New Guidelines for Psychosis Prevention

After 44 randomized trials, no treatment wins, but the clinic model itself does

STUDY: Solmi M et al, World Journal of Biological Psychiatry 2026

STUDY TYPE: Expert consensus guidelines with systematic evidence review

FUNDING: Independent

Background

Youth at high risk for psychosis fall into several categories:

1. Mild changes in perception or thinking that do not meet the clinical threshold for psychosis, eg paranoia, grandiosity, odd communication patterns, or mild perceptual abnormalities, like hearing an indistinct whisper or seeing a shadow out of the corner of the eye.
2. A full psychotic episode that is too brief to meet diagnostic criteria
3. Strong genetic risks for psychosis with a recent decline in functioning

The syndrome goes by various names: Prodromal psychosis, attenuated psychosis, and clinical high risk of psychosis. It is common (around 1 in 5 youth presenting for treatment). Left untreated, roughly 35% transition to a full psychotic disorder within 10 years.

These guidelines from the World Federation of Societies of Biological Psychiatry and EPI Canada synthesize the evidence on who to screen, how to assess risk, and what to offer.

The Study

• Systematic review of risk factors, assessment tools, transition rates, and 44 randomized controlled trials
• Meta-analyses and network meta-analyses pooled across interventions
• Evidence graded using the WFSBP framework; 12 recommendations voted on by an international author panel (consensus defined as ≥ 80% agreement)

Results

Several therapies may work, but the evidence is inconsistent so no single treatment earned a strong recommendation: CBT, omega-3 fatty acids, and antipsychotics.

However, when all interventions were pooled, they outperformed treatment as usual in multiple meta-analyses. And the clinic model itself works. Patients who passed through a Clinical High Risk Prevention service before their first episode had shorter duration of untreated illness and fewer involuntary hospitalizations than those who presented directly with first-episode psychosis.

Three organizational recommendations reached consensus:

• Clinical High Risk Prevention services work best when integrated with early psychosis programs to minimize untreated illness
• Services should accept patients ages 14 to 35
• Services should accept patients with cannabis use disorder

Other recommendations:

• Train staff to administer validated CHR interviews (CAARMS or SIPS).
• Screening whole populations or schools is not supported, as these tools only perform well in help-seeking clinical populations.
• Offer cannabis abstinence treatment
• Treat comorbid disorders (eg, bipolar disorder) using evidence-based guidelines for each
• Offer CHR-specific treatment based on patient preference and the “first do no harm” principle (eg, CBT, omega-3, antipsychotics).

Practice Implications

1. Among these treatments, CBT and omega-3 are the safest, while antipsychotics might be needed for more significant psychotic symptoms. The dose for omega-3 is similar to that used in depression, and quality products are listed here.
2. We are seeing high rates of psychotic symptoms on cannabis. Around 20-50% of these patients convert to a schizophrenia-like picture, with psychosis independent of cannabis. The younger the patient, the more potent the THC, the bigger the risk.
3. Besides the validated CAARMS and SIPS assessments, the Psychotic Spectrum Scale gives a good sense of what prodromal symptoms look like.

— Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

What’s Your Take? Share in Comments