Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

6. Factors Affecting the Duration of Untreated Psychosis in Hong Kong

A reduction in the duration of untreated psychosis (DUP), defined as the timelapse between onset of psychotic symptoms and initiation of treatment, is a key target of early intervention for psychotic disorders (Harrigan, McGorry, & Krstev, 2003; McGlashan & Johannessen, 1996; McGorry, 2000). Many early intervention programmes aim at DUP reduction, considering it a measurable and achievable goal (Johannessen, 1998; Malla et al., 2003). At present, the body of knowledge on DUP has largely been focusing on its relationship with clinical outcomes (Altamura et al., 2001; Amminger et al., 2002; Black et al., 2001). Meta-analyses have provided solid evidence for its role in predicting outcomes (Marshall et al., 2005; Perkins et al., 2005). Yet, given the pivotal role of DUP in early intervention, it should be equally important to identify the factors that may influence DUP. These may include premorbid features, clinical profile, and the sociocultural context of the illness. In particular , the sociocultural context of the illness and the health care system, which includes cultural, family, and service delivery factors, are important, as they are potentially modifiable for shortening DUP. A small number of studies have attempted to look at these issues. Among them, DUP has been linked to clinical features such as poor insight, social withdrawal, and isolation (Barnes et al., 2000; Drake et al., 2000; Larsen, Johannessen, & Opjordsmoen, 1998). Skeate et al. (2002) also found that patients with a shorter DUP have more active help-seeking behaviours and made more contact with their general practitioners six years before onset. Furthermore, Moller (2001) suggested that the acute development of a psychotic episode might be associated with a shorter DUP. Most of these previous studies, however, have focused on referral patterns and patient features; factors related to the patient’s family have seldom been examined in details. Yet, as the majority of first-episode patients reported that others, rather than themselves, 6 Factors Affecting the Duration of Untreated Psychosis in Hong Kong Eric Yu-hai Chen 68 Eric Yu-hai Chen were critical in the initiation of treatment (de Haan et al., 2002), factors that concern caregivers may be important determinants of DUP (see Chapter 17, “Experience of Stigma in Early Psychosis Patients and Caregivers”). In Hong Kong, the relatively lengthy average duration of untreated psychosis (DUP) of over 18 months among first-episode psychosis patients was comparable to that found in many previous studies (Black et al., 2001; Ho et al., 2003; Johannessen, 1998; Kalla et al., 2002; Larsen, McGlashan, & Moe, 1996; Loebel et al., 1992). This chapter will explore features associated with lengthy of DUP, using Hong Kong as an example, but also recognizing that each population might have distinctive determinants of DUP. Previous Familial Experience Compared with many other societies, individuals in Hong Kong are more likely to live with their parents. Whether because of space limitations, high property prices, or cultural trends, single-person households only constitute 17.1% of all households in Hong Kong (Census and Statistics Department, 2002), while the figure is 25.7% in the US, 29.5% in Sweden, and 26.3% in Norway (Ness & Ciment, 1999; Russell, 2000). Therefore, among the potential factors that affect DUP, social isolation is expected to be less prominent in Hong Kong. In contrast, response of the family to the patient’s symptoms may be relatively critical in determining the length of DUP. Where the patient resides with family, whether other family members have adequate knowledge of psychosis may be a decisive factor in help-seeking. Findings from previous studies, which suggest that having another ill family member may lead to improved knowledge about the illness (Chung et al., 1997; Lam, Chan, & Chen, 1996), also demonstrate that previous family experience of psychiatric illness has a significant effect on DUP (Chen et al., 2005). Patients with another family member who had already received psychiatric treatment tended to have a shorter DUP (225 days) compared with patients without a family history of psychiatric treatment (645 days). There are two potential interpretations for this finding. The first is that patients with family history exhibit some biologically determined features that alterthepresentationoftheillnessinawaythatleadstoashorterDUP.Although it has been suggested that familial cases of schizophrenia may be characterized by a distinctive profile (such as age of onset or negative symptoms), studies have failed to find a consistent difference between sporadic and familial cases Factors Affecting the Duration of Untreated Psychosis in Hong Kong 69 (Kendler, Karkowski-Shuman, & Walsh, 1996; Roy et al., 1994). Furthermore, some...