Health Services Determinants of the Duration of Untreated Psychosis Among African-American First-Episode Patients

Abstract

Objective The duration of untreated psychosis is associated with poor outcomes in multiple domains in the early course of nonaffective psychotic disorders, although relatively little is known about determinants of this critical period, particularly health services–level determinants. This study examined three hypothesized predictors of duration of untreated psychosis (lack of insurance, financial problems, and broader barriers) among urban, socioeconomically disadvantaged African Americans, while controlling for the effects of three patient-level predictors (mode of onset of psychosis, living with family versus alone or with others before hospitalization, and living above versus below the federally defined poverty level). Methods Analyses included data from 42 patient–family member dyads from a larger sample of 109 patients with a first episode of nonaffective psychosis. The duration of untreated psychosis and all other variables were measured in a rigorous, standardized fashion in a study designed specifically to examine determinants of treatment delay. Survival analyses and Cox regression assessed the effects of the independent predictors on time from onset of psychosis to hospital admission for initial evaluation and treatment. Results The median duration of untreated psychosis was 24.5 weeks. When the analyses controlled for the three patient-level covariates, patients without health insurance, with financial problems, or with barriers to seeking help had a significantly longer duration of untreated psychosis. Conclusions Health services–related factors, such as lack of insurance, are predictive of longer treatment delay. Efforts to eliminate uninsurance and underinsurance, as well as minimize barriers to treatment, would be beneficial for improving the prognosis of young patients with emerging nonaffective psychotic disorders. (Psychiatric Services 60:1489–1494, 2009)

Demographic, socio-environmental, and substance-related predictors of duration of untreated psychosis (DUP)

“…In fact, aside from our own studies, we are unaware of other research that focuses on this population. In our prior independent sample, we found that DUP is predicted by mode of onset of psychosis, living below the federal poverty level, poor family functioning, not having health insurance, the family’s report of financial problems, and the family’s report of barriers to seeking care (Compton et al, 2009a; Compton et al, 2009b; Compton et al, 2011). In the present study, we extend this line of research by studying additional hypothesized predictors of treatment delay in another sample comprised predominantly of African Americans.…”

“…A rating of “3-recurrent” is defined as “has had the symptom at least half of the time and the symptom has persisted at least three consecutive months. A rating of “4-continuous” is given when the person “has had the symptom everyday or almost everyday continuously up to the initial treatment contact.” Prior reports describe our standardized approach to using the SOS and deriving age at onset and DUP using consensus-based best-estimate methods (Compton et al, 2008a; Compton et al, 2009a; Compton et al, 2009b; Compton et al, 2011). …”

“…Predictors of DUP are known to exist at the patient/illness-, family-, and health-services levels (Compton et al, 2008a; Compton et al, 2009a; Compton et al, 2009b; Compton & Broussard, 2011; Compton et al, 2011). For example, patient/illness-level predictors include single marital status (Pek et al, 2006), living in poverty (Compton et al, 2011), greater negative symptoms (Boonstra et al, 2012), and perhaps most importantly, a more gradual mode of onset of psychosis (Compton et al, 2008a).…”

Marijuana use in the immediate 5-year premorbid period is associated with increased risk of onset of schizophrenia and related psychotic disorders

“…We also conducted a similar in-depth interview with one or two family members/informants when available. Then, we derived consensus-based best estimates of age at onset of the prodrome and age at onset of psychosis in a standardized fashion, using all available information, as described in prior reports (Compton et al, 2008, Compton et al, 2009a, Compton et al, 2009c, Compton et al, 2011, Compton et al, 2012, Broussard et al, 2013). Dates, including a minimum of month and year, of age at onset of these symptoms were recorded, allowing these variables to be coded in months rather than years.…”

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

“…Being uninsured predicts delayed help seeking following onset of psychosis (6) as well as less use of community mental health treatment and greater likelihood of using only crisis or emergency services (7). In the Suffolk County (New York) Mental Health Project, 44% of patients with a first admission for psychosis were uninsured (8).…”