Abstract
Background
People experience delays in receiving effective treatment for many illnesses including psychosis. These delays have adverse consequences in heart disease and cancer, and their causes have been the subject of much research but only in recent years have pathways to care in psychosis received such attention. We sought to establish if, when and where people seek help in the early phase of psychosis in a representative sample.
Methods
One hundred and sixty-five people with first episode psychosis, referred from community-based psychiatric services and a private psychiatric facility to an early intervention service over 18 months, were interviewed with the Structured Clinical Interview for DSM-IV diagnoses. Symptoms were measured using the Schedule for the Assessment of Positive Symptoms, Schedule for the Assessment of Negative Symptoms and the Calgary Scale. Duration of untreated illness (DUI) and duration of untreated psychosis (DUP) were established using the Beiser Scale. Pathways to mental health services were systematically detailed through interviews with patients and their families.
Results
The final sample consisted of 142 (88M, 54F) cases after those with psychosis due to a general medical condition and those without pathway and DUP data were excluded. Less than half of participants initiated help seeking themselves. Of those who did seek help (n = 57) 25% did so during the DUI. Those who had a positive family history of mental illness and poorer premorbid adjustment were significantly less likely to seek help for themselves and those who did not seek help were more likely to require hospitalisation. Families were involved in help seeking for 50% of cases and in 1/3 of cases did so without the affected individual participating in the contact. Being younger and having more negative symptoms were associated with having one’s family involved in help seeking. Delays to effective treatment from the onset of psychosis were evenly split between “help-seeking delays” and “health-system delays”. Having a family member involved in help seeking and better premorbid adjustment were independently associated with shorter help-seeking delays when measured from the onset of psychosis. Being female, having better premorbid adjustment and fewer negative symptoms were associated with shorter help-seeking delays from the onset of illness. Those with a non-affective psychosis had significantly longer system delays.
Conclusion
Many people with first episode psychosis do not initiate help-seeking for themselves particularly those with a relative affected by mental illness. Those with poor premorbid adjustment are at particular risk of longer delays. Poor premorbid adjustment compounded by long delays to effective treatment reduces the likelihood of a good outcome. Families play a vital role in hastening receipt of effective treatment.
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References
Addington D, Addington J, Schissel B (1990) A depression rating scale for schizophrenics. Schizophr Res 3:247–251
Addington J, Van Mastrigt S, Hutchinson J, Addington D (2002) Pathways to care: help-seeking behaviour in first episode psychosis. Acta Psychiatr Scand 106:358–364
Andreasen NC (1983) The scale for the assessment of negative symptoms (SANS). The University of Iowa, Iowa City
Andreasen NC (1984) The scale for the assessment of positive symptoms (SAPS). The University of Iowa, Iowa City
Bechard-Evans L, Schmitz N, Abadi S, Joober R, King S, Malla A (2007) Determinants of help-seeking and system related components of delay in the treatment of first-episode psychosis. Schizophr Res 96:206–214
Behan C, Kennelly B, O’Callaghan E (2008) Economic Cost of Schizophrenia in Ireland: a cost of illness study. Ir J Psychol Med 25(3):80–87
Beiser M, Erickson D, Fleming JA, Iacono WG (1993) Establishing the onset of psychotic illness. Am J Psychiatry 150:1349–1354
Bergner E, Leiner AS, Carter T, Franz L, Thompson NJ, Compton MT (2008) The period of untreated psychosis before treatment initiation: a qualitative study of family members’ perspectives. Compr Psychiatry 49(6):530–536
Birchwood M, Smith J, Drury V, Healy J, Macmillan F, Slade M (1994) A self-report insight scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatr Scand 89:62–67
Bleuler E (1911) Dementia praecox or the group of schizophrenias, translated by Zinkin J. National Universities Press, New York
Brunet K, Birchwood M, Lester H, Thornhill K (2007) Delays in mental health services and duration of untreated psychosis. Psychol Bull 31:408–410
Chen EY, Dunn EL, Miao MY, Yeung WS, Wong CK, Chan WF, Chen RY, Chung KF, Tang WN (2005) The impact of family experience on the duration of untreated psychosis (DUP) in Hong Kong. Soc Psychiatry Psychiatr Epidemiol 40:350–356
Chiang JC, Chow AS, Chan RC, Law CW, Chen EY (2005) Pathways to care for first episode patients with schizophrenia. Hong Kong J Psychiatry 15:18–22
Clarke M, Browne S, McTigue O, Gervin M, Kinsella K, Waddington J, Larkin C, O’Callaghan E (2007) Determinants of duration of untreated psychosis in an Irish catchment area sample. Ir J Psychol Med 24:50–53
Clarke M, Whitty P, Browne S, McTigue O, Kamali M, Gervin M, Kinsella A, Waddington JL, Larkin C, O’Callaghan E (2006) Untreated illness and outcome of psychosis. Br J Psychiatry 189:235–240
Compton MF, Carter T, Bergner E, Lauren F, Stewart T, Trotman H, McGlashan T, McGorry PD (2007) Defining, operationalizing and measuring the duration of untreated psychosis: advances, limitations and future directions. Early Interv Psychiatry 1:236–250
Compton MT, Chien VH, Leiner AS, Goulding SM, Weiss PS (2008) Mode of onset of psychosis and family involvement in help-seeking as determinants of duration of untreated psychosis. Soc Psychiatry Psychiatr Epidemiol 43(12):975–982
Corcoran C, Gerson R, Sills-Shahar R, Nickou C, McGlashan T, Malaspina D, Davidson L (2007) Trajectory to a first episode of psychosis: a qualitative research study with families. Early Interv Psychiatry 1(4):308–315
Cougnard A, Kalmi E, Desage A, Misdrahi D, Abalan F, Brun-Rousseau H, Salmi LR, Verdoux H (2004) Pathways to care of first-admitted subjects with psychosis in South-Western France. Psychol Med 34:267–276
Crumlish N, Whitty P, Clarke M, Browne S, Kamali M, Gervin M, McTigue O, Kinsella A, Waddington JL, Larkin C, O’Callaghan E (2009) Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis. Br J Psychiatry 194(1):18–24
Drake RJ, Haley CJ, Akhter S, Lewis SW (2000) Causes and consequences of duration of untreated psychosis in first episode schizophrenia. Br J Psychiatr 177:511–515
de Haan L, Linszen DH, Lenior ME, de Win ED, Gorsira R (2003) Duration of untreated psychosis and outcome of schizophrenia: delay in intensive psychosocial treatment versus delay in treatment with antipsychotic medication. Schizophr Bull 29:341–348
First MB, Spitzer RL, Gibbon M, Williams JBW (1997) Structured clinical interview for DSM-IV axis I disorders, clinician version (SCID-CV). American Psychiatric Press, Washington, DC
Fuchs J, Steinert T (2004) Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany. Soc Psychiatry Psychiatr Epidemiol 39:375–380
Gavin B, Cullen W, O’Donoghue B, Ascencio-Lane JC, Bury G, O’Callaghan E (2006) First episode schizophrenia in general practice: a national survey. Ir J Psychol Med 23:6–9
Goldberg RJ, Mooradd M, Gurwitz JH, Rogers WJ, French WJ, Barron HV, Gore JM (1998) Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (the second National Registry of Myocardial Infarction). Am J Cardiol 82:259–264
Joa I, Johannessen JO, Auestad B, Friis S, McGlashan T, Melle I (2008) The key to reducing duration of untreated first psychosis: information campaigns. Schizophr Bull 34:466–472
Johannessen JO, Larsen TK, Joa I, Melle I, Friis S, Opjordsmoen S (2005) Pathways to care for first-episode psychosis in an early detection healthcare sector: part of the Scandinavian TIPS study. Br J Psychiatry 187(suppl 48):s24–s28
Johnstone EC, Crow TJ, Johnson AL, MacMillan JF (1986) The Northwick Park Study of first episodes of schizophrenia. I. Presentation of the illness and problems relating to admission. Br J Psychiatry 148:115–120
Kainth A, Hewitt A, Sowden A, Duffy S, Pattenden J, Lewin R, Watt I, Thompson D (2004) Systematic review of interventions to reduce delay in patients with suspected heart attack. Emerg Med J 21:506–508
Kessler RC, Zhao S, Katz SJ, Kouzis AC, Frank RG, Edlund M, Leaf P (1999) Past-year use of outpatient services for psychiatric problems in the national comorbidity survey. Am J Psychiatry 156:115–123
Larsen TK, Johannessen JO, Opjordsmoen S (1998) First-episode schizophrenia with long duration of untreated psychosis: pathways to care. Br J Psychiatry 172(suppl 33):45–52
Lincoln S, McGorry PD (1998) Understanding the topography of the early psychosis pathways. An opportunity to reduce delays in treatment. Br J Psychiatry 172(suppl 33):21–25
Malla A, Norman R, Scholten D, Manchanda R, McLean T (2005) A community intervention for early identification of first episode psychosis: impact on duration of untreated psychosis (DUP) and patient characteristics. Soc Psychiatry Psychiatr Epidemiol 40:337–344
Mangalore R, Knapp M (2007) Cost of schizophrenia in England. J Ment Health Policy Econ 10(1):23–41
Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T (2005) Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 62:975–983
McGlashan T (1999) Duration of untreated psychosis in first episode schizophrenia: marker or determinant of outcome? Biol Psychiatry 46:899–907
Morgan C, Abdul-Al R, Lappin JM, Jones P, Fearon P, Leese M, Croudace T, AESOP Study Group (2006) Clinical and social determinants of duration of untreated psychosis in the AESOP first-episode psychosis study. Br J Psychiatry 189:446–452
Morgan C, Mallett R, Hutchinson G, Bagalkote H, Morgan K, Fearon P, AESOP Study Group (2005) Pathways to care and ethnicity. 2: source of referral and help-seeking. Report from the AESOP study. Br J Psychiatry 186:290–296
Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MR, Kothari RE, Mensah GA, Morris DL, Pancioli AM, Riegel B, Zerwic JJ (2006) Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council. Circulation 114:168–182
Newby LK, Rutsch WR, Califf RM, Simoons ML, Aylward PE, Armstrong PW, Woodlief LH, Lee KL, Topol EJ, Van de Werf F (1996) Time from symptom onset to treatment and outcomes after thrombolytic therapy. GUSTO-1 Investigators. J Am Coll Cardiol 27:1646–1655
Norman RM, Lewis SW, Marshall M (2005) Duration of untreated psychosis and its relationship to clinical outcome. Br J Psychiatry 187(suppl 48):s19–s23
Norman RM, Malla AK, Manchanda R (2007) Delay in treatment for psychosis: its relation to family history. Soc Psychiatry Psychiatr Epidemiol 42:507–512
Norman RM, Malla AK, Verdi MB, Hassall LD, Fazekas C (2004) Understanding delay in treatment for first-episode psychosis. Psychol Med 34:255–266
Phillips L, Yung A, Hearn N, McFarlane C, Hallgren M, McGorry P (1999) Preventative mental health care: accessing the target population. Aust N Z J Psychiatry 33:912–917
Platz C, Umbricht DS, Cattapan-Ludewig K, Dvorsky D, Arbach D, Brenner HD (2006) Help-seeking pathways in early psychosis. Soc Psychiatry Psychiatr Epidemiol 41:967–974
Power P, Iacoponi E, Reynolds N, Fisher H, Russell M, Garety P (2007) The Lambeth Early Onset Crisis Assessment Team Study: general practitioner education and access to an early detection team in first-episode psychosis. Br J Psychiatry 191(suppl 51):s133–s139
Renwick L, Gavin B, McGlade L, Lacey P, Goggins R, Jackson D (2008) Early intervention service for psychosis: views from primary care. Early Interv Psychiatry 2:285–290
Singh SP (2007) Outcome measures in early psychosis; relevance of duration of untreated psychosis. Br J Psychiatry 50:s58–s63
Singh SP, Grange T (2006) Measuring pathways to care in first-episode psychosis: a systematic review. Schizophr Res 81:75–82
Skeate A, Jackson C, Birchwood M, Jones C (2002) Duration of untreated psychosis and pathways to care in first-episode psychosis. Investigation of help-seeking behaviour in primary care. Br J Psychiatry 181:s73–s77
Smith LK, Pope C, Both JL (2005) Patients’ help-seeking experiences and delay in cancer presentation: a qualitative synthesis. Lancet 366(9488):785–786
Thornicroft G (2008) Stigma and discrimination limit access to mental health care. Epidemiol Psychiatr Soc 17:14–19
van Mastrigt S, Addington J (2002) Assessment of premorbid function in first-episode schizophrenia: modifications to the Premorbid Adjustment Scale. J Psychiatry Neurosci 27:92–101
Voruganti LP, Baker LK, Awad AG (2008) New generation antipsychotic drugs and compliance behaviour. Curr Opin Psychiatry 21:133–139
Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC (2005) Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:603–613
Wong DF (2007) Crucial individuals in the help-seeking pathway of Chinese caregivers of relatives with early psychosis in Hong Kong. Soc Work 52(2):127–135
Acknowledgments
The authors acknowledge the members of the Early Intervention in Psychosis (DETECT) consortium; Dr. Siobhan Barry (Cluain Mhuire Service), Dr. Justin Brophy (Newcastle Service), Dr. Melanie Gallagher (Lucena Child and Adolescent Services), Dr. Abbie Lane (St John of God Hospital), Prof. Fiona Mc Nicholas (Lucena Child and Adolescent Services), Dr. Freeda O’Connell (Elm Mount Service), Mr. John Saunders (Schizophrenia Ireland) and Mr. Jim Ryan (HSE). The DETECT Consortium wish to acknowledge all the participants in the service evaluation including the patients their relatives and all the clinicians. This work was funded by St John of God Services and Health Service Executive.
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O’Callaghan, E., Turner, N., Renwick, L. et al. First episode psychosis and the trail to secondary care: help-seeking and health-system delays. Soc Psychiat Epidemiol 45, 381–391 (2010). https://doi.org/10.1007/s00127-009-0081-x
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DOI: https://doi.org/10.1007/s00127-009-0081-x