Subtle motor, emotional, cognitive and behavioural abnormalities are often present in apparently healthy individuals who later develop schizophrenia, suggesting that some aspects of causation are established before overt psychosis.

To outline the development of schizophrenia.

We drew on evidence from The Northern Finland 1966 Birth Cohort supplemented by selected findings from other relevant literature.

The main known risk factors in development of schizophrenia are genetic causes, pregnancy and delivery complications, slow neuromotor development, and deviant cognitive and academic performance. However, their effect size and predictive power are small.

No powerful risk factor, premorbid sign or risk indicator has been identified that is useful for the prediction of schizophrenia in the general population.

Neurobiological studies of the early course of psychoses, such as schizophrenia, allow investigation of pathophysiology without the confounds of illness chronicity and treatment.

To review the recent literature on the biology of the early course of psychoses.

We carried out a critical appraisal of the recent findings in the neurobiology of early psychoses, using structural, functional and neurochemical imaging techniques.

Brain structural alterations are present early in the illness and may predate symptom onset. Some changes, notably those in frontal and temporal lobes, can progress during the early phases of the illness. Functional and neurochemical brain abnormalities can also be seen in the premorbid and the early phases of the illness. Some, although not all, changes can be trait-like whereas some others might progress during the early years.

A better understanding of such changes, especially during the critical periods of the prodrome, around the transition to the psychotic phase and during the early phases of the illness is crucial for continued research into preventive intervention strategies.

A major reason for interest in early intervention for psychotic disorders is the hypothesised relationship between longer duration of untreated psychosis (DUP) and poorer outcome of treatment.

To critically examine the evidence concerning DUP being related to treatment outcome and possible mediators of any such relationship.

A systematic review of studies in which DUP is assessed and its relationship to treatment outcome is examined. In addition, studies relevant to possible neurotoxic effects of DUP were reviewed.

The research is entirely of a correlational nature and, therefore, firm conclusions regarding causation are not possible. There is, however, substantial evidence of DUP being an independent predictor of treatment outcome, particularly remission of positive symptoms, over the first year or so of treatment. Findings regarding the possible neurotoxic effects of DUP are inconsistent.

There continues to be evidence consistent with DUP influencing aspects of treatment outcome. Non-correlational studies, such as quasi-experimental designs, could provide stronger evidence regarding causality.

Early detection programmes aim to reduce the duration of untreated psychosis (DUP) by public education and by prompt access to treatment via active outreach detection teams.

To determine whether those with first-episode psychosis in an early detection healthcare area with existing referral channels differ from those who access care via detection teams.

Those with first-episode psychosis recruited via detection teams were compared with those accessing treatment via conventional channels, at baseline and after 3 months of acute treatment.

Patients recruited via detection teams are younger males with a longer DUP a less dramatic symptom picture and better functioning; however they recover more slowly, and have more symptoms at 3-month follow-up.

After establishing low threshold active case-seeking detection teams, we found clear differences between those patients entering treatment via detection teams v. those obtaining treatment via the usual channels. Such profiling may be informative for early detection service development.

It is unclear whether an early detection programme increases or decreases the number of patients with a long duration of untreated psychosis (DUP), and whether these differ from other patients with a long DUP.

To investigate whether the number and characteristics of patients with a long DUP in the early detection programme differ from those with along DUP in the non-earlydetection programme.

We compared the number and characteristics of patients with a DUP $2 years in an early detection area and a non-early detection area.

The early detection programme recruited slightly fewer patients with a long DUP than the non-early detection programme. The patients in the early detection programme had lower PANSS scores, but more frequently had a deteriorating course of premorbid social functioning.

An early detection programme does not seem to drain a pool of previously undetected patients with a long DUP. The patients in the early detection programme seem to have a lower symptom level at baseline and to have had a deteriorating premorbid social course.

Clinical and research focus has recently shifted from established psychotic disorders to first-episode psychosis and the prepsychotic phase of illness.

To describe the principles, progress and dilemmas associated with the prospective detection, engagement and treatment of young people at risk of developing a psychotic disorder.

Strategies to identify young people at heightened risk of a psychotic disorder are described. Preventive interventions and results of their evaluation are provided.

Well-validated criteria for identifying young people at heightened risk of psychosis have been developed, evidence of the efficacy of various psychological and pharmacological interventions in preventing progression has accumulated and progress towards the identification of clinical and neurobiological predictors of transition to acute psychosis has been made.

The detection, monitoring and treatment of young people in the prepsychotic phase is a growth area in psychiatry. The ethical considerations about treatment options, treatment of minors and provision of information about risk status must be treated with sensitivity if the potential benefit to many young people and their families is to be realised.

The Early Detection and Intervention Programme of the German Research Network on Schizophrenia (GRNS) investigates the initial prodromal phase of psychosis in a multidimensional approach. Two intervention strategies are being studied by two large-scale multicentre projects.

To present the concept of the intervention studies, and to provide an interim report of the recruitment procedure.

Comprehensive cognitive-behavioural therapy has been developed for patients in the ‘early initial prodromal state’. For patients in the ‘late initial prodromal state’ the atypical neuroleptic amisulpride is explored. Both interventions are evaluated in randomised controlled trials using clinical management as the control condition.

Between January 2001 and March 2003, 1212 individuals seeking help for mental health problems were screened for putative prodromal symptoms at four university centres. More than 388 individuals fulfilled criteria for both interventions and 188 (48. 5%) gave informed consent to participate in the trials.

The screening procedure appears to be feasible and trial participation seems to be acceptable to a relevant proportion of people at increased risk of developing psychosis.

The clinical picture of schizotypal disorders is rarely comprehensively described.

To describe psychopathological profiles of patients with ICD-10 schizotypal disorder.

A total of 151 first-admitted patients (with affective and somatic disorders excluded) were given a comprehensive psychopathological evaluation, including the Bonn Scale for the Assessment of Basic Symptoms. Patients with schizotypal disorder (n=50) were compared with those with psychosis (n=51) and those outside the schizophrenia spectrum (other diagnoses, n=50) on a number of psychopathological scales.

Patients with schizotypal disorder scored intermediately between patients with psychosis and other diagnoses on scales related to positive and negative symptoms, disorders of emotional contact and formal thought disorder, but had the same scores as patients with schizophrenia for subtle aberrations of subjective experience. Schizotypal criteria were not normally distributed with an excess of patients between 2 and 6 criteria. Family history of schizophrenia was equally elevated among those with schizotypal disorder and those with psychosis.

ICD-10 schizotypy represents a milder, less psychotic, variant of schizophrenia but there is no clear-cut division between the two disorders.

Contemporary cognitive psychological theories suggest that distress plays a mediating role in delusion formation.

To study the amplifying role of distress from early perceptual intrusions to delusion formation.

A general population sample of 7076 individuals was interviewed with the Composite International Diagnostic Interview (CIDI) in 1996 (baseline), 1997 (T1) and 1999 (T2). At T2, clinicians also scored the Brief Psychiatric Rating Scale (BPRS) item ‘unusual thought content’. Analyses compared hallucinatory experiences with and without subjective distress at baseline for risk of delusion formation at follow-up.

Individuals experiencing hallucinations with distress, compared with those without distress had a fourfold increased risk of subsequent delusion formation.

This finding corroborates the hypothesis that distress associated with early perceptual intrusions serves as a catalyst in the development of delusions.

The factors influencing the development of expressed emotion (EE) are still unclear. Understanding the carer and patient appraisals operating during the initial adaptation to psychosis may help to clarify the early ontogenesis of EE.

Fifty patients and key carers were followed-up over 9 months and their appraisals of loss and burden were measured in relation to the evolution of high emotional overinvolvement (EOI) and critical (CC) relationships.

The appraisal of loss was linked to high EOI but not high CC relationships at baseline. Loss reduced by 9-month follow-up in those changing from high EOI to high CC or low EE. Subjective burden of carers was linked to loss but not to EE status. Patients' and relatives' appraisals of loss were strongly correlated, particularly in high EOI relationships. Longer duration of untreated psychosis was associated with high CC.

The results are consistent with Bowlby's attachment theory, where EOI and coercive criticism maybe understood as adaptive reactions to perceived loss. Implications for family intervention in first-episode psychosis and the prevention of high EE are discussed.

An increased focus in research specific to first-episode schizophrenia has provided a rapidly growing body of evidence that can be directly translated to clinical practice.

To provide clinical recommendations specific to effective pharmacotherapy of first-episode schizophrenia.

Evidence from clinical trials focused on the first-episode population is combined with data from other areas of investigation.

In first-episode psychosis, when to initiate treatment is not always clear, being intimately linked to challenges regarding early detection and diagnosis. There may be differences in antipsychotic dosing, patterns of response and sensitivity to side-effects. Adherence appears to be even more problematic at this stage.

Clinicians currently treating early psychosis have considerably more information to guide their decision-making. However, the speed at which the field is growing is a reminder totreatthis knowledge as a work in progress.

The families of patients with first-episode psychosis often play a major role in care and often experience lack of support.

To determine the effect of integrated treatment v. standard treatment on subjective burden of illness, expressed emotion (EE), knowledge of illness and satisfaction with treatment in key relatives of patients with a first episode of schizophrenia-spectrum disorder.

Patients with ICD-10 schizophrenia-spectrum disorders (first episode) were randomly assigned to integrated treatment or to standard treatment. Integrated treatment consisted of assertive community treatment, psychoeducational multi-family groups and social skills training. Key relatives were assessed with the Social Behaviour Assessment Schedule (SBAS, burden of illness), the 5-min speech sample (EE), and a multiple choice questionnaire at entry and after 1 year.

Relatives in integrated treatment felt less burdened and were significantly more satisfied with treatment than relatives in standard treatment. There were no significant effects of intervention groups on knowledge of illness and EE.

The integrated treatment reduced family burden of illness and improved satisfaction with treatment.

Providing specialised services to individuals experiencing first-episode psychosis (FEP) is a relatively new endeavour.

To overview developing services for newly diagnosed cases of FEP and the context in which they develop.

This paper describes five model multi-element FEP programmes, outlines recent evaluation studies of FEP services, discusses current evidence gaps relating to the evaluation of complex interventions and specific interventions for FEP and illustrates attempts to examine aspects of clinical work practised at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia.

Considerable progress has been made in terms of influencing practice in the assessment and treatment of early psychosis.

There is need for quality clinical and research efforts to inform and accelerate progress in this burgeoning field.

Because early illness course and outcome may affect the long-term outcome of schizophrenia-spectrum disorders, it is especially important to address poor outcome in this early critical period.

To evaluate whether integrated treatment compared with standard treatment reduced the proportion of patients with poor clinical and social outcome after 1 year.

A total of 547 patients with first-episode psychosis were included in the study, 275 randomly assigned to integrated treatment and 272 to standard treatment. Measures assessed psychotic symptoms and social functioning.

There was a significant beneficial effect of integrated treatment v. standard treatment on ‘any poor outcome’. Integrated treatment had a significantly better effect on ‘any poor outcome’ in patients with schizophrenia compared with patients in standard treatment.

The integrated treatment significantly reduced the proportion of patients with poor clinical and social outcome compared with standard treatment.