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A Systematic Review

Max Marshall, MD; Shon Lewis, MD; Austin Lockwood, RMN; Richard Drake, PhD; Peter Jones, PhD; Tim Croudace, PhD

Arch Gen Psychiatry. 2005;62:975-983.

Context  Duration of untreated psychosis (DUP) is the time from manifestation of the first psychotic symptom to initiation of adequate treatment. It has been postulated that a longer DUP leads to a poorer prognosis. If so, outcome might be improved through earlier detection and treatment.

Objectives  To establish whether DUP is associated with prognosis and to determine whether any association is explained by confounding with premorbid adjustment.

Data Sources  The CINAHL (Cumulative Index to Nursing and Allied Health), EMBASE, MEDLINE, and PsychLIT databases were searched from their inception dates to May 2004.

Study Selection  Eligible studies reported the relationship between DUP and outcome in prospective cohorts recruited during their first episode of psychosis. Twenty-six eligible studies involving 4490 participants were identified from 11 458 abstracts, each screened by 2 reviewers.

Data Extraction  Data were extracted independently and were checked by double entry. Sensitivity analyses were conducted excluding studies that had follow-up rates of less than 80%, included affective psychoses, or did not use a standardized assessment of DUP.

Data Synthesis  Independent meta-analyses were conducted of correlational data and of data derived from comparisons of long and short DUP groups. Most data were correlational, and these showed a significant association between DUP and several outcomes at 6 and 12 months (including total symptoms, depression/anxiety, negative symptoms, overall functioning, positive symptoms, and social functioning). Long vs short DUP data showed an association between longer DUP and worse outcome at 6 months in terms of total symptoms, overall functioning, positive symptoms, and quality of life. Patients with a long DUP were significantly less likely to achieve remission. The observed association between DUP and outcome was not explained by premorbid adjustment.

Conclusions  There is convincing evidence of a modest association between DUP and outcome, which supports the case for clinical trials that examine the effect of reducing DUP.

Author Affiliations: Division of Psychiatry, University of Manchester, Manchester (Drs Marshall, Lewis, and Drake and Mr Lockwood); Department of Psychiatry, University of Cambridge, Cambridge (Drs Jones and Croudace), England.

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