Psychosis treatment prior to psychosis onset: ethical issues

Clinical trials have begun of antipsychotic treatments in persons who are prodromally symptomatic and at high risk for schizophrenia but who have not yet become psychotic. The ethical issues connected with intervening prior to making a diagnosis of psychosis are detailed. Compelling but tentative evidence suggests that early treatment may improve course and prognosis, and this has initiated a paradigm shift in thinking about the risks and benefits of early intervention. The nature of this evidence, its implications, its shortcomings, and its effect upon the ethics of treating schizophrenia are elaborated and discussed. It is concluded that clinical psychiatry is currently in a state of "equipoise" or genuine uncertainty about the comparative merits of early treatment, a state which endorses early intervention research, including intervention in the prodromal phase.