Schizophrenia Research 162 (2015) 64–66
Contents lists available at ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Factors contributing to the duration of untreated prodromal positive symptoms in individuals at ultra-high risk for psychosis Myong-Wuk Chon a,b, Tae Young Lee c, Sung Nyun Kim a, Min Jung Huh a,b, Hye Youn Park b, Cho Rong Lee d, Na Young Shin d, Jun Soo Kwon a,b,c,d,⁎ a
Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea Institute of Human Behavioral Medicine, SNU-MRC, Seoul, Republic of Korea d Department of Brain & Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea b c
a r t i c l e
i n f o
Article history: Received 11 September 2014 Received in revised form 26 December 2014 Accepted 6 January 2015 Available online 28 January 2015 Keywords: Ultra-high risk for psychosis Psychosis Duration of untreated prodromal positive symptoms Functional decline Delayed care
a b s t r a c t Individuals at ultra-high risk (UHR) for psychosis experience a considerable delay before appropriate clinical attention is provided. Therefore, we investigated the correlates of this delay by examining clinical, sociodemographic and neuropsychological contributors to the duration of untreated prodromal positive symptoms (DUPP) in them (n = 73). The slowly progressive mode of functional decline, defined as a small percentage drop in the Global Assessment of Functioning (GAF) score within the past year, and male gender, explained a considerable portion of the DUPP in the multivariate regression model (F = 9.269, p b 0.001). Slower functional decline may be correlated with delayed care during the UHR period. © 2015 Elsevier B.V. All rights reserved.
1. Introduction Longer duration of untreated period in individuals at ultra-high risk (UHR) for psychosis has been reported to hinder their functional recovery (Fusar-Poli et al., 2009) and possibly elevate the risk of transition to psychosis (Nelson et al., 2013). Patients who do not convert to psychosis nevertheless remain at an increased risk for psychosis, experiencing significant distress that requires care (Addington et al., 2011), and available interventions can reduce the conversion to psychosis or relieve their distress (Stafford et al., 2013). Therefore, the negative impact of the untreated prodromal period may reflect an unmet clinical need. However, this period received much less attention, compared to the negative influence of the duration of untreated psychosis, or DUP (Penttilä et al., 2014) and its determinants such as a gradual mode of onset (Apeldoorn et al., 2014). To separately investigate the period that requires intervention rather than the entire prodromal period, we measured the “Duration of Untreated Prodromal Positive symptoms
⁎ Corresponding author at: Department of Psychiatry, Seoul National University College of Medicine, 101 Daehak-no, Chongno-gu, Seoul 110-744, Republic of Korea; Department of Brain & Cognitive Sciences, Seoul National University College of Natural Sciences, 101 Daehak-no, Chongno-gu, Seoul 110-744, Republic of Korea. Tel.: + 82 2 2072 2450; fax: +82 2 747 9063. E-mail address: [email protected] (J.S. Kwon).
http://dx.doi.org/10.1016/j.schres.2015.01.013 0920-9964/© 2015 Elsevier B.V. All rights reserved.
(DUPP)”, which we defined as the period from fulfillment of the operational criteria of UHR focused on prodromal positive symptoms until participation in a specialized UHR program. We hypothesized that a slower functional decline would influence the delayed treatment of UHR individuals, along with additional potential contributing variables including demographics and cognitive functioning. Therefore, we investigated the impact of the changing Global Assessment of Functioning (GAF) scores (Hall, 1995) recorded for the time of enrollment, the highest in the past year and the premorbid state, along with that of demographic data and performances in neurocognitive and social cognitive tasks, on the length of DUPP in the UHR participants. 2. Methods Participants with available dataset were selected among the 134 help-seeking individuals who provided written informed consent for participation in an ongoing longitudinal prospective cohort study at the Seoul Youth Clinic (SYC) (Lee et al., 2014) from April 2005 until October 2013, according to the following criteria. UHR status was assessed using the Criteria of Psychosis-risk Syndromes (COPS) criteria from the well-validated Structured Interview for Prodromal Syndromes (SIPS) (Miller et al., 2003; Jung et al., 2010). We included only those individuals with Attenuated Positive Symptom (APS) syndrome to preserve the homogeneity of the samples and minimize genetic influence.
M.-W. Chon et al. / Schizophrenia Research 162 (2015) 64–66
Therefore, those with Brief Intermittent Psychotic Symptom (BIPS) syndrome or Genetic Risk and Deterioration (GRD) syndrome were not included. Exclusion criteria were as follows: (i) medical or neurological illnesses with psychiatric significance; (ii) intellectual disability with IQ b 80 using the Korean version of the Wechsler Adult Intelligence Scale (K-WAIS); (iii) substance abuse or dependence according to the Structured Clinical Interview for the DSM-IV (SCID). A total of 73 individuals with APS syndrome were selected. Sixty-two were drug naïve and the remaining 11 either had received psychiatric pharmacotherapy other than antipsychotics for conditions apart from their UHR status, or the total duration of psychopharmacological treatment did not exceed 1 week. No participant had a 1st or 2nd-degree relative with a psychotic disorder. Among the participants, 57 people were followed up for a mean duration of 32.43 ± 24.35 months, during which 12 (21.1%) converted to psychosis. Participants were interviewed using the SIPS for the onset, duration and severity of prodromal symptoms, and the severity of symptoms were quantified with the Scale of Prodromal Symptoms (SOPS) (Miller et al., 2003; Jung et al., 2010). Comorbidity was assessed using SCID. The DUPP was measured in months, from when the UHR individuals fulfilled the APS criteria of the COPS until when they actually presented for cognitive-behavioral therapy and/or medication. All DUPP values were primarily calculated from the SIPS interview data and cross-checked with a comprehensive review of descriptions regarding sub-threshold psychotic symptoms available in the clinical interview data for the SCID and medical records in SYC. DUPP values were confirmed if separate measurements, performed by at least two psychiatrists among the authors, were in agreement. Any inconsistencies were rigorously resolved by the consensus of all authors. The GAF drop from baseline was defined as ([GAF premorbid] − [GAF current]) / [GAF premorbid] × 100, and the GAF drop in the most recent year was defined as ([GAF highest past year] − [GAF current]) / [GAF highest past year] × 100. Details of neuropsychological and social cognitive functions measured are available in the online data supplements. The DUPP was analyzed according to clinical variables including the GAF and GAF drop using Pearson's correlation analysis, and the DUPP difference between genders were compared with Student's t-test. A general linear regression model was implemented to delineate contributors to the DUPP. For all statistical analyses was used IBM SPSS Statistics 21, and the significance level was set at two-tailed p b .05 with Bonferroni correction for multiple comparisons. Further details of the statistical method are available as online data supplements.
65
3. Results The 73 participants in this study were predominantly male (64.4%), with an average age of 20.79 ± 3.52 years. The mean DUPP was 18.42 ± 16.16 months (ranging from 1 to 60 months, median = 12 months). While males showed a longer DUPP than females (t = 2.872, p = 0.005), other demographic factors indicated no significant correlations with the DUPP (online Table DS1). The GAF drop in the most recent year manifested a significant negative correlation with the DUPP (r = −0.369, p = 0.003, Fig. 1), while symptoms or cognitive performances were not significantly correlated with the DUPP (online Table DS2). The multiple regression model generated showed that the recent percentage drop in the GAF scores, along with male gender, explained a significant portion (F = 9.269, p b 0.001) of the variance in the logarithmic transformed DUPP (Online table DS3).
4. Discussion In the UHR group, the delay in their treatment was negatively correlated with a rapid functional decline measured by the percentage drop in the GAF score within the past year. While research studies pertaining to the length of untreated prodromal psychotic symptoms per se are scarce, the length of our DUPP value was slightly shorter than the duration of ‘at risk’ symptoms (29.29 ± 21.85 months) in a previous study (Fusar-Poli et al., 2009) (n = 49), which also measured a similar construct. The difference might be explained by the involvement of additional subgroups of UHR such as BIPS and GRD, and the difference in the tools for measurement. In line with previous researches, duration until treatment was longer in males (Cocchi et al., 2014). Our results indicate that a gradual onset during the UHR period, in terms of a small percentage decline of the GAF score within the last year, might be related to the delay in help-seeking in the UHR group. Considered along with the observations that longer DUPP negatively influences later functional course (Fusar-Poli et al., 2009), our results suggest the possibility that the slope of functional decline before treatment contact could influence prognosis. Individuals with a more gradual functional decline might have been less likely to seek for help, especially in the context of stigma against psychosis and insufficient mental health awareness in the population (Kwon et al., 2012). This might provide explanation for the variable length of delay in help seeking in this population (von Reventlow et al., 2014), although different duration among
Fig. 1. DUPP and GAF drop in the most recent year. GAF drop (%) in the most recent year = ([GAF highest past year] − [GAF current]) / [GAF highest past year] × 100. Abbreviations: DUPP, Duration of Untreated Prodromal Positive symptoms; GAF, Global Assessment of Functioning.
66
M.-W. Chon et al. / Schizophrenia Research 162 (2015) 64–66
subgroups might also be attributed to different underlying deficits (Schultze-Lutter et al., 2007). Some caveats must be considered. First, the severity and onset of prodromal symptoms used in the calculation of the DUPP were measured retrospectively. Notwithstanding the exhaustive consensus of multiple clinicians and structured assessment tools, recall bias was inevitable. Prospective serial assessments in community settings prior to the beginning of prodromal symptoms might have circumvented this; however, such a study design would have been beyond the feasible coverage of the current study. Another limitation is that the primary aim of the SIPS interview is the detection and severity of psychosisrisk syndromes, not mapping their onset, like the interview for retrospective assessment of onset of schizophrenia (IRAOS) (Hafner et al., 1995) and the early recognition inventory based on IRAOS (ERIraos) (Schultze-Lutter et al., 2010). However, SIPS requires comprehensive data collection, especially for the onset and progression of putative prodromal symptoms, with a special focus on the attenuated positive symptoms critical in the diagnosis of APS syndrome. Additionally, our study lacked direct measurements of help-seeking style or insight with appropriate tools, which could have aided in a better appraisal of our data. Finally, the cross-sectional design of our study also calls for caution in the interpretation of our results as causal relationship. Our study emphasizes the possible correlation between a gradual mode of onset and the unmet need for care in the UHR population. Future studies with additional measurements of insight and information about pathways to care, combined with the interpretation of neurobiological data, may further elucidate the phenomenon of treatment delay during the UHR period.
Role of the funding source This study was supported by a grant from the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A120476).
Contributors Myong-Wuk Chon, Tae Young Lee, Sung Nyun Kim and Jun Soo Kwon conceived and designed this study. Myong-Wuk Chon and Cho Rong Lee performed the statistical analysis and interpreted the data. Tae Young Lee, Sung Nyun Kim and Min Jung Huh gave advice in the statistical analysis and the interpretation of the data. Myong-Wuk Chon wrote the draft of the manuscript. Tae Young Lee, Hye Youn Park and Na Young Shin participated in revising the article by giving critical advice. Jun Soo Kwon managed and supervised the whole procedure of this study. All authors substantially contributed to and approved the final manuscript.
Conflict of interest The authors have no conflict of interest to declare.
Acknowledgment The authors have no acknowledgements to make.
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.schres.2015.01.013. References Addington, J., Cornblatt, B.A., Cadenhead, K.S., Cannon, T.D., McGlashan, T.H., Perkins, D.O., Seidman, L.J., Tsuang, M.T., Walker, E.F., Woods, S.W., Heinssen, R., 2011. At clinical high risk for psychosis: outcome for nonconverters. Am. J. Psychiatry 168 (8), 800–805. Apeldoorn, S.Y., Sterk, B., van den Heuvel, E.R., Schoevers, R.A., Islam, M.A., Genetic, R., Outcome of Psychosis I., Bruggeman, R., Cahn, W., deHaan, L., Kahn, R.S., Meijer, C.J., Myin-Germeys, I., van Os, J., Wiersma, D., 2014. Factors contributing to the duration of untreated psychosis. Schizophr. Res. 158 (1–3), 76–81. Cocchi, A., Lora, A., Meneghelli, A., La Greca, E., Pisano, A., Cascio, M.T., Preti, A., Programma, T., Desio Early Intervention Service T., 2014. Sex differences in firstepisode psychosis and in people at ultra-high risk. Psychiatry Res. 215 (2), 314–322. Fusar-Poli, P., Meneghelli, A., Valmaggia, L., Allen, P., Galvan, F., McGuire, P., Cocci, A., 2009. Duration of untreated prodromal symptoms and 12-month functional outcome of individuals at risk of psychosis. Br. J. Psychiatry 194 (2), 181–182. Hafner, H., Nowotny, B., Loffler, W., an der Heiden, W., Maurer, K., 1995. When and how does schizophrenia produce social deficits? Eur. Arch. Psychiatry Clin. Neurosci. 246 (1), 17–28. Hall, R.C., 1995. Global assessment of functioning. A modified scale. Psychosomatics 36 (3), 267–275. Jung, M.H., Jang, J.H., Kang, D.H., Choi, J.S., Shin, N.Y., Kim, H.S., An, S.K., Shin, M.S., Kwon, J.S., 2010. The reliability and validity of the Korean version of the structured interview for prodromal syndrome. Psychiatry Invest. 7 (4), 257–263. Kwon, J.S., Byun, M.S., Lee, T.Y., An, S.K., 2012. Early intervention in psychosis: insights from Korea. Asian J. Psychiatr. 5 (1), 98–105. Lee, T.Y., Shin, Y.S., Shin, N.Y., Kim, S.N., Jang, J.H., Kang, D.H., Kwon, J.S., 2014. Neurocognitive function as a possible marker for remission from clinical high risk for psychosis. Schizophr. Res. 153 (1), 48–53. Miller, T.J., McGlashan, T.H., Rosen, J.L., Cadenhead, K., Cannon, T., Ventura, J., McFarlane, W., Perkins, D.O., Pearlson, G.D., Woods, S.W., 2003. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr. Bull. 29 (4), 703–715. Nelson, B., Yuen, H.P., Wood, S.J., Lin, A., Spiliotacopoulos, D., Bruxner, A., Broussard, C., Simmons, M., Foley, D.L., Brewer, W.J., Francey, S.M., Amminger, G.P., Thompson, A., McGorry, P.D., Yung, A.R., 2013. Long-term follow-up of a group at ultra high risk (“prodromal”) for psychosis: the PACE 400 study. JAMA psychiatry 70 (8), 793–802. Penttilä, M., Jaaskelainen, E., Hirvonen, N., Isohanni, M., Miettunen, J., 2014. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br. J. Psychiatry 205 (2), 88–94. Schultze-Lutter, F., Ruhrmann, S., Hoyer, C., Klosterkotter, J., Leweke, F.M., 2007. The initial prodrome of schizophrenia: different duration, different underlying deficits? Compr Psychiatry 48 (5), 479–488. Schultze-Lutter, F., Ruhrmann, S., Berning, J., Maier, W., Klosterkotter, J., 2010. Basic symptoms and ultrahigh risk criteria: symptom development in the initial prodromal state. Schizophr. Bull. 36 (1), 182–191. Stafford, M.R., Jackson, H., Mayo-Wilson, E., Morrison, A.P., Kendall, T., 2013. Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ 346 (2013), f185. von Reventlow, H.G., Kruger-Ozgurdal, S., Ruhrmann, S., Schultze-Lutter, F., Heinz, A., Patterson, P., Heinimaa, M., Dingemans, P., French, P., Birchwood, M., Salokangas, R.K., Linszen, D., Morrison, A., Klosterkotter, J., Juckel, G., 2014. Pathways to care in subjects at high risk for psychotic disorders — a European perspective. Schizophr. Res. 152 (2–3), 400–407.
Contents lists available at ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Factors contributing to the duration of untreated prodromal positive symptoms in individuals at ultra-high risk for psychosis Myong-Wuk Chon a,b, Tae Young Lee c, Sung Nyun Kim a, Min Jung Huh a,b, Hye Youn Park b, Cho Rong Lee d, Na Young Shin d, Jun Soo Kwon a,b,c,d,⁎ a
Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea Institute of Human Behavioral Medicine, SNU-MRC, Seoul, Republic of Korea d Department of Brain & Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea b c
a r t i c l e
i n f o
Article history: Received 11 September 2014 Received in revised form 26 December 2014 Accepted 6 January 2015 Available online 28 January 2015 Keywords: Ultra-high risk for psychosis Psychosis Duration of untreated prodromal positive symptoms Functional decline Delayed care
a b s t r a c t Individuals at ultra-high risk (UHR) for psychosis experience a considerable delay before appropriate clinical attention is provided. Therefore, we investigated the correlates of this delay by examining clinical, sociodemographic and neuropsychological contributors to the duration of untreated prodromal positive symptoms (DUPP) in them (n = 73). The slowly progressive mode of functional decline, defined as a small percentage drop in the Global Assessment of Functioning (GAF) score within the past year, and male gender, explained a considerable portion of the DUPP in the multivariate regression model (F = 9.269, p b 0.001). Slower functional decline may be correlated with delayed care during the UHR period. © 2015 Elsevier B.V. All rights reserved.
1. Introduction Longer duration of untreated period in individuals at ultra-high risk (UHR) for psychosis has been reported to hinder their functional recovery (Fusar-Poli et al., 2009) and possibly elevate the risk of transition to psychosis (Nelson et al., 2013). Patients who do not convert to psychosis nevertheless remain at an increased risk for psychosis, experiencing significant distress that requires care (Addington et al., 2011), and available interventions can reduce the conversion to psychosis or relieve their distress (Stafford et al., 2013). Therefore, the negative impact of the untreated prodromal period may reflect an unmet clinical need. However, this period received much less attention, compared to the negative influence of the duration of untreated psychosis, or DUP (Penttilä et al., 2014) and its determinants such as a gradual mode of onset (Apeldoorn et al., 2014). To separately investigate the period that requires intervention rather than the entire prodromal period, we measured the “Duration of Untreated Prodromal Positive symptoms
⁎ Corresponding author at: Department of Psychiatry, Seoul National University College of Medicine, 101 Daehak-no, Chongno-gu, Seoul 110-744, Republic of Korea; Department of Brain & Cognitive Sciences, Seoul National University College of Natural Sciences, 101 Daehak-no, Chongno-gu, Seoul 110-744, Republic of Korea. Tel.: + 82 2 2072 2450; fax: +82 2 747 9063. E-mail address: [email protected] (J.S. Kwon).
http://dx.doi.org/10.1016/j.schres.2015.01.013 0920-9964/© 2015 Elsevier B.V. All rights reserved.
(DUPP)”, which we defined as the period from fulfillment of the operational criteria of UHR focused on prodromal positive symptoms until participation in a specialized UHR program. We hypothesized that a slower functional decline would influence the delayed treatment of UHR individuals, along with additional potential contributing variables including demographics and cognitive functioning. Therefore, we investigated the impact of the changing Global Assessment of Functioning (GAF) scores (Hall, 1995) recorded for the time of enrollment, the highest in the past year and the premorbid state, along with that of demographic data and performances in neurocognitive and social cognitive tasks, on the length of DUPP in the UHR participants. 2. Methods Participants with available dataset were selected among the 134 help-seeking individuals who provided written informed consent for participation in an ongoing longitudinal prospective cohort study at the Seoul Youth Clinic (SYC) (Lee et al., 2014) from April 2005 until October 2013, according to the following criteria. UHR status was assessed using the Criteria of Psychosis-risk Syndromes (COPS) criteria from the well-validated Structured Interview for Prodromal Syndromes (SIPS) (Miller et al., 2003; Jung et al., 2010). We included only those individuals with Attenuated Positive Symptom (APS) syndrome to preserve the homogeneity of the samples and minimize genetic influence.
M.-W. Chon et al. / Schizophrenia Research 162 (2015) 64–66
Therefore, those with Brief Intermittent Psychotic Symptom (BIPS) syndrome or Genetic Risk and Deterioration (GRD) syndrome were not included. Exclusion criteria were as follows: (i) medical or neurological illnesses with psychiatric significance; (ii) intellectual disability with IQ b 80 using the Korean version of the Wechsler Adult Intelligence Scale (K-WAIS); (iii) substance abuse or dependence according to the Structured Clinical Interview for the DSM-IV (SCID). A total of 73 individuals with APS syndrome were selected. Sixty-two were drug naïve and the remaining 11 either had received psychiatric pharmacotherapy other than antipsychotics for conditions apart from their UHR status, or the total duration of psychopharmacological treatment did not exceed 1 week. No participant had a 1st or 2nd-degree relative with a psychotic disorder. Among the participants, 57 people were followed up for a mean duration of 32.43 ± 24.35 months, during which 12 (21.1%) converted to psychosis. Participants were interviewed using the SIPS for the onset, duration and severity of prodromal symptoms, and the severity of symptoms were quantified with the Scale of Prodromal Symptoms (SOPS) (Miller et al., 2003; Jung et al., 2010). Comorbidity was assessed using SCID. The DUPP was measured in months, from when the UHR individuals fulfilled the APS criteria of the COPS until when they actually presented for cognitive-behavioral therapy and/or medication. All DUPP values were primarily calculated from the SIPS interview data and cross-checked with a comprehensive review of descriptions regarding sub-threshold psychotic symptoms available in the clinical interview data for the SCID and medical records in SYC. DUPP values were confirmed if separate measurements, performed by at least two psychiatrists among the authors, were in agreement. Any inconsistencies were rigorously resolved by the consensus of all authors. The GAF drop from baseline was defined as ([GAF premorbid] − [GAF current]) / [GAF premorbid] × 100, and the GAF drop in the most recent year was defined as ([GAF highest past year] − [GAF current]) / [GAF highest past year] × 100. Details of neuropsychological and social cognitive functions measured are available in the online data supplements. The DUPP was analyzed according to clinical variables including the GAF and GAF drop using Pearson's correlation analysis, and the DUPP difference between genders were compared with Student's t-test. A general linear regression model was implemented to delineate contributors to the DUPP. For all statistical analyses was used IBM SPSS Statistics 21, and the significance level was set at two-tailed p b .05 with Bonferroni correction for multiple comparisons. Further details of the statistical method are available as online data supplements.
65
3. Results The 73 participants in this study were predominantly male (64.4%), with an average age of 20.79 ± 3.52 years. The mean DUPP was 18.42 ± 16.16 months (ranging from 1 to 60 months, median = 12 months). While males showed a longer DUPP than females (t = 2.872, p = 0.005), other demographic factors indicated no significant correlations with the DUPP (online Table DS1). The GAF drop in the most recent year manifested a significant negative correlation with the DUPP (r = −0.369, p = 0.003, Fig. 1), while symptoms or cognitive performances were not significantly correlated with the DUPP (online Table DS2). The multiple regression model generated showed that the recent percentage drop in the GAF scores, along with male gender, explained a significant portion (F = 9.269, p b 0.001) of the variance in the logarithmic transformed DUPP (Online table DS3).
4. Discussion In the UHR group, the delay in their treatment was negatively correlated with a rapid functional decline measured by the percentage drop in the GAF score within the past year. While research studies pertaining to the length of untreated prodromal psychotic symptoms per se are scarce, the length of our DUPP value was slightly shorter than the duration of ‘at risk’ symptoms (29.29 ± 21.85 months) in a previous study (Fusar-Poli et al., 2009) (n = 49), which also measured a similar construct. The difference might be explained by the involvement of additional subgroups of UHR such as BIPS and GRD, and the difference in the tools for measurement. In line with previous researches, duration until treatment was longer in males (Cocchi et al., 2014). Our results indicate that a gradual onset during the UHR period, in terms of a small percentage decline of the GAF score within the last year, might be related to the delay in help-seeking in the UHR group. Considered along with the observations that longer DUPP negatively influences later functional course (Fusar-Poli et al., 2009), our results suggest the possibility that the slope of functional decline before treatment contact could influence prognosis. Individuals with a more gradual functional decline might have been less likely to seek for help, especially in the context of stigma against psychosis and insufficient mental health awareness in the population (Kwon et al., 2012). This might provide explanation for the variable length of delay in help seeking in this population (von Reventlow et al., 2014), although different duration among
Fig. 1. DUPP and GAF drop in the most recent year. GAF drop (%) in the most recent year = ([GAF highest past year] − [GAF current]) / [GAF highest past year] × 100. Abbreviations: DUPP, Duration of Untreated Prodromal Positive symptoms; GAF, Global Assessment of Functioning.
66
M.-W. Chon et al. / Schizophrenia Research 162 (2015) 64–66
subgroups might also be attributed to different underlying deficits (Schultze-Lutter et al., 2007). Some caveats must be considered. First, the severity and onset of prodromal symptoms used in the calculation of the DUPP were measured retrospectively. Notwithstanding the exhaustive consensus of multiple clinicians and structured assessment tools, recall bias was inevitable. Prospective serial assessments in community settings prior to the beginning of prodromal symptoms might have circumvented this; however, such a study design would have been beyond the feasible coverage of the current study. Another limitation is that the primary aim of the SIPS interview is the detection and severity of psychosisrisk syndromes, not mapping their onset, like the interview for retrospective assessment of onset of schizophrenia (IRAOS) (Hafner et al., 1995) and the early recognition inventory based on IRAOS (ERIraos) (Schultze-Lutter et al., 2010). However, SIPS requires comprehensive data collection, especially for the onset and progression of putative prodromal symptoms, with a special focus on the attenuated positive symptoms critical in the diagnosis of APS syndrome. Additionally, our study lacked direct measurements of help-seeking style or insight with appropriate tools, which could have aided in a better appraisal of our data. Finally, the cross-sectional design of our study also calls for caution in the interpretation of our results as causal relationship. Our study emphasizes the possible correlation between a gradual mode of onset and the unmet need for care in the UHR population. Future studies with additional measurements of insight and information about pathways to care, combined with the interpretation of neurobiological data, may further elucidate the phenomenon of treatment delay during the UHR period.
Role of the funding source This study was supported by a grant from the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A120476).
Contributors Myong-Wuk Chon, Tae Young Lee, Sung Nyun Kim and Jun Soo Kwon conceived and designed this study. Myong-Wuk Chon and Cho Rong Lee performed the statistical analysis and interpreted the data. Tae Young Lee, Sung Nyun Kim and Min Jung Huh gave advice in the statistical analysis and the interpretation of the data. Myong-Wuk Chon wrote the draft of the manuscript. Tae Young Lee, Hye Youn Park and Na Young Shin participated in revising the article by giving critical advice. Jun Soo Kwon managed and supervised the whole procedure of this study. All authors substantially contributed to and approved the final manuscript.
Conflict of interest The authors have no conflict of interest to declare.
Acknowledgment The authors have no acknowledgements to make.
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