Letter to the Editor: Detecting and treating young people at risk for psychosis is essential, but early intervention for those with a psychotic disorder should be a priority for CAMHS

Abstract

We read the article by Salazar de Pablo and Arango (2023) with great interest. The authors discuss some advantages and limitations from the Clinical high Risk for Psychosis (CHR-P) paradigm; mentioning a few additional perspectives that could be addressed in CAMHS services beyond the current CHR-P model. Among various propositions, they suggest training professionals working in primary care to assess psychosis-like experiences and to propose transdiagnostic cost-effective interventions such as psychoeducation and treatment for those where psychopathology emerges in the form of anxiety and depression. What they propose is very similar to the Head Space model developed in Australia, and which broadens the narrow focus of CHR-P and Early Intervention (EI) for psychosis. Head Space, created in 2006 in Australia, offers support to young people aged 12–25 facing a large range of psychological issues in a low stigma environment. More than 150 centres have now been implemented in Australia, embedded in the community and primary care such as the one proposed by Salazar de Pablo and Arango. Headspace has successfully been granted substantial funding over the last 2 decades and has provided 4.4 million interventions to more than 700,000 young Australians since its creation (McGorry et al., 2007; Rickwood et al., 2023). It is however worth noting that at this stage, considerable concerns have been raised in terms of evidence-base results on the efficacy of this approach, as well as other problems such as the deficient coordination with the standard governmental healthcare services where patients should be referred in case of established disorder or suicidality, leading to duplication in care (Hilferty, Cassells, Muir, & Katz, 2016; Kisely & Looi, 2022). These concerns have reduced the broad exportation of the model to other countries (Looi, Allison, Bastiampillai, & Kisely, 2021), although similar strategies are currently being developed in some places (https://www.birmingham.ac.uk/research/heroes/youth-mental-health.aspx) which is encouraging. Hopefully, new data from Head Space can further help to expand this model as Salazar de Pablo and Arango propose.

There is another point we would like to raise. While Salazar de Pablo and Arango focus their paper on the CHR-P paradigm and suggest it should be implemented in CAMHS, we think the necessity for adequate treatment of patients with First Episode Psychosis (FEP) should not be forgotten. Indeed, if implementation of the identification of at risk mental state is an important step towards preventive treatment, patients with FEP definitely need adequate treatment. FEP programmes have now been implemented around the World for more than 30 years and their positive impact on outcome is strongly established. Despite a very strong accumulation of evidence, many countries in Europe and around the World, still do not have proper FEP programmes. This is even more true in CAMHS services where, at least in the past, there was some reluctance towards diagnosing psychosis. Thus, we would propose that when the clinical elements of psychosis are present among young people, they should be offered the FEP strategies that have improved outcome in young adult patients.