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Reducing the Duration of Untreated Psychosis in the United States


Susan T. Azrin, Ph.D.
Division of Services and Intervention Research


This initiative would support research that tests practical, reproducible strategies for substantially reducing the duration of untreated psychosis (DUP) among persons with first-episode psychosis (FEP) in real-world U.S. settings.


Approximately 100,000 adolescents and young adults in the United States experience a first episode of psychosis (FEP) every year. The early phase of psychotic illness is widely viewed as a critical opportunity for indicated prevention, and a chance to alter the downward trajectory and poor outcomes associated with schizophrenia and related psychotic disorders. Compared to traditional treatment approaches, programs that integrate FEP medication management, cognitive and behavioral therapies, supported employment and education, family psychoeducation and support, case management, and primary care coordination within a shared decision-making framework, i.e., team-based Coordinated Specialty Care (CSC), have been found to produce a range of positive clinical and functional outcomes. However, the timing of this treatment is critical; short and long-term outcomes are much better when individuals begin treatment close to the onset of psychosis. Unfortunately, numerous studies find a substantial delay between the onset of psychotic symptoms and the initiation of FEP care; in the U.S. treatment is typically delayed between one and three years. Early identification of FEP, rapid referral to evidence-based CSC, and effective engagement in CSC services are essential to shortening DUP and pre-empting the functional deterioration common in psychotic disorders. The World Health Organization advocates reducing DUP to 3 months or less.

Previous NIMH-funded initiatives were successful in supporting projects that developed and tested practical DUP reduction strategies, including universal web-based training to improve clinicians’ ability to identify early psychosis and refer to specialized FEP care; universal screening in community mental health clinics and facilitated referral to FEP care; using social media to identify individuals with early psychosis and connect them to FEP care; multi-element psychosis literacy campaigns; psychosis literacy campaigns coupled with a mobile CSC team to engage individuals in FEP care; screening coupled with a mobile CSC team; and psychosis screening in juvenile justice settings with referral to FEP care. This initiative extends prior efforts by encouraging additional research project grant applications that test practical, reproducible strategies for substantially reducing DUP among persons with FEP in the U.S. by eliminating bottlenecks or closing gaps in the pathway to CSC services.

Promising new areas for DUP reduction research include identifying, treating, and monitoring individuals at clinical high risk of psychosis; leveraging college mental health center and school mental health infrastructure to screen for early psychosis and refer to FEP care; leveraging other existing mental health screening infrastructure to promote connection to FEP care; enhancing referrals to FEP care from psychiatric inpatient facilities and emergency departments to promote engagement in that care; partnering with police departments to recognize symptoms of psychosis and divert identified individuals to appropriate care; enhancing the capacity of families to recognize early psychosis symptoms and support their family member in initiating FEP care; and using the internet to facilitate help-seeking in persons with FEP. The proposed initiative would encourage applications that address these opportunities and other research gaps in DUP, including large-scale testing of DUP reduction strategies that have demonstrated preliminary effectiveness and feasibility in pilot clinical trials.