What are the key ingredients of optimal psychosocial treatment for persons recovering from a first episode of psychosis?

In their comprehensive synthesis of what is known and remains to be learned about the treatment of first‐episode psychosis, Fusar‐Poli et al1 offer an intriguing staging model and highlight several important challenges to the field. However, one topic to which they give relatively little attention is identifying the key components of the psychosocial treatments that are essential to comprehensive specialty care for these persons.

Just as pharmacotherapists must adapt what they have learned from treating long‐term consumers to those experiencing a first episode of psychosis, so psychosocial researchers are expected to tailor interventions found effective for those who have been ill for years to meet the needs of those receiving treatment for the first time. In this commentary, we briefly outline two key issues that are yet to be resolved in defining optimal psychosocial treatment for persons experiencing an initial episode of psychosis.

The first key issue is: does cognitive‐behavioral therapy for psychosis (CBTp) alone meet the needs of individuals diagnosed with a first episode of psychosis, or is a broader intervention required?

Most multi‐component interventions referenced by Fusar‐Poli et al have included CBTp, but the defining elements of that therapy are unclear across these studies2. Although there are similarities in the CBTp strategies, the models that have been used with consumers who have been ill for several years incorporate a wide degree of heterogeneity, and not all first‐episode programs have employed individual interventions based on CBT.

Persons who experience their first episode of psychosis are typically in their late teens or early 20s, and often have a diverse set of developmental needs to be addressed in individual therapy. Therefore, a comprehensive yet individualized approach which is more encompassing than a typical course of CBTp may be desirable. For example, the individual resiliency training component of the NAVIGATE program3 incorporates many elements of CBT, but also includes bolstering individuals’ personal resiliency, education about psychosis, processing the psychotic episode, teaching illness self‐management strategies, social skills training, substance abuse treatment, and health and wellness promotion.

A broad‐based model such as this one may offer young people a wider range of options and empirically supported strategies for addressing their individual needs and helping them make progress towards their goals. At this point, we are lacking trials comparing more comprehensive individual interventions to CBTp in first‐episode psychosis, so the optimal breadth of the individual intervention with this consumer group is unclear.

The second key issue is: does the prevailing evidence‐based model of supported employment in psychiatric illness, i.e. individual placement and support, meet the needs of those recovering from a first episode of psychosis?

There is little agreement across the specialized integrated early intervention programs cited by Fusar‐Poli et al in terms of the vocational supports required to help individuals return to school or work following a first episode of psychosis. Although three of the programs cited by the authors refer to vocational help or support, and one program refers to supported employment and education, it is unclear to what extent any of these approaches are suited to address the unique needs of individuals recovering from an initial episode of psychosis.

Recently, it has been suggested that early intervention programs for psychosis should include a component that places a premium on rapid job search or school enrollment for individuals with such goals, and the provision of follow‐along supports to facilitate job retention or completion of educational degrees4, based on the success of the individual placement and support model at improving competitive employment outcomes in persons with (typically longer term) severe mental illness5.

However, there are many developmental challenges commonly experienced by most adolescents and young adults. Identifying and pursuing an appropriate career or educational path can be daunting and involve many false starts, even under the best circumstances. With regard to those recovering from a first episode of psychosis, it is unclear what proportion endorse work or school as an immediate goal6, and individuals frequently cite barriers to returning to work or school7.

Many young people who have developed a psychosis experience a profound sense of loss which further interferes with their ability to articulate work or school goals during early recovery. Most individuals entering a first episode of psychosis are enduring heightened psychiatric symptoms and are new to mental health care. They may be experiencing significant medication side effects and often require time to become socialized into treatment.

These issues can all impact on the “rapid job search” approach. For example, in the trial of the NAVIGATE program, at study entry all participants were assigned a supported employment and education specialist who was a member of their treatment team, but only 68% engaged in that component of the program (defined as meeting with their specialist three or more times)8. Furthermore, about one‐half of the individuals who eventually engaged in that component did so after more than six months into the program.

The NAVIGATE results and other findings raise questions about the emphasis on rapid job search or school enrollment in supported employment and education programs, and suggest that more attention is needed early in the course of treatment to harnessing individuals’ motivation by facilitating the exploration of work, school and career options to foster their ability to articulate specific personal goals related to role functioning.

Resolution of the differing vocational perspectives and goals of the consumer and involved family members may also be required. While individual placement and support may have much to offer to first‐episode consumers, even Bond et al8 note that its effect sizes for competitive employment are smaller in first‐episode samples and are not significant for educational pursuits.

A greater recognition and acknowledgement of the confusion and ambivalence of people who have recently experienced a first episode of psychosis, and a willingness to “meet the person where he or she is at” in order to instill hope and a sense of purpose for one's future, while permitting time for recovery, may be critical to enhancing the successful uptake of supported employment and education services before the mounting pressures of applying for disability become too great, and countervailing financial disincentives to work become a reality9.

The questions posed in this commentary are not meant to be comprehensive. There are other important issues to be resolved in our understanding of optimal psychosocial treatment for first‐episode psychosis, such as defining the role of peer providers, clarifying the necessary elements and ideal formats for family interventions, determining the need to include training in life skills as standard care, and resolving concerns about requisite intensity and duration of treatment to promote recovery. This is an exciting time to be supporting recovery in first episode and there is much to learn.

Kim T. Mueser1, Shirley M. Glynn2, Piper S. Meyer‐Kalos3
1Center for Psychiatric Rehabilitation, Departments of Occupational Therapy, Psychological and Brain Sciences, and Psychiatry, Boston University, Boston, MA, USA; 2Department of Psychiatry and Biobehavioral Sciences, University of California, and VA Greater Los Angeles Health Care System at West Los Angeles, Los Angeles, CA, USA; 3Minnesota Center for Chemical and Mental Health, University of Minnesota School of Social Work, St. Paul, MN, USA