Young people may present with notable risk factors or warning signs that don’t (yet) reach a threshold for a psychosis-specific assessment or intervention. Since this is a tricky call, do not hesitate to seek consultation. Primary examples include:

1. A patient whose EXPERIENCE appears to have mild, vague, or questionably psychotic-like content, but is not IMPACTING, RECURRING, or PROGRESSING.
2. A patient with a close biological relative (typically first- or second-degree) who has been diagnosed with a psychotic-spectrum illness (e.g., schizophrenia, schizoaffective disorder, bipolar or major depressive disorders with psychotic features).

Consider the following steps:

MONITOR THE PATIENT’S SYMPTOMS & SCREEN FOR ADDITIONAL PSYCHOTIC-LIKE EXPERIENCES
If a patient has mild or vague psychotic-like experiences with no other risk indicators, make a note to check in about these symptoms at your follow-up appointments and actively screen for other psychotic-like experiences (see monitoring options outlined below). For those with familial risk, regular monitoring of mental health and functioning may help detect any early warning signs. Even mild warning signs are more concerning in these patients. The monitoring options outlined below may help to identify undisclosed internal experiences or track changes in functioning.

EDUCATE THE PATIENT/FAMILY ON WHEN TO SEEK FURTHER HELP
Although these patients may not be at imminent risk for psychosis, they are at increased long-term risk compared to the general population. In many cases, these patients are quietly worried that they may develop a major mental illness; talking about their worries may provide opportunity to reassure them that it is much more likely that they will not develop a serious disorder than that they will, and that caught early, symptoms are much more treatable than they used to be. This can also be an opportunity to let them know you will check in regularly so that any early symptoms can be treated quickly and they will have a good chance of recovery. Educate the patient and family on general mental health resources, and direct them to call if an experience becomes distressing or affects their behavior (IMPACTING), happens repeatedly (RECURRING), or gets worse in any other way (PROGRESSING).

Destiny is a sophomore in high school whose grades have been in the B-range since she was in elementary school. She isn’t highly social, but plays in her school’s marching band and has a small, close group of friends she sees outside of school about once per week. Three years ago, Destiny’s older brother was diagnosed with schizoaffective disorder.

Destiny would be appropriate to Monitor and Educate.

Monitoring Symptoms, Behavior, & Risk

When monitoring patients presenting with mild symptoms and/or asymptomatic familial risk, it’s important to be thoughtful and thorough without raising alarm or rushing to conclusions. Here are some general guidelines for how often to assess this population for psychosis risk concerns:

Mild, vague, or questionable symptoms occurring less than once a month ​ Asymptomatic relatives of individuals with suspected psychotic disorders	Reassess and screen for psychotic-spectrum symptoms every 12 months, and sooner if they increase in intensity or frequency.
Mild to moderate but non-impactful symptoms occurring more than once per month ​ Familial risk plus a marked change in cognitive, social, or academic functioning	Consider reassessment and/or additional screening every 6 months. Instruct patients and families to be in touch if they experience or observe a meaningful change. As appropriate, educate about what changes (IMPACTING, RECURRING, or PROGRESSING) might warrant attention before the next scheduled appointment.
Complex or diagnostically ambiguous presentations that trigger clinical concern but might easily resolve with time (e.g., concurrent substance misuse in someone willing to try abstinence) ​ Moderate to severe symptoms in someone awaiting mental health assessment or treatment	​Consult with MCPAP, CEDAR, or other mental health provider. ​ Reassess and screen in 1-3 months, depending on significance of symptoms and availability of mental health providers