Four reasons why early detection centers for psychosis should be renamed and their treatment targets reconsidered: we should not catastrophize a future we can neither reliably predict nor change

Abstract

Since the 1990s, facilities for individuals at putative risk for psychosis have mushroomed and within a very short time have become part of the standard psychiatric infrastructure in many countries. The idea of preventing a severe mental disorder before its exacerbation is laudable, and early data indeed strongly suggested that the sooner the intervention, the better the outcome. In this paper, the authors provide four reasons why they think that early detection or prodromal facilities should be renamed and their treatment targets reconsidered. First, the association between the duration of untreated psychosis and outcome is empirically established but has become increasingly weak over the years. Moreover, its applicability to those who are considered at risk remains elusive. Second, instruments designed to identify future psychosis are prone to many biases that are not yet sufficiently controlled. None of these instruments allows an even remotely precise prognosis. Third, the rate of transition to psychosis in at-risk patients is likely lower than initially thought, and evidence for the success of early intervention in preventing future psychosis is promising but still equivocal. Perhaps most importantly, the treatment is not hope-oriented. Patients are more or less told that schizophrenia is looming over them, which may stigmatize individuals who will never, in fact, develop psychosis. In addition self-stigma has been associated with suicidality and depression. The authors recommend that treatment of help-seeking individuals with mental problems but no established diagnosis should be need-based, and the risk of psychosis should be de-emphasized as it is only one of many possible outcomes, including full remission. Prodromal clinics should not be abolished but should be renamed and restructured. Such clinics exist, but the transformation process needs to be facilitated.

Overlooking the transition elephant in the ultra-high-risk room: are we missing functional equivalents of transition to psychosis?

“…Partly amplifying previous observations by Ajnakina, David, and Murray (2018), Moritz, Gaweda, Heinz, and Gallinat (2019) systematically press central trigger points in contemporary early detection conceptual landscape. They highlight four reasons, including decreasing transition rates, why early detection centers for psychosis should be renamed and their treatment targets reconsidered.…”

Association of preceding psychosis risk states and non‐psychotic mental disorders with incidence of clinical psychosis in the general population: a prospective study in the NEMESIS‐2 cohort

“…Following our critical perspective papers on the CHR concept 3,5 , an intense debate has started, splitting the field into proponents 6‐8 , opponents 9‐12 , and those with ambivalent attitudes toward that concept 13‐16 .…”

The reality of at risk mental state services: a response to recent criticisms

“…Recently Psychological Medicine published two articles that criticise services for ARMS individuals and suggest that either they be restructured and renamed (Moritz et al, 2019) or that they should be replaced by a 'public health approach' (Ajnakina et al, 2019). In this paper we present the perspective of some ARMS clinicians and researchers.…”

“…We deal with the specific criticisms and conclude with our recommendations for the future of ARMS services. Moritz et al (2019) provide four criticisms:…”