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The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with firstepisode psychosis Hadi Mo’tamedi, Peyman Rezaiemaram, Maria E. Aguilar-Vafaie, Abaas Tavallaie, Mojtaba Azimian, Hashem Shemshadi, Sima Noohi www.elsevier.com/locate/psychres

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S0165-1781(14)00515-0 http://dx.doi.org/10.1016/j.psychres.2014.06.013 PSY8343

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Psychiatry Research

Received date: 4 February 2014 Revised date: 8 June 2014 Accepted date: 10 June 2014 Cite this article as: Hadi Mo’tamedi, Peyman Rezaiemaram, Maria E. AguilarVafaie, Abaas Tavallaie, Mojtaba Azimian, Hashem Shemshadi, Sima Noohi, The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2014.06.013 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis Hadi Mo’tamedia, Peyman Rezaiemaramb*, Maria E. Aguilar-Vafaieb, Abaas Tavallaiec, Mojtaba Azimiana, Hashem Shemshadid, Sima Noohic a

Department of Clinical Sciences, University of Social Welfare and Rehabilitation

Sciences, Tehran, Iran b

Department of Psychology, Faculty of Humanities, Tarbiat Modares University,

Tehran, Iran c

Behavioral Sciences Research Center, Baqiyatallah Medical University, Tehran, Iran

d

Department of Clinical Sciences and Speech Reconstructive Surgery, University of

Social Welfare and Rehabilitation Sciences, Tehran, Iran

* Corresponding author: Department of Psychology, Faculty of Humanities, Tarbiat Modares University, Tehran, Iran. Tel.: +989354139385, fax: +982155188953 E-mail address: [email protected] (P. Rezaiemaram)

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Abstract Although the family has an important role in the early detection and intervention of first-episode psychosis (FEP), there are few findings reporting associations between family strengths and early treatment-seeking experiences.

This study aimed to

investigate, within the framework of the resiliency model of family stress, adjustment, and adaptation, the association between family coping strategies, resource management factors and duration of untreated psychosis (DUP) in Iranian families with one adult child with FEP.

107 individuals referred to three medical centers in Tehran and

diagnosed with FEP participated in this study. Caregiver-perceived DUP was measured via semi-structured interviews administered to primary caregivers. They also completed two questionnaires regarding family resources of stress management and family coping strategies. Data analysis indicated the Family Inventory of Resources of Management (FIRM) total scale score did not significantly explain the variance of caregiverperceived DUP, but one of the FIRM subscales, the Extended Family Social Support, and the Family Crisis-Oriented Personal Evaluation scale (F-COPES) total score and one its subscales, the Acquiring Social Support, explained a significant amount of the variance of caregiver-perceived DUP. The results suggest that higher family resiliency, especially social support, facilitates the family’s appropriate adaptive reaction (i.e., treatment-seeking), with the consequent decrease of DUP. Keywords: Catastrophic stressor, Duration of untreated psychosis (DUP), Family resiliency, First-episode psychosis (FEP)

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1. Introduction First-episode psychosis (FEP) is typically used to refer to the first time over which one is hospitalized for psychotic symptoms (i.e., delusions and prominent hallucinations) (World Health Organization, 2004); more specifically, the term ‘‘recent onset psychosis’’ has been proposed as a tentative operational definition of FEP, to denote a liberal determination of the duration of psychosis cut-off of less than 5 years since the onset of psychotic symptoms (Breitborde, Srihari, & Woods, 2009). The onset and early stages of psychosis experience is dramatically distressing, frightening and confusing, both for sufferers (Tarrier et al., 2007; Vracotas et al., 2007; So and Wong, 2008) and for their families (Barker et al., 2001; Addington et al., 2003; Askey et al., 2007; Gerson, et al, 2009). Similarly, in Iran, hospitalization due to FEP is very distressing both for sufferers and for their families (Ranjbar-Kermania et al., 2008; Sharifi et al., 2009). The early detection and the early-seeking intervention of FEP are considered important during such a critical period and conditions (Birchwood, 1999, 2000). However, several studies have shown that the opportune treatment is often delayed in various societies (e.g. Large et al., 2008; Ranjbar-Kermania et al., 2008; Compton et al., 2009; Sharifi et al., 2009; Chang et al., 2012; Lihong et al., 2012). Hence, duration of untreated psychosis (DUP) has become one of the mostly addressed variables in FEP research literature. Based on Compton and colleagues (Compton and Esterberg, 2005) research, the present study used the "family-perceived DUP", instead of the usual DUP measures, and was defined as the number of weeks from the onset of positive psychotic symptoms until first hospital admission, measured by the Symptom Onset in Schizophrenia (SOS) (Perkins et al., 2000) and select items from the semi-structured

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Course of Onset and Relapse Schedule/Topography of Psychotic Episode (Norma and Malla, 2002) interview.

Onset of positive symptoms was dichotomously

operationalized as acute (including sudden, precipitous and sub-acute) versus chronic (including gradual, and insidious) (Compton et al., 2008; 2009). There is a growing body of research which investigates the impact of different factors on duration of DUP, in order to help reduce treatment delay. These studies have identified a variety of factors, such as mode of onset and ambiguity of early symptoms (Kalla et al., 2002; Morgan et al., 2006; Compton etal., 2008), age of onset psychosis (Craig et al., 2000; Lihong et al ., 2012), lack of related awareness (Sainsbury Centre for Mental Health, 2003), concerns about stigma (Sainsbury Centre for Mental Health, 2003; Judge et al., 2008; Franz et al., 2010) and socioeconomic factors, such as the treatment cost (Large et al., 2008), occupation and economic status (Oliveira et al., 2010) and social capital (Burns and Kirkbride, 2012). Previous studies have demonstrated that the family has a determinant role in the early detection and in the early treatment-seeking of the first-episode of psychosis in different populations like Brazil (Oliveira et al., 2010), Ireland (O’Callaghan et al., 2010), Hong Kong (Chen et al., 2005; Chang et al., 2012) and African American minority in United States (Compton et al., 2009). Similarly, in Iran, for example, Sharifi et al (2009), after investigating pathways to care in 91 Iranian patients with FEP, concluded that most referrals made to the psychiatric hospitals came from family members. Nevertheless, few research studies have been conducted at the family-level, examining the factors which influence treatment delay. Interestingly, most previous researches on families with a member suffering from psychosis have focused on family deficits, rather than strengths, studying the role of the

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family in the origins and relapse of psychosis (Levene et al., 2009). For instance, it has been within this so called "deficit-based approach" that the much studied construct of expressed emotion (EE)—negative attitudes of family relatives towards their family member with psychosis—that most previous research has take place (e.g., Leff and; Hooley, 1985; Vaughn, 1985; Barrowclough et al., 1996; Wearden et al, 2000; Raune et al., 2004; Patterson et al., 2005). The main impetus for research on EE was the investigation of negative impacts of EE on outcomes and psychotic relapse (Hooley, 1985; Wearden et al, 2000; Yang et al., 2004). In contrast, the limited numbers of research studies have been carried out to determine the role of family strengths in the member's mental illness. More precisely, few studies have been conducted to investigate the relationship between the family system’s assets and illness variables (such a research orientation so called "strengthbased approach"). For example, Goulding et al. (2008) showed that family strengths were inversely correlated with actual DUP. Also, Compton et al. (2009) found that greater family strengths and a better family coping capacity were associated with a shorter actual DUP.

Building on the innovative approach of these two studies

(Goulding et al., 2008; Compton et al., 2009), the present study has attempted to further explain the theory/theories behind their work and replicating/expanding on their results in a new and unique population. Goulding et al. (2008) has noted the dearth of research on the functioning of families beginning to initiate care for individuals with FEP, and suggests that it would be useful to identify family characteristics (especially family strengths) that may play a role in understanding DUP. Accordingly, the present study aimed to investigate the associations between family resiliency factors, as family strengths, and caregiver-perceived DUP among individuals

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with FEP, using the resiliency model of family stress, adjustment, and adaptation (McCubbin et al., 1993, 1996) as a theoretical framework of research (from here on this theoretical model is referred to as "the family resiliency model"). According to this model, "family resiliency" refers to characteristics, dimensions and properties of families that help families to be resistant to disruption in the face of major changes and be adaptive in the face of crisis situations (McCubbin et al., 1996, p. 247). In fact, the family resiliency model is based on a family system perspective, and views the family as a unit or hole consisting of complex interactions between its components, at a level above the individual (Hawley and DeHaan, 1996). As such, this unit, the family, may successfully adapt to distressing conditions, demonstrating resilience, or it may fail to do so, becoming vulnerable to stressful situations. The family resiliency model suggests that there are two main types of stressors that the family system may have to deal with them; "normative" versus "nonnormative" (McCubbin et al., 1996). Normative stressors are expectable family life cycle changes and should not be considered a significant risk for families. In contrast, nonnormative demands, which are unexpected and many times traumatic, are more likely to fit the definition of significant risk. Stress causes imbalance in the family system, and family unit reacts to this condition, in two phases: adjustment and adaptation. When the family is faced with a normative stressor, the family needs only to apply their existing strengths and capabilities to manage the situation or to make minor changes in the established patterns of family functioning (adjustment phase). In dealing with a nonnormative stressor, however, the existing strengths are not sufficient to overcome the demands and to recover family system imbalance. This condition represents a crisis for the family. In this condition, in order to restore balance and to establish a new equilibrium in the

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system, the family should make major changes in the established patterns of family functioning (adaptation phase). In other words, family resilience refers to qualities that enable a family to maintain its adaptive functioning as it experiences a crisis (Hawley and DeHaan, 1996). Although competence in managing normative demands could be characterized as resilience, and similarly, no clear-cut rules determine the meaning of a (non)normative event (it influenced by social and cultural factors which could increase/decrease the risk) (Patterson, 2002), there is one kind of stressor, known as catastrophic stress—the sudden and extreme threat to survival experienced by family members that is associated with a sense of helplessness, disruption, destruction, and loss (McCubbin and Figley, 1983, p. 220)—which inflict nonnormative demands for all families in different cultural contexts. As Saunders (2003) has stated, severe mental illnesses (such as FEP) have been identified as a catastrophic stressor for the family system.

Thus, these will

certainly serve as the stimulus to launch the family adaptation process. In sum, FEP, considered as a catastrophic stressor (Saunders, 2003), will confront the family with a crisis, and consequently, family resiliency would play a pivotal role in the better family adaptation in this family crisis situation. Moreover, early treatmentseeking obviously is one adaptive or problem-focused strategy in coping with such a situation (Gerson et al., 2011), and family has a decisive role in facilitation of it (Chen et al., 2005; Morgan, 2006; Sharifi et al., 2009; Oliveira et al., 2010; O’Callaghan et al., 2010; Gerson et al., 2011; Chang et al., 2012; Rabinovitch ET al., 2013). Therefore, the shorter family-perceived DUP (less delayed treatment-seeking) can be considered an indicator of better adaptation of the family in such crisis (Compton et al., 2006, 2008; Gerson et al., 2011). Then, it follows that stronger levels of family resiliency factors—

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family perceived resources of crisis management and family coping strategies—will be associated with a shorter DUP. Therefore, it was hypothesized then that: (i) there would be an inverse association between family crisis-oriented personal evaluation questionnaire scores and the number of weeks between the caregiver awareness of psychotic symptoms and firs hospital admission (a longer caregiver-perceived DUP); (ii) there would be an inverse association between family resources of management questionnaire scores and a longer family-perceived DUP.

2. Method In the present study, a correlational design was used to investigate the relationship between family resiliency factors and caregiver-perceived DUP among individuals with FEP. In addition, hierarchical regression analyses were applied to demonstrate the amount of variance of caregiver-perceived DUP explained by family resiliency factors.

2.1. Participants Using convenience sampling procedures, one hundred and seven Iranian individuals diagnosed with FEP were recruited from consecutive patients attending and/or referred to psychiatric wards of three reputable hospitals in Tehran, for initial treatment of a psychotic disorder, from March 2009 to July 2011. In the present study, inclusion criteria considered consisted on: (i) having one of the following diagnoses: schizophrenia, schizophreniform, schizoaffective, brief psychosis, delusional disorder, psychosis not elsewhere specified (NOS), and bipolar I disorder “severe with psychotic features’’(Baldwin et al, 2005); (ii) coming in for a first time treatment for a psychotic episode; (iii) patients’ age range of 18 to 35 years; and (iv) adequate skill of the primary

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caregiver in reading Farsi, the official Iranian language, for completing the questionnaires of the study. Participants with the following conditions were excluded from the study: (i) duration of the current psychotic disorder in patient longer than 5 years (Breitborde, Srihari, & Woods, 2009); (ii) history of severe mental illness in patient (before the current episode) and immediate family members, for greater certainty that families have not previously faced with a similar crisis, and they have no previous experience of adaptation with this type of crisis (Otherwise, FEP can not necessarily be considered as a catastrophic stress for family system); (iii) serious mental disabilities, such as mental retardation, or physical disabilities that could compromise ability to participate (Compton et al., 2009). Demographic and selected clinical descriptive information of the sample (Table 1) was uniformly collected using a form designed by the research team.

2.2. Measures Measures used in this study felt into two categories: interviews and questionnaires.

2.2.1. Interviews Diagnoses of psychoses were made using the Structured Clinical Interview for DSMIV, Axis I Disorders (SCID-I) (First and Gibbon, 2004). Also, comorbidities of FEP with Axis-II disorders, as an exclusion criterion, was determined using the Structured Clinical Interview for DSM-IV, Axis II Disorders (SCID-II) (First and Gibbon, 2004).

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Severity of symptoms was rated applying the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987). For the assessment of DUP, based on Compton et al. (2005; 2008, 2009) studies, the date of onset of positive symptoms (i.e., hallucinations or delusions) was obtained using the Symptom Onset in Schizophrenia (SOS) (Perkins et al., 2000) and selected items of the Course of Onset and Relapse Schedule/Topography of Psychotic Episode (CORS/TOPE) (Norman and Malla, 2002). Notwithstanding the fact that DUP has been variously defined (see Morgan et al., 2006; Compton et al., 2007), in this research, consistent with Compton et al. (2005, 2006, 2008) studies, DUP was operationalized as the number of weeks from the onset of the first positive symptoms (PANSS score 3) until the first hospital admission due to psychosis. Note that DUP was determined only based on primary caregiver interview (Compton and Esterberg, 2005), since the present study emphasized family perceived date of psychosis, rather than actual DUP. Therefore, as Compton and Esterberg, (2005) have noted, the DUP from the perspective of a family member differs from the actual DUP that commonly combine data from all available sources, including the patient. Mode of onset of psychotic episode was categorized based on detailed review of all available information—a consensus-based best estimate approach—which was performed by the second and third authors (see Compton et al., 2008). Mode of onset usually has been defined in five subtypes that were put forth by the World Health Organization’s International Pilot Study of Schizophrenia (Jablensky et al., 1992): sudden, precipitous, sub-acute, gradual, and insidious. In the present study, for data analysis, consistent with previous researches (e.g. Morgan et al., 2006; Compton et al.,

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2008, 2009), mode of onset was dichotomously operationalized as acute (including sudden, precipitous and sub-acute) versus chronic (including gradual, and insidious).

2.2.2. Questionnaires Two questionnaires were used for assessment of the family resiliency factors. These self-reported instruments were completed by the primary caregivers. The Family Inventory of Resources of Management (FIRM) (McCubbin et al., 1991) is a self-report questionnaire consisting of 69 items. This instrument was developed to record the kinds of psychological, social, community and financial resources families believe they have available to help them in the management of family life (Fischer and Corcoran, 2007, p. 300). Participants responded to each item on a 4-point Likert scale, of "Not at All"= 1 to "Very Well"= 4. It consists of four subscales including: (i) family strengths-I: esteem & communication; (ii) family strengths-II: mastery & health; (iii) extended family social support; and (iv) financial well-being. The FIRM is a reliable and valid instrument (McCubbin et al., 1991, 1996).

The Family Crisis-Oriented Personal Evaluation Scales (F-COPES) (McCubbin et al., 1987) is a self-report instrument which comprises 30 items. The F-COPES was developed to measure problem solving and behavioral strategies used by families in order to cope with crises faced by family as a whole (McCubbin et al., 1987; McCubbin et al., 1996). The F-COPES consists of 5 subscales: (i) acquiring social support; (ii) reframing; (iii) seeking spiritual support; (iv) mobilizing to acquire and accept help; and (v) passive appraisal. Each item was responded using a 5-point Likert scale, from

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"strongly disagree"= 1 to "strongly agree" = 5 (McCubbin et al., 1987). This measure has adequate reliability and validity (McCubbin et al., 1987; Fischer and Corcoran, 2007).

2.2.3. Reliability of measures In the present study, to ensure the reliability of DUP interviews, first, the second author interviewed the participants regarding the date of onset of psychotic symptoms. The participants’ voices were recorded. Then, two researchers independently calculated DUP, using these recordings. In cases where the DUP assigned by the two researchers was not equal, a final decision was made on the basis of a consensus meeting with the principal investigator, the two members of the research team that assigned the DUP and other members of the research team. This decision strategy was adopted from the study of Oliveira et al. (2010). Diagnostic interviews, also, were independently conducted by the first and fourth authors. If the two researchers did not agree on the diagnosis, the patient was not included in the study. Mode of onset was also separately determined by the second and third authors, inequalities were resolved by consensus with the principal investigator. In addition, since the two standard questionnaires used in the study (the FIRM and the F-COPES) were not previously administered to any Iranian population (or Farsi translation was not available), initially, these measures were translated into Farsi language, then back translated into English. The back translated versions were then compared with the original ones.

Adjustments were made to make sure that the

translated Farsi version reflected the original meanings. Afterwards, as a pilot test, the Farsi versions were performed in a small sample (N = 30), and their reliabilities was

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investigated; the internal consistency of total scores of both the FIRM ( = 0.62) and the F-COPES ( = 0.64) was acceptable. Moreover, the reliability of Farsi versions of the questionnaires was re-investigated using analyses of the present study sample data. In the sample of the present study (N = 107), the coefficient of internal consistency of the Farsi version of the FIRM total score scale was good ( = 0.71) and for the subscales coefficients ranged from 0.70 to 0.57. Also, the internal consistency reliability coefficient for the total score of the Farsi version of the F-COPES was acceptable ( = 0.69) and for its five subscales, listed above, alphas ranged from 0.65 to 0.76.

2.3. Ethical Considerations Ethical approval for the present study was obtained from each one of the three institutions in Tehran which contributed in this study, Board of Advanced Studies and Research of Tarbiat Modares University, Research Office of University of Social Welfare and Rehabilitation Sciences, and Medical Research Ethics Committee of Bagiyatallah Hospital, respectively.

All the participants were informed about the

purpose of the study, their right to either consent or refuse to participate, and to withdraw from the study at any point in time. Finally, authors attempted to provide appropriate professional support for participants as much as possible. Further, upon completion of the study, all participants were given a brochure which contained basic information on FEP characteristics, causes and possible treatments.

2.4. Statistical Analysis Analyses of collected data were conducted using PASW statistics 17 software (SPSS Inc., Chicago, IL, USA). Mean, median and standard deviation (S.D.) were applied for

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description of the sample characteristics in terms of research variables. Also, Pearson correlation coefficients were used to analyze associations of research variables. Afterwards, a series of hierarchical multiple regressions were conducted in order to represent the amount of variance in caregiver-perceived DUP explained by family resiliency factors. Significance of two-tailed tests was interpreted at p < .05. In addition, in order to control for inflated type one error due to multiple testing, if appropriate, the Bonferroni p-value adjustment was used.

3. Results Selected demographic, clinical descriptive statistics and mean of total scores for the F-COPES and the FIRM measures for the total sample are depicted in Table 1.

3.1. Correlation Analyses Correlation coefficients and related significance levels are shown in Table 2. In the inferential analyses, consistent with several previous studies (e.g., Hutton et al., 2004; Gunduz-Bruce et al., 2005; Barnes et al., 2008; Flanagan and Compton, 2012) DUP scores were log10 transformed, because the sample’s distribution in terms of DUP was skewed. Finally, the biserial correlation coefficient was applied to investigate the association between mode of onset, as an artificially dichotomized variable, and the log10 DUP, as an interval variable. No significant relationship was found between these variables (rbis = 0.17, p = n.s.).

3.2. Regression Analyses

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In all Regression Analyses, the log10 DUP scores were entered as the criterion. Because previous studies (Compton et al., 2008; large et al., 2008; Compton et al., 2009) found associations between three demographic variables (patient gender, employment of patient and family income) and DUP, these variables were statistically controlled in regression analyses. For this purpose, after dummy-coding (0, 1 coding) into categorical scores (male = 0, female = 1; employed = 0 unemployed = 1), these variables were entered in the first step of regression models. The family resiliency factors, as predictor variables, were entered in the second step of the regression models. Hierarchical multiple regression analyses are summarized in Tables 3 to 6. According to the data analyses, demographic variables—gender and employment of patients and family income—totally explained 7.30% of the DUP variance. As shown in Table 3, the FIRM total score did not show significant results after controlling the DUP variance explained by demographic variables. Also, the FIRM subscale scores were tested in a separate regression computation (Table 4), after controlling for demographic variables as before. All FIRM subscales considered in one block explained approximately 9% of DUP variance, and only one significant result was obtained with the FIRM subscale, the extended family social support. In the second hierarchical regression model (Table 5), after controlling of demographic variables, the F-COPES total scale score accounted for approximately 19% of explained DUP variance. In addition, the F-COPES subscale scores as one block were tested in a regression computation (Table 6), after controlling for demographic variables as before.

In total, almost 24% of the DUP variance was

explained by scores of the F-COPES subscales. Furthermore, the regression model of

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subscales results of these computations yielded one significant findings with the FCOPES subscales: the acquiring social support (Table 6).

4. Discussion The current research was aimed at investigating the relationships between family resiliency factors—management of psychological, social, community and financial resources, and family problem solving and behavioral strategies used by families in order to cope with crises—and caregiver-perceived DUP among Iranian individuals with first-episode psychosis. In this study, caregiver-perceived DUP defined as the caregiver's report of the number of weeks from the onset of positive psychotic symptoms until first hospital admission, measured by the Symptom Onset in Schizophrenia (SOS) (Perkins et al., 2000) and select items from the semi-structured Course of Onset and Relapse Schedule/Topography of Psychotic Episode (Norma and Malla, 2002) interview.

Also, onset of positive symptoms was dichotomously

operationalized as acute (including sudden, precipitous and sub-acute) versus chronic (including gradual, and insidious) (Compton et al., 2008; 2009). First, correlation analyses revealed significant reverse relationships between a number of family stress management resources and caregiver-perceived DUP. Also, such relationships were found between some of the family coping strategies and caregiver-perceived DUP. These results mean that there is an association between families with resourcefulness in resiliency factors and the time elapsed from the first time onset of positive psychotic symptoms was perceived until first hospital admission. These results are consistent with the findings of previous studies.

For example,

Goulding, et al. (2008) found that the family members of patients with a shorter DUP

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obtained higher scores in family strength scale (including pride and accord dimensions) than those of patients with a longer DUP. Also, Compton et al (2009), studied 42 African American patients with FEP and showed that greater family strengths, including pride and accord dimensions, and a better family coping capacity were associated with a shorter DUP. However, there are an essential difference between and these two studies (Compton et al., 2009; Goulding et al., 2008). Operational definitions of DUP in the present study and in these two studies (Compton et al., 2009; Goulding et al., 2008) are not identical, although the used DUP measurement instruments are the same. In other words, as showed in Figure 1, if actual DUP is divided into two parts, before versus after family awareness of onset of symptoms, the present study only addressed the second part—after family awareness (section A in figure 1), rather than all of the duration. Second, although in regression analyses, the family resource management (FIRM) total scale score did not significantly explain the variance in DUP scores, the extended family social support, one of the FIRM subscales, was found to be significant in the analysis. In line with this finding, Thorup et al. (2006) showed that a small social network size was associated with long DUP period. In fact, extended family networks can supply various kinds of support, such as instrumental and tangible support, which provide emotional care as well as advice and information (Taylor et al., 2001). Rabinovitch et al. (2013) found the association between social support and adherence in 82 patients with FEP. If ‘‘family treatment-seeking’’ is considered an adaptive reaction of the family system faced with FEP (Gerson et al., 2011), and ‘‘family treatment delay’’, a condition which is caused by deficits in motivational processes underling the family’s (lack of) adaptive behavior, it can be argued that social networks can play a

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motivating, encouraging or guiding role in acceleration of the family system’s treatment-seeking (and, the family perception of DUP). For example, in the case of Chinese caregivers of relatives suffering from early psychosis in Hong Kong, although the initial steps in the identification of individuals in the crucial help-seeking phase was done by family caregivers, informal network members were instrumental in confirming the presence of mental illness and encouraging family caregivers to seek external help (Wong, 2007). Also, Larsen et al. (1998) investigated the factors related to a long DUP. Their findings showed that a long DUP period is remarkably associated with weaker social network. In interpreting their findings, they stated that one of the main obstacles for receiving treatment was a poor social network (Larsen et al., 1998). Results from the present study also indicated that among the five family coping strategies measured by the F-COPES, the subscale assessing the ability to secure social support shows the strongest relationship with caregiver-perceived DUP. Some studies also have emphasized the importance of seeking social support in families of persons with FEP (e.g., Gerson et al., 2011; Rabinovitch et al., 2011). However, the Hashemi et al. (2007) indicated that this coping strategy was least adopted by the parents of Iranian children with cancer. Therefore, it seems that families faced with FEP may seriously need to develop this coping strategy in order to deal with of this certain situation, while in other critical situation, such as cancer of child (Hashemi et al., 2007), these strategies may have a less important role. This explanation is further highlighted by the findings obtained regarding the extended family social support subscale—a family stress management resource from the FIRM measure. Thus, it can be concluded that the family’s competencies in obtaining social support during such critical situation caused

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by confronting psychotic symptoms of the family member, a catastrophic stressor, will provide one of the most important management resources. This explanation need to be more addressed in future studies. Moreover, theoretical models based on family systems theory, such as the family resiliency model (McCubbin et al., 1993, 1996), emphasize reciprocal relationships between and among variables, and so, family resiliency is viewed as a systemic quality shared by the family unit as a whole (Hawley and DeHaan, 1996). Therefore, it can be argued that a longer DUP could be the result of a reduced social support of reciprocal relationships among family members, although this is presently only a speculation. Furthermore, considering the notion of "mental illness stigma", in Iranian society there exist stigmas associated with mental illness (Ghanean et al., 2011), as well as, negative attitudes toward psychiatric help-seeking (Ghazi-Moghadam, 2009). These stigmas can lead to the adoption of avoidant coping strategies, by both sufferers (Judge et al., 2008) and families (Franz et al., 2010), such as withdrawal, social isolation and avoiding helpseeking. For example, Franz et al. (2010) suggested that due to fear of the official label of a mental illness, certain coping mechanisms may be adopted by families, which may result in a raised threshold for treatment initiation, and ultimately treatment delay. Therefore, stigma, can lead to increasing withdrawal, avoiding professional help, prolonging of DUP, and consequently, shrinking of social support network which can, in turn, reduce a potential motivation of family treatment-seeking behavior. In sum, social support appears to have both direct and indirect or buffering effects on mental health outcomes of patients and their families (Saunders, 2003). Therefore, with respect to the present findings, it seems that DUP is an important variable in the

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treatment-seeking process of patients with FEP. Suggested relationships are given in Figure 2. In the present study, two findings were obtained that were largely unexpected given previous studies. One of the unforeseen findings is related to the relationship between the family seeking spiritual support and caregiver-perceived DUP. Several studies have shown that spiritual strategies play a determinant role in coping with stressful situations in Iranian populations (Hashemi et al., 2007; Seyedfatemi et al., 2007). For example, Hashemi et al. (2007), using the F-COPES, studied family coping strategies in parents of Iranian children with cancer. They found that the spiritual support ranked among the highest relied strategies by parents. Magliano et al. (2000) identified seeking spiritual help as an important coping strategy in different relatives of patients with schizophrenia, especially in females, parents and older relatives. In sum, a reasonable interpretation could be that although religious/spiritual coping can promote family members’ psychological adaptability and may help relieve their psychological distress, its role in encouraging family to seek professional help needs to be further explored. On the other hand, Tennakoon et al. (2000) showed that caregivers mainly used the spiritual coping strategy to cope with stigma. Therefore, considering the proposed path in Figure 2, it is expected that spiritual coping might be effective in shortening family treatment-seeking delay. On the contrary, in the current study, no significant association was found between seeking spiritual support, one subscale of the F-COPES measure, and the family-perceived DUP. Future studies are warranted to address this issue. Another unexpected finding of the present study is concerned with the relationship between mode of onset and caregiver-perceived DUP. In this study there was no

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significant association between mode of onset of psychosis and DUP, however, in previous studies it has been well documented that a chronic mode of onset is associated with a longer DUP compared with an acute mode of onset (e.g. Kalla et al., 2002; Morgan et al., 2006; Compton et al., 2008), however This lack of congruency can be explained by considering the conceptualization of DUP used in this study.

As

mentioned above, the present study focused on the family-perceived DUP (section B in Figure 1), instead of the actual DUP. Based on the family resiliency model, the time when the family is not aware of the onset of symptoms, the family system is theoretically assumed not to be in a crisis state (Mccubbin et al., 1996). Thus, it can be argued that mode of onset is effective in delay of family awareness, and consequently, it will impact on actual DUP. In addition to the mode of onset, there are several other factors that may affect the actual DUP in the same way. For example, patients typically conceal symptoms from families at onset of psychosis; also, although they recognized changes in themselves, they tend not to understand these as part of a mental illness (Judge et al., 2008). Moreover, psychotic symptoms are often noted and responded to by families without being recognized as psychotic, and are given other attributions (Compton, Kaslow and Walker, 2004). Further studies need to address relationships between such variables and delay in awareness of onset of symptoms, especially in Iran. The present study was not without limitations. The research sample was selected from three psychiatric therapeutic centers at Tehran; thus, the research findings cannot be completely generalized to the Iranian population with FEP and their families, especially those who living in rural areas of Iran.

Also, the present study was

correlational, and due to the lack of effective control of all variables in this type of

22 

studies, causality cannot be conclusively determined. Moreover, since DUP in this study was mainly obtained from primary caregivers' retrospective reports, there is the possibility of bias in estimations. Thus, comparing results from caregiver-perceived DUP with results obtained with DUP measured using a consensus-based best estimate approach warrants future research. Also, there is a significant risk of bias in having DUP and family resiliency factors derive from self-reports by primary caregiver, because the measures of DUP and family variables are not fully independent. Using collateral information from the patient or individuals outside the family (relatives, clinicians, and friends) in terms of duration of psychosis or the families' reaction to it could eliminate the risk of this bias. Finally, although the patient's age has been controlled in the analyses, but due to lack of access to their age at actual onset of symptoms (i.e., patient's age at onset of actual DUP), it was not controlled in data analyses process. In terms of recommendations for future research, the authors suggest replicating this study using the actual DUP assessments. Although onset of psychosis is a nebulous phenomenon that evades close scrutiny (Singh, 2007), for more accurate estimation of its onset, information obtained from various sources should be applied—i.e., the consensus-based best-estimate approach (Compton et al., 2007). However, authors also recommend investigating the role of family resilience in decreasing delay in family perception of onset psychotic symptoms. The use of verifiable methods in family research (Van Breda, 2001) is suggested. In summary, despite aforesaid limitations, the present study highlights the importance of addressing the role of family system strengths, especially the social support and the family's capacities to achieve it, in shortening treatment delay in

23 

patients with FEP—at least after family awareness of onset of symptoms. Further, the study emphasizes the importance of systematic investigation of complex interactions between family system's factors and patient- or illness-level variables, such as DUP.

Acknowledgements Authors would like to thank Dr. Michael Compton, for his support and facilitation of the CORS/TOPE semi-structured interview. Our appreciation goes also for the Staff, patients and families, from three Hospitals at Tehran, who collaborated in the present study.

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33 

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Descriptive statistics of the sample (N = 107). Variable

Descriptive statistics

Age (Years), Mean (S.D.)

27.47 (4.61)

Gender, n (%) Male

58 (54.2)

Female

49 (45.8)

Employment, n (%) Employed

39 (36.4)

Unemployed

68 (63.6)

Diagnosis, n (%) Schizophrenia

35 (35.71)

Schizophreniform

12 (11.21)

Schizoaffective

10 (9.34)

Brief psychosis

5 (4.67)

Delusional disorder

7 (6.54)

NOS

14 (13.1)

Bipolar I disorder

24 (22.43)

Mode of Onset n (%) Chronic

20 (18.7)

Acute

87 (81.3)

DUP (week), Mean (S.D.); median

32.23 (20.33); 26

FIRM total score

93.42 (16.27)

F-COPES total score

85.67 (10.61)

34  S.D.—standard deviation; n (%)—number (percentage); NOS—psychosis not elsewhere specified; DUP— duration of untreated psychosis; FIRM—the Family Inventory of Resources of Management; FCOPES—the Family Crisis-Oriented Personal Evaluation Scales.

Reframing

Seeking spiritual support

Mobilizing to acquire and accept help

Passive appraisal

F-COPES total score

9

10

11

12

FIRM total score

6

8

Financial well-being

5

Acquiring social support

Extended family social support

4

7

Family strengths-II

3

F-COPES

Family strengths-I

2

FIRM

Log10 DUP

1

Variable 1

1

0.04 0.16*

0.47*** 0.14 0.31***

0.40*** 0.87***

0.18**

1

0.55***

1 1 1

0.25***

1

0.12

0.20*

0.04

0.26***

-0.29***

0.19**

0.31***

-0.48***

0.25***

1

0.61***

0.16*

0.26***

1

0.09

0.45***

8

0.46***

7

-0.46***

6

-0.30***

5

-0.36***

4

3

2

Correlation coefficients of research variables (N = 107).

DUP

Table 2

1

1

0.06

1

0.31***

0.49***

0.18** 1

0.39***

0.66***

0.73***

0.37***

0.17*

0.52***

0.26***

0.45***

-0.54***

12

-0.05

0.04

0.17* 0.11

0.02

0.13

0.17*

0.07

0.06

0.06

0.03

0.12

-0.14

11

0.30***

0.13

0.49***

0.28***

0.39***

-0.34***

10

0.10

0.05

0.10

0.08

0.11

-0.08

9



35

*** significant at p < 0.01

** significant at p < 0.0126 (Bonferroni-corrected alpha level).

* significant at p < 0.05

COPES—the Family Crisis-Oriented Personal Evaluation Scales.

Log10 DUP— log10-transformed score of duration of untreated psychosis; FIRM—the Family Inventory of Resources of Management; F-



36

  Table 3

Statistics of hierarchical regression analysis for the FIRM total score Sig.

R2

-0.393

0.721

0.073

-0.250

-2.615

0.009

0.042

-0.017

-0.415

0.803

-0.021

0.094

-0.039

-0.407

0.706

Patient Employment

-0.138

0.012

-0.252

-.2.661

0.001

Family Income

-0.059

0.023

0.112

0.942

0.434

FIRM total score

-0.003

0.051

-0.215

-1.833

0.071

B

SE B



Patient Gender

-0.20

0.096

-0.038

Patient Employment

-0.138

0.071

Family Income

-009

Patient Gender

Model 1

2

t

FIRM—the Family Inventory of Resources of Management. * significant at p < 0.05 ** significant at p < 0.0126 (Bonferroni-corrected alpha level). *** significant at p < 0.01

0.158

R2

F

F

2.704*

0.085

5.058**

2.354

  Table 4

Statistics of hierarchical regression analysis for scores of the FIRM subscales. Sig.

R2

-0.393

0.721

0.073

-0.250

-2.615

0.009

0.042

-0.017

-0.415

0.803

-0.021

0.094

-0.039

-0.407

0.706

Patient Employment

-0.138

0.012

-0.252

-.2.661

0.001

Family Income

-0.059

0.023

0.112

0.942

0.434

Esteem & communication

-0.009

0.005

-0.132

-1.229

0.772

Mastery & health

-0.010

0.006

-0.146

-1.431

0.713

Extended family social support

-0.066

0.037

-0.368

-4.032