Symptomatic and functional remission in patients with first-episode psychosis

Verma S, Subramaniam M, Abdin E, Poon LY, Chong SA. Symptomatic and functional remission in patients with first‐episode psychosis. Objective: For patients suffering from psychotic disorders and their caregivers, ‘recovery’ remains important. Our study aims to examine the rates of both symptomatic and functional remission in first‐episode psychosis (FEP) patients at 2 years and identify sociodemographic and clinical factors associated with recovery. Method: In this naturalistic study, all consecutive FEP patients presenting to an early psychosis intervention programme were recruited. Symptomatic remission was defined by the Schizophrenia Working Group’s criteria; functional remission was defined as a Global Assessment of Functioning (GAF) disability score of ≥61 with engagement in age‐appropriate vocation. Simple and multiple logistic regressions using stepwise method were used. Results: Out of 1175 patients, 636 (54.1%) met criteria for symptomatic remission, 686 (58.4%) for functional remission, while 345 (29.4%) met for both. Multiple logistic regression revealed female gender (OR 1.47; 95%CI, 1.12–1.93), those married (OR 1.49; 95%CI, 1.02–2.18), younger age (OR 0.98; 95%CI, 0.95–0.99), tertiary education (OR 1.56; 95%CI, 1.02–2.38), shorter DUP (OR 0.99; 95%CI, 0.98–0.99), lower baseline PANSS negative scores (OR 0.97; 95%CI, 0.95–0.99), and early response at month 3 (OR 1.78; 95%CI, 1.31–2.42), as significant predictors of recovery at year 2. Conclusion: Our results indicate that strategies to reduce DUP and achieve early response could improve remission rates in FEP patients.     

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.     

A community intervention for early identification of First Episode Psychosis

Abstract Objective The aim of this study was to assess the impact of a community case identification program on duration of untreated psychosis (DUP) (a measure of delay in treatment) and characteristics of patients entering treatment for a first episode of psychosis. Method Using a quasi-experimental historical control design, patients within a defined geographic catchment area who met DSM-IV criteria for a first episode of a psychotic disorder (FEP) were assessed on a number of demographic and clinical variables including DUP, length of prodromal period and symptoms at initial presentation, for 2 years prior to and 2 years after the introduction of a community-wide Early Case Identification Program (ECIP). The ECIP was designed to promote early recognition and referral of individuals with a FEP from any possible source of referral including self-referrals. Treatment interventions offered were the same throughout the two phases. Results In all, 88 and 100 patients met criteria respectively in phases I and II. There were no significant differences in rates of treated incidence or DUP between the two phases. Patients recruited in phase II had significantly longer prodromal periods and higher level of psychotic and disorganization symptoms. There were no differences in level of negative symptoms or pre-morbid adjustment. Conclusion A community-wide approach to early case identification may not be the most effective way to reduce delay in treatment of psychosis, but may bring into treatment patients who have been ill for long periods of time and have a higher level of psychopathology. A more targeted approach directed at primary care and emergency services may achieve different results in reducing delay in treatment.     

Treatment delay and response rate in first episode psychosis

OBJECTIVE: There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population. METHOD: An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year. RESULTS: The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response. CONCLUSION: Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.     

Understanding Components of Duration of Untreated Psychosis and Relevance for Early Intervention Services in the Canadian Context: Comprendre les Composantes de la Durée de la Psychose Non Traitée et la Pertinence de Services D’intervention Précoce Dans le Contexte Canadien

Background:Clinical, functional, and cost-effectiveness outcomes from early intervention services (EIS) for psychosis are significantly associated with the duration of untreated psychosis (DUP) for the patients they serve. However, most EIS patients continue to report long DUP, while a reduction of DUP may improve outcomes. An understanding of different components of DUP and the factors associated with them may assist in targeting interventions toward specific sources of DUP.Objectives:To examine the components of DUP and their respective determinants in order to inform strategies for reducing delay in treatment in the context of an EIS.Methods:Help-seeking (DUP-H), Referral (DUP-R), and Administrative (DUP-A) components of DUP, pathways to care, and patient characteristics were assessed in first episode psychosis (N = 532) patients entering an EIS that focuses on systemic interventions to promote rapid access. Determinants of each component were identified in the present sample using multivariate analyses.Results:DUP-H (mean 25.64 ± 59.00) was longer than DUP-R (mean = 14.95 ± 45.67) and DUP-A (mean 1.48 ± 2.55). Multivariate analyses showed that DUP-H is modestly influenced by patient characteristics (diagnosis and premorbid adjustment; R ² = 0.12) and DUP-R by a combination of personal characteristics (age of onset and education) and systemic factors (first health services contact and final source of referral; R ² = 0.21). Comorbid substance abuse and referral from hospital emergency services have a modest influence on DUP-A (R ² = 0.08). Patients with health care contact prior to onset of psychosis had a shorter DUP-H and DUP-R than those whose first contact was after psychosis onset (F(1, 498) = 4.85, P < 0.03 and F(1, 492) = 3.34, P < 0.07).Conclusions:Although much of the variance in DUP is unexplained, especially for help-seeking component, the systemic portion of DUP may be partially determined by relatively malleable factors. Interventions directed at altering pathways to care and promote rapid access may be important targets for reducing DUP. Simplifying administrative procedures may further assist in reducing DUP.     

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.     

Early detection and intervention in first-episode schizophrenia: a critical review

OBJECTIVE: To review the literature on early intervention in psychosis and to evaluate relevant studies. Method: Early intervention was defined as intervention in the prodromal phase (primary prevention) and intervention after the onset of psychosis, i.e. shortening of duration of untreated psychosis (DUP) (secondary prevention). RESULTS: We found few studies aimed at early intervention, but many papers discussing the idea at a more general level. We identified no studies that prove that intervention in the prodromal phase is possible without a high risk for treating false positives. We identified some studies aimed at reducing DUP, but the results are ambiguous and, until now, no follow-up data showing a positive effect on prognosis have been presented. CONCLUSION: Early intervention in psychosis is a difficult and important challenge for the psychiatric health services. At the time being reduction of DUP seems to be the most promising strategy. Intervention in the prodromal phase is more ethically and conceptually problematic.     

Durée de psychose non traitée : état des lieux et analyse critique

IntroductionPrognosis of schizophrenia has not significantly improved despite extensive research. There is often a relatively long delay between onset of symptoms and treatment initiation. Lately, duration of untreated psychosis (DUP), the time between the onset of psychosis and initiation of treatment, has been one of the most studied variables in patients presenting for a first psychotic episode in order to evaluate the impact of early intervention on the prognosis of schizophrenia. In the literature, a variety of criteria have been used to define both transition to psychosis and initiation of treatment. Furthermore, the dating of both of these variables is usually retrospective, further complicating the measurement of DUP.MethodsWe conducted a comprehensive review about DUP using Pubmed and Google Scholar databases up to January 2015 using the following keywords “schizophrenia”, “duration of untreated psychosis”, “duration of untreated illness” and “early intervention”. Papers were included if they were published in French or English.ResultsThe mean DUP was found to be 2 years but it can vary according to multiple factors such as denial of illness by the patient and family, withdrawal and isolation from friends and relatives, diagnostic errors, paranoid views of the mental health treatment systems, or negative symptoms. Long DUP may also be a correlate of poor premorbid functioning or of an insidiously unfolding psychosis. Considerable discrepancies exist in the way that DUP is estimated in different studies. Although the clinical interview remains the most common way of measuring DUP, so far there is no evidence for favoring one method over another. Regardless of measurement method, a longer DUP is found to be associated with poorer outcome in schizophrenia in both the short and long-term across a number of domains: symptoms severity, remission rates, the risk of relapse, global functioning and quality of life. Its role in functional outcome appears to be mediated largely by negative symptoms, for which there is still no effective treatment. A recent meta-analysis has shown that shorter DUP is associated with less severe negative symptoms at short and long-term follow-up, especially when DUP is shorter than 9 months. The mechanism of the relationship between DUP and outcome is still undefined. A hypothesis is that the shorter the DUP, the more likely the intervention is being applied during the period in which neurobiological deficit processes in schizophrenia are most active.DiscussionA study of the duration of untreated illness (DUI), which is defined as the DUP and the prodromal phase, seems necessary because results of studies evaluating the effect of early detection and intervention in individuals with clinical high risk for psychosis are promising. A number of interventions such as omega 3 fatty acids and integrated psychosocial interventions seem to delay transition in the at-risk population. However, replication studies are lacking, and a great proportion of at high-risk individuals will spontaneously remit or develop diseases other than chronic psychosis, making us question the advantages and disadvantages of a treatment. Taking into consideration the high prevalence of comorbidities in individuals referred for clinical high-risk state and their effect on the individual's functioning, future interventions in the field need to address not only the preventative efficacy on psychosis transition but also their effectiveness in improving the functioning of this population and their effect on the outcome of schizophrenia when transition to psychosis has occurred.ConclusionDespite the huge advances in the field of schizophrenia, many questions remain unanswered and huge efforts are still necessary to understand the pathophysiology of this illness in order to improve its outcome.     

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.     

The key to reducing duration of untreated first psychosis: information campaigns

The TIPS early intervention program reduced the duration of untreated psychosis (DUP) in first-episode schizophrenia from 16 to 5 weeks in a health care sector using a combination of easy access detection teams (DTs) and a massive information campaign (IC) about the signs and symptoms of psychosis. This study reports what happens to DUP and presenting schizophrenia in the same health care sector when the IC is stopped. METHODS: Using an historical control design, we compare 2 cohorts of patients with first-episode Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, non-affective psychosis at admission to treatment. The first cohort (N = 108) was recruited from January 1997 to December 2000, using an IC to raise awareness about recognizing psychosis to the public, the schools, and to general practitioners. The second cohort (N = 75) was recruited from January 2002 to June 2004 with no-IC. Easy access DTs were available to both cohorts. RESULTS: In the no-IC period, DUP increased back up to 15 weeks (median) and fewer patients came to clinical attention through the DTs. No-IC patients were diagnosed less frequently with schizophreniform disorder, more Positive and Negative Syndrome Scale positive and total symptoms, and poorer Global Assessment of Functioning (symptom) Scale scores. CONCLUSIONS: Intensive education campaigns toward the general public, the schools, and the primary health care services appear to be an important and necessary part of an early detection program. When such a campaign was stopped, there was a clear regressive change in help-seeking behavior with an increase in DUP and baseline symptoms.     

Early psychosis intervention outpatient service of the 1st Psychiatric University Clinic in Athens: 3 Years of experience

To present the 3‐year experience of the early intervention in psychosis (EIP) service implementation of the 1st Psychiatric University Clinic in Athens. An overview of: (1) the purpose of our service, (2) the referral network, (3) the selection criteria, (4) the diagnostic procedures, (5) the therapeutic interventions and (6) the research activities. The service was established in 2012 and developed gradually aiming to provide information, early detection, treatment and support to people aged 15 to 40 years with psychotic manifestations, who are either at increased risk of developing psychosis (at‐risk mental state [ARMS]) or with first episode psychosis (FEP). In order to assess individuals with ARMS, we used the comprehensive assessment of at‐risk mental states interview and the Social and Occupational Functioning Assessment Scale The duration of untreated psychosis was estimated by using the Nottingham Onset Schedule. So far we have had 65 referrals, of which 26 were ARMS and 17 FEP. Based on the individual needs, they were offered psychotherapeutic and/or pharmacological treatment. After 3 years, the rate of transition to psychosis was 19.2% and the rate of psychosis relapse was 11.7%. The implementation of our service has had positive results, enabling young people with early psychosis to receive prompt and effective care. The rates of transition to psychosis are the first to be published from a Greek EIP service. Further development of our referral network and inter‐hospital collaboration will allow us to address the needs of a wider part of the population.     

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.     

Validation of the Health of the Nation Outcome Scales as a routine measure of outcome in early intervention programmes

Aim: So far, no study has assessed the validity of the Health of the Nation Outcome Scales (HoNOS) in patients enrolled in early intervention programmes, nor has any study evaluated the validity of the HoNOS in people at ultra high‐risk (UHR) of psychosis. This study set out to assess the validity and reliability of the HoNOS as a measure of outcome in the patients enrolled in an early intervention programme. Methods: The concurrent, discriminant and predictive validity, and the reliability of the HoNOS as a measure of outcome in an early intervention programe were assessed in 87 first‐episode psychosis (FEP) patients, and in 81 patients at UHR of psychosis. Results: Reliability indexes were good in the FEP sample, and less good in the UHR sample. HoNOS total scores differentiated between FEP and UHR patients, and the HoNOS subscales proved able to assess a specific profile of symptoms in the two samples, demonstrating a helpful adjunctive measure of health status without complete overlap with other scales. Sensitivity to change was also very good, again with differences between FEP and UHR patients. HoNOS scores at intake did not predict failure to attain remission in FEP patients. There were too few cases of transition to psychosis (n = 2) to assess predictive validity of HoNOS in the UHR sample. Conclusion: HoNOS possesses satisfactory sensitivity and validity to be used in the routine assessment in early intervention programmes.     

Service Engagement in First-Episode Psychosis: Current Issues and Future Directions

It has been reported that up to 50% of patients receiving mental health services disengage from treatment, with adolescents and young adults being particularly at high risk. Even in the context of specialized services in youth mental health, such as early intervention programs for psychosis, disengagement rates remain high. There is a need for extensive and innovative efforts to address the issue of service disengagement in first-episode psychosis (FEP). A multi-dimensional understanding of the phenomenon of engagement can help to inform the development of strategies to address this important clinical issue. In our paper, we propose a conceptual framework for understanding service engagement, provide an overview of the issues pertaining to service engagement in FEP, and suggest future directions for research and practice.     

On the HORYZON: Moderated online social therapy for long-term recovery in first episode psychosis

BackgroundEarly intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, recent evidence shows that treatment benefits may not be sustainable over time. These findings have resulted in repeated recommendations for the implementation of longer term treatment programs. An Internet-based intervention specifically designed for young people with psychosis may provide a cost-effective alternative to prevent loss of treatment benefits from early intervention.MethodsOur multi-disciplinary team has developed a highly novel online intervention (HORYZONS) in regular consultation with stakeholders within a specialist early psychosis program. HORYZONS integrates: i) peer-to-peer social networking, ii) individually tailored interactive psychosocial interventions, and iii) expert interdisciplinary and peer-moderation in a coherent platform designed to improve long-term outcomes in FEP. The acceptability, safety and initial clinical benefits of HORYZONS were examined through a 1-month pilot study with 20 participants with FEP.ResultsThere were no dropouts during the pilot study. Seventy per cent of participants utilised the system for at least 3 weeks, 95% used the social networking features, and 60% completed at least 3 therapy modules. System usage was high during the study. There were no incidents and the majority of participants reported feeling safe, empowered and more socially connected using HORYZONS. Analysis revealed a significant reduction in depressive symptoms at follow-up.ConclusionsOur results indicate that HORYZONS is feasible, engaging and safe and may augment social connectedness and empowerment in FEP. These findings have significant implications for the enhancement of specialist FEP services. The potential of HORYZONS to improve long-term recovery is worthy of further investigation.     

A descriptive study of 'non-cases' and referral rates to an early intervention for psychosis service

Aim: Despite there being approximately 200 early intervention services for psychosis worldwide, little is known about the referral rates to these services, the diagnoses and needs of individuals found not to have a first episode of psychosis (FEP). Firstly, we aimed to describe the diagnoses for individuals who were found not to have a FEP (non‐cases) following an assessment using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV (SCID). We then aimed to examine the referral rates of cases and non‐cases to an early intervention service. Methods: All individuals referred to the early intervention service underwent a clinical assessment using the SCID. Results: In a 4‐year period, there were 632 referrals to the early intervention service for psychosis, and of these, 53% (n = 338) were found to have a FEP, 5% (n = 34) were found to have an at‐risk mental state for psychosis and 41% (n = 260) were found to be ‘non‐cases’. This represents a ratio of 1.9:1 of referrals to cases, or approximately 2:1. Of the non‐cases, 27% (n = 62) satisfied criteria for a mood disorder, with major depressive disorder the commonest diagnosis. A further 18% (n = 42) of non‐cases satisfied criteria for an anxiety disorder and nearly half of these were diagnosed with social phobia. The ratio of referrals to cases was not consistent over time and rose from 1.3:1 in the first year to 2:1 in the fourth year. Conclusion: A large proportion of individuals referred to an early intervention for psychosis service were found not to have psychotic disorder, however they still have significant needs regarding their mental health.     

Gender and duration of untreated psychosis: a systematic review and meta-analysis

Aim: Duration of untreated psychosis (DUP) can influence the prognosis of schizophrenia. Previous studies have suggested that gender may influence the length of DUP. This study reports the result of the first systematic literature review and meta‐analysis on the role of gender in influencing DUP in first‐episode psychosis. Method: Systematic literature search in PubMed/Medline and Ovid/PsychINFO. Twenty‐seven studies presenting data on 4721 patients diagnosed with psychosis at their first episode (2834 males and 1887 females) were included in the analysis. Results: Samples had a higher proportion of males: odds ratio = 2.5 (95% confidence interval: 1.8–3.3). Mean age at first contact was 25.4 for males and 27.5 for females. Patients from non‐Western countries were older at first contact than patients from Western countries. Average DUP in schizophrenia was 64 weeks and did not differ between genders but was shorter in Western compared with non‐Western countries. Conclusion: Earlier age at first contact and larger incidence in males support the existence of specific gender differences in first‐episode psychosis; however, these are not associated with DUP length.     

Clinical and sociodemographic comparison of people at high‐risk for psychosis and with first‐episode psychosis

Zimbrón J, Ruiz de Azúa S, Khandaker GM, Gandamaneni PK, Crane CM, González‐Pinto A, Stochl J, Jones PB, Pérez J. Clinical and sociodemographic comparison of people at high‐risk for psychosis and with first‐episode psychosis. Objective: To compare clinical and sociodemographic characteristics previously associated with psychosis, between individuals at high‐risk for psychosis (HR) and patients experiencing a first episode psychosis (FEP), to achieve a better understanding of factors associated with psychosis. Method: Cross‐sectional comparison of 30 individuals at HR with 30 age‐gender matched FEP, presenting to an early intervention service for psychosis. Participants were followed‐up for 2 years to establish the proportion of HR who made the transition into FEP. Results: Both groups showed similar socio‐clinical characteristics, including immigration status, employment history, marital status, family history of psychotic illness, self‐harm and alcohol and drug use. The HR group had a lower level of education, higher burden of trauma, earlier onset of psychiatric symptoms and a longer delay in accessing specialised services. A younger onset of symptoms was associated with a longer delay in accessing services in both groups. After a 2 year follow‐up, only three (10%) of the HR group made a transition into FEP. Conclusion: The similarities observed between individuals at HR and those with FEP suggest that known variables associated with psychosis may be equally prevalent in people at HR who do not develop a psychotic disorder.     

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.     

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.