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Abstract

Objectives: To present the clinical and sociodemographic characteristics of patients referred to a New Zealand early intervention for psychosis service and to describe the pathways to care for these patients.

Method: Clinical and sociodemographic characteristics were examined in 200 patients consecutively admitted to an early psychosis service over a 5-year period. Assessment measures included DSM-IV diagnosis, the Quality of Life Scale, Positive and Negative Syndrome Scale and information on pathways to care.

Results: The majority of patients were young (mean age = 22.35), single (90.1%), male (72.5%), of New Zealand European descent (63.7%), living in the parental home (60.2%) and on a government benefit (60.2%). Overall, 40.8% of patients were initially diagnosed with a schizophrenia spectrum disorder, 36.4% with a mood disorder and 22.8% were classified as ‘other psychoses’ (substance-induced psychosis, brief psychotic disorder, etc.). Those with a schizophrenia spectrum disorder had a median duration of untreated psychosis of 120 days compared with 29 days for other diagnoses. Overall, 64.1% of referrals came from the Inpatient Service, 36.3% of patients had a compulsory admission under the Mental Health Act, and 41.8% had contact with police in 6 months prior to referral to the service. No differences in inpatient admission rates, police involvement or compulsory admission were evident for ethnicity or diagnosis.

Conclusions: The pathways to care, clinical and sociodemographic descriptors of the present sample are somewhat different to those previously reported in international cohorts. This reflects the inclusion of patients with affective psychoses, the age range of 18–30 years and New Zealand's distinctive healthcare system. Examination of the sociodemographic characteristics and pathways to care in the present cohort suggests that service reconfigurations are required to optimize the experience of inpatient admission, given the substantial proportion of clients with non-schizophrenia spectrum disorders that present acutely for treatment.

Keywords

cohort study health service accessibility mental health service utilization program evaluation psychotic disorder

The processes that make schizophrenia and other psychoses a long-term disorder may cause more damage in the first few years of the illness [1]. Recognition and intervention at an early stage of psychosis could contribute to quicker psychotic and negative symptom remission, delay in psychotic relapse and prevention of psychosocial deterioration [2–5]. The early phase of psychosis can be seen as a critical period with implications for the prevention of disease and psychosocial deterioration [6]. This has led to a proliferation of early intervention for psychosis services nationally and internationally in recent years.

New Zealand has enthusiastically adopted the concept of early intervention and now has more than 18 statutory mental health services that work, wholly or partly, as early intervention services for young people. Twelve of these services were established after 1997 [7]. This means that most young people with first-episode psychosis in New Zealand receive some form of early intervention. Early intervention services take all young people with first-episode psychosis, including drug-induced psychosis, affective psychosis and psychosis not otherwise specified (NOS), as well as schizophrenia and schizophreniform disorder. Their criteria therefore differ from many European and North American services, which only accept patients with schizophrenia spectrum disorders. The duration of untreated psychosis and pathways to care may vary depending on diagnosis [8–10], and therefore international reports may not be applicable to New Zealand. There are currently no published reports on early intervention services in New Zealand.

Earlier intervention may reduce suffering associated with psychosis. The time between onset of psychotic symptoms and the first effective treatment in patients with schizophrenia (i.e. the duration of untreated psychosis) usually ranges from 1 to 2 years, but can be much longer [8]. The pathways to care and duration of untreated psychosis may vary depending on a number of factors [11, 12]. In New Zealand, for example, it has been suggested that Maori have less desirable pathways to care and access services at a later stage of illness [13, 14].

Examination of a New Zealand cohort is important because different health-care systems lead to different pathways to care in first-episode psychosis [15]. The purposes of this paper are: (i) to describe the presenting characteristics and pathways to care of 200 patients with first-episode psychosis referred to an Early Intervention for Psychosis Service (Totara House) in Christchurch, New Zealand; (ii) to examine differences in pathways to care and duration of untreated psychosis between Maori and non-Maori; (iii) to examine differences in pathways to care and duration of untreated psychosis between patients with a schizophrenia spectrum disorder and other diagnoses; and (iv) to compare the characteristics of the present cohort with other international samples from Australia, North America and Europe.

Method

Totara House provides specialist, multidisciplinary support to individuals who experience their first-episode of psychosis. The service is based on best practice guidelines developed nationally [16, 17] and internationally [18]. A detailed description of the service can be found at the web site: http://www.cdhb.govt.nz/totara

Inclusion criteria

The patient is aged between 18 and 30, or is between 16 and 17 and not currently under the care of Youth Mental Health Services.

The patient has suspected or confirmed psychotic features, or the patient has a suspected prodromal presentation, regardless of diagnosis.

The patient is in their first-presentation of psychosis and has previously received less than 12 weeks of treatment with antipsychotics.

There are no exclusion criteria although patients with an IQ of less than 70, or currently within the criminal justice system, would not be referred to the service.

Assessment

All patients accepted into the service with first-episode psychosis are part of a longitudinal cohort. The study was approved by the Canterbury Ethics Committee. The assessment has two sections.

The psychiatrist interview assesses:

DSM-IV clinical diagnosis [19];

Symptoms of psychosis using the Positive and Negative Syndrome Scale (PANSS) [20];

Duration of untreated psychosis (time between episode onset: defined as 4+ on one of the first three positive symptom items of PANSS and onset of ‘adequate’ treatment: defined as start of antipsychotic medication).

The case manager interview assesses:

‘Pathways to care’ in the 6 months prior to Totara House;

The Quality of Life Scale [21].

Statistics

In order to examine differences between median duration of untreated psychosis for those with different diagnoses, the Kruskal– Wallis test was used to test for statistically significant differences between subgroups. The chi-squared test of independence was used to test for statistically significant differences between pathways to care and ethnicity.

Results

Three of the psychiatrist interviews were incomplete, and 13 were missing (92% completion rate). Five of the case manager assessments were incomplete and 13 were missing (91% completion rate). Missing assessments were due to staff difficulties and administrative issues. The results of the present cohort are compared with first-episode psychosis cohorts from: the Early Psychosis Prevention and Intervention Centre (EPPIC) in Australia [22, 23]; the Calgary Early Psychosis Program (EPP) in Canada [24–27]; and the non-early detection areas of the Early Treatment and Intervention in Psychosis Study (TIPS) in Norway and Denmark [28].

Sociodemographic characteristics

Table 1 shows the gender, ethnicity, marital status, residential circumstances and socioeconomic background of the patients as well as the mean age and age range of patients on entry to the service. Patients are predominantly male, European, single, living with parents and on some form of government benefit.

Table 1.

Sociodemographic characteristics

	n	%
Gender (n =182)
Male	132	72.5
Female	50	27.5
Ethnicity (n =182)
New Zealand European	116	63.7
Maori	29	15.9
Pacific Islander	9	4.9
Asian	10	5.5
European	16	8.8
Other	2	1.1
Current marital status (n =181)
Single	163	90.1
Married/de facto	13	7.2
Separated/divorced	4	2.2
Residential circumstances (n =181)
Renting with non-family	27	14.9
Living with significant other	16	8.8
Living in parental home	109	60.2
Living alone	16	8.8
Residential care	13	7.2
Employment situation (n =181)
Full time employment	19	10.5
Part-time employment	21	11.6
Student	29	16.0
Beneficiary	109	60.2
Parent	3	1.7
	Mean (SD)	Range
Age at entry (year) (n =182)	22.35 (3.31)	16.64–30.09

DSM-IV diagnostic category

Table 2 shows the frequencies and percentages of the principal diagnoses of patients. The most common diagnoses are bipolar disorder (20.1%), schizophreniform disorder (19.6%), schizophrenia (17.9%), depressive disorder (15.8%) and psychotic disorder NOS (13%).

Table 2.

DSM-IV diagnostic category

Primary axis I diagnosis (n=184)	n	%
Schizophrenia	33	17.9
Schizophreniform disorder	36	19.6
Schizoaffective disorder – bipolar type	6	3.3
Brief psychotic disorder	8	4.3
Delusional disorder	1	0.5
Substance-induced psychotic disorder	9	4.9
Psychotic disorder NOS	24	13.0
Bipolar I disorder	37	20.1
Mood disorder NOS	1	0.5
Major depressive disorder	29	15.8

NOS, not otherwise specified.

Symptomatic descriptors

Table 3 provides a summary of the patients' quality of life scores, positive and negative symptom scores and substance misuse disorders (abuse and dependence). The present cohort had poor baseline quality of life scores (mean = 61.65) and high rates of positive (mean = 15.41) and negative (mean = 14.22) symptoms were present.

Table 3.

Symptomatic descriptors

Descriptor	Mean	SD	Range
Quality of Life Scale
Intrapsychic foundations	22.71	8.60	5–42
Interpersonal relations	23.35	11.64	0–48
Instrumental role	7.94	4.44	0–18
Common objects and activities	7.65	2.54	1–12
Total score	61.65	24.12	8–117
Positive and Negative Syndrome Scale
Positive	15.41	6.35	7–34
Negative	14.22	6.31	7–35
General	29.99	9.51	16–56
Total	59.62	18.49	30–104
Substance use	n	%
Substance use disorder (n =181)	62	33.7
Alcohol use disorder (n =181)	43	23.4
Lifetime alcohol or substance use disorder	121	66.9

SD, standard deviation.

One-third (33.7%) of the patients were diagnosed with current substance abuse or dependence (excluding nicotine) and a quarter (23.4%) with current alcohol abuse or dependence. Overall, 39.5% present with a current substance use disorder, while two-thirds of the patients (66.9%) present with lifetime substance and/or alcohol abuse or dependence.

Pathways to care

Table 4 shows the patient contact with social agencies in the 6 months prior to admission to the service. The table shows the different types of help-seeking behaviours initiated, sources of referral, police involvement, rates of psychiatric hospitalization and compulsory admission associated with referral. Finally, the table shows the median and mean duration of untreated psychosis.

Table 4.

Pathways to care

	n	%
Types of help-seeking contact in prior 6 months
General practitioner	86	47.3
School counsellor	9	4.9
Other counsellor	16	8.8
Religious minister	16	8.8
Psychiatric outpatient clinic	87	47.8
Private psychiatrist	18	9.9
Other	17	9.3
Number of help-seeking contacts in prior 6 months
No contacts	45	24.7
One type of contact	63	34.6
Two or more different types of	74	40.7
contacts
Admission rates and legal involvement in prior 6 months
Police contact	76	41.8
Compulsory admission	66	36.3
Hospitalization	115	63.2
Referral source (n =181)
General practitioner	14	7.7
Self-referral	4	2.2
Emergency Services	29	16.0
Inpatient Service	116	64.1
Other Christchurch Mental	6	3.4
Health Service
Non-Christchurch Mental Health	3	1.7
Service
Other (family, etc.)	9	5.0
Duration of symptoms in days Mean (SD)	Median
Duration of untreated psychosis	197 (486)	30
Duration of untreated illness	464 (875)	155

SD, standard deviation.

Patients in the present study reported making an average 3.87 (SD = 6.81) attempts at help-seeking behaviour in the 6 months prior to referral (range = 0–42). The majority (70%) of the sample had contact with a general practitioner (GP) or psychiatric outpatient clinic in the 6 months prior to referral, but these services were low sources of referral (7.7% and 16%, respectively). Most referrals (64%) came from inpatient services. The large discrepancy between the mean and median duration of untreated psychosis is due to a positively skewed distribution. A small group of patients presented with extremely long untreated periods; for example, 14 patients had a duration of untreated psychosis exceeding 4 years.

The associations between diagnostic subgroups and pathways to care

The median duration of untreated psychosis for those with a schizophrenia spectrum disorder was significantly longer at 120 days, compared with 29 days for those with affective psychosis and also 29 days for other types of psychosis (drug-induced psychosis, psychosis NOS, etc.) (see Table 5, χ²[2] = 18.66; p < 0.001). No differences were evident between diagnosis and the number of different types of help seeking (χ²= 2.08; df = 4; p = 0.72), rates of contact with police (χ²= 1.82; df = 2; p = 0.40), outpatient services (χ²= 2.77; df = 2; p = 0.25), or GPs (χ²= 0.75; df = 2; p = 0.68), rates of hospital admission during first-episode of psychosis (χ²= 1.42; df = 2; p = 0.49), or rates of compulsory admission during first-episode of psychosis (χ²= 0.49; df = 2; p = 0.78).

Table 5.

Relationship between the duration of untreated psychosis and diagnostic subgroup

	Schizophrenia spectrum disorder (n =72)	Affective psychosis (n =64)	Other psychosis (n =40)	p
Duration of untreated psychosis (median days)	120	29	29	0.000

The associations between ethnicity and pathways to care

There were no significant differences in duration of untreated psychosis for Maori and non-Maori (χ²= 1.81; df = 1; p = 0.17). No differences were evident between Maori and non-Maori in the number of different types of help seeking (χ²= 0.41; df = 1; p = 0.81), rates of contact with police (χ²= 0.09; df = 1; p = 0.76), outpatient services (χ²= 1.35; df = 1; p = 0.17), or GP's (χ²= 0.01; df = 1; p = 0.53), rates of hospital admission during first-episode of psychosis (χ²= 0.08; df = 1; p = 0.48), or rates of compulsory admission during the firstepisode of psychosis (χ²= 0.60; df = 1; p = 0.43).

Discussion

This is the first published description of the demographic and clinical characteristics of a New Zealand first-episode psychosis cohort. The majority of patients were young, single, male and referred from the regional Acute Inpatient Service. A high proportion of patients were diagnosed with a non-schizophrenia spectrum disorder at admission. The distinctive characteristics are a narrower age range for acceptance (16–30 years), broader diagnostic acceptance criteria including affective and non-specific psychosis, and acceptance of nonhospitalized patients. This results in a higher rate of affective disorders, a younger mean age at referral and a large proportion of men compared with some international samples. While those with a schizophrenia spectrum disorder had a significantly longer median duration of untreated psychosis, no other differences in pathways to care were evident in the present cohort for diagnosis or ethnicity.

Demographic and clinical features

Table 6 shows a comparison between the Christchurch cohort and international samples on selected demographic and clinical variables.

Table 6.

Comparison between Christchurch cohort and international samples

	Christchurch	EPPIC [22, 23] Australia	EPP [24–27] Canada	TIPS [28] Norway
Demographics
Male (%)	72.5	64.7	66.3	56
Single (%)	90.1	88.2	92	63
Living in parental home (%)	60.2	69.4†	78	–
Mean age at entry (year)	22.35	22	24	31.1
DSM-IV diagnosis
Schizophrenia	17.9	45.1	74	29
Schizophreniform disorder	19.6	11.8	14	21
Schizoaffective disorder – bipolar type	3.3	9.8	2	9
Brief psychotic disorder	4.3	–	–	4
Delusional disorder	0.5	2	2	6
Substance-induced psychotic disorder	4.9			–
Psychotic disorder NOS	13	5.9	8	15
Bipolar I disorder	20.1	13.7	–	15‡
Major depressive disorder	15.8	11.8	–	–
Median DUP (day)	30	52	189	112
Current alcohol or other drug misuse	39.5	62	48	27
PANSS positive	15.41	–	16.48	21.7
PANSS negative	14.22	–	14.79	16.6
QLS total	61.65	–	62	–

†Living in parental home or with significant other; ‡Affective psychosis with mood-incongruent delusions. DUP, duration of untreated psychosis; EPP, the Early Psychosis Program; EPPIC, the Early Psychosis Prevention and Intervention Centre; PANSS, Positive and Negative Syndrome Scale; QLS, Quality of Life Scale; TIPS, the Early Treatment and Intervention in Psychosis Study.

The sociodemographic characteristics are similar to those reported by EPP [26] and EPPIC [23]. However, the average age of the EPP [26] and TIPS [28] cohorts are older, reflecting the older age accepted by these services. As women tend to develop psychosis at an older age [29], the younger mean age of the present sample, owing to the lower age limit for acceptance, may be responsible for proportionally fewer women in the EPPIC and Christchurch cohorts. A recent meta-analysis of 26 studies involving 4490 patients [30] found the mean age at presentation was 27.8 years and that women comprised 39% of the sample.

While the diagnostic description of the present sample is similar to that of EPPIC [23], it has a greater proportion of patients with affective psychosis than reported by EPP [24] and TIPS [28]. Many services in North America [26, 31] and Europe [29, 32, 33] do not report on patients with affective psychosis.

Previous first-episode cohorts have shown similar high levels of positive and negative symptoms [24, 28, 34] and low quality of life [24, 35] at referral to early intervention for psychosis services. The high rates of alcohol and other drug misuse (predominantly cannabis) in the present sample are consistent with other first-episode cohorts [22, 27,36–38]. Overall, 39.5% present with a current substance use disorder, while two-thirds of the patients (66.9%) present with lifetime substance and/or alcohol abuse or dependence. This compares with 62% and 74%, respectively, reported by EPPIC [22]. Combined with the fact that substance misuse can have a detrimental effect on the course of psychosis, these results confirm the need for highlighting substance use comorbidity in early intervention services [39, 40]. In summary, the patients' demographic and clinical characteristics are similar to those cohorts with similar acceptance criteria [23, 34, 41, 42].

Duration of untreated psychosis

The median duration of untreated psychosis of 30 days is shorter than that reported by many early intervention services, where periods exceeding 6 months are common [8, 30]. The relatively short duration of untreated psychosis is probably due to the high proportion of patients with non-schizophrenic psychosis. EPPIC [23], which also accept those with affective psychosis, also reported a significantly longer duration of untreated psychosis in patients diagnosed with schizophrenia. In our cohort, patients diagnosed with a schizophrenia spectrum disorder had a significantly longer median duration of untreated psychosis (120 days) compared with patients with other diagnoses (29 days).

The high proportion of patients with a non-schizo-phrenia spectrum disorder in the present cohort partially accounts for the shortened duration of untreated psychosis. In addition, the broad definition of duration of untreated psychosis (i.e. initiation of adequate treatment [30]) used in the present study may shorten the median duration compared with studies that use more stringent definitions with regard to adequacy of initial antipsychotic treatment. Another contributing factor may be associated with the small population of the Christchurch catchment area (344 100) and relatively low rates of homelessness. This may lead to overt psychosis being more noticeable in the community and patients coming to the attention of services more rapidly.

Pathways to care

Patients had an average of 3.87 attempts at helpseeking behaviour in the 6 months prior to referral, with 47.3% contacting a GP and 47.8% an outpatient clinic. Only 7.7% of patients are referred directly from a GP, although most of those referred from other Christchurch Mental Health Services may have been referred to these services by a GP initially. This is similar to findings of McGorry et al. [23] who report that while 50% of subjects had GP contact prior to initial effective treatment, only 5% of referrals for specialist psychiatric care came from GPs. As with similar studies from Australia [41], the UK [42] and Canada [43], the large number of patient contacts prior to referral indicates that GPs may have a crucial gate-keeping role. Of particular concern is that the early signs of psychosis in Maori (and Pacific peoples) may be missed by health practitioners, and that Maori (and health professionals) may reframe psychosis in a cultural context (Durie M., personal communication, 2002).

The short median duration of untreated psychosis in the sample is positive, but the fact that two-thirds of referrals come from Acute Inpatient Services suggests that symptoms appear rapidly and are of sufficient severity to warrant admission. With the deleterious effects that may be associated with acute admissions [44, 45], this represents significant potential suffering for the individual and their families. The rates of compulsory admission (36.3%) in the present study are similar to those previously reported in first-episode psychosis (37.9%) [12].

Effects of ethnicity on pathways to care

Although there was a higher proportion of Maori patients in the cohort (15.9%) than in the general Christchurch population of 15–29-years-olds (8.8%) (Statistics New Zealand, 2001 unpublished Census data), no associations were found between ethnicity and pathways to care. It has been suggested that Maori access services at a far later stage of illness and are more likely to be admitted to psychiatric institutions as a result of compulsory admission [13]. However, no differences in duration of untreated psychosis, hospitalization rates, compulsory treatment or police contact were evident between Maori and non-Maori in the present sample. Less desirable routes of admission for African-Caribbean patients have been reported in London but do not apply to their first admission, instead developing over repeated contact with services [11].

Limitations

We believe that the sample is representative as it includes all those with first-episode psychosis referred into the only early intervention for psychosis service in the Christchurch catchment area. Overall, 92% of eligible patients had a psychiatrist interview completed and 91% had a case manager interview completed. As the reasons for non-completion of evaluations were largely administrative, rather than reflecting patient characteristics, this limits the probability of selection bias. The major limitation is that findings on pathways to care and duration of untreated psychosis are predominantly based on patients' self-reports, which may be prone to recall errors and selective reporting. In addition, the pathways to care data only examine the number of contacts rather than the chronology of contacts and only look at the 6 months preceding admission to the service rather than all contacts.

Conclusion

The current cohort is similar to early intervention services with comparable health-care systems and acceptance criteria [23, 42]. Many patients with first-episode psychosis are making several attempts to obtain help before admission. Education of both health professionals and the general public to attempt to reduce duration of untreated psychosis [28, 46], particularly for those eventually diagnosed with a schizophrenia spectrum disorder, is needed.

Our results suggest that pathways to care are specific to health-care systems [15]. The high proportion of patients with diagnoses other than schizophrenia in the present study suggest that overt symptoms of psychosis requiring acute, rapid hospitalization are more common in comparison with most international samples. Greater liaison with inpatient services and primary referrers may be desirable in order to reduce the negative aspects of hospitalization for those with affective psychosis, where early detection is problematic because of rapid onset.

Footnotes

Acknowledgements

This paper would not have been possible without continued financial support for the research position at Totara House from the Mental Health Division of the Canterbury District Health Board. We also thank the Totara House team for their commitment to completing the measures.

References

1. McGlashan

. Early detection and intervention in schizophrenia: research. Schizophrenia Bulletin 1996; 22: 327–345.

2. Wyatt

. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 1991; 17: 325–351.

3. Birchwood

Macmillan

. Early intervention in schizophrenia. Australian and New Zealand Journal of Psychiatry 1993; 27: 374–378.

4. Harrison

Hopper

Craig

. Recovery from psychotic illness: a 15- and 25-year international follow-up study. British Journal of Psychiatry 2001; 178: 506–517.

5. McGlashan

. Early detection and intervention in schizophrenia: editor's introduction. Schizophrenia Bulletin. 1996; 22: 197–199.

6. Birchwood

. Early intervention in psychosis. The critical period hypothesis. British Journal of Psychiatry. Supplement 1998; 172: 53–59.

7. Turner

Smith-Hamel

Nightingale

Mulder

. Early intervention for psychosis in New Zealand. New Zealand Medical Journal 2004; 117, [Cited 11 Aug 2004.] Available from URL: http://www.nzma.org.nz/journal/2117-1199/1001/ .

8. Norman

Malla

. Duration of untreated psychosis: a critical examination of the concept and its importance. Psychological Medicine 2001; 31: 381–400.

9. Sipos

Harrison

Gunnell

Amin

Singh

. Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study. British Journal of Psychiatry 2001; 178: 518–523.

10.

10. Yung

McGorry

. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophrenia Bulletin 1996; 22: 353–370.

11.

11. Burnett

Mallett

Bhugra

Der Hutchinson

Leff

. The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multi-ethnic population. Psychological Medicine 1999; 29: 475–483.

12.

12. Morgan

Mallett

Hutchinson

. Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study. British Journal of Psychiatry 2005; 186: 281–289.

13.

13. Mental Health

Commission

. Blueprint for mental health services in New Zealand: how things need to be. Mental Health Commission, Wellington 1998.

14.

14. Ministry of Health . Te Tähuhu: improving mental health 2005–2015: the second New Zealand mental health and addiction plan. Ministry of Health . Ministry of Health, Wellington 2005.

15.

15. Vaglum

. Earlier detection and intervention in schizophrenia: unsolved questions. Schizophrenia Bulletin 1996; 22: 347–351.

16.

16. Mental Health Commission . Early intervention in psychosis: guidance note. Mental Health Commission, Wellington 1999.

17.

17. Turner

. Evaluation of early intervention services in New Zealand: what works?. Health Research Council of New Zealand, Wellington 2002.

18.

18. Edwards

McGorry

. Implementing early intervention in psychosis: a guide to establishing early psychosis services. Martin Dunitz, London 2002.

19.

19. American Psychiatric Association . Diagnostic and statistical manual of mental disorders DSM-IV, 4th edn. American Psychiatric Association, Washington, DC 1994.

20.

20. Kay

Fiszbein

Opler

. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 1987; 13: 261–276.

21.

21. Heinrichs

. The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. Schizophrenia Bulletin 1984; 10: 388–398.

22.

22. Lambert

Conus

Lubman

. The impact of substance use disorders on clinical outcome in 643 patients with first episode psychosis. Acta Psychiatrica Scandinavica 2005; 112: 141–148.

23.

23. McGorry

Edwards

Mihalopoulos

Harrigan

Jackson

. EPPIC: an evolving system of early detection and optimal management. Schizophrenia Bulletin 1996; 22: 305–326.

24.

24. Addington

. An early psychosis program: more than early intervention for the treatment of schizophrenia. In the Second National Conference on Early Psychosis: Realising the Potential, HobartAustralia, 1998.

25.

25. Addington

Brooks

Addington

. Cognitive functioning in first-episode psychosis: initial presentation. Schizophrenia Research 2003; 62: 59–64.

26.

26. Addington

Leriger

Addington

. Symptom outcome 1 year after admission to an early psychosis program. Canadian Journal of Psychiatry –Revue Canadienne de Psychiatrie 2003; 48: 204–207.

27.

27. Pencer

Addington

. Substance use and cognition in early psychosis. Journal of Psychiatry and Neuroscience 2003; 28: 48–54.

28.

28. Melle

Larsen

Haahr

. Reducing the duration of untreated first-episode psychosis: effects on clinical presentation. Archives of General Psychiatry 2004; 61: 143–150.

29.

29. Hafner

. Gender differences in first-episode schizophrenia. Gender and its effects on psychopathology, Frank

. American Psychiatric Publishing, Washington, DC 2000; 187–228.

30.

30. Marshall

Lewis

Lockwood

Drake

Jones

Croudace

. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Archives of General Psychiatry 2005; 62: 975–983.

31.

31. Malla

Norman

McLean

McIntosh

. Impact of phase-specific treatment of first-episode of psychosis on Wisconsin Quality of Life Index (client version). Acta Psychiatrica Scandinavica 2001; 103: 355–361.

32.

32. Linszen

Dingemans

Lenior

. Early intervention and a five year follow up in young adults with a short duration of untreated psychosis: ethical implications. Schizophrenia Research 2001; 51: 55–61.

33.

33. Jeppesen

Petersen

Thorup

. Integrated treatment of first-episode psychosis: effect of treatment on family burden: OPUS trial. British Journal of Psychiatry. Supplement 2005; 48: S85–S90.

34.

34. Harris

Brennan

Anderson

. Clinical profiles, scope and general findings of the Western Sydney First-Episode Psychosis Project. Australian and New Zealand Journal of Psychiatry 2005; 39: 36–43.

35.

35. Browne

Clarke

Gervin

Waddington

Larkin

O'Callaghan

. Determinants of quality of life at first presentation with schizophrenia. British Journal of Psychiatry 2000; 176: 173–176.

36.

36. Addington

Addington

. Effect of substance misuse in early psychosis. British Journal of Psychiatry 1998; 172: 134–136.

37.

37. Cantwell

Brewin

Glazebrook

. Prevalence of substance misuse in first-episode psychosis. British Journal of Psychiatry 1999; 174: 150–153.

38.

38. Strakowski

Tohen

Stoll

. Comorbidity in psychosis at first hospitalization. American Journal of Psychiatry 1993; 150: 752–757.

39.

39. Addington

Addington

. Impact of an early psychosis program on substance use. Psychiatric Rehabilitation Journal 2001; 25: 60–67.

40.

40. Van Mastrigt

Addington

. Substance misuse at presentation to an early psychosis program. Social Psychiatry and Psychiatric Epidemiology 2004; 39: 69–72.

41.

41. Lincoln

Harrigan

McGorry

. Understanding the topography of the early psychosis pathways: an opportunity to reduce delays in treatment. British Journal of Psychiatry 1998; 172: 21–25.

42.

42. Skeate

Jackson

Birchwood

Jones

. Duration of untreated psychosis and pathways to care in first-episode psychosis. Investigation of help-seeking behaviour in primary care. British Journal of Psychiatry. Supplement 2002; 43: s73–s77.

43.

43. Addington

Van Mastrigt

Hutchinson

Addington

. Pathways to care: help seeking behaviour in first-episode psychosis. Acta Psychiatrica Scandinavica 2002; 106: 358–364.

44.

44. Etheridge

Yarrow

Peet

. Pathways to care in first-episode psychosis. Journal of Psychiatric and Mental Health Nursing 2004; 11: 125–128.

45.

45. McGorry

Jackson

. The recognition and management of early psychosis: a preventive approach, McGorry

Jackson

. Cambridge University Press, New York 1999.

46.

46. Scholten

Malla

Norman

. Removing barriers to treatment of first-episode psychotic disorders. Canadian Journal of Psychiatry 2003; 48: 561–565.

Pathways to Care in a New Zealand Firstepisode of Psychosis Cohort

Abstract

Keywords

Method

Inclusion criteria

Assessment

Statistics

Results

Sociodemographic characteristics

DSM-IV diagnostic category

Symptomatic descriptors

Pathways to care

The associations between diagnostic subgroups and pathways to care

The associations between ethnicity and pathways to care

Discussion

Demographic and clinical features

Duration of untreated psychosis

Pathways to care

Effects of ethnicity on pathways to care

Limitations

Conclusion

Footnotes

Acknowledgements

References