Antipsychotic medication in individuals at Clinical High Risk for Psychosis: what recommendations for clinicians?

The "Early Intervention in Psychosis" (EIP) paradigm resulted in relevant promise for preventing the onset of severe mental disorders. International guidelines on early treatment of young people at Clinical High Risk for Psychosis (CHR-P) (not updated in the last 5 years) recommend individual psychotherapy as first-line treatment, while Antipsychotics (AP) should be used only when psychosocial interventions has shown to be ineffective. However, the use of APs in people at CHR-P still remains a complex, often divisive issue, where official guidelines and real-world prescription habits seldom correspond, especially in adolescence. Indeed, it has been reported baseline AP exposure rates ranging from 25% to 75% in different studies. Why these findings in ostensible tension (if not in open contradiction) with current treatment guidelines for CHR-P individuals? Moreover, recent evidence notably showed that people at CHR-P with AP exposure at the recruitment in EIP services, have higher rates of psychosis transition compared to CHR-P subjects without AP prescription in different follow-ups. Is it an iatrogenic effect of AP drug? Should AP prescription to CHR-P people be halted? In the current paper, we reviewed international guidelines on AP treatment in CHR-P individuals, with the purpose of updating mental health clinicians on an ongoing debated topic and encouraging prescribing habits aligned with expert advice and evidence.