As a medical student in the 1970s, my deep concern about the civil rights of the mentally ill was one of the main reasons for my interest in psychiatry and which ultimately inspired me to enter the field. These were “negative rights” which needed to be addressed and still do.

Galderisi et al¹ devote most of their paper to the protection of these civil rights. Less extensively addressed are the “positive rights”, that is the economic, social and cultural rights of the mentally ill. This includes the structural neglect of the mentally ill within the health care and medical research systems across all societies, including high-income countries².

A global average of just around 2% of the health care budget is spent on the care of the mentally ill. Even in WEIRD (Western, Educated, Industrialized, Rich and Democratic) countries of the Global North, access to and quality of care are dramatically lower than for physical illness, such as cancer and cardiovascular diseases.

This gross global neglect is a major driver of coercive cultures of care, which in turn are an inevitable result of late intervention, with treatment only being offered as a last resort. Neglect also contributes to high rates of premature death from suicide and preventable and treatable medical causes, marginalization and immiseration.

In 2023, the World Mental Health Day celebrated mental health as a universal human right. However, the meaning of this – as eloquently argued by Patel³ – is ideologically loaded. He points out that the population has the right to be protected from “known harms to mental health”. Such harms result from government policies and new megatrends that have created powerful structural forces which undermine mental health and produce higher levels of mental ill-health. They do so through creating increased poverty and marginalization, disproportionate exposure to violence and displacement, and surging wealth inequality.

The paradigm shift that began in the early 1990s to make early intervention a belated addition to the spectrum of treatment and care in psychiatry should be seen as part of the response to the above gross global neglect. Early intervention began within the field of schizophrenia and psychotic disorders and profoundly challenged and ultimately transformed this field. Subsequently it spread as a principle and goal across the full spectrum of mental disorders.

With K. Schaffner, I co-edited a special issue of Schizophrenia Research in 2001 on the ethics of early detection and intervention in schizophrenia. The main topic clearly is the balance between non-maleficence and beneficence, or risks versus benefits. Galderisi et al focus on the clinical high risk (CHR) for psychosis field in discussing the relevant issues. Ultra high risk (UHR) – or, in the US, CHR – is a concept that my colleagues and I introduced and operationally defined in the early 1990s. Proof of concept then led to our formulation of a wider transdiagnostic clinical and research framework, the clinical staging model, which allows ethical issues to be considered while enhancing the clinical utility of diagnosis⁴.

The ethical issues in psychiatry are very similar to those which apply in medicine generally, with the added complexity of enhanced stigma and challenges in establishing competency to give informed consent in certain obvious circumstances. The goal of early intervention is to reduce the impact of a potentially serious and persistent illness, via either cure or disease modification and amelioration. This means a proactive approach to treatment rather than a reactive and delayed one, which is in itself manifestly harmful, while guarding against over-treatment of patients, which may unnecessarily expose them to harmful effects. Clinical research has helped to define this “sweet spot”.

While Galderisi et al ultimately come to a largely valid set of conclusions, their account of the CHR literature and field is somewhat US- and UK/Euro-centric, with a tendency to rely on meta-analyses rather than work of those who conducted and interpreted the landmark studies in the field. Furthermore, the critiques of the CHR concept and its value are fully cited, while the rebuttals are mostly not, particularly those demonstrating the value of offering interventions at this stage in terms of ameliorating and perhaps even delaying transition⁵. The studies supporting the cost-effectiveness of intervening in the CHR stage, and those showing that positive predictive values can be enhanced through such strategies as risk calculators or joint modelling⁶, are neglected.

Finally, the research on stigma is more mixed than the authors suggest. Crucially, this is a risk that can be minimized through communicating in an accurate but broadly optimistic manner about care for current needs and future potential risk, not merely of psychosis, but of ongoing symptoms and disability. Stigma can also be greatly reduced by offering the care in youth-friendly, co-designed settings, and not in clinics which also provide care to older patients with longer-standing and established psychotic illness.

Nevertheless, consistent with my own experience over 30 years of treating such patients, the authors do ultimately conclude that offering care to help-seeking young people with genuine warning signs of psychosis, along with other comorbid symptoms and functional impairment, which may turn out to be the first stage of a sustained psychotic disorder, is of definite value under the right conditions.

One of the valid points raised by critics of the CHR concept is that the standalone, “pure” or narrow-cast CHR clinic model, relying on passive help-seeking alone, implies that only a small percentage of those who manifest the CHR phenotype and who progress to a fully-fledged stage of sustained or “first episode” psychosis are able to be engaged, with the remainder entering care via emergency departments and other pathways when they have already crossed the boundary to psychosis.

Galderisi et al are correct to state that universal, one-step screening strategies are not the appropriate solution to this problem. Instead, the enhanced primary care or integrated youth services model of care, as developed in Australia and subsequently in many other countries⁷, is a potential solution. For example, we were able to recruit 310 CHR patients from a local headspace system for a clinical trial in just over 2 years⁸, and we estimated that at least 20-30% of all patients who access headspace services experience attenuated psychotic symptoms.

However, the advantages of such a “soft entry”, co-designed, and therefore low-stigma and youth-friendly portal and care environment are much broader. They allow early intervention across the full spectrum of emerging mental ill-health in young people, and dilute the need to focus on specific trajectories of illness. Young people can be helped with their presenting clinical issues and their broader needs, including vocational support and other personal and social needs.

More general statements can be made about the need to act now, aiming to prevent the symptoms and syndromes getting worse or developing into other or additional problems. This approach is well accepted, and even the introduction of such terms as bipolar or psychosis can be held without the deterministic and pessimistic shadows that traditional psychiatry tends to cast.

Headspace has operated in Australia for 18 years and is now in over 160 communities. It has had its opponents, as do all genuine reforms. However, the rebuttals that dealt with these critiques are sometimes overlooked. Ultimately, this is a model of care with strong consumer and community support, and a recent independent evaluation has confirmed that it is effective and cost-effective, particularly for early stage and mild-to-moderate levels of disorder⁹. Similar studies have been conducted in a range of service settings in Europe and Canada.

Future progress will depend on strengthening the clinical capacity of these frontline primary care platforms, and backing them up with options for more specialized multidisciplinary care for later stages of illness.

作为 20 世纪 70 年代的一名医学生，我对精神病患者公民权利的深切关注是我对精神病学感兴趣的主要原因之一，并最终激励我进入这个领域。这些都是“消极权利”，需要解决，而且仍然需要解决。

Galderisi 等人¹将其论文的大部分内容用于保护这些公民权利。不太广泛涉及的是“积极权利”，即精神病患者的经济、社会和文化权利。这包括所有社会（包括高收入国家）的卫生保健和医学研究系统对精神疾病患者的结构性忽视² 。

全球平均只有约 2% 的医疗保健预算用于治疗精神病患者。即使在北半球的“WEIRD”（西方、受教育、工业化、富裕和民主）国家，获得医疗服务的机会和质量也远远低于癌症和心血管疾病等身体疾病的医疗服务。

这种全球性的严重忽视是强制性护理文化的主要驱动力，而这反过来又是后期干预的不可避免的结果，治疗只能作为最后的手段。忽视还导致因自杀、可预防和可治疗的医疗原因、边缘化和贫困而导致的高比例过早死亡。

2023 年世界心理健康日将心理健康视为一项普遍人权。然而，正如 Patel ³雄辩地论证的那样，这一含义具有意识形态色彩。他指出，人们有权受到保护，免受“已知的心理健康危害”。这些危害是由政府政策和新的大趋势造成的，这些政策和新的大趋势创造了强大的结构性力量，破坏心理健康并导致更高水平的心理不健康。它们通过加剧贫困和边缘化、过度遭受暴力和流离失所以及财富不平等加剧来实现这一目标。

20世纪90年代初开始的范式转变，使早期干预成为精神病学治疗和护理范围中迟来的补充，这应该被视为对上述全球严重忽视的回应的一部分。早期干预始于精神分裂症和精神病领域，并对这一领域提出了深刻的挑战并最终改变了这一领域。随后，它作为一项原则和目标传播到所有精神障碍领域。

2001 年，我与 K. Schaffner 共同编辑了《精神分裂症研究》特刊，主题是精神分裂症早期检测和干预的伦理问题。主题显然是非恶意与善意，或风险与收益之间的平衡。 Galderisi等人重点关注精神病临床高风险（CHR）领域讨论相关问题。超高风险（UHR）——或者在美国，CHR——是我和我的同事在 20 世纪 90 年代初提出并在操作上定义的一个概念。概念验证导致我们制定了更广泛的跨诊断临床和研究框架，即临床分期模型，该模型允许在提高诊断的临床实用性的同时考虑伦理问题⁴ 。

精神病学中的伦理问题与一般医学中应用的伦理问题非常相似，但在某些明显情况下，在建立给予知情同意的能力方面增加了耻辱感和挑战的复杂性。早期干预的目标是通过治愈或疾病改变和改善来减少潜在严重和持续性疾病的影响。这意味着采取积极主动的治疗方法，而不是被动和延迟的治疗方法，后者本身显然是有害的，同时要防止对患者的过度治疗，这可能会使他们不必要地受到有害影响。临床研究帮助定义了这个“最佳点”。

虽然 Galderisi 等人最终得出了一组基本有效的结论，但他们对 CHR 文献和领域的描述有些以美国和英国/欧洲为中心，倾向于依赖荟萃分析，而不是那些进行和研究的人的工作。解读了该领域的里程碑式研究。此外，对 CHR 概念及其价值的批评被充分引用，而反驳大多没有被引用，特别是那些证明在现阶段提供干预措施在改善甚至延迟过渡方面的价值的反驳⁵ 。支持 CHR 阶段干预的成本效益的研究，以及那些表明可以通过风险计算器或联合建模等策略增强阳性预测值的研究⁶都被忽视了。

最后，关于耻辱的研究比作者想象的更加复杂。至关重要的是，通过以准确但广泛乐观的方式就当前需求和未来潜在风险（不仅是精神病，还包括持续症状和残疾的风险）的护理进行沟通，可以将这种风险降至最低。通过在年轻人友好的、共同设计的环境中提供护理，而不是在也为患有长期和既定精神病的老年患者提供护理的诊所中提供护理，也可以大大减少耻辱感。

尽管如此，根据我自己 30 多年治疗此类患者的经验，作者最终得出的结论是，为具有精神病真正警告信号以及其他共病症状和功能障碍的寻求帮助的年轻人提供护理，这可能会导致是持续性精神障碍的第一阶段，在适当的条件下具有明确的价值。

CHR 概念的批评者提出的有效观点之一是，独立的、“纯粹的”或狭隘的 CHR 诊所模式仅依赖于被动寻求帮助，这意味着只有一小部分人表现出 CHR 表型并且那些发展到持续或“首次发作”精神病的完全阶段的人能够参与其中，其余的人在已经跨越精神病的界限时通过急诊室和其他途径进入护理。

Galderisi 等人正确地指出，通用的一步筛选策略并不是解决这一问题的适当方法。相反，澳大利亚以及随后许多其他国家⁷开发的强化初级保健或综合青少年服务模式是一个潜在的解决方案。例如，我们在短短 2 年多的时间里就从当地顶空系统招募了 310 名 CHR 患者进行临床试验⁸ ，并且我们估计所有接受顶空服务的患者中至少有 20-30% 的精神病症状有所减轻。

然而，这种“软进入”、共同设计、因此耻辱感低且对年轻人友好的门户和护理环境的优势要广泛得多。它们允许对年轻人中出现的各种精神疾病进行早期干预，并减少对特定疾病轨迹的关注。年轻人可以得到帮助解决他们提出的临床问题和更广泛的需求，包括职业支持和其他个人和社会需求。

可以就立即采取行动的必要性做出更一般性的陈述，旨在防止症状和综合症恶化或发展成其他或额外的问题。这种方法被广泛接受，甚至引入双相情感障碍或精神病等术语也可以避免传统精神病学往往投射的确定性和悲观主义阴影。

Headspace 已在澳大利亚运营 18 年，现已覆盖 160 多个社区。正如所有真正的改革一样，它也有反对者。然而，针对这些批评的反驳有时会被忽视。最终，这是一种得到消费者和社区大力支持的护理模式，最近的一项独立评估已证实它是有效且具有成本效益的，特别是对于早期和轻度至中度的疾病⁹ 。在欧洲和加拿大的一系列服务环境中也进行了类似的研究。

未来的进展将取决于加强这些一线初级保健平台的临床能力，并为它们提供针对疾病后期更专业的多学科护理的选择。