In most societies, the treatment of mental disorders and mental health problems is a low priority.1 Even in affluent nations, and even though they are the major cause of non-fatal disability,2 the coverage of these disorders by the health system is poor.5 Only a fraction of those with so-called high prevalence disorders, such as depression and anxiety, receive any treatment at all—while even those with lower-prevalence, more severe disorders (such as schizophrenia and bipolar disorder) typically obtain intermittent care of substandard quality, overly focused on acute episodes.

Mental healthcare is predominantly reactive, and often unnecessarily iatrogenic as a result. Stigma, prejudice, and ignorance combine to maintain a silence throughout the community, which (until recently) allowed this neglect to continue. Pervasive therapeutic nihilism, especially regarding psychotic disorders like schizophrenia, has undermined efforts to reduce the human and economic costs of these illnesses. Consequently, preventive thinking and early diagnosis has been unable to germinate or flourish in this hostile environment (until recently).

However, over the past decade, we have seen this situation begin to transform. With the advent of new treatments, new service models and increased visibility of mental health problems within the community, the early intervention paradigm has gained momentum internationally.4 So, for the first time, the principles of early diagnosis and phase-specific treatment have been applied to potentially serious mental disorders.

The notion—if a disease is serious and that effective treatments exist, then the diagnosis should be made at the earliest point possible—is compelling. Indeed, in cancer, heart disease, and other serious medical illnesses, it has been pursued vigorously with positive effects on morbidity and mortality. Staging is a related idea, which proposes that the specific content or mix of treatments will differ according the stage of development of the disease, as will both the efficacy and the risks of treatment. There are many challenges raised in attempting early diagnosis,3 and these are made more complex in psychiatry by the lack of tests or markers of our diagnostic syndromes.

Nevertheless, the worldwide experience6 of this reform-process demonstrates several things. Firstly, that the available evidence supports its continued expansion.7 It is even proving feasible to identify and treat some patients in the pre-psychotic or prodromal phase of schizophrenia.8 Secondly, that it represents a realistic way forward for improved morale and workforce development—and better quality within mental health services. Treatment success, which is readily achievable at this stage, challenges therapeutic nihilism and can inspire confidence in mental healthcare, something that is in short supply as a result of the severe rationing of resources and all that flows from this. Thirdly, the success of the early psychosis paradigm may lead to a more substantial reform of healthcare—so that the major peak in incidence and prevalence in adolescence and early adulthood for a whole range of mental and substance-use disorders can be responded to in a cohesive, logical, and acceptable manner within a youth health model.9 Finally, a clinical focus on onset and early course is also likely to facilitate neuroscientific advances in knowledge.10

New Zealand (like Canada, the UK, and Scandinavia) has established growth points for this reform process in many centres (as a result of outstanding clinical leadership and a national commitment to better outcomes in mental health). Sustained and extended structural reform, as engineered in many places, is essential. This means a streamed system of care for young people with early psychosis—focused on detection, engagement and expert intervention during the first few years post-onset, which is known as the critical period.11

However, such a stream of care must have links with yet be distinct from standard adult psychiatric services.12 If this does not occur, international experience shows that no sustained change in approach or quality results. Special models of primary care are also required to feed and work in synergy with such a strengthened specialist model. Ultimately, this type of reform could result in better health care for young people with any kind of potentially serious mental health problem, not only a psychosis. At the present time, it represents the best buy in mental health service development internationally.

Author information: Patrick D. McGorry, Professor of Psychiatry, University of Melbourne, Melbourne, Australia