Reviews and Overviews

Psychosocial Treatment for First-Episode Psychosis:

A Research Update
David L. Penn, Ph.D.
Evan J. Waldheter, M.A.
Diana O. Perkins, M.D.
Kim T. Mueser, Ph.D.
Jeffrey A. Lieberman, M.D.

Objective: This article reviews research

on psychosocial treatment for first-episode psychosis.
Method: PsycINFO and MEDLINE were
systematically searched for studies that
evaluated psychosocial interventions for
first-episode psychosis.

sisting individuals in adjusting to their illness, and improving subjective quality of

life, but it has shown minimal efficacy in reducing relapse. Some controlled research
supports the benefits of family interventions, while less controlled research has
evaluated group interventions.

Results: Comprehensive (i.e., multielement) treatment approaches show promise in reducing symptoms and hospital readmissions, as well as improving functional
outcomes, although few rigorously controlled trials have been conducted. Individual cognitive behavior therapy has shown
modest efficacy in reducing symptoms, as-

Conclusions: Adjunctive psychosocial interventions early in psychosis may be beneficial across a variety of domains and can
assist with symptomatic and functional recovery. More randomized, controlled trials
are needed to evaluate the effectiveness of
these interventions, particularly for multielement, group, and family treatments.
(Am J Psychiatry 2005; 162:22202232)

sychotic disorders, particularly schizophrenia, are the

most disabling of all mental illnesses. In fact, schizophrenia
is included among the worlds top 10 causes of disabilityadjusted life-years (1). The majority of individuals with
schizophrenia have a poor long-term outcome (24), which
results in great personal suffering and societal cost. The
largest expenditure for mental health in the United States is
for schizophrenia (5), with an annual cost of $32.5 billion
(68). Most of this cost can be attributed to repeated hospitalizations following relapse (9).
In an effort to improve the long-term outcome for individuals with schizophrenia, research has focused on early
identification and intervention for psychosis. This approach to secondary prevention has been bolstered by
findings that the sooner antipsychotic treatment is initiated after the emergence of psychosis, the better the clinical response (for example, see reference 10; see references
11 and 12 for reviews and references 1316 for exceptions).
In addition, most clinical and psychosocial deterioration in
schizophrenia occurs within the first 5 years of the onset of
the illness (11), suggesting that this is a critical period for
treatment initiation (17, 18). Thus, pharmacological and
psychosocial treatment delivered during this critical period has been hypothesized to have a stronger impact than
comparable treatment provided later in the illness (17). Finally, there is a growing risk of treatment-resistant symptoms with each subsequent relapse (1924). This is consistent with findings that show progressive loss of brain gray
matter associated with recurrent episodes, suggesting that
each relapse may reduce the individuals capacity to re-

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spond to subsequent treatment (25, 26). Early intervention

may therefore reduce the risk of relapse and long-term disability associated with chronic schizophrenia (2729).

Pharmacological Treatment
of First-Episode Psychosis
Most individuals with first-episode psychosis are responsive to antipsychotic medication (30). Remission of
psychotic symptoms occurs in 50% of individuals with
first-episode psychosis within the first 3 months after initiation of treatment with antipsychotic medication (24, 31,
32), 75% within the first 6 months (32), and up to 80% at 1
year (31, 3335).
The beneficial effects of antipsychotic medication on
first-episode psychosis are tempered by the following issues: 1) individuals with first-episode psychosis are particularly sensitive to the side effects of antipsychotics, such
as weight gain (36, 37), 2) medication adherence is variable, with 612-month adherence rates in the 33%50%
range (38, 39), 3) up to 20% of individuals with first-episode psychosis show persistent psychotic symptoms (40),
and 4) over 50% of individuals with first-episode psychosis
report significant depression and/or anxiety secondary to
the traumatic nature of psychosis (4143).
In addition, despite initial symptom reduction, there is
poor functional recovery following a first psychotic episode. Tohen et al. (32) found that although approximately
75% of individuals with first-episode psychosis showed
symptom remission at 6 months, most (79.8%) failed to
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PENN, WALDHETER, PERKINS, ET AL.

TABLE 1. Characteristics of Selected Comprehensive (i.e., Multielement) Treatment Programs for Early Psychosis

Program
Early Psychosis Prevention
and Intervention Centre,
Melbourne, Victoria,
Australia
Prevention and Early
Intervention Program
for Psychosis, London,
Ont., Canada
Early Psychosis Program,
Calgary, Alta., Canada
Early Treatment and
Identification of Psychosis
project, Norway and
Denmark
a

Individual
Community
Cognitive
Intake
Outreach/
Behavior
Individual
Age
Early
Therapy and Supportive
In- and
Atypical
Range Outpatient Antipsychotic Supportive
Detection
Therapy
Group
Family
Case
(years)
Efforts
Therapy
Services
Only
Therapy Therapy Managementb
Treatmenta
1525
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes

1650

Yes

1645 Outpatient
only
1865 Outpatient
only

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

All programs initially prescribe low doses of atypical antipsychotics as first-line pharmacological treatment.
programs adhere to an assertive case management model, in which the case manager coordinates all treatment for the client, serves
as primary contact for the program, and may also assist with vocational and/or housing needs.

b Most

show functional recovery during the same time period (see

also reference 35). Individuals with first-episode psychosis
tend to have impairments in general social functioning (44,
45), quality of life (46, 47), and occupational functioning
(48) despite clinical recovery. These functional impairments are present up to 5 years after illness onset even
when optimal pharmacological treatment is provided (49).

Psychosocial Interventions
for First-Episode Psychosis
Clearly, pharmacotherapy alone is not sufficient to prevent relapses or assure functional recovery from acute psychosis. Thus, there is a growing interest in psychosocial interventions as a means of facilitating recovery from an
initial episode of psychosis and reducing the long-term disability associated with schizophrenia (50). Work in this area
is still in its infancy, however. Treatment guidelines for firstepisode psychosis, which include therapeutic engagement,
targeting psychological and social adjustment, developing
an active relapse prevention plan, and identifying barriers
to treatment (42, 51, 52), are based on clinical experience
and not controlled research evaluating standardized psychosocial programs. There is a need for updated guidelines,
informed by a rigorous review of available research.
According to Edwards and colleagues (5355), the literature on psychosocial interventions for first-episode psychosis can be conceptualized as constituting two broad
categories: 1) studies evaluating comprehensive (i.e., multielement) interventions, which typically include community outreach/early detection efforts, in- and outpatient
individual, group, and/or family therapy, and case management, in addition to pharmacological treatment (see
Table 1 for examples), and 2) studies evaluating specific
(i.e., single-element) psychosocial interventions (e.g., individual cognitive behavior therapy). In this article we reAm J Psychiatry 162:12, December 2005

view the extant literature on psychosocial interventions

for early psychosis in light of these two categories.

Search Strategy
A comprehensive search of the PsycINFO and MEDLINE
databases (January 1983 to October 2004) was conducted
by using the following terms: 1) first-episode schizophrenia and psychosocial treatment (or therapy or treatment), 2) first-episode psychosis and psychosocial
treatment (or therapy or treatment), and 3) early psychosis and psychosocial treatment (or therapy or treatment). The results were evaluated for relevance, and only
the studies evaluating psychosocial interventions for firstepisode psychosis were selected for review. Specifically, we
selected papers that quantitatively evaluated multielement
interventions, individual cognitive behavior and supportive therapy approaches, and group and family interventions. The designs of the studies reported in the selected
articles included experimental/randomized-controlled
(i.e., comparing outcomes in randomized groups), quasiexperimental (i.e., comparing outcomes in nonrandomized groups), and single-group (i.e., evaluating change over
time in one group of individuals receiving treatment).
Studies that compared subgroups of patients within a particular intervention or program (e.g., patients with short
durations of untreated psychosis versus patients with long
durations of untreated psychosis) were excluded. Finally,
to ensure that our search was as comprehensive and current as possible, we also conducted independent searches
for recent publications by leading psychosocial researchers
in the field of early psychosis (e.g., Addington, Birchwood,
Edwards, Jackson, Lewis, Linszen, Malla, McGorry, Morrison, Tarrier). The findings of all of the selected studies are
summarized in Table 2 (multielement studies) and Table 3
(single-element studies).
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PSYCHOSOCIAL TREATMENT
TABLE 2. Summary of Studies Evaluating the Effectiveness of Comprehensive (i.e., Multielement) Treatment for Early Psychosis
Subjects

Study
McGorry et al.,
1996 (56)
Power et al.,
1998 (57)
Carbone et al.,
1999 (58)
Malla et al.,
2001 (59)
Malla et al.,
2002 (60)
Malla et al.,
2002 (61)
Addington and
Addington,
2001 (62)
Addington
et al., 2003
(33)
Addington
et al., 2003
(46)
Addington
et al., 2004
(63)
Mintz et al.,
2004 (64)
Larsen et al.,
2001 (65)

Descriptionb
Nonaffective or
affective firstepisode psychosis
231 (longitudinal Nonaffective or
data on 120)
affective firstepisode psychosis
250
Nonaffective or
affective firstepisode psychosis
41
Nonaffective firstepisode psychosis
N

102

85 (longitudinal Nonaffective firstdata on 53)

episode psychosis
66
Nonaffective firstepisode psychosis
93
Nonaffective firstepisode psychosis

Design
Interventionc
Comparison Group(s)d
QuasiEarly Psychosis Prevention Before EPPIC (historical
experimental
and Intervention Centre
control)
(EPPIC)
Single group
EPPIC
QuasiEPPIC
experimental
Single group

Before EPPIC (historical

control)

Follow-Up
Period
(months)
12
3
12

Single group

Prevention and Early

Intervention Program
for Psychosis (PEPP)
PEPP

12

Single group

PEPP

12

Single group

Calgary Early Psychosis

Program

12

12

180

Nonaffective firstepisode psychosis

Single group

Calgary Early Psychosis

Program

12

177

Nonaffective firstepisode psychosis

Single group

Calgary Early Psychosis

Program

12

238

Nonaffective firstepisode psychosis

Single group

Calgary Early Psychosis

Program

12

180

Nonaffective firstepisode psychosis

Nonaffective firstepisode psychosis

Single group

109

Calgary Early Psychosis

Program
QuasiEarly Treatment and
experimental
Identification of
Psychosis (TIPS) project

Cullberg et al.,
2002 (66)i

297

Nonaffective or
affective firstepisode psychosis

QuasiIntegrated treatment
experimental
(Parachute Project)

Nordentoft
et al., 2002
(67, 68)j

341

Nonaffective firstepisode psychosis

Randomized,
controlled
trial

Integrated treatment
(OPUS Project)

12
Before TIPS (historical
control)

None

Before Parachute
Project (historical
control); inpatient
treatment as usual
(prospective control)
Outpatient treatment
as usual (prospective
control)

12

12

Better denotes that patients in the intervention program did significantly better than the comparison group(s) in studies with an experimental or quasi-experimental design or that there was significant improvement over time in studies with a single-group design. No group
differences denotes no significant difference between the intervention and comparison groups in studies with an experimental or quasiexperimental design or that there was no change over time in studies with a single-group design.
b Nonaffective first-episode psychoses were schizophrenia spectrum disorders. Affective first-episode psychoses were mood disorders with psychotic features.
c The elements of the EPPIC, PEPP, Calgary, and TIPS interventions are shown in Table 1.
d Care before the multielement program typically consisted of standard inpatient services, limited outpatient services, limited emphasis on
phase-specific psychosocial treatment, and limited outreach and early detection efforts.
e Measures were the Brief Psychiatric Rating Scale, the Scale for the Assessment of Positive Symptoms, and the Positive and Negative Syndrome Scale.
f Measures were the Scale for the Assessment of Negative Symptoms and the Positive and Negative Syndrome Scale.
g Measures were the Quality of Life Scale, the Wisconsin Quality of Life Index, and the Global Assessment of Functioning Scale.

Multielement Interventions
Multielement programs offer a comprehensive array of
specialized in- and outpatient services designed for individuals experiencing first-episode psychosis, and they
emphasize both symptomatic and functional recovery.
Further, many of the issues that are particularly problematic among young individuals experiencing psychosis

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(e.g., substance abuse, suicidality, engagement with the

mental health system) are addressed through a variety of
targeted therapeutic approaches. Table 1 provides general
information about several multielement programs and
their respective components (for a full description of these
and additional programs, see reference 55).
The Early Psychosis Prevention and Intervention Centre
in Australia is an exemplar of multielement care for firstAm J Psychiatry 162:12, December 2005

PENN, WALDHETER, PERKINS, ET AL.

Outcome With Interventiona

Positive Symptomse
Negative Symptomsf
No group differences Better

Relapse/
Hospitalizations
Better

Social
Functioning/
Quality of Lifeg
Better

Better

No difference

Better

63% in remission at follow-up; reduction in

aggression and self-harm behaviors

Better

Only EPPIC patients with midrange duration

of untreated psychosis (16 months) had
better outcomes on Quality of Life Scale

Better

Better

Better

Better

Better

Better

70% in remission at follow-up

Better

Better

Better

74% in remission at follow-up; improvements

in cognitive functioning
Reductions in hallucinogen, cannabis, and
alcohol use (among heavy users)

Better

No difference

Improvements in depression

Better

Reduction in parasuicidal behavior; patients

who attempted suicide before program
made no further attempts
Improvements in insight

No group differences No group differences

Better (Parachute
Project)

Better

Better

Other/Commenth
Reduced trauma associated with psychosis
and hospitalization

TIPS more successful at early identification of

psychosis; shorter median duration of
untreated psychosis in TIPS group (4.5
weeks versus 26 weeks)
Better (Parachute Project High level of consumer satisfaction in
and prospective
Parachute Project group
control)
Better

Less hopelessness in OPUS group; suicidal

ideation and attempts reduced in both
groups

h Trauma

symptoms were measured by the Structured Interview for PTSD. Aggression/self-harm symptoms were measured by the Health of
the Nation Outcome Scale and medical records. Cognitive functioning was measured by the WAIS-III, Wechsler Memory Scale, 3rd ed., Wisconsin Card Sorting Test, National Adult Reading Task, Paced Auditory Serial Addition Task, Continuous Performance Test, and Word Fluency
Test. Substance use was measured by case manager ratings. Depression was measured by the Calgary Depression Rating Scale for Schizophrenia. Insight was measured by item G12 from the Positive and Negative Syndrome Scale. Hopelessness was measured by the Schedules
for Clinical Assessment in Neuropsychiatry interview (version 2.0).
The Parachute Project entailed collaboration between multiple clinics in Sweden, with treatment consisting of comprehensive outpatient
services (low-dose atypical antipsychotics, individual and family therapy), available overnight crisis home (in place of inpatient ward), case
management, and continuity of care. The historical control consisted of conventional antipsychotic medications and supportive therapy,
and the prospective control consisted of inpatient treatment as usual (low-dose atypical antipsychotic medications, no phase-specific psychosocial treatment).
The OPUS Project group received comprehensive outpatient services (low-dose atypical antipsychotics, family psychoeducation and therapy,
social skills training) and assertive community treatment. The control group received standard treatment at community mental health centers.

episode psychosis and consists of a mobile assessment

and treatment team; a 16-bed inpatient unit; in- and outpatient case management (including housing and vocational assistance); individual, group, and family therapy;
pharmacological management (emphasizing low doses of
atypical antipsychotic medication as first-line treatment);
and specialized treatment for individuals with persistent
psychotic symptoms. The Prevention and Early IntervenAm J Psychiatry 162:12, December 2005

tion Program for Psychosis and the Calgary Early Psychosis Program are additional examples of established early
intervention centers (55). There have also been several
large-scale efforts to evaluate the effectiveness of multielement treatment approaches for early psychosis delivered in the context of existing systems of care. For example, the Early Treatment and Identification of Psychosis
project is a prospective, longitudinal 5-year study investihttp://ajp.psychiatryonline.org

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PSYCHOSOCIAL TREATMENT
TABLE 3. Summary of Studies Evaluating the Effectiveness of Specific (i.e., Single-Element) Treatments for Early Psychosis
Subjects
Treatment Length/
Follow-Up Period
5 weeks; booster
sessions over 4
months

Descriptionb
Nonaffective early
psychosis (first
episode or <5 years
since first episode)
Lewis
309 Nonaffective early
et al.,
psychosis (83% with
2002 (70)
first episode)
Tarrier
225 Nonaffective early
et al.,
psychosis (83% with
2004 (71)
first episode)

Design
Randomized,
controlled trial

Interventionc
Individual cognitive behavior therapy (CBT)

Comparison Condition(s)c,d
Supportive counseling

Randomized,
controlled trial

Individual CBT

Supportive counseling,
routine care

Randomized,
controlled trial

Individual CBT

Supportive counseling,
routine care

Jackson
et al.,
1998 (72)

80

Nonaffective or
affective firstepisode psychosis

Jackson
et al.,
2001 (73)

51

Nonaffective or
affective firstepisode psychosis

Power
et al.,
2003 (74)

56

EPPIC services without CBT 12 months

Quasi-experimental Individual CBTj at Early
Psychosis Prevention
(refusers); EPPIC inpatient
(median=
and Intervention Centre
care only, no post19 sessions)
(EPPIC)
discharge services (control)
Quasi-experimental Individual CBTj at EPPIC
EPPIC services without CBT 12-month follow(refusers); EPPIC inpatient
up of 1998
care only, no postJackson et al.
discharge services (control)
study (72)
Randomized,
Individual CBT targeting EPPIC services without CBT 810 sessions; 6(control)
month follow-up
controlled trial
suicidalityk at EPPIC

Study
Haddock
et al.,
1999 (69)

N
21

Nonaffective or
affective firstepisode psychosis
with acute suicidality
Jolley
21 Nonaffective early
Randomized,
Individual CBT
et al.,
psychosis (first
controlled trial
2003 (75)
or second episode)
Wang
251 Nonaffective firstRandomized,
Individual CBT
et al.,
episode psychosis
controlled trial
2003 (76)
Albiston
95 Nonaffective or
Quasi-experimental EPPIC group programl
et al.,
affective first1998 (77)
episode psychosis
Miller and
Mason,
2001 (78)
Lecomte
et al.,
2003 (79)
Linszen
et al.,
1996 (80)
Lenior
et al.,
2001 (81)
Lenior
et al.,
2002 (82)
Zhang
et al.,
1994 (83)
Lehtinen,
1993 (84)

77

Nonaffective firstepisode psychosis

Quasi-experimental Group therapy

Nonaffective firstepisode psychosis

Single group

Group CBT

76

Nonaffective early
psychosis

Randomized,
controlled trial

73

Nonaffective early
psychosis

Randomized,
controlled trial

73

Nonaffective early
psychosis

Randomized,
controlled trial

83

Nonaffective firstepisode psychosis

Randomized,
controlled trial

Behavioral family
therapy (and individual
therapy)m
Behavioral family
therapy (and individual
therapy)m
Behavioral family
therapy (and individual
therapy)m
Family therapyn

81

Nonaffective early
psychosis

Quasi-experimental Family-oriented
treatmento

5 weeks; booster
sessions over 3
months
18-month followup of Lewis et al.
study (70)

Routine care

6 months (mean=
11 sessions)

Routine care

2-year follow-up

EPPIC services without

groups

Multiple groups
per week; 6month follow-up

Individual therapy

Once per week for

2 years
Twice per week for
3 months

Individual therapy only

12 months

Individual therapy only

5-year follow-up of
study by Linszen
et al. (80)
5-year follow-up of
study by Linszen
et al. (80)
18 months

Individual therapy only

Routine care
Individual-oriented
treatment (historical
cohort)o

5-year follow-up

Better denotes that patients in the intervention program did significantly better than the comparison group(s) in studies with an experimental or quasi-experimental design or that there was significant improvement over time in studies with a single-group design. No group differences denotes no significant difference
between the intervention and comparison groups in studies with an experimental or quasi-experimental design or that there was no change over time in studies
with a single-group design.
b Nonaffective first-episode psychoses were schizophrenia spectrum disorders. Affective first-episode psychoses were mood disorders with psychotic features.
c The elements of the EPPIC intervention are shown in Table 1. Psychosocial treatments were always adjunctive to pharmacological treatment unless otherwise
noted.
d Routine care was primarily medication management.
e Measures were the Brief Psychiatric Rating Scale, Psychotic Symptom Rating Scales, Positive and Negative Syndrome Scale, and chart notes.
f Measure was the Scale for the Assessment of Negative Symptoms.
g Relapse was variably defined as change in patient management (per medical records), hospital admission, and score on Life Chart Schedule.
h Measures were the Quality of Life Scale, Global Assessment of Functioning Scale score, and Life Chart Schedule.
i Measures were the Beck Depression Inventory, Explanatory Model Scale (insight/beliefs about illness), Integration/Sealing Over Measure (adaptation to illness), Suicide
Ideation Questionnaire, Suicide Intent Scale, Reasons for Living Inventory, Beck Hopelessness Scale, Self-Esteem Scale, and Self-Report Problem-Solving Rating Scale.

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PENN, WALDHETER, PERKINS, ET AL.

Outcome With Interventiona

Positive Symptomse
No group differences

Negative
Symptomsf

Relapse/
Social Functioning/
Hospitalizationsg
Quality of Lifeh
No group

differences

No group differences

No group
differences

No group
differences

CBT better than

control

No difference between CBT

and supportive counseling,

which were both better
than routine care
No group differences
CBT better
than
control

Other/Commenti

CBT group improved nonsignificantly faster;

auditory hallucinations responded better to CBT
than to supportive counseling
Auditory hallucinations responded better to CBT
than to supportive counseling
Patients receiving CBT did better than refusers and
control subjects in adaptation to illness; CBT was
better than control for insight/attitudes toward
treatment
Patients receiving CBT did better than refusers in
adaptation to illness

No group differences

No group
differences

No group
differences

No group
differences

No group differences

No group
differences

Better

Targeted CBT was better than control for

hopelessness; both groups improved on suicidal
ideation and attempts

No group differences

No group
differences

CBT group spent less time in hospital

Better

Better

CBT was better than routine care for insight,

treatment adherence

No group
differences

No group
differences

At baseline, group participants had lower

premorbid functioning and nonsignificantly more
negative symptoms; group treatment was
associated with prevention of illness-related
deterioration
Group therapy associated with better treatment
adherence (i.e., fewer dropouts)

Group therapy associated with high treatment

satisfaction and decrease in psychotic symptoms

No group
differences

No group
differences

No group
differences

No group
differences

Family therapy associated with slightly higher

relapse rate (nonsignificant difference) among
families with low expressed emotion
Family therapy group spent less time in hospitals;
65% of all patients relapsed at least once in 5
years
No differential effect of family therapy on expressed
emotion

Better (in patients not

admitted to hospital)

Better

Better

Better

Better (in patients

not admitted to
hospital)

Family group spent less time in hospital

Family group spent less time in hospital

The program of cognitively oriented psychotherapy for early psychosis (COPE) consisted of individual therapy in conjunction with other EPPIC services. It promoted adjustment to illness, recovery, and stigma reduction and targeted associated depression and anxiety.
k This program, known as LifeSPAN, was conducted in conjunction with other EPPIC services and emphasized distress management, problem solving, self-esteem,
hopelessness, warning signs, and aftercare planning.
l Content areas included vocational skills, creative expression, social and recreational skills, health promotion, and personal development.
m Behavioral family therapy emphasized communication skills training and reduction of high expressed emotion.
n Family therapy consisted of family groups and individual family therapy sessions, and emphases included psychoeducation, identification of warning signs,
stress management, importance of attributing maladaptive behavior to illness, communication skills training, and reduction of high expressed emotion.
o In the family-oriented treatment, family therapy was primary, with emphasis on crisis intervention, systemic factors, life difficulties, and short-term treatment. In
the individual-oriented treatment, individual dynamic therapy was primary, with focus on intrapsychic factors and long-term treatment.

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PSYCHOSOCIAL TREATMENT

gating whether early detection and treatment of psychosis

can lead to better long-term outcomes (85). A quasi-experimental design is comparing outcomes among individuals with nonaffective first-episode psychosis at three
sites: 1) Rogaland, Norway, 2) Oslo, Norway, and 3) Roskilde, Denmark. All three sites offer multielement care, including individual supportive therapy, family work, case
management, and pharmacological treatment; however,
only the Rogaland site includes specialized early detection
and community outreach efforts. Additional efforts to evaluate multielement models of care include the Parachute
Project in Sweden, a collaboration among multiple psychiatric clinics to adapt and implement comprehensive firstepisode services (i.e., low-dose atypical antipsychotic
treatment, case management, individual and family therapy, and access to overnight crisis homes as an alternative
to hospitalization) (66), and the OPUS Project in Denmark,
which evaluated the effectiveness of comprehensive, integrated care across a variety of treatment modalities (i.e.,
low-dose atypical antipsychotic treatment, assertive community treatment, family psychoeducation, and social
skills training) (67, 68). Indeed, the multielement model of
care for early psychosis has been in existence for only a little over a decade but has already garnered significant research support across a variety of programs.
Examination of Table 2 reveals that only one randomized, controlled trial of a multielement intervention has
been conducted thus far (67, 68). While additional programs are currently being evaluated in randomized, controlled designs, e.g., at the Early Psychosis Prevention and
Intervention Centre (55), the majority of published research in this area has utilized quasi-experimental and
single-group designs to evaluate program effectiveness.
Thus, the findings should be viewed with caution. Nevertheless, data emerging from these interventions have been
encouraging.
A review of Table 2 indicates that multielement interventions for early psychosis have been associated with symptom reduction and/or remission (33, 56, 57, 5961, 68), improved quality of life and social functioning (46, 56, 58, 59,
61, 68), improved cognitive functioning (61), reduced duration of untreated psychosis (65), low rates of inpatient
admissions (56, 60, 66), improved insight (64), high level of
satisfaction with treatment (66), less time spent in the hospital (56, 66), decreased substance abuse (62), fewer selfharm behaviors (57, 63, 67), and reduced trauma secondary to psychosis and hospitalization (56). It should be
noted that the foregoing results primarily refer to 1-year
outcomes; longer-term benefits conferred by multielement programs have not been widely reported. Finally, a
recent study suggests that these comprehensive and specialized first-episode services are likely to yield superior
outcomes (e.g., shorter duration of untreated psychosis,
fewer inpatient admissions, less time in the hospital) when
compared with generic mental health services (86).

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Single-Element Interventions
Single-element studies have evaluated the effectiveness
of specific psychosocial interventions, rather than assessing the effects of a comprehensive, multielement intervention as a whole. That is, these studies sought to measure
the relative utility of various adjunctive psychosocial interventions in the treatment of early psychosis. These interventions were offered in addition to pharmacological treatment and, in some cases, other services as well (e.g., case
management). Examination of Table 3 reveals that several
randomized, controlled trials have been conducted with
respect to individual cognitive behavior therapy in early
psychosis, but less controlled research has evaluated group
and family interventions. Findings from many of these
studies have been promising, and the results are discussed
in more detail in the following sections.

Individual Therapy
Individual therapy for first-episode psychosis has been
examined both for facilitating recovery from acute psychosis and for improving longer-term outcome following remission of acute psychosis. With respect to the former, the
Study of Cognitive Reality Alignment Therapy in Early
Schizophrenia was a large, multisite randomized, controlled trial of cognitive behavior therapy for recent-onset
acute psychosis. On the basis of a pilot study by Haddock et
al. (69), Lewis and colleagues (70) randomly assigned 309
individuals who had either a first (83%) or second psychiatric admission for psychosis to 5 weeks of cognitive behavior
therapy and routine care, supportive counseling and routine care, or routine care alone. While all groups improved
over the course of treatment, the group receiving cognitive
behavior therapy improved nonsignificantly faster. Further,
auditory hallucinations improved significantly faster in that
group than in the group receiving supportive counseling.
There were no significant group differences, however, in
symptoms at the end of treatment. At 18-month follow-up,
Tarrier and colleagues (71) found that both cognitive behavior therapy and supportive counseling were significantly better than routine care in reducing symptoms. Further, auditory hallucinations responded better to cognitive
behavior therapy than to supportive counseling. However,
there were no group differences in relapse rates, with high
overall rates of relapse across the total study group. Tarrier
et al. hypothesized that the short duration of treatment, a
failure of treatment effects to generalize outside the hospital, potential exposure to environmental stressors after discharge, and the tendency for relapse to accumulate over
time in first-episode psychosis may explain the lack of an
impact on relapse conferred by cognitive behavior therapy
or supportive counseling. Nevertheless, these results suggest that individual therapy (i.e., cognitive behavior therapy
or supportive counseling) may have beneficial long-term
effects on symptoms in early psychosis.
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PENN, WALDHETER, PERKINS, ET AL.

Promising results have also been reported with respect

to cognitive behavior therapy conducted during the period of recovery following reduction of acute psychotic
symptoms. Jackson and colleagues (72) conducted a prospective study of cognitively oriented psychotherapy for
early psychosis with 80 individuals in the Early Psychosis
Prevention and Intervention Centre program who were
experiencing nonaffective or affective first-episode psychosis. Cognitively oriented psychotherapy for early psychosis promoted adjustment to the illness, helped individuals resume developmental tasks, and focused on overall
recovery, in addition to targeting secondary morbidity
(i.e., depression, anxiety). Forty-four individuals received
cognitively oriented psychotherapy as part of their outpatient care, 21 refused but received all of the centers other
services, and 15 individuals received inpatient care only
with no additional services following discharge (they were
designated the control group). At the end of treatment, the
patients receiving cognitively oriented psychotherapy
performed significantly better than the control group on
measures of insight and attitudes toward treatment, adaptation to illness, quality of life, and negative symptoms,
but they significantly outperformed the refusal group only
with respect to adaptation to illness. There were no significant differences in relapse rates among the three groups.
At 1 year following treatment, the group receiving cognitively oriented psychotherapy maintained significantly
better adaptation to their illness than the refusal group;
however, the group differences were not maintained for
the other outcomes, and there were no group differences
in relapse rate or time to readmission (73). These findings
are based on a quasi-experimental design and need to be
interpreted with caution; nevertheless, the results suggest
that individual cognitive behavior therapy may be beneficial in assisting patients to adjust to the experience of psychosis following remission of first-episode symptoms.
Individual cognitive behavior approaches have been
developed to target specific challenges facing patients experiencing first-episode psychosis, such as suicidality,
substance abuse, and persistent symptoms. In a study focusing on suicidal ideation and behavior in early psychosis, Power and colleagues (74) randomly assigned 56
suicidal individuals with nonaffective or affective firstepisode psychosis in the Early Psychosis Prevention and
Intervention Centre program to either LifeSPAN therapy
plus the centers other services or regular services without
LifeSPAN therapy. LifeSPAN therapy is based on cognitively oriented psychotherapy for early psychosis as well
as cognitive therapy for suicide, and it emphasizes distress
management, problem-solving skills, identification of
warning signs, and development of an aftercare plan. In
addition, low self-esteem and feelings of hopelessness are
specifically targeted. In this study, both groups improved
on ratings of suicidal ideation and number of suicide attempts. However, the results showed an advantage for
LifeSPAN therapy on self-reported hopelessness and qualAm J Psychiatry 162:12, December 2005

ity of life at both 10 weeks posttreatment and 6-month follow-up. Power et al. concluded that adding cognitive behavior therapy to treatment for first-episode psychosis
may lead to significant improvements in factors associated with suicide, such as hopelessness.
Edwards and colleagues at the Early Psychosis Prevention and Intervention Centre have developed cognitive
behavior interventions targeting substance use and persistent psychotic symptoms (87, 88). One intervention
focuses on reducing problematic cannabis use in individuals with first-episode psychosis and consists of psychoeducation, motivational interviewing, goal setting, and
discussion about goal achievement and relapse prevention. A randomized, controlled trial comparing the cannabis and psychosis intervention with psychoeducation
alone was conducted, and the preliminary results suggested that cannabis use in both groups decreased, with
no clear advantages for the cannabis and psychosis intervention over psychoeducation alone (89). Edwards and
colleagues have also developed systematic treatment of
persistent psychosis, given that approximately 20% of individuals with first-episode psychosis may experience
persistent psychotic symptoms (40). This therapy is based
on the cognitively oriented psychotherapy for early psychosis at the Early Psychosis Prevention and Intervention
Centre and is designed to facilitate recovery in patients experiencing persistent positive symptoms. A randomized,
controlled trial evaluating the relative and combined effects of clozapine and systematic treatment of persistent
psychosis in the treatment of individuals with persistent
symptoms is currently being conducted at the Early Psychosis Prevention and Intervention Centre (88).
Other randomized, controlled studies of individual cognitive behavior therapy for first-episode psychosis have
demonstrated the following benefits over routine care:
fewer days spent in the hospital (75), reduced psychotic
symptoms, fewer hospital admissions, increased insight,
and better treatment adherence (76). The foregoing findings suggest that individual cognitive behavior therapy
may provide some benefits in the treatment of first-episode psychosis, especially in the areas of symptom reduction, adaptation to ones illness, and improvements in
subjective quality of life. Most studies have not shown individual therapy to be effective in reducing relapses or rehospitalizations. Finally, the long-term findings are mixed;
the follow-up data reported thus far have demonstrated
some long-term benefits associated with individual therapy (e.g., references 71 and 73) but also suggest that some
of the initial gains made in treatment may not persist over
time (e.g., reference 73).

Group and Family Treatment

Unlike individual therapy, group treatment for first-episode psychosis does not appear to have been examined for
efficacy in randomized, controlled studies. Quasi-experimental research has demonstrated benefits of group therhttp://ajp.psychiatryonline.org

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PSYCHOSOCIAL TREATMENT

apy with respect to prevention of illness-related deterioration and disability, especially for individuals with poor
premorbid functioning (77). Additional uncontrolled
studies have shown improved treatment adherence (78)
and increased treatment satisfaction (79) associated with
group participation. However, given the uncontrolled nature of these studies, these findings need to be interpreted
with caution.
Family therapy for first-episode psychosis has been
more systematically investigated. Linszen and colleagues
(80) randomly assigned 76 outpatients to 12 months of behavioral family therapy (focusing on communication and
problem-solving skills training) plus individual-oriented
treatment (focusing on relapse prevention and psychoeducation) or individual-oriented treatment without family
therapy. Both groups had recently been discharged after 3
months of inpatient treatment emphasizing integrated
psychosocial and pharmacological treatment, and they
were currently receiving outpatient medication management. After 1 year, there was no differential effect of the
family treatment on relapse; the two groups had similar
relapse rates, and the overall relapse rate was low (i.e.,
16%). Five-year follow-up (81, 82) also indicated no added
benefit of family treatment over individual treatment for
relapse rates, and it showed that 65% of the patients in the
total group with nonchronic symptoms relapsed at least
once over the course of 5 years. In addition, this study
showed no differential effect of family treatment on social
functioning or expressed emotion. However, individuals
who received family treatment spent significantly less
time in hospitals and/or shelters.
Other research on family therapy for early psychosis has
demonstrated more positive results. For example, Zhang
and colleagues (83) randomly assigned 83 outpatients with
first-episode psychosis to 18 months of family therapy and
routine care or to routine care alone. The family therapy intervention consisted of family groups and individual family
therapy sessions, and it emphasized psychoeducation,
identification of warning signs, stress management, the importance of attributing maladaptive behavior to the illness
(rather than to personality or laziness), communication
skills training, and reduction of high expressed emotion
(i.e., decreasing familial criticism, hostility, and overinvolvement). There was contact with the families at least
once every 3 months, and families who did not attend appointments were visited in their homes. The results showed
that the family intervention was associated with a significantly lower rate of hospital readmissions and fewer days
spent in the hospital. Indeed, the authors concluded that
the patients not receiving the family intervention were 3.5
times as likely to be readmitted to the hospital during the
study period as the patients who did receive family therapy.
This effect remained even after differences in medication
compliance were controlled for. Further, the patients receiving family therapy who were not readmitted to the hospital demonstrated significant improvements in positive

2228

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symptoms and social functioning. Additional research has

shown similar favorable outcomes associated with family
treatment, such as fewer hospital admissions, less time
spent in the hospital, and symptom reduction (84).
Thus, while some research has indicated that family interventions in early psychosis are beneficial with respect to
reducing relapse and improving clinical and functional status (e.g., reference 83), other findings have not been as encouraging (e.g., reference 80). More empirical work needs
to be done before any firm conclusions can be made.
Finally, Drury and colleagues (90, 91) specifically evaluated the effects of a multimodal treatment approach combining individual and group cognitive behavior therapy
with family therapy in the treatment of recent-onset acute
psychosis. In a randomized, controlled trial, the combination treatment, compared with basic support and recreational activities, yielded faster and greater improvements
of positive symptoms, reduced recovery time by 25%50%,
and led to improvements in insight, dysphoria, and lowlevel psychotic thinking (e.g., suspiciousness). In a 5-year
follow-up, Drury et al. (92) found enduring positive effects
for the combination therapy group relative to the control
group; however, these benefits were predominantly observed in individuals who had experienced at most one relapse over the course of follow-up. The long-term benefits
in this subgroup included fewer positive symptoms, less
delusional conviction and thought disorder, and better
subjective control over illness. While these findings are
positive, this study has been criticized for methodological
flaws in its design, such as nonblinded assessments (93)
and baseline differences in medication doses between the
two groups (94).

Discussion
The findings reviewed suggest that adjunctive psychosocial interventions for patients experiencing early psychosis are beneficial across a variety of domains and can
assist with symptomatic and functional recovery. Research on multielement interventions indicates that following an initial episode of psychosis, these comprehensive treatment approaches may positively influence shortterm outcomes, such as clinical status and social functioning, as well as time spent in the hospital and likelihood of
hospital readmission. However, as noted in another recent
review of this area (53), most of the research on multielement programs is based on quasi-experimental designs
using historical (56, 58, 65, 66) or prospective (66) comparison groups or on single-group designs, which track the
progress of one group over a specified period of time (33,
46, 57, 5964). Indeed, there is still a paucity of randomized, controlled research in this area; thus, these findings
need to be interpreted with caution. Other methodological issues making interpretation of these results challenging include subject heterogeneity (e.g., affective versus
nonaffective first-episode psychosis) and varying definiAm J Psychiatry 162:12, December 2005

PENN, WALDHETER, PERKINS, ET AL.

tions for certain outcomes, such as relapse and remission,

across studies.
One important caveat regarding multielement interventions is that the scope of these programs makes them difficult to implement on a widespread basis, particularly in
countries whose public health care systems do not support the necessary infrastructure or do not recognize best
treatment practices for early psychosis (95). Indeed, given
the wide range of services offered in these programs, it
would be helpful to isolate the effective ingredients
when evaluating a programs utility. Understanding which
elements are critical can help inform program development in areas currently lacking such specialized first-episode treatment services. Thus, the current findings in this
area point to two important future research directions: 1) a
greater number of randomized, controlled designs to provide a more stringent test of the efficacy of multielement
programs and 2) utilization of research designs that will allow one to deconstruct the key ingredients of these programs and to determine the specific types of patients for
whom these services are particularly beneficial. Single-element studies can be quite helpful in this regard.
With respect to research on single-element interventions, support for individual cognitive behavior therapy in
early psychosis is modest yet encouraging, especially regarding symptom improvements (particularly positive
symptoms), adaptation to ones illness, and increased subjective quality of life (e.g., references 7174). In addition,
the majority of studies evaluating individual cognitive behavior therapy have used randomized, controlled designs.
However, individual therapy has not been shown to be effective in reducing relapse or rehospitalization in early
psychosis, and some findings suggest that early treatment
gains may not be maintained over time.
No firm conclusions can yet be drawn from the literature on group and family therapies for this population.
Group therapy is a widely used treatment modality for
early psychosis, but to our knowledge, no randomized,
controlled trials have been conducted. Research findings
on family therapy in early psychosis have been mixed,
with some studies documenting benefits with respect to
symptoms, social functioning, and likelihood of rehospitalization (e.g., reference 83) and other studies having less
favorable results (e.g., reference 80). One possible interpretation of these findings is that family interventions are
indeed beneficial to individuals with early psychosis although they may not add significant benefit above and beyond concurrent individual therapy. Additional well-controlled research is needed to clarify the impact of family
and group therapy in first-episode psychosis.
In general, while the research done to date on specific
(i.e., single-element) psychosocial treatments for early
psychosis is promising, there are few robust findings.
Many of the aforementioned single-element studies were
conducted in the context of large multielement programs
(e.g., references 7274); it is therefore difficult to yield roAm J Psychiatry 162:12, December 2005

bust additive effects of a specific intervention, when such

a large degree of improvement is likely due to the impact
of the program as a whole. Further, as with the literature
on multielement treatments, significant obstacles to
drawing broader conclusions with respect to specific psychosocial treatments for first-episode psychosis include
the paucity of well-controlled studies, as well as methodological variation among studies (e.g., study group composition, definitions for remission and relapse).
Future work should take an increasingly integrative approach to psychosocial treatment, drawing on a variety of
empirically validated treatment approaches to address the
variety of challenges that individuals with first-episode psychosis experience (e.g., positive and negative symptoms,
medication adherence, substance use, functional impairments). Indeed, future studies should place more emphasis
on measuring functional recovery (i.e., social, work, and
school functioning, recreation, and social relationships
[96]) both during and after treatment. Despite demonstrated short-term benefits, the ability of psychosocial interventions delivered early in psychosis to effect long-term
improvement, particularly with respect to social/occupational disability, is still unknown. Additional longitudinal
research is needed to shed light on this question.
Some findings suggest that many of the initial benefits
achieved in treatment may not be maintained over time in
patients with first-episode psychosis (97). This may be addressed through greater efforts to improve ongoing engagement with available services (which is a significant
challenge in the field of early psychosis [e.g., reference 98])
and to lengthen the duration of active interventions, if necessary. Studies of individuals with chronic schizophrenia
suggest that longer-term treatments are often associated
with more favorable outcomes (99). In addition, naturalistic studies of psychological treatments for a variety of nonpsychotic disorders have demonstrated that patients tend
to show greater degrees of improvement with longer periods of treatment (100). Clinicians and researchers alike
should utilize these findings to inform the delivery of psychosocial interventions in early psychosis. Ideally, these efforts will be successful at improving both short- and longterm outcomes, thus reducing the morbidity and mortality
so often associated with this devastating illness.
Received Jan. 19, 2004; revision received Jan. 3, 2005; accepted
Jan. 6, 2005. From the Department of Psychology and the Department of Psychiatry, University of North Carolina; the Department of
Psychiatry, Dartmouth Medical School, Hanover, N.H.; and the Department of Psychiatry, Columbia University College of Physicians
and Surgeons, New York. Address correspondence and reprint requests to Dr. Penn, Department of Psychology, CB#3270, Davie Hall,
University of North Carolina-Chapel Hill, Chapel Hill, NC 27599-3270;
[email protected] (e-mail).

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