Abstract
Purpose
The observed association between treatment delay and poor outcomes in first-episode psychosis has led to an interest in the topography of symptom development preceding the onset of psychosis and associated help-seeking behaviors. We estimated the extent to which socio-demographic, clinical, and health service indicators are associated with patterns of service use for mental health reasons preceding a first diagnosis of psychosis.
Methods
Population-based administrative data from physician billings, hospitalizations, and public health clinics were used to identify incident cases of schizophrenia-spectrum psychosis among individuals aged 14–25 years in Montréal. Mental health contacts in the 4 years preceding the index diagnosis were analyzed.
Results
Thirty-two percent of cases had no contact with services for a mental health reason preceding the index diagnosis, and nearly 50 % received the index diagnosis of psychosis in the emergency department. Individuals in contact with primary care had a reduced likelihood of contact with the emergency department and inpatient services (OR = 0.15, 0.06–0.39) and of receiving the index diagnosis in the emergency department (OR = 0.36, 0.24–0.54), but also had a longer time to contact with a psychiatrist (HR = 0.32, 0.23–0.45).
Conclusions
Improving access to primary care may reduce the burden on emergency departments and inpatient units; however, primary care providers may need additional training in the symptoms of early psychosis and referral protocols. Given the limitations associated with using clinical samples from specialized services, population-based administrative data are an important source of information for understanding patterns of health services use preceding a first diagnosis of psychosis.
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References
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(9):975–983
Perkins DO, Gu H, Boteva K, Lieberman JA (2005) Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 162(10):1785–1804
McGorry PD, Killackey E, Yung AR (2007) Early intervention in psychotic disorders: detection and treatment of the first episode and the critical early stages. Med J Aust 187(7 Suppl):S8–S10
Bird V, Premkumar P, Kendall T, Whittington C, Mitchell J, Kuipers E (2010) Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J Psychiatry 197(5):350–356
Harvey PO, Lepage M, Malla A (2007) Benefits of enriched intervention compared with standard care for patients with recent-onset psychosis: a metaanalytic approach. Can J Psychiatry 52(7):464–472
Petersen L, Jeppesen P, Thorup A, Abel MB, Ohlenschlaeger J, Christensen TO, Krarup G, Jorgensen P, Nordentoft M (2005) A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ 331(7517):602
Yung AR, McGorry PD (1996) The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull 22(2):353–370
Yung AR, Nelson B (2011) Young people at ultra high risk for psychosis: a research update. Early Interv Psychiatry 5(Suppl 1):52–57
Addington J, Addington D (2006) Early intervention for psychosis: who refers? Schizophr Res 84(1):176–177
Norman RMG, Malla AK, Verdi MB, Hassall LD, Fazekas C (2004) Understanding delay in treatment for first-episode psychosis. Psychol Med 34(2):255–266
Platz C, Umbricht DS, Cattapan-Ludewig K, Dvorsky D, Arbach D, Brenner HD, Simon AE (2006) Help-seeking pathways in early psychosis. Soc Psychiatry Psychiatr Epidemiol 41(12):967–974
Anderson KK, Fuhrer R, Schmitz N, Malla AK. (2012) Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis. Soc Psychiatry Psychiatr Epidemiol (in press). doi: 10.1007/s00127-012-0571-0
Phillips L, Yung AR, Hearn N, McFarlane C, Hallgren M, McGorry PD (1999) Preventative mental health care: accessing the target population. Aust N Z J Psychiatry 33(6):912–917
Shin YM, Jung HY, Kim SW, Lee SH, Shin SE, Park JI, An SK, Kim YH, Chung YC (2010) A descriptive study of pathways to care of high risk for psychosis adolescents in Korea. Early Interv Psychiatry 4(2):119–123
Anderson KK, Fuhrer R, Malla AK (2010) The pathways to mental health care of first-episode psychosis patients: a systematic review. Psychol Med 40(10):1585–1597
Rietdijk J, Hogerzeil SJ, van Hemert AM, Cuijpers P, Linszen DH, van der Gaag M (2011) Pathways to psychosis: help-seeking behavior in the prodromal phase. Schizophr Res 132(2–3):213–219
Anderson KK, Fuhrer R, Abrahamowicz M, Malla AK (2012) The incidence of first-episode schizophrenia-spectrum psychosis in adolescents and young adults in Montréal: an estimate from an administrative claims database. Can J Psychiatry 57(10):626–633
Pampalon R, Raymond G (2000) A deprivation index for health and welfare planning in Quebec. Chronic Dis Can 21(3):104–113
Gamache P, Pampalon R, Hamel D. (2010) The material and social deprivation index: a summary. Institut National de Santé Publique Québec [cited 2011 Feb 20]; Available from: URL: http://www.inspq.qc.ca/santescope/documents/Guide_Metho_Indice_defavo_Sept_2010_A.pdf
Pampalon R, Hamel D, Gamache P (2009) A comparison of individual and area-based socio-economic data for monitoring social inequalities in health. Health Rep 20(4):85–94
Pampalon R, Hamel D, Gamache P, Raymond G (2009) A deprivation index for health planning in Canada. Chronic Dis Can 29(4):178–191
Ng’andu NH (1997) An empirical comparison of statistical tests for assessing the proportional hazards assumption of Cox’s model. Stat Med 16(6):611–626
Abrahamowicz M, MacKenzie TA (2007) Joint estimation of time-dependent and non-linear effects of continuous covariates on survival. Stat Med 26(2):392–408
SAS. (2008) Version 9.2., SAS Institute, North Carolina
R (2010). Version 2.12.1., R foundation for statistical computing, Vienna
Sturmer T, Schneeweiss S, Avorn J, Glynn RJ (2005) Adjusting effect estimates for unmeasured confounding with validation data using propensity score calibration. Am J Epidemiol 162(3):279–289
Sturmer T, Schneeweiss S, Rothman KJ, Avorn J, Glynn RJ (2007) Performance of propensity score calibration—a simulation study. Am J Epidemiol 165(10):1110–1118
Rosner B, Spiegelman D, Willett WC (1990) Correction of logistic regression relative risk estimates and confidence intervals for measurement error: the case of multiple covariates measured with error. Am J Epidemiol 132(4):734–745
Malla A, Norman R, McLean T, Scholten D, Townsend L (2003) A Canadian programme for early intervention in non-affective psychotic disorders. Aust N Z J Psychiatry 37(4):407–413
Logan R, Spiegelman D. (2004) The SAS %BLINPLUS Macro. Harvard School of Public Health Available from: URL: http://www.hsph.harvard.edu/faculty/donna-spiegelman/software/blinplus-macro/index.html
Vanasse A, Courteau J, Fleury MJ, Gregoire JP, Lesage A, Moisan J (2012) Treatment prevalence and incidence of schizophrenia in Quebec using a population health services perspective: different algorithms, different estimates. Soc Psychiatry Psychiatr Epidemiol 47(4):533–543
Jin H, Folsom DP, Lindamer L, Bailey A, Hawthorne W, Garcia P, Jeste DV (2003) Patterns of public mental health service use by age in patients with schizophrenia. Am J Geriatr Psychiatry 11(5):525–533
Compton MT (2005) Barriers to initial outpatient treatment engagement following first hospitalization for a first episode of nonaffective psychosis: a descriptive case series. J Psychiatr Pract 11(1):62–69
Bhugra D, Harding C, Lippett R (2004) Pathways into care and satisfaction with primary care for black patients in South London. J Ment Health 13(2):171–183
Monteiro VBM, Dos Santos JQ, Martin D (2006) Patients’ relatives delayed help seeking after a first psychotic episode. Rev Bras Psiquiatr 28(2):104–110
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(1–3):206–214
Boonstra N, Sterk B, Wunderink L, Sytema S, de HL, Wiersma D (2012) Association of treatment delay, migration and urbanicity in psychosis. Eur Psychiatry 27(7):500–505
Vasiliadis HM, Lesage A, Adair C, Boyer R (2005) Service use for mental health reasons: cross-provincial differences in rates, determinants, and equity of access. Can J Psychiatry 50:614–619
McGorry P, Bates T, Birchwood M (2013) Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. Br J Psythiatry Suppl 202:s30–s35
Steele LS, Glazier RH, Lin E (2006) Inequity in mental health care under Canadian universal health coverage. Psychiatr Serv 57(3):317–324
Steele L, Dewa C, Lee K (2007) Socioeconomic status and self-reported barriers to mental health service use. Can J Psychiatry 52(3):201–206
Veen ND, Selten JP, Schols D, Laan W, Hoek HW, van der Tweel I, Kahn RS (2004) Diagnostic stability in a Dutch psychosis incidence cohort. Br J Psychiatry 185:460–464
Malla AK, Norman RM, Manchanda R, Ahmed MR, Scholten D, Harricharan R, Cortese L, Takhar J (2002) One year outcome in first episode psychosis: influence of DUP and other predictors. Schizophr Res 54(3):231–242
Statistics Canada. (1986) Canadian classification of diagnostic, therapeutic, and surgical procedures. 2nd[82-562-XPE]. Ottawa, Statistics Canada Health Division
World Health Organization (1977) Manual of the international statistical classification of diseases, injuries, and cause of death - 9th revision [PHS 80–1260]. World Health Organization, Geneva
World Health Organization (1992) Manual of the international statistical classification of diseases, injuries, and cause of death - 10th revision. World Health Organization, Geneva
Acknowledgments
We gratefully acknowledge Jean-Pierre Bluteau and the Agence de la Santé & des Services Sociaux (ASSS) of Montréal for assistance with and access to the administrative database. This study was funded by a Canadian Institutes of Health Research (CIHR) Interdisciplinary Capacity Enhancement Grant in Health Inequalities (Project # HOA-80072). The flexible proportional hazards analyses were supported by a CIHR operating grant (MOP-81275). Kelly Anderson is supported by a Frederick Banting and Charles Best Canada Graduate Scholarship from the Canadian Institutes of Health Research (CIHR). Dr. Fuhrer holds a CIHR Canada Research Chair in Psychosocial Epidemiology, Dr. Malla holds a CIHR Canada Research Chair in Early Psychosis, and Dr. Buckeridge holds a CIHR Canada Research Chair in Public Health Informatics. Dr. Abrahamowicz is a James McGill Professor at McGill University.
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The authors have no conflicts of interest with respect to the publication of this manuscript.
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Anderson, K.K., Fuhrer, R., Wynant, W. et al. Patterns of health services use prior to a first diagnosis of psychosis: the importance of primary care. Soc Psychiatry Psychiatr Epidemiol 48, 1389–1398 (2013). https://doi.org/10.1007/s00127-013-0665-3
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DOI: https://doi.org/10.1007/s00127-013-0665-3