The recognition and optimal management of early psychosis: an evidence-based reform.

The quality of health care for schizophrenia and other psychoses around the world remains unacceptably poor (1-3). Serious under-resourcing of mental health care is a major factor in most countries, but even when this is less of a problem (e.g., parts of Western Europe), there is still a large gap between efficacy (what can be achieved under optimal conditions) and effectiveness (what can be achieved under routine conditions). Typically, Falloon recognised this in conceiving the optimal treatment project (OTP) for schizophrenia (4). Many factors are responsible for this efficacy-effectiveness gap, including community-wide stigma and pessimistic beliefs about outcome, the low status of psychiatry in the health care system with consequent underfunding and poor workforce quality, the failure in the developed world to fully implement, resource and sustain the reforms associated with deinstitutionalisation, and the lack of translation of genuine advances in treatment into clinical settings (5). In fact, reform and the evidence base actually are not as closely related as might be expected, and while the former tends to lag well behind the latter, sometimes the opposite occurs based on fashion or enthusiasm alone. In psychiatry, given our fragile position in the health care system and a legacy of errors and scandal, this rightly concerns us. Hence our desire to get it right. We remain unclear as to how much evidence is required before reform is justified, and even what kind of evidence is necessary. There is also the key practical issue that to produce evidence, a certain amount of reform needs to be carried out anyway.