670429 research-article2016

ISP0010.1177/0020764016670429International Journal of Social PsychiatryOkasha et al.

E CAMDEN SCHIZOPH

Original Article

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

International Journal of Social Psychiatry 1­–11 © The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764016670429 isp.sagepub.com

Tarek Okasha, Nivert Zaki, Marwa Abd El Meguid, Marwa El-Missiry, Walaa Sabry, Mostafa Kamel Ismaeil and Samar M Fouad

Abstract Background: Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP. Aims: To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP. Method: The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale. Results: Mean (±standard deviation (SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors. Conclusion: Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors. Keywords Duration of untreated psychosis, psychotic disorder, schizophrenia, traditional healer, predicting factors

Introduction Duration of untreated psychosis (DUP) had been defined by many authors. According to their systematic review, Compton et al. (2007) found that DUP was defined as ‘time from onset of psychotic symptoms to first treatment with antipsychotic medication’ (Barnes et al., 2000) or ‘period from initial onset of psychosis to treatment’ (Norman & Malla, 2001). Thus, DUP represents a continuous period of psychotic illness – the time interval from the emergence of psychotic symptoms to the initiation of treatment (Compton et al., 2007). Caton et al. (2006) and Chen et al. (2005) had stated that the effect of DUP on the prognosis of psychotic illness in low- and middle-income (LAMI) countries is not known, due to the small number of studies investigating DUP. They pointed to the more severe consequences of long DUP in

low-income countries. In a systematic review performed on 2008, Large, Farooq, Nielssen, and Slade found 23 researches only from LAMIs in comparison with 98 researches from high-income countries; they found out an inverse relationship between income and DUP in LAMIs. Haan, Linszen, Lenior, de Win, and Gorsira (2003) reported that DUP is linked to unfavourable outcome of WHO Collaborating Centre for Mental Health Research and Training, Institute of Psychiatry, Ain Shams University, Cairo, Egypt Corresponding author: Marwa Abd El Meguid, WHO Collaborating Centre for Mental Health Research and Training, Institute of Psychiatry, Ain Shams University, 65, El Nozha Street, Heliopolis, 11341 Cairo, Egypt. Email: [email protected]

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schizophrenia. Saravanan et al. (2010) found that outcome of first episode schizophrenia in India was strongly predicted by DUP. Many studies have shown that longer DUP is associated with poor response to antipsychotic medications and an unfavourable short- and long-term outcome (Marshall et al., 2005; Perkins, Gu, Botiva, & Libermans, 2005; Primavera et al., 2012; Wyatt & Henter, 2001). Sociodemographic variables including age, gender and socioeconomic status have been linked to DUP in some studies, while other studies have revealed conflicting results. They found a statistically significant association between brief DUP and married status, higher educational status of the patient, acute mode of onset, lower age, higher Positive and Negative Syndrome Scale (PANSS) Negative Symptom Score and higher PANSS General Psychopathology Score, while they did not find relation with the following variables: sex, residence, educational status of caregiver, occupation of patient, socioeconomic status, past history of physical illness, family history of mental illness and pathways to seeking care (Kini, Tharayil, Prabhavathy, & Haridas, 2015). It has been postulated that the lag between receiving the onset of psychotic symptoms and proper antipsychotic treatment might either causally induce a poorer outcome through a neurotoxic effect on the brain or other biologic and psychosocial mechanisms (Compton, Goulding, Broussard, & Trotman, 2008; McGlashan, 2008). Meanwhile, reducing DUP from a median of 1.5 to 0.5 years led to a markedly improved clinical presentation and an improved mediumand long-term (5-year) outcome (Larsen et al., 2011). DUP has been investigated in many studies, with variable duration ranging from 24.5 weeks in African American patients (Compton et al., 2008) to 3.2 and 3.1 years for Egyptian and Saudi Arabian patient groups (Fawzi, El Amin, & Fawzi, 2011). Given the burden imposed by untreated psychosis on individuals, families and societies, identification of the predictors of such delay is becoming an important research goal worldwide (Compton et al., 2011). Reduction in DUP should be a target for intervention (Saravanan et al., 2010). In addition, identification of predictors of DUP is crucial in the implementation of clinical and community-wide interventions aimed at reducing treatment delays. Beside patient- and illness-related factors, socio-cultural factors may contribute to delays in seeking treatments and prolonged DUP, especially in developing countries where the primary care system is either poorly developed or unavailable (Fawzi et al., 2011). The stigma of mental illness has been implicated as one of the causes for not seeking psychiatric advice (Perkins et al., 2005; Srihari et al., 2014). Thus, patients’ families may adopt certain coping mechanisms that result in a raised threshold for treatment initiation and ultimately a delay in treatment (Franz et al., 2010). Longer DUP predicted worse clinical, functional and cognitive outcomes (Diaz-Caneja et al., 2016). Studying specific predictors in an Egyptian sample may help in

early intervention in patients with psychotic disorders so this study aimed to estimate the sociodemographic and clinical predictors that prolong DUP.

Aim of the study To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

Subjects and methods This study is a cross-sectional descriptive study. Patients were recruited by a convenience sampling method from the inpatient and outpatient departments of the Institute of Psychiatry, Ain Shams University, which is located in Eastern Cairo and serves a catchment area for about a third of Greater Cairo. It serves both urban and rural areas.

Ethical consideration Ethical approval of the research protocol was obtained by authority of the Ain Shams University Ethical and Research Committee. The researchers described the study to the patients, ensured the confidentiality of their information and obtained their written informed consent for participation. The researchers stated that participation in the study was voluntary and that the patients had the freedom to withdraw from the assessment at any time.

Participants During 6-month period from January to June 2014, 118 patients selected from the Institute of Psychiatry with a primary diagnosis of a psychotic disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR), not secondary to substance misuse, medical disorders or organic brain damage. Patients aged 18 years or older, both male and female, were included. Patients also had to have presented to psychiatric services for the first time and never been prescribed psychiatric medications despite having a history of mental illness. Patients who were agitated or were extremely violent were excluded due to the researchers’ inability to assess them. A total of 18 patients were excluded because of their refusal to participate or their withdrawal during the interview. Thus, 100 patients were ultimately enrolled in the study.

Tools and assessment Clinical psychiatric interview and assessment of DUP by designed questionnaire by the authors All patients were subjected to a clinical psychiatric interview according to Ain Shams University’s psychiatric

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Okasha et al. sheet, which examines demographic data. The history was obtained from the patient and a reliable family member who was living with the patient. DUP is operationally defined as the interval between the first onset of psychotic symptoms and the administration of the first adequate pharmacological treatment. DUP was estimated in months. The mode of onset of psychosis was operationally defined as acute (less than one month) or insidious (more than one month). In this study, we measured DUP by developed questionnaire to assess the onset of psychotic symptoms (Joyce et al., 2002; Kalla et al., 2002; Verdoux et al., 2001). Accordingly, patients and family members were asked to state when the patient first experienced (or when the family member first noticed) behavioural changes – positive or negative symptoms that, in retrospect, appeared to be related to the onset of illness. These changes must have lasted through the day for several days or several times a week and must not have been limited to a few brief moments. Additional questions about the pathway to service were added to ask about the use of psychiatric services or a traditional healer at the start of illness, and who initiated first contact (a patient, relative, neighbours, medical staff or police) and what treatment was offered (spiritual, herbs or non-psychiatric medications).

Structured clinical interview for DSM-IV (SCID-I clinical version)

him or herself or others, or the patient has a persistent inability to maintain minimal personal hygiene or intends to perform a suicidal act with a clear expectation of death.

Statistical analysis The collected data were revised, coded, tabulated and introduced to a PC using Statistical Package for Social Science (SPSS 15.0.1 for Windows; SPSS Inc., Chicago, IL, 2001). Data were presented and suitable analysis was done according to the type of data obtained for each parameter.

Descriptive statistics 1. Mean, standard deviation (±SD), range and median for non-parametric numerical data. 2. Frequency and percentage of non-numerical data.

Analytical statistics 1. The Mann–Whitney U test was used to assess the statistical significance of the difference of a nonparametric variable between two study groups. 2. The Kruskal–Wallis test was used to assess the statistical significance of the difference between more than two study group ordinal variables. 3. Linear regression after log transformation of DUP was used to test and estimate the dependence of a quantitative variable based on its relationship with a set of independent variables. (Log transformation was done to the values of the observations of DUP variable as it showed non-parametric distribution, this was done so as to be used in linear regression with other variables.)

This is a clinician-administered semi-structured interview for use in psychiatric patients (First, Spitzer, Gibbon, & William, 1997). It provides a broad coverage of psychiatric diagnoses according to the DSM-IV. We used the clinical version for relatively easier administration in a clinical setting. To conform to the cultural norms, we used the Arabic translated and validated version of the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I) (Missiry et al., 2004).

*p-value was used to indicate the level of significance, where p ⩽ .05 was considered significant (SIG).

The PANSS

Results

This scale is a semi-structured clinical interview, which is well defined and standardised for typological and dimensional assessment of schizophrenic phenomena (Kay, Fiszbein, & Opler, 1987).

A total of 100 patients were recruited from the inpatient and outpatient clinic of the Institute of Psychiatry. This was their first presentation to psychiatric services. The mean DUP (in months) of the recruited sample was 36.93 ± 45.27. The mean age was 30.88 ± 11.43; the sociodemographic characteristics of the studied sample are described in Table 1.

Global Assessment of Functioning This is a numeric scale (0–100) used by clinicians and physicians to subjectively rate a patient’s social, occupational and psychological functioning (Jones, Thornicroft, Coffey, & Dunn, 1995). The highest ratings are 91–100, indicating superior functioning in a wide range of activities (no symptoms). The lowest ratings are 1–10, meaning there is persistent danger or the patient is severely hurting

Diagnostic categories According to SCID-I, the diagnoses of the studied sample were as follows: 64% had schizophrenia, 16% had schizophreniform disorder, 16% had acute psychotic disorder and 4% had delusional disorder (Figure 1).

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Table 1.  Sociodemographic data of the study sample.

Table 2.  Clinical characteristics of the studied patients.

Total sample (n = 100)

Mean ± SD

 

Age

30.88 ± 11.43

 

 

N

%

56 20 20 4

56.0 20.0 20.0 4.0

68 32

68.0 32.0

72 28

72.0 28.0

20 32 48

20.0 32.0 48.0

16 12 72

16.0 12.0 72.0

56 32 12

56.0 32.0 12.0

24 60 16

24.0 60.0 16.0

60 40

60.0 40.0

56 24 8 12

56.0 24.0 8.0 12.0

Age group (years)  18–30  >30–40  >40–50  >50 Sex  Male  Female Residence  Urban  Rural Social class (sherbiny)  High  Middle   Low/very low Education  Illiterate  Preparatory  High/technical school/ university Occupation  Employed/student  Unemployed/retired   House wife Marital status  Married  Unmarried  Divorced/widowed Family history  Negative   Positive psychiatric condition Current caregiver  Parent  Spouse  Sibs  None SD: standard deviation.

4 16

Mean

±SD

Minimum Maximum Median

DUP (months) 36.93 45.27 0.25 PANSS total 115.16 21.67 68.00 PANSS negative 36.40 8.67 12.00 PANSS positive 22.12 13.16 7.00 PANSS 56.64 12.58 24.00 psychopathology GAF 21.92 10.80 9.00

180.00 160.00 55.00 49.00 87.00

12.00 115.00 36.00 16.00 57.00

45.00

23.00

 

%

 

68 12 12 8

       

36 64

   

64 36

   

92 8

   

32 0 68

     

20 80

   

N

Age of onset (years) 68  18–30  >30–40 12  >40–50 12 8  >50 Mode of onset 36  Acute 64  Insidious First symptom seen 64  Positive 36  Negative Presenting symptom to psychiatric services 92  Positive 8  Negative First seen by   Traditional healers 32 0  GP 68  None Treatment offered   Spiritual and herbs 20 80  None

SD: standard deviation; DUP: duration of untreated psychosis; PANSS: Positive and Negative Syndrome Scale; GAF: Global Assessment of Function; GP: general practitioner.

Clinical characteristics of the studied sample Symptom severity was assessed using the positive and negative symptom scale (PANSS) while the level of functioning of the studied patients was assessed using Global Assessment of Functioning (GAF). Scores of patients in PANSS, GAF and other clinical variables are illustrated in Table 2.

16 Schizophrenia

64

Schizophreniform Delusional Disorder Acute Psychoc disorer

Figure 1.  Diagnostic categories of the studied patients.

The relationship between DUP, sociodemographic and clinical variables Table 3 displays the sociodemographic variables in relation to DUP. DUP was found to be statistically significantly higher in patients belonging to the 40–50 years age group, male gender, patients living in a rural area, who had

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Okasha et al. Table 3.  Relation of sociodemographic characteristics and DUP. Mean ± SD Age group (years)  18–30  >30–40  >40–50  >50 Sex  Male  Female Residence  Urban  Rural Education  Illiterate  Elementary  High school/ technical school/ university Occupation  Employed/students  Unemployed/retired   House wife Marital status  Married  Single  Divorced/widowed Social class  High  Middle   Low/very low

Test

p-value

13.18 ± 19.67 df = 3 (X2 = 37.527) 67.20 ± 41.64 70.95 ± 62.89 48.00 ± .00

.001

42.18 ± 50.11 Z = −2.609 25.78 ± 30.51

.009  

28.79 ± 35.36 Z = −2.649 57.86 ± 59.97

.008  

     

33.75 ± 37.91 df = 2 (X2 = 4.9) .08 78.00 ± 77.43   30.79 ± 36  

20.89 ± 32.1 df = 2 (X2 = 27) .001   68.25 ± 54.6 28.25 ± 25.46   29.83 ± 32.2 37.17 ± 37.2 46.12 ± 77.3

df = 2 (X2 = 5.1) .07    

29.25 ± 52.83 df = 2 (X2 = 6.7) .03   35.59 ± 28.78 41.02 ± 50.9  

SD: standard deviation.

received elementary education, unemployed or retired, divorced or widowed and from a middle social class.

The relationship between DUP and clinical variables It was found that DUP was the shortest in those who had an age of onset before 18 years, followed by those who had age of onset between 40 and 50 years, with a significant statistical difference between the different age groups. A high statistical difference was found among those who had caregivers. On the other hand, patients who had a positive family history were found to have a non-significantly shorter DUP. A high significant statistical difference was noticed between patients with different mode of onset and the first symptoms noticed by the caregiver; a shorter DUP was linked to acute onset patient over those with insidious onset, and shorter DUP was also seen in patients who started with positive symptoms.

Studying DUP in relation to diagnoses of the recruited patients showed a high significant statistical difference between DUP in different diagnoses; DUP was shortest in patients who had an acute psychotic episode, followed by those who had schizophreniform disorder, schizophrenia and delusional disorder. Patients were asked about pathway to service; interestingly, patients who visited traditional healers had a significantly longer DUP than those who had never visited them; consequently, patients with longer DUP received herbal and spiritual treatment with a high significant statistical difference compared to patients who did not receive such treatment (Table 4). Following log transformation of DUP, correlation with PANSS scores was done and revealed high significant statistical relation of DUP to PANSS negative and PANSS positive scores (Table 5). When variables were entered into a linear regression analysis after log transformation of DUP, it was found that age (whether used as a continuous variable or as age range), the age of onset, rural residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors (Table 6).

Discussion The duration of psychosis before initiation of treatment is a potentially modifiable prognostic factor (Perkins et al., 2005). Understanding the causes and consequences of untreated psychosis is important to help improve therapeutic strategies and public health initiatives. Community ignorance, stigma and poor mental health literacy all form obstacles to reforming systems that focus on early intervention. Culture is a major determinant that not only impacts health but also impacts disease and determines when and where help is sought (Okasha, 2001). Our study is one of the few that has investigated how DUP correlates in Egyptian patients with different psychotic disorders presented for the first time to psychiatric services. The aim of our study was to estimate the length of DUP and study the possible clinical and sociodemographic correlates. We found that the mean (±SD) DUP of our patients was 36.93 ± 45.27 months (3.07 years), which is almost similar to that reported by Fawzi et al. (2011), who found that DUP was 3.2 years in a sample of Egyptian patients and 3.1 years in a sample of Saudi patients with psychotic disorders. On the other hand, shorter DUP was estimated by Al Fayez, Lappin, Murray, and Boydell (2015); the median DUP found was 1.41 years, while the longest time to contact was 9.86 years – though 90% had a DUP shorter than 5 years. The differences in DUP estimation in different studies could be attributed to the difference in the operational definition of DUP (Polari et al., 2011). On the

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Table 4.  Relation of different clinical characteristics and DUP. Mean ± SD Age of onset

30–40 years >40–50 years >50 years Negative Positive Absent Present Acute Insidious Positive Negative Positive Negative Schizophrenia Schizophreniform Delusional disorder Acute psychotic disorder Traditional healer None Spiritual and herbs None

Family history Caregiver Mode of onset First symptom seen Presenting symptom to the psychiatric services SCID-I

First seen by Treatment offered

3.00 ± 0.00 37.50 ± 51.94 48.00 ± 27.08 30.25 ± 25.26 48.00 ± 0.00 41.45 ± 48.98 30.15 ± 38.67 54.00 ± 23.45 34.60 ± 47.09 3.25 ± 3.60 55.88 ± 46.92 33.45 ± 51.07 43.11 ± 32.27 33.88 ± 45.41 72.00 ± 25.66 51.38 ± 47.46 3.75 ± 1.34 84.00 ± 0.00 00.56 ± 0.21 56.12 ± 63.02 27.90 ± 30.53 78.40 ± 69.43 26.56 ± 29.41

Test

p-value

df = 4 (X2 = 10.064)

.039*

Z = −1.186 U=1032.00 Z=-2.313 U=942.00 Z = −7.837 U=64.00 Z = −3.112 U=720.00 Z = −2.957 U=136.00 df = 3 (X2 = 68.73)

.236**

Z = −2.31 U=154.00 Z = −3.66 U=645.00

.021

.008** .001** .002** .003** .001*

.001

DUP: duration of untreated psychosis; SD: standard deviation; SCID-I: Structured Clinical Interview for DSM-IV axis I disorders. *Kruskal Wallis test ** Mann Whitney test

Table 5.  Correlation of DUP (after log transformation) and symptom severity by PANSS.

PANSS negative PANSS positive PANSS general psychopathology PANSS total

Pearson correlation

Sig. (two-tailed)

−.319 .422 −.038

.001 .000 .710

.107

.291

DUP: duration of untreated psychosis; PANSS: Positive and Negative Syndrome Scale.

contrary, the median DUP in our study is longer than the median estimated in recent Western studies, such as the ones done by Drake, Haley, Akhtar, and Lewis (2000) who reported that the median DUP was 12 weeks, and by Archie et al. (2010) who reported a median DUP of 22 weeks.

Sociodemographic variables The identification of different sociodemographic characteristics and clinical variables in patients with untreated psychosis is of utmost importance when it comes to estimating the magnitude of the problem of treatment delay in patients with psychotic disorders (Oliveira et al.,

2010). Studying the sociodemographic characteristics of our patients in relation to DUP revealed that shorter DUP was found in patients between 18 and 30 years of age and those who had an age of onset below 18 years. This is in contrast with Dominguez et al. (2013), who found that adolescents presented with a significantly greater median DUP (179 days) than adults (81 days) (p = .005), and Al Fayez et al. (2015) who also found a longer DUP in adolescents and young adults. Bechard-Evans et al. (2007) and Hui et al. (2015) found that onset at a younger age (less than 18 years) predicted a longer delay in first treatment, but this was not replicated in other studies (Larsen et al., 2011). Other studies showed no association between DUP and age (Drake et al., 2000; Shrivastava et al., 2010). The role of family remains an important resource for the support and care of patients with mental disorders (Compton, Goulding, Gordon, Weissb, & Kaslowa, 2009; Gureje & Alem, 2000). In Egyptian culture, like elsewhere in the Arab world, the role of family is different from Western society. Dependence extends beyond childhood and even beyond adolescence. Extended families are much more represented in Egyptian society, as stated by El-Rakhawy (2001); this could explain the fact that the majority of the studied patients were brought in by a family member for their first contact with mental services.

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Okasha et al. Despite univariate analysis, which showed that men had significantly longer DUP, the linear regression analysis failed to show that gender was a predictive factor for DUP. This was in accordance with a previous study done by Lay, Blanz, Hartmann, and Schmidt (2000) which used regression models. While delayed help seeking in men was previously reported by many authors (Chang et al., 2011; Fridgen et al., 2012; Thorup et al., 2007), Koster, Lajer, Lindhardt, and Rosenbaum (2008) found that women actually had longer DUP than male patients. The decision to seek treatment is often made by the family and not by the individual (Chen et al., 2005; Okazaki, 2000). In Arab families, the husband or father is the authority figure who decides whether a family member seeks treatment. This finding also could be attributed to the role of the female in families, as the mother or wife is the one responsible for home management – so functional impairment could be detected once she is unable to perform her usual household duties. On the other hand, delayed marriage or failure to maintain her marital life out of her illness could also be the main signal for the presence of an illness in females. In this study, longer DUP was associated with low/very low social class. This finding is supported by previous studies (Compton et al., 2011; Kurihara, Kato, Reverger, & Tirta, 2006) that found that in LAMI social classes, large numbers of people subscribe to culturally specified traditional and religious beliefs that involve not seeking psychiatric services. In contrast, it was found that in high social classes, both patients with psychosis and their relatives tend to attribute their illness to biological or natural causes (Silove et al., 2008). Our study showed a longer DUP in patients who had received less education. This was consistent with two previous studies (Chen et al., 2005; Koster et al., 2008) that both reported a significant delay in help seeking for psychotic patients with a relatively low level of education. However, it is still debatable that being unable to finish a standard level of education leads to a long DUP or that long DUP increases school withdrawal and negatively affects functioning. Patients who lived in a rural area were found to have longer DUP than those who were living in an urban area. This finding was not in accordance with Sharifi et al. (2009) who reported that patients from rural areas might have been discovered earlier by the active case finding of their national mental health programmes in rural areas. Our study revealed that patients who had a good social network, supportive family (an available caregiver, being married) and a high level of functioning (being employed or students) had shorter DUP. This is in accordance with previous studies (McGorry, Harrigan, Amminger, Norman, & Malla, 2001; Pek, Mythily, & Chong, 2006) that indicated that the availability of a social network outside family and being employed could act as predictors of shorter DUP. On the other hand, other studies could not find any

association between marital status and DUP (Craig et al., 2000; Naqvi, Hussain, Zaman, & Islam, 2009).

Clinical variables and DUP Various clinical variables have been related to DUP. In our study, the association between an insidious mode of onset and longer DUP was expected and in line with previous findings (Compton et al., 2011; Fawzi et al., 2011; Larsen et al., 2011; Morgan et al., 2006). We also found that patients who first presented with negative symptoms had longer DUP, which is in agreement with other studies (Addington, Van Mastrigt, & Addington, 2004; Drake et al., 2000). More abrupt changes in behaviour induced by having positive symptoms are more likely to be intolerable by the patient’s family and help in seeking early psychiatric help (Kalla et al., 2002; Üςok, Polat, Genς, Çakir, & Turan, 2004). This is more likely to trigger help-seeking behaviour early, compared with an insidious onset and negative symptoms. Regarding illness severity, significant heterogeneity was present between studies that correlated data on DUP and severity of either negative or positive symptoms. In their meta-analysis of DUP studies, Perkins et al. (2005) concluded that the duration of initially untreated psychosis was associated with the severity of negative symptoms, but not with the severity of positive symptoms or general psychopathology at the time of initial clinical evaluation. In our study, there was a significant correlation between DUP, PANSS negative and PANSS positive scores. Our findings were in accordance with Boonstra et al. (2012) and Fawzi et al. (2011) who found an association between long DUP and negative symptoms. The relation between negative symptoms and longer DUP may be mediated by social factors (e.g. unemployment and single marital status), given that social isolation would limit the likelihood of others detecting illness-related changes and seeking treatment. Addington et al. (2004) found that longer periods of untreated psychosis were significantly associated with higher levels of positive symptoms. In the regression analysis, PANSS negative and positive scores were found to be among the predictive factors for DUP. In our study, longer DUP has been associated with the diagnosis of delusional disorder more than other psychotic disorders. A study by Ho, Andreasen, Flaum, Nopoulos, and Miller (2000) found a difference in untreated initial psychosis duration between various diagnostic categories, where the median duration of untreated psychosis was 122 days for patients with schizophrenia – longer than for patients with other psychotic disorders. Our finding could be explained by the fact that patients with delusional disorder usually present with non-bizarre delusions that could potentially occur in real life – ones that are not accompanied by prominent hallucinations, thought disorder, mood disorder or flattening of affect. In addition, people with

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Table 6.  Predictive factors for DUP. Unstandardised coefficients   Age (as continuous variable) Age (years)   18 to 50 Education  Illiterate  Elementary   High school/university Residence  Urban  Rural Caregiver  Absent  Present Mode of onset  Acute  Insidious First symptom seen  Positive  Negative PANSS   PANSS Negative   PANSS Positive   PANSS general pathology Family history  Negative  Positive

Regression coefficient

Standardised coefficients Standard error

t

Sig.

Beta

0.230

0.020

1.438

11.324

.000

1.575 2.441 1.791 2.296

0.200 0.389 0.389 0.773

0.537 0.394 0.274

7.887 6.269 4.601 2.968

.000 .000 .000 .004

−1.223 1.409 0.081 1.550

0.907 0.552 0.552 0.907

−0.132 0.252 0.014 0.167

−1.349 2.554 0.147 1.709

.181 .012 .883 .091

2.831 0.787 −0.573

0.477 0.683 0.494

0.141 −0.141

6.337 1.153 −1.160

.000 .252 .249

2.208 1.092

0.209 0.394

0.270

10.588 2.772

.000 .007

3.901 −1.577

.509 .542

−.0.282

7.666 −2.907

.000 .005

0.546 3.073

0.179 0.224

0.811

3.051 13.729

.003 .000

2.049 1.291

0.216 0.360

−0.341

9.488 3.586

.000 .001

−0.32 .046 −.026

0.014 0.013 0.011

−.154 .334 −.178

−2.245 3.505 −2.327

.027 .001 .022

2.635 −0.304

0.236 0.374

−0.082

11.146 −0.813

.000 .418

DUP: duration of untreated psychosis; PANSS: Positive and Negative Syndrome Scale.

delusional disorder may continue to socialise and function in a normal manner; their behaviour does not generally seem odd or bizarre, and their level of functioning is maintained for a longer period so that they do not draw the attention of their family or caregiver for the presence of illness. In our results, we found that traditional healers were the first contact that our study participants sought out; none of our patients visited a general practitioner. This makes their role questionable in our society compared to the role they play in developed countries, where general practitioners are considered to be the gate keeper to psychiatric services. Moreover, we found that 20% of the study patients received

herbal and spiritual treatment, while 80% did not receive any treatment at all. Previous Egyptian studies have found that the majority of Egyptian patients usually resort to traditional healers (El Amin & Refat, 1997; El Defrawi, Sobhy, El-Sheikh, Tantawy, & Embaby, 2000; Khalil, 2001; Okasha, Kamel, & Hassan, 1968). Longer DUP was found to be associated with spiritual attribution and seeking help from traditional healers (Al Fayez et al., 2015). Studies in other Islamic and non-Islamic countries report percentages as high as ours. In Pakistan, Saeed, Gater, Hussain, and Mubbashar (2000) found that 60% of attendees of faith healers had mental disorders. In Malaysia, Razali and Najib (2000) reported that 69% of their psychiatric patients

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Okasha et al. visited traditional healers; in Nigeria, Abiodun (1995) reported that 40% of patients sought help from traditional or religious healers. The World Health Organization (WHO, 2006), reported that Egyptian patients, especially from rural areas, often go to traditional and religious healers before or after seeking medical advice from the health system. The WHO found that this trend is difficult to study, especially with regard to patients who use the health system in parallel with traditional ways. Help-seeking through traditional healers was found to be a predictive factor in a regression model performed by Fawzi et al. (2011).

Conclusion and recommendations DUP is considered to be an outcome predictor for patients with psychotic disorders. Early intervention is one of the unmet needs in managing psychotic disorders, while identification of factors leading to increased DUP and planning for its reduction should be one of the main goals for improving the outcome of psychotic disorders. Efforts directed towards raising community awareness of psychiatric illnesses and fighting their stigma could play a major role in shortening DUP. In addition, increasing the awareness of non-psychiatric medical staff regarding different psychiatric symptomatology and implementing the role of primary services, especially in areas where specialised psychiatric services are not available, could help in reducing DUP.

Strengths and limitations Few studies in the Arab world and Egypt have explored the problem of DUP. Although the number of cases was relatively small in this study, it is one of the first to evaluate the different factors that could be correlated to DUP in Egypt. Another limitation of this study was the crosssectional, rather than prospective, design; because of this, causal factors, as well as the comparison of outcome between patients with long DUP versus short DUP, could not be assessed. Acknowledgements The authors thank Professor Afaf Hamed Khalil (Professor of Psychiatry, Ain Shams University, Cairo, Egypt) for her valuable suggestions and guidance. The authors also thank Dr Mostafa Bastawy (Lecturer of Psychiatry, Aswan University) for his help in performing the statistical analysis of this work. In addition, we are indebted to our patients and their families for their cooperation.

Conflict of interest The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship and/or publication of this article.

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