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Relationship between gross domestic product and duration of untreated psychosis in low- and middle-income countries

  • Matthew Large (a1), Saeed Farooq (a2), Olav Nielssen (a3) and Tim Slade (a4)
Abstract
Background

The duration of untreated psychosis (DUP), the period between the first onset of psychotic symptoms and treatment, has an important influence on the outcome of schizophrenia.

Aims

To compare the published studies of DUP in low- and middle-income (LAMI) countries with the DUP of high-income countries, and examine a possible association between DUP and per capita income.

Method

We used six search strategies to locate studies of the DUP from LAMI countries published between January 1975 and January 2008. We then examined the relationship between DUP and measures of economic activity, which was assessed using the LAMI classification of countries and gross domestic product (GDP) purchasing power parity.

Results

The average mean DUP in studies from LAMI countries was 125.0 weeks compared with 63.4 weeks in studies from high-income countries (P=0.012). Within the studies from LAMI countries, mean DUP fell by 6 weeks for every $1000 of GDP purchasing power parity.

Conclusions

There appears to be an inverse relationship between income and DUP in LAMI countries. The cost of treatment is an impediment to care and subsidised antipsychotic medication would improve the access to treatment and the outcome of psychotic illness in LAMI countries.

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Copyright
Corresponding author
Dr Matthew Large, PO Box 110, Double Bay 1360, NSW, Australia. Email: MMBL@bigpond.com
References
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1 Saraceno, B. The WHO World Health Report 2001 on mental health. Epidemiol Psichiatr Soc 2002; 11: 83–7.
2 Marshall, M, Lewis, S, Lockwood, A, Drake, R, Jones, P, Croudace, T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 2005; 62: 975–83.
3 Perkins, DO, Gu, H, Boteva, K, Lieberman, JA. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 2005; 162: 1785–804.
4 Altamura, AC, Bassetti, R, Bignotti, S, Pioli, R, Mundo, E. Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr Res 2003; 60: 4755.
5 Melle, I, Johannesen, JO, Friis, S, Haahr, U, Joa, I, Larsen, TK, Opjordsmoen, S, Rund, BR, Simonsen, E, Vaglum, P, McGlashan, T. Early detection of the first episode of schizophrenia and suicidal behavior. Am J Psychiatry 2006; 163: 800–4.
6 Clarke, M, Whitty, P, Browne, S, Mc Tigue, O, Kinsella, A, Waddington, JL, Larkin, C, O'Callaghan, E. Suicidality in first episode psychosis. Schizophr Res 2006; 86: 221–5.
7 Humphreys, MS, Johnstone, EC, MacMillan, JF, Taylor, PJ. Dangerous behaviour preceding first admissions for schizophrenia. Br J Psychiatry 1992; 161: 501–5.
8 Milton, J, Amin, S, Singh, SP, Harrison, G, Jones, P, Croudace, T, Medley, I, Brewin, J. Aggressive incidents in first-episode psychosis. Br J Psychiatry 2001; 178: 433–40.
9 Verma, S, Poon, LY, Subramaniam, M, Chong, SA. Aggression in Asian patients with first-episode psychosis. Int J Soc Psychiatry 2005; 51: 365–71.
10 Large, M, Nielssen, O. Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 3744.
11 Lieberman, JA, Fenton, WS. Delayed detection of psychosis: causes, consequences, and effect on public health. Am J Psychiatry 2000; 157: 1727–30.
12 Dube, KC, Kumar, N, Dube, S. Long term course and outcome of the Agra cases in the International Pilot Study of Schizophrenia. Acta Psychiatr Scand 1984; 70: 170–9.
13 Mojtabai, R, Varma, VK, Malhotra, S, Mattoo, SK, Misra, AK, Wig, NN, Susser, E. Mortality and long-term course in schizophrenia with a poor 2-year course: a study in a developing country. Br J Psychiatry 2001; 178: 71–5.
14 World Bank. World Development Indicators. World Bank, 2006.
15 International Monetary Fund. Gross Domestic Product, Purchasing Power Parity. International Monetary Fund, 2005.
16 Norman, RM, Malla, AK. Duration of untreated psychosis: a critical examination of the concept and its importance. Psychol Med 2001; 31: 381400.
17 Alptekin, K, Erkoç, S, Göğüs̨, AK, Kültür, S, Mete, L, Uçok, A, Yazici, KM. Disability in schizophrenia: clinical correlates and prediction over 1-year follow-up. Psychiatry Res 2005; 135: 103–11.
18 Apiquian, R, Ulloa, RE, Paez, F, Nicolini, H. The Mexican first-episode psychotic study: clinical characteristics and premorbid adjustment. Schizophr Res 2002; 53: 161–3.
19 Ayres, AM, Busatto, GF, Menezes, PR, Schaufelberger, MS, Coutinho, L, Murray, RM, McGuire, PK, Rushe, T, Scazufca, M. Cognitive deficits in first-episode psychosis: a population-based study in São Paulo, Brazil. Schizophr Res 2007; 90: 338–43.
20 Calvó de Padilla, M, Padilla, E, González Alemán, G, Bourdieu, M, Guerrero, G, Strejilevich, S, Escobar, JI, Svrakic, N, Cloninger, CR, de Erausquin, GA. Temperament traits associated with risk of schizophrenia in an indigenous population of Argentina. Schizophr Res 2006; 83: 299302.
21 El-Adl, M, EL-Mahdy, M, AL-Azhar, MA. First Episode Psychosis: Factors Associated with Delayed Access to Care in a Rural Egyptian Setting. Mansoura General Hospital, Egypt, 2006 (http://www.ajman.ac.ae/arabmed/Abstracts/Psychiatry.pdf).
22 Fresán, A, Apiquian, R, Ulloa, RE, Loyzaga, C, Nicolini, H, Gómez, L. Premorbid functioning by gender and its relationship with duration of untreated psychosis in first psychotic episode. Actas Esp Psiquiatr 2003; 31: 53–8.
23 Gangadhar, BN, Panner Selvan, C, Subbakrishna, DK, Janakiramaiah, N. Age-at-onset and schizophrenia: reversed gender effect. Acta Psychiatr Scand 2002; 105: 317–9.
24 Galińska, B, Szulc, A, Czernikiewicz, A. Duration of untreated psychosis in first-episode schizophrenia: clinical and cognitive correlates [Polish]. Psychiatr Pol 2005; 39: 859–68.
25 Gill, JS, Koh, OH, Jambunathan, ST. First-episode psychosis in Malaysian Chinese population. Hong Kong J Psychiatry 2005; 15: 54–9.
26 Gorwood, P, Leboyer, M, Jay, M, Payan, C, Feingold, J. Gender and age at onset in schizophrenia: impact of family history. Am J Psychiatry 1995; 152: 208–12.
27 Gureje, O, Bamidele, RW. Gender and schizophrenia: association of age at onset with antecedent, clinical and outcome features. Aust N Z J Psychiatry 1998; 32: 415–23.
28 Kurihara, T, Kato, M, Kashima, H, Takebayashi, T, Reverger, R, Gusti Rai Tirta, I. Excess mortality of schizophrenia in the developing country of Bali. Schizophr Res 2006; 83: 103–5.
29 Kurihara, T, Kato, M, Reverger, R, Yagi, G. Clinical outcome of patients with schizophrenia without maintenance treatment in a nonindustrialized society. Schizophr Bull 2002; 28: 515–24.
30 Lieberman, JA, Phillips, M, Gu, H, Stroup, S, Zhang, P, Kong, L, Ji, Z, Koch, G, Hamer, RM. Atypical and conventional antipsychotic drugs in treatment-naive first-episode schizophrenia: a 52-week randomized trial of clozapine vs chlorpromazine. Neuropsychopharmacology 2003; 28: 9951003.
31 Mbewe, E, Haworth, A, Welham, J, Mubanga, D, Chazulwa, R, Zulu, MM, Mayeya, J, McGrath, J. Clinical and demographic features of treated first-episode psychotic disorders: a Zambian study. Schizophr Res 2006; 86: 202–7.
32 McCreadie, RG, Srinivasan, TN, Padmavati, R, Thara, R. Extrapyramidal symptoms in unmedicated schizophrenia. J Psychiatr Res 2005; 39: 261–6.
33 Murthy, GV, Janakiramaiah, N, Gangadhar, BN, Subbakrishna, DK. Sex difference in age at onset of schizophrenia: discrepant findings from India. Acta Psychiatr Scand 1998; 97: 321–5.
34 Naqvi, H, Khan, MM, Faizi, A. Gender differences in age at onset of schizophrenia. J Coll Physicians Surg Pak 2005; 15: 345–8.
35 Oosthuizen, P, Emsley, RA, Keyter, N, Niehaus, DJ, Koen, L. Duration of untreated psychosis and outcome in first-episode psychosis. Perspective from a developing country. Acta Psychiatr Scand 2005; 111: 214–9.
36 Ran, MS, Xiang, MZ, Li, SX, Shan, YH, Huang, MS, Li, SG, Liu, ZR, Chen, EY, Chan, CL. Prevalence and course of schizophrenia in a Chinese rural area. Aust N Z J Psychiatry 2003; 37: 452–7.
37 Ran, M, Xiang, M, Huang, M, Shan, Y. Natural course of schizophrenia: 2-year follow-up study in a rural Chinese community. Br J Psychiatry 2001; 178: 154–8.
38 Ranjbar, TK, Sharifi, V, Alaghband-rad, J, Amini, H, Seddigh, A, Salesian, N, Tabatabai, M. Duration of untreated psychosis and pathways to care in patients with first episode psychosis in Iran. Schizophr Res 2006; 86: s1189.
39 Selten, JP, Zeyl, C, Dwarkasing, R, Lumsden, V, Kahn, RS, Van Harten, PN. First-contact incidence of schizophrenia in Surinam. Br J Psychiatry 2005; 186: 74–5.
40 Tang, YL, Sevigny, R, Mao, PX, Jiang, F, Cai, Z. Help-seeking behaviors of Chinese patients with schizophrenia admitted to a psychiatric hospital. Adm Policy Ment Health 2007; 34: 101–7.
41 Thirthalli, J, Phillip, M, Gangadhar, BN. Influence of duration of untreated psychosis on treatment response in schizophrenia: a report from India. Schizophr Bull 2005; 31: 183.
42 Tirupati, NS, Rangaswamy, T, Raman, P. Duration of untreated psychosis and treatment outcome in schizophrenia patients untreated for many years. Aust N Z J Psychiatry 2004; 38: 339–43.
43 Large, MM, Nielssen, O, Ryan, CJ, Hayes, R. Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 251–6.
44 Patel, V, Sumathipala, A. International representation in psychiatric literature: survey of six leading journals. Br J Psychiatry 2001; 178: 406–9.
45 McCreadie, RG, Ohaeri, JU. Movement disorder in never and minimally treated Nigerian schizophrenic patients. Br J psychiatry 1994; 164: 184–9.
46 Grover, S, Avasthi, A, Chakrabarti, S, Bhansali, A, Kulhara, P. Cost of care of schizophrenia: a study of Indian out-patient attenders. Acta Psychiatr Scand 2005; 112: 5463.
47 Cohen, A, Patel, V, Thara, R, Gureje, O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull 2008; 34: 229–44.
48 Green, CA, Fenn, DS, Moussaoui, D, Kadri, N, Hoffman, WF. Quality of life in treated and never-treated schizophrenic patients. Acta Psychiatr Scand 2001; 103: 131–42.
49 Ran, MS, Chen, EY, Conwell, Y, Chan, CL, Yip, PS, Xiang, MZ, Caine, ED. Mortality in people with schizophrenia in rural China: 10-year cohort study. Br J Psychiatry 2007; 190: 237–42.
50 Rössler, W, Salize, HJ, van Os, J, Riecher-Rössler, A. Size of burden of schizophrenia and psychotic disorders. Eur Neuropsychopharmacol 2005; 15: 399409.
51 Patel, V, Farooq, S, Thara, R. What is the best approach to treating schizophrenia in developing countries? PLoS Med 2007; 4: e159.
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Relationship between gross domestic product and duration of untreated psychosis in low- and middle-income countries

  • Matthew Large (a1), Saeed Farooq (a2), Olav Nielssen (a3) and Tim Slade (a4)
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eLetters

Implications and probable associations of DUP in Low income Countries

Ademola Bello, CT2 Specialist Registrar
10 December 2008

In the above study the author states that “there appears to be an inverse relationship between income and DUP in LAMI countries”.

The author also rightly surmises that we have more work to do in thisarea.

In considering the long term implications of long DUP in LAMI countries, it is also important to consider the nature and diagnostic stability of the psychotic conditions in question – schizophrenia versus affective/ reactive psychosis 1.

As a psychiatrist with over three years post graduate experience in Nigeria I can comment that we definitely saw more cases of affective and reactive psychosis although the schizophrenic cases we treated tended to be more debilitating and chronic for the reasons highlighted by the author.

There is often a complex interplay of cultural and financial issues in mental healthcare delivery in these countries.

More often than not, LAMI countries represent a heterogeneous mix of diverse tribes, languages and cultures; each with its own unique beliefs and attitudes. Psychiatrists that have not worked in LAMI countries shouldbe wary of the “ecological fallacy” in population based research like the one conducted by the author.

In proposing probable reasons for the longer DUP in LAMI countries, cultural reasons including religious beliefs and issues of stigmatization appears not to have been considered; these play a huge role in DUP countries2.

To procure a solution that will be acceptable to the patients from LAMI countries, it will be necessary to consider their values and beliefs.

REFERENCES

1 Bromet, Evelyn J, Naz, Bushra et al. Long-term diagnostic stabilityand outcome in recent first-episode cohort studies of schizophrenia. Schizophrenia Bulletin, July 2005, vol. 31/3(639-649)

2 Cohen A., Patel V., Thara R., Gureje O. Questioning an axiom: Better prognosis for schizophrenia in the developing world? Schizophrenia Bulletin, March 2008, vol. 34/2(229-244)
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Conflict of interest: None Declared

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Economics and mental health: is cheap medication really the solution?

Jacob Alexander, Snr. Psychiatry Registrar
25 October 2008

The authors raise a valid point in their article where they point outthat the prohibitive cost of medications is often a serious impediment to accessing early and effective treatment in the management of psychosis. Itfollows, logically therefore, that increasing the availability of subsidised medication will significantly reduce the duration of untreated psychosis (1). Having trained in a low income country (India), my concern is that this does not seem to be the case. Loopholes in current patent laws mean that more than 20 brands of olanzapine and risperidone are available in India at a fraction of ‘Western’ prices (2).

Access to treatment is often governed by more complex issues including probably most importantly, access to the machinery that prescribes these treatments. 72.2 % of the Indian population lives in rural India while the majority of its practitioners of modern medicine areconcentrated in the urban centres where socio economic conditions are better. Surveys of the geographical distribution of hospitals in India seem to suggest that this is directly linked to the socioeconomic conditions in the region (3) with affluent regions having an increased concentration. Pathways to care in third world countries often involve more readily accessible and culturally acceptable traditional healers contributing to delays in treatment (4). Other issues that delay treatmentinclude stigma, inadequate knowledge about mental illness and competing interests that include the struggle for daily sustenance.

I argue that an over all improvement in economic conditions translates into better health care as evidenced by the allocation of more resources to areas such as mental health in the more developed nations. Maslow’s theory on the hierarchy of needs (5) gives one a plausible explanation as to why disadvantaged sections of the community such as the mentally ill and women’s health miss out when resources are allocated in resource poor countries. Making cheap drugs available may not be as effective a tool in shortening the duration of untreated psychosis as an overall improvement in economic conditions as evidenced by an increased GDP.

References:1. Large M, Farooq S,Nielssen O, Slade. Relationship between gross domestic product and duration of untreated psychosis in low- and middle- income countries. The British Journal of Psychiatry (2008) 193: 272-2782. Adams CE, Tharyan P, Coutinho ES, Stroup ST. The schizophrenia drug-treatment paradox: pharmacological treatment based on best possible evidence may be hardest to practise in high-income countries. The British Journal of Psychiatry (2006) 189: 391-3923. Official site of the Ministry of Health- India http://mohfw.nic.in/ (accessed on 20th October, 2008)4. Temmingh HS, Oosthuizen PP. Pathways to care and treatment delays in first and multi episode psychosis. Findings from a developing country.Soc Psychiatry Psychiatr Epidemiol (2008) 43:727–7355. A.H. Maslow. A Theory of Human Motivation. Psychological Review 50 (1943):370-96.
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