Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia

  • Matthew M. Large
  • Olav Nielssen
  • Christopher James Ryan
  • Robert Hayes



A long duration of untreated psychosis (DUP) is associated with a worse prognosis, an increased risk of suicide and may be linked to serious violence. Mental health laws that require patients to be dangerous to themselves or to others before they can receive involuntary psychiatric treatment may make it more difficult to treat patients in their first episode of psychosis.


The mean and median DUP reported in studies of schizophrenia related psychoses were examined. A comparison was made between the DUP reported from jurisdictions that had an obligatory dangerousness criterion (ODC) and those with other criteria for involuntary treatment.


The average mean DUP in samples from jurisdictions with an ODC was 79.5 weeks, but was only 55.6 weeks in those jurisdictions that did not have an ODC (P < 0.007).


Mental health laws that require the patient to be assessed as dangerous before they can receive involuntary treatment are associated with significantly longer DUP. As reducing DUP is an intervention that can improve the prognosis of schizophrenia, this finding suggests that mental health laws should be amended to allow treatment on grounds other than dangerousness, at least in the crucial first episode of psychosis.

Key words

schizophrenia duration of untreated psychosis mental health services 


  1. 1.
    Addington J, Van Mastrigt S, Addington D (2004) Duration of untreated psychosis: impact on 2-year outcome. Psychol Med 34:277–284PubMedCrossRefGoogle Scholar
  2. 2.
    Altamura AC, Bassetti R, Sassella F, Salvadori D, Mundo E (2001) Duration of untreated psychosis as a predictor of outcome in first-episode schizophrenia: a retrospective study. Schizophr Res 52:29–36PubMedCrossRefGoogle Scholar
  3. 3.
    Altamura AC, Bassetti R, Bignotti S, Pioli R, Mundo E (2003) Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr Res 60:47–55PubMedCrossRefGoogle Scholar
  4. 4.
    Anfang SA, Appelbaum PS (2006) Civil commitment—the American experience. Isr J Psychiatry Relat Sci 43:209–218PubMedGoogle Scholar
  5. 5.
    Appelbaum PS (1997) Almost a revolution: an international perspective on the law of involuntary commitment. J Am Acad Psychiatry Law 25:135–147PubMedGoogle Scholar
  6. 6.
    Ballageer T, Malla A, Manchanda R, Takhar J, Haricharan R (2005) Is adolescent-onset first-episode psychosis different from adult onset? J Am Acad Child Adolesc Psychiatry 44:782–789PubMedCrossRefGoogle Scholar
  7. 7.
    Barnes TR, Hutton SB, Chapman MJ, Mutsatsa S, Puri BK, Joyce EM (2000) West London first-episode study of schizophrenia. Clinical correlates of duration of untreated psychosis. Br J Psychiatry 177:207–211PubMedCrossRefGoogle Scholar
  8. 8.
    Beiser M, Erickson D, Fleming JA, Iacono WG (1993) Establishing the onset of psychotic illness. Am J Psychiatry 150:1349–1354PubMedGoogle Scholar
  9. 9.
    Birchwood M, Cochrane R, Macmillan F, Copestake S, Kucharska J, Carriss M (1992) The influence of ethnicity and family structure on relapse in first-episode schizophrenia. A comparison of Asian, Afro-Caribbean, and white patients. Br J Psychiatry 161:783–790PubMedGoogle Scholar
  10. 10.
    Black K, Peters L, Rui Q, Milliken H, Whitehorn D, Kopala LC (2001) Duration of untreated psychosis predicts treatment outcome in an early psychosis program. Schizophr Res 47:215–222PubMedCrossRefGoogle Scholar
  11. 11.
    Carlsson R, Nyman H, Ganse G, Cullberg J (2006) Neuropsychological functions predict 1- and 3-year outcome in first-episode psychosis. Acta Psychiatr Scand 113:102–111PubMedCrossRefGoogle Scholar
  12. 12.
    Caton CL, Hasin DS, Shrout PE et al (2006) Predictors of psychosis remission in psychotic disorders that co-occur with substance use. Schizophr Bull 32:618–625PubMedCrossRefGoogle Scholar
  13. 13.
    Clarke M, Whitty P, Browne S et al (2006) Untreated illness and outcome of psychosis. Br J Psychiatry 189:235–240PubMedCrossRefGoogle Scholar
  14. 14.
    Clarke M, Whitty P, Browne S et al (2006) Suicidality in first episode psychosis. Schizophr Res 86:221–225PubMedCrossRefGoogle Scholar
  15. 15.
    Cohen RZ, Gotowiec A, Seeman MV (2000) Duration of pre-treatment phases in schizophrenia: women and men. Can J Psychiatry 45:544–547PubMedGoogle Scholar
  16. 16.
    Compton MT, Esterberg Ml, Druss Bg, Walker Ef, Kaslow NJ (2006) A descriptive study of pathways to care among hospitalized urban African American first-episode schizophrenia-spectrum patients. Soc Psychiatry Psychiatr Epidemiol 41:566–573PubMedCrossRefGoogle Scholar
  17. 17.
    Craig TJ, 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
  18. 18.
    Crespo-Facorro B, Pelayo-Teran JM, Perez-Iglesias R et al (2007) Predictors of acute treatment response in patients with a first episode of non-affective psychosis: sociodemographics, premorbid and clinical variables. J Psychiatr Res 41:659–666PubMedCrossRefGoogle Scholar
  19. 19.
    Drake RJ, Haley CJ, Akhtar S, Lewis SW (2000) Causes and consequences of duration of untreated psychosis in schizophrenia. Br J Psychol 177:511–515CrossRefGoogle Scholar
  20. 20.
    Dressing H, Salize HJ (2004) Compulsory admission of mentally ill patients in European Union Member States. Soc Psychiatry Psychiatr Epidemiol 39:797–803PubMedGoogle Scholar
  21. 21.
    Fannon D, Chitnis X, Doku V et al (2000) Features of structural brain abnormality detected in first-episode psychosis. Am J Psychol 157:1829–1834CrossRefGoogle Scholar
  22. 22.
    Fennig S, Everett E, Bromet EJ et al (1996) Insight in first-admission psychotic patients. Schizophr Res 22:257–263PubMedCrossRefGoogle Scholar
  23. 23.
    Friis S, Melle I, Larsen TK et al (2004) Does duration of untreated psychosis bias study samples of first-episode psychosis? Acta Psychiatr Scand 110:286–289PubMedCrossRefGoogle Scholar
  24. 24.
    Fuchs J, Steinert T (2004) Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany. Soc Psychiatry Psychiatr Epidemiol 39:375–380PubMedCrossRefGoogle Scholar
  25. 25.
    Gunduz-Bruce H, McMeniman M, Robinson DG et al (2005) Duration of untreated psychosis and time to treatment response for delusions and hallucinations. Am J Psychiatry 162:1966–1969PubMedCrossRefGoogle Scholar
  26. 26.
    Gray JE, O’Reilly RL (2001) Clinically significant differences among Canadian mental health acts. Can J Psychiatry 46:315–321PubMedGoogle Scholar
  27. 27.
    Haas GL, Sweeney JA (1992) Premorbid and onset features of first-episode schizophrenia. Schizophr Bull 18:373–386PubMedGoogle Scholar
  28. 28.
    Hatling T, Krogen T, Ulleberg P (2002) Compulsory admissions to psychiatric hospitals in Norway—international comparisons and regional variations. J Mental Health 11:623–634CrossRefGoogle Scholar
  29. 29.
    Hafner H, Maurer K, Loffler W, Riecher-Rossler A (1993) The influence of age and sex on the onset and early course of schizophrenia. Br J Psychiatry 162:80–86PubMedGoogle Scholar
  30. 30.
    Haley CJ, Drake RJ, Bentall RP Lewis SW (2003) Health beliefs link to duration of untreated psychosis and attitudes to later treatment in early psychosis. Soc Psychiatry Psychiatr Epidemiol 38:311–316PubMedGoogle Scholar
  31. 31.
    Harding TW, Curran WJ (1979) Mental health legislation and its relationship to program development: an international review. Harvard J Legis 16:19–57PubMedGoogle Scholar
  32. 32.
    Harris A, Brennan J, Anderson J et al (2005) Clinical profiles, scope and general findings of the Western Sydney first episode Psychosis Project. Aust N Z J Psychiatry 39:36–43PubMedCrossRefGoogle Scholar
  33. 33.
    Ho Bc, Alicata D, Ward J et al (2003) Untreated initial psychosis: relation to cognitive deficits and brain morphology in first-episode schizophrenia. Am J Psychiatry 160:142–148PubMedCrossRefGoogle Scholar
  34. 34.
    Humphreys MS, Johnstone EC, Macmillan JF, Taylor PJ (1992) Dangerous behaviour preceding first admissions for schizophrenia. Br J Psychiatry 161:501–505PubMedCrossRefGoogle Scholar
  35. 35.
    Kalla O, Aaltonen J, Wahlström J, Lehtinen V, García Cabeza I, González DE Chávez M (2002) Duration of untreated psychosis and its correlates in first-episode psychosis in Finland and Spain. Acta Psychiatr Scand 106:265–275PubMedCrossRefGoogle Scholar
  36. 36.
    Large M, Nielssen O (2007) Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment. Soc Psychiatry Psychiatr Epidemiol. (in press)Google Scholar
  37. 37.
    Larsen TK, McGlashan TH, Johannessen JO et al (2001) Shortened duration of untreated first episode of psychosis: changes in patient characteristics at treatment. Am J Psychiatry 158:1917–1919PubMedCrossRefGoogle Scholar
  38. 38.
    Lieberman JA, Fenton WS (2000) Delayed detection of psychosis: causes, consequences, and effect on public health. Am J Psychiatry 157:1727–1730PubMedCrossRefGoogle Scholar
  39. 39.
    Linszen D, Dingemans P, Lenior M (2001) Early intervention and a five year follow up in young adults with a short duration of untreated psychosis: ethical implications. Schizophr Res 51:55–56PubMedCrossRefGoogle Scholar
  40. 40.
    Loebel AD, 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
  41. 41.
    Loranger AW (1984) Sex difference in age at onset of schizophrenia. Arch Gen Psychiatry 41:157–161PubMedGoogle Scholar
  42. 42.
    Madsen AL, Karle A, Rubin P, Cortsen M, Andersen HS, Hemmingsen R (1999) Progressive atrophy of the frontal lobes in first-episode schizophrenia: interaction with clinical course and neuroleptic treatment. Acta Psychiatr Scand 100:367–374PubMedCrossRefGoogle Scholar
  43. 43.
    Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T (2005) Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 62:975–983PubMedCrossRefGoogle Scholar
  44. 44.
    Mauri M, Volonteri L, De Gaspari I, Colasanti A, Brambilla M, Cerruti L (2006) Substance abuse in first-episode schizophrenic patients: a retrospective study. Clin Pract Epidemol Ment Health 2:4PubMedCrossRefGoogle Scholar
  45. 45.
    Melle I, Haahr U, Friis S et al (2005) Reducing the duration of untreated first-episode psychosis—effects on baseline social functioning and quality of life. Acta Psychiatr Scand 112:469–473PubMedCrossRefGoogle Scholar
  46. 46.
    Melle I, Johannesen JO, Friis S (2006) Early detection of the first episode of schizophrenia and suicidal behavior. Am J Psychiatry 163:800–804PubMedCrossRefGoogle Scholar
  47. 47.
    Milton J, Amin S, Singh SP et al (2001) Aggressive incidents in first-episode psychosis. Br J Psychiatry 178:433–440PubMedCrossRefGoogle Scholar
  48. 48.
    Moller P (2000) First-episode schizophrenia: do grandiosity, disorganization, and acute initial development reduce duration of untreated psychosis? An exploratory naturalistic case study. Compr Psychiatry 41:184–190PubMedCrossRefGoogle Scholar
  49. 49.
    Moscarelli M, Capri S, Neri L (1991) Cost evaluation of chronic schizophrenic patients during the first 3 years after the first contact. Schizophr Bull 17:421–426PubMedGoogle Scholar
  50. 50.
    Norman RM, Malla AK (2001) Duration of untreated psychosis: a critical examination of the concept and its importance. Psychol Med 31:381–400PubMedGoogle Scholar
  51. 51.
    Nordentoft M, Jeppesen P, Abel M et al (2002) OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial. Br J Psychiatry 181:s98–106CrossRefGoogle Scholar
  52. 52.
    Peralta V, Cuesta MJ, Martinez-Larrea A, Serrano JF, Langarica M (2005) Duration of untreated psychotic illness: the role of premorbid social support networks. Soc Psychiatry Psychiatr Epidemiol 40:345–349PubMedCrossRefGoogle Scholar
  53. 53.
    Perkins DO, Gu H, Boteva K, Lieberman JA (2005) Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 162:1785–1804PubMedCrossRefGoogle Scholar
  54. 54.
    Petersen L, Nordentoft M, Jeppesen P et al (2005) Improving 1-year outcome in first-episode psychosis: OPUS trial. Br J Psychiatry Suppl 48:s98–s103PubMedCrossRefGoogle Scholar
  55. 55.
    Reilly JL, Harris MS, Keshavan MS, Sweeney JA (2006) Adverse effects of risperidone on spatial working memory in first-episode schizophrenia. Arch Gen Psychiatry 63:1189–1197PubMedCrossRefGoogle Scholar
  56. 56.
    Ropcke B, Eggers C (2005) Early-onset schizophrenia: a 15-year follow-up. Eur Child Adolesc Psychiatry 14:341–350PubMedCrossRefGoogle Scholar
  57. 57.
    Rosen K, Garety P (2005) Predicting recovery from schizophrenia: a retrospective comparison of characteristics at onset of people with single and multiple episodes. Schizophr Bull 31:735–750PubMedCrossRefGoogle Scholar
  58. 58.
    Seikkula J, Aaltonen J, Alakare B, Haarakangas K, Keränen J, Lehtinen K (2006) Five-year experience of first-episode non affective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychother Res 16:214–228CrossRefGoogle Scholar
  59. 59.
    Singh SP, Cooper JE, Fisher HL et al (2005) Determining the chronology and components of psychosis onset: the Nottingham onset schedule (NOS). Schizophr Res 80:117–130PubMedCrossRefGoogle Scholar
  60. 60.
    Sipos A, Harrison G, Gunnell D, Amin S, Singh SP (2001) Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study. Br J Psychiatry 178:518–523PubMedCrossRefGoogle Scholar
  61. 61.
    Skeate A, Jackson C, Birchwood M, Jones C (2002) Duration of untreated psychosis and pathways to care in first-episode psychosis. Investigation of help-seeking behaviour in primary care. Br J Psychiatry 181:s73–s77CrossRefGoogle Scholar
  62. 62.
    Strakowski SM, Keck PE Jr, Mcelroy SL, Lonczak HS, West SA (1995) Chronology of comorbid and principal syndromes in first-episode psychosis. Compr Psychiatry 36:106–112PubMedCrossRefGoogle Scholar
  63. 63.
    Szymanski SR, Cannon TD, Gallacher F, Erwin RJ, Gur RE (1996) Course of treatment response in first-episode and chronic schizophrenia. Am J Psychiatry 153:519–525PubMedGoogle Scholar
  64. 64.
    Thompson KN, McGorry PD, Harrigan SM (2001) Reduced awareness of illness in first-episode psychosis. Compr Psychiatry 42:498–503PubMedCrossRefGoogle Scholar
  65. 65.
    Turner MA, Finch PJ, McKechanie AG et al (2006) Psychosis in the British army: a 2-year follow-up study. Mil Med 171:1215–1219PubMedGoogle Scholar
  66. 66.
    United Nations national populations profiles (2005) Accessed ( 10 August 2007)
  67. 67.
    Verma S, Poon LY, Subramaniam M, Chong SA (2005) Aggression in Asian patients with first-episode psychosis. Int J Soc Psychiatry 51:365–371PubMedCrossRefGoogle Scholar
  68. 68.
    Volavka J, Laska E, Baker S, Meisner M, Czobor P, Krivelevich I (1997) History of violent behaviour and schizophrenia in different cultures. Analyses based on the WHO study on determinants of outcome of severe mental disorders. Br J Psychiatry 171:9–14PubMedGoogle Scholar
  69. 69.
    Wade D, Harrigan S, Harris MG, Edwards J, McGorry PD (2006) Pattern and correlates of inpatient admission during the initial acute phase of first-episode psychosis. Aust N Z J Psychiatry 40:429–436PubMedCrossRefGoogle Scholar
  70. 70.
    WHO project atlas of the department of mental health and substance abuse available for 2005 (accessed 10 June 2001)
  71. 71.
    Wunderink A, Nienhuis FJ, Sytema S, Wiersma D (2006) Treatment delay and response rate in first episode psychosis. Acta Psychiatr Scand 113:332–339PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Matthew M. Large
    • 1
    • 2
  • Olav Nielssen
    • 1
    • 3
    • 4
  • Christopher James Ryan
    • 4
    • 5
  • Robert Hayes
    • 6
  1. 1.Private PracticePaddingtonAustralia
  2. 2.Double BayAustralia
  3. 3.Clinical Research Unit for Anxiety Disorders, School of PsychiatryUNSW at St Vincent’s HospitalSydneyAustralia
  4. 4.Psychological MedicineUniversity of SydneySydneyAustralia
  5. 5.Westmead HospitalWestmeadAustralia
  6. 6.Mental Health Research and Training Centre (MHRTC), Law SchoolUniversity of Western SydneyCampbelltownAustralia

Personalised recommendations