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Objective An extensive international literature demonstrates that understanding pathways to care (PTC) is essential for efforts to reduce community Duration of Untreated Psychosis (DUP). However, knowledge from these studies is difficult to translate to new settings. We present a novel approach to characterize and analyze PTC and demonstrate its value for the design and implementation of early detection efforts. Methods Type and date of every encounter, or node, along the PTC were encoded for 156 participants enrolled in the clinic for Specialized Treatment Early in Psychosis (STEP), within the context of an early detection campaign. Marginal-delay, or the portion of overall delay attributable to a specific node, was computed as the number of days between the start dates of contiguous nodes on the PTC. Sources of delay within the network of care were quantified and patient characteristic (sex, age, race, income, insurance, living, education, employment, and function) influences on such delays were analyzed via bivariate and mixed model testing. Results The period from psychosis onset to antipsychotic prescription was significantly longer (52 vs. 20.5 days, [p = 0.004]), involved more interactions (3 vs. 1 nodes, [p<0.001]), and was predominated by encounters with non-clinical nodes while the period from antipsychotic to STEP enrollment was shorter and predominated by clinical nodes. Outpatient programs were the greatest contributor of marginal delays on both before antipsychotic prescription (median [IQR] of 36.5 [1.3–132.8] days) and (median [IQR] of 56 [15–210.5] days). Sharper functional declines in the year before enrollment correlated significantly with longer DUP (p<0.001), while those with higher functioning moved significantly faster through nodes (p<0.001). No other associations were found with patient characteristics and PTCs. Conclusions The conceptual model and analytic approach outlined in this study give first episode services tools to measure, analyze, and inform strategies to reduce untreated psychosis.

BackgroundProlonged duration of untreated psychosis (DUP) is associated with poor outcome. The Scandinavian TIPS study deployed an early detection (ED) campaign to halve DUP. However, while reducing DUP will improve outcomes for most patients, there are some for whom prolonged DUP is a byproduct of an insidiously illness rather than a modifiable prognostic factor. It is also unclear whether the success of an ED program relies on targeting those with longer or shorter DUP. Previously, we demonstrated that quantile regression (QR) can both manage skewed distributions and allow analysis for meaningful heterogeneity in DUP. The current study aims to investigate the utility of QR to analyze the impact of an ED campaign across the DUP distribution, using data from the TIPS study. We hypothesized the effectiveness of TIPS’s ED campaign will vary across different quantiles of DUP.MethodsBetween 1997 and 2000, a comprehensive early detection (ED) program with public information campaigns and low-threshold psychosis detection teams was established in one health-care area (ED-area), but not in a comparable area (No-ED area). Users with DSM IV non-organic non-affective first episode psychosis were consecutively recruited. Demographic, social and clinical characteristics of people enrolled in an ED area were compared to those coming from a No-ED area. Quantile regression can model the relationship between conditional quantiles of response and independent variables. Unlike ordinary least-squares regression that focuses on conditional mean response, QR estimates the heterogeneous effects of ED across different quantiles of DUP, rather than presuming a uniform mean effect. It is particularly useful when the differential effect of predictors on lower or upper quantile of outcome are of interest. In this study, we examined the impact of ED across the entire quantiles of DUP, particularly on Q1, Q2, Q3, dividing data into four quartiles. A post hoc analysis of the effect of gender, marital status, premorbid adjustment social level, and social cluster on quartiles of DUP was also conducted.ResultsThe total sample included 301 subjects, of which 161 belonged to an early detection (ED) area. If compared to users from No-ED area, ED users were younger (mean age 25 vs 31), and mainly unmarried (80% vs 62%).QR highlighted that ED had no effect on the first quartile (Q1) of DUP, with very short DUP, even in the No-ED area. ED was significantly associated with a reduction in the second quartile of DUP (median) (11 weeks reduction, p<0.001), and the third quartile of DUP (Q3) (41 weeks reduction, p=0.01). The effect of ED was significantly stronger on last quartile than Q1(p=0.01) and Q2 (p=0.04) suggesting a stronger effect of campaign on people with longer DUP.After controlling for age and marital status, the ED campaign’s effect on Q3 of DUP significantly differed by gender: only male users in the ED group showed a significant reduction in this quartile of DUP (coefficient [SE] at Q3=−46.6; P = .01), suggesting an interaction bet...

BackgroundEarly interventions services (EIS) for psychosis are not uniformly available in the Italian public mental health care system. In 2012, Region Emilia Romagna funded the implementation of a comprehensive population based program to deliver EIS. These services provide a package of care including psychiatric consultation, family psychoeducation, case management, recovery oriented activities (e.g. supported employment, social inclusion), and physical health monitoring, consistent with international models but embedded within community mental health services (CMHS). We report feasibility, descriptors of enrolled samples, and clinical variables associated with remission.MethodsDemographic and clinical data of CMHS users that accepted EIS from January 1st, 2013 to December 31st, 2016 were acquired from paper and electronic health records in each province. Inclusion criteria were: residence in Regione Emilia Romagna, age 18–35, presence of non-organic, affective and non-affective psychotic symptoms within two years of onset. Exclusion criteria included severe intellectual disability and non-fluency in Italian. Remission was defined as a total score of 8 on the Health of Nation Outcome Scale (HoNOS) at 6 months after enrollment.ResultsSix hundred and eighty-nine patients accepted EIS. Median age was 22, 93% had diagnoses of non-affective psychosis, whereas 7% affective psychosis, with a median duration of untreated psychosis (DUP) of 6 months [IQR=10; 0–120], 41% had comorbid substance use disorders, 31.1% had personality disorders, and 39% had a previous hospitalization. The proportion of migrants (23%) was almost twice that of the entire Region (11.9%). Psychiatric visits represented 44% of total utilization, whereas only 14% received at least one case management visit, 79% a family session, 19% a recovery oriented activity, and 1% physical health monitoring.Of the sample, 460 subjects (67%) improved as presented with significant reduction in the 4 subscales scores of the follow up HoNOS, and 164 (35.7%) showed remission. Shorter DUP and lower HoNOS scores at baseline were associated with an increased likelihood of achieving remission (OR=1.03, p=0.0068, and OR=1.04, p=<0.0001, respectively), whereas the presence of personality disorder was associated with a reduced likelihood of remission (OR=0.48, p=0.0057).DiscussionEIS was acceptable to most eligible patients in regional CMHS. EIS enrollees evidenced significant clinical improvement in the first 6 months. Only a minority was diagnosed with bipolar disorder, suggesting a possible later onset of affective psychosis and reduced chance of accessing the Program.The correlation of comorbid personality disorder with worse outcomes, suggests the need to develop a targeted treatment. The EIS were also well accepted by the high proportion of migrants. Further work is required to understand possible social determinants of psychosis onset and pathways to care in these fragile communities. The high rate of concomitant substance use at intake must be considered f...

Background The Specialized Treatment Early in Psychosis (STEP) program has delivered a specialty-team based first-episode service (FES) since 2006 in New Haven. In 2015, STEP launched a 4-year early detection (ED) campaign (Mindmap), adapted from the Scandinavian TIPS approach, to shorten Duration of Untreated Psychosis (DUP) in a 10-town catchment (popn. 400,000). Methods Mindmap’s social-ecological model targeted demand (delays in identifying illness and help-seeking) and supply (delays in referring to and providing FES) side constituents of DUP. Mindmap used mass and social media messaging, professional detailing, and rapid triage of referrals. DUP was measured as the time between the onset of psychosis and initiation of antipsychotic treatment (DUP1) and FES care (DUP2). A control FES (PREP, Boston) supported the quasi-experimental design. Quantile regression was used to interrogate the impact of the campaign across the full range of DUP. The campaign was launched in 2015, after a one-year baseline. Results The third quartile of DUP1 fell significantly at the intervention site in the pre- vs. post-campaign period (329 to 185 days, p=0.03). A time-series analysis revealed a cumulative effect of the campaign over time i.e. for each year of campaigning a 46-day reduction was achieved at STEP. DUP1 at the other quartiles and DUP2 across all quartiles showed a consistent trend of reduction over time at STEP, but this did not reach conventional statistical significance. At PREP both DUP1 & DUP2 remain unchanged, and comparable to baseline levels at STEP. Discussion Mindmap has shown promise in reducing delays to care and this is the first controlled demonstration of DUP reduction in a U.S. community setting. Additional data on help-seeking events and pathways to care and social media metrics will be presented as mediating variables. Mindmap was an early detection campaign hosted by an established FES and targeting a defined geographic catchment to recruit all incident cases. As such, this effort included a wide range of community and clinical stakeholders and modeled a population health based approach to the care of early psychosis. The lessons are relevant for burgeoning FES implementations across the world, and these will be elaborated based on the data and experience of implementing this study.