Examining the Effectiveness of a Digital Media Campaign at Reducing the Duration of Untreated Psychosis in New York State: Results From a Stepped-wedge Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

Longer duration of untreated psychosis (DUP) predicts worse outcomes in First Episode Psychosis (FEP). Searching online represents one of the first proactive step toward treatment initiation for many, yet few studies have informed how best to support FEP youth as they engage in early online help-seeking steps to care.

STUDY DESIGN

Using a stepped-wedge randomized design, this project evaluated the effectiveness of a digital marketing campaign at reducing DUP and raising rates of referrals to FEP services by proactively targeting and engaging prospective patients and their adult allies online.

STUDY RESULTS

Throughout the 18-month campaign, 41 372 individuals visited our website, and 371 advanced to remote clinical assessment (median age = 24.4), including 53 allies and 318 youth. Among those assessed (n = 371), 53 individuals (14.3%) reported symptoms consistent with psychotic spectrum disorders (62.2% female, mean age 20.7 years) including 39 (10.5%) reporting symptoms consistent with either Clinical High Risk (ie, attenuated psychotic symptoms; n = 26) or FEP (n = 13). Among those with either suspected CHR or FEP (n = 39), 20 (51.3%) successfully connected with care. The campaign did not result in significant differences in DUP.

CONCLUSION

This study highlights the potential to leverage digital media to help identify and engage youth with early psychosis online. However, despite its potential, online education and professional support alone are not yet sufficient to expedite treatment initiation and reduce DUP.

Duration of untreated psychosis and its 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' socio-demographic and clinical factors.

METHODS

A cross-sectional, descriptive study was conducted in the department of psychiatry, of Tertiary Hospital in the Eastern part of Nepal. Eighty-six patients were enrolled. ICD-10 was used to make the diagnosis. 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 region, the 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 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.

Time is the enemy: Negative symptoms are related to even slight differences in the duration of untreated psychosis

BACKGROUND

Negative symptoms (NS) represent a detrimental symptomatic domain in schizophrenia affecting social and occupational outcomes.

AIMS

We aimed to identify factors from the baseline visit (V1) - with a mean illness duration of 0.47 years (SD = 0.45) - that predict the magnitude of NS at the follow-up visit (V3), occurring 4.4 years later (mean +/- 0.45).

METHOD

Using longitudinal data from 77 first-episode schizophrenia spectrum patients, we analysed eight predictors of NS severity at V3: (1) the age at disease onset, (2) age at V1, (3) sex, (4) diagnosis, (5) NS severity at V1, (6) the dose of antipsychotic medication at V3, (7) hospitalisation days before V1 and; (8) the duration of untreated psychosis /DUP/). Secondly, using a multiple linear regression model, we studied the longitudinal relationship between such identified predictors and NS severity at V3 using a multiple linear regression model.

RESULTS

DUP (Pearson's r = 0.37, p = 0.001) and NS severity at V1 (Pearson's r = 0.49, p < 0.001) survived correction for multiple comparisons. The logarithmic-like relationship between DUP and NS was responsible for the initial stunning incremental contribution of DUP to the severity of NS. For DUP < 6 months, with the sharpest DUP/NS correlation, prolonging DUP by five days resulted in a measurable one-point increase in the 6-item negative symptoms PANSS domain assessed 4.9 (+/- 0.6) years after the illness onset. Prolongation of DUP to 14.7 days doubled this NS gain, whereas 39 days longer DUP tripled NS increase.

CONCLUSION

The results suggest the petrification of NS during the early stages of the schizophrenia spectrum and a crucial dependence of this symptom domain on DUP. These findings are clinically significant and highlight the need for primary preventive actions.

Duration of Untreated Psychosis and Outcomes in First-Episode Psychosis: Systematic Review and Meta-analysis of Early Detection and Intervention Strategies

BACKGROUND

The role of duration of untreated psychosis (DUP) as an early detection and intervention target to improve outcomes for individuals with first-episode psychosis is unknown.

STUDY DESIGN

PRISMA/MOOSE-compliant systematic review to identify studies until February 1, 2023, with an intervention and a control group, reporting DUP in both groups. Random effects meta-analysis to evaluate (1) differences in DUP in early detection/intervention services vs the control group, (2) the efficacy of early detection strategies regarding eight real-world outcomes at baseline (service entry), and (3) the efficacy of early intervention strategies on ten real-world outcomes at follow-up. We conducted quality assessment, heterogeneity, publication bias, and meta-regression analyses (PROSPERO: CRD42020163640).

STUDY RESULTS

From 6229 citations, 33 intervention studies were retrieved. The intervention group achieved a small DUP reduction (Hedges' g = 0.168, 95% CI = 0.055-0.283) vs the control group. The early detection group had better functioning levels (g = 0.281, 95% CI = 0.073-0.488) at baseline. Both groups did not differ regarding total psychopathology, admission rates, quality of life, positive/negative/depressive symptoms, and employment rates (P > .05). Early interventions improved quality of life (g = 0.600, 95% CI = 0.408-0.791), employment rates (g = 0.427, 95% CI = 0.135-0.718), negative symptoms (g = 0.417, 95% CI = 0.153-0.682), relapse rates (g = 0.364, 95% CI = 0.117-0.612), admissions rates (g = 0.335, 95% CI = 0.198-0.468), total psychopathology (g = 0.298, 95% CI = 0.014-0.582), depressive symptoms (g = 0.268, 95% CI = 0.008-0.528), and functioning (g = 0.180, 95% CI = 0.065-0.295) at follow-up but not positive symptoms or remission (P > .05).

CONCLUSIONS

Comparing interventions targeting DUP and control groups, the impact of early detection strategies on DUP and other correlates is limited. However, the impact of early intervention was significant regarding relevant outcomes, underscoring the importance of supporting early intervention services worldwide.

What is the duration of untreated psychosis worldwide? - A meta-analysis of pooled mean and median time and regional trends and other correlates across 369 studies

Duration of untreated psychosis (DUP) has been associated with poor mental health outcomes. We aimed to meta-analytically estimate the mean and median DUP worldwide, evaluating also the influence of several moderating factors. This PRISMA/MOOSE-compliant meta-analysis searched for non-overlapping individual studies from inception until 9/12/2022, reporting mean ± s.d. or median DUP in patients with first episode psychosis (FEP), without language restrictions. We conducted random-effect meta-analyses, stratified analyses, heterogeneity analyses, meta-regression analyses, and quality assessment (PROSPERO:CRD42020163640). From 12 461 citations, 369 studies were included. The mean DUP was 42.6 weeks (95% confidence interval (CI) 40.6-44.6, k = 283, n = 41 320), varying significantly across continents (p < 0.001). DUP was (in descending order) 70.0 weeks (95% CI 51.6-88.4, k = 11, n = 1508) in Africa; 48.8 weeks (95% CI 43.8-53.9, k = 73, n = 12 223) in Asia; 48.7 weeks (95% CI 43.0-54.4, k = 36, n = 5838) in North America; 38.6 weeks (95% CI 36.0-41.3, k = 145, n = 19 389) in Europe; 34.9 weeks (95% CI 23.0-46.9, k = 11, n = 1159) in South America and 28.0 weeks (95% CI 20.9-35.0, k = 6, n = 1203) in Australasia. There were differences depending on the income of countries: DUP was 48.4 weeks (95% CI 43.0-48.4, k = 58, n = 5635) in middle-low income countries and 41.2 weeks (95% CI 39.0-43.4, k = 222, n = 35 685) in high income countries. Longer DUP was significantly associated with older age (β = 0.836, p < 0.001), older publication year (β = 0.404, p = 0.038) and higher proportion of non-White FEP patients (β = 0.232, p < 0.001). Median DUP was 14 weeks (Interquartile range = 8.8-28.0, k = 206, n = 37 215). In conclusion, DUP is high throughout the world, with marked variation. Efforts to identify and intervene sooner in patients with FEP, and to promote global mental health and access to early intervention services (EIS) are critical, especially in developing countries.

Carepath for overcoming psychosis early (COPE): first 5 years of clinical operation and prospective research in the Cavan-Monaghan early intervention service

OBJECTIVES

As Ireland confronts the many challenges of broadening the introduction of early intervention services (EIS) for first episode psychosis (FEP) as national policy, this article describes Carepath for Overcoming Psychosis Early (COPE), the EIS of Cavan-Monaghan Mental Health Service, and presents prospective research findings during its first 5 years of operation.

METHODS

COPE was launched as a rural EIS with an embedded research protocol in early 2012, following an education programme for general practitioners (GPs). Here, operational activities are documented and research findings presented through to late 2016.

RESULTS

During this period, 115 instances of FEP were incepted into COPE, 70.4% via their GP and 29.6% via the Emergency Department. The annual rate of inception was 24.8/100,000 of population aged > 15 years and was 2.1-fold more common among men than women. Mean duration of untreated psychosis was 5.7 months and median time from first psychotic presentation to initiation of antipsychotic treatment was zero days. Assessments of psychopathology, neuropsychology, neurology, premorbid functioning, quality of life, insight, and functionality compared across 10 DSM-IV psychotic diagnoses made at six months following presentation indicated minimal differences between them, other than more prominent negative symptoms in schizophrenia and more prominent mania in bipolar disorder.

CONCLUSIONS

COPE illustrates the actuality of introducing and the challenges of operating a rural EIS for FEP. Prospective follow-up studies of the 5-year COPE cohort should inform on the effectiveness of this EIS model in relation to long-term outcome in psychotic illness across what appear to be arbitrary diagnostic boundaries at FEP.

Psychosocial stress moderates the relationship between cerebrospinal fluid lactate dehydrogenase and the duration of untreated psychosis in first-episode psychosis

Introduction

Previous research has shown that lower lactate dehydrogenase (LDH) concentrations in cerebrospinal fluid (CSF) are associated with longer prodromal symptoms in first-episode psychosis (FEP). We aimed to study whether there is a relationship between the duration of untreated psychosis (DUP) and LDH and other CSF biomarkers in FEP and whether stressful life events moderate this association.

Methods

Ninety-five inpatients with FEP and with less than 6 weeks of antipsychotic treatment were included in the study. All participants were informed about the nature of the study, which was approved by the local ethics committee, and signed an informed consent form. A lumbar puncture was performed at index admission (baseline) to measure CSF parameters (glucose, total protein, LDH). The DUP was assessed with the Quick Psychosis Onset and Prodromal Symptoms Inventory (Q-POPSI). Stressful life events (SLEs) in the previous 6 months were assessed with the List of Threatening Experiences. We dichotomized the SLE variable into having experienced at least one SLE or no experience of SLEs. Statistical analyses were performed with SPSS v. 25.0. Total protein and LDH concentrations were natural log transformed (ln) to reduce skewness. Multiple linear regression analyses were conducted to explore the association between the DUP and CSF parameters (considered the dependent variable). Age, sex, DUP and SLEs were considered independent variables. We tested the DUP by SLE interaction. Significant interactions were included in the final model. The threshold for significance was set at p<0.05.

Results

Fifty-four FEP patients (56.8%) reported an SLE in the previous 6 months. There were no significant differences in the DUP between patients with or without SLEs. There were no significant differences in CSF biomarkers between the SLE groups. In the multiple linear regression analyses, we found a significant DUP by SLE interaction effect on CSF LDH concentrations (standardized beta= -0.320, t= -2.084, p= 0.040). In patients with SLEs, a shorter DUP was associated with higher CSF LDH concentrations and vice versa. No significant associations were found between the DUP or SLEs and other CSF biomarkers (glucose, total proteins).

Conclusions

Our study suggests that psychosocial stress moderates the relationship between the onset of psychosis and CSF biomarkers related to bioenergetic systems.

Early intervention in psychosis services: A systematic review and narrative synthesis of barriers and facilitators to seeking access

BACKGROUND

The duration of untreated psychosis (DUP) continues to be a global priority. Early intervention services were established to reduce treatment delays but have had limited impact. This systematic review examines barriers and facilitators to seeking access to these services, to identify targets for service level change.

METHODS

We conducted a systematic review of relevant databases (PsychINFO, MEDLINE, CINAHL, and PsychARTICLES) using pre-defined search terms for psychosis, early intervention, and barriers and facilitators. Given the majority of qualitative studies, a thematic synthesis rather than meta-analysis was indicated.

RESULTS

The search yielded 10 studies. Mental health stigma and discrimination predict DUP, compounded by structural barriers which limit the impact of early intervention services on timely access to recommended treatments. Synthesis of the qualitative studies generated three themes: knowledge, relationships, and stigma. Lack of knowledge, absence of supportive relationships (social and professional), and self-stigma constitute significant barriers to seeking access to early intervention services.

CONCLUSIONS

This is the first review of the barriers and facilitators to seeking access to early intervention services. The findings highlight public health and secondary care service targets to expedite access to recommended treatments and thereby reduce the DUP.

A case of schizophrenia refuting mind-body dualism

Introduction

The case report depicts the complex interplay between mental and physical illness and contests the notion of mind-body dualism in medicine. It emphasises the importance of holistic management of patients and the misnomer of schizophrenia as a purely mental illness.

Patient presentation

Mr S is a 35-year-old male who presented to a South African specialist psychiatric hospital via the forensic system. He had multiple physical symptoms involving the abdominal, haematological, dermatological and neurological systems, in addition to an eight year duration of untreated psychosis with a marked decline in cognition and functioning.

Management and outcome

An extensive medical examination during his admission excluded conditions such as early onset dementia, Huntington's disease, pellagra, Wilson's disease, autoimmune encephalitis and substance-related complications. A definitive diagnosis of schizophrenia was made, and both physical and psychiatric symptoms responded well to the administration of an antipsychotic resulting in an eventual discharge from the hospital.

Conclusion

Mind-body dualism can result in a delayed diagnosis of schizophrenia and subsequent increased duration of untreated psychosis and other complications.

Contribution

This case emphasises the flaws of mind-body dualism, and the interplay of mental and physical illness.

Examining Risk Factors for Suicidality in Adolescents and Adults Experiencing Their First Episode of Psychosis

This narrative review aimed to identify the risk factors associated with suicidality in adolescents and adults with first-episode psychosis. The review included studies that examined various factors such as psychiatric, familial, and social factors, as well as previous self-harm, suicidal ideation, and comorbid mental health disorders. A comprehensive literature search was conducted across three publicly available databases (Embase, American Psychological Association PsycINFO, and PubMed) using specific search terms related to first-episode psychosis, suicide, self-harm, and children/adolescents and adults. The inclusion criteria included original articles focusing on prospective and retrospective cohort trials, with substantial data on first-episode psychosis and self-harm, measuring both suicidal intent and outcome. Non-original studies, case reports, case series, non-English-language publications, and studies examining violence and self-harm related to substance-induced psychosis were excluded. After manual screening and removing duplicate articles, 13 articles met the established criteria for inclusion in this review. Included studies adhered to similar inclusion and exclusion criteria, had long-term follow-up, and assessed outcomes at least twice. The findings suggest that depressive symptoms, substance use disorders, previous self-harm or suicidal ideation, and longer duration of untreated psychosis are associated with an increased risk of suicidality. However, insights into psychosis and premorbid intellectual functioning did not show a direct association with suicidality.

Rate and correlates of self-stigma in adult patients with early psychosis

Introduction

Self-stigma impedes recovery process and is associated with poorer clinical and functional outcomes in people with psychotic disorders. However, there is limited research specifically examining self-stigma in the early stage of illness, and mixed findings were observed regarding factors associated with increased self-stigma. We aimed to investigate the rate and correlates of self-stigma in a cohort of adult patients with early psychosis using a comprehensive array of clinical, treatment and other illness-related variables.

Methods

A total of 101 Chinese adult early psychosis patients aged 26-55 years who had received three-year psychiatric treatment for first psychotic episode in Hong Kong and completed self-stigma assessment were included for the current investigation. A broad range of assessments encompassing socio-demographics, premorbid adjustment, onset and illness profiles, symptom severity, psychosocial functioning, treatment characteristics and medication side-effects were conducted.

Results

Twenty-eight (27.7%) patients had moderate-to-high levels of self-stigma. Univariate linear regression analyses showed that age at study entry, sex, educational level, age at psychosis onset, duration of untreated psychosis (DUP), insight level, global psychosocial functioning, and the use of second-generation antipsychotic were related to self-stigma levels. Final multivariable regression model revealed that female sex, younger age at entry, longer DUP and better insight were independently associated with higher levels of self-stigma.

Conclusion

More than one-fourth of early psychosis patients experienced significant self-stigma, highlighting an unmet need for early detection and intervention of self-stigma in the initial years of illness. Further investigation is warranted to clarify trajectories and predictors of self-stigma in the early illness course.

Latinxs and social and clinical correlates

Purpose

This study (a) documents the duration of untreated psychosis (DUP) and (b) examines both social and clinical correlates of DUP in a sample of U.S. Latinxs with first-episode psychosis (FEP).

Methods

Data were collected for a longitudinal study evaluating a community education campaign to help primarily Spanish-speaking Latinxs recognize psychotic symptoms and reduce the DUP, or the delay to first prescribed antipsychotic medication after the onset of psychotic symptoms. Social and clinical variables were assessed at first treatment presentation. A sequential hierarchical regression was conducted using √DUP to identify independent predictors of the DUP. A structural equation model was used to explore the association between DUP predictors, DUP, and clinical and social correlates.

Results

In a sample of 122 Latinxs with FEP, the median DUP was 39 weeks (M = 137.78, SD = 220.31; IQR = 160.39-5.57). For the full sample, being an immigrant and having self-reported relatively poor English-speaking proficiency and self-reported strong Spanish-speaking proficiency were related to a longer delay to first prescribed medication after psychosis onset. For the immigrant subgroup, being older at the time of migration was related to a longer delay. Self-reported English-speaking proficiency emerged as an independent predictor of the DUP. Although the DUP was not related to symptomatology, it was associated with poorer social functioning. Low self-reported English-speaking ability is associated with poorer social functioning via the DUP.

Conclusion

Latinxs with limited English language skills are especially at high risk for experiencing prolonged delays to care and poor social functioning. Intervention efforts to reduce the delay in Latinx communities should pay particular attention to this subgroup.

The differential impact of duration of untreated psychosis on functioning and quality of life: A threshold analysis

AIM

Reduction of duration of untreated psychosis (DUP) remains a key goal of early intervention programs. While a significant body of literature suggests that a short DUP has a positive impact on outcome, little is known regarding the threshold above which various dimensions of outcome are impaired. In this study, we explore the DUP threshold that best discriminates subgroups with poorer outcome regarding global functioning and quality of life after 3 years of treatment.

METHOD

A total of 432 patients were followed-up prospectively over 3 years. Several hypothetical cut-off points for DUP were tested in order to maximize differences in effect size for quality of life and general functioning.

RESULTS

While a DUP cut-off of 86 weeks defined two subpopulations with a difference of greatest effect size in quality of life after 3 years, it is already at a cut-off of 3 weeks of DUP that two subpopulations with a difference in global functioning of the greatest effect size was reached.

CONCLUSION

DUP seems to have a differential impact on the various components of outcome, and in particular on quality of life and global functioning. Our data suggest that aiming at very short DUP is justified, but that DUP over 3 weeks are still compatible with good quality of life after 3 years of treatment.

Social work training to reduce duration of untreated psychosis: Methodology and considerations of a web-based training for community providers

AIM

Outcomes for individuals with psychotic disorders can be improved through early intervention services; however, identification continues to be a major problem in connecting individuals with these services. Social workers form a vast majority of the human service and mental health workforce in the United States and therefore have the potential to play a unique role in identifying and referring those who may benefit from specialty early intervention services.

METHODS

The current article describes the methodological design, implementation, and participant recruitment procedures of a large-scale, web-based training program for social workers promoting identification and referral of individuals with emerging symptoms of a mental illness with psychosis in the context of a randomized clinical trial.

RESULTS

The web-based study enrolled 1384 individuals. More than half of study participants enrolled within the first 3 months of the 14-month recruitment period. Completion of all study components was achieved by 959 individuals (69% of total enrolled), and completion status did not vary significantly by gender, ethnicity, or facility at which the individual was employed. Completion rates varied by race, such that participants identifying as White were more likely to complete the study, while those identifying as Black were less likely.

DISCUSSION

The results suggest the feasibility of using a web-based training program to engage social workers in early psychosis identification practices. Challenges related to encouraging participants to complete the training and lessons learned during the study recruitment are discussed.

Understanding Components of Duration of Untreated Psychosis and Relevance for Early Intervention Services in the Canadian Context: Comprendre les Composantes de la Durée de la Psychose Non Traitée et la Pertinence de Services D'intervention Précoce Dans le Contexte Canadien

BACKGROUND

Clinical, functional, and cost-effectiveness outcomes from early intervention services (EIS) for psychosis are significantly associated with the duration of untreated psychosis (DUP) for the patients they serve. However, most EIS patients continue to report long DUP, while a reduction of DUP may improve outcomes. An understanding of different components of DUP and the factors associated with them may assist in targeting interventions toward specific sources of DUP.

OBJECTIVES

To examine the components of DUP and their respective determinants in order to inform strategies for reducing delay in treatment in the context of an EIS.

METHODS

Help-seeking (DUP-H), Referral (DUP-R), and Administrative (DUP-A) components of DUP, pathways to care, and patient characteristics were assessed in first episode psychosis (N = 532) patients entering an EIS that focuses on systemic interventions to promote rapid access. Determinants of each component were identified in the present sample using multivariate analyses.

RESULTS

DUP-H (mean 25.64 ± 59.00) was longer than DUP-R (mean = 14.95 ± 45.67) and DUP-A (mean 1.48 ± 2.55). Multivariate analyses showed that DUP-H is modestly influenced by patient characteristics (diagnosis and premorbid adjustment; R2 = 0.12) and DUP-R by a combination of personal characteristics (age of onset and education) and systemic factors (first health services contact and final source of referral; R2 = 0.21). Comorbid substance abuse and referral from hospital emergency services have a modest influence on DUP-A (R2 = 0.08). Patients with health care contact prior to onset of psychosis had a shorter DUP-H and DUP-R than those whose first contact was after psychosis onset (F(1, 498) = 4.85, P < 0.03 and F(1, 492) = 3.34, P < 0.07).

CONCLUSIONS

Although much of the variance in DUP is unexplained, especially for help-seeking component, the systemic portion of DUP may be partially determined by relatively malleable factors. Interventions directed at altering pathways to care and promote rapid access may be important targets for reducing DUP. Simplifying administrative procedures may further assist in reducing DUP.

The impact of manic symptoms in first-episode psychosis: Findings from the UK National EDEN study

OBJECTIVE

The extant literature is inconsistent over whether manic symptoms in first-episode psychosis (FEP) impact on its development and trajectory. This study addressed the following: (1) Does Duration of Untreated Illness (DUI) and Duration of Untreated Psychosis (DUP) differ between FEP patients with and without manic symptoms? (2) Do manic symptoms in FEP have an impact on time to remission over 1 year?

METHODS

We used data from the National EDEN study, a longitudinal cohort of patients with FEP accessing early intervention services (EIS) in England, which measured manic, positive and negative psychotic symptoms, depression and functioning at service entry and 1 year. Data from 913 patients with FEP (639 without manic symptoms, 237 with manic symptoms) were analysed using both general linear modelling and survival analysis.

RESULTS

Compared to FEP patients without manic symptoms, those with manic symptoms had a significantly longer DUI, though no difference in DUP. At baseline, people with manic symptoms had higher levels of positive and negative psychotic symptoms, depression and worse functioning. At 12 months, people with manic symptoms had significantly poorer functioning and more positive psychotic symptoms. The presence of manic symptoms delayed time to remission over 1 year. There was a 19% reduced rate of remission for people with manic symptoms compared to those without.

CONCLUSIONS

Manic symptoms in FEP are associated with delays to treatment. This poorer trajectory persists over 1 year. They appear to be a vulnerable and under-recognised group for poor outcome and need more focussed early intervention treatment.

Structural Covariance of Depth-Dependent Intracortical Myelination in the Human Brain and Its Application to Drug-Naïve Schizophrenia: A T1w/T2w MRI Study

Aberrations in intracortical myelination are increasingly being considered as a cardinal feature in the pathophysiology of schizophrenia. We investigated the network-level distribution of intracortical myelination across various cortex depths. We enrolled 126 healthy subjects and 106 first-episode drug-naïve schizophrenia patients. We used T1w/T2w ratio as a proxy of intracortical myelination, parcellated cortex into several equivolumetric surfaces based on cortical depths and mapped T1w/T2w ratios to each surface. Non-negative matrix factorization was used to generate depth-dependent structural covariance networks (dSCNs) of intracortical myelination from 2 healthy controls datasets-one from our study and another from 100-unrelated dataset of the Human Connectome Project. For patient versus control comparisons, partial least squares approach was used; we also related myelination to clinical features of schizophrenia. We found that dSCNs were highly reproducible in 2 independent samples. Network-level myelination was reduced in prefrontal and cingulate cortex and increased in perisylvian cortex in schizophrenia. The abnormal network-level myelination had a canonical correlation with symptom burden in schizophrenia. Moreover, myelination of prefrontal cortex correlated with duration of untreated psychosis. In conclusion, we offer a feasible and sensitive framework to study depth-dependent myelination and its relationship with clinical features.

The effects of patient personality traits and family cohesion on the treatment delay for patients with first-episode schizophrenia spectrum disorder

AIM

The duration of untreated psychosis (DUP) is an important prognostic indicator of schizophrenia. We explored the effects of patient personality and family relationships on delayed schizophrenia treatment.

METHODS

We prospectively included data from 169 patients diagnosed with first-episode schizophrenia. Personality traits were investigated using the Big Five Inventory (BFI-10) and family relationship was assessed employing the Family Adaptability and Cohesion Evaluation Scale-III (FACES-III). We explored patient clinical characteristics using the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Scale (SOFAS). The DUP was defined as the time between the first appearance of psychotic symptoms and commencement of adequate antipsychotic treatment. Subjects were divided into two groups by the 3-month median DUP cutoff.

RESULTS

The average and median DUPs were 12 and 3 months, respectively. A longer DUP was associated with older age, a higher PANSS score, and a lower SOFAS score. The frequency of suicide attempts tended to be higher in the delayed treatment group (P = .055). The delayed treatment group scored significantly higher in conscientiousness factor of the BFI-10 and scored significantly lower family cohesion and adaptability factors of the FACES-III. Logistic regression showed that a longer DUP was significantly associated with higher-level conscientiousness on the BFI-10 and poorer family cohesion on the FACES-III.

CONCLUSION

Treatment delay was associated with reduced family cohesion and higher patient conscientiousness, suggesting that the family plays a crucial role in terms of patient access to mental health services when early psychotic symptoms appear.

The Influence of Mental Health Literacy, Migration, and Education on the Duration of Untreated Psychosis

Background: Duration of untreated psychosis (DUP) is associated with outcome in psychotic disorders and influenced by contextual factors such as immigration. Here we aimed to investigate the effect of mental health literacy (MHL) on duration of untreated psychosis considering the influence of migration and education.

Methods: A total of 269 participants who received their first adequate medical treatment for a psychotic disorder within the current or past year were included to the Thematically Organized Psychosis study in Oslo, Norway. Sociodemographic and clinical information was collected through systematic interviews. MHL was measured as “recognition of psychotic symptoms” and assessed by “The Attitudes and Beliefs about Mental Health Problems” schizophrenia version. Influence of education, migration and MHL on DUP was analyzed with hierarchical block-wise multiple regression analysis.

Results: Recognition of psychotic symptoms explained a small but unique variance (2.3%) in DUP after the effects of other important predictors were controlled for. Longer DUP was also associated with less education, lower premorbid social, and academic functioning, a diagnosis within schizophrenia spectrum disorder, and earlier age of onset. The model explained 26% of variance in DUP. Migration after the age of six and length of education were associated with MHL but did not have a significant interaction with MHL in predicting DUP.

Conclusions: MHL, measured as recognition of psychotic symptoms, has a small but significant independent effect on DUP. The effect of MHL was larger than years of education and migration history, and did not interact with either, in predicting DUP. This suggests that MHL is an independent factor in prevention strategies for early psychosis.

Exploration of symptom dimensions and duration of untreated psychosis within a staging model of schizophrenia spectrum disorders

AIM

Clinical staging of schizophrenia entails a new method that identifies clusters of symptoms and variation in level of remission, with the goal to create a framework for early intervention. Additionally, duration of untreated psychosis (DUP) may influence symptom severity in the first episode of psychosis (FEP) and could necessitate refining of the staging model. However, consistent evidence concerning variation in symptom severity and DUP between stages is missing. Therefore, we evaluated the clinical validity of the staging model by investigating differences in symptom severity across stages in schizophrenia spectrum disorders. Second, we assessed if a prolonged DUP is associated with higher symptom severity in FEP.

METHODS

We performed a cross-sectional study of 291 acutely admitted patients with a schizophrenia spectrum disorder. Patients were assigned to clinical stages following the definition of McGorry. Symptom severity was evaluated with the new DSM-5 Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS). In FEP, we determined the DUP.

RESULTS

Significantly higher severity scores of CRDPSS items hallucinations (H = 14.34, df = 4, P-value = .006), negative symptoms (H = 19.678, df = 4, P-value = .001) and impaired cognition (H = 26.294, df = 4, P-value = <.001) were found in more advanced stages of disease. Moreover, patients with FEP and a DUP longer than 1 year showed significantly more severe negative symptoms (U = 314 000, P = .015) compared to patients with a DUP shorter than 1 year.

CONCLUSIONS

The present study found supporting evidence for the clinical validity of the staging model in schizophrenia spectrum disorders. In addition, we found support for refining the stage "first episode" with information concerning the DUP.

Duration of Untreated Psychosis in First-Episode Psychosis is not Associated With Common Genetic Variants for Major Psychiatric Conditions: Results From the Multi-Center EU-GEI Study

Duration of untreated psychosis (DUP) is associated with clinical outcomes in people with a diagnosis of first-episode psychosis (FEP), but factors associated with length of DUP are still poorly understood. Aiming to obtain insights into the possible biological impact on DUP, we report genetic analyses of a large multi-center phenotypically well-defined sample encompassing individuals with a diagnosis of FEP recruited from 6 countries spanning 17 research sites, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study. Genetic propensity was measured using polygenic scores for schizophrenia (SZ-PGS), bipolar disorder (BD-PGS), major depressive disorder (MDD-PGS), and intelligence (IQ-PGS), which were calculated based on the results from the most recent genome-wide association meta-analyses. Following imputation for missing data and log transformation of DUP to handle skewedness, the association between DUP and polygenic scores (PGS), adjusting for important confounders, was investigated with multivariable linear regression models. The sample comprised 619 individuals with a diagnosis of FEP disorders with a median age at first contact of 29.0 years (interquartile range [IQR] = 22.0-38.0). The median length of DUP in the sample was 10.1 weeks (IQR = 3.8-30.8). One SD increases in SZ-PGS, BD-PGS, MDD-PGS or IQ-PGS were not significantly associated with the length of DUP. Our results suggest that genetic variation does not contribute to the DUP in patients with a diagnosis of FEP disorders.

First-episode psychosis in the ultra-Orthodox Jewish population

Few if any methodologically robust studies of first-episode psychosis have been carried out in the ultra-Orthodox Jewish population. The opening of an inpatient psychiatry department within an ultra-Orthodox neighborhood in Israel offered the unique opportunity to study the specifics of first -episode psychosis in this subpopulation. Medical records of 60 ultra-Orthodox male Jewish patients with first-episode psychosis were examined over the first 18 months of the new department's operation. Data regarding the patients' demographical status, anamnestic information, clinical presentation, and psychiatric care were analyzed. Participants were 18-30 years old; 15 (25%) were already engaged or married. Most patients (37, 61.7%) had not been employed in any formal activity prior to their hospitalization, with 21 patients (35%) studying in a Talmudical school. Religion-related delusions were noted in 20 patients (33.3%), and community/rabbi-related delusions in 18 patients (30%). Only three patients (5%) reported suicidal attempts. Duration of untreated psychosis (DUP) ranged between 1-48 months (mean 10.4, SD 9.5). In contrast to other first-episode psychosis studies, this study highlights specific features of first-episode psychosis in the ultra-Orthodox Jewish population, which is characterized by a high marriage rate, short DUP, low rates of substance use and suicidal attempts, expression of religious- and community-related themes in delusion content, and limited cooperation with health care providers. A better understanding of the cultural specifics of first-episode psychosis in this subpopulation may enable earlier treatment, improve prognosis, and facilitate compliance with medications and rehabilitation programs.

Neuroimaging as a Window Into the Pathophysiological Mechanisms of Schizophrenia

Schizophrenia is a complex neuropsychiatric disorder with a diverse clinical phenotype that has a substantial personal and public health burden. To advance the mechanistic understanding of the illness, neuroimaging can be utilized to capture different aspects of brain pathology in vivo, including brain structural integrity deficits, functional dysconnectivity, and altered neurotransmitter systems. In this review, we consider a number of key scientific questions relevant in the context of neuroimaging studies aimed at unraveling the pathophysiology of schizophrenia and take the opportunity to reflect on our progress toward advancing the mechanistic understanding of the illness. Our data is congruent with the idea that the brain is fundamentally affected in the illness, where widespread structural gray and white matter involvement, functionally abnormal cortical and subcortical information processing, and neurometabolic dysregulation are present in patients. Importantly, certain brain circuits appear preferentially affected and subtle abnormalities are already evident in first episode psychosis patients. We also demonstrated that brain circuitry alterations are clinically relevant by showing that these pathological signatures can be leveraged for predicting subsequent response to antipsychotic treatment. Interestingly, dopamine D2 receptor blockers alleviate neural abnormalities to some extent. Taken together, it is highly unlikely that the pathogenesis of schizophrenia is uniform, it is more plausible that there may be multiple different etiologies that converge to the behavioral phenotype of schizophrenia. Our data underscore that mechanistically oriented neuroimaging studies must take non-specific factors such as antipsychotic drug exposure or illness chronicity into consideration when interpreting disease signatures, as a clear characterization of primary pathophysiological processes is an imperative prerequisite for rational drug development and for alleviating disease burden in our patients.

Impact of duration of untreated psychosis in short-term response to treatment and outcome in antipsychotic naïve first-episode psychosis

AIM

Duration of untreated psychosis (DUP) is one of the few potentially modifiable outcome predictors in psychosis. Previous studies have associated a longer DUP with a poor prognosis, but few of them were performed in countries with low and middle level of income. This study aimed to investigate the DUP in a Brazilian sample of antipsychotic-naïve first-episode psychosis (AN-FEP) patients and its association with clinical characteristics and treatment outcomes in a short-term follow-up.

METHODS

One hundred forty-five AN-FEP patients between 16 and 40 years were enrolled and were reassessed 10 weeks after risperidone treatment. We investigated the association between DUP and symptom severity, functionality and response to treatment, using the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression-Severity Scale (CGI) and the Global Assessment of Functionality (GAF) scale. DUP was defined as the period between the onset of the first psychotic symptoms and the first effective antipsychotic treatment. For the analysis, we performed multivariate linear regressions.

RESULTS

The DUP's median was 61 days. At baseline, we did not find any significant association between DUP and clinical characteristics. After treatment, the longer DUP predicted worse positive and negative symptom dimensions, worse total PANSS, GAF and CGI scores and poorer response to treatment.

CONCLUSION

Our results showed that DUP is associated with worse outcomes after short treatment, but it does not modify the baseline clinical profile of the AN-FEP patients. Such results reinforce the need to develop early intervention strategies, reducing DUP.

Determinants of pathways to care among young adults with early psychosis entering a coordinated specialty care program

AIM

To describe the characteristics of the pathway to coordinated specialty care for young adults with early psychosis in the United States, to examine how various factors correlate with the duration of untreated psychosis (DUP), and to explore factors associated with time from onset of symptoms to first mental health service contact (help-seeking DUP).

METHODS

The sample included 779 individuals ages 16 to 30 with recent-onset non-affective psychosis enrolled in OnTrackNY. Domains assessed included demographics, clinical characteristics, mental health service utilization and characteristics of the pathway to care. Primary outcomes included the time from onset of psychotic symptoms to admission to OnTrackNY (DUP) and time from onset of psychotic symptoms to first mental health service contact (help-seeking DUP).

RESULTS

The mean DUP was 231.2 days (SD = 87.7, median = 169) and mean help-seeking DUP was 73.7 days (SD = 110.8, median = 27). Being in school, better social functioning, and greater number of ER visits or hospitalizations were associated with shorter DUP. Violent ideation or behaviour and having an outpatient mental health visit as the first service contact or hallucinations as the reason for first service contact were significantly associated with longer DUP. Only the type of first service contact (outpatient mental health treatment or other non-mental health service provider) and having hallucinations as the clinical reason for the first service contact were associated with help-seeking DUP.

CONCLUSIONS

Referral delays were longer than help-seeking delays. Strategies to reduce treatment referral delays through systems-level interventions may be most likely to reduce the overall DUP in this population.

Association between referral source and duration of untreated psychosis in pathways to care among first episode psychosis patients in Northern Malawi

AIMS

To examine the association between referral source and duration of untreated psychosis (DUP) and explore determinants of referral source; when adjusting for pathways to care, positive and negative symptoms, diagnosis and socio-demographic characteristics.

METHODS

A total of 140 subjects with first episode psychosis (FEP) were enrolled from a pilot early intervention service for psychosis in Northern Malawi between June 2009 and September 2012. Logistic regression analyses were used to quantify the associations between variables of interest.

RESULTS

Age ranged between 18 and 65 at assessment, with median, 33. Median DUP was 12.5 months. First contact did not independently determine DUP. Long DUP (>6 months) was associated with referral from community based volunteer (CBV) or traditional healer (TH), a unit increase in severity of negative symptoms and having schizophrenia, which was also associated with referral from CBV or TH. Additionally, being unemployed was associated with referral from CBV or TH. However, a unit increase in the number of times religious advice (RA) was sought, GP was contacted and severity of positive symptoms was associated with referral by GP.

CONCLUSIONS

Mental health awareness is justified for this population and collaboration with THs in identifying and treating patients with psychosis may help reduce treatment delays. Access to mental health services ought to improve, particularly for the unemployed group. Future studies should consider adjusting for referral source when ascertaining first contact source as a predictor of DUP.

Economic Evaluation of Extended Early Intervention Service vs Regular Care Following 2 Years of Early Intervention: Secondary Analysis of a Randomized Controlled Trial

Cost-effectiveness studies of early intervention services (EIS) for psychosis have not included extension beyond the first 2 years. We sought to evaluate the cost-effectiveness of a 3-year extension of EIS compared to regular care (RC) from the public health care payer's perspective. Following 2 years of EIS in a university setting in Montreal, Canada, patients were randomized to a 3-year extension of EIS (n = 110) or RC (n = 110). Months of total symptom remission served as the main outcome measure. Resource use and cost data for publicly covered health care services were derived mostly from administrative systems. The incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curve were produced. Relative cost-effectiveness was estimated for those with duration of untreated psychosis (DUP) of 12 weeks or less vs longer. Extended early intervention had higher costs for psychiatrist and nonphysician interventions, but total costs were not significantly different. The ICER was $1627 per month in total remission. For the intervention to have an 80% chance of being cost-effective, the decision-maker needs to be willing to pay $5942 per month of total symptom remission. DUP ≤ 12 weeks was associated with a reduction in costs of $12 276 even if no value is placed on additional months in total remission. Extending EIS for psychosis for people, such as those included in this study, may be cost-effective if the decision-maker is willing to pay a high price for additional months of total symptom remission, though one commensurate with currently funded interventions. Cost-effectiveness was much greater for people with DUP ≤12 weeks.

Psychosis screening in schools: Considerations and implementation strategies

AIM

Duration of untreated psychosis, or the time between onset of psychosis symptoms and accurate diagnosis and treatment, is a significant predictor of both initial treatment response and long-term outcomes. As such, efforts to improve rapid identification are key. Because early signs of psychosis commonly emerge in adolescence, schools have the potential to play an important role in the identification of psychosis-spectrum disorders.

METHODS

To illustrate the potential role of schools in this effort, the current paper describes implementation of a psychosis screening tool as part of a larger study focused on reducing the duration of untreated psychosis in Sacramento, CA.

RESULTS

Clinical considerations related to screening for psychosis in schools, including ethical concerns, logistics, screening population and stigma are addressed. Implementation strategies to address these concerns are suggested.

CONCLUSIONS

Early psychosis screening in the school system could improve early identification, reduce stigma and may represent an important further step towards an integrative system of mental health.

Early and very early-onset schizophrenia compared with adult-onset schizophrenia: French FACE-SZ database

OBJECTIVE

To compare the clinical symptomatology in patients with Early-Onset Schizophrenia (EOS, N = 176), especially the subgroup Very Early Onset Schizophrenia (VEOS) and Adult Onset Schizophrenia (AOS, N = 551).

METHOD

In a large French multicentric sample, 727 stable schizophrenia patients, classified by age at onset of the disorder, were assessed using standardized and extensive clinical and neuropsychological batteries: AOS with onset ≥ 18 years and EOS with onset < 18 years (including 22 VEOS < 13 years).

RESULTS

The importance of better diagnosing EOS group, and in particularly VEOS, appeared in a longer DUP Duration of Untreated Psychosis (respectively, 2.6 years ± 4.1 and 8.1 years ± 5.7 vs. 1.0 years ± 2.5), more severe symptomatology (PANSS Positive And Negative Syndrome Scale scores), and lower educational level than the AOS group. In addition, the VEOS subgroup had a more frequent childhood history of learning disabilities and lower prevalence of right-handedness quotient than the AOS.

CONCLUSION

The study demonstrates the existence of an increased gradient of clinical severity from AOS to VEOS. In order to improve the prognosis of the early forms of schizophrenia and to reduce the DUP, clinicians need to pay attention to the prodromal manifestations of the disease.

Clinical and demographic correlates of stigma in first-episode psychosis: the impact of duration of untreated psychosis

OBJECTIVE

To evaluate the relationships between perceived stigma and duration of untreated psychosis (DUP), demographic characteristics, and clinical and psychosocial functioning in persons with a first episode of psychosis (FEP).

METHOD

A total of 399 participants with FEP presenting for treatment at 34 sites in 21 states throughout the United States were evaluated using standardized instruments to assess diagnosis, symptoms, psychosocial functioning, perceived stigma, wellbeing, and subjective recovery.

RESULTS

Perceived stigma was correlated with a range of demographic and clinical variables, including DUP, symptoms, psychosocial functioning, and subjective experience. After controlling for symptom severity, perceived stigma was related to longer DUP, schizoaffective disorder diagnosis, more severe depression, and lower wellbeing and recovery. The associations between stigma and depression, wellbeing, and recovery were stronger in individuals with long than short DUP, suggesting the effects of stigma on psychological functioning may be cumulative over the period of untreated psychosis.

CONCLUSION

The findings suggest that independent of symptom severity, perceived stigma may contribute to delay in seeking treatment for FEP, and this delay may amplify the deleterious effects of stigma on psychological functioning. The results point to the importance of reducing DUP and validating interventions targeting the psychological effects of stigma in people with FEP.

Cardiometabolic Risk in First Episode Psychosis Patients

Previous research in patients with schizophrenia in European and USA population groups has demonstrated a high prevalence of metabolic syndrome and disease progression (~35%-40%) and increased risk for cardiovascular disease and long-term mortality. Limited research has determined the prevalence of existing cardiometabolic risk factors at onset of a first episode psychosis. This cross-sectional study presents a clinical overview of the cardiometabolic risk profile in young people with first episode psychosis in the UK. Forty-six participants (72% male) clinically diagnosed with first episode psychosis (n = 25), schizophrenia (n = 13), bipolar disorder (n = 4), unspecified non-organic psychosis (n = 2) or acute psychotic episode (n = 2) with < 6 months Duration of Untreated Psychosis (DUP; mean 33.4 ± 37.2 days) were assessed for anthropometric, health risk behaviors and clinical measurements including resting heart rate, blood pressure, blood lipids, glycated hemoglobin, and prolactin. Overall, participants (aged 18-37 years) had a high prevalence of cardiometabolic risk factors due to: elevated values for BMI (73%) and abdominal adiposity (50%), blood pressure (47% prehypertensive; 23% hypertensive), resting heart rate (43%); hypercholesterolemia (32%); suboptimal HDL-C levels (36%); and hypertriglyceridemia (40%). Participants also self-reported poor health risk habits including smoking (55%), alcohol use (39%), substance use (18%), poor diet (52%), and sedentary behavior (29%). Young people with psychosis are at increased risk for cardiometabolic disorders due to elevated clinical markers and health risk behaviors. Physical health interventions (including health behavior advice) are needed early in the treatment process to address this increased risk for cardiometabolic disorders in individuals recently diagnosed with psychosis.

Subjective Quality of Life and Its Associations among First Episode Psychosis Patients in Singapore

Background—Mental disorders have been found to affect quality of life (QOL) in patients. The current study aimed to determine QOL among first episode psychosis (FEP) patients and explore its associations with sociodemographic as well as clinical factors. Methods—Data for this study were collected as a part of an Early Psychosis Intervention Program (EPIP)-Smoking and Alcohol use survey. At baseline, 280 outpatients aged 15–40 years old diagnosed with FEP, with no prior or minimal treatment, no history of medical or neurological disorder, and no history of substance abuse, were recruited. Sociodemographic details, diagnosis, length of duration of untreated psychosis (DUP), and World Health Organization Quality of Life assessment—abbreviated version (WHOQOL-BREF) scores were obtained. Results—After adjusting for all covariates, older age (p = 0.036), females, and participants diagnosed with brief psychotic disorder (p = 0.04) were associated positively, whereas separated/divorced participants, those with lower education, unemployed (p = 0.01), and longer DUP were seen to be negatively associated with different domains of QOL. Conclusion—Higher WHOQOL-BREF scores denote better QOL. Overall, female participants as compared to male participants and those diagnosed with brief psychotic disorder in this sample reported better QOL.

Simulated long-term outcomes of early use of long-acting injectable antipsychotics in early schizophrenia

AIM

Duration of untreated psychosis in early schizophrenia impacts long-term outcomes. Because long-acting injectable (LAI) antipsychotic drugs improve adherence in early-stage patients, they could reduce additional time in uncontrolled psychosis (TUP) during the critical period of the illness. However, the long-term benefit of early LAI use over oral formulations has not been quantified. This study explores the potential magnitude of the benefit with a simulation approach.

METHODS

A microsimulation models the effects of 11 treatment pathways reflecting alternative decisions on whether and when LAI agents are used during a "calibration phase" that starts at treatment entry and lasts until the end of the 3-year critical period. Treatment failure prolongs time in psychosis. Long-term outcomes are predicted over the ensuing 7-year period as a function of TUP.

RESULTS

An "early LAI" pathway where LAI treatment follows the second oral treatment failure is compared to an oral-only pathway. Under these pathways, 69% and 46% of patients, respectively, are estimated to exit the calibration phase with adequate symptom control (total positive and negative syndrome scale score below 68). Relative to the oral-only pathway, the early LAI pathway is predicted to increase competitive employment by 39% (25% vs 18%) and independent or family living by 22% (71% vs 58%), and to decrease receipt of disability benefits by 36% (42% vs 66%) and hospital admissions per 1000 patient-years by 15% (249% vs 294%).

CONCLUSIONS

While these simulation results need to be confirmed empirically, they suggest that earlier use of LAI antipsychotics can meaningfully improve patient outcomes.

Family processes and duration of untreated psychosis among US Latinos

AIM

Little is known about family processes and treatment seeking among Latinos with first-episode psychosis (FEP) living in the United States. This study examined family processes prior to treatment and their relation to duration of untreated psychosis (DUP) among Latinos with FEP and their family caregivers.

METHODS

Thirty-three Latinos with FEP and their low-acculturated family caregivers (n = 33) participated in qualitative semi-structured interviews focused on treatment-seeking experience and family relationships. Transcripts were analysed using thematic analysis and themes were grouped based on short (n = 18) or long (n = 15) DUP.

RESULTS

Findings revealed differences based on DUP length. Patients with short DUP had stronger family relationships characterized by open communication and disclosure of symptoms that facilitated awareness and direct action by family caregivers. However, patients with long DUP had more troubled family relationships that often challenged early treatment seeking.

CONCLUSIONS

Findings highlight the relevance of family context in the provision of early treatment for Latinos with FEP. Family-based services are needed that increase awareness of symptoms and provide families with support that can facilitate ongoing patient treatment during this critical period.

The outcome of early intervention in first episode psychosis

The last 20 years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.

A cross-sectional mixed methods protocol to describe correlates and explanations for a long duration of untreated psychosis among patients with first episode psychosis in Uganda

INTRODUCTION

Among patients with psychotic disorders, the 'duration of untreated psychosis' (DUP) is a predictor of key outcomes such as symptom remission and quality of life. In sub-Saharan Africa, DUP is up to five times longer than in high-income countries, with many patients going without antipsychotic medication for 5 years or longer. One contributor to this high DUP may relate to cultural norms that drive use of alternative and complementary therapies (ACTs) as first-line treatment strategies, rather than biomedical care with antipsychotic medicine. We aim to1 determine the prevalence and factors associated with DUP and ACT use in Uganda, and2 Identify factors that drive patient and family choices to use ACT as a first-line treatment strategy.

METHODS AND ANALYSIS

We will leverage on an ongoing cohort study at the national psychiatric and teaching hospital in Uganda. The parent study is an observational cohort design following antipsychotic naïve adults with a first episode of psychosis without substance use, HIV/AIDS or syphilis. The embedded study will use a mixed methods design including quantitative assessment of parent study participants with the Nottingham Onset Schedule-DUP to determine the DUP. Qualitative assessment will focus on patient and caregiver perceptions and use of ACT and its impact on DUP among patients with psychosis using in-depth interviews.

ETHICS AND DISSEMINATION

The study has received ethical approval from the school of medicine research and ethics committee of the college of health sciences at Makerere University. It has also received institutional support to perform the study from the Infectious Diseases Institute and Butabika hospital. Besides publication of the work in reputable peer-reviewed journals, we hope that this work will lead to evidence-based discussions on the need for early interventions to reduce DUP in Uganda.

Predictors of Hospitalization of Individuals With First-Episode Psychosis: Data From a 2-Year Follow-Up of the RAISE-ETP

OBJECTIVE

Despite treatment advances in other domains, inpatient psychiatric hospitalization rates for individuals with first-episode psychosis remain high. Even with early intervention services, a third or more of individuals are hospitalized over the first 2 years of treatment. Reducing hospitalization is desirable from the individual's perspective and for public health reasons because hospitalization costs are a major component of treatment costs.

METHODS

Univariate and multivariate baseline and time-varying covariate analyses were conducted to identify predictors of hospitalization in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, a 2-year cluster randomized trial for participants experiencing a first episode of psychosis who were outpatients at study entry. The trial compared an early intervention treatment model (NAVIGATE) with usual community care at 34 clinics across the United States.

RESULTS

RAISE-ETP enrolled 404 participants of whom 382 had one or more postbaseline assessments that included hospitalization data. Thirty-four percent of NAVIGATE and 37% of usual-care participants were hospitalized during the trial. Risk analyses revealed significant predictors of hospitalization to be the number of hospitalizations before study entry; duration of untreated psychosis; and time-varying days of substance misuse, presence of positive symptoms, and beliefs about the value of medication.

CONCLUSIONS

These results indicate that hospital use may be decreased by reducing the duration of untreated psychosis and prior hospitalizations, minimizing residual symptoms, preventing substance misuse, and facilitating adherence to medication taking. Addressing these factors could enhance the impact of first-episode early intervention treatment models and also enhance outcomes of people with first-episode psychosis treated using other models.

Factors related to duration of untreated psychosis of first episode schizophrenia spectrum disorder

AIM

Duration of untreated psychosis (DUP) is associated with outcome and functioning. It is expected that scientists will find factors that modulate DUP, but thus far, research on this topic has shown inconsistent results. Furthermore, similar studies in China are insufficient. This study aims to explore social and clinical factors for DUP in South China and to learn the influence that family plays on DUP through their awareness of psychosis.

METHODS

Participants included 216 patients with first episode schizophrenia spectrum disorder. The Nottingham Onset Schedule was used to assess DUP. The relationship between DUP and social and clinical characteristics were then analysed by correlation analysis, survival analysis and Cox regression analysis. The awareness of the patient's family for the cause of psychosis, the reason for treatment and the cause for delay of treatment were investigated using a questionnaire.

RESULTS

The median DUP was 64.5 days. Insidious onset and being unemployed were found to be risk factors for a long DUP. The family attributed the main cause of psychosis to stress. The main cause for the delay of treatment was because families misjudged the patients' disease. More family members of long DUP patients compared to short DUP patients thought the causes were due to ideological problems or puberty, rather than to mental health.

CONCLUSION

The results of this study indicated that some social or clinical characteristics influence DUP. The family's awareness plays an important role when seeking help. To reduce DUP, the public needs more knowledge of mental illness.

Blind Spots: Spatial analytics can identify nonrandom geographic variation in first episode psychosis program enrollments

AIM

To apply spatial analytics to an underway first episode psychosis program to identify areas of significant variation in the geographical distribution of program enrollees from an underlying at-risk population.

METHODS

Adaptive bandwidth kernel smoothing was used to estimate spatial density functions from program enrollee home addresses and a control population computed from US Census data. A relative risk surface derived from the ratio of these functions was used to discover under-represented areas, or areas from which fewer enrollees where produced than suggested by the underlying population density at the P < .05 level of statistical significance. As a test application of this analysis, a comprehensive list of primary care providers in the program catchment was extracted from the National Plan and Provider Enumeration System and spatially compared to the under-represented areas.

RESULTS

This approach identified under-represented areas containing 27.5% of the total program catchment area and 16% of the control population, yet had yielded zero program participants. These under-represented areas contained 179 primary care providers of the 2,337 in the total catchment area.

CONCLUSIONS

Findings of nonrandom spatial variation in program enrollment is valuable data for those evaluating the impact of and implementing improvements for recruitment to specialty clinics serving geographically-defined catchments. Positive findings from this preliminary study warrant further development of the predictive model as well as measurement of the impact on enrollment from recruitment interventions driven by these findings.

The Duration of Untreated Psychosis: A Phenomenological Study

Mounting evidence has indicated that early intervention leads to improved clinical and functional outcomes for young persons experiencing recent onset psychosis. As part of a large early detection campaign, the present study aimed to investigate subjective experiences during the duration of untreated psychosis (DUP), or time between psychosis onset and treatment contact. Participants were 10 young adults participating in early intervention services for psychosis. After DUP was estimated during standardized baseline assessment, participants engaged in qualitative interviews focused on their life experiences prior to treatment and leading up to the present. Mixed methods data analyses compared standardized DUP estimates with participants' subjective narratives. Findings revealed that participants experienced and conceptualized a longer trajectory of subjective difficulties (TSD) beginning before and extending beyond standardized DUP estimates. Participants emphasized striving for independence and social belonging. The majority of participants reported benefiting from their current services and believed that earlier support of some kind would have been beneficial. These findings support previous research on subjective barriers to early detection and treatment seeking in young adults experiencing psychosis. Implications and future research directions include further efforts to differentiate the struggles unique to early psychosis from psychosocial risk factors and other challenges of young adulthood.

Can We Reduce the Duration of Untreated Psychosis? A Systematic Review and Meta-Analysis of Controlled Interventional Studies

Reduction of duration of untreated psychosis (DUP) is the key strategy of early interventions for improving the outcomes of first-episode psychosis. Although several controlled interventional studies have been conducted with the aim of reducing DUP, the results are highly inconsistent and conflicting. The current study systematically searches Web of Science and Ovid for English original articles investigating interventions adopted to reduce DUP, compared to a control intervention, up to April 6, 2017. Sixteen controlled interventional studies were retrieved, including 1964 patients in the intervention arm and 1358 in the control arm. The controlled intervention studies were characterized by standalone first episode psychosis services, standalone clinical high risk services, community interventions, healthcare professional training, and multifocus interventions. Random effects meta-analyses were conducted. There was no summary evidence that available interventions are successful in reducing DUP during the first episode of psychosis (Hedges' g = -0.12, 95% CI = -0.25 to 0.01). Subgroup analyses showed no differences within each subgroup, with the exception of clinical high risk services (Hedges' g = -0.386, 95% CI = -0.726 to -0.045). These negative findings may reflect a parceled research base in the area, lack of prospective randomized controlled trials (only 2 randomized cluster designed studies were present) and small sample sizes. There was substantial heterogeneity (I2 = 66.4%), most of which was accounted by different definitions of DUP onset (R2 = .88). Psychometric standardization of DUP definition, improvement of study design, and implementation of preventative strategies seem the most promising avenues for reducing DUP and improving outcomes of first-episode psychosis.

Understanding the relationship between duration of untreated psychosis and outcomes: A statistical perspective

AIM

Although the relationships between duration of untreated psychosis (DUP) and outcomes are often assumed to be linear, few studies have explored the functional form of these relationships. The aim of this study is to demonstrate the potential of recent advances in curve fitting approaches (splines) to explore the form of the relationship between DUP and global assessment of functioning (GAF).

METHODS

Curve fitting approaches were used in models to predict change in GAF at long-term follow-up using DUP for a sample of 83 individuals with schizophrenia.

RESULTS

The form of the relationship between DUP and GAF was non-linear. Accounting for non-linearity increased the percentage of variance in GAF explained by the model, resulting in better prediction and understanding of the relationship.

CONCLUSION

The relationship between DUP and outcomes may be complex and model fit may be improved by accounting for the form of the relationship. This should be routinely assessed and new statistical approaches for non-linear relationships exploited, if appropriate.

Duration of untreated prodromal symptoms in a Chinese sample at a high risk for psychosis: demographic, clinical, and outcome

BACKGROUND

The duration of untreated psychosis (DUP) has been widely studied. However, for individuals with attenuated psychosis syndrome (APS), it is unclear whether the duration of untreated prodromal symptoms (DUPrS) also has a negative effect on the progression of psychosis. Our aim was to identify demographic and clinical factors contributing to the DUPrS in a large sample of individuals with APS, and to evaluate the association between DUPrS and the conversion to psychosis.

METHOD

A sample of 391 individuals with APS, who were identified through a structured interview for prodromal syndromes, were included in this study, of whom a total of 334 patients had completed at least a 1-year clinical follow-up. A total of 57 individuals had converted to psychosis.

RESULTS

The average DUPrS was 4.8 months for the whole sample. Individuals with a longer DUPrS were likely to be men, non-local residents, with abnormal thought symptoms, a higher severity level of negative symptoms, the lower severity level of general symptoms, and lower level of general function before the onset of attenuated positive symptoms. A DUPrS of less than 2 months, or more than 6 months, lowered the risk for conversion to psychosis.

CONCLUSIONS

Our data suggested that the association between the DUPrS and outcome in individuals with APS were likely to be different, which is either long or short DUPrS was not related to future psychosis onset. Individuals with APS were more likely to have a group of features associated with a longer DUPrS.

Long term effect of early intervention service on duration of untreated psychosis in youth and adult population in Hong Kong

AIM

The current study explored the effect of an early intervention (EI) service for psychosis in Hong Kong (EASY) on the reduction of the duration of untreated psychosis (DUP) at 10 years, in adolescent and adult patients.

METHOD

Data from three first-episode psychosis (FEP) studies conducted over 10 years using the same DUP assessment was analysed. FEP study 1 year before the EI service (2000) was used as a control, with those aged <25 comprising the youth psychosis control group and those aged over 25 comprising the adult psychosis control group. Data from the EASY service collected in 2010 constituted the youth psychosis EI group and data from an adult EI service collected from 2009 to 2011 constituted the adult psychosis EI group. DUP of EI and control groups was compared. The effect of the mode of onset and family history of psychosis on DUP was studied.

RESULTS

DUP in the adult group was significantly reduced from median of 180 days to 93 days after 10 years (U = 12 906.50, P = 0.01), particularly in those with gradual onset and without family history. However, no significant change of DUP was found in the youth psychosis group.

CONCLUSIONS

Results of the current study provide evidence that EI programmes with public awareness campaign can significantly reduce DUP of adult patients but not in youth group. The effect is more specific in those with long DUP. Further research should explore the specific factors contributed to the long DUP of patients of different age groups so as to establish targeted intervention strategies.

Steinberg and Durell (1968) revisited: increased rates of First Episode Psychosis following military induction in Greek Army Recruits

Since the seminal study of Steinbeck and Durell (1968), few epidemiological studies have attempted to replicate whether psychosocial stress precipitates the onset of a first psychotic episode. Our aim was to support or refute the finding of elevated psychosis incidence in the first month of army induction and to examine factors impacting the timing of onset. Data were collected from medical files of 186 army conscripts, hospitalized with a diagnosis of First Episode Psychosis (FEP) between 2005 and 2014 in the Psychiatric Military Hospital in Athens, Greece. FEP rates were at least 4.5 times higher in the first month of military service, compared with any other month. Earlier FEP onset was associated with rural environment at the time of birth, multiple drug use and service away from home. Psychosocial stress precipitates FEP, particularly in those exposed to other risk factors.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative analysis of pathways to early intervention services and duration of untreated psychosis in two Canadian cities

AIM

Understanding pathways to early intervention services for psychosis in the local context is crucial, as the structure and organization of services need to be considered. This study compared pathways to early intervention services in two Canadian cities.

METHODS

Data on pathways to care and duration of untreated psychosis were collected from 171 people admitted to early intervention services in Toronto (n = 150) and Hamilton (n = 21). We compared the cities on several indicators of pathway to care and duration of untreated psychosis.

RESULTS

Pathways to care were more complex in Toronto, where people saw a greater number of health care services (median = 6, interquartile range = 3-9) than those in Hamilton (median = 3, IQR = 1-4). General practitioner involvement was higher in Toronto (56.0% vs. 33.3%). We did not find differences in the median duration of untreated psychosis.

CONCLUSIONS

Pathways to early intervention services could be streamlined, and general practitioners may be a target for strategies to improve pathways to care.

Ethnic and Age Disparities in Patients Taking Long-acting Injectable Atypical Antipsychotics

Introduction

This study will determine whether different ethnicities and different age groups receive equal amounts of long-acting atypical antipsychotics in comparison to their oral equivalents.

Methods

Secondary analyses of data from the Los Angeles County Department of Health Services Electronic Health Record (total N=63,134 inpatient visits) were performed. Chi-squared statistics were used to compare ethnicity and age with the use of either risperidone injectable or paliperidone palmitate (r-LAIs) versus risperidone oral.

Results

Among the 63,134 total inpatient visits, there were 3,011 patient visits that included the use of an atypical antipsychotic. Of these 3,011 visits, 452 (15.0%) were on r-LAIs and 2,559 (85.0%) were on risperidone oral. No statistically significant disparities were identified with the use of r-LAIs as compared to oral risperidone amongst ethnic groups (chi-square = 0.88, df = 3, p = 0.831). However, there was a statistically significant difference with the use of r-LAIs as compared to oral Risperidone amongst age groups, favoring younger patients (chi-square = 13.46, df = 3, p < 0.004).

Conclusion

Our data indicate a lack of ethnic disparities in prescribing long-acting atypical antipsychotics and an increased percentage of younger patients being treated with atypical depot antipsychotics over their oral equivalents.

Clients and carers perception of mental illness and factors that influence help-seeking: Where they go first and why

OBJECTIVE

In Northern Malawi, the duration of untreated psychosis (DUP) is longer than that in high-income countries. The reasons for the delay in help-seeking are not known, although studies show multiple reasons. This research was conducted to establish health care help-seeking behaviours and identify barriers that exist between service users and health care providers. The study also intended to establish the beliefs that clients and family members have regarding the causes of mental illness which profoundly shape help-seeking, care giving process and outcomes.

METHODOLOGY

The study employed the exploratory phenomenological method, utilizing focus group discussions (FGDs) in the sampled population. The Health Belief Model and Disease Explanatory Models were conveniently chosen a priori by researchers to develop guide questions to explore clients' and carers' perceptions of the illness and their health care help-seeking behaviours.

RESULTS

Results show a bio-psycho-social inclination of disease causation and help-seeking behaviour. Causes of mental illness are understood in three categories, namely: physical/biological, psychological and socio-cultural. The majority of participants attributed mental illness to socio-cultural factors, with witchcraft, spirit possession and curses as main determinants. Causal perceptions also influenced help-seeking pathways. Many participants reported consulting traditional healers first, for diagnosis and to know who was responsible.

CONCLUSION

In this study, it has been found that help-seeking is influenced by the understanding of the source of the illness - which has a bio-psychosocial inclination. The socio-cultural explanation of witchcraft and spirit possession is dominant and a determinant of help-seeking behaviour. While participants noted benefits to hospital treatment, barriers and bio-psychosocial in nature were also noted. Guardians and not clients hold the key to choice of treatment modality and therefore a potential ally in all treatment interventions promotive, preventive and curative. There is need for strengthening of a bio-psychosocial intervention model in the treatment of mental illness.

Prolonged duration of untreated psychosis: a problem that needs addressing

AIM

The duration of untreated psychosis (DUP) refers to the period of time between the emergence of psychotic symptoms and the initiation of appropriate clinical treatment. Prolonged DUP is associated with a range of adverse consequences, including more severe illness course, cognitive deficits and poor functioning. Problems with recognition of illness and in seeking help contribute to DUP, but another major cause of prolonged DUP is delays within secondary mental health services. In an attempt to reduce these delays, National Health Service England and the Department of Health have set new targets to improve access to early intervention services which will come into effect in April 2016. Given this background, we aimed to examine the DUP and pathways to care of new patients entering an early intervention service. We also examined whether they were receiving National Institute for Health and Care Excellence (NICE) concordant treatment. This will enable us to establish a baseline so that the impact of the new targets can be determined and to assess the degree of change that will be required to implement these.

METHODS

De-identified electronic records of 165 patients accepted into the service over a 12-month period were analysed.

RESULTS

Median DUP was 6 months. There was a median of 2 contacts prior to service entry. Community Mental Health Teams were the largest source of referrals.

CONCLUSIONS

The majority of patients had a DUP exceeding the international target of 3 months. The findings appear to support previous evidence that this may be partially attributable to significant delays within the mental health care system.