Psychoeducation for Individuals at Clinical High Risk for Psychosis: A Scoping Review

Abstract

Psychoeducation is recommended in the treatment of patients with schizophrenia and has been shown to improve satisfaction with mental health service and treatment adherence, reduce relapse and hospital readmission rates, and enhance functioning and quality of life. Youth at clinical high risk for psychosis (CHR) may also benefit from receiving psychoeducation as part of their treatment. The goal of this study was to conduct a scoping review to map out the existing literature on psychoeducation for CHR individuals, including content, utilization, and benefits, in order to identify areas for future research and clinical care. Following PRISMA guidelines, we conducted a systematic search of electronic databases (MEDLINE, Embase, PsycINFO, Scopus, and Web of Science Core Collection) to identify literature through 02/25/2022 that provided data or significant commentary about the provision of psychoeducation to CHR individuals. After screening titles and abstracts, four co-authors assessed full-text articles for eligibility. Thirty-three studies were included in the review. Psychoeducation is recommended in the treatment of CHR individuals, is a preferred treatment option among CHR individuals, and many CHR programs report offering psychoeducation. However, details about the psychoeducational content and method of delivery are notably absent from recommendations and reports on the provision of CHR psychoeducation in real-world settings. We identified two brief and structured CHR psychoeducation interventions and one longer-term psychoeducational multifamily group model for CHR that show feasibility and promise, though they have not yet undergone randomized trials to evaluate effectiveness of the psychoeducation. We also identified several comprehensive CHR interventions that included an explicit psychoeducation module, though the unique role of the psychoeducational component is unknown. Despite being recommended as a critical component of treatment for CHR individuals and preferred by CHR individuals, the ways in which psychoeducation are being delivered to CHR individuals in real-world practice is still largely ambiguous. Rigorous evaluations of psychoeducation treatment models are needed, as well as investment from clinical programs to facilitate the implementation and dissemination of standardized psychoeducation for CHR individuals.

Introduction

Psychoeducation is considered to be an important aspect of psychological treatment and is recommended in the treatment of schizophrenia (American Psychiatric Association, 2021). For patients with schizophrenia, psychoeducation was first described as summarizing clear information to patients and/or families related to the phenomenology, onset, course, treatment, and outcome of schizophrenia (Anderson et al., 1980). Family involvement is considered an important component of psychoeducation in order to engage and educate family members so that they can best support their loved one with mental illness. Psychoeducation has a robust evidence base in serious mental illness work (Lucksted et al., 2012; McFarlane et al., 2003; Murray-Swank and Dixon, 2004; Rummel-Kluge and Kissling, 2008) and has been associated with reductions in relapse rates, treatment non-adherence, and hospital readmission rates, as well as increased satisfaction with treatment, functioning, and overall quality of life in schizophrenia (Xia et al., 2011).

Psychoeducation is a relatively low-risk psychosocial treatment and thus can play a major role in preventative and early treatment interventions such as those for youth and young adults at elevated risk for psychosis (McGorry et al., 2010). There are worldwide efforts to implement clinical services for this population (Kotlicka-Antczak et al., 2020), which is most commonly referred to as Clinical High Risk (CHR; used hereafter), Ultra-High Risk (UHR), At Risk Mental State (ARMS), or prodromal psychosis. The CHR state is typically characterized by attenuated psychotic symptoms (Miller et al., 2003), as well as social, cognitive, and academic/vocational functional impairment that often warrants treatment (Carrion et al., 2018; Seidman et al., 2010). Psychosocial interventions are recommended as the first-line treatment for CHR individuals (Addington et al., 2017) and may help to avert the risks of using antipsychotic medications with CHR individuals. However, the degree to which CHR youth are delivered psychoeducation as part of their treatment package, and whether psychoeducation is beneficial for CHR on its own, is less known.

It is important to understand the role of psychoeducation in the treatment of CHR individuals given the ethical considerations in communicating with patients about their CHR status (Corcoran, 2016; Mittal et al., 2015; Yang et al., 2010). Youth report that psychiatric labels impact how they view themselves (Yang et al., 2019), and have nuanced positive and negative emotional experiences regarding being told of their risk status (Woodberry et al., 2021). Qualitative interviews with CHR youth reveal that they prefer having their CHR status disclosed to them by treatment providers, they value the discussion, and feel relieved to have a label for their symptoms (Uttinger et al., 2018; Welsh and Tiffin, 2012). When properly utilized, psychoeducation could potentially reduce stigma associated with CHR symptoms.

Although mental health consumers indicate a preference for psychoeducation, their needs often go unmet. Patient and caregiver preferences for clear, direct communication about psychiatric diagnoses, prognosis, and treatment options (Milton & Mullan, 2014) are often not fulfilled by treatment providers, particularly when the patient has a serious mental illness such as schizophrenia (Farooq et al., 2016; Loughland et al., 2015; Outram et al., 2015; Ucok et al., 2004). Providers report a broad range of concerns about psychoeducation, including providing an incorrect diagnosis, the patient not understanding the information, increasing stigma or distress in the patient, and precipitating treatment-drop out (Farooq et al., 2016; Outram et al., 2014; Ucok et al., 2004). Providers likely have similar reservations about discussing the CHR condition with patients and families given the complexities around the CHR state, including heterogeneity of the CHR state, uncertain outcomes and illness trajectories, and concerns about stigma (Malhi et al., 2021; Woods et al., 2021). In order to best serve patients, families, and providers, there is a need to examine the utilization of CHR psychoeducation and evidence on the effects of providing CHR psychoeducation.

To date, there has only been one narrative review on psychoeducation for CHR with authors concluding that this is an under-investigated area in the field based on the limited literature (Hauser and Juckel, 2012). The goal of this scoping review was to update and expand upon the previous review by mapping out the current body of literature on psychoeducation for CHR individuals. We aimed to synthesize literature on the content, utilization, and benefits of CHR psychoeducation in order to identify gaps in the literature and inform next steps for research and best practices for clinical care.

Methods

Defining Psychoeducation

In this scoping review, we used a narrow definition of psychoeducation. Psychoeducation was defined as a therapeutic intervention with systematic, structured, and purely didactic knowledge about the CHR condition and its treatment to people seeking or receiving mental health services. We do not use psychoeducation as a broad term for teaching and educating patients and families on a range of topics (e.g., teaching a new skill to manage distress or a maladaptive behavior). The goal of psychoeducation is to convey new knowledge that promotes action, rather than teach an action (e.g., teach a new skill to manage symptoms).

Defining the Population

In this review we included literature on youth and young adults at elevated risk for psychosis based on a valid assessment measure: Structured Interview for Psychosis-Risk Syndromes/Scale of Psychosis-Risk Symptoms (SIPS/SOPS) or Comprehensive Assessment of at-Risk Mental States (CAARMS). The population who meets criteria for elevated risk for psychosis on these measures have been more broadly referred to as Clinical High Risk (CHR), At Risk Mental State (ARMS), and Ultra High Risk (UHR), among others. Prodromal psychosis has also been used, though is less common as it implies an impending psychosis. In this paper we use the term CHR for simplicity, although publications that were considered and included in the review may utilize other terms for this population.

Search Procedure

PRISMA-ScR guidelines were followed for conducting this scoping review (Tricco et al., 2018). This review was registered in Open Science Framework (OSF) on 07/07/2021 at 9:28AM. Search terms were developed and agreed upon by co-authors for each database. Appropriate truncation symbols and controlled vocabulary terms were used. A sample search strategy is provided in the Appendix.

MEDLINE, Embase, PsycINFO, Scopus, and Web of Science Core Collection electronic databases were systematically searched. The search did not include restrictions on publication date. The database search for published literature was conducted on July 15, 2021, and re-ran on February 25, 2022 to identify any additional articles. No articles were added based on the second database search. The reference lists of included articles were manually checked to identify additional studies that met inclusion criteria but were not identified in the electronic database search. A grey literature search was also conducted on Google during July 2021 by SNH and MFD.

Eligibility Criteria

Studies included in the review met the following inclusion criteria: (1a) provided data (using qualitative, quantitative, or case study methods) about a standalone CHR psychoeducation intervention, or a comprehensive CHR intervention with an explicit and well-defined psychoeducation module that meets the definition above, OR (1b) provided explicit commentary about psychoeducation for CHR individuals in the form of reviews, or treatment recommendations from an organization; (2) related to individuals who have been identified as CHR based on a valid assessment such as the Structured Interview for Psychosis-Risk Syndromes/Scale of Psychosis-Risk Symptoms (SIPS/SOPS), or The Comprehensive Assessment of at-Risk Mental States (CAARMS); and (3) were available in English. Exclusion criteria include literature that: (1) relates to populations who have already developed psychosis (e.g., first episode psychosis, schizophrenia); (2) describes a CHR clinic or program and did not include data or details on psychoeducation provided within that program; (3) utilizes psychoeducation only as the control/comparison group if the study was not designed to evaluate psychoeducation.

Study Identification and Selection

All articles returned from the database search were uploaded to Covidence, a software that facilitates the screening process for systematic reviews (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). After duplicates were removed, two reviewers (JG and AP) independently screened and assessed each title and abstract for suitability (κ = .50, moderate agreement). Discrepancies were resolved by a third reviewer (CS) through discussion, until an agreement was reached. In cases when a decision could not be made based on the title and abstract due to limited information, the full publication was retrieved and reviewed. Studies that did not meet inclusion criteria based on titles and abstract were excluded from further assessment. The remaining studies were independently assessed for full-text eligibility by pairs of reviewers (AP, CS, JG, and SNH), with Cohen’s Kappa coefficients ranging from .88 to 1.0 (almost perfect agreement) for pairs of reviewers. Studies that failed to meet eligibility criteria were excluded, resulting in 25 included studies from the database search. Thirty-two additional articles were identified through the gray-literature search and references of included articles, and a similar process was repeated for determining inclusion, resulting in nine articles meeting inclusion criteria. This resulted in a final sample of 35 articles (See Figure 1 for PRISMA flow diagram).

Figure 1.

PRISMA flow diagram from search in July 2021. Of note, a second search was conducted in February 2022, but did not result in any additional articles identified for inclusion.

Data Charting and Synthesis

A data charting form was jointly developed by four reviewers to determine which variables to extract. Data were extracted through an iterative process; charts were continuously updated based on the discussions of the results. The following descriptive data were charted: article and study characteristics (e.g., authors, year, country, sample size, and methodology), aims/purpose, and study results (e.g., primary outcomes, key findings/conclusions, and treatment or psychoeducation descriptions).

Results

Included literature is presented in Tables 1-3. Studies were grouped by: (1) standalone CHR psychoeducation interventions, or CHR psychosocial treatments that include an explicit psychoeducation module (see Table 1); (2) Consumer interest in, and uptake of, CHR psychoeducation (see Table 2); and (3) treatment recommendations, guidelines, and reviews related to the provision of CHR psychoeducation (see Table 3). Some studies in Table 1 were grouped together if, for example, they reported on primary and secondary outcomes of an efficacy trial and/or described the rationale and design of the trial or intervention. In these cases, only details for the main study are described, but all references are provided.

Table 1.

CHR Psychoeducation Interventions

Standalone Psychoeducation Interventions for CHR
Authors & Year; Country	Aims/purpose	Sample	Methodology	Psychoeducation Content & Materials	Psychoeducation Format & Length	Primary outcome(s)	Key finding(s)
(Hauser et al., 2009a); Germany	Introduce and evaluate a psychoeducational program for ARMS patients	16 ARMS	Uncontrolled prospective exploratory pilot trial	Purely informative sessions on: Goals, prodromal symptoms, concept of illness, burden and coping strategies, neurobiological hypothesis, planning next therapeutic steps.	Individual, seven 1-hr sessions	Psychopathology, functioning, quality of life, locus of control, knowledge of ARMS, appreciation and interest in topics addressed	Improvements in all primary outcomes Patients felt that psychoed reduced illness burden & stigma
(Herrera et al., 2021); USA	Describe the development of BEGIN: Brief Educational Guide for Individuals in Need	5 CHR, 5 parents	Descriptive and qualitative	Structured sessions with slideshow presentation incorporating lessons, activities, and discussions on 1. Psychosis-risk education, 2. Self-assessment of symptoms, 3. Individual goals, 4. Treatment options, 5. Decision-making and next steps	Individual or family, five 1-hr sessions	Stakeholder feedback	Psychoed is desired Structured design and slideshow was helpful and unique Appears to encourage agency Good first step in treatment
(McFarlane, 2001); USA	Describe family psychoeducation for adolescent prodromal and psychotic disorders	10 families (3 CHR, 7 psychosis)	Descriptive, pilot study	Consists of 4 phases: engagement, education, re-entry, and social/vocational rehabilitation. Includes lectures, video, handouts, visits from community representatives, problem-solving, and discussions.	Multifamily group (5-7 families), biweekly sessions for two years	N/A	Families were receptive, expressed relief, gratitude 100% attendance Promoted medication compliance Preference for professional explanations and written materials, emotional support
(O"Brien et al., 2007); USA	Evaluate feasibility and acceptability of PMFG for UHR	16 CHR + family	Feasibility and acceptability trial	Workshop with PowerPoint about prodromal state, reasons for early intervention, biological bases for psychiatric symptoms, diathesis-stress theories, psychopharmacological treatment, psychological treatment, school interventions and recommendations for creating a protective environment. PMFGs focus on social, communication and problem-solving skills.	Multifamily groups (~5 families), 90-min biweekly sessions over 9 months	SIPS symptoms, functional outcomes, coping, family adaptability and cohesion	Participants felt comfortable, found it helpful Improvement in positive and general symptoms, and functioning Good adherence by group facilitators to the PMFG format 75% patient attendance
Psychoeducation as an explicit, structured module of a psychosocial treatment for CHR
Authors & Year; Country	Aims/purpose	Sample	Methodology	Treatment description	Format & Length	Primary outcome(s)*	Key finding(s)*
(Landa et al., 2016); USA	Evaluate the feasibility of Group and Family Based CBT (GF-CBT)	6 ARMS	Uncontrolled pilot trial of GF-CBT	15 CBT skills groups, 15 individual sessions for youth, and 15 CBT skills groups for family members. Sessions use workbooks, video demonstrations and role plays. Sessions include “What is paranoia?” (session 1), role of risk factors such as stress (session 3), and normalizing throughout.	12 of 30 youth sessions and all 15 family sessions include psychoeducation	CAARMS symptoms, functioning and cognitive biases, and family members’ communication and use of CBT skills.	All participants remitted from ARMS Decreases in attenuated psychotic symptoms, negative symptoms, depression, cognitive biases, improvements in functioning Family members enhanced communication/CBT skills
(Miklowitz et al., 2014) a(Schlosser et al., 2012) b(O'Brien et al., 2014; O'Brien et al., 2015; Rinne et al., 2021); USA	Determine whether Family Focused Therapy (FFT) reduced symptom severity and enhanced functioning among CHR	129 CHR	Randomized controlled trial of FFT vs. enhanced care (EC; 3 sessions of psychoeducation)	FFT consists of psychoed (6), communication enhancement (5), and problem solving (7). Psychoed consists of discussion of youth’s symptoms/UHR syndrome, role of stress, personalized prevention plan, identifying stressors and coping strategies. Informational handouts are provided during most sessions.	Family, 6 (of 18) 1-hr sessions dedicated to psychoeducation	Symptoms, social/role functioning, conversion to psychosis	FFT resulted in reduced positive symptoms compared to EC Age-dependent effect of treatment group on role improvement: individuals 19+ years old showed more role improvement in FFT-CHR, and 16–19-year-olds showed more role improvement in EC.
(McFarlane et al., 2015) (McFarlane etal.,2012a)c; USA	Test effectiveness of the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP)	337 CHR + FEP (250) vs. control group (87)	Risk-based allocation design comparing FACT for CHR or FEP vs. monitoring for low-risk patients	Family-aided Assertive Community Treatment (FACT)d includes PMFG. Topics include reinforcing family role in alleviating and buffering stresses, emphasize skill building and coping. Handouts provided at most sessions.	6-hr educational workshop followed by biweekly multifamily groups (5-7 families), 1.5-2 hr sessions, for two years	Symptoms, Functioning	FACT resulted in reduced symptoms and increased functioning
(van der Gaag et al., 2012) e(van der Gaag et al., 2013) fIsing et al., 2016; (Pozza et al., 2019); Netherlands	Test effectiveness of a CBT intervention for UHR subjects (EDIE-NL: Dutch Early Detection and Intervention Evaluation)	201 UHR	RCT of CBTuhr added onto TAU vs. TAU	CBT treatment. Sessions 1 & 2 include discussion of SIPS/CAARMS outcome, examples of symptoms, and rationale for treatment. Session 3 includes additional psychoed on dopamine and normalizing.	3 of 26 weekly sessions dedicated to psychoed	Transition to psychosis, subclinical psychotic-like symptoms	CBT reduced transition to psychosis and improved subclinical psychotic symptoms

Note. The following terms refer to psychosis-risk and use varies per study: ARMS = At risk mental state, CHR= clinical high risk for psychosis, UHR = ultra high risk for psychosis; FEP = first episode psychosis, psychoed = psychoeducation, SIPS = Structured Interview for Psychosis Risk Syndromes, TAU = treatment as usual, USA = United States of America, CBT = Cognitive Behavioral Therapy, CAARMS.

^*Outcomes and findings refer to the overall intervention and cannot be attributed to the psychoeducational component specifically.

^aDescribes the rationale and design of the efficacy trial for FFT

^bAdditional studies reporting secondary outcomes of FFT

^cDescribes the rationale and design of the EDIPPP trial

^dDetails of FACT for patients with schizophrenia can be found in: McFarlane, W., Stastny, P., & Deakins, S (1992). Family-aided assertive community treatment: A comprehensive rehabilitation and intensive case management approach for persons with schizophrenic disorders. New Directions in Mental Health Services, 53, 43-54.

^eDetailed description of the CBTuhr treatment, including psychoeducational component

^fAdditional studies using the CBTuhr protocol

Table 3.

Recommendations and Reviews Related to CHR Psychoeducation

Authors & Year; Country	Aims/purpose	Type of Review / Recommendation	Key conclusion(s)
(Cadenhead and Mirzakhanian, 2016); USA	Describe early intervention in the psychosis risk syndrome and illustrate a case vignette	Narrative review & case vignette	Recommendation: Recommended Content: Emphasis of initial education should be on health promotion and early treatment rather than risk for psychosis.
(Early Psychosis Guidelines Writing Group and EPPIC National Support Program); Australia	Develop Australian Clinical Guidelines for Early Psychosis	Clinical guidelines	Recommendation: Recommended Content: Explanation of the illness and recovery, treatment options, agency in treatment, and prospects for the future and how these can be influenced. Material: should be appropriate for young people and for early psychosis, and be available to people from diverse backgrounds. Provider responsibility: providers are responsible for ensuring access to psychoed.
(Elauser and Juckel, 2012); Germany	Critically review the current state of CHR psychoed	Narrative review	Recommendation: Promising but “no definite recommendation” Content: diagnostic uncertainty, managing stigma, developmental significance, treatment. Provider responsibility: Providers need to update their knowledge, adapt psychoed with new updates in the field. More explicit provision is needed. Evidence/research: More research is needed to understand the needs of CHR regarding psychoed and evaluate CHR psychoed.
(Headspace National Youth Mental Health Foundation, 2015); Australia	Summary of evidence for different treatment options available to young people at UHR	Clinical guidelines	Recommendation: Recommended. Should be provided as part of CBT/supportive therapy for UHR. Content: begin with psychoeducation about psychosis and risk, describe as occurring on a continuum, provide prevalence rates, normalize, and use up-to-date evidence. Strengthen coping resources and reduce impact of stressors.
(Hetrick et al., 2018); Australia	Develop an implementation guide for scaling up an early intervention in psychosis services model (EPPIC) informed by analyzing barriers and enablers, behavior change theory, and effects of implementation	Implementation guide	Recommendation: Recommended. Psychoed is provided to patients and families on initial and as needed basis via individual, group, or family work. Family work consists of, at a minimum, psychoed relevant to the phase of illness. Provider responsibility: Case manager provides access to evidence-based treatment. Barriers to implementation include inexperience in CHR population, lack of skills/knowledge, and confidence in providing psychoeducation.
(International Early Psychosis Association Writing Group, 2005); International	Develop international clinical practice guidelines for early psychosis	Clinical guidelines	Recommendation: Recommended. Help-seeking ARMS patients need to be provided psychoed. Content: ARMS patients should be encouraged to develop coping skills for attenuated psychosis.
(McFarlane et al., 2012b); USA	Review family psychoeducation in CHR and FEP	Narrative review	Recommendation: Not specified. Content: emphasis on stress sensitivity, information sharing among family, early warning signs, indications for crisis Evidence/research: PMFGs and FACT show promising outcomes in early phases of psychosis. Family psychoed is acceptable to families and meets many of their needs. The multifamily group format adds an element of social support, network expansion.
Müller and Bechdolf, 2016); Germany	Discuss psychological interventions for CHR individuals	Narrative review	Recommendation: Evidence is encouraging but not sufficient. Content: Goals of CHR psychoed should convey realistic assessment of risk for psychosis, achieve a better understanding of risk symptoms, and improve skills for managing risk symptoms. Evidence/research: There have not been any RCTs for CHR psychoeducation.
(Stain et al., 2010); Australia	Review evidence for ARMS concept and effectiveness of early intervention to provide recommendations for community mental health services	Narrative review and clinical guidelines	Recommendation: Recommended. Core treatment approaches for help seeking UHR youth should include psychoed. Content: Understanding symptoms and treatments for those symptoms. Evidence/research: More research needed to provide clear evidence on efficacy.
(Thompson et al., 2015); USA	Describe psychosocial interventions that have demonstrated efficacy in treating CHR individuals	Narrative review	Recommendation: Promising. Psychoed is a core treatment element for CHR. Provider responsibility: Psychoed is a necessary process in a decision-making model that may guide clinicians in the selection of treatment components for CHR.
(van der Gaag et al., 2019); Netherlands	Review and propose next steps for CBT in the prevention of psychosis	Treatment protocol	Recommendation: Not specified. ARMS patients, compared to those with psychosis, are more receptive to psychoed and eager for therapy, as they maintain insight.

ARMS = At risk mental state, CHR= clinical high risk for psychosis, UHR = ultra high risk for psychosis, FEP = first episode psychosis, psychoed = psychoeducation, USA = United States of America

Table 2.

Preferences for, and Uptake of, CHR Psychoeducation

Authors, Year; Country	Aims/purpose	Sample Size	Methodology	Key finding(s) related to psychoeducation	Content and Modality of the Psychoeducation
(Brummitt and Addington, 2013); Canada	Understand the treatments that CHR are interested in pursuing	30 CHR	Questionnaire	66.7% reported psychoed would be helpful Most common treatments participants reported willingness to participate in: Psychoed (63.3%) and CBT (63.3%) None reported already participating in psychoed	N/A
(Cocchi et al., 2008); Italy	Describe Programma 2000, a program for the early detection &intervention of recent onset &at-risk patients	50 CHR subjects	Descriptive	Treatment packages may include individual and family psychoed (determined by patient’s needs) 10% of at-risk patients received psychoed	Individual and family psychoeducation. No other details provided.
(Cocchi et al., 2018); Italy	Collect evidence about implementation & development of early intervention services (EIP) in Italy based on Programma 2000	103 directors	Nationwide survey of directors of public mental health services	95% of early intervention services reported delivering psychoed One third of EIPs reported that interventions were not evidence-based, but ad-hoc protocols developed locally	“Some form of structured psychoeducation.” No other details provided.
(Salazar de Pablo et al., 2021); UK	Systematize the knowledge regarding CHR-P services & provide guidelines for implementation	51 CHR-P services	Systematic review	81.1% of CHR-P services provided psychoed	No details provided.
(Stain et al., 2019); UK	Examine service provision for UHR within the National Health Service in England	50 clinical leaders of CHR programs	Self-report online survey	96% utilized psychoed in their services 64% provided staff training for delivering psychoed	Individual and family psychoed. Staff training. No other details provided.
(Welsh and Tiffin, 2014); UK	Investigate treatment preferences for individuals with ARMS & FEP	40 with ARMS (n=24), and FEP (n=16)	Self-report survey	Leaflets/informational booklets containing psychoed were the most preferred treatment option (90%) compared to CBT and other treatments	Psychoeducational material. No other details provided.
(White et al., 2015); USA	Examine characteristics & components of specialized early intervention programs in US	31 program representatives (20 CHR, or CHR + FEP)	Semi-structured telephone interview	100% of early intervention programs reported using individual psychoed.	Individual psychoed. No other details provided.

Note. ARMS = At risk mental state, CHR/CHR-P = clinical high risk for psychosis, CBT = Cognitive Behavioral Therapy, FEP = first episode of psychosis, psychoed = psychoeducation, USA = United States of America, UK = United Kingdom.

Three standalone psychoeducation interventions for CHR were identified (Table 1): Psychoeducational Multifamily Groups (PMFG) (McFarlane, 2001; O'Brien et al., 2007), a 7-session psychoeducation program for ARMS patients (Hauser et al., 2009a), and BEGIN: Brief Educational Guide for Individuals in Need (Herrera et al., 2021). BEGIN (5 sessions) and the Hauser intervention (7 sessions) focus on the core features psychoeducation, including CHR symptoms, causes, course, and treatment options. BEGIN can be delivered in an individual or family format, and Hauser’s intervention is delivered to the CHR individual. The content and format of PMFG-CHR differs from that of BEGIN and Hauser’s intervention in that it involves multiple families in a group setting, is a longer treatment (up to two years), and incorporates interventions beyond the core components of psychoeducation, such as family problem solving. BEGIN and PFMG-CHR utilize visual and written materials, such as PowerPoint presentations and handouts.

Empirical research on BEGIN and the Hauser intervention is limited thus far. BEGIN was recently developed in 2021 and shows initial acceptability based on qualitative interviews with 10 CHR youth and family members, with a pilot trial underway as noted by authors (Herrera et al., 2021). Hauser’s 7-session intervention reported outcomes of an exploratory pilot trial in 2009 showing improvements in all primary outcomes, including psychopathology, functioning, quality of life, locus of control, knowledge of CHR (Hauser et al., 2009b). PMFGs for CHR have shown feasibility and acceptability (O'Brien et al., 2007), and were included as part of a larger CHR intervention program known as FACT (see below for results of FACT trial). It is important to note that PMFGs for schizophrenia have been around since the late 1970s, and there is significant empirical support for PMFGs in reducing relapse rates, improving recovery, and improving family well-being for people with schizophrenia (McFarlane et al., 2003).

Four psychosocial interventions for CHR that included an explicit, well-defined psychoeducational module were identified: Family-Focused Therapy (FFT) for CHR (Miklowitz et al., 2014), Family-aided Assertive Community Treatment (FACT) (McFarlane et al., 2015), Cognitive Behavioral Therapy for Ultra-High Risk patients (CBTuhr) (van der Gaag et al., 2012), and Group and Family Based Cognitive Behavioral Therapy (GF-CBT) (Landa et al., 2016). FFT is an 18-session family therapy that is comprised of three major components: psychoeducation, communication training, and problem-solving training. FACT is a treatment package consisting of PMFG (6-hour educational workshop and 1.5-to-2-hour biweekly group sessions over the course of two years), elements of assertive community treatment, supported education and employment, and treatment with psychotropic medication. CBTuhr consists of a maximum of 26 sessions over six months, combining CBT for reducing the distress associated with attenuated positive symptoms with treatment as usual for addressing comorbid psychopathology such as anxiety and depression. Sessions 1-3 are the psychoeducational sessions consisting of a discussion about CHR assessment results, CHR symptoms, rationale for treatment, normalizing symptoms, and information on the role of dopamine in psychosis. GF-CBT is a 15-week intervention involving weekly CBT skills group and individual sessions for CHR youth, and a weekly CBT skills group for family members. Psychoeducation of symptoms and their precipitants occurs throughout, notably “What is paranoia?” (session 1) and the role of risk factors such as stress (session 3). Although psychoeducation has been identified as a key component in each of these therapies, there are clearly other active components (e.g. cognitive restructuring in CBT), and therefore it is not possible to parse out the potential effect of the psychoeducational component in the studies.

Table 2 highlights the five publications that reported on the utilization of psychoeducation in CHR programs at a national level in Italy (Cocchi et al., 2018; Cocchi et al., 2008), United Kingdom (Salazar de Pablo et al., 2021; Stain et al., 2019), and United States (White et al., 2015). The majority of CHR individuals (64% to 100%) reportedly receive psychoeducation, but there was a notable lack of detail beyond these percentages. There was no information provided about how psychoeducation was delivered (e.g., no information reported on the topics covered, format of delivery, length, individual vs. family), and why some individuals did not receive psychoeducation. These programs did not report using the structured CHR psychoeducation interventions mentioned above. This suggests that CHR psychoeducation may not be delivered in a systematic or standardized manner, and that not all CHR individuals are receiving psychoeducation.

In the two studies that asked CHR individuals about their treatment preferences (Brummitt and Addington, 2013; Welsh and Tiffin, 2014) psychoeducation emerged as one of the most popular treatment choices, with patients reporting more willingness to participate in psychoeducation compared to other treatment options such as medication, family therapy, and social skills training, to name a few (Table 2). This preference for psychoeducation is consistent with findings from the feasibility and acceptability trials for the three standalone psychoeducation interventions.

Table 3 shows that many guidelines and review articles conclude that psychoeducation is recommended in the treatment of CHR individuals (55%), while some indicate that psychoeducation is encouraging/promising (27%). The remaining (18%) did not comment on a recommendation. A 2012 critical review by Hauser & Juckel on the state of CHR psychoeducation noted that their psychoeducation intervention for ARMS patients (Hauser et al., 2009a) was the only one reporting results. Although there still have not been any randomized trials evaluating CHR psychoeducation on its own since that time, the present review has identified additional CHR psychoeducation interventions and their pilot results (Table 1), suggesting that progress has been made in the past decade. Additional research since their 2012 review has emphasized the role of psychoeducation as a starting point for treatment and a decision-making tool for clinicians in the selection of treatment modalities (Thompson et al., 2015). Barriers to the implementation of CHR psychoeducation have also been identified, such as clinicians’ limited or lacking knowledge of CHR and subsequent hesitation in their skills and confidence to provide psychoeducation (Hetrick et al., 2018). Providers and program developers need to remain up-to-date on the latest research in this emergent field in order to update psychoeducational content based on new information. Thus, more explicit provision, standardization, and maintenance of materials is still needed (Hauser and Juckel, 2012).

Table 3 also includes publications that discuss the goals of CHR psychoeducation, which include developing and strengthening coping skills, reducing impact of stressors ((International Early Psychosis Association Writing Group, 2005), achieving a better understanding of risk symptoms, and improve skills for managing risk symptoms (Müller and Bechdolf, 2016). Recommended topics for CHR psychoeducation include information about psychosis and risk, description of symptoms as occurring on a continuum, prevalence rates to normalize experiences, the nature of the illness and recovery, treatment options, agency in treatment, prospects for the future and how these can be influenced, diagnostic uncertainty, managing stigma, and developmental significance to help youth at CHR understand symptoms and treatment approaches. Materials should be appropriate and available for people from diverse backgrounds and ages and use up-to-date evidence in the presentation of the recommended content (Early Psychosis Guidelines Writing Group and EPPIC National Support Program; (Headspace National Youth Mental Health Foundation, 2015). One study emphasized that initial psychoeducation should not focus on risk for psychosis, but instead on health promotion and early treatment (Cadenhead and Mirzakhanian, 2016).

Figure 2 conveys the overall key findings uncovered in the scoping review determined by a discussion between four co-authors who had reviewed the articles for inclusion and extracted data from included articles. Disagreements were resolved by consensus and co-authors agreed on the final figure as a gist representation of the findings.

Figure 2.

Synthesis of Results

Discussion

This scoping review synthesized available literature on psychoeducation for CHR. Overall, psychoeducation is recommended in the treatment of CHR individuals, stakeholders believe that psychoeducation is an important component of CHR treatment, and many CHR programs report offering psychoeducation. Three standalone psychoeducation interventions developed or adapted specifically to the CHR population were identified, as well as four CHR interventions that include a significant psychoeducational component. However, there were notable gaps in the literature, including the lack of detail on the provision of psychoeducation in CHR services, and the absence of randomized trials investigating the effects of psychoeducation in the CHR population. The methods used and quality of psychoeducation being delivered to CHR individuals in real-world practice is still largely unknown.

The evidence for CHR psychoeducation is promising (McFarlane et al., 2012b), and there appears to be good evidence for the feasibility and acceptability of the three standalone CHR psychoeducation interventions: Psychoeducational Multifamily Groups (PMFGs), Brief Educational Guide for Individuals in Need (BEGIN), and a psychoeducational programs for at risk mental state (ARMS) patients. All interventions recognize the importance of providing education about attenuated psychotic symptoms and incorporate visual materials, such as PowerPoint slideshow presentations and handouts. Each of these interventions also has unique strengths that will cater to the diverse clinical needs of the CHR population. For instance, PMFGs may be appropriate for CHR patients who have family support and require longer-term intensive treatment. The BEGIN and ARMS psychoeducational programs, which are 5- and 7-sessions in length respectively, may be useful for CHR patients who do not have caregiver involvement or who do not require, or are unwilling to commit to, long-term intensive treatment. Some research finds that longer family treatments are advantageous (Cuijpers, 1999), though meta analyses were unable to assess if and how different lengths and formats may impact the effectiveness of psychoeducation and conclude that this should be the focus of future research (Pekkala and Merinder, 2002; Pilling et al., 2002; Xia et al., 2011). The needs of individuals with schizophrenia are quite different than those of CHR individuals, and thus future research with the CHR population should also compare the potential effects of various lengths and formats.

Although the feasibility and pilot trials are encouraging (Hauser et al., 2009a; Herrera et al., 2021; O'Brien et al., 2007), there have not been any randomized trials investigating the efficacy or effectiveness of these interventions for CHR individuals. Nonetheless, results from these pilot studies on CHR psychoeducation signal effects that are comparable to the well-researched effects of psychoeducation for people with schizophrenia and their caregivers in randomized trials, such as improvements in symptoms, knowledge, functioning, quality of life, and coping (Lucksted et al., 2012; Sin et al., 2017). Other key significant outcomes of psychoeducation for schizophrenia such as increased treatment adherence and reduced hospitalization rates and stays (Lucksted et al., 2012; Xia et al., 2011) have not yet been investigated in the CHR population, but represent outcomes to be tested in future research. CHR psychosocial interventions that incorporate a significant psychoeducational component include Family-focused therapy (FFT), Family-Aided Assertive Community Treatment (FACT), Cognitive Behavioral Therapy for Ultra High Risk patients (CBTuhr), and Group and Family-based Cognitive Behavioral Therapy (GF-CBT). These interventions have been evaluated in larger trials and show good outcomes such as reductions in positive symptoms and improved functioning (McFarlane et al., 2015; Miklowitz et al., 2014; van der Gaag et al., 2012), but conclusions cannot be drawn about the unique contribution of the psychoeducational component of the interventions.

There appears to be a strong desire for psychoeducation among CHR individuals. Psychoeducation is identified as a strongly preferred treatment option (Brummitt and Addington, 2013; Welsh and Tiffin, 2014), and qualitative interviews reveal that CHR individuals value the discussion about their risk, feel relieved to have a label for their experiences, and found the support they received after learning about their condition to be helpful (Uttinger et al., 2018; Welsh and Tiffin, 2012). Consumer desire for psychoeducation is consistent with the impression that the CHR population is more receptive to psychoeducation compared to patients with psychosis given that they maintain insight into their symptoms (van der Gaag et al., 2019). Providers also generally agree that psychoeducation should be available to CHR patients and their families, and that it is providers’ responsibility to provide that psychoeducation (Early Psychosis Guidelines Writing Group and EPPIC National Support Program).

Despite strong consumer interest in psychoeducation (Brummitt and Addington, 2013; Welsh and Tiffin, 2014), results suggests that standardized psychoeducation models are likely not being utilized in many CHR programs. Most CHR programs reported providing psychoeducation, but any detail beyond this was scarce. Perhaps CHR individuals do not receive, or do not recall receiving, psychoeducation because explicit methods are not being used (Hauser and Juckel, 2012). Providers report barriers to providing psychoeducation to CHR individuals, including lack of specialized knowledge and training (Hetrick et al., 2018). The provision of CHR psychoeducation in real-world settings likely relies on individual provider and patient circumstances rather than empirically-supported models or interventions (Cocchi et al., 2018). Without clear training and intervention models, therapists may avoid the explicit provision of CHR psychoeducation due to stigma. Implementation and dissemination of standardized CHR psychoeducation interventions will require accessible, flexible interventions and therapist training programs (Selick et al., 2017).

Continued research on psychoeducation for the CHR population is needed to help resolve ethical debates about communicating with patients and families about CHR (Corcoran, 2016; Mittal et al., 2015; Yang et al., 2010), and help clinicians grapple with how to communicate about CHR with patients and families (Schiffman et al., 2022). Clinicians would likely benefit from having access to psychoeducation models and materials. Communicating about CHR with patients and families should be a process rather than event in order to manage the nuanced positive and negative emotional experiences associated with learning about one’s psychiatric condition (Woodberry et al., 2021; Yang et al., 2019).

Although evidence for CHR psychoeducation is promising, it is certainly not sufficient (Müller and Bechdolf, 2016). A 2012 critical review of psychoeducation for CHR individuals came to a similar conclusion that psychoeducation is a useful but under-investigated area in the field (Hauser and Juckel, 2012). More rigorous research is needed, as well as investment from CHR clinical programs in order to facilitate the implementation and dissemination of standardized psychoeducation models for CHR individuals. Future work should focus on the continued development and evaluation of psychoeducation models for CHR, including randomized trials assessing outcomes of PFMGs in CHR, BEGIN, and the psychoeducational program for ARMS patients. The individual needs, backgrounds, and identities of CHR patients (DeLuca et al., 2022) should be considered and incorporated into psychoeducation models as needed given that psychoeducation may be the first treatment contact for many.

There are limitations to this scoping review. As the goal of a scoping review is to provide a preliminary map of the evidence without appraising the quality and validity of the results, we did not draw conclusions on the strength of evidence for CHR psychoeducation and did not include a risk of bias assessment. We included interventions that included an explicit psychoeducational module despite being unable to draw conclusions about the unique contribution of that module in order to capture all available information about psychoeducation for CHR that may contribute to future work in this area. It is likely that additional literature exists on psychosocial interventions for CHR individuals that incorporates key aspects of psychoeducation, though did not emerge in our search given that they were not conceptualized as psychoeducation. For example, the shared-decision making approach for CHR patients appears to overlap in many ways with the goal and content of psychoeducation (Simmons et al., 2021). Clarifying, and even standardizing, the nomenclature around CHR psychoeducation will be important. Given our focus on the provision of CHR psychoeducation directly to the CHR individual, we excluded studies that were focused on education about CHR exclusively for providers or caregivers (Tham et al., 2021). There are likely many situations in which psychoeducation occurs informally in clinical care, and this information will not be captured by a literature review.

Overall, this scoping review found that both patients and providers acknowledge the importance of psychoeducation in the treatment of CHR individuals and several CHR psychoeducation interventions are promising. However, rigorous research is needed to establish evidence-based CHR psychoeducation models that are scalable and can reach more CHR patients to have a positive impact.