Duration of untreated psychotic illness

Soc Psychiatry Psychiatr Epidemiol (2005) 40 : 345 349 DOI 10.1007/s00127-005-0905-2 ORIGINAL PAPER Victor Peralta Manuel J. Cuesta Alfredo Martinez-Larrea Jose F. Serrano Myriam Langarica Duration of untreated psychotic illness The role of premorbid social support networks Accepted: 2 December 2004 Abstract Background A lengthy delay often exists between the onset of psychotic symptoms and the start of appropriate treatment. However, the causes of this long delay remain poorly understood, and there is a need to search for the factors involved in such a delay in order to reduce the time of untreated psychosis. This study aimed at examining the influence of premorbid social networks on the duration of untreated psychotic illness. Method One hundred subjects with a first episode of schizophrenia or related psychotic disorders never treated with antipsychotics made up the study sample. Social support was assessed by means of the Sturtees s social support scale that comprises two subscales measuring close and diffuse social support. Duration of untreated illness was assessed according to three definitions: duration of untreated unspecific symptoms, duration of untreated psychotic symptoms, and duration of untreated continuous psychotic symptoms. We also examined the effect of putative confounding factors such as gender, residence (urban-rural), age at illness onset, years of education, and parental socio-economic status. Results Correlational analysis showed that poor diffuse social support, but not poor close social support, predicted long duration of untreated illness according to the three definitions; this association being mainly due to poor work/academic support. Logistic regression analysis confirmed such an association, but it was limited to duration of continuous psychotic symptoms (unadjusted OR = 3.44, 95 % CI = 1.51 7.83); this association persisted after adjusting for the confounding variables (adjusted OR = 3.39, 95 % CI = 1.39 8.29). We V. Peralta, M.D. ( ) M. J. Cuesta, M.D. A. Martinez-Larrea, M.D. J. F. Serrano, M.D. M. Langarica, M.D. Psychiatric Unit Virgen del Camino Hospital Irunlarrea 4 31008 Pamplona, Spain Tel.: +34-848/422-488 Fax: +34-848/429-924 E-Mail: victor.peralta.martin@cfnavarra.es also found that subjects with low socio-economic status were depending on the definition of duration of untreated illness considered, between 2.7 and 4.3 times more likely to present with a long duration of untreated illness. Conclusion Both poor diffuse social support and a low socio-economic status seem to be relevant factors of a prolonged duration of untreated psychosis. Key words psychotic disorder duration of untreated illness social networks Introduction Studies of first-episode psychosis from around the world have consistently shown that there is an average of 1 2 years between the onset of psychotic symptoms and the start of treatment (McGlashan 1999). This is the socalled duration of untreated illness (DUI), which results in a range of negative psychosocial outcomes for patients and their families. Attempts to reduce this protracted delay in the treatment of first-episode psychoses are likely to be more effective when we understand the reason for such a delay. However, while a great deal of research has been devoted to address the putative consequences of delay in treatment, only a few studies have addressed its putative causal factors, and most of these studies have examined cross-sectional associations with symptoms or illness-related variables. For example, several studies have found an association between poor psychosocial support during the period of untreated illness and a longer duration of this period (Larsen et al. 1998; Drake et al. 2000; Barnes et al. 2000). However, these studies do not provide information as to whether poor social support is a cause of the long delay or a consequence of the psychotic disorder itself, given that a long DUI may have a deleterious impact on pre-existing social network (Cougnard et al. 2004). One putative factor underlying the protracted treatment delay of the psychotic illness could be the premorbid existence of poor social networks of the subject. SPPE 905

346 Available persons such as family members, friends, acquaintances or work associates can not only notice symptoms, but they can also provide information, support, and assistance for professional help-seeking. Therefore, we reasoned that poor premorbid social ties would be associated with longer DUI. Interest in premorbid social support rests not only upon its potential importance as a cause of treatment delay, but in particular upon the possible benefit of developing interventions to reduce the time lag between illness onset and treatment. The aim of the present study was to test the hypothesis that subjects with deficient social networks would have a longer DUI in a sample of first-admitted, nevertreated psychotic patients. We examined two aspects of social support, namely diffuse and close social support, as well as three alternative definitions of DUI. Subjects and methods Subjects The study sample was made up of 100 non-affective psychotic patients who were consecutively admitted for the first time to the psychiatric ward of the Virgen del Camino Hospital in Pamplona (Spain) between 1998 and 2002. The hospital serves a predominantly urban geographic area of 250,000 inhabitants with no other psychiatric hospitals in this area. Other psychiatric devices of this catchment area include four mental health outpatient centers and one day hospital. To be included in the study,patients had to fulfill the following criteria: (1) no previous antipsychotic treatment; (2) a DSM-IV diagnosis of a non-affective psychotic disorder not due to substance/medical condition; (3) written informed consent to participate in the study; and (4) age range between 14 and 65 years. From the 118 eligible patients, 14 refused to participate and 4 were not included because of unreliable information regarding the main outcome variables (duration of untreated illness or premorbid social support). Included and excluded patients did not display any statistically significant differences for the main socio-demographic and clinical variables. The socio-demographic and clinical characteristics of the study s sample are presented in Table 1. Assessment instruments All the assessments were conducted by the first author (VP) using multiple and independent sources of information including those provided by the patient,family members,significant others,and medical and social records. Demographic variables, clinical symptoms and DSM-IV diagnosis were assessed by means of the Comprehensive Assessment of Symptoms and History (CASH) (Andreasen et al. 1992). We defined three types of DUI (in months): duration of untreated unspecific symptoms (DUUS), duration of untreated psychosis (DUP), and duration of untreated continuous psychosis (DUCP). DUUS was defined according to Beiser et al. (1993) as the time since the first appearance of any illness-related cognitive or affective complaints as well as any behavioral change from the individual s previous stable level of functioning. DUP was defined as the time since the first manifestation of delusions or hallucinations. Lastly, DUCP was defined as the time since delusions or hallucinations were present during most of the days until admission. To assess all these features we elaborated a semi-structured questionnaire in order to standardize data collection. Premorbid social support networks were assessed over the year before any sign of the psychotic illness was evident by means of the Social Support Index (Sturtees 1980). This rating scale addresses six Table 1 Sample characteristics (n = 100) Gender (male) 66 Civil status (single) 79 Diagnosis Schizophrenia 49 Schizophreniform 23 Schizo-affective 7 Other non-affective psychoses 21 Residence at illness onset (urban) 69 different components of social support: (1) existence of a confidant; (2) contact with close relatives; (3) living group; (4) work/academic associates; (5) contact with neighbors; and (6) contacts with clubs, social organizations and church. Items 1 3 are intended to provide an index of close social support, and items 4 6 are intended to provide an index of diffuse social support. Higher ratings in the scale indicate poorer social support. The parental Socio-Economic Status (SES) was determined using the Hollingshead (1958) two-factor index of social position, which combines occupational status and education of both parents of the subject into a five-level scale. Statistics Given that the different DUI definitions typically have non-normal and positively skewed distributions (Norman and Malla 2001), and that items from the social support scale are rated according to different score ranges, we used Spearman rank correlations coefficients to examine the association between the two sets of variables. The differentiation between short and long duration of untreated illness across the three definitions is conceptually and clinically appealing; accordingly, these durations were dichotomized using the median split. The same procedure was used with the social support ratings for differentiating between poor and good premorbid social support. Using logistic regression analysis, we examined whether poor social support predicted longer DUI before and after controlling for the confounding variables. We examined five putative confounding variables: gender, residence at illness onset (urban vs. rural), age at illness onset, years of education, and socio-economic status.all statistical tests were two-tailed. Results Correlational analysis Table 2 shows the correlation coefficients between social support ratings and the three definitions of DUI. Close social support ratings were unrelated to either DUI def- N Mean SD Range Socio-Economic Status 3.2 0.6 2 5 Years of education 10.4 3.4 6 20 Age at illness onset 24.9 9.3 12 55 Duration of untreated illness (months) DUUS 56.4 74.2 0 408 DUP 39.4 53.8 0 216 DUCP 27.7 51.3 0 216 DUUS duration of untreated unspecific symptoms; DUP duration of untreated psychosis; DUCP duration of untreated continuous psychosis

Table 2 Spearman correlation coefficients between premorbid social support ratings and three definitions of duration (in months) of untreated illness inition, but the global diffuse social support rating was significantly related to all three DUI definitions, indicating that the poorer the diffuse social networks, the longer the duration of the three DUI definitions. These significant associations were mainly due to associations with work/academic support, the strongest association being with DUCP. Furthermore, DUCP was also significantly related to less contacts through attendance at clubs, associations or church. An unexpected and interesting finding was that SES level was associated with all three definitions of duration of untreated illness (DUUS r s = 0.34, p = 0.001; DUP r s = 0.34, p = 0.000; DUCP r s = 0.30, p < 0.01). More specifically, the respective ORs (95 % CI) for a poor SES (Hollingshead s level IV and V) to predict long DUUS, DUP and DUCP were 4.27 (1.72 10.59), 3.02 (1.26 7.06) and 2.66 (1.12 6.35), respectively. Multivariate analysis Mean (SD) DUUS DUP DUCP Close social support 2.79 (2.28) 0.03 0.09 0.14 Confiding relationship 1.12 (1.35) 0.11 0.13 0.11 Close relatives 0.67 (0.85) 0.12 0.15 0.19 Living group 0.99 (0.75) 0.18 0.11 0.03 Diffuse social support 1.70 (1.38) 0.20* 0.24* 0.29** Work associates 0.81 (0.81) 0.21* 0.25* 0.31** Neighbors 0.39 (0.49) 0.03 0.09 0.07 Clubs/associations/church 0.50 (0.50) 0.16 0.16 0.24* Social support total score 4.48 (3.30) 0.13 0.19 0.23* DUUS duration of untreated unspecific symptoms; DUP duration of untreated psychosis; DUCP duration of untreated continuous psychosis * p < 0.05; **p < 0.01 Given that correlational analysis showed no association between DUI definitions and close social support ratings, multivariate analyses were limited to examine associations with diffuse social support ratings. Table 3 presents unadjusted and adjusted OR for the association between poor diffuse social support and long DUI according to the three definitions. After controlling for the 347 potential confounders, both the association pattern and the strength of the associations remained virtually unmodified. Significant associations of diffuse social support were confined to long DUCP (OR = 3.44, 95 % CI = 1.51 7.83, p = 0.003; adjusted OR = 3.39, 95 % CI = 1.39 8.29, p = 0.007), this association being mainly due to poor work/academic support (OR = 3.76, 95 % CI = 1.63 8.66, p = 0.002; adjusted OR = 3.28, 95 % CI = 1.36 7.89, p = 0.008), and, to a lesser extent, to poor associations/club/church support (OR = 2.66, 95 % CI = 1.18 5.98, p = 0.017; adjusted OR = 2.70, 95 % CI = 1.06 6.85, p = 0.036). Discussion This is the first study examining the relationship between premorbid social networks and duration of untreated psychosis. Our hypothesis of a positive association was partially confirmed in that poor diffuse social support, but not poor close social support, predicted long duration of untreated illness; this association being mainly due to poor work/academic ties. We also found that SES was a predictor of duration of untreated illness, a finding not reported previously. Depending on the DUI definition considered, subjects with poor SES were between 2.7 and 4.3 times more likely to present with a long DUI. This finding is not surprising at all, since poor SES is a predictor of a great number of poor health outcomes, including protracted treatment (Hollingshead 1958). Our three definitions of duration of untreated illness, namely DUUS, DUP and DUCP, can be viewed as successive phases of increasing severity of the pre-treatment period, and given that correlational analysis showed a monotonic increase in the effect size of the statistically significant associations from DUUS to DUCP, it could be argued that the effect of poor diffuse social support upon the duration of untreated illness increases with severity of the pre-treatment period. In logistic regression analysis, the association between poor diffuse social support (and more specifically, poor work/academic and associations/clubs/church support) was limited to DUCP. This association seemed to be genuine, since it persisted after controlling for a number of confounding factors such as gender, residence, age at illness onset, ed- Table 3 Association between premorbid diffuse social support and three definitions of duration of untreated illness before and after controlling for confounding variables Long DUUS (> 16 months) Long DUP (> 11 months) Long DUCP (> 5 months) OR (95% CI) Adj* OR (95% CI) OR (95% CI) Adj* OR (95% CI) OR (95% CI) Adj* OR (95% CI) Poor diffuse social support 1.61 (0.73 3.56) 2.01 (0.53 4.85) 1.75 (0.79 3.88) 1.96 (0.83 4.63) 3.44 (1.51 7.83) 3.39 (1.39 8.29) Work/academic associates 1.48 (0.67 3.29) 1.56 (0.65 3.71) 1.38 (0.62 3.05) 1.33 (0.57 3.09) 3.76 (1.63 8.66) 3.28 (1.36 7.89) Neighbors 1.01 (0.45 2.27) 1.06 (0.45 2.50) 1.08 (0.48 2.43) 1.14 (0.41 2.62) 1.58 (0.70 3.57) 1.58 (0.66 3.75) Associations/clubs/church 1.27 (0.58 2.79) 1.84 (0.73 2.63) 1.37 (0.62 3.02) 1.62 (0.66 3.99) 2.66 (1.18 5.98) 2.70 (1.06 6.85) DUUS duration of untreated unspecific symptoms; DUP duration of untreated psychosis; DUCP duration of untreated continuous psychosis * Adjusted for gender, residence (urban-rural), age at illness onset, socio-economic status and years of education

348 ucational level, and SES. Both unadjusted and adjusted OR indicated that subjects with poor diffuse social support were three times more likely to present with a long DUCP. The reasons why poor diffuse social networks, rather than close social networks, influence DUI remains unclear. A possible explanation might be that diffuse social ties such as attendance at a variety of associations or work/academic activities usually require more regular and intensive interpersonal contacts than any other social activity. Therefore, the lack of such regular and intensive contacts makes it less likely that the behavioral disturbances of the patients are detected, thus producing a longer treatment delay. Evidence exists for an association between long DUI and poor functional outcome (McGorry et al. 2000), and between poor functional outcome and poor social networks (Brugha et al. 1993; Evert et al. 2003). Thus, given the close link between premorbid and postmorbid social networks in schizophrenia (Gittelman-Klein and Klein 1969), we can speculate that the association between long DUI and poor outcome may be spurious and confounded by the fact that poor social background may cause both long treatment delay and poor outcome. A similar explanation has been proposed for the observed relationships of poor premorbid functioning with long DUI and poor outcome (Verdoux et al. 2001). Therefore, a long DUI could be interpreted as an epiphenomenon of the underlying association between poor global premorbid functioning, including poor social ties, and poor global clinical outcome, also including social declining. Two study limitations should be considered when interpreting the findings. First, assessment of both premorbid social networks and duration of untreated illness was retrospective, accordingly no definitive causal inference can be made of the observed associations, and longitudinal studies are clearly needed to answer this question. The alternative explanation that a common underlying factor would cause both low premorbid social background and the psychotic illness cannot be disregarded, since social decline may begin long before schizophrenia is clearly manifested (MacEwan et al. 1997), and subjects may contribute to creating their own social environments through the so-called genetic control of exposure to the environment (Kendler 1997); therefore, treating social support solely as an environmental variable may be misleading. The second limitation concerns the generalizability of the results, since, although our study was population based, the representativeness of the sample might be questioned in that the study sample was limited to the more severe (thus, hospitalized) patients. In fact, our figures of DUI were in the highest range of those reported in previous studies. We found, for example, that six patients had a DUP of between 150 and 216 months. However, examination of the distributional pattern of that variable showed that these extreme scores were part of the resulting distribution rather than being outliers. Conclusions Our findings underscore the role of low SES and poor premorbid diffuse social support in the duration of untreated psychosis. More specifically, the existence of poor work/academic and associations/clubs/church networks was related to the most severe pre-treatment period when the subjects present continuous psychotic symptoms. 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