Any concern about a possible underlying psychotic process should trigger a referral for psychosis-specific assessment and treatment. We specifically recommend this for patients who have the following, particularly in combination:

1. The patient discloses, or you observe:
   1. ATYPICAL perceptual experiences or hallucinations
   2. THOUGHT disturbance or delusions
   3. SPEECH or behavior that is disorganized
2. The patient’s psychotic-like EXPERIENCE is either IMPACTING, RECURRING, or PROGRESSING

​Because evidence supports the use of specialized interventions with youth at imminent risk, we recommend referral to a specialized service that can conduct appropriate assessment and consult on treatment options. Information about local services is available here. Additional services may be helpful for addressing a young person’s life goals, but many specialized programs offer comprehensive services. Consider the following steps:

CONSULT WITH AN EARLY PSYCHOSIS SPECIALTY SERVICE TO IDENTIFY BEST OPTIONS
Early consultation with a specialized service can provide guidance on managing a patient’s mental health care while waiting for an assessment.

REFER THE PATIENT TO SPECIALIZED ASSESSMENT
A structured interview conducted by a highly trained clinician is essential to careful assessment of psychotic symptoms and psychosis risk. If your suspicions are confirmed by a specialized structured interview, the patient is likely to have or be at imminent risk for developing a psychotic disorder.

MANAGE PSYCHOSIS OR PSYCHOTIC-LIKE SYMPTOMS WITHIN YOUR INTEGRATED PRACTICE
In some cases, it may be appropriate or necessary to assess and treat patients with psychotic symptoms internally; this may be because you/your practice are equipped to do so, or because a patient is unwilling or unable to utilize specialized treatment. Some considerations and best practice guidelines are outlined below.

REFER THE PATIENT TO SPECIALIZED TREATMENT
Individuals with acute psychosis or at imminent risk should be offered specialized treatment, as available. Specialized treatment programs typically serve either acutely psychotic or at-risk individuals, but not both. However, distinguishing between those at very high risk and those newly psychotic is not easy. Let CEDAR or a similar resource help (e.g., MAPNET).

​Generally speaking, the key difference between psychosis risk and fully psychotic symptoms is insight—patients who maintain insight into the fact that their experiences are not real are not considered ”fully psychotic.” Depending on their exact symptom picture, however, they may be at “imminent risk.” Patients who completely believe that their experiences are real, or who have displayed dangerous or grossly disorganized behavior specifically related to their psychotic-spectrum symptoms, are considered fully psychotic.
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Managing Early Psychosis within Integrated Practice

Responding to symptoms of psychosis and psychosis risk in an effective, balanced way, one that neither under- nor over-reacts to a patient’s experiences, typically requires specialized training. To assess your practice’s capacity to provide appropriate care, we recommend you consider the degree to which you have staff who:

• Are knowledgeable about psychotic/psychosis risk symptoms and best practices
• Are able to provide thorough, targeted assessment of psychotic/psychosis risk symptoms and common comorbid or differential diagnoses
• Have access to consultation/supervision with colleagues knowledgeable about psychotic/psychosis risk symptoms and best practices

CURRENTLY, THE EVIDENCE SUPPORTS:​

• Specialized, comprehensive assessment of symptoms and potential differential diagnoses using a validated structured interview such as the Structured Interview for Psychosis-Risk Syndromes (SIPS) or the Structured Clinical Interview of DSM-5 Disorders (SCID-5)
• Psychoeducation about psychotic and psychosis risk symptoms, expectation of recovery with treatment, biosocial model for understanding risk and protective factors, and both pharmacological and psychosocial, and treatment options for both parents and families, including peer, educational, and occupational support
• Having direct conversations about patients’ and families’ concerns, acknowledging and addressing stigma around psychosis spectrum illnesses, addressing familial and cultural beliefs about mental health and illness, and providing hope and a recovery perspective​

• Targeting both psychotic and non-psychotic symptoms and life goals with therapeutic treatment modalities such as Cognitive Behavioral Therapy, Family Focused Therapy or Multifamily Psychoeducation, Social Skills Training, Cognitive Enhancement Therapy, Supported Employment or Education, and Acceptance and Commitment Therapy
• Psychopharmacological evaluation and monitoring as needed and acceptable to the youth and family
• Psychoeducation and support around pertinent lifestyle factors, including stress management, substance use, sleep hygiene, and nutrition/physical activity
• Regular assessment and monitoring of risk for violence toward self or others

With the proper training and resources, the integrated care setting may be ideal for reducing stigma and addressing psychotic spectrum experiences within the context of an individual’s overall health and wellbeing.