Treatment delay in first-episode nonaffective psychosis: a pilot study with African American family members and the theory of planned behavior

Gender-affirming care in the assessment and treatment of psychosis risk: Considering minority stress in current practice and future research

INTRODUCTION

Although research has documented the marked disparities in rates of psychosis-spectrum diagnoses in various socially marginalized populations, there is limited research addressing the needs of gender expansive individuals in the context of psychosis-spectrum illnesses using a minority stress lens. As clinical high-risk for psychosis (CHR-p) assessment and treatment becomes accessible to increasingly diverse populations, there is a need for clinicians to demonstrate greater clinical competency working with individuals across diverse social backgrounds and identities.

METHODS

We examined rates of gender expansive (GE) patients seeking evaluation at an urban-based CHR-p clinic and compared the diagnostic profile of GE individuals to cisgender patients. Post-hoc analyses were conducted on clinical variables with significant differences between the cisgender and GE groups.

RESULTS

The proportion of GE patients seeking evaluation increased from 2017 (9.3%) to 2021 (16.7%). Compared to cisgender youth, GE patients had significantly higher depressive, social anxiety, borderline personality disorder symptoms, higher levels of suicidality and non-suicidal self-injurious behaviour, and lower role functioning. Gender identity was predictive of suicidality controlling for social anxiety, borderline symptoms, and role functioning.

CONCLUSIONS

We review implications for CHR-p treatment and discuss ways to integrate minority stress theory and gender-affirming practices into coordinated specialty care for CHR-p patients.

Delayed treatment seeking and its associated factors among people with schizophrenia spectrum disorders who are on follow-up at Dilla University Referral Hospital in the southern region of Ethiopia, 2022: a cross-sectional study

Background

Delay in psychiatric treatment leads to increased morbidity and mortality, as well as the emergence of several psychiatric and physical comorbidities and the use of life-threatening and life-altering self-treatments (such as licit and illicit substance misuse). Delaying detection and taking preventive measures against its modifiable factors are crucial for a better prognosis.

Objective

To assess delayed treatment seeking and its associated factors among people with schizophrenia spectrum disorders who are on follow-up at Dilla University Referral Hospital in the southern region of Ethiopia.

Method

An institution-based cross-sectional study was conducted between 8 June and 11 September at Dilla University Referral Hospital in the southern region of Ethiopia in 2022. Epicollect was used to collect data from 414 randomly selected participants using an interviewer-administered questionnaire. Delayed treatment seeking was determined using participants' medical records and a semi-structured questionnaire. The data were analyzed using Statistical Package for Social Sciences (SPSS) version 26. A logistic regression analysis was conducted to identify the explanatory variables for delayed treatment.

Results

The magnitude of delayed treatment seeking was 49.8% (95%CI = 44.9, 54.3). Study participants with disengaged family cohesion [AOR = 3.97, 95%CI = (2.999, 7.193)], inflexible family adaptability [AOR = 2.00, 95%CI = (1.686, 4.044)], who lack awareness about the availability of psychiatric treatment [AOR = 1.63, 95%CI = (1.362, 2.626)], high internalized stigma [AOR = 3.24, 95%CI = (2.770, 5.514)], and those with a negative attitude toward psychiatric treatment [AOR = 2.88, 95%CI = (2.034, 4.469)] had delayed seeking treatment. However, the participants whose educational status was higher than diploma [AOR = 0.040, 95%CI = (0.026, 0.077)] and high school [AOR = 0.09, 95%CI = (0.071, 0.204)] were less likely to have delayed seeking treatment.

Conclusions

There is a significant delay in seeking modern psychiatric treatment. Stigma, a lack of awareness of where treatment is available, disengaged family cohesion, inflexible family adaptability, distance to a health facility >5 km, and a negative attitude toward psychiatric treatment were barriers to seeking appropriate care.

Using the Theory of Planned Behavior to Understand How Crisis Intervention Team (CIT) Training Facilitates Police Officers' Mental Health Referrals

The Theory of Planned Behavior posits that behaviors are predicted by one's intention to perform them; intention is driven by attitude toward the behavior, subjective norm, and perceived behavioral control. We used this theory to predict Crisis Intervention Team (CIT)-trained and non-CIT officers' intention to facilitate referral of persons with suspected mental illnesses to mental health services. CIT-trained (n = 251) and non-CIT (n = 335) officers from six law enforcement agencies participated. CIT-trained officers had significantly greater scores on all constructs. Theory constructs fit the data well, and fit did not differ meaningfully between the two groups. Direct and indirect predictors together accounted for 28% and 21%, respectively, of variance in behavioral intention. Attitude was the strongest predictor. Intentions to facilitate mental health referrals may be driven by the same factors among CIT-trained and non-CIT officers, but CIT officers, even at a median of 22 months after training, have significantly higher scores on those factors.

Systematic review of pathways to care in the U.S. for Black individuals with early psychosis

The pathway to receiving specialty care for first episode psychosis (FEP) among Black youth in the US has received little attention despite documented challenges that negatively impact engagement in care and clinical outcomes. We conducted a systematic review of US-based research, reporting findings related to the pathway experiences of Black individuals with FEP and their family members. A systematic search of PubMed, PsycInfo, and Embase/Medline was performed with no date restrictions up to April 2021. Included studies had samples with at least 75% Black individuals and/or their family members or explicitly examined racial differences. Of the 80 abstracts screened, 28 peer-reviewed articles met the inclusion criteria. Studies were categorized into three categories: premordid and prodromal phase, help-seeking experiences, and the duration of untreated psychosis (DUP). Compounding factors such as trauma, substance use, and structural barriers that occur during the premorbid and prodromal contribute to delays in treatment initiation and highlight the limited use of services for traumatic childhood experiences (e.g., sexual abuse). Studies focused on help-seeking experiences demonstrated the limited use of mental health services and the potentially traumatic entry to services (e.g., law enforcement), which is associated with a longer DUP. Although the majority of studies focused on help-seeking experiences and predictors of DUP, findings suggests that for Black populations, there is a link between trauma and substance use in the pathway to care that impacts the severity of symptoms, initiation of treatment, and DUP. The present review also identifies the need for more representative studies of Black individuals with FEP.

Similarities and Differences in Associations Between Duration of Untreated Psychosis (DUP) and Demographic, Premorbid, and Symptom Severity Measures in Two Samples of First-Episode Psychosis Patients from Mexico and the United States

Early-psychosis researchers have documented that duration of untreated psychosis (DUP) is an important predictor of outcomes in first-episode psychosis. Very few cross-national studies have been conducted, and none have been carried out involving patients from both Mexico and the U.S. We collaborated to answer three questions: (1) Are DUP estimates similar in two very different settings and samples? (2) Are demographic variables, premorbid adjustment, and symptom severity similarly related to DUP in the two different settings? (3) Does the same set of variables account for a similar proportion of variance in DUP in the two settings? Data on sociodemographic characteristics, premorbid adjustment, symptom severity, and DUP were available for 145 Mexican and 247 U.S. first-episode psychosis patients. DUP was compared, and bivariate analyses and multiple linear regressions were carried out in each sample. DUP estimates were similar (medians of 35 weeks in Mexico and 38 weeks in the U.S.). In the Mexican sample, DUP was associated with gender, employment status, premorbid social adjustment, and positive symptom severity (explaining 18% of variance). In the U.S. sample, DUP was associated with age, employment status, premorbid social adjustment, and positive symptom severity (but in the opposite direction of that observed in the Mexican sample), accounting for 25% of variance. Additional cross-national collaborations examining key facets of early-course psychotic disorders, including DUP, will clarify the extent of generalizability of findings, strengthen partnerships for more internationally relevant studies, and support the global movement to help young people struggling with first-episode psychosis and their families.

Childhood-Onset Schizophrenia and Early-onset Schizophrenia Spectrum Disorders: An Update

The clinical severity, impact on development, and poor prognosis of childhood-onset schizophrenia may represent a more homogeneous group. Positive symptoms in children are necessary for the diagnosis, and hallucinations are more often multimodal. In healthy children and children with a variety of other psychiatric illnesses, hallucinations are not uncommon and diagnosis should not be based on these alone. Childhood-onset schizophrenia is an extraordinarily rare illness that is poorly understood but seems continuous with the adult-onset disorder. Once a diagnosis is confirmed, aggressive medication treatment combined with family education and individual counseling may prevent further deterioration.

Feasibility of a family-centered intervention for depressed older men in primary care

OBJECTIVE

Families provide considerable support to many older adults with depression, yet few intervention studies have sought to include them. Family participation in depression treatment aligns with the preferences of older men, a group at high risk for depression under treatment. This study examined the feasibility of a family-centered depression intervention for older men in a primary care setting.

METHODS

A clinical trial was conducted in a Federally Qualified Health Center (FQHC) in California's Central Valley. Depressed older men (age 50 and older) were allocated to usual care enhanced by depression psychoeducation or a family-centered depression intervention delivered by a licensed clinical social worker. Intervention feasibility was assessed in terms of recruitment, retention, and extent of family engagement. The PHQ-9 was administered at baseline, 1, 3, and 6 months.

RESULTS

For more than 6 months, 45 men were referred to the study; 31 met the inclusion criteria, 23 were successfully enrolled, and 20 (88%) participated in more than or equal to one treatment sessions. Overall, 85% (11 of 13) of men allocated to the intervention engaged a family member in more than or equal to one session and 54% (7 of 13) engaged the family member in more than or equal to three sessions. While men in both groups showed evidence of a significant decline in PHQ-9 scores early on, which attenuated over time, there were no significant between group differences.

CONCLUSIONS

Our family-centered depression intervention showed acceptable feasibility on the basis of a variety of parameters. Future research on family-based approaches may benefit from longer duration and more intensive treatment as well as additional strategies to overcome recruitment barriers.

Stigma and access to care in first-episode psychosis

AIM

Mental health-related stigma is considered a significant barrier to help-seeking and accessing care in those experiencing mental illness. Long duration of untreated psychosis is associated with poorer outcomes. The impact of stigma on the duration of untreated psychosis, in first-episode psychosis remains unexplored. To examine the association between mental health-related stigma and access to care in people experiencing first-episode psychosis in Birmingham, UK.

METHODS

We collected data on a prospective cohort of first-episode psychosis. The Stigma Scale was used as a measure of mental health-related stigma, and duration of untreated psychosis as a measure of delay in accessing care. We performed logistic and linear regression analyses to explore the relationship between mental health-related stigma and duration of untreated psychosis, adjusting for sex, age, educational level, religion and ethnicity.

RESULTS

On the 89 participants included in this study, linear regression analysis revealed that overall stigma and the discrimination sub-factor were significant predictors of longer duration of untreated psychosis, whereas logistic regression identified the disclosure sub-factor to be a significant predictor of longer duration of untreated psychosis.

CONCLUSIONS

These findings demonstrate that stigmatizing views of mental illness from the patient's perspectives can result in delayed access to care. This emphasizes the importance of tackling mental health-related stigma to ensure early treatment and improved outcomes for people experiencing first-episode psychosis.

First-episode psychosis: primary care experience and implications for service development

Aim and Methods

To capture the local primary care experience of first-episode psychosis before developing a local early intervention in psychosis service. A survey of Northamptonshire general practitioners (GPs) using a confidential questionnaire was carried out.

Results

Out of 284 GPs, 123 (43%) responded. General practitioners are unlikely to start treatment before referring to a specialist service: 63 GPs (51% of responders) start treatment in 10% or less of individuals with first-episode psychosis and 19 (15.5%) GPs start treatment in 75% or more before referring them to psychiatric service; 42 GPs (34%) refer those who request/accept a referral and 66 GPs (53%) refer all even if they refuse. Overall, 92 GPs (74%) agreed that an early intervention in psychosis service is needed and 77 (63%) GPs welcome having a mental health clinic in their surgery.

Clinical Implications

Individuals are more likely to accept referral to a psychiatric service if offered than to ask for it. People disengaging, stigma, the service being difficult to access/inappropriate and carers' lack of knowledge about mental illness are the likely causes for delayed referral.

Family-centered depression treatment for older men in primary care: a qualitative study of stakeholder perspectives

Background

Family members often play important roles in the lives of depressed older men and frequently attend primary care visits with their loved ones, yet surprisingly little is known about how to most effectively engage and include family members in depression treatment. However, including family in depression treatment may be difficult due to several factors, such as depression stigma and family conflicts. The objective of this study was to describe challenges in engaging family members in older men’s depression treatment and potential strategies to overcome those challenges.

Methods

A cross-sectional, qualitative descriptive interview study was conducted in a safety-net, Federally Qualified Health Center in California’s Central Valley. A total of 37 stakeholders were recruited, including 15 depressed older (i.e. age ≥ 60) men, 12 family members, and 10 clinic staff. Depressed men were identified through mail outreach, waiting room screening, and referral. Depressed men identified family members who were later approached to participate. We also recruited a purposeful sample of clinic staff. Interviews explored stakeholder perspectives on family involvement in men’s depression treatment as part of a primary care intervention. Interviews were conducted using a semi-structured interview guide, tape-recorded, transcribed verbatim, and translated if the interview was conducted in Spanish.

Results

Four themes were identified representing core challenges: engaging men at the right time; preserving men’s sense of autonomy; managing privacy concerns; and navigating family tensions. Stakeholders also provided practical suggestions and advice about how each of these challenges might be addressed.

Conclusions

While engaging family is a promising approach to strengthen depression care for older men in primary care settings, several potential challenges exist. Family- centered depression intervention development and clinical practice need to anticipate these challenges and to develop approaches and guidelines to address them.

Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis: a systematic review

BACKGROUND

Stigma associated with mental illness can delay or prevent help-seeking and service contact. Stigma-related influences on pathways to care in the early stages of psychotic disorders have not been systematically examined.

METHOD

This review systematically assessed findings from qualitative, quantitative and mixed-methods research studies on the relationship between stigma and pathways to care (i.e. processes associated with help-seeking and health service contact) among people experiencing first-episode psychosis or at clinically defined increased risk of developing psychotic disorder. Forty studies were identified through searches of electronic databases (CINAHL, EMBASE, Medline, PsycINFO, Sociological Abstracts) from 1996 to 2016, supplemented by reference searches and expert consultations. Data synthesis involved thematic analysis of qualitative findings, narrative synthesis of quantitative findings, and a meta-synthesis combining these results.

RESULTS

The meta-synthesis identified six themes in relation to stigma on pathways to care among the target population: 'sense of difference', 'characterizing difference negatively', 'negative reactions (anticipated and experienced)', 'strategies', 'lack of knowledge and understanding', and 'service-related factors'. This synthesis constitutes a comprehensive overview of the current evidence regarding stigma and pathways to care at early stages of psychotic disorders, and illustrates the complex manner in which stigma-related processes can influence help-seeking and service contact among first-episode psychosis and at-risk groups.

CONCLUSIONS

Our findings can serve as a foundation for future research in the area, and inform early intervention efforts and approaches to mitigate stigma-related concerns that currently influence recognition of early difficulties and contribute to delayed help-seeking and access to care.

Feasibility and Accessibility of a Tailored Intervention for Informal Caregivers of People with Severe Psychiatric Disorders: a Pilot Study

OBJECTIVES

This study aimed to assess the acceptability and feasibility of a new tailored intervention for informal caregivers: the Ensemble (Together) program.

METHODS

An open pre-post within-subject comparison pilot study was conducted. Twenty-one informal caregivers completed the five-session Ensemble program. Two measurement tools were used: The Brief Symptom Inventory (BSI) and the Life Orientation Scale (LOT-R).

RESULTS

The results showed that informal caregivers were in need of individual support and were ready to participate in the Ensemble program independent of the patient's diagnosis or stage of illness. The participants were very satisfied, and 95.4% completed the program. The preliminary results also showed that in five sessions, informal caregivers' Global Severity Index measured by the BSI and their optimism about their future (measured by the LOT-R) were significantly improved.

CONCLUSION

This pilot study provided preliminary results concerning the feasibility and acceptability of the tailored Ensemble program and indicates the need for a randomized trial. The Ensemble program is appropriate for both the acute and chronic phases of disease. Individualized brief and useful interventions for informal caregivers may provide more positive outcomes in care.

The Application of the Theory of Reasoned Action and Planned Behavior to Prevention Science in Counseling Psychology

The theory of reasoned action and planned behavior (TRA/PB) is a model of behavior change that has been extensively studied in the health sciences but has had limited exposure in the counseling psychology literature. The model offers counseling psychologists a framework to conceptualize prevention research and practice. The model is important to consider since the training of counseling psychologists is heavily dominated by theories of psychotherapy that emphasize remediation rather than prevention. This article discusses a brief history and explanation of TRA/PB along with relevant research, limitations, and multicultural considerations. Elicitation research, an important component of the model, receives emphasis because it solicits population-specific cognitions and social influences relevant to targeted behaviors, thus strengthening prevention interventions. An example demonstrates how TRA/PB can be used as a theoretical framework to support prevention research. Recommendations for prevention training of counseling psychologists are presented.

The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis

Although the family has an important role in the early detection and intervention of first-episode psychosis (FEP), there are few findings reporting associations between family strengths and early treatment-seeking experiences. This study aimed to investigate, within the framework of the resiliency model of family stress, adjustment, and adaptation, the association between family coping strategies, resource management factors and duration of untreated psychosis (DUP) in Iranian families with one adult child with FEP. Hundred and seven individuals referred to three medical centers in Tehran and diagnosed with FEP participated in this study. Caregiver-perceived DUP was measured via semi-structured interviews administered to primary caregivers. They also completed two questionnaires regarding family resources of stress management and family coping strategies. Data analysis indicated that the Family Inventory of Resources of Management (FIRM) total scale score did not significantly explain the variance of caregiver-perceived DUP, but one of the FIRM subscales, the Extended Family Social Support, and the Family Crisis-Oriented Personal Evaluation scale (F-COPES) total score and one its subscales, the Acquiring Social Support, explained a significant amount of the variance of caregiver-perceived DUP. The results suggest that higher family resiliency, especially social support, facilitates the family's appropriate adaptive reaction (i.e., treatment-seeking), with the consequent decrease of DUP.

Childhood onset schizophrenia and early onset schizophrenia spectrum disorders

The clinical severity, impact on development, and poor prognosis of childhood onset schizophrenia may represent a more homogeneous group. Positive symptoms in children are necessary for the diagnosis and hallucinations are more often multimodal. In healthy children and children with a variety of other psychiatric illnesses, hallucinations are not uncommon and diagnosis should not be based on these alone. Childhood onset schizophrenia is an extraordinarily rare illness that is poorly understood but seems continuous with the adult onset disorder. Once a diagnosis is affirmed, aggressive medication treatment combined with family education and individual counseling may defer further deterioration.

Reducing treatment delay for early intervention: evaluation of a community based crisis helpline

BACKGROUND

A limited number of studies have assessed the pathways to care of patients experiencing psychosis for the first time. Helpline/clinic programs may offer patients who are still functional but have potential for crisis an alternative that is free from judgment.

METHODS

In this study we report on patient calling a round-the-clock crisis helpline for suicide prevention supported by psychiatric facilities in Mumbai, India. Chi-square and test of mean differences were used to compare outcomes between first-episode patients and those with a previous history.

RESULTS

Within five years, the helpline received 15,169 calls. Of those callers, 2341 (15.4%) experienced suicidal ideation. Two hundred and thirty four patients opting for counseling lasting 12 months agreed to a psychiatric assessment. Of those, 32 were fist time psychosis sufferers, whereas, 54 had previously been psychotic. Of all psychiatric assessments, the clinic received 94 patients with 'first-episode psychosis'. We found that the duration of illness was significantly shorter (17 vs. 28 months) and suicide attempts were fewer (16 vs. 21) in first-time psychosis sufferers compared to those with a treatment history.

CONCLUSIONS

We conclude that some first-episode patients of schizophrenia and other disorders do access services by using helplines. We also argue that helplines may be somewhat immune to stigma, allowing patients a safe alternative when finding help.

Health Behavior Theories and Research: Implications for Suicidal Individuals' Treatment Linkage and Adherence

Treatment linkage and adherence to psychotherapeutic interventions can be challenging with suicidal individuals. Health behavior theories, specifically the Health Belief Model, Stages of Change, and Theory of Planned Behavior, focus on individuals' beliefs, their readiness to change, their perceptions of illness severity and "threat," their perceptions of significant others' attitudes toward illness and treatment, and their behavioral intentions to change. These constructs have relevance both for understanding suicidal individuals' behaviors related to treatment utilization and for understanding cultural variations in these behaviors. Furthermore, these theories have implications for clinical practices aimed at facilitating improved treatment follow-through and adherence. After describing the theories and their constructs, clinical examples are provided to illustrate applications to practice with suicidal individuals.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

OBJECTIVE

We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.

METHODS

We explore the characteristics and techniques of patient-clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.

RESULTS

We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.

CONCLUSIONS

It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes.

Ethnic diversity and pathways to care for a first episode of psychosis in Ontario

OBJECTIVE

To examine ethnic variations in the pathways to care for persons accessing early intervention (EI) services in Ontario.

METHOD

The pathways to care and the duration of untreated psychosis were assessed for first-episode psychosis patients who entered specialized EI services in Ontario. The sample was assigned to the following ethnic classifications: the White (Caucasian), Black (African descent), and Asian (ancestry from the continent) groups, plus all the "other ethnicities" group.

RESULTS

There were 200 participants: 78% were male; 61% from the White, 15% Black, 13% Asian, and 11% were from the other ethnicities group. At the first point of contact, more participants used nonmedical contacts (12%), such as clergy and naturopathic healers, than psychologists (8%) or psychiatrists (7%). There were no ethnic differences for duration of untreated psychosis (median 22 weeks) or for initiation of help seeking by family/friends (53%), police (15%), or self (33%). After adjusting for relevant clinical and demographic factors, the Asian and other ethnicities groups were 4 and 3 times (respectively) more likely than the White or Black groups (P = .017) to use emergency room services as the first point of contact in the pathways to care. Participants from the Asian group experienced less involuntary hospitalizations (P = .023) than all the other groups. Yet overall, there were many more similarities than significant differences in the pathways to care.

CONCLUSION

EI services should monitor the pathways to care for young people of diverse ethnic backgrounds to address any disparities in accessing care.

Improving antidepressant adherence and depression outcomes in primary care: the treatment initiation and participation (TIP) program

OBJECTIVE

To test the impact of a novel psychosocial intervention to improve antidepressant adherence and depression outcomes among older adults prescribed pharmacotherapy by their primary care physician (PCP).

DESIGN

A randomized controlled pilot study was conducted to examine the usefulness of the Treatment Initiation and Participation (TIP) program as an intervention to improve antidepressant adherence and depression outcomes.

SETTING

The study was conducted at two primary care clinics in New York city: one clinic served geriatric adults and the second clinic served a diverse group of mixed aged adults.

PARTICIPANTS

The sample consisted of adults aged 60 years and older with major depression who were recommended antidepressant therapy by their PCPs.

INTERVENTION

All participants were prescribed antidepressant therapy and randomly assigned to either the intervention (TIP) or the treatment as usual (TAU) group. The TIP intervention identifies and targets psychological barriers to depression care, especially stigma, as well as fears and misconceptions of depression and its treatment. TIP participants are encouraged to develop a treatment goal and create an adherence strategy.

MEASUREMENT

Study participants were assessed at entry, 6, 12, and 24 weeks later. Adherence was measured based on self-report with chart verification. Depression severity was measured using the Hamilton Depression Rating Scale.

RESULTS

Participants in TIP were significantly more adherent to their antidepressant pharmacotherapy at all assessment time points and had a significantly greater decrease in depressive symptoms than older adults who received TAU.

CONCLUSION

The results provide support for the usefulness of TIP as a brief intervention to improve adherence to depression medication treatment provided in primary care settings.

The relationship between stigma and other treatment concerns and subsequent treatment engagement among black mental health clients

This study examined stigma (both the perception that mental illness is stigmatized and stigma concerns about entering treatment) and other treatment concerns along with subsequent treatment engagement within three months in a sample of 42 black adults referred to public-sector outpatient treatment. Contrary to expectation, perceived stigma of mental illness was unrelated to treatment engagement; however having stigma or other concerns about treatment was associated with increased odds of engagement. Findings indicate the importance of examining stigma as a multi-dimensional construct and raise questions about the utility of addressing stigma as a way of promoting service use in black adults. More work is clearly needed to understand the complex relationship between stigma and help-seeking in black populations and other underserved groups.

Stigma and treatment delay in first-episode psychosis: a grounded theory study

AIM

A longer duration of untreated psychosis (DUP) is associated with greater morbidity in the early course of schizophrenia. This formative, hypothesis-generating study explored the effects of stigma, as perceived by family members, on DUP.

METHODS

Qualitative interviews were conducted with 12 African American family members directly involved in treatment initiation for a relative with first-episode psychosis. Data analysis relied on a grounded theory approach. A testable model informed by constructs of Link's modified labelling theory was developed.

RESULTS

Four main themes were identified, including: (i) society's beliefs about mental illnesses; (ii) families' beliefs about mental illnesses; (iii) fear of the label of a mental illness; and (iv) a raised threshold for the initiation of treatment. A grounded theory model was developed as a schematic representation of the themes and subthemes uncovered in the family members' narratives.

CONCLUSIONS

The findings suggest that due to fear of the official label of a mental illness, certain coping mechanisms may be adopted by families, which may result in a raised threshold for treatment initiation, and ultimately treatment delay. If the relationships within the grounded theory model are confirmed by further qualitative and quantitative research, public educational programs could be developed with the aim of reducing this threshold, ultimately decreasing DUP.

Family strengths: a potential determinant of the duration of untreated psychosis among hospitalized African-American first-episode patients

AIM

Evidence suggests that treatment delay, represented by the duration of untreated illness (DUI) and the duration of untreated psychosis (DUP), may be a potentially powerful determinant of the early course of primary psychotic disorders. Yet, research on the predictors of treatment delay has only just begun. To date, there are virtually no empirical data on the relationship between family functioning and treatment delay in the context of first-episode psychosis. In this study, it was hypothesized that family strengths would be inversely correlated with DUI and DUP; and families of patients with a short DUI/DUP would have greater family strengths than those of patients with a long DUI/DUP.

METHODS

Family strengths (including pride and accord dimensions), DUI and DUP were assessed in 34 African Americans hospitalized for first-episode psychosis and their respective 34 family members most involved in initiating care.

RESULTS

The total score of the Family Strengths scale and the accord subscale score were significantly inversely correlated with both DUI and DUP, although the correlation between the pride subscale score and DUI/DUP was not as strong and failed to reach statistical significance. Similarly, the family members of patients with a short DUI/DUP had higher family strength scores than those of patients with a long DUI/DUP.

CONCLUSIONS

Given the dearth of research on the functioning of families beginning to initiate care for individuals with first-episode psychosis, it is imperative to further clarify the role family characteristics may play in understanding treatment delay (DUI/DUP) and in the development of preventive interventions to facilitate early intervention for at-risk populations.