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Research to Inform Stepped-Care Interventions for Persons at Clinical High Risk for Psychosis


Robert K. Heinssen, Ph.D., ABPP
Division of Services and Intervention Research


The goals of this concept are to encourage research to test the feasibility and effectiveness of a stepped-care intervention model; to improve symptoms and functioning for individuals at “clinical high risk” (CHR) for psychosis; and to reduce rates of transition to a psychotic disorder.


At any given time, over one million adolescents and young adults in the U.S. experience problems in perception, thinking, and functioning suggestive of a pre-psychosis risk state. Given the highly disruptive and disabling nature of psychotic disorders, early intervention is recommended to prevent or delay psychosis onset among at-risk individuals, and possibly to lessen other difficulties such as comorbid mental disorders, substance use problems, and impaired social and role performance.  

A growing body of evidence supports early intervention as a means for preventing first episode psychosis among help-seeking individuals who meet diagnostic criteria for CHR syndromes. Efficacy findings are strongest for cognitive-behavioral therapy (CBT), which improves symptoms and reduces the relative risk of developing psychosis by more than 50% after 12 months.

This concept aims to support research to develop and test a stepped-wise approach to CHR care that targets psychosis risk, mood and anxiety symptoms, substance use, and compromised functioning.  Building upon existing evidence-based approaches to screening, diagnosis, and treatment, the research would develop and evaluate a stepped-care intervention for CHR that features lower intensity/lower risk treatments as first-line interventions, with decisions regarding treatment completion, maintenance therapy, or step-up to more intensive care based on a priori definitions of recovery, stabilization, and worsening. Randomized controlled trials, conducted in community-based clinics, are envisioned.

Anticipated outcomes from this program of research include, but are not limited to:

  • Interventions of varying complexity, intensity, and duration that target symptoms, problems, and functional impairments that characterize different clinical high-risk states;
  • Data regarding the effectiveness, risks, and benefits of various intervention strategies;
  • Predictors of individual treatment response at each stage of care, to inform subsequent personalization of CHR interventions; and
  • Information regarding the feasibility of implementing promising therapies in community treatment settings in the United States.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has expressed interest  in implementing community-based programs to improve outcomes for youth and young adults identified at clinical high risk for developing a first episode of psychosis. As appropriate and feasible, NIMH plans to pursue the current concept in coordination with SAMHSA and other relevant federal partners.