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.

Fig 1. Conceptual and analytic model of Pathway to Care (PTC) with example values.

This figure depicts the pathway to care described by the following narrative (durations are shorter than sample data for illustrative purposes): Peter began experiencing concerning auditory hallucinations on Day 0 (Onset). Two days later, his mother observes him responding to internal stimuli (first community node) and takes him to an urgent care clinic (first clinical node) the same day. They recommend watchful waiting and outpatient follow up. The next day, Peter is more bothered with the hallucinations and makes an appointment for himself (second community node) at an urgent care psychiatric service the next day. On that visit on Day 4 (second clinical node), Peter is prescribed an antipsychotic to help with his symptoms and an appointment is made for an outpatient psychiatrist, whom he sees 3 days later (third clinical node). On Day 8, Peter’s father observes increasingly concerning behaviors (third community node) and takes him to see a youth counselor at their church (fourth community node) who recommends taking him to the local Emergency Department, which they do (fourth clinical node). The ED refers Peter to STEP and he is enrolled the next day, Day 9 (STEP). DUP-total: Duration of Untreated Psychosis. DUP-demand: Demand-side duration of untreated psychosis, number of days from Onset until antipsychotic. DUP-supply: Supply-side duration of untreated psychosis, number of days from antipsychotic until STEP. Onset: Onset of psychosis, as ascertained by POPS criteria on the SIPS scale. STEP: Enrollment in Specialized Treatment Early in Psychosis clinic. Onset delay: Time in days from onset of psychosis first help-seeking node. Marginal-delay: Time in days until the next node.

Fig 2. A directional graph of all PTCs collected in this study.

Arrows depict the sequential progression individuals took from Onset to STEP enrollment. Clinical nodes are on the top, community nodes on the bottom. The thickness of the edge (line) between nodes reflects the frequency of traffic between them, and the size of each node reflects the cumulative number of interactions with the node type across all PTCs. Abbreviations: Self—self-presented; Education—teacher or school counsellor; Other—community caregiver not otherwise included; ED—Emergency Department; Inpt—Inpatient Admission; Outpt—Outpatient Mental Health; IOP—Intensive Outpatient; Acute—Acute Evaluation; PCP—Primary Care Provider; Mobile—Mobile Evaluation; OtherMH—Prison mental health, in-home psychiatric services, substance use disorder inpatient and outpatient; OtherMed—Outpatient non-psychiatric, non-PCP (e.g., neurologist), Inpatient medical.