Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec

Scoping review on mental health standards for Black youth: identifying gaps and promoting equity in community, primary care, and educational settings

BACKGROUND

Youth mental health is a growing concern in research, practice, and policy. Practice standards, guidelines, or strategies provide an invisible infrastructure that fosters equity, quality, and safety, potentially addressing inconsistencies and more effectively attending to the mental wellness of Black youth as a particular population of concern. This scoping review aimed to address the following question: What standards exist for the delivery of mental health services to Black youth in community, primary care, and educational settings? Due to a limited initial search yield on publications about standards for the delivery of mental health services for Black youth population, our goal was then to identify and map mental health standards, recommendations, or guidelines for the delivery of mental health services using the same settings to all youth.

METHODS

Searches were conducted in various databases, including PubMed/MEDLINE, PsycINFO, Embase, SocINDEX, CINAHL, Gender Studies Database, Social Services Abstracts, Sociological Abstracts, Scopus, Web of Science, and Google Scholar. Screening was independently conducted by two reviewers, with disagreements resolved by a third. Information extraction was performed by two independent reviewers.

RESULTS

Out of the 2,701 screened publications, 54 were included in this scoping review. Among them, 38.9% were published between 2020 and 2023, with 40.7% originating from the United States of America, 20.4% from the United Kingdom, and 13% from Canada. Concerning the settings, 25.9% of the publications focused on primary care, 24.1% on health care services, 20.4% on educational settings, and 3.7% on the community. Additionally, 25.9% were classified as general because recommendations were applicable to various settings. Attention-deficit/hyperactivity disorder (11.1%) was the most frequently considered specific condition, followed by autism spectrum disorder (9.3%) and depression (9.3%). However, 31.5% of the included references addressed mental health in general. Only three references provided specific recommendations for the Black population.

CONCLUSIONS

Recommendations, guidelines, or standards for Black youth mental health services in community, primary care, or educational settings are scarce and limited to North American countries. This scoping review emphasizes the need to consider ethnicity when developing guidelines or standards to improve racial equity and reduce disparities in access to mental health services.

Development and implementation determinants of competency frameworks for mental health clinicians and service providers working with youth: a scoping review protocol

INTRODUCTION

Despite high prevalence, access to mental healthcare for Canadian youth is limited, with less than 20% receiving adequate treatment. Marginalised and at-risk youth face particular challenges, including cultural misunderstandings, long wait times and negative care experiences. A competency framework for mental health clinicians working with youth can be a tool to increase the capacity of the health workforce to deliver culturally responsive care. This scoping review aims to comprehensively summarise the existing literature on competency frameworks for mental health clinicians and youth service providers, assessing how these frameworks align with culturally responsive care and examining their development, evaluation and implementation methods.

METHODS AND ANALYSIS

This review protocol is guided by the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines and registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/EY7NF). The search strategy, developed with an Information Specialist, comprises a three-step process: preliminary searches in two databases, expansion of the search across Medline, CINAHL, EMBASE, PsycInfo, CENTRAL and dissertations and theses databases and examination of reference lists and hand-searching for additional sources. The search strategy was reviewed using the Peer Review of Electronic Search Strategies checklist. Eligible English language articles will be selected through title and abstract screening (level 1) and full-text review (level 2). The search dates are 18 July and 21 August 2023, as well as 19 January 2024. Data from eligible articles will be extracted in duplicate and independently using a data extraction form. The data will then be summarised descriptively and qualitatively using content analysis mapped to the four evidence-based conceptual frameworks and presented in a table.

ETHICS AND DISSEMINATION

As the scoping review involves gathering and describing existing literature, it is exempt from ethical approval requirements. The findings of this scoping review will be presented at relevant local and international conferences and published in a peer-reviewed journal. The findings will also be disseminated and shared with professional organisations to enhance healthcare workforce capacity and drive systemic change. Furthermore, the findings will be used to inform doctoral work and future mental health and health education research related to underserved youth.

Incidence, Racial Disparities and Factors Related to Psychosis among Black Individuals in Canada: A Scoping Review

OBJECTIVE

Black communities are increasingly concerned about psychosis, a worry echoed by provincial health-care systems across Canada. Responding to the lack of evidence on psychosis in Black communities, this scoping review examined the incidence and prevalence of psychosis, access to care (pathways to care, coercive referrals, interventions, etc.), treatments received, and stigma faced by individuals with psychosis.

METHOD

To identify studies, a comprehensive search strategy was developed and executed in December 2021 across 10 databases, including APA PsycInfo, CINAHL, MEDLINE and Web of Science. Subject headings and keywords relating to Black communities, psychosis, health inequalities, Canada and its provinces and territories were used and combined. The scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping review (PRISMA-ScR) reporting standard.

RESULTS

A total of 15 studies met the inclusion criteria, all of them conducted in Ontario and Quebec. Results highlight different disparities in psychosis among Black communities. Compared to other Canadian ethnic groups, Black individuals are more likely to be diagnosed with psychosis. Black individuals with psychosis are more likely to have their first contact with health-care settings through emergency departments, to be referred by police and ambulance services, and to experience coercive referrals and interventions, and involuntary admission. Black individuals experience a lower quality of care and are the ethnic group most likely to disengage from treatment.

CONCLUSION

This scoping review reveals many gaps in research, prevention, promotion and intervention on psychosis in Black individuals in Canada. Future studies should explore factors related to age, gender, social and economic factors, interpersonal, institutional and systemic racism, and psychosis-related stigma. Efforts should be directed toward developing trainings for health-care professionals and promotion and prevention programs within Black communities. Culturally adapted interventions, racially disaggregated data, and increased research funding are needed.

Clinical and psychosocial outcomes of Black Americans in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study

PURPOSE

In the US, Black people diagnosed with schizophrenia experience worse psychosocial and clinical outcomes than their White counterparts. While racism-related factors contribute to these disparities, an additional understudied explanation may be that psychosocial treatments for psychotic disorders are less effective for Black than White individuals. The purpose of this study is to examine the extent to which best treatment practices for first-episode psychosis (FEP) are effective for Black and White participants.

METHODS

We conducted a secondary data analysis of the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP), a two-year multisite trial that compared a coordinated specialty care intervention for FEP (NAVIGATE) to community care as usual (CC) in 34 sites across the US. Specifically, we compared interviewer-rated quality of life and symptoms, as well as self-reported mental health and stigma, between 139 Non-Latinx Black and 172 Non-Latinx White participants with FEP in NAVIGATE and CC.

RESULTS

We found few differences between Black and White participants over two-year outcomes, either overall or in terms of benefit from NAVIGATE. Across both treatment conditions, Black participants improved less than White participants on positive symptoms, an effect driven primarily by suspiciousness/persecution. In NAVIGATE, self-reported mental health stigma decreased for both Black and White participants, while in CC stigma decreased for White participants but increased for Black participants. This effect was driven primarily by experienced stigma rather than self-stigma.

CONCLUSION

NAVIGATE benefits both Black and White individuals diagnosed with FEP. Mental health stigma and positive symptoms may be particularly important aspects of treatment for Black individuals diagnosed with FEP.

An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care

Importance

Intersecting factors of social position including ethnoracial background may provide meaningful ways to understand disparities in pathways to care for people with a first episode of psychosis.

Objective

To examine differences in pathways to care by ethnoracial groups and by empirically derived clusters combining multiple factors of social and clinical context in an ethnoracially diverse multisite early-intervention service program for first-episode psychosis.

Design, Setting, and Participants

This cohort study used data collected on individuals with recent-onset psychosis (<2 years) by clinicians with standardized forms from October 2013 to January 2020 from a network of 21 coordinated specialty care (CSC) programs in New York State providing recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis.

Exposures

Ethnoracial group and other factors of social position (eg, insurance status, living situation, English fluency, geographic region) intersecting with first-contact experiences (ie, type of first service, referral source, and symptoms at referral).

Main Outcomes and Measures

Outcome measures were time from onset to first contact, first contact to CSC, and onset to CSC.

Results

The total study sample consists of 1726 individuals aged 16 to 30 years and included 452 women (26%), 1263 men (73%), and 11 (<1%) with another gender enrolled in the network of CSC programs. The total sample consisted of 153 Asian (9%), 599 Black (35%), 454 Latinx (26%), and 417 White individuals (24%). White individuals had a significantly shorter time from onset to first contact (median [IQR], 17 [0-80] days) than Asian (median [IQR], 34 [7-94] days) and Black (median [IQR], 30 [1-108] days) individuals but had the longest period from first contact to CSC (median [IQR], 102.5 [45-258] days). Five distinct clusters of individuals emerged that cut across ethnoracial groups. The more disadvantaged clusters in terms of both social position and first-contact experiences had the longest time from onset to first contact, which were longer than for any single ethnoracial group.

Conclusions and Relevance

In this cohort study of individuals with recent-onset psychosis, time-to-treatment outcomes differed by ethnoracial group and by empirically derived clusters combining multiple factors of social and clinical context. The examination of disparities in durations to treatment through an intersectional, ethnoracial lens may improve understanding of the inequities resulting from the various intersecting factors that may compound delays in treatment initiation.

Feasibility of conducting a pilot randomized control trial of a psycho-education intervention in patients with a first episode psychosis in Uganda—A study protocol

Background

Psychotic disorders contribute to significant morbidity and mortality partly due to the chronicity of the illness and high relapse rates. Delivering psycho-education messages about disease etiology, their signs and symptoms and the benefits of treatment adherence have been shown to improve clinical outcomes among individuals with psychoses. However, little has been done to examine the feasibility and efficacy of this intervention in low resourced settings.

Objective

Our primary objective will be to determine the feasibility of recruiting and retaining patients with a first episode psychosis (FEP) and for the secondary objective, we will determine the preliminary efficacy of psycho-education on illness self-management, stigma, adherence to medications and symptom severity.

Hypothesis

We hypothesize that (i) we will recruit 70% of eligible participants and accrue a sample size of 80 over 20-weeks, retaining 80% of the sample size for 24 weeks, (ii) the intervention will lead to improvement in clinical outcomes (described above).

Methods

We will recruit 80 adult patients who have been diagnosed with a FEP, received antipsychotic medication at Butabika Hospital and reside within 21km from the Hospital. Trained village health team (VHTs) members will deliver 6 psycho-education sessions to 40 participants and their family members (intervention arm). Participants in the control arm (n = 40) will receive routine care. We will document how feasible it will be to recruit and retain participants over 24 weeks and document the preliminary efficacy of the intervention on illness self-management, stigma, adherence to medications and severity of symptoms.

Data analysis

We will document the proportion of participants who consent and get recruited, the proportion of those who will get retained and reasons for drop out. We will conduct an intention to treat analysis comparing the groups at weeks 4, 12, 24 and assess the effect of the intervention on the clinical outcomes (described above). We will use the Bonferroni approach to correct for multiple comparisons.

Trial registration

Clinical trials.gov registration number: NCT 04602585.

Comparison of antipsychotic naïve first-episode psychosis patients and healthy controls in Uganda

INTRODUCTION

The risk factors for a first episode of psychosis in low and middle-income countries (LMICs) are not well described. The study compared the association of different risk factors in patients with first-episode psychosis patients and healthy controls from an LMIC context.

METHODS

A comparative, descriptive, cross-sectional study was performed in antipsychotic naïve first-episode psychosis patients and healthy controls at the National referral hospital in Uganda. Standardized tools were used to assess sociodemographic (e.g., age, sex, socioeconomic status) and clinical (e.g., childhood trauma, quality of life) variables. First episode psychosis participants were compared to healthy controls in terms of sociodemographic and clinical variables, and logistic regression was used to determine predictors of FEP.

RESULTS

Our final sample included 198 antipsychotic naïve first-episode psychosis participants and 82 controls. Most participants were female (68.5%) with a mean age of 29.4 years. After adjusting for age and sex, FEP patients when compared to controls were less likely to be female [AOR 0.18 (95%CI 0.03-0.85; p = .031)], more likely to have experienced emotional abuse [AOR 1.30 (95%CI 1.02-1.65; p = .032)] and more likely to have a poor quality of life [AOR 0.93 (95%CI 0.89-0.97; p = .002)].

DISCUSSION

The risk factors for a first episode of psychosis in this low and middle-income population were like those described in high-income countries. Further studies on interventions to prevent the transition to psychotic disorders in this sub-groups of patients are recommended. Also, the use of specialized early intervention services in improving the quality of life needs to be evaluated.

First-episode psychosis in the Ferrara Mental Health Department: Incidence and clinical course within the first 2 years

AIM

To examine the incidence of with first-episode psychosis (FEP) in the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, and to examine the association between the Duration of Untreated Psychosis (DUP) and the clinical course.

METHODS

Participants recruited in 2013-2019 were assessed with the Health of the Nation Outcome Scale (HoNOS) every 6 months for 24 months. Hierarchical growth models analysed changes of global severity (HoNOS total scores) and symptom dimensions. Regression modelled factors associated with remission (HoNOS < 8) and clinical improvement (<12).

RESULTS

The incidence of FEP was 21.5 (95%CI: 21.2-21.9) cases per 100 000 person year. Among participants (n = 86, mean age 23, 76% males), baseline HoNOS scores were higher for those with a longer DUP. More than half subjects reached clinical remission (61.6%) or improvement (82.6%), while very few (2.3%) were re-hospitalized. HoNOS total scores decayed with a mixed linear/quadratic trend, with a slower decay among migrants. A longer DUP was associated with reduced improvements of positive symptoms and lower likelihood of clinical improvement (OR: 0.84; 95%CI: 0.73-0.96).

CONCLUSIONS

Patients from the FEP program of Ferrara reached good clinical outcomes. Nonetheless, individuals with a longer DUP may need additional clinical attention. Systematic monitoring of clinical outcomes may be an optimal strategy to improve the outcomes of FEP in the real world.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

INTREPID II: protocol for a multistudy programme of research on untreated psychosis in India, Nigeria and Trinidad

INTRODUCTION

There are few robust and directly comparable studies of the epidemiology of psychotic disorders in the Global South. INTREPID II is designed to investigate variations in untreated psychotic disorders in the Global South in (1) incidence and presentation (2) 2-year course and outcome, (3) help-seeking and impact, and (4) physical health.

METHODS

INTREPID II is a programme of research incorporating incidence, case-control and cohort studies of psychoses in contiguous urban and rural areas in India, Nigeria and Trinidad. In each country, the target samples are 240 untreated cases with a psychotic disorder, 240 age-matched, sex-matched and neighbourhood-matched controls, and 240 relatives or caregivers. Participants will be followed, in the first instance, for 2 years. In each setting, we have developed and are employing comprehensive case-finding methods to ensure cohorts are representative of the target populations. Using methods developed during pilot work, extensive data are being collected at baseline and 2-year follow-up across several domains: clinical, social, help-seeking and impact, and biological.

ETHICS AND DISSEMINATION

Informed consent is sought, and participants are free to withdraw from the study at any time. Participants are referred to mental health services if not already in contact with these and emergency treatment arranged where necessary. All data collected are confidential, except when a participant presents a serious risk to either themselves or others. This programme has been approved by ethical review boards at all participating centres. Findings will be disseminated through international conferences, publications in international journals, and through local events for key stakeholders.

Clinical outcomes among individuals with a first episode psychosis attending Butabika National Mental Referral Hospital in Uganda: a longitudinal cohort study. A study protocol for a longitudinal cohort study

INTRODUCTION

Psychotic disorders significantly contribute to high morbidity and mortality. In high-income countries, the predictors of mortality, relapse and barriers to care among patients with first episode psychoses (FEP) have been studied as a means of tailoring interventions to improve patient outcomes. However, little has been done to document relapse rates and their predictors in patients with FEP in low resourced, high disease burdened sub-Saharan Africa.

OBJECTIVE

We shall estimate the rates of relapse of psychotic symptoms and the factors that predict them in patients with FEP over 4 years.

METHODS AND ANALYSIS

We will assemble a cohort of patients with an FEP seen at the Butabika National Mental Referral Hospital in Kampala over a 4-year period. Participants will be adults (≥18 years old), who have received a diagnosis of a psychosis according to the Mini International Neuropsychiatric Instrument (M.I.N.I.), with a demonstrable resolution of active symptoms following the use of antipsychotic medications, and deemed clinically stable for a discharge by the healthcare practitioner. All participants will be required to provide written informed consent. Trained research assistants will collect Demographic and clinical parameters, age of onset of symptoms, diagnostic data using the M.I.N.I., physical examination data, symptom severity, level of social and occupational functioning and household income, during the 4-year study period. We will conduct a verbal audit in the event of loss of life. We shall perform survival analysis using the Aalen-Johansen estimator, and describe the population characteristics by demographics, social and economic strata using simple proportions.

ETHICS AND DISSEMINATION

All participants will provide written informed consent. Ethical approvals for the study have been obtained from the Makerere University School of Medicine Research and Ethics Committee and the Uganda National Council for Science and Technology. Findings will be published in peer reviewed journals.

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.

Psychopathology, cognition and outcome in Dutch and immigrant first-episode psychosis patients

AIM

The primary aim was to examine differences in baseline symptom expression, neurocognition, social cognition and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis (FEP). The secondary aim was to examine functional and symptomatic change and between-group differences at 12-months follow-up. Associations between migration, baseline characteristics and outcome were explored.

METHODS

Forty-six Dutch, 56 second-generation- and 60 first-generation immigrant patients completed baseline measures for 6 symptom dimensions (positive symptoms, negative symptoms, neurocognitive functioning, social cognitive functioning, excitement and emotional distress) and 5 domains of psychosocial functioning (general functioning, work and study, relationships, self-care and disturbing behaviour). Functioning and psychotic symptoms were assessed at baseline and 12-months follow-up. ANCOVA and t tests were used to assess between-group differences. General linear models were used to explore within-group differences. Backward-regression was used to explore predictors of outcome.

RESULTS

Levels of positive symptoms, excitement and emotional distress did not differ between groups at baseline or follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at follow-up. On neurocognition and social cognition, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Psychosocial functioning across all domains at baseline and at 12-months follow-up was similar across groups. Baseline levels of general psychosocial functioning and income were the strongest predictors of outcome at follow-up.

CONCLUSIONS

Psychosocial functioning and symptom profiles are comparable between Dutch, first-generation immigrant and second-generation immigrant FEP patients, excluding neurocognitive and social cognitive deficits. A range of baseline characteristics predicted outcome.

Is early management of psychosis designed for migrants? Improving transcultural variable collection when measuring duration of untreated psychosis

AIM

A background of migration is an established risk factor for psychosis. At the same time, over the last 25 years, many countries have developed specialized services for the assessment and care of people with early psychosis. Evaluation of these services often focuses on the duration of untreated psychosis (DUP).

METHODS

We conducted a systematic review with an electronic search of key words in 3 databases to determine the extent to which studies measuring DUP consider transcultural variables, including migration status, national origin, ethnicity and language.

RESULTS

We identified 18 studies that included transcultural variables and measured DUP. They differed in their design, aims and methodology, and could not be directly compared. Common themes nonetheless appeared.

CONCLUSIONS

Most of the studies exploring DUP took little account of transcultural variables. Definitions of transcultural indicators were heterogeneous and often vague. Lack of language proficiency was often an exclusion criterion, and none of the studies used interpreters. We propose some basic transcultural variable and recommendations to include in future studies and recommendations to improve their internal and external validity.

Symptom profiles and explanatory models of first-episode psychosis in African-, Caribbean- and European-origin groups in Ontario

AIM

To assess variability in symptom presentation and explanatory models of psychosis for people from different ethnic groups.

METHODS

Clients with first-episode psychosis (n = 171) who identified as black African, black Caribbean or white European were recruited from early intervention programmes in Toronto and Hamilton. We compared results by ethnic group for symptom profiles and explanatory models of illness.

RESULTS

Clients of black Caribbean origin had a lower odds of reporting that they were speaking incomprehensibly (OR = 0.36; 95% CI: 0.14-0.90) and black African clients had a greater odds of reporting persistent aches or pains (OR = 2.92; 95% CI: 1.32-6.50). Black African clients had a lower odds of attributing the cause of psychosis to hereditary factors (OR = 0.41; 95% CI: 0.19-0.89) or to substance abuse (OR = 0.29; 95% CI: 0.13-0.67) and had a lower odds of assigning responsibility for their illness to themselves (OR = 0.41; 95% CI: 0.19-0.89).

CONCLUSIONS

Understanding the differences in illness models for ethnic minority groups may help improve the cultural competence of mental health services.

Does ethnicity have an impact on duration of untreated psychoses: A retrospective study in Singapore

BACKGROUND

Some studies have suggested ethnicity as being one of the causes leading to a longer duration of untreated psychosis (DUP) in first episode psychosis.

AIM

We sought to investigate this issue, in a large cohort of patients with a first episode of psychosis, in Singapore.

METHOD

In this naturalistic retrospective study, 794 patients accepted into Early Psychosis Intervention Programme (EPIP) services in Singapore were recruited. Diagnosis was made based on SCID 1 (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Axis I Disorders). Information about DUP and sociodemographic characteristics was collected from patients and relatives. Positive and Negative Symptom Scale (PANSS) and Global Assessment of Functioning (GAF) Scale were used as tools to assess the severity of symptoms and functioning of the patient, respectively, at baseline, 3, 6, 12 and 24  months.

RESULTS

The mean and 50th quantile (median) of DUP for this sample were 14.2 and 6, respectively. The mean and median DUP were higher among Indians than in the other ethnic groups. After adjusting for demographic variables, Indian ethnicity was significantly associated with higher median and 75th Percentile DUP than Chinese. Secondary and tertiary education and diagnosis of affective psychosis and brief psychotic disorder (vs. schizophrenia spectrum and delusional disorder) were also significantly associated with lower mean, median and 75th percentile DUP symptoms. Increase in age was significantly associated with higher mean, median and 75th percentile DUP while married and separated/divorced (vs. single) was significantly associated with lower mean and 75th percentile DUP.

CONCLUSION

This study found a positive correlation between certain ethnic groups and DUP. Indian ethnicity, older age, single, lower education and patients diagnosed with schizophrenia spectrum and delusional disorders were more likely to be associated with longer DUP.

Environmental factors and the age at onset in first episode psychosis

OBJECTIVE

Factors that influence the age at onset in psychotic disorders could provide valuable insights into precipitating or causative factors of the disorder. Despite being established risk factors, it is not yet known whether migration status, place of birth, social class at birth and season of birth influence the age at onset of psychotic disorders. This study aimed to determine whether these environmental factors, in addition to cannabis abuse and obstetric complications, influence the age at onset. Additionally, we investigated whether environmental factors could have a cumulative effect on the age at onset.

METHOD

Data was obtained from two first episode of psychosis (FEP) cohort studies. Diagnosis was established using the Structured Clinical Interview for DSM IV diagnoses.

RESULTS

The age at onset was determined for 555 individuals with a FEP and the median age at onset was 27.3years. Individuals with a history of cannabis abuse had an earlier age at onset by nearly six years. There was a trend for a history of obstetric complications to be associated with a younger age at onset by 2.7years and this was significant in the subgroup with a family history of psychosis. Social class at birth, migration status, place of birth and season of birth were not associated with the age at onset. Exposure to a higher number of environmental factors was associated with an earlier age at onset.

CONCLUSIONS

Cannabis and obstetric complications are associated with an earlier age at onset and there appears to be a cumulative effect of exposure to multiple environmental factors.

Pathways to First-Episode Care for Psychosis in African-, Caribbean-, and European-Origin Groups in Ontario

OBJECTIVE

To compare the pathways to care and duration of untreated psychosis (DUP) for people of Black-African, Black-Caribbean, or White-European origin with first-episode psychosis (FEP).

METHODS

We recruited a sample of 171 patients with FEP of Black-African, Black-Caribbean, and White-European origin from hospital- and community-based early intervention services (EIS) in the cities of Toronto and Hamilton. We compared the 3 groups on DUP and key indicators of the pathway to care.

RESULTS

We observed differences in pathways to care across the 3 groups. Black-Caribbean participants had an increased odds of referral from an inpatient unit to EIS (OR 3.33; 95% CI 1.46 to 7.60) and a decreased odds of general practitioner involvement on the pathway to care (OR 0.17; 95% CI 0.07 to 0.46), as well as fewer total contacts (exp[β] 0.77; 95% CI 0.60 to 0.99) when compared with White-European participants. Black-African participants had an increased odds of contact with the emergency department at first contact (OR 3.78; 95% CI 1.31 to 10.92). The differences in the DUP between groups were not statistically significant.

CONCLUSIONS

Our findings suggest that there are significant differences in the pathways to EIS for psychosis for people of African and Caribbean origin in our Canadian context. It is essential to gain a comprehensive understanding of the pathways that different population groups take to mental health services, and the reasons behind observed differences, to inform the development of equitable services, targeting patients in the critical early stages of psychotic disorder.

Migrant background and ethnic minority status as predictors for duration of untreated psychosis

AIM

The aim of the study was to explore if patients with migration and/or ethnic minority background have longer duration of untreated psychosis (DUP) than patients from the reference population, and in case to what extent this was best explained by ethnic minority status or migration background, including age at migration.

METHODS

Four hundred sixty-two first-episode patients were included. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders was used for diagnostic purposes. Patients were interviewed about migration history and ethnicity using structured questionnaires.

RESULTS

Being part of an ethnic minority group had a trend-level significance, and migration after the age of 6 had a statistically significant association with prolonged DUP.

CONCLUSIONS

Age at migration has a moderate, but statistically significant effect on DUP. The findings indicate migrating after school start is associated with a longer DUP in immigrant populations.

The impact of immigration and visible minority status on psychosis symptom profile

PURPOSE

Immigrants have heightened risks of psychotic disorders, and it is proposed that migration influences symptom profiles. The purpose of this study was to investigate if either migration experience and/or visible minority status affected symptom profiles, using a cross-culturally validated five-factor model of the Positive and Negative Syndrome Scale (PANSS), in patients with broadly defined psychotic disorders.

METHODS

PANSS was assessed in a large catchment area based sample of patients with psychotic disorders verified with the Structured Clinical Interview for DSM-IV (n = 1,081). Symptom profiles based on Wallwork et al. five-factor model were compared for Norwegians (73 %), white immigrants (10.5 %), and visible minority groups (16.5 %).

RESULTS

Visible minorities were significantly younger, had less education, more often a schizophrenia diagnosis and higher PANSS positive, negative and disorganized/concrete factor scores than Norwegians and white immigrants. After controlling for confounders only the items "Delusions" and "Difficulty in abstract thinking" differed between groups. Multivariate analyses indicated that these items were not associated with immigration per se, but rather belonging to a visible minority.

CONCLUSION

We found mostly similarities in psychotic symptoms between immigrants and Norwegians when using a cross-culturally validated five-factor model of the PANSS. Immigration did not directly influence psychotic symptom profiles but visible minority groups had higher levels of "Delusions" and "Difficulty in abstract thinking", both symptoms that are partially context dependent.

A meta-analysis of ethnic differences in pathways to care at the first episode of psychosis

OBJECTIVE

We sought to systematically review the literature on ethnic differences in the likelihood of general practitioner (GP) involvement, police involvement, and involuntary admission on the pathway to care of patients with first-episode psychosis (FEP).

METHOD

We searched electronic databases and conducted forward and backward tracking to identify relevant studies. We calculated pooled odds ratios (OR) to examine the variation between aggregated ethnic groups in the indicators of the pathway to care.

RESULTS

We identified seven studies from Canada and England that looked at ethnic differences in GP involvement (n=7), police involvement (n=7), or involuntary admission (n=5). Aggregated ethnic groups were most often compared. The pooled ORs suggest that Black patients have a decreased likelihood of GP involvement (OR=0.70, 0.57-0.86) and an increased likelihood of police involvement (OR=2.11, 1.67-2.66), relative to White patients. The pooled ORs were not statistically significant for patients with Asian backgrounds (GP involvement OR=1.23, 0.87-1.75; police involvement OR=0.86, 0.57-1.30). There is also evidence to suggest that there may be ethnic differences in the likelihood of involuntary admission; however, effect modification by several sociodemographic factors precluded a pooling of these data.

CONCLUSION

Ethnic differences in pathways to care are present at the first episode of psychosis.

Race, ethnicity, and the duration of untreated psychosis: a systematic review

PURPOSE

An extended duration of untreated psychosis (DUP) is associated with poor outcome in first-episode psychosis (FEP). Some have suggested that minority ethnic groups have longer treatment delays, and this could lead to worse outcomes. We systematically reviewed the literature on racial and ethnic differences in DUP in patients with FEP.

METHODS

We searched electronic databases and conducted forward and backward tracking to identify studies that had compared DUP for people with FEP from different racial or ethnic groups.

RESULTS

We identified ten papers that reported on the association between race or ethnicity and DUP. Overall, these studies did not find evidence of differences between groups; however, three of ten studies suggested that Black patients generally, and Black-African patients specifically, may have a shorter DUP relative to White patients. There were methodological limitations in most studies with respect to ethnicity classification, sample size, and adjustment for potential confounders.

CONCLUSION

Racial and ethnic differences in DUP were rarely found. This could reflect that DUP does not differ between groups, or may reflect the methodological limitations of prior research. Studies that are designed and powered to examine these differences in treatment delay are needed to determine whether there are differences in DUP for minority groups.

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.