Clinical high risk and attenuated psychosis — assessment to stepped care (MEQ)

(i) Definition and criteria. Clinical high risk / ultra-high risk is an indicated-risk construct for help-seeking people with subthreshold or briefly frank psychotic phenomena plus clinical need who do not yet meet sustained full-threshold first-episode psychosis. Classic entry groups: attenuated psychotic symptoms (APS), brief limited intermittent psychotic symptoms (BLIPS), and genetic/trait vulnerability plus functional decline. This student has attenuated referential ideas and perceptual anomalies with residual insight, functional drop, family history — she may meet APS and also sits near genetic risk + decline elements; confirm duration/frequency on CAARMS (or SIPS).[1]

(ii) Conversion expectations. Meta-analyses show a substantial minority convert over 1–3 years in help-seeking samples; the majority do not. Risk is stratified: BLIPS highest, APS intermediate, genetic-risk-plus-decline lowest. Long-term cohorts show heterogeneous outcomes including remission, persistent attenuated symptoms, and non-psychotic disorders.[2][3]

(iii) Assessment and investigations. Structured history and collateral; MSE with conviction/insight ratings; suicide/violence/vulnerability risk; depression/anxiety comorbidity; cannabis timeline; capacity. Complete CAARMS/SIPS in specialist service. Physical exam; urine drug screen as adjunct; organic tests if red flags. If any antipsychotic later considered, full metabolic panel and ECG baseline first.[1][7]

(iv) Stepped management. Engage; safety plan for passive ideation; treat mood/anxiety as indicated; motivational cannabis reduction; family psychoeducation; CBT-informed therapy for appraisals of anomalous experiences (prevention trial meta-analytic support); school/functional support. Omega-3: Amminger positive signal but NEURAPRO non-replication — equipoise, not mandate. Antipsychotics not routine first-line for pure UHR; consider only with specialist rationale, low dose, monitoring, shared decision. Network meta-analyses caution against claiming a single superior preventive drug.[4][5][6][7]

(v) Monitoring and FEP switch. Early clinical reviews (e.g. 1–4 weekly while unstable); structured recheck at intervals (e.g. 3 months); crisis contacts. Switch to FEP multi-element pathway when symptoms become frank, sustained, insight-lost, or BLIPS stop remitting — then stop debating the risk label and treat as first-episode psychosis.[2][7]