Social Psychiatry and Psychiatric Epidemiology

, Volume 39, Issue 9, pp 711–719 | Cite as

Early intervention in first-episode psychosis

The impact of a community development campaign
  • Helen Krstev
  • Steve Carbone
  • Susy M. Harrigan
  • Christina Curry
  • Kathryn Elkins
  • Patrick D. McGorry



Substantial delays in providing access to treatment in first-episode psychosis have been well documented. The present study examines the impact of strategies aimed at improving access and reducing delays.


A pilot community education campaign was conducted with the aim of reducing the duration of untreated psychosis (DUP) in a geographically defined intervention sector located in the north-western region of Melbourne, Australia. Utilising a quasi-experimental design, a comparison sector with similar demographics was selected from another part of the north-western region. A mobile early detection team and the same treatment system served both sectors.


While there was no significant difference between the mean DUP for intervention and comparison sectors, the distributional features of DUP between the two regions were significantly different. In the intervention sector, disproportionately more cases with very long DUP were detected. When a small number of outliers were removed, the mean and median DUP in the intervention sector was reduced.


These findings highlight the complexity of treatment access and delay and suggest that efforts to reduce DUP may have two effects, not one. Firstly, a different sample of cases is treated through the detection of hidden “long DUP” cases that otherwise may have remained untreated. Secondly, the DUP for the remainder may indeed be reduced. More research with larger samples and more potent campaign strategies is clearly required. It may also be worth considering whether there is a safe and ethical way to undertake a RCT of early versus delayed antipsychotic treatment to perhaps settle the DUP debate once and for all.

Key words

early psychosis community development duration of untreated psychosis prevention early intervention 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Allardyce J, Boydell J, Van Os J, Morrison G, Castle D, Murray RM, McCreadie RG (2001) Comparison of the incidence of schizophrenia in rural Dumfries and Galloway and urban Camberwell. Brit J Psychiatry 179:335–339CrossRefGoogle Scholar
  2. 2.
    American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, APA, Washington D. C.Google Scholar
  3. 3.
    Andreasen N (1983) Schedule for the Assessment of Negative Symptoms. University of Iowa, Iowa CityGoogle Scholar
  4. 4.
    Beck AT, Beck RW (1972) Screening depressed patients in family practice.A rapid technique. Postgrad Med 52:81–85PubMedGoogle Scholar
  5. 5.
    Beiser MD, Erickson D, Fleming JA, Iacono WG (1993) Establishing the onset of psychotic illness. Am J Psychiatry 150:1349–1354PubMedGoogle Scholar
  6. 6.
    Bottlender R, Moller HJ (2003) The impact of the duration of untreated psychosis on short- and long-term outcome in schizophrenia. Curr Opin Psychiatry 16(Suppl 2):S39–S43CrossRefGoogle Scholar
  7. 7.
    Bromet EJ, Jandorf L, Fennig S, Lavelle J, Kovasznay B, Ram R, Tanenberg-Karant M, Craig T (1996) The Suffolk County Mental Health Project: demographic, pre-morbid and clinical correlates of 6-month outcome. Psychol Med 26:953–962PubMedGoogle Scholar
  8. 8.
    Cannon-Spoor HE, Potkin SG, Wyatt RJ (1982) Measurement of premorbid adjustment in chronic schizophrenia. Schizophr Bull 8:470–484PubMedGoogle Scholar
  9. 9.
    Cohen, J (1992) A power primer. Psychol Bull 112:155–159CrossRefGoogle Scholar
  10. 10.
    Craig TE, Bromet EJ, Fennig S, Tanenberg-Karant M, Lavelle J, Galambos N (2000) Is there an association between duration of untreated psychosis and 24-month clinical outcome in a first-admission series? Am J Psychiatry 157:60–66PubMedGoogle Scholar
  11. 11.
    Crow T, MacMillan JF, Johnson AL, Johnstone EC (1986) A randomized controlled trial of prophylactic neuroleptic treatment. Brit J Psychiatry 148:120–127Google Scholar
  12. 12.
    Drake RJ, Haley CJ, Akhtar S, Lewis SW (2000) Causes and consequences of duration of untreated psychosis in schizophrenia. Brit J Psychiatry 177:511–515CrossRefGoogle Scholar
  13. 13.
    Eaton WW, Thara R, Federman E, Tien A (1998) Remission and relapse in schizophrenia: The Madras longitudinal study. J Nerv Ment Dis 186:357–363CrossRefPubMedGoogle Scholar
  14. 14.
    Edwards J, Francey SM, McGorry PD, Jackson HJ (1994) Early psychosis prevention and intervention: Evolution of a comprehensive community-based specialised service. Behaviour Change 11:223–233Google Scholar
  15. 15.
    Friis S, Melle IS, Larsen TK, Johannesen JO Simonsen E, Vaglum PJW, McGlashan TH (2001) Does duration of untreated psychosis (DUP) bias schizophrenia study samples? Schizophr Res 49(Suppl 1–2):260Google Scholar
  16. 16.
    Friis S, Melle I, Haahr U, Larsen TK, Johannessen JO, Simonsen E, Vaglum PJW, McGlashan T (1999) Threats to validity in outcome studies of early intervention in schizophrenia. Schizophr Res 36:340Google Scholar
  17. 17.
    Goldman HH, Skodol AE, Lave TR (1992) Revising axis V for DSM-IV: A review of measures of social functioning. Am J Psychiatry 149:1148–1156PubMedGoogle Scholar
  18. 18.
    Green LW, Kreuter MW (1991) Health Promotion Planning: An Educational and Environmental Approach. Second ed, Mountain View, MayfieldGoogle Scholar
  19. 19.
    Haas G, Garratt LS, Sweeney JA (1998) Delay to antipsychotic medication in schizophrenia: impact on symptomatology and clinical course of illness. J Psychiatric Res 32:151–159CrossRefGoogle Scholar
  20. 20.
    Harrigan S, McGorry PD, Krstev H (2003) Does treatment delay in first-episode psychosis really matter? Psychol Med 33:97–110CrossRefPubMedGoogle Scholar
  21. 21.
    Harrison G, Glazebrook C, Brewin J, Cantwell R, Dalkin T, Fox R, Jones P, Medley I (1997) Increased incidence of psychotic disorders in African Caribbean migrants to the United Kingdom. Psychol Med 27:799–806CrossRefPubMedGoogle Scholar
  22. 22.
    Helgason L (1990) Twenty years’ follow-up of first-presentation for schizophrenia: What could have been prevented? Acta Psychiatr Scand 81:231–235PubMedGoogle Scholar
  23. 23.
    Ho BC, Andreasen NC, Flaum M, Nopoulos P, Miller D (2000) Untreated initial psychosis: its relation to quality of life and symptom remission in first-episode schizophrenia. Am J Psychiatry 157:808–815CrossRefPubMedGoogle Scholar
  24. 24.
    Humphreys MS, Johnstone EC, MacMillan JF, Taylor PJ (1992) Dangerous behaviour preceding first admissions for schizophrenia (comment). Brit J Psychiatry 161:501–505Google Scholar
  25. 25.
    Johannessen JO, McGlashan TH, Larsen TK, Horneland M, Joa I, Mardal S, Kvebaek R, Friis S, Melle I, Opjordsmoen S, Simonsen E, Ulrik H, Vaglum P (2001) Early detection strategies for untreated first-episode psychosis. Schizophr Res 51:39–46CrossRefPubMedGoogle Scholar
  26. 26.
    Johnstone EC, Crow TJ, Johnson AL, MacMillan JF (1986) The Northwick Park study of first-episodes of schizophrenia. I. Presentation of the illness and problems relating to admission. Brit J Psychiatry 148:115–120Google Scholar
  27. 27.
    Larsen TK, McGlashan TH, Johannessen JO, Friis S, Guldberg C, Haahr U, Horneland M, Melle I, Moe LC, Opjordsmoen S, Simonsen E, Vaglum P (2001) Shortened duration of untreated first episode of psychosis: changes in patient characteristics at treatment. Am J Psychiatry 158:1917–1919CrossRefPubMedGoogle Scholar
  28. 28.
    Larsen T, Moe LC, Vibe-Hansen L, Johannessen JO (2000) Premorbid functioning versus duration of untreated psychosis in 1 year outcome in first-episode psychosis. Schizophr Res 45:1–9CrossRefPubMedGoogle Scholar
  29. 29.
    Larsen T, McGlashan TH, Moe LC (1996) First-episode schizophrenia: I Early course parameters. Schizophr Bull 22:241–256CrossRefPubMedGoogle Scholar
  30. 30.
    Lewis S (2002) Integrating individuals psychosocial treatments in early psychosis. Acta Psychiatr Scand 106(Suppl 414):S32Google Scholar
  31. 31.
    Lieberman J, Fenton W (2000) Delayed detection of psychosis: Causes, consequences, and effect on public health. Am J Psychiatry 157:1727–1730CrossRefPubMedGoogle Scholar
  32. 32.
    Lincoln CV, McGorry PD (1995) Who cares? Pathways to psychiatric care for young people experiencing a first episode of psychosis. Psychiatr Serv 46:1166–1171PubMedGoogle Scholar
  33. 33.
    Lincoln CV, Harrigan S, McGorry PD (1998) Understanding the topography of the early psychosis pathways. Brit J Psychiatry 172(Suppl 33):21–25Google Scholar
  34. 34.
    Loebel A, Lieberman JA, Alvir JM, Mayerhoff DI, Geisler SH, Szymanski SR (1992) Duration of psychosis and outcome in first-episode schizophrenia. Am J Psychiatry 149:1183–1188PubMedGoogle Scholar
  35. 35.
    Lukoff D, Neuchterlein KH,Ventura J (1986) Manual for the Expanded Brief Psychiatric Rating Scale. Schizophr Bull 12:594–602Google Scholar
  36. 36.
    Malla AK, Norman RMG (2002) Early intervention in schizophrenia and related disorders: advantages and pitfalls. Curr Opin Psychiatry 15:17–23CrossRefGoogle Scholar
  37. 37.
    McGlashan T (1998) Early detection and intervention of schizophrenia: rationale and research. Brit J Psychiatry 172(Suppl 33):3–6Google Scholar
  38. 38.
    McGlashan T (1999) Duration of untreated psychosis in first-episode schizophrenia: Marker or determinant of course? Biol Psychiatry 46:899–907CrossRefPubMedGoogle Scholar
  39. 39.
    McGlashan T (1996) Early detection and intervention with schizophrenia: Research. Schizophr Bull 22:327–345PubMedGoogle Scholar
  40. 40.
    McGorry PD (1995) A treatment-relevant classification of psychotic disorders. Aust NZJ Psychiatry 29:555–558Google Scholar
  41. 41.
    McGorry PD (2000) Evaluating the importance of reducing the duration of untreated psychosis. Aust NZJ Psychiatry 34(Suppl):145–149CrossRefGoogle Scholar
  42. 42.
    McGorry PD, Copolov D, Singh B (1990a) Royal Park Multidiagnostic Instrument for Psychosis: Part 1. Rationale and review. Schizophr Bull 16:501–515Google Scholar
  43. 43.
    McGorry PD, Singh BS, Copolov DL, Kaplan I, Dossetor CR, van Riel RJ (1990b) The Royal Park Multidiagnostic Instrument for Psychosis: Part II. Development, reliability and validity. Schizophr Bull 16:517–536Google Scholar
  44. 44.
    McGorry PD, Copolov DL, Singh BS (1989) The validity of the assessment of psychopathology in the psychoses. Aust NZJ Psychiatry 23:469–82Google Scholar
  45. 45.
    Norman RM, Malla AK (2001) Duration of untreated psychosis: A critical examination of the concept and its importance. Psychol Med 31:381–400PubMedGoogle Scholar
  46. 46.
    Overall JE, Gorham DR (1962) The Brief Psychiatric Rating Scale. Psychol Rep 10:799–102Google Scholar
  47. 47.
    Pedersen CB, Mortensen, PB (2001) Family history, place and season of birth as risk factors for schizophrenia in Denmark: a replication and analysis. Brit J Psychiatry 179:46–52CrossRefGoogle Scholar
  48. 48.
    Quinn J, Moran M, Lane A, Kinsella A, Waddington J (2000) Long-term adaptive life functioning in relation to initiation of treatment with antipsychotics over the lifetime trajectory of schizophrenia. Biol Psych 48:163–166CrossRefGoogle Scholar
  49. 49.
    Rabiner CJ, Wegner JT, Kane JM (1986) Outcome study of firstepisode psychosis. I: Relapse rates after 1 year. Am J Psychiatry 143:1155–1158PubMedGoogle Scholar
  50. 50.
    Regier D (1988) The NIMH depression awareness recognition and treatment program: Structure, aims and scientific basis. JAMA 145:1351–1357Google Scholar
  51. 51.
    Scully P, Coakley G, Kinsella A, Waddington J (1997) Psychopathology, executive (frontal) and general cognitive impairment in relation to duration of initially untreated versus subsequently treated psychosis in chronic schizophrenia. Psychol Med 27:1303–1310CrossRefPubMedGoogle Scholar
  52. 52.
    Selten JP, Veen N, Feller W, Blom JD, Schols D, Camoenie W, Oolders J, van der Velden M, Hoek HW, Rivero VM, van der Graaf Y, Kahn R (2001) Incidence of psychotic disorders in immigrant groups to The Netherlands. Brit J Psychiatry 178:367–372CrossRefGoogle Scholar
  53. 53.
    van Os J, Hanssen M, Bijl RV, Vollebergh W (2001) Prevalence of psychotic disorder and community level of psychotic symptoms: An urban-rural comparison. Arch Gen Psychiatry 58:663–668Google Scholar
  54. 54.
    Verdoux H, Liraud F, Bergey C, Assens F, Abalan F, van Os J (2001) Is the association between duration of untreated psychosis and outcome confounded? A two year follow-up study of first-admitted patients. Schizophr Res 49:231–241CrossRefPubMedGoogle Scholar
  55. 55.
    Verdoux H, Bergey C, Assens F, Abalan F, Gonzales B, Pauillac P, Fournet O, Liraud F, Beaussier J, Gaussares C, Etchegaray B, Bourgeois M, van Os J (1998) Prediction of duration of psychosis before first admission. Eur Psychiatry 13:346–352CrossRefGoogle Scholar
  56. 56.
    Wyatt R (1991) Neuroleptics and the natural course of schizophrenia. Schizophr Bull 17:325–351PubMedGoogle Scholar

Copyright information

© Steinkopff Verlag 2004

Authors and Affiliations

  • Helen Krstev
    • 1
    • 2
  • Steve Carbone
    • 1
    • 2
  • Susy M. Harrigan
    • 1
    • 2
  • Christina Curry
    • 1
    • 2
  • Kathryn Elkins
    • 1
    • 2
  • Patrick D. McGorry
    • 1
    • 2
  1. 1.Early Psychosis Prevention & Intervention CentreParkville (Vic) 3052Australia
  2. 2.The University of Melbourne Parkville (Vic)Australia

Personalised recommendations