Missed Opportunities in Earlier Identification of Individuals With First-Episode Psychosis

Abstract

the patient to offer services to improve linkage to care and transition back into the community.To identify missed opportunities to intervene with young adults with FEP before the first hospitalization, we manually reviewed hospital discharge summaries from 145 NYC START enrollees discharged between January 1 and July 31, 2016. We noted time from behavior change to hospitalization (TBCH), measured from the time when the patient or others reported first noticing behavior suggestive of early psychosis (e.g., withdrawing or talking to self ) to time of admission as a proxy for duration of untreated psychosis (DUP). Because the World Health Organization recommends limiting DUP to less than 90 days (2), we divided the sample into TBCH #90 days versus .90 days. We reviewed 30 discharge summaries to identify common areas of potential missed opportunities, then coded these opportunities as present or absent in the remaining summaries.Of 145 discharge summaries examined, 38 were removed from analysis, 31 (82%) of which indicated psychiatric hospitalization prior to that precipitating NYC START referral, six (16%) indicated lengthy prior outpatient treatment for psychosis, and one (2%) indicated substanceinduced psychosis. Of 107 remaining, there were no statistically significant differences in gender, age, race, or insurance between those with TBCH #90 days (N555) and those with TBCH .90 days (N552). After adjusted logistic regression analysis, we found that discharged patients with declines in educational performance or discontinued education had greater odds of TBCH .90 days compared with those who stayed in school or had completed a degree (odds ratio [OR]5 4.33, 95% confidence interval [CI]51.72-10.87). Those with family or friends noticing behavior changes had greater odds of TBCH .90 days compared with those who did not (OR54.01, 95% CI51.31-12.34). [A table in the online supplement indicates demographic and additional information.]Findings suggest that family and friends often identify behavior changes that constitute the prodromal phase of psychosis. Also, expectedly, FEP may cause major