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First-episode schizophrenia with long duration of untreated psychosis: pathways to care.

Larsen TK, Johannessen JO, Opjordsmoen S (1998).

British Journal of Psychiatry 172 (Suppl 33): 45-52.

Long duration of untreated psychosis has been associated with worse outcome in schizophrenia. This study divided a group of 34 first-episode patients with schizophrenia into two groups: those with a long and short duration of untreated psychosis. The main obstacles to receiving treatment were found to be withdrawal and having a poor social network, suggesting that, in order to identify people earlier, a system of detection must be attentive to the early symptoms of psychosis and include provisions for follow-up care. The social network related to the individual should also be educated as to the importance of early treatment.

The goal of this study was to assess the impact of duration of untreated psychosis in individuals suffering from first-episode schizophrenia. Most studies of first-episode schizophrenia have suggested that treatment delay is a serious problem because the beneficial effects of treatment may be strongest in the earliest phases of the illness. The authors assumed that people with schizophrenia who had a long duration of untreated psychosis would have poorer premorbid functioning and more negative symptoms at onset, and that the main obstacles to receiving treatment would be social withdrawal, a poorly functioning social network, and the misinterpretation of early symptoms of psychosis by primary health services.

Individuals studied were 34 people with schizophrenia admitted to Rogaland Psychiatric Hospital in Norway. All were recruited as part of a first-episode study of non-affective psychosis. Functioning was assessed using the Positive and Negative Syndrome Scale (PANSS), the Structured Clinical Interview for DSM-III-R (SCID), the Premorbid Adjustment Scale (PAS), and the Global Assessment of Functioning Scale (GAF). Duration of untreated psychosis was defined as the time interval between the onset of psychotic symptoms and hospitalization for psychosis or initiation of adequate treatment (defined as sufficient quantities of antipsychotic medications). The mean value of duration of untreated psychosis was 130 weeks; the median value of duration of untreated psychosis was 54 weeks. Participants were thus split into two groups: short duration of untreated psychosis was considered less than 54 weeks (mean: 15 weeks), and long duration of untreated psychosis 54 weeks or longer (mean: 244 weeks).

No statistically significant differences between the two groups were found for age at onset of psychosis, age at hospitalization, premorbid functioning (as measured by the PAS), or GAF scores in the last week before hospitalization. There was, however, a trend for the long duration of untreated psychosis group to have poorer premorbid functioning in late adolescence and adulthood than the group with short duration of untreated psychosis. Not working and having few friends were found to significantly increase the risk of having a long duration of untreated psychosis. Furthermore, there was a trend for the long duration of untreated psychosis group to have more negative symptoms at hospitalization (as measured by the PANSS), and that group had the worst scores on the three variables of the PANSS that describe withdrawal (emotional withdrawal, passive/apathetic social withdrawal, and active social avoidance).

When reviewing individual cases, the authors found that for most cases, treatment was offered long before adequate treatment was initiated; in only one case was the individual not identified because of poor assessment. For most of the 34 cases, withdrawal was rated as the most important reason for late detection. Poor social network was the second strongest factor. Differences in how schizophrenia presented itself did emerge between the two groups, however. Most patients in the short duration of untreated psychosis group had a more obvious change in functioning from the prodromal stage to psychosis, although these individuals also seemed to have a better social network and more insight regarding their symptoms.

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