Factors Associated with Timely Physician Follow-up after a First Diagnosis of Psychotic Disorder

Objective: Physician follow-up after a first diagnosis of psychotic disorder is crucial for improving treatment engagement. We examined the factors associated with physician follow-up within 30 days of a first diagnosis of schizophrenia. Method: We conducted a retrospective cohort study using linked health administrative data to identify incident cases of schizophrenia between 1999 and 2008 among people aged 14 to 35 years in Ontario. We estimated the proportion of patients who had physician follow-up within 30 days of the index diagnosis. We used multilevel logistic regression models to examine the factors associated with any physician follow-up and follow-up by a psychiatrist. Results: We identified 20,096 people with a first diagnosis of schizophrenia. Approximately 40% of people did not receive any physician follow-up within 30 days, and nearly 60% did not receive follow-up by a psychiatrist. Males had lower odds of receiving any physician follow-up, and the odds of psychiatrist follow-up decreased with increasing age and were lower for those living in rural areas. Both prior contact with a general practitioner for a mental health reason and prior contact with a psychiatrist were strongly associated with higher odds of receiving both types of follow-up. Conclusions: Many people do not have any physician contact within 30 days of the first diagnosis of schizophrenia, and patients without prior engagement with mental health services are at highest risk. We need information on the reasons behind this lack of physician follow-up to inform strategies aimed at improving engagement with services during the early stages of psychosis

The pathways to mental health care of first-episode psychosis patients: a systematic review.

BACKGROUND: Although there is agreement on the association between delay in treatment of psychosis and outcome, less is known regarding the pathways to care of patients suffering from a first psychotic episode. Pathways are complex, involve a diverse range of contacts, and are likely to influence delay in treatment. We conducted a systematic review on the nature and determinants of the pathway to care of patients experiencing a first psychotic episode. METHOD: We searched four databases (Medline, HealthStar, EMBASE, PsycINFO) to identify articles published between 1985 and 2009. We manually searched reference lists and relevant journals and used forward citation searching to identify additional articles. Studies were included if they used an observational design to assess the pathways to care of patients with first-episode psychosis (FEP). RESULTS: Included studies (n=30) explored the first contact in the pathway and/or the referral source that led to treatment. In 13 of 21 studies, the first contact for the largest proportion of patients was a physician. However, in nine of 22 studies, the referral source for the greatest proportion of patients was emergency services. We did not find consistent results across the studies that explored the sex, socio-economic, and/or ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay. CONCLUSIONS: Additional research is needed to understand the help-seeking behavior of patients experiencing a first-episode of psychosis, service response to such contacts, and the determinants of the pathways to mental health care, to inform the provision of mental health services

The incidence of first-episode schizophrenia-spectrum psychosis in adolescents and young adults in Montreal: An estimate from an administrative claims database

Objective: There has been increasing interest in the psychiatric literature on research and service delivery focused on first-episode psychosis (FEP), and accurate information on the incidence of FEP is crucial for the development of services targeting patients in the early stages of illness. We sought to obtain a population-based estimate of the incidence of first-episode schizophrenia-spectrum psychosis (SSP) among adolescents and young adults in Montreal. Methods: Population-based administrative data from physician billings, hospitalizations, pharmacies, and public health clinics were used to estimate the incidence of first-episode SSP in Montreal. A 3-year period (2004-2006) was used to identify patients with SSP aged 14 to 25 years. We used a 4- to 6-year clearance period to remove patients with a history of any psychotic disorder or prescription for an antipsychotic. Results: We identified 456 patients with SSP, yielding a standardized annual incidence of 82.9 per 100 000 for males (95% CI 73.7 to 92.1), and 32.2 per 100 000 for females (95% CI 26.7 to 37.8). Using ecologic indicators of material and social deprivation, we found a higher-incidence proportion of SSP among people living in the most deprived areas, relative to people living in the least deprived areas. Conclusions: Clinical samples obtained from psychiatric services are unlikely to capture all treatment-seeking patients, and epidemiologic surveys have resource-intensive constraints, making this approach challenging for rare forms of psychopathology; therefore, population-based administrative data may be a useful tool for studying the frequency of psychotic disorders

Differences in duration of untreated psychosis for racial and ethnic minority groups with first-episode psychosis: an updated systematic review and meta-analysis.

PURPOSE: Ethnic minority groups with early psychosis may have longer treatment delays, potentially leading to poorer outcomes. We updated a previous systematic review of the literature on racial and ethnic differences in duration of untreated psychosis (DUP) among people with first-episode psychosis. RESULTS: Six of 17 studies described significant differences across aggregated racial groups; however, the pooled estimates did not show differences across groups. Additional data from this update allowed for disaggregated analyses, finding that Black-African groups have a shorter DUP, whereas Black-Caribbean groups have longer DUP, relative to White groups. CONCLUSIONS: These findings highlight the importance of in-depth research on disaggregated ethnic groups to inform targeted early intervention strategies for minority populations

Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis.

PURPOSE: Although there have been numerous studies on pathways to care in first-episode psychosis (FEP), few have examined the determinants of the pathway to care and its impact on subsequent engagement with mental health services. METHODS: Using a sample of 324 FEP patients from a catchment area-based early intervention (EI) program in Montréal, we estimated the association of several socio-demographic, clinical, and service-level factors with negative pathways to care and treatment delay. We also assessed the impact of the pathway to care on time to disengagement from EI services. RESULTS: Few socio-demographic or clinical factors were predictive of negative pathways to care. Rather, service-level factors, such as contact with primary care providers, have a stronger impact on patterns of health service use across multiple indicators. Patients who were in contact with primary care had a reduced likelihood of negative pathways to care, but also had longer referral delays to EI services. Socio-demographic and clinical factors were more relevant for predicting subsequent engagement with EI services, and indicators of negative pathways to care were not associated with service disengagement. CONCLUSIONS: Primary care providers may be an efficacious target for interventions aimed at reducing overall treatment delay. Increasing the uptake of primary care services may also reduce the likelihood of negative pathways to care. Our findings draw attention to the need for further investigations of the role that the primary care system plays in early intervention for FEP, and strategies for supporting service providers in this role

The Incidence of Psychotic Disorders and Area-level Marginalization in Ontario, Canada: A Population-based Retrospective Cohort Study

Background: There is limited Canadian evidence on the impact of socio-environmental factors on psychosis risk. We sought to examine the relationship between area-level indicators of marginalization and the incidence of psychotic disorders in Ontario. Methods: We conducted a retrospective cohort study of all people aged 14 to 40 years living in Ontario in 1999 using health administrative data and identified incident cases of psychotic disorders over a 10-year follow-up period. Age-standardized incidence rates were estimated for census metropolitan areas (CMAs). Poisson regression models adjusting for age and sex were used to calculate incidence rate ratios (IRRs) based on CMA and area-level marginalization indices. Results: There is variation in the incidence of psychotic disorders across the CMAs. Our findings suggest a higher rate of psychotic disorders in areas with the highest levels of residential instability (IRR = 1.26, 95% confidence interval [CI], 1.18 to 1.35), material deprivation (IRR = 1.30, 95% CI, 1.16 to 1.45), ethnic concentration (IRR = 1.61, 95% CI, 1.38 to 1.89), and dependency (IRR = 1.35, 95% CI, 1.18 to 1.54) when compared to areas with the lowest levels of marginalization. Marginalization attenuates the risk in some CMAs. Conclusions: There is geographic variation in the incidence of psychotic disorders across the province of Ontario. Areas with greater levels of marginalization have a higher incidence of psychotic disorders, and marginalization attenuates the differences in risk across geographic location. With further study, replication, and the use of the most up-to-date data, a case may be made to consider social policy interventions as preventative measures and to direct services to areas with the highest risk. Future research should examine how marginalization may interact with other social factors including ethnicity and immigration