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Introduction: The progressive shifts in the legal and social contexts, along with major changes in information seeking habits with the development of the Internet, have placed patients' information at the core of medical practice. This has to be applied to the psychiatric fields as well, and to questions about how schizophrenic patients are being told their diagnosis nowadays in France., Methods: This paper is a national and international literature review about schizophrenia diagnosis disclosure practices, from 1972 to 2014, using French and English languages and various psychology and medical databases. The used key words were "diagnosis", "disclosure", "communication", "breaking bad news", "information", "schizophrenia" and "psychosis"., Results: Proportions of diagnosis announcement: our results show that the proportion of psychiatrists delivering schizophrenia diagnosis to their patients varies between countries. Although we must acknowledge that the questionnaires and samples are diverse, we have found that psychiatrists are in general less prone to deliver diagnosis information in France (from 13,5% to 39% given the studies), Germany (28%), Italy (30%), and Japan (30%), than in Anglo-Saxon countries. Thus, 70% of the psychiatrists in North America and 56% in Australia claim that they disclose their diagnosis to schizophrenic patients. In the United-Kingdom, a study targeting psychotic patients themselves has shown that 47% of them had been told their diagnosis by their doctor. Even in the countries where the proportion of diagnosis disclosure is the highest, there remains a substantial difference with other mental illnesses such as affective or anxiety disorders, which are almost always labeled as such in the information communicated to the patient (90% in North America). Diagnostic information about schizophrenia continues therefore to appear problematic for health professionals, which can seem a paradox given the recent social and legal evolutions, the therapeutic progress, the proved benefits of disclosure on compliance and therapeutic alliance, and the fact that numerous studies have shown that a majority of patients already know their diagnosis having discovered it on the Internet or by reading their treatments' notice. Reasons alleged for not disclosing diagnosis: the reasons alleged by psychiatrists for not disclosing diagnosis are various, including fear of aggravating the stigma and the emotional state of the patient, fear of giving a wrong diagnosis, fear of suicidal behavior, risk of misunderstanding, low level of patient's insight, absence of therapeutic advantage, or absence of request from the patient. Evolution of the French position about diagnosis disclosure: The publication of the relatively large study of Baylé et al. in 1999, as well as the patients' rights evolutions, has led to a debate among psychiatrists about the reasons alleged in France for not disclosing diagnosis. Among other explanations, it appeared that the theoretical reference of the psychiatrist plays a role, a psychoanalytic practice leading to increased reluctance in breaking the bad news. Thus, the psychiatrist's view of the disease, in terms of etiology and prognosis, is important as the diagnosis could become accusing if the psychiatrist believes the family environment played a role, or harmful if he has a pessimistic conception of prognosis. The question of stigma: among other reasons alleged by psychiatrists for not announcing the diagnosis, the fear of causing an increased stigma is frequently reported by professionals. In France, stigma about schizophrenia is high, not only among the general population but also among health practitioners. Even if the context has evolved during the past 30 years and the therapeutic efficiency has improved, French representations of schizophrenia remain often tinted with catastrophism and should be modified. Benefits of diagnosis disclosure: however, the benefits of disclosing diagnosis have been constantly proved in France as in other environments. Several studies have shown that patients knowing their diagnosis were likely to develop a better compliance and a stronger therapeutic alliance with their doctor. No aggravation of symptoms, suicidal risk or anxiety has been linked to the diagnosis disclosure. On the contrary, the relief of being able to put some words on symptoms, better recognize them and anticipate them, and be part of a group of patients sharing the same symptomatology has been described by patients. Furthermore, disclosing a schizophrenia diagnosis can be essential to the psychotherapeutic project, in the sense that it places the patient into an active role towards the disease and the care plan. Last but not least, the relatives can benefit from the disclosure as well and build a partnership with health professionals about medical care. Existing recommendations: in the French context, apart from individual recommendations produced by a few authors in the literature, there are no official specific recommendations about how to disclose a difficult diagnosis in the psychiatric field; only recommendations concerning severe chronic somatic disease are available. The complexity of the schizophrenia diagnosis disclosure has led some researchers - especially in North America and Australia - to adapt and use in the context of schizophrenia protocols, recommendations and even communication skills training programs that have been developed in oncology or in the field of severe chronic somatic disease., Discussion: For the situation to evolve in France, tools able to measure patients' consent - including consent to hear the bad news - ability could be used. The question of how much information and what kind of information the patients really wish should therefore be explored in deep. Also, we have seen that schizophrenia representations should be modified in the general public understanding as well as in the professional environment. Families should be more included in the reflection about diagnosis announcement, as psycho-education programs have shown their efficiency and usefulness for both patients and relatives. Finally, in order to overcome some of the difficulties related to breaking the bad news about a schizophrenia diagnosis, developing the existing Anglo-Saxon models and recommendations in France, where only very few protocols exist, could allow a positive evolution in clinical practice and help to set a therapeutic and partnering approach of diagnosis disclosure. However, in order to better understand the situation in France regarding schizophrenia diagnosis disclosure, the present state of clinical practice still remains to be analyzed precisely, as the last study on a relatively large sample was made only in 1999. Thus, the obvious limits of our study lie in the fact that most available surveys in France are not recent enough to have taken into account legal and social evolutions. Also, the studies that we used for this paper use different methodologies, in the majority focus solely on health professionals, and they are not representative enough in terms of size or sample to inform about the present state of the practice., Conclusion: As a conclusion, having stressed the lack of recent data about schizophrenia diagnosis disclosure in France, we suggest a new study using validated tools on a representative sample and taking into account both perceptions of psychiatrist and patient. As has been the case for other severe pathologies, we also suggest that a consensus conference take place on the subject of schizophrenia diagnostic information in order to elaborate guidelines to support this difficult disclosure., (Copyright © 2016 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Prognosis of schizophrenia has not significantly improved despite extensive research. There is often a relatively long delay between onset of symptoms and treatment initiation. Lately, duration of untreated psychosis (DUP), the time between the onset of psychosis and initiation of treatment, has been one of the most studied variables in patients presenting for a first psychotic episode in order to evaluate the impact of early intervention on the prognosis of schizophrenia. In the literature, a variety of criteria have been used to define both transition to psychosis and initiation of treatment. Furthermore, the dating of both of these variables is usually retrospective, further complicating the measurement of DUP., Methods: We conducted a comprehensive review about DUP using Pubmed and Google Scholar databases up to January 2015 using the following keywords "schizophrenia", "duration of untreated psychosis", "duration of untreated illness" and "early intervention". Papers were included if they were published in French or English., Results: The mean DUP was found to be 2 years but it can vary according to multiple factors such as denial of illness by the patient and family, withdrawal and isolation from friends and relatives, diagnostic errors, paranoid views of the mental health treatment systems, or negative symptoms. Long DUP may also be a correlate of poor premorbid functioning or of an insidiously unfolding psychosis. Considerable discrepancies exist in the way that DUP is estimated in different studies. Although the clinical interview remains the most common way of measuring DUP, so far there is no evidence for favoring one method over another. Regardless of measurement method, a longer DUP is found to be associated with poorer outcome in schizophrenia in both the short and long-term across a number of domains: symptoms severity, remission rates, the risk of relapse, global functioning and quality of life. Its role in functional outcome appears to be mediated largely by negative symptoms, for which there is still no effective treatment. A recent meta-analysis has shown that shorter DUP is associated with less severe negative symptoms at short and long-term follow-up, especially when DUP is shorter than 9 months. The mechanism of the relationship between DUP and outcome is still undefined. A hypothesis is that the shorter the DUP, the more likely the intervention is being applied during the period in which neurobiological deficit processes in schizophrenia are most active., Discussion: A study of the duration of untreated illness (DUI), which is defined as the DUP and the prodromal phase, seems necessary because results of studies evaluating the effect of early detection and intervention in individuals with clinical high risk for psychosis are promising. A number of interventions such as omega 3 fatty acids and integrated psychosocial interventions seem to delay transition in the at-risk population. However, replication studies are lacking, and a great proportion of at high-risk individuals will spontaneously remit or develop diseases other than chronic psychosis, making us question the advantages and disadvantages of a treatment. Taking into consideration the high prevalence of comorbidities in individuals referred for clinical high-risk state and their effect on the individual's functioning, future interventions in the field need to address not only the preventative efficacy on psychosis transition but also their effectiveness in improving the functioning of this population and their effect on the outcome of schizophrenia when transition to psychosis has occurred., Conclusion: Despite the huge advances in the field of schizophrenia, many questions remain unanswered and huge efforts are still necessary to understand the pathophysiology of this illness in order to improve its outcome., (Copyright © 2016 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Context: Informed consent to research remains a complex issue, while sometimes staying difficult to obtain, even in the general population. This problem may be maximized with patients suffering from schizophrenia., Objective: This paper summarizes available data in the literature about informed consent for research involving patients suffering from schizophrenia., Method: Medline and Google Scholar searches were conducted using the following MESH terms: schizophrenia, informed consent and research., Results: Studies using dedicated standardized scales (e.g. MacCAT-CR) revealed a decrease in the capacity to consent of patients with schizophrenia when compared with healthy individuals. Keeping in mind that schizophrenia is an heterogeneous disorder, patients with the lowest insight as well as those with the most severe cognitive symptoms appeared more impaired in their capacity to consent. Such a poor capacity to understand and consent to trials was shown linked with alterations in decision-making. For these specific patients, interventions may be set up to increase their capacity to consent. Various strategies were proposed: enhanced consent forms, extended discussion, test/feedback method or multimedia interventions. Among them, interventions relying on communication and the growing field of information technologies (e.g. web-based tools) seem promising. Finally, associations grouping families and patients (like the French Association UNAFAM) may facilitate the involvement of patients in research programs with safer conditions., Conclusion: Patients suffering from schizophrenia appear able to consent to research programs when suitable interventions are proposed. Further studies are now needed to optimize and individualize such interventions., (Copyright © 2014 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)