Prospective study of duration of untreated psychosis and outcome of never-treated patients with schizophrenia in India

Duration of untreated psychosis and associated sociodemographic and clinical factors in first-episode psychosis: A study from Eastern Nepal

OBJECTIVE

Duration of untreated psychosis (DUP) is considered an important factor in outcome. Individual, familial and illness factors may prolong DUP. Little data on this issue is available from the country of Nepal. The purpose of the present study was to assess DUP in patients with first-episode psychosis and identify associations with patients' sociodemographic and clinical factors.

METHODS

A cross-sectional, descriptive study was conducted in the department of psychiatry at Tertiary Hospital in the Eastern part of Nepal. Eighty-six patients were enrolled. ICD-10 was used to make the diagnosis. The Nottingham Onset Schedule-DUP version (NOS-DUP) was used to assess DUP. Positive and Negative Syndrome Scale (PANSS) was used to assess patients' clinical symptoms.

RESULTS

The mean (SD) DUP was 21.4 (42.1) months and median DUP was 3.0 months (IQR = 23.5). Participants from mountainous regions, those who were unemployed, having an insidious onset of illness, and patients with a diagnosis of schizophrenia had significantly longer DUP (P < .005). Duration of untreated psychosis was also positively correlated with negative symptoms (r = .42, P < .001) and total PANSS score (r = .42, P < .001).

CONCLUSION

Duration of untreated psychosis in first-episode psychotic patients was relatively long (compared to studies in other countries) and was found to be positively associated with living in mountainous regions of Nepal, being unemployed, having an insidious onset of illness, and having a diagnosis of schizophrenia. Programs and educational efforts are needed to ensure early treatment of patients with first-episode psychosis, especially in the mountainous rural areas of Nepal.

Identification of youth at clinical high-risk for psychosis: A community-based study from India

AIM

A two-stage process, wherein self-report screening precedes the structured interview, is suggested for identifying individuals at clinical high-risk for psychosis (CHR-P) in community samples. Aim of this study was to screen a community youth sample from India for CHR-P using the two-stage method. Specific objectives were to assess concordant validity of the self-report measure and predictive validity of the two-stage method.

METHODS

Based on probability sampling, 2025 youth aged 15-24 years were recruited from one rural and one urban area of Telangana, a Telugu-speaking state in India. Telugu version of the PRIME Screen-Revised (PS-R) and structured interview for psychosis-risk syndromes (SIPS) were used. CHR-P positive and negative cohorts were followed-up for transition to psychosis at 3-monthly intervals.

RESULTS

One hundred ten individuals screened positive on PS-R. SIPS conducted on 67 out of 110 individuals confirmed 62 (92.54%) to be CHR-P positive. PS-R showed 98.41% sensitivity and 90.74% specificity. Among CHR-P positive, three participants transitioned to psychosis in 15 months. The hazard ratio for psychosis transition was 11.4.

CONCLUSIONS

Screening accuracy of PS-R in the community youth sample in Telangana is optimum. The hazard ratio for psychosis transition in the community identified CHR-P indicates good predictive validity for the two-stage method.

"Short" Versus "Long" Duration of Untreated Psychosis in People with First-Episode Psychosis: A Systematic Review and Meta-Analysis of Baseline Status and Follow-Up Outcomes

BACKGROUND AND HYPOTHESIS

Duration of untreated psychosis (DUP) has been linked to worse mental health outcomes in psychotic disorders. We meta-analytically studied the relationship between "long" vs. "short" DUP and mental health outcomes.

STUDY DESIGN

This PRISMA/MOOSE-compliant meta-analysis searched for nonoverlapping individual studies from database inception until November 01, 2023, reporting data from author-defined "short"/"long" DUP (according to author's definition) in patients with first-episode psychosis (FEP). We compared differences between "short"/"long" DUP groups at baseline and/or follow-up in continuous and binary outcomes. We conducted random-effects meta-analyses, stratified analyses, heterogeneity analyses, meta-regression analyses, and quality assessment (PROSPERO: CRD42023479321).

STUDY RESULTS

From 16,055 citations, 34 studies were included (n = 6,425, age = 27.5 ± 7.1 years, males = 60.4%, white = 70.2%, DUP: mean = 60.8 ± 43.8 weeks, median = 52.5, interquartile range = 31.3, 68.0 weeks, follow-up = 19.2 ± 35.0 months). The definition of "short"/"long" varies significantly between the studies. Compared to "short" DUP (mean = 10.2 ± 11.2 weeks), "long" DUP (mean = 58.8 ± 76.4 weeks) was associated with higher baseline Positive and Negative Syndrome Scale (PANSS) negative (k = 14, ES = 0.45, 95%CI = 0.16, 0.74) and Scale for the Assessment of Negative Symptoms (k = 7, ES = 0.29, 95%CI = 0.11, 0.47) scores, lower remission (k = 7, OR = 0.40, 95%CI = 0.24, 0.67) and more suicide attempts (k = 4, OR = 2.01, 95%CI = 1.36, 2.96). At follow-up, compared to "short" DUP, "long" DUP was associated with lower Global Assessment of Functioning (k = 4, ES = -0.63, 95%CI = -0.83, -0.43) and higher PANSS negative subscale scores (k = 5, ES = 0.66, 95%CI = 0.05, 1.27).

CONCLUSIONS

In FEP, longer DUP is related to greater baseline negative symptoms, less remission, and more suicide attempts, as well as greater postbaseline negative symptom severity and functional disability. To what degree longer DUP contributes to poorer outcomes or whether DUP only correlates with these outcomes requires further study. A greater consensus on the definition of long DUP is needed to make comparisons between studies more feasible.

Short-term Clinical Outcome of Previously Untreated and Treated Schizophrenia and Impact of Duration of Untreated Psychosis

Background

Duration of untreated psychosis (DUP) is an important modifiable factor affecting schizophrenia outcomes. A dearth of research in India on untreated versus treated schizophrenia warrants further research.

Methods

This was a longitudinal study in a tertiary hospital over 2 years. Inpatients diagnosed with schizophrenia (N = 116), aged 18-45, were divided into untreated and treated groups. Diagnostic confirmation, severity assessment, and clinical outcome were done using ICD-10 criteria, Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impression (CGI) scale. Follow-up was done at 12 and 24 weeks. DUP was measured, and its association with the outcome was assessed.

Results

Final analysis included 100 patients, 50 each of previously untreated and treated. Untreated patients had lower age and duration of illness (DOI), but higher DUP (p < .001). Treated patients showed much improvement on CGI-I at 12 weeks (p = .029), with no difference at 24 weeks. PANSS severity comparison showed no difference, and both groups followed a declining trend. In untreated patients, age of onset (AoO) was negatively correlated with severity (except general symptoms at baseline) at all follow-ups ('r' range = -0.32 to -0.49, p < .05), while DOI showed a positive correlation with negative and general symptoms at 12 weeks (r ~ 0.3, p < .05). Treated patients showed inconsistent and lower negative correlation between AoO and PANSS, with no correlation between severity and DOI. The mean sample DUP was 17.9 ± 31.6 weeks; it negatively correlated with education (r = -0.25, p = .01) and positively with PANSS severity ('r' range = 0.22 to 0.30, p < .05) at all follow-ups, especially negative symptoms. Patients with no or minimal improvement on CGI at 24 weeks had higher DUP (Quade's ANOVA F[1,98] = 6.24, p = .014).

Conclusion

Illness variables in untreated schizophrenia affect severity, which has delayed improvement than treated schizophrenia. Higher DUP is associated with negative symptoms of schizophrenia.

Evaluating construct and criterion validity of NeuroScreen in assessing neurocognition among hospitalized Ugandan first-episode psychosis patients

Introduction

Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda.

Methods

We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion.

Results

There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [r(112) = 0.64, p < .001]. Small to large correlations were found between tests in the MCCB and NeuroScreen batteries. The ROC curve of NeuroScreen performance to detect MCCB-defined NCI had an area under curve of 0.80 and optimal sensitivity and specificity of 83 % and 60 %, respectively.

Conclusion

There was a moderate positive correlation between overall performance on both batteries. NeuroScreen shows promise as a valid assessment battery to assess neurocognition and detect NCI in FEP patients in Uganda. Further studies of NeuroScreen in healthy individuals and in a range of mental disorders are recommended.

An exploratory evaluation of predictors of duration of untreated psychosis in first-episode psychosis in lower income patients

A longer duration of untreated psychosis (DUP) may adversely affect the course and impact of the illness. Little is known about predictors of duration of untreated psychosis in lower socioeconomic strata (SES) in urban India. We examined variables associated with DUP in 60 urban lower SES patients diagnosed with first-episode, untreated psychosis. Instruments used included the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF), the UCLA Social Attainment Scale (SAS), and the Stigma Subscale from the Family Interview Schedule. The mean age of the sample was 30.5 years. The sample was 50% male. Most patients (90%) were living in a nuclear family. The median DUP was 120 days. DUP was <6 months in 31.7% of the sample and >2 years in 23.3%. A third of the sample had been taken to faith healers before being brought into medical care. DUP was not significantly associated with age, sex, religion, education, family history of mental illness, marital status, employment status, income, substance use, PANSS subscale and total scale scores, and GAF scores. Presence of an antecedent stressor, acute onset of psychosis, presence of medical co-morbidities, lower stigma scores, and higher SAS scores were significantly associated with shorter DUP.

Social cognition in patients with first episode of psychosis in remission

AIM

The present study aimed to compare the social cognition (SC) deficits in patients with first-episode psychosis (FEP) and healthy controls and evaluate the association of SC deficits with socio-occupational functioning, insight, quality of life, and stigma.

METHODS

This study included 30 patients with FEP in remission phase and 26 healthy controls matched for age, gender, education, and intelligent quotient. SC was assessed on the domains of theory of mind (ToM), social perception, and attributional bias.

RESULTS

Compared to healthy controls, patients with FEP had significantly higher deficits in the domains of second-order ToM (unpaired t = 4.447, P < 0.001) and Faux Pas Composite Index (unpaired t = 2.824, P = 0.007). In the correlation analysis, higher age of patients with FEP was significantly associated with more externalizing bias (Pearson's correlation coefficient = 0.38, P = 0.039) and those with lower level of education had more social cognitive deficits in the domains of Faux Pas Composite Index (Pearson's correlation coefficient = 0.43, P = 0.018), Social Perception Index (Pearson's correlation coefficient = 0.38, P = 0.04), and Nonsocial Perception Index (Pearson's correlation coefficient = 0.5, P = 0.005). Duration of untreated psychosis was associated with higher deficits in the first-order ToM (Pearson's correlation coefficient = -0.38, P = 0.04) and Externalizing Bias Index (Pearson's correlation coefficient = -0.49, P = 0.006). Longer duration of treatment was associated with higher impairment in first-order ToM index (Pearson's correlation coefficient = -0.42, P = 0.02). General psychopathology and total Positive and Negative Syndrome Scale total score correlated significantly with externalizing bias, with a higher level of psychopathology associated with more severe deficits in this domain. There was no correlation of SC with the quality of life, cognitive insight, and stigma (except for occasional correlation of stereotype endorsement and externalizing bias).

CONCLUSION

The present study suggests that compared to healthy controls, patients with FEP have impairment in the domains of second-order ToM and Faux Pas Composite Index. However, social cognitive deficits have only a few correlations with various psychosocial outcomes of FEP.

Advancing study of cognitive impairments for antipsychotic-naïve psychosis comparing high-income versus low- and middle-income countries with a focus on urban China: Systematic review of cognition and study methodology

BACKGROUND

Comparing the course of antipsychotic-naïve psychosis in low- and middle-income countries (LMIC) may help to illuminate core pathophysiologies associated with this condition. Previous reviews-primarily from high-income countries (HIC)-identified cognitive deficits in antipsychotic-naïve, first-episode psychosis, but did not examine whether individuals with psychosis with longer duration of untreated psychosis (DUP > 5 years) were included, nor whether LMIC were broadly represented.

METHOD

A comprehensive search of PUBMED from January 2002-August 2018 identified 36 studies that compared cognitive functioning in antipsychotic-naïve individuals with psychosis (IWP) and healthy controls, 20 from HIC and 16 from LMIC.

RESULTS

A key gap was identified in that LMIC study samples were primarily shorter DUP (<5 years) and were primarily conducted in urban China. Most studies matched cases and controls for age and gender but only 9 (24%) had sufficient statistical power for cognitive comparisons. Compared with healthy controls, performance of antipsychotic-naïve IWP was significantly worse in 81.3% (230/283) of different tests of cognitive domains assessed (90.1% in LMIC [118/131] and 73.7% [112/152] in HIC).

CONCLUSIONS

Most LMIC studies of cognition in antipsychotic-naïve IWP adopted standardized procedures and, like HIC studies, found broad-based impairments in cognitive functioning. However, these LMIC studies were often underpowered and primarily included samples typical of HIC: primarily male, young-adult, high-school educated IWP, in their first episode of illness with relatively short DUP (<5 years). To enhance understanding of the long-term natural course of cognitive impairments in untreated psychosis, future studies from LMIC should recruit community-dwelling IWP from rural areas where DUP may be longer.

The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies

Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.

Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol

BACKGROUND

The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts.

METHODS

One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy).

DISCUSSION

Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.

Improving detection of mental health problems in community settings in Nepal: development and pilot testing of the community informant detection tool

Background

Despite increasing efforts to expand availability of mental health services throughout the world, there continues to be limited utilization of these services by persons with mental illness and their families. Community-based detection that facilitates identification and referral of people with mental health problems has been advocated as an effective strategy to increase help-seeking and service utilization. The Community Informant Detection Tool (CIDT) was developed for the community informants to identify people with depression, psychosis, alcohol use problems, epilepsy, and child behavioral problems in community settings. The CIDT has been validated in Nepal and found to be effective in promoting treatment initiation. To facilitate replication in other settings, this paper describes the development process of CIDT and the steps to achieve comprehensibility, utility and feasibility.

Methods

The CIDT was developed in four steps. First, case vignettes and illustrations were created incorporating local idioms of distress for symptoms of each disorder with an expert panel of 25 Nepali mental health professionals. Second, the utility of a draft tool was assessed through focus group discussions (n = 19) and in-depth interviews (n = 6). Third, a practice run was conducted assessing applicability of the tool through IDI among purposively selected community informants (n = 8). Finally, surveys were administered to 105 community informants to assess feasibility.

Results

The first through third steps led to modifications in the format and presentation of the CIDT. The pilot test found CIDT to be comprehensible and feasible for detection and referral of all conditions except child behavioral problems. Female community health volunteers were recommended as the most appropriate persons to utilize the CIDT.

Conclusion

Community-based detection using the CIDT for persons in need of mental health care is perceived to be useful and feasible by key community stakeholders who would integrate the tool into their daily activities.

Electronic supplementary material

The online version of this article (10.1186/s13031-017-0132-y) contains supplementary material, which is available to authorized users.

Do stress and support matter for caring? The role of perceived stress and social support on expressed emotion of carers of persons with first episode psychosis

BACKGROUND

Caring for a person with first episode psychosis (FEP) is a challenging and distressing task for the carers. The carers' stress in the early stage of psychosis can increase their expressed emotion (EE) while social support is hypothesized to decrease EE. However, the influence of stress and social support on carers' EE is not well understood in FEP.

AIM

To examine how the stress and social support shape expressed emotion in the carers of FEP.

METHODS

Seventy one carers of the patients with non-affective FEP were recruited from the inpatient psychiatry ward of a tertiary mental health care center in South India. The family questionnaire, perceived stress scale and multidimensional scale of perceived social support were used to measure their EE, stress and social support respectively.

RESULTS

Carers experienced high level of perceived stress, EE and poor social support. Perceived stress significantly increased EE (β=0.834; p<0.001) and social support did not significantly influence EE (β=-0.065; p>0.05). Perceived stress predicted 76 percent of the variance on EE (Adjusted R²=0.761).

CONCLUSION

The results emphasize high level of stress and EE in carers of patients with FEP that implies the need for appropriate psychosocial interventions to manage their stress.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

Factors Affecting Well-being and Socio-occupational Functioning in Schizophrenia Patients Following an Acute Exacerbation: A Hospital Based Observational Study

BACKGROUND

Improving functioning levels are an important goal of treatment in schizophrenia. Most studies have described long-term course and outcome in schizophrenia. However, understanding factors influencing functioning in the immediate recovery period following an acute exacerbation may be of important clinical relevance.

AIM

The aim of this study is to assess the factors that influence well-being and socio-occupational functioning following an acute exacerbation in schizophrenia patients.

MATERIALS AND METHODS

The study included 40 patients during the period from June 2013 to June 2014. The possible effect of gender, duration of illness, duration of untreated psychosis, premorbid adjustment, cognitive impairment, facial affect perception and treatment compliance on well-being, and socio-occupational functioning was examined.

RESULTS

About 45% of the individuals experienced below average well-being. On logistic regression analysis poor compliance with medication and poorer cognitive functioning significantly differentiated the patient group with below average well-being from those with an above average well-being. Male gender, poor premorbid adjustment, poor compliance to treatment, poor cognitive functioning, and greater duration of untreated psychosis were found to be associated with a poorer socio-occupational functioning.

CONCLUSION

Clinical interventions focusing on improving cognitive impairment and compliance to treatment could play a role in improving well-being, and socio-occupational functioning in schizophrenia patients following an acute exacerbation.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

Predictors of response to second generation antipsychotics in drug naïve patients with schizophrenia: a 1 year follow-up study in Shanghai

Response and remission are of great importance to patients with first-episode schizophrenia. Although previous researches have revealed characteristics related to medication response, there is rarely data over remission-related factors. We presume that factors correlated to response may also influence remission in 1 year treatment for first-episode schizophrenia. 398 drug-naïve patients met the criteria of schizophrenia using ICD-10 criteria were recruited from Shanghai Mental Health Center and treated with one of three second generation antipsychotics (risperidone, olanzapine or quetiapine). Patients were followed up for 1 year and assessed at 2 weeks, and then 2, 3, 6, 8 and 12 months. Severity of symptom was evaluated using the Chinese version of the Positive and Negative Syndrome Scale (PANSS). Response was defined as a reduction of 50% or more PANSS scores. The 8-item criteria of remission (proposed by the Remission of Schizophrenia Working Group) were used. Logistic regression analysis revealed that shorter duration of untreated psychosis (DUP), longer treatment time, higher baseline PANSS positive score and higher PANSS general pathological scores predicted response, and acute prodromal phase was the independent factor for remission. These results indicate baseline characters that related to response and those related to remission may be different for patients with schizophrenia.

Substance use disorders among treatment naïve first-episode psychosis patients

OBJECTIVES

To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India.

METHODS

The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients.

RESULTS

Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen.

CONCLUSION

The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK.

Duration of untreated psychosis in a high-income versus a low- and middle-income region

OBJECTIVE

Most data on duration of untreated psychosis (DUP) derives from high-income countries. An inverse relationship between DUP and income and a longer DUP in low- and middle-income (LAMI) countries has been reported. The aim of this study was to compare DUP in a high-income country with that in a LAMI country using the same methodology.

METHODS

The sample consisted of in- and outpatients, aged 15-35 years for the Vienna site and 18-35 years for the Pakistani sites, with first-episode psychosis (FEP). DUP was evaluated using psychiatric interviews, medical charts and the Nottingham Onset Schedule. Differentiated reporting of duration of untreated illness (DUI) from prodrome to start of treatment, and DUP from manifest psychotic symptoms to start of treatment was ensured. Primary outcome measures, DUI and DUP, were measured at a 0.025 level of significance.

RESULTS

Thirty-one FEP patients in Vienna (mean age 20.03 years, SD 4.2) and 60 FEP patients from the Pakistani sites (mean age 26.15 years, SD 5.29) participated. The mean age in Vienna was younger due to the different age range inclusion criteria. The severity of psychopathology was more pronounced in the Pakistani sample. Log DUP was significantly different between groups (i.e. longer in the Pakistani sample (p=0.001)). Log DUI showed a trend for longer duration in the Vienna sample; however, this did not reach statistical significance (p=0.036). The severity of positive psychotic symptoms was associated with length of DUI in both regions.

CONCLUSION

The longer DUP in Pakistan confirms the need to provide affordable treatment for psychosis for young FEP patients in Pakistan and in other LAMI countries. The relatively long period from prodrome to treatment initiation in both regions underlines the need to further establish low-threshold early intervention strategies in order to increase detection rates and reduce factors limiting patients seeking treatment.

Early intervention in schizophrenia in developing countries: focus on duration of untreated psychosis and remission as a treatment goal

Early intervention services are based on the premise that untreated psychosis may have a deleterious effect on outcome, particularly in the early years of illness. The majority of the studies on duration of untreated psychosis have been conducted in developed countries; therefore this review focuses on publications from developing countries. We also review studies from developing countries that have been published following the Remission in Schizophrenia Working Group criteria. The duration of untreated psychosis is longer in developing countries, and is also associated with poor outcome, whereas remission rates following treatment of first-episode schizophrenia in developing countries appear to be higher than in developed countries. These two findings strongly argue for the establishment of early intervention services for schizophrenia in developing countries.