Authors' reply

Professor Chaturvedi raises the possibility that our systematic review of the length of the duration of untreated psychosis in LAMI countries was confounded by a definition of treatment that was based on presentation to psychiatric services and did not account for presentations to traditional healers.

We acknowledge that a minority of the studies included in our review were based on population-based surveys of psychosis and that most of the studies did not include patients who only presented to traditional healers or did not receive any psychiatric treatment.

However, poor outcome in schizophrenia is known to be associated with delay in commencing treatment with antipsychotic medication, whereas little is known about the effects of a delay in non-pharmacological treatment. Furthermore, in a literature review (submitted for publication: details available on request) we confirmed the findings of Marshall et al ¹ that the adverse effects of delaying antipsychotic treatment are similar in high-income and LAMI countries. Hence, we believe that non-psychiatric treatment for psychosis is best thought of as a potential cause of prolonged duration of untreated psychosis, rather than a confounding factor in the definition of duration of untreated psychosis.

Psychoses with acute onset and short duration that might remit without treatment may be more common in LAMI countries. ^2,3 Patients with a short-lived psychosis might not always present to psychiatric services in LAMI countries, although in high-income countries acute psychosis is associated with a shorter duration of untreated psychosis. We do not know whether the exclusion of patients with a potentially short duration of untreated psychosis and those who only present to traditional healers would increase or decrease the mean period of non-treatment. In our review, population-based studies tended to report much longer mean periods of non-treatment than studies based on presentation to psychiatric services, although it is also possible that the lower mean duration of untreated psychosis found in upper-middle income countries was due to more individuals with an acute onset presenting for treatment early in their illness.

We agree that the pathways to care through non-psychiatric treatments warrant further investigation, but these studies should be conducted as part of an effort to reduce the unacceptably long duration of untreated psychosis in many LAMI countries.