This paper attempts to discuss why the early intervention agenda based on the current convention of ‘ultra-high risk’ (UHR) or ‘clinical high risk’ (CHR) for ‘transition’ to psychosis framework has been destined to fall short of generating a measurable and economically feasible public health impact. To summarise: (1) the primary determinant of the ‘transition’ rate is not the predictive value of the UHR/CHR but the degree of the risk-enrichment; (2) even with a significant pre-test risk enrichment, the prognostic accuracy of the assessment tools in help-seeking population is mediocre, failing to meet the bare minimum thresholds; (3) therapeutic interventions arguably prolong the time-to-onset of psychotic symptoms instead of preventing ‘transition’, given that the UHR/CHR and ‘transition’ lie on the same unidimensional scale of positive psychotic symptoms; (4) meta-analytical evidence confirms that specific effective treatment for preventing ‘transition’ (the goal—primary outcome—of the UHR/CHR framework) is not available; (5) the UHR/CHR-‘transition’ is a precarious target for research given the unpredictability driven by the sampling strategies and the natural ebb and flow of psychotic symptoms within and between individuals, leading to false positives; (6) only a negligible portion of those who develop psychosis benefits from UHR/CHR services (see prevention paradox); (7) limited data on the cost-effectiveness of these services exist. Given the pitfalls of the narrow focus of the UHR/CHR framework, a broader prevention strategy embracing pluripotency of early psychopathology seems to serve as a better alternative. Nevertheless, there is a need for economic evaluation of these extended transdiagnostic early intervention programmes.
- adult psychiatry
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Contributors Both authors wrote the paper. They contributed to the final version and have approved the final manuscript.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.