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Clinical staging models rest on the assumption that treatments that are offered earlier in the emergence of psychotic illness have the potential to be more effective, are safer and more affordable than those provided once illness has become entrenched. This chapter will introduce readers to clinical staging models and recent adaptations and consensus statements on the better provision of care for young people in the early stages of psychotic disorder. Trainees will learn about the potential benefits and risks of identifying and proactively treating individuals at risk of psychosis, will understand the evidence regarding the effectiveness of early intervention programs for psychosis, and be aware of challenges experienced in the implementation of early intervention services internationally and the benefits of including family and carers in treatment planning. The chapter will also discuss the multidisciplinary team make up of early intervention services, and gain a strong appreciation of the distinct contribution that psychologists—as research-practitioners—can provide in this context.

Although there is an increasing amount of literature on the key principles for the design of mental health services, the contribution of the built environment to outcomes for the service user is a largely neglected area. To help address this gap, we present evidence that highlights the pivotal role of evidence-based architectural design in service users' experience of mental health services. We propose six important design principles to enhance the care of mental health service users. Drawing on research into the delivery of mental health services and best-practice approaches to their architectural design, we outline a holistic conceptual model for designing mental health services that enhance treatment outcomes and experiences, provide benefits to families and the community, and promote community resilience. In this Personal View, we argue that the design of mental health services needs to extend across disciplinary boundaries to integrate evidence-informed practice across individual, interpersonal, and community levels.

AIM: Approximately 15 years ago, four youth access clinics (YACs) were established in the Gippsland region to improve mental and general healthcare for young people living in the region. The aim of the study was to examine the barriers and enablers for young people accessing the YACs in Gippsland. METHODS: Using qualitative methodology, nine female YAC staff members and seven youth YAC consumers were interviewed. Thematic analysis was utilized to identify important and consistent themes in the data derived through the consultation process. RESULTS: Barriers under four themes were identified: environmental (eg, limited transport); service (ie, limited opening hours); client (eg, parent permission) and staff (ie, retention of staff). Enablers were identified as environmental (ie, high social proximity), service (eg, funding), client (ie, awareness of service) and staff (eg, champion staff). CONCLUSION: The success of new rural service models will likely depend on learning from what has already worked in some of the many small communities in this region. Beyond learning, further success and uptake of new service offerings will be enhanced through understanding community needs, obtaining community support and enhancing high social proximity.

Recent studies have shown that neuropsychological assessment is a scarce resource in youth mental health settings. The need for neuropsychological assessment might differ in metropolitan and nonmetropolitan areas due to characteristics inherent to these different regions. However, no formal studies have investigated this question. The aim of this research was to investigate whether need for neuropsychological assessment in youth mental health settings varies by geographic location. A cross-sectional online survey was completed by clinicians (N = 532) treating or assessing adolescents and young adults attending Australian primary care mental health (headspace) centers. Results indicated a similar need for neuropsychological assessment across the geographic areas. However, neuropsychological assessment was significantly less available to clients in outer regional, remote and very remote areas compared to major cities. Exploratory analyses further revealed that there were significantly fewer clinicians with a postgraduate degree and more clinicians with a bachelor degree in outer regional, remote and very remote areas than in major cities. Given the negative impact of cognitive impairments in youth with a mental illness, these findings reveal a necessity to enhance the availability and access to neuropsychological assessment in rural settings. Several plausible avenues to achieving increased access include increasing the funding available for this resource; providing nonmetropolitan clinicians with sufficient neuropsychological consultation, including rural training and rotations in neuropsychologists' postgraduate training; and exploring the use of tele-health in the provision of neuropsychological assessments in nonmetropolitan settings.

Social inclusion is an important contributor to good mental health and greater mental health outcomes for people with psychiatric disorders. A psychometrically-sound measure of social inclusion is required to facilitate progress in this area. The aim here was to report on preliminary findings from a novel, user-friendly measure of social inclusion that comprehensively assesses the construct. Preliminary testing of the Filia Social Inclusion Measure (F-SIM) was conducted with ninety participants (30 consumers; 30 family members/carers; 30 community members). Participants completed the self-report measure and a usability questionnaire. Preliminary findings demonstrated poorer social inclusion for people with mental illness compared to those without, with differences seen in each of five domains (housing and services, social functioning, occupational functioning, finances and health). Differences were also seen regarding family members or carers, with consistently poorer social inclusion than general community members observed. Participants reported the F-SIM as easy to use, and considered it to measure social inclusion well, indicating good face validity. The F-SIM demonstrates an ability to differentiate between groups. Implications for use and suggestions for future research are detailed. Following further psychometric assessment, the F-SIM will have wide applicability in clinical and research settings.

The poor physical health of people with mental illness is a multifaceted, transdiagnostic, and global problem. People with mental illness have an increased risk of physical disease, as well as reduced access to adequate health care. As a result, physical health disparities are observed across the entire spectrum of mental illnesses in low-income, middle-income, and high-income countries. The high rate of physical comorbidity, which often has poor clinical management, drastically reduces life expectancy for people with mental illness, and also increases the personal, social, and economic burden of mental illness across the lifespan. This Commission summarises advances in understanding on the topic of physical health in people with mental illness, and presents clear directions for health promotion, clinical care, and future research. The wide range and multifactorial nature of physical health disparities across the range of mental health diagnoses generate a vast number of potential considerations. Therefore, rather than attempting to discuss all possible combinations of physical and mental comorbidities individually, the aims of this Commission are to: (1) establish highly pertinent aspects of physical health-related morbidity and mortality that have transdiagnostic applications; (2) highlight the common modifiable factors that drive disparities in physical health; (3) present actions and initiatives for health policy and clinical services to address these issues; and (4) identify promising areas for future research that could identify novel solutions. These aims are addressed across the five parts of the Commission: in Parts 1 and 2 we describe the scope, priorities, and key targets for physical health improvement across multiple mental illnesses; in Parts 3, 4, and 5, we highlight emerging strategies and present recommendations for improving physical health outcomes in people with mental illness.

Aim A growing number of quantitative studies have investigated the utility of neuropsychological assessment in mental health settings. However, to the best of our knowledge, no previous study has qualitatively explored youth mental health providers' perceptions of neuropsychological assessment services. A more in-depth understanding of the perceived advantages and barriers associated with neuropsychological assessment in youth mental health settings is critical to better inform policy, practice and service uptake. Thus, the aim of this study was to qualitatively explore clinicians' views about neuropsychological assessments for youth with mental health concerns. Methods A single open-ended qualitative question, included as part of an anonymous cross-sectional online survey, was completed by clinicians (N = 206) treating or assessing adolescents and young adults within Australian primary care mental health centres (headspace). Responses were analysed using an inductive approach to thematic analysis. Results Five main themes were identified. Clinicians (a) identified barriers to accessing neuropsychological assessments (53%), (b) indicated a range of mixed outcomes following neuropsychological assessment (39%), (c) highlighted a need for neuropsychological assessments (22%), (d) reported a lack of awareness about this resource (10%) and (e) described practice issues associated with neuropsychological services (4%). Conclusion This study uncovered perceived factors contributing to reduced access to neuropsychological assessment in Australian youth mental health settings. Given potential adverse outcomes resulting from this clinical service gap, efforts should be made to address factors contributing to poorer access, thereby mitigating the impact of poor access on the management of mental illness in youth. Several strategies, including funding neuropsychological assessments, are discussed.

Cognitive impairment is common in first-episode psychosis (FEP); however, the relationship between duration of untreated psychosis (DUP) and neurocognition remains controversial, and no studies have examined the relationship between DUP and social cognition. This study involved secondary data analysis of baseline data from a randomised controlled trial of supported employment; 122 out 146 young people with FEP met inclusion criteria for this study. Results showed that DUP was not associated with neurocognitive or social cognitive performance. Results do not provide support for the neurotoxicity hypothesis of psychosis.

To examine the associations between depression course, functional disability, and Not in Education or Training (NEET) status in a clinical sample of young adults with mental health problems. Young adults aged 15–25 years seeking help from four primary mental health services were invited to participate in a prospective cohort study evaluating the course of psychiatric disorders in youth. Demographic and clinical characteristics, including depressive symptomatology and functioning, were evaluated through clinical interview and self-report at baseline and 12 month follow-up. A total of 448 young adults participated (70 % female; M: 20.05 years, SD = 2.85). A significant interaction effect for time and depression course was found, such that those who became depressed reported an increase in functional disability and those whose depression remitted reported a significant reduction in functional disability. Developing depression was not a significant predictor of becoming NEET and vice versa: remitted depression did not make a person more likely to reengage in employment or education. This is the first study to examine the course of depression, functional disability, and NEET rates among help-seeking young adults. This study confirms the importance of symptom reduction for improved functioning; however, functional disability remained greater than that seen in young people in the community and there was no association between a change in depression and a change in NEET status. These results argue that services need to address functional outcomes and reengagement with education and employment in addition to symptom reduction.

BackgroundIndividual placement and support (IPS) is a vocational rehabilitation programme that was developed in the USA to improve employment outcomes for people with severe mental illness. Its ability to be generalised to other countries and its effectiveness in varying economic conditions remains to be ascertained.AimsTo investigate whether IPS is effective across international settings and in different economic conditions.MethodA systematic review and meta-analysis of randomised controlled trials comparing IPS with traditional vocational services was undertaken; 17 studies, as well as 2 follow-up studies, were included. Meta-regressions were carried out to examine whether IPS effectiveness varied according to geographic location, unemployment rates or gross domestic product (GDP) growth.ResultsThe overall pooled risk ratio for competitive employment using IPS compared with traditional vocational rehabilitation was 2.40 (95% CI 1.99–2.90). Meta-regressions indicated that neither geographic area nor unemployment rates affected the overall effectiveness of IPS. Even when a country's GDP growth was less than 2% IPS was significantly more effective than traditional vocational training, and its benefits remained evident over 2 years.ConclusionsIndividual placement and support is an effective intervention across a variety of settings and economic conditions and is more than twice as likely to lead to competitive employment when compared with traditional vocational rehabilitation.

Aim This study aimed to evaluate the feasibility and effectiveness of adapting individual placement and support (IPS) to education for young people presenting to a tertiary mental health service who wished to re-engage with or be supported in their education. Methods The study was an uncontrolled trial. Twenty young people with severe mental illness were recruited and worked with an educational specialist providing adapted IPS for education (IPSed). Demographic, educational and symptom measures were collected at baseline. Educational outcome was collected at the end of the 6-month intervention. Data presented are descriptive. Results Individual placement and support for education was found to be feasible with 95% of the participants successfully completing the intervention. Eighteen of the 19 who participated through to the conclusion of the intervention achieved positive educational outcomes. Conclusions It is well established that education is the foundation of career, but many people with mental illness drop out of their education with the onset of illness in adolescence or early adulthood. There has been a dearth of interventions to reconnect people with mental illness to secondary education and training. This study demonstrates that it is feasible to adapt IPS to focus exclusively on education at the outset of illness. Further larger studies are needed to confirm these results and create an evidence base for implementation of IPSed in routine practice for the treatment of early stage mental illness.

Treatment guidelines for first episode psychosis (FEP) recommend at least 1 year of antipsychotic treatment following remission; however, in light of some recent research and the preference of some individuals to discontinue their medication sooner, this recommendation can be questioned. The aim of this article is to appraise the current discontinuation studies given our views on how this field should progress. We conducted a review of randomized controlled trials investigating dose-reduction/medication discontinuation compared with treatment maintenance in clinically remitted FEP patients. Seven trials were identified, and these reported a higher rate of relapse in the dose reduction or discontinuation groups. Relapse rates were higher when a lower threshold for relapse was utilized. However, only three studies specified that concurrent psychosocial interventions were also provided, despite an evidence base for these interventions in reducing symptom severity and relapse. Length of follow-up may also be important, as the study with the longest follow-up (7 years), albeit with some methodological shortcomings, found greater functional recovery in the dose-reduction group and that relapse rates between the two groups (dose-reduction vs. maintenance) were equal after 3 years. Finally, in addition to discontinuation or dose reduction, a diagnosis of schizophrenia, a longer duration of illness, and poor premorbid functioning were associated with a greater risk of relapse. Further trials are needed in this area to establish the long-term risk-benefit ratio of antipsychotic medication in FEP. Meanwhile, young people with FEP who do not fulfil criteria for a diagnosis of a schizophrenia disorder, achieve clinical remission for at least 3 months, attain early functional recovery, and have good social support may be possible candidates for discontinuation of antipsychotic medication bolstered by effective psychosocial interventions provided in the context of a specialized FEP service.

Objectives: The recently published RANZCP guidelines for schizophrenia and related disorders reviewed recent scientific evidence, and, where lacking, referred to clinical expertise to supply a template for raising the standard of care. This paper builds on the guidelines and recommends how they might be used to improve outcomes. Methods: The guidelines call for evidence-based mental health policies, inclusive of mobilising affected families, communities and the public in support of policies that ensure better care and protect the wellbeing of people with severe mental disorders. The process of preparing the guidelines highlighted the limits of our scientific understanding of schizophrenia and shortcomings in the care currently provided. Results: Writing the guidelines evinced the need for a culture of measuring outcomes and response to treatment, and harnessing such data to monitoring and optimising patient care. Conclusions: We recommend creation of a national case cohort for mental health research involving a collaborative network of clinical research centres, using the guidelines and generating scientific evidence for translation into clinical practice protocols that enable personalised treatment plans for patients and criteria for the performance of clinical services.

IntroductionSpecialised early intervention services have demonstrated improved outcomes in first-episode psychosis (FEP); however, clinical gains may not be sustained after patients are transferred to regular care. Moreover, many patients with FEP remain socially isolated with poor functional outcomes. To address this, our multidisciplinary team has developed a moderated online social media therapy (HORYZONS) designed to enhance social functioning and maintain clinical gains from specialist FEP services. HORYZONS merges: (1) peer-to-peer social networking; (2) tailored therapeutic interventions; (3) expert and peer-moderation; and (4) new models of psychological therapy (strengths and mindfulness-based interventions) targeting social functioning. The aim of this trial is to determine whether following 2 years of specialised support and 18-month online social media-based intervention (HORYZONS) is superior to 18 months of regular care.Methods and analysisThis study is a single-blind randomised controlled trial. The treatment conditions include HORYZONS plus treatment as usual (TAU) or TAU alone. We recruited 170 young people with FEP, aged 16–27 years, in clinical remission and nearing discharge from Early Psychosis Prevention and Intervention Centre, Melbourne. The study includes four assessment time points, namely, baseline, 6-month, 12-month and 18-month follow-up. The study is due for completion in July 2018 and included a 40-month recruitment period and an 18-month treatment phase. The primary outcome is social functioning at 18 months. Secondary outcome measures include rate of hospital admissions, cost-effectiveness, vocational status, depression, social support, loneliness, self-esteem, self-efficacy, anxiety, psychological well-being, satisfaction with life, quality of life, positive and negative psychotic symptoms and substance use. Social functioning will be also assessed in real time through our Smartphone Ecological Momentary Assessment tool.Ethics and disseminationMelbourne Health Human Research Ethics Committee (2013.146) provided ethics approval for this study. Findings will be made available through scientific journals and forums and to the public via social media and the Orygen website.Trial registration numberACTRN12614000009617; Pre-results.

The aim of the study was to elucidate the association between performance-related neurocognitive abilities and Theory of Mind (ToM) as measured by the Hinting Task (HT) performance and investigate the psychometric properties of the HT for use in First-Episode Psychosis (FEP).Cross-sectional data of 132 participants with FEP, aged 15-25 years, enrolled in a randomised controlled trial of vocational intervention, were analysed. A comprehensive cognitive battery including social cognitive and neurocognitive measures, a social and occupational functioning measure and psychopathological measures, were used. Psychometric properties were measured through bivariate correlations and associations with neurocognitive domains were assessed through hierarchical regression.Low convergent validity of the HT with other ToM measures, moderate discriminant validity with an emotion recognition task, low predictive validity with social and occupational functioning, and high internal consistency were revealed. HT performance was significantly associated with verbal reasoning and verbal memory.Results provide preliminary evidence of low convergent validity and moderate discriminant validity of the HT in FEP, and the influence of verbal reasoning and verbal memory on HT performance, indicating that caution is warranted when employing the HT as a screening tool in isolation for detection of ToM deficits in FEP.

Antipsychotic medication has been the mainstay of treatment for psychotic illnesses for over 60 years. This has been associated with improvements in positive psychotic symptoms and a reduction in relapse rates. However, there has been little improvement in functional outcomes for people with psychosis. At the same time there is increasing evidence that medications contribute to life shortening metabolic and cardiovascular illnesses. There is also uncertainty as to the role played by antipsychotic medication in brain volume changes. Aim The primary aim of the study is, in a population of young people with first-episode psychosis, to compare functional outcomes between an antipsychotic dose reduction strategy with evidence-based intensive recovery treatment (EBIRT) group (DRS+) and an antipsychotic maintenance treatment with EBIRT group (AMTx+) at 24-months follow-up. Methods Our single-blind randomized controlled trial, within a specialist early psychosis treatment setting, will test the whether the DRS+ group leads to better vocational and social recovery than, the AMTx+ group over a 2-year period in 180 remitted first-episode psychosis patients. Additionally, we will examine the effect of DRS+ vs AMTx+ on physical health, brain volume and cognitive functioning. This study will also determine whether the group receiving DRS+ will be no worse off in terms of psychotic relapses over 2 years follow-up. Results This paper presents the protocol, rationale and hypotheses for this study which commenced recruitment in July 2017. Conclusion This study will provide evidence as to whether an antipsychotic dose-reduction recovery treatment leads to improved functioning and safer outcomes in first-episode psychosis patients. In addition, it will be the first-controlled experiment of the effect of exposure to antipsychotic maintenance treatment on brain volume changes in this population.

AIM:\ud The purpose of this paper is to review fidelity and outcome measures which can be used to support broad implementation of first episode psychosis services and ensure quality of existing services. First episode psychosis services use a combination of evidence-based practices to improve the outcome of a first episode of psychosis and the early stages of schizophrenia. Now that there is an established international evidence base to show that they are effective, efforts are being made to make such services widely available as a routine part of health care.\ud \ud METHODS:\ud We provide an overview of the literature from the perspective of an expert task force that was commissioned to report to the board of the International Early Psychosis Association IEPA. First, we examined the evidence-based components that underpin first episode psychosis services and identified common elements. Next, we reviewed the availability of fidelity measures and outcome indicators, finally we reviewed how broadly these services are delivered internationally, and the barriers to ensuring broad access to quality services.\ud \ud RESULTS:\ud There is a growing consensus about the elements required to deliver effective services. Fidelity scales and performance measures are available to assess quality, access, and outcome. First episode psychosis services are variably offered in high-income countries and rarely with attention to access and quality of services. Several strategies to promote implementation are identified.\ud \ud CONCLUSIONS:\ud Fidelity scales and outcome measure are valuable resources to support widespread implementation and quality assurance for first episode psychosis services.

AIM: Young people with psychotic disorders have poorer physical health compared to their healthy peers, a state compounded by the metabolic side-effects of antipsychotic medications. To address this, Orygen Youth Health has introduced physical health services including exercise physiologists and dieticians. These services are typically coordinated by the case manager and doctor. It is not yet known whether a treating team member dedicated to physical health will improve engagement, adherence and outcomes with these services. Hence, the protocol is presented here for a trial to evaluate the effect of including a physical health nurse in the care of young people with first-episode psychosis. METHODS: This will be a single-blind randomized controlled trial that includes 15- to 24-year-olds with first-episode psychosis who have just commenced (within 30 days) antipsychotic medication. The primary outcome will be the event of clinically significant weight gain (≥7% body weight). Participants will be assigned either a physical health nurse in their treating team (in addition to the case manager and doctor) for a 12-week period, or treatment as usual (case manager and doctor). Research assessments will be conducted at baseline, 12 and 26 weeks. Activity trackers worn by participants for the study's duration will measure sleep and physical activity. CONCLUSION: The present study will determine whether a physical health nurse will facilitate participants in attending and engaging in physical health interventions and whether this will be associated with physical health improvements or the prevention of worsening physical health.

OBJECTIVE Social inclusion is increasingly recognized as an important contributor to positive mental health outcomes, particularly for people with mental illness. There is a lack of consensus regarding what it means to be socially included and what the key contributors to social inclusion may be. The aim of this investigation was to determine such key contributors, as identified by those with professional experience. METHOD A thematic analysis of literature regarding social inclusion was conducted to obtain the opinions of professionals regarding key contributors of social inclusion. Seventy-one pieces of literature were reviewed: peer-reviewed literature (academic literature regarding social inclusion in general [n = 25] and social inclusion and mental illness [n = 26]), and gray literature (organizational reports [n = 20]). Within- and between-groups analyses were performed to determine group differences and increase understanding of which contributors were deemed important consistently across groups. RESULTS A comprehensive list of 90 contributors to social inclusion and exclusion was compiled, categorized into 13 domains based on commonalities. Contributors related to employment and education, housing and neighborhood, and social activities and support were highly cited. Differences were observed between-groups regarding specificity of contributors, with organizational reports reporting more detailed contributors. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE A comprehensive and specific understanding of social inclusion was obtained. This improved understanding will allow for better measurement of social inclusion which will assist in evaluating programs and interventions, identifying areas of greatest need, and in planning services, policy and strategies to target specific contributors proven to improve social inclusion and subsequent mental health outcomes. (PsycINFO Database Record

Findings are unclear as to whether cannabis use is associated with better cognitive functioning in individuals with psychosis.To elucidate the association between cannabis use, neurocognition and social cognition in first-episode psychosis (FEP).Secondary data analysis was conducted on data from 133 FEP participants who had enrolled in a randomized controlled trial of a vocational intervention. Participants completed a neurocognitive and social cognitive battery and characteristics of cannabis use were documented (disorder, recency, frequency and dose). Principal axis factor analysis was used to determine the underlying structure of the cognitive batteries. Regression techniques were used to examine cognitive predictors of current cannabis use disorder (CUD), and recency and frequency of cannabis use. Bivariate correlations were used to examine associations between cognition and dose of cannabis consumption.Male gender (p=.037) was the only significant predictor of having a current CUD. Better processing speed (p=.022) and social cognition (p=.039), male gender (p.001), and fewer negative symptoms (p=.036) predicted recency of cannabis use. Faster processing speed (p=.007) and male gender (p=.006) also predicted frequency of cannabis use. No variables were significantly associated with dose of cannabis consumption.Better social cognition and processing speed abilities predicting recency and frequency of cannabis use are consistent with cannabis users having higher cognitive abilities. A positive relationship between cannabis use and cognition may be the result of more drug taking opportunities in less cognitively impaired individuals with psychosis.

To investigate the relationship between cognition and employment duration in first-episode psychosis (FEP), and establish if a "fit" between cognition and job complexity is associated with longer employment duration.This study involved secondary data analysis of a subsample of FEP individuals (n = 65) who participated in a randomized controlled trial comparing Individual Placement and Support plus treatment as usual (TAU), versus TAU alone, over 6 months. A cognitive battery was administered at baseline and employment duration (hours) and job complexity in the longest held job over 6 months were measured.Factor analysis with promax rotation of the cognitive battery revealed 4 cognitive domains: (a) attention and processing speed; (b) verbal learning and memory; (c) verbal comprehension and fluency; and (d) visual organization and memory (VOM). The final hierarchical regression model found that VOM and job complexity independently predicted employment duration in longest held job; however, the "fit" (or interaction) between VOM and job complexity was not significant.These findings suggest that VOM and job complexity are important predictors of employment duration, but it is not necessary to ensure VOM ability matches job complexity. However, there are limited comparative studies in this area, and other aspects of the person-organization fit perspective may still be useful to optimize vocational outcomes in FEP.

Objectives: The aim of this study was to identify the most effective interventions for early intervention in psychosocial disability in the National Disability Insurance Scheme (NDIS) through an evidence review. Methods: A series of rapid reviews were undertaken to establish possible interventions for psychosocial disability, to develop our understanding of early intervention criteria for the NDIS and to determine which interventions would meet these criteria. Results: Three interventions (social skills training, supported employment and supported housing) have a strong evidence base for effectiveness in early intervention in people with psychosocial disability, with the potential for adoption by the NDIS. They support personal choice and recovery outcomes. Illness self-management, cognitive remediation and cognitive behavioural therapy for psychosis demonstrate outcomes to mitigate impairment. The evidence for family psycho-education is also very strong. Conclusions: This review identified evidence-based, recovery-oriented approaches to early intervention in psychosocial disability. They meet the criteria for early intervention in the NDIS, are relevant to participants and consider their preferences. Early intervention has the potential to save costs by reducing participant reliance on the scheme.

An inverse association between psychosocial functioning and psychotic experiences is now established in both clinical and non-clinical populations, however the mechanisms which drive this are unclear. Adolescents with subclinical psychotic experiences (SPE) are more likely to use maladaptive coping strategies and less likely to use adaptive ones, and maladaptive coping has also been associated with poor functioning. A within study replication in two adolescent samples from the general populations of Melbourne, Australia (n=723) and Birmingham, United Kingdom (n=239), was conducted to determine whether the association between SPE and psychosocial functioning is mediated by coping style. SPE were associated with reduced general and family functioning and to a lesser extent with reduced peer functioning. Task-oriented (focusing on solving the problem) and emotion-oriented (negative emotional responses) coping were found to mediate the relationship between SPE and three types of functioning in both the Melbourne and the Birmingham samples. The within study replication consistently found that coping style mediates SPE and psychosocial functioning, despite significant differences in age, gender, functioning, use of coping styles, and level of subclinical psychotic experiences between the two samples. Longitudinal research is needed to fully understand any causal role coping may play in the relationship between SPE and poor functioning. The results have important public health and clinical implications, and suggest that techniques which increase levels of adaptive coping and reduce levels of maladaptive coping (in particular emotion-oriented styles) may help to break the cycle between SPE, functional decline, and eventual need for care.

Background: Psychological and pharmacological treatments have been shown to reduce rates of transition to psychosis in Ultra High Risk (UHR) young people. However, social functioning deficits have been unresponsive to current treatments. Aims: The study aims were to: i) describe the theoretical basis and therapeutic targets of a novel intervention targeting social functioning in UHR young people; and ii) examine its acceptability, safety and preliminary effect on social functioning. Methods: An international, multidisciplinary team developed a new intervention (MOMENTUM) to improve social functioning in UHR young people. MOMENTUM blends two novel approaches to social recovery: strengths and mindfulness-based intervention embedded within a social media environment, and application of the self-determination theory of motivation. The acceptability and safety of MOMENTUM were tested through a 2-month pilot study with 14 UHR participants. Results: System usage was high, with over 70% of users being actively engaged over the trial. All participants reported a positive experience using MOMENTUM, considered it safe and would recommend it to others. 93% reported it to be helpful. There were large, reliable improvements in social functioning (d = 1.83, p < 0.001) and subjective wellbeing (d = 0.75, p = 0.03) at follow-up. There were significant increases in the mechanisms targeted by the intervention including strengths usage (d = 0.70, p = 0.03), mindfulness skills (d = 0.66, p = 0.04) and components of social support. Social functioning improvement was significantly correlated with indicators of system usage. Conclusion: MOMENTUM is engaging and safe. MOMENTUM appeared to engage the hypothesized mechanisms and showed promise as a new avenue to improve social functioning in UHR young people.

Now in a new Fourth Edition, Psychiatry remains the leading reference on all aspects of the current practice and latest developments in psychiatry. From an international team of recognised expert editors and contributors, Psychiatry provides a truly comprehensive overview of the entire field of psychiatry in 132 chapters across two volumes. It includes two new sections, on psychosomatic medicine and collaborative care, and on emergency psychiatry, and compares Diagnostic and Statistical Manual (DSM-5) and International Classification of Diseases (ICD10) classifications for every psychiatric disorder. Psychiatry, Fourth Edition is an essential reference for psychiatrists in clinical practice and clinical research, residents in training, and for all those involved in the treatment psychiatric disorders.

Theory of mind deficit is a core feature of schizophrenia and is considered a vulnerability marker of the disorder. The majority of studies measuring theory of mind in schizophrenia involve multiple-episode or chronic schizophrenia patients, and therefore it is important to delineate whether these deficits occur before or following illness-onset by assessing high-risk subjects (clinical high risk and ultra-high risk), early-onset psychosis, and first-degree relatives. We address the question of whether theory of mind impairment is specific or a facet of general cognitive impairment in these clinical populations, and incorporate genetic and neuroimaging studies on the theory of mind. The review provides a succinct evaluation of the literature, discusses current limitations and proposes future directions.

AIM: Clinical staging models offer a useful framework for understanding illness trajectories, where individuals are located on a continuum of illness progression from stage 0 (at-risk but asymptomatic) to stage 4 (end-stage disease). Importantly, clinical staging allows investigation of risk factors for illness progression with the potential to target trans-diagnostic mechanisms at an early stage, especially in help-seeking youth who often present with sub-threshold syndromes. While depressive symptoms, rumination and sleep-wake disturbances may worsen syndrome outcomes, the role of these related phenomena has yet to be examined as risk factors for trans-diagnostic illness progression in at-risk youth. METHODS: This study is a prospective follow-up of 248 individuals aged 12 to 25 years presenting to headspace services with sub-threshold syndromes (stage 1) classified under the clinical staging model to determine transition to threshold syndromes (stage 2). Factor analysis of depression, rumination and sleep-wake patterns was used to identify key dimensions and any associations between factors and transition to stage 2 at follow-up. RESULTS: At 1 year, 9% of cases met criteria for stage 2 (n = 22). One of three identified factors, namely the factor reflecting the commonalities shared between rumination and sleep-wake disturbance, significantly differentiated cases that transitioned to stage 2 vs those that did not demonstrate transition. Items loading onto this factor, labelled Anergia, included depression severity and aspects of rumination and sleep-wake disturbance that were characterized as introceptive. CONCLUSIONS: Common dimensions between rumination and sleep-wake disturbance present a detectable trans-diagnostic marker of illness progression in youth, and may represent a target for early intervention.

Background Both major depressive disorder (MDD) and first episode schizophrenia spectrum (FES) are associated with significant neurocognitive deficits. However, it remains unclear whether the neurocognitive deficits in individuals with FES are more severe if there is comorbid depressive disorder. The aim of this study was to compare the neurocognitive profiles between those with and without full-threshold depressive disorder in FES. Method This study involved secondary analysis of baseline data from a randomized controlled trial of vocational intervention for young people with first-episode psychosis (N = 82; age range: 15–25 years). Results Those with full-threshold depressive disorder (n = 24) had significantly better information processing speed than those without full-threshold depressive disorder. Severity of depressive symptoms was also associated with better information processing speed. Limitations In additional to the cross-sectional design, limitations of this study include the absence of assessing insight as a potential mediator. Conclusions After the first psychotic episode, it could be speculated that those with better information processing speed may be more likely to develop full-threshold depressive disorder, as their ability to efficiently process information may allow them to be more aware of their situations and environments, and consequently to have greater insight into the devastating consequences of FES. Such novel findings support the examination of full-threshold depressive disorder in relation to neurocognitive performance across illness phases in future work.

Objective To identify cognitive subgroups (comprising neurocognition and social cognition domains) within first-episode psychosis (FEP) patients including a healthy control group for comparison. Predictive validity of cognitive clusters in relation to symptoms and functioning was also investigated. Method A comprehensive cognitive battery was administered to 133 FEP participants and 46 healthy controls. Ward's method hierarchical agglomerative cluster analysis with k-means verification was used to determine clusters. Clusters were externally validated and 6-month predictive validity was also examined. Results Three distinct clusters were identified and were defined by degree of impairment rather than specific deficit profiles. Social-cognitive performance mirrored neurocognitive performance in each cluster. Cluster 1 was characterized by significant widespread cognitive impairments (1-2 SD below the mean) and solely comprised FEP participants (n = 24). Cluster 2 suggested moderately impaired cognitive functioning (within 0.5 SD below the mean), and comprised mostly FEP participants and 2 healthy controls (n = 73). Cluster 3 showed a pattern of cognitively intact performance across domains and comprised 37 FEP participants and 44 healthy controls (n = 81). Premorbid IQ, negative symptom severity, and functioning were significantly associated with cluster membership at baseline. At 6-month follow-up, cluster membership remained significantly associated with negative symptoms and functioning. Conclusions The heterogeneity of cognition in FEP may be based on degree of impairment across both neurocognitive and social-cognitive domains. Cognitive clusters were associated with symptom and functional outcome, suggesting that measurement of cognition at entry to treatment may be useful for prognosis and treatment. (PsycINFO Database Record

Aim People with psychosis are at risk of social exclusion. Research is needed in this area due to the lack of direct measurement of social inclusion, which becomes salient in adolescence and is relevant to first-episode psychosis (FEP; the onset of which typically occurs during or shortly after adolescence). Social inclusion may be impacted by impaired social cognition and social functioning, which are related features observed in psychosis. The aim of this study was to explore interrelationship(s) between social cognition, social functioning and social inclusion in FEP while controlling for symptomatology (positive, negative and depressive symptoms) and demographic characteristics. Methods A series of cross-sectional hierarchical multiple regressions were conducted to examine whether: social cognition (theory of mind, emotion recognition) predicted social functioning; social functioning predicted social inclusion, and whether social functioning mediated the relationship between social cognition and social inclusion in people aged 15 to 25 (M = 20.49, SD = 2.41) with FEP (N = 146). Age, sex, premorbid IQ, positive and negative psychotic symptoms and depression were control variables. Results Poor facial emotion recognition (β = −.22, P < .05) and negative symptoms (β = −.45, P < .001) predicted lower social functioning. Role-specific social functioning (ie, current employment) predicted greater social inclusion (β = .17, P < .05). Higher depression symptomatology predicted lower social inclusion (β = −.43, P < .001). Social functioning did not mediate the relationship between social cognition and inclusion. Psychotic symptoms were unrelated to social inclusion. Conclusions Employment and depression may influence social inclusion somewhat independently of psychotic symptomatology in FEP. Inferences should be viewed with caution given this study did not involve longitudinal data.

Background Cognitive Adaptation Training (CAT) uses compensatory strategies and environmental supports to support cognitive impairments and improve functioning. CAT may be useful for addressing vocational recovery in first-episode psychosis (FEP) because cognitive impairments are common and vocational recovery is a key goal of young people with FEP. Objective To describe clinical observations and practice experience when delivering CAT with FEP clients and explore potential benefits via objective outcome measures for improving vocational outcomes. Methods In this pilot study, five FEP participants received 9 months of CAT. Participant goals and functional needs and clinical observations were recorded. Formal measures of functioning, quality of life and motivation were independently administered pre- and post-intervention. Results Vocational recovery (education, employment) was found to be a primary functional goal of FEP participants. Accordingly, CAT had a strong focus on vocational functioning, including functional domains required for successful work or educational outcomes, such as organization and planning, transportation and activities of daily living. Factors of clinical importance when delivering CAT with the FEP participants included cognitive heterogeneity, family involvement, flexibility in compensatory and environmental supports used, and experience of stigma. Improvements from baseline to post-intervention were observed on most measures, with the largest improvements seen in global functioning (including vocation), planning and organization, and quality of life. Conclusions CAT is an intervention that appears well suited to addressing vocational functioning in FEP, but larger controlled trials are needed.

Aim The Transitions Study was designed to establish a cohort of young people (12–25 years) seeking help for mental health problems, in order to longitudinally explore and refine a clinical staging model of the development and progression of mental disorders. This paper presents the baseline demographic and clinical characteristics of the cohort, particularly the nature and severity of psychopathology. Method All eligible young people attending one of four headspace clinical services were invited to participate, and completed a battery of self-report and interviewer-administered measures of psychopathology and functional impairment at baseline, which will be repeated at the annual follow up. Results Of 1615 eligible clients, 802 young people (66% women; mean age = 18.3 years) consented to participate and completed baseline assessments (participation rate = 50%). The severity of mental health problems varied, with 51% meeting the criteria for probable caseness related to generalized anxiety, 45% presenting with moderate to severe depressive symptoms and over a third experiencing subthreshold psychotic symptomatology. Disordered eating (32%) and problematic tobacco (56%), cannabis (30%) and alcohol (38%) use also affected a significant proportion. Overall, 39% of the cohort were classed as being functionally impaired at baseline. Conclusion The Transitions Study recruited a heterogeneous cohort at baseline in relation to the nature and severity of mental health problems and levels of functional impairment. The variation in clinical presentations within the cohort, from mild, through moderate to severe levels of psychopathology and impairment, increases the likelihood of the Transitions Study ultimately being able to achieve its aims of empirically testing a clinical staging model for mental disorders.

Background Cognitive impairments in domains such as attention, memory, processing speed and executive functions are a central feature of psychotic disorders that have significant negative consequences for daily functioning, including activities of daily living, social and vocational roles. Compensatory approaches aim to minimise the impact of cognitive impairment on daily functioning through the use of aids or strategies to reduce cognitive load, in much the same way as glasses reduce the impact of vision impairment. The primary treatment target is real world community functioning and functional capacity, rather than cognition. There is now a need to synthesise the available evidence in this field so that treatment recommendations and future research directions can be better informed. A large body of research into compensatory approaches to cognition in psychosis exists, but this has never been comprehensively synthesised. The aim of this systematic review and meta-analysis is to examine the effects of compensatory approaches for cognitive deficits in psychotic disorders on i) functional outcomes and ii) other outcomes such as symptoms and quality of life. Methods A systematic review and meta-analysis was conducted according to PRISMA guidelines. PsycINFO and MEDLINE electronic databases were searched from inception to October 2017 using multiple terms for ‘psychosis’, ‘cognition’ and ‘compensatory’. All papers retrieved from this search were double-screened and final inclusion/exclusion was determine by consensus. Data were double-extracted and risk of bias rated by two independent authors. Meta-analysis only included randomised-controlled trials. Standardised Mean Differences (SMD) were calculated to produce a single summary estimate using the random-effects model with 95% Confidence Intervals using Comprehensive Meta-Analysis (CMA) software. When means or standard deviations were not reported in the original articles, SMDs were calculated from data provided by the study authors. Results 2192 articles were identified via electronic and manual searches. Forty-two papers describing 40 independent studies were included in the review: case studies (n=4), case series (n=2), uncontrolled single arm pilot studies (n=5), within-subjects designs (n=1), quasi-randomised trials (n=2), and randomised controlled trials (n=26). The types of compensatory interventions included environmental adaptation and supports, internal and external self-management strategies, and errorless learning. Compensatory interventions were associated with improvements in global functioning post intervention (N=1,449; SMD=0.506; 95%CI=0.347, 0.665; p

Background: High quality randomized controlled trials (RCT) of psychotherapeutic interventions should ensure that the therapy being tested is what is actually delivered. However, contamination of one therapy into the other, a critical component of treatment adherence, is seldom measured in psychotherapy trials of psychosis. Aims: The aim of the study was to determine whether a purpose-designed measure, the ACE Treatment Integrity Measure (ATIM) could detect therapy contaminations within a controlled trial of cognitive behavioural therapy (CBT) versus Befriending for first-episode psychosis and to compare the ATIM to a more traditional adherence measure, the Cognitive Therapy Scale (CTS). Method: Therapy sessions were audio-recorded and at least one therapy session from 53 of the 62 participants in the RCT was rated by an independent rater using the CTS and ATIM. Results: Ninety-nine therapy sessions were rated. All Befriending sessions and all but three CBT sessions were correctly identified. The ATIM showed that 29 of the 99 (29%) sessions were contaminated by techniques from the other therapy. Within the CBT sessions, 19 of the 51 sessions (37%) were contaminated by one or more Befriending techniques. Of the Befriending sessions, 10 of 48 (21%) were contaminated by ACE techniques. The mean CTS score was higher in the CBT than the Befriending group. Conclusions: The ATIM was able to detect contaminations and revealed more meaningful, fine-grained analysis of what therapy techniques were being delivered and what contaminations occurred. The study highlights the benefit of employing purpose-designed measures that include contamination when assessing treatment adherence.

During recovery, young people with psychosis need attention paid not only to their psychotic symptoms but also to the areas of functioning that restrict their capacity to live a fulfilled life in the community. Despite improvements in medications and psychological therapies, people with psychosis still have poor outcomes in functional domains such as vocation, physical health, housing, and imprisonment. This article reviews 2 of these areas: vocational functioning and physical health. It examines the extent of each of these issues, provides guidance as to what evidence there exists on which to base interventions, and describes such evidence.

Aim An estimated 75% of mental disorders begin before the age of 24 and approximately 25% of 13–24-year-olds are affected by mental disorders at any one time. To better understand and ideally prevent the onset of post-pubertal mental disorders, a clinical staging model has been proposed that provides a longitudinal perspective of illness development. This heuristic model takes account of the differential effects of both genetic and environmental risk factors, as well as markers relevant to the stage of illness, course or prognosis. The aim of the Transitions Study is to test empirically the assumptions that underpin the clinical staging model. Additionally, it will permit investigation of a range of psychological, social and genetic markers in terms of their capacity to define current clinical stage or predict transition from less severe or enduring to more severe and persistent stages of mental disorder. Method This paper describes the study methodology, which involves a longitudinal cohort design implemented within four headspace youth mental health services in Australia. Participants are young people aged 12–25 years who have sought help at headspace and consented to complete a comprehensive assessment of clinical state and psychosocial risk factors. A total of 802 young people (66% female) completed baseline assessments. Annual follow-up assessments have commenced. Conclusions The results of this study may have implications for the way mental disorders are diagnosed and treated, and progress our understanding of the pathophysiologies of complex mental disorders by identifying genetic or psychosocial markers of illness stage or progression.

Aim: Young people who are experiencing first-episode psychosis (FEP) are at increased risk of being unemployed compared to either their same age peers in the general population, or those with other mental illnesses. Significant research has been conducted examining employment interventions for those with chronic psychotic illness. This has yielded strong results in favour of an intervention called individual placement and support (IPS). However, significantly less work has examined the benefit of this approach to those in FEP when the potential for vocational rehabilitation is perhaps greater. This study adds to the knowledge of vocational intervention in first-episode psychotic illness. Additionally, it expands this work into the areas of cognition, social cognition, social inclusion and economics.

Education is recognized in many sectors of society as essential for empowerment and better lives, and postsecondary education is increasingly a prerequisite for many occupations. Given its onset in late adolescence and early adulthood, mental illness frequently disrupts secondary or tertiary education, and resulting lower educational attainment contributes to reduced lifetime employment and earning potential. Yet, supporting people with mental illnesses to pursue postsecondary education offers pathways to vocational qualifications and more diverse opportunities for employment and career advancement. While substantial efforts have been made to develop evidence-based interventions to improve employment outcomes for people with mental ill health, less is known about the best ways to enable people with mental illness to successfully return to study and to pursue their educational goals. This paper briefly discusses supported education, an approach designed to provide pathways and supports for reengagement in education; it highlights the potential of modeling educational support on Individual Placement and Support principles used in supported employment programs; and calls for greater efforts in research and practice to enable youth or adults with mental illness to reengage in education so as to improve their educational outcomes and career prospects.

Poor vocational engagement is well documented among young people experiencing first-episode psychosis (FEP). The aim of the present study was to establish and compare rates of vocational engagement across young people with first-episode psychosis, depression, and borderline personality pathology. A file audit was used to collect vocational data of young people aged 15-25 entering tertiary mental health treatment in 2011. Rates of vocational engagement were similar across groups, indicating that like those with FEP, young people with depression and borderline personality pathology experience impaired vocational engagement and are in need of targeted vocational interventions. Post hoc analysis indicated that that the depression group had significantly more people who were partially vocationally engaged compared with the psychosis group, suggesting that vocational interventions might need to be targeted differently across different diagnostic groups. Future research should explore risk factors for vocational disengagement across diagnostic groups in order to inform intervention development.

AIM: The aim of this study was to identify the core competencies required of mental health professionals working in the early psychosis field, which could function as an evidence-based tool to support the early psychosis workforce and in turn assist early psychosis service implementation and strengthen early psychosis model fidelity. METHOD: The Delphi method was used to establish expert consensus on the core competencies. In the first stage, a systematic literature search was conducted to generate competency items. In the second stage, a panel consisting of expert early psychosis clinicians from around the world was formed. Panel members then rated each of the competency items on how essential they are to the clinical practice of all early psychosis clinicians. RESULTS: In total, 1023 pieces of literature including textbooks, journal articles and grey literature were reviewed. A final 542 competency items were identified for inclusion in the questionnaire. A total of 63 early psychosis experts participated in 3 rating rounds. Of the 542 competency items, 242 were endorsed as the required core competencies. There were 29 competency items that were endorsed by 62 or more experts, and these may be considered the foundational competencies for early psychosis practice. CONCLUSION: The study generated a set of core competencies that provide a common language for early psychosis clinicians across professional disciplines and country of practice, and potentially are a useful professional resource to support early psychosis workforce development and service reform.

Background: Social cognitive deficits have a detrimental effect on social and role functioning at both early and late stages of psychotic illness. Aim: To assess the feasibility of social cognition and interaction training (SCIT) in first-episode psychosis (FEP). Methods: A total of 12 FEP participants were sequentially allocated to one of two SCIT groups, each of which met once per week for 10 consecutive weeks. Social cognition and functioning was assessed at baseline and post-intervention. Results: SCIT was well-tolerated and retention was good. FEP participants improved significantly on measures of emotion recognition and social and occupational functioning. CONCLUSIONS: This study extends previous research by applying SCIT early in the course of illness, with the rationale that there is greater brain plasticity in this developmental phase of life, and greater scope to reduce or prevent disability. Results suggest SCIT is acceptable to and potentially helpful for this young population, thus a large randomized controlled trial is warranted.

PURPOSE: Everyday functioning is an important outcome for studies of the developmental psychopathology of adolescence. An unbiased, well-validated, and easy-to-use instrument to specifically assess normal adolescent functioning is not yet available. The current study aimed to introduce and validate the Multidimensional Adolescent Functioning Scale (MAFS).METHODS: The MAFS was developed by clinical consensus, resulting in a 23-item self-report questionnaire with three distinct subscales: general functioning, family-related functioning, and peer-related functioning. MAFS data were collected in a general population sample (N = 842; mean age = 15.0 years [standard deviation = .4]) at baseline and again at 1- and 3-year follow-up. Psychometric analyses included confirmatory factor analysis, calculations of internal consistency, scale correlations, and correlations with the abridged General Health Questionnaire.RESULTS: Confirmatory factor analysis showed that the hypothesized 3-factor structure fits well to the MAFS data. All scales showed adequate internal consistency (greatest lower bound: .75-.91) and sufficient discriminative ability (scale intercorrelations: ρ = .15-.52). Of the scales, general functioning was most strongly correlated with the General Health Questionnaire, whereas family- and peer-related functioning showed weaker correlations with this general measure. The results were stable across repeated measurements and gender groups.CONCLUSIONS: The MAFS is an easy-to-use instrument with good psychometric characteristics, which could be suitable for a broad range of future research applications, especially when a multidimensional and unbiased indication of normal adolescent functioning is required.

Aims: Individual Placement and Support is the most defined and evidence-based approach to supported employment for severe mental illness, including recent-onset psychosis. However, there is limited evidence or detailed guidelines informing the management of mental illness disclosure to educators or employers when delivering Individual Placement and Support. In this paper, we describe the initial disclosure preferences of young people with recent-onset psychosis enrolled in Individual Placement and Support and provide guidance for managing disclosure when delivering Individual Placement and Support with this population. Methods: Drawing from sites in Melbourne, Australia and Los Angeles, USA, clients' initial disclosure preferences were examined. We describe approaches to providing IndividualPlacement and Support when no disclosure is permitted compared withwhen disclosure is permitted, including two illustrative case vignettes. Results: No disclosure of mental illness or disability was requested by 54–59% of clients; 41–46% of clients permitted partial or complete disclosure. The ‘no disclosure’ scenario required the Individual Placement and Support worker to provide support ‘behind the scenes’, whereas when disclosure was permitted, the Individual Placement and Support worker could have contact with instructors/employers and work ‘on the front lines’. The case vignettes illustrate how both approaches can lead to successful vocational outcomes. Conclusions: We found that Individual Placement and Support can be provided in an educative, flexible, creative and collaborative manner according to client disclosure preferences. We suggest that disclosure preferences do not prevent successful vocational outcomes, although this supposition requires empirical investigation.

Depressive pathology is common in first-episode schizophrenia spectrum disorders (FES), and is frequently assessed using the Center for Epidemiological Studies - Depression Scale (CES-D), an instrument designed for use in community samples. Despite its widespread use, no prior study has examined the psychometric validity of the CES-D in assessing depressive pathology in FES. The aim of this study was to examine the psychometric validity of the CES-D in FES. This study involved secondary analysis of baseline data from a single blind, randomized controlled trial of vocational intervention for individuals with FES (N=91; age range: 15-25 years). Measures used were: CES-D, Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Negative Symptoms (SANS), and Structured Clinical Interview for DSM-IV-TR (SCID-I/P). The CES-D strongly correlated with the depression subscale of the BPRS, and with the presence of full-threshold depressive disorder on the SCID-I/P. There was minimal overlap between the CES-D and SANS, with weak correlations emerging for avolition and anhedonia, and not for affective flattening, alogia, and attention. The CES-D cut-off of ≥23 produced high sensitivity and specificity values for determining full-threshold comorbid depressive disorder. Such findings indicate that the CES-D is effective for assessing and measuring depressive pathology in FES.

Introduction: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management of schizophrenia and related disorders provide evidence-based recommendations for optimising treatment and prognosis. This update to the 2005 RANZCP guidelines has a greater emphasis on psychosocial treatments, physical health comorbidities and vocational rehabilitation. Main recommendations: The guidelines advise a clinical staging approach and deliver specific recommendations for: · comprehensive treatment using second generation antipsychotic agents continuously for 2-5 years; · early treatment of comorbid substance use; · community treatment after initial contact, during crises and after discharge from hospital; · physical health monitoring and management of comorbidities, particularly metabolic health; · interventions to optimise recovery of social function and return to study or work; and · management of schizophrenia in specific populations and circumstances. Changes in management as a result of the guidelines: The guidelines provide benchmarks against which the performance of services and clinical teams can be assessed. Measuring treatment response and clinical outcome is essential. General practitioners have an important role, particularly in monitoring and reducing the high cardiovascular risk in this population. Clinical services focusing on early detection, treatment and recovery need continuous funding to be proactive in implementing the guidelines and closing the gap between what is possible and what actually occurs.