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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.
RESUMEN
BACKGROUND: Prolonged duration of untreated psychosis (DUP) is associated with poor outcomes. The TIPS study halved DUP with an early detection (ED) campaign; however, conventional statistical analyses, focused on mean estimates, failed to reveal the effects of ED across the full DUP distribution, restricting inferences about ED's effectiveness. Utilizing a novel quantile regression based analysis, we examined the differential impact of ED across DUP. Secondary analysis explored possible predictors of DUP, and moderators of the effect of the campaign. METHODS: The TIPS ED campaign was conducted in two health care sectors in Norway, with two equivalent health care sectors serving as controls. Quantile regression analysis was performed to analyze ED campaign's effect. RESULTS: 281 patients with first episode psychosis were recruited, including 141 from the ED area. ED had no effect on the first quartile (Q1) of DUP, whereas a significant reduction in Q2 (11weeks), and Q3 (41weeks) of DUP was observed. The effect of ED was significantly stronger on reducing Q3 than Q1 or Q2, suggesting that the campaign was more effective in longer DUP samples. Male gender and single status predicted longer DUP in Q3: by 38 and 27weeks, respectively. Single status, but not gender, emerged as a significant moderator of ED campaign effect. CONCLUSIONS: Quantile regression provided in depth information about the non-uniformity, and moderators, of TIPS's ED effort across the full distribution of DUP, demonstrating the value of this analytic approach to re-examine prior, and plan analyses for future, early detection efforts.