Causes and consequences of duration of untreated psychosis in schizophrenia

The effect of duration of untreated psychosis and treatment delay on the outcomes of prolonged early intervention in psychotic disorders

The duration of untreated psychosis (DUP) has been shown to have an effect on outcome after first-episode psychosis. The premise of specialized early intervention (SEI) services is that intervention in the early years of illness can affect long-term outcomes. In this study, we investigate whether DUP affects treatment response after 5 years of SEI treatment compared to 2 years of SEI treatment. As part of a randomized controlled trial testing the effect of prolonged SEI treatment 400 participants diagnosed within the schizophrenia spectrum were recruited. For this specific study participants were dichotomized based on DUP, treatment delay, and time from first symptom until start of SEI treatment. The groups were analyzed with regard to treatment response on psychopathology, level of functioning, and cognitive functioning. The participants with a short DUP had a tendency to respond better to the prolonged treatment with regards to disorganized and negative dimension. For participants with short duration from first symptom until start of SEI treatment there was a significant difference on the negative dimension favoring the prolonged OPUS treatment. The finding of an effect of prolonged treatment for participants with a short total treatment delay could mean that prolonged SEI treatment is more beneficial than treatment as usual (TAU) so long as it is provided in the early years of illness and not just in the early years after diagnosis.

TREATMENT TIMING

THE EARLIER THE BETTER: The duration of untreated psychosis influences the long-term outcomes of treatment. Nikolai Albert, at the Copenhagen Mental Health Centre, and a team of Danish researchers have investigated the effects of a specialized early intervention program (OPUS) in 400 patients diagnosed with schizophrenia spectrum disorders and compared the effects of OPUS after two and five years. Their findings suggest that five years of specialized early intervention was most beneficial when the total duration from symptom start to treatment was shorter than 6 months. The treatment was particularly effective at improving patients' disorganized behavior and negative symptoms such as blunted emotions and lack of motivation. These findings support previous studies suggesting that patients are more responsive to treatment in the early years of illness and highlight the importance of avoiding delays within the mental health service provision.

Predictors of change in social networks, support and satisfaction following a first episode psychosis: A cohort study

BACKGROUND

Diminished social networks are common in psychosis but few studies have measured these comprehensively and prospectively to determine how networks and support evolve during the early phase. There is little information regarding perceived support in the early phase of illness. The aim of this study was to describe social support, networks and perceived satisfaction, explore the clinical correlates of these outcomes and examine whether phases of untreated psychosis are linked with social network variables to determine potential opportunities for intervention.

METHODS

During the study period, we assessed 222 people with first-episode psychosis at entry into treatment using valid and reliable measures of diagnosis, positive and negative symptoms, periods of untreated psychosis and prodrome and premorbid adjustment. For follow-up we contacted participants to conduct a second assessment (n=158). There were 97 people who participated which represented 61% of those eligible. Social network and support information obtained at both time points included the number of friends, self-reported satisfaction with support and social network size and clinician's evaluation of the degree of support received through networks. Mixed effects modelling determined the contribution of potential explanatory variables to social support measured.

RESULTS

A number of clinical variables were linked with social networks, support and perceived support and satisfaction. The size of networks did not change over time but those with no friends and duration of untreated psychosis was significantly longer for those with no friends at entry into treatment (n=129, Median=24.5mths, IQR=7.25-69.25; Mann-Whitney U=11.78, p=0.008). Social support at baseline and at one year was predicted by homelessness (t=-2.98, p=0.001, CI -4.74 to -1.21), duration of untreated psychosis (t=-0.86, p=0.031, CI -1.65 to -0.08) and premorbid adjustment (t=-2.26, p=0.017, CI -4.11 to -0.42). Social support improved over time but the duration of untreated psychosis was not linked with the rate of improvement in this outcome.

CONCLUSIONS

Improved social support could indicate greater reliance on social support or becoming more adept at mobilising resources to meet social needs. Particularly vulnerable groups with very long duration of untreated psychosis confirm the need for earlier intervention or targeted social network interventions to preserve social connectedness.

Only a small proportion of patients with first episode psychosis come via prodromal services: a retrospective survey of a large UK mental health programme

BACKGROUND

Little is known about patients with a first episode of psychosis (FEP) who had first presented to prodromal services with an "at risk mental state" (ARMS) before making the transition to psychosis. We set out to identify the proportion of patients with a FEP who had first presented to prodromal services in the ARMS state, and to compare these FEP patients with FEP patients who did not have prior contact with prodromal services.

METHODS

In this study information on 338 patients aged ≤37 years who presented to mental health services between 2010 and 2012 with a FEP was examined. The data on pathways to care, clinical and socio-demographic characteristics were extracted from the Biomedical Research Council Case Register for the South London and Maudsley NHS Trust.

RESULTS

Over 2 years, 14 (4.1% of n = 338) young adults presented with FEP and had been seen previously by the prodromal services. These ARMS patients were more likely to enter their pathway to psychiatric care via referral from General Practice, be born in the UK and to have had an insidious mode of illness onset than FEP patients without prior contact with the prodromal services.

CONCLUSIONS

In the current pathways to care configuration, prodromal services are likely to prevent only a few at-risk individuals from transitioning to psychosis even if effective preventative treatments become available.

Listen and learn: engaging young people, their families and schools in early intervention research

Recent policy guidelines highlight the importance of increasing the identification of young people at risk of developing mental health problems in order to prevent their transition to long-term problems, avoid crisis and remove the need for care through specialist mental health services or hospitalisation. Early awareness of the often insidious behavioural and cognitive changes associated with deteriorating mental well-being, however, is difficult, but it is vital if young people, their families and those who work with them are to be fully equipped with the skills to aid early help-seeking. Our early intervention research continues to highlight the necessity of engaging with and listening to the voices of young people, families and those who work with children and young people, in developing greater understanding of why some young people may be more at risk in terms of their mental health, and to provide children and young people with the best mental health support we can. Collaborative working with young people, their families and those who work with them has been an essential dimension of our youth mental health research in Birmingham, UK, enabling us to listen to the personal narratives of those with lived experience and to work alongside them. This paper highlights some of our key studies and how we have endeavoured to make intra-agency working successful at each stage of the research process through increasing use of digital and youth-informed resources to engage young people: a methodology which continues to inform, guide and develop our early intervention research and implementation.

Long-term employment among people at ultra-high risk for psychosis

BACKGROUND

Psychotic disorders are associated with high rates of sustained unemployment, however, little is known about the long-term employment outcome of people at ultra-high risk (UHR) of developing psychosis. We sought to investigate the long-term unemployment rate and baseline predictors of employment status at follow-up in a large UHR cohort.

METHOD

268 UHR patients recruited from the Personal Assessment and Crisis Evaluation clinic in Melbourne, Australia were followed-up over 2-14years after initial presentation to the service. Individuals in no form of employment or education were classed as unemployed. Logistic regression analyses were used to examine predictors of employment outcome.

RESULTS

A high rate of unemployment was present at follow-up in this UHR sample (23%). At baseline, those who were unemployed at follow-up had a longer duration of untreated illness, more severe negative symptoms, lower IQ, poorer social and occupational functioning and reported more childhood trauma than the employed group. At follow-up, unemployed individuals exhibited significantly more severe symptoms on all measures and were more likely to have been diagnosed with a mood, anxiety, psychotic or substance use disorder. Childhood trauma and the duration of untreated illness at baseline were significant independent predictors of employment status at follow-up in the multivariate analyses.

CONCLUSIONS

Nearly a quarter of this UHR sample was unemployed at long-term follow-up. The duration of untreated illness and the effects of childhood trauma are potentially modifiable risk factors for long-term employment outcome in this group. Vocational support may be beneficial for many UHR patients presenting to services.

High levels of anomalous self-experience are associated with longer duration of untreated psychosis

AIM

To investigate the relationship between anomalous self-experiences and duration of untreated psychosis in a sample of patients with first-episode schizophrenia spectrum disorders.

METHODS

Anomalous self-experiences were assessed by means of the Examination of Anomalous Self-Experience manual in 55 patients referred to their first adequate treatment for schizophrenia. Diagnoses, symptom severity, functioning and childhood trauma were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Premorbid Adjustment Scale, Social Functioning Scale and Childhood Trauma Questionnaire. Substance misuse was measured with the Drug Use Disorder Identification Test, and alcohol use was measured with the Alcohol Use Disorder Identification Test. Duration of untreated psychosis was measured in accordance with a standardized procedure.

RESULTS

High levels of anomalous self-experiences are significantly associated with longer duration of untreated psychosis, an association which held after correcting for other variables associated with long duration of untreated psychosis.

CONCLUSIONS

The field of early detection in psychosis is in need of additional clinical perspectives to make further progress. Improved understanding and assessment of anomalous self-experiences may help clinicians to detect these important phenomena and provide earlier help, and thus reduce treatment delay.

Changes in Neuronal Oscillations Accompany the Loss of Hippocampal LTP that Occurs in an Animal Model of Psychosis

The first-episode of psychosis is followed by a transient time-window of ca. 60 days during which therapeutic interventions have a higher likelihood of being effective than interventions that are started with a greater latency. This suggests that, in the immediate time-period after first-episode psychosis, functional changes occur in the brain that render it increasingly resistant to intervention. The precise mechanistic nature of these changes is unclear, but at the cognitive level, sensory and hippocampus-based dysfunctions become increasingly manifest. In an animal model of first-episode psychosis that comprises acute treatment of rats with the irreversible N-methyl-D-aspartate receptor (NMDAR)-antagonist, MK801, acute but also chronic deficits in long-term potentiation (LTP) and spatial memory occur. Neuronal oscillations, especially in the form of information transfer through θ and γ frequency oscillations are an intrinsic component of normal information processing in the hippocampus. Changes in θ-γ coupling and power are known to accompany deficits in hippocampal plasticity. Here, we examined whether changes in δ, θ, α, β and γ oscillations, or θ-γ coupling accompany the chronic loss of LTP that is observed in the MK801-animal model of psychosis. One and 4 weeks after acute systemic treatment of adult rats with MK801, a potent loss of hippocampal in vivo LTP was evident compared to vehicle-treated controls. Overall, the typical pattern of θ-γ oscillations that are characteristic for the successful induction of LTP was altered. In particular, θ-power was lower and an uncoupling of θ-γ oscillations was evident in MK801-treated rats. The alterations in network oscillations that accompany LTP deficits in this animal model may comprise a mechanism through which disturbances in sensory information processing and hippocampal function occur in psychosis. These data suggest that the hippocampus is likely to comprise a very early locus of functional change after instigation of a first-episode psychosis-like state in rodents.

Duration of active psychosis and first-episode psychosis negative symptoms

AIM

Duration of untreated psychosis (DUP) has been associated with negative symptoms in several studies; however, longitudinal findings have been inconsistent. No previous study has accounted for active psychosis after presentation, although this could impact on outcomes in a manner similar to DUP.

METHODS

We measured Scale for the Assessment of Positive Symptoms at frequent intervals during the 12 months after initial presentation to determine the active psychosis duration for 230 individuals with first-episode psychosis. This duration was added to DUP prior to presentation to create a new variable, duration of active psychosis (DAP). Negative symptoms were divided into expressivity and motivation/pleasure domains as measured by Scale for the Assessment of Negative Symptoms (SANS). The relationship of DUP and DAP with negative symptoms at 24-month follow up was determined and confounders controlled for using regression analysis.

RESULTS

When DUP and DAP were compared as binary variables with long and short groups, 25.2% of individuals had differing category membership. DAP had a significant uncorrected association with both expressivity domain and motivation/pleasure domains at 24 months; however, relationship with DUP was not significant. DAP remained a significant predictor of 24-month expressivity domain after controlling for potential confounders.

CONCLUSIONS

Active psychosis after presentation is substantial, which is a limitation of DUP studies if active psychosis is considered as the key factor within DUP. DAP is a better predictor of negative symptoms than DUP at 2-year follow up, which suggests this concept requires further research.

Duration of untreated psychosis and pathway to care in Riyadh, Saudi Arabia

AIM

Recent studies of 'duration of untreated psychosis' (DUP) indicate that some patients remain untreated in the community for some time. Considerable emphasis has been placed on reducing the DUP. However, most studies investigating DUP have been conducted in Western countries, where well-developed primary care systems are available. This study aims to describe DUP and its association with both demographic factors and pathways to care in Riyadh, Saudi Arabia.

METHODS

A retrospective study of 421 new case records of all Saudi schizophrenia patients over a 2-year period in six governmental hospitals in Riyadh, Saudi Arabia.

RESULTS

The median DUP was 1.41 years (interquartile range 0.35-2.81 years). The longest time to contact was 9.86 years but 90% had a DUP shorter than 5 years. Older age at onset, single marital status and higher educational level were associated with shorter DUP. Long DUP was associated with help seeking from traditional healers.

CONCLUSION

In Saudi Arabia, it usually takes longer for patients to seek help from psychiatric services after their first psychosis onset than it does in Western countries. The results suggest that the DUP is influenced by both demographic factors and pathways to care.

Protocol for a multicentre study to assess feasibility, acceptability, effectiveness and direct costs of TRIumPH (Treatment and Recovery In PsycHosis): integrated care pathway for psychosis

INTRODUCTION

Duration of untreated psychosis (time between the onset of symptoms and start of treatment) is considered the strongest predictor of symptom severity and outcome. Integrated care pathways that prescribe timeframes around access and interventions can potentially improve quality of care.

METHODS AND ANALYSIS

A multicentre mixed methods study to assess feasibility, acceptability, effectiveness and analysis of direct costs of an integrated care pathway for psychosis. A pragmatic, non-randomised, controlled trial design is used to compare the impact of Treatment and Recovery In PsycHosis (TRIumPH; Intervention) by comparison between NHS organisations that adopt TRIumPH and those that continue with care as usual (Control). Quantitative and qualitative methods will be used. We will use routinely collected quantitative data and study-specific questionnaires and focus groups to compare service user outcomes, satisfaction and adherence to intervention between sites that adopt TRIumPH versus sites that continue with usual care pathways.

SETTING

4 UK Mental health organisations. Two will implement TRIumPH whereas two will continue care as usual.

PARTICIPANTS

Staff, carers, individuals accepted to early intervention in psychosis teams in participating organisations for the study period.

INTERVENTION

TRIumPH-Integrated Care Pathway for psychosis that has a holistic approach and prescribes time frames against interventions; developed using intelligence from data; co-produced with patients, carers, clinicians and other stakeholders.

OUTCOMES

Feasibility will be assessed through adherence to the process measures. Satisfaction and acceptability will be assessed using questionnaires and focus groups. Effectiveness will be assessed through data collection and evaluation of patient outcomes, including clinical, functional and recovery outcomes, physical health, acute care use. Outcome measures will be assessed at baseline, 12 and 24 months to measure whether there is an effect and if so, whether this is sustained over time. Outcomes measures at the adopter sites will be compared to their own baseline and against comparator sites.

ETHICS AND DISSEMINATION

Ethics approval was obtained from East of Scotland Research Ethics Service (REC Ref no: LR/15/ES/0091). The results will be disseminated through publications, conference presentations, reports to the organisation.

STUDY REGISTRATION

UK Clinical Research Network Portfolio: 19187.

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

BACKGROUND

Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP.

AIMS

To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

METHOD

The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale.

RESULTS

Mean (±standard deviation ( SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors.

CONCLUSION

Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors.

Impact of duration of untreated psychosis and premorbid intelligence on cognitive functioning in patients with first-episode schizophrenia

BACKGROUND

The neurotoxic hypothesis suggests that psychosis is toxic to the brain leading to clinical consequences. In this study, we hypothesized that a longer duration of untreated psychosis (DUP) in first episode schizophrenia (FES) patients is associated with poorer cognitive functioning, and that higher premorbid intelligence buffers against DUP-related cognitive impairment.

METHOD

Eighty-one FES patients completed a neuropsychological battery, the Brief Assessment of Cognition in Schizophrenia (BACS). Composite scores of the BACS, which were normalized to a matched healthy control of seventy-three subjects, were used as an index of general cognition. A median split using the Wide Range Achievement Test-Reading Test scores was used to divide the patients into low versus high premorbid IQ groups. Hierarchical linear regression was performed to examine predictors of general cognition, including DUP.

RESULTS

Longer DUP was found to be a significant predictor of poorer general cognition. In addition, DUP predicted general cognition in the low premorbid IQ group but not in the high premorbid IQ group.

CONCLUSIONS

Our findings demonstrate that longer DUP in FES patients is associated with worse cognitive scores, and that this association is more pronounced in a subgroup of patients who have lower premorbid intelligence. Our results suggest the importance of earlier identification and management of patients with low premorbid IQ, given that their cognition may be more vulnerable to the toxicity of psychosis.

Family Aided Community Treatment for the Treatment of Early Psychosis: A Proof of Concept Study

Major psychotic disorders are one of the leading causes of disability worldwide. If these conditions are identified early and treatment promptly implemented, the prognosis is improved. This study examined the impact of a yearlong family aided community treatment (FACT) intervention upon psychiatric symptoms. Psychiatric symptom scores improved with the FACT intervention. Improved training on early recognition for mental health clinicians, implementation of a specific treatment model in community settings and policy around treatment funding allocation are implications of this study.

Association between Medication Adherence and Duration of Outpatient Treatment in Patients with Schizophrenia

OBJECTIVE

Medication adherence is important in the treatment of schizophrenia, and critical periods during treatment may be associated with relapse. However, the relationship between adherence and duration of outpatient treatment (DOT) remains unclear. The authors aimed to clarify the relationship between adherence and DOT at a psychiatric hospital in Japan.

METHODS

For outpatients with schizophrenia who regularly visit Shin-Abuyama hospital, the authors conducted a single questionnaire survey (five questions covering gender, age, DOT, medication shortages, and residual medication) over one month period. Participants were divided into two groups whether DOT were from more than one year to within five years or not. Mantel-Haenszel analysis and logistic regression analysis were performed on the data regarding the medication adherence.

RESULTS

Effective answers were received for 328 patients. The residual medication rate was significantly higher among those receiving outpatient treatment from more than one year to within five years than five years than those receiving outpatient treatment for more than five years or less than one year (p=0.016).

CONCLUSION

This survey suggests that there are critical periods during which patients are most prone to poor adherence. Because poor adherence increases the risk of relapse, specific measures must be taken to improve adherence during these periods.

An integrative model of the impairments in insight in schizophrenia: emerging research on causal factors and treatments

INTRODUCTION

Poor insight, or unawareness of some major aspect of mental illness, is a major barrier to wellness when it interferes with persons seeking out treatment or forming their own understanding of the challenges they face. One barrier to addressing impaired insight is the absence of a comprehensive model of how poor insight develops.

AREAS COVERED

To explore this issue we review how poor insight is the result of multiple phenomena which interfere with the construction of narrative accounts of psychiatric challenges, rather than a single social or biological cause. Expert commentary: We propose an integrative model of poor insight in schizophrenia which involves the interaction of symptoms, deficits in neurocognition, social cognition, metacognition, and stigma. Emerging treatments for poor insight including therapies which focus on the development of metacognition are discussed.

Don't turn your back on the symptoms of psychosis: the results of a proof-of-principle, quasi-experimental intervention to reduce duration of untreated psychosis

BACKGROUND

No evidence based approach to reduce duration of untreated psychosis (DUP) has been effective in the UK. Existing interventions have many components and have been difficult to replicate. The majority of DUP in Birmingham, UK is accounted for by delays within mental health services (MHS) followed by help-seeking delay and, we hypothesise, these require explicit targeting. This study examined the feasibility and impact of an intervention to reduce DUP, targeting help-seeking and MHSs delays.

METHODS

A dual-component intervention, comprising a direct care pathway, for 16-25 year olds, and a community psychosis awareness campaign, using our youth-friendly website as the central hub, was implemented, targeting the primary sources of care pathway delays experienced by those with long DUP. Evaluation, using a quasi-experimental, design compared DUP of cases in two areas of the city receiving early detection vs detection as usual, controlling for baseline DUP in each area.

RESULTS

DUP in the intervention area was reduced from a median 71 days (mean 285) to 39 days (mean 104) following the intervention, with no change in the control area. Relative risk for the reduction in DUP was 0.74 (95% CI 0.35 to 0.89; p = .004). Delays in MHSs and help-seeking were also reduced.

CONCLUSIONS

Our targeted approach appears to be successful in reducing DUP and could provide a generalizable methodology applicable in a variety of healthcare contexts with differing sources of delay. More research is needed, however, to establish whether our approach is truly effective.

TRIAL REGISTRATION

ISRCTN45058713 - 30 December 2012.

Criminal justice pathways to psychiatric care for psychosis

BACKGROUND

Some patients are at higher risk of contact with criminal justice agencies when experiencing a first episode of psychosis.

AIMS

To investigate whether violence explains criminal justice pathways (CJPs) for psychosis in general, and ethnic vulnerability to CJPs.

METHOD

Two-year population-based survey of people presenting with a first-episode of psychosis. A total of 481 patients provided information on pathways to psychiatric care. The main outcome was a CJP at first contact compared with other services on the care pathway.

RESULTS

CJPs were more common if there was violence at first presentation (odds ratio (OR) = 4.23, 95% CI 2.74-6.54, P<0.001), drug use in the previous year (OR = 2.28, 95% CI 1.50-3.48, P<0.001) and for high psychopathy scores (OR = 2.54, 95% CI 1.43-4.53, P = 0.002). Compared with White British, CJPs were more common among Black Caribbean (OR = 2.97, 95% CI 1.54-5.72, P<0.001) and Black African patients (OR = 1.95, 95% CI 1.02-3.72, P = 0.01). Violence mediated 30.2% of the association for Black Caribbeans, but was not a mediator for Black African patients. These findings were sustained after adjustment for age, marital status, gender and employment.

CONCLUSIONS

CJPs were more common in violent presentations, for greater psychopathy levels and drug use. Violence presentations did not fully explain ethnic vulnerability to CJPs.

Ethnicity and pathways to care during first episode psychosis: the role of cultural illness attributions

BACKGROUND

Studies demonstrate ethnic variations in pathways to care during first episode psychosis (FEP). There are no extant studies, however, that have statistically examined the influence of culturally mediated illness attributions on these variations.

METHODS

We conducted an observational study of 123 (45 White; 35 Black; 43 Asian) patients recruited over a two-year period from an Early Intervention Service (EIS) in Birmingham, UK. Sociodemographic factors (age; sex; education; country of birth; religious practice; marital status; living alone), duration of untreated psychosis (DUP), service contacts (general practitioner; emergency services; faith-based; compulsory detention; criminal justice) and illness attributions ("individual;" "natural;" "social;" "supernatural;" "no attribution") were assessed.

RESULTS

Ethnic groups did not differ in DUP (p = 0.86). Asian patients were more likely to report supernatural illness attributions in comparison to White (Odds Ratio: 4.02; 95 % Confidence Intervals: 1.52, 10.62) and Black (OR: 3.48; 95 % CI: 1.25, 9.67) patients. In logistic regressions controlling for confounders and illness attributions, Black (OR: 14.00; 95 % CI: 1.30, 151.11) and Asian (OR: 13.29; 95 % CI: 1.26, 140.47) patients were more likely to consult faith-based institutions than White patients. Black patients were more likely to be compulsorily detained than White patients (OR: 4.56; 95 % CI: 1.40, 14.85).

CONCLUSION

Illness attributions and sociodemographic confounders do not fully explain the ethnic tendency to seek out faith-based institutions. While Asian and Black patients are more likely to seek help from faith-based organisations, this does not appear to lead to a delay in contact with mental health services.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

Duration of untreated psychosis and need for admission in patients who engage with mental health services in the prodromal phase

BACKGROUND

It is unknown whether prodromal services improve outcomes in those who go on to develop psychosis, and whether these patients are demographically different from the overall first-episode population.

AIMS

To compare sociodemographic features, duration of untreated psychosis, hospital admission and frequency of compulsory treatment in the first year after the onset of psychosis in patients who present to prodromal services with patients who did not present to services until the first episode of psychosis.

METHOD

We compared two groups of patients with first-episode psychosis: one who made transition after presenting in the prodromal phase and the other who had presented with a first episode.

RESULTS

The patients who had presented before the first episode were more likely to be employed and less likely to belong to an ethnic minority group. They had a shorter duration of untreated psychosis, and were less likely to have been admitted to hospital and to have required compulsory treatment.

CONCLUSIONS

Patients who develop psychosis after being engaged in the prodromal phase have a better short-term clinical outcome than patients who do not present until the first episode. Patients who present during first episodes may be more likely to have sociodemographic features associated with relatively poor outcomes.

Clinical and social correlates of duration of untreated psychosis among adult-onset psychosis in Hong Kong Chinese: the JCEP study

AIM

Understanding factors that contribute to treatment delay would inform early detection and intervention strategies in psychotic disorders. However, existing data were mixed and primarily conducted among early-onset young patients. We examined duration of untreated psychosis (DUP) and its clinical and sociodemographic correlates in a large cohort of adult-onset patients with psychosis.

METHODS

A total of 360 patients with first-onset psychosis aged 26-55 years were recruited consecutively as part of a controlled study of an early psychosis intervention service in Hong Kong Chinese. Demographic, sociodemographic and clinical characteristics relating to DUP were assessed within 4 months of onset.

RESULTS

The population had a mean onset age of 36.6 years (SD = 8.7). The mean and median DUP were 515 days (SD = 1091) and 93 days (inter-quartile range from 20 to 382.3), respectively. Multivariate regression analysis suggested that insidious mode of onset, hospitalization, a diagnosis of schizophrenia, poorer insight and younger age at onset significantly prolonged DUP. DUP was not related to premorbid functioning, family involvement during help seeking and living alone.

CONCLUSIONS

The initial period of untreated psychosis is determined by multiple factors. Whether family involvement is considered a kind of social support in shortening or prolonging DUP needs further examination. Local early intervention program for psychosis should take reference from these findings when formulating personalized plans to reduce delay.

School-based approaches to reducing the duration of untreated psychosis

Students with emerging psychosis often experience delays in diagnosis and treatment that impact mental health and academic outcomes. School systems have tremendous potential to improve early identification and treatment of adolescent psychosis. As a community-based resource, schools can support outreach, education, and screening for adolescents with psychosis and engage identified students and their families for treatment. The concept of duration of untreated psychosis (DUP; the gap between symptom onset and treatment initiation) in adolescent psychosis and the potential role of schools in reducing DUP are reviewed. Future directions for clinical care and research needed to support school-based interventions are proposed.

The benefit of minocycline on negative symptoms in early-phase psychosis in addition to standard care - extent and mechanism (BeneMin): study protocol for a randomised controlled trial

BACKGROUND

Negative symptoms of psychosis do not respond to the traditional therapy with first- or second-generation antipsychotics and are among main causes of a decrease in quality of life observed in individuals suffering from the disorder. Minocycline, a broad-spectrum tetracyclic antibiotic displaying neuroprotective properties has been suggested as a new potential therapy for negative symptoms. In the two previous clinical trials comparing minocycline and placebo, both added to the standard care, patients receiving minocycline showed increased reduction in negative symptoms. Three routes to neuroprotection by minocycline have been identified: neuroprotection against grey matter loss, anti-inflammatory action and stabilisation of glutamate receptors. However, it is not yet certain what the extent of the benefit of minocycline in psychosis is and what its mechanism is. We present a protocol for a multi-centre double-blind randomised placebo-controlled clinical trial entitled The Benefit of Minocycline on Negative Symptoms of Psychosis: Extent and Mechanism (BeneMin).

METHODS

After providing informed consent, 226 participants in the early phase of psychosis will be randomised to receive either 100 mg modified-release capsules of minocycline or similar capsules with placebo for 12 months in addition to standard care. The participants will be tested for outcome variables before and after the intervention period. The extent of benefit will be tested via clinical outcome measures, namely the Positive and Negative Syndrome Scale score, social and cognitive functioning scores, antipsychotic medication dose equivalent and level of weight gain. The mechanism of action of minocycline will be tested via blood screening for circulating cytokines and magnetic resonance imaging with three-dimensional T1-weighted rapid gradient-echo, proton density T2-weighted dual echo and T2*-weighted gradient echo planar imaging with N-back task and resting state. Eight research centres in UK and 15 National Health Service Trusts and Health Boards will be involved in recruiting participants, performing the study and analysing the data.

DISCUSSION

The BeneMin trial can inform as to whether in minocycline we have found a new and effective therapy against negative symptoms of psychosis. The European Union Clinical Trial Register: EudraCT 2010-022463-35 with the registration finalised in July 2011. The recruitment in the trial started in January 2013 with the first patient recruited in March 2013.

Reducing the duration of untreated psychosis and its impact in the U.S.: the STEP-ED study

BACKGROUND

Early intervention services for psychotic disorders optimally interlock strategies to deliver: (i) Early Detection (ED) to shorten the time between onset of psychotic symptoms and effective treatment (i.e. Duration of Untreated Psychosis, DUP); and (ii) comprehensive intervention during the subsequent 2 to 5 years. In the latter category, are teams ('First-episode Services' or FES) that integrate several empirically supported treatments and adapt their delivery to younger patients and caregivers. There is an urgent need to hasten access to established FES in the U.S. Despite improved outcomes for those in treatment, these FES routinely engage patients a year or more after psychosis onset. The Scandinavian TIPS study was able to effectively reduce DUP in a defined geographic catchment. The guiding questions for this study are: can a U.S. adaptation of the TIPS approach to ED substantially reduce DUP and improve outcomes beyond existing FES?

METHODS/DESIGN

The primary aim is to determine whether ED can reduce DUP in the US, as compared to usual detection. ED will be implemented by one FES (STEP) based in southern Connecticut, and usual detection efforts will continue at a comparable FES (PREP(R)) serving the greater Boston metropolitan area. The secondary aim is to determine whether DUP reduction can improve presentation, engagement and early outcomes in FES care. A quasi-experimental design will compare the impact of ED on DUP at STEP compared to PREP(R) over 3 successive campaign years. The campaign will deploy 3 components that seek to transform pathways to care in 8 towns surrounding STEP. Social marketing approaches will inform a public education campaign to enable rapid and effective help-seeking behavior. Professional outreach and detailing to a wide variety of care providers, including those in the healthcare, educational and judicial sectors, will facilitate rapid redirection of appropriate patients to STEP. Finally, performance improvement measures within STEP will hasten engagement upon referral.

DISCUSSION

STEP-ED will test an ED campaign adapted to heterogeneous U.S. pathways to care while also improving our understanding of these pathways and their impact on early outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02069925 . Registered 20 February 2014.

Reliability and validity of methods for measuring the duration of untreated psychosis: a quantitative review and meta-analysis

BACKGROUND

The duration of untreated psychosis (DUP) has been associated with a wide range of clinical outcomes, and is considered to be one of the key parameters in managing clinical high risk and first episode psychosis patients. However, considerable discrepancies exist in the way that DUP is estimated in different studies. There is no standard or consensus on which method is most reliable and valid for assessing DUP.

METHODS

This review aimed to quantitatively assess different DUP measurement instruments and definitions by comparing their inter-rater reliability, and their strength of validity in predicting biological and clinical outcomes.

RESULTS

Nine instruments designed for measuring DUP were found. Their inter-rater reliability were found to be adequate to excellent, although quite varied. This analysis did not show that any instrument was clearly outstanding compared to the others, although the limited available data do not exclude this possibility. DUP was also significantly associated with a range of outcomes, although mostly with small effect sizes. However, non-instrument based, ad hoc clinical interviews remained the most common way of measuring DUP. Definitions of onset of psychosis and onset of treatment were inconsistent among studies.

CONCLUSIONS

This review did not find quantitative evidence to support the use of one instrument over another. DUP remains a promising modifiable risk factor for a range of long-term clinical outcomes. Future research should quantify and improve the reliability and validity of the structured instruments for DUP measurement.

Detection and characteristics of individuals with a very long duration of untreated psychosis in an early intervention for psychosis service

AIM

Early intervention (EI) services for psychosis aim to reduce the duration of untreated psychosis (DUP) with intensive large-scale multi-focus initiatives, including public awareness campaigns. As a consequence of this approach, individuals with a very long DUP who might have otherwise remained undiagnosed may come to medical attention. The aim of this study was to investigate if an EI service detected additional cases of individuals with a first-episode psychosis (FEP) with a very long DUP and identify demographic and clinical characteristics associated with a very long DUP.

METHODS

We compared the distribution of the DUP in cases with FEP in a cohort from an EI service in a geographically defined catchment area with a historical control group. Participants were interviewed using the Structured Clinical Interview for DSM IV (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) diagnoses and the Beiser scale to determine the DUP.

RESULTS

A total of 172 individuals were included in the EI service and 151 were included from the historical control. There was no difference in the distribution of the DUP in the EI service compared with the historical control group (χ(2)  = 3.77, degrees of freedom (d.f.) = 3, P = 0.29). In the EI service, 7.6% of cases had a DUP between 24 and 35.9 months compared to 3.3% in the historical control, and 13.4% of cases in the EI service had a DUP of greater than three years compared to 10.6% in the historical control. A very long DUP was associated with unemployment, less insight and involuntary treatment.

CONCLUSION

Further examination of the pathways to care in cases with a long DUP may clarify the contribution of help-seeking and health system delays for these individuals.

Pharmacogenetics of adverse events in schizophrenia treatment: comparison study of ziprasidone, olanzapine and perazine

The primary aim of the present study was to assess the possible associations between dopaminergic, serotonergic, and glutamatergic system-related genes and adverse events after antipsychotic treatment in paranoid schizophrenia patients. The second aim of the study was to compare the intensity of these symptoms between atypical (ziprasidone and olanzapine) and typical (perazine) antipsychotic drugs. One-hundred and ninety-one Polish patients suffering from paranoid schizophrenia were genotyped for polymorphisms of DRD2, DAT1, COMT, MAOA, SERT, 5HT2A, and GRIK3. The patients were randomized to treatment with perazine, olanzapine or ziprasidone monotherapy for 3 months. The intensity of side effects (changes in body weights and extrapyramidal symptoms (EPS)) was measured at baseline and after 12 weeks of antipsychotic treatment. After 3 months of therapy, the weight increase was the greatest in the group treated with olanzapine and the least in the group treated with ziprasidone. None of the examined gene polymorphisms was associated with the body weight changes. Perazine treatment was associated with the significantly highest intensity of EPS. None of the examined polymorphisms was associated with the changes in extrapyramidal adverse events after antipsychotic treatment. The selected polymorphisms are not primarily involved in changes in body weights and EPS related to antipsychotic treatment in paranoid schizophrenia patients.

Are the effects of duration of untreated psychosis socially mediated?

Investigation of possible mechanisms by which longer duration of untreated psychosis (DUP) could influence treatment outcomes has focused primarily on evidence for neurotoxic effects. It is also possible that longer DUP has psychosocial effects, which could mediate its impact on outcomes. The evidence of relevance to such socially toxic effects is reviewed, with particular reference to the possible role of social support. There is no definite evidence for social support as a mediator of the influence of DUP, but further investigation of this issue is warranted.

Factors contributing to the duration of untreated psychosis

BACKGROUND

Shortening the duration of untreated psychosis (DUP) - with the aim of improving the prognosis of psychotic disorders - requires an understanding of the causes of treatment delay. Current findings concerning several candidate risk factors of a longer DUP are inconsistent. Our aim was to identify factors contributing to DUP in a large sample that represents the treated prevalence of non-affective psychotic disorders.

METHOD

Patients with a non-affective psychotic disorder were recruited from mental health care institutes from 2004 to 2008. Of the 1120 patients enrolled, 852 could be included in the present analysis. Examined candidate factors were gender, educational level, migration status, premorbid adjustment and age at onset of the psychotic disorder. DUP was divided into five ordinal categories: less than one month, one month to three months, three months to six months, six months to twelve months and twelve months and over. An ordinal logistic regression analysis was used to identify the risk factors of a longer DUP.

RESULTS

Median DUP was less than one month (IQR 2). The factors migration status (p=0.028), age at onset of the psychotic disorder (p=0.003) and gender (p=0.034) were significantly associated with DUP in our analysis.

CONCLUSION

First generation immigrant patients, patients with an early onset of their psychotic disorder and male patients seem at risk of a longer DUP. These findings can assist in designing specific interventions to shorten treatment delay.

Qualitative investigation of targets for and barriers to interventions to prevent psychosis relapse

BACKGROUND

Early signs based relapse prevention interventions for psychosis show promise. In order to examine how they might be improved we sought to better understand the early relapse process, service users' abilities to identify early signs, and any potential facilitators and barriers to early signs interventions.

METHODS

Data from in-depth interviews with a convenience sample of service users with psychosis varying in gender, age, duration of mental health problems, and time since last relapse were analysed using a thematic approach. Interview transcripts were coded inductively and relationships between emerging themes were examined by the research team to provide a thorough synthesis of the data.

RESULTS

Three central themes emerged from the analysis: 1) recognising risk factors (how risk factors were identified and linked to relapse, and reactions to such risk factors); 2) identifying early signs (issues related to both recognising and recalling signs of relapse); 3) reacting to deterioration (participants' thoughts and feelings in response to early signs, including help seeking and its challenges).

CONCLUSIONS

There was considerable variation in the attention participants had paid to pre-relapse signs, the ease with which they were able to recall them, and their reactions to them. For many, there were substantial barriers to help seeking from services. A family or friend confidant was an important means of assistance, although the supportive presence of significant others was not always available. Based on these results, a number of recommendations about facilitating service users' recognition of early signs and targeting potential accelerants of relapse are made.

Race, ethnicity, and the duration of untreated psychosis: a systematic review

PURPOSE

An extended duration of untreated psychosis (DUP) is associated with poor outcome in first-episode psychosis (FEP). Some have suggested that minority ethnic groups have longer treatment delays, and this could lead to worse outcomes. We systematically reviewed the literature on racial and ethnic differences in DUP in patients with FEP.

METHODS

We searched electronic databases and conducted forward and backward tracking to identify studies that had compared DUP for people with FEP from different racial or ethnic groups.

RESULTS

We identified ten papers that reported on the association between race or ethnicity and DUP. Overall, these studies did not find evidence of differences between groups; however, three of ten studies suggested that Black patients generally, and Black-African patients specifically, may have a shorter DUP relative to White patients. There were methodological limitations in most studies with respect to ethnicity classification, sample size, and adjustment for potential confounders.

CONCLUSION

Racial and ethnic differences in DUP were rarely found. This could reflect that DUP does not differ between groups, or may reflect the methodological limitations of prior research. Studies that are designed and powered to examine these differences in treatment delay are needed to determine whether there are differences in DUP for minority groups.

Determinants of duration of untreated psychosis in an Irish catchment area sample

Objective: To examine the variables that influence of duration of untreated psychosis (DUP) prior to presentation in persons with a first episode of psychosis.

Method: Prospective examination of consecutive first presentations with DSM-IV psychosis attending a community based psychiatric service.

Results: One hundred and seventy-one patients had an average duration of untreated psychosis of 18 months and a median of five months. The mean duration of untreated mania was 1.5 months, median 0.75 months. DUP was predicted by social withdrawal and diagnosis in the total group and by prodrome in the schizophrenia/schizophreniform group. DUP was not associated with age at onset of psychosis, educational years or living status.

Conclusions: There are significant differences in DUP between diagnostic groups. Increased social withdrawal is associated with a longer DUP.

First episode schizophrenia in general practice: a national survey

Objective: We sought to establish the views of general practitioners about detecting and managing patients with a first episode of schizophrenia in Ireland.

Method: Twenty per cent of GPs were invited to participate in a cross-sectional postal survey.

Results: Sixty-two per cent (n = 261) participated. Almost all (99.2%) see at least one case of suspected first episode schizophrenia annually. The most commonly (80.7%) encountered symptom is ‘bizarre behaviour’. Many (47.7%) rarely or never prescribe antipsychotics to patients whom they suspect have a first episode of schizophrenia. However, 80.6% of GPs reported that they ‘always’ refer this group of patients to psychiatric services. Over half (57.8%) advised patients with schizophrenia to continue medication for less than a year. A large number of respondents reported that it is difficult to obtain a rapid psychiatric assessment.

Conclusions: GPs want more information about identifying early psychosis, a closer liaison with psychiatric services and a rapid intervention service.

Insight and suicidality in first-episode psychosis: understanding the influence of suicidal history on insight dimensions at first presentation

AIM

Lack of insight is a cardinal feature of psychosis with crucial implications for outcome. Concerns have been raised regarding a link between insight and suicidality. This study aimed to test the relationship between suicidal behaviour preceding first-episode psychosis (FEP) and insight dimensions at treatment onset.

METHODS

A total of 112 FEP inpatients were recruited. Suicidal events prior to admission were recorded. Insight was assessed multidimensionally with the Schedule for the Assessment of Insight - Expanded version shortly after admission. Suicidal and non-suicidal patients were compared regarding scores on 'total insight' and three insight domains: 'awareness of mental illness', 'relabeling of psychotic experiences as abnormal' and 'compliance'. This analysis was also adjusted for a set of sociodemographic, clinical, neurocognitive and psychopathological variables.

RESULTS

Bivariate analyses demonstrated a direct association between previous suicidality and all insight domains. However, these associations did not survive multivariable regression models, which demonstrated gender (female), shorter duration of untreated psychosis (DUP) and psychopathological symptoms - depression and disorganization - to mediate the influence of suicidal history on insight, and therefore to underlie the latter.

CONCLUSIONS

Insight dimensions in FEP patients are influenced by having suicidal antecedents through some mediating variables such as gender, DUP and depression. Further prospective studies are needed to clarify the potential implications of these findings on the management of insight in FEP. As suicidal history is associated with greater levels of both depression and insight at first presentation, these three variables might be useful in predicting further suicidal events.

Predictive value of prospective memory for remission in first-episode schizophrenia

PURPOSE

The study examined the rate of remission in individuals experiencing a first episode of schizophrenia (FES) in China and explored predictors of remission in the acute phase of the illness.

DESIGN AND METHODS

Fifty-five FES patients were randomly treated with risperidone, olanzapine, or aripiprazole at therapeutic doses for 8 weeks, and their clinical profiles and cognition were assessed using standardized assessment instruments at entry and the end of the study.

FINDINGS

Of the 55 patients, 30 (54.5%) remitted by the end of the 8-week study. In univariate analyses, shorter duration of untreated psychosis, higher scores on both the time-based prospective memory (TBPM) and event-based prospective memory tasks and the Hopkins Verbal Learning Test-revised, and less severe negative symptoms were significantly associated with remission. In stepwise multiple logistic regression analyses, only higher scores on the TBPM significantly predicted remission. Individuals having higher scores reflecting better TBPM at baseline were more likely to achieve remission after 8 weeks of optimized antipsychotic treatment.

PRACTICE IMPLICATIONS

TPBM may be useful in helping clinicians identify those FES patients most likely to achieve a favorable treatment response.

Differential associations of cognitive insight components with pretreatment characteristics in first-episode psychosis

An increasing number of studies have focused on cognitive insight (i.e. awareness of one's own thinking) in psychotic disorders. However, little is known about the premorbid and pretreatment correlates of cognitive insight in the early course of psychosis. One hundred and three patients experiencing first-episode psychosis (FEP) were assessed shortly after treatment initiation for cognitive insight. Pretreatment and baseline clinical, functional and neurocognitive characteristics were examined. The self-reflectiveness dimension of cognitive insight was independently associated with clinical insight and executive functioning, whereas self-certainty was associated with premorbid IQ, premorbid academic adjustment and clinical insight. The amount of variance explained by the independent variables was small to moderate. Self-reflectiveness and self-certainty have differential pretreatment correlates in FEP and may reflect separate cognitive processes which require targeted interventions.

An investigation of duration of untreated psychosis and the affecting factors

One of the main goals in treatment planning of psychiatric disorders is early diagnosis of patients in the early psychosis period so that duration of untreated psychosis (DUP) is decreased and the treatment response and outcome is improved. The aim of this study was to investigate the DUP of psychosis and factors affecting it. In this cross-sectional study, 80 patients from the psychiatric clinic of Fatemi hospital in Ardabil and Razi hospital in Tabriz who were in the first episode of psychosis completed a questionnaire. The data were analysed by SPSS statistical software. In this study, the mean DUP measured from the appearance of the first symptoms of psychosis were 261.3 ± 110.8 and 212.5 ± 143.5 days for patients referring to Razi and Fatemi hospital, respectively. About 65% of the patients in Fatemi hospital and 32.5% of them in Razi hospital considered visiting a psychiatrist as hard and very hard. The DUP mean here was found to be higher as compared with that of the developed countries. The following factors were found to be playing a role in making DUP longer: lower education, implausible beliefs and culturally rooted social stigma status of visiting a psychiatrist.

Duration of untreated illness (DUI) and schizophrenia sub-types: a collaborative study between the universities of Milan and Moscow

BACKGROUND

Several studies show an association between a long duration of untreated illness (DUI) and poor outcome in schizophrenic patients. DUI, in turn, may be influenced by different variables including specific illness-related factors as well as access to local psychiatric services.

AIMS

The purposes of the present study were to detect differences in terms of DUI among schizophrenics coming from different geographic areas and to evaluate differences in DUI across diagnostic sub-types.

METHOD

One hundred and twenty-five (125) schizophrenic patients of the Psychiatric Clinic of Milan (n = 51) and Moscow (n = 74) were enrolled. SCID-I was administered to all patients and information about DUI was obtained by consulting clinical charts and health system databases, and by means of clinical interviews with patients and their relatives. DUI was defined as the time between the onset of illness and the administration of the first antipsychotic drug. One-way analyses of variance (ANOVAs) were performed to find eventual differences in terms of DUI across diagnostic sub-types.

RESULTS

Italian patients showed a longer DUI (M = 4.14 years, SD = 4.95) than Russians (M = 1.16 years, SD = 1.43) (F = 24.03, p < .001). DUI was found to be longer in paranoid schizophrenics (M = 3.47 years, SD = 4.19) compared to catatonic patients (M = 0.96 years, SD = 0.94) (F = 3.56, p = .016).

CONCLUSIONS

The results of the present study suggest that the different schizophrenic sub-types may differ in terms of DUI, likely due to different clinical severity and social functioning. Studies with larger samples are needed to confirm the data of the present study.

Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study

Background

Black and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.

Aims and objectives

Study 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.

Methods

Study 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’

Results

There were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.

Conclusions

Statutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Psychometric properties of the abbreviated version of the Scale to Assess Unawareness in Mental Disorder in schizophrenia

BACKGROUND

The Scale to Assess Unawareness in Mental Disorder (SUMD) is widely used in clinical trials and epidemiological studies but more rarely in clinical practice because of its length (74 items). In clinical practice, it is necessary to provide shorter instruments. The aim of this study was to investigate the validity and reliability of the abbreviated version of the SUMD.

DESIGN

We used data from four cross-sectional studies conducted in several psychiatric hospitals in France.

INCLUSION CRITERIA

a diagnosis of schizophrenia based on DSM-IV criteria.

DATA COLLECTION

socio-demographic and clinical data (including duration of illness, Positive and Negative Syndrome Scale, and the Calgary Depression Scale); quality of life; SUMD.

STATISTICAL ANALYSIS

confirmatory factor analyses, item-dimension correlations, Cronbach's alpha coefficients, Rasch statistics, relationships between the SUMD and other parameters. We tested two different scoring models and considered the response 'not applicable' as '0' or as missing data.

RESULTS

Five hundred and thirty-one patients participated in this study. The 3-factor structure of the SUMD (awareness of the disease, consequences and need for treatment; awareness of positive symptoms; and awareness of negative symptoms) was confirmed using LISREL confirmatory factor analysis for the two models. Internal item consistency and reliability were satisfactory for all dimensions. External validity testing revealed that dimension scores correlated significantly with all PANSS scores, especially with the G12 item (lack of judgement and awareness). Significant associations with age, disease duration, education level, and living arrangements showed good discriminant validity.

CONCLUSION

The abbreviated version of the SUMD appears to be a valid and reliable instrument for measuring insight in patients with schizophrenia and may be used by clinicians to accurately assess insight in clinical settings.

Prediction of acute clinical response following a first episode of non affective psychosis: results of a cohort of 375 patients from the Spanish PAFIP study

OBJECTIVE

Predicting response to antipsychotic treatment might optimize treatment strategies in early phases of schizophrenia. We aimed to investigate sociodemographic, premorbid and clinical predictors of response to antipsychotic treatment after a first episode of non-affective psychosis.

METHOD

375 (216 males) patients with a diagnosis of non affective psychosis entered the study. The main outcome measure was clinical response at 6 weeks and variables at baseline were evaluated as predictors of response. ANOVA for continuous and chi-square for categorical data were used to compare responders and non-responders. Multivariate logistic regression was used to establish a prediction model.

RESULTS

53.3% of study subjects responded to antipsychotic treatment. The following variables were associated with an unfavorable response: 1.--lower severity of symptoms at baseline; 2.--diagnosis of schizophrenia; 3.--longer DUI and DUP; 4.--poorer premorbid adjustment during adolescence and adulthood; 5.--family history of psychosis, and 6.--hospitalization. Patients with a family history of psychosis, longer DUP, poor premorbid functioning and lower severity of psychotic symptoms at intake have a reduced likelihood of responding to antipsychotic treatment.

CONCLUSION

Helping clinicians to identify those first episode patients with a lower probability of having a favorable clinical response is meant as a first step to achieve a successful initial treatment.

Reducing duration of untreated psychosis: care pathways to early intervention in psychosis services

BACKGROUND

Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed.

AIMS

To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway.

METHOD

Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed.

RESULTS

A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP.

CONCLUSIONS

Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.

The development of psychotic disorders in adolescence: a potential role for hormones

This article is part of a Special Issue "Puberty and Adolescence". The notion that adolescence is characterized by dramatic changes in behavior, and often by emotional upheaval, is widespread and longstanding in popular western culture. In recent decades, this notion has gained increasing support from empirical research showing that the peri- and post-pubertal developmental stages are associated with a significant rise in the rate of psychiatric symptoms and syndromes. As a result, interest in adolescent development has burgeoned among researchers focused on the origins of schizophrenia and other psychotic disorders. Two factors have fueled this trend: 1) increasing evidence from longitudinal research that adolescence is the modal period for the emergence of "prodromal" manifestations, or precursors of psychotic symptoms, and 2) the rapidly accumulating scientific findings on brain structural and functional changes occurring during adolescence and young adulthood. Further, gonadal and adrenal hormones are beginning to play a more prominent role in conceptualizations of adolescent brain development, as well as in the origins of psychiatric symptoms during this period (Walker and Bollini, 2002; Walker et al., 2008). In this paper, we begin by providing an overview of the nature and course of psychotic disorders during adolescence/young adulthood. We then turn to the role of hormones in modulating normal brain development, and the potential role they might play in the abnormal brain changes that characterize youth at clinical high-risk (CHR) for psychosis. The activational and organizational effects of hormones are explored, with a focus on how hormone-induced changes might be linked with neuropathological processes in the emergence of psychosis.

Social dysfunction in first-episode psychosis and relations to neurocognition, duration of untreated psychosis and clinical symptoms

Signs of social dysfunction are present early in the course of psychotic disorders. There is a lack of knowledge about how premorbid function, illness history, psychotic symptoms and neurocognitive characteristics are related to social function in patients with first episode psychosis (FEP). The relationship between these factors could provide important information about the psychopathology underlying social dysfunction and have implications for future prevention and treatment efforts. Our objective is to identify early predictors of social functioning in patients with FEP. We examined 166 patients and 166 age- and gender-matched healthy controls (HC). We used a validated and comprehensive measure of social functioning (the Social Functioning Scale), a comprehensive neurocognitive test battery, in addition to measures of psychotic symptoms, duration of untreated psychosis (DUP) and premorbid adjustment (the Premorbid Adjustment Scale). Lower childhood level of social adjustment and lower psychomotor speed had the strongest influence across measures of social functioning while symptoms and DUP had a weaker influence. The main result of the current study is that premorbid social adjustment and psychomotor speed had the strongest association with measures of social functioning in patients with FEP.

Don't turn your back on the symptoms of psychosis: a proof-of-principle, quasi-experimental public health trial to reduce the duration of untreated psychosis in Birmingham, UK

BACKGROUND

Reducing the duration of untreated psychosis (DUP) is an aspiration of international guidelines for first episode psychosis; however, public health initiatives have met with mixed results. Systematic reviews suggest that greater focus on the sources of delay within care pathways, (which will vary between healthcare settings) is needed to achieve sustainable reductions in DUP (BJP 198: 256-263; 2011).

METHODS/DESIGN

A quasi-experimental trial, comparing a targeted intervention area with a 'detection as usual' area in the same city. A proof-of-principle trial, no a priori assumptions are made regarding effect size; key outcome will be an estimate of the potential effect size for a definitive trial. DUP and number of new cases will be collected over an 18-month period in target and control areas and compared; historical data on DUP collected in both areas over the previous three years, will serve as a benchmark. The intervention will focus on reducing two significant DUP component delays within the overall care pathway: delays within the mental health service and help-seeking delay.

DISCUSSION

This pragmatic trial will be the first to target known delays within the care pathway for those with a first episode of psychosis. If successful, this will provide a generalizable methodology that can be implemented in a variety of healthcare contexts with differing sources of delay.

The duration of untreated psychosis is associated with social support and temperament

The duration of untreated psychosis (DUP) has been suggested to be a modifiable factor influencing psychosis outcome. There are many studies on the factors that predict DUP, although with contradictory findings. Although temperament has been associated with seeking help in other pathologies, studies about how temperament influences DUP are lacking. This study explored the role of temperament (measured by the Eysenck Personality Inventory Questionnaire) on DUP and tested the hypothesis that social support modifies the effects of neuroticism and extraversion on DUP. We evaluated 97 first-episode psychosis patients. The effect of temperament, affective diagnosis and social support (measured by the Social Support Index) on DUP was explored through a multivariate analysis using Cox regression model. Once psychotic symptoms had started, a patient with affective psychosis was 76% more likely to start antipsychotic medications than a patient with non-affective psychosis of comparable time without treatment (adjusted hazard ratio, HR, 1.76; 95% CI, (1.07, 2.9)). There was a significant interaction between diffuse social support and neuroticism (p=0.04). Among patients who had a good diffuse social support, a patient with a high neuroticism score was 45% less likely to start antipsychotic medication than a time-comparable patient with a low neuroticism (HR, 0.55 (0.32, 0.95)). Among patients who had a low neuroticism score, a patient with poor diffuse social support was 56% less likely to start antipsychotic medication than a comparable patient with good support (HR, 0.44 (0.23, 0.86)). In conclusion, patients with affective psychosis had significantly shorter DUPs. In patients with a good diffuse social support, low neuroticism scores were significantly associated with decreased DUP. In patients with low neuroticism scores, a poor diffuse social support was associated with a significant increase in DUP.

Pathway to psychiatric care in a tertiary mental health facility in Jaipur, India

PURPOSE

This study was planned to evaluate the pathway to care of mentally ill patients attending a tertiary mental health facility in Jaipur to highlight the difficulties of mentally ill and their relatives in accessing appropriate care.

METHODS

Seventy-six patients, who attended the Out Patient Department of Psychiatry of a tertiary care hospital in Jaipur, India for the first time, were enrolled in this study. The family members of the patients were interviewed to evaluate the pathway to care using the Encounter form developed by the WHO.

RESULTS

The patients were predominantly young adults, male, from rural, agrarian but educated background and a majority of them presented with psychotic illnesses. It was seen that there were five major gateways to care of the mentally ill in the region, Faith healers being the most popular portal of care. The median duration of untreated illness (DUI) was 6 months, and subjects had already visited, 2 carers before visiting any mental health professional. The median monetary cost of the pathway was Rs. 3565. Patients suffering from psychotic illnesses presented earlier. Those who used psychiatric services as first portal of care had different socio-demographic variables as compared to clients who used other services.

CONCLUSION

This pathway to psychiatric care study in Jaipur, India demonstrated that referral pathway heavily relies on faith healers. The study indicates possible fields and gives indications, underlining the importance of improving awareness campaigns that will facilitate the recognition of psychiatric disorders.