Duration of untreated psychosis

Delays from the onset of psychosis to initiation of pharmacotherapy were longest in White British patients for whom the median value was almost twice that of some BME groups and extended beyond the National Health Service policy target of 3 months. ³ Delays from the onset of psychosis to referral to early intervention services were overall longer than delays to initiation of drug treatment, suggesting that for many individuals, early intervention service teams do not play a part in the initiation of antipsychotic medication and referral to these services occurs somewhat later. Again, the interval from onset of psychosis to early intervention services referral was longest in White British individuals with an even greater deviation from other ethnic groups. These interesting findings are contrary to much of the existing literature. ^{Reference Bechard-Evans, Schmitz, Abadi, Joober, King and Malla4,Reference Archie, Akhtar-Danesh, Norman, Malla, Roy and Zipursky9,Reference Cole, Leavey, King, Johnson-Sabine and Hoar17,Reference Turner, Smith-Hamel and Mulder18} Among studies of first-episode psychosis cohorts, only the ÆSOP study ^{Reference Morgan, Fearon, Hutchinson, McKenzie, Lappin and Abdul-Al6} has produced results in this direction, identifying briefer DUP in Black African patients but no other BME group.

Pathway contacts

Rates of contact with primary care were highest in White British and South Asian patients, with just over half attending the GP practice during their pathway into early intervention services. Adjustment for confounding ameliorated this disparity, with a difference persisting only for Black British patients who were less than two-thirds as likely as White British individuals to visit their GP. Emergency medical services, on the other hand, were more commonly accessed by individuals from BME groups. All three

Table 3 Ethnicity and use of three pathway contacts: uni- and multivariate analyses using White British group as comparator ^a

	General practitioner			Emergency medical services			Criminal justice system
	n (%)	Odds ratio (95% CI)	P	n (%)	Odds ratio (95% CI)	P	n (%)	Odds ratio (95% CI)	P
White British	99 (54)	–	–	60 (33)	–	–	31 (17)	–	–
White Other	40 (39)	0.55 (0.34–0.91)	0.019	55 (54)	2.42 (1.47–3.97)	<0.001	23 (23)	1.44 (0.79–2.63)	0.24
		0.86 a	0.69 b		4.22 c	<0.001 c		2.14 d	0.11 d
South Asian	41 (53)	0.95 (0.56–1.62)	0.85	40 (51)	2.18 (1.27–3.74)	0.005	12 (15)	0.90 (0.43–1.86)	0.77
		1.16 b	0.64 b		2.72 c	0.002 c		1.20 d	0.66 d
Black British	63 (42)	0.62 (0.40–0.96)	0.032	74 (49)	2.01 (1.29–3.14)	0.002	41 (27)	1.86 (1.10–3.15)	0.021
		0.60 b	0.029 b		1.97 c	0.004 c		2.15 d	0.007 d
Black Caribbean	7 (26)	0.30 (0.12–0.75)	0.009	20 (74)	5.91 (2.37–14.7)	<0.001	9 (33)	2.47 (1.02–6.00)	0.046
		0.49 b	0.24 b		9.94 c	<0.001 c		4.47 d	0.034 d
Black African	60 (44)	0.69 (0.44–1.07)	0.099	58 (43)	1.56 (0.98–2.47)	0.059	48 (36)	2.72 (1.62–4.59)	<0.001
		1.39 b	0.47 b		2.99 c	0.018 c		4.03 d	0.012 d

a SPSS 17.0 unable to generate odds ratio confidence intervals for pooled logistic regression analyses derived from imputed data-sets.

b Adjusted for age, gender, marital status, having children, UK birth, living arrangements, educational status, social support, asylum status, substance misuse, insight and presence of clinical mania symptoms.

c Adjusted for age, gender, marital status, UK birth, living arrangements, educational status, social support, asylum status, substance misuse, and Positive and Negative Syndrome Scale total score.

d Adjusted for age, gender, marital status, having children, UK birth, living arrangements, educational and employment status, social support, asylum status, substance misuse, insight and presence of clinical mania symptoms.

Black groups appeared more likely than White British individuals to make contact with early intervention services via criminal justice agencies and after adjustment for confounding, the magnitude of this difference for first-generation individuals was more than fivefold. These findings are more familiar. Perhaps the most relevant comparator, the ÆSOP study, showed similar disparities regarding GP and criminal justice agency contact between Black and White individuals. Looking beyond studies restricted to early psychosis, a finding of higher rates of GP attendance in South Asians for psychiatric ^{Reference Commander, Dharan, Odell and Surtees19} and general complaints ^{Reference Gillam, Jarman, White and Law20} was not replicated here, with this group showing similar use of primary care to White British patients.

Almost a quarter of individuals made contact with the criminal justice system as part of their pathway to care and this is comparable to findings of the ÆSOP study. Increased involvement of these agencies for Black patients is frequently ^{Reference Bhui, Stansfeld, Hull, Priebe, Mole and Feder8} but not consistently reported in the literature; ^{Reference Moodley and Perkins21} a finding that cannot be explained by differential rates of police contact across ethnic groups in the general population. A household survey ^{Reference Sharp and Budd22} exploring offending behaviour and contact with the criminal justice system in individuals from 10 to 65 years of age in England and Wales showed that Black individuals were no more likely to have ever been arrested or convicted. They did however show higher rates of detention into custody. Interestingly, South Asians showed very low rates of criminality and contact with the police in this study.

Explaining the findings

With regard to overall length of DUP, comparing our findings with previous papers, ^{Reference Cole, Leavey, King, Johnson-Sabine and Hoar17,Reference Burnett, Mallett, Bhugra, Hutchinson, Der and Leff23,Reference Skeate, Jackson, Birchwood and Jones24} our post hoc findings that GP attendance is associated with prolonged DUP, and emergency

Table 4 Median DUP values in weeks according to use of three pathway contacts

	General practitioner				Emergency medical services				Criminal justice system
	No	Yes	t (d.f.)	P a	No	Yes	t (d.f.) a	P a	No	Yes	t (d.f.) a	P a
Treatment DUP	7.3	16.2	–5.11 (509)	<0.001	15.2	7.1	5.09 (491)	<0.001	12.8	10.1	2.33 (509)	0.020
Service DUP	12.0	23.0	–5.31 (567)	<0.001	20.9	12.0	4.05 (567)	<0.001	17.5	13.6	2.26 (567)	0.024

DUP, duration of untreated psychosis.

a Derived from independent samples t-test.

medical services and criminal justice agency contact with briefer DUP, may help us to theorise about the mechanism for treatment delays in White British patients. Slower referral from primary care might be explained in two main ways. First, it may be that GPs see less acute and apparently risky presentations, reflected in greater delays in families seeking help and in less tendency to initiate medication urgently and, if necessary, coercively following first presentation to health services. Second, aspects of GPs' approach and knowledge may result in delays: they may as yet lack the skills to recognise early psychosis or if they do, may be uncertain how to approach the many young people with first-episode psychosis who decline most help and are resistant to referral to mental health services. ^{Reference EL Adl, Burke and Little25}

With regard to the unanticipated difference in DUP between ethnic groups, its persistence despite adjusting for a range of social and clinical potential confounders suggests that differences in pathway to care may well contribute substantially, with the tendency of White British patients to seek help via GPs ultimately contributing to a longer DUP. Potential reasons for this pattern of help-seeking include greater likelihood of being registered with a GP, greater use of and trust in primary care services, and greater inclination among White British people to understand the symptoms of psychosis in terms of mental ill health. Young Black British men tend to show high levels of dissatisfaction with most aspects of mental health services, ^{Reference Parkman, Davies, Leese, Phelan and Thornicroft26} often viewing them as simply another branch of the criminal justice system. ^{Reference Appleby27} Avoidance by the person with psychosis and their family of a service that they perceive to be unnecessary, unhelpful or discriminatory may result in delays in presentation until a crisis emerges. This is supported by research in Black groups showing that patients do indeed tend to present in crisis when they are more likely to be seen by the duty psychiatrist in the accident and emergency department. ^{Reference Cole, Leavey, King, Johnson-Sabine and Hoar17,Reference Turner, Smith-Hamel and Mulder18} Furthermore, their family and friends are more likely to seek help directly from the police than those of other ethnic groups. ^{Reference Morgan, Mallett, Hutchinson, Bagalkote, Morgan and Fearon7,Reference Owens, Harrison and Boot28}

Other possible explanations for these differences relate to ethnic variations in the clinical presentation of psychotic illness or to clinicians' responses to it. Mode of psychosis onset, as a variable, tends to plague studies exploring DUP as its insidious form has been shown to be associated with prolonged DUP and may therefore exert a confounding effect. ^{Reference Norman and Malla29,Reference Morgan, Abdul-Al, Lappin, Jones, Fearon and Leese30} A propensity for White British patients to undergo a more insidious illness onset or a protracted prodrome must therefore also be considered as a possible explanation for differences in DUP. However, a small study finding similar modes of onset across ethnic groups provides some evidence against this. ^{Reference King, Coker, Leavey, Hoare and Johnson-Sabine31}

Implications

Across all ethnic groups, a striking finding is that there is little evidence that early intervention service introduction has had a substantial effect either on DUP or on routes into services. Long delays in obtaining potentially effective treatment are still frequent, and many access services via emergency or criminal justice services. This lack of impact is not a great surprise given that many services appear to focus primarily on improving social recovery and preventing relapse once patients have entered services, often beginning their active work with patients only as they are discharged from an episode of acute care. ^{Reference Fisher, Theodore, Power, Chisholm, Fuller and Marlowe10} Thus, further service development is required if the original aspiration for these services of reducing DUP and promoting non-coercieve community-based pathways into care is to be achieved. How might this be done? This paper indicates ethnic differences in the challenges to be addressed.

For White British patients, reducing delays currently encountered in pathways via primary care is central. An obvious strategy might be education and promotion of prompt referral from GPs. However, studies thus far suggest little effect from early detection strategies focusing on primary care. ^{Reference Power, Iacoponi, Reynolds, Fisher, Russell and Garety32-Reference Lloyd-Evans, Crosby, Stockton, Pilling, Hobbs, Hinton and Johnson34} This may be due to the difficulties in identifying psychosis at an early stage ^{Reference Tanskanen, Morant, Hinton, Lloyd-Evans, Crosby and Killaspy35} and the limited willingness and capacity of primary care professionals with large case-loads to spend time seeking to engage people who resist assessment of their mental health. Considering alternative strategies for early detection, the only type of initiative to have demonstrated effectiveness in at least some settings is public education campaigns accompanied by direct access to specialist services for people with incipient psychosis and their carers. Our findings regarding long delays in access via primary care lend weight to the idea that such public health campaigns may be the best prospect for reducing DUP.

For the Black ethnic groups investigated in this study, the most prominent challenge is not so much shortening DUP but reducing coercive routes to services that may well contribute to subsequent high rates of disengagement from services and compulsory treatment. ^{Reference Lawlor, Johnson, Cole and Howard36} Again, we need to consider what alternative pathways into services might realistically divert people from these routes. Primary care is still a less plausible focus than for the White British group, given that patients from these backgrounds tend not to be seeking help from any health service prior to crisis point. Some form of public education and direct access to services ^{Reference Lloyd-Evans, Crosby, Stockton, Pilling, Hobbs, Hinton and Johnson34} again seems the most plausible potential route, but the challenges are considerable given the low rates of seeking any healthcare. Public education campaigns which focus on the explanatory models of illness and help-seeking patterns of particular minorities appear the most promising focus.

Thus, while obstacles to prompt treatment and a benign first experience of mental healthcare appear to vary across ethnic groups, in each case some form of initiative providing education and direct access to services to the public seems the most feasible approach. This has previously shown benefits, ^{Reference Lloyd-Evans, Crosby, Stockton, Pilling, Hobbs, Hinton and Johnson34} but so far only from studies where it has been very intensively implemented with most people in the study areas likely to be repeatedly exposed to messages about psychosis, and in areas without great ethnic diversity. The challenge is to find cost-effective ways of doing this without unjustifiable expenditure and with reach across a reasonable range of groups. Social media may hold a key to achieving this, and it may be that generic youth mental health services, with less pressure to identify psychosis specifically, are better placed to engage people with early psychosis. Furthermore, once psychotic symptoms are identified it would seem more appropriate to focus on getting people into early intervention services faster rather than simply handing out antipsychotics earlier. This is important in order to ensure that individuals whose symptoms may resolve quickly do not receive unnecessary medications that in some cases produce harmful side-effects and may have a negative impact on engagement.

Limitations

Although the pragmatic approach taken in this study and the use of a large number of patients from a range of early intervention services allows us to feel more confident that these are real-world findings, there are a number of potential limitations.

1. (a) Selection bias – although some services collected data regarding each consecutive referral meeting the entry criteria for early intervention services, this was not performed uniformly.

2. (b) Sampling issues – there were insufficient numbers to examine South Asian ethnic groups separately and data were drawn mainly from inner-city areas. This limits the generalisability of the results.

3. (c) Measurement bias – data regarding onset of psychosis and the pathway to care were collected retrospectively and therefore prone to recall bias. Definitions and measurements of ethnicity and DUP are especially complex, limiting reliability of clinician recording and direct comparability across studies.

4. (d) Missing data bias – although statistically managed using multiple imputation for regression analyses, the variability of data completeness remains an inevitable disadvantage of the naturalistic methodology.