Causes and consequences of duration of untreated psychosis in schizophrenia

Duration of untreated psychosis and negative symptoms--a systematic review and meta-analysis of individual patient data

BACKGROUND

Longer duration of untreated psychosis (DUP) is associated with poorer outcome in terms of positive symptoms, relapse rate, and time to remission. In contrast, the association with negative symptoms is less consistent.

AIMS

The study had three aims. First, to arrive at a more precise estimate of the correlation between DUP and negative symptoms than previous reviews, by substantially increasing the amount of available data. Second, to see whether the strength of this correlation attenuated over longer follow-up intervals. Third, to determine whether there is a relationship between DUP and changes in negative symptoms.

METHOD

Relevant databases were searched for studies published between December 1992 and March 2009 that reported data on DUP and negative symptoms. We obtained individual patient data where possible and calculated summary correlations between DUP and negative symptoms for each study at baseline, short and long-term follow-up. We used multilevel regression analysis to examine whether the effect of DUP on negative symptoms was the greatest in the early stages of illness.

RESULTS

We included 28 non-overlapping studies from the 402 papers detected by the search strategy. After contacting the authors we obtained individual patient data from 16 of these studies involving 3339 participants. The mean DUP was 61.4 weeks (SD=132.7, median DUP=12.0). Shorter DUP was significantly associated with less severe negative symptoms at baseline and also at short (1-2 years) and longer term follow-up (5-8 years) (r=0.117, 0.180 and 0.202 respectively, p<0.001). The relationship between improvement in negative symptoms and DUP was found to be non-linear: people with a DUP shorter than 9 months showed substantially greater negative symptom reduction than those with a DUP of greater than 9 months.

CONCLUSIONS

Shorter DUP is associated with less severe negative symptoms at short and long-term follow up, especially when the DUP is less than 9 months. Since there is no effective treatment for negative symptoms, reducing DUP to less than 9 months may be the best way to ameliorate them.

Duration of untreated negative and positive symptoms of psychosis and cognitive impairment in first episode psychosis

BACKGROUND

Duration of untreated psychosis (DUP) has been significantly associated with poor clinical and social outcomes in First Episode Psychosis (FEP) patients, but an association with cognitive outcomes has not been clearly established.

METHOD

Seventy-seven consecutively admitted, drug-naïve patients with FEP were assessed at baseline and at 1month and 6months. Underlying dimensions of DUP (general prodrome and positive, negative and disorganisation symptoms) were assessed using the Symptom Onset in Schizophrenia (SOS) inventory (Perkins et al., 2000). To assess the effect of DUP on the neuropsychological status of the patients, a linear mixed-effect model was fitted to each neuropsychological dimension. These models included a dichotomised version of DUP (short versus long duration) as a fixed effect, several adjusting variables to account for patient differences, and a random effect to incorporate the longitudinal structure of the data.

RESULTS

Patients with a short duration of untreated negative symptoms (DUNS) or a short duration of untreated positive symptoms (DUPS) outperformed patients with a long duration of untreated symptoms on memory tasks and a pre-attentional visual task but not on measures of verbal fluency, attention, reaction time, visual processing and executive functions.

CONCLUSIONS

This study provides additional support for an early intervention to shorten DUP to facilitate a better outcome in memory and attentional domains of FEP patients.

Does duration of untreated psychosis predict very long term outcome of schizophrenic disorders? results of a retrospective study

BACKGROUND

Studies performed to assess the relevance of duration of untreated psychosis (DUP) as a predictor of long-term outcome (i.e. follow-ups of ten years or more) are somewhat limited. The aim of this study was to evaluate the potential association between DUP and very long-term outcome (16-33 yrs) of schizophrenia by means of a retrospective design.

METHODS

Retrospective data obtained from clinical records were collected regarding DUP and outcome variables (number of hospitalizations; number of attempted suicides; course of illness; GAF scores at last observation) for a cohort of 80 outpatients (52 Males, 28 Females, mean age 51.0+/-11.58 years) affected by schizophrenia according to DSMIVTR attending a university community mental health centre.

RESULTS

Mean duration of follow up was 25.2 +/- 8.68 years; mean duration of untreated psychosis was 49.00 months (range 1-312 mo), with no significant difference according to gender. Patients with a shorter DUP (=/< 1 year) displayed more frequent "favourable" courses of illness (28.9% vs 8.6%) (p = 0.025), more frequent cases with limited (=/< 3) number of hospital admissions (85.7% vs 62.1%) (p = 0.047) and a better functioning (mean GAF score = 50.32+/-16.49 vs 40.26+/-9.60, p = 0.002); regression analyses confirmed that shorter DUP independently predicted a more positive outcome in terms of number of hospital admissions, course of illness, functioning (GAF scores).

CONCLUSION

A shorter DUP appears to act as a significant predictor of better outcome in schizophrenia even in the very long-term.

Identifying men at ultra high risk of psychosis in a prison population

BACKGROUND

The prevalence of psychotic disorders among prisoners is relatively high. We sought to investigate the prevalence of men who have a very high risk of developing psychosis in a prison population.

METHODS

The Prodromal Questionnaire - Brief Version (Loewy, Pearson, Vinogradov, Bearden and Cannon, 2011), was used to screen newly-arrived prisoners in a London prison for features associated with an increased risk of psychosis. Concurrent validity was evaluated using the Comprehensive Assessment for At Risk Mental State (Yung et al., 2005).

RESULTS

750 prisoners were screened and 301 were underwent further clinical assessment. 5% the total number of those screened met diagnostic criteria for the ARMS and 3% had recently developed a first episode of psychosis. Using endorsement of items that also caused distress, the PQ-B predicted an ARMS or a psychotic disorder with 90% sensitivity and 44% specificity.

CONCLUSIONS

The PQ-B is effective in identifying people who are vulnerable to developing psychosis in a prison population.

Are there specific neuropsychological deficits underlying poor insight in first episode psychosis?

Insight in psychosis is a multi-dimensional phenomenon, and has been hypothesised to have some sort of neuropsychological basis. It is unclear to what extent specific neuropsychological abilities are able to predict insight beyond the effect of generalised cognitive ability. We aimed to test this association, alongside the relationship of insight with illness duration and diagnosis, in a sample of first episode psychosis patients. 110 first episode psychosis patients were recruited and a comprehensive assessment was administered, including insight, symptoms, diagnosis and neuropsychological function. Low insight was related to worse performance in a variety of neuropsychological tasks. Regression analysis tested whether any specific tasks were related to insight (or dimensions of insight) beyond the effect of IQ. Verbal memory had an effect on total insight and all dimensions of insight (except compliance) beyond the effect of IQ. Insight appeared to vary with diagnosis, with those diagnosed with depressive affective psychoses having better insight than those with manic affective psychoses. There was no relationship between insight and DUP, but there was a relationship between time spent in treatment before assessment and insight, even after controlling for severity of symptoms. These results suggest a model of insight in early psychosis with a significant neuropsychological component, particularly with verbal memory but also with generalised cognitive ability. There is likely to be a social component to insight affected by initial time spent in contact with treatment, helping patients to understand and come to terms with their illness.

Gender differences in mental health literacy among Chinese-speaking Australians in Melbourne, Australia

OBJECTIVE

This study attempted to understand gender differences in knowledge of mental illness, preference for professional help, and medications and treatment methods among Australians of Chinese-speaking background.

METHODS

This study adopted a cluster convenience sampling method in which subjects were taken from the four major areas in cosmopolitan Melbourne where most Chinese people are living. A total of 200 Chinese-speaking Australians participated in the study. They were presented with two vignettes describing an individual with acute depression or acute schizophrenia and then questions were asked to assess their understanding of the conditions, preference for professional help, medications and treatment methods.

RESULTS

More female than male respondents could correctly identify the conditions in the two vignettes. Female participants also perceived medications to be relatively more harmful than their male counterparts. In contrast, there were significantly more males than females who adhered to traditional views on the causation of mental illness; had significantly higher percentages of endorsement of 'deal with it alone'; believed 'traditional Chinese medical doctor' and 'Chinese herbal medicines' to be helpful to the person in the schizophrenia vignette; and significantly endorsed 'psychiatric ward', 'electro-convulsive treatment', 'changing fungshui' and 'traditional Chinese worship' to be helpful for the persons in both vignettes. A combination of factors, which included age, duration of migration and traditional Chinese cultural values, were put forward to explain the above differences.

CONCLUSIONS

Campaigns to improve the mental health literacy of Chinese-speaking Australians must take into account the gender differences between male and female Chinese-speaking Australians so that culturally relevant and gender-specific education programmes can be developed.

Drug-induced supersensitivity psychosis revisited: characteristics of relapse in treatment-compliant patients

BACKGROUND

An association between abnormal involuntary movements and psychotic relapse was previously reported in a group of patients compliant with antipsychotic medication (Fallon and Dursun 2011). This was interpreted as the presence of an antipsychotic medication-induced supersensitivity psychosis.

METHOD

From the results of that study and the Chouinard diagnostic criteria for supersensitivity psychosis an abbreviated diagnostic checklist was developed to identify the phenomenon. In the present study the checklist was used on a larger sample of medication-compliant individuals experiencing a psychotic relapse.

RESULTS

The checklist demonstrated its utility by identifying a cause of relapse in 70% (29/41) of patients. Furthermore, it identified the presence of supersensitivity psychosis in 39% (16/41) of patients. This study also replicated a number of findings from the previous paper supporting the idea that supersensitivity psychosis is one cause of relapse in psychosis.

DISCUSSION

These results suggested that clinicians should exercise caution in prescribing and may have to augment treatment with other agents or switch to low dopamine-affinity antipsychotics.

The role of treatment delay in predicting 5-year outcomes in an early intervention program

BACKGROUND

Past research on the relationship between treatment delay and outcomes for first-episode psychosis has primarily focused on the role of duration of untreated psychosis (DUP) in predicting symptomatic outcomes up to 2 years. In the current study we examine the influence of both DUP and duration of untreated illness (DUI) on symptoms and functioning at 5 years follow-up while controlling for other early characteristics.

METHOD

A total of 132 patients with first-episode psychosis and treated in an early intervention program were prospectively followed up for 5 years. Outcomes assessed included positive and negative symptoms, overall functioning, weeks on disability pension and weeks of full-time competitive employment.

RESULTS

While DUP showed a significant correlation with level of positive symptoms at follow-up, this was not independent of pre-morbid social adjustment. DUI emerged as a more robust independent predictor of negative symptoms, social and occupational functioning and use of a disability pension.

CONCLUSIONS

Delay between onset of non-specific symptoms and treatment may be a more important influence on long-term functioning for first-episode patients than DUP. This suggests the possible value of treating such signs and symptoms as early as possible regardless of the effectiveness of such interventions in reducing likelihood or severity of psychotic symptoms.

Risk factors for poor work functioning of persons with schizophrenia in rural China

BACKGROUND

The long-term work performance of persons with schizophrenia in the community is unclear. This study examined the status of long-term work functioning and the predictors of poor work status among patients with schizophrenia in a Chinese rural area.

METHODS

A 10-year follow-up investigation (1994-2004) of a cohort (n = 510) of persons with schizophrenia was conducted in Xinjin County, Chengdu, China.

RESULTS

Compared with baseline data, work functioning of patients with schizophrenia deteriorated after 10 years. The rates of not working increased significantly from 12.0% in 1994 to 23.0% in 2004. Bivariate analyses showed that the poor work functioning in 2004 was significantly associated with male gender, older age, older age of first onset, higher level of education, longer duration of illness, lower family economic status, lack of caregivers, poor work status in 1994, living in shabby or unstable house, marked symptoms, and higher score on the Social Disability Screening Schedule (SDSS). In multiple logistic regression analyses, higher score of SDSS and poor work status in 1994 were identified as unique predictors of poor work status in 2004.

CONCLUSION

The status of work functioning of persons with schizophrenia decreased over the course of the illness. The risk factors for poor work functioning and specific socio-cultural environment should be considered in planning community mental health services and rehabilitation for these patients.

Life and treatment goals of individuals hospitalized for first-episode nonaffective psychosis

First-episode psychosis typically emerges during late adolescence or young adulthood, interrupting achievement of crucial educational, occupational, and social milestones. Recovery-oriented approaches to treatment may be particularly applicable to this critical phase of the illness, but more research is needed on the life and treatment goals of individuals at this stage. Open-ended questions were used to elicit life and treatment goals from a sample of 100 people hospitalized for first-episode psychosis in an urban, public-sector setting in the southeastern United States. Employment, education, relationships, housing, health, and transportation were the most frequently stated life goals. When asked about treatment goals, participants' responses included wanting medication management, reducing troubling symptoms, a desire to simply be well, engaging in counseling, and attending to their physical health. In response to queries about specific services, most indicated a desire for both vocational and educational services, as well as assistance with symptoms and drug abuse. These findings are interpreted and discussed in light of emerging or recently advanced treatment paradigms-recovery and empowerment, shared decision-making, community and social reintegration, and phase-specific psychosocial treatment. Integration of these paradigms would likely promote recovery-oriented tailoring of early psychosocial interventions, such as supported employment and supported education, for first-episode psychosis.

Can insight be predicted in first-episode psychosis patients? A longitudinal and hierarchical analysis of predictors in a drug-naïve sample

Poor insight is a ubiquitous phenomenon in psychosis with great repercussions on clinical practise and the outcomes of patients. Poor insight comprises "state" and "trait" components. This paper targeted predictors of global insight and insight dimensions at baseline in the drug-naïve status of first-episode psychosis patients and during a 6-month follow up after episode remission. Seventy-seven consecutive and previously unmedicated patients with first-episode schizophrenia-spectrum disorders (FESSD) completed baseline and 6-month insight, premorbid, symptomatological and neuropsychological assessments. Insight measures served as dependent variables for a set of hierarchical multiple regression models. Premorbid personality abnormalities and duration of untreated psychosis (DUP) significantly predicted 'state' and 'trait' insight global scores. Duration of untreated psychosis (DUP) significantly predicted 'state' insight, measured as refusal of treatment at baseline. Moreover, premorbid personality abnormalities and DUP with minor contributions of demographic variables, cognitive functioning and psychopathological dimensions predicted 'trait insight', defined as insight after remission of the psychosis episode 'Insight improver' FESSD patients showed better late adolescent premorbid adjustment, lower personality disturbances (sociopathic, schizoid and schizotypy dimensions), shorter DUP, and lower positive, negative and disorganisation symptoms and better cognitive performance on the Trail Making B test at the 6-month follow-up assessment. Premorbid personality abnormalities and DUP were predictors of 'state' and 'trait' insight, both at global scores and dimension levels. Moreover, insight improvement in patients with FESSD was related to premorbid abnormalities (in both adjustment and personality), shorter DUP, fewer positive and negative symptoms and better performance in cognitive tests at the 6-month follow up.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcomes might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection, and phase-specific treatment (phase-specific treatment is a psychological, social or physical treatment developed, or modified, specifically for use with people at an early stage of the illness).Early detection and phase-specific treatment may both be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia.

OBJECTIVES

To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first-episode psychosis.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (March 2009), inspected reference lists of all identified trials and reviews and contacted experts in the field.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first-episode psychosis. Eligible interventions, alone and in combination, included: early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).

MAIN RESULTS

Studies were diverse, mostly small, undertaken by pioneering researchers and with many methodological limitations (18 RCTs, total n=1808). Mostly, meta-analyses were inappropriate. For the six studies addressing prevention of psychosis for people with prodromal symptoms, olanzapine seemed of little benefit (n=60, 1 RCT, RR conversion to psychosis 0.58 CI 0.3 to 1.2), and cognitive behavioural therapy (CBT) equally so (n=60, 1 RCT, RR conversion to psychosis 0.50 CI 0.2 to 1.7). A risperidone plus CBT plus specialised team did have benefit over specialist team alone at six months (n=59, 1 RCT, RR conversion to psychosis 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20), but this was not seen by 12 months (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). Omega 3 fatty acids (EPA) had advantage over placebo (n=76, 1 RCT, RR transition to psychosis 0.13 CI 0.02 to 1.0, NNT 6 CI 5 to 96). We know of no replications of this finding.The remaining trials aimed to improve outcome in first-episode psychosis. Phase-specific CBT for suicidality seemed to have little effect, but the single study was small (n=56, 1 RCT, RR suicide 0.81 CI 0.05 to 12.26). Family therapy plus a specialised team in the Netherlands did not clearly affect relapse (n=76, RR 1.05 CI 0.4 to 3.0), but without the specialised team in China it may (n=83, 1 RCT, RR admitted to hospital 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The largest and highest quality study compared specialised team with standard care. Leaving the study early was reduced (n=547, 1 RCT, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) and compliance with treatment improved (n=507, RR stopped treatment 0.20 CI 0.1 to 0.4, NNT 9 CI 8 to 12). The mean number of days spent in hospital at one year were not significantly different (n=507, WMD, -1.39 CI -2.8 to 0.1), neither were data for 'Not hospitalised' by five years (n=547, RR 1.05 CI 0.90 to 1.2). There were no significant differences in numbers 'not living independently' by one year (n=507, RR 0.55 CI 0.3 to 1.2). At five years significantly fewer participants in the treatment group were 'not living independently' (n=547, RR 0.42 CI 0.21 to 0.8, NNT 19 CI 14 to 62). When phase-specific treatment (CBT) was compared with befriending no significant differences emerged in the number of participants being hospitalised over the 12 months (n=62, 1 RCT, RR 1.08 CI 0.59 to 1.99).Phase-specific treatment E-EPA oils suggested no benefit (n=80, 1 RCT, RR no response 0.90 CI 0.6 to 1.4) as did phase-specific treatment brief intervention (n=106, 1 RCT, RR admission 0.86 CI 0.4 to 1.7). Phase-specific ACE found no benefit but participants given vocational intervention were more likely to be employed (n=41, 1 RCT, RR 0.39 CI 0.21 to 0.7, NNT 2 CI 2 to 4). Phase-specific cannabis and psychosis therapy did not show benefit (n=47, RR cannabis use 1.30 CI 0.8 to 2.2) and crisis assessment did not reduce hospitalisation (n=98, RR 0.85 CI 0.6 to 1.3). Weight was unaffected by early behavioural intervention.

AUTHORS' CONCLUSIONS

There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.

White matter integrity and lack of insight in schizophrenia and schizoaffective disorder

OBJECTIVE

Poor insight into illness is commonly associated with schizophrenia and has implications for the clinical outcome of the disease. A better understanding of the neurobiology of these insight deficits may help the development of new treatments targeting insight. Despite the importance of this issue, the neural correlates of insight deficits in schizophrenia remain poorly understood.

METHOD

Thirty-six individuals diagnosed with schizophrenia or schizoaffective disorder underwent diffusion tensor imaging (DTI). The subjects were assessed on two dimensions of insight (symptom awareness and attribution of symptoms) using the Scale to Assess Unawareness of Mental Disorder (SUMD). Level of psychosis was assessed with the Positive and Negative Syndrome Scale (PANSS).

RESULTS

White matter abnormalities in the right superior frontal gyrus, left middle frontal gyrus, bilateral parahippocampal gyrus, adjacent to the right caudate head, right thalamus, left insula, left lentiform nucleus, left fusiform gyrus, bilateral posterior cingulate, left anterior cingulate, right cingulate gyrus, left lingual gyrus, and bilateral claustrum were associated with symptom unawareness. Misattribution of symptoms was related to deficits in the white matter adjacent to the right lentiform nucleus, left middle temporal gyrus, and the right precuneus.

CONCLUSIONS

Impaired insight in schizophrenia implicates a complex neural circuitry: white matter deficits in fronto-temporo brain regions are linked to symptom unawareness; compromised temporal and parietal white matter regions are involved in the misattribution of symptoms. These findings suggest the multidimensional construct of insight has multiple neural determinants.

Prisoners with psychosis in England and Wales: diversion to psychiatric inpatient services?

The prevalence of psychosis among prisoners in England and Wales is ten times that in the household population and UK government policy is that prisoners should receive equivalent care to those in the community. This study investigated the implications of policy to divert more from the criminal justice system for psychiatric treatment. Psychotic prisoners were compared with psychotic persons in households and with other prisoners in two surveys of psychiatric morbidity in representative samples of the UK population. Psychotic prisoners were younger, more from ethnic minorities, with comorbid anxiety, substance misuse, ASPD, and childhood behavioural problems compared to psychotic persons in households. Less than a third had received previous inpatient treatment. Psychotic prisoners had similar criminal histories and higher psychopathy scores than non-psychopathic prisoners. Diversion is unfeasible without improved screening for psychosis and increasing bed numbers at higher levels of security to accommodate more patients who would pose high risk to the public. Future research should investigate why UK psychiatric services fail to identify psychotic prisoners and provide aftercare.

Prediction of a single psychotic episode: a 7.5-year, prospective study in first-episode psychosis

BACKGROUND

Around 20% of patients who suffer from psychosis will experience a single psychotic episode (SPE), but relatively little is known about the characteristics and predictors for this group of patients. This study sought to: 1) characterise the subgroup of first-episode psychosis (FEP) patients who experienced a SPE over a 7.5-year follow-up; and 2) to identify significant predictors for this subgroup independent of potential confounders.

METHODS

A representative sample of 413 FEP patients treated at a specialist early psychosis service were assessed at baseline and followed-up for 7.5 years. Binary logistic regression models were employed to investigate univariate and adjusted associations between baseline predictors and experiencing a SPE. Results were adjusted for the influence of known prognostic factors for psychosis.

RESULTS

Follow-up data was available for 274 participants. Forty-six (16.5%) achieved clinical remission and experienced no recurrence over the follow-up period. Duration of untreated psychosis (DUP) shorter than 60 days (OR=3.89, p=0.007), more rapid response to antipsychotic treatment (OR=0.33, p=0.019) and no parental loss (OR=5.25, p=0.045) significantly predicted a SPE. The association remained significant after controlling for potential confounders.

CONCLUSIONS

Early treatment (within two months of onset of psychotic symptoms) and social support significantly reduce vulnerability to subsequent psychotic episodes. Future studies need to investigate the interplay between biological factors (i.e. sensitized dopaminergic system), environmental variables (i.e. exposure to trauma, stigma and discrimination), and psychological attributes (i.e. cognitive schemata) in order to elucidate the processes underlying the vulnerability to recurrent psychotic episodes.

Outreach and Support in South London (OASIS). Outcomes of non-attenders to a service for people at high risk of psychosis: the case for a more assertive approach to assessment

BACKGROUND

International agreement dictates that clients must be help-seeking before any assessment or intervention can be implemented by an 'at-risk service'. Little is known about individuals who decline input. This study aimed to define the size of the unengaged population of an 'at-risk service', to compare this group to those who did engage in terms of sociodemographic and clinical features and to assess the clinical outcomes of those who did not engage with the service.

METHOD

Groups were compared using data collected routinely as part of the service's clinical protocol. Data on service use and psychopathology since referral to Outreach and Support in South London (OASIS) were collected indirectly from clients' general practitioners (GPs) and by screening electronic patient notes held by the local Mental Health Trust.

RESULTS

Over one-fifth (n=91, 21.2%) of those referred did not attend or engage with the service. Approximately half of this group subsequently received a diagnosis of mental illness. A diagnosis of psychosis was given to 22.6%. Nearly 70% presented to other mental health services. There were no demographic differences, except that those who engaged with the service were more likely to be employed.

CONCLUSIONS

Over one-fifth of those referred to services for people at high risk of psychosis do not attend or engage. However, many of this group require mental health care, and a substantial proportion has, or will later develop, psychosis. A more assertive approach to assessing individuals who are at high risk of psychosis but fail to engage may be indicated.

The 2nd Schizophrenia International Research Society Conference, 10-14 April 2010, Florence, Italy: summaries of oral sessions

The 2nd Schizophrenia International Research Society Conference, was held in Florence, Italy, April 10-15, 2010. Student travel awardees served as rapporteurs of each oral session and focused their summaries on the most significant findings that emerged from each session and the discussions that followed. The following report is a composite of these reviews. It is hoped that it will provide an overview for those who were present, but could not participate in all sessions, and those who did not have the opportunity to attend, but who would be interested in an update on current investigations ongoing in the field of schizophrenia research.

Illness perceptions: are beliefs about mental health problems associated with self-perceptions of engagement in people with psychosis?

BACKGROUND

The Self-Regulation Model (SRM) has been presented as a framework for assessing the perceptions people hold about their mental health problem. Currently no direct attempts have been made to assess the association between illness perceptions and engagement in psychosis. Engagement is an important issue for health professionals providing support to people with psychosis; therefore, research demonstrating a link between illness perceptions and engagement may enable targeted interventions to facilitate engagement and enhance outcome.

AIM

To assess whether beliefs about mental health are associated with self-perceptions of engagement in people with psychosis.

METHOD

Participants with psychosis completed two questionnaires; beliefs about mental health and self-perceptions of engagement with mental health services.

RESULTS

A belief that the mental health difficulty has fewer negative consequences, increased perceptions of personal ability to control the mental health difficulty, a belief that treatment is helpful in controlling symptoms and a more coherent understanding of the mental health difficulty were all associated with higher self-perception engagement scores. Multivariate analyses indicated that a more coherent understanding and a belief that treatment is helpful were the strongest and most consistent predictors of higher self-perception engagement scores. However, the direction of the associations cannot be established.

CONCLUSIONS

This study suggests that the SRM is a promising model for mental health problems and that beliefs about mental health are associated with self-perceptions of engagement in people with psychosis. The importance of further intervention-based research studies that examines causality is highlighted.

Clinical predictors of response to olanzapine or risperidone during acute episode of schizophrenia

The study attempted to identify clinical variables which could predict the response to a second-generation antipsychotic treatment during acute episodes among schizophrenic patients. Socio-demographic, premorbid and clinical variables were studied in a population of 95 diagnosed with schizophrenia, as defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSMIV), during an acute treated phase, in a multicentre prospective study. Patients were assigned to olanzapine or risperidone treatment in an open design. Clinical evaluations were performed at D0, D42 and D180. Good response to treatment was defined as a Positive and Negative Syndrome Scale (PANSS) reduction greater than 20% and a Brief Psychiatric Rating Scale (BPRS) score lower than 35. Univariate analysis revealed earlier age at onset of schizophrenia and earlier age at first prescription of antipsychotic among non-responders compared with good responders at D42. Non-responders also had a clinical profile at the onset of antipsychotic treatment characterised by more severe forms of the acute episode as shown by higher scores at the positive, general and overall PANSS scale and on CGI-S and BPRS scores. With a multivariate logistic regression model, age at onset and overall duration of illness remained the only clinical criteria identified as predictors of response to antipsychotic treatment at D42. Clinical variables do not clearly appear to be good predictors of treatment efficacy.

Are cannabis use disorders associated with an earlier age at onset of psychosis? A study in first episode schizophrenia

INTRODUCTION

The purpose of this study is to determine if an earlier age at onset of positive symptoms in schizophrenia is associated with cannabis use disorders (CUD).

METHODS

49 first-episode schizophrenia subjects with CUD were compared to 51 first-episode schizophrenia subjects with no substance use disorders for demographic and clinical variables. A multivariate logistic regression was performed to determine the joint relationship between variables significantly associated with CUD on univariate testing and ascertain if these variables independently predict CUD. Significance level was set at p<0.05.

RESULTS

74% of CUD subjects had the onset of CUD before the onset of positive symptoms. Compared to non-substance abusing subjects, CUD subjects were predominantly male, younger at study entry, had an earlier age at onset of positive symptoms, less educational attainment, a lower self-socioeconomic status, better premorbid childhood social adjustment, a trend for poorer premorbid childhood academic adjustment, less motor abnormalities but more severe hallucinations and delusions. In the multivariate analysis, only male gender, worse socio-economic status, better premorbid childhood social adjustment, and more severe positive symptoms at study entry were associated with a lifetime history of CUD.

DISCUSSION

Although cannabis use precedes the onset of illness in most patients, there was no significant association between onset of illness and CUD that was not accounted for by demographic and clinical variables. Previous studies implicating CUD in the onset of schizophrenia may need to more comprehensively assess the relationship between CUD and schizophrenia, and take into account additional variables that we found associated with CUD.

Family context and duration of untreated psychosis (DUP): results from the Sao Paulo Study

BACKGROUND

Duration of untreated psychosis (DUP) depends on several factors, including socio-demographic, socioeconomic, clinical and contextual circumstances, such as availability of mental health services. Living arrangements may also play a role, especially in low- and middle-income countries, where most people who develop psychosis live with their relatives.

METHODS

Population-based study of first-episode psychosis in São Paulo, Brazil. Participants were aged 18-64 years, lived in a defined geographic area of the city and had a first contact in life with mental health services due to a psychotic episode. Duration of untreated psychosis was defined as the period between onset of first psychotic symptom and first contact with health service due to psychosis. The median DUP was used to classify participants into short and long DUP. Psychopathology, social adjustment and psychiatric diagnoses were made with standardized assessments. Type of service sought and living arrangements were examined.

RESULTS

Two hundred participants were included (52% women, 61% non-affective psychoses). The median DUP was 4.1 weeks (inter-quartile range: 1.9-11.4), and was shorter for affective psychoses. Most participants had their first contact with psychiatric emergency services. Those who did not live with a relative (children older than 18 years, parents, partner) were more likely to present long DUP (OR: 2.63; 95%CI: 0.98-7.04); p=0.05).

CONCLUSION

The DUP in São Paulo was shorter than expected. Living arrangements may play an important role in shortening the DUP in urban centres of low- and middle income countries that have a network of mental health services.

Outcome of first-episode schizophrenia in India: longitudinal study of effect of insight and psychopathology

BACKGROUND

Transcultural studies have found lack of insight to be an almost invariable feature of acute and chronic schizophrenia, but its influence on prognosis is unclear.

AIMS

To investigate the relationship between insight, psychopathology and outcome of first-episode schizophrenia in Vellore, India.

METHOD

Patients with a DSM-IV diagnosis of schizophrenia (n = 131) were assessed prospectively at baseline and at 6-month and 12-month follow-up. Demographic and clinical measures included insight, psychopathology, duration of untreated psychosis (DUP) and social functioning. Linear and logistic regression was used to measure predictors of outcome.

RESULTS

Follow-up data were available for 115 patients at 1 year. All achieved remission, half of them with and half without residual symptoms. Changes in psychopathology and insight during the first 6 months and DUP strongly predicted outcome (relapse or functional impairment), controlling for baseline measures.

CONCLUSIONS

Outcome of schizophrenia in this setting is driven by early symptomatic improvement and is relatively favourable, in line with other studies from low- and middle-income countries. Early improvement in insight might be a useful clinical guide to future outcome. Reduction of DUP should be a target for intervention.

Duration of untreated illness and outcome in schizophrenia: test of predictions in relation to relapse risk

BACKGROUND

The nature of the relationship between duration of the pre-diagnostic interval in schizophrenia and better outcomes remains unclear.

AIMS

To re-examine data from one of the earliest studies suggesting an association between long pre-treatment interval and compromised outcome, assessing the relationship between symptomatic and social variables and increased relapse risk at 1 year.

METHOD

Symptomatic, social and demographic data from participants in the Northwick Park Study of First Episodes who completed 12-month follow-up (n = 101) were re-analysed in the context of duration of untreated illness (DUI).

RESULTS

At admission, those with long DUI were more likely to have lower scores on tension derived from the Present State Examination, exhibited more behaviour threatening to others and more bizarre behaviour, were more likely to be single, to live alone or dependently, to be unemployed and to have experienced more adverse life events prior to admission. Logistic regression showed that diminished tension, bizarre behaviour and unemployed status independently increased the risk of relapse, bizarre behaviour making the single biggest contribution. Tension did not remain significant with log-transformation of data.

CONCLUSIONS

Findings are consistent with the conclusion that long DUI can reflect characteristics of the psychosis itself rather than delay in treatment.

Effects of duration of untreated psychosis on long-term outcome of people hospitalized with first episode schizophrenia

Duration of untreated psychosis (DUP) has emerged as a reliable predictor of outcome but continues to remain under scientific scrutiny. The present study examines the effect of differential periods of DUP on long-term outcome of first episode schizophrenia at Mumbai, India. This research was a prospective, 10-year follow-up naturalistic study. Hospitalized patients of first episode schizophrenia were selected and followed up. Results showed that the mean DUP was higher for a group which showed clinical recovery on Clinical Global Impression Scale [14.0 months (SD=8.0) in recovered and 10.8 months (SD=5.7) in non-recovered group (P=0.091)]. DUP was not found to be significantly associated with any of the end point parameters of good clinical or social outcome. Thus, this study found that DUP alone does not determine outcome status confirming the role of psychopathological heterogeneity.

Social dysfunction predicts two years clinical outcome in people at ultra high risk for psychosis

The experience of a first psychotic episode is associated with a marked impairment in psychosocial functioning. However, the decline may be already evident in the pre-psychotic phases and play a significant role in the etiopathology of the disease onset. A sample of subjects at ultra high clinical risk for psychosis ("At Risk Mental State", ARMS, n=152) was compared with a demographically-matched general population (n=98,072) on different measures of psychosocial functioning. The proportion of subjects with an ARMS living in communal establishments or living at home with their parents was significantly higher than that of the local population (p<0.001). Subjects with an ARMS showed also higher rates of unemployment as compared to the general population (p<0.001). GAF scores at baseline were significantly lower in unemployed ARMS as compared to students and employed ARMS (p=0.002). ARMS subjects living in communal establishments presented higher rates of co-morbid psychiatric conditions (p=0.007) and lower GAF scores at baseline (p=0.017). Finally, baseline unemployment and living in a communal establishment were associated with an increased risk of developing a psychotic episode within the following two years (p<0.05). We concluded that the "At Risk Mental State" is a clinical condition which is characterized by marked psychosocial impairment and by an increased vulnerability to psychosis. Unemployment at the first contact with the prodromal service may be a risk factor for the development of a psychotic episode.

Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches

The literature that is relevant to evaluation of treatment effectiveness is large, scattered and difficult to assemble for appraisal. This scoping review first develops a conceptual framework to help organize the field, and second, uses the framework to appraise early psychosis intervention (EPI) studies. Literature searches were used to identify representative study designs, which were then sorted according to evaluation approach. The groupings provided a conceptual framework upon which a map of the field could be drawn. Key words were cross-checked against definitions in dictionaries of scientific terms and the National Library of Medicine Medical Subject Headings (MeSH) browser. Using the final list of key words as search terms, the EPI evaluation literature was appraised. Experimental studies could be grouped into two classes: efficacy and effectiveness randomized controlled trials. Non-experimental studies could be subgrouped into at least four overlapping categories: clinical epidemiological; health service evaluations; quality assurance studies; and, quasi-experimental assessments of treatment effects. Applying this framework to appraise EPI studies indicated promising evidence for the effectiveness of EPI irrespective of study design type, and a clearer picture of where future evaluation efforts should be focused. Reliance on clinical trials alone will restrict the type of information that can inform clinical practice. There is convergent evidence for the benefits of specialized EPI service functions across a range of study designs. Greater investment in health services research and quality assurance approaches in evaluating EPI effectiveness should be made, which will involve scaling up of study sizes and development of an EPI programme fidelity rating template. The degree of complexity of the evaluation field suggests that greater focus on research methodology in the training of Australasian psychiatrists is urgently needed.

First episode psychosis and the trail to secondary care: help-seeking and health-system delays

BACKGROUND

People experience delays in receiving effective treatment for many illnesses including psychosis. These delays have adverse consequences in heart disease and cancer, and their causes have been the subject of much research but only in recent years have pathways to care in psychosis received such attention. We sought to establish if, when and where people seek help in the early phase of psychosis in a representative sample.

METHODS

One hundred and sixty-five people with first episode psychosis, referred from community-based psychiatric services and a private psychiatric facility to an early intervention service over 18 months, were interviewed with the Structured Clinical Interview for DSM-IV diagnoses. Symptoms were measured using the Schedule for the Assessment of Positive Symptoms, Schedule for the Assessment of Negative Symptoms and the Calgary Scale. Duration of untreated illness (DUI) and duration of untreated psychosis (DUP) were established using the Beiser Scale. Pathways to mental health services were systematically detailed through interviews with patients and their families.

RESULTS

The final sample consisted of 142 (88M, 54F) cases after those with psychosis due to a general medical condition and those without pathway and DUP data were excluded. Less than half of participants initiated help seeking themselves. Of those who did seek help (n = 57) 25% did so during the DUI. Those who had a positive family history of mental illness and poorer premorbid adjustment were significantly less likely to seek help for themselves and those who did not seek help were more likely to require hospitalisation. Families were involved in help seeking for 50% of cases and in 1/3 of cases did so without the affected individual participating in the contact. Being younger and having more negative symptoms were associated with having one's family involved in help seeking. Delays to effective treatment from the onset of psychosis were evenly split between "help-seeking delays" and "health-system delays". Having a family member involved in help seeking and better premorbid adjustment were independently associated with shorter help-seeking delays when measured from the onset of psychosis. Being female, having better premorbid adjustment and fewer negative symptoms were associated with shorter help-seeking delays from the onset of illness. Those with a non-affective psychosis had significantly longer system delays.

CONCLUSION

Many people with first episode psychosis do not initiate help-seeking for themselves particularly those with a relative affected by mental illness. Those with poor premorbid adjustment are at particular risk of longer delays. Poor premorbid adjustment compounded by long delays to effective treatment reduces the likelihood of a good outcome. Families play a vital role in hastening receipt of effective treatment.

Examining critical health policy issues within and beyond the clinical encounter: patient-provider relationships and help-seeking behaviors

Among notable issues in health care policy and practice over the past 50 years have been those centered on the changing dynamics in clinical encounters, predominantly the relationship between physicians and patients and access to health care. Patient roles have become more active, diverse, long-term, and risk-based, while patient-provider relationships are multifaceted, less paternalistic, and more pivotal to health outcomes. Extensive literatures on help-seeking show how much social influences affect both undertreatment and inappropriate high utilization of health care. The challenge in trying to contain the growth of health care costs is two-fold: developing better ways of defining need for care and promoting better access for those who could benefit most from health care. Both of these strategies need to be considered in the context of addressing racial, ethnic, socioeconomic, and health status disparities. Rebuilding the primary care sector as a sociologically informed strategy and a key component of health care reform may optimize both health care delivery and patient outcomes.

Review of the operational definition for first-episode psychosis

AIM

Given the growing interest in the study of first-episode psychosis, clinical and research programmes would benefit from a conceptual clarification of how to operationalize 'first-episode psychosis'. We review the variety of definitions in use and discuss their relative merits with respect to both clinical (e.g. early treatment) and research (e.g. obtaining meaningfully homogeneous populations) agendas.

METHODS

We completed a selective review of the literature to investigate how first-episode psychosis was operationally defined.

RESULTS

Operational definitions for 'first-episode psychosis' fall largely into three categories: (i) first treatment contact; (ii) duration of antipsychotic medication use; and (iii) duration of psychosis. Each definitional category contains a number of underlying assumptions that contribute to the strengths and weaknesses of the definition.

CONCLUSIONS

The term 'first-episode psychosis' as used within clinical and research settings is misleading regardless of which operational definition is used. This term is typically used to refer to individuals early in the course of a psychotic illness or treatment rather than individuals who are truly in the midst of a first 'episode' of illness. The alternative of 'recent-onset psychosis' with related definitions based on 'duration of psychosis' is proposed. Based on this review, we provide suggestions with regard to the overarching pragmatic consideration of setting up a clinical service that can attract and assemble a population of early psychosis patients for the related purposes of treatment and research.

Improving detection of first-episode psychosis by mental health-care services using a self-report questionnaire

OBJECTIVE

To examine the utility of the Community Assessment of Psychic Experiences (CAPE)-42, a self-report questionnaire, to improve detection of first-episode psychosis in new referrals to mental health services.

METHOD

At first contact with mental health-care services patients were asked to complete the CAPE-42 and were then routinely diagnosed by a clinician. Standard diagnoses were obtained by means of the mini-Schedule for Clinical Assessment in Neuropsychiatry.

RESULTS

Of the 246 included patients, 26 (10.6%) were diagnosed with psychosis according to the mini-Schedule for Clinical Assessment in Neuropsychiatry. Only 10 of them were recognized by clinical routine, and 16 psychotic patients were not properly identified. Using an optimal cut-off of 50 on the frequency or distress dimension of the positive subscale of the CAPE-42 detected 14 of these misdiagnosed patients. The sensitivity of the CAPE-42 at this cut-off point was 77.5 and the specificity 70.5.

CONCLUSION

Systematic screening of patients using a self-report questionnaire for psychotic symptoms improves routine detection of psychotic patients when they first come into contact with mental health services.

Pathways to care: duration of untreated psychosis from Karachi, Pakistan

Background

Substantial amount of time is lost before initiation of treatment in Schizophrenia. The delay in treatment is labelled as Duration of Untreated Psychosis (DUP). Most of these estimates come from western countries, where health systems are relatively better developed. There is dearth of information on pathway to care from developing countries.

Methods and Results

Patients with ICD-10 based diagnosis of Schizophrenia were enrolled by convenient method of sampling. The pathway to care was explored through a semi-structured questionnaire. Onset, course and symptoms of psychosis were assessed using Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). Ethical approval of the project was taken from The Aga Khan University, Ethics Review Committee. Of the enrolled 93 subjects, 55 (59%) were males and 38 (41%) were females. In our sample, 1.56 mean (median, 2) attempts were made prior to successful help seeking. The duration of untreated psychosis was 14.8 months (St. Deviation; 29.4). DUP was 16.8 months (St. Deviation; 34.9) for males and 11.8 months (St. Deviation; 18.9) for females. In the pathway to care, psychiatrists featured prominently as initial care providers. In the first attempt at help-seeking, 43% patients were initially taken to psychiatrists. After the initial consultation, 45% were prescribed psychotropic medication while 7% were hospitalized. Only 9% subjects were given the diagnosis of schizophrenia initially. When participants were inquired about the reasons for delay, 29% reported financial difficulties as the barrier to care. Positive symptoms of psychosis were present in 57% subjects while negative symptoms were present in 30% subjects. There was a statistically significant difference (Chi-square; 7.928, df: 1, Sig 0.005) between DUP and the positive and negative symptoms category.

Conclusion

In the absence of well developed primary care health system in Pakistan, majority of patients present to psychiatrists as a first contact. DUP, as a measurement of help seeking behaviour, tends to be shorter with positive symptoms of Schizophrenia. Substantial amount of time is lost due to non recognition of disease and subsequently, inadequate treatment. Secondary prevention strategies should focus on families, which play an important role in the treatment-seeking process of psychotic patients.

Antipsychotic drugs for first-episode schizophrenia: a comparative review

Increasingly, it is recognized that first-episode schizophrenia represents a critical stage of illness during which the effectiveness of therapeutic interventions can affect long-term outcome. In this regard, the advent of clozapine and subsequent atypical antipsychotic drugs held promise for improved outcomes in patients with first-episode schizophrenia, given the expectation of improved therapeutic efficacy and a more benign side effect burden compared with typical antipsychotic drugs. A growing number of large clinical trials have evaluated the merits of atypical antipsychotic drugs in the early stages of psychosis. A number of conclusions can be drawn from studies completed to date, with the caveat that data are either limited or unavailable for the antipsychotic drugs most recently approved by the US FDA. Studies of atypical antipsychotic drugs support data obtained with typical agents indicating that positive symptoms of psychosis are very treatment responsive and generally at lower doses than in chronic illness. It also appears that first-episode patients tend to stay on atypical antipsychotic drugs longer than on typical agents when all-cause discontinuation criteria are considered as the primary outcome measure. However, there are few differential advantages of clinical efficacy among the individual atypical antipsychotic drugs and there is little evidence to support distinct therapeutic advantages for negative symptoms or cognitive symptoms for atypical agents. Furthermore, while new-onset psychosis patients are particularly susceptible to extrapyramidal symptoms, they are also prone to gain weight and related metabolic adverse effects associated with many, but not all, atypical antipsychotic drugs. Recent data indicating that certain atypical antipsychotic drugs may have a sparing effect on cortical grey matter loss in first-episode schizophrenia is intriguing, given the potential long-term benefits. In summary, atypical antipsychotic drugs represent an incremental advance for patients in first-episode schizophrenia, especially in the area of neurological tolerability. However, metabolic concerns associated with many atypical agents along with limited benefits in cognition and negative symptom domains highlight the persistent therapeutic needs of these patients.

Predictors of 10-year outcome of first-episode psychosis

BACKGROUND

Predictors of outcome for psychosis are poorly understood. Duration of untreated psychosis (DUP) appears to predict short-term outcome although its medium- to long-term role remains unclear. Neurodevelopmental indices such as pre-morbid function and/or neurological soft signs may predict longer-term outcome. We aimed to assess the impact of a range of clinical and demographic variables on long-term outcome of a geographically defined, epidemiological first-episode psychosis cohort.

METHOD

A 10-year follow-up was undertaken of a consecutively presenting sample of 109 cases of first-episode psychosis aged 16-50 years. Baseline assessments included positive, negative and depression symptoms, DUP, neurological soft signs and pre-morbid functioning. Multi-dimensional outcomes were assessed blind to baseline data.

RESULTS

All participants were traced at a mean of 10.5 years post-index admission: 11 had died, 10 from non-natural causes. Of the surviving cases, 70% were comprehensively re-assessed by interview. Summary data on the remainder were collected from their family practitioner and chart review. Poor 10-year outcomes were predicted independently by poor pre-morbid functioning, baseline negative symptoms and longer DUP. The same measures, plus neurological soft signs, appeared to predict outcomes in a DSM-IV schizophrenia/schizo-affective subgroup.

CONCLUSIONS

Poor pre-morbid functioning, baseline symptoms, DUP and neurological soft signs at onset independently predict poor long-term outcome in first-episode psychosis.

REDIRECT: cluster randomised controlled trial of GP training in first-episode psychosis

BACKGROUND

Delays in accessing care for young people with a first episode of psychosis are significantly associated with poorer treatment response and higher relapse rates.

AIM

To assess the effect of an educational intervention for GPs on referral rates to early-intervention services and the duration of untreated psychosis for young people with first-episode psychosis.

DESIGN OF STUDY

Stratified cluster randomised controlled trial, clustered at practice level.

SETTING

Birmingham, England.

METHOD

Practices with access to the three early-intervention services in three inner-city primary care trusts in Birmingham were eligible for inclusion. Intervention practices received an educational intervention addressing GP knowledge, skills, and attitudes about first-episode psychosis. The primary outcome was the difference in the number of referrals to early-intervention services between practices. Secondary outcomes were duration of untreated psychosis, time to recovery, use of the Mental Health Act, and GP consultation rate during the developing illness.

RESULTS

A total of 110 of 135 eligible practices (81%) were recruited; 179 young people were referred, 97 from intervention and 82 from control practices. The relative risk of referral was not significant: 1.20 (95% confidence interval [CI] = 0.74 to 1.95; P = 0.48). No effect was observed on secondary outcomes except for 'delay in reaching early-intervention services', which was statistically significantly shorter in patients registered in intervention practices (95% CI = 83.5 to 360.5; P = 0.002).

CONCLUSION

GP training on first-episode psychosis is insufficient to alter referral rates to early-intervention services or reduce the duration of untreated psychosis; however, there is a suggestion that training facilitates access to the new specialist teams for early psychosis.

Untreated illness duration correlates with gray matter loss in first-episode psychoses

Frontolimbic neural circuit dysfunction has been thought to underlie schizophrenia. Prolonged duration of untreated illness (DUI) is associated with frontolimbic structural changes. We present data addressing this question in minimally treated first-episode patients with psychoses. To determine the relationship between DUI and gray matter changes in schizophrenia, we analyzed the structural magnetic resonance images of 82 minimally treated first-episode patients with psychotic disorder by using optimized voxel-based morphometry. DUI inversely correlated with gray matter in the left fusiform gyrus extending into the lingual gyrus, cerebellum, and the parahippocampal gyrus. The observed inverse relationship between DUI and temporal gray matter density is consistent with a progressive process during the early course of schizophrenia.

A comparison of mental health legislation from diverse Commonwealth jurisdictions

INTRODUCTION

In the regulation of involuntary treatment, a balance must be found between duties of care and protection and the right to self-determination. Despite its shared common roots, the mental health legislation of Commonwealth countries approaches this balance in different ways. When reform is planned, lessons can be learned from the experiences of other countries.

METHOD

Criteria for involuntary treatment used in a sample of 32 Commonwealth Mental Health Acts were compared using a framework developed from standards derived from the Universal Declaration of Human Rights. Reasons for non-compliance were considered and examples of good practice were noted. Changes in the criteria used over time and across areas with differing levels of economic development were analysed.

RESULTS

1. Widespread deviation from standards was demonstrated, suggesting that some current legislation may be inadequate for the protection of the human rights of people with mental disorders. 2. Current trends in Commonwealth mental health law reform include a move towards broad diagnostic criteria, use of capacity and treatability tests, treatment in the interests of health rather than safety, and regular reviews of treatment orders. Nevertheless, there are some striking exceptions.

DISCUSSION

Explanations for deviation from the standards include differing value perspectives underpinning approaches to balancing conflicting principles, failure to keep pace with changing attitudes to mental disorder, and variations in the resources available for providing treatment and undertaking law reform. Current good practice provides examples of ways of dealing with some of these difficulties.

Mode of onset of psychosis and family involvement in help-seeking as determinants of duration of untreated psychosis

BACKGROUND

The duration of untreated psychosis (DUP) is a potentially modifiable determinant of the early course of nonaffective psychotic disorders, though a paucity of research has addressed determinants of DUP. Recent data from London and Nottingham, UK indicated that a shorter DUP was predicted by: (1) an acute mode of onset, (2) employment, and (3) active involvement of at least one family member in seeking evaluation (Morgan et al. Br J Psychiatry 189:446-452, 2006). The present analysis was conducted in an effort to replicate those findings in a predominantly low-income, urban, African American sample.

METHOD

DUP and the three key predictors of interest were assessed using standardized procedures. All analytic plans replicated those of Morgan and colleagues (Morgan et al. Br J Psychiatry 189:446-452, 2006) to the largest extent possible. Sufficient information was available to rate DUP for 73 patients.

RESULTS

The median DUP was 23.4 weeks. Bivariate tests, survival analysis, and Cox regression revealed that an insidious mode of onset was associated with a substantially longer DUP compared with an acute onset, and that family involvement in help-seeking was independently associated with a longer duration.

CONCLUSIONS

While mode of onset is a reliable illness-related determinant of DUP, further research is needed on the complex ways in which family-related variables influence DUP.

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.

Unemployment, social isolation, achievement-expectation mismatch and psychosis: findings from the AESOP Study

INTRODUCTION

In this study, we aimed to establish: (1) whether social isolation modifies the effect of unemployment on first episode psychosis and duration of untreated psychosis (DUP); and (2) whether the gap between high employment expectations and perceived poor employment achievement is associated with first-episode psychosis; and (3) whether the relationship of this achievement-expectation gap and first-episode psychosis is strongest in the African-Caribbean population.

METHOD

All patients with a first episode of psychosis presenting to specialist mental health services within tightly defined catchment areas in south-east London and Nottingham over a 2-year period were included in the study. A random sample of healthy participants living within the same catchment areas was also recruited. Data were collected on socio-demographic and clinical characteristics, DUP, social contacts, and perceived levels of employment achievement and expectation. Analysis was conducted on data of 546 participants (224 cases, 322 controls) from the AESOP study.

RESULTS

The relationship between unemployment and risk of non-affective psychosis was moderated by social contacts (unemployed/low social contacts, OR 7.52, 95% CI 2.97-19.08; unemployed/medium social contacts, OR 3.27, 95% CI 1.66-6.47; unemployed/high social contacts, OR 1.36, 95% CI 0.47-3.93). Unemployed patients experienced a longer DUP when having reported lower levels of social contacts. Participants whose employment achievement was lower than their expectations were more likely to be cases than those in whom achievement matched or exceeded expectations (adjusted OR 1.84, 95% CI 1.13-3.02). This applied equally to both African-Caribbean and White British participants (the Mantel-Haenszel test for homogeneity of odds ratios, chi (2 )= 0.96, P = 0.33).

CONCLUSIONS

This study suggests that unemployment, social isolation, employment achievement and expectations are important environmental factors associated with risk of psychosis. More attention needs to be focused on interactions between environmental factors as well as subjective experience of those factors in future research on the aetiology of psychosis.

Duration of untreated psychosis and social function: 1-year follow-up study of first-episode schizophrenia

BACKGROUND

In first-episode schizophrenia, longer duration of untreated psychosis (DUP) predicts poorer outcomes.

AIMS

To address whether the relationship between DUP and outcome is a direct causal one or the result of association between symptoms and/or cognitive functioning and social functioning at the same time point.

METHOD

Symptoms, social function and cognitive function were assessed in 98 patients with first-episode schizphrenia at presentation and 1 year later.

RESULTS

There was no significant clinical difference between participants with short and long DUP at presentation. Linear regression analyses revealed that longer DUP significantly predicted more severe positive and negative symptoms and poorer social function at 1 year, independent of scores at presentation. Path analyses revealed independent direct relationships between DUP and social function, core negative symptoms and positive symptoms. There was no significant association between DUP and cognition.

CONCLUSIONS

Longer DUP predicts poor social function independently of symptoms. The findings underline the importance of taking account of the phenomenological overlap between measures of negative symptoms and social function when investigating the effects of DUP.

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.

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.

First aid recommendations for psychosis: using the Delphi method to gain consensus between mental health consumers, carers, and clinicians

BACKGROUND

Members of the general public often lack the knowledge and skills to intervene effectively to help someone who may be developing a psychotic illness before appropriate professional help is received.

METHODS

We used the Delphi method to determine recommendations on first aid for psychosis. An international panel of 157 mental health consumers, carers, and clinicians completed a 146-item questionnaire about how a member of the public could help someone who may be experiencing psychosis. The panel members rated each questionnaire item according to whether they believed the statement should be included in the first aid recommendations. The results were analyzed by comparing consensus rates across the 3 groups. Three rounds of ratings were required to consolidate consensus levels.

RESULTS

Eighty-nine items were endorsed by >or=80% of panel members from all 3 groups as essential or important for psychosis first aid. These items were grouped under the following 9 headings: how to know if someone is experiencing psychosis; how to approach someone who may be experiencing psychosis; how to be supportive; how to deal with delusions and hallucinations; how to deal with communication difficulties; whether to encourage the person to seek professional help; what to do if the person does not want help; what to do in a crisis situation when the person has become acutely unwell; what to do if the person becomes aggressive.

CONCLUSIONS

These recommendations will improve the provision of first aid to individuals who are developing a psychotic disorder by informing the content of training courses.

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.

Insight in first episode psychosis: who is measuring what?

AIMS

To compare different self-administered or clinician-rated insight scales in an FEP population.

METHODS

A self-administered measure (Beck Cognitive Insight Scale - BCIS) and clinician-rated scales (Scale of Unawareness of Mental Disorder - SUMD and Positive And Negative Symptoms Scale - PANSS-G12 insight item) were completed by 38 patients with a diagnosis of FEP.

RESULTS

The scales had good internal consistency and only the clinician-rated scales were intercorrelated (SUMD - awareness of mental disorder and PANSS-G12 items (r=0.657, P<0.001)). Moreover, we observed a significant association of SUMD and PANSS positive and general subscales and a trend association for BCIS and PANSS negative subscale.

CONCLUSION

Differential associations observed between insight and symptoms may suggest different clinical predictive values for each measure. Our results suggest the necessity to qualify the term 'insight' when discussing research results, most notably with respect to who is rating and what aspect of insight is being rated.

Association between duration of untreated psychosis, premorbid functioning, and cognitive performance and the outcome of first-episode schizophrenia in Japanese patients: prospective study

OBJECTIVE

The aim of the present study was to identify the relationship between duration of untreated psychosis (DUP), premorbid functioning, and cognitive dysfunction and the outcome of first-episode schizophrenia.

METHOD

Thirty-four neuroleptic-naïve patients who consulted hospitals in Tokyo and who were treated by psychiatrists for the first time were evaluated with regard to DUP, premorbid functioning, psychiatric symptoms, and global functioning. The neuropsychological test battery consisted of the Letter Cancellation Test, Trail-Making Test, Digit Span and Verbal Fluency Test. One year later, 24 of the subjects were reassessed for psychiatric symptoms, global functioning, and social functioning, and the relationships between DUP, premorbid functioning, and cognitive performance and the outcome was investigated.

RESULTS

Short DUP, good premorbid functioning, and good Letter Cancellation Test, Digit Span and Verbal Fluency Test scores were significantly associated with good outcome.

CONCLUSIONS

The present results in a Japanese sample are consistent with previous international evidence that delay of initial treatment, premorbid functioning, and cognitive deficits are associated with outcome. A major limitation of the present study was the small size of the subject group. But because the subjects were relatively homogeneous and not influenced by psychoactive substances, the results reflect the essence of the disorder.

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.