The study was carried out on the basis of the specialist psychiatric services in 4 Scandinavian health care sectors (2 health care sectors in Rogaland County, Norway, with a total of 370 000 inhabitants and the Ullevaal health care sector, Oslo County, Norway, and the midsector, Roskilde County, Denmark, with a combined total of 295 000 inhabitants). Rogaland County comprised the ED sector and the combined Ullevaal and Roskilde sites comprised the no-ED sector. Both sectors had urban and suburban elements with 84% of the ED population living in urban areas vs 96% of the no-ED population (P = .001, the Fisher exact test). There were no differences in age and sex distribution between the 2 areas and no differences in main income levels and unemployment rates in the total population. Patients from the no-ED area were more often immigrants from a nonwestern country (12% vs 4%) and had more education after high school (31% vs 21%) (P = .001 for both, the Fisher exact test).
All 4 health care sectors are part of a national health care system. In Norway and Denmark, these are essentially the only systems available for the treatment of psychotic disorders, and the samples collected represent most, if not all, cases of psychosis ascertained and treated. As such, these are clinical epidemiologic samples.
In all 4 health care sectors, the treatment systems were catchment area based and publicly funded. The core basis of the psychiatric specialist treatment system was the subsector catchment area-based outpatient units, with the addition of short-term, acute-care inpatient units and a restricted number of specialized long-term wards (4 different outpatient units and 2 hospitals in the ED area and 5 outpatient units and 2 hospitals in the no-ED area). The treatment system was based on referral from general practitioners, but the assessment and treatment of first-episode psychosis was considered a task for the specialized psychiatric treatment system, with immediate transfer of recognized cases as standard practice. There were no differences in the use of inpatient psychiatric services across the areas.
From January 1, 1997, the specialized psychiatric services of the 4 health care sectors established equivalent treatment programs for patients with first-episode psychosis. All first-episode patients from all 4 sectors underwent assessment by trained personnel as soon as possible after first contact with the specialized treatment system and were assigned to the treatment program without delay. The program consisted of defined treatment algorithms for antipsychotic medication (low-dose second-generation antipsychotic medication), individual psychosocial treatment (a trained psychiatric case worker offering weekly sessions), and psychoeducational family work (multifamily groups). The program was based on experiences from other first-episode treatment programs and the recommendations of the Schizophrenia Patients Outcomes Research Team.13
In 2 of the health care sectors (Rogaland County), an extensive ED program was added that was not present in the 2 other participating health care sectors (Oslo and Roskilde counties). The ED program consisted of educational campaigns about psychotic symptoms and their treatment directed at the general population through newspaper, radio, and cinema advertisements and targeted information campaigns directed at general practitioners, social workers, and high school health care personnel. In addition, specialized low-threshold ED teams were established that could be reached by a single telephone call from potential patients, family, and friends, and the telephone number was made part of the information campaign. The organization of the ED program was based on the idea that treatment could be delayed owing to lack of awareness or to prejudices about psychotic disorders and their treatments in the psychotic person, in the person's network, and/or among first-line health care and social welfare personnel. Treatment could secondarily be delayed owing to difficulties in accessing psychiatric services. A tertiary delaying factor could be delays in identifying cases and/or resource limitations in assigning adequate treatment for first-episode patients at the level of the specialized psychiatric services. The ED program addressed the first 2 factors, with the intention of bringing first-episode patients earlier into the specialized psychiatric services assessment and treatment programs. Establishing equivalent treatment programs in the ED and no-ED areas would necessarily reduce delays on the level of the specialized services equally and thus carried the possibility of shortening the DUP in the no-ED area.
The study included all eligible patients meeting study criteria for the period of January 1, 1997, through December 31, 2000. Participants were followed up with personal interviews after 3 months and 1, 2, and 5 years. This communication reports the 1-year results.
The Regional Committee for Research Ethics approved the study. All patients entering the study gave written informed consent. Information regarding nonparticipants is based on data gathered anonymously for the purpose of bias testing.
Inclusion criteria consisted of living in the catchment area of 1 of the 4 health care areas; age 18–65 years; meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
) criteria for schizophrenia, schizophreniform disorder, schizoaffective disorder (narrow schizophrenia spectrum disorders) or brief psychotic episode, delusional disorder, affective psychosis with mood-incongruent delusions, or psychotic disorder not otherwise specified; being actively psychotic, as measured by the Positive and Negative Syndrome Scale (PANSS)14
score of 4 or more on at least 1 of positive subscale items for delusions, hallucinatory behavior, grandiosity, or suspiciousness/persecution or general subscale item unusual thought content; not receiving previous adequate treatment for psychosis (defined as antipsychotic medication of 3.5 haloperidol equivalents for 12 weeks or until remission of the psychotic symptoms); having no neurological or endocrine disorders with relationship to the psychosis; having no contraindications to antipsychotic medication; understanding and/or speaking a Scandinavian language; having an IQ score of above 70; and being willing and able to give informed consent.
During the 4-year period, 380 patients were identified, and 284 gave informed consent to enter the study. The refuser rate for study inclusion was 23%, and no major differences for key characteristics were found when compared with the included sample. For details see previous publications.12
Three patients withdrew consent during the first year, leaving 281. These 281 patients were distributed with 141 in the ED area and 140 in the no-ED area. From the initial sample of 281 patients, we were able to reassess diagnosis in 272 cases (97%) and to carry out complete assessments of 239 (85%) at 1-year follow-up. The patients lost to follow-up did not differ from the original sample on any major characteristics such as gender, age, diagnosis, premorbid functioning, or symptom level at baseline.
The assessment team at all sites consisted of clinically experienced and trained research personnel who performed all evaluations.9
The Structured Clinical Interview for the DSM-IV
Axis I Disorders (SCID) was used for diagnostic purposes.15
If patients abused drugs, we would initiate a longer period (> 4 weeks) of drug-free observation (mostly involuntarily) before a diagnostic conclusion was made. Symptom levels were measured by means of the PANSS.14
Global functioning was measured by the Global Assessment of Functioning Scale (GAF),16
and the scores were split into symptom (GAFs) and function (GAFf) scores to improve psychometric properties. QoL was measured with the Lehman Quality of Life Interview, brief version.17
Misuse of alcohol and other drugs was measured by the Drake Scale.18
The DUP was measured as the time from the onset of psychosis until the start of adequate treatment; for details see previous publications.12
After 3 months, we repeated PANSS, GAF, and deficit assessment. At 1 year, all assessments were repeated including SCID. For the 1-year follow-up, a separate summary interview was conducted in which we gathered information regarding 3 different outcome domains: (1) psychosis development: time to remission, duration and number of relapses, and remission status at follow-up; (2) use of treatment offered in weeks of participation: hospitalizations, individual supportive psychotherapy (at least weekly sessions), family work, and use of antipsychotic medication; and (3) use of rehabilitation services. All major baseline assessments such as diagnosis, PANSS, GAF, drug abuse, and DUP underwent tests of intra- and intersite reliability with satisfactory results. The definition of remission at follow-up was equal to the definition of DUP at baseline; retrospective estimation of time period with or without positive symptoms defined as a rating of four or more on specific PANSS items. Raters trained to reliability for DUP made assessment of remission at follow-up. For details see previous publications.9
Regarding reliability for the follow-up, 31 vignettes were randomly selected from 1- and 2-year follow-ups and rated by 2 experienced psychiatrists on the following variables: diagnosis, GAFs, GAFf, and alcohol and drug scores. For all dimensions the reliability was clearly satisfactory. For diagnosis, kappa = 0.81; for the other dimensions, Intra Class Correlation (1.1) were GAFf: 0.86, GAFs: 0.91, alcohol: 0.75, and drugs: 0.86.
Analyses were performed with the statistical package SPSS (version 12.0; SPSS Inc., Chicago, Ill). The applied methods are reported for all group comparisons. All tests were 2-tailed. We used nonparametric tests for data without normal distribution. As noted in several other studies, the DUP does not seem to have a normal distribution, whereas its natural logarithm does. In multiple linear regression analyses, DUP was transformed to its natural logarithm.
Multiple linear regression analyses with different aspects of 1-year outcome as dependent variables were performed to check the influence of possible confounders such as sampling effects. The selection of variables to be included in the regression model was based on a forward selection procedure, in addition to a set of variables based on assumed clinical importance through reviews of relevant studies and a set of variables comprising measures of differences between the areas. These last sets of variables were included in the model prior to the stepwise procedure. Candidate variables to the forward selection procedure were found by choosing those that showed at least a moderate association with the dependent variable (P value ≤ .25) in a regression analysis with only that variable as covariate in addition to coming from the ED sites. In the resulting multivariate analyses, “Coming from the ED sector” was included in the last step. The final model was examined for interaction effects and the effects of outliers and influential observations, including leverages. In order to study time to remission, we used Kaplan-Meier survival analysis, and the groups were compared using the log rank test.