Duration of untreated psychosis and its correlates in first-episode psychosis in Finland and Spain
Kalla O, Aaltonen J, Wahlström J, Lehtinen V, García Cabeza I & González de Chávez M;
Commented by , 21 Oct 2002
Aim
There are reports which have shown that delays in initial treatment can be related to prognosis and outcome in schizophrenia and that duration of untreated psychosis (DUP) is correlated with substantial functional decline, treatment resistance and increased rates of relapse. However, the available data are not unambiguous and more recent studies have not always been able to replicate these findings.
The authors hypothesized that there might also be cross-cultural differences related to DUP. Therefore, they compared the duration of untreated psychosis in two cohorts of Spanish and Finnish patients with schizophrenia and explored which correlates of DUP are common to both groups and which are culture specific.
Method
The study was part of a collaborative longitudinal study on first-episode psychosis carried out between Kupittaa and Keroputaa hospitals in Finland and Gregorio Maranon hospital in Spain. The most important inclusion criteria were
- a DSM-III-R diagnosis of first-episode schizophrenia
- 16-44 years of age
- no earlier psychotherapy longer than 30 sessions
- no previous antipsychotic drug treatment.
The patients were examined with psychiatric ratings scales and a semi-structured questionnaire about the patients’ pre-morbid, and more recent, social functioning, family relations, clinical state and onset characteristics. Furthermore, four onset measures were assessed – duration of untreated psychosis, duration of prodromal symptoms, age at onset of psychosis, and mode of onset.
Results
Both groups were comparable for most baseline characteristics. The mean value of DUP was significantly shorter (4.0 months, median 2 months) for the Finnish patients than for the Spanish patients (9.9 months, median 2 months). In both groups, long DUP was associated with insidious onset, poor global functioning, and work incapability.
Among the Finnish patients exclusively, long DUP correlated with a weak earlier social network, instability of professional identity, long duration of prodromal symptoms, psychological dependency on the family, and criticism by the parents of the patient. Among the Spanish patients only, longer DUP was associated with more severe positive symptoms at admission.
Discussion
Overall, the authors could replicate the finding of previous investigations that DUP is associated with poorer outcome in schizophrenia. This association was first shown in studies carried out in the early 1990s and stimulated an important worldwide scientific activity in this field. However, more recent findings could not always find an association between DUP and outcome of schizophrenia.
Furthermore, it is not clear whether early identification is the real cause of better outcome or whether there are specific characteristics which make patients get into treatment earlier or later. The present study cannot solve these methodological problems. Secondly, the authors discuss that in addition to some universal psychosocial factors influencing DUP, cultural differences may also have an impact on the treatment delay.
There are again several limitations concerning this conclusion. The most important one is that the findings might reflect differences in family and social networks, i.e. that in Spain the family may play more important role as a care provider.