Birmingham Early Intervention Service Northern Birmingham Mental Health Trust, UK
Birmingham Early Intervention Service and School of Psychology, University of Birmingham, UK
School of Psychology, University of Birmingham, UK
Correspondence: Amanda Skeate, Birmingham Early Intervention Service, Harry Watton House, 97 Church Lane, Aston, Birmingham B6 5UG, UK. Tel: 0121 685 6477; e-mail: A_Skeate{at}hotmail.com
Unconditional funding from University of Birmingham.
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ABSTRACT |
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Aims To examine psychological processes that influence the decision-making process to contact primary care, in individuals with emerging psychosis.
Method The influence of coping style, health locus of control and past health help-seeking behaviour on DUP was investigated in clients with a first episode of psychosis. This involved scrutiny of general practitioner (GP) records in an average of 6 years before the first treatment.
Results Shorter DUP was associated with more frequent GP attendance in the 6 years before the onset of psychosis and lower health threat avoidant coping scores.
Conclusions Patients with short DUP have a history of higher contact with their GP and, as a group, tend not to avoid health threats. The study underlines the importance of engaging young people and their families with primary care as one of a series of strategies to reduce DUP.
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INTRODUCTION |
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METHOD |
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Measures
Duration of untreated psychosis
The DUP was operationalised as the time interval between the onset of
psychotic symptoms and onset of treatment. A semi-structured interview
following the model of Beiser et al
(1993) was conducted with the
participant and carer to obtain information about the onset and development of
symptoms and the early stages of treatment. Additional information was
extracted from the participant's psychiatric records in order to verify dates
about the onset of symptoms and treatment. Definitions of DUP have differed in
previous studies. In the present study, DUP was calculated according to a
stringent protocol adapted from criteria developed by Larsen et al
(1998). They report good
testretest reliability (intraclass correlation, r=0.96,
P<0.01). Eighteen cases were selected at random from the sample
and rated independently by two assessors, rounding to whole weeks. The average
intraclass correlation was unity, which indicates an excellent degree of
consistency between the raters.
Miller Behavioral Style Scale
The Miller Behavioral Style Scale (MBSS;
Miller, 1987) has been used
widely in various health settings to assess individual coping styles on the
basis of self-reported preferences for information and distraction in
anxiety-provoking situations. The MBSS consists of four hypothetical
stress-evoking scenes of an uncontrollable nature (e.g. a possible aeroplane
disaster, potential job redundancy). These scenes are intended to be similar
in context to a threatening health situation/hospital visit (Miller &
Magnan, 1983). Participants are asked to choose one or more items from a total
of eight statements that represent their preferred way of responding to each
situation presented. Four of the statements correspond to information-seeking
(monitoring) and four relate to information-avoiding
(blunting); consequently each sub-scale consists of 16 items.
Two scores can be obtained for each participant: (a) a total
monitoring score; and (b) a total blunting
score.
Reliability analyses show the MBSS sub-scales to be stable over a 4-month period (monitoring: r (98)=0.72, P<0.01; blunting: r (98)=0.75; P<0.01) Miller & Mischel, 1986: cited in Miller, 1987).
Multi-dimensional Health Locus of Control scale
The Multi-dimensional Health Locus of Control (MHLC) scale
(Wallston et al,
1978) measures the extent to which an individual believes that the
locus of control for health is: (a) internal, that is, as a result of their
own behaviour (IHLC); (b) under the control of powerful others,
that is health professionals (PHLC); and (c) determined by external factors
such as chance or fate (CHLC). This self-report questionnaire comprises six
items for each scale. The instructions of the MHLC questionnaire were amended
to inform participants that the words ill and
illness referred to general health problems.
The MHLC scale is the most widely used measure of health locus of control (Norman & Bennett, 1995). This questionnaire has been designed for use with adults and is applied to both clinical and nonclinical populations. Two equivalent forms with matching items were found to have acceptable alpha reliabilities for each scale ranging from 0.67 to 0.77. In the original study, the authors reported adequate construct validity and an indication of predictive validity (Wallston et al, 1978). Form A was used in this study, as the factor structure and reliability of this version has been generally confirmed as satisfactory (Hartke & Kunce, 1982; Marshall et al, 1990).
Past health help-seeking behaviour
To obtain an objective measure of how often the participant sought help
from a GP, the frequency of contact from 16 years of age (early
adulthood) to the onset of psychosis was assessed from GP
medical records. As well as the date of the visit, information about the
presenting symptoms/complaint, GP's diagnosis and intervention was noted.
Different types of appointments (e.g. health checks, missed appointments, follow-up appointments) were coded and divided into simple categories to reflect the nature of the consultation (see Atkinson & Coffey, 1996); each appointment was then classified according to this protocol. The frequency of visits to the GP for health problems (general GP attendance) was derived by aggregating all appointments attended by the participant. Interrater reliability was calculated for eight randomly selected cases. The average intraclass correlation was r=0.99 (P<0.01), indicating very high reliability.
Data analysis
Data were analysed using SPSS 10.0.0 for Windows. DUP was divided into
three pre-defined categories based on the time intervals described by Carbone
et al (1999): brief
DUP (1 month or less); moderate DUP (greater than 1 month but less than/equal
to 6 months); long DUP (greater than 6 months). The analysis of variance
(ANOVA) was the main analytical technique.
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RESULTS |
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Duration of untreated psychosis
The DUP had a median of 15.4 weeks. The distribution of this sample was
positively skewed, because of a number of outliers with extremely long DUPs
(one-sample KolmogorovSmirnov (KS) Z=1.901,
P<0.01). The median represents a more meaningful measure of
central tendency in this case. A total of 12 (28.6%) had brief DUP (1
month); 17 (40.5%) had moderate DUP and 13 (30.9%) long DUP.
GP attendance
Four participants were excluded from this part of the analysis: two had
experienced an onset of psychosis before the age of 16 years, one had
incomplete GP medical records and another withdrew consent for this section of
the study. Participants' consultations with a GP were recorded for a specific
period (from age 16 to onset of psychosis). The mean for this period was 6.6
(s.d.=4.5) years and the distribution was normal (one-sample KS
Z=1.19, P=0.11, NS). There was a significant difference
between the DUP groups regarding their mean frequency of general GP attendance
(see Table 2;
F2,35=5.57, P<0.01).
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Post hoc analysis using Fisher's least significant difference (LSD) test showed that the brief DUP group had higher GP attendance than the long DUP group (mean difference 2.70, p<0.01). No differences were found between mean attendance for the moderate and long DUP groups. Thus, the results indicate that participants who consulted their GP more frequently in the 6 years before the onset of psychosis were more likely to have a shorter DUP.
Miller Behavioral Style Scale
As distributions of monitoring and blunting
sub-scale scores were found to be normal, one-way ANOVA was computed to test
the hypothesis of a difference between DUP groups with regard to coping style.
For the blunting sub-scale there was a significant effect of DUP
(F2,37=3.77, P<0.05) (see
Table 3). Post hoc
analysis applying Fisher's LSD indicated that the difference was between the
brief and moderate DUP groups (mean difference was 2.96, P<0.05)
and the brief and long DUP groups (mean difference was 2.75,
P<0.05). For the monitoring sub-scale no significant differences
were found (F2,37=0.2, NS). A one-tail correlation between
DUP (transformed to the natural logarithm in order to achieve normality) and
monitoring was also non-significant (Pearson's r=0.12,
P=0.22, NS).
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A one-tailed correlation between DUP and blunting was positive, but failed to reach significance at the 5% level (Pearson's r=0.22, P=0.01, NS). In other words, only patients with a brief DUP (compared with patients in the moderate and long DUP groups) were significantly less likely to display a blunting coping style.
Multi-dimensional Health Locus of Control scale
Two participants were excluded from this section because of missing data.
Scores on the MHLC indicate how strongly the individual believes in each
dimension of control; the higher the score the stronger the belief. Analysis
using a one-sample K-S Z test indicated that all sub-scales were distributed
normally. No differences were found between the DUP groups on any of the MHLC
sub-scales: internal HLC, F2,37=1.0, NS; chance HLC,
F2,37=0.7, NS; and powerful others HLC,
F2,37=1.5, NS. Comparing the mean scores of the present
sample for each sub-scale with normative data from other samples
(Table 4), it can be seen that
the early psychosis sample had a lower internal HLC mean score and higher
chance and powerful others HLC mean scores compared with other
samples.
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One-tail correlations between DUP (transformed to the natural logarithm in order to achieve normality) and each MHLC sub-scale were found to be non-significant (IHLC Pearson's r=0.16, P=0.16, NS; CHLC Pearson's r=-0.16, P=0.16, NS; PHLC Pearson's r=0.11, P=0.24, NS).
GP attendance and health coping style
Further analysis revealed a significant negative correlation between
general GP attendance and scores on the MBSS blunting sub-scale
(Pearson's r=-0.40, P=0.02, n=37), suggesting that
participants who visit their GP less frequently are more likely to endorse a
blunting style on the MBSS. This relationship confirms previous
observations of the validity of Miller's blunting/monitoring
concept and supports the validity of the link between DUP and
blunting.
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DISCUSSION |
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It has been found that blunters experience less anxiety when faced with an unavoidable stressor and cope better in situations where they can avoid threatening information (Miller & Mangan, 1983; Miller, 1987). Thus, perhaps, a blunting coping style might reduce distress caused by psychotic symptoms, enabling the individual to cope adequately for longer periods compared with low blunters. Lending partial support to this theory, Drake et al (2000) found that long DUP was linked to poor insight and preserved coping skills; similarly Birchwood et al (2000a) found that high insight was linked to a raised likelihood of post-psychotic depression. It is difficult to establish, however, whether those with short DUP contact their GP more because they are monitors or simply because they have more physical illness; nevertheless the outcome is the same, i.e. greater GP contact. We argue that this greater contact, for whatever reason, increases the propensity of clients to seek help through primary care when they experience distress. In a future communication, we will present data on the timing of GP contact and the nature of the presenting symptoms.
The aggregate figure for GP contacts is a blunt instrument and may include contacts for prodromal as well as true (physical) illness symptoms. Following this argument through, it would be expected that a greater number of contacts would be a sign of a long or intense prodrome. However, long prodrome is associated with a long DUP (Beiser et al, 1993): the very opposite of that observed here (i.e. more contacts linked with short DUP). We conclude, therefore, that the link we have observed reflects the impact of help-seeking behaviour for health concerns per se and is not an artefact of prodromal psychosis.
Monitoring coping style
Research has indicated that individuals with a monitoring
coping style are more likely to detect physical symptoms, demand more tests
and information and seek help for relatively trivial problems, leading to
early detection and treatment (Miller,
1987; Miller et al,
1988; Steptoe & Vogele,
1992). However, although the blunting scale was
found to be significant, the monitoring sub-scale showed no relationship to
DUP. An explanation for this finding may be the way high
monitors perceive psychotic symptoms. High monitors have
been reported to overestimate the potential severity, likelihood and
unpredictability of threatening events
(Davey et al, 1993;
Miller et al, 1996).
Furthermore, they experience higher levels of worry and distress in medically
threatening situations, which may interfere with effective problem-solving
behaviour and result in denial and disengagement
(Miller, 1996;
Miller et al, 1996). Thus, predicting behaviour based on the monitoring coping style
is a complex issue and is related to how the threat is perceived.
Duration of untreated psychosis
The low refusal rate to participate in our study mitigates the likelihood
of sample bias. DUP is similar to other studies (e.g.
Carbone et al, 1999;
Barnes et al, 2000;
Drake et al, 2000)
and is comparable with other similar studies. By its very nature, DUP is
difficult to calculate as it relies on a respondent's memory, and can only
ever be a best estimate. Previous studies have differed widely
in their operational definitions and procedures and thus their accuracy of
this time interval is variable (Norman
& Malla, 2001). In the present study, a stringent protocol was
adhered to, including use of multiple sources in order to increase the
accuracy of DUP and inter-rater reliability was found to be excellent.
The role of GPs
General practitioners have been identified as an important contact in the
pathway to care of a young person with first-episode psychosis. GP involvement
has been associated with more desirable pathways, including decreased
likelihood of police involvement and compulsory admissions
(Cole et al, 1995;
Lincoln et al, 1998;
Burnett et al, 1999).
These findings support the finding of many previous studies
(Cole et al, 1995;
Burnett et al, 1999)
that contact with primary care is a key factor in reducing DUP, distress and
access to sustained treatment. These data reinforce previous suggestions that
normal psychological factors are at play in this process (i.e.
help-seeking behaviour for health concerns), in addition to those such as
shame, which may be specific to a major mental illness
(Birchwood et al,
2000b). We are about to embark on a large-scale
replication of these findings and to explore help-seeking behaviour in other
family members.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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