Pathways to care and DUP

Relevant literature was searched from Medline (Ovid), PsychINFO (Ovid) and Embase (Ovid), using the following search strategy: duration of untreated psychosis OR therapy delay OR delay in treatment OR initiation of treatment AND psychosis OR psychotic disorders OR schizophrenia OR schizoaffective OR schizofreniform AND clinical pathway OR pathways OR pathways to care. The bibliographies of these papers and previously published reviews (listed in table 3) was also scanned to locate additional studies. Only quantitative studies specifically addressing descriptive analysis of pathways to care in relation to DUP were finally selected.

The following studies were reviewed in detail. First author, publication year, location, sample size, sampling source, methods used in data analysis, DUP, pathways indicators, and strength and limitations are presented in table 1. Relevant findings from this review are summarized briefly in the text.

Table 1: Original studies on pathways to care in relation to DUP.

Authors, Year and

Location Study design Participants, sources

and analysis DUP and pathways

indicators Strenghts and limitations delay as a problem.

Cohort with 1 year

= not stated (ns) Referral source = ns

delay. Noted some Referral source = ns

First on

Referral source = ns

Multi-site study.

Sample = catchment.

Patient/family Referral source = na

Retrospective and Referral source = ns

Retrospective and recall bias, use of WHO encounter discussion of 3 case studies with long

Referral source = ns

Small sample, few covariates in regression model.

(Burnett et al., 1999),

UK Observational,

Sample = catchment.

Median DUP = ns First contact = GP Referral source = ns

Retrospective analysis, not equal groups, recruitment area not

Patient/family Referral source = ns

Two sites, no interrater reliability tests, gender

distribution different.

(Garety & Rigg,

2001), UK Observational, cross-sectional survey with

(Skeate, 2002), UK Observational.

Cross-sectional N = 42 Referral source = ns

Investigates help-seeking, ordinal DUP, retrospective recall bias.

(Fuchs & Steinert,

2002), Germany Observational,

cross-sectional N = 50

2003), Canada Observational,

cross-sectional N = 134

interview and medical records.

Descriptive frequency analysis.

(Yamazawa et al.,

2004), Japan Observational, cross-sectonal, two First contact = direct referral

2004), Germany Observationa,

cross-sectional N = 66

Referral source = ns

Retrospective data,

Referral source = ns

Paper in German, possible selection bias, only inpatients included.

(Norman et al.,

2004), Canada Observational,

cross-sectional N = 110 Referral source = ns

Structured interviews used, investigated two components of delay,

(Cougnard et al.,

2004), France Observational,

cross-sectional N = 86

Referral source = ns

Regression model, First contact = social worker

Jambunathan, 2005),

Referral source = ns

skewed outcome, Referral source = GP

Regression models Referral source = ns

Long DUP, used regression model, retrospective and possible recall bias.

(Pek, Mythily, &

Sample = specialized.

Patient interview.

First contact = family Referral source = ns

Did not use

First contact = GP Prodromal clinic study, structured

% sz = ns

Referral source = ns assessment of variables,

2007), Canada Observational,

cross-sectional N = 98

Referral source = ns

Structured First contact = social worker

Referral source = ns

Interviews with bias and recall bias because of related to lower DUP.

Small sample and multiple testing.

(Razali & Mohd Yasin, 2008), Malaysia data and recall bias.

psychosis and

Referral source = ns

(Temmingh & Referral source = GP

Small sample.

Recruitment from inpatient, may not be representative.

Referral source = ns

Data from developing

2009), Ireland Observational,

cross-sectional N = 142 Referral source = ns

Analysis of

(Sharifi et al., 2009),

Iran Observational, sources of data. Not structured

Referral source = ns

First study of ethnic variation in Canada.

Korea sectional % male = 72.2

First contact = family, teacher or internet.

Referral source = ns

Korea, on Referral source = ns

Inpatient sample, several exclusion criteria.

Retrospective data, but multiple sources.

(Boonstra et al.,

2012), Netherlands Observational,

cross-sectional N = 182 Referral source = ns

Analysis of used. Did not include premorbid function Referral source = ns

Ethnic variation in

bivariate, ANOVA,

2013a), UK Observational,

cross-sectional N = 343 possible recall bias.

(Cocchi et al., 2013),

Referral source = ns

UHR and FEP patients followed for 11

Referral source = ns

Understudied (Fridgen et al., 2013),

Germany practice, may not be representative sample.

(Ehmann et al.,

2013), Canada Observational,

cross-sectional N = 104 Referral source = ns

Comparison of community and inpatient pathways.

Recruitment from several sources.

(Bhui, Ullrich, & Coid, 2014), UK. pathway is related to shorter DUP. Large

Sample = catchment.

Referral source = ns sample. Structured instruments. First contact = faith based healers Referral source = ns

Culturally influenced beliefs on the causes of schizophrenia may contribute to treatment delay.

Possible confounders noted as limitation.

(Singh et al., 2015), Referral source = ns

First study examining ethnic variations in pathways to care and how they are noted as limitations.

(Tomita et al., 2015), Referral source = ns

Traditiona health

Referral source = ns

Large study. Some patients treated in private practice, possibly not included.

Tertiary treatment

This review includes studies from many different countries and diverse healthcare contexts. Several pathways indicators are reported on, although most frequently reported is point of entry and which contact made the referral to mental health services. A main finding

is that the pathways to care taken by FEP patients is largely dependent on the specific

healthcare context. In most European studies the General Practitioner (GP) is the first contact, in the US and Japan hospitals are often the first contact, in China/Hong Kong social workers are contacted, while in many developing countries a traditional healer is the first contact after the onset of psychosis. The importance of geographical region as a determinant of pathways, indicate that differences in social, cultural and specific healthcare system are important determinants of the pathway taken.

Regarding DUP there is also great variability in reported median values. This ranges from 4 weeks in a study from New Zealand (Turner et al., 2006), to 48 weeks in a study conducted in Nigeria (Odinka et al., 2014). This may also be related to issues of representativeness.

Several studies are based on special samples and not units with catchment area

responsibilities. This makes generalizability to ordinary clinical samples difficult. In addition, few studies report on the rate of patient refusals, also important for analysis of

representativeness. Although the patient delay/interval is noted to contribute significantly to DUP in many studies, several recent studies from European countries report significant service/system delay. In some studies, this delay contributes almost as much as the patient interval. The reasons for this delay is unclear.

This review raises several important questions. Given the importance of healthcare context, are there also local and regional differences? Can difference in geographical context influence pathways and treatment delay? The GP is an important point of entry, but do they recognize the early presentation of psychosis? When do they decide to refer? A recent finding is that delay after entry to mental health services is sometimes considerable, what are possible the reasons for this delay?

In document STUDIES IN PATHWAYS TO CARE (sider 22-32)