Longer duration of untreated psychosis (DUP) is related to poor clinical and functional outcomes in patients with first-episode psychosis (FEP). The WHO recommends DUP should be ≤ 3 months; however mean DUP in the United States of America is 2 years. Why is this?
The National Institute of Mental Health (NIMH) has funded a series of studies designed to identify barriers to early intervention (EI) (i.e. delays in help-seeking, screening/referral, and treatment) and to develop strategies for overcoming these barriers, including psychosis awareness campaigns, enhanced screening, and rapid referral strategies.
Why are treatment delays so long?
DUP was largely determined by delays in help-seeking, patient screening/referral, and time to effective treatment
OnTrackNY is a novel specialty care program for young adults with FEP in New York.1 Real-world data from 674 adults enrolled in OnTrackNY within 2 years of FEP found that mean time to any treatment was 234 days, mean time to first mental health treatment contact was 73.7 days, and mean time to all mental health contact was 160.6 days. The study also found that DUP was largely determined by delays in help-seeking, patient screening/referral, and time to effective treatment. Identifying risk factors for delays in each of these treatment phases will facilitate the development of effective strategies for reducing DUP.
Help-seeking delays were more common among people with hallucinations as the reason for first contact, and for those making first contact as an outpatient. Factors related to referral delays included:
- not being enrolled in school
- living alone
- having fewer symptoms
- prior antipsychotic treatment
- prior hospitalization/number of hospitalizations
- first treatment contact via outpatient visit, and;
- the number of prior treatment contacts.
Factors related to increased DUP included:
- not being enrolled in school
- living alone
- first treatment contact during an outpatient visit, and;
- number of prior treatment contacts
Reducing help-seeking delays through psychosis awareness campaigns
Compared to other US populations, US Latinos have a higher incidence of psychosis, reduced access to treatment and longer DUP. Steven Lopez from the University of Southern California reasoned that increasing psychosis awareness among this high-risk population using a multifaceted bilingual communication campaign might decrease DUP. Slide decks, videos and flip charts were developed using non-technical language that enabled non-healthcare professionals (ministers, police, teachers, etc.) to explain the early signs of psychosis to Latino groups, providing details on how to access care. Advertisements were placed in newspapers, and on bus boards, Internet and radio.
The effects of the 2-year campaign were examined in 114 adult Latinos with untreated FEP from a public mental health unit in Los Angeles. The number of calls to psychosis treatment centers increased considerably in the weeks following the campaign, suggesting the message was effectively delivered and well-received.
Overall, no significant mean differences were observed between the campaign condition and the control condition for 3 measures of DUP: onset to first seeking any services for the disorder (DUP1), first prescription for antipsychotic medication (DUP2), and taking any treatment for at least 3 months (DUP3). However, there were significant differences in the variance of DUP1, but DUP2/DUP3. This suggests that the awareness campaign contributed to a reduction in time to help-seeking but not to a reduction in time to first medication. Future studies designed to strengthen the campaign are planned.
Reducing referral time through enhanced screening
A review of 17 studies on EI delivery models found that patient evaluation time could be reducing using tele-psychiatry assessments (reducing time to evaluation in a rural emergency hospital setting from 16.2 to 5.2 hours),2 interactive online referral tools, databases linking clinicians within a community, tele-health therapy programs, and 24/7 emergency phone/video triage services.3 The same study found that referral delays at each site could be reduced by appointing a single clinician at the point of entry and a designated care coordinator. Service-based protocols, open referral systems, use of specific timeslots for urgent assessments, and increased collaboration between services (e.g. a telephone hot line linking primary care clinicians to a dedicated team of psychiatrists4) helped enhance access to the most appropriate services.
Cameron Carter from the University of California reasoned that early psychosis identification and referral to EI might be further enhanced by the development of a novel hand-held electronic screening device. The device, based on the Prodromal Questionnaire-Brief version (PQ-B), was tested at 22 sites randomized within 3 strata (community mental health, schools, and primary care). All staff received a 1-hour training session on how to identify individuals with FEP and half the group were given access to the device.
More than twice as many individuals with psychosis-spectrum symptoms were identified using the electronic device than with education alone
Use of the device proved feasible across each of the community settings. Of the 822 individuals screened with the device, 43.2% scored above the PQ-B cut-off for FEP, and 1 in 7 was diagnosed with threshold psychosis. More than twice as many individuals with psychosis-spectrum symptoms were identified using the electronic device than with education alone.
Reducing time to help-seeking, screening and referral through enhanced awareness
The Specialized Treatment Early in Psychosis (STEP) program has successfully reduced DUP in New Haven. Mindmap is a 4-year early detection campaign designed to raise awareness of psychosis in order to further reduce DUP by accelerating a patient’s referral to STEP.
Mean time between the onset of psychosis and initiation of antipsychotic treatment (DUP1) at STEP was significantly reduced from 153 days at baseline to 40 days 2.5 years after the launch of Mindmap
Based on the highly successful Scandinavian TIPS approach, Mindmap aims to reduce delays in illness identification and help-seeking (demand), whilst reducing delays in referrals and treatment (supply).5 Strategies include raising awareness of psychosis among patients, friends/peers and families using traditional media (TV/radio advertising, bus boards, etc.), social media (e.g. websites, Facebook, Twitter, u-Tube, etc.), professional outreach and detailing (presentations and videos delivered to branches of government, mental health service providers, primary care hospitals, social services, police, public charities/clergy, education providers, and consumer organizations), and rapid triage of referrals.
Increases in Mindmap websites/social media usage and numbers of treatment center calls showed that messages were effectively delivered and that users were highly engaged. Mean time between the onset of psychosis and initiation of antipsychotic treatment (DUP1) at STEP was significantly reduced from 153 days at baseline to 40 days 2.5 years after the launch of Mindmap in New Haven, CT in the US, with no significant change at the control site (Boston). Over time, reductions in DUP1 were greatest in patients with longer DUP at baseline.
