Early detection and intervention in psychosis: A long-term perspective.

Dissertation for the degree philosophiae doctor (PhD) at the University of Bergen

Dissertation date:

(DUO\GHWHFWLRQDQGLQWHUYHQWLRQLQ SV\FKRVLV

$ORQJWHUPSHUVSHFWLYH

:HQFKHWHQ9HOGHQ+HJHOVWDG

1

© Copyright Wenche ten Velden Hegelstad

Materialet i denne publikasjonen er omfattet av åndverkslovens bestemmelser.

.A \Z[^

%00!(A .(5 !0!0%+** %*0!.2!*0%+*%*,/5$+/%/B(+*#D0!.),!./,!0%2!B +."00!.A !*$!0!*!( !* !#!(/0

Trykk: AIT OSLO AS / Universitetet i Bergen

2

$!!.(5.!0)!*0* *0!.2!*0%+*%*/5$+/%/01 5OP%/+((+.0%+*

!03!!*02*#!.*%2!./%05 +/,%0(?/(+*%2!./%05 +/,%0(((!2(?*

+/'%( !)0/5#!$1/?!*).'* 3%0$(!! %($++(OPB$!0!*D5!.

"+((+3D1,/01 5(/+++,!.0!/3%0$0$!$!)0%/5$+/%/01 5OP?0/(+

*%2!./%05 +/,%0(B

$!* % 0!%/!*.+((! %*0$!*0!#.0! . 10!$++(+"*0!#.0!

!1.+/%!*!?*/0%010!+"%+(+#%(* ! %(/5$+(+#5?1(05+"

/5$+(+#5?00$!*%2!./%05+"!.#!*B

$%//01 53/"1* ! 5).!% /+.#*!0 !(/!!/0O+((+.0%+*!03!!*

0$!*%2!./%05+"!.#!** !(0$!/0?+.35P* 502*#!.*%2!./%05 +/,%0(B

3

$%//01 53/"1* ! 5#.*0".+)0$!!/0!.*+.35!#%+*( !(0$

10$+.%05 !(/!!/0?* 502*#!.*%2!./%05 +/,%0(?%2%/%+*+"

/5$%0.5B

%./0+"((?3*00+0$*'((0$!/01 5,.0%%,*0/B*!$1* .! * "+1.0!!*+"

0$!)(!0)!%*0!.2%!30$!)"+./!2!.($+1./B*5(!0)!0'!0$!)0+0$!(0+

$2!(++ D/),(!/0'!*A$%.0!!*01!/+"(++ B(/+?0$!5(!0)!/1)%00$!) 0+*!1.+,/5$+(+#%(0!/0/B1%0!*1)!.+",0%!*0/(!0)!%*0+0$!%.$+)!0+

+* 100$!%*0!.2%!3%*#0$!.!?3$%$3/3!(+)!$*#!".+)0$!+""%!B +)!(/++*/!*0! 0+D/**%*#?-1%0!(1/0.+,$+%!* !2+1.?

$+3!2!.) !!/%!.50$!'%* /1,!.2%/%+*+"+),!0!*0. %+(+#%/0/B

$%/3+.'+1( *+0$2!!!*,+//%(!3%0$+100$!+))!*0/?/1##!/0%+*/?

!*+1.#!)!*0?* /1,,+.0(35/+""!.! /3%"0(5* ".%!* (%(5?5,.%).5

%*2!/0%#0+.2!%*.%%/B/+*!3$+'*+3/0$!/01 5(%'!*++0$!.?$%/

!4,!.0%/!* ,0%!*!!4,(%*%*#0$%*#/0+)!$2!!!*%*2(1(!B#%2!

0$*'/0+)5/1,!.2%/+.?./!*?"+.#1% *!?+))!*0/?.!2%/%+*/*

/1##!/0%+*/B0$*'$%)(/+"+.)+.(/1,,+.0?!4!((!*0+""!!* %*0!.!/0%*#

* %*/,%.%*#+*2!./0%+*/+*0$%/3+.'* ((+0$!.0+,%/B(/+0$*')5+D /1,!.2%/+. */*#!2!( ?"+. %/1//%+*/%*10$B$*'5+1(/+,.+"B

!**!0$ 1# $("+.+))!*0/+*0$!"%*(0$!/%/B

$!.!/!.$0!)+*/%/0/+"$%#$(5/'%((! .!/!.$!./".+)3$+)$2!

(!.*! )1$B*/(+A*#.% !((!?&:.*%/$+2 1* ?&!0%(1* !0?*2.

://!.#?!.#(1)?0!%*,&+. /)+!*?1(%!2!*/!*? !(!*!. !.B*

!*).'A(.%' $.* .%'%)+*/!*B*0$!A$+)/(/$*B0$/

4

!!*,.%2%(!#!(!.*%*#".+)5+1B$*'5+1((B3%(()%//0$!.!/!.$

)!!0%*#/* 0$!(+2!(5 %**!./B

002*#!.*%2!./%05 +/,%0(?0$*'"+.)!.$%!",/5$%0.%/0?*+3$! +"

.!/!.$* +D"+1* !.+"?*(2+$**!//!*?* (! !.+"0$!!#%+*(

!*0.!"+.(%*%(!/!.$%*/5$+/%/?*#!+?"+.,.+2% %*#)!3%0$0$!

+,,+.01*%050+"%*%/$)5$D3+.'* +)%*%*#%03%0$(%*%(3+.'B(/+

0$*'5+1+0$"+.(+*#!.0$* ! !#%2%*#)!0.1!/!*/!+"!(+*#%*#*

"*0/0%".!! +)0+,1./1!)5+3*%*%0%0%2!/* % !/B

*50$*'/(/+"+.)5+D3+.'!./00$!.!/!.$!*0.!A!(%//!%!((?

!0.+/.+/+/?!*/%//!(#7. * +(&:.*.:**%'? "+.!%*#

,!%(0$*'/0+0$!,!+,(!3$+$2!3+.'! %*0$! !0!0%+*0!) 1.%*#0$!

5!./$2!!!*3%0$?* 0$!%.(! !.+!.0:.#!*/!*B3+1( (%'!0+

)!*0%+*5*)!1 .1*1/0 ?+**5!00!./!*?+** !./!***?&!./0%

! .!:?.% ! !*?.%/0%* 0(:5?/!* !./.1 !.#!/!*B$*'/0+

2!%*1*#52%#3$+%/0$!,!./+*3$+) !((0$! 2!.0%/!)!*0/*

$!(,! )!,.+2% %*#0$!)!.%*+1.*(+"/5$%0.5+2!.B$*'/0+/1,!.D /!.!0.5* %+'*"+.0.*/.%%*#%*0!.2%!3/?* "+.+""!!.!'/B

$*'5+1?+((!#1!/00$!10!,/5$%0.%3. \?3$!.!$2!3+.'!

"+./+)*55!./?* 0$!D3. ]?"+./1,,+.0* +). !/$%,*

,(!%*5+1..+'* B$*'/0+(()5".%!* /?!/,!%((5!* !%0)**?3$+

%/3+.'%*#3%0$2+0%+*(.!$%(%00%+*+",0%!*0/3%0$,/5$+/%/?/+)!0$%*#

0$0%/2!.5(+/!0+)5$!.0B

supportive colleagues and friends.

, Liss-Gøril Anda

5 /0?10*+0(!/0?0$*'5+1)5/+(10!(5/1,!.$%( .!*!/,!.* %*!?*

)5$1/* /?"+.*!2!."%(%*#0+.%*#)!*%*#?(1#$0!.?/1.,.%/!* ((

/+.0/+"+0$!4%0%*#* +. %*.5!2!.5 5&+5/%*0+)5(%"!B

02*#!.?1*!\Z[]

!*$!0!*!( !* !#!(/0

6

&,*'-,!'&

2!.0$!(/0 ! !/0$!.!$/!!*#.+3%*#%*0!.!/0%*!.(5 !0!0%+**

%*0!.2!*0%+*%*"%./0!,%/+ !,/5$+/%/OPB/5$+0% %/+. !./.!.#1(5 )+*#0$!)+/0/!.%+1/)!*0( %/+. !./* $2!!!*'*+3*0+$2!

.!(0%2!(5,++.,.+#*+/%/B 1)** /+%!0(+/0/.!$%#$B/5$+0% %/+. !./

/0.%'!,.! +)%**0(5%*!.(5 1(0$++ * %*0!."!.!3%0$.!!.*

,.0*!./$%,/$+%!/B*"+.01*0!(5?)!*0($!(0$.!+"0!*$//!!*,0%!*0/%*

(0!/0#!+"0$! %/+. !.B*/,%0!+"%),.+2! ,.+#*+/%/"0!.0$!%*0.+ 10%+*

+"*!1.+(!,0%/* )+.!$1)*!0.!0)!*0?)*5,0%!*0//0%((/1""!.

$.+*%((5".+)/5),0+)/* ,++."1*0%+*%*#B2!.0$!5!./0$!-1!/0%+*

.+/!3$!0$!. !0!0%*#,/5$+/%/!.(%!.+1( %),.+2!,.+#*+/%/B!.$,/

I,,(5%*#!4%/0%*#/$%6+,$.!*%0.!0)!*0///++*/,+//%(!%*0$!+1./!+"

0$! %/+. !.)5/(+3+./0+, !0!.%+.0%+*JO(/$** +$**!//!*?[cc`PB

$0)!*/? !0!0%*#* %*0!.2!*%*#%*,/5$+/%/!.(%!.B*0$%/0$!/%/?(+*#D 0!.)"+((+3D1,/01 5+"!.(5 !0!0%+*+",/5$+/%/3%((!,.!/!*0! B%./0?"0!.

*%*0.+ 10%+*+*,/5$+/%/%*#!*!.(?3%((,.!/!*0.%!"$%/0+.5+"!.(5 !0!0%+*%*,/5$%0.5B3%((#++*0+,.+2% !*+2!.2%!3+"(+*#D0!.)/01 %!/

+"+10+)!* .!+2!.5%*,/5$+/%/%*#!*!.(* %*,.0%1(.B1.0%+*

+"*0.!0! /5$+/%/OP3%((! !/.%! * %/1//! B*+2!.2%!3+"

!.(5 !0!0%+*,.+#.))!/?)!*00+.! 1!?3%((!,.!/!*0! B3%((0$!*

!/.%!0$!)!0$+ /* 0$!+*0!*0+"0$!.(5!0!0%+*,.+#.))!?

* ,.!/!*0.!/1(0/".+)0$!/01 5B%*((5?.!/1(0/3%((! %/1//! ?* /+)!

)!0$+ +(+#%(* !0$%(+*/% !.0%+*/,.!/!*0! B

7

%%&*;+-%%*1!&'*/!&<

#*-&&6 /5'+/!(% !(/!. !. (*0 ! (2+.(%#/0! ,/5'%/'! (% !(/!*! +#

'&!**!0!#*!/22.*#"+.!/0%((%*#!.?"+.2%..%*#+#M!((!.$((1/%*/&+*!.O,+/%0%2!

/5),0+)!.P? 0%('!0.!'*%*# +#M!((!. ,0% O*!#0%2! /5),0+)!.P? +#M!((!.

'+#*%0%2! "1*'/&+*/"+./05..!(/!.B !. !** _Zd 2 ,/%!*0!. $. ".!) !(!/

/5),0+)!. !00!. 0% 7.? +# 2.%!.!* ! #. !. 2 "1*'/&+*/*! /!00!(/! $!))!.

+,,0%(cZdB01 %!.$.2%/00% "./5' +)//0.00%(!$* (%*#$!*#!./))!*

)! ,.+#*+/!B % (%# *0!.2!*/&+* 2! 5'+/! OPD,.+/&!'0!0 102%'(!0 +#

%),(!)!*0!.0! !0 %*0!*/%20 ,.+#.) "+. 7 "+.'+.0! 2.%#$!0 2 1!$* (!0 ,/5'+/! OPB !/07. 2 %*0!*/%2! %*"+.)/&+*/'),*&!. .!00!0 )+0 (()!**!"+('*%*#? /'+(!.? $!(/!,!./+*!(( +# * .! .!(!2*0! ,.0!.? /)0 !0 (20!./'!(0% (%#+,, #!(/!/0!)BD,.+/&!'0!0$.'+*0%*1!.0 !00!.!% !0%

[]7.B*'2/%D!'/,!.%)!*0!((/01 %!/+)/))!*(%'*!00% (%#%*0!.2!*/&+*

2! ,/5'+/!)! 2*(%#+,, #!(/!(!#&!**+)":.0)!((+)[cca+#\ZZZB% (%#

*0!.2!*/&+*//!'0+. OD/!'0+.P /!'0+. 2. +#(* ? )!*/ '+*0.+((/!'0+.!. 2.

/(+O/(+*%2/!./%0!0//5'!$1/?((!27(P+#+/'%( !%*).'BD/!'0+.(!

.! 1/!.0".\`0%(^B_1'!.?)! %*2!. %B'+*0.+((/!'0+.2.)! %*[`

1'!.B/%!*0!.".D/!'0+.$ !(2!.!/5),0+)*%272! /0.02!$* (%*#?

(2!.! *%27 2 *!#0%2! /5),0+)!. !00!. !00 +# (2!.! *%27 2 *!#0%2!?

!,.!//%2!+#'+#*%0%2!/5),0+)!.!00!.0++#"!)7.B%0!!.'&!*0+)2.%/&+*%

+2!.0% +#(*#0%" /"+.(:,2! 0% (%#%*0!.2!*/&+*2! ,/5'+/!B

3$+,&!&*6!0":./0!)7(!0)! /01 %!*2.71* !./:'!2.%/&+*!.%

+2!.!*[bD7./,!.%+ !O[cc]D\Z[ZP)! 2.%!.!* !D%*0!*/%0!0B!0* .!

)7(!02.71* !./:'!+)"+./'&!((!*!)!((+)D'+*0.+((/!'0+.N"+./'&!((!.%

/5),0+)*%27$+( 0/!#%!00%7./,!./,!'0%2B+./'&!((!.%.0!.20%(".%/'*%*#?/+)

!.!*'+)%*/&+*2/5),0+).!)%/&+*+#"1*'/&+*/".%/'$!0?(!+#/71* !./:'0B

8 +)/%/0! !(2/01 %!*(! !01* !./:'0$2%('!"'0+.!./+)% ..0%(0!* !(

,/%!*0!.%''!+,,*7./5),0+).!)%/&+*,70.+//20% (%#%*0!.2!*/&+*B

,'*6**01.(%/0%/'(*#0% //01 %!(!.1'0"+.71* !./:'!2.%/&+*%

B(!.!#%/0.!.0,7((!*5!,/%!*0!./+)):00!'.%0!.%!."+.":./0!

!,%/+ !,/5'+/!OP)!((+)[cc]D[cc^O,%(+0"/!P+#[ccaD\Z[ZB01 %!*(!

!(0%**%[O[ccaD\ZZZ@+,, #!(/!/0!),(1//%*"+.)/&+*/'),*&!.P?

\O\ZZ\D\ZZ^?'1*+,, #!(/!/0!)P?\?]O\ZZ_D\ZZ`@

+,, #!(/!/0!)/,(1//%*"+.)/&+*/'),*&!.P+#^O\ZZaD\Z[Z@

+,, #!(/!/0!),(1//%*"+.)/&+*/'),*&!.?*7)! "+'1/102% !0)!

.1/%* 1/!.0!,/5'+/!.PB((!,/%!*0!./Of`Z\PD2!. %!.(!%*'(1 !.0%

/01 %!*?1*/!00+),/%!*0!*!:*/'!0728.!)! %!*'(%*%/'+,,":(#%*#//01 %!

!((!.%''!B!00!#!01*%'0.!,.!/!*00%20 0#.1**(#B+./))!*(%'*%*#!*2 D/!'0+.)! '+*0.+((/!'0+.(!f\b[,/%!*0!.?( !.[bD`_?%*'(1 !.0)!((+) [cca+#\ZZZ?)! %*"+.)!.0/)05''!B2 %//!(![Z[+#a]

'+*0.+((/!'0+.,/%!*0!.1* !./:'0%#&!*!00!.0%7.,7'(%*%/'+#"1*'/&+*/)!//%#

10"((B%(/(100(!,/%!*0!.%/5),0+).!)%/&+*/))!*(%'*!0)! ,/%!*0!.

%''!%/5),0+).!)%/&+*,70% (%#/5),0+)/001/+#!$* (%*#?+#(+#%/0%/' .!#.!/&+*(!.1'0"+.7% !*0%"%/!.!2.%(!./+)'1**!,.! %'!.!%''!D .!)%/&+*B

+-$,,*6D"+. !(%*#!*!%* %'!.!.0.! 1/!.0!2! 7.!'.100!.!

"(!.!,/%!*0!./28.00% (%#B!*(2!/0!)! %*2!. %!*(!.!#%/0.!.0%[?

+#!*0%(/2.!* !(22!. %(!%''!+,,*7 %#&!*":.%\ZZcB+.0!.!2%/0!!*

#!*!.!((/))!*$!*#)! %*"+.)/&+*/'),*&!.?)!*:'0!

)7(#.1,,!*"+.'),*&!*!%\ZZa(!102% !0)! .1/%* 1/!.0!,/5'+/!.B ))!*(%'*%*#!*)!((+)+#'+*0.+((/!'0+.2%/0!0/%#*%"%'*0"(!.!,/%!*0!.

".D/!'0+.2."1((00%(".%/'*!0!00!.0%7.O][2/[_dPB)!.!**"+. +(!0 /&*/!*!,70%(".%/'*%*#O+ /.0%+\B_@'+*"% !*/%*0!.2(([B\D_B^P?%*'(1/%2!

9 /0%(/5),0+).!)%/&+*+#"1((0% /+. %*8.0!0(0.!% B!00!"1**!02.

.+1/0,70.+//20/%#*%"%'*0"(!.!,/%!*0!./+)$ !$00$:5!

/5),0+)*%272! 0% (%#!.!)7(%*#!. .+,,!010%'+*0.+((/!'0+.B1((0%(".%/'*%*#

$*#+#/7/))!*)! *%272*!#0%2!/5),0+)!.$!(0%/0.0!*2!$* (%*#B

! 1**0'2!'/%00+.%/'!O#%0/&+*)B)P/5),0+)!.?/+)$ !$:5!.!

2!. %!.%D/!'0+.?2. !0%*#!*"+./'&!((!.%#&!**+)/*%00(%#/5),0+)*%27!00!.

0%7.?%)+0/!0*%*#0%($2!*"*02! !00?0++#"!)7.B

!)0%0.!,.+/!*02D,/%!*0!.+#^bd2'+*0.+((/!'0+.,/%!*0!.2.%

/5),0+).!)%/&+*2! 0%D7./+,,":(#%*#!*B''!D.!)%/&+*(!,.! %'!.02 2.%#$!0+#*%272,+/%0%2!/5),0+)!.?/,!/%!(0$((1/%*/&+*!.?% !0+":./0!

7.!*!!00!.!$* (%*#//0.0B!02.%*#!*"+./'&!((%!$* (%*#)!((+)

,/%!*0!./+)$ !+#%''!$ !2! 2.!* !,+/%0%2!/5),0+)!.% %//!7.!*!B

'&#$-+"'&*6"+.'+.0!02! 7.!'.100!.!"(!.!,/%!*0!./28.00% (%#B%(

0.+//"+. !00!2.(*#"+.!* !(2,/%!*0!*!)! 7.(%#,.+#*+/!B%//!

,/%!*0!*!'*0!*'!/7$28.0)+0/0* / 5'0%#!)+0D.!% !0B!0'*

/,!'1(!.!/0"+.*!'0%*#!((!.02%(.1* 0)%* .!%:5!*"((!* !*!#0%2!

/5),0+)!.$./,%(0!*.+((!B% !.!%* %'!.!..!/1(00!*!2:.$!0/0%(0 +#2! 2.!* !%*0!*/0"+'1/B

/!.%!0(*#0% /,!./,!'0%2100%(7:'!/&*/!*!"+.!0)%( !.!/5' +)/"+.(:, )! )%* .!*!#0%2!/5),0+)!.+#! .!"1*'/&+*B!'*%/)!*!' !00!!.

".!) !(!/%''!'(.!?)!*.!/1(00!*!%* %'!.!.!*/))!*$!*#)!((+)0%)%*#

2!$* (%*#+#10"((B5),0+)0%/'%''!D.!)%/&+*,7 !** .!/% !*2%/!.

/))!*$!*#)! 0% (%#!,+/%0%2!/5),0+)!.B!0'*/!10/+)0*!#0%2!+#

"1*'/&+*!((!,7 !*!*!?+#,+/%0%2!/5),0+)!.,7 !** .!?":(#!.1(%'!0./!!.B

% !*/5),0+).!)%/&+*!.!*"+.10/!0*%*#"+."1((0%(".%/'*%*#%* %'!.!. %//!

10 .!/1(00!*!0!*)!.'0%2!$* (%*#22! 2.!* !,+/%0%2!/5),0+)!.% !

":./0!7.!*!2!$* (%*#!.*: 2!* %#?12$!*#%#2+),/%!*0!.$.(%00 +,, #!00% (%#!((!.%''!B

11 +,*,:*++*$+

#*'-&6$! * %*2%* !.(5 .!0)!*0 * *0!.2!*0%+* %* /5$+/%/

01 5 OP !*#%*!!.! * !.(5 !0!0%+* OP +" ,/5$+/%/ ,.+#.))! 0$0 /+1#$0 0+ .! 1! 0$! 1.0%+* +" 1*0.!0! ,/5$+/%/ OP 0$.+1#$ !.(5 !0!0%+* 0!)/ * !40!*/%2! %*"+.)0%+* ),%#*/B $! ,.+#.))! 3/

+*0%*1! "+.+2!.[]5!./B-1/%D!4,!.%)!*0(/01 5.*".+)[cca0$.+1#$

\ZZZ?+),.%*#*.!,.0%/%*#O.!P0+*.!3%0$1/1( !0!0%+*

O+ .!PB * 0$! .! 3/ .! 1! ".+) \` 0+ ^B_ 3!!'/? )! %*

2(1!B %* 0$! + .! 3/ [` 3!!'/B 0%!*0/ ".+) 0$! .! $ /%#*%"%*0(5 (+3!. +2!.(( /5),0+) (!2!(/ 0 /01 5 %*(1/%+*? )%( !. *!#0%2!

/5),0+)/0+*!D5!.* )%( !.*!#0%2!* +#*%0%2!/5),0+)/003+*

"%2!5!./"+((+3D1,B%00(!%/'*+3*+10(+*#D0!.)2.%0%+*%** (+*#D 0!.),0%!*0+10+)!/%*+",/5$+/%/B

!%+6%./0?0$!+&!0%2!3/0+0.'2%%//%01 !/+"+2!.*[bD5!.,!.%+

O[cc]D\Z[ZP3%0$ %""!.%*#!""+.0/B$!/!+* +&!0%2!+"0$%//01 53/0+

%*2!/0%#0!0!*D5!.D+ %""!.!*!/%*/5),0+)/* .!+2!.5?3$%$%/

+)%*0%+*+"/5),0+)0%.!)%//%+** #++ "1*0%+*(+10+)!B$%. ?

"0+./!4,(%*%*#,++./5),0+)+10+)!3%0$* 3%0$+103!.!!4,(+.! B

, '+6$!+"((,0%!*0/)!!0%*#.%0!.%"+."%./0!,%/+ !,/5$+/%/

OP3/)!/1.! [cc]D[cc^O,%(+0,$/!P* ".+)[cca0$.+1#$\Z[Z?%*

*01.(%/0%(+*#D0!.)/01 5B$!/01 53/ %2% ! %*0+[O[ccaD\ZZZ@

!0!0%+*0!)/,(1/%*"+.)0%+*),%#*/P?\O\ZZ\D\ZZ^@ !0!0%+*

0!)/+*(5P?]O\ZZ_D\ZZ`@ !0!0%+*0!)/,(1/%*"+.)0%+*),%#*/P

* ^O\ZZaD\Z[Z@ !0!0%+*0!)/,(1/%*"+.)0%+*),%#*/?*+3(/+

.!//%*#/1/0*!%* 1! ,/5$+/%/PB2(1!/+"((,0%!*0/3!.!

12

%*(1 ! Of`Z\P?%..!/,!0%2!+",0%!*0/H,.0%%,0%+*%*0$!(%*%("+((+3D1, /01 5?5%!( %*#$%#$(5.!,.!/!*00%2!/),(!B+.0$!0!*D5!.D+

+),.%/+*?\b[OA[^[?+A[^ZP,0%!*0/#! [bD`_3%0$"%./0!,%/+ !+"

*+*D""!0%2!,/5$+/%/3!.!%*(1 ! !03!!*[cca* \ZZ[B"0$!/!?[Z[

* a]+,0%!*0/3!.!"+((+3! 1,0[Z5!./* +),.! +*/5),0+) (!2!(/?.!)%//%+** *+*D.!)%//%+*?* .!+2!.5B%*((5?.!)%00! * *+*D .!)%00! ,0%!*0/3!.!+),.! +*!.(5/5),0+),.+#.!//%+*?* (+#%/0%

.!#.!//%+*3/,,(%! 0+% !*0%"52.%(!/,.! %0%*#*+*D.!)%//%+*B

+-$,+6$! %/0.%10%+*/+"%* %0!0$0)*#!/0+.! 1!)% D*

(+*#D.*#!5.!.1%0%*#)+.!,0%!*0/2!.5!.(5B +3!2!.?0$!(+3)! %*

0$03/$%!2! %*[ccaD\ZZZ3/*+0.!D$%!2! 1*0%(\ZZcB$+.0!.

3///+%0! 3%0$0$!,.!/!*!+"%*"+.)0%+*),%#*/?$+3!2!.

%*.!/! 3$!*0.#!0,+,1(0%+*$*#! 0+%*(1 !,0%!*0/3%0$/1/0*!D

%* 1! ,/5$+/%/%*\ZZa? *+0/00%/0%((5/%#*%"%*0B*0$!/!+*

/01 5?/%#*%"%*0(5$%#$!.,!.!*0#!+"+),.! 0++,0%!*0/3!.!

.!+2!.! 00!*5!./O][d2/B[_dP?(.#!(5!1/!+"$%#$!.!),(+5)!*0 .0!/"+.,0%!*0/%*0$%/#.+1,B$%/$!( 0.1! !/,%0!)+.!/!2!.!(5%((,0%!*0/

.+,,%*#+10+"0$!/01 5%*0$!+.!B4!,0"+.$%#$!.(!2!(/+"!4%00%2!

/5),0+)/%*0$!.!?0$!.!3!.!*+)!*/5),0+) %""!.!*!/!03!!*0$!

#.+1,/B%"05D0$.!!,!.!*0+"* ^bd+"+,0%!*0/3!.!%*

/5),0+)0%.!)%//%+*B!#. (!//+"?/5),0+)0%*+*D.!)%//%+*3/

,.! %0! 5,+/%0%2!/5),0+)/0%*(1/%+** ,!./%/0%*#,+/%0%2!/5),0+)/

1.%*#0$!"%./05!.+"0.!0)!*0B"%* %2% 1(/5),0+)/+*(5$((1%*0%+*/

3!.!/%#*%"%*0(5,.! %0%2!+"0!*D5!.*+*D.!)%//%+*B.(5/5),0+) %""!.!*!/3!.!*+0.!"(!0! 5 %""!.!*!/%*0.!0)!*0B

'&$-+!'&+6%./0?0$!1.2!/3$+(!$/!!*)+2! 0+3. /0$!

/$+.0!.O(!"0P!* +"0$!+*0%*11)B +3!2!.?/!!)/0+$2!"%(! %*,%'%*#

though

13 1,/+)!+"0$!,++.!.D,.+#*+/%/(+*#,0%!*0/B!.$,/ !*%(* /0%#)?

(+*#3%0$ +10//0+0$!)+.!%*/% %+1//5),0+)/?*!! 0+! .!//! )+.!

!4,(%%0(5B1.0$!.)+.!?%0/!!)/0$0%*"+.)0%+*),%#*//$+1( $2!

/0(!0.#!0#.+1,?/0(!"+1/* $%#$%*0!*/%05(!2!(B101.!.!/!.$

/$+1( "1.0$!.!(1% 0!,0$35/0+.!%*+. !.0+!/0(%/$,.%*%,(0.#!0/

"+.%*"+.)0%+*),%#*/B!+* ?,,!./0+%*.!/!0$!$*!+")%( !.

!"%%0"+.)0%+*/* /1,!.%+."1*0%+*%*#B$!)!$*%/)/53$%$0$%/

/0.0!#5%),.+2!/0$!(+*#D0!.),.+#*+/%/+",/5$+/%/.!)%*/,!1(0%2!B

!2!.0$!(!//?+1."%* %*#/+2!.0!*5!./)5%* %0!0$0,.+#*+/0%(%*'

!4%/0/!03!!*0%)%*#+"%*0!.2!*0%+** +10+)!0$0 !/!.2!/"1.0$!./01 5B

$%. ?(+*#D0!.)/5),0+)0%*+*D.!)%//%+*/!!)///+%0! 3%0$!.(5 ,+/%0%2!/5),0+)/B0,,!./0$0"1*0%+*(* /5),0+)0% !2!(+,)!*0

"+((+3 %""!.!*0?,.0(5%* !,!* !*00.'/?*!#0%2!/5),0+)/!%*#)+.!

(+/!(5(%*'! 0+"1*0%+*(+10+)!?3$%(!,+/%0%2!/5),0+)/.!)%*//+%0!

3%0$/5),0+)+10+)!B+.!//!.0%2!%*0!.2!*0%+*)5!*!! ! %*,0%!*0/

3$+ +*+0.!/,+* .+1/0(5%*0$!"%./05!.+"0.!0)!*0?3$!0$!.+.*+00$!5

$2!!!* !0!0! I!.(5JB

14

!+,'(-$!,!'&+;!&'**'((*&<

[B !#!(/0 ?B!*!( !*@./!*?B?1!/0 ?B?2!*/!*?B@ $.?B@

+?B@+$**!/!*?B@*#!2!( ? B@!((!?B@,&+. /)+!*?B@+//!.#?

B@1* ?B@%)+*/!*?B@1* !0?B@#(1)?B@.%%/?B@?(/$*?B -$" '-%! $"($$ !#( ###$%(+$#

21-(" %$ B)/5$%0.5@\Z[\@[`cA,B]a^D]bZB

\B !#!(/0 ?B0!*!( !*@./!*?B?1!/0 ?B?2!*/!*?B@ $.?B@

+?B@+$**!/!*?B@*#!2!( ? B@!((!?B@,&+. /)+!*?B@+//!.#?

B@1* ?B@%)+*/!*?B@#(1)?B@(/$*?B@.%%/?B"(

$$ *"(#(!$ !" "## #(!$ $"## #$$%#

$"$("#"#$!# !#( ###$%(,$%6+,$.!/@\Z[]@

[^]@,B]]aD]^]B

]B !#!(/0 ?B0!*!( !*@./!*?B?1!/0 ?B?2!*/!*?B@ $.?B@

+?B@+$**!/!*?B@*#!2!( ? B@!((!?B@,&+. /)+!*?B@+//!.#?

B@1* ?B@%)+*/!*?B@#(1)?B@(/$*?B@.%%/?B"$

%"$ $"$#( ##23-("!"#!$&*.(5*0%*

/5$@!,0! B

15 '&,&,

"

;<#

:

;<

>7 %

>7> +1 '+!+77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777>F

>7? *! !+,'*1'*$1!&,*.&,!'&&(+1 '+!+777777777777777777777777777777777777777777777777777777777777777777777777777777?=

>7@ !*+,(!+'(+1 '+!+;<777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777?@

>7A '-*+&-,'%77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777?A

>7B '.*1777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777?B 01 %!/+*.!+2!.5BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB\a

[B_B[

>7C *!,*!'*'.*17777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777@=

?7> -*,!'&'&,*,+1 '+!+;<7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777@?

?7? &,*&,!'&$!&!&+7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777@?

?7@ *'*%%+,'*-6*$1,,!'&777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777@A

?7A ,'*+!&$-&!&7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777@E

?7B *.&,!'&+,*,!+!&(+1 '+!+77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777A=

.%).5,.!2!*0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB^Z

\B_B[

!+* .5,.!2!*0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB^[

\B_B\

!.0%.5,.!2!*0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB^\

\B_B]

*%2!./(?/!(!0%2!?* %* %0! ,.!2!*0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB^\

\B_B^

16

?7C -!&6'%!&!&!*&,$.$+'(*.&,!'&7777777777777777777777777777777777777777777777777777777777777777777A@

@7> ",!.+&*+* )-+,!'&+77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777AA

@7? 1(', ++7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777AB

@7@ , '+7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777AB !/%#*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB^_

]B]B[

.0%%,*0/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB^`

]B]B\

@7A *$1,,!'&!&,*.&,!'&7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777B>

$!%*"+.)0%+*),%#*/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB_[

]B^B[

!0!0%+*0!)/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB_a

]B^B\

.!0)!*0,.+0++(BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB_b

]B^B]

@7B ++++%&,+77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777BE !(%%(%05BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB`[

]B_B[

@7C ,,!+,!$&$1++77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777C?

"!

A7> *!,!'&!&-*,!'&'&,*,+1 '+!+!&&>E81*(*+(,!.77777777777777777777777777777777777777CB

A7? '&8*%'$$'/8-(', *$1,,!'&!&+1 '+!+,-16,+'&&8*

-,'%777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777CC

A7@ *$1,,!'&5*$1+1%(,'%(*'*++!'&&+1%(,'%,!*%!++!'&,*,&1*+!&

!*+,(!+''(+1 '+!++,-17777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777CD

! "%

B7> '&!,-!&$8+,-17777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777CF ),(!$.0!.%/0%/.+//,$/!/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB`c

_B[B[

% *+0.!)%*0/0(!(+3(!2!(/ 1.%*#,!.%+ /3%0$0$!"1((D,.+#.))!BBBBBBBBBBBBBBBBBBBBa[

_B[B\

3///+%0! 3%0$0$!,.!/!*!+"%*"+.)0%+*),%#*/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBa\

_B[B]

B7? &81*8''%(*!+'&77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777D?

5),0+) 2*0#!/".+)%*(1/%+*?+*!?03+?* "%2!5!."+((+3D1,3!.!*+0)%*0%*!

_B\B[

00$!0!*D5!."+((+3D1,BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBa\

$!D.!$/$%#$!..0!/+".!+2!.500!*D5!."+((+3D1,BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBab

_B\B\

B7@ &81*(*!,!'&'&'&8*%!++!'&7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777E=

" $

C7> *!,!'&!&777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777E?

!.!/%*#/(%!*!+",/5$%0.%%*"+.)0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBb\

`B[B[

4,* ! "+1/+"%*"+.)0%+*),%#*/)5$2!(! 0+!4,* ! ,+,1(0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBb\

`B[B\

C7? &'*%,!'&%(!&+/*++'!,/!, 7777777777777777777777777777777777777777777777777777777777777777777777777777777E@

17 !(,D/!!'%*# !(5/* $!(0$D/5/0!) !(5/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBb]

`B\B[

C7@ '+1%(,'%!*&+,,&1*+777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777EA !(!0%2!00.%0%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBb^

`B]B[

!(0%2!(5/$+.0+BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBb_

`B]B\

C7A ! **'.*1*,+!&777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777EB .%0%%/)+"%*0!.,.!00%+*+".!/1(0/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBb`

`B^B[

C7B *!,!'&'&'&8*%!++!'&77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777ED !#0%2!* ,+/%0%2!%((*!//0.&!0+.%!/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBba

`B_B[

+*D+),(%*!BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBbb

`B_B\

C7C 55+1%(,'%+5&'-,'%777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777EF

# %

D7> +-*%&, $$&+!&, +,-17777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777F>

D7? ' '*,,+777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777F@

D7@ &,*&$&0,*&$.$!!,1!&, 8''%(*!+'&7777777777777777777777777777777777777777777777777777777777777777FA

D7A !*-%+,&+7777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777FC ,%*D+""!""!0/+"A+*"+1* !./+.)+ !.0+./FBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBc`

aB^B[

!#.!!+"1.*%%05BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBca

aB^B\

!(!0%+*%/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBca

aB^B]

10+*+)+1/$*#!3%0$%*0$!/1&!0/+2!.0%)!BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBcc

aB^B^

!0!/0D!""!0BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB[ZZ

aB^B_

!/1.!)!*0/0+*!0%)!,+%*0)5 %""!.".+))!/1.!)!*0/+*0$!*!40BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB[ZZ

aB^B`

00%/0%(.!#.!//%+*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB[Z[

aB^Ba

.+,+10BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB[Z[

aB^Bb

$

E7> $+('+!,!.+77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777>=@

E7? ,!%,!+,!'&777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777>=@

E7@ &'*%'&+&,77777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777>=A

E7A ,9+-&, !$&',,'!&,*.&777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777>=B

% "

>=7> $7'&8,*%'-,'%+,-!+!&(+1 '+!+777777777777777777777777777777777777777777777777777777777777777777777777777777>@?

>=7? $7!&!,!'&+&$&, +'*'++, /'*$77777777777777777777777777777777777777777777777777777777777777>@F

>=7@ ,,*1*7%'+,', !,'*', %*!&'-*&$'+1 !,*1&*+('&+1

*'-( >AB

18 #

19

>7 #*'-&

1.1 Psychosis

/5$+/%/?+. %*#0+0$!4"+. %0%+*.5?%/ !"%*! /I/!2!.!)!*0(

%/+. !.%*3$%$0$+1#$0* !)+0%+*/.!/+%),%.! 0$0+*00%/(+/03%0$

!40!.*(.!(%05JB/5$+0%/5),0+)/)5.%/!3%0$+10*5'*+3*

!*2%.+*)!*0(+.%+(+#%(0.%##!.?+."+((+3%*#/0.!//O0/0!.!0(B?\Z[\P?

.1#1/!O.!* 0!0(B?\ZZ_@!0%*!0(B?\ZZ`@0!(* !((?[cc[P?!.0%*

)! %(+* %0%+*/?0.*!/00!/O/0%((+?\ZZ]P?+./(!!, !,.%20%+*

O+%2%*?\ZZZ@+00!/)**?\ZZ`PB$!5%*(1 !$((1%*0%+*/?)+/0+"0!*

1 %0+.5$((1%*0%+*/%*0$!"+.)+"2+%!$!.%*#?102%/1(?00%(!?+("0+.5 +.0/0!$((1%*0%+*/)5+1.B$!5(/+%*(1 !0$+1#$0 %/+.#*%/0%+*?0+

!+/!.2! /%*+$!.!*0/,!!$+. %/+.#*%/! !$2%+1.?* !(1/%+*/?

%6..!+.*+*D%6..!B$!/!.!(((!((! ,+/%0%2!/5),0+)/B$!)+.!

/!.%+1/"+.)/+",/5$+/!/#%2!.%/!0+*!#0%2!/5),0+)/?/1$/('+"

)+0%20%+** %*%0%0%2!?,/5$+)+0+.,+2!.05?"(0""!0?,0$5?* /+%(

3%0$ .3(B

/5$+0%/5),0+)/ +*+0+1.3%0$%*,/5$+0% %/+. !./+*(5B$!5)5!

,.!/!*03%0$%*3% !.*#!+" %#*+/0%0!#+.%!/ !/.%! %*0$!%#*+/0%

* 00%/0%(*1(ODP+"0$!)!.%*/5$%0.%//+%0%+*

OPO//+%0%+*?\ZZZP?/1$/""!0%2! %/+. !./?,+/00.1)0%/0.!//

%/+. !.O! !0(B?\ZZ_P? %//+%0%2! %/+. !./O+//!0(B?[cc\P@+. !.(%*!

,!./+*(%05 %/+. !.O!!!0(B?\ZZ_P?%*/$%6+05,(* /$%6+% ,!./+*(%05 %/+. !./?* %*/,!.#!.H//5* .+)!O'+'1/'/* ((#$!.?\Z[ZPB+)!

"%* %*#/!2!*/1##!/00$0,+/%0%2!,/5$+0%/5),0+)/+1.%*_Dbd+"0$!

#!*!.(,+,1(0%+**+0,.!/!*0%*#"+.0.!0)!*0O2*/?\ZZ]PB

20 ,!%"%,/5$+0% %/+. !./%*(1 !/$%6+,$.!*%? !(1/%+*( %/+. !.?

/$%6+""!0%2! %/+. !.?/$%6+,$.!*%"+.) %/+. !.?.%!",/5$+0% %/+. !.*

,/5$+/%/*+0+0$!.3%/!/,!%"%! B$%6+,$.!*%%/0$!)+/0/!2!.!"+.)B0/

,+%*0,.!2(!*!%/,,.+4%)0!(5^B_,!.[ZZZ?(%"!0%)!,.!2(!*!+10[d?

* 5!.(5%*% !*!+*2!.#![_,!.[ZZZZZ+"0$!,+,1(0%+*O* +*!0 (B?\ZZbPB0%/ %#*+/! +*0$!/%/+"0$!*1)!.?/!2!.%05* 1.0%+*+"

,/5$+0%/5),0+)/B*/$%6+,$.!*%,/5$+0%/5),0+)/+"0!*"(1010!%**

!,%/+ %)**!.?3%0$.!1..%*#,/5$+0%!,%/+ !/* %*0!.)%00%*#,!.%+ /+"

.!)%//%+*B*+10\ZD]Zd+",0%!*0/?0$!+1./!%/$.+*%B1.0$!.)+.!?

/$%6+,$.!*%%///+%0! 3%0$$!%#$0!*! )+.0(%05O1/$!*!0(B?[ccbPB 0!/+"+),(!0! /1%% !$2!!!*"+1* 0+.*#!!03!!*_* []dO+),%(%

!0(B?\Z[[PB**%/$/01 5?[_D\`d+",0%!*0/$ ) !+*!+.)+.!/1%% ! 00!),0/!"+.!0$!%."%./0+*003%0$)!*0($!(0$.!O+. !*0+"0!0

(B?\ZZ^PB+*!(%*!//* /+%((%!*0%+*.!%),+.0*0%//1!/@+),.! 0+0$!

#!*!.(,+,1(0%+*?/$%6+,$.!*%,0%!*0/(/+$2!aD[Z0%)!/$%#$!..%/'+"

!%*#/%*#(![Z5!./"0!."%./0 )%//%+*O#!.+!0(B?\ZZ^PB*/1)?0$!

$1)*+/0%/2/0* +"0!* !2/00%*#B

1.2 A brief history of early intervention and psychosis

$!+*!,0+"!.(5%*0!.2!*0%+*%*,/5$%0.5 !2!(+,! %*0$!(0!/0 !!**%

+"0$!\Z^0$!*01.53%0$%*0$!".)!3+.'+")%*(5%+(+#%(,. %#)?0.%*#

'0+0$![c[Z/* D\Z/?3$!*,/5$%0.53//+)!0$%*#0$03/,.0%/! %*

)!*0(/5(1)/+*!.*%*#2!.5%((* !2%*0,0%!*0/B$!!.)*,/5$%0.%/0 .!,!(%*/0.+*#(5 $!.! 0+)! %()+ !(+")!*0( %/+. !./?+.#*%/%*#

(1/0!./+"/5),0+)/%*0+(//%"%0%+*+"*+/+(+#%( %/!/!!*0%0%!/B$%/

!)!3% !(51/! 5(%*%%*/%*0$!!/0!.*3+.( B"0!.+.( .?0$!

.!(%/0%+*+"0$!%),00$0I/0.!//J?* 0.1)?+1( $2!+*)!*0($!(0$

21

#.!3?!/,!%((5%*0$!B$!!4%/0%*#,/5$%0.%*+/+(+#%!/"%(! 0+,01.!

0$0B!1.+0%/5),0+)//1$/*4%!05,.+(!)/.!!%2! %*.!/! %*0!.!/0B

*0!.2!*%*#%*0$!/!/00!/3/0$+1#$00+,+//%(5,.!2!*0)+.!/!2!.!

,/5$+(+#%(/5),0+)/@,.!1./+.+"0+ 5H/!.(5%*0!.2!*0%+*%*,/5$%0.5B

$!.!3/(/+.!*!3! %*0!.!/0%*,/5$+*(50%(0$%*'%*#B

!*0(%((*!//)!0+!/!!*/.!/1(0+",/5$+(+#%(+*"(%0*

!*2%.+*)!*0("0+./+((% %*#O%./0* '!"%!( ?\Z[ZPB* %0%+*?/+%+(+#5

* *0$.+,+(+#5#%*! %*"(1!*!!1/!+"0$!/%-1!/0%+*/0$0.+/!+10 3.* %0/1/!/* !""!0/B

$!#.+3%*#%*"(1!*!+"0$!/!/%!*0%"% %/%,(%*!/3/(/+,,.!*03%0$%*

,/5$%0.5B+%((//?"+.%*/0*!?3/0$.+1#$/!2!.(/01 %!/!/0(%/$! / !0!.)%**0+")!*0( %/+. !./O(!.)*!0(B?[cb_PB$!/+%(* *(50%(

35/+"0$%*'%*#3!.!+)%*! %*0+,/5$+/+%()+ !(+")!*0( %/+. !.?

3$%$.!)%*! 0$!,.!2%(%*#,. %#)%*,/5$%0.51*0%(0$!)% DaZ/B$!"%./0

%#*+/0%* 00%/0%(*1("+.!*0(%/+. !./?,1(%/$! %*0$!

[c_\?3/,.+ 10+"0$%/,. %#)B/5$+(+#%(/5),0+)/ % *+0.!"(!0 %/!/!!*0%0%!/?10.0$!."1("%((! "1*0%+*+" %/#1%/%*#1* !.(5%*#+*"(%0B*

0$!"%!( +",/5$+/%/?,/5$+(+#%/0/* ,/5$%0.%/0/(++'! "+.!0%+(+#%(

"0+./* !4,(*0%+*/%* 2!./!$%( $++ !4,!.%!*!/?,.0%1(.(5

!)+0%+*(!4,!.%!*!/.!(0! 0++))1*%0%+*B5,%((5?,/5$+/!/3!.!

((! I/$%6+,$.!*%.!0%+*/J?* I,/5$+0% !,.!//%2!.!0%+*/J?* /+

"+.0$B*0$!1.+,!** * %*2%*+1*0.%!/?$+3!2!.?,/5$%0.50!* ! 0+

)%*0%*0$!.!,!(%*%*0. %0%+*?%*3$%$ %/!/!!*0%0%!//1$/,/5$+/%/

3!.!!(%!2! 0+$2!/,!%"%%+(+#%(1/!/B !*!?%*0$!+.0$)!.%*

0. %0%+*00$%/0%)!?)!*0(%((*!//3/)1$)+.!1*%0.5+*!,0?3$!.!

%#*+/0%#.+1,/3!.!-1*0%00%2!(5?*+0-1(%00%2!(5? %""!.!*0)*%"!/00%+*/

+"0$!/)!?!*2%.+*)!*0((5 !0!.)%*! 1/!/?3$!.!/%*0$!1.+,!*

0. %0%+*? %""!.!*0!0%+(+#%!//0%((3!.!0$+1#$00+1/! %""!.!*0 %/!/!/B

22

!1/!%*0$!+.0$)!.%*0. %0%+*+1* .%!/!03!!*0$!3!((* 0$!

/%'!)! %""1/!?0$!*0%D,/5$%0.5)+2!)!*0#%*! 0!..%*O6/6?[ca^PA

$!(!((%*#+",!+,(!/I)!*0((5 %/+. !.! J3/)!$*%/)+"/+%!0(

+*0.+(O+"")**?[c`[@$!""?[caZP?* +),.+)%/! 0$!(!#(* $1)*

.%#$0/+",0%!*0/B1.0$!.)+.!?%*)+ !(3$!.!)!*0( %/!/!/*!*0%05 %

*+0!4%/0?2(% %05* .!(%%(%05+" %#*+/!/3!.!2%#+.+1/(5 %/,10! B/

.!0%+*?0$!.!(%%(%05+" %#*+/!/3/!2(10! !),%.%((5O+%*/*

16!?[caZPB+"%(%00!0$%/3+.'/0.101.! %*/0.1)!*0/0+)'! %#*+/0%

(//%"%0%+*/3!.! !2!(+,! B(/+?*%*.!/%*#*1)!.+",/5$%0.%/0/

.%0%%/! *0%D,/5$%0.5?0+ !"!* 0$!%.,.+"!//%+*?3$%$?/.!/1(0+"/+%(

,/5$%0.5* /+%(0%2%/)?3/+*I0$!! #!+"!40%*0%+*J+. %*#0+0$!

,.!/% !*0+"0$!)!.%*/5$%0.%//+%0%+*00$00%)!O%(/+*?[cc]PB 1.0$!.)+.!?0$!.#1)!*03/) !0$0/!2!.!(5%((,0%!*0/ % *+0#!00$!

0.!0)!*00$!5*!! ! B$%/).'! .!01.*0+0$!)! %()+ !(+" %/!/!?

.!01.*0$03/"1!((! 50$!#.+3%*#1/!+")! %0%+*(%'!(%0$%1)*

*!1.+(!,0%/?%*0.+ 1! %*0$![c_Z/* [c`Z/B$!/!%),.+2! 0$!+1./!+"

/5),0+)/B1.%*#0$![caZH/0$! !2!(+,! *!32!./%+*+"0$!?3$%$

3/"%*%/$! %*[cbZB03+1( ! !/.%,0%2!)*1("+.0$!//!//)!*0+"

!/%(5+/!.2(!/5),0+)/B03/%),+.0*00+((0$!(%/0! %#*+/!/

I %/+. !./J?I %/!/!J?I%((*!//J+.I/5* .+)!/J?*+0+*(5"+.% !+(+#%(.!/+*/

(%/0! +2!10(/+"+.!+*+)%(.!/+*/D%*/1.*!+),*%!/3+1( *+0 .!%)1./!0.!0)!*0+"3$03/*+ %/+. !.? %/!/!?%((*!//?+./5* .+)!B ,. %#)/$%"0'0+%+(+#53/*+3"0?* 0$!$+,!3/0$0 %/!/!/

3%0$'*+3*?,.! +)%**0(5%+(+#%(?!0%+(+#%!/3+1( 3%0$0%)!* .!/!.$

.!,(!0$!0$!+.5D*!10.(0!#+.%(* !/.%,0%2! %#*+/!/%*0$!B

$%/+1./!+"$%/0+.5(/+%*"(1!*! 0$!1* !./0* %*#* 0.!0)!*0+"0$!

,/5$+/!/* 0$!+*!,0+"!.(5%*0!.2!*0%+*B2!.0$! ! !/0$!+*!,0+"

23

*!1.+0%!.(5/5),0+)//)%( 2.%!0%!/+"(0!./!2!.!,/5$+,0$+(+#5?/

/!!*"0!.+.( .?&+%*! 3%0$0$!%+(+#%(,. %#)B.(5 !0!0%+**

%*0!.2!*0%+*%*,/5$+/%/3//% 0+!I/! +*0$!+*2%0%+*0$01..!*0 0.!0)!*0)+ (%0%!/"+./$%6+,$.!*%.!!40.0%*# %)%*%/$%*#.!01.*/

!1/!0$!5 +*+0 .!//0$!/%*!1.+%+(+#%( !0!.%+.0%+*+. !"%%0

"+.)0%+*///+%0! 3%0$0$! %/+. !.JO(/$** +$**!//!*?[cc`PB

$%/*+0%+*,.!/1,,+/!//+)!/+.0+" !#!*!.0%2!,.+!//?3%0$.++0/%*0$!

%+(+#%(,. %#)%*,/5$+(+#5* ,/5$%0.5B

1.3 First episode psychosis (FEP)

$%(!,0%!*0/)5!4,!.%!*!+*!!,%/+ !+*(5?)+/0 +*+0B*10$

%*% !*!/01 5O,.0+"0$!*0!.*0%+*(01 5+"$%6+,$.!*%O/+P?a_d+"

"%./0!,%/+ !/$%6+,$.!*%,0%!*0/$ 0(!/0+*!)+.!!,%/+ !50$![_D5!.

"+((+3D1,B"0$+/!3$+.!(,/! ?bZd$ )+.!0$*03+.!(,/!/B !*!?%/

,.! %0+.+""101.!,/5$+0%!,%/+ !/ B!/!.$%* %0!/

0$0!.(5%((*!//

"+."101.!+1./!O%.$3++ !0(B?[[email protected])(%/$!0(B?\ZZcPB0$/

+"*!1.+ !2!(+,)!*0?* 3$!*0$%/ !2!(+,)!*0/0+,/?/+ +!/

!0!.%+.0%+*O(/$** !*0+*?[cc]PB+.%*/0*!?/5),0+)0+(+#5 O%.$3++ !0(B?[[email protected])(%/$!0(B?\ZZcP/$+3/ !(%*! 1.%*#0$!"%./0\D]

5!./+"%((*!//?10(!2!(/+""* /0%(%6!/?/ +!/*!1.+,/5$+(+#%(

"1*0%+*%*#O+6%'/* * .!+1?\Z[[@1* !0(B?\ZZ^PB!(5! ?+.*+*D .!/,+*/!0+,/5$+,$.)+(+#%(0.!0)!*0O ..%/+*!0(B?\ZZ[@!.'%*/!0 (B?\ZZ^P.!/1(0%*#%*)+.!0%)!%*,/5$+/%/ 1.%*#0$!"%./003+5!./+"%((*!//

,.! %0,++.!.+10+)!%*0!.)/+"$%#$!.(+*#D0!.)/5),0+)(!2!(/B

(Wiersma et al., 1998)

,$/!/* .!/,+*/!0+0.!0)!*0 1.%*#0$!"%./05!./"0!.+*/!0 .!.!(!2*0

!!*$5,+0$!/%6! 0$0%+(+#%((5 .%2!* !0!.%+.0%+*+,!.0!/3%0$%*0$!3%* +3

24

1.4 Course and Outcome

+/0+"0$!'*+3(! #!+"+10+)!%*,/5$+/%//0!)/".+)!%0$!.$.+*%?0.!0!

%*% !*!?+.I"%./0!,%/+ !/$%6+,$.!*%J/),(!/?+.)%401.!+"((0$!/!?+"0!*

+*2!*%!*!/),(!/".+)$+/,%0(/B$%/$),!./+),.%(%05O(!/!**

+.0!*/!*?\ZZ\PB$!/!/01 %!/%* %0!0$0!2!*0$+1#$+1./!* ,.+#*+/%/

$2!%),.+2! "0!.0$!%*0.+ 10%+*+"*0%,/5$+0%)! %0%+*

O(!*/'5?[cca@$3.06!0(B?[cc]P* /0.101.! ,/5$+/+%(0.!0)!*0/

O%((%*#!0(B?\ZZ\P?1,0+bZd+",0%!*0/3%0$0$!)+/0/!2!.!

"+.)/+",/5$+/%//0%((/1""!.*+10+)!$.0!.%6! 5!%0$!..!(,/%*#

/5),0+)/?"1*0%+*(%*,%05+.+0$O+00(!* !.!0(B?\ZZ]@+00(!* !.!0 (B?\Z[Z@*!2!0(B?[ccb@ ..%/+*!0(B?\ZZ[@ +,,!.* * !.(%*#?\ZZZ@

.*!.+/!0(B?[cbc@+ !/0%*!0(B?\ZZ]@%!./)!0(B?[ccbPB$', ((&!0/$+3/+10+)!/?/),(!/?* !"%*%0%+*/+"(+*#D0!.)/01 %!/Oh[Z 5!./PB++.+10+)!%///+%0! 3%0$)(!#!* !.* 5+1*##!M!.(5#!+"

+*/!0O(0)1.!0(B?\ZZa@* +*!0(B?\ZZc@%!./)!0(B?[ccbP?,++.

,.!)+.% "1*0%+*%*#O./!*!0(B?\ZZ^@+'!0(B?\ZZ^P?/1/0*!

1/!O.!!*!0(B?\ZZ^P?* ,/5$+(+#%(0.1)O + #%*/!0(B?\ZZc@5/'!.

!0(B?\ZZcPB

0(!/0_Zd+"/$%6+,$.!*%,0%!*0/$2!!!*"+1* 0+!4,!.%!*!,+/%0%2!

,/5$+0%/5),0+)/!5+* [Z5!./"0!.+*/!0O.+)!0!0(B?\ZZ_@0+((!0 (B?[cc]PB1.0$!.)+.!?,,.+4%)0!(5[_d %/,(5 !"%%0,0$+(+#5?%B!B /5* .+)!/$.0!.%6! 5$.+*%*!#0%2!/5),0+)/* ,++.+10+)!?

.%/%*#0+\_D]Zd%*$.+*%,+,1(0%+*/O%.',0.%'!0(B?\ZZ[@0.1//!0 (B?\Z[ZPB50$![ccZH/?%03/+*/% !.! *!/0(%/$! "00$0*!#0%2!

/5),0+)/.!)+*#0$+/!0$0)+/0 2!./!(5%*"(1!*!+10+)!O!!"!!0 (B?[cbaPB!03!!*\ZD^_d+"/$%6+,$.!*%,0%!*0/.!""!0! ? !,!* %*#+*

0$!"+((+3D1,0%)!+"0$!/),(!O++*/0.!0(B?\Z[\PB$!5.!//+%0! 3%0$

25

%),%.)!*0/%*%* !,!* !*0(%2%*#/'%((/?/+%("1*0%+*%*#?* -1(%05+"(%"!

O(2.!6D%)!*!6!0(B?\Z[\@.+3*!!0(B?\ZZZ@%.',0.%'* %/$!.?\ZZ`@

%(!2!0(B?\ZZ_@+.)*!0(B?\ZZZ@!0!./!*!0(B?\ZZb@)/5!0(B?\Z[[@

$)%06!0(B?\ZZa@1.*!.!0(B?\ZZcPB(%*'!03!!**!#0%2!/5),0+)/*

%+(+#%(,.+!//!/$/!!*/1##!/0! B.!!*0)!0D*(5/%//$+3! 0$0

*!#0%2!/5),0+)/.!(%*'! 0+#!*!0%/1/!,0%%(%05O/0!.!.#!0(B?\Z[ZPB 1.0$!.)+.!?+#*%0%2! 5/"1*0%+*/O+.!0(B?\ZZcP?#.!5)00!..! 10%+*/

O+.!0(B?\Z[[P?* +0$!..%**+.)(%0%!/.!)+.!+))+*%*0$!)+.!

/!2!.!/!/+"/$%6+,$.!*%3%0$*!#0%2!/5),0+)/O((%/+*D.%#$0!0 (B?\ZZbPB$!/!*+.)(%0%!//!!).!(0! 0+0+0( 1.0%+*+"%((*!//B!3(+*#D 0!.)/01 %!/? !"%*! /h[Z5!./?+"$2!!!*+),(!0! B4%/0%*#/01 %!/

.!,+.0+10`Zd,++.+10+)!?3%0$/+)!2.%%(%05%*3$0+*/0%010!/I#++

+10+)!JO !*.5!0(B?\Z[Z@$%0!!0(B?\ZZcP;$><7

1.5 Recovery

!+2!.5%/0$!+,,+/%0!+",++.+10+)!3%0$(/0%*#/5),0+)/* "1*0%+*(

%),%.)!*0B0%/(+/!(5(%*'! 0+"1*0%+*(+10+)!B0$/!!*+"%*0!.!/0/%*!

.!,!(%* .!//! 0$%/00$!!#%**%*#+"0$!\Z^0$!*01.5B.!,!(%*3/

1* !.0$!%),.!//%+*0$0/+)!,0%!*0/3%0$/$%6+,$.!*%.!+2!.! ?3$%(!

1#!*!(!1(!.$ )1$)+.!,!//%)%/0%+10(++'+*,.+#*+/%/?/00%*#0$0

$!$ *!2!./!!*/%*#(!,0%!*0!+)%*#+),(!0!(5".!!+"/5),0+)/"0!.

*!,%/+ !+"/$%6+,$.!*%,/5$+/%/B*[c`\?(%*%(/01 5OfI+10J\ZZP +*.!+2!.5%*/$%6+,$.!*%3/,1(%/$! O%((*0?[c`\P? !"%*%*#.!+2!.5/

+)%*0%+*+"('+",+/%0%2!* *!#0%2!/5),0+)//3!((/I.!01.*0+

0$!$%#$!/0,.!)+.% (!2!(+""1*0%+*%*#JB%"0!!*,!.!*0+",0%!*0/%*0$!%.

/),(!"1("%((! 0$%/.%0!.%+*"0!."+((+3D1,,!.%+ +"0(!/0+*!5!.B*!

+0$!.+( !./01 5O !(#/+*?[ccZPO,0%!*0/.!.1%0! %*[c``D`a* //!//! %*

26

$>7'&8,*%'-,'%!&+,-!+

!"!.!*!/ +0%+*M/01 5 %)!

/,*

!+2!.5M+10+)!

!"%*%0%+*

.!+2!.5@

!),(+5)!*0?

+10+)!

O$%0!!0 (B?\ZZcP

*$!/0!.?

f[Zc [Z 5!./

U++.)!*0(

$!(0$* *+

3+.'?,++./+%(

"1*0%+*%*#

U3+.'%*#00%)!

+"//!//)!*0 U3+.'(/05!.

U3+.'%*#)+.!

0$*_+"(/0[Z 5!./

`]d [cd

\]d

^^d

O'%*!*

!0 (B?\Z[ZP

%*(* f^`

O[c``

%.0$

+$+.0P [Z

5!./ !#0%2!

/5),0+)/ ]cd

O !*.5!0

(B?\Z[ZP !(+1.*!?

1/0.(%

OP

f`_[ a

5!./ Uh`Z

U5),0+) .!)%//%+*

U+%(.!+2!.5A /+%(?/%(%2%*#

0/'/?* 3+.'?

O*5,%

!),(+5)!*0?+.

/$++(h$("0%)!P

^\B[d ]`Bbd ]ZB_d

\]B_d

U!)%//%+*e/+%(

.!+2!.5 O %((!0

(B?\Z[\P

1(%*?.!(* f[\] [\

5!./

U!)%//%+*

U* !,!* !*0 (%2%*#A

U),(+5)!*0 O$+1./

1*/,!%"%! P

`ZB\d

^Zd ]ad

27

[cbaP(/+.!,+.0! +*"1*0%+*(+10+)!B$!5+*(1 !+*[Za,0%!*0/3%0$

/$%6+,$.!*%?"+((+3! 1,+2!.\Z5!./?0$0AI2!.$("+"0$!)*!2!.)..%! ? ]\d+"0$+/!3$+)..%! $ %2+.! * /%)%(.*1)!.$ (+/00$!

/1,,+.0+"0$!%.")%(%!/BJ

!+2!.5/+*!,0#%*! )+)!*01) 1.%*#0$!(0!.[cbZH/?* $/!!*

!/.%! /I !!,(5,!./+*(?1*%-1!,.+!//+"$*#%*#+*!H/00%01 !/?

2(1!/?"!!(%*#/?#+(/?/'%((/* M+..+(!/B0%/35+"(%2%*#/0%/"5%*#?$+,!"1(?

* +*0.%10%*#(%"!!2!*3%0$(%)%00%+*/1/! 50$!%((*!//B!+2!.5

%*2+(2!/0$! !2!(+,)!*0+"*!3)!*%*#* ,1.,+/!%*+*!H/(%"!/+*!#.+3/

!5+* 0$!0/0.+,$%!""!0/+")!*0(%((*!//XO*0$+*5?[cc]PB

Studies on recovery 1.5.1

!+2!.5$/!!*+,!.0%+*(%6! %* %""!.%*#35/B*+2!.2%!3%/,.!/!*0! %*

0$!,,!* %4;,$<7*!.)*5?%0$/!!*//!//! 1/%*#0$!**$!%)

%/%(%05//!//)!*0$! 1(!O+00(!* !.!0(B?\Z[ZP? !.%20!+"0$!

%/%(%05//!//)!*0$! 1(!O DP//!//%*#?)+*#+0$!./?3+.'*

/+%("1*0%+*%*#(/0)+*0$O(!*/'5!0(B?[cbZ@*!0(B?[cc`PB*0$

/01 5?+*(5[^d+"/$%6+,$.!*%,0%!*0/Of`[P$ I*+/+%(%),%.)!*0J O+00(!* !.!0(B?\ZZ]@+00(!* !.!0(B?\Z[Z@#!.!0(B?\ZZ^@+((!.!0(B?\Z[Z@

+((!.!0(B?\Z[ZP"0!.[_5!./B(.#!/01 5%*0$!1/! /(!((!

!2!*/0!%*D(!%*D+(('/(! !2!*/0!%*? [c`` +)%*! 3%0$0$!

0.1//D.,!*0!.(!O0.1//* .,!*0!.?[caaP?* !"%*! .!+2!.5/

5!.+"*+/5),0+)/?*+ )%//%+*/?*+,++./+%("1*0%+*%*#?(%2%*#

%* !,!* !*0(5?* 3+.'%*#$("0%)!+.)+.!O ..+3* +!?\ZZ_PB+10 at

( )

one

28

\Zd+",0%!*0/3%0$/$%6+,$.!*%+./$%6+,$.!*%"+.) %#*+/!/0/01 5

%*(1/%+*?* ^Zd+",0%!*0/3%0$I+0$!.,/5$+/!/J%*(1 %*#""!0%2!

,/5$+/%/?"1("%((! 0$!/!.%0!.%"0!.[_5!./B10+"0$!0+0(#.+1,+"//!//!

,0%!*0/Of\a^P?^Zd$ $ 0(!/0+*!,!.%+ +".!+2!.5 1.%*#0$!"+((+3D 1,,!.%+ B*!)&+.,1(%0%+*O ..%/+*!0(B?\ZZ[P".+)0$!(.#!?)1(0%D/%0!

*0!.*0%+*(01 5+"$%6+,$.!*%O+P.!,+.0/.!+2!.5.0!/%*

%* 1/0.%(%/! +1*0.%!/+"[_d"0!.[_5!./?/! +*0$!(!1(!.(!+"

!+2!.5O/5),0+)/(/0)+*0$PO(!1(!.?[cabP* 0$! DB$%/%/%*

+*+. *!3%0$*+0$!.,1(%0%+*".+)0$%//01 5?(++'%*#01.+,!*

+1*0.%!/+*(5* 1/%*#0$!/)!)!/1.!)!*0/?* "%* %*#[^d+",0%!*0/

.!+2!.! "0!.[_5!./O%!./)!0(B?\ZZZPB*/01 5?0$!%"!$.0

$! 1(!O1//!.!0(B?\ZZZP?)!/1.%*#"1*0%+*%*#* /5),0+)/+2!.0$!,/0 03+5!./?/$+3! 0$0[ad+"0.!0! %*% !*!+$+.0+"/$%6+,$.!*%

,0%!*0/3!.!%*I"1((.!+2!.5J"0!.)!*"+((+3D1,0%)!+"[]5!./O/+*!0 (B?[cc_PB)+.!"2+1.(!+10+)!3/"+1* %*1(#.%?3$!.!][d+"

I.!!*0+*/!0JO3%0$%*03+5!./,.%+.0+%*(1/%+*P/$%6+,$.!*%,0%!*0/0[`

5!./"+((+3D1,?"+.0$!,/003+5!./$ $ *+,/5$+0%/5),0+)/?$ $!(

&+?$ (%2! %* !,!* !*0(5* 3!.!)..%! +. %2+.! O*!2!0(B?[ccbPB (/+?0$+1#$1/%*#1*/0* . %6! //!//)!*0/?0$!(.#!!.)+*0D/01 5%*0$!

$ )+.!"2+1.(!+10+)!/?/\`dO%*!P^adO!.)+*0P+"$.+*%

/$%6+,$.!*%/),(!I3+.'! %*/+)!,%05J"0!.]Z5!./O!%/0+!0 (B?[cc_PB*/),(!+".!!*0(5/01 %! %*0$!?/5),0+)+10+)!

+. %*#0+I!*!.(.0%0%+*!.1!/0%+**%.!J3/I,++.J%*`]d+"/!/

"0!.[Z5!./?3$%(!\]d$ !!*!),(+5! O,.0D+."1((0%)!P0$!(/05!.

O$%0!!0(B?\ZZcPB*+0$!.(+*#D0!.)/01 5.0! \]B_d+",0%!*0//

.!+2!.! ? !"%*! /$2%*#/5),0+).!)%//%+** 1*%),%.! /+%(*

2+0%+*("1*0%+*%*#"0!./!2!*5!./O !*.5!0(B?\Z[ZPB** %*/01 51/!

.!+2!.5)!/1.!+),+/%0!+"I+$+/,%0(%/0%+*(/0\5!./J?/+.!h bZ?1(%05+"%"!(!/+.!hbZ?]+.$%#$!.O+*]D_/(!P+*/(!"+.K/+%(

29

"1*0%+*%*#?%* !,!* !*0(%2%*#?! 10%+** /+%(1. !*L* K(%*%(

(+(),.!//%+*(!L* "+1* 0$0!03!!*]\d* ^`d+"0$!/01 %!

[Z[/$%6+,$.!*%,0%!*0/"1("%((! 0$!/!.%0!.%"0!.[Z5!./O$.%2/02!0 (B?\Z[ZPB

),(+5)!*0%/,.0+")+/0 !"%*%0%+*/+".!+2!.5B*.!2%!3?.3$*

+$*/+*"+1* 0$0+*(5[ZD\Zd+",0%!*0/3%0$$.+*%/$%6+,$.!*%?* []D

^]d+""%./0D!,%/+ !+",/5$+/%/,0%!*0/$ *5!),(+5)!*0O.3$*

+$*/+*?\ZZ^PB%'!./+** +((!#1!/"+1* 0$0]`d+",0%!*0/$+/,%0(%6!

3%0$,/5$+0%/5),0+)/?+0$""!0%2!* *+*D""!0%2!?$ *+3+.'+./$++(

0%2%050((3%0$%*03+5!./+"%((*!//O%'!./+*!0(B?\ZZaPB$!

1*!),(+5)!*0.0!"+.D,0%!*0/%**+0$!./01 53/`_d"+.0$!)+*0$

,.%+.0+$+/,%0( )%//%+*O)/5!0(B?\Z[\PB

+.35$/(+31*!),(+5)!*0.0!/A\B]d%*\Z[\B$!* "%#1.!/"+.

0$!/)!5!..![ZdO.*#!_dD\`dP* ad?.!/,!0%2!(5?* .%/%*#/

.!/1(0+"0$!"%**%(.%/%/B*+*0./0?+.3!#%* %/%(%05,!*/%+*.0!/.!

$%#$@+10[ZdB*0$!??1/0.(%* 0$!0$!/!.0!/.!+10^D_dB

*\ZZZ?+.3!#%*/01 5,1(%/$! 1*!),(+5)!*0"%#1.!/+"/),(!+"a`

/$%6+,$.!*%,0%!*0/O!((!!0(B?\ZZZPB!2!*5!./"0!. %#*+/%/ )%//%+*

0+*10!1*%0?c^d$ *+!),(+5)!*0* $ %/%(%05,!*/%+*+.+0$!.

%((*!//!*!"%0B%)%(.(5?(.#!.!#%/0!.D/! Of^`Z^P/01 5.!,+.0! I*+

%*+)!".+)!),(+5)!*0J%*c]d+"/$%6+,$.!*%,0%!*0/O !((!*

.73!?\ZZaPB*/01 51/%*# 0?_cd0/0.0+"0.!0)!*0* `\d 0\D5!."+((+3D1, % *+0$2!!),(+5)!*0D/! %*+)!O* !.#!0 (B?\Z[[PB$%/%* %0!/0$0+10`Zd+",0%!*0/.!!%2!/+)!"+.)+"

%/%(%05,!*/%+*(.! 5"0!.03+5!./?* 0$%/"%#1.!/!!)/0+%*.!/!

1.%*#(+*#!.D0!.)"+((+3D1,O!((!!0(B?\ZZZPB !*!?+*!)5+*(1 !0$0 .0!/+"1*!),(+5)!*0.!2!.5$%#$)+*#,0%!*0/3%0$,/5$+/%/?!/,!%((5

30 +),.! 0+0$!#!*!.(,+,1(0%+*?(/+%*+.353$!.!1*!),(+5)!*0/!!)/

(+3B

1.6 Criteria of recovery

*)+/0/01 %!/?.!+2!.5%*+.,+.0!//+)!2!./%+*+"/5),0+)0%.!)%//%+*B 10+)!.!/!.$$/!!*$),!.! 5 %2!.#!*0.!)%//%+*.%0!.%?* %0$/

!!*/$+3*$+30$!/! %""!.!*!/5%!( %""!.!*0.!)%//%+*.0!/B*!/01 5 0!/0! 0$%/!4,(%%0(5?1/%*#"+1. %""!.!*0/!0/+".!)%//%+*.%0!.%A%0$*

3%0$+10*!#0%2!/5),0+)/%* %0%+*0+,+/%0%2!/5),0+)/?* 0%)!/,*/+"]

* `)+*0$/+"/0(!.!)%//%+*B/%*#,+/%0%2!/5),0+)/+*(5* ])+*0$/H /0(!.!)%//%+*?.0!+"c^d3/$%!2! %*/),(!+"[^[,0%!*0/B+.

`)+*0$/?0$%/.0!3/b^dB*(1 %*#*!#0%2!/5),0+)//3!((?.!)%//%+*

.0!/ .+,,! 0+aZd* _`d"+.]* `)+*0$/?.!/,!0%2!(5O//% 5!0 (B?\Z[ZPB1.0$!.)+.!?*+0+*(5/5),0+)/%*(1 ! %*.%0!.%2.5?/+ +

//!//)!*0%*/0.1)!*0/1/! AO*!2!0(B?[ccb@ ..%/+*!0(B?\ZZ[@ !*.5

!0(B?\Z[Z@/+*!0(B?[cc_P?O+((!.?\ZZ\P@O/+*!0(B?[cc`@

+((!.?\ZZ\P?O.!*#+!0(B?\ZZZP?* O*!2!0(B?[ccb@/+*!0 (B?[cc`@%!./)!0(B?\ZZZP!%*#)+*#0$!+*!/)+/0".!-1!*0(51/! B 1.0$!.)+.!?/),(!//01 %! $2!!!*$!0!.+#!*!+1//3!((?+*/%/0%*#+"

)%4+"$.+*%O!%/0+!0(B?[cc_@+ !/0%*!0(B?\ZZ]P?I.!!*0J+."%./0+*/!0 /$%6+,$.!*%O+00(!* !.!0(B?\ZZ]@*!2!0(B?[ccb@ ..%/+*!0(B?\ZZ[@

+,,!.* * !.(%*#?\ZZZ@1!0(B?\ZZ]@$.%2/02!0(B?\Z[ZP?

O !*.5!0(B?\Z[Z@'%*!*!0(B?\Z[Z@$%0!!0(B?\ZZcP?*+*D""!0%2!+*(5 O ..+3!0(B?\ZZ_@+((!.?\ZZ\@0!,$!*/!0(B?[cca@%!./)!0(B?[ccb@

%!./)!0(B?\ZZZP@+.)%4! ""!0%2!* *+*D""!0%2!O.*!.+/!0(B?[cc\@

.*!.+/!0(B?[cbc@+((!.!0(B?\Z[Z@!*/0!%*!0(B?\ZZ\P/),(!/B+*#D 0!.)"+((+3D1,%*? !"%*! /h[Z5!./?%/..!?+*(50$.!!/01 %!/.!

31 .!,+.0! %*0$!(%0!.01.!O %((!0(B?\Z[\@'%*!*!0(B?\Z[Z@$%0!!0(B?\ZZcPB

/**/3!.0+0$!%//1!/+*!.*%*#('+"+),.%(%05* (.%05+"

.!)%//%+*.%0!.%*%*0!.*0%+*(3+.'#.+1,(! 5*5* .!/!**

/1,,+.0! 50$! !2!(+,! /!0+".%0!.%B$!%)3/0$00$%/!

%),(!)!*0! %*.!/!.$%*0!.*0%+*((5B!/% !//%!*0%"%1/!"1(*!//?0$!

3+.'#.+1,(/+%)! "+.(%*%(%),.+2!)!*0B$!5.#1! 0$00$!1/!+"

/0* . %/! .%0!.%3%((I"%(%00!+),.%/+*/.+//0.!0)!*0/*

,+,1(0%+*/?* ,.+2% !0$!/%/"+.)+.!(!.(5"+.)1(0! #+(/*

!4,!00%+*/"+.,0%!*0/?.!#%2!./* ")%(%!/JO* .!/!*!0(B?\ZZ_PB 1.0$!.)+.!?.!+#*%/%*#0$!%),+.0*!+"*!#0%2!/5),0+)/+*.!(0%+*0+

+10+)!?0$!.%0!.%%*(1 !/!2!.(*!#0%2!%0!)/".+)0$!B$!.%0!.%

.!/"+((+3/A+/+.!+"^O)+ !.0!P+.$%#$!."+.0$!,/0`)+*0$/+**5+"

0$!"+((+3%*#D%0!)/A[ !(1/%+*/?\ %/+.#*%6! 0$+1#$0?]

$((1%*0+.5!$2%+1.?[""!0%2!"(00!*%*#?^//%2!/+%(3%0$ .3(?`

('+"/,+*0*!%05?_%6..!,+/01.!?+.c1*1/1(0$+1#$0+*0!*0

O* .!/!*!0(B?\ZZ_PB//1$?+10+)!.!/!.$$/!!*,.+2% ! 3%0$*

//!//)!*00++(?/0* . 0%)!.%0!.%+*?* "%4! /!0+"/5),0+)/0+!

/+.! 3%0$"%4! 10D+""/+.!B$%/%/)&+.%),.+2!)!*0"+.0$!.!/!.$

"%!( B +3!2!.?0$!3+.'#.+1,(/+,+%*0! 0+0$!*!! +""1*0%+*()!/1.!/+"

+10+)!/3!((?0+)'!.!(!2*0* .!(%(!)!/1.!+".!+2!.5?/#++

+10+)!0'!/)+.!0$*/5),0+)+*0.+((+*!B

32

2. Duration of untreated psychosis and prevention strategies

2.1 Duration of Untreated Psychosis (DUP)

+*/%/0/+"0$!!)!.#!*!+",/5$+0%/5),0+)/* 0$!/0.0+"0.!0)!*0?

* %/1/1((5 !"%*! /0$!0%)!%*3!!'/+.)+*0$/!03!!*0$!/!03+B*

[c`\?/01 53/,1(%/$! %*0.+ 1%*#+*!,0((! I(!*#0$+"+*/!0+"/%4 )+*0$/+.(!//JB03///+%0! 3%0$#++ +10+)!O%((*0?[c`\PB1.%*#0$!

(0![caZH/?0$!bZH/* 0$!!.(5cZH/?/!2!.(/01 %!//$+3! 0$0(+*#!.

1.0%+*+"%((*!//!"+.!+))!*!)!*0+"0.!0)!*03///+%0! 3%0$

,++.!.+10+)!O.+3!0(B?[cb`@ !(#/+*?[ccZ@+* +?[caa@+!!(!0 (B?[cc\@+/.!((%?[cc^@%*!.!0(B?[cb`PB$!% !!)!.#! 0$0,!.$,/

%*0!.2!*%*#!.(%!.+1( ,.!2!*0/!2!.!,/5$+,0$+(+#5* $.+*%%05".+) !2!(+,%*#B$%/3/(0!.3..*0! 503+)!0D*(5/!/+** +10+)!?

+*"%.)%*#0$!//+%0%+*!03!!*0$!03+O./$((!0(B?\ZZ_ !.'%*/ !0 (B?\ZZ_PB+0$$2!%* %0! 0$0%/)+.!/0.+*#(5//+%0! 3%0$(!2!(+"

*!#0%2!?0$*,+/%0%2!/5),0+)/B.!!*0)!0D*(5/%//$+3! 0$!/)!

O++*/0.!0(B?\Z[\PB$!10$+./.#1!0$00$%/%/+*/%/0!*03%0$0$!*+0%+*

0$0%+(+#%( !0!.%+.0%+*?!4,.!//! /*!#0%2!/5),0+)/?)5!

)!(%+.0! 5!.(5 !0!0%+** 0.!0)!*0B

2.2 International DUP findings

$!!.(%!/0/01 %!/ %/1//%*#* !4,(%%0(5.!,+.0%*#+*/0!)".+)0$!(0!

[caZ/B*!+"0$!"%./0/01 %!/3/+* 10! %*$%*O+* +?[caaP?

;

33 ,+%#**0(5/$/!!*"+1/)+/0(5%*0$!!/0!.*3+.( B!"%*%0%+*/*

+,!.0%+*(%60%+*/ %""!.!03!!*/01 %!/B*/+)!/01 %!/?/0.0+"0.!0)!*0

!-1(/0%)!+""%./0$+/,%0(%/0%+*?%*+0$!./%0%/)+.!/0.%*#!*0(5 !"%*! %*

0!.)/+")! %0%+** ,/5$+0$!.,5B*0(!,.+2% ! %*0$!,,!* %4?

/!2!.('*+3*(!*#0$/+".!,.!/!*0! (+*#3%0$(+0%+*?/01 5?

!"%*%0%+*?* /),(!/%6!OPB/%*#0$!/!.$3+. /%"$ %$"$

!#( ##*$"$$(*#) !"*!#( ##*$ $"$$**

#) !" #$+*1! ?"+1* ^\/01 %!/.!,+.0%*#I*01.(J?0$0

%/?2(1!/1*""!0! 5%*0!.2!*0%+*/)!*00+/$+.0!*%0B),(!/+*/%/0!

+",0%!*0/3%0$ %#*+/!/%*0$!/$%6+,$.!*%D/,!0.1) /$%6+,$.!*%?

/$%6+,$.!*%"+.) %/+. !.?+./$%6+""!0%2! %/+. !.%"*+0+0$!.3%/!.!,+.0! ?

* .*#! %*/%6!".+)^\O))%*#!.!0(B?\ZZ\P0+ccbO+00(!* !.!0 (B?\ZZZPB%2!+"0$!^\/01 %!/,,(%! /0* . %/! %*0!.2%!3/,!%"%((5 .!//%*#0$!0%)%*#+"/5),0+)+*/!0@"+1.1/! 0$!O %*#0+*!0 (B?\ZZ^@ "*!.!0(B?[cc]@+,'!* ##!./?\ZZ_@+3*/!* !0(B?\ZZ\P?*

+*!1/! 0$!O!.'%*/!0(B?\ZZ^PB*0$!/01 %!/3$!.!*+/0* . %/!

%*/0.1)!*03/1/! ?3/!/0%)0! +*0$!/%/+"((/+1.!/+"

%*"+.)0%+*2%((!?%B!B%*0!.2%!3/3%0$,0%!*0/?%*0!.2%!3/3%0$.!(0%2!/?

,.0*!./+".!#%2!./?* )! %(.!+. /B!*2(1!/.*#! ".+)[^B_0+

[]ZB_3!!'/O!4!,0%*#+*!/01 5%*(1 %*#,0%!*0/%*0$!,.!D*!1.+(!,0%!.

* %*2!/0%#0%*#!40.!)!(5(+*#/O1((5!0(B?[ccaP ? * )! %*2(1!/

".+)`0+^a3!!'/@0$1/?0$!2.%0%+*%//1/0*0%(B/0!.*+1*0.%!/O* %?

%*#,+.!P%*0$!/!/01 %!/0!* +*"!2(1!0+$2!(+*#!.)! %*/?

$+3!2!.?(!.#!+#.,$%(,00!.*%/ %""%1(00+ !0!0/+0$0$!*

!.)*5(/+$2!/),(!/3%0$2!.5(+*#/O "*!.!0(B?[cc\@ +!0 (B?\ZZZ@%*!.!0(B?[cb`PB(+/!0++.35?0$!0.%(.!,+.0! )! %*

+"^_B_3!!'/%*/),(!.!!%2%*#/,!%(%/! !.(5,/5$+/%/0.!0)!*0?

* _]3!!'/%*0.!0)!*0/1/1(#.+1,O!0!./!*!0(B?\ZZ_PB$!(.#!/0

#.+1,+"D2(1!/(%!!03!!*[Z* ]Z3!!'/?* 0$!/$+.0!/0.!`3!!'/

:

P

34 O1/0.(%PO+..5!0(B?[cc`P* +10b3!!'/)! %*O??%*(* ? ,%*?* PO!%/!.!0(B?[cc]@((!0(B?\ZZ\@!.'%*/!0(B?\ZZ^@$%0!!0 (B?\ZZcPB$!(+*#!/0%/"+1* %** %?3%0$)! %*2(1!+"^a3!!'/%*+*!

/01 5* )! %*0+!"+1* !03!!*`* [_5!./O)! %*%/*+0.!,+.0!

%.!0(5P%**+0$!.O$.%2/02!0(B?\Z[ZPB

2.3 Programmes to reduce DUP: Early Detection

.(5%*0!.2!*0%+**!2%!3! /$2%*#03+ %/0%*#1%/$(!!(!)!*0/A.(5?

,$/!D/,!%"%0.!0)!*0* !.(5 !0!0%+*O./$((* 0$+*!?\Z[[PB

!2!.(0.!0)!*0,.+#.))!/.+1* 0$!3+.( $2!/,!%(%/! %*0$!!.(5 ,$/!D/,!%"%0.!0)!*0?#!*!.((53%0$+,0%)%/0%.!/1(0/O!.0!(/!*!0(B?\ZZb@

.%#!0(B?\ZZ^@'/+*!0(B?\ZZb@!*%+.!0(B?\ZZ[PB$!5.!*+00+!

+*"1/! 3%0$!.(5 !0!0%+*,.+#.))!/B$!/!3!.!.!!*0(5.!2%!3! 5 (+5 D2*/!0B(O(+5 D2*/!0(B?\Z[[PB$!5"+1* !%#$0,.+#.))!/0$0"%0 0$! !"%*! .%0!.%+"!%*#I !/%#*! 0+!*$*!0$!% !*0%"%0%+** ,.+),0 0.!0)!*0+",!+,(!3%0$"%./0D!,%/+ !,/5$+/%/JA$!%)%*#$).(5

!0!0%+**1*00! ,/5$+/%/.%(OPO!/0!.!0(B?\ZZcP* $!

)!0$.(5*/!0%*,/5$+/%/0.%(OPO+3!.!0(B?\ZZaP%*0$!*%0!

%*# +)?O!*3%'!0(B?\ZZbP%*.!(* ?.(5/5$+/%/.!2!*0%+*

* *0!.2!*0%+*!*0.!OP[* \O+..5!0(B?[cc`PO1*#!0(B?\ZZ]P O./0!2!0(B?\ZZ^P%*1/0.(%?.(5/5$+/%/*0!.2!*0%+*.+#.))!OP

%*%*#,+.!O$+*#!0(B?\ZZ_P?.(5/! !*0%"%0%+*.+#.)OPO((

!0(B?\ZZ_P%** ?* 0$!!.(5.!0)!*0* *0!.2!*0%+*%*5$+/%/

OP%*+.35O+$**!//!*!0(B?\ZZ[P?".+)3$%$0$%/ %//!.00%+*/0!)/B

?* ((,.+2% ! %*"+.)0%+*0+#!*!.(,.0%0%+*!./

O/P+*(5B[1* !.0++'I1*/,!%"%*!03+.'%*#* +))1*%05! 10%+*J

* +.#*%/! *!.(5%*0!.2!*0%+*0!)0+$!(, !0!0/!/%*0$!$!(0$.!

35 /5/0!)B\3/)+.!!40!*/%2!@%*0$%/,.+&!00$!.!3!.!)+%(!

//!//)!*00!)/?! 10%+*(/!//%+*/%*/$++(/?* %*"+.)0%+*"+.*

%*0!.0%+*3%0$/B$%/,,.+$(+5 D2*/((! I)1(0%D"+1/JB$!/)!

)1(0%D"+1/,,.+$3/1/! %** ?/3!((/B*,$??

.!/1(0/+"0$!/!,.+#.))!/.! %/,(5! B

*?0$!.!3/? !/,%0!+"*+/%#*%"%*0.! 10%+*+"+2!.((?

/%#*%"%*0 !.!/!+" !(5%*0%)!".+)/!!'%*#$!(,0+.!$%*#!.(5

%*0!.2!*0%+*//!.2%!/?+.?$!(0$/5/0!) !(5/B$!/)!0!* !*53/"+1* %*

B+0$0$%/* 3!.!,.+#.))!/"+.H/)%*(5B\%*

1/0.(%% !*0%"%! /+)!,0%!*0/3%0$*!40.!)!(5(+*#Oh[ZZZ 5/P*

)*#! 0+.! 1!)% D.*#!B*?*%*.!/!+",0%!*0/3%0$

.!(0%2!(5/$+.0Og[\3!!'/P+1( !+/!.2! ?(+*#3%0$*%*.!/!+"

,0%!*0/3%0$h[5!.?/3!((B* 3!.!0$!)+/0

+),.!$!*/%2!,.+#.))!/?* 0$!+*!/5%!( %*#0$!)+/0"2+1.(!.!/1(0/B

*/1)?.!2%!3%*#0$!(%0!.01.!.!2!(/2.%0%+*!03!!*+*0!*0* %*0!*/%05 +",.+#.))!/?(!*#0$+",.+#.))!/?/),(!/%6!/? !"%*%0%+*/* //!//)!*0/

+"?* 2(1!/B +3!2!.?/+)!"0+.//!!)0+%*"(1!*!.+//

/01 %!/* +1*0.%!/B

36

$?78*-,!'&(*'*%%+5%&&%!&7

.+#.))!

M 1.0%+*

!"%*%0%+* .!D+.

+*0.+( +/0D+.

!4,!.%)!*0(

00%/0%(

/%#*%"%*!

*%0!

%*# +)

\a)+*0$/

\ZZ]D\ZZ_

(1/0!.

.* +)%6!

0.%(O+3!.!0 (B?\ZZaP

J$!0%)!".+)0$!

0.*/%0%+*0+,/5$+/%/H O1*.!)%00%*#,/5$+0%

/5),0+)/"+.[3!!'P 0+0$!+))!*!)!*0 +**0%,/5$+0%

)! %0%+*O#.!0!.

0$*_Zd0.!0)!*0 $!.!*!"+.

)%*%)1)+"[)+*0$PB

[[] !*cbB^

3!!'/O

\]ZP

! %*A&',

*('*,

!*A_ZB\

3!!'/

O[^aBaP

! %*A>=7>

3!!'/

*#!A Z3!!'/N\^

5!./

BB

*%0!

%*# +) ]Z)+*0$/

\ZZ]D\ZZ`

0.0%"%!

(1/0!.

.* +)%6!

0.%(O!/0!.!0 (B?\ZZcP

J$!0%)!%*0!.2(

!03!!*0$!+*/!0+"

,/5$+0%/5),0+)/

* 0$!%*%0%0%+*+"

0.!0)!*03%0$

*!1.+(!,0%

)! %0%+*?*

(1(0! +. %*#0+

/0.%*#!*0,.+0++(

,0! ".+).%0!.%

!2!(+,! 5./!*$

BJO/!+"!%/!.

%*0!.2%!3P

b] !*A\]\B\

5/

O\cZBZP

! %*Aa[BZ 5/O,,.+4B

>=3!!'/P

!*A\^aB[

5/O

^_^B\P! %*A _`B` 5/

O,,.+4BE 3!!'/P

BB

[ 1/0.(%

b)+*0$/[cc]

.!D,+/0 )0$!

+*0.+(-1/%D

!4,!.%)!*0(

!/%#*

O+..5!0 (B?[cc`PM .((!(

+),.%/+*

#.+1,O1*#!0 (B?\ZZ]P

I%)!".+)+*/!0+"

,/5$+/%/0+$+/,%0(

)%//%+*J

[Z\

M_] !*A\]`B`

5/

OaZ\B\P

! %*A]Z 5/O,,.+4B A3!!'/P

!*A^`c 5/

Oc_]P

! %*Ac\

5/O,,.+4B

>@3!!'/P

!*A[c[B^

5/

O^b]B`P

! %*A_\ 5/

O,,.+4BD 3!!'/P

BB

\ 1/0.(%

[\)+*0$/

[cc`D[cca 1/%D

!4,!.%)!*0(

,.((!(

!/%#*O./0!2

!0(B?\ZZ^P

J$!(!*#0$+"0%)!

!03!!*0$!+*/!0+"

,/5$+/%/* 0$!

+))!*!)!*0+"

0.!0)!*0BJ

cb !*A\_^B^

5/O ]acBaP

! %*A[Z^B_

5/O,,.+4B

>B3!!'/P

!*A][]Bb O__bB`P

! %*A_c 5/O,,.+4BE 3!!'/P

BB

* O((!0 (B?\ZZ_P

\`)+*0$/

J$!,!.%+ !03!!*

0$!0%)!+"+*/!0+"

,/5$+0%/5),0+)/

+*0%#1+1/3%0$0$!

[bb ! %*A?>7F

3!!'/ ! %*A?A7@

3!!'/P BB

37

\ZZZD\ZZ\

1/%D

!4,!.%)!*0(

$%/0+.%(

+*0.+( !/%#*

,.!/!*0%*#!,%/+ !?

,(1/*5,.!2%+1/

!,%/+ !/+",/5$+0%

/5),0+)/?0+0$!0%)!

+" !-10!0.!0)!*0 3%0$*0%,/5$+0%/BJ O/! P

%*#,+.!

\^)+*0$/

\ZZ[D

\ZZ]O$+*#!0 (B?\ZZ_P

J$!0%)!!03!!*0$!

+*/!0+",/5$+0%

/5),0+)/O%B!B

$((1%*0%+*/?

!(1/%+*/?* M+.

0$+1#$0 %/+. !.+.

%/+.#*%6!

!$2%+1.P* 0$!

0%)!3$!* !"%*%0%2!

%#*+/%/*

0.!0)!*03!.!

!/0(%/$! BJ

]b^ !*A]\

)+*0$/

O_cB]P

! %*A[\

)+*0$/

O,,.+4BB?

3!!'/P

*#!AZB[D ]]`)+*0$/

!*A[]B]

)+*0$/O\`P

! %*A

^)+*0$/

O,,.+4B>D 3!!'/P

*#!AZD\^Z )+*0$/

,gBZZ\

+.35

^b)+*0$/

[ccaD\ZZZ 1/%D

!4,!.%)!*0(

!/%#*3%0$

$%/0+.%(*

,.((!(+*0.+(

O!((!!0 (B?\ZZ^P

I%)!".+)/+.!+"^

+.$%#$!.+*0(!/0 +*!,+/%0%2!

/1/(!%0!)?

0$.+1#$+100$! 5"+.

/!2!.( 5/+./!2!.(

5/3!!'0+

%*%0%0%+*+" !-10!

0.!0)!*0O !"%*! PBJ

^]M

\b[

!*A[[^B\

3!!'/O [a]B`P

! %*A?C 3!!'/

! %*A>C 3!!'/

*#!AZDc``

3!!'/

! %*AB 3!!'/*#!A ZD[[c`3!!'/

,gBZZ]

[$!.!,+//%(!?)! %* 1.0%+*/+".!.!,+.0! %*3!!'/* ,.%*0! %*+( ?"+..! %(%05

* !*$*!)!*0+"-1%'+2!.2%!3B*#!* /0* . !2%0%+*/.!+*(5.!,+.0! 3$!*

,.+2% ! %*0$!+.%#%*(,,!.B

38

2.4 Factors influencing DUP

(+*#%* %0!/0.!0)!*0 !(5?* /!2!.("0+./+*0.%10%*#$2!!!*

/1##!/0! ".+)/01 5"%* %*#/B('+"%*/%#$0%*0+*!! "+.0.!0)!*0+*0$!

$* +"0$!,0%!*0@00%01 !/+"")%(%!/0+3. //5),0+)/* )!*0($!(0$

.!@('+"/'%((/.!+#*%/%*#,/5$+/%/+*0$!$* +"$!(0$.!+0$/,!%(%/0

* #!*!.(?* /+%(3%0$ .3(* ,++./+%(*!03+.'$2!!!*.!,+.0!

%*0$!D/01 5+"3$%$0$%/ %//!.00%+*%/,.0O./!*!0(B?[cc`PB

*(0!.5!./?0$!%//1!+" !(5/%*0$!/+D((! I,0$35/0+.!J$2!!!*

/01 %! %*.!/%*#(5%*0!*/%2!(5* /5/0!)0%((5B-1(%00%2!/01 5+"

,0$35/0+.!%*".%*)!.%*")%(%!/"+1* "+1.)%*0$!)!/ !(5%*#

$!(,D/!!'%*#AO%P/+%!05W/!(%!"/+10)!*0(%((*!//!/@O%%P")%(%!/W!(%!"/

+10)!*0(%((*!//!/@O%%%P"!.+"0$!(!(+")!*0(%((*!//@* O%2P.%/!

0$.!/$+( "+.0$!%*%0%0%+*+"0.!0)!*0O.*6!0(B?\Z[ZPB0/!!)/".+)+0$!.

/01 %!/0$00$!/)!)!$*%/)/+,!.0!%*J3$%0!J1(01.!/O*/'*!*!0 (B?\Z[[PB!.!%2! /0%#)+10,/5$+/%/,,!./0+,(5.+(!+0$.!#. %*#

!(%!"/+0$+10/5),0+)/* )!*0($!(0$.!B1""!.!./)5!".% 0$0 0$!5.!J.65J?0$00$!53%((!.!&!0! 50$!%.,!!./?* 2+% "!.!

+*".+*00%+*3%0$$!(0$.!B(/+?)!*0($!(0$.!..%!/0$!/0%#)+"

J%*&!0%+*/* /!0%+*/JO%B!B+),(1/+.5 !0%*P?* ,0%!*0/!%*#J,1035J

"+.(+*#0%)!1/%*#$!/%0*5%*/!!'%*#0.!0)!*0B)%(%!/.!(%'!(50+

00.%10!,+/%0%2!/5),0+)/* !$2%+1.( %/01.*!/0+J +(!/!*0 .!!((%+*J* 0+*+0.!+#*%/!*!#0%2!/5),0+)/O!.#*!.!0(B?\ZZbPB

1.0$!.)+.!?,++.,.!)+.% &1/0)!*0* %*/% %+1/+*/!0(/+/!!) //+%0! 3%0$(+*#B*+2%+1/ !(%*!%*"1*0%+*%*#,.+),0/$!(,D /!!'%*#)1$)+.!0$*)+.!0.%0D(%'!"%(1.!0+)!!0 &1/0)!*0/0* . /B

39 +3!2!.?/!2!.(/01 %!/,+%*00+ !(5! .!/,+*/!".+)$!(0$.!(/+

+*0.%10%*#0+(+*#BH((#$*!0B("+1* 0$00$!.!3/*!2!*/,(%0

!03!!*J$!(,D/!!'%*# !(5/J* J$!(0$/5/0!) !(5/JOW((#$*!0 (B?\Z[ZPB+),0+*!0(*!0(5/1)1,,.!2%+1/"%* %*#/.!#. %*#$!(,D/!!'%*#

!(5/A!2!(+"")%(5%*2+(2!)!*0%*$!(,D/!!'%*#?/!*!+"")%(5$%/0+.5+"

,/5$+/%/?(+3!.(!2!(/+"3.!*!//* '*+3(! #!+")!*0(%((*!//?0!* !*5 0+3. / !*%(+")!*0(%((*!///!4%/0%*#?(+3!.%(%05+"0+(!.*!*

+,%*#?* ,++.!.")%(5/0.!*#0$/((,+0!*0%((5)5+/0.100$!,0$35/0+

.!O+),0+*!0(B?\ZZ^PB*0$!/% !+"$!(0$D/5/0!) !(5/?J3%0* /!!JD 00%01 !,.!/!*0! 5)5 !(50.!0)!*0O*/'*!*!0(B?\Z[[PB*!

/01 5"+1* *2!.#!+"0$.!!"%./0(%*!$!(0$.!+*/1(00%+*/!"+.!"%./0 +*003%0$)!*0($!(0$.!O0!!(!0(B?\ZZ`PB100$!*?1*"+.01*0!(5?

.!$%*#)!*0($!(0$.!%/(/+*+#1.*0!!"+.-1%'$!(,B*.!!*0/01 5 5./$((!0(B?%03/+*(1 ! 0$0.!!%2%*#0.!0)!*0%*5+10$*

+(!/!*0)!*0($!(0$.!3///+%0! 3%0$(+*#O./$((?,!./+*(

+))1*%0%+*?0+!.\Z[\PB* !./+*!0(,.!/!*0.!2%!3+"]Z/01 %!/

O* !./+*!0(B?\Z[ZP%*0+O)+*#+0$!."0+./P$!(0$/5/0!) !(5/B$!5

"+1* /+)! %""!.!*!/!03!!*+1*0.%!/B*1.+,!* * ?"%./0+*00 3%0$*+*D,$5/%%*/!!)! 0+ !(50.!0)!*0"+.,/5$+/%/B1.0$!.)+.!?

,.%20!,/5$%0.%/0/* ,/5$+(+#%/03!.!)+*#0$!3+./0I0.!0)!*0D !(5!./J+0$%*1.+,!?* ?* $%*B*0$!?$+3!2!.?#!*!.(

,.0%0%+*!./0!* ! 0+,+/0,+*!.!"!..(/+./0.0+"*0%D,/5$+0%0.!0)!*0/B

*%*#,+.!?%001.*! +10,0%!*0)%#$0/3!((#+0+I$!(!.J/0+$!(0$

,.+"!//%+*(@0.!0)!*0 !(5/3!.!!-1(D* /1/0*0%(B$""*!.!0(

+*(1 !0$0AI%*!*!#0%2!"0+./%*,0$35/D0+D.!%*2+(2!"!01.!/+*((

.!(!2*0(!2!(/O,0%!*0?/+%(!*2%.+*)!*0* $!(0$D.!/5/0!)P?*

+,0%)%/0%+*+",0$35/D0+D.!3%((.!-1%.!0$!%*0!#.0%+*+"/!.2%!/*

+*0%*1+1/3.!*!//,.+#.))!/0.#!0%*#0$!#!*!.(,+,1(0%+** )!*0(

$!(0$D.!,.+"!//%+*(/BJO$""*!.!0(B?\Z[\PB