Stepped care for young people at clinical high risk for psychosis: a real-world study

Despite recommendations that young people at clinical high risk (CHR) for psychosis receive stepped treatment, few programs have published details of their clinical models or outcomes. This study describes the preliminary effectiveness of a risk calculator-informed stepped care model used at the Yale PRIME Clinic, a specialized outpatient clinic for young people at CHR.

Seventy-one individuals (ages 12-25) at CHR enrolled in Yale's PRIME Clinic during the first four years of the treatment program. Participants completed clinical assessments at six timepoints over two years of treatment within a care model informed by an empirically grounded psychosis risk calculator. Linear mixed-effect models were fit to examine changes in clinical symptoms over time, and sensitivity analyses evaluated differences in clinical trajectories between completers and non-completers.

Individuals engaged in treatment demonstrated significant and sustained improvements in positive, negative, general, disorganized, and depressive symptoms. Improvements in positive symptoms emerged by 6 months and continued to improve across most subsequent timepoints (6, 12, and 24 months). Pattern mixture analyses suggested that clinical trajectories did not significantly differ between completers and non-completers, though non-completers possessed more heterogeneous trajectories.

A stepped care model informed by individualized risk calculator scores was feasible for delivery in a specialized outpatient setting, and was associated with broad symptom improvement for young people at CHR. Further controlled studies with blinded raters are needed to further confirm the efficacy of stepped care models and isolate the active components of treatment.

Participants at clinical high risk for psychosis experienced significant reductions in attenuated psychotic symptoms and improvements in mood while enrolled in a risk-calculator-informed stepped care treatment model.Participants who disengaged from treatment did not have significantly different clinical trajectories than those who remained in care.The results suggest preliminary evidence for the feasibility of implementing a risk-calculator-informed stepped care model.