Reducing the Duration of Untreated Psychosis in the United States
Thomas Insel, M.D.
Director, National Institute of Mental Health
The goal of this initiative is to support research to identify gaps and bottlenecks in the identification and referral of individuals experiencing first episode psychosis (FEP) in order to develop and test strategies for substantially reducing the duration of untreated psychosis among these individuals.
Approximately 100,000 adolescents and young adults in the United States experience FEP every year (calculated from McGrath, Saha, Chant, et al., 2008). The early phase of psychotic illness is widely viewed as a promising opportunity for indicated prevention, and a chance to alter the downward trajectory and poor outcomes associated with serious mental disorders such as schizophrenia. Compared to traditional treatment approaches, specialty care programs that integrate pharmacologic, psychological, and rehabilitation interventions for FEP are associated with a range of positive outcomes, including remission of psychotic symptoms, lower-rates of re-hospitalization, shorter hospital stays, improved quality of life and social functioning, increased cognitive performance, and decreased substance abuse (Penn, Waldheter, Perkins, et al., 2005). The timing of treatment is critical, however; short and long-term outcomes are better when individuals begin treatment close to the onset of psychosis (Marshall, Lewis, Lockwood, et al., 2005; Perkins, Gu, Boteva, et al., 2005).
International consensus statements recommend that specialty care interventions for FEP start within 3 months of illness onset (Bertolote and McGorry, 2005). However, more than two dozen studies conducted worldwide have observed a substantial delay (on average 2 years) between the appearance of psychotic symptoms and the initiation of appropriate treatment (Marshall et al., 2005). Two influential meta-analyses have established that duration of untreated psychosis (DUP), the time between the onset of psychosis and initiation of appropriate treatment, is correlated with poor outcome (Marshall et al., 2005; Perkins et al., 2005). In the United States, DUP ranges between one and three years (e.g., Hass and Sweeney, 1992; Ho, Andreasen, Flaum, et al., 2000), suggesting that many persons with FEP are missing a critical opportunity to benefit from early intervention. Research suggests that DUP can be reduced within public health systems by enhancing early detection and treatment referral mechanisms (Melle, Larsen, Haahr, et al., 2004).
This initiative aims to support research to (1) identify gaps and bottlenecks in the FEP case identification and referral chain in the United States, and (2) develop and test feasible strategies for reducing delays in early detection, speedy referral, and rapid initiation of stage-specific FEP treatment. Anticipated outcomes might include, but not be limited to:
- Better detection of psychosis onset, or symptoms suggesting high clinical risk of psychosis, within primary care settings, schools, child/youth mental health services, college counseling centers, emergency departments, criminal justice agencies, and/or other promising community settings;
- Methods to achieve expeditious referral of persons with FEP, or those at high clinical risk of psychosis, to an appropriate specialty care treatment program; and,
- Strategies for achieving rapid engagement and initiation of stage-specific FEP treatment.
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Ho B, Andreasen NC, Flaum M, Nopoulos P, Miller D. Untreated initial psychosis: Its relation to quality of life and symptom remission in first-episode schizophrenia. American Journal of Psychiatry 2000;157:808-815.
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. Archives of General Psychiatry, 62:975-983.
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Penn D, Waldheter E, Perkins D, Mueser K, Lieberman J. (2005). Psychosocial treatment for first-episode psychosis: A research update. American Journal of Psychiatry,162:2220–2232.
Perkins D, Gu H, Boteva K, Lieberman J. (2005). Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: A critical review and meta-analysis. American Journal of Psychiatry, 162:1785–1804.