Long-term effects of a community intervention for early identification of first-episode psychosis

Objective: To assess whether an Early Case Identification Program (ECIP) for first‐episode psychosis (FEP), which showed no significant short‐term effects, has a delayed impact on duration of untreated psychosis (DUP). Method: Using a historical control design, FEP patients were assessed on clinical variables over three consecutive phases, 2 years prior, 2 years during and 3 years after implementation of the ECIP. Additional analyses were conducted on non‐affective and schizophrenia spectrum psychoses cases only. Results: There was no overall significant difference in DUP across the three phases. For cases treated within the first year of illness a nonsignificant reduction in DUP to less than 2 months observed during the active phase was sustained post‐ECIP. Conclusion: In some jurisdictions community‐wide early case detection may fail to have an immediate or delayed effect on DUP, especially for cases who normally present for treatment with DUP >1 year.     

When things are not as they seem: detecting first‐episode psychosis upon referral to ultra high risk (‘prodromal’) clinics

The current paper examines a neglected function of ‘ultra high risk’ (UHR) clinics: to detect first‐episode psychosis (FEP) mistakenly identified as a prodrome. A clinical audit was conducted of referrals to a UHR service, the Personal Assessment and Crisis Evaluation Clinic, over a 12‐month period (April 2005–March 2006). In this audit, 11.4% of the total number of referrals (n= 149) and 11.9% of those who attended a first appointment were psychotic on referral. These figures indicate that a substantial proportion of individuals thought to be prodromal are in fact suffering FEP. UHR clinics minimize duration of untreated psychosis for FEP patients mistaken as prodromal.     

The outcome of early intervention in first episode psychosis

Abstract

The last 20?years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.     

Family strengths: a potential determinant of the duration of untreated psychosis among hospitalized African-American first-episode patients

Aim: Evidence suggests that treatment delay, represented by the duration of untreated illness (DUI) and the duration of untreated psychosis (DUP), may be a potentially powerful determinant of the early course of primary psychotic disorders. Yet, research on the predictors of treatment delay has only just begun. To date, there are virtually no empirical data on the relationship between family functioning and treatment delay in the context of first‐episode psychosis. In this study, it was hypothesized that family strengths would be inversely correlated with DUI and DUP; and families of patients with a short DUI/DUP would have greater family strengths than those of patients with a long DUI/DUP. Methods: Family strengths (including pride and accord dimensions), DUI and DUP were assessed in 34 African Americans hospitalized for first‐episode psychosis and their respective 34 family members most involved in initiating care. Results: The total score of the Family Strengths scale and the accord subscale score were significantly inversely correlated with both DUI and DUP, although the correlation between the pride subscale score and DUI/DUP was not as strong and failed to reach statistical significance. Similarly, the family members of patients with a short DUI/DUP had higher family strength scores than those of patients with a long DUI/DUP. Conclusions: Given the dearth of research on the functioning of families beginning to initiate care for individuals with first‐episode psychosis, it is imperative to further clarify the role family characteristics may play in understanding treatment delay (DUI/DUP) and in the development of preventive interventions to facilitate early intervention for at‐risk populations.     

Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy

Purpose

This study set out to investigate the patterns of referral in a sample (n = 206) of patients having first-time access to an Italian comprehensive program that targets the early detection of and early intervention on subjects at the onset of psychosis. The primary goal of the study was to investigate the duration of untreated illness (DUI) and/or the duration of untreated psychosis (DUP) in the sample since the implementation of the program.

Method

Data on pathways of referrals prospectively collected over a 11-year period, from 1999 to 2010; data referred to patients from a defined catchment area, and who met ICD-10 criteria for a first episode of a psychotic disorder (FEP) or were classified to be at ultra-high risk of psychosis (UHR) according to the criteria developed by the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne. Changes over time in the DUI and DUP were investigated in the sample.

Results

Referrals increased over time, with 20 subjects enrolled per year in the latter years of the study. A large majority of patients contacted a public or private mental health care professional along their pathway to treatment, occurring more often in FEP than in UHR patients. FEP patients who had contact with a non-psychiatric health care professional had a longer DUP. Over time, DUP and DUI did not change in FEP patients, but DUI increased, on average, in UHR patients.

Conclusions

The establishment of an EIP in a large metropolitan area led to an increase of referrals from people and agencies that are not directly involved in the mental health care system; over time, there was an increase in the number of patients with longer DUI and DUP than those who normally apply for psychiatric services.     

Predictors of cognition in first episode psychosis

PurposeCognitive deficits are common in the first episode of psychosis (FEP) and may begin much earlier. While some evidence suggests that the decline in cognition occurs over the untreated symptomatic period, including the prodromal phase, others point to these deficits being present even earlier. We aimed to investigate the differential effect of untreated symptomatic and pre-morbid phases on cognition in a large sample of FEP.MethodsTwo hundred and sixty eight FEP patients, admitted into a specialized early intervention service, were administered neuro-cognitive tests. The Circumstances of Onset and Relapse Schedule (CORS) was administered for measurement of duration of untreated psychosis (DUP), the duration of untreated illness (DUI) and demographic factors. The Pre-morbid Adjustment Scale (PAS) was used to measure different domains of pre-morbid adjustment. Seventy three healthy controls were also recruited for neuro-cognitive comparison.ResultsWe observed no effect of DUP and a minimal effect of DUI on cognitive functioning in FEP. Instead, the early educational pre-morbid adjustment domain was most strongly associated with cognition and predicted both global cognitive and verbal memory outcome in FEP.ConclusionOur results suggest that symptoms associated with the symptomatic phase of a FEP do not influence cognitive functioning in FEP. Instead, cognitive deficits in FEP may predate illness onset and may indicate susceptibility to such illness.     

Does a detection team shorten duration of untreated psychosis?

Introduction: Duration of untreated psychosis (DUP) is shown to be associated with poor outcome in many domains. It has been shown that it is possible to shorten DUP when combining a detection team and an information campaign. The aim of this study was to evaluate whether DUP was shortened during the first 3 years after establishing detection teams without a concomitant information campaign. Methods: All patients included in the OPUS trial were examined with the Instrument for Retrospective Assessment of Onset of Psychosis to determine DUP. A total of 552 patients with first episode psychotic disorder (n = 470) or schizotypal disorder (n = 82) were included in the study. The 3‐year inclusion period was divided into six consecutive periods of 6 months each. Results: The median DUP was 52 weeks. DUP was not significantly reduced during the 3‐year inclusion period, but a larger proportion of patients with symptoms below the threshold for frank psychosis were included compared with the beginning of the trial. The proportion referred from primary care remained small (8–10%) and unchanged during the inclusion period. Discussion: The availability of a detection team increased the referral of patients with schizotypal disorder, but the DUP among psychotic patients remained almost unaltered throughout the period. It seems that an information campaign and possibilities for direct access and self‐referral are necessary in order to shorten DUP.     

Determinants of help-seeking and system related components of delay in the treatment of first-episode psychosis

INTRODUCTION: Knowledge about factors that influence different components of duration of untreated psychosis (DUP) is important for designing interventions to reduce DUP. METHOD: We tested associations between help-seeking and referral components of DUP (DUP-H and DUP-R, respectively) and the following predictor variables: age, gender, ethnicity, living arrangement, pre-morbid adjustment, age at onset of psychosis, diagnosis, level of symptoms, type of first and total number of mental health contacts prior to and after the onset of psychosis in a sample of 98 first-episode psychosis patients (FEP). RESULTS: Longer DUP-HS was significantly associated with earlier age at onset, diagnosis of schizophrenia spectrum psychosis and poor pre-morbid adjustment during adolescence. Longer DUP-R was associated with earlier age at onset and first help-seeking contact having been made with a non-medical professional. CONCLUSIONS: Relatively non-malleable patient characteristics are likely to influence delay in help-seeking while more malleable systemic characteristics influence delay associated with referral for specialized treatment.     

The evolution of depression and suicidality in first episode psychosis

Upthegrove R, Birchwood M, Ross K, Brunett K, McCollum R, Jones L. The evolution of depression and suicidality in first episode psychosis. Objective: To have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms. Method: Ninety‐two patients with first episode psychosis (FEP) completed measures of depression, including prodromal depression, self‐harm and duration of untreated psychosis. Follow‐up took place over 12 months. Results: Depression occurred in 80% of patients at one or more phases of FEP; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self‐harm. Conclusion: Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking. Efforts to predict and reduce depression and deliberate self‐harm in psychosis may need to target this early phase to reduce later risk.     

One year outcome in first episode psychosis: influence of DUP and other predictors

BACKGROUND: A number of studies have reported evidence of a relationship between longer duration of untreated psychosis (DUP) and poorer outcome at 1 year while others have failed to find such evidence. It is possible that several other predictors may confound this relationship and there may be different predictors for different dimensions of outcome. In the current study we examined relationship between DUP and several other predictors, and 1 year outcome on rate and level of remission as well as level of positive, negative, depressive and anxiety symptoms in a community cohort of first episode psychosis patients. METHOD: All potential cases of a first episode of non-affective psychosis were assessed and offered treatment in a comprehensive treatment program. Data were collected on all patients who completed 1 year of treatment on a number of predictor variables (DUP, length of the prodromal period, age of onset, gender, pre-morbid adjustment during childhood and adolescence, diagnosis) and outcome variables (level of remission, positive, negative, depression and anxiety symptoms based on ratings on SAPS, SANS, CDS and HAS, respectively). Data were analysed using an analysis of variance, bivariate correlations and hierarchical regression analysis. RESULTS: Of a total of 130 patients were offered treatment, 106 completed 1 year of treatment and complete data were available on 88 subjects, 80% of whom met criteria for schizophrenia spectrum psychosis. The rate and level of remission were significantly higher for patients with shorter DUP (<22 weeks). DUP was the only independent predictor of the level of remission as well as reality distortion at 1 year; for disorganization syndrome and negative symptoms it was the age of onset and level of premorbid adjustment in adolescence, respectively; while the level of anxiety was predicted by the length of the prodrome. Additional predictors increased the variance explained by each model. CONCLUSION: Our results confirmed the independent role of DUP in remission and positive symptom outcome at 1 year, thus providing support for the enthusiasm for early intervention. However, the model including DUP and premorbid adjustment in early adolescence explained a greater amount of variance in outcome on positive symptoms than DUP alone. On the other hand, outcome on negative symptoms, disorganization and anxiety are more likely to be influenced by longer term characteristics such as premorbid adjustment, earlier age of onset, gender and the length of the prodromal period, and therefore may not be as responsive to effects of early intervention.     

Stress et transition psychotique : revue de la littérature

BackgroundPsychiatric disorders are consistent with the gene x environment model, and non-specific environmental factors such as childhood trauma, urbanity, and migration have been implicated. All of these factors have in common to dysregulate the biological pathways involved in response to stress. Stress is a well-known precipitating factor implicated in psychiatric disorders such as depression, bipolar disorder, anxiety, and possibly schizophrenia. More precisely, psychosocial stress induces dysregulation of the hypothalamic-pituitary-adrenal axis (HPA) and could modify neurotransmission, which raises the question of the involvement of stress-related biological changes in psychotic disorders. Indeed, the literature reveals dysregulation of the HPA axis in schizophrenia. This dysregulation seems to be present in the prodromal phases (UHR subjects for ultra-high risk) and early schizophrenia (FEP for first episode psychosis). Thus, and following the stress–vulnerability model, stress could act directly on psychotic onset and precipitate the transition of vulnerable subjects to a full-blown psychosis.ObjectiveThe present paper reviews the literature on stress and onset of schizophrenia, with consideration for the causal role vs. associated role of HPA axis dysregulation in schizophrenia and the factors that influence it, in particular during prodromal and earlier phases. We also discuss different methods developed to measure stress in humans.MethodologyWe performed a bibliographic search using the keywords ‘cortisol’, ‘glucocorticoid’, ‘HPA’ with ‘UHR’, ‘CHR’, ‘at-risk mental state’, ‘first episode psychosis’, ‘schizotypal’, ‘prodromal schizophrenia’ in Medline, Web of Knowledge (WOS), and EBSCO completed by a screening of the references of the selected articles.ResultsStress has been studied for many years in schizophrenia, either by subjective methods (questionnaires), or objective methods (standardized experimental protocols) with biological sampling and/or brain imaging methods. These methods have suggested a link between dysregulation of the HPA axis and psychotic symptoms both through abnormal basal levels of cortisol and flattened reactivity to social stress. Imaging results suggest indirect modifications, including abnormal pituitary or hippocampal volume. Several factors dysregulating the HPA axis have also been highlighted, such as consumption of drugs (i.e. cannabis), childhood trauma or genetic factors (such as COMT, or MTHFR variants). Psychological stress induces subcortical dopaminergic activation attributable to hypothalamic-pituitary-adrenal (HPA) axis dysregulation. This dysregulation is present in the prodromal phase (UHR) in patients who have experienced a first psychotic episode (FEP) and in siblings of schizophrenic patients. Stress dysregulation is a plausible hypothesis to understand the psychosis onset.DiscussionThe effect of stress on brain pathways could participate to the mechanisms underlying the onset of psychotic symptoms, both as a precipitating factor and as a marker of a predisposing vulnerability. This dysregulation fits into the gene x environment model: in subjects with genetic predispositions, stressful environmental factors can modify biological pathways implicated in psychiatric disorders, promoting the emergence of symptoms. However, many confounding factors obscure the literature, and further studies are needed in schizophrenic patients, UHR and FEP patients to clarify the precise role of stress in psychotic transition. Identification of stress biomarkers could help diagnosis and prognosis, and pave the way for specific care strategies based on stress-targeted therapies.     

The relationship between duration of untreated psychosis and outcome: an eight-year prospective study

Longer duration of untreated psychosis (DUP) prior to the initiation of treatment has been found to predict poorer short-term clinical and functional outcomes in patients with first-episode psychosis (FEP). The extent to which the relationship between DUP and outcome is maintained in the medium-to-long term however remains unclear. We examined the influence of DUP on clinical and functional outcomes in a prospective, naturalistic study of 318 FEP patients followed up 8 years after initial treatment at a specialist early psychosis service. Quality of life, social and occupational functioning, positive and negative symptoms at 8 years were assessed using standardized instruments. Multiple linear regression analyses indicated that, after controlling for the effects of other factors, shorter DUP correlated moderately with decreased severity of positive symptoms, and enhanced social and occupational functioning and quality of life. There was no uniform point associated with medium-to-long term impairment, with some domains of outcome more sensitive to treatment delay than others. However a consistent finding was that outcomes for these domains were significantly worse when DUP exceeded 3 months. Among those with a schizophrenia-spectrum diagnosis, DUP exceeding 1 year was associated with poorer outcome. No association was found between DUP and negative symptoms in either diagnostic group. As with short-term prognosis, DUP appears to be an independent predictor of prognosis in the medium-to-long term. Results support the need for assertive early detection strategies to facilitate the timely delivery of effective intervention programs to those with emerging psychotic illness in order to reduce the risk of long term deleterious outcomes.     

Inconsistency in the relationship between duration of untreated psychosis (DUP) and negative symptoms: sorting out the problem of heterogeneity

BACKGROUND: Several studies have found an association between duration of untreated psychosis (DUP) and clinical outcomes. However, there is inconsistency concerning the association between outcome on negative symptoms and DUP with some studies having found a correlation between DUP and negative symptoms, while other studies did not find such an association. OBJECTIVE: The aim of the present study was to investigate the role of heterogeneity associated with the relationship between DUP and negative symptoms in a sample of first episode psychosis (FEP) patients from a multicentre treatment study and a replication sample of subjects from a specialized service in a different jurisdiction. METHOD: FEP patients (n=116) treated in specialized programs in two medium sized and one large urban centre were evaluated. Latent class regression was employed to simultaneously classify respondents and estimate the effect of DUP on negative symptoms after one year. The process was repeated on 59 consecutive FEP patients in a specialized service in Montreal. RESULTS: The final model reflected three distinct sub-groups with different associations between DUP and negative symptoms: (a) for one fourth of the subjects there was a positive association between DUP and negative symptoms, indicating that long DUP was associated with poor negative symptoms outcome; (b) an opposite effect was observed for another sub-group of patients: patients with short DUP scored high on the negative symptoms scale and patients with long DUP reported only a few negative symptoms; (c) there was no association between DUP and negative symptoms outcome for nearly half of the patients. These models were replicated in the Montreal sample. CONCLUSIONS: The association between DUP and negative symptoms outcome might differ among sub-groups of first episode patients. Latent class regression analysis offers a flexible way to include unmeasured heterogeneity in outcome analyses.     

Early identification of non‐remission in first‐episode psychosis in a two‐year outcome study

Simonsen E, Friis S, Opjordsmoen S, Mortensen EL, Haahr U, Melle I, Joa I, Johannessen JO, Larsen TK, Røssberg JI, Rund BR, Vaglum P, McGlashan TH. Early identification of non‐remission in first‐episode psychosis in a two‐year outcome study. Objective: To identify predictors of non‐remission in first‐episode, non‐affective psychosis. Method: During 4 years, we recruited 301 patients consecutively. Information about first remission at 3 months was available for 299 and at 2 years for 293 cases. Symptomatic and social outcomes were assessed at 3 months, 1 and 2 years. Results: One hundred and twenty‐nine patients (43%) remained psychotic at 3 months and 48 patients (16.4%) remained psychotic over 2 years. When we compared premorbid and baseline data for the three groups, the non‐remitted (n = 48), remitted for <6 months (n = 38) and for more than 6 months (n = 207), duration of untreated psychosis (DUP) was the only variable that significantly differentiated the groups (median DUP: 25.5, 14.4 and 6.0 weeks, respectively). Three months univariate predictors of non‐remission were being single, longer DUP, core schizophrenia, and less excitative and more negative symptoms at baseline. Two‐year predictors were younger age, being single and male, deteriorating premorbid social functioning, longer DUP and core schizophrenia. In multivariate analyses DUP, negative and excitative symptoms predicted non‐remission at 3 months, but only DUP predicted at 2 years. Conclusion: Long DUP predicted both 3 month and 2‐year non‐remission rates in first‐episode psychosis.     

A controlled evaluation of a targeted early case detection intervention for reducing delay in treatment of first episode psychosis

Purpose

Interventions aimed at influencing specific pathways to care may reduce the duration of untreated psychosis (DUP). The purpose of this study was to reduce delay in referral to an early intervention service following first contact for help seeking for psychosis in a defined urban catchment area.

Methods

Using a historical control design, we conducted a targeted intervention comprised of intensive training and education regarding first onset of psychosis and benefits of early intervention with all potential points of contact in pathways to care in a defined catchment area of a specialized early intervention (EI) service. Data collected on different components of DUP [help seeking (H-DUP) and referral (R-DUP)] and demographic and clinical characteristics on patients seeking treatment of first episode of a psychotic (FEP) disorder accepted in the EI service for 3 years before and 3 years after the intervention were contrasted. No other systemic changes occurred in this catchment area during this period.

Results

There was a significant increase in the number of cases of FEP referred to the EI service post-intervention from hospitals other than the parent institute, in the proportion with a diagnosis of affective psychosis and proportion of patients from a lower socioeconomic status (SES). Although largest proportion of patients continued to make their first contact with community services, the latter failed to refer cases of psychosis to the EI service despite making a large number of mostly non-cases (for psychosis). The intervention had no direct effect on total DUP, R-DUP or H-DUP. After controlling for diagnosis and SES, post-intervention, R-DUP remained significantly lower for patients making first contact with the emergency service of the parent institute.

Conclusions

The intervention failed to reduce R-DUP for patients making contact with or referred from community services and most patients still used hospital resources to enter treatment at the EI service.     

Negative symptoms in first episode non-affective psychosis

OBJECTIVE: To determine the prevalence of negative symptoms and to examine secondary sources of influence on negative symptoms and the role of specific negative symptoms in delay associated with seeking treatment in first episode non-affective psychosis. METHOD: One hundred and ten patients who met Diagnostic Statistical Manual-IV (DSM-IV) criteria for a first episode of schizophrenia spectrum psychoses were rated for assessment of negative, positive, depressive and extrapyramidal symptoms, the premorbid adjustment scale and assessment of demographic and clinical characteristics including duration of untreated psychosis (DUP). RESULTS: Alogia/flat affect and avolition/anhedonia were strongly influenced by parkinsonian and depressive symptoms, respectively. A substantial proportion (26.8%) of patients showed at a least moderate level of negative symptoms not confounded by depression and Parkinsonism. DUP was related only to avolition/anhedonia while flat affect/alogia was related to male gender, diagnosis of schizophrenia, age of onset and the length of the prodrome. CONCLUSION: Negative symptoms that are independent of the influence of positive symptoms, depression and extra pyramidal symptoms (EPS) are present in a substantial proportion of first episode psychosis patients and delay in seeking treatment is associated mainly with avolition and anhedonia.     

Background factors as determinants of satisfaction with care among first-episode psychosis patients

Objective To evaluate the impact of demographic and psychosocial background factors and psychiatric and functional status before and at admission on the patients' satisfaction with care (PSC) among first-episode psychosis (FEP) patients. Method One year after entering the Parachute Project, 134 FEP patients completed a patient satisfaction questionnaire. The association with demographic and psychosocial background factors, together with psychiatric and functional status before and after admission, was analysed. Results Twenty-nine per cent of the variance of PSC was explained by factors such as educational level, social network, duration of untreated psychosis (DUP) and Global Assessment of Functioning (GAF) the year prior to onset. Negative symptoms and lack of hope at admission were also predictors of PSC. The strongest predictor was DUP. Conclusion Affecting the public knowledge in psychiatric problems and psychiatric treatment, together with early intervention strategies aiming to decrease the prodromal and DUP period among FEP patients, can positively influence the patients' experience of given care. By increasing the knowledge of available psychiatric treatment, the sense of powerlessness might decrease among the affected persons, and the possibility of early help seeking might increase.     

Duration of untreated psychosis and neuropsychological function in first episode psychosis

PURPOSE: We investigated whether duration of untreated psychosis (DUP) prior to first presentation was associated with cognitive function in first episode psychosis (FEP) subjects. We predicted that longer DUP would be associated with greater neurocognitive impairment. METHOD: 180 subjects with schizophrenia (and 93 subjects with Other Psychoses) performed a neurocognitive battery assessing IQ, verbal learning, working memory, visual learning and speed of processing. DUP was defined as the number of days between first onset of psychotic symptoms and first contact with psychiatric services. RESULTS: Longer DUP was associated with impaired performance in verbal IQ (p=0.04), verbal learning (p=0.02), and verbal working memory (p=0.04) in FEP subjects with schizophrenia. These associations remained significant for verbal IQ when scores were corrected for age, gender, educational level and ethnicity. CONCLUSIONS: Longer DUP is associated with poorer neurocognitive ability in schizophrenia subjects at time of first presentation. Since this was a cross-sectional study we can not tell whether longer DUP was a cause or a consequence of the poorer performance.     

Is violence at presentation by patients with first-episode psychosis associated with duration of untreated psychosis?

Introduction Violence in first episode psychosis poses significant challenges for mental health staff and patients’ families. Violence has been shown to be related to psychopathology. Duration of untreated psychosis (DUP) has been shown to influence psychopathology at presentation in first-episode psychosis, but little is known about the direct relationship between violence at presentation and DUP. We therefore sought to examine the relationship between these two variables. Methods Patients were all individuals aged between 16 and 65 years, with a DSM-III-R diagnosis of psychotic illness, taking part in a First Episode study. We used the Structured Clinical Interview (SCID-I), Positive and Negative Symptom Scale (PANSS), Beiser Scale and the Modified Overt Aggression Scale (MOAS) to evaluate diagnosis, psychopathology, DUP and violent behaviour respectively. Data for each case were retrospectively examined for violence, for the week prior to and week following first contact with psychiatric services, blind to diagnosis, DUP and psychopathology scores. Results We assessed 157 patients. About 46 patients (29%) were violent. Violence rates did not differ across diagnostic groups, while DUP varied significantly across diagnostic groups (P = 0.001). Violence was not associated with DUP across all psychoses (P = 0.41). In the schizophrenia subgroup (n = 94), thirty individuals (32%) were violent. In a logistic regression, logDUP was not associated with violence (P = 0.11). Violence was predicted by involuntary admission status (P = 0.04) and global positive symptoms (P = 0.03). DUP was associated weakly with negative symptoms (P = 0.01) but not associated with positive or general psychopathology. Neither pre nor post-contact violence was associated (P = 0.79 and P = 0.09 respectively) with DUP. Discussion Contrary to a recent study, we did not find an association between violence at presentation and DUP. The relationships between violence, DUP and psychopathology are complex and may be compounded by potential difficulties inherent in the PANSS. Conclusion Programs to reduce DUP may not impact on rates of violence at presentation in First Episode Psychosis (FEP).