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

Pathways to Mental Health Care in a Defined Geographic Area of Athens

The purpose of the present study was to explore the duration between the onset of psychopathology and the first contact either with a sectorized Community Mental Health Centre (CMHC) of Athens area or other mental health services, identify the pathways to the CMHC as well as possible sociodemographic and clinical factors affecting help-seeking behavior. The sample consisted of 355 individuals who visited the CMHC, but had sought help from another mental health care source prior to their visit to the Centre (group A), and was compared with 398 individuals who had no previous contact with any other psychiatric service (group B). The average duration of untreated mental disorders was found to be 19.85 (SD 23.113) for males of group A and 26.26 (SD 41.158) for males of group B. Among females the mean duration was found to be 18.11 (SD 27.293) for group A and 22.21 (SD 29.440) for group B, a statistically significant difference. In group A, the intervening services referred the clients at an earlier stage. The striking difference is that only eight individuals (2%) of group B (first timers) were diagnosed as suffering from schizophrenia contrasting to the 61 (17.4%) counterparts of group A. Individuals in our study diagnosed with psychosis seemed to have sought help first from other mental health services and delay to visit a CMHC. People who face problems resulting from their interpersonal or professional relationships often choose to have a first contact with a CMHC. Reduction of the delay in treatment will require clearer understanding of the contributing factors. Liaison activities with public and mental health sector services and outreach interventions to increase awareness on the early recognition of psychopathologic symptoms and the need for early referral could reduce the duration of untreated mental disorders.

Duration of Untreated Disorder and Cannabis Use: An Observational Study on a Cohort of Young Italian Patients Experiencing Psychotic Experiences and Dissociative Symptoms

BACKGROUND

The Duration of Untreated Psychosis (DUP) is the time between the first-episode psychosis (FEP) and the initiation of antipsychotic treatment. It is an important predictor of several disease-related outcomes in psychotic disorders. The aim of this manuscript is investigating the influence of cannabis on the DUP and its clinical correlates.

METHODS

During years 2014-2019, sixty-two FEP patients with and without cannabis use disorder (CUD) were recruited from several Italian psychiatric hospitals. The subjects were then divided into two groups based on the duration of the DUP and assessed at the beginning of the antipsychotic treatment and after 3 and 6 months, using the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF) scale, and the Dissociative Experiences Scale (DES-II).

RESULTS

As expected, a longer DUP was associated with worse symptoms and cannabis use did not seem to affect the DUP, but both were related with more dissociative symptoms at onset and over time.

DISCUSSION

According to our study, cannabis use can be a predictor of FEP and DUP, and of disease outcome. However, several factors might influence the relationship between cannabis use and DUP. Preventing cannabis use and early diagnosis of psychotic disorders might impact the disease by reducing the persistence of symptoms and limiting dissociative experiences.

Gender-specific experiences of serious mental illness in rural Ethiopia: A qualitative study

Considerable variation in the gender-specific prevalence of serious mental illness (SMI) has been reported in low- and middle-income countries (LMICs). In the rural setting of Butajira, Ethiopia, the male-to-female prevalence ratio of schizophrenia was reported to be 5:1. This qualitative study explores gender-specific experiences of SMI and the extent to which sociocultural factors may explain the observed difference in prevalence estimates. Using purposive sampling, 39 in-depth interviews were conducted with community members from Butajira, a rural district in South Central Ethiopia. Transcripts were analysed using thematic analysis to elicit community perspectives on cultural explanatory models of SMI and experiences in this region. Gender-specific experiences were reported to differ due to visibility of symptoms, community responses, and varying levels of family support towards individuals with SMI. Overall, respondents described how various sociocultural factors subject women with SMI to higher levels of physical and social isolation compared to men, greatly affecting community health workers' ability to identify and provide care to women with mental illness. Future case detection methods should involve family members as they interact with women with SMI early on in the development of their symptoms and play an essential role in their path to mental health care.

Improving access to Early Intervention in Psychosis (EIP): the 2-week wait for cancer comes to psychosis

Early Intervention in Psychosis (EIP) services aim to rapidly initiate specialist packages of care for those people newly experiencing symptoms. The intention of such rapid engagement is to mitigate the negative effects of a prolonged duration of untreated psychosis. Aiming to achieve a ‘parity of esteem’ between mental and physical health, a new target was introduced by the National Health Service (NHS) England, where 50% of new referrals were expected to receive a concordant package of care within 2 weeks from the National Institute for Health and Care Excellence. A baseline assessment in late 2014 found that just 21% of all referrals received and accepted met this target within the EIP Team for the North-East London NHS Foundation Trust. This project sought to improve the team’s performance, seeking input from all team members and using an iterative process with the primary aim of meeting the target ahead of its roll-out. It was determined that the relatively high number of inappropriate referrals (34% at baseline) is a key causative agent in delaying staff from processing eligible cases in a timely fashion. These are defined as referrals which do not meet basic eligibility criteria such as no previous treatment for psychosis. Interventions were therefore designed targeting three domains of improving staff awareness of the new target, improving efficiency by changing the case allocation process and improving the referral pathway for external sources. The impact of these changes was re-evaluated over two cycles beyond baseline. By the final cycle, 62% of new referrals were seen within 2 weeks, while inappropriate referrals declined to just 3%. The multi-interventional nature of this project limits its generalisability and further work should be carried out to identify those changes that were most impactful. Nevertheless, focused targeting of the referral pathway may prove to be of benefit to other EIP services struggling with lengthy wait times.

Untreated illness and recovery in clients of an early psychosis intervention program: a 10-year prospective cohort study

PURPOSE

To investigate whether duration of untreated psychosis (DUP) and duration of untreated illness (DUI) are associated with measures of both subjective and objective recovery 10 years after a first episode of psychosis.

METHODS

A cohort of 65 clients from an early psychosis intervention program completed a battery of outcome measures 10 years following initial treatment for first-episode psychosis (FEP). The outcomes of interest were self-perceived recovery scores (Maryland Assessment of Recovery in People with Serious Mental Illness Scale) and occupational activity, defined as engagement in work and/or school on a full/part-time basis. Multiple linear and logistic regression analyses were used to estimate the associations between DUP and DUI with each measure of recovery, adjusting for potential confounding factors.

RESULTS

We did not find a statistically significant association between DUP and either occupational activity (OR = 1.26, 95% CI 0.81-1.95) or self-perceived recovery score (β = - 0.73, 95% CI - 2.42 to 0.97). However, we found a significant negative association between DUI and self-perceived recovery score (β = - 0.52, 95% CI - 0.87 to - 0.16).

CONCLUSIONS

Our findings suggest that DUI may have a stronger influence than DUP on recovery from FEP at 10-year follow-up. This suggests the potential value in targeted interventions for people with a long DUI to increase the likelihood of achieving recovery after the first episode of psychosis.

Barriers to Seeking Early Psychiatric Treatment amongst First-episode Psychosis Patients: A Qualitative Study

AIMS

The aim of this study was to explore the family members' determinant of the delay in seeking psychiatric care to patients diagnosed with psychosis.

METHODS

Qualitative semi-structured interviews were carried out with twenty-seven family members of patients with psychosis at psychiatric outpatient clinics in Amman, Jordan.

RESULTS

The findings revealed that perceived stigma and fears about being labelled are the main barriers to requesting early psychiatric health care. The participants cited many different reasons linked to finding help led to delay in seeking help in the early stages of the illness including misattribution of the cause and symptoms of mental illness, family and financial factors.

CONCLUSIONS

The study highlights the importance of enhancing knowledge about the schizophrenia-related spectrum to ensure patients seek treatment in a more timely manner.

Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis

Family interventions for psychosis (FIp) are effective in reducing service user relapse and carer distress in people with schizophrenia-spectrum conditions. Several treatment and best practice guidelines recommend FIp for all people with schizophrenia. However, outcome findings in relation to early psychosis groups have been inconsistent. The current paper reports a systematic review and meta-analyses of articles that evaluated FIp in early psychosis with a clearly defined comparison group. A combination of electronic database searches (using PsychINFO, Medline, and CENTRAL), citation searches and hand searches of key journals and reviews was conducted. Peer-reviewed articles published in English from database inception to June 2016 were included. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Seventeen papers from 14 studies met inclusion criteria for review, the overall quality of which was moderate. Meta-analytic synthesis showed that FIp improved service user functioning and reduced the likelihood of relapse by the end of treatment. Psychotic symptoms were significantly reduced in the FIp group at follow up, but this was not evident at end of treatment. In terms of FIp target mechanisms, carers receiving FIp were more likely to shift from high to low expressed emotion and less likely to report patient focused criticism or engage in conflict communication than carers randomized to standard care. Carer burden and well-being were improved by the end of treatment but gains were not sustained at follow up. FIp had no impact on carer emotional over-involvement. The findings indicate that FIp is an effective intervention for early psychosis service users and their relatives. However, further research is required to establish which key therapeutic components of FIp are most effective for whom, in addition to understanding the mechanisms by which FIp might affect positive change.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Duration of untreated psychosis (DUP) and the course of schizophrenia in a 20-year follow-up study

Our aims were to analyze the relationship between the duration of psychosis (DUP) and short- and long-term outcomes of treatment, and to determine the cut-off point between short and long DUP at which differences in treatment outcomes are most significant. We assessed 80 participants with schizophrenia at the point of their first hospitalization. Fifty participated in all four follow-ups over 20 years. DUP was divided into short (up to 6 months) and long (over 6 months). ANOVA and Chi-square tests were employed to identify significant differences in both clinical and social indicators of functioning. ROC curves were used to estimate the best DUP division point. Significant differences favoring the short-DUP group were found for: GAF, total severity of symptoms and severity of positive symptoms, social functioning measured according to DSM-III criteria, employment, and social contacts. The optimal cut-off point for DUP was the 23rd week. We concluded that: (1) the relationship between longer DUP and worse overall treatment outcomes was sustained throughout the 20 years, (2) a positive correlation between DUP and the severity of psychopathological symptoms was observed over the first 12 years of illness, (3) the results indicate the efficacy of early therapeutic interventions in psychosis.

Duration of untreated psychosis and clinical outcomes of first-episode schizophrenia: a 4-year follow-up study

Background

The relationship between the duration of untreated psychosis and long-term clinical outcomes remains uncertain.

Objective

Prospectively assess the relationship of the duration of untreated psychosis on clinical outcomes in a sample of individuals with first-onset schizophrenia treated at the Pudong Mental Health Center from January 2007 to December 2008.

Methods

Information about general health, psychotic symptoms and social functioning were collected using the Brief Psychiatric Rating Scale (BPRS), Treatment Emergent Symptom Scale (TESS), Morningside Rehabilitation Status Scale (MRSS), and Social Disability Screening Schedule (SDSS) at baseline and in June 2010 and June 2012.

Results

The 43 individuals with first-episode schizophrenia participating in the study were divided into short (<24 weeks) and long (>24weeks) duration of untreated psychosis (DUP) groups. The mean (sd) duration of follow-up was 1197 (401) days in the short DUP group and 1412 (306) days in the long DUP group (t=9.98, p=0.055). Despite less prominent psychotic symptoms at the time of first diagnosis among patients who had a long DUP compared to those with a short DUP (BPRS mean scores, 42.5 [8.4] v. 50.0 [10.6], t=2.42, p=0.0210) and a similar number of clinical relapses (based on positive symptoms assessed by the BPRS), patients with a long DUP were more likely to require hospitalization at the time of first diagnosis (52% [11/21] v. 9% [2/22], χ²=9.55, p=0.002) and more likely to require re-hospitalization during the first two years of treatment (67% [14/21] v. 32% [7/22], χ²=5.22, p=0.022). Moreover, after four years of routine treatment, despite a similar severity of positive symptoms, patients who had had a long DUP prior to initiating treatment had significantly poorer social functioning than those who had had a short DUP (SDSS mean scores, 7.0 [5.2] v. 3.4 [4.9], t=2.20, p=0.035).

Conclusions

These findings show that despite having a similar level of psychotic symptoms – as measured by the BPRS – compared to patients with a short DUP, patients with schizophrenia who have a long DUP prior to initial treatment have poorer long-term social functioning. This confirms the clinical importance of the early recognition and treatment of individuals with chronic psychotic conditions.

Association between the duration of untreated psychosis and short- and long-term outcome in schizophrenia within the Northern Finland 1966 Birth Cohort

BACKGROUND

Long duration of untreated psychosis (DUP) may relate to poor outcome in schizophrenia. However, the associations between DUP and outcomes, particularly in later course of illness, remain unclear. Our aim was to explore the associations between DUP and short- and long-term outcomes in schizophrenia.

METHODS

Data was collected for subjects with schizophrenia (n=89) in the population-based Northern Finland 1966 Birth Cohort. DUP was obtained from medical records, and its associations with short- (under 2years) and long-term clinical and social outcomes were assessed extending to 20years after the onset of the illness.

RESULTS

Longer DUP predicted longer length of first hospitalisation and increased the risk of rehospitalisation during the first two years. Longer DUP associated with decreased probability of disability pension, smaller amount of time spent in hospital, and higher proportion of time at work during the first 10years of the follow-up.

CONCLUSIONS

Regarding early outcome, long DUP may be a modest marker and proxy measure of a more severe clinical phenotype. The divergent results of earlier studies and the association between long DUP and better long-term outcome in our study, indicate that the length of DUP does not necessarily predict poor outcome in long-term follow-up. This may also be due to methodical difficulties, e.g. insufficient power and residual confounding linked to long follow-up studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intervention for first episode psychosis in India - The SCARF experience

INTRODUCTION

There have been very few studies or programs in India on early intervention for first episode psychoses. This paper reports the findings of a pilot program, part of a collaboration with the Prevention and Early Intervention Program for Psychoses, Montreal.

METHODOLOGY

A sample of 47 patients with first episode psychosis were followed up for 2 years. Complete data was available on 39 subjects at 2 years. This data was analyzed for socio-demographic and clinical variables and its relationship with outcomes and DUP. Those who had a PANSS score <60 and GAF >80 were categorized to be in remission (N=28) and others as continually ill (N=10).

RESULTS

There was significant improvement from baseline to 1st year with maximal improvement seen at 3 months after intake. However, improvement between 1 and 2 years was not significant. More women relapsed and more men dropped out. 25 out of 28 subjects with shorter DUP (<2 years) were in remission at 2 years as against 3 out of 10 with >2 years DUP. Three different patterns of course of the disorder were found. Single episode followed by total remission for 2 years (N=20; 52.6%) was the commonest. The others were relapses followed by remissions (N=8; 21.1%), and continuous illness (N=10; 26.3%).

CONCLUSION

Early intervention is effective and more so if DUP is shorter. PANSS scores and GAF at baseline are not predictive of later outcomes. Medication adherence in therapeutic engagement and psychosocial needs should be considered in the implementation of early intervention programs in our cultural context.