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Psychology Research and Behavior Management 2017:10 119–128

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Open Access Full Text Article

http://dx.doi.org/10.2147/PRBM.S111593

Optimizing psychosocial interventions in first‑episode psychosis: current perspectives and future directions

Nicholas JK Breitborde1,2

Aubrey M Moe1

Arielle Ered3

Lauren M Ellman3

Emily K Bell4

1Department of Psychiatry and Behavioral Health, 2Department of Psychology, The Ohio State University, Columbus, OH, 3Department of Psychology, Temple University, Philadelphia, PA, 4Department of Psychiatry, University of Arizona, Tucson, AZ, USA

Abstract: Psychotic-spectrum disorders such as schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features are devastating illnesses accompanied by high levels of

morbidity and mortality. Growing evidence suggests that outcomes for individuals with psychotic-

spectrum disorders can be meaningfully improved by increasing the quality of mental health

care provided to these individuals and reducing the delay between the first onset of psychotic

symptoms and the receipt of adequate psychiatric care. More specifically, multicomponent treat-

ment packages that 1) simultaneously target multiple symptomatic and functional needs and

2) are provided as soon as possible following the initial onset of psychotic symptoms appear

to have disproportionately positive effects on the course of psychotic-spectrum disorders. Yet,

despite the benefit of multicomponent care for first-episode psychosis, clinical and functional

outcomes among individuals with first-episode psychosis participating in such services are

still suboptimal. Thus, the goal of this review is to highlight putative strategies to improve care

for individuals with first-episode psychosis with specific attention to optimizing psychosocial

interventions. To address this goal, we highlight four burgeoning areas of research with regard

to optimization of psychosocial interventions for first-episode psychosis: 1) reducing the delay

in receipt of evidence-based psychosocial treatments; 2) synergistic pairing of psychosocial

interventions; 3) personalized delivery of psychosocial interventions; and 4) technological

enhancement of psychosocial interventions. Future research on these topics has the potential to

optimize the treatment response to evidence-based psychosocial interventions and to enhance

the improved (but still suboptimal) treatment outcomes commonly experienced by individuals

with first-episode psychosis.

Keywords: first-episode psychosis; multicomponent care; psychosocial treatment; personal- ized medicine

Introduction Psychotic-spectrum disorders such as schizophrenia, schizoaffective disorder, and

bipolar disorder with psychotic features are devastating illnesses accompanied by

high levels of morbidity and mortality. Under usual systems of care, these disorders

are characterized by repeated symptomatic relapses,1–3 elevated rates of psychiatric

comorbidities such as anxiety, depressive, and substance use disorders,4,5 reduced rates

of participation in competitive occupational and educational activities,6–8 severe deficits

in cognitive abilities,9–11 rates of death by suicide up to 12 times greater than popula-

tion norms,12,13 and a life expectancy reduced by up to 25 years14,15 due primarily to

cardiovascular, infectious, and pulmonary diseases.13,16 The severity of these disorders

was recently highlighted within the Global Burden of Disease (GBD) Study.17–19 As part

Correspondence: Nicholas JK Breitborde Department of Psychiatry and Behavioral Health, The Ohio State University, 1670 Upham Dr., Columbus, OH 43210, USA Tel +1 614 685 6052 Email nicholas.breitborde@osumc.edu

Journal name: Psychology Research and Behavior Management Article Designation: REVIEW Year: 2017 Volume: 10 Running head verso: Breitborde et al Running head recto: Psychosocial interventions in first-episode psychosis DOI: http://dx.doi.org/10.2147/PRBM.S111593

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Breitborde et al

of a larger effort to quantify the deleterious effects of various

health conditions worldwide, the GBD Study assigns a dis-

ability weight to over 300 illnesses and injuries – a numerical

value indicating where a particular health state exists on a

range from 0 (i.e., a state of perfect health) to 1 (i.e., a health

state equivalent to death). Within the two past iterations of

the GBD study, the acute presentation of schizophrenia – the

prototypical psychotic-spectrum disorder – where active hal-

lucinations and delusions are present was assigned the highest

disability weight among all illness and injuries.20,21 In fact,

while achieving remission of hallucinations and delusions is

often considered a “treatment success” for individuals with

schizophrenia,22,23 this health state (i.e., schizophrenia in its

residual state) was assigned the ninth highest disability weight

among all illnesses and injuries in the GBD study.20,21 When

a “successful” treatment outcome equates to the ninth worst

health state that humans can experience other than death, there

is significant room for improvement in existing treatments for

a given disorder.

Growing evidence suggests that outcomes for individu-

als with psychotic-spectrum disorders can be meaningfully

improved by increasing the quality of mental health care pro-

vided to these individuals and reducing the delay between the

first onset of psychotic symptoms and the receipt of adequate

psychiatric care.24,25 More specifically, multicomponent

treatment packages that 1) simultaneously target multiple

symptomatic and functional needs and 2) are provided as

soon as possible following the initial onset of psychotic

symptoms, appear to have disproportionately positive effects

on the course of psychotic-spectrum disorders.26,27 To date,

numerous trials of multicomponent treatment packages for

individuals early in the course of a psychotic-spectrum disor-

der – a period frequently referred to as “first-episode psycho-

sis”28 – have been completed by independent research teams

across four continents. Although there is some variation in

the results, overall, these studies suggest that multicomponent

care for first-episode psychosis may produce improved out-

comes across numerous psychiatric (e.g., positive symptoms,

negative symptoms, and depressive symptomatology) and

functional domains (e.g., cognition, social functioning, and

participation in competitive work and school).29–40 In response

to these findings, multicomponent care provided as soon as

possible following the first onset of psychotic symptoms is

now recognized as the new “gold standard” in the treatment

of psychotic-spectrum disorders. Such treatment programs

are now available in every continent with the exception of

Antarctica,41,42 and several countries have launched federally-

supported efforts to disseminate multicomponent care for

first-episode psychosis nationwide.43–45 For example, between

fiscal year 2014 and 2016, the federal government of the USA

dedicated nearly $100 million to support the dissemination

of Coordinated Specialty Care for first-episode psychosis – a

multicomponent treatment program comprised of individual

psychotherapy, family psychoeducation, medication manage-

ment, and supported employment and education.46

A key contribution of the recent movement toward multi-

component treatment programs for first-episode psychosis is