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Q Does an early detection programme decrease the duration of untreated first episode psychosis?
Follow up period:
Four healthcare sectors in Norway and Denmark; recruitment period 1997 to 2000.
The study catchment area had 665 000 inhabitants. 874 people with psychosis like symptoms were assessed. 284 people met inclusion criteria: DSM-IV diagnosis of psychotic disorder; actively psychotic (Positive and Negative Syndrome Scale score (PANSS) ⩾4 on positive subscale items 1, 3, 5, or 6 or general subscale item 9); no adequate previous medication for psychosis (>3.5 haloperidol equivalents for >12 weeks or until resolution of symptoms); no related neurological or endocrine disorders; age 18–65 years, and IQ score >70.
The early detection (ED) programme ran in two of four healthcare sectors, and involved media campaigns educating the general population about psychosis symptoms and treatment, plus targeted high school healthcare workers, social workers, and general practitioners with information campaigns. Information included a telephone number for the public to contact specialised low threshold ED teams. The specialised psychiatric services in all four sectors instituted the same assessment and treatment programme for first episode psychosis. Individuals were assessed as early as possible with the Structured Clinical Interview for DSM-IV Axis I disorders. At diagnosis, prespecified treatment procedures involving antipsychotic medication, individual psychosocial treatment, and group psychoeducational family work commenced.
Duration of untreated psychosis (DUP) defined as time between onset of psychosis to the start of adequate treatment; clinical status (PANSS; Global Assessment of Functioning scale (GAF)).
Patient follow up:
Early detection programmes significantly reduced DUP compared with non-ED areas (median DUP: 5 weeks ED v 16 weeks non-ED, p = 0.003). Participants in the ED areas had significantly better global functioning and lower levels of symptoms at the start of treatment than those from non-ED areas (see http://www.ebmentalhealth.com/supplemental for table). The ED area participants continued to have lower levels of symptoms at 3 months although the difference was not significant for all symptom scores.
The ED programme can reduce the duration of untreated first episode psychosis and allows people to start treatment at lower symptom levels.
This is the third report of a sample of first episode psychosis patients ascertained over four years (1997–2001) in four Scandinavian healthcare sectors with similar specialised assessment and treatment procedures for such patients. Two of the sectors introduced an extensive early detection (ED) programme before the start of this longitudinal outcome study.
The first report from this group detailed their early detection strategies.1 The second report showed that the introduction of the ED programme successfully shortened the duration of untreated psychosis (DUP).2 Because a historical control design cannot account for cohort effects such as a reduction in stigma and subsequent earlier treatment seeking, the authors conducted this parallel control design study. Comparing the two health sectors with ED programmes with the two sectors that lacked an ED programme, and defining DUP as time between the appearance of positive psychotic symptoms (determined by semistructured interview with patients and relatives) until the start of adequate treatment, the results showed a highly significant reduction in DUP.
In addition, PANSS positive symptoms, negative symptoms, and general symptoms were all significantly lower in the ED area and GAF symptom and function scores were significantly higher at presentation for treatment. In other words, shortening the DUP resulted in patients initiating treatment before their illness had become severe.
Various potential confounders (demographic and illness variables) were entered into a multiple regression analysis into which ED status was entered last. The results showed that the shortening of the DUP was attributable, in the main, to ED status and, thus, to the early detection programme itself.
The health policy importance of this study is that it shows that implementation of early detection programmes (educational media campaigns about psychotic symptoms directed at general practitioners, social workers, high school teachers, and the general public) do work in bringing nascent psychotic problems to early attention, thus minimising the harmful influences of psychotic thinking and behaviour on a young person’s social, occupational, and interpersonal functioning.
Clinicians need to differentiate the benefit of early detection of psychotic symptoms from early detection of prodromal symptoms, which the present study found it could not reliably measure.
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For correspondence: Dr Ingrid Melle, Division of Psychiatry, Ullevaal University Hospital, Kirkeveien 166, N-0407 Oslo, Norway;
Sources of funding: see http://www.ebmentalhealth.com/supplemental
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