Resumo

GARCIA, Isis; FRESAN, Ana; MEDINA-MORA, María Elena  e  RUIZ, Gabriela Mariana. Impact of Duration of Untreated Psychosis (DUP) in the course and outcome of schizophrenia. Salud Ment [online]. 2008, vol.31, n.6, pp.479-485. ISSN 0185-3325.

The duration of Untreated Psychosis (DUP), defined as the period of time between the onset of psychotic symptoms, such as hallucinations and delusions, and the first effective treatment, has been associated to prognosis of schizophrenia. It has been demonstrated that although psychotic symptoms are initially detected by relatives of patients with schizophrenia, they take a long time to seek specialized attention, which in turn leads to a delay in the diagnosis and treatment of the disorder. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. Thus, DUP represents part of this public health problem. In Mexico, the average DUP lasts 64 weeks, which is very similar to the average observed in other countries, where the mean DUP in psychotic patients varies between one and two years. One of the main reasons of a prolonged DUP is that patients and their families first assist with a general practitioner which, in many cases, does not perform an adequate diagnosis with the subsequent referral to a psychiatric facility, and the treatment given for the patient is based on sedative medication. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. It has been established that early treatment is related to a better prognosis and outcome, while treatment delay has been related to a longer time to achieve symptom remission. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. Through the use of neuroimaging, several studies have found the relation between DUP and brain morphology in patients with schizophrenia. Studies using Magnetic Resonance Imaging (MRI) have reported that patients with longer DUP show a significant reduction in the gray matter of the temporal planum, in the left middle, inferior temporal, left occipital and left fusiform cortices, with an increase of grey matter in the left basal ganglia, and a volume reduction of the caudate nucleus. These results may be related to the clinical course of the disorder in terms of a higher symptom severity and poor treatment response. In regard to psychosocial variables related to DUP, it has been observed that men have a longer DUP when compared to women and patients that are single and unemployed also have a longer DUP. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. Premorbid adjustment is defined as the psychosocial functioning in the educational, occupational, social and interpersonal relations areas before the evidence of positive characteristic symptomatology, where symptoms are not secondary to an organic cause and cover a period of six months before the first psychiatric hospitalization or contact with a psychiatric facility. In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. This association may suggest the presence of prodromic symptoms secondary to the physiopathological process of psychosis. Consequently, if a patient shows some of the initial symptoms of the disorder, including psychosocial impairment, his/her abilities to be aware of the symptoms may be limited to seek for medical care, which may in turn increase DUP. Furthermore, some authors have reported that some variables related to the patient's environment are related with DUP. The main variable pointed out is: the previous experience with mental disorders and psychiatric facilities. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. Based on these results, some authors have proposed two phenotypes for psychotic disorders: the first one characterized by males, poor premorbid adjustment, long DUP, insidious onset of the disorder and a stable pattern of negative symptoms. The second phenotype was one characterized by the following variables: females, good premorbid adjustment, a shorter DUP, acute illness onset and absence of a stable pattern of negative symptoms. This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. Thus, DUP can be used as an indicator of prognosis in patients with schizophrenia and its evaluation should be promoted. Although these two phenotypes are very useful, caution should be warranted in their use to avoid generalization. By and large, the studies related to the clinical impact of DUP emphasized the need to reduce DUP through early detection programs, including psychoeducation. We believe that this approach will be useful to identify individuals at an early development of a psychotic illness so that interventions can begin before symptoms have reached a level of significant impairment for the patient and warranting referrals by the family, school or health providers. Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia.

Palavras-chave : Duration of untreated psychosis; schizophrenia; psychosis; early detection.

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