Ullevål University Hospital, Oslo
Department of Behavioural Medicine, University of Oslo, Norway
Roskilde Psychiatric University Hospital Fjorden, Roskilde, Denmark
Rogaland Psychiatric Hospital, Stavanger
Ullevål University Hospital, Oslo
Institute of Psychology, University of Oslo, Norway
Roskilde Psychiatric University, Hospital Fjorden, Roskilde, Denmark
Yale University School of Medicine, New Haven, Connecticut, USA
Correspondence: Professor Svein Friis, Department of Research and Education, Division of Psychiatry, Ullevål University Hospital, Oslo N-0407, Norway. Tel: +47 22 11 84 40; fax: +47 22 11 78 48; e-mail: svein.friis{at}medsin.uio.no
Declaration of interest Supporters included Lundbeck Pharma, Eli Lilly and Janssen-Cilag Pharmaceuticals; full details in Acknowledgements.
* Paper presented at the Third International Early Psychosis Conference,
Copenhagen, Denmark, September 2002.
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ABSTRACT |
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Aims To investigate whether the number and characteristics of patients with a long DUP in the early detection programme differ from those with a long DUP in the non-early detection programme.
Method We compared the number and characteristics of patients with a
DUP 2 years in an early detection area and a non-early detection area.
Results The early detection programme recruited slightly fewer patients with a long DUP than the non-early detection programme. The patients in the early detection programme had lower PANSS scores, but more frequently had a deteriorating course of premorbid social functioning.
Conclusions An early detection programme does not seem to drain a pool of previously undetected patients with a long DUP. The patients in the early detection programme seem to have a lower symptomlevel at baseline and to have had a deteriorating premorbid social course.
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INTRODUCTION |
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Are the patients with a very long DUP in an early detection programme different from the patients with a long DUP in a non-early detection programme regarding gender, age, symptoms and premorbid function?
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METHOD |
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Patients
All possible patients with first-episode psychosis from these sectors
admitted to in-patient or out-patient treatment were assessed without delay at
first contact. Patients were eligible for participation in the study if they
met the following inclusion criteria: living in the catchment area of one of
the four healthcare areas, age between 18 (15 in Rogaland County) and 65,
meeting the DSMIV (American
Psychiatric Association, 1994) criteria of schizophrenia,
schizophreniform disorder, schizoaffective disorder (narrow
schizophrenia-spectrum disorder), brief psychotic episode, delusional
disorder, affective psychosis with mood incongruent delusions, psychotic
disorder not otherwise specified (non-narrow schizophrenia-spectrum
disorders), actively psychotic, not previously adequately treated for
psychosis, no neurological or endocrine disorders with relationship to the
psychosis, no contraindications to antipsychotic medication,
understands/speaks one of the Scandinavian languages, IQ over 70 and willing
and able to give informed consent.
During 19972000 a total of 423 patients with first-episode psychosis
met the diagnostic criteria, of these, 26 were not asked to enter the study
due to either severe language problems (16), inability to give consent (three)
or other reasons (seven). The remaining 397 were considered study-appropriate
and before they were asked to sign an informed consent form were given
detailed verbal and written information about the studys assessment and
treatment procedures, including their right to withdraw at any time. A total
of 93 patients refused to participate
(Friis et al, 2004)
and three more withdrew their consent and demanded that their data were
erased. The remaining 301 patients formed the study sample. This paper is
based on these patients (age 18 years: non-early detection group=14;
early detection group = 14).
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RESULTS |
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With regard to premorbid function we investigated differences in childhood
level and the course of social and academic functioning as defined by Larsen
et al (2004). We
found no clear differences in childhood level between the groups, either for
social or academic functioning. However, we found a clear difference for the
course of social functioning. Whereas 69% of early detection patients having a
long DUP had a deteriorating social course, only 37% of the patients in the
non-early detection group had such a course. This difference was marginally
statistically significant (2 = 3.89, d.f.=1,
P=0.05).
As seen in Fig. 2, there was a clear difference between the groups in PANSS symptoms. The patients in the early detection group had clearly lower levels of positive as well as negative and general symptoms. The difference was statistically significant for all groups (positive: t=3.06, d.f.=36.72, P=0.002; negative: t=3.07, d.f.=36.87, P=0.004; general: t=2.56, d.f.=36,P=0.014).
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DISCUSSION |
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Symptom level and premorbid function
We also found that the early detection group of patients had lower symptom
levels at admittance than the non-early detection group. This indicates that
the programme meets its aim of recruiting patients with a shorter DUP by
encouraging them to seek help with a lower symptom level
(Larsen et al, 2001).
This also holds true for the patients with a long DUP. The early detection
patients with a long DUP have probably had a relatively slow onset of
psychotic symptoms as well as few symptoms that raise serious concerns in
their social network. However, it is of interest that there was a higher
percentage with deteriorating social functioning among the early detection
group with a long DUP. This may indicate that the early detection programme
has increased the awareness of the importance of social decline, so that
patients with long-standing low-level symptoms are brought to treatment more
easily.
Definition of long DUP
It might be argued that we ought to have used a different cut-off point
than a DUP of 2 years. However, a different cut-off point (for instance, 1
year or 3 years), would have given similar results. We chose the 2-year
cut-off, as the psychosis often seems to plateau after 2 years
(Birchwood et al,
1998).
Limitations and strengths
The results should be interpreted in the context of the following
limitations. First, the early detection programme was implemented in an area
with a previous study of patients with first-episode psychosis. Although the
latter preceded the early detection programme and study, we cannot totally
rule out the possibility that this study perhaps lowered the number of
patients with a long DUP in the early detection programme. Second, the study
was carried out in areas with a very well-developed, publicly funded
healthcare system. Consequently, the threshold was low for seeking psychiatric
treatment even in the control programme. Third, even if the study recruited a
fairly high number of patients, the number of patients with a long DUP is, at
best, moderate. Therefore, the possibility of random error has to be
considered.
On the other hand, the study has several strengths. First, it comprises consecutively admitted patients from catchment areas. Second, we can document that selective refusal to participate cannot explain the results and, consequently, the generalisability should be high. Third, a comprehensive effort has been implemented to quality-assure data (Friis et al, 2003).
In this context, the study seems to indicate that early detection programmes recruit patients with a lower symptom level than usual programmes. There is no indication that this implies a recruitment of many unidentified patients with a long DUP, at least in areas with a well-developed, publicly funded healthcare system. Therefore, there should be no reason to be concerned that the recruitment of a large number of patients with a long DUP should overshadow the benefits of an early detection programme.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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From the Department of Psychiatry, Yale University, New Haven, Connecticut, USA, Roskilde County Psychiatric Hospital Fjorden, Roskilde, Denmark; Rogaland Psychiatric Hospital, Haugesund Hospital, Ullevål University Hospital and the Departments of Psychiatry, Psychology and Behavioural Sciences, University of Oslo, Norway. The study was supported by the Norwegian National Research Council (nos 133897/320 and 154642/320), the Norwegian Department of Health and Social Affairs, the National Council for Mental Health/Health and Rehabilitation (nos 1997/41 and 2002/306), Rogaland County and Oslo County (P.V., J.O.J., S.F., T.K.L., I.M. and S.O.). Also funded by the Theodore and Vada Stanley Foundation, the Regional Health Research Foundation for Eastern Region, Denmark; Roskilde County, Denmark, Helsefonden, Lundbeck Pharma, Eli Lilly and Janssen-Cilag Pharmaceuticals (E.S. and U.H.). Also supported by a National Alliance for Research on Schizophrenia and Depression (NARSAD) Distinguished Investigator Award and National Institute of Mental Health grant MH-01654 (T.H.McG.) and a NARSAD Young Investigator Award (T.K.L.).
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