Objective Longitudinal studies have begun to clarify the phenotypic characteristics of adolescents and young adults at clinical high risk for psychosis. This 8-site randomized trial examined whether a 6-month program of family psychoeducation was effective in reducing the severity of attenuated positive and negative psychotic symptoms and enhancing functioning among individuals at high risk. Method Adolescents and young adults (mean 17.4±4.1 years) with attenuated positive psychotic symptoms, brief and intermittent psychosis, or genetic risk with functional deterioration were randomly assigned to 18 sessions of family-focused therapy for individuals at clinical high risk (FFT-CHR) in 6 months or 3 sessions of family psychoeducation (enhanced care, or EC). FFT-CHR included psychoeducation about early signs of psychosis, stress management, communication training, and problem-solving skills training, whereas EC focused on symptom prevention. Independent evaluators assessed participants at baseline and 6 months on positive and negative symptoms and social-role functioning. Results Of 129 participants, 102 (79.1%) were followed at 6 months. Participants in FFT-CHR showed greater improvements in attenuated positive symptoms over 6 months than participants in EC (F[1,97]=5.49, P=.02). Negative symptoms improved independently of psychosocial treatments. Changes in psychosocial functioning depended on age: participants over 19 years showed more role improvement in FFT-CHR, whereas participants between 16 and 19 years showed more role improvement in EC. The results were independent of concurrent pharmacotherapy. Conclusion Interventions that focus on improving family relationships may have prophylactic efficacy in individuals at high risk for psychosis. Future studies should examine the specificity of effects of family intervention compared to individual therapy of the same duration and frequency.

Objective Most previous studies of the incidence of tardive dyskinesia with atypical compared to conventional antipsychotics have not had tardive dyskinesia as their primary focus. The current study aimed to compare the incidence of tardive dyskinesia with atypical vs. conventional antipsychotics using methods similar to those from a previous prospective cohort study at our site in the 1980s. Method 352 initially tardive dyskinesia-free psychiatric outpatients were examined for a new diagnosis of tardive dyskinesia every 6 months for up to 4 years at a community mental health center. At baseline, subjects were receiving conventional antipsychotics only (23%), atypicals only (64%), or both (14%). Only 26 subjects had never received conventional antipsychotics. Results Compared with subjects treated with conventional antipsychotics alone since the previous visit, the adjusted tardive dyskinesia incidence rate-ratio for subjects treated with atypical antipsychotics alone was 0.68 (95% confidence interval 0.29 to 1.64). The incidence and prevalence of tardive dyskinesia was similar to previous findings at this site in the 1980s. Conclusion The incidence of tardive dyskinesia with recent exposure to atypical antipsychotics alone was more similar to that for conventional antipsychotics than in most previous studies. Despite high penetration of atypical antipsychotics into clinical practice, the incidence and prevalence of tardive dyskinesia appeared relatively unchanged since the 1980s. Clinicians should continue to monitor for tardive dyskinesia, and researchers should continue to pursue efforts to treat or prevent it.

The American Psychiatric Association Task Force on DSM-5 has recently proposed consideration of Attenuated Psychotic Symptoms Syndrome as a new diagnosis, based on nearly 15 years of prospective research in centers across the globe. The condition is also known as "psychosis risk syndrome," "at-risk mental state," "ultra-high risk," and "putative prodrome." We review evidence favoring its inclusion as a new diagnosis in DSM-5 and report new preliminary findings on DSM-IV diagnoses in current clinical use for these patients and on results of diagnostic interviews in unselected volunteers.The main evidence supporting inclusion is: (1) the patients are currently ill, (2) the patients are at high risk for getting worse, (3) no DSM-IV diagnosis accurately captures their current illness or future risk, (4) the diagnosis has been made with reliability and validity in the research setting, and (5) placement in DSM-5 would help promote the needed treatment and prevention research to enable articulation of a standard of care to benefit these patients and their families. Potential harms can be minimized by patient, family, and provider education. It will be important to demonstrate through well-designed field trials whether the diagnostic criteria can be used with reliability in everyday clinical practice.

Objective This study seeks to determine the effectiveness of a comprehensive first-episode service (the clinic for Specialized Treatment Early in Psychosis, STEP) based in an urban U.S. community mental health center, compared to treatment as usual. Methods This pragmatic randomized controlled trial enrolled 120 ‘first-episode psychosis’ patients within 5 years of illness onset and 12 weeks of antipsychotic exposure. Referrals were mostly from area inpatient psychiatric units and enrollees were randomly allocated to STEP or referral to routine care (TU). Main outcomes included hospital utilization (primary), ability to work, attend age-appropriate schooling or actively seek these opportunities (‘vocational engagement’), and general functioning. Analysis was by modified intent to treat (excluding only 3 who withdrew consent) for hospitalization and completers for other outcomes. Results After one year, STEP effected reductions on all measures of inpatient utilization vs. usual treatment: not psychiatrically hospitalized (77% vs. 56%, RR 1.38, 95% confidence interval (CI) 1.08–1.58); mean hospitalizations (0.33±0.70 vs. 0.68±0.92, p=0.02) and mean bed days (5.34±13.53 vs. 11.51±15.04, p=0.05). For every 5 patients allocated in STEP vs. usual treatment, one additional patient avoided psychiatric hospitalization over the first year (NNT = 5, CI 2.7–26.5). STEP also delivered better vocational engagement (91.7% vs. 66.7%, RR 1.40, 95% CI 1.18–1.48) and salutary trends in measures of global functioning. Conclusions This trial demonstrates the feasibility and effectiveness of a U.S. public sector model of early intervention for psychotic illnesses. Such services can also support translational research and are a relevant model for other serious mental illnesses. Trial registration www.ClinicalTrials.gov: NCT00309452.