Dear Editor:
In a recent systematic review on the efficacy of specialized early intervention in mental health targeting simultaneously adolescents and young adults, Ly et al. (Reference Ly, Tremblay and Beauchamp1) have identified five studies, three of which focused on early intervention for psychosis. The population of interest was defined as composed by adolescents and young adults experiencing a mental health disorder or “at risk of developing one (mood, psychotic, anxiety or personality disorders)”. On this basis, the authors concluded that there are only promising results which deserve future research and validation.
Surprisingly, the authors did not include any study describing specialized clinical services for patients at Clinical High Risk for Psychosis (CHR-P (Reference Fusar-Poli2)), which are falling under the population of interest prespecified by Ly et al. The CHR-P paradigm has been unequivocally successful worldwide. CHR-P individuals are detected and evaluated with established psychometric tools that have been validated in the 8–40 age group, although the most frequent age range for this population is 14–35 (for details see (Reference Fusar-Poli, Borgwardt and Bechdolf3)), thus meeting the focus of the Ly's review. CHR-P individuals display attenuated psychotic symptoms and overall functional impairment (Reference Fusar-Poli, Rocchetti and Sardella4) have 20 percent probability of developing emerging psychotic disorders (but not other non-psychotic disorders (Reference Fusar-Poli, Rutigliano and Stahl5)) over a relatively short period of 2 years (Reference Fusar-Poli, Cappucciati and Borgwardt6). These problems impel these adolescents and young adult to seek help at specialized clinical services such as the Outreach and Support In South-London (OASIS) clinic, at the Maudsley NHS Foundation Trust (Reference Fusar-Poli, Byrne, Badger, Valmaggia and McGuire7). The clinical care provided at the OASIS, as well as in other CHR-P services worldwide, crucially involves the development of extensive collaborations between adult mental health services and children and adolescent mental health services. Therefore, specialized CHR-P services target simultaneously adolescents and young adults and provide care to them during their fragile transitional periods, preventing them from falling through the cracks of adult and adolescent mental health services.
The inclusion of the CHR-P literature in Ly's review would have changed the overall strength of the findings because CHR-P services are effective for both adolescents and adults on several of the outcomes analyzed by Ly et al. First, primary indicated prevention in CHR-P individuals has the unique potential to alter the course of psychosis and reduce the duration of untreated psychosis and secondary prevention in adolescent and adult individuals can ameliorate the severity of the first-episode of psychosis (8;9). More to this point, tertiary prevention of relapses or other adverse clinical outcomes/behaviors in adolescent and adult patients experiencing a first episode of psychosis can improve their long-term outcomes. Therefore, the inclusion of the CHR-P studies would have better supported the efficacy of early interventions for adolescents and young adults. Ly also observed that early intervention programs alone do not seem to decrease the duration of untreated psychosis (Reference Ly, Tremblay and Beauchamp1). However, a recent meta-analysis (falling outside Ly's original article search criteria) that specifically explores this issue was not cited. This study clarified that CHR-P services have the potential to reduce the duration of untreated psychosis, compared to other types of early intervention services (Reference Oliver, Davies and Crossland9).
The substantial impact of CHR-P services on both adolescents and young adults has been so relevant that NHS England implemented a new standard mandating an evidence-based nationwide detection and rapid treatment of CHR-P patients. Therefore, although Ly et al. speculate that there are several implementation challenges for transitional mental health services, the CHR-P paradigm could serve as an ideal platform to further refine the development of similar mental health services. Early detection and intervention approaches for depression in young people aged 12–25 years could be included in a refined version of the CHR-P paradigm. Similarly, the CHR-P paradigm could additionally accommodate early intervention in bipolar disorder across adults and adolescents, which is gaining momentum. New psychometric instruments have been developed in order to identify young people aged 14–35 years who may be at risk of developing bipolar disorders (Reference Fusar-Poli, De Micheli and Rocchetti10) and preventive treatments are under development.
In conclusion, the review by Ly et al. focuses on a timely and important topic which is at the core of modern and innovative models of mental health care. Appraising the effectiveness of mental health services that target simultaneously adolescents and young adults should not disregard the consolidated successes of the CHR-P services which have already been implemented worldwide to take care of young people during their fragile transitional period.
