Editorial Credits/ Crédits éditorials

Subscription Rates /Prix d'abonnements

Advertising Rates / Tarifs publicitaires (PDF)

Editorial
Thanks to Our Reviewers in 2005
Joel Paris, MD
(PDF)

In Debate
Do Many Patients With Depression Suffer From Bipolar Disorder?
Jules Angst, MD
(PDF)

Does Almost Everybody Suffer From a Bipolar Disorder?
Scott B Patten, MD, FRCPC, PhD
(PDF)

Original Research Community Survey of Bipolar Disorder in Canada: Lifetime Prevalence and Illness Characteristics
Ayal Schaffer, John Cairney, Amy Cheung, Scott Veldhuizen, Anthony Levitt,
(PDF)

Correlates of Methylphenidate Use in Canadian Children: A Cross-Sectional Study
Alice Charach, Hongmei Cao, Russell Schachar, Teresa To
(PDF)

Polysomnographic and Symptomatological Analyses of Major Depressive Disorder Patients Treated With Mirtazapine
Jianhua Shen, Sharon A Chung, Leonid Kayumov, Henry Moller, Naheed Hossain, Xuehua Wang, Prativa Deb, Frank Sun, Xin Huang, Marta Novak, Darryl Appleton, Colin M Shapiro
(PDF)

Suicidality, Depression, and Mental Health Service Use in Canada
Anne E Rhodes, Jennifer Bethell, Susan J Bondy
(PDF)

Status of First-Episode Psychosis Patients Presenting for Routine Care in a Defined Catchment Area
Jennifer Payne, Ashok Malla, Ross Norman, Deborah Windell, Nicole Brown
(PDF)

Test Wisconsin chez les patients souffrant de schizophrιnie, et leurs frθres et soeurs
Youssef El Hamaoui, Meryem Elyazaji, Sakina Yaalaoui, Linda Rachidi, Mohamed Saoud, Thierry d’Amato, Driss Moussaoui, Jean Dalery, Omar Battas
(PDF)

Book Reviews
(PDF)

Clinical Handbook of Psychotropic Drugs. 14th revised edition
Review by
Nicholas Delva

Marijuana and Madness
Review by
Nady el-Guebaly

Manual of Psychiatric Care for the Medically Ill
Review by
Franηois M Mai

Guidebook on Helping Persons with Mental Retardation Mourn
Review by
Bruce D McCreary

Ethical Issues in Forensic Mental Health Research
Review by
Paul Fedoroff

Letters to the Editor
(PDF)

Re: Listening to the Past: History, Psychiatry, and Anxiety

Reply: Listening to the Past: History, Psychiatry, and Anxiety

Original Research

Status of First-Episode Psychosis Patients Presenting for Routine Care in a Defined Catchment Area

Jennifer Payne MD, FRCPC¹, Ashok Malla, MBBS², Ross Norman PhD³, Deborah Windell, BA Hons⁴, Nicole Brown BScN⁵

Patients suffering from schizophrenia make many demands on the health care system over the course of their illness. Treatment of the first episode or early phase of schizophrenia is regarded as a crucial time for intervention (1). The literature supports the notion of a plateau effect (2), whereby any deterioration occurs aggressively in the first 2 to 3 years and critical psychosocial influences, including family’s response and psychological reactions to psychosis and psychiatric services, develop during this period.

Admission to hospital is the first psychiatric contact for most patients’ FEP (3–4). Many of these patients obtain admission to hospital via the hospital emergency service, often with an involuntary status (5). Further, behavioural (for example, suicidal and aggressive behaviour) and social difficulties (for example, unemployment and level of social support) of patients seeking treatment for the first time are also likely to influence service response as much as, if not more than, the nature of the specific psychopathology (that is, positive and negative symptoms) or cognitive difficulties (6–10).

Recently there has been a burgeoning interest and growing enthusiasm in the area of FEP and EI (1,11–14). A large part of this interest has focused on the implementation of specialized services for this phase of the illness, often referred to as EI services (12,15). While several EI programs have provided data on patients treated within their respective services (12,15–18), there is relatively little information on behavioural characteristics and service use for FEP patients who enter hospital for the first time in jurisdictions where there are no specialized services in place. Most of the existing data provide information on psychopathology and outcome; however, McGorry and others did report some data on FEP patients admitted to hospital before any EI services were established (12).

To assist adequate planning for, and to study the impact of, future EI services, it is critical to obtain information on new FEP patients entering the health care system. Variations in the nature of the health care system, local circumstances, and availability of community alternatives or other supports may influence the organization of adequate services for patients with FEP and render data from other countries less beneficial. However, given the uniqueness of the publically funded health care system in Canada, such data should be of value to service providers and policy advisers.

This study aimed to examine specific social, clinical, and behavioural characteristics of FEP patients presenting for treatment to acute care hospitals in a defined catchment area in Canada as part of an evaluation of the impact of introducing an EI service in the same jurisdiction. Such data are also likely to guide development of other specialized FEP programs and better inform their resource allocation. The parameters examined included demographics, hospitalization data, involuntary admissions, suicidal and aggressive behaviour, violence, and legal involvement at the time of their first admission to hospital.

Methods

Setting

We collected data from all hospitals in London, Ontario, which has a catchment area of 390 000 (at the time of the study), covering a period of 3 years (1993–1995) prior to the establishment of an EI psychosis service in 1997. There were 3 general hospital units with 78 acute care beds and a supplementary acute inpatient service provided at the local psychiatric hospital. An average of 10 beds were available in emergency situations when the general hospital beds were either occupied or when an intensive observation bed was not available. The total complement of psychiatric beds did not change during this period, and there were no other competing public or private hospitals in the region.

All hospitals are required to follow the same procedures regarding identification of their first admissions to hospital and to report to the Ministry of Health all relevant data regarding patients admitted to and discharged from their respective institutions. This reporting, done in a standard format through a centralized system, includes discharge diagnosis and whether the patient had previously been admitted to that institution. We obtained ethics approval from each hospital to search their records.

Data Collection

Two trained research workers (a BScN clinical nurse and an honours psychology graduate) with experience in the field of psychosis examined case records of all first admissions to all hospitals and used a structured protocol to identify all patients (aged 16 to 50 years) with a discharge diagnosis of nonaffective FEP (that is, schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, or psychosis NOS). Cases were included when a thorough search of the records clearly indicated that there had not been a previous admission to hospital for treatment of a psychotic disorder. If there were doubts about the diagnosis after the review was completed, the details of the case were discussed with the senior investigators before it was included or rejected for the study. The review included reading all detailed admission notes, notes from the emergency hospital service, and notes made by each discipline during the hospital admission and discharge summary. Each case was cross-checked with other hospitals to ensure that there had not been an admission to hospital in the catchment area prior to the index admission for treatment of psychosis. The first admission for treatment for psychosis at any of these hospitals within the time frame was considered the index admission. The review also included examination of the case records for any possibility of a previous admission to a hospital outside the catchment area. We excluded cases where there had been a hospital admission prior to the index episode to another hospital outside the catchment area. We collected data on the following variables: age, sex, marital status, employment history, primary diagnosis, number of days of first hospital admission, first admission involuntary status, number of days spent in a psychiatric intensive care unit, number of preadmission suicide attempts, preadmission violent acts, preadmission injuries, and aggressive behaviour during the index admission.

Results

The defined catchment area, London and Middlesex, Ontario, had a population of 390 000 during the study period. Over the 3 years, 146 cases of first admission for treatment of nonaffective FEP were identified. This suggests an IR of 12.5 per 100 000 yearly. The corresponding treated IR for the population at risk (aged 16 to 50 years) is 15.6 per 100 000 yearly (see Table 1).

Most patients were male 93 (63.7%), single 118 (80.9 %), and unemployed 109 (74.6%), with a mean age of 31.3 years (range 17 to 51 years) at the time of their first admission. Nineteen (13%) patients were registered as students. Most (124, 85%) had a primary diagnosis in the schizophrenia spectrum (schizophrenia, schizophreniform, and schizoaffective psychosis), while the rest had diagnoses of psychosis NOS and delusional disorder. The mean length of the first hospital admission in an open psychiatric inpatient unit was 31.03 days, SD (67.8 range 1 to 731), and patients spent a mean of 2.93 days, SD 4.9 (range 0 to 26) in an intensive care psychiatric unit with 24-hour intensive nursing observation. On first admission, 88 (60.3%) patients were admitted involuntarily under either a Form 1 (application for psychiatric assessment) or a Form 3 (involuntary admission) of the Ontario Mental Health Act. The former allows a compulsory admission to hospital primarily for assessment and management of acute crises lasting a maximum of 72 hours, whereas the latter is a compulsory order for admission to hospital for treatment lasting a period of 2 weeks with a possibility of renewals for periods of 1 month each. Nearly one-fifth (18.8%) of the patients had attempted suicide prior to the first hospital admission. Nearly one-third (31.5%) had demonstrated aggressive behaviour toward people, property, or animals prior to hospitalization, and 23 (15.9%) had shown aggressive behaviour during the index hospital admission. Twenty-one (14.4%) patients suffered physical injuries as a result of suicidal behaviour or aggression from others. Finally, more than one-third (34.2%) of patients had a history of legal involvement comprising mostly minor offenses.

Discussion

In recent years, there has been a great deal of interest in establishing innovative and specialized services for individuals suffering from their first psychotic episode; however, several questions must be raised at this stage. For example, are these services targeting the population of FEP patients who would normally be admitted to hospital, and are they responding to the specific needs of these individuals?

On the basis of first-ever admission to hospital for treatment of a nonaffective psychosis, we report a yearly treated incidence of 12.5 per 100 000 for the entire population, while the rate for the population at risk (aged 16 to 51 years) for an FEP was 15.6. The incidence of FEP has been reported to range from 16.5 (19) to 42 per 100 000 yearly (20), the variation being explained partly by inclusion or exclusion of psychotic disorders other than schizophrenia spectrum disorders. Higher IRs for schizophrenia and related disorders have been associated with large urban areas (21) and minority ethnicity (for example 2 to 4 times rates in individuals of African-Caribbean origin) (22,23). The relatively low IRs reported here may be partly related to the characteristics of this jurisdiction and the composition of its population. London, Ontario, is a medium-sized city with a small industrial base; health care and educational sectors are the largest employers. The population is relatively homogenous and predominantly white, with only 18% born outside the country. There is little urban decay, and social and community services are relatively well-endowed. Further, our treated IRs are based entirely on hospital admissions and do not account for cases that might have either been treated in nonhospital settings, in forensic systems, or not treated at all. It is possible that the treated IRs are somewhat inflated by a university student population, some of whom may not be registered as residents of this jurisdiction. The impact of this is likely to be minimal, even if 50% of students were not registered as residents within the catchment area, resulting in a treated IR of 11.6 per 100 000 when the number of cases is reduced to 136.

Our finding that FEP patients admitted to hospital for the first time are predominantly male is in keeping with several other studies (24–26). The somewhat older age at first admission (31 years, range 17 to 51 years), compared with previous reports (14,19,27,28), could be the result of relatively long periods of untreated psychosis prior to treatment entry or of previous treatment attempts as outpatients. Alternatively, it could simply be an artifact of a broader age range for inclusion in our sample (16 to 51 years). The relatively high unemployment rate in our sample (74.6%) was likely related to the method of recording employment status without specifying the time period covered. The rates of unemployment among FEP patients are usually high (range10% to 86%), depending on the population served, local circumstances (10,29–31), and variable definitions of unemployment.

We have reported a relatively short length of first hospitalization (mean 31 days) for treatment of psychosis, compared with what has been reported earlier (54 to 240 days) (12, 29,32). The length of time that patients spent in IOUs was also relatively brief. Patients were admitted to IOUs equipped with complete and separate intensive nursing observation for reasons of threats of violence or suicide or if they were clinically unmanageable on a regular inpatient unit. Our literature search failed to locate any previous reports on use of psychiatric IOUs for FEP patients. This is an important parameter to examine, for 2 reasons: 1) psychiatric IOUs are relatively more cost-intensive and 2) prolonged isolation in a closed IOU may have a negative impact on patients with no previous exposure to mental health services (33).

Suicide is the leading cause of premature death among individuals with schizophrenia (34–36), and the rate of attempted suicide in psychosis patients is also high (range 10% to 50%) (37,38). The rate of suicidal attempts reported here (18%) is in keeping with other reports for FEP patients (11% to 26.6 %) (6,40,41). Increased risk for violence is also associated with schizophrenia, especially when these data are based on evaluation of criminal records (42–46). The observation of high rates (31.5 %) of some form of violence toward people, property, or animals, albeit with mostly minor consequences, prior to their first admission and a relatively high rate (15.8%) of aggressive behaviour during the index hospitalization is consistent with what has been reported in the literature (8) and should be a target of prevention and intervention in an early psychosis service. One-third of patients also reported a history of legal involvement that included being fined, arrested, placed in a holding cell, placed on probation or parole, and having parole officer visits, legal appointments, police contact, and (or) nights in prison. It is possible that patients charged with serious and violent offenses could have been assessed and treated within a forensic psychiatric service and would therefore be excluded from this sample. There is no relevant literature on minor legal problems reported by FEP patients on their first admission to hospital. The proportion of patients with even minor legal problems that may end up in the justice system could be influenced by recognition of the association between FEP and minor legal problems and the availability of treatment in the mental health system. The relatively high prevalence of concurrent and lifetime substance abuse in the FEP population (range 6.5% to 53%) (47–51) may also increase the likelihood of suicidal and aggressive behaviour (52). Unfortunately, in routine care, reliable data are not collected on substance abuse; hence, we cannot comment on this possibility in our data.

A high rate of involuntary hospitalization for FEP is in keeping with previous reports of relatively high rates (12% to 62%) (5,27,28) for schizophrenia and related disorders at different illness stages. The variation in involuntary hospitalization rates may be related to such nonclinical factors as mental health policy, ethnic composition of the patient population, and individual physician practices (53,54). The impact of involuntary hospitalization as an introduction to mental health services for patients with FEP, who are most likely to require subsequent care for years, remains unknown. However, given the lack of insight into the nature of their presenting problem (55), the resulting general reluctance to receive treatment, as well as the high frequency of suicidal and violent behaviour, often leaves clinicians with little choice, especially when issues of risk to the patient or others are considered. This may be true of most jurisdictions where no clear alternatives to acute hospital care are available.

In conclusion, our findings suggest that patients admitted to hospital for the first time for treatment of psychosis are likely to be young, male, unemployed, and unwilling to be admitted voluntarily. They often present with significant behavioural problems, such as suicidal attempts, aggressive behaviour, and legal problems. We have shown that treatment in hospital can be relatively brief, especially for periods of intense observation. In a subsequent paper, we will report on whether a new EI program targets patients with similar characteristics to those admitted to hospital in routine care and whether an EI service has an impact on such indicators of patients’ needs and service use.

Funding and Support

The data collection for this paper was made possible by a grant from the Ontario Ministry of Health. Additional funds for data analyses were provided by the senior author from clinical research funds.

Acknowledgements

We acknowledge the assistance of Adrian Leipsic and Janine Ward for data entry and analysis, respectively.

References

1. Birchwood M, Spencer E. Early intervention in psychotic relapse. Clin Psychol Rev 2001;21:1211–26.

2. McGlashan TH, FentonWS. Subtype progression and patho-physiologic deterioration in early schizophrenia. Schizophr Bull 1993;19:71–84.

3. Whitehorn D, Richard JC, Kopala LC. Hospitalization in the first year of treatment for schizophrenia. Can J Psychiatry 2004;49:635–8.

4. Sipos A, Harrison G, Gunnell D, Amin S, Singh SP. Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study. Br J Psychiatry 2001;178:518–23.

5. Fennig S, Rabinowitz J, Fennig S. Involuntary first admission of patients with schizophrenia as a predictor of future admissions. Psychiatr Serv 1999;50:1049–52.

6. Verdoux H, Liraud F, Gonzales B, Assens F, Abalan F, Van Os J. Suicidality and substance misuse in first-admitted subjects with psychotic disorder. Acta Psychiatr Scand 1999;100:389–95.

7. Milton J, Amin S, Singh SP, Harrison G, Jones P, Croudace T, and others. Aggressive incidents in first-episode psychosis. Br J Psychiatry 2001;178:433–40.

8. Steinert T, Wiebe C, Gebhardt RP. Aggressive behaviour against self and others among first-admission patients with schizophrenia. Psychiatr Serv 1999;50(1):85–90.

9. Bailer J, Brauer W, Rey ER. Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study. Acta Psychiatr Scand 1996;93:368–77.

10. Marwaha S, Johnson S. Schizophrenia and employment–a review. Soc Psychiatry Psychiatr Epidemiol 2004;39:337–49.

11. Loebel AD, Lieberman JA, Alvir JM, Mayerhoff DI, Geisler SH, Szymanski SR. Duration of psychosis and outcome in first-episode schizophrenia. Am J Psychiatry 1992;149:1183–8.

12. McGorry PD, Edwards J, Mihalopoulos C, Harrigan SM, Jackson HJ. EPPIC: an evolving system of early detection and optimal management. Schizophr Bull 1996;22:305–26.

13. Malla A, Norman RMG. Facing the challenges of intervening early in psychosis. Ann R Coll Physicians Surg Can 1999;32:394–7.

14. Malla AK, Norman RM, Manchanda R, McLean TS, Harricharan R, Cortese L, and others. Status of patients with first-episode psychosis after one year of phase-specific community-oriented treatment. Psychiatr Serv 2002;53:458–63.

15. McGlashan TH. Early detection and intervention in schizophrenia: research. Schizophr Bull 1996;22:327–45.

16. Birchwood M. Early intervention and sustaining the management of vulnerability. Aust N Z J Psychiatry 2000;34:181–4.

17. Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, and others. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 2002;329:1067–81.

18. Kuipers E, Holloway F, Rabe-Hesketh S, Tennakoon L. Croydon Outreach and Assertive Support Team (COAST). An RCT of early intervention in psychosis: Croydon Outreach and Assertive Support Team (COAST). Soc Psychiatry Psychiatr Epidemiol 2004;39:358–63.

19. Svedberg B, Mesterton A, Cullberg J. First episode non-affective psychosis in a total urban population: a 5-year follow-up. Soc Psychiatry Psychiatr Epidemiol 2001;36:332–7.

20. Garety PA, Rigg A. Early psychosis in the inner city: a survey to inform service planning. Soc Psychiatry Psychiatr Epidemiol 2001;36:537–44.

21. Torrey EF, Bowler A. Geographical distribution of insanity in America: evidence of an urban factor. Schizophr Bull 1991;16:591–604.

22. Sharpley M, Hutchinson G, McKenzie K, Murray R. Understanding the excess of psychosis among African-Carribean population in England: review of hypotheses. Br J Psychiatry 2001;178(Suppl 40):S60–S68.

23. Strakowski SM, Flaum M, Amador X, Bracha HS, Pandurangi AK, Robinson D, and others. Racial differences in the diagnosis of psychosis. Schizophr Res 1996;21:117–24.

24. Kendler KS, Walsh D. Schizophreniform disorder, delusional disorder and psychotic disorder not otherwise specified: clinical features, outcome and familial psychopathology. Acta Psychiatr Scand 1995;91:370–8.

25. Zhankg-Wong J, Beiser M, Bean G, Iacono WG. Five-year course of schizophreniform disorder. Schizophr Res 1995;59:109–17.

26. Harrow M, Sands JR, Silverstein ML, Goldberg JF. Course and outcome for schizophrenia versus other psychotic patients: a longitudinal study. Schizophr Bull 1997;23:287–303.

27. Hafner H. Onset and course of the first schizophrenic episode. Kaohsiung Journal of Medical Science 1998;14:413–31.

28. Kelly BD, Clarke M, Browne S, McTigue O, Kamali M, Gervin M, and others. Clinical predictors of admission status in first episode schizophrenia. Eur Psychiatry 2004;19:67–71.

29. Munk-Jorgensen P, Mortensen PB, Machon RA. Hospitalization patterns in schizophrenia: a 13-year follow-up. Schizophr Res 1991;4(1):1–9.

30. Harvey CA. The Camden Schizophrenia Surveys I. The psychiatric, behavioural, and social characteristics of the severely mentally ill in an inner London health district. Br J Psychiatry 1996;168:410–7.

31. Harvey CA, Pantelis C, Taylor J, McCabe PJ, Lefevre K, Campbell PG, and others. The Camden Schizophrenia Surveys II. High prevalence of schizophrenia in an inner London borough and its relationship to socio-demographic factors. Br J Psychiatry 1996;168:418–26.

32. Mihalopoulos C, McGorry PD, Carter RC. Is phase-specific, community-oriented treatment of early psychosis an economically viable method of improving outcome? Acta Psychiatr Scand 1999;100(1):47–55.

33. McGorry PD, Chanen A, McCarthy E, van Riel RJ, McKenzie D, Singh BS. Posttraumatic stress disorder following recent-onset psychosis: an unrecognized postpsychotic syndrome. Journal of Nervous and Mental Diseases 1991;179:253–8.

34. Radomsky ED, Haas GL, Mann J J, Sweeney JA. Suicidal behaviour in patients with schizophrenia and other psychotic disorders. Am J Psychiatry 1999;156:1590–5.

35. Modestin J, Zarro I, Waldvogel D. A study of suicide in schizophrenic in-patients. Br J Psychiatry 1992;160:867.

36. Tsuang MT, Woolson RF, Flemming JA. Premature death in schizophrenia and affective disorder. Arch Gen Psychiatry 1980;37:979–83.

37. Caldwell CB, Gottesman II. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull 1990;16:571–89.

38. Wilkinson G, Bacon NA. A clinical and epidemiological survey of parasuicide and suicide in Edinburgh schizophrenics. Psychol Med 1984;14:899–912.

39. Roy A. Depression, attempted suicide, and suicide in patients with chronic schizophrenia. Psychiatr Clin North Am 1986;9:193–206.

40. Nordentoft M, Jeppesen P, Abel M, Kassow P, Petersen L, Thorup A, and others. OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial. Br J Psychiatry 2002;43(Suppl):S98–S106.

41. Addington J, Williams J, Young J, Addington D. Suicidal behaviour in early psychosis. Acta Psychiatr Scand 2004;109:116–20.

42. Hodgins S. Mental disorder, intellectual deficiency, and crime. Evidence from a birth cohort. Arch Gen Psychiatry 1992;49:476–83.

43. Wessely SC, Castle D, Douglas AJ, Taylor P J. The criminal careers of incident cases of schizophrenia. Psychol Med 1994;24:483–502.

44. Lindqvist P, Allebeck P. Schizophrenia and crime. A longitudinal follow-up of 644 schizophrenics in Stockholm. Br J Psychiatry 1990;157:345–50.

45. Brennan PA, Mednick SA, Hodgins S. Major mental disorders and criminal violence in a Danish birth cohort. Arc Gen Psychiatry 2000;7:494–500.

46. Swanson JW. Mental disorder, substance abuse, and community violence: and epidemiological approach. In: Monahan J, Steadman HJ, editors. Violence and mental disorder. Developments in risk assessment. Chicago (IL): University of Chicago Press; 1994. p. 101–36.

47. Eronen M, Tiihonen J, Hakola P. Schizophrenia and homicidal behaviour. Schizophr Bull 1996;22:83–9.

48. Hambrecht M, Hafner H. Substance abuse and the onset of schizophrenia. Biol Psychiatry 1996;40:1155–63.

49. Sevy S, Robinson DG, Holloway S, Alvir JM, Woerner MG, Bilder R, and others. Correlates of substance misuse in patients with first-episode schizophrenia and schizoaffective disorder. Acta Psychiatr Scand 2001;104:367–74.

50. Rabinowitz J, Bromet EJ, Lavelle J, Carlson G, Kovasznay B, Schwartz JE. Prevalence and severity of substance use disorders and onset of psychosis in first-admission psychotic patients. Psychol Med 1998;28:1411–9.

51. Van Mastrigt S, Addington J, Addington D. Substance misuse at presentation to an early psychosis program. Soc Psychiatry Psychiatr Epidemiol 2004;39(1):69–72.

52. Cantwell R, Brewin J, Glazebrook C, Dalkin T, Fox R, Medley I, and others. Prevalence of substance misuse in first-episode psychosis. Br J Psychiatry 1999;174:150–3.

53. Verdoux H, Liraud F, Gonzales B, Assens F, Abalan F, van Os J. Predictors and outcome characteristics associated with suicidal behaviour in early psychosis: a two-year follow-up of first-admitted subjects. Acta Psychiatr Scand 2001;103:347–54.

54. Malla A, Norman RM, Helmes E. Factors associated with involuntary admission to psychiatric facilities in Newfoundland. CMAJ 1987;136:1166–71.

55. Lindsey KP, Paul GL. Involuntary commitments to public mental institutions: issues involving the overrepresentation of blacks and assessment of relevant functioning. Psychol Bull 1989;106:171–83.

56. Mintz AR, Dobson KS, Romney DM. Insight in schizophrenia: a meta-analysis. Schizophr Res 2003;61(1):75–88.

Author(s)

Manuscript received March 2005, revised, and accepted May 2005.

1. Research Fellow, Department of Psychiatry, McGill University, Montreal QC.

2. Professor, Department of Psychiatry, McGill University, Montreal, QC.

3. Professor, Departments of Psychiatry and Epidemiology and Biostatistics, University of Western Ontario, London, ON.

4. Research Coordinator, Prevention and Early intervention Program, Department of Psychiatry, University of Western Ontario, London, ON.

5. Child and Youth Mental Health Services, Ministry of Children and Family Development for British Columbia, Cranbrook, BC.

Address for correspondence: Professor A Malla, Department of Psychiatry, McGill University Douglas Hospital Research Centre, 6875 Boul Lasalle, Montreal, QC, H4H 1R3

e-mail: ashok.malla@douglas.mcgill.ca

1 | 2