Treating Patients With First-Episode Psychosis: Lessons From McLean OnTrack

In the United States, approximately 100,000 individuals experience first-episode psychosis (FEP) each year.^1,2 Patients with FEP benefit from enrolling in coordinated specialty care (CSC) clinics like McLean OnTrack. These multidisciplinary clinics can include psychiatrists, therapists, case managers, occupational therapists, and peer specialists. The Recovery After an Initial Schizophrenia Episode (RAISE) trial, a large multicenter study, demonstrated the benefits of the CSC model compared with usual care.³ However, the geographic reach of CSCs remains limited, and even in places where CSCs exist, there may be long waits to access care. More than 90% of patients with FEP are not enrolled in a CSC.¹ Here, we present some principles and lessons that we have learned in our CSC, McLean OnTrack, that can be applied by clinicians taking care of patients with FEP outside of a CSC.

Assembling a Team

It is best to recruit a team. Psychiatrists and therapists should seek out like-minded colleagues and form informal treatment teams when working with patients with FEP. Patients may be variably engaged with medication or psychotherapy, so having different people for these roles may increase the likelihood that a person engages with at least some treatment.

Patients with FEP are often high acuity. Having a team means more individuals are available to help in a crisis and can decrease the risk of burnout. Frequent communication between members of the treatment team is incredibly valuable. We recommend regular, scheduled team meetings, ideally at least once a month. The team can expand beyond the clinic’s borders. Patients with FEP may enroll in a college in another city or state, so it is advisable to connect with on-campus mental health resources and ensure lines of communication are open.

Medication Management

Medication guidelines for FEP emphasize the importance of using low doses of medication and, preferably, using medications with lower risks of adverse effects. In patients with FEP and intermittent adherence, long-acting injectable medications should be strongly considered. In patients who have had inadequate responses to at least 2 antipsychotic medications, we recommend clozapine. The recent elimination of the clozapine Risk Evaluation and Mitigation Strategy program will increase access to this underused and potentially lifesaving medication.

Patients with FEP are often concerned about how long they need to take medication. We discuss this with patients at our first meeting. Patients often attend an intake shortly after being discharged from a hospital on high doses of antipsychotic medication, and we are often able to make at least a small decrease early in the treatment. We counsel patients with nonaffective psychoses that some individuals can safely taper off antipsychotic medication, but that most do best when they take at least a small dose. If patients want to try tapering off, we support this after about a year of sustained remission. We encourage patients who taper off medications to remain in close contact with their prescribers. We counsel these patients that their symptoms may recur, and that if that happens, they should contact their psychiatrist, who will likely recommend a short course of antipsychotics.

For patients with affective psychoses, we recommend continuing to take a mood stabilizer medication. Here, we often transition from lithium or divalproex, effective medications with substantial adverse effect burden, to less effective but better-tolerated medications like lamotrigine. Medication adverse effects, and in particular metabolic effects, are a major contributing factor to nonadherence and can cause considerable morbidity. We have a low threshold for prescribing medications like glucagon-like peptide-1 receptor agonists or atomoxetine to help ameliorate adverse effects.

Psychosocial Treatment

In terms of psychosocial treatment, using a formulation-based method rather than a diagnosis-based method of assessing treatment needs makes sense due to the variation in symptom presentations in early psychosis care. The “5 Ps” approach of evaluating (1) presenting problems, (2) predisposing factors, (3) precipitating factors, (4) perpetuating factors, and (5) protective/positive factors captures the key elements necessary to an individualized conceptualization, which will guide the development of each patient’s treatment goals.⁴ Although each treatment plan is tailored to the individual patient and their unique strengths and needs, there are several common therapy and case management treatment goals (Table).

Psychotherapy can promote symptom stabilization beyond what can be achieved with medications alone, through lifestyle changes, communication style changes, stress management, and cognitive remediation. We suggest incorporating individualized relapse prevention planning, including identifying potential early warning signs to share with their support system. We incorporate psychoeducation about psychosis with emphasis on normalization to decrease stigma. Patients may need to process what occurred during their episode of psychosis. They often have negative feelings about things they did or said while experiencing psychosis, and they may have trauma from being hospitalized.

Additional Support

Above all, we support young adults in moving toward recovery as they define it for themselves, which often emphasizes functional recovery over complete symptom remission. We focus on reducing disruption to their lives as much as possible by supporting their goals of returning to work or school and reconnecting with social supports. Therapists and patients collaboratively identify and address potential barriers. We provide practical support in contacting the school and providing documentation for return from leave and academic accommodations. It is impossible to overestimate the potential demoralization of believing they may not be able to return to the school or work they had previously planned, and therefore, we focus on restoring a sense of agency.

Therapists can use a variety of techniques, including cognitive behavioral therapy (CBT), CBT for psychosis, individual resiliency training, acceptance and commitment therapy, and motivational interviewing interventions as appropriate.^5-7 Additionally, whenever possible, case management can help address concrete needs like health insurance, housing, and income. Vocational support can help with returning to school/job-seeking, and peer support groups can provide social contact and a sense of universality.

FEP usually occurs in people in their late teens or early 20s. Patients may be preparing to graduate high school, working their first job, or living away from home on a college campus. At this time, relationships between young adults and their parents are complicated and dynamic. Parents and their young adult children must navigate a complicated shifting of responsibilities and perspectives, and this navigation can be especially challenging with co-occurring psychosis. In McLean OnTrack, we balance 2 key principles. First, we involve families, most often parents, in the treatment. This involvement is always done with the patient’s positive consent and takes up only a small minority of treatment time. In the same way we recommend team meetings for clinicians, we also recommend them for families/support networks. For some people, these meetings are every week. More often, they occur a few times per year. Family meetings are opportunities to identify shared goals and track our progress. Second, we emphasize the difference between a parent and a clinician. Parents often feel a need to be highly involved in their children’s treatment, and their actions often backfire and engender negative feelings between the patient and their parents. Furthermore, parental involvement in treatment can cause the patient to identify the clinicians as aligned with the parents and in a parental-like role, which can make them less likely to be forthcoming about topics like medication adherence and cannabis use. Centering the patient with FEP as the authority and decision-maker around treatment choices may help ameliorate this risk. We often refer parents to the National Alliance on Mental Illness’ Family-to-Family program.

Cannabis Use

Over the past decade, there has been a dramatic expansion of legalized cannabis. Many patients come to our clinic having had months or even years of daily use. Cannabis is easily accessible and widely used by young adults. However, there is overwhelming evidence that cannabis use is linked to increased psychosis symptoms and worse outcomes.⁸ Patients with FEP often feel that it is unfair that they are being told to no longer use a substance that they have previously enjoyed, that their peers use without incident, and that society has told them is safe. Clinicians need to be aware of the importance of cannabis and ask about use regularly. Treating problematic cannabis use can be challenging. We recommend motivational interviewing and peer support groups, and we may offer supportive medications such as N-acetylcysteine. We take a harm-reduction approach, such as recommending products with low Δ-9-tetrahydrocannabinol, when patients choose to use.

Concluding Thoughts

We hope these approaches are useful to clinicians working with patients outside the CSC structure. The guiding principles of low medication, functional recovery, family involvement, and sobriety can be helpful for patients with FEP regardless of where they are seen.

Dr Murphy is a psychiatrist at McLean OnTrack and an assistant professor of psychiatry at Harvard Medical School.

Mr Nelson-Eliot is the program director at McLean OnTrack.

References

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2. Simon GE, Coleman KJ, Yarborough BJH, et al. First presentation with psychotic symptoms in a population-based sample. Psychiatr Serv. 2017;68(5):456-461.

3. Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program. Am J Psychiatry. 2016;173(4):362-372.

4. Macneil CA, Hasty MK, Conus P, Berk M. Is diagnosis enough to guide interventions in mental health? using case formulation in clinical practice. BMC Med. 2012;10:111.

5. Álvarez-Jiménez M, Parker AG, Hetrick SE, et al. Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis. Schizophr Bull. 2011;37(3):619-630.

6. Mueser KT, Penn DL, Addington J, et al. The NAVIGATE program for first-episode psychosis: rationale, overview, and description of psychosocial components. Psychiatr Serv. 2015;66(7):680-690.

7. Pena-Garijo J, Baeza-Mor T, Martinez-Raga J. Acceptance and commitment therapy applied to early psychosis: therapeutic foundations and a narrative systematic review. World J Psychiatry. 2025;15(8):107313.

8. Schoeler T, Monk A, Sami MB, et al. Continued versus discontinued cannabis use in patients with psychosis: a systematic review and meta-analysis. Lancet Psychiatry. 2016;3(3):215-225.