Elsevier

Schizophrenia Research

Volume 51, Issue 1, 1 August 2001, Pages 39-46
Schizophrenia Research

Early detection strategies for untreated first-episode psychosis

https://doi.org/10.1016/S0920-9964(01)00237-7Get rights and content

Abstract

Some studies in first-episode schizophrenia correlate shorter duration of untreated psychosis (DUP) with better prognosis, suggesting that timing of treatment may be important. A three-site prospective clinical trial in Norway and Denmark is underway to investigate the effect of the timing of treatment in first-episode psychosis. One health care sector (Rogaland, Norway) is experimental and has developed an early detection (ED) system to reduce DUP. Two other sectors (Ullevål, Norway, and Roskilde, Denmark) are comparison sectors and rely on existing detection and referral systems for first-episode cases. The study ultimately will compare early detected with usual detected patients. This paper describes the study's major independent intervention variable, i.e. a comprehensive education and detection system to change DUP in first onset psychosis.

System variables and first results from the four-year inclusion period (1997–2000) are described. It includes targeted information towards the general public, health professionals and schools, and ED teams to recruit appropriate patients into treatment as soon as possible. This plus easy access to psychiatric services via ED teams systematically changed referral patterns of first-episode schizophrenia. DUP was reduced by 1.5 years (mean) from before the time the ED system was instituted (to 0.5 years). The ED strategies appear to be effective and to influence directly the community's help-seeking behaviour.

Introduction

Early detection and intervention in first-episode schizophrenia can be important because schizophrenia remains a chronic disorder and current treatments are at best palliative and keep illness in control only so long as they are actively applied (McGlashan and Johannessen, 1996). The early course of schizophrenia is important because it may be during this time that the chronicity of schizophrenia ‘happens’; this chronicity could be the consequence of being psychotic over time without receiving proper treatment. Recent studies suggest that applying existing treatments for schizophrenia earlier in the course may reduce ‘deterioration’ (McGlashan and Johannessen, 1996). While the evidence is by no means definitive, it is suggestive enough, for both biological and psychosocial treatments, to support further investigation (McGlashan, 1996).

The onset of schizophrenia may be the most important event in an individual's life, but it often escapes notice and goes unattended. The signs may be subtle and/or denied, and the affected person may at first appear to function ‘as usual’. The abnormalities introduced by psychosis too often are recognized only retrospectively. These include unpredictable behaviours (Steiner et al., 1999) and symptoms and functional deficits that can be significantly disabling (McGlashan, 1988). At the onset, the problems generated by psychotic symptoms and behaviours are confounded by the fact that they are regarded as a product of the person rather than an illness, thus adding insult to reputation and injury to social network.

Untreated psychosis at the onset of schizophrenia is usually defined as the period of time between the emergence of positive psychotic symptoms and initiation of adequate treatment, usually medication and hospitalization. Recent studies estimate DUP to vary between one and two years on average, making it a public health problem of considerable magnitude (Loebel et al., 1992, Haas and Sweeney, 1992, Haefner et al., 1996, Beiser et al., 1994, McGlashan, 1999, Johannessen et al., 1999). The frequency distributions of DUP are regularly skewed with very long DUP outliers. Recent investigations link long DUP to male gender, poor premorbid functioning, and an insidious presentation heavily loaded with negative symptoms (Larsen et al., 1996a, Drake et al., 2000).

The reasons for treatment delay leading to long DUP are several and include ignorance, denial, stigma, lack of motivation, absence of information about early psychosis, and lack of access to appropriate interventions. Lincoln et al. (1998) studied people suffering from first-episode psychosis in Melbourne, Australia, and found their pathways to care to be highly variable because of a lack of knowledge about mental illness and mental health services in the general community, the health care delivery system, and the educational system. In a study on 43 patients with non-affective psychosis in Rogaland county, Norway, we found that the treatment delay was correlated with social withdrawal and poor social network (Larsen et al., 1998).

Jorm (2000) studied knowledge and attitudes regarding mental health and help seeking. He concluded that if mental disorders are to be recognized early and appropriate action taken, then mental health literacy must be raised. Mental health literacy is defined as ‘the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, of professional help available; and attitudes that promote recognition and appropriate help seeking’ (page 396).

Modern service systems research states that effective health promotion programs must incorporate multi-level strategies that include individuals, families, neighbourhoods, schools, work places and communities (Mittlemark, 1996). Most current health promotion studies target cardiovascular risk behaviour and smoking. Those that include media plus intensive community interventions seem to be most effective (Green and Kreuter, 1991). The community component includes modifying the organisation of health services to emphasize prevention and supplementary training for health personnel. Media-alone interventions appear to have little impact on behaviour (Redman et al., 1990).

Several studies have examined the effects of education on attitudes about severe mental illness. Members of the general public who have more knowledge about mental illness are less likely to endorse stigmatizing attitudes (Holmes et al., 1999). Søgaard and Fønnebø (1995) state that mental health campaigns can change knowledge about and attitudes towards mental health problems in a general population. The strategies that are likely to work best are those that use multiple access points, e.g. media, health services, and schools (US Department of Health and Human Services, 1994). Rutz et al. (1997) have demonstrated the effectiveness of educating general practitioners, while Olin et al. (1998) have shown that teachers are capable of identifying individuals who later develop serious mental illness.

One of the earliest efforts to raise the ‘general level of awareness’ about psychosis began in the city of Stavanger on the south-western coast of Norway (Johannessen et al., 2000). The town sits in the Norwegian sectorized mental health care district of Rogaland County. Since 1989, the psychiatric community of Rogaland has organized an annual week-long conference about schizophrenia and other forms of severe mental illness. The conference is designed for both lay and professional audiences, and is conducted with high visibility in the town centre. In addition to scientific presentations, it includes arts, such as plays, movies, picture exhibitions of psychosis and public lectures by patients, families, politicians, and professionals. A special target audience is young people. Currently, the event is attended by around 1000 professional people and 2000–4000 lay people each year. This plus broad local media coverage in the newspapers and TV provide general, anti-stigma-oriented information about schizophrenia annually to the entire county of 370,000 people.

In Melbourne, Australia, a first-episode psychosis centre was established in 1992 dedicated to bringing treatment to patients with first episode psychosis as rapidly as possible (McGorry et al., 1996, Edwards et al., 1994). In addition to using the media for raising awareness about early psychosis and treatment, these clinical administrators established a special ‘early detection (ED) team’ to streamline access to mental health treatment services. The team consists of mental health clinicians who are available by phone 24 h per day to evaluate potential first-episode cases within minutes to hours, and initiate appropriate treatment immediately when cases prove to be first onset.

The study ultimately will compare early detected patients in Rogaland (the experimental sector) with patients detected as usual in the other sectors (comparison sites). This report addresses the following specific questions:

  • 1.

    Is it possible to establish a working ED system based on

    • (a) information programs directed towards the general population, health professionals and schools and

    • (b) easy-access ED teams?

  • 2.

    Is this reflected through a change in the population's help-seeking behaviour as measured by the referral pattern?

  • 3.

    Does this eventually reduce DUP?

Section snippets

The TIPS project

The early treatment and intervention in psychosis (TIPS) project is a prospective clinical trial designed to test whether the timing of treatment in first-episode psychosis can improve the course of the disorder. It includes three first-episode psychosis centres: Rogaland County, Norway (370,000 inhabitants), Ullevål sector, Oslo, Norway (190,000 inhabitants) and Roskilde County, Denmark (100,000 inhabitants). First-episode, non-affective psychosis patients are treated with the same drug and

Help-seeking behaviour

For the period 1997–2000 contacts to the DT equilibrated to approximately one call per day. Many anonymous, especially at first, with the caller choosing not to be identified or to identify the person about whom he/she was calling. Out of 1696 referrals to the DT (including anonymous and non-psychiatric diagnosis), 100 had a first-episode psychosis, and 54 were finally included in TIPS. Out of 156 included patients in Rogaland, 54 came through the DT, and accounted for 35% of the included

Discussion

The creation of a low threshold easy-access psychiatric service, i.e. DTs, coupled with targeted information seems to have catalyzed referrals of cases that were largely appropriate. The referrals came from various sources but mostly the families, schools, and patients themselves, as opposed to prior to the TIPS project, when all referrals had to come via the GPs.

First-episode psychosis constituted 6% of referrals, a satisfactory percentage given that the actual rate (incidence) of such cases

Acknowledgements

The study was supported by The Norwegian National Reserach Council, The Norwegian Department of Health and Social Affairs, the Oslo County Department of Health and Social Affairs and the Rogaland County Department of Health and Social Affairs (Drs Vaglum, Johannessen, Larsen, Horneland, Friis, Melle, Opjordsmoen), the NARSAD Distinguished Investigator Award and NIMH Grant # K05 MH01654 (Dr McGlashan).

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