Duration of untreated psychosis and duration of untreated illness: new vistas

The Impact of Prolonged Duration of Untreated Illness on Clinical Correlates in Chronic Schizophrenia: Exploring the Relationship With Suicide Risk

OBJECTIVE

Studies on duration of untreated psychosis are common in patients with schizophrenia, but few studies have investigated the relationship between duration of untreated illness (DUI) and suicide, especially in patients with chronic schizophrenia. Therefore, we intended to investigate the relationship between DUI and suicide and clinical correlates in patients with chronic schizophrenia.

METHODS

A total of 1,555 Chinese patients with chronic schizophrenia were enrolled in this study. DUI was measured in years, reflecting the prolonged untreated periods observed in this population. Clinical correlates were assessed, including symptoms, cognitive functioning, and body mass index. Suicidal ideation and attempts were also examined. Statistical analyses, including multivariate models, were employed to investigate the associations between DUI and clinical correlates while controlling for potential confounders.

RESULTS

The study revealed a significant proportion (23.3%) of patients with chronic schizophrenia in China received their first treatment after a 4-year delay, with the longest untreated duration reaching 39 years. Patients with longer DUI exhibited more severe negative symptoms, lower immediate memory scores, a higher likelihood of being overweight, and surprisingly, a reduced likelihood of suicidal ideation and attempts. Each additional year of untreated illness was associated with a 3% decrease in the risk of suicidal ideation and attempts.

CONCLUSION

The findings underscore the prevalence of extended untreated periods in Chinese patients with chronic schizophrenia and highlight the impact of DUI on negative symptoms, cognitive function, and body weight. Intriguingly, a longer DUI was associated with a lower risk of suicidal ideation and attempts.

An ecological momentary assessment study of age effects on perceptive and non-perceptive clinical high-risk symptoms of psychosis

Among individuals with clinical high risk for psychosis (CHR), perceptive symptoms are more frequent but have less clinical significance in children/adolescents compared to adults. However, findings are based on clinical interviews relying on patient's recall capacity. Ecological momentary assessment (EMA) can be used to explore experiences in real-time in the subject's daily life. The aim of this study was to assess frequency and stability of (perceptive and non-perceptive) CHR symptoms and to explore potential age effects. EMA was used in a sample of an early detection for psychosis service in Bern, Switzerland (N = 66; 11-36 years). CHR symptoms were recorded in random time intervals for seven days: eight assessments per day per subject, minimum time between prompts set at 25 min. CHR symptoms were additionally assessed with semi-structured interviews including the 'Structured Interview for Psychosis-Risk Syndromes' and the 'Schizophrenia Proneness Instruments'. Mixed-effects linear regression analysis on the frequency of CHR symptoms revealed a significant effect of age group, and the interaction CHR symptoms x age group for both perceptive and non-perceptive symptoms. Further, regarding stability of CHR symptoms, there was a significant effect of the interaction CHR symptoms x age group for perceptive symptoms only. Based on EMA, perceptive CHR symptoms were more frequently reported but less stable in children/adolescents compared with adults. Together with previous findings, our finding of higher instability/variability of perceptive symptoms in younger persons might suggest that with advancing age and more stability of CHR symptoms, clinical relevance (reduced psychosocial functioning) may increase.

Criteria for detection of possible risk factors for mental health problems in undergraduate university students

Introduction

Developing approaches for early detection of possible risk clusters for mental health problems among undergraduate university students is warranted to reduce the duration of untreated illness (DUI). However, little is known about indicators of need for care by others. Herein, we aimed to clarify the specific value of study engagement and lifestyle habit variables in predicting potentially high-risk cluster of mental health problems among undergraduate university students.

Methods

This cross-sectional study used a web-based demographic questionnaire [the Utrecht Work Engagement Scale for Students (UWES-S-J)] as study engagement scale. Moreover, information regarding life habits such as sleep duration and meal frequency, along with mental health problems such as depression and fatigue were also collected. Students with both mental health problems were classified as high risk. Characteristics of students in the two groups were compared. Univariate logistic regression was performed to identify predictors of membership. Receiver Operating Characteristic (ROC) curve was used to clarify the specific values that differentiated the groups in terms of significant predictors in univariate logistic analysis. Cut-off point was calculated using Youden index. Statistical significance was set at p < 0.05.

Results

A total of 1,644 students were assessed, and 30.1% were classified as high-risk for mental health problems. Significant differences were found between the two groups in terms of sex, age, study engagement, weekday sleep duration, and meal frequency. In the ROC curve, students who had lower study engagement with UWES-S-J score < 37.5 points (sensitivity, 81.5%; specificity, 38.0%), <6 h sleep duration on weekdays (sensitivity, 82.0%; specificity, 24.0%), and < 2.5 times of meals per day (sensitivity, 73.3%; specificity, 35.8%), were more likely to be classified into the high-risk group for mental health problems.

Conclusion

Academic staff should detect students who meet these criteria at the earliest and provide mental health support to reduce DUI among undergraduate university students.

Duration of untreated illness and clinical correlates in first-episode and drug-naïve patients with major depressive disorder

BACKGROUNDS

The notion that a prolonged duration of untreated illness (DUI) leads to poorer outcomes has contributed to extensive changes in mental health services worldwide. However, most studies on DUI have focused on schizophrenia and related psychosis. This study aimed to assess the possible relationship between DUI and certain clinical correlates in first-episode and drug-naïve patients with major depressive disorder (MDD).

METHODS

This cross-sectional study recruited 1718 first-episode and drug-naïve MDD outpatients. All participants were scored on the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale, and thyroid hormone and metabolic parameters were measured. We used the Structure Clinical Interview for DSM-IV for clinical diagnosis and investigated suicide attempts through face-to-face interviews.

RESULTS

A total of 171 (10%) of MDD patients had co-morbid psychiatric symptoms. Participants who were older, with lower education level, and married were less likely to seek a timely treatment compared to the counterparts. One-month longer untreated duration was associated with 2% to 9% higher odds of being with most of the investigated clinical conditions. For those with the longest DUI, the risk was increased for most of the investigated clinical conditions, with absolute risk differences ranging from 5.19% to 29.48%.

CONCLUSIONS

These findings suggest that longer DUI may be negatively associated with clinical correlates in MDD. Further long-term follow-up studies are warranted to confirm these preliminary results.

Latency to selective serotonin reuptake inhibitor vs benzodiazepine treatment in patients with panic disorder: a naturalistic study

BACKGROUND

Panic disorder (PD) is a prevalent and impairing anxiety disorder with previous reports suggesting that the longer the condition remains untreated, the greater the likelihood of nonresponse. However, patients with PD may wait for years before receiving a guideline-recommended pharmacological treatment. The widespread prescription of benzodiazepines (BDZ) for managing anxiety symptoms and disorders might delay the administration of pharmacotherapy according to guidelines (eg, selective serotonin reuptake inhibitors, SSRIs). The present study aimed to determine the mean duration of untreated illness (DUI) in a sample of PD patients, to quantify and compare DUI-SSRI to DUI-BDZ, and to compare findings with those from previous investigations.

METHODS

Three hundred and fourteen patients with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of PD were recruited from an Italian outpatient psychotherapy unit, and epidemiological and clinical variables were retrieved from medical records. Descriptive statistical analyses were undertaken for sociodemographic and clinical variables, Wilcoxon matched-pair signed rank test was applied to compare the distribution of DUI-SSRI vs DUI-BDZ, and Welch's t test was performed to compare findings with those from previous studies.

RESULTS

The mean DUI-SSRI of the total sample was 64.25 ± 112.74 months, while the mean DUI-BDZ was significantly shorter (35.09 ± 78.62 months; P < 0.0001). A significantly longer DUI-SSRI, compared to findings from previous studies, was also observed.

CONCLUSIONS

The present results confirm a substantial delay in implementing adequate pharmacological treatments in patients with PD, and highlight the discrepancy between recommendations from international treatment guidelines and common clinical practice in relation to BDZ prescription.

Which Clinical and Biochemical Parameters Are Associated with Lifetime Suicide Attempts in Bipolar Disorder?

Introduction: Bipolar Disorder (BD) is a disabling condition with suicidal behavior as one of the most common adverse outcomes. The purpose of the present research is to investigate the relationship between lifetime suicide attempts and the clinical factors/biochemical parameters in a large sample of bipolar patients. Methods: A total of 561 patients, consecutively hospitalized for BD in Milan and Monza (Italy), were recruited. Data about the demographic and clinical variables, as well as the values of blood analyses, were collected. The groups identified according to the presence/absence of lifetime suicide attempts were compared using univariate analyses. Then, three preliminary binary logistic regressions and a final logistic regression model were performed to identify the clinical and biochemical parameters associated with lifetime suicide attempts in BD. Results: Lifetime suicide attempts in BD were predicted by a longer duration of untreated illness (DUI) (p = 0.005), absence of lifetime psychotic symptoms (p = 0.025), presence of poly-substance use disorders (p = 0.033), comorbidity with obesity (p = 0.022), a last mood episode of manic polarity (p = 0.044), and lower bilirubin serum levels (p = 0.002); higher total cholesterol serum levels showed a trend toward statistical significance (p = 0.058). Conclusions: BD patients with lifetime suicide attempts present unfavorable clinical features. Some specific biochemical characteristics of bipolar patients may represent potential markers of suicidal behavior and need to be better investigated to identify new targets of treatment in the framework of personalized medicine. These preliminary findings have to be confirmed by further studies in different clinical settings.

Clinical and psychopathological correlates of duration of untreated illness (DUI) in affective spectrum disorders

Affective disorders represent psychopathological entities lying on a continuum, characterized by high prevalence and functional impairment. A delay in treatment initiation might increase the burden associated with affective spectrum disorders. The present study was aimed at analyzing the correlates of a long duration of untreated illness (DUI) in these conditions. We recruited subjects diagnosed with affective disorders, both in- and outpatients, and collected information concerning socio-demographic, clinical, and psychopathological characteristics. Long DUI was defined according to previous research criteria as >2 years for Bipolar Disorders or >1 year for Depressive Disorders. Bivariate analyses were performed to compare subjects with a long and short DUI (p<0.05). A logistic regression was operated to evaluate the correlates of long DUI. In the present sample (n=135), 34.1% (n=46) subjects showed a long DUI. This subgroup presented with more physical comorbidities (p=0.003), higher body mass index (BMI) (p<0.001), more frequent anxiety onset (p=0.018), younger onset age (p=0.042), and more severe depressive symptoms (Hamilton Depression Rating Scale item 1-depressed mood (p=0.032) and item 2-guilt feelings (p=0.018)). At the logistic regression, higher severity of depressed mood (OR 1.568), higher BMI (OR 1.264), and younger age at onset (OR 0.935) were associated with long DUI. The present study confirmed a possible role of DUI as a construct underpinning higher clinical severity in affective spectrum disorders, possibly linked to worse illness course and unfavorable outcomes. Intervention strategies targeting physical comorbidities and depressive symptoms severity may decrease disease burden in subjects with a long DUI.

Clinical high-risk criteria of psychosis in 8–17-year-old community subjects and inpatients not suspected of developing psychosis

BACKGROUND

In children and adolescents compared to adults, clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and less clinically relevant. Based on high rates of non-converters to psychosis, especially in children and adolescents, it was suggested that CHR criteria were: (1) Pluripotential; (2) A transdiagnostic risk factor; and (3) Simply a severity marker of mental disorders rather than specifically psychosis-predictive. If any of these three alternative explanatory models were true, their prevalence should differ between persons with and without mental disorders, and their severity should be associated with functional impairment as a measure of severity.

AIM

To compare the prevalence and severity of CHR criteria/symptoms in children and adolescents of the community and inpatients.

METHODS

In the mainly cross-sectional examinations, 8–17-year-old community subjects (n = 233) randomly chosen from the population register of the Swiss Canton Bern, and inpatients (n = 306) with primary diagnosis of attention-deficit/hyperactivity disorder (n = 86), eating disorder (n = 97), anxiety including obsessive–compulsive disorder (n = 94), or autism spectrum disorder (n = 29), not clinically suspected to develop psychosis, were examined for CHR symptoms/criteria. Positive items of the Structured Interview for Psychosis-Risk Syndromes (SIPS) were used to assess the symptomatic ultra-high-risk criteria, and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was used to assess the 14 basic symptoms relevant to basic symptom criteria. We examined group differences in frequency and severity of CHR symptoms/criteria using χ² tests and nonparametric tests with Cramer’s V and Rosenthal’s r as effect sizes, and their association with functioning using correlation analyses.

RESULTS

The 7.3% prevalence rate of CHR criteria in community subjects did not differ significantly from the 9.5% rate in inpatients. Frequency and severity of CHR criteria never differed between the community and the four inpatient groups, while the frequency and severity of CHR symptoms differed only minimally. Group differences were found in only four CHR symptoms: suspiciousness/persecutory ideas of the SIPS [χ² (4) = 9.425; P = 0.051, Cramer’s V = 0.132; and Z = -4.281, P < 0.001; Rosenthal’s r = 0.184], and thought pressure [χ² (4) = 11.019; P = 0.026, Cramer’s V = 0.143; and Z = -2.639, P = 0.008; Rosenthal’s r = 0.114], derealization [χ² (4) = 32.380; P < 0.001, Cramer’s V = 0.245; and Z = -3.924, P < 0.001; Rosenthal’s r = 0.169] and visual perception disturbances [χ² (4) = 10.652; P = 0.031, Cramer’s V = 0.141; and Z = -2.822, P = 0.005; Rosenthal’s r = 0.122] of the SPI-CY. These were consistent with a transdiagnostic risk factor or dimension, i.e., displayed higher frequency and severity in inpatients, in particular in those with eating, anxiety/obsessive–compulsive and autism spectrum disorders. Low functioning, however, was at most weakly related to the severity of CHR criteria/symptoms, with the highest correlation yielded for suspiciousness/persecutory ideas (Kendall’s tau = -0.172, P < 0.001).

CONCLUSION

The lack of systematic differences between inpatients and community subjects does not support suggestions that CHR criteria/symptoms are pluripotential or transdiagnostic syndromes, or merely markers of symptom severity.

The Bern Early Recognition and Intervention Centre for mental crisis (FETZ Bern)-An 8-year evaluation

AIM

Early detection of, and intervention for, psychosis during its prodromal phase has the potential to alter the course of the disease and has therefore become a major objective of modern clinical psychiatry. An increasing number of early detection and intervention services have been established in Europe and worldwide. This study aims to describe and evaluate an early detection and intervention service for children, adolescents and adults (FETZ Bern) aged from eight to 40 years with a population catchment area of 1.035 million in Bern, Switzerland.

METHODS

Routine demographic, diagnostic and service usage data were collected upon admission to the service. Using a retrospective, descriptive and naturalistic study design, data was analysed for different age groups (children, adolescents and adults) and where available, outcome data after 12 and 24 months was evaluated.

RESULTS

The FETZ Bern has received 827 referrals with full diagnostic data available for 353 patients. The majority of the assessed patients were young males. While 40% met criteria for a clinical high-risk state of psychosis, 20% were diagnosed with fully manifest psychosis at time of admission, and another 40% had one or more non-psychotic axis-I diagnoses.

CONCLUSIONS

The FETZ Bern is the first early detection centre worldwide assessing children aged younger than 12 years, as well as adolescents and young adults in one service. Given that developmental peculiarities are important in understanding and ultimately treating psychosis, the FETZ Bern, with its emphasis on developmental peculiarities, should be considered as a model for other similar services.

Systematic comparison of duration of untreated illness versus duration of untreated psychosis in relation to psychopathology and dysfunction in the Cavan-Monaghan first episode psychosis study (CAMFEPS)

This study systematically compared duration of untreated illness (DUI) with duration of untreated psychosis (DUP) in prediction of impairment at first-episode psychosis and investigated the extent to which these relationships are influenced by premorbid features. The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first-episode psychosis in rural Ireland via all routes to care with limited variations in socioeconomic milieu. Cases were evaluated for DUI and DUP and assessed clinically for psychopathology, neuropsychology, neurology, insight and quality of life, together with premorbid features. Analyses then determined prediction of clinical assessments by DUI versus DUP. The study population consisted of 163 cases of first episode psychosis, among which 74 had a schizophrenia spectrum disorder. Shorter DUI but not DUP predicted less severe positive and general symptoms, while shorter DUP and particularly DUI predicted less severe negative symptoms; neither shorter DUP nor shorter DUI predicted less severe cognitive impairment or fewer neurological soft signs; shorter DUP and DUI predicted increased quality of life; shorter DUI but not DUP predicted greater insight. Only prediction of quality of life was weakened by consideration of premorbid features. Results were generally similar across the two diagnostic groupings. The present findings systematically delineate associations with DUI versus DUP across domains of impairment in first episode psychosis. They suggest that DUI may reflect a more insidious process than DUP and that reduction in DUI may be associated with more consistent and broader diminutions in impairment than for DUP.

Clinical features associated with early drop-out among outpatients with unipolar and bipolar depression

Drop-out from follow-up visits carries significant burden for people diagnosed with depression. The present study assesses multiple clinical moderators of drop-out among depressed outpatients. We retrospectively followed-up 131 outpatients over 6 months: 78 major depressive disorder (MDD), and 53 bipolar disorder (BD-I = 24; BD-II = 29) patients diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Participants were assessed with standard rating scales administered by experienced psychiatrists. Upon descriptive and Cox regression analyses, 17/53 BDs (32%) dropped-out; the overall survival time until drop-out was 57.94 ± 17.79 days. BD drop-outs were younger, had an earlier age at onset, shorter illness duration, lower rates of lifetime obsessive-compulsive disorder/suicidal behavior, higher rates of substance use disorder (SUD), anxious and mixed features of depression compared to BDs attending up to six months. Among MDD patients, 10/78 cases (13%) dropped-out by month-6 with an average survival of 42.40 ± 16.45 days. Earlier age of onset, younger age, positive family history for mood disorders, lower rates of lifetime generalized anxiety disorder were significantly more frequent among drop-outs than completers, as opposite to SUD, and lifetime recurrent depression. Older age predicted lower drop-out among BDs and MDDs, although with almost null hazard ratio (HR) = 0.928, p < 0.01 vs. HR = 0.941, p < 0.01, respectively. Higher rates of lifetime SUD predicted higher drop-out rates by month-6 among MDDs (HR = 5.477, p = 0.02). Limitations of the study: retrospective design, small sample size, lack of objective measures of treatment-adherence/mood rating during follow-up. Drop-out is common in the real-world setting, warranting specific interventions since the beginning of the treatment.

Main Symptomatic Treatment Targets in Suspected and Early Psychosis: New Insights From Network Analysis

The early detection and intervention in psychoses prior to their first episode are presently based on the symptomatic ultra-high-risk and the basic symptom criteria. Current models of symptom development assume that basic symptoms develop first, followed by attenuated and, finally, frank psychotic symptoms, though interrelations of these symptoms are yet unknown. Therefore, we studied for the first time their interrelations using a network approach in 460 patients of an early detection service (mean age = 26.3 y, SD = 6.4; 65% male; n = 203 clinical high-risk [CHR], n = 153 first-episode psychosis, and n = 104 depression). Basic, attenuated, and frank psychotic symptoms were assessed using the Schizophrenia Proneness Instrument, Adult version (SPI-A), the Structured Interview for Psychosis-Risk Syndromes (SIPS), and the Positive And Negative Syndrome Scale (PANSS). Using the R package qgraph, network analysis of the altogether 86 symptoms revealed a single dense network of highly interrelated symptoms with 5 discernible symptom subgroups. Disorganized communication was the most central symptom, followed by delusions and hallucinations. In line with current models of symptom development, the network was distinguished by symptom severity running from SPI-A via SIPS to PANSS assessments. This suggests that positive symptoms developed from cognitive and perceptual disturbances included basic symptom criteria. Possibly conveying important insight for clinical practice, central symptoms, and symptoms "bridging" the association between symptom subgroups may be regarded as the main treatment targets, in order to prevent symptomatology from spreading or increasing across the whole network.

Factors that influence psychiatric help-seeking behavior in Japanese university students

We investigated the periods from symptom onset to the first visit to the psychiatric consultation and the factors that influence psychiatric help-seeking behavior in university students. Students who first visited the psychiatric department of university health care center were the study participants. We surveyed the elicited information such as age, sex, period from symptom onset to the first visit, main symptoms, General Health Questionnaire GHQ-12, and perception of stigma associated with receiving a psychiatric consultation. We analyzed the factors affecting the duration until a psychiatric consultation was made using logistic regression analysis, examining age, sex, contents of the problem, GHQ-12, and stigma as independent variables. Of the participants, 48.2 % did not consult with a psychiatrist for more than 6 months and 51 participants (36.7 %) took more than a year before a consultation. We divided the study participants into two groups: early examinees and delayed examinees. In order to investigate the factors affecting the two groups, logistic regression analysis was performed. Of the independent variables, one consultation content (physical symptoms; odds ratio (OR) = 9.21, 95 % CI (confidence interval) = 2.00-42.62, p = 0.004) and the GHQ-12 (OR = 1.17, 95 % CI = 1.05-1.31, p = 0.005) were significant factors. It became clear that physical symptoms significantly accelerated consultation with psychiatry. When various problems occurred, the decision to seek a psychiatry consultation required a long time. Health education focusing on the values of seeking an early consultation is required so that when students have mental health problems they will seek psychiatric services in a timely manner.

Predictors of Treatment Resistance Across Different Clinical Subtypes of Depression: Comparison of Unipolar vs. Bipolar Cases

OBJECTIVE

Treatment-resistant depression (TRD) and treatment-resistant bipolar depression (TRBD) poses a significant clinical and societal burden, relying on different operational definitions and treatment approaches. The detection of clinical predictors of resistance is elusive, soliciting clinical subtyping of the depressive episodes, which represents the goal of the present study.

METHODS

A hundred and thirty-one depressed outpatients underwent psychopathological evaluation using major rating tools, including the Hamilton Rating Scale for Depression, which served for subsequent principal component analysis, followed-up by cluster analysis, with the ultimate goal to fetch different clinical subtypes of depression.

RESULTS

The cluster analysis identified two clinically interpretable, yet distinctive, groups among 53 bipolar (resistant cases = 15, or 28.3%) and 78 unipolar (resistant cases = 20, or 25.6%) patients. Among the MDD patients, cluster "1" included the following components: "Psychic symptoms, depressed mood, suicide, guilty, insomnia" and "genitourinary, gastrointestinal, weight loss, insight". Altogether, with broadly defined "mixed features," this latter cluster correctly predicted treatment outcome in 80.8% cases of MDD. The same "broadly-defined" mixed features of depression (namely, the standard Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition-DSM-5-specifier plus increased energy, psychomotor activity, irritability) correctly classified 71.7% of BD cases, either as TRBD or not.

LIMITATIONS

Small sample size and high rate of comorbidity.

CONCLUSIONS

Although relying on different operational criteria and treatment history, TRD and TRBD seem to be consistently predicted by broadly defined mixed features among different clinical subtypes of depression, either unipolar or bipolar cases. If replicated by upcoming studies to encompass also biological and neuropsychological measures, the present study may aid in precision medicine and informed pharmacotherapy.

Investigating duration of illness and duration of untreated illness in obsessive compulsive disorder reveals patients remain at length pharmacologically untreated

Aim: Obsessive compulsive disorder (OCD) is a disabling condition, often associated with early onset and chronic course. Early onset combined to the secretiveness that frequently characterises the condition, as well as patient's beliefs that OC symptoms do not represent a medical condition and that OCD can remit spontaneously, are all factors contributing to delayed diagnosis and first treatment, particularly of pharmacological nature.Methods: In this short report, authors performed a review of the most recent literature in the field.Conclusions: The current literature clearly delineates a duration of untreated illness of several years (around 7 years in the majority of the reports), which represented, on average, a portion ranging between the 40 and 70% of the overall duration of untreated illness.

A minimum evaluation protocol and stepped-wedge cluster randomized trial of ACCESS Open Minds, a large Canadian youth mental health services transformation project

BACKGROUND

Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families.

METHODS

The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention.

DISCUSSION

Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

Psychosis and Schizophrenia-Spectrum Personality Disorders Require Early Detection on Different Symptom Dimensions

Psychotic disorders and schizophrenia-spectrum personality disorders (PD) with psychotic/psychotic-like symptoms are considerably linked both historically and phenomenologically. In particular with regard to schizotypal and schizotypal personality disorder (SPD), this is evidenced by their placement in a joint diagnostic category of non-affective psychoses in the InternationaI Classification of Diseases 10th Revision, (CD-10) and, half-heartedly, the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, (DSM-5). Historically, this close link resulted from observations of peculiarities that resembled subthreshold features of psychosis in the (premorbid) personality of schizophrenia patients and their biological relatives. These personality organizations were therefore called "borderline (schizophrenia)" in the first half of the 20th century. In the 1970s, they were renamed to "schizotypal" and separated from psychotic disorders on axis-I and from other PD on axis-II, including modern borderline PD, in the DSM. The phenomenological and historical overlap, however, has led to the common assumption that the main difference between psychotic disorders and SPD in particular was mainly one of severity or trajectory, with SPD representing a latent form of schizophrenia and/or a precursor of psychosis. Thus, psychosis proneness and schizotypy are often assessed using SPD questionnaires. In this perspective-piece, we revisit these assumptions in light of recent evidence. We conclude that schizotypy, SPD (and other schizophrenia-spectrum PD) and psychotic disorder are not merely states of different severity on one common but on qualitatively different dimensions, with the negative dimension being predictive of SPD and the positive of psychosis. Consequently, in light of the merits of early diagnosis, the differential early detection of incipient psychosis and schizophrenia-spectrum PD should be guided by the assessment of different schizotypy dimensions.

Treatment outcomes and associations in an adolescent-specific early intervention for psychosis service

AIM

Compared with adult onset psychosis, adolescent psychosis has been associated with poorer outcomes in terms of social and cognitive functioning and negative symptoms. Young people experiencing first episode psychosis have developmental needs that frequently pre-date and are compounded by psychosis onset (a previous study). There is a lack of published studies of adolescent onset psychosis and further information is needed so that developmentally appropriate interventions can be developed. We report an observational naturalistic cohort study of an adolescent specific service, the Early Psychosis Support service (EPSS).

METHOD

We examined baseline demographic and clinical variables, treatments outcomes and predictors of outcome for this population.

RESULTS

The mean age of our sample was 16.3 years. Median duration of untreated illness (DUI) was 88 weeks, and median duration of untreated psychosis (DUP) was 16 weeks. We found significant improvements in positive symptoms, negative symptoms, disorganization, excitement, emotional distress and depression from 0 to 12 months. We found that baseline positive symptoms and DUI significantly predicted positive symptoms at 12 months and only negative symptoms at baseline predicted 12-month negative symptoms.

CONCLUSION

Our finding that specialist early intervention for adolescents experiencing psychosis is effective suggests that such treatment should be routinely offered in line with existing clinical guidelines. Our finding that DUI is predictive of poorer outcome at 12 months suggests that even earlier intervention from a specialist team may further improve treatment outcomes.

Exploring characteristics associated with first benzodiazepine prescription in patients with affective disorders and related diagnoses

OBJECTIVE

In patients with affective disorders, benzodiazepines (BZDs) are frequently administered at the onset, sometimes inappropriately. We sought to identify clinical variables associated with first BZD prescription in a large sample of patients with affective disorders.

METHODS

Four hundred sixty patients with mood or anxiety disorders attending different psychiatric services were assessed comparing those who received BZD as first treatment (BZD w/) and those who did not (BZD w/o).

RESULTS

More than one third (35.7%) of the total sample had received BZDs as first prescription. In relation to mood disorders, BZD w/ subjects more frequently (a) had not a psychiatrist as first therapist, (b) had anxious symptoms at onset, (c) had adjustment disorder as first diagnosis, (d) were treated as outpatients. In relation to specific diagnoses, (a) personal decision of treatment for major depressive disorder, (b) outpatient status for bipolar disorder and (c) longer duration of untreated illness for adjustment disorder were more frequently associated with first BZD prescription. For anxiety disorders, the presence of stressful life events and the diagnoses of panic disorder or specific phobias were more frequently observed in BZD w/ patients.

CONCLUSION

Patients with affective disorders frequently received BZDs as first prescription with significant differences between and within mood and anxiety disorders.

Early intervention for obsessive compulsive disorder: An expert consensus statement

Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the 'toxic' effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.

Pathways to mental health services for young people: a systematic review

PURPOSE

While early access to appropriate care can minimise the sequelae of mental illnesses, little is known about how youths come to access mental healthcare. We therefore conducted a systematic review to synthesise literature on the pathways to care of youths across a range of mental health problems.

METHODS

Studies were identified through searches of electronic databases (MEDLINE, PsycINFO, Embase, HealthSTAR and CINAHL), supplemented by backward and forward mapping and hand searching. We included studies on the pathways to mental healthcare of individuals aged 11-30 years. Two reviewers independently screened articles and extracted data.

RESULTS

Forty-five studies from 26 countries met eligibility criteria. The majority of these studies were from settings that offered services for the early stages of psychosis, and others included inpatient and outpatient settings targeting wide-ranging mental health problems. Generally, youths' pathways to mental healthcare were complex, involved diverse contacts, and, sometimes, undue treatment delays. Across contexts, family/carers, general practitioners and emergency rooms featured prominently in care pathways. There was little standardization in the measurement of pathways.

CONCLUSIONS

Except in psychosis, youths' pathways to mental healthcare remain understudied. Pathways to care research may need to be reconceptualised to account for the often transient and overlapping nature of youth mental health presentations, and the possibility that what constitutes optimal care may vary. Despite these complexities, additional research, using standardized methodology, can yield a greater understanding of the help-seeking behaviours of youths and those acting on their behalf; service responses to help-seeking; and the determinants of pathways. This understanding is critical to inform ongoing initatives to transform youth mental healthcare.

Does initial use of benzodiazepines delay an adequate pharmacological treatment? A multicentre analysis in patients with psychotic and affective disorders

It is established that delayed effective pharmacotherapy plays a significant role in the overall burden of psychiatric disorders, which are often treated with symptomatic drugs, that is benzodiazepines (BZDs), in relation to their rapid onset of action and safety, despite long-term side effects. We aimed to assess the influence of initial treatment with BZDs on the duration of untreated illness (DUI) and whether specific sociodemographic and clinical factors could influence the choice of BZDs as first treatment in 545 patients affected by schizophrenia, mood and anxiety spectrum disorders. Statistical analyses (one-way analysis of variance and χ) were carried out to compare patients who used BZDs as first treatment (BZD w/) and those who did not (BZD w/o). The overall DUI, irrespective of diagnosis, resulted in significantly longer in BZD w/ versus w/o patients, who also experienced more frequently anxious/depressive symptoms at onset. Furthermore, BZD w/ patients more frequently autonomously decided to look for treatment (mainly refering to psychologists or general practitioners) and experimented more frequently phobias, than BZD w/o ones. The present findings suggest that initial BZDs treatment may prolong the overall DUI, although their prescription seems to be influenced by specific sociodemographic and clinical factors. Further studies are needed to confirm the present findings.

Possible predictors of age at illness onset and illness duration in a cohort study comparing younger adults and older major affective patients

BACKGROUND

Major affective conditions are associated with significant disability and psychosocial impairment. Whether specific socio-demographic and clinical characteristics may distinguish subgroups of patients in terms of prognosis and illness trajectories is a matter of debate.

METHODS

The sample of this naturalistic cohort study included 675 currently euthymic patients with major affective disorders of which 428 (63.4%) were diagnosed with unipolar and 247 (36.6%) with bipolar disorders.

RESULTS

Younger adults with a longer duration of untreated illness and residual inter-episodic symptoms were more likely to be single or divorced, students, with an earlier age of first treatment/hospitalization, longer duration of substance abuse and duration of illness than older patients who were, conversely, more likely to be widowed and retired. Multivariate analyses showed a significant positive contribution to age at illness onset by marital status, nonpsychiatric medications, substance abuse, psychiatric diagnosis (bipolar vs. unipolar), age at first treatment/hospitalization, duration of illness, and current age. According to a further analysis, we also found a significant positive contribution to duration of illness by marital status, educational level, positive history of psychiatric conditions in family, substance abuse, psychiatric diagnosis (bipolar vs. unipolar), age at illness onset, age at first treatment, and certain cardiovascular disorders.

CONCLUSIONS

There are substantial socio-demographic and clinical differences that may help to distinguish specific subgroups of patients; however, additional studies are requested to replicate these results and further investigate the main factors underlying our findings.

Time-to-treatment of mental disorders in a community sample of Dutch adolescents. A TRAILS study

AIMS

Timely recognition and treatment of mental disorders with an onset in childhood and adolescence is paramount, as these are characterized by greater severity and longer persistence than disorders with an onset in adulthood. Studies examining time-to-treatment, also referred to as treatment delay, duration of untreated illness or latency to treatment, and defined as the time between disorder onset and initial treatment contact, are sparse and all based on adult samples. The aim of this study was to describe time-to-treatment and its correlates for any health care professional (any care) and secondary mental health care (secondary care), for a broad range of mental disorders, in adolescents.

METHODS

Data from the Dutch community-based cohort study TRacking Adolescents' Individual Lives Survey (TRAILS; N = 2230) were used. The Composite International Diagnostic Interview (CIDI) was administered to assess DSM-IV disorders, the age of onset, and the age of initial treatment contact with any health care professional in 1584 adolescents of 18-20 years old. In total 43% of the adolescents (n = 675) were diagnosed with a lifetime DSM-IV disorder. The age of initial treatment contact with secondary care was based on administrative records from 321 adolescents without a disorder onset before the age of 10. Descriptive statistics, cumulative lifetime probability plots, and Cox regression analyses were used analyze time-to-treatment.

RESULTS

The proportion of adolescents who reported lifetime treatment contact with any care varied from 15% for alcohol dependence to 82% for dysthymia. Regarding secondary care, proportions of lifetime treatment contact were lower for mood disorders and higher for substance dependence. Time-to-treatment for any care varied considerably between and within diagnostic classes. The probability of lifetime treatment contact for mood disorders was above 90%, whereas for other mental disorders this was substantially lower. An earlier age of onset predicted a longer, and the presence of a co-morbid mood disorder predicted a shorter time-to-treatment in general. Disorder severity predicted a shorter time-to-treatment for any care, but not for secondary care. Time-to-treatment for secondary care was shorter for adolescents from low and middle socioeconomic background than for adolescents from a high socioeconomic background.

CONCLUSION

Although the time-to-treatment was shorter for adolescents than for adults, it was still substantial, and the overall patterns were remarkably similar to those found in adults. Efforts to reduce time-to-treatment should therefore be aimed at children and adolescents. Future research should address mechanisms underlying time-to-treatment and its consequences for early-onset disorders in particular.

Italian patients with more recent onset of Major Depressive Disorder have a shorter duration of untreated illness

BACKGROUND

Previous investigation on the duration of untreated illness (DUI) in patients with Major Depressive Disorder (MDD) revealed a different latency to first antidepressant treatment, with adverse consequences in terms of outcome for individuals with a longer DUI. Recent reports, moreover, documented a reduced DUI, as observed with the passage of time, in patients with different psychiatric disorders. Hence, the present study was aimed to assess DUI and related variables in a sample of Italian patients with MDD as well as to investigate potential differences in subjects with onset before and after 2000.

METHODS

An overall sample of 188 patients with MDD was assessed through a specific questionnaire investigating DUI and other variables related to the psychopathological onset and latency to first antidepressant treatment, after dividing them in two different subgroups on the basis of their epoch of onset.

RESULTS

The whole sample showed a mean DUI of approximately 4.5 years, with patients with more recent onset showing a significantly shorter latency to treatment compared with the other group (27.1±42.6 vs 75.8±105.2 months, P<.05). Other significant differences emerged between the two subgroups, in terms of rates of onset-related stressful events and benzodiazepine prescription, respectively, higher and lower in patients with more recent onset.

CONCLUSIONS

Our findings indicate a significant DUI reduction in MDD patients whose onset occurred after vs before 2000, along with other relevant differences in terms of onset-related correlates and first pharmacotherapy. Further studies with larger samples are warranted to confirm the present findings in Italy and other countries.

Which factors influence onset and latency to treatment in generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder?

Anxiety disorders are common, comorbid, and disabling conditions, often underdiagnosed and under-treated, typically with an early onset, chronic course, and prolonged duration of untreated illness. The present study aimed to explore the influence of sociodemographic and clinical factors in relation to onset and latency to treatment in patients with generalized anxiety disorder (GAD), panic disorder (PD), and obsessive-compulsive disorder (OCD). A total of 157 patients with a Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR) diagnosis of PD (n=49), GAD (n=68), and OCD (n=40) were recruited, and epidemiological and clinical variables were collected through a specific questionnaire. Statistical analyses were carried out to compare variables across diagnostic groups. PD, GAD, and OCD patients showed a duration of untreated illness of 53.9±81.5, 77.47±95.76, and 90.6±112.1 months, respectively. Significant differences between groups were found with respect to age, age of first diagnosis, age of first treatment, family history of psychiatric illness, onset-related stressful events, benzodiazepine prescription as first treatment, antidepressant prescription as first treatment, and help-seeking (self-initiated vs. initiated by others). Patients with GAD, PD, and OCD showed significant differences in factors influencing onset and latency to treatment, which may, in turn, affect condition-related outcome and overall prognosis. Further studies with larger samples are warranted in the field.

Reduced duration of untreated illness over time in patients with schizophrenia spectrum, mood and anxiety disorders

AIMS

Psychiatric disorders represent highly impairing conditions, often underdiagnosed and undertreated, with a conspicuous duration of untreated illness (DUI). Given that social and cultural factors influence the DUI and assuming that progress in diagnosis and treatment determines a reduced latency to pharmacotherapy, we assessed and compared DUI and related variables in a large sample of psychiatric patients (n = 562) whose onset occurred within three different a priori-defined epochs.

METHODS

Two temporal cut-offs were established - the year 1978, when Law 180 (redefining standards for mental care) was introduced in Italy, and the year 2000 - in order to divide patients into three subgroups: onset before 1978, onset 1978-2000 and onset after 2000.

RESULTS

A significant difference in terms of age at onset, age at first diagnosis and age at first treatment was observed in patients with onset 1978-2000 and in those with onset after 2000. In addition, a significant reduction of the DUI was found across epochs (onset before 1978: 192.25 ± 184.52 months; onset 1978-2000: 77.00 ± 96.63 months; and onset after 2000: 19.00 ± 31.67 months; P < 0.001). Furthermore, the proportion of patients with onset-related stressful events, use of benzodiazepines and neurological referral was found to be significantly different between the three epochs (χ(2) = 23.4, P < 0.001; χ(2) = 9.92, P = 0.007; χ(2) = 16.50, P = 0.011).

CONCLUSIONS

Present data indicate a progressive, statistically significant reduction of latency to treatment and other related changes across subsequent epochs of onset in patients with different psychiatric disorders. Future studies will assess specific changes within homogeneous diagnostic subgroups.

Access and latency to first antipsychotic treatment in Italian patients with schizophrenia and other schizophrenic spectrum disorders across different epochs

BACKGROUND

The duration of untreated illness (DUI) is a measure to express the latency to first psychopharmacological treatment: it differs among psychiatric disorders, being influenced by several illness-intrinsic and environmental factors. The present study aimed to assess differences in DUI and related variables in patients with schizophrenia (SKZ) versus other schizophrenic spectrum disorders (SSDs) across different epochs.

METHODS

101 SKZ or SSD patients were assessed with respect to DUI and related variables through clinical interview and questionnaire.

RESULTS

Patients with SKZ showed earlier ages of onset, first diagnosis and first antipsychotic treatment compared with patients with other SSDs (F = 11.02, p < 0.001; F = 12.68, p < 0.001; F = 13.74, p < 0.001, respectively) who showed an earlier access to benzodiazepines than SKZ patients (F = 6.547; p < 0.05). Dividing the total sample by the epoch of onset (before 1978; between 1978-2000; after 2000) showed a significantly later age of onset in patients with onset within the two most recent epochs (F = 7.46; p < 0.001) and a reduced DUI across epochs (from 144 to 41 to 20 months, on average; F = 11.78, p < 0.001).

CONCLUSION

Schizophrenic patients showed earlier onset and longer DUI compared with patients with other SSDs. Data on the total sample showed a later age of onset and a reduced DUI across epochs.

[Integrated care for patients with first and multiple episodes of severe psychotic illnesses: 3-year results of the Hamburg model]

BACKGROUND

The so-called "Hamburg model" is a designated integrated care model according to § 140 of the Social Code Book (SGB) V for psychosis patients fulfilling the definition of severe mental illness (SMI).

OBJECTIVES

Description of the model and evaluation of efficacy of all patients being treated for ≥ 3 years.

MATERIALS AND METHODS

Service entry illness status, course of illness, and interventions were assessed within a continuous quality assurance study. One hundred and fifty-eight patients who fulfilled the criterion of being treated for ≥ 3 years were analyzed.

RESULTS

At service entry, SMI were among others mirrored by a high level of psychopathology (Brief Psychiatric Rating Scale [BPRS]: 80.3) and severity of illness (Clinical Global Impression Severity [CGI-S]/Clinical Global Impression Bipolar scales [CGI-BP]: 5.8), low functioning level (Global Assessment of Functioning scale [GAF]: 35.9), and high rates of comorbid psychiatric (94.3 %) and somatic (81.6 %) disorders. Only 8 patients (5.1 %) disengaged from the service within the 3-year treatment period. The course of the illness over 3 years showed significant and stable improvements in psychopathology (BPRS: p < 0.001), the severity of illness (CGI-S/CGI-BP: p < 0.001), functioning (GAF: p < 0.001), quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q-18]: p < 0.001), and satisfaction with care (Client Satisfaction Questionnaire [CSQ-8]: 2.0 to 3.3; p = 0.164; nonsignificant because of early improvements). Further, compulsory admissions were reduced and medication adherence in addition to working ability improved (all p < 0.001). Data on interventions showed a continuously high frequency of outpatient interventions over time (on average 112.0 per year), a high percentage of patients in psychotherapy (67 %), and a nearly 90 % reduction in inpatient treatment days from year 1 to year 3.

CONCLUSION

Integrated care in severely ill patients with psychotic disorders leads to multidimensional illness improvement and stabilization by offering intensive outpatient care.

The role of comorbidities in duration of untreated illness for bipolar spectrum disorders

BACKGROUND

Growing interest has been given to the construct of Duration of untreated illness (DUI) on the outcome of bipolar disorder (BD), due to its potentially modifiable nature. The aim of this study was to identify possible clinical correlates of DUI in a sample of BD patients.

METHOD

119 BD spectrum patients included. DUI rate was calculated and dichotomized into short DUI and long DUI subgroups, cut-off 24 months. These subgroups were compared for socio-demographic and clinical variables. Significant results were included into direct logistic regressions to assess their impact on the likelihood of presenting with long DUI.

RESULTS

Mean DUI±SD was 75.6±98.3 months. Short DUI subgroup comprised 56 (47.1%), long DUI 60 (52.9%) patients. Age at onset of BD was lower in the long DUI subgroup (p=0.021), illness duration longer (p=0.011). Long DUI subgroup showed significantly more comorbidity with Axis I (p=0.002) and personality disorders (p=0.017), less interepisodic recovery (p<0.001) and less Manic Predominant Polarity (p=0.009). Direct logistic regression as a full model was significant, correctly classifying 76.7% of cases. A unique statistically significant contribution was made by: Manic Predominant Polarity, Personality Disorder Comorbidity, and Total Changes in Medications.

LIMITATIONS

Partial retrospective data, cross sectional study.

CONCLUSIONS

DUI was longer than 24 months in half of the sample. Psychotic /Manic onset contributed to a quick diagnostic classification. Personality disorders in depressed patients could delay a correct diagnosis of BD, factors associated with an increased likelihood of BD must be considered. More research on personality disorder comorbidities is needed.

Differences in duration of untreated illness, duration, and severity of illness among clinical phenotypes of obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent, disabling, and comorbid condition that is frequently under-recognized and poorly treated. OCD phenotypes may differ in terms of clinical presentation and severity. However, few studies have investigated whether clinical phenotypes differ in terms of latency to treatment (ie, duration of untreated illness[DUI]), duration, and severity of illness. The present study was aimed to quantify the aforementioned variables in a sample of OCD patients.

METHODS

One hundred fourteen outpatients with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnosis of OCD were recruited, and their main clinical features were collected. Severity of illness was assessed through the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and the main phenotypes were identified through the Y-BOCS Symptom Checklist. A one-way analysis of variance (ANOVA) test, followed by a Bonferroni post-hoc test, were performed to compare DUI, duration, and severity of illness across subgroups.

RESULTS

In the whole sample, the mean DUI exceeded 7 years (87.35±11.75 months), accounting for approximately half of the mean duration of illness (172.2±13.36 months). When subjects were categorized into 4 main clinical phenotypes, respectively, aggressive/checking (n=31), contamination/cleaning (n=37), symmetry/ordering (n=32), and multiple phenotypes (n=14), DUI, duration, and severity of illness resulted significantly higher in the aggressive/checking subgroup, compared to other subgroups (F=3.58, p<0.01; F=3.07, p<0.01; F=4.390, p<0.01).

DISCUSSION

In a sample of OCD patients, along with a mean latency to treatment of approximately 7 years, regardless of the phenotype, patients had spent half of their duration of illness (DI) without being treated. DUI, duration, and severity of illness resulted significantly higher in the aggressive/checking subgroup.

Neuropsychological profile and treatment-related features among patients with comorbidity between schizophrenia spectrum disorder and obsessive–compulsive disorder: is there evidence for a “schizo-obsessive” subtype?

Epidemiological studies have found that obsessive–compulsive disorder (OCD) is estimated to occur in 12% of patients with schizophrenia. Whether this “schizo-obsessive” subgroup may be posited as a clinical entity with a distinct neuropsychological profile and treatment-related features remains unclear. A sample of 30 patients who met DSM-IV criteria for both schizophrenia/schizoaffective disorder and OCD was compared with 30 OCD subjects and with 37 patients with schizophrenia/schizoaffective disorder. Neuropsychological domains were measured by the Wechsler Adult Intelligence Scale - Third Edition (WAIS-III), the Trail Making Test (TMT), and the verbal fluency test (FAS). Treatment-related variables were assessed with the Clinical Global Improvement scale (CGI), the Drug Attitude Inventory (DAI), and dosage/type of antipsychotic medications. One-way analysis of variance revealed statistically significant differences among the three groups in “working memory,” “block design,” “semantic fluency,” TMT-A, and TMT-B. However, the Bonferroni correction showed no statistical differences between both psychotic groups. In addition, there were no significant differences among the three groups in the CGI and DAI, although “schizo-obsessive” patients tended to display slightly higher scores on these variables than the other groups. Overall, these findings do not support the hypothesis that comorbidity between schizophrenia spectrum disorders and OCD may reflect a distinct clinical entity. However, further research with larger sample sizes and a more comprehensive clinical assessment are needed. Our findings also underscore the fact that divergences among assessment instruments, as well as confounding variables, may influence results on neuropsychological domains.

Potential predictors of delay in initial treatment contact after the first onset of depression in Japan: a clinical sample study

Background

A growing body of evidence shows that reducing the duration of untreated illness (DUI) correlates with improved clinical outcome and course of depression. However, the factors involved in delaying treatment contact after the first onset of lifetime depression are not fully understood. This cross-sectional study aims to identify the characteristics that may predict the delay in initial treatment contact after the first onset of lifetime depression by comparing the socio-demographics and clinical characteristics between those with longer and shorter DUI in a well-characterized Japanese clinical sample.

Methods

Ninety-five patients with depression with longer (>12 months) and shorter DUI (≤12 months) at three Japanese outpatient clinics were studied. Subjects received a comprehensive evaluation, including semi-structured clinical interviews and assessment battery, and their clinical charts were reviewed.

Results

Of the total sample, the median of DUI was 4 months (interquartile range (IQR) 25th–75th percentile, 2–13). We found that 72.6% of patients seek treatment contact within the first year of depression onset. Multivariate logistic regression analysis showed that longer DUI in patients was associated with marital status (never married). Further, the DSM-IV melancholic features approached significance.

Conclusions

Our findings suggest that most Japanese patients with depression are likely to seek treatment within 1 year of onset, and that marital status and melancholia may be potential predictors of the delay in the initial treatment contact after the first onset of lifetime depression.

Duration of untreated illness and outcomes in unipolar depression: a systematic review and meta-analysis

BACKGROUND

To systematically review evidence of the effects of the duration of untreated depression on the clinical outcomes of patients suffering from Unipolar Major Depression.

METHODS

A systematic review and meta-analysis of the evidence of duration of untreated depression and the effect it has on clinical outcomes in Unipolar Major Depression. Data used to this purpose were obtained from a literature search of the MEDLINE, Psychoinfo and Embase databases. Comparable data extracted from studies were entered and analysed using Cochrane Collaboration's Review Manager software Version 5.2.

RESULTS

Ten studies were identified as meeting the inclusion criteria. Only three studies reported comparable data and were consequently used for the meta-analysis. Pooled data indicates the overall positive effect of shorter duration of untreated illness both in a patient's response to treatment (RR 1.70) and remission (RR 1.65). Other studies which were not included in the meta-analysis confirmed the importance of reducing delays in the treatment of depression in order to prevent the risk of worse outcomes and chronicity, in particular in patients presenting with a first episode of depression. Data regarding the association between the duration of untreated episode in recurrent depression and clinical outcomes are less evident.

LIMITATIONS

The heterogeneity of the selected studies was cause for limitations with regard to the carrying out of adequate meta-analysis.

CONCLUSIONS

There is evidence highlighting the importance of a reduced no-treatment interval for patients suffering Unipolar Depression. In particular, there is emphasis on the first episode of depression corresponding to the notion of reducing the duration of untreated illness.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Differences in latency to first pharmacological treatment (duration of untreated illness) in anxiety disorders: a study on patients with panic disorder, generalized anxiety disorder and obsessive-compulsive disorder

AIM

The latency to first pharmacological treatment (duration of untreated illness or 'DUI') is supposed to play a major role in terms of outcome in psychotic conditions. Interest in the field of affective disorders and, in particular, of duration of untreated anxiety, has been recently registered as well. However, a preliminary epidemiologic investigation of the phenomenon is necessary. The present study was aimed to investigate and compare age at onset, age at first pharmacological treatment and DUI in a sample of patients affected by different anxiety disorders. DUI was defined as the interval between the onset of the specific anxiety disorder and the administration of the first adequate pharmacological treatment in compliant subjects.

METHODS

Study sample included 350 patients, of both sexes, with a DSM-IV-TR diagnosis of panic disorder (n = 138), generalized anxiety disorder (n = 127) and obsessive-compulsive disorder (n = 85).

RESULTS

Panic disorder was associated with the shortest DUI (39.5 months), whereas obsessive-compulsive disorder was associated with the longest latency to treatment (94.5 months) (F = 13.333; P < 0.0001). Patients with generalized anxiety disorder showed a mean DUI of 81.6 months.

CONCLUSION

Present results indicate that patients with different anxiety disorders may wait for years (from 3 up to 8) before receiving a first adequate pharmacological treatment. Differences in terms of age at onset, age at the first pharmacological treatment and, ultimately, in DUI in specific anxiety disorders may depend on multiple clinical and environmental factors. Latency to non-pharmacological interventions (e.g. psychoeducation and different forms of psychotherapy) needs to be addressed and correlated with DUI in future studies.

Diagnosis delay in first episodes of major depression: a study of primary care patients in Spain

BACKGROUND

Diagnosis delay may negatively influence the clinical course of major depression; however, few studies have analysed the role of environmental factors on diagnosis delay. This study was aimed to identify personal and environmental factors related to a longer delay.

METHODS

A cross-sectional observational study with 3615 primary care patients with a first diagnosis of major depression was conducted. Diagnosis delay was defined as the time between onset of symptoms and diagnosis of major depression.

RESULTS

Mean of delay was 9.89 weeks. Lower years of education, triggering stressful life events before the current episode, history of previous undiagnosed depressive episodes and somatic comorbidity were related to longer delay. Health system variables, such as urban setting, public health care setting, younger doctors and female doctors were also related to a longer delay.

LIMITATIONS

Onset of first depressive symptoms was retrospectively collected. The cross-sectional design does not allow making inferences about the temporal ordering between predictors and outcomes.

CONCLUSIONS

Both personal and environmental variables were related to diagnosis delay. Identification of these factors helps to design early diagnosis programs to ultimate reduce the morbidity associated with major depression.

The effect of prolonged duration of untreated depression on antidepressant treatment outcome

BACKGROUND

The duration of untreated illness has been considered a likely predictor of the course of psychotic disorders. However, there is only sparse data concerning the influence of treatment delay on the outcome of mood disorders. The present study aimed to assess the effect of prolonged untreated depression on the outcome of antidepressant treatment.

METHOD

Patients aged 18-70 years with recent onset of the first lifetime depressive episode were systematically recruited by the Danish Psychiatric Central Research Register during a 2-year period. A total number of 399 individuals out of 1006 potential participants in the Register were interviewed, and 270 fulfilled the inclusion criteria. The validity of the diagnosis, duration of untreated illness, remission on first-line antidepressant treatment and a number of covariates, including psychiatric co-morbidity, personality disorders and traits, stressful life events prior to onset, and family history of psychiatric illness, were assessed by structured interviews.

RESULTS

The remission rate was significantly decreased among patients with six months or more of untreated depression as compared to patients who were treated with antidepressant medication earlier after onset (21.1% versus 33.7%, OR=0.5, 95% CI 0.3 to 0.9, p=0.03). The negative influence of a prolonged DUI on the outcome did not seem confounded by any of a wide range of demographic and clinical variables.

LIMITATIONS

The outcome was evaluated retrospectively. The findings cannot be generalized to patients outside hospital settings.

CONCLUSION

Initiation of antidepressant treatment more than six months after onset of first episode depression reduces the chance of obtaining remission. The results emphasize the importance of early recognition and treatment of patients suffering from depression.

Duration of untreated bipolar disorder: missed opportunities on the long road to optimal treatment

OBJECTIVE

Duration of untreated illness represents a potentially modifiable component of any diagnosis-treatment pathway. In bipolar disorder (BD), this concept has rarely been systematically defined or not been applied to large clinically representative samples.

METHOD

In a well-characterized sample of 501 patients with BD, we estimated the duration of untreated bipolar disorder (DUB: the interval between the first major mood episode and first treatment with a mood stabilizer). Associations between DUB and clinical onset and the temporal sequence of key clinical milestones were examined.

RESULTS

The mean DUB was 9.6 years (SD 9.7; median 6). The median DUB for those with a hypomanic onset (14.5 years) exceeded that for depressive (13 years) and manic onset (8 years). Early onset BD cases have the longest DUB (P < 0.0001). An extended DUB was associated with more mood episodes (P < 0.0001), more suicidal behaviour (P = 0.0003) and a trend towards greater lifetime mood instability (e.g. rapid cycling, possible antidepressant-induced mania).

CONCLUSION

Duration of untreated bipolar disorder (DUB) will only be significantly reduced by more aggressive case finding strategies. Reliable diagnosis (especially for BD-II) and/or instigation of recommended treatments is currently delayed by insufficient awareness of the early, polymorphous presentations of BD, lack of systematic screening and/or failure to follow established guidelines.

Are lay people good at recognising the symptoms of schizophrenia?

AIM

The aim of this study was to explore the general public's perception of schizophrenia symptoms and the need to seek-help for symptoms. The recognition (or 'labelling') of schizophrenia symptoms, help-seeking behaviours and public awareness of schizophrenia have been suggested as potentially important factors relating to untreated psychosis.

METHOD

Participants were asked to rate to what extent they believe vignettes describing classic symptoms (positive and negative) of schizophrenia indicate mental illness. They were also asked if the individuals depicted in the vignettes required help or treatment and asked to suggest what kind of help or treatment.

RESULTS

Only three positive symptoms (i.e., Hallucinatory behaviour, Unusual thought content and Suspiciousness) of schizophrenia were reasonably well perceived (above 70%) as indicating mental illness more than the other positive or negative symptoms. Even when the participants recognised that the symptoms indicated mental illness, not everyone recommended professional help.

CONCLUSION

There may be a need to improve public awareness of schizophrenia and psychosis symptoms, particularly regarding an awareness of the importance of early intervention for psychosis.

Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework

The duration of untreated illness (DUI), meaning the latency to the pharmacological treatment, has been increasingly investigated in the last decade as a predictor of outcome across different psychiatric conditions, particularly in psychotic disorders. DUI is essentially computed by subtracting the age of onset of a specific disorder from the age at which the first adequate pharmacological treatment is administered. Assessment of the latency to treatment represents one of the first steps in planning early interventions. This review examines the role of the DUI in psychotic and affective disorders, focusing on neuropathological, epidemiologic, clinical and prognostic factors related to a longer latency to treatment. Through a Medline and Cochrane Library search, relevant studies up to June 2011 and other pertinent articles including meta-analyses, randomized controlled trials, naturalistic studies and clinical reviews were identified. Converging evidence indicates that a prolonged DUI negatively influences the outcome of first-episode psychosis and schizophrenia in different ways, and increasing data point toward a similar conclusion in affective disorders. Even though methodological limitations related to investigation of the DUI need to be considered, research and interventions aimed to reduce latency to treatments are object of increasing implementation worldwide. The assessment of the DUI represents one of the most important parameters to consider in this perspective, in order to quantify different latency to treatment in specific disorders and to plan related, targeted interventions.

Managing the prodrome of schizophrenia

It is a well-known fact that managing schizophrenia patients as early as possible has a positive impact on the psychopathological and psychosocial outcomes of the disorder. Identifying people at risk for this serious disorder before its outbreak has become a major research aim in the past decade. Consequently, the intuitive notion that intervening at this early stage, before a diagnosis of schizophrenia is established, could be a preventive measure has been scientifically studied. In this context, a number of interventions, both pharmacological and psychosocial, have been evaluated in prospective controlled clinical trials. Amisulpride, olanzapine, risperidone, omega-3 fatty acids, and antidepressants have been compared to placebo or other control interventions and have been found somewhat helpful. With the exception of omega-3 fatty acids, however, the original positive findings were not maintained in follow-up studies. In addition, the rates of conversion to psychosis, although generally lower in the experimental treatment groups, were also reasonably low in the control groups. Similar findings have been established in psychotherapy trials.All evidence taken together makes it difficult to justify specific interventions at the prodromal stage of schizophrenia from the perspective of preventing or delaying the onset of the disorder. On the other hand, as many of the affected individuals suffer considerably, symptomatic treatment certainly is called for even though the evidence whether it should be pharmacological or psychosocial is not yet available.