Causes and consequences of duration of untreated psychosis in schizophrenia

The promise of early intervention

The focus of this review is the research and clinical work in early psychosis and early intervention which over the past 10-15 years has had a tremendous impact on the field of schizophrenia. Unparalleled progress has been made in programme and service development with a wide range of reported research results, outcome studies, treatment approaches and new initiatives. Traditional areas are being explored in the first episode that can add to our knowledge of schizophrenia. New areas that have a specific relevance for early intervention such as the duration of untreated psychosis and pathways to care are being widely studied. Despite the criticism of the lack of randomized controlled trials, there is a wealth of positive outcome from both effectiveness studies and limited controlled trials. However, there are still many unanswered issues which are in developing stages or which require further investigation.

Predictors of acute treatment response in patients with a first episode of non-affective psychosis: sociodemographics, premorbid and clinical variables

Approximately 60% of patients with a first episode of psychosis will significantly reduce the severity of their positive symptomatology with antipsychotic drugs. The aim of this study was to investigate predictors of response to antipsychotic treatment during the first episode of non-affective psychosis. 172 patients (107 male) with a diagnosis of schizophreniform, schizophrenia, schizoaffective, brief reactive psychosis, schizotypal personality disorder or psychosis non-otherwise specified entered the study. Sociodemographic, premorbid and clinical data at baseline were evaluated. Unpaired t-test for continuous and chi2 for categorical data, respectively, were used to compare responders and non-responders selected variables. Multivariate logistic regression was used to establish a prediction model. 57.6% of study subjects (99 of 172) responded to antipsychotic treatment. The following variables were significantly associated with less likelihood of response: 1.--lower severity of general psychopathology, positive symptoms and disorganized symptoms at baseline; 2.--earlier age of onset; 3.--diagnosis of schizophrenia; 4.--longer DUP; 5.--poorer premorbid adjustment during adolescence, and 6.--hospitalization. Multivariate logistic regression demonstrated that differences between responders and non-responders were largely accounted for by BPRS total score, age of onset, premorbid adjustment at early adolescence, and diagnosis. Patients with an early age of onset of schizophrenia, a poor premorbid adolescent functioning, and with a lower severity of psychopathology at intake seem to have a decrease likelihood of responding to antipsychotic treatment. Helping clinicians to identify non-responders is meant as a first step to optimise therapeutic effort to benefit individuals in this vulnerable group.

The evaluation and management of patients with first-episode schizophrenia: a selective, clinical review of diagnosis, treatment, and prognosis

Patients who present with a first episode of psychosis pose many challenges to psychiatry. While some morbidity from schizophrenia is probably not modifiable once acute psychosis has occurred, the best management of this stage of illness nevertheless holds the promise of improving long-term outcomes. We review the clinical literature on first-episode psychosis to derive clinical guidance with regard to timely diagnosis and optimal pharmacological and nonpharmacological treatment. We describe the illness course and the prognosis for this acute phase of illness and the immediate, postpsychotic period.

Understanding and treating "first-episode" schizophrenia

"First-episode schizophrenia" is a clinical and research term that often is used to emphasize the special issues that arise when working with this patient population. The notion that schizophrenia has an inexorable downhill course or is a deteriorating illness is being challenged by more sophisticated understanding of what happens before the initial episode and new understanding of the interactions between biologic vulnerabilities and specific environmental risk during adolescence and early adulthood, such as marijuana use. While the incidence rate of "first-episode" will make this a relatively small percentage of a usual clinical caseload, it is a critically important time for the future course of the illness. The hope is that proper management during this critical period will favorably influence the long-term trajectory of outcome for this individual patient. A growing body of evidence suggests that certain approaches and interventions are more helpful than others, such as understanding of the overwhelming nature of the experience to patients and families, aiming to achieve a full and broad pharmacologic response to initial antipsychotic therapy, while also being on the lookout for vulnerability and extreme sensitivity to side effects, and to anticipate a high likelihood of premature medication discontinuation. Clinicians and treatment services should try to identify "first-episode" patients in time to be able to anticipate and address these issues.

Pharmacogenetics and pharmacogenomics of schizophrenia: a review of last decade of research

The last decade of research into the pharmacogenetics of antipsychotics has seen the development of genetic tests to determine the patients' metabolic status and the first attempts at personalization of antipsychotic treatment. The most significant results are the association between drug metabolic polymorphisms, mainly in cytochrome P450 genes, with variations in drug metabolic rates and side effects. Patients with genetically determined CYP2D6 poor metabolizer (PMs) status may require lower doses of antipsychotic. Alternatively, CYP2D6 ultrarapid matabolizers (UMs) will need increased drug dosage to obtain therapeutic response. Additionally, polymorphisms in dopamine and serotonin receptor genes are repeatedly found associated with response phenotypes, probably reflecting the strong affinities that most antipsychotics display for these receptors. In particular, there is important evidence suggesting association between dopamine 2 receptor (D2) polymorphisms (Taq I and -141-C Ins/Del) and a dopamine 3 receptor (D3) polymorphism (Ser9Gly) with antipsychotic response and drug-induced tardive dyskinesia. Additionally, there is accumulating evidence indicating the influence of a 5-HT2C polymorphism (-759-T/C) in antipsychotic-induced weight gain. Application of this knowledge to clinical practice is slowly gathering pace, with pretreatment determination of individual's drug metabolic rates, via CYP genotyping, leading the field. Genetic determination of patients' metabolic status is expected to bring clinical benefits by helping to adjust therapeutic doses and reduce adverse reactions. Genetic tests for the pretreatment prediction of antipsychotic response, although still in its infancy, have obvious implications for the selection and improvement of antipsychotic treatment. These developments can be considered as successes, but the objectives of bringing pharmacogenetic and pharmacogenomic research in psychiatric clinical practice are far from being realized. Further development of genetic tests is required before the concept of tailored treatment can be applied to psychopharmatherapy. This review aims to summarize the key findings from the last decade of research in the field. Current knowledge on genetic prediction of drug metabolic status, general response and drug-induced side effects will be reviewed and future pharmacogenomic and epigenetic research will be discussed.

Insight and psychopathology in never-treated schizophrenia

Insight is a feature of schizophrenia related to psychopathology, which could be modified by treatment. The real relationship will be more evident in the never-treated state. This study compared insight and its relationship to psychopathology in 143 never-treated patients with chronic schizophrenia with 183 treated patients. The treated patients had not received any structured intervention for improvement of insight. The item on insight and judgment from the Positive and Negative Syndrome Scale for schizophrenia was used as a measure of insight. Never-treated patients were more ill and poorer in insight than the TT group. Sex, age, duration of illness, negative symptoms related to insight only in the TT group. Positive symptoms score correlated with insight in both the groups, but negative symptoms correlated with insight only among the treated patients. Delusions, uncooperativeness, and poor attention predicted 27% of variation in the level of insight in the never-treated, whereas age; duration of illness; and symptoms of emotional withdrawal, difficulty in abstract thinking, and uncooperativeness predicted 30.3% of variation in insight of the TT group. The observed differences between the never-treated and treated subjects were due to influence of treatment on the association between insight and psychopathology. A subgroup of patients with a treatment-resistant trait of negative symptoms associated with poor insight was hypothesized.

Uncovering sociocultural factors influencing the pathway to care of Chinese caregivers with relatives suffering from early psychosis in Hong Kong

I used a qualitative approach to explore the sociocultural factors influencing the pattern of the help-seeking pathway of Chinese caregivers with relatives suffering from early psychosis in Hong Kong. Analyses of the interview scripts of 58 caregivers revealed that they required an average of 5 months and 2.14 helpers before their ill relatives could receive formal psychiatric services. Drawing on Lin and Lin's model of the Chinese help-seeking pathway as a basis for discussion, this study finds that family caregivers engaged in intrafamilial coping and expanded in concentric circles to include relatives and friends as helpers in the help-seeking pathway. Contrary to Lin and Lin's view that informal network members might cause a delay in the help-seeking process, it is revealed that informal network members who possessed adequate knowledge of mental illness were able to encourage family caregivers to seek help from formal psychiatric services. The duration leading to extrafamilial coping was shorter than the one implied in Lin and Lin's model. Family caregivers were quite ready to seek help from professionals in the formal psychiatric services despite the fact that the ill relatives were reluctant to seek treatment due to psychiatric stigma. Finally, the findings of this study do not support the existence of the "rejection phase" of the help-seeking process proposed by Lin and Lin.

The Basel early-detection-of-psychosis (FEPSY)-study--design and preliminary results

Early detection and therapy of schizophrenic psychoses have become broadly accepted aims in psychiatry, recently even in very early stages of the disorder when clear diagnostic criteria are not yet fulfilled. However, reliable and widely applicable methods do not yet exist. This study aims at contributing to the improvement of the early assessment of psychosis.

METHOD

Individuals potentially at risk are identified by a newly developed stepwise screening procedure. Identified subjects are then examined extensively and followed-up for at least 5 years to detect actual transition to psychosis.

RESULTS

Of 50 subjects who have been followed up for 1-5 years by now, 16 have progressed to frank psychosis, 12 of them during the first 12 months of follow-up.

CONCLUSION

At this stage, our approach seems to be promising for the early detection of psychosis. Further results from this ongoing study will hopefully permit us to optimize the assessment procedure.

Gender differences in the prediction of 5-year outcome in first episode psychosis

OBJECTIVE

To examine gender differences in prediction of long-term outcome in first episode psychosis (FEP).

METHOD

Eighty-one male and 72 female FEP patients were compared regarding the sensitivity and specificity of the Predictive Rating Scale (PRS). The contributions of pre-admission clinical and socio-demographic characteristics to a poor 5-year outcome were analysed for males and females separately. Gender differences in the relations between predictors and outcome were examined using the equality of correlation comparing correlation coefficients.

RESULTS

The sensitivity of the PRS was significantly better for males than for females. The following items: 'the highest Global Assessment of Functioning (GAF) the year before first admission < or =70' and 'GAF at first admission < or =30' explained most of the variance of a poor 5-year outcome for males, whereas for females the corresponding items were 'the highest educational level is compulsory school', 'living with parents' and 'contact with friends < or =2-3 times/month'. When the PRS was adapted assigning a weight of two to the item 'the highest educational level is compulsory school' for females, the sensitivity increased.

CONCLUSION

This study revealed that the predictors for poor outcome differ between male and female patients with FEP.

[Early recognition and intervention for schizophrenia]

Studies dealing with the prodromal stage of schizophrenia point to the possibility of early detection and early intervention. Major socioeconomic and social consequences are associated with this disorder. The duration of untreated psychosis seems to play an important role in the course of the disease; i.e. a prolonged duration until adequate treatment is obtained correlates to poorer prognosis. Social, cognitive, affective, and structural brain variations appear in the early prodromal stage. Recent early intervention studies show the possibility of reducing transition rates by preventive treatment of patients at a higher risk of psychosis and already manifesting impaired function. In this review, prodromal signs and possibilities for early detection and intervention in schizophrenia are presented.

Clinical and social determinants of duration of untreated psychosis in the AESOP first-episode psychosis study

BACKGROUND

Despite considerable research investigating the relationship between a long duration of untreated psychosis (DUP) and outcomes, there has been much less considering predictors of a long DUP.

AIMS

To investigate the clinical and social determinants of DUP in a large sample of patients with a first episode of psychosis.

METHOD

All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined catchment areas in London and Nottingham, UK were included in the AESOP study. Data relating to clinical and social variables and to DUP were collected from patients, relatives and case notes.

RESULTS

An insidious mode of onset was associated with a substantially longer DUP compared with an acute onset, independent of other factors. Unemployment had a similar, if less strong, effect. Conversely, family involvement in help-seeking was independently associated with a shorter duration. There was weak evidence that durations were longer in London than in Nottingham.

CONCLUSIONS

These findings suggest that DUP is influenced both by aspects of the early clinical course and by the social context.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcome 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. Both elements may 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, but it is unclear how far early detection, phase-specific treatments, and the use of early intervention teams are underpinned by evidence of effectiveness.

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 CINAHL (1982-2002), The Cochrane Controlled Trials Register (November 2001), The Cochrane Schizophrenia Group Register (July 2003), EMBASE (1980-2002), MEDLINE (1966-2002), PsycINFO (1967-2002), reference lists and contacted the European First Episode Network (2003). For the 2006 update we searched the Cochrane Schizophrenia Group's register.

SELECTION CRITERIA

We included all randomised controlled trials 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

We included seven studies with a total of 941 participants. Six studies were small with numbers of participants ranging between 56 and 83, and one study randomised 547 people. None of the studies had similar interventions and therefore they were analysed separately. One small Australian trial (n=59) was concerned with a phase-specific intervention (low dose risperidone and cognitive behavioural therapy) for people with prodromal symptoms. This group were significantly less likely to develop psychosis at a six month follow up than people who only received care from a specialised team which did not involve phase-specific treatment (n=59, RR 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20). This effect was not significant at 12 month follow up (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). A UK-based study (EDIE) randomised 60 people with prodromal symptoms, to cognitive behavioural therapy (CBT) or a monitoring group. Only two outcomes were reported: leaving the study early and transition to psychosis, both sets of data were non-significant. A Chinese trial used a phase-specific intervention (family therapy) plus out patient care trial for people in their first episode of psychosis and found reduced admission rates care compared with those who received only outpatient care (n=83, RR 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The applicability of this finding was, however, questionable. One Dutch study (n=76) comparing phase-specific intervention (family therapy) plus specialised team with specialised team for people in their first episode of schizophrenia found no difference between intervention and control groups at 12 months for the outcome of relapse (n=76, RR 1.05 CI 0.4 to 3.0). The large Scandinavian study (n=547) allocated people with first episode schizophrenia to integrated treatment (assertive community treatment plus family therapy, social skills training and a modified medication regime) or standard care. Global state outcome GAF significantly favoured integrated treatment (n=419, WMD -3.71 CI -6.7 to -0.7) by one year, but by two years data were non-significant. Rates of attrition were significantly lower (n=547, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) for integrated treatment by one and two year follow-up. PRIME (USA) was the only double blind study and allocated people with prodromal symptoms to olanzapine or placebo. No significant differences were found between olanzapine and placebo in preventing conversion to psychosis by about 12 months (n=60, RR 0.58 CI 0.3 to 1.2). Clinical Global Impression change scores 'severity of illness' were equivocal by 12 months. Scale of Prodromal Symptoms (SOPS) scores were also equivocal and the PANSS, total, positive and negative outcomes were non-significant. There were no significant differences between the olanzapine and placebo group on adverse effects rating scales - SAS, BAS and AIMS scores; Weight gain was significantly higher in the olanzapine group (n=59, WMD 7.63 CI 4.0 to 11.2) by 12 months. Finally one more Australian study included people in their first episode of psychosis who were acutely suicidal and allocated people to phase-specific cognitively orientated therapy or standard care. Outcome data for leaving the study early and suicide were equivocal.

AUTHORS' CONCLUSIONS

We identified insufficient trials to draw any definitive conclusions. The substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but making the most of this opportunity requires a concerted international programme of research to address key unanswered questions.

Social network among young adults with first-episode schizophrenia spectrum disorders: results from the Danish OPUS trial

BACKGROUND

Social network has considerable impact on physical and mental health. Patients experiencing first-episode psychosis early in adult life may experience severe problems concerning development and maintenance of their social network.

METHODS

A total of 547 first-episode psychotic patients (18-45) were randomised to standard or integrated treatment, (ACT, social skills training and family intervention), and followed up at 2 years.

RESULTS

Service use or psychotic symptom score did not influence the social network size, measured after the first 2 years of treatment. Small network size was associated with long duration of untreated psychosis (DUP), poor premorbid adjustment, male gender and severe negative symptoms. The number of friends at 2-year follow-up was predicted by age, A-level status, negative symptoms and number of friends at entry, while the determinants for number of family contacts were age, gender, disorganised dimension and family contacts at entry.

CONCLUSIONS

Premorbid functioning, network size at entry and DUP is closely related to small social network size. The integrated psychosocial treatment programme was not sufficient to address this problem.

Relationship between insight, cognitive function, social function and symptomatology in schizophrenia: the West London first episode study

OBJECTIVE

To examine the nature and clinical correlates of insight in first-episode schizophrenia, and how these differ from findings in established schizophrenia.

METHOD

Insight (and insight dimensions), clinical symptoms, neurocognitive function and social function were assessed in 94 patients with first-episode schizophrenia or schizophreniform disorder according to DSM-IV criteria.

RESULTS

Greater global insight was associated with more severe depression. Poor overall insight was associated significantly with more severe negative and disorganisation symptoms as well as poor working memory, and at a trend level with lower current IQ. Patients with poor insight perceived themselves to have a better level of independent performance at daily living activities.

CONCLUSION

In first-episode psychosis, the clinical correlates of poor insight are similar to those reported for established schizophrenia. Those patients with greater insight may be at risk of depression. The complex relationships between insight, positive and negative symptoms, neurocognitive dysfunction and social function may reflect the multidimensional nature of insight.

Duration of untreated symptoms in common mental disorders: association with outcomes: International study

Studies have assessed the association between a longer duration of untreated symptoms and outcome for psychoses in specialist care. We investigated the effect of longer duration on the outcome of common psychiatric disorders in primary care, where most patients are treated. Patients presenting to primary care for new episodes in 10 countries were recruited into a prospective cohort study. Information on duration of untreated symptoms and psychosocial status was collected for 351 individuals using standardised instruments and this was repeated 1 year later. At 1-year follow-up, longer duration was associated with worse psychiatric outcome even after controlling for potential confounders.

The influence of religious affiliation on time to first treatment and hospitalization

Longer duration of untreated psychosis (DUP) has been associated with treatment-refractory illness, significant cognitive decline, and poorer long-term outcomes. There are many factors, including social and cultural, that promote longer DUP. To date, there have been no studies to evaluate religion's effect on DUP. In this study, we evaluated the effect of certain religious affiliations and degree of religious practice on the DUP.

METHODS

A total of 195 patients were recruited aged 18 to 45 years with the presence of at least 1 psychotic symptom (delusions, hallucinations, or prominent thought disorder). Patients were evaluated on their religious practice prior to the index episode using a Likert-style scale. Using a similar scale, patients were asked about their religious affiliation categorized as Catholic, Protestant, or neither.

RESULTS

Correlational analysis revealed that the time to first treatment and time to first hospitalization were both was negatively related to degree of religious practice (r = -0.15, N = 161, p < 0.05 and r = -0.18, N = 161, p < 0.05, respectively). Between-group comparisons revealed longer DUP in the Protestant group compared to the no affiliation and Catholic groups (p = 0.05).

CONCLUSION

From our results, it appears that the degree of religious practice does not affect length of time to treatment in psychotic patients. However, having a Protestant religious affiliation is strongly associated with having a greater delay in treatment seeking for psychosis. Factors contributing to a longer DUP in this group warrant further study.

Treatment delay and response rate in first episode psychosis

OBJECTIVE

There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population.

METHOD

An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year.

RESULTS

The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response.

CONCLUSION

Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.

Influence of age on outcome of psychological treatments in first-episode psychosis

BACKGROUND

Psychological treatments have been shown to be effective in patients with psychosis. However, the studies published to date have included participants across wide age ranges, so few conclusions can be reached about the effectiveness of such treatments in relation to age.

AIMS

To evaluate outcomes by age in a randomised controlled trial designed to evaluate the effectiveness of cognitive-behavioural therapy (CBT), supportive counselling and treatment as usual.

METHOD

Outcomes were evaluated in terms of symptoms, social functioning, insight and therapeutic alliance according to age at 3- and 18-month follow-up.

RESULTS

Younger participants responded better to supportive counselling than to treatment as usual and CBTover 3 months. Older participants responded better to CBT than to supportive counselling over 18 months. Younger participants showed a greater increase in insight after CBT compared with treatment as usual and supportive counselling, and were more difficult to engage in therapy.

CONCLUSIONS

Young people may have different needs with regard to engagement in psychological treatments. Treatment providers need to take age-specific factors into account.

One year outcome in first episode schizophrenia. Predictors of relapse

The aim of this study was to identify the predictors of outcome at one year follow-up after the first psychotic episode of schizophrenia. Seventy-nine first-episode schizophrenia patients were assessed monthly with the Brief Psychiatric Rating Scale (BPRS), Scale for Assessment of Positive Symptoms (SAPS), and Scale for Assessment of Negative Symptoms (SANS) after discharge from their first hospitalization. Outcome measures were presence of relapse and rehospitalization, level of global functioning, employment status and severity of symptoms at one year. A total of 33% of the patients had a relapse, and 12.1% were rehospitalized during one year follow-up. Premorbid childhood functionality was worse in patients who had relapse, but there was no correlation between premorbid adjustment scores and BPRS, SANS and SAPS scores at one year. There was no difference in duration of untreated psychosis (DUP) between patients who had relapse and not; however, the patients who had double relapse, had longer DUP than those without relapse. The time period between discharge and rehospitalization was shorter in patients with longer DUP. Functionality in childhood and noncompliance to the treatment independently contributed to the relapse rate. Functionality in late adolescence independently contributed to the Global Assessment of Functioning (GAF) scale score at one year and the GAF score at discharge appeared as a predictor of employment. The results of the present study suggest that treatment compliance and early premorbid adjustment level seem to be important predictors of relapse rate in first episode schizophrenia.

Early detection and treatment of schizophrenia: how early?

OBJECTIVE

Whereas early detection and therapy of schizophrenic psychoses until some time ago concentrated on frank schizophrenia, during the last years some centres have also started to treat patients even before a clear diagnosis could be established. This paper attempts to discuss if and when this is justified in the light of recent research.

METHOD

Mini review of literature.

RESULTS

The rationale for early detection and treatment of schizophrenia is based on several observations: diagnosis and treatment of schizophrenia are often seriously delayed. Consequences of the disease are severe already in the early undiagnosed phase of the disorder and early treatment seems to improve the course of the disease. It can therefore be stated quite safely that patients should be treated as early as possible. However, the question of how early has not been sufficiently answered up to now.

CONCLUSION

We are at the moment in an ethical dilemma between either diagnosing and treating this disorder too late or too early. The only way and prerequisite for solving this dilemma is a more reliable identification of individuals at risk and the beginning disease process.

Prolonged duration of untreated psychosis in nonaffective first-episode psychotic disorders compared to other psychoses

Introduction. While the consequences of the duration of untreated psychosis (DUP) represent an active area of research, less attention has been focused on the determinants of the DUP. This analysis assessed several potential determinants of the DUP from a practice-based survey. Method. Data on selected patients in their first treatment episode for psychotic symptoms were obtained from 104 practicing physicians. Patients with a long DUP (n=31), defined as >4 weeks, were compared to patients with a short DUP (≤4 weeks, n=28). Results. The long-DUP group had a higher percentage of patients with nonaffective psychotic disorders (58%) compared to the short-DUP group (29%). The median DUP among those with nonaffective psychotic disorders was 8 weeks, compared to 3 weeks among those with other psychotic disorders. The long-DUP group had a higher percentage of patients rated as uncertain about or denying a mental illness (55% compared to 25% in the short-DUP group). The presence of negative symptoms approached significance in terms of differentiating between the two groups, with 66% of the long-DUP group having negative symptoms compared to 39% of the short-DUP group. When three variables (nonaffective psychotic disorder versus other psychoses, insight, and negative symptoms) were entered into a logistic regression model, only diagnostic category remained an independently significant predictor. Conclusion. In this practice-based sample, patients with nonaffective psychotic disorders were more likely to have a longer DUP than patients who developed psychotic symptoms in the context of mood disorders, substance use disorders, or other disorders.

Measuring pathways to care in first-episode psychosis: a systematic review

BACKGROUND

Adequately understanding and measuring pathways to care is a prerequisite for early detection and effective treatment of first-episode psychosis.

METHOD

We conducted a systematic review of studies on pathways to care in first-episode psychosis to establish what measures currently exist to assess pathways in first-episode psychosis and to compare these measures.

RESULTS

We identified 15 studies which had used six different measures of pathways to care. Differences in aims, methodology and lack of psychometric data did not allow a direct comparison of pathways measures but certain common themes emerged.

DISCUSSION

Pathways to care in first-episode psychosis are diverse and varied. There is no measure with established psychometric properties that has been devised on a well-developed theoretical or conceptual framework and had its psychometric properties established. The conflict between exploring the patient's narrative and journey through the healthcare system and developing an empirical measure of pathways with optimal outcomes has hindered the development of such a measure.

Social support and three-year symptom and admission outcomes for first episode psychosis

This paper presents the first published findings examining the relationship of social support to three-year symptom outcome and hospitalizations for a group of first episode patients with psychotic disorders. Social support was measured using items from the provider version of the Wisconsin Quality of Life Scale as assessed at the time of initiation of treatment for 113 patients. Outcome was assessed by level of positive and negative symptoms at three-year follow-up and number of psychiatric admissions during those three years. Higher levels of social support were found to correlate with lower levels of positive symptoms and few hospitalizations at follow-up. The relationship of social support to follow-up symptoms and hospitalization was independent of other potential predictors such as gender, age, premorbid adjustment and duration of untreated illness.

Reducing the duration of untreated first-episode psychosis -- effects on baseline social functioning and quality of life

OBJECTIVE

Long duration of untreated psychosis (DUP) is associated with poorer outcome. The TIPS study demonstrated that DUP can be reduced through early detection (ED). As quality of life (QoL) is associated with DUP it is expected that reduction of DUP leads to better QoL.

METHOD

Consecutive first-episode patients with a DSM-IV diagnosis of non-organic, non-affective psychosis were included, 281 patients gave informed consent and 263 completed a full evaluation of QoL.

RESULTS

There were no differences in subjective QoL between ED and No-ED groups attributable to reduction in DUP. There were significant bivariate differences in frequency of family and social contacts in favor of the ED group, but multivariate analyses indicated that these differences were based on differences in sample characteristics.

CONCLUSION

Deterioration in QoL may precede overt symptom formation. Focus on functional loss in ED educational campaigns may identify risk subjects earlier in the course of the disorder.

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

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

Pathways to care for first-episode psychosis in an early detection healthcare sector: part of the Scandinavian TIPS study

BACKGROUND

Early detection programmes aim to reduce the duration of untreated psychosis (DUP) by public education and by prompt access to treatment via active outreach detection teams.

AIMS

To determine whether those with first-episode psychosis in an early detection healthcare area with existing referral channels differ from those who access care via detection teams.

METHOD

Those with first-episode psychosis recruited via detection teams were compared with those accessing treatment via conventional channels, at baseline and after 3 months of acute treatment.

RESULTS

Patients recruited via detection teams are younger males with a longer DUP, a less dramatic symptom picture and better functioning; however they recover more slowly, and have more symptoms at 3-month follow-up.

CONCLUSIONS

After establishing low threshold active case-seeking detection teams, we found clear differences between those patients entering treatment via detection teams v. those obtaining treatment via the usual channels. Such profiling may be informative for early detection service development.

Outreach and support in south London (OASIS): implementation of a clinical service for prodromal psychosis and the at risk mental state

BACKGROUND

While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear.

AIMS

To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor.

METHOD

Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months.

RESULTS

People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year.

CONCLUSION

It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.

Hallucinations in children and adolescents

Clinicians need to consider a wide range of differential diagnoses when children and adolescents present with hallucinations. This includes considering whether it is a developmentally normal phenomenon or if there is a psychiatric, medical, or neurologic diagnosis. Nonpsychotic children with hallucinations can be differentiated from psychotic children. Nonpsychotic children who are at risk (or prodromal) for future psychosis can be differentiated from nonprodromal healthier children. We examine the epidemiology, prognosis, and neurobiological research. Lastly, we discuss treatment approaches, including medication and cognitive behavioral therapy.

Duration of untreated psychotic illness: the role of premorbid social support networks

BACKGROUND

A lengthy delay often exists between the onset of psychotic symptoms and the start of appropriate treatment. However, the causes of this long delay remain poorly understood, and there is a need to search for the factors involved in such a delay in order to reduce the time of untreated psychosis. This study aimed at examining the influence of premorbid social networks on the duration of untreated psychotic illness.

METHOD

One hundred subjects with a first episode of schizophrenia or related psychotic disorders never treated with antipsychotics made up the study sample. Social support was assessed by means of the Sturtees's social support scale that comprises two subscales measuring close and diffuse social support. Duration of untreated illness was assessed according to three definitions: duration of untreated unspecific symptoms, duration of untreated psychotic symptoms, and duration of untreated continuous psychotic symptoms. We also examined the effect of putative confounding factors such as gender, residence (urban-rural), age at illness onset, years of education, and parental socio-economic status.

RESULTS

Correlational analysis showed that poor diffuse social support, but not poor close social support, predicted long duration of untreated illness according to the three definitions; this association being mainly due to poor work/academic support. Logistic regression analysis confirmed such an association, but it was limited to duration of continuous psychotic symptoms (unadjusted OR=3.44, 95% CI=1.51-7.83); this association persisted after adjusting for the confounding variables (adjusted OR=3.39, 95% CI=1.39-8.29). We also found that subjects with low socio-economic status were depending on the definition of duration of untreated illness considered, between 2.7 and 4.3 times more likely to present with a long duration of untreated illness.

CONCLUSION

Both poor diffuse social support and a low socio-economic status seem to be relevant factors of a prolonged duration of untreated psychosis.

The impact of family experience on the duration of untreated psychosis (DUP) in Hong Kong

BACKGROUND

Previous family experience of psychotic illness may play an important role in whether and when a patient seeks help in first-episode psychosis. This study investigated the relationship between family experience of psychosis and the duration of untreated psychosis in a prospective sample of first-episode psychosis patients in Hong Kong. We also studied the effects of pre-morbid adjustment, educational level, living alone, and mode of onset as potential determinants of the duration of untreated psychosis (DUP).

METHODS

A total of 131 first-episode psychosis patients in Hong Kong were recruited in a study of the DUP and related factors. The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) was used to measure the DUP and to provide a structured assessment of family history, educational level, household arrangement, and mode of onset.

RESULTS

Previous family experience of psychiatric illness (the presence of another family member who has been receiving psychiatric treatment) and an acute mode of onset were significant predictors of a shorter DUP. Educational level had a modest effect on its own, but was not significant in the binary logistic regression model. Living alone had a moderate effect size, but was non-significant, possibly because of the small proportion of single-person households in the sample. The symptom profile, pre-morbid adjustment, and other demographic factors were not significantly related to the DUP.

CONCLUSION

In addition to the mode of onset, previous family experience plays an important role in the presentation of early psychosis. Educational efforts that target the family should be an important part of any strategy for the early detection of psychosis.

Prevention of schizophrenia: can it be achieved?

Schizophrenia is a serious mental disorder with a profound impact on patients, their caregivers and society. It is also an expensive disorder to treat, despite being relatively rare. In this paper, prevention of schizophrenia is described in terms of primary, secondary and tertiary prevention. Schizophrenia is regarded as a neurodevelopmental disorder with different phases. Primary prevention essentially involves education programmes about the association of obstetric complications and the increased risk of schizophrenia. Secondary prevention involves intervention at the prodromal phase. We review the literature and discuss the evidence relating to intervention in this phase of the illness. Early intervention could result in reduction in morbidity and better quality of life for the patients and their families. The prodromal phase can now be identified, based on current symptoms, with reliability and predictive validity for the risk of development of schizophrenia in the following year. We also discuss possible risks faced by prodromal patients, such as unnecessary stigmatisation, and the role of drug treatment during intervention at this stage. Any recommendation that anti-psychotic medications be routinely prescribed in this phase should be supported by more research work. Drug and psychosocial intervention is indicated as part of tertiary prevention to prevent further disability in the illness.

Design of the BiRmingham Early Detection In untREated psyChosis Trial (REDIRECT): cluster randomised controlled trial of general practitioner education in detection of first episode psychosis [ISRCTN87898421]

Background

Treatment delay in first episode psychosis is common. As general practitioners are the first point of contact for many individuals with first episode psychosis, they are well placed to detect the early symptoms and make urgent referrals to specialist secondary care services. However, early psychosis is often difficult to detect. The primary objective of the Redirect trial is to estimate whether an educational intervention targeted at general practitioners increases the general practitioner referral rate of young people with first episode psychosis to Early Intervention Services.

Methods/design

This paper describes the design of a stratified-cluster randomised controlled trial of an educational intervention on first episode psychosis in primary care. The primary outcome is the number of general practitioner referrals of young people with first episode psychosis to Early Intervention Services. Secondary outcomes are duration of untreated psychosis, time to recovery, use of the Mental Health Act, and general practitioner consultation rate. Young people with first episode psychosis referred to Early Intervention Services will be recruited over a two-year period from 1 March 2004. Seventy-eight out of 89 eligible general practices were recruited. The educational intervention has been implemented and evaluated by general practitioners. The education was well received and considered relevant to clinical practice by the general practitioners.

Discussion

The results suggest that the recruitment strategy and implementation of the educational intervention are feasible and acceptable in a primary care setting. The Redirect trial will provide robust information about the efficacy of an evidence-based complex educational intervention targeted at general practitioners on referral rates of young people with first episode psychosis to Early Intervention Services.

Determinants of duration of untreated psychosis and the pathway to care in Singapore

INTRODUCTION

Delays in providing effective treatment for a patient with psychosis has significant negative effects on the outcome. This includes more hospitalizations, longer periods of inpatient care, slower and less complete recovery, and more frequent relapses. In this study, we established the Duration of Psychosis (DUP) in a sample of patients with first-episode psychosis and examined the pathways to care.

METHODS

The sample comprised patients presenting with first-episode psychosis to the psychiatric services of the Institute of Mental Health, Singapore, from January to December 2000. The association between the DUP and demographic, clinical and social variables was examined.

RESULTS

The DUP ranged from 0.1 to 336 months. The mean DUP was 32.6 (SD = 59.8) months, with a median of 12 months. Twenty four percent of the patients had sought consultation with a traditional healer prior to consulting a psychiatrist. The DUP of this group of patients was not significantly different from those who sought help elsewhere.

CONCLUSIONS

The DUP of our patients was longer than that reported in studies done in the West. The attitudes and beliefs of family in the Asian society are likely to be crucial in the pathways to care.

Early detection of schizophrenia

PURPOSE OF REVIEW

This article will evaluate the rationale and feasibility of detecting psychosis and schizophrenia earlier than is currently the case.

RECENT FINDINGS

Schizophrenia incidence may vary more than has been believed previously. Early detection studies fall into two groups. Firstly, operational criteria now exist for prodromal or at risk mental states which predict transition to psychosis of 20-40% over 1 year. The first randomized trials of antipsychotic drug and psychological interventions aimed at reducing this transition rate have shown promising results. Secondly, duration of untreated psychosis in the first episode seems genuinely to be associated with clinical outcome but how much of the association is truly causal remains disputed.

SUMMARY

Shortening duration of untreated psychosis by early detection of full psychosis appears feasible but its benefits are not yet unequivocally demonstrated.

Prodromal interventions for schizophrenia vulnerability: the risks of being "at risk"

Given the morbidity and difficulty of treating psychotic disorders, including schizophrenia, there has been a move toward identifying and treating adolescents and young adults who appear to be clinically at risk or "prodromal" to psychosis. The field now has greater specificity in identification, with rates of 40-50% conversion to frank psychosis within 1-2 years. There is further evidence that medications and other treatments may have some efficacy for "prodromal" patients, though with variable side effects. However, controversy remains about some of the inherent risks in prodromal research, such as medication exposure and stigma among false-positives. In this paper, we add to this discussion through an analysis of ethics in prodromal research from the more established field of predictive genetic testing. Issues are raised about the effects of information on patients, families, and institutions, as well as future insurability, the limits of confidentiality (as it relies on discretion of patients and families), the autonomy of minors with psychiatric symptoms, and even the risks for the true-positive patient.

Validation of Surrogate Markers in Multiple Randomized Clinical Trials with Repeated Measurements: Canonical Correlation Approach

Part of the recent literature on the evaluation of biomarkers as surrogate endpoints starts from a multitrial context, which leads to a definition of validity in terms of the quality of both trial-level and individual-level association between the surrogate and true endpoints (Buyse et al., 2000, Biostatistics1, 49-67). These authors concentrated on cross-sectional continuous responses. However, in many randomized clinical studies, repeated measurements are encountered on either or both endpoints. A challenge in this setting is the formulation of a simple and meaningful concept of "surrogacy."Alonso et al. (2003, Biometrical Journal45, 931-945) proposed the variance reduction factor (VRF) to evaluate surrogacy at the individual level. They also showed how and when this concept should be extended to study surrogacy at the trial level. Here, we approach the problem from the natural canonical correlation perspective. We define a class of canonical correlation functions that can be used to study surrogacy at the trial and individual level. We show that the VRF and the R2 measure defined by Buyse et al. (2000) follow as special cases. Simulations are conducted to evaluate the performance of different members of this family. The methodology is illustrated on data from a meta-analysis of five clinical trials comparing antipsychotic agents for the treatment of chronic schizophrenia.

The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis

OBJECTIVE

To evaluate the effectiveness of a service for early psychosis.

DESIGN

Randomised controlled clinical trial.

SETTING

Community mental health teams in one London borough.

PARTICIPANTS

144 people aged 16-40 years presenting to mental health services for the first or second time with non-organic, non-affective psychosis.

INTERVENTIONS

Assertive outreach with evidence based biopsychosocial interventions (specialised care group) and standard care (control group) delivered by community mental health teams.

PRIMARY OUTCOME MEASURES

Rates of relapse and readmission to hospital.

RESULTS

Compared with patients in the standard care group, those in the specialised care group were less likely to relapse (odds ratio 0.46, 95% confidence interval 0.22 to 0.97), were readmitted fewer times (beta 0.39, 0.10 to 0.68), and were less likely to drop out of the study (odds ratio 0.35, 0.15 to 0.81). When rates were adjusted for sex, previous psychotic episode, and ethnicity, the difference in relapse was no longer significant (odds ratio 0.55, 0.24 to 1.26); only total number of readmissions (beta 0.36, 0.04 to 0.66) and dropout rates (beta 0.28, 0.12 to 0.73) remained significant.

CONCLUSIONS

Limited evidence shows that a team delivering specialised care for patients with early psychosis is superior to standard care for maintaining contact with professionals and for reducing readmissions to hospital. No firm conclusions can, however, be drawn owing to the modest sample size.

Insight into schizophrenia: a comparative study between patients and family members

CONTEXT

Despite the recognition of the role that sociocultural factors play in the process of acquiring insight, recent research on this issue is scarce.

OBJECTIVES

1) to translate and adapt the Schedule for Assessment of Insight (SAI) to Portuguese; 2) to use a modified version of it to evaluate family members' insight into schizophrenia; 3) to compare patients' insight with family members' insight.

TYPE OF STUDY

Cross-sectional study.

SETTING

Schizophrenia Project Outpatient Clinic (Projesq), Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo.

METHODS

40 patients with schizophrenia (Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition-DSM-IV) undergoing outpatient treatment and members of their respective families were interviewed using the SAI and a modified version of this instrument, respectively.

RESULTS

Family members performed better than patients in the total and partial SAI scores [total: 13.0 to 8.75 (p < 0.001); adherence: 3.9 to 3.4 (p < 0.005); recognition of illness: 5.5 to 3.5 (p < 0.001); relabeling of psychotic phenomena: 3.6 to 1.9 (p < 0.001)]. However, when the scores were correlated for each patient-family member pair, the only partial score that had a negative correlation was the relabeling of psychotic phenomena (r = -0.14), while the others had positive correlations (total r = 0.401; adherence r = 0.410; recognition of illness r = 0.422).

DISCUSSION

There was a lack of correlation between the scores of family members and patients regarding the ability to relabel psychotic phenomena as abnormal. This might be understood as a smaller influence of sociocultural factors in this dimension than in other dimensions. The fact that family members were not assessed for the presence of psychopathology is a limitation of this study.

CONCLUSIONS

Different dimensions of insight are not equally influenced by disease and sociocultural factors. The recognition of illness is more strongly influenced by sociocultural factors than the ability to relabel psychotic phenomena as abnormal.

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

OBJECTIVE

While findings are contradictory, many studies report that long Duration of Untreated Psychosis (DUP) correlates with poorer outcome in first episode psychosis. In an outcome study of first-episode psychosis, we compared the patients who refused to participate in a follow-along with those who consented to estimate the importance of this factor in sample recruitment bias. Our questions were: (i) What is the percentage of refusers? (ii) Are there systematic differences between refusers and consenters on DUP and/or other admission variables? (iii) What is the risk of refusal for different values of DUP?

METHOD

In an unselected group of consecutively admitted patients we compared follow-along refusers and consenters on the following admission variables: sex, age, diagnostic group, substance abuse, being in-patient, coming from an early detection site and DUP. We conducted a logistic regression analysis with refusal as the outcome variable.

RESULTS

Ninety-three of 397 patients (23%) were refusers. In univariate analyses the only significant difference was found for DUP. The median DUP for consenters was 10 weeks and for refusers 32 weeks. DUP remained significant when all independent variables were controlled for.

CONCLUSION

DUP was significantly related to risk for refusal. For tests of the impact of DUP on outcome, this may introduce a type II error bias.

Early intervention in first-episode psychosis--the impact of a community development campaign

OBJECTIVE

Substantial delays in providing access to treatment in first-episode psychosis have been well documented. The present study examines the impact of strategies aimed at improving access and reducing delays.

METHOD

A pilot community education campaign was conducted with the aim of reducing the duration of untreated psychosis (DUP) in a geographically defined intervention sector located in the northwestern region of Melbourne, Australia. Utilising a quasi-experimental design, a comparison sector with similar demographics was selected from another part of the north-western region. A mobile early detection team and the same treatment system served both sectors.

RESULTS

While there was no significant difference between the mean DUP for intervention and comparison sectors, the distributional features of DUP between the two regions were significantly different. In the intervention sector, disproportionately more cases with very long DUP were detected. When a small number of outliers were removed, the mean and median DUP in the intervention sector was reduced.

CONCLUSION

These findings highlight the complexity of treatment access and delay and suggest that efforts to reduce DUP may have two effects, not one. Firstly, a different sample of cases is treated through the detection of hidden "long DUP" cases that otherwise may have remained untreated. Secondly, the DUP for the remainder may indeed be reduced. More research with larger samples and more potent campaign strategies is clearly required. It may also be worth considering whether there is a safe and ethical way to undertake a RCT of early versus delayed antipsychotic treatment to perhaps settle the DUP debate once and for all.

Mourning, insight, and reduction of suicide risk in schizophrenia

Literature on the assessment of suicide risk in individuals with schizophrenia is summarized, including the risk factors shared in common with the general population, illness-specific risk factors, and times of heightened risk in the course of the illness. Because depression emerges as a significant risk factor, it is differentiated from conditions that can mimic depression: mourning, aprosodia, and negative symptoms. Because insight or awareness of illness carries risk, as does the lack of insight, the psychological and neurocognitive components of impaired and of accurate insight are described. Finally, the role of mourning in the attainment of accurate, usable insight that can reduce suicidal risk is described.

The use of pharmacotherapy in the prodrome of schizophrenia

In treating schizophrenia there has been a shift in focus, with more attention being paid to early intervention based on the notion that effective treatment at this point can improve outcome. Most of this work has centred on pharmacotherapeutic interventions during the first psychotic break. More recently, attention has turned to the potential value of intervening even earlier, that is during the so-called "prodrome" that has been identified as predating the first psychotic break by as much as 4-5 years. We now have a limited number of published reports addressing this topic and these are reviewed here.

Longitudinal assessment of psychopathological domains over late-stage schizophrenia in relation to duration of initially untreated psychosis: 3-year prospective study in a long-term inpatient population

There remains uncertainty regarding any progressive nature of psychopathology and cognitive dysfunction in late-stage schizophrenia, and whether duration of initially untreated psychosis (DUP) might be associated with such 'progression'. This study examines longitudinally, over 3 years, the psychopathology and neuropsychology in 82 inpatients with DSM-IV schizophrenia, many of whom were admitted in the pre-neuroleptic era. Increase in executive dysfunction exceeded that in general cognitive impairment. Positive but not negative symptom severity decreased modestly; the primary predictor of negative symptom severity was DUP. On index assessment, psychopathology evidenced a three-factor structure; at follow-up, psychomotor poverty evidenced greater prominence and cohesion, and was on both occasions predicted primarily by DUP, while reality distortion was altered and disorganisation disassembled into alternative elements. It would appear that as years of chronic, refractory illness accrue, psychomotor poverty becomes more sharply delineated and dominant within the overall structure of psychopathology, and its prominence is predicted enduringly by DUP.

Duration of untreated psychosis and treatment outcome in schizophrenia patients untreated for many years

OBJECTIVE

The duration of untreated psychosis (DUP) influences treatment outcome in schizophrenia but its relevance in untreated patients, ill for a very long duration, is not known. This study examined outcome and factors related to it after one year of treatment of schizophrenia patients who were ill for many years and not previously treated.

METHOD

Among 75 never-treated patients with schizophrenia detected in a community survey in Chennai, India, 49 took treatment and were followed up prospectively for one year. Evaluation at intake and outcome was carried out using standardized methods.

RESULTS

A good clinical outcome in 29%, social outcome in 35%, occupational outcome in 51% and global outcome in 31% was observed at the end of one year. Patients with poor global outcome did not significantly differ from those with good outcome on demographic and clinical variables at intake but for the presence of delusions and formal thought disorder. The proportion with good outcome in clinical, work and global measures fell steadily with increasing DUP. This difference was significant for clinical and global outcomes after a DUP of 5 years.

CONCLUSIONS

The relationship between DUP and response to treatment held good even in chronic stages of schizophrenia with longer DUP associated with poorer outcome.

Duration of untreated psychosis may predict acute treatment response in first-episode schizophrenia

There is growing evidence for a relationship between the duration of untreated psychosis (DUP) and the prognosis in schizophrenia. The objective of this study is to evaluate whether DUP and premorbid level of social functioning are related to treatment response in acute treatment of first-episode schizophrenia. Seventy-nine first-episode schizophrenia patients were assessed with BPRS, SAPS, and SANS on admission and discharge during their first hospitalisation. Percentage of the difference between admission and discharge in total scores of all scales were taken as measures of absolute symptom reduction. The median DUP was 6 months (mean=8.6). DUP was correlated with reduction in BPRS and SAPS scores but not SANS scores. Patients with a short DUP (n=41) also showed a higher reduction in BPRS, and SAPS scores than those with a long DUP. Premorbid Adjustment Scale (PAS) scores were inversely correlated with age at onset and positively correlated with BPRS scores at admission. We did not find any relationship between PAS scores and response to treatment. Our findings suggest that DUP may be an important predictor of response in acute treatment of first-episode schizophrenia and thus, attempts for early diagnosis may also have a positive effect on acute treatment response.

Relationship of good and poor Wisconsin Card Sorting Test performance to illness duration in schizophrenia: a cross-sectional analysis

The authors investigated whether schizophrenic patients with good and poor performance on the Wisconsin Card Sorting Test (WCST) showed cognitive modifications related to duration of illness. Of the 154 patients evaluated with the WCST, 56 subjects had normal or mildly impaired performance and 98 showed impairment on the basis of the number of categories achieved (0-3 categories = poor performance). These subsamples were then cross-sectionally divided into three subsamples depending on length of illness (< 5 years, 6-10 years, > 10 years). The inclusion of 69 healthy controls allowed the effect of age to be taken into account. The schizophrenic group as a whole and the group of poor performers did not show differences in any of the WCST indices related to length of illness. Good performers instead showed improvement on the intermediate length-of-illness group (6-10 years of illness), and then decline in the third one (> 10 years). Good performers only showed a positive significant correlation between age, age at onset, educational level and successful WCST performance. Results for the poor performers support the hypothesis of no progressive 'deteriorating' course of schizophrenia, while good performers show an unstable pattern of cognitive functions. These data support the hypothesis that cognitive deficits associated with schizophrenia cannot be considered a unitary trait, but emerge along different hypothetical trajectories.

Early Intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcome might be improved if more therapeutic effort were focused on the early stages of schizophrenia. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection and phase-specific treatment. Both elements may be offered in addition to standard care, or may be provided by a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia, but it is unclear how far early detection, phase-specific treatments, and the use of early intervention teams are underpinned by evidence of effectiveness.

OBJECTIVES

This review aims to evaluate the effects of: i. early detection and treatment of people with prodromal symptoms; ii. the use of early intervention teams for people in their first episode of psychosis; and iii. phase-specific treatments for people in their first episode of psychosis.

SEARCH STRATEGY

We searched CINAHL (1982-2002), The Cochrane Controlled Trials Register (November 2001), The Cochrane Schizophrenia Group Register (July 2003), EMBASE (1980-2002), MEDLINE (1966-2002), PsycINFO (1967-2002), reference lists and contacted the European First Episode Network (2003).

SELECTION CRITERIA

Randomised controlled trials designed to prevent progression to psychosis in people showing prodromal symptoms, or 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. Non-randomised trials would only have been included if they had been studies of the effects of early detection strategies in reducing the duration of untreated psychosis (since this issue cannot be addressed by simple randomisation).

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers and cross-checked. Relative risks (RR) and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted mean differences (WMD) were calculated for continuous data.

MAIN RESULTS

In theory, seventeen different comparisons are possible, but the review only identified three studies that met inclusion criteria. One small trial (n=59) was concerned with a phase-specific intervention (low dose risperidone and cognitive behavioural therapy) for people with prodromal symptoms. This group were significantly less likely to develop psychosis at 6 month follow up than people who only received care from a specialised team which did not involve phase-specific treatment (n=59, 1 RCT, RR 0.27 CI 0.08 to 0.89, NNT 4 CI 2 to 20). This effect was not significant at 12 month follow up (n=59, 1 RCT, RR 0.54 CI 0.23 to 1.30). Another trial found that people in their first episode receiving a phase-specific intervention (family therapy) plus out patient care did have reduced admission rates care compared with those who received only outpatient care (n=83, 1 RCT, RR 0.28 CI 0.13 to 0.62, NNT 3 CI 2 to 6). The applicability of this finding was, however, questionable.Finally, one last study (n=76), comparing phase-specific intervention (family therapy) plus specialised team with specialised team for people in their first episode of schizophrenia found no difference between intervention and control groups at 12 months for the outcome of relapse but confidence intervals were wide (n=76, RR 1.06 CI 0.31 to 3.65).

REVIEWERS' CONCLUSIONS

We identified insufficient trials to draw any definitive conclusions, although five ongoing trials should report shortly. The substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but this opportunity may be missed without a concerted international programme of research to address key unanswered questions.

Placebo-free designs for evaluating new mental health treatments: the use of adaptive treatment strategies

The dominant pre-marketing clinical trial in psychopharmacology is a non-equivalence design that randomizes patients to one of three treatments: an accepted standard, the innovation (new drug), or placebo, with the main efficacy comparison being innovation vs placebo. The reasons behind the choice of placebo control in new drug development include anticipated small effect size for active-controlled comparisons and the sufficiency of demonstrated treatment effect (new drug vs placebo) for regulatory approval. These reasons have led to great reliance on placebo control in drug evaluation studies, despite the ethical controversy over the use of placebo when there are known effective standard treatments. While the use of placebo controls has been widely debated, a less considered aspect of the usual placebo-controlled non-equivalence design is the disparity between the decisions that it supports and those that pervade clinical practice. We propose an alternative approach that randomizes one group of patients to an adaptive treatment strategy that exemplifies the adaptive nature of clinical decision-making in the treatment of ongoing mental health disorders. The basic idea is to compare the adaptive strategy, which uses a patient's outcomes to date to determine when to switch from an initial treatment (e.g. an accepted standard) to an alternative (e.g. the new) treatment, to fixed trials of either treatment option. We state the conditions under which the adaptive treatment RCT is attractive to implement and the requirements for doing so.

Randomized trial of olanzapine versus placebo in the symptomatic acute treatment of the schizophrenic prodrome

BACKGROUND

The prodromal phase of schizophrenic disorders has been described prospectively. The present study aimed to determine the short-term efficacy and safety of olanzapine treatment of prodromal symptoms compared with placebo.

METHODS

This was a double-blind, randomized, parallel-groups, placebo-controlled trial with fixed-flexible dosing conducted at four sites. Sixty patients met prodromal diagnostic criteria, including attenuated psychotic symptoms, as determined by structured interviews. Olanzapine 5-15 mg daily or placebo was prescribed for 8 weeks.

RESULTS

In the mixed-effects, repeated-measures analysis, the treatment x time interaction for the change from baseline on the Scale of Prodromal Symptoms total score was statistically significant, and post hoc analyses revealed that the olanzapine-placebo difference reached p<.10 by week 6 and p<.05 at week 8. Ratings of extrapyramidal symptoms remained low in each group and were not significantly different. Olanzapine patients gained 9.9 lb versus.7 lb for placebo patients (p<.001).

CONCLUSIONS

This short-term analysis suggests olanzapine is associated with significantly greater symptomatic improvement but significantly greater weight gain than is placebo in prodromal patients. Extrapyramidal symptoms with olanzapine were minimal and similar to those with placebo. Future research over the longer term with more patients will be needed before recommendations can be made regarding routine treatment.