Racial differences in pathways to care preceding first episode mania or psychosis: a historical cohort prodromal study

Abstract

BackgroundThere is evidence suggesting racial disparities in diagnosis and treatment in bipolar disorder (BD) and schizophrenia (SZ). The purpose of this study is to compare psychiatric diagnoses and psychotropic use preceding a first episode of mania (FEM) or psychosis (FEP) in racially diverse patients.MethodsUsing a comprehensive medical records linkage system (Rochester Epidemiology Project, REP), we retrospectively identified individuals diagnosed with BD or SZ and a documented first episode of mania or psychosis. Illness trajectory before FEP/FEM were characterized as the time from first visit for a mental health complaint to incident case. Pathways to care and clinical events preceding FEP/FEM were compared based on subsequent incident case diagnosis (BD or SZ) and self-reported race (White vs. non-White).ResultsA total of 205 (FEM = 74; FEP = 131) incident cases were identified in the REP. Duration of psychiatric antecedents was significantly shorter in non-White patients, compared to White patients (2.2 ± 4.3 vs. 7.4 ± 6.6 years; p < 0.001) with an older age at time of first visit for a mental health complaint (15.7 ± 6.3 vs. 11.1 ± 6.0 years; p = 0.005). There were no significant differences by race in FEM pathway to care or age of first seeking mental health. Overall non-White patients had lower rates of psychotropic use.ConclusionThese data are unable to ascertain reasons for shorter duration of psychiatric antecedents and later age of seeking care, and more broadly first age of initial symptom presentation. If symptoms are confirmed to be earlier than first time seeking care in both groups, it would be important to identify barriers that racial minorities face to access timely psychiatric care and optimize early intervention strategies.

Factors associated with suicide attempts in the antecedent illness trajectory of bipolar disorder and schizophrenia

“…First, the retrospective study design may introduce inherent limitations such as information bias and missing data, which may limit our ability to establish causality in the current findings. Nonetheless, previous REP studies have demonstrated validity and reliability, as evidenced by previous reports [Capasso et al 2008 ; Prieto et al 2016 ; Gardea-Resendez et al 2023 ; Ortiz-Orendain et al 2023 ]. Second, the REP demographics may limit the study’s generalizability due to a less diverse population (higher prevalence of white population), and of higher socioeconomic status [St Sauver et al 2012 ].…”

“…The REP is a population-based registry that allows to retrospectively analyze the history of individuals who developed an illness while mitigating risks of sampling, recall, referral, and response biases [Allebeck et al 2009 ; Maret-Ouda et al 2017 ]. The REP contains sociodemographic and clinical information of all residents of Olmsted County who had received treatment from 1986 onwards and has shown its validity in previous studies both for BD and SZ [Capasso et al 2008 ; Prieto et al 2016 ; Gardea-Resendez et al 2023 ; Ortiz-Orendain et al 2023 ].…”

“…Specifically, we collected data for the following variables: suicidal ideation with plan, self-harm, suicide attempts, psychiatric hospitalizations, alcohol and substance use, previous childhood adversities, and psychiatric diagnosis during the illness trajectory before FEM/FEP. A full description of the other extracted variables has been thoroughly documented in recent reports carried out by our group [Gardea-Resendez et al 2023 ; Ortiz-Orendain et al 2023 ]. Considering the lack of consensus on the operationalization of the prodrome phase [Geoffroy et al 2017 ; Kupka et al 2021 ], the psychiatric antecedent onset was defined as the date in which the first psychiatric symptoms, including neurodevelopmental disorders, was first coded in the patients’ health record or the first time a mental health problem was reported in the problem list of a clinical note [Ortiz-Orendain et al 2023 ].…”