Psychiatry Research EG

The duration of untreated psychosis (DUP), which represents the delay in initiation of treatment, is a concept of paramount importance in schizophrenia research, at least from the point of view of secondary prevention. Its importance began to be appreciated in the mid 1980s when the Northwick Park Study of firstepisode schizophrenia found that the most important determinant of relapse was the duration of illness before starting antipsychotics [1]. Interest in the topic has increased even more in recent years, with a growing sense of optimism derived from the understanding that attention to the early phases of illness could result in a substantial reduction in morbidity and lead to a better quality of life. Moreover, although there is some controversy about whether long DUP is associated with poor outcome, the weight of evidence supports an association that, although not strong, is persistent; for example, [2–5]. Thus, in a systematic review of literature,Marshall et al. [6] concluded that there is convincing evidence of an association, albeit small to moderate, between DUP and outcome. Similarly, literature review in low and middleincome countries by Farooq et al. [7] showed that the lack of treatment for psychotic illness early in its course is associated with poor outcomes, irrespective of the income or cultural status of the setting. Long DUP was frequently reported to be associated with increased mortality and poor prognosis [8,9]. The relationship between DUP and 1-year outcome, as demonstrated by two large studies from UK [10] and Australia [11], is curvilinear, with greater improvement in outcome if DUP is reduced from 6 to 3 weeks compared with reduction from 6 to 3 months. In other words, the maximum benefit of early intervention services will be obtained only by shifting patients to the shortest part of the DUP range. However, the mechanism by which long DUP might lead to poor outcome is still uncertain. It has been postulated that a long DUP might lead to neurotoxic processes, manifested as persistent morbidity, treatment resistance, and symptom worsening [12], and that there is a critical period, postulated to be up to 5 years from the onset of psychosis, for intervention before psychosis can be established [13,14]. Biological mechanisms involving dopaminergic and glutamatergic processes have also been suggested to explain how prolonged active psychosis will result in treatment refractoriness. Recently, neuroimaging studies have demonstrated reductions in hippocampus volume [15] and temporal gray matter [16] in patients with long DUP. These findings could reflect a progressive pathological process that is active before treatment. In contrast, these abnormalities could be associated with a more insidious onset of illness and a later presentation to services. Thus, possible explanatory mechanisms would also include psychosocial processes, with prolonged untreated psychosis increasingly producing psychological and social dysfunction. In an attempt to reduce DUP, many countries have implemented early intervention programs [17–19] as a target for secondary preventive efforts [20]. The aim of these programs is not limited to the reduction of DUP to improve outcome; they also attempt to promote recovery through the evidence-based use of drug treatments, cognitive behavioral therapies, and family interventions, provided in a setting specifically designed to be accessible and nonstigmatizing. Although some studies indicate that specialized early psychosis intervention programs can deliver a higher recovery rate and at a cost lower than that of standard public mental health services [21,22], other studies suggest that improvement in outcome is not as promising as hoped [23]. Addressing factors that have a strong influence on DUP and that are also changeable is important. This may be a key for the success of any program attempting to reduce potentially deleterious treatment delays [24]. Data on treatment delay in psychosis, however, are still rather limited, especially from developing countries. Most available studies indicate that DUP has an average of approximately 1–2 years [25]. It is noted that DUP varies considerably across different cultures and settings [25]. Thus, although DUP was found by Oliveira et al. [26] in Sa˜o Paulo (Brazil) to be shorter than expected, with a mean of only 4.1 weeks, Nishii et al. [27] found that the mean of DUP in three cities in Japan (Tokyo, Toyama, and Kochi) was relatively long (20.3 months), and Haas and Sweeney [28] in New York (USA) found DUP to have a mean as long as 3 years. Our own pilot study in Zagazig (Egypt) that we reported in 2005 [29] found a still longer duration with a mean of 3.1 years. Although the earliest manifestations of psychosis may be universal, the impact of individual, familial, social, and health service-related factors on psychiatric help-seeking behavior might vary according to different cultural contexts [25], and, although cross-cultural data on incidence and prevalence, rates of admission, psychopathological aspects, symptoms, course, and outcome are available [30,31], formal studies on DUP-related factors in different cultures are hard to find. Cross-cultural studies on the characteristics of the early course of psychosis and pathways to psychiatric care have mostly tended to be either comparisons between developed and developing countries [32] or unicultural studies that have examined the differences between different ethnic groups in one country [33,34]. Thus, data from studies comparing more socioculturally related countries, for example, studies between Arab countries, are required. Although both Egypt and Saudi Arabia represent Arab countries, there are many differences between them in terms of religious affiliation, level of secularism, level of democracy, and economic status [35]. These differences may have an influence on the factors associated with delay in treatment seeking. However, no previous studies, to the best of our knowledge, have compared DUP between these two countries. Our aims in this study were to determine the DUP length in two samples of patients, from Egypt and Saudi Arabia, with first-episode psychosis, who had received no previous psychiatric treatment; to explore the sociodemographic,clinical, and help-seeking characteristics that are associated with DUP in these two groups; to distinguish which of these sociodemographic, clinical and help-seeking correlates of DUP are shared by Egyptian and Saudi patient groups and which are more culture specific, and (4) to find out whether severity of illness would predict the length of DUP at presentation. The null hypothesis (H0) is that no significant correlation would exist between severity of illness and length of DUP. The alternative hypothesis (H1) is that a significant correlation would exist between severity of illness and length of DUP.