Download Duration of untreated symptoms in common mental disorders

B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 6 ) , 1 8 9 , 7 9 ^ 8 0 . d o i : 1 0 . 11 9 2 / b j p . b p . 1 0 5 . 0 1 9 8 6 9
Duration of untreated symptoms in common
mental disorders: association with outcomes
International study
STEPHEN KISELY, ANITA SCOT T, JENNIFER DENNEY and GREGORY SIMON
Summary Studies have assessed the
association between a longer duration of
untreated symptoms and outcome for
psychoses in specialist care.We
investigated the effect of longer duration
on the outcome of common psychiatric
disorders in primary care, where most
patients are treated.Patients presenting
to primary care for new episodes in10
countries were recruited into a
prospective cohort study.Information on
duration of untreated symptoms and
psychosocial status was collected for 351
individuals using standardised instruments
and
andthis
this wasrepeated1yearlater. At1-year
follow-up, longer duration was associated
with worse psychiatric outcome even after
controlling for potential confounders.
Declaration of interest None.
Funding detailed in Acknowledgement
.
Studies on the duration of untreated symptoms focus on time to admission for severe
mental illness such as schizophrenia and
affective psychosis in Europe, Australasia
and North America, rather than on common mental disorders in primary care
(Craig et al,
al, 2000; Drake et al,
al, 2000;
McGorry, 2000). The longer depression,
anxiety and somatic disorders last, the
worse the response to appropriate intervention: inadequacy of treatment leading to
symptom persistence may be one reason.
The kindling hypothesis suggests that
longer waits for treatment may also
contribute (Kendler et al,
al, 2000).
METHOD
We investigated the effect of duration of
untreated symptoms on 1-year outcome
in primary care, using data from the
1990–1993 World Health Organization
Collaboration Study of Psychological Problems in General Health Care (Ustun &
Sartorius, 1995). Data were available for
Ankara, Athens, Bangalore, Groningen,
Ibadan, Manchester, Rio de Janeiro,
Santiago, Seattle and Verona. Overall study
methods are described elsewhere (Sartorius
et al,
al, 1993; Ustun & Sartorius, 1995). Studies of duration of untreated psychosis indicated that up to 250 participants were
required to have an 80% chance of detecting
a statistically significant result at the 95%
level (Craig et al,
al, 2000; Drake et al,
al, 2000).
We focused on overall psychiatric morbidity as our outcome, because patients in
primary care are more likely to have a mixture of depression, anxiety and somatoform
symptoms than discrete syndromes. We
analysed psychiatric outcome as a continuous variable, instead of dichotomously (e.g.
caseness), to obtain more information on
severity, including subclinical symptoms.
We screened patients aged between 16
and 65 years who had not visited the clinic
in the previous 3 months, using the 12-item
General Health Questionnaire (GHQ;
Goldberg & Williams, 1988). A stratified
random sample of the study population
(weighted towards higher GHQ scorers)
were then interviewed, using the primary
healthcare version of the Composite International Diagnostic Interview (CIDI–PHC;
Robins et al,
al, 1988; Sartorius et al,
al, 1993).
This included the Pathways to Care Interview to record the onset and duration of
presenting symptoms (depressive, anxious
or somatic); whether this was the initial
visit for this problem; the profession of each
person consulted for those symptoms; and
the main treatment offered at each step.
We calculated the duration of untreated
symptoms by subtracting the time from first
seeking treatment in any setting and arriving
at the participating clinic (duration of pathway in treatment) from the total duration
of presenting symptoms. We only included
people whose current presentation was their
S HOR T R E P OR T
initial visit to the participating clinic for this
problem. Duration of untreated symptoms
was assessed in weeks; zero meant symptoms
had lasted less than a week.
We used the CIDI–PHC sections on
somatisation, anxiety, depression, hypochondriasis and neurasthenia to measure
psychiatric morbidity. Medically explained
and unexplained somatic symptoms were
counted using a flow chart to establish
aetiology (Robins et al,
al, 1988). We assessed
disability using the Groningen Social Disability Schedule (GSDS), a semi-structured
interview that considers local norms
(Wiersma et al,
al, 1990).
At baseline, the family physician completed a questionnaire on the presence of
psychiatric disorder and any treatment
offered. All patients with significant psychological problems, and a 20% random
sample of ‘non-cases’, were contacted for
12-month follow-up. Bangalore and Seattle
followed up every patient. We repeated the
CIDI–PHC and collected information on
visits to the participating clinic or other
clinics and any hospital admissions, irrespective of diagnosis, during the intervening year.
The interviewer–observer reliability coefficient for the CIDI–PHC (including the
Pathways to Care Interview) was 0.92, and
0.85 for the GSDS (Sartorius et al,
al, 1993).
We restricted our analysis to patients
who had not visited the practice previously
for their presenting problem and who had
an ICD–10 (World Health Organization,
1992) psychiatric diagnosis, as determined
by the CIDI–PHC. We excluded patients
with non-psychiatric presentations such as
visits for family planning or antenatal care.
RESULTS
In all, 3321 patients completed the
baseline interview, of whom 2767 were
eligible for follow-up. Details of duration
of untreated symptoms were available for
2579 people (93%). Of these, 1791 (70%)
were successfully followed-up.
Those who had not previously visited
the participating practice for their presenting problem numbered 900, of whom 351
met our remaining criteria of reason for
presentation and psychiatric caseness. The
majority had depression (n
(n¼210);
210); 73%
were women or girls (n
(n¼256);
256); 81.9% had
an educational level of less than grade 12
(usually age 18 years) (n
(n¼290);
290); 40.7%
were single (n
(n¼143);
143); and 21.4% were unemployed (n
(n¼75).
75). Age ranged from 15 to
79
K I S E LY E T A L
50 years with a mean of 37.7 years
(s.d.¼12.9).
(s.d. 12.9).
Duration of untreated symptoms was
skewed, with a mean of 19.1 weeks
(s.d.¼74.1)
(s.d. 74.1) and a median of 1. We
normalised the duration by taking the
logarithm of the base, rather than dichotomising or dividing into quintiles, to maximise power. We added one to each value
before transformation because of zeros
(Kirkwood, 1992). The mean was 0.57
(s.d.¼0.67).
(s.d. 0.67).
We obtained information on health
service use for 317 participants. Patients
averaged five visits to the participating
clinic and three to other clinics; 12%
(n¼41)
41) had been admitted to hospital at
least once.
On multiple regression, the duration of
untreated symptoms showed a significant
association with overall psychiatric symptoms 1 year later (B
(B¼3.61,
3.61, s.e.¼1.60,
s.e. 1.60,
P¼0.02),
0.02), as did initial psychiatric symptom
count, older age, lower educational levels,
medically unexplained somatic symptoms,
and visits to the participating clinic (see
data supplement to the online version of
this paper for results on all variables).
The duration of untreated symptoms
also showed an association with anxiety
symptoms (B
(B¼0.46,
0.46, s.e.¼0.18,
s.e. 0.18, P¼0.02)
0.02)
and depression (B
(B¼0.97,
0.97, s.e.¼0.49,
s.e. 0.49,
P¼0.05),
0.05), using the same model. There
was no statistically significant association
when using untransformed duration of
symptoms (B
(B¼0.01,
0.01, s.e.¼0.02,
s.e. 0.02, P¼0.37).
0.37).
DISCUSSION
The outcome and response to treatment for
common psychological disorders such as
depression and anxiety are inversely proportional to their chronicity (Seivewright
et al,
al, 1998. One explanation is that inadequate intervention leads to persistence of
symptoms, and collaboration between specialists and family practitioners can help
address this (Andrews, 2001; Roy-Byrne
& Wagner, 2004). We suggest another explanation, i.e. longer waits for treatment.
This association is modest, but still significant, after controlling for other variables
including demographics, centre attended
and initial severity of symptoms (see online
data supplement).
These results support the kindling
hypothesis of depression (Kendler et al,
al,
2000), which has parallels with the critical
period hypothesis in early psychosis
80
STEPHEN KISELY, MD, MSc, ANITA SCOTT, MSc, JENNIFER DENNEY, BSc, Department of Psychiatry, Dalhousie
University, Halifax, Canada; GREGORY SIMON, MD, MPH,Group Health Co-operative, Seattle, USA
Correspondence: Dr S.Kisely, Dalhousie University Psychiatry,Centre for Clinical Research, 5790
University Avenue, Halifax, NS B3H1V7,Canada.Tel.: +1 902 494 7075; fax: +1 902 494 1597,
email: Stephen.Kisely@
Stephen.Kisely @cdha.nshealth.ca
(First received 22 November 2005, final revision 22 November 2005, accepted 31 January 2006)
(Birchwood et al,
al, 1998). The association
between depressive episodes and adverse
life events weakens with successive illnesses, suggesting biological or psychological adaptation so that psychosocial
precipitants are no longer necessary for relapse.
Limitations include our demonstration
of only an association between duration
of untreated symptoms and subsequent
psychiatric morbidity, not direct causation. Furthermore, our analysis may have
been confounded by variables for which
we were unable to control. We considered
new episodes of care and not necessarily
first presentations of an illness. There
may have been selection bias, as patients
with a short duration may have improved
and never sought care (McGorry, 2000).
Depression or anxiety may be harder to
recognise than psychosis, and we did not
get corroboration from family members.
Data were collected a decade ago, and
so may be less applicable now. However,
it is unethical to collect further data, with
the consequent cost and inconvenience to
patients, without first analysing available
datasets.
Our results provide a wider perspective
on the duration of untreated symptoms.
Research on the effects of such duration
in psychosis is conflicting. Explanations
have included differences in demographic
characteristics, diagnostic criteria, measures of onset (first symptom or full
syndrome), treatment definition (medication or hospital admission), outcome
measures and follow-up periods. Studies
that use transformation to normalise the
positive skew of duration tend to show
an association with outcome in contrast
to those that do not (Norman et al,
al,
2005). This supports our negative finding,
and that of others, when using untransformed duration of symptoms (Drake et
al,
al, 2000).
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ACKNOWLEDGEMENT
(2nd edn). Groningen: University of Groningen.
World Health Organization (1992) Tenth Revision of
Anita Scott and Jennifer Denney were funded by the
Nova Scotia Health Research Foundation.
the International Classification of Diseases and Related
Health Problems (ICD ^10).
^10).Geneva:
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Data supplement
Variables contributing to model predicting psychiatric symptoms for patients at follow up1
Cases (n
(n¼317)
317)2
Variable
Unadjusted
Adjusted
B4
s.e.
P
Age (years)
5.99
1.67
Gender
0.07
1.92
72.49
1.72
Employed
B4
s.e.
P
0.00
4.25
1.57
0.01
0.98
72.16
1.81
0.22
0.15
70.13
1.64
0.94
0.03
Not married
1.53
1.74
0.40
1.05
0.48
Education less than 12th grade
5.60
2.16
0.01
4.68
2.07
0.02
Psychiatric symptom score
0.68
0.08
0.00
0.55
0.03
0.00
Medically explained somatic symptoms
0.84
0.49
0.09
0.66
0.44
0.13
Medically unexplained somatic symptoms
1.20
0.20
0.00
0.50
0.21
0.02
Social disability
2.02
1.29
0.15
1.11
1.06
0.30
Duration of untreated symptoms3
1.83
1.29
0.15
3.61
1.60
0.02
Number of clinic visits over subsequent 12 months
0.40
0.09
0.00
0.27
0.10
0.01
1. Adjusted for centre, demographics, initial severity of psychiatric symptoms, medically explained and unexplained
somatic symptoms, duration of untreated symptoms, duration of pathway in treatment, recognition of psychiatric
disorder by the treating primary care physician, pharmacotherapy of psychiatric disorder, number of clinic visits, other
clinic visits, hospital admission and social disability.
2. Data on health service use in the intervening year were missing for 34 participants.
3. Logarithmically transformed variable (log10 ).
4. The regression coefficient (B
(B ) represents the amount the dependent or outcome variable changes when the
independent or predictor variable changes by one unit. In the case of the logarithmically transformed duration score, it
represents the increase by a factor of exp(B
exp(B ).
DATA SUP P LE
L E MENT TO B R I T IS
ISH
H JOURNAL OF P S YCHIAT RY ( 2 0 0 6 ) , 1 8 9, 7 9 ^ 8 0
1
Duration of untreated symptoms in common mental disorders:
association with outcomes: International study
Stephen Kisely, Anita Scott, Jennifer Denney and Gregory Simon
BJP 2006, 189:79-80.
Access the most recent version at DOI: 10.1192/bjp.bp.105.019869
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