It has been suggested that treatment delay in psychotic disorders may be related to poor outcome (1–3). Some studies have failed to demonstrate such a relation (4,5); however, 2 recent reviews have concluded that, unresolved methodological differences among studies notwithstanding, sufficient evidence exists to support an inverse relation between treatment delay in first-episode psychotic (FEP) disorders and clinical outcome (6,7). It has also been proposed that improving FEP outcome involves providing phase-specific treatment in addition to reducing treatment delays (7,8).
A substantial proportion of individuals experiencing FEP disorder face long treatment delays, ranging from a few weeks up to an average of 1 to 2 years. Barriers to appropriate care, likely to exist at different levels of traditional referral and treatment systems, often result in multiple visits before an appropriate referral is made (9,10). More recent work at a specialized early-psychosis program in Canada has indicated that, on average, FEP patients make 2.3 (range, 1 to 6) help-seeking contacts following the onset of psychosis; most of these are made to emergency services and family physicians (11).
This paper outlines an approach to reducing barriers to appropriate treatment. It involves systemic changes implemented in an early-intervention clinical program in an urban setting. We present preliminary data on treated incidence, referral patterns, and treatment delay during the program’s first 3 years.
General Program Description
Changes to Promote Early Access
Prompt Response to Referrals. A quick-response system was put in place. This consisted of immediate contact by an experienced mental health nurse and an offer for initial assessment within 24 to 48 hours.
Data Collection and Analysis
Details on assessment procedures and methods used to calculate duration of untreated psychosis (DUP) are available from previous publications (12,13). We applied a significance level of 5% to all statistical tests. Ethics approval for this study was provided by the Research Ethics Board for Health Sciences Research Involving Human Subjects of the University of Western Ontario.
Case Definition and Treated Incidence
Figure 1 Proportion of diagnostic subgroups over the 3-year period
Figure 2 Median DUP in weeks by referral source
Following changes designed to improve access for potential FEP patients, treated incidence increased, the annual proportion of patients with a diagnosis of schizophrenia decreased, and there was some shift in the referral sources of positive cases. In addition, treatment delay was reduced, especially for cases referred from sources other than health care. While substantial, these changes failed to reach statistical significance—very likely because small numbers were involved. While the observational nature of this study and lack of statistical significance of the findings may limit their generalizability, the data do suggest several potentially important patterns that need to be tested in larger samples over longer periods of time.
The observed decrease in treatment delay in year 3 suggests that the changes designed to improve access may have removed certain barriers over time, although its real significance can only be confirmed if this reduction is sustained in future. The pattern reported here also suggests that the systemic changes may have circumvented the traditional community-based health referral system and its associated delays (16). If replicated, it will confirm the suspected potential of school counsellors and family members to initiate referrals early after the onset of psychosis, provided there is a clinical service that will respond promptly to their referral. The observed lack of change in DUP over the 3 years in cases arriving through acute or hospital-based sources also suggests that a proportion of patients are unaffected by such systemic changes.
In conclusion, relatively simple changes in service delivery to FEP patients appear to initially increase the number of identified cases requiring treatment and lead to reduced DUP. While these findings are encouraging, the nature of this study and the relatively small sample limits their generalizability. A longer study period is needed to ascertain the stability of these changes.
Funding and Support
This study was part of a larger study on the impact of early intervention in schizophrenia and related disorders funded by the Canadian Institutes of Health Research. Additional seed funding for the specific analyses was provided by the Department of Psychiatry, University of Western Ontario.
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Manuscript received January 2003, revised, and accepted April 2003.
1. Graduate Student, Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario; Research Associate, Department of Psychiatry, University of Western Ontario, London, Ontario.
2. Director, Division of Clinical Research, Douglas Hospital Research Centre, Montreal, Quebec; Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Scientist, Lawson Health Research Institute, London, Ontario.
3. Professor, Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario; Professor, Department of Psychiatry, University of Western Ontario, London, Ontario.
4. Coordinator, PEPP-Montreal, Douglas Hospital Research Centre, Montreal, Quebec.
5. Nurse Case Manager, London Health Sciences Centre, London, Ontario.
6. Associate Professor of Biostatistics, Departments of Comunity Health Sciences and of Clinical Neurosciences, University of Calgary, Calgary, Alberta.
7. Associate Professor, Department of Pediatrics, University of Western Ontario, London, Ontario; Associate Professor, Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario; Scientist, Child Health Research Institute, London, Ontario.
Address for correspondence: DJ Scholten, Room 129B, WMCH Bldg, LHSC-SSC, 392 South Street, London, ON N6A 4G5
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