6090: Schizophrenia Over Time: Experiences Living With the Illness

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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 [email protected]

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 specif ically, 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

increased recognition of the value of psychosocial interventions

for psychotic-spectrum disorders. Although existing treatment

guidelines typically identify pharmacological treatment as the

“cornerstone” or “first-line” treatment of psychotic-spectrum

disorders,47–49 there is growing recognition that medication

alone cannot fully ameliorate the morbidity and mortality

associated with these disorders.50–53 For example, while anti-

psychotic medications have clear efficacy with regard to the

treatment of psychotic symptomatology,54,55 available evidence

suggests that such symptoms may account for <1% of the illness-related disability experienced by individuals with first-

episode psychosis (Moe and Breitborde, unpublished data,

2017). Effects of antipsychotic medication on other meaningful

outcomes in psychotic-spectrum disorders (e.g., employment,

cognition, and social functioning) are small and may not be

clinically significant.11,51,56,57 Current multicomponent treatment

programs for first-episode psychosis emphasize a combination

of psychosocial and pharmacological interventions as first-line

treatment58,59 and available data have demonstrated that such

combined treatment produces improved outcomes among

individuals with psychotic-spectrum disorders – including first-

episode psychosis – when compared with medication alone.60–62

Yet, despite the benefit of multicomponent care for first-

episode psychosis, clinical and functional outcomes among

individuals participating in such services are still subop-

timal.26,63,64 Among such individuals, inpatient psychiatric

hospitalizations are common,31 substance use – especially

tobacco – is high,29 poor physical health outcomes are the

norm,65 and rates of participation in competitive employ-

ment remain lower than their age-matched peers without

psychotic-spectrum disorders.30 Consequently, there is still

significant room for improvement in the treatment of first-

episode psychosis.26,63

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 several opti-

mization strategies with the potential to enhance the benefits

associated with these interventions. In particular, we focus

our review on burgeoning areas of research with regard to

optimization of psychosocial interventions for first-episode

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Psychosocial interventions in first‑episode psychosis

psychosis and avoid reviewing strategies that are already

clearly documented elsewhere (e.g., building a strong thera-

peutic alliance66 and addressing the comorbid psychiatric

symptoms, functional deficits, and cognitive decline that

accompany first-episode psychosis67–73).

Strategy 1: reduce the delay in receipt of evidence-based psychosocial treatments Within the first-episode psychosis literature, there is a clear

association between the duration of untreated psychosis

(DUP; i.e., the time between the first onset of psychotic

symptoms and the receipt of adequate mental health care)

and the course of psychotic-spectrum disorders. More spe-

cifically, a longer DUP is associated with a worse course of

illness and poorer response to treatment.25,31,32,74 Many stud-

ies have defined the endpoint of the DUP (i.e., the receipt

of adequate mental health care) as participation in some

duration of antipsychotic medication.75,76 However, time

until the start of evidence-based psychosocial interventions

may also be an important endpoint following the first onset

of psychotic symptoms. For example, in a seminal paper, de

Haan et al76 examined the association between the duration of

time between the first onset of psychotic symptoms and the

first receipt of intensive psychosocial treatment (i.e., delay

in intensive psychosocial treatment [DIPT]) and the course

of schizophrenia. Given the limited availability of evidence-

based psychosocial treatments for psychosis in usual care

settings,77 it is not surprising that de Haan et al found that

the mean DIPT (19 months) was nearly twice as long as the

mean DUP (8.6 months). Among their sample, there were

positive univariate associations between negative symptoms

at 6-year follow-up and both DUP and DIPT (i.e., greater

negative symptoms associated with longer DUP and DIPT,

respectively). However, in multivariate analyses simultane-

ously examining DUP and DIPT, only DIPT was found to

be a statistically significant predictor of negative symptoms

at 6-year follow-up. These results raise the possibility that

reducing the delay between the first onset of psychotic

symptoms and the receipt of evidence-based psychosocial

care may be a modifiable risk factor through which providers

can improve the course of psychotic-spectrum disorders. This

hypothesis comports with data suggesting that individuals

earlier in the course of psychotic-spectrum disorders have a

greater response to psychosocial treatments when compared

with individuals with more longstanding illnesses.78–80

Despite the potential importance of DIPT to the course

of psychotic-spectrum disorders, we are unaware of any

subsequent studies that have investigated this concept in the

13 years since the paper by de Haan et al.76 Consequently,

there is a great utility for additional research to clarify the

association between delay in access to psychosocial treat-

ments and the course of psychotic-spectrum disorders. In

addition, psychiatric service research may benefit from

examining how evidence-based psychosocial services can be

incorporated within inpatient psychiatric settings. Although

the inpatient psychiatric unit is often the first care setting for

individuals with first-episode psychosis,81 evidence-based

psychosocial treatments for f irst-episode psychosis are

typically available in outpatient settings only. Thus, incor-

porating specialized psychosocial treatments in inpatient

settings may be an important strategy in reducing delay of

appropriate psychosocial care.

Strategy 2: synergistic pairing of psychosocial interventions Kern et al62 have highlighted that although numerous

evidence-based psychosocial interventions are available

for psychotic-spectrum disorders, no single psychosocial

intervention is sufficient to address numerous health and

functional consequences associated with these disorders.

Thus, there is growing interest in examining how best to pair

psychosocial interventions to improve outcomes among indi-

viduals with first-episode psychosis. Although research in this

area is still developing, promising results from the broader

literature on psychotic-spectrum disorders are already avail-

able with regard to effective pairing of psychosocial interven-

tions with cognitive remediation – an intervention defined

by the 2010 Cognitive Remediation Experts Workshop as “a

behavioral training based intervention that aims to improve

cognitive processes (attention, memory, executive function,

social cognition, or metacognition) with the goal of durabil-

ity and generalization.” To date, studies have examined the

benefits of pairing cognitive remediation with several addi-

tional psychosocial interventions, including work therapy

and supported employment programs,82–84 functional skills

training,85 and even an aerobic exercise program.86

Bell et al82 examined a combined cognitive remediation

and work therapy program, which involved individuals with

schizophrenia or schizoaffective disorder being randomly

assigned to receive cognitive remediation – characterized by

completion of computerized cognitive exercises and weekly

processing groups – plus work therapy or work therapy alone

for 6 months. Although both groups showed improvements,

individuals in the cognitive remediation and work therapy

group evidenced greater mean differences and larger effect-

size changes on cognitive performance, including working

memory, attention, and executive functioning. An additional

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Breitborde et al

study by the same group83 using the same methodology but

with an extended treatment period of 1 year similarly revealed

that individuals who received combined cognitive remedia-

tion and work therapy had significantly better performance

on measures of executive functioning and working memory

post-treatment compared with those who received work

therapy alone. In a sample of 44 individuals with schizo-

phrenia, McGurk et al84 compared the effects of 12 weeks

of supported employment and computerized cognitive

training against supported employment alone. Post-treatment

cognitive testing revealed that those in the combined cogni-

tive training plus supported employed group performed

significantly better on an overall composite cognition score

than those receiving supported employment alone, and that

these individuals in the combined condition also showed

significant reduction in depression and autistic preoccupa-

tion and better work outcomes compared with individuals in

the supported employment-alone condition. The functional

outcome improvements, particularly in work functioning,

can be directly attributed to the addition of cognitive reme-

diation in this case, as all other aspects of treatment were

matched. Although work training and supported employment

programs target work functioning directly, the addition of

cognitive training led to greater levels of employment, more

hours worked, and better functioning at work in individuals

with schizophrenia. In addition, those receiving cognitive

remediation also showed improvement in other domains (i.e.,

symptom levels and neurocognitive functioning).

In an additional study, Bowie et al85 randomly assigned

individuals with schizophrenia to receive cognitive remedia-

tion, functional adaptation skills training, or a combination

of both treatments. Although improvements in neurocogni-

tion were observed in both the cognitive training and com-

bined treatment groups and social competence significantly

improved in the functional skills and combined treatment

group, the combined treatment group showed significantly

greater improvements in functional competence and real-

world community activities than either the functional skills

training and cognitive remediation-only groups. Importantly,

the durability of these gains was greatest in the combined

treatment group. Taken together, these results suggest that

a combined treatment approach may produce better gains

across domains that are more likely to persist over time.

The utility of combining cognitive remediation and

physical activity has also been explored. In a recently

published pilot study,86 individuals early in the course of a

schizophrenia-spectrum disorder were randomly assigned

to 10 weeks of either cognitive training alone or cognitive

training combined with aerobic exercise sessions. Even with a

small sample and short training period, individuals receiving

combined cognitive training and exercise demonstrated larger

gains in overall cognitive abilities compared with participants

receiving cognitive training alone. These preliminary data

suggest that a combination approach including both exercise

and cognitive remediation allows for even larger gains in

cognition than cognitive remediation alone.

Thus, research on cognitive remediation has highlighted

strategies to increase the size, breadth, and durability of

treatment effects via the deliberate pairing of psychosocial

interventions. These findings are especially relevant to the

treatment of first-episode psychosis given the improved,

but still suboptimal benefits associated with current mul-

ticomponent treatment programs64 and questions about

the durability of these benefits after discharge from such

multicomponent treatment programs.87,88 Moreover, within

most multicomponent treatment for first-episode psychosis,

decisions with regard to psychosocial intervention uptake are

typically individual preferences of providers and individuals

with first-episode psychosis. Although such preferences are

valuable – especially those of individuals with first-episode

psychosis – future research exploring how specific psy-

chosocial interventions can be synergistically paired may

enhance clinical outcomes among individuals participating

in multicomponent care for first-episode psychosis.

Strategy 3: personalized delivery of psychosocial interventions Within the larger psychiatric literature, there is significant

interest in advancing personalized medicine89 – “the prescrip-

tion of specific treatments and therapeutics best suited for an

individual taking into consideration both genetic and environ-

mental factors that influence response to therapy”.90 The treat-

ment decisions resulting from these considerations fall under

the categories of “macrotreatment” and “microtreatment”

decisions.91 Macrotreatment decisions are those that guide

selection of specific interventions, whereas microtreatment

decisions guide the delivery of specific aspects of an inter-

vention. Given the heterogeneous presentation and course of

psychotic-spectrum disorder,92–94 personalized prescription of

psychosocial intervention may help to maximize treatment

outcomes among individuals with first-episode psychosis.

In recent years, there has been increasing focus on

research suggesting that genetic variants associated with

psychosis can be used to guide antipsychotic medication man-

agement decisions.95 Genetic variants could also potentially

be used to guide macrotreatment decisions concerning which

psychosocial interventions are prescribed to specific indi-

viduals with first-episode psychosis. For example, growing

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Psychosocial interventions in first‑episode psychosis

research has considered whether an individual’s response to

cognitive remediation may be moderated by genetic factors.

To date, several studies have examined whether response to

cognitive remediation may be predicted by the catechol-O-

methyltransferase (COMT) gene via its putative influence

on prefrontal dopamine functioning.96–98 However, results

from these studies are equivocal. There is some evidence that

response to cognitive remediation among individuals with

first-episode psychosis may be influenced by the expression

of genes involved in memory and synaptic plasticity (e.g.,

activity-regulated cytoskeleton-associated protein [ARC]).

In one recent study,99 individuals identified as carriers of

the ARC T allele showed significant improvement in overall

cognitive functioning after participating in metacognitive

remediation therapy, whereas non-T-carriers did not.

Another potential characteristic that could be used to

personalize psychosocial intervention prescription for indi-

viduals with first-episode psychosis is personality traits. It

has been demonstrated that non-pathological personality

traits are associated with course of illnesss and subjective

experiences of symptoms in individuals with psychosis,100

as well as other relevant correlates of psychotic-spectrum

disorders such as social cognitive abilities.101 A framework

for considering both research and theory of personality

in first-episode psychosis intervention decisions has been

proposed102 that would first involve formal assessment of

personality characteristics. These assessment data could

then be used to inform macrotreatment decisions, such as

choice of intervention formats (e.g., group interventions,

caregiver involvement) and microtreatment decisions, such

as how to tailor interventions for specific individuals to best

address their unique symptomatology, functional deficits,

and treatment goals.

Finally, the typical emergence of psychotic symptoms

in the late teens to early 20’s103 raises the possibility that

psychosocial interventions for first-episode psychosis may

be enhanced by tailoring them to the unique needs of indi-

viduals in this developmental stage. In his seminal writings,

Arnett has referred to this developmental stage as “emerging

adulthood” and has described it as “a period characterized by

change and exploration for most people, as they examine the

life possibilities open to them and gradually arrive at more

enduring choices in love, work, and worldviews.”104 Draw-

ing on this research, McGorry et al have advocated for the

development of youth-friendly mental health services that

promote shared decision-making in treatment and emphasize

social and vocational outcomes (as opposed to symptomatic

remission) as key treatment goals.105,106 Such characteristics

are not only consistent with the norms of this developmental

stage (e.g., movement toward greater autonomy and estab-

lishing the foundation for longstanding vocational and rela-

tionship roles) but may also play a role in whether emerging

adults access and remain engaged in specialized services for

first-episode psychosis.105 For example, early evidence from

existing youth-friendly mental health services suggests that

they may be successful in increasing rates of youth and young

adults from traditionally underserved populations who choose

to access mental health services.107,108

Strategy 4: technological enhancement of psychosocial interventions Another promising avenue for optimization of psychosocial

treatment for first-episode psychosis involves integration

of technological advances. Although clinical research has

benef itted for several decades from emerging imaging

and psychophysiological measurement technologies, these

advancements are increasingly proliferated into people’s

typical, everyday activities (e.g., smartphones, digital

streaming technologies, and fitness trackers equipped with

heart-rate monitors). As these technologies continually

interface with normative human activities, they represent an

important avenue for advancement and expansion of health

care and treatment. Interventions delivered via technology

or technology-enhanced treatment may be a cost-effective

way to provide personalized, flexible, and evidence-based

interventions directly to individuals in their communities

or homes.109 The use of technology-enhanced treatment

has a myriad of potential clinical benefits for individuals

with first-episode psychosis, including the capability of

providing real-time cues to engage in particular behaviors

as a compensatory mechanism for memory deficits (e.g., to

encourage medication adherence110), as well as the ability

to alert individuals to physiological early warning signs of

symptomatic exacerbations in a personalized manner (e.g.,

changes in heart-rate variability111).

Although the use of technological advancements in

psychiatric treatment is in its relative infancy,112 the ready

availability and sophistication of these technologies is prom-

ising. This has been particularly true for smartphones and

apps, which represent one of the most rapidly expanding and

adopted forms of technology in human history.113 Available

research suggests that up to 90% of individuals with first-

episode psychosis have access to smartphones.114,115 Given the

wide availability of this technology, these devices are ideal

for assessment of in vivo experiences of individuals with

psychosis. Ecological momentary assessment (EMA) – a

method for collecting information on naturalistic behaviors

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Breitborde et al

and experiences that has previously been done with paper-

and-pencil methodology – has been enhanced by the use of

smartphones. Smartphones offer participants the opportunity

to record information about their symptoms, feelings, and

thoughts in an immediately accessible forum that can auto-

matically sync with an external database. This approach can

mitigate the impact of cognitive deficits on memory and

recall, and can also provide cues for individuals to engage

in reflecting on internal processes and recording information

that can minimize the impact of deficits in the initiation of

behaviors that accompany psychotic-spectrum disorders.

Further, research suggests that symptom ratings collected

from individuals with psychosis via smartphone technology

have greater concordance with clinician ratings compared

with self-ratings made with paper and pencil.116 In addition

to being used to enhance treatment via self-monitoring,

smartphone technology can also be used to deliver interven-

tions directly to individuals with psychosis. Ben-Zeev et al117

recently investigated the efficacy of a smartphone-based

treatment to people with schizophrenia. This intervention was

designed to provide automated real-time/real-place illness

management support to individuals and was found to produce

improvements in mood regulation, medication adherence,

social functioning, and sleep. The demonstrated feasibility,

acceptability, and preliminary efficacy of this smartphone

intervention for schizophrenia offer promise for extending

evidence-based treatment for first-episode psychosis beyond

physical clinics and into the literal pockets of individuals via

widely available smartphone technology. As the benefits of

specialized care for first-episode psychosis may disappear

when young adults return to usual care,87,88 the extension

of evidence-based psychosocial treatment via smartphone

technology could potentially be leveraged to increase the

durability of the benefits produced by such specialized, but

typically time-limited, care.

Of note, the possibilities for integration of technology into

psychosocial treatment for first-episode psychosis also extend

to social media more broadly. For example, Alvarez-Jimenez

et al118 developed HORYZONS, an online intervention specif-

ically for youth with first-episode psychosis. Individuals with

first-episode psychosis could engage in a variety of interac-

tive psychosocial interventions on this moderated forum and

were also able to engage in peer-to-peer social networking.

Results indicated that this approach was feasible, engaging,

and safe for participants. The use of online forums to enhance

other psychosocial treatments for first-episode psychosis is

especially attractive, given its cost-effective nature, as well

as its potential to provide ongoing support that may prevent

disengagement from clinical services.

Technological advances are an evolving and exciting area

for clinical service delivery. However, the importance of an

evidence-based approach to treatment should not be forgotten.

Thus, there is a great need for additional research of smart-

phone and other technology enhancements for first-episode

psychosis. In the interim, mental health providers should

strive to be both open-minded and prudent in the integra-

tion of technology into treatment for first-episode psychosis.

Although many mental health apps are currently available,

the vast majority have not been scientifically evaluated.112,119

However, the literature on the use of apps for clinical treatment

of psychotic-spectrum disorders – despite being limited – does

provide strong evidence for the feasibility of this approach as

well as high rates of patient engagement and interaction.120

Conclusion Outside of the first-episode psychosis literature, Guralnick121

has highlighted the distinction between first-generation and

second-generation research – research designed to investigate

the efficacy/effectiveness of an intervention versus research

designed to investigate how to optimize outcomes associated

with a proven intervention. With the efficacy and effective-

ness of numerous psychosocial interventions for first-episode

psychosis clearly established, scholars have noted the growing

need for a shift toward second-generation research within the

field.122 The optimization strategies described above highlight

some of the increasing corpus of second-generation research

on the treatment of first-episode psychosis that is emerging

internationally. Ultimately, such research has the potential to

optimize the treatment response to evidence-based psycho-

social interventions and to enhance the improved (but still

suboptimal) treatment outcomes commonly experienced

by individuals with first-episode psychosis. Moreover, as

interest in intervention for psychosis before the first-episode

grows,123,124 continued research on the optimization of psy-

chosocial interventions may also highlight ways to improve

the prevention of psychotic disorders among those at clinical

high risk.

Disclosure Drs Breitborde and Moe have both received salary support

from the Institute for Mental Health Research (IMHR)

to support the launch of IMHR’s new clinical service for

individuals with first-episode psychosis. They also received

salary support from the Ohio Department of Mental Health

and Addiction Services to support the launch of a new

clinical service for individuals with first-episode psychosis

in Fairfield County, Ohio. This project was supported by

funds provided by The Ohio State University Department of

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Psychosocial interventions in first‑episode psychosis

Psychiatry and Mental Health to Dr Breitborde. The authors

report no other conflicts of interest in this work.

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