Measures

Data analysis

Data were analysed using SPSS 10.0.0 for Windows. DUP was divided into three pre-defined categories based on the time intervals described by Carbone et al (Reference Carbone, Harrigan and McGorry1999): brief DUP (1 month or less); moderate DUP (greater than 1 month but less than/equal to 6 months); long DUP (greater than 6 months). The analysis of variance (ANOVA) was the main analytical technique.

Sample

Forty-eight participants were contacted, six (12.5%) refused. Demographic and clinical characteristics of the participants are shown in Table 1.

Table 1

Demographic and clinical characteristics of the participants (n=42)

Variable	n (%)	Mean (s.d.)	Median
Gender
Male	32 (76.2%)
Female	10 (23.8%)
Ethnicity
Caucasian	16 (38.1%)
African—Caribbean	26 (61.9%)
Living situation before onset of psychosis
Living with family/friends	27 (64.3%)
Living alone	15 (35.7%)
Employment situation before onset of psychosis
Unemployed	25 (59.5%)
Employed (including students)	17 (40.5%)
Duration of untreated psychosis (weeks)		42.1 (77.1)	15.4
Age at onset of psychotic symptoms (years)		22.33 (4.91)	21.03

Duration of untreated psychosis

The DUP had a median of 15.4 weeks. The distribution of this sample was positively skewed, because of a number of outliers with extremely long DUPs (one-sample Kolmogorov—Smirnov (K—S) Z=1.901, P<0.01). The median represents a more meaningful measure of central tendency in this case. A total of 12 (28.6%) had brief DUP (≤1 month); 17 (40.5%) had moderate DUP and 13 (30.9%) long DUP.

GP attendance

Four participants were excluded from this part of the analysis: two had experienced an onset of psychosis before the age of 16 years, one had incomplete GP medical records and another withdrew consent for this section of the study. Participants' consultations with a GP were recorded for a specific period (from age 16 to onset of psychosis). The mean for this period was 6.6 (s.d.=4.5) years and the distribution was normal (one-sample K—S Z=1.19, P=0.11, NS). There was a significant difference between the DUP groups regarding their mean frequency of general GP attendance (see Table 2; F _2,35=5.57, P<0.01).

Table 2

Duration of untreated psychosis (DUP) category and general practitioner (GP) attendance

	Brief DUP ≤ 1 month n=12	Moderate DUP > 1 month, ≤ 6 months n=16	Long DUP > 6 months n=10	Total n=38
GPs attendances per year (mean, s.d.)	4.25 (2.10)	2.66 (2.59)	1.55 (1.78)	2.69 (2.36)

Post hoc analysis using Fisher's least significant difference (LSD) test showed that the brief DUP group had higher GP attendance than the long DUP group (mean difference 2.70, p<0.01). No differences were found between mean attendance for the moderate and long DUP groups. Thus, the results indicate that participants who consulted their GP more frequently in the 6 years before the onset of psychosis were more likely to have a shorter DUP.

Miller Behavioral Style Scale

As distributions of ‘monitoring’ and ‘blunting’ sub-scale scores were found to be normal, one-way ANOVA was computed to test the hypothesis of a difference between DUP groups with regard to coping style. For the ‘blunting’ sub-scale there was a significant effect of DUP (F _2,37=3.77, P<0.05) (see Table 3). Post hoc analysis applying Fisher's LSD indicated that the difference was between the brief and moderate DUP groups (mean difference was 2.96, P<0.05) and the brief and long DUP groups (mean difference was 2.75, P<0.05). For the monitoring sub-scale no significant differences were found (F _2,37=0.2, NS). A one-tail correlation between DUP (transformed to the natural logarithm in order to achieve normality) and monitoring was also non-significant (Pearson's r=0.12, P=0.22, NS).

Table 3

Duration of untreated psychosis (DUP) category and coping style on the Miller Behavioral Style Scale (MBSS)

MBSS sub-scale	Brief DUP ≤ 1 month n=12	Moderate DUP > 1 month, ≤ 6 months n=16	Long DUP > 6 months n=12	Total n=40
‘Monitoring’ (mean, s.d.)	10.42 (3.60)	11.00 (4.03)	11.17 (4.35)	10.88 (3.92)
‘Blunting’ (mean, s.d.)	3.17 (2.33)	6.13 (3.70)	5.92 (2.61)	5.18 (3.24)

A one-tailed correlation between DUP and ‘blunting’ was positive, but failed to reach significance at the 5% level (Pearson's r=0.22, P=0.01, NS). In other words, only patients with a brief DUP (compared with patients in the moderate and long DUP groups) were significantly less likely to display a blunting coping style.

Multi-dimensional Health Locus of Control scale

Two participants were excluded from this section because of missing data. Scores on the MHLC indicate how strongly the individual believes in each dimension of control; the higher the score the stronger the belief. Analysis using a one-sample K-S Z test indicated that all sub-scales were distributed normally. No differences were found between the DUP groups on any of the MHLC sub-scales: internal HLC, F _2,37=1.0, NS; chance HLC, F _2,37=0.7, NS; and ‘powerful others’ HLC, F _2,37=1.5, NS. Comparing the mean scores of the present sample for each sub-scale with normative data from other samples (Table 4), it can be seen that the early psychosis sample had a lower internal HLC mean score and higher chance and ‘powerful others’ HLC mean scores compared with other samples.

Table 4

Mean scores on the Multi-dimensional Health Locus of Control (MHLC) scale for early psychosis sample with comparative samples¹

Sample	n	Internal HLC (s.d.)	Chance HLC (s.d.)	‘Powerful other’ HLC (s.d.)
First-episode psychosis	40	24.58 (5.13)	20.78 (5.60)	24.75 (5.68)
Chronic patients2	609	25.78	17.64	22.54
College students2	749	26.68	16.72	17.87
Healthy adults2	1287	25.55	16.21	19.16
Persons engaged in preventive health behaviours2	720	27.38	15.52	18.44

One-tail correlations between DUP (transformed to the natural logarithm in order to achieve normality) and each MHLC sub-scale were found to be non-significant (IHLC Pearson's r=0.16, P=0.16, NS; CHLC Pearson's r=-0.16, P=0.16, NS; PHLC Pearson's r=0.11, P=0.24, NS).

GP attendance and health coping style

Further analysis revealed a significant negative correlation between general GP attendance and scores on the MBSS ‘blunting’ sub-scale (Pearson's r=-0.40, P=0.02, n=37), suggesting that participants who visit their GP less frequently are more likely to endorse a ‘blunting’ style on the MBSS. This relationship confirms previous observations of the validity of Miller's ‘blunting/monitoring’ concept and supports the validity of the link between DUP and ‘blunting’.

Health behaviour and ‘blunting’ coping style

These findings support our hypotheses that those with a long DUP are more likely to use avoidance as a general coping strategy when faced with health threat and are less likely to have visited their GP on a regular basis over a long period of time (6 years). This is consistent with studies indicating that employment of a ‘blunting’ coping style is associated with protracted delay in treatment-seeking and more severe symptoms (both psychological and physical) upon presentation to services (Reference Steptoe and VogeleSteptoe & Vogele, 1992; Reference Davey, Tallis and HodgsonDavey et al, 1993); similarly, first-episode studies have found that a longer DUP is related to more severe symptoms on first admission to psychiatric services (Reference Larsen, McGlashan and MoeLarsen et al, 1996; Reference Verdoux, Bergey and AssensVerdoux et al, 1998; Reference Browne, Clarke and GervinBrowne et al, 2000; Reference Drake, Haley and AkhtarDrake et al, 2000).

It has been found that ‘blunters’ experience less anxiety when faced with an unavoidable stressor and cope better in situations where they can avoid threatening information (Reference Miller and ManganMiller & Mangan, 1983; Reference MillerMiller, 1987). Thus, perhaps, a ‘blunting’ coping style might reduce distress caused by psychotic symptoms, enabling the individual to cope adequately for longer periods compared with ‘low blunters’. Lending partial support to this theory, Drake et al (Reference Drake, Haley and Akhtar2000) found that long DUP was linked to poor insight and preserved coping skills; similarly Birchwood et al (Reference Birchwood, Iqbal and Chadwick2000a ) found that high insight was linked to a raised likelihood of post-psychotic depression. It is difficult to establish, however, whether those with short DUP contact their GP more because they are ‘monitors’ or simply because they have more physical illness; nevertheless the outcome is the same, i.e. greater GP contact. We argue that this greater contact, for whatever reason, increases the propensity of clients to seek help through primary care when they experience distress. In a future communication, we will present data on the timing of GP contact and the nature of the presenting symptoms.

The aggregate figure for GP contacts is a blunt instrument and may include contacts for ‘prodromal’ as well as ‘true’ (physical) illness symptoms. Following this argument through, it would be expected that a greater number of contacts would be a sign of a long or intense prodrome. However, long prodrome is associated with a long DUP (Reference Beiser, Erickson and FlemingBeiser et al, 1993): the very opposite of that observed here (i.e. more contacts linked with short DUP). We conclude, therefore, that the link we have observed reflects the impact of help-seeking behaviour for health concerns per se and is not an artefact of prodromal psychosis.

‘Monitoring’ coping style

Research has indicated that individuals with a ‘monitoring’ coping style are more likely to detect physical symptoms, demand more tests and information and seek help for relatively trivial problems, leading to early detection and treatment (Reference MillerMiller, 1987; Reference Miller, Brody and SummertonMiller et al, 1988; Reference Steptoe and VogeleSteptoe & Vogele, 1992). However, although the ‘blunting’ scale was found to be significant, the monitoring sub-scale showed no relationship to DUP. An explanation for this finding may be the way ‘high monitors’ perceive psychotic symptoms. ‘High monitors’ have been reported to overestimate the potential severity, likelihood and unpredictability of threatening events (Reference Davey, Tallis and HodgsonDavey et al, 1993; Reference Miller, Rodoletz and SchroederMiller et al, 1996). Furthermore, they experience higher levels of worry and distress in medically threatening situations, which may interfere with effective problem-solving behaviour and result in denial and disengagement (Reference Miller, Sarason, Sarason and PierceMiller, 1996; Reference Miller, Rodoletz and SchroederMiller et al, 1996). Thus, predicting behaviour based on the ‘monitoring’ coping style is a complex issue and is related to how the threat is perceived.

Duration of untreated psychosis

The low refusal rate to participate in our study mitigates the likelihood of sample bias. DUP is similar to other studies (e.g. Reference Carbone, Harrigan and McGorryCarbone et al, 1999; Reference Barnes, Hutton and ChapmanBarnes et al, 2000; Reference Drake, Haley and AkhtarDrake et al, 2000) and is comparable with other similar studies. By its very nature, DUP is difficult to calculate as it relies on a respondent's memory, and can only ever be a ‘best estimate’. Previous studies have differed widely in their operational definitions and procedures and thus their accuracy of this time interval is variable (Reference Norman and MallaNorman & Malla, 2001). In the present study, a stringent protocol was adhered to, including use of multiple sources in order to increase the accuracy of DUP and inter-rater reliability was found to be excellent.

The role of GPs

General practitioners have been identified as an important contact in the pathway to care of a young person with first-episode psychosis. GP involvement has been associated with more desirable pathways, including decreased likelihood of police involvement and compulsory admissions (Reference Cole, Leavey and KingCole et al, 1995; Reference Lincoln, Harrigan and McGorryLincoln et al, 1998; Reference Burnett, Mallett and BhugraBurnett et al, 1999). These findings support the finding of many previous studies (Reference Cole, Leavey and KingCole et al, 1995; Reference Burnett, Mallett and BhugraBurnett et al, 1999) that contact with primary care is a key factor in reducing DUP, distress and access to sustained treatment. These data reinforce previous suggestions that ‘normal’ psychological factors are at play in this process (i.e. help-seeking behaviour for health concerns), in addition to those such as shame, which may be specific to a major mental illness (Reference Birchwood, Spencer and McGovernBirchwood et al, 2000b ). We are about to embark on a large-scale replication of these findings and to explore help-seeking behaviour in other family members.