Improving Care for First Episode Psychosis (FEP): Challenges and Recommendations

Drew Madore (1), Yveton Isnor (1)
1. RISE Program, Cambridge Health Alliance

Coordinated Specialty Care (CSC) is the standard of care for individuals with first episode psychosis (FEP). It includes individual therapy, small caseloads (Heinssen et al., 2014), medication management (often low dose antipsychotics), case management, employment and education support, family education and support, and peer support (Heinssen and Azrin, 2022). Although CSC improves functional and clinical outcomes for FEP, it has several limitations. Powell and colleagues (2021) outline several barriers to CSC including stigma, cultural competence, disengagement, workforce development, measurement and evaluation, implementation in rural settings, and financial constraints.

This poster synthesizes the literature on domains that are insufficiently addressed by standard CSC interventions, particularly regarding psychotherapy interventions. These domains include: trauma, suicidality, identity formation, interpersonal challenges (e.g., domestic violence), and existential concerns. Evidence indicates that trauma exposure and instability in living environments are linked to poorer prognosis and elevated suicide risk (Conus et al., 2007; Phalen et al., 2024). While participating in CSC programs reduces suicidal ideation by up to 77% within six months, no standardized interventions that address suicidality in FEP exist, which highlights a need for individualized approaches (Breitborde et al., 2021; Anderson et al., 2018; Phalen et. al., 2024).

We critique the medical approach widely used in CSC, noting that psychotherapy’s relational, humanistic approaches are underemphasized (Elkin, 2009). We propose that alternative approaches (e.g., relational, humanistic, and mentalization-based interventions) offer unique opportunities to address clients’ complexities and heterogeneity. Given that FEP often emerges during critical developmental stages, a flexible, trauma-informed, and culturally-sensitive approach could be beneficial. By highlighting clients’ complexity through composite cases, the researchers demonstrate the necessity of multimodal, individualized interventions to improve outcomes. We propose that addressing the identified gaps will increase the effectiveness of CSC and improve long-term outcomes for individuals who experience FEP.