Predictors of help-seeking duration in adult-onset psychosis in Hong Kong

Purpose

Delay in receiving treatment in psychosis may lead to adverse consequences. We examined the predictors for help-seeking duration in adult-onset psychosis Chinese patients in Hong Kong. We hypothesized that factors which are more related to the illness manifestation would be predictive of waiting time before any help-seeking initiation, and factors which are more related to one’s knowledge about mental health services would be predictive of help-seeking duration.

Methods

First-episode patients with psychosis were recruited from the Jockey Club Early Psychosis project. They were asked to report retrospectively all help-seeking behaviors involved since their first occurrence of psychotic symptoms until receipt of effective psychiatric treatment. Baseline characteristics, pre-morbid functioning and traits, and mode of illness onset were assessed.

Results

Help-seeking pattern was analyzed in 360 patients who had subsequently reached the psychiatric services. They had an average of 2.5 help-seeking contacts. Nearly half of the first help-seeking process was initiated by family members. Only 1 % approached priests or traditional healers as the first step in help-seeking. Whereas a gradual mode of onset was significantly associated with longer waiting time to first help-seeking initiation, more premorbid schizoid and schizotypal traits and a migrant status were related to longer help-seeking duration.

Conclusions

Current findings suggested that family members were the key decision makers in initiating help-seeking. Longer help-seeking duration in migrants has significant implications to both local and global mental health policy.     

Effects of labeling and interpersonal contact upon attitudes towards schizophrenia: implications for reducing mental illness stigma in urban China

Purpose

As mental illness stigma contributes to poor outcomes for schizophrenia in China, locating strategies to reduce public stigma is imperative. It is currently unknown whether diagnostic labeling and contact with different help-seeking sources increase or decrease public stigma in China. Further, it remains unresolved whether prior personal contact acts to reduce stigma in this context. Advancing understanding of these processes may facilitate stigma-reduction strategies.

Methods

We administered an experimental vignette randomly assigning one of four labeling conditions to respondents to assess social distance towards a psychotic vignette individual in a sample of 160 Northern, urban Chinese community respondents.

Results

As expected, respondents given a “non-psychiatric, indigenous label”?+?“lay help-seeking” condition endorsed the least social distance. Unexpectedly, the labeling condition with a “psychiatric diagnostic label”?+?“lay help-seeking” condition elicited the greatest social distance. Unlike Western studies, personal contact did not independently decrease community stigma. However, prior contact reduced social distance to a greater extent in the labeling condition with a “non-psychiatric, indigenous label”?+?“lay help-seeking” condition when compared with all other labeling conditions.

Conclusion

The results indicate that cultural idioms do provide some protection from stigma, but only among respondents who are already familiar with what mental illness is. Our finding that the condition that depicted untreated psychosis elicited the greatest amount of stigma, while the “treated psychosis” condition was viewed relatively benignly in China, suggests that improved access to mental health services in urban China has the potential to decrease public stigma via labeling mechanisms.     

A controlled evaluation of a targeted early case detection intervention for reducing delay in treatment of first episode psychosis

Purpose

Interventions aimed at influencing specific pathways to care may reduce the duration of untreated psychosis (DUP). The purpose of this study was to reduce delay in referral to an early intervention service following first contact for help seeking for psychosis in a defined urban catchment area.

Methods

Using a historical control design, we conducted a targeted intervention comprised of intensive training and education regarding first onset of psychosis and benefits of early intervention with all potential points of contact in pathways to care in a defined catchment area of a specialized early intervention (EI) service. Data collected on different components of DUP [help seeking (H-DUP) and referral (R-DUP)] and demographic and clinical characteristics on patients seeking treatment of first episode of a psychotic (FEP) disorder accepted in the EI service for 3 years before and 3 years after the intervention were contrasted. No other systemic changes occurred in this catchment area during this period.

Results

There was a significant increase in the number of cases of FEP referred to the EI service post-intervention from hospitals other than the parent institute, in the proportion with a diagnosis of affective psychosis and proportion of patients from a lower socioeconomic status (SES). Although largest proportion of patients continued to make their first contact with community services, the latter failed to refer cases of psychosis to the EI service despite making a large number of mostly non-cases (for psychosis). The intervention had no direct effect on total DUP, R-DUP or H-DUP. After controlling for diagnosis and SES, post-intervention, R-DUP remained significantly lower for patients making first contact with the emergency service of the parent institute.

Conclusions

The intervention failed to reduce R-DUP for patients making contact with or referred from community services and most patients still used hospital resources to enter treatment at the EI service.     

Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy

Purpose

This study set out to investigate the patterns of referral in a sample (n = 206) of patients having first-time access to an Italian comprehensive program that targets the early detection of and early intervention on subjects at the onset of psychosis. The primary goal of the study was to investigate the duration of untreated illness (DUI) and/or the duration of untreated psychosis (DUP) in the sample since the implementation of the program.

Method

Data on pathways of referrals prospectively collected over a 11-year period, from 1999 to 2010; data referred to patients from a defined catchment area, and who met ICD-10 criteria for a first episode of a psychotic disorder (FEP) or were classified to be at ultra-high risk of psychosis (UHR) according to the criteria developed by the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne. Changes over time in the DUI and DUP were investigated in the sample.

Results

Referrals increased over time, with 20 subjects enrolled per year in the latter years of the study. A large majority of patients contacted a public or private mental health care professional along their pathway to treatment, occurring more often in FEP than in UHR patients. FEP patients who had contact with a non-psychiatric health care professional had a longer DUP. Over time, DUP and DUI did not change in FEP patients, but DUI increased, on average, in UHR patients.

Conclusions

The establishment of an EIP in a large metropolitan area led to an increase of referrals from people and agencies that are not directly involved in the mental health care system; over time, there was an increase in the number of patients with longer DUI and DUP than those who normally apply for psychiatric services.     

Help-seeking and pathways to care in the early stages of psychosis

Purpose

Delay in the treatment of a first psychotic episode can have a negative influence on the future course of the disease. In this context, it is important to examine pathways to care to understand factors contributing to delay in access to adequate care.

Methods

Using the Basel Interview for Psychosis, we examined the help-seeking behaviour of 61 individuals with an at-risk mental state for psychosis and 37 patients with a first episode of psychosis in a low threshold health care system as part of the Basel early detection of psychosis study.

Results

The median duration of untreated illness was 3.4 years, of untreated psychosis 12 months. Eighty-six percent of all individuals sought help of some kind before reaching our specialised early detection outpatient clinic, with a mean number of help-seeking contacts of 1.5 prior to referral. The most frequent first help-seeking contacts were family members or relatives n = 24 (26.7 %), close friends n = 17 (17.9 %), psychiatrists in private practice n = 13 (14.4 %) or general practitioners n = 11 (12.2 %). Most patients consulted other health professionals in the early course of the illness before reaching our specialised service; help-seeking with non-medical institutions was rare. Women had more help-seeking contacts than men before contact with our early detection clinic.

Conclusions

Family, close friends and medical professionals play an important role in help-seeking leading to specialised psychiatric care. Men seek help less often; specific strategies for encouraging young, at-risk men to seek help should be developed.     

Patterns of health services use prior to a first diagnosis of psychosis: the importance of primary care

Purpose

The observed association between treatment delay and poor outcomes in first-episode psychosis has led to an interest in the topography of symptom development preceding the onset of psychosis and associated help-seeking behaviors. We estimated the extent to which socio-demographic, clinical, and health service indicators are associated with patterns of service use for mental health reasons preceding a first diagnosis of psychosis.

Methods

Population-based administrative data from physician billings, hospitalizations, and public health clinics were used to identify incident cases of schizophrenia-spectrum psychosis among individuals aged 14–25 years in Montréal. Mental health contacts in the 4 years preceding the index diagnosis were analyzed.

Results

Thirty-two percent of cases had no contact with services for a mental health reason preceding the index diagnosis, and nearly 50 % received the index diagnosis of psychosis in the emergency department. Individuals in contact with primary care had a reduced likelihood of contact with the emergency department and inpatient services (OR = 0.15, 0.06–0.39) and of receiving the index diagnosis in the emergency department (OR = 0.36, 0.24–0.54), but also had a longer time to contact with a psychiatrist (HR = 0.32, 0.23–0.45).

Conclusions

Improving access to primary care may reduce the burden on emergency departments and inpatient units; however, primary care providers may need additional training in the symptoms of early psychosis and referral protocols. Given the limitations associated with using clinical samples from specialized services, population-based administrative data are an important source of information for understanding patterns of health services use preceding a first diagnosis of psychosis.     

Routine evaluation in first episode psychosis services: feasibility and results from the MiData project

Background

Early intervention services (EIS) for psychosis are becoming widespread. Structured methods of assessment are advocated in these services, but a consensus is still needed on a package of measures with good psychometric properties that is feasible and reliable for routine use in this setting.

Methods

A computerised assessment package (MiData) was designed to provide clinicians with easy-to-understand feedback about clients’ progress and to allow evaluation of the whole service for both audit and research purposes. Core areas include symptoms, duration of untreated psychosis (DUP), pathways into care, social functioning, and substance misuse at initial intake and annually thereafter.

Results

MiData has been adopted by EIS throughout London and in some other centres. Baseline data are now available regarding 533 first-episode psychosis patients who presented to 8 London teams. The completeness of the data varied across teams and measures, with fullest completion for sociodemographic data (99% on some measures) and poorest for DUP. The average London EIS client is male, single, unemployed and comes from Black or Minority Ethnic group. Most (70%) demonstrated poor social functioning at intake, over a third (38%) reported substance abuse problems and 23% had harmed themselves or others in the previous 6 months.

Conclusions

MiData provides a clinician-friendly system of evaluating first-episode psychosis services but requires further refinement and dedicated resources to improve completion rates. This method of collecting routine data is of use to clinicians, managers, health service researchers and commissioners and potentially it may enable naturalistic comparisons between different models of care.     

The distribution of self-reported psychotic-like experiences in non-psychotic help-seeking mental health patients in the general population; a factor mixture analysis

Purpose

Factor mixture analysis (FMA) and item response mixture models in the general population have shown that the psychosis phenotype has four classes. This study attempted to replicate this finding in help-seeking people accessing mental health services for symptoms of non-psychotic mental disorders.

Methods

All patients (18–35 years old) referred for non-psychotic mental health problems to the secondary mental healthcare service in The Hague between February 2008 to February 2010 (N = 3,694), were included. Patients completed the Prodromal Questionnaire (PQ). Hybrid latent class analysis was applied to explore the number, size and symptom profiles of the classes.

Results

The FMA resulted in four classes. Class 1 (N = 1,039, 28.1 %) scored high on conceptual disorganization, inattention and mood disorder. Patients in Class 2 (N = 619, 16.8 %) endorsed almost all PQ-items, were more often screened as being psychotic or at high risk of developing psychosis, without care takers noticing. In Class 3 (N = 1,747, 47.3 %) perplexity, paranoia and negative symptoms were more prevalent. Patients were more often at high risk of developing psychosis. Class 4 (N = 286, 7.7 %) represented the ‘normative’ group with low probabilities for all items.

Discussion

The results support the hypothesis that a representation in four classes of psychotic-like experiences can also be applied in a help-seeking population.     

The application of the theory of planned behavior to help-seeking intention in a Chinese society

Purpose

This study tested the efficacy of Ajzen’s theory of planned behavior (TPB) in explaining intention to seek mental health services and compared the traditional TPB model with a TPB partial mediation model. It also aimed to understand factors related to intention to seek mental health services in Macao to inform local policies.

Method

The present study consisted of two phases: (a) a pilot study to develop belief-based measures used in the main study, and (b) a cross-sectional study to investigate the application of TPB in understanding help-seeking intention. In the main study, 337 Macao residents (age range 18–65) participated in a survey conducted in the community.

Results

The TPB partial mediation model was better than the traditional TPB model in explaining help-seeking intention in Macao. The model also suggested that attitude, subjective norm, and perceived behavioral control were all significant predictors of help-seeking intention. However, symptom severity, prior help-seeking, and gender did not significantly directly predict help-seeking intention.

Conclusion

Preference for the TPB partial mediation model may be culturally relevant. The implications of the findings are discussed in relation to the salient beliefs about help-seeking. Limitations and recommendations for future research are provided.     

A NEET distinction: youths not in employment,education or training follow different pathways to illness and care in psychosis

Purpose

The early phases of psychosis, including the prodrome, often feature educational/occupational difficulties and various symptoms and signs, that can render or keep youths “Not in Employment, Education or Training” (NEET). Conversely, NEET status itself may increase risk for illness progression and impaired functioning, and impede access to appropriate services for psychosis. As these issues have not been investigated, we aimed to examine differences in the illness and care pathways and characteristics of youths with psychosis who are NEET and non-NEET.

Methods

Youths entering a catchment-based Canadian early intervention service for psychosis (N?=?416) were assessed as being NEET or non-NEET and compared on symptomatology, premorbid adjustment, prodrome and duration of untreated psychosis (DUP).

Results

Thirty-nine percent of the sample was NEET. Compared to non-NEET youths, NEET youths had 34% higher negative symptoms scores, longer prodromes (median of 52 weeks vs. 24 weeks), and were more often continuously ill after their first psychiatric change until the onset of psychosis (62% vs. 45%). Both groups had similar premorbid adjustment scores until late adolescence when scores were significantly worse for NEET youths. Accounting for other predictors, NEET youths had 23% longer DUPs on average, despite having made more help-seeking attempts.

Conclusions

Despite being more narrowly defined, NEET status was thrice as prevalent in our sample as in the Canadian population. The NEET group followed a distinct trajectory of persistent symptoms and functional decline before presenting with a psychotic disorder. The systemic delays that NEET youths encountered indicate a need for better-targeted early identification efforts.

     

Profiles of and practices in crisis resolution and home treatment teams in Norway: a longitudinal survey study

Background

Crisis resolution and home treatment (CRHT) is one of the more recent modes of delivering acute mental health care in the community. The objective of the study was to describe the standardizations and variations in the CRHT teams in Norway in order to gain knowledge regarding the structures and processes of CRHT teams.

Methods

A longitudinal survey of five CRHT teams in Norway was carried out for a period of 18 months with two sets of questionnaires-one for CRHT team profiles for a bi-yearly survey and the other for services and practices of CRHT teams for a monthly survey.

Results

The five CRHT teams were configured by a set of common basic characteristics in their operations, while at the same time were variant in several areas of the teams' structures and processes. Significant differences among the teams were evident in terms of the structural aspects such as service locality, staffing and team make-up, caseload, service hours, and travel time, and the process aspects such as the number of referrals received, referral source, admission, service duration, and discharge destination. These variations are reflected upon the perspectives regarding the nature of mental health crisis, the conflicting policies in mental health services, and the nature of home-based mental health care.

Conclusions

The diversity in the way CRHT teams are established and operate needs to be examined further in order to understand the reasons for such variations and their impact on the quality of services to service users and in relation to the total mental health service system in a community.     

Providing support to psychiatric patients living in the community in Japan: patient needs and care providers perceptions

Background

Social support programs are a critical component of care for psychiatric patients living in community or residential settings. There is little information, however, on how to optimally deliver these services in the Japanese context.

Methods

We selected ten community life support centers for patients with major mental illness and administered questionnaires to 199 pairs of patients and staff members. These questionnaires consisted of twenty-six items from six categories: difficulties with interpersonal relationships; risks to physical well-being; risks to mental health; difficulties with life skills; challenges regarding living conditions; risks towards community safety. For each of these items, patients were asked whether they had experienced difficulties during the previous month, and staff members were asked the extent to which their patients needed support.

Results

The results demonstrated that staff members tended to understate patients' needs regarding chronic medical conditions (p < 0.01), dietary habits (< 0.01), and excessive smoking or alcohol drinking (< 0.05). On the other hand, staff members recognized patients' needs regarding mental health problems to a greater extent than patients themselves (< 0.05).

Conclusion

Results of this study suggest that social services geared towards specific tasks of daily living form an important component of comprehensive care for psychiatric patients living in community settings in Japan.     

Pathways-to-Care for First-Episode psychotic patients--an overview of international studies

A longer duration of untreated psychosis (DUP) as well as of untreated illness (DUI) was found to be associated with a negative course of psychosis. Thus, increasing efforts are made to reduce the DUP and provide adequate treatment as early as possible. But, in order to overcome obstacles to early help-seeking, these have to be identified first. Thus, an overview on initial help-seeking behaviour and predictors of DUP is given. Across 25 identified studies, the DUP, at about one year on average, is still unfavourably long and includes on average of three help-seeking contacts prior to the initiation of adequate treatment. Since negative factors in pathways-to-care involve features on all relevant levels (patient, social environment and health-care system), an optimisation of pathways-to-care will require the integration of services and continuous awareness programmes targeting the general population and mental health-care professionals.     

Service Priority and Standard Performance of Community Mental Health Centers in South Korea: A Delphi Approach

Objective

The role of community mental health centers (CMHCs) in Korea is quite different than that of these centers in Western countries due to nation-specific health care system characteristics. For example, CMHCs of Korea are expected to provide services for serious mental illness in addition to other services in response to community needs, such as internet addiction of adolescents. Consequently, it is important to determine service priorities of CMHCs and to define standard service performances in order to maximize their effectiveness with limited resources. The present study aimed to generate expert consensus on service priorities and to identify standard service performances of CMHCs in South Korea.

Methods

Forty-five mental health professionals participated as experts in a Delphi survey. We made a survey questionnaire based on Korean and international data and guidelines of some countries such as the UK and Australia. Experts answered the first and second round questionnaires and their answers were analyzed using frequency analysis.

Results

For the question about future directions of CMHCs, twenty-two experts (49%) answered that the growth of services for serious mental illness should be preferred to other areas. The service for chronic mental illness was thought to be the most important service area (27.1%) and, early psychosis (10.5%) is included, the services for serious mental illness should be regarded as the most important service area of Korean CMHCs. It is followed by child and adolescent services (13.2%) and mental health promotion services (10.8%). The relative importance of service performances on each service domain were given by answers of experts.

Conclusion

CMHCs in Korea should focus their priority on the management of serious mental illness. Service standardization by the relative importance of service performances on each service domain is needed.     

What do people in forensic secure and community settings think of their personality disorder diagnosis? A qualitative study

Purpose

The aim of this study was to explore the experience of having a personality disorder diagnosis within the context of forensic secure and community services.

Methods

We used an interpretative phenomenological analysis to analyse interviews with 10 service users purposively recruited from services in South London.

Results

Participants described two facets of their lived experience: (1) the way they see themselves now, in light of their offending and social background and (2) the pejorative nature of the personality disorder label, its relationship to mental illness and their need to distance themselves from it.

Conclusions

Having a forensic identity affects participants’ perceptions of their diagnosis and its treatment as well as their views about themselves.     

Pathway for inpatients with depressive episode in Flemish psychiatric hospitals: a qualitative study

Background

While the mental health situation for most people in low and middle-income countries is unsatisfactory, there is a renewed commitment to focus attention on the mental health of populations and on the scaling up of mental health services that have the capacity to respond to mental health service needs. There is general agreement that scaling up activities must be evidence-based and that the effectiveness of such activities must be evaluated. If these requirements are to be realised it will be essential to strengthen capacity in countries to conduct rigorous monitoring and evaluation of system development projects and to demonstrate sustained benefit to populations.

The Observatory

The International Observatory on Mental Health Systems (IOMHS) will build capacity to measure and to track mental health system performance in participating countries at national and sub-national (provincial and district) levels. The work of IOMHS will depend on the establishment of robust partnerships among the key stakeholder groups. The Observatory will build the capability of partner organisations and networks to provide evidence-based advice to policy makers, service planners and implementers, and will monitor the progress of mental health service scaling up activities.

Summary

The International Observatory on Mental Health Systems will be a mental health research and development network that will monitor and evaluate mental health system performance in low and middle-income countries.     

Personality-related factors as predictors of help-seeking for depression: a population-based study applying the Behavioral Model of Health Services Use

Background

Although the prevalence of mental disorders and the demand for mental health services are increasing, little is known about the impact of personality-related factors on help-seeking among depressive individuals. We, therefore, investigated the relationship between the “Big Five” personality traits, resilience, alexithymia, childhood neglect or abuse, and help-seeking among depressive individuals.

Methods

We used data from 354 persons with a diagnosis of major depression from the population-based cohort study of health in Pomerania within the theoretical framework of the Andersen Behavioral Model of Health Services Use.

Results

Using stepwise regression techniques, we found that older age, higher education, more perceived social support, presence of childhood abuse, higher levels of conscientiousness, lower levels of resilience, and more severe depression were associated with help-seeking for depression. In contrast, gender, extraversion, openness, agreeableness, neuroticism, and alexithymia did not significantly predict help-seeking. In addition, no evidence for gender-specific effects was observed.

Conclusion

Personality-related predisposing factors are important predictors of help-seeking. The influence of resilience on help-seeking among depressed individuals merits further exploration.     

Understanding reduced activity in psychosis: the roles of stigma and illness appraisals

Purpose

Increasing activity and social inclusion for people with psychosis is a primary goal of mental health services. Understanding the psychological mechanisms underlying reduced activity will inform more carefully targeted and effective interventions. Anxiety, depression, positive symptom distress and negative symptoms all make a contribution, but much of the variance in activity remains unaccounted for and is poorly understood. Appraisals of illness impact on adjustment to illness: mood, engagement in treatment and quality of life are all affected. It is plausible that illness appraisals will also influence activity. This study investigated the extent to which three components of illness appraisal accounted for variance in activity.

Method

50 people with psychosis completed measures of activity, positive and negative symptoms, anxiety and depression, cognitive functioning, stigma, insight and illness perceptions.

Results

Multiple regression revealed that internalised stigma, but not insight or illness perception, was significantly correlated with reduced activity. 42% of the variance in activity was accounted for by stigma, negative symptoms, positive symptom distress and social support. Affect, cognitive functioning and positive symptoms were not associated with activity.

Conclusion

For people with psychosis, activity levels appear to be compromised particularly by fears of what others think of them and how they will be treated by others. Directly targeting these fears should improve the impact of psychological interventions on functioning. Specific, individualised cognitive behavioural interventions could be a useful adjunct to recovery-focused narrative therapies and complement public information campaigns to reduce discriminatory attitudes and behaviours.     

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.