Prediction of duration of psychosis before first admission

The role of religiosity types in the phenomenology of hallucinations: A large cross-sectional community-based study in a predominantly Muslim society

Religiosity is a multidimensional construct known to influence the occurrence of hallucinations. However, it remains unknown how different religiosity types affect clinically relevant phenomenological features of hallucinations. Therefore, we wished to explore associations between intrinsic and extrinsic (non-organizational and organizational) religiosity and hallucinations severity, distress or impact on daily function in a non-clinical Muslim population. We recruited a representative sample of full-time students at Qatar's only national university via systematic random sampling and administered the Questionnaire of Psychotic Experiences online. The study design was cross-sectional. Using structural equation modeling, we estimated effects of the religiosity types on hallucinations severity, distress or impact on daily function in the past week while accounting for sociodemographic variables, anxiety, depressive symptoms, and, delusions. Extrinsic non-organizational religiosity (ENORG) was associated with experiencing reduced distress or impact on daily function from hallucinations both directly and indirectly through intrinsic religiosity. In contrast, extrinsic non-organizational religiosity (EORG) was associated with increased hallucinations distress or impact albeit only through higher intrinsic religiosity. We found no association between any religiosity types and hallucinations severity. Younger and married participants from lower socio-economic class had comparatively more severe hallucinations and more distress from them. Qatari nationality was positively associated EORG and negatively associated with hallucinations distress or impact. Evidence of differential associations between the religiosity types, socioeconomic and cultural groups, and distress or impact from past week's hallucinations supports the importance of alignment between religious, mental health, and well-being education.

Seventeen-year clinical outcome of schizophrenia in Bali

Objective

To examine the 17-year clinical outcome of schizophrenia and its predictors in Bali.

Methods

Subjects were 59 consecutively admitted first-episode schizophrenia patients. Their clinical outcome was evaluated by standardized symptomatic remission criteria based on Positive and Negative Syndrome Scale (PANSS) scores and operational functional remission criteria at 17-year follow-up. The standardized mortality ratio (SMR) over 17 years was also calculated as another index of clinical outcome.

Results

Among these 59 patients, 43 (72.9%) could be followed-up, 15 (25.4%) had died, and one (1.7%) was alive but refused to participate in the study. Combined remission (i.e. symptomatic and functional remission) was achieved in 14 patients (23.7% of original sample). Duration of untreated psychosis (DUP) was a significant baseline predictor of combined remission. Mean age at death of deceased subjects was 35.7, and SMR was 4.85 (95% CI: 2.4–7.3), indicating that deaths were premature. Longer DUP was associated with excess mortality.

Conclusions

The long-term outcome of schizophrenia in Bali was heterogeneous, demonstrating that a quarter achieved combined remission, half were in nonremission, and a quarter had died at 17-year follow-up. DUP was a significant predictor both for combined remission and mortality.

Duration of untreated psychosis and clinical outcomes of first episode psychosis: An observational and an instrumental variables analysis

AIM

Duration of untreated psychosis (DUP) is considered as a key prognostic variable in psychosis. Yet, it is unclear whether a longer DUP causes worse outcomes or whether reported associations have alternative explanations.

METHODS

Data from 2 cohorts of patients with first episode psychosis were used (n = 2134). Measures of DUP were assessed at baseline and outcomes at 12 months. Regression models were used to investigate the associations between DUP and outcomes. We also investigated whether any associations were replicated using instrumental variables (IV) analysis to reduce the effect of residual confounding and measurement bias.

RESULTS

There were associations between DUP per 1-year increase and positive psychotic symptoms (7.0% in symptom score increase 95% confidence interval (CI) 4.0%, 10.0%, P < .001), worse recovery (risk difference [RD] 0.78, 95%, CI 0.68, 0.83, P < .001) and worse global functioning (0.62 decrease in functioning score 95% CI -1.19, -0.04, P = .035). There was no evidence of an association with negative psychotic symptoms (1.0%, 95%, CI -2.0%, 5.0%, P = .455). The IV analysis showed weaker evidence of associations in the same direction between DUP per 1-year increase and positive psychotic symptoms, recovery and global functioning. However, there was evidence of an inverse association with negative psychotic symptoms (decrease of 15.0% in symptom score 95% CI -26.0%, -3.0%, P = .016).

CONCLUSIONS

We have confirmed previous findings of a positive association between positive psychotic symptoms, global functioning and recovery and DUP using regression analysis. IV analysis shows some support for these findings. Future investigation using IV analysis should be repeated in large data sets.

Individual factors influencing the duration of untreated psychosis

AIM

Duration of untreated psychosis (DUP), or the time between onset of psychosis and treatment initiation, is a prognostic factor of schizophrenia. However, few studies evaluated the relative influence of individual-related factors on this duration. The objective of this study was to evaluate the influence of socio-demographic, clinical and cannabis use on DUP.

METHODS

This study was part of a large prospective study in help-seeking individuals referred to our specialized early detection / intervention clinic in the Service Hospitalo-Universitaire of Sainte-Anne Hospital in Paris (ICAAR study). We explored 33 consecutive patients who crossed the CAARMS' threshold of psychosis. The DUP and cannabis consumption history were explored during the baseline comprehensive assessment using all available sources (direct interviews of patients, parents, practitioners). Correlations between socio-demographic, clinical and cannabis use, and DUP were studied. A multiple linear regression model was used to determine the variables that could significantly predict DUP.

RESULTS

When considered individually, none of the socio-demographic and disease characteristic factors was associated with DUP, with the exception of level of education. In the multivariate analysis, age at inclusion, negative symptoms and history of cannabis use significantly influenced DUP.

CONCLUSION

The determinants of DUP are multi-factorial and include individual centred factors, such as age, cannabis and negative symptoms. The identification of factors resulting in delayed access to care may promote the development of effective strategies to reduce DUP in early psychosis and target effective early intervention.

Duration of untreated illness in patients with somatoform disorders

OBJECTIVE

A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders.

METHODS

In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI.

RESULTS

A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI.

CONCLUSIONS

The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.

Openness to experience shortens duration of untreated psychosis in Serbian clinical population

AIM

To determine duration of untreated psychosis (DUP) in patients with schizophrenia-spectrum disorders from Serbia and to analyse factors that potentially contribute to the treatment delay, with focus on personality traits.

METHODS

Fifty seven patients (males 54.4%; age = 29.9 ± 6.0 yrs; age at the illness onset = 24.9 ± 5.1 yrs; IQ = 93.5 ± 12.2) were included. The assessment consisted of Nottingham Onset Schedule (NOS), Premorbid Adjustment Scale (PAS) and NEO Personality Inventory (NEO-PI-R). We used Cox regression model to evaluate relationship between DUP and explanatory variables.

RESULTS

Based on the most restrictive definition, the length of DUP in our sample was 77.8 ± 120.6 weeks (MED = 25.0 weeks). DUP was negatively associated with openness to experience (B = -0.804, P = 0.024).

CONCLUSIONS

We report the first evidence of DUP in Serbia, emphasizing that the personality domains are likely to impact the use of mental health care in persons with psychosis.

Duration of untreated psychosis and its relationship to clinical outcome

Background

A major reason for interest in early intervention for psychotic disorders is the hypothesised relationship between longer duration of untreated psychosis (DUP) and poorer outcome of treatment.

Aims

To critically examine the evidence concerning DUP being related to treatment outcome and possible mediators of any such relationship.

Method

A systematic review of studies in which DUP is assessed and its relationship to treatment outcome is examined. In addition, studies relevant to possible neurotoxic effects of DUP were reviewed.

Results

The research is entirely of a correlational nature and, therefore, firm conclusions regarding causation are not possible. There is, however, substantial evidence of DUP being an independent predictor of treatment outcome, particularly remission of positive symptoms, over the first year or so of treatment. Findings regarding the possible neurotoxic effects of DUP are inconsistent.

Conclusions

There continues to be evidence consistent with DUP influencing aspects of treatment outcome. Non-correlational studies, such as quasi-experimental designs, could provide stronger evidence regarding causality.

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

Background

Studies have consistently found that many individuals with first-episode psychosis experience significant delays before receiving treatment. Current research investigating treatment delays has focused on the relationship between demographic factors and duration of untreated psychosis (DUP). However, treatment-seeking behaviours in this group have not been investigated.

Aims

To examine psychological processes that influence the decision-making process to contact primary care, in individuals with emerging psychosis.

Method

The influence of coping style, health locus of control and past health help-seeking behaviour on DUP was investigated in clients with a first episode of psychosis. This involved scrutiny of general practitioner (GP) records in an average of 6 years before the first treatment.

Results

Shorter DUP was associated with more frequent GP attendance in the 6 years before the onset of psychosis and lower health threat avoidant coping scores.

Conclusions

Patients with short DUP have a history of higher contact with their GP and, as a group, tend not to avoid health threats. The study underlines the importance of engaging young people and their families with primary care as one of a series of strategies to reduce DUP.

Geographical accessibility and duration of untreated psychosis: distance as a determinant of treatment delay

BACKGROUND

The duration of untreated psychosis is determined by both patient and service related factors. Few studies have considered the geographical accessibility of services in relation to treatment delay in early psychosis. To address this, we investigated whether treatment delay is co-determined by straight-line distance to hospital based specialist services in a mainly rural mental health context.

METHODS

A naturalistic cross-sectional study was conducted among a sample of recent onset psychosis patients in northern Norway (n = 62). Data on patient and service related determinants were analysed.

RESULTS

Half of the cohort had a treatment delay longer than 4.5 months. In a binary logistic regression model, straight-line distance was found to make an independent contribution to delay in which we controlled for other known risk factors.

CONCLUSIONS

The determinants of treatment delay are complex. This study adds to previous studies on treatment delay by showing that the spatial location of services also makes an independent contribution. In addition, it may be that insidious onset is a more important factor in treatment delay in remote areas, as the logistical implications of specialist referral are much greater than for urban dwellers. The threshold for making a diagnosis in a remote location may therefore be higher. Strategies to reduce the duration of untreated psychosis in rural areas would benefit from improving appropriate referral by crisis services, and the detection of insidious onset of psychosis in community based specialist services.

Does ethnicity have an impact on duration of untreated psychoses: A retrospective study in Singapore

BACKGROUND

Some studies have suggested ethnicity as being one of the causes leading to a longer duration of untreated psychosis (DUP) in first episode psychosis.

AIM

We sought to investigate this issue, in a large cohort of patients with a first episode of psychosis, in Singapore.

METHOD

In this naturalistic retrospective study, 794 patients accepted into Early Psychosis Intervention Programme (EPIP) services in Singapore were recruited. Diagnosis was made based on SCID 1 (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Axis I Disorders). Information about DUP and sociodemographic characteristics was collected from patients and relatives. Positive and Negative Symptom Scale (PANSS) and Global Assessment of Functioning (GAF) Scale were used as tools to assess the severity of symptoms and functioning of the patient, respectively, at baseline, 3, 6, 12 and 24  months.

RESULTS

The mean and 50th quantile (median) of DUP for this sample were 14.2 and 6, respectively. The mean and median DUP were higher among Indians than in the other ethnic groups. After adjusting for demographic variables, Indian ethnicity was significantly associated with higher median and 75th Percentile DUP than Chinese. Secondary and tertiary education and diagnosis of affective psychosis and brief psychotic disorder (vs. schizophrenia spectrum and delusional disorder) were also significantly associated with lower mean, median and 75th percentile DUP symptoms. Increase in age was significantly associated with higher mean, median and 75th percentile DUP while married and separated/divorced (vs. single) was significantly associated with lower mean and 75th percentile DUP.

CONCLUSION

This study found a positive correlation between certain ethnic groups and DUP. Indian ethnicity, older age, single, lower education and patients diagnosed with schizophrenia spectrum and delusional disorders were more likely to be associated with longer DUP.

The impact of caregiver familiarity with mental disorders on timing of intervention in first-episode psychosis

AIM

Based on prior research, we hypothesized that personal or family familiarity with psychosis would have a different effect on pathways to care as compared to personal or family familiarity with mental disorders.

METHODS

Caregivers of 32 patients receiving treatment for a first episode of psychosis at a specialized early intervention centre provided information regarding their familiarity with psychosis and mental disorders. Information on the duration of untreated psychosis (DUP) and on the duration of untreated illness (DUI) was collected from patients and their caregivers.

RESULTS

Although we found a trend in the direction of lowered DUP and longer DUI for those with personal or family familiarity with psychosis, these effects were not statistically significant. A trend was found for a higher DUI for those with personal or family familiarity with mental disorders in general, but this effect was not significant.

CONCLUSION

We did not find that differential familiarity with mental disorders and by extension, personal or family familiarity, affected measures of delay in treatment of a first episode of psychosis. Trends in our findings in the hypothesized directions suggest that a larger sample size may reveal significant differential effects of previous experience with mental disorders in general and psychosis in particular on delay in help seeking during different phases of the illness.

The role of untreated psychosis in neurodegeneration: a review of hypothesized mechanisms of neurotoxicity in first-episode psychosis

For over 20 years, studies have tried to measure the association between the duration of untreated psychosis (DUP) and changes in brain morphology. A hypothesis that untreated psychosis is neurotoxic has been postulated, but the mechanisms of that toxicity have not been described. We re-analyzed papers collected for a systematic review to extract data on the hypotheses that have been generated on the potential mechanisms by which DUP could impact brain morphology in first-episode psychosis. Dopaminergic hyperactivity, prolonged hypothalamic-pituitary-adrenal activation, and persistent activity of catecholamines have been hypothesized as mechanisms to explain these associations. However, the question remains as to whether the observed structural changes are permanent or may be reversed via antipsychotic treatment.

Factors contributing to the duration of untreated psychosis

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Outcome studies in schizophrenia

Objectives:To outline the limitations of traditional studies of outcome in schizophrenia and to review the findings arising from ‘first episode’ psychosis studies.

Method:An extensive literature search was performed and relevant papers were examined and analysed.

Results:Current knowledge regarding outcome predictors in schizophrenia has primarily been derived from a series of ‘consecutive admission’ and ‘long-term follow-back’ studies. However, methodological considerations may limit the generalisability of these studies' findings. The prospective evaluation of first episode cohorts has advanced our knowledge regarding the relative importance of premorbid and intercurrent factors in determining outcome in schizophrenia.

Conclusions:To date, the ‘first episode’ strategy has highlighted some potentially clinically modifiable outcome predictors. These findings may open the way for targeted introduction of measures aimed at preventing poor outcomes in schizophrenia.

Rates of first episode of psychosis in a defined catchment area in Greece

This is the first Greek study presenting epidemiologic data on first-episode psychosis (FEP) patients in a defined catchment area. Data for first episode psychotic patients during a two-year period (2008 and 2009) were obtained by all the mental health providers in the area, public or private. A total of 132 FEP patients were examined in the 2-year period in the catchment area. Most of the patients (61.4%) were diagnosed and treated by private practicing psychiatrists. Statistical analysis showed no differences between the two sectors in terms of patients’ age, gender, family and social status, profession and duration of untreated psychosis (median duration 6 months). Patients who were abusing substances and had no family psychiatric history were less likely been treated in the public sector. Immigrants comprised only a small proportion of the patients, probably because they have difficulties in accessing the mental health system.

Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy

PURPOSE

This study set out to investigate the patterns of referral in a sample (n = 206) of patients having first-time access to an Italian comprehensive program that targets the early detection of and early intervention on subjects at the onset of psychosis. The primary goal of the study was to investigate the duration of untreated illness (DUI) and/or the duration of untreated psychosis (DUP) in the sample since the implementation of the program.

METHOD

Data on pathways of referrals prospectively collected over a 11-year period, from 1999 to 2010; data referred to patients from a defined catchment area, and who met ICD-10 criteria for a first episode of a psychotic disorder (FEP) or were classified to be at ultra-high risk of psychosis (UHR) according to the criteria developed by the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne. Changes over time in the DUI and DUP were investigated in the sample.

RESULTS

Referrals increased over time, with 20 subjects enrolled per year in the latter years of the study. A large majority of patients contacted a public or private mental health care professional along their pathway to treatment, occurring more often in FEP than in UHR patients. FEP patients who had contact with a non-psychiatric health care professional had a longer DUP. Over time, DUP and DUI did not change in FEP patients, but DUI increased, on average, in UHR patients.

CONCLUSIONS

The establishment of an EIP in a large metropolitan area led to an increase of referrals from people and agencies that are not directly involved in the mental health care system; over time, there was an increase in the number of patients with longer DUI and DUP than those who normally apply for psychiatric services.

Onset Pattern and Long-Term Prognosis in Schizophrenia: 10-Year Longitudinal Follow-Up Study

BACKGROUND

Although the duration of untreated psychosis (DUP) plays an important role in the short-term prognosis of patients with schizophrenia, their long-term prognosis generally is not determined by DUP alone. It is important to explore how other clinical factors in the early stage are related to DUP and consequent disease courses.

METHODS

A total of 664 patients with untreated psychosis were surveyed for this study. At the first examination, we divided them into the severe positive symptoms cases (SC) or the less severe cases (NonSC) and compared the prognosis among the two groups after a 10-year follow-up. In all, 113 patients in the SC group and 43 patients in the NonSC group were follow-up completers.

RESULTS

Whereas DUP was not different between the two groups, patients with nonacute onset in both groups had significantly longer DUP than those in patients with acute onset. For all clinical measures, there was no difference in prognosis between the two groups or among the four groups classified by mode of onset (MoO) and initial severity of positive symptoms. However, the degree of improvement of global assessment of functioning (GAF) was significantly smaller in the NonSC-nonacute group than in the SC-acute and SC-nonacute groups.

CONCLUSIONS

These results suggest that neither DUP nor MoO alone necessarily affects the initial severity of positive symptoms. Moreover, it is possible that patients with low impetus of positive symptoms onset within long DUP experience profound pathologic processes. Therefore, the current study results indicated that long DUP and nonacute onset were related to poor long-term prognosis, regardless of initial positive symptoms.

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

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

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

AIM

Duration of untreated psychosis (DUP) can influence the prognosis of schizophrenia. Previous studies have suggested that gender may influence the length of DUP. This study reports the result of the first systematic literature review and meta-analysis on the role of gender in influencing DUP in first-episode psychosis.

METHOD

Systematic literature search in PubMed/Medline and Ovid/PsychINFO. Twenty-seven studies presenting data on 4721 patients diagnosed with psychosis at their first episode (2834 males and 1887 females) were included in the analysis.

RESULTS

Samples had a higher proportion of males: odds ratio = 2.5 (95% confidence interval: 1.8-3.3). Mean age at first contact was 25.4 for males and 27.5 for females. Patients from non-Western countries were older at first contact than patients from Western countries. Average DUP in schizophrenia was 64 weeks and did not differ between genders but was shorter in Western compared with non-Western countries.

CONCLUSION

Earlier age at first contact and larger incidence in males support the existence of specific gender differences in first-episode psychosis; however, these are not associated with DUP length.

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.

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.

Family-level predictors and correlates of the duration of untreated psychosis in African American first-episode patients

BACKGROUND

Little is known about how family-level factors are associated with duration of untreated psychosis (DUP), especially in ethnic/racial minority groups, such as African Americans. This study involved African American first-episode patients and their family members who initiated evaluation and treatment for them. It was hypothesized that a longer DUP would be predicted by family members' endorsement of: (1) less knowledge about schizophrenia, (2) greater perceptions of stigma, (3) lower levels of insight, (4) fewer family strengths, (5) more limited family coping capacity, and (6) lower levels of caregiver strain.

METHODS

From a sample of 109 patients, 42 African American patients with family-level data were included. Cox proportional hazard models quantified associations between family-level predictors and DUP, and analyses controlled for effects of three previously determined patient-level predictors of DUP - mode of onset of psychosis, living with family members versus alone or with others, and living above versus below the federal poverty level.

RESULTS

The median DUP was 24.5 weeks. Greater family strengths and a better family coping capacity were associated with a shorter DUP, whereas higher insight among informants and greater level of perceived caregiver strain were associated with a longer DUP.

CONCLUSIONS

Whereas family strengths and coping likely account for a significant portion of variability in DUP, both insight and caregiver strain probably evolve as a consequence of DUP. Efforts to strengthen families and tap into existing strengths of families in specific cultural groups would likely enhance early treatment-seeking for psychotic disorders.

When should clozapine be initiated in schizophrenia?: Some arguments for and against earlier use of clozapine

Clozapine is one of the original atypical antipsychotics. It was withdrawn from the market in 1974 because of haematological safety concerns, but since 1989 has enjoyed a renaissance for the management of treatment-resistant schizophrenia under systems where case registration allows regular haematological monitoring. Clozapine continues to show enduring superiority across many aspects of the clinical pharmacology of the treatment of schizophrenia, e.g. it has specific anti-suicidal properties and recent broader trials have shown continuing superiority in wide groups of patients. This article considers some of the arguments for unshackling clozapine from its current license for schizophrenia (its superiority overall in treatment-resistant schizophrenia, its potential for use in first-episode patients, and its anti-suicidal potential), and tries to synthesise these into some of the national guidelines available for the treatment of schizophrenia.

Delay in treatment for psychosis : its relation to family history

BACKGROUND

Recent evidence that treatment delay may compromise the potential for recovery from psychotic disorders has resulted in increased interest in factors that influence help seeking. In this paper, we test the hypotheses, derived from past research, that having a positive family history of a psychotic disorder in first or second degree relatives will be associated with a shorter duration of untreated psychosis (DUP), but a longer duration of untreated illness (DUI). Data were derived from 169 patients who presented for treatment to a first episode psychotic disorders program. Information was collected concerning family history, DUP, DUI and the timing of family recognition of the need for help.

RESULTS

The findings failed to confirm a positive family history being associated with shorter DUP, but did support the prediction of such a history being related to longer DUI. Paradoxically, given the latter findings, families with a history of psychotic illness were more likely to recognize the need for help for the ill person prior to the onset of psychotic symptoms. The difference in DUI appears to reflect the presence of a longer period of early signs prior to the emergence of psychosis in those cases with a positive family history.

CONCLUSIONS

These findings suggest the importance of examining family history as a possible confound of any relationship between DUI and long-term course of illness.

Gray matter abnormalities associated with duration of untreated psychosis

PURPOSE

A long duration of untreated psychosis (DUP) is associated with relatively poor clinical and social outcomes. In order to identify whether an anatomically mediated mechanism may give rise to poorer outcomes, it is important to identify whether a long DUP is associated with greater brain structural abnormalities.

METHOD

81 patients with first-episode psychosis (schizophrenia, affective, and other psychoses) were scanned using high resolution Magnetic Resonance Imaging. DUP was defined as the number of days between first onset of psychotic symptoms and first contact with mental health services. High-resolution MRI images and voxel-based methods of image analysis were used to investigate brain structure in these patients.

RESULTS

Longer DUP was associated with gray matter reductions in left middle and inferior temporal, left occipital and left fusiform cortices, and with gray matter excess of the left basal ganglia. All findings remained significant when co-varying for exposure to antipsychotic treatment.

CONCLUSIONS

Temporal gray matter reductions are more marked in patients with a long DUP. This could reflect a progressive pathological process that is active prior to treatment. Alternatively, these abnormalities could be associated with a more insidious onset of illness and a later presentation to services.

Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study

OBJECTIVE

To explore the pattern of health service utilization over 2 years following a first admission for psychosis and the baseline characteristics predicting readmission.

METHOD

Patients included in a cohort of first-admitted subjects with psychosis (n = 84) were assessed at the end of a 2-year follow-up using multiple sources of information.

RESULTS

At the end of the follow-up, one of three subjects had no contact with any mental health professional, and 38% of subjects had no contact with a psychiatrist. Half of the patients were readmitted over the 2-year follow-up. The baseline characteristics independently predicting psychiatric readmission were a high number of helping contacts before first admission and persistence of psychotic symptoms at discharge.

CONCLUSION

Decreasing the frequency of readmission in the early course of psychosis is a public health priority. Development of psychotherapeutic programs for subjects with early psychosis who have enduring psychotic symptoms at first discharge should be promoted.

Clinical and Social Correlates of Duration of Untreated Psychosis in First-episode Psychosis Patients

Introduction: This study aims to examine the socio-demographic and clinical correlates of the duration of untreated psychosis (DUP) in first-episode psychosis patients in an Asian country. Materials and Methods: Three hundred thirty-four patients from the Early Psychosis Intervention Programme (EPIP) of Singapore were recruited for the study. Socio-demographic data were collected and patients were diagnosed using SCID I (Structural Clinical Interview for DSM-IV Axis I Disorders). Other assessment scales were used to assess the level of psychopathology, overall functioning and the awareness of mental illness. Results: Mean (SD) DUP was 16.3 (31.5) months. Patients who were single, unemployed, or brought by the police had a significantly longer DUP. Patients with a diagnosis of schizophrenia had a longer DUP as compared to patients with other forms of psychosis. The better functioning patients as indicated by a higher Global Assessment of Functioning score and those who were more insightful had a shorter DUP. Conclusions: This study suggests that certain socio-demographic features and clinical diagnosis may determine DUP. Key words: Psychotic disorder, Schizophrenia

Toward a world consensus on prevention of schizophrenia

Screening for preschizophrenia in the general population with the aim of preventing transition to full-blown illness is an epidemiological impossibility because a rare disease cannot be predicted. The lack of specificity resulting in abundance of false-positives can be remedied in part by using much more restrictive screening criteria that combine several indicators of risk for transition to schizophrenia. Raising the specificity (reducing the false-positives), however, can only be done at the expense of sensitivity (increasing the false-negatives). The most commonly used strategy to raise specificity is the sample enrichment strategy. This involves the creation of samples enriched with schizophrenia risk by selectively filtering at-risk people out over a range of consecutive referral processes starting in the general population, through to general practioners, mental health services, and the early detection clinic. However, improvements in specificity obtained by the sample enrichment strategy should not be attributed to the use of some predictive instrument that supposedly identifies high-risk individuals. The epidemiologically and ethically most viable way for screening and early detection is to selectively increase the permeability of the filters on the pathway to mental health care. This will occasion samples of help-seekers enriched with schizophrenia risk at the level of mental health services (thus reducing false-positives), while at the same time making an attempt to "attract" as many detectable schizophrenia prodromes as possible through the filters along the pathway to mental health care (thus reducing false-negatives). Early psychosis research has yielded some useful suggestions in that it is becoming increasingly clear that it is not just psychosis itself, but rather the clinical context of the psychotic experience that determines risk for transition to schizophrenia. Thus, risk for transition to full-blown psychotic disorder is to a large degree determined by size of psychosis "load," comorbid distress and depression, cannabis use, cognitive ability, and subjective reports of impairment and coping. Making a diagnosis of psychotic disorder is not an exact science: it involves an arbitrary cutoff imposed on dimensional variation of psychopathology and need for care over time. Gaining insight into the cognitive and biological factors that drive the dimensional variation, including therapeutic interventions, is arguably more useful than sterile dichotomous prediction models.

[Wiscosin card sorting task in patients with schizophrenia and thier siblings]

OBJECTIVE

This study's first objective was to confirm that patients with schizophrenia and their nonmentally ill siblings share the same impaired executive function when compared to healthy control subjects. The second objective was to study the relation between Wisconsin card sorting task (WCST) performance and the persistence and severity of clinical symptoms, as well as different clinical dimensions.

METHOD

Ninety subjects were involved in this study, divided in 3 groups of 30 each: one group of patients with schizophrenia, one group of their siblings, and a control group. Symptom severity was assessed with the Positive and Negative Syndrome Scale (PANSS), and social functioning was measured by the Global functioning scale (GFS). The WCST was administered to all 3 groups.

RESULTS

Patients with schizophrenia and their siblings had a significantly lower WCST performance than control subjects. Statistical analysis showed that the patient group had a significantly greater impaired WCST performance than the 2 other groups. Siblings also had a significantly lower performance than the control subjects. Furthermore, no significant relation was found between WCST performance and other variables, including age, gender, education, illness duration, treatment, and different PANSS and GFS scores.

CONCLUSION

Patients with schizophrenia and their nonmentally ill siblings share the same impaired executive function. These findings suggest that WCST performance can be considered a schizophrenia vulnerability marker in siblings of patients with schizophrenia.

Impact of substance use on the onset and course of early psychosis

The strong comorbidity between psychosis and substance use is already identifiable in early psychosis, raising the question of the direction of the association between substance use and psychosis onset. It has long been considered that this association was explained by the self-medication hypothesis. This hypothesis has been recently challenged by several prospective studies carried out in population-based samples, showing a dose-response relationship between cannabis exposure and risk of psychosis. This association was independent from potential confounding factors such as exposure to other drugs and pre-existence of psychotic symptoms. As a large percentage of subjects from the general population is now exposed to this drug, even a small increase in the risk of adverse effects may have significant deleterious consequences for the health of the population. Hence, reducing exposure to cannabis may contribute to prevention of some incident cases of psychosis. Regarding prognosis, persistent substance misuse after the onset of psychosis has a deleterious impact on clinical outcome. Therapeutic programs for subjects with dual diagnosis should be implemented early in the course of psychosis to maximise their impact on the course of illness.

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.

Do different psychotic experiences differentially predict need for care in the general population?

INTRODUCTION

The pathway from subclinical psychotic experiences to need for care may depend on type of psychotic experience, level of associated distress, and previous experience of psychosis.

METHOD

In a general population sample with no previous Diagnostic and Statistical Manual of Mental Disorders , Revised Third Edition , psychotic disorder (n = 4722), 83 subjects displayed at least one psychotic experience. Within the group of 83, subjects with (n = 24) and without need for care (n = 59) were compared. Presence of psychotic experiences at younger ages had been assessed at earlier interviews.

RESULTS

Of 7 different psychotic experiences, only hearing voices, nonverbal hallucinations, and passivity phenomena were significantly associated with need for care. These associations were largely explained by the distress associated with the psychotic experience, but whether individuals had had psychotic experiences at earlier ages did not matter.

CONCLUSIONS

Different psychotic experiences differ in the associated level of need for care and the mediating role of distress. Longer prior exposure to psychosis may not influence the pathway from subclinical to clinical.

Schizophrenia and deliberate self-harm: a systematic review of risk factors

Deliberate self-harm (DSH) is a strong predictor of suicide in schizophrenia. The aim of this review was to identify risk factors for DSH in schizophrenia. This systematic review of the international literature examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Studies were identified by searching electronic databases and reference lists, and by consulting international experts. Fourteen studies met the eligibility criteria. Of the 29 variables examined by two or more studies, five (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, and one (unemployment) was associated with a reduced risk. Schizophrenic patients with these risk factors need careful follow-up and monitoring, with treatment of any associated comorbid depression or drug abuse. Large, prospective studies of DSH in schizophrenia are needed to further define risk factors and to build on the findings of this review.

Factors influencing compulsory admission in first-admitted subjects with psychosis

BACKGROUND

There is a growing body of evidence that patients with early psychosis have undesirable pathways to care, yet few studies have explored the factors related to compulsory admission in patients with psychosis. The aim of the present study was to examine the demographic and clinical factors and pathways to care influencing compulsory admission in first-admitted subjects with psychosis.

METHODS

Pathways to care, clinical and demographic characteristics, were assessed using multiple sources of information in 86 subjects with psychosis first admitted in two hospitals of South-Western France. Characteristics independently associated with compulsory admission were explored using logistic regressions.

RESULTS

Nearly two-thirds of the subjects (61.6%) were compulsorily admitted. Compulsory admission was independently predicted by being a male (adjusted OR = 3.2, 95 % CI 1.2-8.6, p = 0.02), having a diagnosis of schizophrenia broadly defined (adjusted OR = 2.8, 95 % CI 1.02-7.4, p = 0.04) and absence of depressive or anxiety symptoms (adjusted OR = 0.05, 95% CI 0.005-0.5, p=0.01).

CONCLUSION

These results suggest that factors related to the disease itself play an important role in decisions concerning compulsory admission. The high frequency of compulsory admission as the first mode of contact with psychiatric hospital in subjects with psychosis constitutes a major public health issue. Further research on the strategies aimed at avoiding compulsory admission in subjects with incipient psychosis is necessary.

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.

Substance use and the course of early psychosis: a 2-year follow-up of first-admitted subjects

OBJECTIVE

To examine the impact of alcohol and substance use on the early course of psychosis.

METHODS

First-admitted subjects with psychosis (n = 58) were assessed at 6-month intervals over a 2-year follow-up. Information on substance and alcohol misuse and clinical and social outcome was collected using multiple sources of information.

RESULTS

After adjustment for potential confounding factors, subjects with persistent substance misuse over the follow-up were at increased risk of readmission (OR = 3.1; 95%CI = 1.0-9.4; P = 0.05), of presenting with psychotic symptoms (OR = 4.3; 95%CI = 1.0-18.1; P = 0.04), and with a non-continuous course of illness (OR = 11; 95%CI = 1-122; P = 0.05). No significant association was found between substance misuse and social outcome, or between alcohol misuse and clinical and social outcome.

CONCLUSION

Persistent substance misuse after a first admission for psychosis has a deleterious impact on clinical outcome. Early identification and treatment of substance use is essential in the care of subjects with incipient psychosis.

Pathways to care: help seeking behaviour in first episode psychosis

OBJECTIVE

To determine the number of attempts it took before patients with a first episode of psychosis received adequate help, the signs or symptoms that led them to seek help and the people from whom they attempted to seek help.

METHOD

Subjects were 86 individuals with a schizophrenia spectrum disorder, mainly schizophrenia, who were attending a comprehensive program for early psychosis treatment.

RESULTS

Help-seeking attempts began in the prodromal phase of the illness and continued into the psychotic phase. Concerning behaviours ranged from more general symptoms to psychotic symptoms. A range of contacts were made early on but emergency services were most often the contact that helped individuals obtain appropriate treatment for psychosis.

CONCLUSION

Improved public education and gatekeeper education might reduce the time required for individuals developing a psychosis to receive timely and adequate care.

Social and clinical consequences of cognitive deficits in early psychosis: a two-year follow-up study of first-admitted patients

OBJECTIVE

To explore whether baseline memory and executive deficits predicted poor social and clinical outcome over the 2 years following a first admission for psychosis, regardless of categorical diagnosis.

METHOD

Cognitive functioning was assessed in first-admitted subjects with psychosis (n=35) with a neuropsychological battery of tests measuring executive, language and memory functions. Social and clinical outcome were assessed at 6-monthly intervals over a two-year follow-up using multiple sources of information.

RESULTS

A dose-response relationship was found between visual and verbal memory performance at first admission and clinical outcome over the 2-year follow-up: the poorer the memory performance, the more likely the risk of presenting with psychotic symptoms and rehospitalization. Poor baseline performance on the WCST executive function predicted better medication adherence. No association was found between cognitive performance and occupational or residential outcome.

CONCLUSION

Cognitive performance was a better predictor of clinical than social outcome in this sample of first-episode patients. The association between cognitive deficits and poor social outcome may be more marked in subjects with chronic psychosis than in first-episode subjects. The finding that cognitive deficits predict better medication adherence is in need of further exploration.

Ethics and early intervention in psychosis: keeping up the pace and staying in step

The intense clinical and research interest in early psychosis in recent years has highlighted a range of ethical issues which need to be considered carefully. Our perspective is based on 16 years of clinical and research experience with young people at this phase of illness as well as the research contributions of many others. We discuss the ethical dilemmas in relation to the three key foci, which make up the early psychosis paradigm. These are the pre-psychotic or prodromal phase, the period of untreated psychosis and the first psychotic episode and the critical period of recovery, which follows this. Most attention is devoted to the pre-psychotic period, however ethical considerations related to research in the other two clinical foci are briefly covered as well. Our contention is that the ethical issues are essentially identical to those arising in early intervention research in mainstream medicine. This has been concealed by inconsistency and emotion, which has great potential to confuse, politicize and derail rational debate. The legacy of the isolation of psychiatry from medicine and consequent prejudice and stigma in the professional as well as the public mind seems to be fueling a tendency in some societies to view psychiatric research as qualitatively different from other medical research. Sound clinical research data should be allowed to illuminate the options for potential consumers across all phases of illness. The alternative is research paralysis, which would force clinical practice to expand blindly without an evidence base.

Predictors and outcome characteristics associated with suicidal behaviour in early psychosis: a two-year follow-up of first-admitted subjects

OBJECTIVE

To assess the baseline characteristics associated with a greater risk of suicidal behaviour (suicide and parasuicide) over the 2 years following a first admission for psychosis, and the associations between suicidality and outcome.

METHOD

First-admitted subjects with psychosis (n=65) were assessed at 6-monthly intervals over a 2-year follow-up period.

RESULTS

Over this period, 11.3% of the patients displayed suicidal behaviour. Baseline predictors of suicidal behaviour were a lifetime history of parasuicide before first admission (OR=5.9, 95% CI 1.5-23.4), lower Positive And Negative Symptom Scale positive subscores (OR=0.8, 95% CI 0.6-0.97) and a longer duration of first admission (OR=1.1, 95% CI 1-1.2). Subjects with suicidal behaviour presented with a longer duration of psychotic symptoms (OR=1.1, 95% CI 1.02-1.2) and a greater risk of being readmitted (OR=4.6, 95%CI 1.1-19.1). Subjects with substance misuse over the follow-up period were seven times (95%CI 1.3-39) more likely to engage in suicidal behaviour.

CONCLUSION

Subjects with a previous history of parasuicide, with a deteriorating clinical course, or with substance misuse are at increased risk of suicidal behaviour in the 2 years after the onset of a first psychotic episode.

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

OBJECTIVE

To review the literature on early intervention in psychosis and to evaluate relevant studies.

METHOD

Early intervention was defined as intervention in the prodromal phase (primary prevention) and intervention after the onset of psychosis, i.e. shortening of duration of untreated psychosis (DUP) (secondary prevention).

RESULTS

We found few studies aimed at early intervention, but many papers discussing the idea at a more general level. We identified no studies that prove that intervention in the prodromal phase is possible without a high risk for treating false positives. We identified some studies aimed at reducing DUP, but the results are ambiguous and, until now, no follow-up data showing a positive effect on prognosis have been presented.

CONCLUSION

Early intervention in psychosis is a difficult and important challenge for the psychiatric health services. At the time being reduction of DUP seems to be the most promising strategy. Intervention in the prodromal phase is more ethically and conceptually problematic.

Is the association between duration of untreated psychosis and outcome confounded? A two year follow-up study of first-admitted patients

OBJECTIVE

To assess whether a long duration of untreated psychosis (DUP) before first admission predicts poor clinical and social outcome, and whether this association, if any, is confounded by premorbid and clinical characteristics.

METHOD

A population-based sample of first-admitted subjects with psychosis (n = 65) was assessed at six monthly intervals over a two year follow-up using multiple sources of information.

RESULTS

Most subjects (87%) with a life-chart 'continuous' course of psychotic symptoms had a history of a 'long' delay between onset of psychotic symptoms and first admission (> or = 3 months, median split), compared with 55% of subjects with a course of 'neither episodic nor continuous', 42% of subjects with an 'episodic' course, and 33% of subjects with 'no psychotic symptoms' during the follow-up period (RR = 9; 95%CI 1.5-54.8, P = 0.02). The strength of association between DUP and continuous course of psychosis was strongly reduced (63%) after adjustment for premorbid functioning, and to a lesser extent for the severity of illness and for the intensity of negative symptoms at first admission.

CONCLUSIONS

The association between DUP and poor outcome may be spurious, confounded by the fact that poor premorbid functioning is independently associated with both DUP and poor outcome, with no direct causal link between these two latter variables. DUP may also be on the causal pathway between poor premorbid functioning and poor outcome, poor adjustment delaying access to care, and subsequently increasing the risk of presenting with a non-remitting course of illness. The links between premorbid functioning, DUP and outcome have to be further explored to clarify the directions of the associations between these variables.

The nature of schizophrenia: signposts to prevention

OBJECTIVE

To describe the characteristics of schizophrenia relevant to conducting indicated preventive interventions.

METHOD

A systematic review of the literature informed by experiences at the Personal Assistance and Crisis Evaluation (PACE) clinic.

RESULTS

Primary prevention requires a sophisticated knowledge of key causal risk factors relevant to the expression of a disorder. The causal risk factors most useful from an intervention standpoint may turn out to be somewhat removed from the neurobiology of the disorder and may even be relatively non-specific, so that tackling them could reduce the risks for a range of mental disorders. The frontier for more specific prevention in schizophrenia and related psychosis is currently represented by indicated preventive interventions for subthreshold symptoms. Again, these may be relatively broad spectrum early in the prepsychotic phase but more proximal to onset, greater treatment specificity can be explored. However, this can be viewed more as preventively orientated treatment rather than primary prevention per se. Early detection of first episode psychosis and optimal intensive treatment of first episodes and the critical early years after diagnosis also represent increasingly attractive preventive foci in psychotic disorders.

CONCLUSION

As evidence accumulates, implementation of evidence-based practice in real work settings is a major challenge as it is throughout the mental health service system. The momentum of preventively orientated treatment must be maintained through the 2nd National Mental Health Strategy and in the face of recent misleading polemic regarding the treatability of psychotic disorders, especially schizophrenia. The evidence demonstrates that schizophrenia and related disorders have never been more treatable.

West London first-episode study of schizophrenia. Clinical correlates of duration of untreated psychosis

BACKGROUND

Studies in schizophrenia suggest that a longer initial period of untreated illness is associated with a poorer clinical outcome.

AIMS

To determine whether, in first-episode schizophrenia, a longer duration of untreated psychosis (DUP) or of untreated illness (DUI) (DUP plus any prodrome) is associated with clinical variables that could mediate a poor prognosis.

METHOD

Clinical, social, neuropsychological and oculomotor function data on 53 patients with first-episode schizophrenia were related to the DUP and DUI.

RESULTS

Comparing short and long DUP groups split around the median showed no statistically significant differences (except age); patients in the latter group tended to perform worse on an executive attentional set-shifting task, and were more likely to be unemployed, and living alone or homeless.

CONCLUSIONS

There was little evidence of any association between either DUP or DUI and progressive deterioration in the schizophrenic illness or the development of resistance to initial drug treatment. Social variables that augur a poor prognosis may be associated with delayed presentation of schizophrenia to psychiatric services.

Neuropsychological function in subjects with psychotic and affective disorders. Relationship to diagnostic category and duration of illness

OBJECTIVE

To explore the links between neuropsychological performance, diagnostic category and duration of illness in subjects with psychotic and affective disorders.

METHODS

Memory and executive abilities were tested in consecutively admitted patients with schizophrenia (N = 20), other non-schizophrenic psychotic disorders (N = 29), bipolar disorder (N = 33) and major depression (N = 19).

RESULTS

Subjects with schizophrenia had poorer global memory performances than subjects with major depression, and poorer delayed verbal memory abilities than those from the other three diagnostic groups. Executive abilities explored by the Stroop test and the Wisconsin Card Sorting Test did not differ between diagnostic groups. Neuropsychological performances were not influenced by previous duration of illness.

CONCLUSION

Memory deficits are the most discriminatory cognitive features between subjects with schizophrenia and those with other psychotic or mood disorders. The fact that cognitive deficits are static whatever the diagnostic group indirectly suggests that they may have a neurodevelopmental origin in subjects with schizophrenia, but perhaps also in subjects with other psychotic and mood disorders.

Suicidality and substance misuse in first-admitted subjects with psychotic disorder

OBJECTIVE

The aim of this study was to examine the links between suicidality and substance misuse (abuse or dependence) in subjects with early psychosis.

METHOD

Data were collected on a sample of first-admitted subjects with psychosis (n=64).

RESULTS

More than 1 in 4 patients had a history of parasuicide, and more than 1 in 10 patients were referred to the psychiatric hospital after such an act. Parasuicide was more frequent in subjects with a history of drug misuse (OR=4, 95% CI= 1.1-14.0, P=0.03), and especially of polysubstance use (OR=6.6, 95% CI=1.2-34.7, P=0.03).

CONCLUSION

The association between substance misuse and suicidality found in subjects with psychosis is similar to that which exists in the general population. Since early psychosis is a high-risk period for substance misuse, subjects with incipient psychosis may be especially vulnerable to the devastating consequences of drug use with regard to increased risk of suicide.

Duration of untreated psychosis and 12-month outcome in first-episode psychosis: the impact of treatment approach

OBJECTIVE

Early intervention research is examining whether reducing the duration of untreated psychosis (DUP) leads to improved outcome from first-episode psychosis. Another key influence may be the quality of treatment after initiation of care. This study examined the effect of phase-specific treatment on 12-month outcome for different categories of DUP.

METHOD

A total of 250 first-episode psychosis cases were followed up 12 months after stabilization. The sample consisted of two historically sequential cohorts treated in the same region within different service models, one of which was more intensive and phase-specific. Outcome was compared according to four predefined categories of DUP.

RESULTS

Only patients with a mid-range DUP of 1-6 months who were treated within the phase-specific model experienced significantly better outcomes than patients treated within the previous model.

CONCLUSION

These data suggest that there may be a limited window of opportunity in which to influence outcome. However, the complexity of this relationship is emphasized.