Granular analysis of pathways to care and durations of untreated psychosis: A marginal delay model

Abstract

Objective An extensive international literature demonstrates that understanding pathways to care (PTC) is essential for efforts to reduce community Duration of Untreated Psychosis (DUP). However, knowledge from these studies is difficult to translate to new settings. We present a novel approach to characterize and analyze PTC and demonstrate its value for the design and implementation of early detection efforts. Methods Type and date of every encounter, or node, along the PTC were encoded for 156 participants enrolled in the clinic for Specialized Treatment Early in Psychosis (STEP), within the context of an early detection campaign. Marginal-delay, or the portion of overall delay attributable to a specific node, was computed as the number of days between the start dates of contiguous nodes on the PTC. Sources of delay within the network of care were quantified and patient characteristic (sex, age, race, income, insurance, living, education, employment, and function) influences on such delays were analyzed via bivariate and mixed model testing. Results The period from psychosis onset to antipsychotic prescription was significantly longer (52 vs. 20.5 days, [p = 0.004]), involved more interactions (3 vs. 1 nodes, [p<0.001]), and was predominated by encounters with non-clinical nodes while the period from antipsychotic to STEP enrollment was shorter and predominated by clinical nodes. Outpatient programs were the greatest contributor of marginal delays on both before antipsychotic prescription (median [IQR] of 36.5 [1.3–132.8] days) and (median [IQR] of 56 [15–210.5] days). Sharper functional declines in the year before enrollment correlated significantly with longer DUP (p<0.001), while those with higher functioning moved significantly faster through nodes (p<0.001). No other associations were found with patient characteristics and PTCs. Conclusions The conceptual model and analytic approach outlined in this study give first episode services tools to measure, analyze, and inform strategies to reduce untreated psychosis.

The Anomalous Effect of COVID-19 Pandemic Restrictions on the Duration of Untreated Psychosis (DUP)

“…This may have led to quicker help-seeking. Our prior analysis demonstrated that the single largest contributor to DUP in our region was between psychosis onset and first-initiation of help seeking, and that family members were key facilitators 8 . Additionally, reduced patient flow to normally crowded emergency services may have allowed greater attention by clinicians to the identification and management of psychotic symptoms.…”

“…Both could have led to reductions in DUP-Demand. Since most patients in the catchment receive their first antipsychotic via emergency and inpatient services 8 , this reduction in DUP-Demand is unlikely to be explained by the increasing availability of telehealth services.…”