Race, ethnicity, and the duration of untreated psychosis: a systematic review.

PURPOSE: An extended duration of untreated psychosis (DUP) is associated with poor outcome in first-episode psychosis (FEP). Some have suggested that minority ethnic groups have longer treatment delays, and this could lead to worse outcomes. We systematically reviewed the literature on racial and ethnic differences in DUP in patients with FEP. METHODS: We searched electronic databases and conducted forward and backward tracking to identify studies that had compared DUP for people with FEP from different racial or ethnic groups. RESULTS: We identified ten papers that reported on the association between race or ethnicity and DUP. Overall, these studies did not find evidence of differences between groups; however, three of ten studies suggested that Black patients generally, and Black-African patients specifically, may have a shorter DUP relative to White patients. There were methodological limitations in most studies with respect to ethnicity classification, sample size, and adjustment for potential confounders. CONCLUSION: Racial and ethnic differences in DUP were rarely found. This could reflect that DUP does not differ between groups, or may reflect the methodological limitations of prior research. Studies that are designed and powered to examine these differences in treatment delay are needed to determine whether there are differences in DUP for minority groups.

Gender differences in pathways to care for early psychosis.

AIMS: Gender is a critical demographic determinant in first-episode psychosis research. We used data from the ACE Pathways to Care Project, which examined pathways to care in African-origin, Caribbean-origin and European-origin participants, to investigate the role of gender in pathways to early intervention programmes. METHOD: A qualitative approach was used to examine gender differences in the routes to care. We conducted four focus groups and four individual in-depth interviews with 25 service users of early intervention services from African-origin, Caribbean-origin and European-origin populations. RESULTS: Gender stereotypes negatively influence the first service contact for women, and the early phase of the help seeking process for men. Women reported trying to seek care. However, family members and service providers often questioned their calls for help. Men described having difficulties in talking about their symptoms, as the act of seeking help was perceived as a sign of weakness by peers. CONCLUSIONS: The findings of this study suggest that gender stereotypes shape the journey to specialized care in different ways for men and women. Awareness of the impact that gender stereotypes have when a young person is seeking care for psychosis could help to promote a shift in attitudes among health-care providers and the provision of more compassionate and patient-centred care during this critical time.

Symptom profiles and explanatory models of first-episode psychosis in African-, Caribbean- and European-origin groups in Ontario.

AIM: To assess variability in symptom presentation and explanatory models of psychosis for people from different ethnic groups. METHODS: Clients with first-episode psychosis (n = 171) who identified as black African, black Caribbean or white European were recruited from early intervention programmes in Toronto and Hamilton. We compared results by ethnic group for symptom profiles and explanatory models of illness. RESULTS: Clients of black Caribbean origin had a lower odds of reporting that they were speaking incomprehensibly (OR = 0.36; 95% CI: 0.14-0.90) and black African clients had a greater odds of reporting persistent aches or pains (OR = 2.92; 95% CI: 1.32-6.50). Black African clients had a lower odds of attributing the cause of psychosis to hereditary factors (OR = 0.41; 95% CI: 0.19-0.89) or to substance abuse (OR = 0.29; 95% CI: 0.13-0.67) and had a lower odds of assigning responsibility for their illness to themselves (OR = 0.41; 95% CI: 0.19-0.89). CONCLUSIONS: Understanding the differences in illness models for ethnic minority groups may help improve the cultural competence of mental health services.

Comparative analysis of pathways to early intervention services and duration of untreated psychosis in two Canadian cities.

AIM: Understanding pathways to early intervention services for psychosis in the local context is crucial, as the structure and organization of services need to be considered. This study compared pathways to early intervention services in two Canadian cities. METHODS: Data on pathways to care and duration of untreated psychosis were collected from 171 people admitted to early intervention services in Toronto (n = 150) and Hamilton (n = 21). We compared the cities on several indicators of pathway to care and duration of untreated psychosis. RESULTS: Pathways to care were more complex in Toronto, where people saw a greater number of health care services (median = 6, interquartile range = 3-9) than those in Hamilton (median = 3, IQR = 1-4). General practitioner involvement was higher in Toronto (56.0% vs. 33.3%). We did not find differences in the median duration of untreated psychosis. CONCLUSIONS: Pathways to early intervention services could be streamlined, and general practitioners may be a target for strategies to improve pathways to care.

The African, Caribbean and European (ACE) Pathways to Care study: a qualitative exploration of similarities and differences between African-origin, Caribbean-origin and European-origin groups in pathways to care for psychosis.

OBJECTIVES: This paper reports on a qualitative exploration of the reasons for differences in pathways to care and duration of untreated psychosis (DUP) in the African, Caribbean and European (ACE) Pathways to Care study from the perspective of respondents to the study and their families. SETTING: Ontario, Canada. PARTICIPANTS: Thirty-four participants in total. Twenty-five young people who had experienced a first episode of psychosis and nine family members. Participants were part of the ACE Pathways to Care study. DESIGN: We implemented six focus groups. Furthermore, we implemented four in-depth interviews with two African-origin young women, one Caribbean-origin woman, and one European-origin woman with lived experience of psychosis. RESULTS: Factors that influenced help-seeking delays across the three groups were: personal awareness of symptoms, family members' knowledge of psychotic symptoms and knowledge of mental health services. Youth and their family members described how stigma played a key role in pathways to care by stopping them from asking for help. The way in which stigma operated on the three groups' members, from feeling ashamed to feeling guilty for their mental illnesses, helped to explain differences in DUP between the groups. Guilt feelings emerged as a prominent theme among members from the African and Caribbean groups and it was not discussed in the European focus group. Delay in entering into first-episode psychosis programmes was also influenced by the stigma perceived by young people in healthcare settings. This had an impact on the therapeutic relationships, disclosure of symptoms and overall trust in the healthcare system. CONCLUSIONS: The findings of this paper suggest that stigma, especially internalised stigma, may operate in different ways in European-origin, African-origin and Caribbean-origin groups. These findings could inform the development of more equitable services for people in early stages of psychosis.

Pathways to First-Episode Care for Psychosis in African-, Caribbean-, and European-Origin Groups in Ontario.

OBJECTIVE: To compare the pathways to care and duration of untreated psychosis (DUP) for people of Black-African, Black-Caribbean, or White-European origin with first-episode psychosis (FEP). METHODS: We recruited a sample of 171 patients with FEP of Black-African, Black-Caribbean, and White-European origin from hospital- and community-based early intervention services (EIS) in the cities of Toronto and Hamilton. We compared the 3 groups on DUP and key indicators of the pathway to care. RESULTS: We observed differences in pathways to care across the 3 groups. Black-Caribbean participants had an increased odds of referral from an inpatient unit to EIS (OR 3.33; 95% CI 1.46 to 7.60) and a decreased odds of general practitioner involvement on the pathway to care (OR 0.17; 95% CI 0.07 to 0.46), as well as fewer total contacts (exp[ß] 0.77; 95% CI 0.60 to 0.99) when compared with White-European participants. Black-African participants had an increased odds of contact with the emergency department at first contact (OR 3.78; 95% CI 1.31 to 10.92). The differences in the DUP between groups were not statistically significant. CONCLUSIONS: Our findings suggest that there are significant differences in the pathways to EIS for psychosis for people of African and Caribbean origin in our Canadian context. It is essential to gain a comprehensive understanding of the pathways that different population groups take to mental health services, and the reasons behind observed differences, to inform the development of equitable services, targeting patients in the critical early stages of psychotic disorder.

Pathways to forensic mental health care in Toronto: a comparison of European, African-Caribbean, and other ethnoracial groups in Toronto.

OBJECTIVE: To describe pathways taken to care by a sample of patients in a secure forensic unit who have been found not criminally responsible or unfit to stand trial, and to investigate the pathways taken by patients within 3 ethnoracial subgroups of origin: European, African or Caribbean, and Other. METHOD: Fifty patients from secure forensic units were interviewed using the Encounter Form developed for pathways mapping undertaken in the World Health Organization field trials. Differences in the types of caregivers seen, the total number of caregivers seen, and the time taken to reach forensic psychiatric services were compared across the 3 ethnoracial groupings. RESULTS: Most people committed their index offence after they had already had contact with general mental health services. Few significant differences were observed in the pathways to secure forensic units across the European, African-Caribbean, and Other ethnoracial groups. CONCLUSIONS: These findings suggest that improvements in general mental health services may be a key to decreasing the use of forensic psychiatric services. Further research is required to explore factors that may predict and prevent offending. Larger studies are needed to examine ethnoracial differences in pathways to care.

Insulin regulates glucagon-like peptide-1 secretion from the enteroendocrine L cell.

Insulin resistance and type 2 diabetes mellitus are associated with impaired postprandial secretion of glucagon-like peptide-1 (GLP-1), a potent insulinotropic hormone. The direct effects of insulin and insulin resistance on the L cell are unknown. We therefore hypothesized that the L cell is responsive to insulin and that insulin resistance impairs GLP-1 secretion. The effects of insulin and insulin resistance were examined in well-characterized L cell models: murine GLUTag, human NCI-H716, and fetal rat intestinal cells. MKR mice, a model of chronic hyperinsulinemia, were used to assess the function of the L cell in vivo. In all cells, insulin activated the phosphatidylinositol 3 kinase-Akt and MAPK kinase (MEK)-ERK1/2 pathways and stimulated GLP-1 secretion by up to 275 +/- 58%. Insulin resistance was induced by 24 h pretreatment with 10(-7) m insulin, causing a marked reduction in activation of Akt and ERK1/2. Furthermore, both insulin-induced GLP-1 release and secretion in response to glucose-dependent insulinotropic peptide and phorbol-12-myristate-13-acetate were significantly attenuated. Whereas inhibition of phosphatidylinositol 3 kinase with LY294002 potentiated insulin-induced GLP-1 release, secretion was abrogated by inhibiting the MEK-ERK1/2 pathway with PD98059 or by overexpression of a kinase-dead MEK1-ERK2 fusion protein. Compared with controls, MKR mice were insulin resistant and displayed significantly higher fasting plasma insulin levels. Furthermore, they had significantly higher basal GLP-1 levels but displayed impaired GLP-1 secretion after an oral glucose challenge. These findings indicate that the intestinal L cell is responsive to insulin and that insulin resistance in vitro and in vivo is associated with impaired GLP-1 secretion.