Early intervention in psychosis: Strategies, predictors and challenges

Early onset psychosis: Global scope and prevalence

EOP constitutes a substantial portion of overall psychosis cases:

• Psychotic disorders, such as schizophrenia, usually show their first manifestations during childhood and adolescence. Nearly 80% of individuals develop FEP during adolescence or early adulthood.⁶

• Globally, 11-18% of patients present with their FEP before age 18 (EOP).²

• Psychotic disorders are ranked among the top 20 leading contributors to disability. Neuropsychiatric disorders specifically are the greatest contributor to the global burden of disease in adolescents and young adults worldwide ^1,7

Magnitude in the Indian context

LMICs, including India, bear a particularly heavy burden related to psychosis:

• The burden of disease and disability is particularly high in LMICs. Almost 80% of all patients with FEP live in LMICs.⁷

• A major structural challenge in LMICs is the mental health treatment gap, which exceeds 75% in places like India.⁸ India has a large pool of undetected and untreated patients with psychosis.⁷

• The prevalence of psychotic disorders in adolescents between the ages of 13 and 17 years in India was 1.3%, according to the National Mental Health Survey conducted in 2015-2016.⁴

• A 3-year retrospective review at a tertiary care center in New Delhi, focusing on child and adolescent patients, found the clinic prevalence for schizophrenia and other psychotic disorders to be 2.47%.⁹ This finding is similar to other Indian clinic-based studies, which have shown prevalence rates ranging between 2.4-2.7%.¹⁰

Components of early intervention

The primary goals of EIP are to reduce the duration of untreated psychosis (DUP) and to provide consistent, comprehensive care during the critical early years of illness.¹¹ EIP encompasses three main paradigms:

• 1.

  Assertive, high-quality evidence-based care delivered by specialist teams for FEP.⁸

• 2.

  Early detection of untreated cases in the community to shorten DUP.⁸

• 3.

  Interventions for young people identified as clinical high risk (CHR) or ultra-high risk for developing a psychotic disorder.¹²

Effective care in this critical period involves proactive engagement, initiation of both pharmacological and psychosocial treatments, and aims for maximal symptomatic and functional recovery while preventing relapse.¹¹

Predictors of outcome in EOP

A systematic review on EOP outcomes identified several consistent predictors of a worse trajectory across clinical, functional, cognitive, and biological domains:

• 1.

  Premorbid difficulties: These include poorer premorbid adjustment and a history of developmental disorders.¹³ Patients presenting with poorer premorbid adjustment and prominent negative symptoms are at an elevated risk for poor outcomes, highlighting the need for careful monitoring and intensive interventions in this subgroup.¹⁴

• 2.

  Greater symptom severity at baseline: Severe negative symptoms, in particular, were strongly predictive of worse outcomes.¹⁴

• 3.

  Longer DUP: Predicts worse clinical, functional, and cognitive domains.¹⁵

• 4.

  Cognitive variables: Lower intelligence quotient (IQ) at baseline was linked to poorer insight and worse functional outcomes.¹⁶

• 5.

  Biological markers: Lower antioxidant levels at baseline predicted greater brain volume changes and worse cognitive functioning. Specific neuroimaging markers like regional cortical thickness and grey matter at baseline were found to predict remission and better insight, respectively.^17,18

• 6.

  Age at onset and sex were not found to be consistent predictors in most multivariate models.¹⁹

Effectiveness and cost-effectiveness of EIP services

Specialized early intervention services have become widespread globally over the past 15 years.¹¹ Evidence from various studies and meta-analyses supports their effectiveness:

• 1.

  EIP services demonstrably reduce DUP and lead to better symptomatic and functional recovery.²⁰

• 2.

  The Norwegian Treatment and Intervention in Psychosis (TIPS) Study, for example, showed that early detection programs could substantially reduce DUP to a matter of weeks, resulting in better clinical condition, lower suicide risk, reduced negative symptoms, and improved social recovery.²⁰

• 3.

  The Danish OPUS trial found that integrated, intensive treatment led to beneficial symptomatic and functional outcomes and reduced family burden at 1 and 2 years.^21,22 While some gains might be lost if care reverts to generic teams, patients in early intervention programs were more likely to live independently and have fewer inpatient days over a 5-year period.²³

• 4.

  The Lambeth Early Onset (LEO) trial in the UK demonstrated gains in clinical, functional, and social aspects, including reduced readmissions, relapses, and drop-outs, as well as improved medication adherence and engagement in educational/vocational pursuits.²⁴

Crucially, EIP services are also more cost-effective than standard models of mental health care, primarily by reducing expensive inpatient stays.²⁵ The Early Psychosis Prevention and Intervention Centre (EPPIC) Program in Melbourne showed significant long-term savings, with costs associated with EPPIC patients being half of those in standard care at 8-year follow-up.²⁶ The suggested “critical period” for sustained intervention is estimated to be the first 5 years of illness.²⁷

Challenges and adaptations in LMICs

Despite these benefits, significant challenges are associated with implementing EIP in LMICs with a high burden of FEP patients.²⁸ These countries have scarce mental health services, inadequate funding, a lack of trained professionals, and treatment gaps exceeding 75% in places like India. Exact adaptation of Western models is often not feasible or practical.⁷

The World Psychiatric Association (WPA) has initiated an expert panel to develop priorities and guidelines for EIP in LMICs, emphasizing a coordinated public health approach, integration into existing service structures, and leveraging community strengths.⁸ Interventions must be culturally adapted, appropriate, accessible, and acceptable.

Pathways to care and treatment delays: Comparison between high-income countries (HICs) and LMICs

A study comparing early intervention pathways in Montreal, Canada (HIC) and Chennai, India (LMIC) revealed interesting differences:²⁹

• 1.

  Overall, help-seeking DUPs (weeks from onset of present psychotic episode to first help-seeking contact) were not significantly different between the two sites.

• 2.

  However, Chennai patients had significantly shorter referral DUPs (weeks from first help-seeking contact to entry to the early intervention service). This was notably due to the early intervention service itself being the first contact for 44% of Chennai patients (compared to 5% in Montreal)

• 3.

  In Chennai, faith healers comprised 25% of first contacts, leading to significantly shorter help-seeking DUPs (mean 6.6 weeks) but longer referral DUPs (mean 21.0 weeks). This suggests that while these informal pathways are accessed early, they can prolong the time to formal treatment.

• 4.

  In Montreal, most referrals (93%) originated from medical sources, with hospital emergency services being the first contact for over half of the patients. Interestingly, contact with psychologists, counsellors, or social workers as a first step was associated with longer DUPs in the Montreal sample.

• 5.

  These differences highlight the influence of both structural elements (e.g., healthcare system organization, referral gatekeepers) and cultural elements (e.g., trust in faith healers, family involvement) on pathways of care.

Early-onset psychotic Disorders in the Indian context

A retrospective review of child and adolescent (≤16 years) psychotic disorders at a tertiary care center in New Delhi, India, provided insights into their clinical profile:⁹

• 1.

  The clinic prevalence for mood and psychotic disorders was 2.47% (40 out of 1618 total patients evaluated)

• 2.

  Nearly half (48.3%) of the sample had a very early onset (≤12 years).

• 3.

  There was an almost equal representation of males and females.

• 4.

  Universal disruption in social, interpersonal, and academic functioning was observed in all patients, with 17.1% leaving school after psychosis onset.

• 5.

  Auditory hallucinations were common (51.5%), often inferred from a patient’s behavior rather than self-report. Delusions were present in 40% and visual hallucinations (often with ghost or animal themes) in 17.1%.

• 6.

  Comorbid subnormal intellectual functioning was present in 14.5% of the sample.