mental
• Availability of clinical guidelines and health practitioners in rural and remote areas to
protocols facilitate links with early psychosis services. These
should not, however, be seen as a replacement for
visiting specialists [348].GPP
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FOR EARLY PSYCHOSIS
Guideline 4.4. LGBTIQ – Same-sex attracted and gender diverse
Box 38. Definitions in LGBTIQ
Lesbian An individual identifying as a woman whose primary emotional or sexual attraction is

towards other women.
Gay An individual whose primary emotional and sexual attraction is towards people of the same sex.
The term is most commonly applied to men, although some women use this term.
Bisexual An individual who is sexually and emotionally attracted to people of both sexes.
Transgender An individual whose gender identity does not match the gender they were assigned at
birth.
Intersex An individual who is born with physical, hormonal or genetic features that are neither wholly
female nor wholly male; or a combination of female and male; or neither female nor male.
Queer An umbrella term that includes a range of alternative sexual and gender identities, including
gay, lesbian, bisexual and transgender.
Gender identity An individual’s sense of identity defined in relation to the categories male and female.
Some people may identify as both male and female while others may identify as male in one setting
and female in other. Others identify as androgynous or intersex without identifying as female or male.
Gender expression The way in which someone chooses to physically express their gender, through
name, pronoun, clothing, haircut, mannerisms, etc. This is not the same as gender identity, which
refers to an internal sense of one’s own gender.
Gender diverse Not all individuals who identify as a gender different to that assigned at birth
necessary identify as strictly male or female. Gender diverse acknowledges the many different ways
people may identify their gender (e.g., genderqueer, non-binary, agender and gender-fluid).
Transition The process by which a gender diverse person affirms their gender, whether through name
change, clothing or medical support, etc. Some people may do all or none of these things, for a range
of reasons. It is important to remember that gender is an internal sense of self. There is no right or
wrong way to transition.
Same-sex attracted An individual who is attracted to people of the same sex. This is a sexual
orientation, not a gender identity.
Background 724]. More research is needed investigating early

psychosis and LGBTIQ young people in order to
People who consider themselves lesbian, gay, formulate targeted clinical practice points.
bisexual, transgender, intersex or queer (LGBTIQ)
comprise approximately 11% of Australia’s Young people aged 16–24 are most likely to hide
population [714]. LGBTIQ young people are their sexuality or gender identity [722] (relative
subjected to lower levels of parental support to other age groups). In 2014, one study reported
[715], higher rates of physical and verbal abuse 16% of same-sex attracted Australian young
[716, 717], discrimination and stigma [718] and people have attempted suicide [716], while
homelessness [719, 720], and have higher rates another study reported 38% of intersex and
of substance use [715, 721], all factors associated transgender Australian young people have had
with increased risk of psychosis. suicidal ideation and not reported this to a medical
professional [717]. Clinicians should therefore
In Australia, LGBTIQ people have higher include questions that explore gender and/or
incidences of all types of mental illness [722]. sexual identity as part of routine assessment.
Two studies in comparable countries have found Linking the individual with specialised LGBTIQ
that LGBTIQ people have 3–4 times higher rate services, relevant support networks, including
of psychosis than non-LGBTIQ people [723, (where appropriate) seeking support from peers,
and teachers facilitates wellbeing [717]. Family
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support predicts greater self-esteem, and is Guideline 4.5. Young people

protective against depression, substance use
and suicidal ideation/behaviours [725] in young
experiencing homelessness
LGBTIQ people, and may therefore be a focus for
intervention.
Background
Between the ages of 15–25, biological, social
It is important to acknowledge the key role
and vocational skills are acquired that enable
that ‘minority stress’ [726] (stress arising from
independent living. Home-leaving is an important
negative social attitudes and discriminatory
part in the emergence of adult identity and
practices) has in the psychological wellness of
social roles. When psychosis co-occurs with
LGBTIQ young people. Two large independent
homelessness, there is a greater likelihood of a
general population samples (total N in excess
deficit in skills required for independent living, and
of 10 000) reported a higher incidence of
a greater need for these same skills to survive.
psychotic symptoms in lesbian, gay or bisexual
participants, compared with heterosexual people There is a longstanding, bidirectional association
[727]. Importantly, minority stress (in particular between homelessness and mental illness
bullying, discrimination, and trauma) partly [728]. In the last Australian Census (2011) the
contributes to the association between LGBTIQ population of young people (12–24 years old)
status and psychotic symptoms. Minority stress experiencing homelessness was estimated to be
is therefore an important mechanism by which 26 238, or 25% of the homeless population. The
LGBTIQ people are at increased risk for psychosis. Cost of Youth Homelessness in Australia Survey
When undertaking a mental health assessment, found that 53% of young people experiencing
clinicians should therefore be mindful of, and homelessness have a diagnosed mental illness, of
identify the circumstances and stressors common which 14% report a psychotic disorder [729].
to LGBTIQ people that are also risk-factors for
psychosis. It is important that clinicians are Stable housing is a key part of recovery from
familiar with, and able to use appropriate terms mental health issues. Without a stable home,
and language around gender diversity (see Box 38 young people can struggle to work on recovery
above). goals, such as engaging in employment or
education [730]. Moreover, the longer that people
are homeless, the more likely they are to develop
severe and persistent mental health issues [731]
and are less likely to adhere to treatment [732].
Recommendations
Wherever possible the aim is to prevent
4.4.1 Clinicians should avoid assuming what homelessness and intervene when someone is at
a young person’s gender identity or sexual risk of homelessness. It is therefore a key part of
attraction is. This should be ascertained as part of the clinician’s role to take a proactive approach
a comprehensive mental health assessment. GPP in both early intervention and prevention of
homelessness as well as practical based support
4.4.2 Clinicians should pay careful attention to
for those that are homeless. Recognising the risk
risk and its assessment in LGBTIQ people. GPP
factors associated with homelessness is therefore
4.4.3 Clinicians should identify and address essential. Risk factors include early exit from
stressors that LGBTIQ young people have that education, family breakdown, financial hardship,
also comprise risk factors for psychosis (i.e., by unemployment [729], criminality, and substance
referring to specialised LGBTIQ services, building use [733]. Young people at risk of homelessness
coping strategies and resilience in response to should be referred to housing services in the local
potential bullying, discrimination, and trauma). GPP area. Most specialist housing services accept
referrals for young people who are homeless and
4.4.4 LGBTIQ young people should be linked
at risk of homelessness. A collaborative response
with supportive communities, and group support
with both services is best practice in this area. A
networks. GPP
key role for clinicians is to advocate for the young
person within homelessness services and assist
with service navigation[734].
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A focus on development of independent living Young people experiencing homelessness and

skills such as budgeting, money management, mental health issues are less likely to have
social skills and problem solving is important to family or social support and in some cases the
facilitate stable housing [734]. Young people who complex mental health issues can contribute to
are homeless are less likely to be employed, have homelessness. Family work is important when
greater difficulty becoming employed and are less working with both psychosis and homelessness.
likely to be educated [729]. Clinicians working Improved familial relationships is a key reason
with young people should widen the social and for young people returning to their family home
vocational opportunities for young people in order and is a key area for prevention of homelessness
to improve housing stability and satisfaction when working with young people at risk of
[735]. homelessness [734, 736-738].
Recommendations 4.5.3 Early psychosis services should partner and

collaborate with youth homelessness services
4.5.1 Early psychosis clinicians should recognise in order to facilitate access to services and co-
that stable, secure and appropriate housing is ordinated care.GPP
essential to recovery from mental illness and the 4.5.4 Early psychosis clinicians should focus on
maintenance of wellness.GPP the development of independent living skills in
4.5.2 Early psychosis clinicians should recognise their young people with early psychosis.GPP
risk factors for homelessness in people with early 4.5.5 Early psychosis clinicians should work on
psychosis in order to intervene early.GPP maintaining and improving familial relationships
even if a young person is homeless.GPP
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Appendices
Glossary of terms
Acute phase The period in which a person is experiencing frank psychotic symptoms
(positive symptoms). It begins when active symptoms commence and finishes
when symptoms have remitted.
Adolescence A stage of mental and physical development occurring between childhood and
adulthood where many transitions occur. Generally occurs between the ages
of 13 and 19, but may vary.
At risk mental state A state in which predictive criteria are met in which someone has an increased
(ARMS or ARMS-P) chance of experiencing a psychotic illness.
Attenuated psychotic Symptoms that are of a reduced intensity or frequency. Not severe enough or
symptoms sufficiently frequent to elicit a psychosis diagnosis.
Brief limited psychotic A brief period of threshold-level psychotic symptoms that spontaneously
symptoms (BLIPS) resolve.
Duration of untreated Time interval between the first onset of psychiatric symptoms and initiation
illness (DUI) of treatment for psychosis. This includes the period during which psychotic
symptom develop (i.e., the prodrome).
Duration of untreated Time interval between the onset of psychotic symptoms and initiation of
psychosis (DUP) treatment.
Early intervention Interventions targeting people displaying the early signs and symptoms
of a mental health problem or mental disorder. Early intervention also
encompasses the early identification of people suffering from a first episode of
disorder.
Early psychosis While there is no single authoritative definition of ‘early psychosis’, it clearly
has an onset focus. It includes the period described retrospectively as the
‘prodrome’ or prospectively as the UHR phase, and is also considered to
include the critical period up to 5 years from entry into treatment for the first
episode.
First episode psychosis The first onset of a psychotic disorder in the lifetime of an individual.
Frank psychosis Presence of prominent positive psychotic symptoms.
Functional recovery A recovery in which there has been improvement in the person’s practical life
skills and ability to fulfill appropriate social and occupational roles.
Incomplete recovery phase A phase in which active symptoms and/or functional impairment remains
whilst clinical intervention is being undertaken.
Negative psychotic The group of symptoms that are characterised by the absence or loss of
symptoms experience. Examples include decreased speaking, decreased emotional
reactions and reduced drive to do things.
Positive psychotic Positive symptoms are characterized by the presence of unusual feelings,
symptoms thoughts or behaviours. Positive symptoms include such experiences as
hallucinations or delusions. A hallucination could be hearing voices that no
one else can hear, or seeing things that are not really there.
Pre-morbid phase A period before someone develops an illness. Normal development and
activity is occurring.
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Prodrome (prodromal) A medical term describing a symptom or group of experiences that precede
definitive symptoms of a disorder.
Psychosis prodrome Retrospective concept – after someone has experienced an acute psychosis,
the prodrome is the period preceding the psychosis during which symptoms
develop and behaviour change is noticed.
Psychosis A condition in which there is misinterpretation and misapprehension of the
nature of reality as reflected in certain symptoms, particularly disturbances
in perception (hallucinations), disturbances of belief and interpretation of
the environment (delusions), and disorganised speech patterns (thought
disorder).
Psychosis spectrum An illness in which the symptoms involve psychosis. Includes schizophrenia,
bipolar disorder, and major depressive disorder with psychotic features.
Schizophrenia spectrum An illness in which the diagnostic features fit within the family of
schizophrenia illnesses. Includes, but is not limited to: schizophrenia,
schizophreniform psychosis, delusional disorder, schizoaffective disorder, and
brief psychotic disorder.
Ultra high risk A state in which specific predictive criteria are met which indicate that the
(UHR) person has an increased chance of transitioning to a psychotic illness in the
future.
Vulnerability to psychosis An increased risk of developing the symptoms of psychosis due to various
factors.
Youth A description of an age range that overlaps the periods of adolescence and
young adulthood. Generally defined as between the ages of 15 and 25.
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Contributors to the second edition update

We would like to acknowledge the contribution of those listed below, who provided specific feedback and
content during development of this guidelines update.
Staff of the EPPIC National Staff of Orygen Youth Health, Members of the Australian Early
Support Program at Orygen, The Northwestern Mental Health, Psychosis Research Network
National Centre of Excellence in Melbourne Health
Youth Mental Health
Contributors to the second edition

We would like to acknowledge the contribution of the individuals and groups listed below who provided
specific feedback and content during development of these guidelines.
Dr Alexandra Parker Deepika Ratnaike Mary Macrae

Dr Barnaby Nelson Esther Singer Pauline McEntee
Dr Rick Fraser Donna Gee Beverly Moss
Kingsley Crisp Dr Margaret Leggatt Dr David Shiers
Kathryn Elkins Dr Enrico Cementon Dr Gordon Shymko
Jo Robinson Karen Dickinson Dr Russell Slater
Dr Shona Francey Stephen Druit Dr Ben Thomas
Associate Professor Jane Associate Professor Paul Ned Tkalcevic
Edwards Fitzgerald Dr Paul Woodhouse
Dianne Albiston Meredith Harris The Victorian Youth Early
Dr Lisa Phillips Dr Tracey Harrison Psychosis Services (YEPS)
Helen Osman Sal Hosking All attempts have been made to
Frank Hughes Vivien Lebnan acknowledge contributors to the
second edition.
Swagata Bapat Dr Margaret Leggatt
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Contributors to the first edition

Dr J Edwards B Hoclding K Robinson
D Albiston Dr H Hustig V Ryan
Central Coast Area Health Associate Professor H Jackson K ScanIon
Service – NSW J Jones Professor B Singh
C Curran Associate Professor F Judd Western Australian NEPP
Dr P Dignam V MiIler Steering Committee
Dr N Ford M Mooney Western Sydney Area Mental
C Gardner Health Service
Dr P Morgan
Gold Coast Psychiatric Swan Hill Community Mental
Dr L Nash
Services – QLD Health Services
W Radcliffe
L O’Brien
We remain indebted to the original group who led the National Early Psychosis Project (1996–98)
Professor Patrick McGorry Stephen Haines, Victoria Christopher Wigg, South

(Project Director) (State Coordinator) Australia
Kerryn Pennell Peter Handley, Tasmania (State Coordinator)
(National Project Manager) (State Coordinator) Julie Kempton, Queensland
Hilary Berry, Northern Territory Amanda Urbanc, Australian (State Coordinator)
(State Coordinator) Capital Territory (State Bernadette Pound, Western
Bernadette Dagg, Coordinator) Australia
New South Wales (State Coordinator)
(State Coordinator)
Further information on early psychosis services go to www.iepa.org.au

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Australian Clinical Guidelines

for Early Psychosis

The National Early Psychosis Project is indebted to the

Contents Diversity and

The nature of psychosis 20 Guideline 3. Treatment 49

Guideline 3.3.11. Group programs 93 Appendices 109

Guideline 4. Diversity and specific

Access to care 1.3.3 Undergraduate and postgraduate medical

Assessment 2.4.1 Assessment of the personal context of illness

3.2.1.5 Antipsychotic medication should not be

Recommendations for treatment of 3.2.4.6 CBT should be considered as an adjunctive

3.3.2.3 Potential physical side effects (including

Sexual health 3.3.5.2 Clinicians should promote functional

Least restrictive treatment by helping the family, where necessary, develop

Suicide prevention Comorbidities

Diversity and Culturally and linguistically

Rural and remote populations Homelessness

4.4.2 Clinicians should pay careful attention to

4.4.3 Clinicians should identify and address

4.4.4 LGBTIQ young people should be linked

Table 1. Levels of evidence ratings (NHMRC, 1998)

NHMRC Level Basis of evidence

III – 1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate

IV Evidence obtained from case series, either post-test or pre-test/post-test

Table 2. NHMRC grades of recommendation

Grade of recommendation Description

A Body of evidence can be trusted to guide practice

B Body of evidence can be trusted to guide practice in most situations

D Body of evidence is weak and recommendation must be applied with caution

The process, structure, Process of the update

The development process involved:

Structure of the update to the Limitations of the update to the

Guideline 4, ‘Specific populations’, now contains The nature of psychosis

‘Early psychosis’ refers to the early course of

Table 3. Risk factors for psychosis onset

Distal (premorbid) risk factors Proximal risk factors

Foetal life: Late childhood/adolescence:

Epidemiology Experiencing psychotic symptoms does not,

Estimates of the incidence of early psychosis

Figure 1. Example of the continuum of psychotic-like experiences

Mental Mental Mental

Course of illness be selected by consumers and clinicians on the

Table 4. Clinical staging model for psychotic disorders

Clinical Definition Definition in the Target populations Potential interventions

0 Increased risk of Premorbid First-degree teenage Indicated prevention of

1a Mild or non-specific Possible prodrome Screening of teenage Indicated secondary

1b Ultra high risk of Possible prodrome Referral by: Indicated secondary

3a Incomplete Late/incomplete Primary and Early intervention for FEP

Clinical Definition Definition in the Target populations Potential interventions

3b Recurrence or Late/incomplete Primary and Early intervention for FEP

3c Multiple relapses, Late/incomplete Specialist care Early intervention for FEP

Other symptoms Obsessive compulsive

Behavioural changes Deterioration in role

Adapted from Yung, Phillips and McGorry, 2004 [95].

Box 1. Criteria for identification of ultra high Box 2. CAARMS domains