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QUESTION: In patients with a first admission of schizophrenia, what patterns of symptoms and social functioning predict prolonged duration of untreated psychosis (DUP)?
Inception cohort with re-interview at 6–12 weeks.
3 UK centres (Manchester, Liverpool, and North Nottinghamshire).
248 patients who were 16–64 years of age (median age 27 y, 70% men) with a first admission of schizophreniform disorder, schizophrenia, schizoaffective disorder, delusional disorder, or psychosis not otherwise specified. Patients were excluded if substance misuse was judged to be the cause of the psychosis.
Assessment of prognostic factors
DUP was measured from the first onset of delusions and hallucinations. The independent variables were insight, measured by the Positive and Negative Syndrome Scale (PANSS) item G12, social avoidance by the PANSS item G16, and social integration and coping derived from the Social Functioning Scale (SFS). Confounding variables were ethnicity, sex, substance misuse, age at onset, years of education, and all other PANSS items.
Main outcome measures
Predictors of prolonged DUP and PANSS scores at 6–12 weeks of follow up.
DUP ranged from 4–624 weeks (median 12, mean 38 wks). After log transformation, the mean DUP was 14.9 weeks. Prolonged DUP correlated with lack of insight (p<0.001), poor social integration (p=0.004), poor volition (p=0.02), preserved coping skills (p=0.04), low preoccupation (p=0.02), and low hostility (p=0.03) (table⇓). Of patients reassessed with the PANSS at 6–12 weeks (87%), mean PANSS score decreased by 23.9 points (40%). Longer DUP predicted less improvement in PANSS (p<0.001). Greater improvement in PANSS was predicted by better preadmission social integration (p=0.046). Less improvement was predicted by better preadmission coping (p=0.001). Initial insight was not associated with change in PANSS (p=0.64).
In patients with a first admission of schizophrenia, prolonged duration of untreated psychosis (DUP) was predicted by poor insight, poor social integration, lack of volition, relatively good coping, low preoccupation, and low hostility. Prolonged DUP predicted poorer treatment response at 6–12 weeks of follow up.
The prognosis of most medical and surgical illnesses improves if treatment starts early. This correlation has never been shown in psychiatric illness, perhaps because identification and treatment of mental illnesses have, at least in the past, been associated with negative labelling and stigmatisation. More recently, as reported by Drake et al, many investigators, although not all,1, 2 have found a correlation between the DUP and short term illness prognosis: the faster the treatment, the larger the improvement. This correlation may be because the factors that delay the time between having a psychotic symptom and seeking help for it are the same ones that prevent effective treatment response. Or it may be because a lengthy period of untreated psychosis somehow impairs the brain's ability to recuperate. Whatever the case, determining the reasons for delayed treatment is important.
Psychotic symptoms are frightening for the individual and for family and friends. They interrupt school, work, and interpersonal relationships. Allowed to continue unabated, they potentially undermine self confidence, friendships, family cohesion, and academic and vocational success. The study by Drake et al is important because it identifies important correlates of delayed treatment: lack of insight, social isolation, and relatively good coping skills. The last factor must be viewed as controversial because other investigators have found that poor premorbid coping correlated with a longer DUP.3 The first 2 factors have face validity and important public health relevance. Lack of insight can be addressed by public education. Social isolation can be identified in school. It is time to develop interventions for psychosis that emphasise early detection and address the obstacles to treatment.
Sources of funding: The Medical Research Council and Stanley Foundation.
For correspondence: Dr R J Drake, SOCRATES, University Department of Psychiatry, Withington Hospital, Manchester M20 8LR, UK. Fax +44 (0)161 445 9263.
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