The major finding in this study is that DUP lengthens when ICs about psychosis cease. Coming to first psychosis treatment during the no-IC period is associated with less schizophreniform disorder and more positive and total symptoms. ICs thus appear to be a critical element for the reduction of DUP such that when the campaigns are stopped we observe a reversal of such reduction.
The DUP in the TIPS II no-IC sample is comparable to the DUP in the no–early detection site of the TIPS I parallel control study,3
but the TIPS II no-IC DUP is not as lengthy as in the pre-TIPS period 1993–1994.13
In a first-episode psychosis study in Denmark (the OPUS study) carried out during 1998–1999, DUP was not measured against a non-OPUS comparison sample.14
The Median DUP in the Integrated Treatment site was 46 weeks. In OPUS, early DTs were established with a low threshold to treatment. The project offered no intensive IC aimed at the general public and no educational program aimed toward teachers and pupils. Information about the project and the DT was mainly provided to the GPs and health/social professionals working in the local communities. An Australian study15
found that adding a community development campaign to DTs in one county did not clearly reduce DUP. Compared with the TIPS IC sector the Australian project was shorter (12 months) and did not include IC to the general public but instead concentrated on schools and GPs. The common factor for these 2 studies is that their campaigns did not target multiple community groups, particularly the general public. We conclude that our study shows that an effective early detection program in first-episode psychosis requires educating the public as well as school personnel and primary health care professionals. In addition, the program included low-threshold DTs that were able to detect some patients with poor prognostic features (including those with long DUP).
A methodological weakness of our study is that it uses a quasi-experimental, historical control design that theoretically cannot control for major sources of population, measurement, and treatment variance between groups. At the same time the quasi-experimental design is the only design that can ethically test the effects of later vs earlier treatment of first-break schizophrenia. Furthermore, we believe we have minimized differences in the sources of variance between the IC and no-IC groups by selecting samples from the same health care sector with only 1 year separating them, by using the same assessment instruments and virtually the same raters, and by limiting group comparisons to baseline measures that are unaffected by treatment differences. The fact that the study used the overlapping raters also implies that they would have known whether the patient was being seen during the IC period or during the no-IC period. This may have led to potential bias in ratings. An additional weakness is that the estimate of DUP for obvious reasons had to be made retrospectively. However, we built upon all available information in making the estimate, and the reliability scores for DUP and other central measures have remained acceptable.
Selecting samples with only 1-year difference means that a substantial proportion of the no-IC sample became psychotic in the IC period. That they avoided recognition and treatment in the midst of an IC blitz demonstrates how robust denial and the impairment in insight can be. If becoming psychotic in the IC period had any effect on the no-IC sample, we think it probably was in the direction of bringing such persons to treatment somewhat earlier than if there had been no IC at all. Indeed, without this overlap, the IC/no-IC difference we found in DUP may have actually been greater.
The major strength of this study is that, at least for the foreseeable future, it is the only place where such a study can be done at all given that the TIPS project is the first (and so far the only) project to engineer changes in DUP. All other studies have simply reported DUP, not changed it in ways that the effects of such change can be measured. Another strength of the study is its location in a publicly paid catchment area treatment system that provides all possible treatment services for first-episode patients and recruits virtually all such patients from that particular geographical area. The study sample is thus clinically an incidence sample.
In conclusion, our study indicates that well-planned educational campaigns toward the general public and targeted groups, combined with low-threshold DTs, are key components of early detection efforts that successfully bring patients with first-episode psychosis into treatment earlier than otherwise.