Disparities in Access to Early Psychosis Intervention Services: Comparison of Service Users and Nonusers in Health Administrative Data

Development of an early intervention in psychosis services fidelity questionnaire

PURPOSE

We describe the development of an online fidelity questionnaire for early intervention in psychosis (EIP) services, to be used in population-level research, and that can be completed using self-reports from EIP staff.

METHODS

A review of key literature sources on the components of EIP services was used to identify those components eligible for inclusion in the questionnaire. A modified Delphi approach, using experts in EIP services, was used to select the most important components to include in the questionnaire. To pilot test the questionnaire, two EIP staff members completed one fidelity questionnaire each, and a third questionnaire was completed by an external rater. Responses from the three sources were compared and used to revise the fidelity questionnaire.

RESULTS

Twenty-two experts from England and Canada responded to two Delphi rounds, identifying the top 25 most important EIP service components. Some evidence-based components were not rated as highly as some non-evidence-based components. Pilot testing showed that the EIP staff rated fidelity higher than the external rater. Several questions were removed and/or revised based on the pilot study findings.

CONCLUSIONS

Fidelity instruments are limited by the available evidence and the personal experiences of experts used to develop them. As such, fidelity instruments and EIP services should continually be updated to reflect new knowledge. The online fidelity questionnaire was a simple and efficient way to collect data. Future evaluations of the fidelity questionnaire need to ensure that externally collected fidelity data are comprehensive and accurate.

Models of shared care for the management of psychotic disorder after first diagnosis in Ontario

OBJECTIVE

To describe the provision of care for young people following first diagnosis of psychotic disorder.

DESIGN

Retrospective cohort study using health administrative data.

SETTING

Ontario.

PARTICIPANTS

People aged 14 to 35 years with a first diagnosis of nonaffective psychotic disorder in Ontario between 2005 and 2015 (N=39,449).

MAIN OUTCOME MEASURES

Models of care, defined by psychosis-related service contacts with primary care physicians and psychiatrists during the 2 years after first diagnosis of psychotic disorder.

RESULTS

During the 2-year follow-up period, 29% of the cohort received only primary care, 30% received only psychiatric care, and 32% received both primary and psychiatric care (shared care). Among the shared care group, 72% received care predominantly from psychiatrists, 20% received care predominantly from primary care physicians, and 9% received approximately equal care from psychiatry and primary care. Variation in patient and physician characteristics was observed across the different models of care.

CONCLUSION

One in 3 young people with psychotic disorder received shared care during the 2-year period after first diagnosis. The findings highlight opportunities for increasing collaboration between primary care physicians and psychiatrists to enhance the quality of care for those with early psychosis.

Care Pathways and Initial Engagement in Early Psychosis Intervention Services Among Youths and Young Adults

Importance

Broad efforts to improve access to early psychosis intervention (EPI) services may not address health disparities in pathways to care and initial engagement in treatment.

Objective

To understand factors associated with referral from acute hospital-based settings and initial engagement in EPI services.

Design, Setting, and Participants

This retrospective cohort study used electronic medical record data from all patients aged 16 to 29 years who were referred to a large EPI program between January 2018 and December 2019. Statistical analysis was performed from March 2022 to February 2023.

Exposures

Patients self-reported demographic information in a structured questionnaire. The main outcome for the first research question (referral source) was an exposure for the second research question (initial attendance).

Main Outcomes and Measures

Rate of EPI referral from acute pathways compared with other referral sources, and rate of attendance at the consultation appointment.

Results

The final study population included 999 unique patient referrals. At referral, patients were a mean (SD) age of 22.5 (3.5) years; 654 (65.5%) identified as male, 323 (32.3%) female, and 22 (2.2%) transgender, 2-spirit, nonbinary, do not know, or prefer not to answer; 199 (19.9%) identified as Asian, 176 (17.6%) Black, 384 (38.4%) White, and 167 (16.7%) other racial or ethnic groups, do not know, or prefer not to answer. Participants more likely to be referred to EPI services from inpatient units included those who were older (relative risk ratio [RRR], 1.10; 95% CI, 1.05-1.15) and those who identified as Black (RRR, 2.11; 95% CI, 1.38-3.22) or belonging to other minoritized racial or ethnic groups (RRR, 1.79; 95% CI, 1.14-2.79) compared with White participants. Older patients (RRR, 1.16; 95% CI, 1.11-1.22) and those who identified as Black (RRR, 1.67; 95% CI, 1.04-2.70) or belonging to other minoritized racial or ethnic groups (RRR, 2.11; 95% CI, 1.33-3.36) were more likely to be referred from the emergency department (ED) compared with White participants, whereas participants who identified as female (RRR, 0.51 95% CI, 0.34-.74) had a lower risk of ED referral compared with male participants. Being older (odds ratio [OR], 0.95; 95% CI, 0.90-1.00) and referred from the ED (OR, 0.40; 95% CI, 0.27-0.58) were associated with decreased odds of attendance at the consultation appointment.

Conclusions and relevance

In this cohort study of patients referred to EPI services, disparities existed in referral pathways and initial engagement in services. Improving entry into EPI services may help facilitate a key step on the path to recovery among youths and young adults with psychosis.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

OBJECTIVE

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

METHODS

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

RESULTS

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.

CONCLUSIONS

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

An NIMH Workshop on Non-Affective Psychosis in Midlife and Beyond: Research Agenda on Phenomenology, Clinical Trajectories, Underlying Mechanisms, and Intervention Targets

We present a review of the state of the research in the phenomenology, clinical trajectories, biological mechanisms, aging biomarkers, and treatments for middle-aged and older people with schizophrenia (PwS) discussed at the NIMH sponsored workshop "Non-affective Psychosis in Midlife and Beyond." The growing population of PwS has specific clinical needs that require tailored and mechanistically derived interventions. Differentiating between the effects of aging and disease progression is a key challenge of studying older PwS. This review of the workshop highlights the recent findings in this understudied clinical population and the critical gaps in knowledge and consensus for research priorities. This review showcases the major challenges and opportunities for research to advance clinical care for this growing and understudied population.

Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care

Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35 years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate that primary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. For physicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be provided to support them in caring for patients with early psychosis.

Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective

BACKGROUND

Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status.

AIMS

The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada.

METHODS

A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars.

RESULTS

Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000.

CONCLUSIONS

In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view .

Sex and gender differences in symptoms of early psychosis: a systematic review and meta-analysis

First-episode psychosis (FEP) can be quite variable in clinical presentation, and both sex and gender may account for some of this variability. Prior literature on sex or gender differences in symptoms of psychosis have been inconclusive, and a comprehensive summary of evidence on the early course of illness is lacking. The objective of this study was to conduct a systematic review and meta-analysis of the literature to summarize prior evidence on the sex and gender differences in the symptoms of early psychosis. We conducted an electronic database search (MEDLINE, Scopus, PsycINFO, and CINAHL) from 1990 to present to identify quantitative studies focused on sex or gender differences in the symptoms of early psychosis. We used random effects models to compute pooled standardized mean differences (SMD) and risk ratios (RR), with 95% confidence intervals (CI), for a range of symptoms. Thirty-five studies met the inclusion criteria for the systematic review, and 30 studies were included in the meta-analysis. All studies examined sex differences. Men experienced more severe negative symptoms (SMD =  - 0.15, 95%CI =  - 0.21, - 0.09), whereas women experienced more severe depressive symptoms (SMD = 0.21, 95%CI = 0.14, 0.27) and had higher functioning (SMD = 0.16, 95%CI = 0.10, 0.23). Women also had a lower prevalence of substance use issues (RR = 0.65, 95%CI = 0.61, 0.69). Symptoms of early psychosis varied between men and women; however, we were limited in our ability to differentiate between biological sex and gender factors. These findings may help to inform early detection and intervention efforts to better account for sex and gender differences in early psychosis presentation.

The Impact of Policy Changes, Dedicated Funding and Implementation Support on Early Intervention Programs for Psychosis

INTRODUCTION

Early intervention services for psychosis (EIS) are associated with improved clinical and economic outcomes. In Quebec, clinicians led the development of EIS from the late 1980s until 2017 when the provincial government announced EIS-specific funding, implementation support and provincial standards. This provides an interesting context to understand the impacts of policy commitments on EIS. Our primary objective was to describe the implementation of EIS three years after this increased political involvement.

METHODS

This cross-sectional descriptive study was conducted in 2020 through a 161-question online survey, modeled after our team's earlier surveys, on the following themes: program characteristics, accessibility, program operations, clinical services, training/supervision, and quality assurance. Descriptive statistics were performed. When relevant, we compared data on programs founded before and after 2017.

RESULTS

Twenty-eight of 33 existing EIS completed the survey. Between 2016 and 2020, the proportion of Quebec's population having access to EIS rose from 46% to 88%; >1,300 yearly admissions were reported by surveyed EIS, surpassing governments' epidemiological estimates. Most programs set accessibility targets; adopted inclusive intake criteria and an open referral policy; engaged in education of referral sources. A wide range of biopsychosocial interventions and assertive outreach were offered by interdisciplinary teams. Administrative/organisational components were less widely implemented, such as clinical/administrative data collection, respecting recommended patient-to-case manager ratios and quality assurance.

CONCLUSION

Increased governmental implementation support including dedicated funding led to widespread implementation of good-quality, accessible EIS. Though some differences were found between programs founded before and after 2017, there was no overall discernible impact of year of implementation. Persisting challenges to collecting data may impede monitoring, data-informed decision-making, and quality improvement. Maintaining fidelity and meeting provincial standards may prove challenging as programs mature and adapt to their catchment area's specificities and as caseloads increase. Governmental incidence estimates may need recalculation considering recent epidemiological data.

What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future

PURPOSE OF REVIEW

Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs.

RECENT FINDINGS

FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP.

SUMMARY

Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.

Towards better care for women with schizophrenia-spectrum disorders

Women with a schizophrenia-spectrum disorder (SSD) have a better clinical profile than do men at the start of their illness but progress to the same state within the first few years of living with SSD. There are benefits to be gained across different areas in the care currently offered to women with psychosis. An important point for improvement is the early detection of female-specific signs of a first episode of psychosis, to shorten the duration of untreated psychosis, with prompt access to early intervention services. Special attention should be paid to sexual health, and to any history of childhood trauma. Antipsychotics require dosing and prescription tailored to the female physiology that consider hormonal life phases such as menopause. Switching to prolactin-sparing medications can benefit both mental and somatic health. Finally, hormone replacement therapy should be considered for postmenopausal women. By providing female-specific care, women with schizophrenia-spectrum disorders will have optimal chances to fare well.

The prevalence of physical multimorbidity among people with non-affective psychotic disorders 10 years after first diagnosis: a matched retrospective cohort study

AIMS

The higher prevalence of chronic physical health conditions among people with psychotic disorders may result in a reduced life expectancy as compared to the general population. More research is needed on the risk of multiple co-occurring chronic health conditions, known as multimorbidity, for people with psychotic disorders.

METHODS

We conducted a matched retrospective cohort study to quantify the prevalence of multimorbidity and associated factors among people with psychotic disorders over the 10-year period following first diagnosis, relative to those without psychosis. Data from an early psychosis intervention program in London, Canada were linked to population-based health administrative data to identify patients with first-episode psychosis (n = 439), and a comparison group from the general population (n = 1759) matched on age, sex, and postal code. We followed the cohort for 10 years to ascertain the prevalence of multimorbidity. We compared people with and without psychosis using modified Poisson regression models, and explored risk factors for multimorbidity among those with psychotic disorders.

RESULTS

People with psychotic disorders may have a 26% higher prevalence of multimorbidity 10 years following first diagnosis, although our findings include the possibility of a null effect (PR = 1.26, 95% CI 0.96-1.66). People with psychosis living in areas with the highest levels of material deprivation had a threefold higher prevalence of multimorbidity as compared to those in the lowest areas of material deprivation (PR = 3.09, 95% CI 1.21-7.90).

CONCLUSION

Multimorbidity is prevalent among those with psychosis, and assessment for chronic health conditions should be integrated into clinical care for younger populations with psychotic illness.

Governance of mental healthcare: Fragmented accountability

Within international healthcare systems the neglect of mental health and challenge in shifting from institutional to community care have been recurrent themes. In analysing the challenges, we focus on the case study of Canada by exploring the manner in which health law and policy evolved to inhibit community-based mental healthcare, and compare the resulting funding landscape from an international perspective. The historical institutionalist analysis draws on the literature and healthcare finance data. As a spending statute, the Canada Health Act defines the terms on which the federal government finances publicly insured provincial healthcare. Despite the goal to support physical and mental well-being by removing financial barriers to access health services, exclusion of community care offered by non-physicians (such as psychotherapy) from the terms of the Act inhibited its fulfilment. Diminished federal transfers deepened the disincentive for provinces to establish community care: mental health declined from 11 to 7 percent of provincial healthcare spending from 1979 to 2014. Governance oversight was passed to provinces whose competing demands on diminished resources limited their capacity to extend care. Accountability was found fragmented as neither government stepped-in to ensure the continuum of care, even as federal transfers were restored and evidence of cost-effectiveness grew. Although American and Canadian funding patterns are similar, other OECD countries invest between 13 and 18 percent of healthcare expenditures on mental health. Lessons from the Canadian case are the manner in which its federal structure and intergovernmental dynamics shaped health policy, and the importance of ensuring representation from a range of perspectives in policy development. Federal financial incentives were also found to profoundly impact the expansion of community-based mental healthcare. Evidence shows that public insurance for community supports would reduce healthcare expenditures and employer productivity loss, resulting in savings of $255 billion over 30 years.

Risk of involuntary admission among first-generation ethnic minority groups with early psychosis: a retrospective cohort study using health administrative data

AIMS

Ethnic minority groups often have more complex and aversive pathways to mental health care. However, large population-based studies are lacking, particularly regarding involuntary hospitalisation. We sought to examine the risk of involuntary admission among first-generation ethnic minority groups with early psychosis in Ontario, Canada.

METHODS

Using health administrative data, we constructed a retrospective cohort (2009-2013) of people with first-onset non-affective psychotic disorder aged 16-35 years. This cohort was linked to immigration data to ascertain migrant status and country of birth. We identified the first involuntary admission within 2 years and compared the risk of involuntary admission for first-generation migrant groups to the general population. To control for the role of migrant status, we restricted the sample to first-generation migrants and examined differences by country of birth, comparing risk of involuntary admission among ethnic minority groups to a European reference. We further explored the role of migrant class by adjusting for immigrant vs refugee status within the migrant cohort. We also explored effect modification of migrant class by ethnic minority group.

RESULTS

We identified 15 844 incident cases of psychotic disorder, of whom 19% (n = 3049) were first-generation migrants. Risk of involuntary admission was higher than the general population in five of seven ethnic minority groups. African and Caribbean migrants had the highest risk of involuntary admission (African: risk ratio (RR) = 1.52, 95% CI = 1.34-1.73; Caribbean: RR = 1.58, 95% CI = 1.37-1.82), and were the only groups where the elevated risk persisted when compared to the European reference group within the migrant cohort (African: RR = 1.24, 95% CI = 1.04-1.48; Caribbean: RR = 1.29, 95% CI = 1.07-1.56). Refugee status was independently associated with involuntary admission (RR = 1.16, 95% CI = 1.02-1.32); however, this risk varied by ethnic minority group, with Caribbean refugees having an elevated risk of involuntary admission compared with Caribbean immigrants (RR = 1.72, 95% CI = 1.15-2.58).

CONCLUSIONS

Our findings are consistent with the international literature showing increased rates of involuntary admission among some ethnic minority groups with early psychosis. Interventions aimed at improving pathways to care could be targeted at these groups to reduce disparities.

Estimating the incidence of first-episode psychosis using population-based health administrative data to inform early psychosis intervention services

BACKGROUND

Discrepancies between population-based estimates of the incidence of psychotic disorder and the treated incidence reported by early psychosis intervention (EPI) programs suggest additional cases may be receiving services elsewhere in the health system. Our objective was to estimate the incidence of non-affective psychotic disorder in the catchment area of an EPI program, and compare this to EPI-treated incidence estimates.

METHODS

We constructed a retrospective cohort (1997-2015) of incident cases of non-affective psychosis aged 16-50 years in an EPI program catchment using population-based linked health administrative data. Cases were identified by either one hospitalization or two outpatient physician billings within a 12-month period with a diagnosis of non-affective psychosis. We estimated the cumulative incidence and EPI-treated incidence of non-affective psychosis using denominator data from the census. We also estimated the incidence of first-episode psychosis (people who would meet the case definition for an EPI program) using a novel approach.

RESULTS

Our case definition identified 3245 cases of incident non-affective psychosis over the 17-year period. We estimate that the incidence of first-episode non-affective psychosis in the program catchment area is 33.3 per 100 000 per year (95% CI 31.4-35.1), which is more than twice as high as the EPI-treated incidence of 18.8 per 100 000 per year (95% CI 17.4-20.3).

CONCLUSIONS

Case ascertainment strategies limited to specialized psychiatric services may substantially underestimate the incidence of non-affective psychotic disorders, relative to population-based estimates. Accurate information on the epidemiology of first-episode psychosis will enable us to more effectively resource EPI services and evaluate their coverage.

Risk and associated factors for a future schizophrenia diagnosis after an index diagnosis of unspecified psychotic disorder: A population-based study

A significant minority of unspecified psychosis presentations progress to schizophrenia. Clinical risk factors can inform targeted referral to specialized treatment programs, but few population studies have examined this. In this study, we used health administrative data for a population-based cohort from Manitoba, Canada to characterize the risk and identify vulnerable subgroups for a future diagnosis of schizophrenia after a diagnosis of unspecified psychotic disorder. Individuals aged 13-60 years with an inpatient or outpatient diagnosis of unspecified psychotic disorder between April 1, 2007 and March 31, 2012, and without any prior diagnosis of schizophrenia or related disorder, were identified (N = 3, 289). The primary outcome was a diagnosis of schizophrenia recorded after the index diagnosis of unspecified psychotic disorder and before March 31, 2015. Adjusted hazard ratios were computed controlling for age, sex, urbanicity, income, prior diagnosis of unspecified psychotic disorder, provider making the diagnosis, prior 12-month psychiatric hospitalization, and prior 12-month diagnoses of mood, anxiety, substance use, or personality disorders, and substance-induced psychosis. A classification tree identified vulnerable subgroups. The cumulative risk of a future diagnosis of schizophrenia was 26% during the follow-up period (mean 4.5 years), with a mean time to diagnosis of 2.0 years. The most vulnerable subgroup was diagnosed by a psychiatrist, younger than 27 years, without a mood or anxiety disorder, male, and residing in a low-income neighborhood; the rate of a subsequent schizophrenia diagnosis was 61.2%. These results support that identification of specific sociodemographic and clinical factors can help clinicians counsel and intervene with those at highest risk.

International incidence of psychotic disorders, 2002-17: a systematic review and meta-analysis

BACKGROUND

The last comprehensive systematic review of the incidence of psychotic disorders was published in 2004. New epidemiological data from different settings now permit a broader understanding of global variation. We examined the variation in psychosis by demographic characteristics and study method.

METHODS

For this systematic review and meta-analysis, we searched PubMed, Embase, Web of Science, PsycINFO, and bibliographies, and directly contacted first authors. We sought to obtain citations of original research published between Jan 1, 2002, and Dec 31, 2017, on incidence of non-organic adult-onset psychotic disorder. We included papers that were published or in grey literature and had no language restrictions. Data were extracted from published reports, where possible, by sex, age, and ethnic group. Quality of yield was assessed. Data were assessed using univariable random-effects meta-analysis and meta-regression. We registered our systematic review on PROSPERO, number CRD42018086800.

FINDINGS

From 56 721 records identified, 177 met inclusion criteria. The pooled incidence of all psychotic disorders was 26·6 per 100 000 person-years (95% CI 22·0-31·7). Heterogeneity was high (I2≥98·5%). Men were at higher risk of all psychotic disorders (incidence rate ratio 1·44 [1·27-1·62]) and non-affective disorders (1·60 [1·44-1·77]) than women, but not affective psychotic disorders (0·87 [0·75-1·00]). Ethnic minorities were also at excess risk of all psychotic disorders (1·75 [1·53-2·00]), including non-affective disorders (1·71 [1·40-2·09]). Meta-regression revealed that population registers reported higher rates of non-affective disorders (9·64 [2·72-31·82]), schizophrenia (2·51 [1·24-5·21]), and bipolar disorder (4·53 [2·41-8·51]) than first contact study designs.

INTERPRETATION

We found marked variation in incidence of psychotic disorders by personal characteristics and place. Some geographical variation could be partially explained by differences in case ascertainment methods.

FUNDING

None.

Unmet need for mental health services among people screened but not admitted to an early psychosis intervention program

Information is lacking on people screened for early psychosis intervention (EPI) but not admitted to the program. Using health administrative data, we constructed a retrospective cohort of incident cases of psychosis in the catchment of an EPI program. Use of mental health services was compared between people screened and not admitted with an EPI-admitted group. The non-admitted group had higher rates of subsequent emergency department visits, psychiatric hospitalizations, and involuntary admissions. These patterns are indicative of unmet need, and people screened but not admitted to EPI may benefit from protocols to improve transitions of care with other service providers.

Understanding the role of the family physician in early psychosis intervention

BACKGROUND

The family physician is key to facilitating access to psychiatric treatment for young people with first-episode psychosis, and this involvement can reduce aversive events in pathways to care. Those who seek help from primary care tend to have longer intervals to psychiatric care, and some people receive ongoing psychiatric treatment from the family physician.

AIMS

Our objective is to understand the role of the family physician in help-seeking, recognition and ongoing management of first-episode psychosis.

METHOD

We will use a mixed-methods approach, incorporating health administrative data, electronic medical records (EMRs) and qualitative methodologies to study the role of the family physician at three points on the pathway to care. First, help-seeking: we will use health administrative data to examine access to a family physician and patterns of primary care use preceding the first diagnosis of psychosis; second, recognition: we will identify first-onset cases of psychosis in health administrative data, and look back at linked EMRs from primary care to define a risk profile for undetected cases; and third, management: we will examine service provision to identified patients through EMR data, including patterns of contacts, prescriptions and referrals to specialised care. We will then conduct qualitative interviews and focus groups with key stakeholders to better understand the trends observed in the quantitative data.

DISCUSSION

These findings will provide an in-depth description of first-episode psychosis in primary care, informing strategies to build linkages between family physicians and psychiatric services to improve transitions of care during the crucial early stages of psychosis.

DECLARATION OF INTEREST

None.