Beyond Psychosis Risk: Early Clinical Phenotypes in Mental Disorder and the Subthreshold Pathway to Safe, Timely and Effective Care

tion of ‘normality’. It is challenging to rigidly define the boundary between this ‘normality’ and the earliest clinical phenotypes of mental disorder with a need for care. A key question is how critical or feasible it is to create such a precise definition. Both contributors to the current debate in Psychopathology agree that the ultra-high risk concept has been a genuine advance, one which justifies its inclusion in the DSM-5 at least as a condition requiring further study. In my view, Carpenter [3] has dealt effectively with most of the arguments against its full inclusion, which generally relate to the poor quality and resourcing of mental health care rather than the validity of the approach. We know, as Nelson [4] points out, that the universal neglect of mental health care, and particularly the failure to fund psychosocial care, will often lead to premature treatment with medications as well as potentially enhancing stigma through late intervention in tertiary settings. However, the latter, as we know from our experience in Australia, are problems that can be solved [5] . Furthermore, these genuine fears of overtreatment and harm need to be balanced against the current reality of undertreatment, which is the norm. The case for full inclusion, however, was probably undermined not so much by the poor reliability found in the flawed field trial, but by the reducing The past two decades have witnessed a genuine paradigm shift, which has enabled the earliest clinical phenotypes of psychotic illness to be defined, and for the prediction and indicated prevention of fully-fledged psychotic disorder to become a realistic possibility [1] . This development has not been without controversy. Ambivalence, within not only the general public but also the mental health professions, concerning the safety and value of mental health care as currently delivered has meant that moving to treat mental disorders in their earliest clinical stages has led to intense debate. This debate, while distorted at times by ideological forces and vested interests, is nevertheless a healthy and necessary one. However, it has wider implications for early intervention beyond psychosis. The key and potent concept here is indicated prevention, where subthreshold symptoms, buttressed where possible with key biomarkers, can be used not only to define a need for care in their own right but also a substantial but not inevitable risk of more serious disorder [2] . This is different from selective prevention, where asymptomatic patients, such as those with elevated fasting blood glucose and ‘prediabetes’, are at elevated risk of future fully-fledged illness. In defining subthreshold mental states that justify a need for care, we need to consider the complex issue of the boundary with the rather fuzzy noPublished online: July 24, 2014