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Patterns of health services use prior to a first diagnosis of psychosis: the importance of primary care

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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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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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Correspondence to Rebecca Fuhrer.

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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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