Pathways to care: duration of untreated psychosis from Karachi, Pakistan

An analysis of financial hardship faced by patients with First Episode Psychosis, and their families, in an Indian setting

BACKGROUND

The economic burden of psychotic disorders is not well documented in LMICs like India, due to several bottlenecks present in Indian healthcare system like lack of adequate resources, low budget for mental health services and inequity in accessibility of treatment. Hence, a large proportion of health expenditure is paid out of pocket by the households.

OBJECTIVE

To evaluate the direct and indirect costs incurred by patients with First Episode Psychosis and their families in a North Indian setting.

METHOD

Direct and Indirect costs were estimated for 87 patients diagnosed at AIIMS, New Delhi with first-episode psychosis (nonaffective) in the first- and sixth month following diagnosis, and the six months before diagnosis, using a bespoke questionnaire. Indirect costs were valued using the Human Capital Approach.

RESULTS

Mean total costs in month one were INR 7991 ($107.5). Indirect costs were 78.3% of this total. Productivity losses was a major component of the indirect cost. Transportation was a key component of direct costs. Costs fell substantially at six months (INR 2732, Indirect Costs 61%). Respondents incurred substantial costs pre-diagnosis, related to formal and informal care seeking and loss of income.

CONCLUSION

Families suffered substantial productivity loss. Care models and financial protection that address this could substantially reduce the financial burden of mental illness. Measures to address disruption to work and education during FEP are likely to have significant long-term benefits. Families also suffered prolonged income loss pre-diagnosis, highlighting the benefits of early and effective diagnosis.

A systematic review of factors prolonging or reducing the duration of untreated psychosis for people with psychosis in low- and middle-income countries

AIM

This review aims to identify factors that may prolong or reduce the duration of untreated psychosis for people with psychosis in low- and middle-income countries.

METHODS

Electronic searches of six databases were conducted, to find studies from low- and middle-income countries on people with psychotic disorders provided they statistically measured an association between factors that may prolong or reduce the duration of untreated psychosis. Studies were critically appraised and a narrative synthesis exploring differences between and within studies is presented. A socio-ecological model is used to convey the main findings.

RESULTS

Thirty studies of 16 473 participants in total were included in this review. Taken together participants were 51.5% male and 48.5% female. Various factors potentially associated with longer duration of untreated psychosis for people with psychosis in low- and middle-income countries were found. Examples of these factors are an insidious mode of onset, greater family stigma and low social class. Other factors, such as marital status, educational level, diagnostic type, predominant symptoms and employment status, yielded inconsistent results.

CONCLUSIONS

The methodological quality of the included studies limits the conclusions of this review. The results indicate an urgent need for further high-quality research in these countries. The socio-ecological model is a helpful framework for clinicians, scholars, and decision-makers to conceptualize factors that may affect the duration of untreated psychosis, highlight gaps in the literature as well as reflect on potential prevention strategies that may ultimately support early intervention services for people with psychosis in developing countries.

Exploring biomedical and traditional care pathways for people with psychosis in Karachi, Pakistan

Background

Psychosis is known to have an adverse impact on an individual's quality of life, social and occupational functioning. A lack of treatment options for psychotic disorders such as schizophrenia contributes to adverse outcomes for individuals. A significant proportion of people with psychosis consult both formal and traditional routes of care. This warrants a need to explore perceptions around treatment options provided by diverse care providers, as the identification of avenues for support can improve psychiatric, alternative treatment and social outcomes.

Methods

Focus groups discussions (FGDs) and in-depth interviews (IDIs) were used. Interactive Research and Development (IRD) research staff conducted 20 IDIs and 2 FGDs to obtain information about the perspectives, treatment pathways and experiences of individuals with psychosis, their caregivers, and service providers. Questions for clinician care providers and faith healers revolved around perceptions of psychosis, service users' background, subject knowledge and treatment, feedback and referral mechanisms, and promotion of services. A thematic analysis was used to analyze the interviews and coding was conducted on NVivo.

Results

The results were categorized into five themes: perception of psychosis, experience of seeking/receiving care, assessment and diagnosis methods, promotion of services, and living with psychosis. Across service providers and patients, there was a wide variety of causes attributed to psychosis, and an overall lack of awareness regarding severe mental health conditions from both formal and informal care-providers. Biomedical treatment received mixed reviews, while some reported it as beneficial, the limited number of institutes and clinicians to cater for patients, stigma within society and care providers, the burden of caregiving, and misinformation from faith healers were all significant barriers to treatment.

Conclusion

The results highlight the use of traditional healing practices for psychosis in Pakistan, which, coupled with inadequate referral mechanisms, present an opportunity to bridge the treatment gap between clinical and traditional healing practices through integration of treatment within community structures and systems. Better awareness of psychosis and its treatment methods, alongside interventions that reduce stigma could help facilitate help-seeking behavior and reduce the burden of caregiving.

Pathways to the first contact with mental health services among patients with schizophrenia: A cross-sectional observational study

Background

Schizophrenia is a mental illness with a profound impact on patient and their caregivers. There is increasing evidence that delay in the commencement of treatment following the onset of illness may be related to the pathways; patients navigate before accessing mental health services.

Aim

The aim of this study is to assess the pathways of care to the first contact with mental health services among patients with schizophrenia.

Methods

A total of 150 diagnosed schizophrenia patients aged 12-60 years were recruited as per inclusion and exclusion criteria. The sociodemographic details were gathered using semistructured sociodemographic data sheets; semistructured pathways to care questionnaire and positive and negative syndrome scale for schizophrenia were administered.

Results

The most common first pathway to care was faith healers. The education of the head of family, socioeconomic status, rural background, and occupational status of patients have a significant impact on the first pathway of psychiatric care. The findings suggest that while planning mental health services, emphasis should be made on collaboration between psychiatric and nonpsychiatric services.

Conclusion

The pathways patient choose depend on a number of factors like their socio-cultural background, belief about the supernatural causation of psychiatric illness, stigma associated with psychiatric illness, lack of knowledge about the mental illness, and influence of close family relatives on the choice of treatment.

Pathways to care for substance use treatment among tribal patients at a psychiatric hospital: A comparative study

Objectives

According to the national mental health survey, substance use disorders (SUDs) are prevalent in 22.4% of the population above 18 years, whereas the same is 26% among the tribal population. The treatment gap is also high in substance-addictive disorders. Our study aimed to compare the severity of substance use, pathways to psychiatric care, and treatment-seeking behavior among the tribal and non-tribal populations.

Materials and Methods

The study was conducted at a tertiary psychiatric teaching institute in India. It was a cross-sectional comparative study. Patients fulfilling the International Classification of Disease 10 diagnostic criteria of mental and behavioral disorders due to substance use, with active dependence, were taken without comorbidity. Forty patients in tribal and non-tribal groups were recruited with consecutive sampling. The samples were assessed with a semi-structured interview schedule, addiction severity index, attitudes toward help-seeking, and pathways-to-care.

Results

Excessive substance use median was for 7.00 (± 5.00) years in tribal and 6.00 (± 4.00) years in non-tribal; in tribal, substance intake was younger than non-tribal (P = 0.167), and general health-care system more distance than the non-tribal (P < 0.001). Around 65% of the persons with SUD never consulted their general practitioner and primary health-care facilities. Alcohol severity was higher in the tribal population than in the non-tribal population. The cannabis and opioid severity was high in the non-tribal population. Help-seeking behavior was deficient in both groups.

Conclusion

Most of the substance abuse tribal and non-tribal populations reach healthcare very late and do not consider it as a health issue initially. The major reason for the delayed pathway is a lack of awareness about mental health care facilities and stigma in both populations. The stigma is high in non-tribal communities compared to the tribal community. There is a need to improve the identification and treatment of alcohol morbidity in primary care.

Evaluating the maturation of mental health systems in developing countries

Background

Given the need for a simple tool to evaluate mental healthcare provision at the local level, we compared the duration of untreated mental illness (DUM) and duration of untreated psychosis (DUP) between rural and urban areas in Cambodia, and Cambodia's DUP was also compared with that of other countries.

Methods

DUM and background data were obtained at the first consultation from 940 participants in Phnom Penh (PP), the capital city, and Siem Reap province (SR) in 2016-2017. DUP data were obtained from DUM by excluding individuals with nonpsychotic mental illnesses (e.g., mood disorders, neurotic disorders, substance use, epilepsy). Student's t-test was used to compare DUM and DUP, and analysis of variance was conducted to identify associations.

Results

Mean DUM significantly differed between PP (0.6 [SD 2.3] years) and SR (4.2 [5.9] years). Mean DUP was also significantly different (0.5 [2.2] years in PP vs. 4.3 [6.7] years in SR). DUM was strongly associated with DUP. The prevalence of the various disorders differed between rural and urban areas. DUM also varied by diagnosis, indicating that DUP is a better index than DUM. However, in some cases DUM can be used, given its strong association with DUP. DUP in PP was almost the same as in developed countries and was about four times longer in SR.

Conclusion

DUP in rural areas is much longer than in urban areas in developing countries. Although DUP is an effective index, more data from other places and before/after interventions are required to verify it further.

Pathways to Mental Health Care in a Defined Geographic Area of Athens

The purpose of the present study was to explore the duration between the onset of psychopathology and the first contact either with a sectorized Community Mental Health Centre (CMHC) of Athens area or other mental health services, identify the pathways to the CMHC as well as possible sociodemographic and clinical factors affecting help-seeking behavior. The sample consisted of 355 individuals who visited the CMHC, but had sought help from another mental health care source prior to their visit to the Centre (group A), and was compared with 398 individuals who had no previous contact with any other psychiatric service (group B). The average duration of untreated mental disorders was found to be 19.85 (SD 23.113) for males of group A and 26.26 (SD 41.158) for males of group B. Among females the mean duration was found to be 18.11 (SD 27.293) for group A and 22.21 (SD 29.440) for group B, a statistically significant difference. In group A, the intervening services referred the clients at an earlier stage. The striking difference is that only eight individuals (2%) of group B (first timers) were diagnosed as suffering from schizophrenia contrasting to the 61 (17.4%) counterparts of group A. Individuals in our study diagnosed with psychosis seemed to have sought help first from other mental health services and delay to visit a CMHC. People who face problems resulting from their interpersonal or professional relationships often choose to have a first contact with a CMHC. Reduction of the delay in treatment will require clearer understanding of the contributing factors. Liaison activities with public and mental health sector services and outreach interventions to increase awareness on the early recognition of psychopathologic symptoms and the need for early referral could reduce the duration of untreated mental disorders.

Pathways to care and supernatural beliefs among patients with psychotic disorders in Nepal

Background

Longer pathways to care worsen the course of psychotic illness as well. The study aimed to assess the pathways to care, supernatural beliefs, and impact on the duration of untreated psychosis in patients with schizophrenia. It was a cross-sectional, observational study that involved 133 patients and their caregivers. Supernatural Attitude Questionnaire and World Health Organization Encounter form for Pathways to care were used to evaluate the pathways to care, supernatural beliefs in caregivers, and duration of untreated psychosis. SPSS descriptive and non-parametric tests were used for analysis.

Results

Overall, 59.4% of the participants had a non-medical person as the first treatment contact. Duration of untreated psychosis (DUP) for the whole study sample was 6.04 (SD 15.14) months and when it was compared among the first contact with a medical person (mean 4.43; SD 14.39) and non-medical person (mean 7.15; SD 15.63), the later had significantly longer (Mann-Whitney U = 1278; p < 0.001) DUP. More than half of the patients had one or more supernatural beliefs. Having supernatural beliefs and carryout rituals related to these beliefs is associated with a higher number of visits to different professionals before reaching a psychiatrist.

Conclusions

Patients with psychosis and their caregivers seek first help from non-medical persons, especially faith healers. This is associated with a longer duration of untreated psychosis and supernatural beliefs in caregivers. Thus, there is a need to improve mental health literacy and have public awareness programs to address the belief systems and clarify the prevailing myths in society.

[The impact of territorial care in the treatment of people diagnosed with schizophrenia and delusional disorders in a Rio de Janeiro community]

Care for people diagnosed with schizophrenia and delusional disorders involves many challenges, especially in territorial contexts of pronounced social vulnerability. In Rio de Janeiro, the two decades after the passing of Federal Law 10,216 on Psychiatric Reform in 2001 have been characterized by the transition from a hospital-centered model to one based on community services. Taking the case of a community in Rio de Janeiro, data was extracted from the medical records of 94 patients diagnosed with schizophrenia, schizotypal disorders, and delusional disorders (ICD-10 codes F20 to F29) in five public health services. Covering the period from 2003 to 2016, indicators of the quality of treatment provided were analyzed. As a result of this transition, psychiatric hospitals have all but emptied and a low number of currently untreated patients can be observed. In addition, crisis care and long-term hospitalizations have been replaced by territorial care, and clinical comorbidities are monitored and treated at Family Health Units.

A systematic review of care pathways for psychosis in low-and middle-income countries

Pathways to care for psychosis in high-income countries have been well studied, with the finding of an association between longer duration of untreated psychosis (DUP) and poorer outcomes focusing interest on care pathways to minimise treatment delay. Little is known about how people with psychosis in low-to middle-income countries (LMIC) present for help and specific care pathways that might be associated with treatment delays in those contexts. We conducted a systematic review using electronic databases (MEDLINE, PsychINFO, Embase, Ovid) to explore what proportion of patients with psychosis in LMIC are accessing care through traditional healers and whether this is associated with treatment delay. Studies were included if they assessed the pathway to care for participants with a psychotic illness in a LMIC. From 3929 results, 15 studies met our inclusion criteria. In 7 out of 15 studies first contact for the majority of patients were traditional health practitioners (THPs). In 5 out of 15 studies, mental health practitioners (MHPs) were most often the initial care pathway and in 3 studies first contact was with primary care. DUP ranged from a mean of 30 weeks to 225 weeks. Accessing THPs as initial contact was associated with a longer DUP. In LMICs, a large proportion of patients use THP as their first point of contact for accessing care. This is associated with longer DUP. Services in these countries need to focus both on raising public awareness and collaborative working with THPs to facilitate access to biomedical care.

A systematic review of mental health literacy in Pakistan

Individual mental health has become a primary global concern. In Pakistan, the prevalence of mental health issues is still unclear, as not many studies have assessed the level of mental health literacy (MHL) in the country. This systematic review aims to bridge this gap by encouraging the early detection of mental disorders, lessening stigma, and improving help-seeking behavior. Nine electronic databases were searched to identify empirical literature in this area. Only studies that evaluated MHL efficacy and those published in English were selected. Non-peer reviewed articles and gray literature were excluded. From 613 studies retrieved, 59 studies met the inclusion criteria and were reviewed. Forty-three of the included studies mentioned mental health outcome measures (of which only four mentioned reliability indices), 13 discussed stigma, 18 examined help-seeking approaches to mental illness treatments, and 47 discussed mental health knowledge. Additionally, the outcome of the MHL measures had considerable heterogeneity and limited validity. Meta-analysis was not conducted due to a lack of MHL operationalization. Besides, the measurement tools in the studies lacked consistency and standardization. This review compiled the available studies on MHL to assist researchers currently studying the various dimensions of MHL, as well as those designing new studies or investigating effective methods to increase MHL. This review highlights the need for well-designed controlled intervention studies. Further implications for researchers, practitioners, and policymakers are mentioned.

Time delay in seeking treatment for first-episode schizophrenia: a retrospective study

AIM

A longer duration of untreated psychosis (DUP) is associated with higher risk of relapse and a poorer overall prognosis. The study is designed to explore the duration of untreated schizophrenia and associated factors in Northwest China.

METHODS

A total of 7252 patients with first-episode schizophrenia registered from 1 January 2011 to 31 December 2018 in Yulin of China were included. The median delay time was estimated by Kaplan-Meier survival curve. Two-level mixed-effects survival model was used to calculate the hazard ratio and 95% confidence interval for factors associated with treatment delay. The outcome variable of interest was defined as 'receiving antipsychotic treatment'.

RESULTS

Up to 40.4% of patients with schizophrenia were illiterate and 78% were farmers and 75.6% were living under the national poverty line. The median treatment delay was 30 months (Interquartile range: 2-217). Older age at onset (age group 21-28, HR 1.3; 29-39, HR 1.3; 40 above, HR 1.4), female gender (HR 1.1), unmarried status(HR 1.1) and high educational level (primary, HR 1.4; Junior HR 1.8 and high school and above, HR 1.8) were found to be associated with lower risk of treatment delay. Widowed status (HR 0.6) was associated with an increased risk of treatment delay.

CONCLUSIONS

The median duration of untreated schizophrenia in this study was longer than findings reported in many prior studies. Early age of onset, male patients, widowed status and low education level were at high risk of treatment delay. Early detection, diagnosis and treatment of schizophrenia in northwest China should be strengthened.

Pathways to psychiatric care and factors associated with delayed help-seeking among patients with mental illness in Northern Ethiopia: a cross-sectional study

OBJECTIVE

This study aimed to assess pathways to psychiatric care and factors associated with delayed help-seeking among patients with mental illness in Northern Ethiopia using the WHO Pathway Study Encounter Form.

DESIGN

A cross-sectional study design was used.

SETTING

Data were collected using face-to-face interview from patients with various diagnoses of mental illness attending outpatient treatment at Ayder Comprehensive Specialized Hospital in Mekelle City, Tigray, Northern Ethiopia.

PARTICIPANTS

Participants who came to attend outpatient treatment during the study period were included in the study using consecutive sampling technique.

OUTCOME MEASURES

Pathways to psychiatric care, delayed psychiatric treatment and factors affecting delayed psychiatric treatment.

RESULTS

The median duration from problem onset to contact with first care provider was 4 weeks, whereas contact with modern psychiatric services was 52.0 weeks. Study participants who were single (adjusted OR (AOR)=2.91, 95% CI 1.19 to 7.11), divorced (AOR=3.73, 95% CI 1.33 to 10.49) and who perceived mental illness as shameful (AOR=3.29, 95% CI 1.15 to 9.41) had delayed treatment-seeking behaviour, whereas participants with no history of substance use (AOR=0.43, 95% CI 0.20 to 0.92) were less likely to have delayed treatment-seeking behaviour.

CONCLUSIONS

There is significant delay in seeking modern psychiatric treatment. Religious healers were the first source of help for mental illness. Majority of the respondents described that mental illness was due to supernatural causes. Stigma and lack of awareness about where treatment is available were barriers to seeking appropriate care.

Pathways to mental health care for patients with severe mental illness in Tunisia

Introduction

Schizophrenia, bipolar disorder and schizoaffective disorders are severe mental illnesses (SMI) associated with high levels of co-morbid psychopathology and premature mortality. Reducing delays in accessing services and providing early intervention are key strategies in preventing morbidity and mortality associated with these diseases. The pathways to psychiatric care have been studied in many countries worldwide. To the best of our knowledge, no study on this subject has so far been conducted in Tunisia. The purpose of the present study was to understand the pathways of care adopted by patients, to determine the care delay and to explore the relationship between delayed consultation and socio-demographic and clinical variables.

Methods

This is a cross-sectional descriptive study conducted at the Department Psychiatry A of Razi Hospital including patients with SMI consulting the outpatient clinic between January and March 2018. Data was collected by one medical investigator who conducted face-to-face interviews with patients using a questionnaire based on the World Health Organization's "Pathway Questionnaire". Data analysis was done using the SPSS software version 17. A multivariate analysis was performed to study the relation between delayed consultation and socio-demographic and clinical variables.

Results

A total of 232 patients responded to the questionnaire. The average age was 41.3 years ± 10.1 and the gender ratio was 1.2. More than the third of the study population consulted a traditional healer in the first place and sixty percent of the patients had recourse to a medical doctor. The average consultation delay was 15 months (±23.0) with a median of 6 months. The delay was more than 6 months in around half of the cases. The symptoms that motivated the first consultation were hallucinations, sleep disorders and aggressive behavior. The main reason of delayed consultation was lack of knowledge about psychiatric symptoms followed by illness beliefs and insidious onset of the illness. The multivariate analysis showed a significant relationship between aggressive behavior and non-delayed consultation.

Conclusion

The principal recommendations are to strengthen public education and awareness about SMI in the Tunisian population and to implement an early detection program of these disorders.

Factors that influence delaying initial psychiatric treatment in rural Cambodia: A pilot study

BACKGROUND

The WHO reported the gap between the need for treatment and its provision is huge in low- and middle-income countries. It is estimated there are lots of burden to obtain treatment in these countries. This survey intended to show the delay of their first visit to a psychiatric department and the factors that influence the delay. To elucidate the factors affecting medical accessibility for people with mental illness, we propose the concept of duration of untreated mental illness (DUM), which is the duration between the onset or first symptom of mental illness and the first visit to a psychiatric department or clinic.

METHODS

Participants were 109 Cambodian adults (18 years old and up) who had a psychiatric consultation in one of the following hospitals. We analyzed the relationships between DUM and patients' background; age, gender, economic status, education level, occupation, hospital access, and diagnosis.

RESULTS

The average DUM of all participants was 34.8 ± 42.4 months, ranging from 0 to 240 There was no significant difference in DUM by difference in hospital, gender, age, hospital access, education level, occupation, or economic status. Only patient diagnosis was related to DUM. The DUM for patients with schizophrenia and epilepsy was long, while the DUM for patients with neurosis and substance use were short.

CONCLUSION

To compare DUM with that of other low- and middle-income countries, DUM of our survey is extremely long. However, those reports were from urban areas within the low- and middle-income countries. We considered our report to include a very important sample showing the condition of psychiatric services in rural areas of low-income countries.

Pathways to mental health services for young people: a systematic review

PURPOSE

While early access to appropriate care can minimise the sequelae of mental illnesses, little is known about how youths come to access mental healthcare. We therefore conducted a systematic review to synthesise literature on the pathways to care of youths across a range of mental health problems.

METHODS

Studies were identified through searches of electronic databases (MEDLINE, PsycINFO, Embase, HealthSTAR and CINAHL), supplemented by backward and forward mapping and hand searching. We included studies on the pathways to mental healthcare of individuals aged 11-30 years. Two reviewers independently screened articles and extracted data.

RESULTS

Forty-five studies from 26 countries met eligibility criteria. The majority of these studies were from settings that offered services for the early stages of psychosis, and others included inpatient and outpatient settings targeting wide-ranging mental health problems. Generally, youths' pathways to mental healthcare were complex, involved diverse contacts, and, sometimes, undue treatment delays. Across contexts, family/carers, general practitioners and emergency rooms featured prominently in care pathways. There was little standardization in the measurement of pathways.

CONCLUSIONS

Except in psychosis, youths' pathways to mental healthcare remain understudied. Pathways to care research may need to be reconceptualised to account for the often transient and overlapping nature of youth mental health presentations, and the possibility that what constitutes optimal care may vary. Despite these complexities, additional research, using standardized methodology, can yield a greater understanding of the help-seeking behaviours of youths and those acting on their behalf; service responses to help-seeking; and the determinants of pathways. This understanding is critical to inform ongoing initatives to transform youth mental healthcare.

Pathways to care among psychiatric outpatients in a tertiary mental health institution in Singapore

BACKGROUND

Pathways to care studies in Singapore are of high interest given the cultural diversity and various sources of help available for those with mental illnesses, ranging from the more traditional to tertiary-level mental health care services.

AIM

The current study aimed to explore the associations of patients' socio-demographic characteristics with pathways to first contact and duration of untreated mental illness.

METHOD

A total of 402 participants were recruited through convenience sampling. A pathway to care form was used to gather systematic information about the sources of care utilized by participants before approaching a mental health professional. Data were analysed using multinomial logistic regression and multiple linear regression models to assess the associations.

RESULTS

Majority of participants reported primary care (36.0%) as their first point of contact, followed by non-formal sources of help (33.8%), specialist care (21.8%), police/court (4.0%), websites/media (3.3%) and religious/traditional treatment (1.3%). Those belonging to Malay and Indian ethnicity (vs Chinese) were more likely to make first contact with non-formal sources of help than primary care. Those who received a diagnosis of any mood or anxiety disorder (vs schizophrenia and related psychoses) were less likely to make first contact with specialist care or non-formal sources of help than primary care. Those who were separated/divorced/widowed were significantly associated with higher duration of untreated illness compared to those who were single. Participants whose family/relative initiated the first contact were significantly associated with a shorter duration of untreated illness compared to those who initiated first contact on their own.

CONCLUSION

Findings suggest the determinants of the pathways to first contact and duration of untreated illness included diagnosis, ethnicity, marital status and family initiating the first contact. The pathways adopted by these participants need to be kept in mind for planning mental health programmes.

Patient healthcare trajectory. An essential monitoring tool: a systematic review

BACKGROUND

Patient healthcare trajectory is a recent emergent topic in the literature, encompassing broad concepts. However, the rationale for studying patients' trajectories, and how this trajectory concept is defined remains a public health challenge. Our research was focused on patients' trajectories based on disease management and care, while also considering medico-economic aspects of the associated management. We illustrated this concept with an example: a myocardial infarction (MI) occurring in a patient's hospital trajectory of care. The patient follow-up was traced via the prospective payment system. We applied a semi-automatic text mining process to conduct a comprehensive review of patient healthcare trajectory studies. This review investigated how the concept of trajectory is defined, studied and what it achieves.

METHODS

We performed a PubMed search to identify reports that had been published in peer-reviewed journals between January 1, 2000 and October 31, 2015. Fourteen search questions were formulated to guide our review. A semi-automatic text mining process based on a semantic approach was performed to conduct a comprehensive review of patient healthcare trajectory studies. Text mining techniques were used to explore the corpus in a semantic perspective in order to answer non-a priori questions. Complementary review methods on a selected subset were used to answer a priori questions.

RESULTS

Among the 33,514 publications initially selected for analysis, only 70 relevant articles were semi-automatically extracted and thoroughly analysed. Oncology is particularly prevalent due to its already well-established processes of care. For the trajectory thema, 80% of articles were distributed in 11 clusters. These clusters contain distinct semantic information, for example health outcomes (29%), care process (26%) and administrative and financial aspects (16%).

CONCLUSION

This literature review highlights the recent interest in the trajectory concept. The approach is also gradually being used to monitor trajectories of care for chronic diseases such as diabetes, organ failure or coronary artery and MI trajectory of care, to improve care and reduce costs. Patient trajectory is undoubtedly an essential approach to be further explored in order to improve healthcare monitoring.

Duration of untreated psychosis and pathway to care in Riyadh, Saudi Arabia

AIM

Recent studies of 'duration of untreated psychosis' (DUP) indicate that some patients remain untreated in the community for some time. Considerable emphasis has been placed on reducing the DUP. However, most studies investigating DUP have been conducted in Western countries, where well-developed primary care systems are available. This study aims to describe DUP and its association with both demographic factors and pathways to care in Riyadh, Saudi Arabia.

METHODS

A retrospective study of 421 new case records of all Saudi schizophrenia patients over a 2-year period in six governmental hospitals in Riyadh, Saudi Arabia.

RESULTS

The median DUP was 1.41 years (interquartile range 0.35-2.81 years). The longest time to contact was 9.86 years but 90% had a DUP shorter than 5 years. Older age at onset, single marital status and higher educational level were associated with shorter DUP. Long DUP was associated with help seeking from traditional healers.

CONCLUSION

In Saudi Arabia, it usually takes longer for patients to seek help from psychiatric services after their first psychosis onset than it does in Western countries. The results suggest that the DUP is influenced by both demographic factors and pathways to care.

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

BACKGROUND

Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP.

AIMS

To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

METHOD

The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale.

RESULTS

Mean (±standard deviation ( SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors.

CONCLUSION

Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors.

Duration of Untreated Psychosis in Chinese and Mauritian: Impact of Clinical Characteristics and Patients' and Families' Perspectives on Psychosis

Background

Duration of untreated psychosis (DUP) is a potentially modifiable prognostic factor of course and prognosis of psychiatric disorders. Few studies have demonstrated that different cultural backgrounds or perspectives on psychosis may be important factors to the DUP. This study attempted to explore whether the DUP was different in Chinese and Mauritians and to clarify potential influencing factors to a long DUP (>3 months).

Methods

200 patients from China and 100 patients from Mauritius were enrolled in the study. Their respective family members were also recruited. Demographic and clinical characteristics were collected, and the Internalized Stigma of Mental Illness (ISMI) scale was adapted to measure the stigma in all subjects. Binary logistic regression analysis was used to find the potential influencing factors to the long DUP.

Results

35.3% of the enrolled patients had a long DUP. No significant difference was found in frequency of long DUP between the two countries. Chinese patients had relatively less perceptions of stigma. Furthermore, Chinese patients with a long DUP had more perception of breakup due to mental illness (OR = 2.22, p = 0.04) and more families’ perception of the patient being disinherited due to mental illness (OR = 6.47, p = 0.01). Mauritian patients with a long DUP were less likely to have high monthly income (OR = 0.12, p<0.01), while they had less patients’ awareness of mental illness (OR = 0.31, p<0.05) and less families’ awareness of mental illness (OR = 0.14, p<0.01).

Conclusion

The results of this study underlined the importance of DUP in economic conditions, racial and sociocultural factors, and public awareness on psychosis in developing countries.

Pathways to Care for Patients With First-Episode Psychosis in Singapore

In this study, we aim to describe the pathways to care for patients with first-episode psychosis in Singapore. We analyzed data from 900 individuals accepted by the Singapore Early Psychosis Intervention Programme between 2007 and 2012. The most common first contacts were specialist care (59%), primary care (27%), and the police (12%). Multivariate regression models showed that first contact with services varied according to demographic variables and diagnosis. The duration of untreated psychosis, total number of contacts before referral, and rate of referral to the Early Psychosis Intervention Programme varied according to demographic and clinical variables and first contact. We hope that this information will enable clinicians, managers, and other service providers to target interventions to streamline referrals, reduce distress, and improve the treatment of young people with psychotic illnesses.

Combining depot antipsychotic with an assertive monitoring programme for treating first-episode schizophrenia in a resource-constrained setting

AIM

To assess the feasibility and effectiveness of depot antipsychotic (flupenthixol decanoate) combined with an assertive monitoring programme (AMP) in first-episode schizophrenia.

METHODS

This was a prospective, non-comparative, longitudinal study conducted over 12 months assessing patient acceptance, adherence, outcome in domains of psychopathology, functionality and quality of life, and tolerability.

RESULTS

Of 207 participants, 149 (72%) completed 12 months of treatment. Acceptance of and adherence to depot was good. Treatment response was achieved by 170 (82%) participants and remission by 124 (60%). Thirty-three (19%) responders relapsed and 10 (5%) participants met a priori criteria for treatment resistance. Treatment was generally well tolerated.

CONCLUSIONS

Combination of depot antipsychotic with an AMP may be an effective and safe intervention in early phases of schizophrenia, and may be particularly suitable for resource-constrained settings.

Duration of untreated psychosis in a high-income versus a low- and middle-income region

OBJECTIVE

Most data on duration of untreated psychosis (DUP) derives from high-income countries. An inverse relationship between DUP and income and a longer DUP in low- and middle-income (LAMI) countries has been reported. The aim of this study was to compare DUP in a high-income country with that in a LAMI country using the same methodology.

METHODS

The sample consisted of in- and outpatients, aged 15-35 years for the Vienna site and 18-35 years for the Pakistani sites, with first-episode psychosis (FEP). DUP was evaluated using psychiatric interviews, medical charts and the Nottingham Onset Schedule. Differentiated reporting of duration of untreated illness (DUI) from prodrome to start of treatment, and DUP from manifest psychotic symptoms to start of treatment was ensured. Primary outcome measures, DUI and DUP, were measured at a 0.025 level of significance.

RESULTS

Thirty-one FEP patients in Vienna (mean age 20.03 years, SD 4.2) and 60 FEP patients from the Pakistani sites (mean age 26.15 years, SD 5.29) participated. The mean age in Vienna was younger due to the different age range inclusion criteria. The severity of psychopathology was more pronounced in the Pakistani sample. Log DUP was significantly different between groups (i.e. longer in the Pakistani sample (p=0.001)). Log DUI showed a trend for longer duration in the Vienna sample; however, this did not reach statistical significance (p=0.036). The severity of positive psychotic symptoms was associated with length of DUI in both regions.

CONCLUSION

The longer DUP in Pakistan confirms the need to provide affordable treatment for psychosis for young FEP patients in Pakistan and in other LAMI countries. The relatively long period from prodrome to treatment initiation in both regions underlines the need to further establish low-threshold early intervention strategies in order to increase detection rates and reduce factors limiting patients seeking treatment.

Duration of untreated negative and positive symptoms of psychosis and cognitive impairment in first episode psychosis

BACKGROUND

Duration of untreated psychosis (DUP) has been significantly associated with poor clinical and social outcomes in First Episode Psychosis (FEP) patients, but an association with cognitive outcomes has not been clearly established.

METHOD

Seventy-seven consecutively admitted, drug-naïve patients with FEP were assessed at baseline and at 1month and 6months. Underlying dimensions of DUP (general prodrome and positive, negative and disorganisation symptoms) were assessed using the Symptom Onset in Schizophrenia (SOS) inventory (Perkins et al., 2000). To assess the effect of DUP on the neuropsychological status of the patients, a linear mixed-effect model was fitted to each neuropsychological dimension. These models included a dichotomised version of DUP (short versus long duration) as a fixed effect, several adjusting variables to account for patient differences, and a random effect to incorporate the longitudinal structure of the data.

RESULTS

Patients with a short duration of untreated negative symptoms (DUNS) or a short duration of untreated positive symptoms (DUPS) outperformed patients with a long duration of untreated symptoms on memory tasks and a pre-attentional visual task but not on measures of verbal fluency, attention, reaction time, visual processing and executive functions.

CONCLUSIONS

This study provides additional support for an early intervention to shorten DUP to facilitate a better outcome in memory and attentional domains of FEP patients.

Early intervention in schizophrenia in developing countries: focus on duration of untreated psychosis and remission as a treatment goal

Early intervention services are based on the premise that untreated psychosis may have a deleterious effect on outcome, particularly in the early years of illness. The majority of the studies on duration of untreated psychosis have been conducted in developed countries; therefore this review focuses on publications from developing countries. We also review studies from developing countries that have been published following the Remission in Schizophrenia Working Group criteria. The duration of untreated psychosis is longer in developing countries, and is also associated with poor outcome, whereas remission rates following treatment of first-episode schizophrenia in developing countries appear to be higher than in developed countries. These two findings strongly argue for the establishment of early intervention services for schizophrenia in developing countries.

Gender and duration of untreated psychosis: a systematic review and meta-analysis

AIM

Duration of untreated psychosis (DUP) can influence the prognosis of schizophrenia. Previous studies have suggested that gender may influence the length of DUP. This study reports the result of the first systematic literature review and meta-analysis on the role of gender in influencing DUP in first-episode psychosis.

METHOD

Systematic literature search in PubMed/Medline and Ovid/PsychINFO. Twenty-seven studies presenting data on 4721 patients diagnosed with psychosis at their first episode (2834 males and 1887 females) were included in the analysis.

RESULTS

Samples had a higher proportion of males: odds ratio = 2.5 (95% confidence interval: 1.8-3.3). Mean age at first contact was 25.4 for males and 27.5 for females. Patients from non-Western countries were older at first contact than patients from Western countries. Average DUP in schizophrenia was 64 weeks and did not differ between genders but was shorter in Western compared with non-Western countries.

CONCLUSION

Earlier age at first contact and larger incidence in males support the existence of specific gender differences in first-episode psychosis; however, these are not associated with DUP length.