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.     

Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia

Introduction A long duration of untreated psychosis (DUP) is associated with a worse prognosis, an increased risk of suicide and may be linked to serious violence. Mental health laws that require patients to be dangerous to themselves or to others before they can receive involuntary psychiatric treatment may make it more difficult to treat patients in their first episode of psychosis. Methods The mean and median DUP reported in studies of schizophrenia related psychoses were examined. A comparison was made between the DUP reported from jurisdictions that had an obligatory dangerousness criterion (ODC) and those with other criteria for involuntary treatment. Results The average mean DUP in samples from jurisdictions with an ODC was 79.5 weeks, but was only 55.6 weeks in those jurisdictions that did not have an ODC (P < 0.007). Conclusions Mental health laws that require the patient to be assessed as dangerous before they can receive involuntary treatment are associated with significantly longer DUP. As reducing DUP is an intervention that can improve the prognosis of schizophrenia, this finding suggests that mental health laws should be amended to allow treatment on grounds other than dangerousness, at least in the crucial first episode of psychosis.     

Duration of untreated psychosis in a rural/suburban region of Japan

Aims: We examined the duration of untreated psychosis (DUP) and its social and clinical correlates in patients with schizophrenia in a rural/suburban region of Japan. Methods: We conducted a retrospective cohort study of patients with first‐episode psychosis from 11 hospitals in Kochi Prefecture. There were 108 patients who met the eligibility criteria, and data regarding their DUP and social/clinical variables were collected. Results: The median (mean) DUP of our cohort was 10.5 (34.6) months. Longer DUP was associated with younger age at onset, older age at first consultation, less educational attainment, insidious mode of onset and not being accompanied by another person at first consultation. After adjusting for confounding factors, age at onset, age at first consultation and mode of onset remained significantly and independently associated with DUP. In terms of treatment and response, longer DUP was associated with less antipsychotics prescribed upon first visit, and worse Clinical Global Impression Severity and Improvement scores after 1 year. Conclusion: The patients treated in a rural/suburban region of Japan had a long DUP, and shortening their DUP through promoting family involvement could improve their 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.     

Duration of untreated psychosis and pathways to care in patients with first-episode psychosis in Iran

Aim: This is the first study on the duration of untreated psychosis and pathways to care among patients with first‐episode psychosis in Iran as a developing country. Methods: Ninety‐one patients with a first episode of non‐organic psychosis admitted to a university‐affiliated psychiatric hospital in Iran were assessed for duration of untreated psychosis (DUP), pathways to care and mode of onset. Results: Median DUP was 11 weeks (mean = 52.3 weeks). Following the onset of psychosis, most patients were first seen by a psychiatrist (n = 23, 25.3%), a traditional healer (n = 21, 23.1%) or a general practitioner (n = 16, 17.6%). Most referrals to the psychiatric hospital were made by the family (n = 30, 33.1%), or health professionals (n = 29, 31.9%). Acute onset and rural place of residence were associated with shorter DUP in multivariate analysis. Conclusions: Median DUP was not long in an inpatient sample with first‐episode psychosis, which may be due to the preponderance of affective and acute psychoses in this sample and some help‐seeking or service variables.     

Early premorbid adjustment as a moderator of the impact of duration of untreated psychosis

OBJECTIVES: Shorter duration of untreated psychosis (DUP) is often correlated with a poorer response to treatment. In this paper we test the hypothesis that the importance of DUP is moderated by early premorbid adjustment. METHOD: Three year prospective data were collected for 154 first episode patients. DUP, premorbid adjustment and symptoms were assessed at time of presentation for treatment and symptoms were reassessed after three years of treatment. RESULTS: DUP was correlated with level of symptoms at three years only for patients with better premorbid adjustment in childhood and early adolescence. CONCLUSIONS: These results suggest that DUP may have more of an impact on treatment response for those with a less pernicious, more reversible form of illness.     

Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment

BACKGROUND: Recent studies of homicide during psychotic illness have shown that the risk of homicide is greatest during the first episode of psychosis. It is also possible that the proportion of patients who commit homicide before they receive effective treatment may be associated with the length of time they were unwell. We aimed to establish whether there was an association between the average duration of untreated psychosis and the proportion of homicides committed during the first episode of psychosis in the same countries. METHODS: Systematic searches of published studies of homicide in psychosis and the duration of untreated psychosis were conducted. The results were combined to examine the relationship between the reported delay in receiving treatment and the proportion of homicides committed before initial treatment. RESULTS: We found 16 studies that reported the proportion of psychotic patients who committed homicide prior to treatment. The proportion of first episode patients ranged from 13% to 76%. We were able to match 13 of those studies with DUP studies from the same country. Longer average DUP was associated with a higher proportion of patients who committed homicide prior to receiving treatment. CONCLUSIONS: The possibility that the proportion of patients who commit homicide before receiving treatment may be related to the average treatment delay in the region that the homicide occurs needs to be examined using a case controlled design. If this finding were confirmed, then any measure that reduced the delay in treating emerging psychosis would save lives.     

Pathways to care and treatment delays in first and multi episode psychosis

BACKGROUND: In contrast to findings from the developed world where general practitioners and mental health professionals are central in first episode psychosis pathways, studies from Africa have found GPs to play a less prominent role with other help providers such as traditional healers being more important. METHODS: We compared pathways to care, treatment delays and gender differences in patients with first versus multi episode psychosis. RESULTS: Private sector GPs were first contacts in first episode patients in as many as 38% of patients and were significantly more likely to be the first contact (odds ratio = 4.5, 95% CI = 1.38-14.67) and final referring agent (odds ratio = 6.8, 95% CI = 1.56-25.12) in first episode patients. Female multi episode patients were significantly more likely to make first contact with primary care practitioners whereas male multi episode patients were more likely to first come into contact with the police (P = 0.003) and be admitted compulsorily (P = 0.009). Only 5.6% (n = 4) of patients contacted traditional healers at some point in their pathway to care. Treatment delays and DUP in first episode patients were longer and reached a median of 4.5 versus 2.5 months in multi episode patients. Treatment discontinuation of antipsychotics occurred in 82% of multi episode patients. Despite significantly longer overall treatment delays in first episode patients the distribution of treatment delays in multi episode patients followed a similar pattern to DUP in first episode patients with a subgroup having very long delays. CONCLUSIONS: Pathways to care in this treatment setting correspond more to findings from first world and newly industrialized countries. A subgroup of multi episode patients had very long periods of untreated illness. Limitations include small sample size and the retrospective nature of data collection.     

Does duration of untreated psychosis bias study samples of first‐episode psychosis?

Objective: While findings are contradictory, many studies report that long Duration of Untreated Psychosis (DUP) correlates with poorer outcome in first episode psychosis. In an outcome study of first‐episode psychosis, we compared the patients who refused to participate in a follow‐along with those who consented to estimate the importance of this factor in sample recruitment bias. Our questions were: (i) What is the percentage of refusers? (ii) Are there systematic differences between refusers and consenters on DUP and/or other admission variables? (iii) What is the risk of refusal for different values of DUP? Method: In an unselected group of consecutively admitted patients we compared follow‐along refusers and consenters on the following admission variables: sex, age, diagnostic group, substance abuse, being in‐patient, coming from an early detection site and DUP. We conducted a logistic regression analysis with refusal as the outcome variable. Results: Ninety‐three of 397 patients (23%) were refusers. In univariate analyses the only significant difference was found for DUP. The median DUP for consenters was 10 weeks and for refusers 32 weeks. DUP remained significant when all independent variables were controlled for. Conclusion: DUP was significantly related to risk for refusal. For tests of the impact of DUP on outcome, this may introduce a type II error bias.     

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.     

Duration of untreated psychosis: a proposition regarding treatment definition

Aim: Duration of untreated psychosis (DUP) refers to the time elapsing between psychosis onset and treatment initiation. Despite a certain degree of consensus regarding the definition of psychosis onset, the definition of treatment commencement varies greatly between studies and DUP may be underestimated due to lack of agreement. In the present study, three sets of criteria to define the end of the untreated period were applied in a first‐episode psychosis cohort to assess the impact of the choice of definition on DUP estimation. Methods: The DUP of 117 patients admitted in the Treatment and Early Intervention in Psychosis Program Psychosis in Lausanne was measured using the following sets of criteria to define treatment onset: (i) initiation of antipsychotic medication; (ii) entry into a specialized programme; and (iii) entry into a specialized programme and adequate medication with a good compliance. Results: DUP varied greatly according to definitions, the most restrictive criteria leading to the longest DUP (median DUP1 = 2.2 months, DUP2 = 7.4 months and DUP3 = 13.6 months). A percentage of 19.7 of the patients who did not meet these restrictive criteria had poorer premorbid functioning and were more likely to use cannabis. Longer DUP3 was associated with poorer premorbid functioning and with younger age at onset of psychosis. Conclusion: These results underline the need for a unique and standardized definition of the end of DUP. We suggest that the most restrictive definition of treatment should be used when using the DUP concept in future research.     

Measurement and reporting of the duration of untreated psychosis

Aim: The aim of this study was to investigate the demographic, illness and methodological factors associated with mean and median duration of untreated psychosis (DUP). Methods: A systematic review and meta‐analysis of the published studies of DUP and an examination of available DUP distributions. Results: DUP was longer in samples with a higher proportion of patients with schizophrenia and was shorter in samples that included affective psychosis. Sex, age, and the methods of measuring the onset and end‐point of DUP and the type of service in which the studies were performed did not contribute to the heterogeneity of the mean or median DUP values. Mean DUP is significantly prolonged by a small number of patients, and the median DUP is a poor indicator of the rate at which patients present. Conclusions: The DUP of patients with affective and non‐affective psychosis should be examined separately in order to make measures of DUP more meaningful and comparable, and DUP should be reported using more comprehensive measures. We suggest a method of reporting DUP based on the rate of presentation of first‐episode psychosis patients rather than the length of DUP.     

Cognitive deterioration and duration of untreated psychosis

Aim: To examine the relationship between cognitive deterioration and the duration of untreated psychosis (DUP) in a first‐episode psychosis sample. Method: We assessed a consecutive sample of first‐episode psychosis participants (N = 50) with measures of cognitive deterioration and DUP. Results: Using correlations and stepwise linear regressions, we found strong relationships between DUP and measures of cognitive deterioration. Conclusions: The length of DUP predicted cognitive deterioration. These results highlight a potential DUP grace period (>6 months) in which significant cognitive deterioration may be averted.     

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.     

Lack of an inverse relationship between duration of untreated psychosis and cognitive function in first episode schizophrenia

This study assessed the relationship between duration of untreated psychosis (DUP) and cognitive measures in order to assess if longer DUP was associated with worse performance. One hundred two patients with first episode schizophrenia or schizoaffective disorder were assessed on cognitive measures of speed of processing, episodic memory, executive function, and visual spatial processing at baseline (when patients were drug naive and after 16 weeks of olanzapine or risperidone treatment), so that a change score could be derived. DUP was defined by the emergence of psychiatric symptoms and the emergence of psychotic symptoms. Data were analyzed correlationally, parametrically (after the group was divided into long and short DUP by median split), and by regression. We found that DUP for psychotic symptoms in this group of patients was long, with a median of 46 weeks. Neither correlational, parametric analyses in which DUP served as a class variable, nor multiple regression indicated that longer DUP was associated with worse cognition at baseline or smaller magnitude of improvement in cognition. Our results suggest that while early intervention may be critical for symptom amelioration by shortening DUP, early intervention for treatment of psychiatric symptoms may have little or no impact on cognitive function. Furthermore, assuming that cognition is a core symptom of schizophrenia, the notion that ongoing psychosis is somehow toxic for a variety of information processing domains appears questionable.     

Duration of untreated psychosis and outcome in first-episode psychosis. Perspective from a developing country

OBJECTIVE: To investigate the association between duration of untreated psychosis (DUP) and treatment outcome in a sample of subjects from a developing country. METHOD: Forty-eight subjects with a first episode of psychosis were evaluated prior to treatment and at 3-month intervals over a period of 24 months. We first examined correlations between DUP and symptom improvement as measured on the Positive and Negative Symptom Scale (PANSS), and then performed multivariate analysis to determine the validity of DUP as a predictor of outcome. RESULTS: DUP was significantly correlated with improvement in PANSS total and negative subscale scores as well as the PANSS depression factor at 21 and 24 months. Multivariate analysis found DUP to be the only significant predictor of improvement in negative symptoms at 24 months. CONCLUSION: DUP was a significant predictor of outcome in a cohort form a developing country. This study provides support for early detection and intervention strategies.     

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.     

Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany

Abstract.Background: Several first-episode studies of schizophrenia suggest that many patients experience psychotic symptoms for a long time before receiving appropriate treatment. To reduce the time of untreated psychosis, it is necessary to know the patients pathways to psychiatric care. This study was designed to examine patients help-seeking contacts and the delays on their pathways to psychiatric care in Germany.Method: Sixty-six patients with first episode of schizophrenia spectrum psychosis were assessed by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) and were interviewed about their helpseeking contacts before psychiatric admission.Results: In contrast to other findings of long duration of untreated psychosis (DUP), 53% of our patients were admitted after 8 weeks (median) of untreated positive symptoms, although the mean value of 71 weeks corresponds well with the results of other studies. There were important differences in DUP depending on which kind of statistical parameter (median or mean) was used. In contrast to studies from other countries, only 18% of our patients had their first contact with a general practitioner. However, this was the fastest way to psychiatric admission. No differences were found between patients with short (< 1 year) and long (> 1 year) DUP in the duration of time from the first help-seeking contact up to admission.Conclusion: In Germany, a large number of mental health professionals in private practice or different services of psychosocial contact facilities exist in every region and general practitioners are not so important as a link to psychiatric care, although they seem to be functioning well if it is necessary. Therefore, programs designed to reduce the delay of treatment should focus less on general practitioners than on other health services.     

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.