Prevention in Psychiatry › Preventing psychosis
Thirty years ago, a small clinic in Melbourne asked a radical question: what if we could meet young people before psychosis takes hold? This is the story of that idea, what the evidence now shows, and how we might bring it home to Bihar.
About a 14-minute read · Part of the Prevention in Psychiatry series
A story I have heard, in many versions
Ritesh is nineteen and in his second year of college in Patna. Over six months he has changed. He sleeps through the day and lies awake at night. He has stopped attending lectures because he feels people on the road are looking at him and talking about him - though he admits he cannot be sure. He has started smoking ganja with friends "to calm down". His parents first took him to a baba, then to a general physician who prescribed sleeping tablets. By the time they reached a psychiatrist, nearly a year had passed.
Composite illustration drawn from common clinical patterns; not a real individual.
Ritesh was not yet psychotic. He still knew, somewhere, that his suspicions might not be true. He was in what psychiatrists now call a clinical high-risk state for psychosis - a period of subtle but real change that, for some young people, comes before illnesses such as schizophrenia. For decades, nobody looked for this period. People like Ritesh were simply sent home until the illness was impossible to miss.
That changed in Melbourne in the 1990s. And the lesson that followed - sometimes hopeful, sometimes humbling - is one every family, doctor and policymaker in India should know.
The PACE story: a clinic built for the in-between
In 1994, Professor Patrick McGorry, Alison Yung and their colleagues opened the Personal Assessment and Crisis Evaluation (PACE) clinic in Melbourne. Their idea was simple and bold: rather than waiting for a first psychotic episode, they would offer care to young people who were struggling and showing early warning signs.1
To do this, they needed a way to tell who was genuinely at risk. They developed the ultra high-risk criteria - now called clinical high risk for psychosis - which identify three groups of young people seeking help.1,2 The 2021 World Psychiatry blueprint on preventive psychiatry summarises how common each group is today:5
~85%Attenuated symptoms
Unusual thoughts, suspiciousness or perceptual changes that are milder than full psychosis - the person still has some doubt about them.
~10%Brief intermittent psychosis
Short-lived psychotic symptoms that resolve on their own within a week.
~5%Genetic risk with decline
A close relative with psychosis, or schizotypal traits, plus a clear fall in day-to-day functioning.
The early results were striking. In PACE's first cohorts, around four in ten young people meeting these criteria developed psychosis within a year.2 Later, the landmark PACE 400 study followed 416 young people for up to 15 years. About 35% developed a psychotic disorder over ten years - most in the first two years, but some much later.3
The highest risk is in the first two years - but the door should stay open long after.
Just as importantly, PACE taught us that these young people were not simply "at risk". They were already suffering. Most had depression or anxiety, many had dropped out of study or work, and nearly all were asking for help.5,6 The clinic's purpose was never only to prevent a diagnosis. It was to relieve present distress and protect a young life.
What happens to young people seen at a high-risk clinic?
The most recent meta-analysis pooled 130 studies and more than 9,000 young people at clinical high risk.4 Choose a time point to see how many, out of 100, developed psychosis.
25 in 100
developed a psychotic disorder within three years.
That also means most did not. Many recovered; some continued to live with depression, anxiety or difficulties in functioning. A high-risk assessment is not a prediction of schizophrenia - it is an invitation to care.
Cumulative risk: about 15% at 1 year, 25% at 3 years and 35% at 10 years (Salazar de Pablo et al., JAMA Psychiatry 2021).
From one clinic to a worldwide movement
PACE's model spread across the world. By 2017-18, specialist services were caring for more than 22,000 young people across Western Europe, North America, East Asia, Australia, South America and Africa.5 Each programme added something new.
1994 · Melbourne, Australia
PACE clinic
The first dedicated service; developed the ultra high-risk criteria and long-term follow-up.1,3
1990s · Cologne, Germany
Early Recognition and Intervention Centre (FETZ)
Showed that subtle "basic symptoms" - changes in thinking and perception the person notices in themselves - can predict schizophrenia years ahead.9
Late 1990s · New Haven, USA
PRIME clinic, Yale
Developed the widely used SIPS interview, and ran an early medication trial that ultimately taught caution about using antipsychotics for prevention.10
2001 · London, UK
OASIS service
Built outreach with schools, GPs and youth services across south London, and showed how a community-facing service can find young people earlier.7
2004 · Manchester, UK
EDIE trial
One of the first randomised trials of cognitive therapy for high-risk young people.8
2008-2016 · North America
NAPLS consortium
Pooled eight centres to study who develops psychosis, and built an individual risk calculator.11
2010s · Shanghai, China
SHARP programme
Brought high-risk care to Asia and validated prediction tools in Chinese youth.13
2018 · Europe
PRONIA
Combined clinical data, brain imaging and genetics with machine learning to predict functional outcomes.14
2020s · Five continents
AMP SCZ (ProNET and PRESCIENT)
The largest prospective study of clinical high risk, spanning 43 sites in 13 countries, searching for biomarkers to guide future treatment trials.15
2024 · India
Community screening, Telangana (AIIMS New Delhi team)
A two-stage screen of rural and urban Indian youth identified young people at high risk who went on to develop psychosis at a markedly higher rate - evidence that the approach can work in India.16
India's own early-intervention story began with first-episode psychosis. The Schizophrenia Research Foundation (SCARF) in Chennai, working with Canadian colleagues, showed in the 2000s that focused early care is feasible and effective in an Indian setting.17 What we still lack, especially in eastern India, are services designed for the period before the first episode.
What actually helps? An honest look at the evidence
This is where we must be careful. Early trials were very encouraging, but larger and better studies have tempered some of that optimism. Families deserve the plain truth.
| Approach | What the research shows |
|---|---|
| Specialist assessment and monitoring | Strong Structured interviews reliably identify a group at much higher risk than the general population, and specialist services shorten the time before untreated psychosis is recognised and treated.4,6,23 |
| Treating present problems - depression, anxiety, sleep, family stress | Strong, and recommended Most high-risk young people have these difficulties, and they deserve treatment in their own right.5,6 |
| Cognitive behavioural therapy (CBT), with family involvement | Recommended, but not proven superior Recommended by NICE.22 Earlier trials suggested CBT reduces transition,8 but the latest network and Cochrane meta-analyses found no robust evidence that any specific intervention prevents psychosis better than good needs-based care.18,19 |
| Omega-3 fish oils | Not supported A promising early trial20 was not confirmed by the larger NEURAPRO study.21 |
| Antipsychotic medicines for prevention | Not recommended Not advised simply to prevent psychosis, given side-effects and lack of benefit.5,10,22 |
| Reducing cannabis use | Strong rationale Daily high-potency cannabis use is linked with around five times the odds of psychotic disorder.26 |
| Cost-effectiveness | Encouraging Early intervention in psychosis, including high-risk care, appears cost-effective, though more studies are needed - especially in low-resource settings.5,25 |
Why, then, do these services matter if no single therapy has been proven to prevent psychosis? Because when psychosis does develop, it is picked up early - and the longer psychosis goes untreated, the worse the long-term outcome tends to be.23,24 And because the young people who come to them are in genuine distress today, and they receive care they would otherwise not have had.
My reading of the World Psychiatry blueprint
In 2021, six leading researchers - including Paolo Fusar-Poli, Vikram Patel and John Ioannidis - published a blueprint for preventive psychiatry in young people.5 I have read it many times, and three of its conclusions shape how I think about psychosis prevention.
First, the high-risk model is the best-validated form of indicated prevention in psychiatry. The criteria are robustly linked with later psychosis, and the services built around them have spread worldwide. Of all our preventive tools, this is the most mature.
Second, the evidence for specific preventive treatments is weaker than we once hoped. The authors are refreshingly direct that a noble aim does not justify claims the data do not support. Future progress depends on larger trials, better prediction and personalised care.
Third, high-risk clinics catch only part of the picture. Most people who develop psychosis never pass through such a clinic; many first show depression or anxiety. That is why the authors argue for services that are transdiagnostic, youth-friendly, linked to primary care, and combined with public-health action on drivers such as cannabis, poverty and adversity.
The paper's limits are worth naming too. It is written for researchers, and almost all of its evidence comes from wealthy countries. Translating it to Bihar - where most families first approach a faith healer or a general physician, and where specialist services are scarce - needs a model shaped for our realities.
How a high-risk service works
Whatever the country, successful programmes share the same five steps.1,6,7
1
Reach out
Teach schools, colleges, GPs and families the early signs.
2
Open the door
Easy referral - by phone, by a teacher, or by the young person themselves.
3
Assess carefully
A trained clinician uses a structured interview such as CAARMS or SIPS.
4
Support the whole person
Therapy, family work, sleep, substance use, study and work.
5
Stay in touch
Monitor for at least two years, with an open door afterwards.
Bringing it home: a practical plan for Bihar
Bihar has one of the youngest populations in India, and the years between 15 and 30 are when psychosis most often begins. Yet a young person here may wait many months - sometimes years - between the first change and the first psychiatric assessment. Drawing on the programmes above and on the realities of our clinics, this is the model I believe we can build.
- Train the first doorsMost families first go to a general physician, a school teacher, a coaching-centre counsellor or a faith healer. Short training for these first contacts - what to notice, where to refer - can shorten the delay more than any new building.
- Screen in two steps, not oneA brief self-report questionnaire in Hindi, followed by a structured interview for those who screen positive, is the approach validated in Indian youth.16 It avoids both missing young people and frightening those who are simply stressed.
- Assess with trained cliniciansDistinguishing an attenuated symptom from ordinary stress or cultural belief requires skill and context. Structured tools such as CAARMS or SIPS, used by trained staff, keep assessments consistent.5
- Offer needs-based careCBT and family psychoeducation; treatment for depression, anxiety and sleep; help with study, exams and employment; and frank conversations about ganja, bhang and other cannabis use.22,26
- Hold back on medicines that are not neededAntipsychotics are reserved for those who develop psychosis, not prescribed simply because of risk.22
- Follow up for at least two yearsRegular review, with a clear route back if things worsen later.3
- Measure, learn and shareRecord who comes, how they do and what helps - so that Bihar contributes its own evidence instead of borrowing everyone else's.
The language we use matters
Stigma is a real fear for families. Research suggests young people often worry less about a "risk" label than clinicians assume, but words still matter.5 In our clinic, we talk about early support, not about "pre-schizophrenia".
Avoid saying
Say instead
“He is going to get schizophrenia.”
“He is going through changes that deserve care, and most young people in this situation do not develop psychosis.”
“It is just a phase; leave him alone.”
“Let us get it checked early - it costs little to be sure.”
“Someone has done something to her.”
“Her brain is under strain. Help is available, and it works best early.”
Early signs families should not ignore
These changes, lasting several weeks, are worth an early conversation with a psychiatrist. They do not mean psychosis is inevitable.
- Becoming unusually suspicious, or feeling watched or talked about
- Hearing, seeing or sensing things others do not, even briefly
- Thoughts that feel strange, muddled or "not my own"
- A marked fall in studies or work, without a clear reason
- Withdrawing from friends and family; losing interest in everything
- Sleep turned upside down - awake at night, sleeping by day
- Neglecting self-care and appearance
- Heavier use of ganja, bhang or alcohol to cope
- A family history of psychosis together with any of the above
- Any talk of hopelessness or not wanting to live - seek help the same day
Help you can reach right now
A last word, to families like Ritesh's
When Ritesh's parents finally sat in front of me, his mother asked the question I hear most often: "Doctor sahab, did we come too late?" I told her what I believe the evidence allows me to say. It is rarely too late to help. But the earlier we meet a young person, the more of their life we can protect - their studies, their friendships, their confidence, their future.
Psychosis prevention began as a single clinic in Melbourne. Today it is a worldwide effort, honest about its limits and stubborn in its hope. Bihar's young people deserve to be part of it.
Dr. Saurabh Kumar
MD (Psychiatry) AIIMS New Delhi · Associate Professor & HOD, RDJM Medical College · Ex-Assistant Professor, PMCH Patna · Consultant, Healthy Minds Clinic, Patna
Worried about someone?
An early assessment is a conversation, not a verdict. Healthy Minds Clinic, House No. 46/B, Sahdeo Mahto Marg, near Sri Krishna Puri Park (Children's Park), Patna 800001. Open Monday, Tuesday, Wednesday, Friday and Sunday, 9 a.m. to 7 p.m. For appointments only - in an emergency, call 112.
