Stigma and treatment delay in first-episode psychosis: a grounded theory study

Improving access to specialized care for first-episode psychosis: an ecological model

Psychotic spectrum disorders are serious illnesses with symptoms that significantly impact functioning and quality of life. An accumulating body of literature has demonstrated that specialized treatments that are offered early after symptom onset are disproportionately more effective in managing symptoms and improving outcomes than when these same treatments are provided later in the course of illness. Specialized, multicomponent treatment packages are of particular importance, which are comprised of services offered as soon as possible after the onset of psychosis with the goal of addressing multiple care needs within a single care setting. As specialized programs continue to develop worldwide, it is crucial to consider how to increase access to such specialized services. In the current review, we utilize an ecological model of understanding barriers to care, with emphasis on understanding how individuals with first-episode psychosis interact with and are influenced by a variety of systemic factors that impact help-seeking behaviors and engagement with treatment. Future work in this area will be important in understanding how to most effectively design and implement specialized care for individuals early in the course of a psychotic disorder.

Effects of Renaming Schizophrenia in Korea: from "Split-Mind Disorder" to "Attunement Disorder"

OBJECTIVE

Korean Neuropsychiatric Association changed the Korean name of schizophrenia from 'Split-mind Disorder' to 'Attunement Disorder' in 2012. This study assessed attitudes towards the renaming of schizophrenia among mental health practitioners (n=440), patients with schizophrenia and their guardians (n=396), and the university students (n=140) using self-administered questionnaires.

METHODS

The questionnaire included items related to participants' perception of the renaming of the disease, the nature of informing about the disease to confirm the effect of the name change.

RESULTS

It was confirmed the notification rate of disease name by mental health practitioners was increased significantly after the renaming. Among patients and their guardians, 24.9% and 15.0%, respectively, perceived their own or the family member's illness as 'attunement disorder'.

CONCLUSION

Patients and their guardians continue to display a low awareness about the name of the disease as 'attunement disorder.' However, mental health practitioners were found to be able to easily use the name 'attunement disorder' as a result of the increased notification rate of the new disease name.

Does initial use of benzodiazepines delay an adequate pharmacological treatment? A multicentre analysis in patients with psychotic and affective disorders

It is established that delayed effective pharmacotherapy plays a significant role in the overall burden of psychiatric disorders, which are often treated with symptomatic drugs, that is benzodiazepines (BZDs), in relation to their rapid onset of action and safety, despite long-term side effects. We aimed to assess the influence of initial treatment with BZDs on the duration of untreated illness (DUI) and whether specific sociodemographic and clinical factors could influence the choice of BZDs as first treatment in 545 patients affected by schizophrenia, mood and anxiety spectrum disorders. Statistical analyses (one-way analysis of variance and χ) were carried out to compare patients who used BZDs as first treatment (BZD w/) and those who did not (BZD w/o). The overall DUI, irrespective of diagnosis, resulted in significantly longer in BZD w/ versus w/o patients, who also experienced more frequently anxious/depressive symptoms at onset. Furthermore, BZD w/ patients more frequently autonomously decided to look for treatment (mainly refering to psychologists or general practitioners) and experimented more frequently phobias, than BZD w/o ones. The present findings suggest that initial BZDs treatment may prolong the overall DUI, although their prescription seems to be influenced by specific sociodemographic and clinical factors. Further studies are needed to confirm the present findings.

Career Decision-Making Processes of Young Adults With First-Episode Psychosis

The first episode of psychosis often emerges during young adulthood, when individuals are pursuing important educational and career goals that can become derailed because of the development of major impairments. Past research has neglected the developmental nature of employment and education decisions that young adults with first-episode psychosis make within the context of their lives. The purpose of this grounded theory study was to advance a model of the career decision-making processes of young adults with first-episode psychosis, and the influences that affect their career decision-making. The career decision-making of young adults with first-episode psychosis emerged as a multistaged, iterative process that unfolded over three phases of illness, and was affected by several internal and environmental influences. These findings suggest the phase of illness and career decision-making stage should be considered in future vocational programming for young adults with first-episode psychosis.

Prediction of self-stigma in early psychosis: 3-Year follow-up of the randomized-controlled trial on extended early intervention

BACKGROUND

Self-stigma represents a major barrier to recovery in people with psychotic disorders but is understudied in early illness stage. Longitudinal investigation of prediction for self-stigma is scarce and none is conducted in early psychosis. We aimed to prospectively examine baseline predictors of self-stigma in early psychosis patients in the context of a 3-year follow-up of a randomized-controlled trial (RCT) comparing 1-year extension of early intervention (EI) with step-down psychiatric care for first-episode psychosis (FEP).

METHOD

One hundred sixty Chinese patients were recruited from a specialized EI program for FEP in Hong Kong after they had completed this 2-year EI service, and underwent a 12-month RCT. Participants were followed up and reassessed 3years after inclusion to the trial. Comprehensive evaluation encompassing clinical, functional, subjective quality of life and treatment-related variables were conducted. Data analysis was based on 136 participants who completed self-stigma assessment at 3-year follow-up.

RESULTS

Fifty patients (36.8%) had moderate to high levels of self-stigma at 3-year follow-up. Multivariate regression analysis revealed that female gender, prior psychiatric hospitalization, longer duration of untreated psychosis and greater positive symptom severity at study intake independently predicted self-stigma at the end of 3-year study period.

CONCLUSION

Our results of more than one-third of early psychosis patients experienced significant self-stigma underscore the clinical needs for early identification and intervention of self-stigmatization in the initial years of psychotic illness. Further research is warranted to clarify prediction profile and longitudinal course of self-stigma in the early illness phase.

A brief cognitive therapy intervention for internalised stigma in acute inpatients who experience psychosis: A feasibility randomised controlled trial

Internalised stigma is problematic for people who experience psychosis therefore psychological interventions are required. This study examine the feasibility and acceptability of a brief Cognitive Behavioural Therapy (CBT) intervention for internalised stigma with psychiatric inpatients experiencing psychosis. A feasibility randomised controlled trial was conducted, comparing CBT with a psychoeducational (PE) control arm. Thirty participants (aged 18-65, with psychosis, and currently admitted to a psychiatric hospital) were randomised to one of two conditions. Participants were assessed at baseline, post-intervention (two weeks) and at follow-up (one month). Both interventions incorporated two hours of sessions over a two week period. The outcomes examined were internalised stigma (primary outcome), stigma, attitudes toward mental health problems, personal recovery, depression and self-esteem. Recruitment was conducted over a seven month period from five psychiatric wards. Forty five potential participants were approached and 30 (66%) consented to take part. Fifteen participants were randomised to CBT and 15 to PE. Feasibility data demonstrated that both the research process and interventions were feasible and acceptable. Examination of outcomes demonstrated that there was no identified benefit of one intervention type over another. There were no adverse events related to study participation. A future definitive trial is required with improved methodological rigor.

Development of a Boston Treatment Program for Youth at Clinical High Risk for Psychosis: Center for Early Detection, Assessment, and Response to Risk (CEDAR)

Over the past two decades, increasing attention has been given to the importance of early intervention for psychosis. This article describes the development of the Center for Early Detection, Assessment and Response to Risk (CEDAR), which focuses on early identification and treatment of youth at clinical high risk for psychosis. There are relatively few models in the United States for such programs, and we present our developmental story, focusing mainly on the CEDAR Clinic, as a case study of how such a program can develop. We describe the rationale, infrastructure, and services provided at the CEDAR Clinic, and present some descriptive data from the CEDAR Clinic through 2016. A case example is provided to illustrate treatment at CEDAR. We hope that the cultural history of our program's development is informative for clinicians and policy makers as one model of how to build an early intervention service. We believe that this article is timely in view of the growing momentum in the United States for developing programs for intervening as early as possible for youth at clinical high risk for psychosis.

A Survey of Health Equity Practices in Early Psychosis Intervention Programs: A Starting Point for Improvement

Equity has been identified as a core component of quality healthcare in Ontario. However, translating policy into practice can be challenging. This paper reports results from a province-wide survey of early psychosis intervention programs to assess the extent to which equity has been incorporated into program delivery. All 56 programs (100%) completed the survey. Results found that while most programs perceive that they are meeting equity aims, they reported limited use of practices to support this aim, and few systematically collect information on performance. Strategies to improve equity in practice are discussed.

Conditional Disclosure on Pathways to Care: Coping Preferences of Young People at Risk of Psychosis

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. "Pathways to care" was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as "conditional disclosure," a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people's perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms.

Detecting and Managing Mental Health Issues within Young Adults. A Systematic Review on College Counselling in Italy

Background:

College counselling can be considered as a front-line service in detecting and managing mental health issues within young adults. In this sense, it is important to investigate the effectiveness of counselling interventions.

Objective:

To provide a systematic review about college counselling in Italy; to assess which psychological interventions really meet student needs, and their effectiveness; to focus on the level of cohesion between Italian counselling services and the international guidelines about college counselling.

Method:

A systematic review about college counselling through PsycInfo and PubMed was carried out. Because of the scarceness of pertinent available articles, the survey was extended to Google Scholar and Riviste Web. Keywords: counselling, mental health, wellbeing, psychological support, university, students, Italy.

Results:

Out of thirty-four articles retrieved, 16 are relevant to academic counselling, the other 18 have been considered not pertinent to the aim of the present review. Data show a lack of homogeneity in methodology and organization between each University: different approaches towards students’ needs. Furthermore, no follow-up studies or measurement of effectiveness were found.

Conclusion:

This review is a contribution to disseminate the results of counselling experiences in Italy and represents an effort to encourage colleagues working in a web environment to share results and methods for a more organized protocol application.

Barriers to Seeking Early Psychiatric Treatment amongst First-episode Psychosis Patients: A Qualitative Study

AIMS

The aim of this study was to explore the family members' determinant of the delay in seeking psychiatric care to patients diagnosed with psychosis.

METHODS

Qualitative semi-structured interviews were carried out with twenty-seven family members of patients with psychosis at psychiatric outpatient clinics in Amman, Jordan.

RESULTS

The findings revealed that perceived stigma and fears about being labelled are the main barriers to requesting early psychiatric health care. The participants cited many different reasons linked to finding help led to delay in seeking help in the early stages of the illness including misattribution of the cause and symptoms of mental illness, family and financial factors.

CONCLUSIONS

The study highlights the importance of enhancing knowledge about the schizophrenia-related spectrum to ensure patients seek treatment in a more timely manner.

An Integrative Cognitive Model of Internalized Stigma in Psychosis

Background:Internalized stigma is a significant difficulty for those who experience psychosis, but it has never been conceptualized using cognitive theory.Aims:The aim of this paper is to outline a cognitive model conceptualizing internalized stigma experienced by people who also experience psychosis.Method:Previous literature is reviewed, critiqued and synthesized to develop the model. It draws upon previous social cognitive models of internalized stigma and integrates cognitive behavioural theory and social mentality theory.Results:This paper identifies key cognitive, behavioural and emotional processes that contribute to the development and maintenance of internalized stigma, whilst also recognizing the central importance of cultural context in creating negative stereotypes of psychosis. Moreover, therapeutic strategies to alleviate internalized stigma are identified. A case example is explored and a formulation and brief intervention plan was developed in order to illustrate the model in practice.Conclusion:An integrative cognitive model is presented, which can be used to develop individualized case formulations, which can guide cognitive behavioural interventions targeting internalized stigma in those who experience psychosis. More research is required to examine the efficacy of such interventions. In addition, it is imperative to continue to research interventions that create change in stigma at a societal level.

Characterizing Awareness of Schizophrenia Among Facebook Users by Leveraging Facebook Advertisement Estimates

Background

Schizophrenia is a rare but devastating condition, affecting about 1% of the world’s population and resulting in about 2% of the US health care expenditure. Major impediments to appropriate and timely care include misconceptions, high levels of stigma, and lack of public awareness. Facebook offers novel opportunities to understand public awareness and information access related to schizophrenia, and thus can complement survey-based approaches to assessing awareness that are limited in scale, robustness, and temporal and demographic granularity.

Objective

The aims of this study were to (1) construct an index that measured the awareness of different demographic groups around schizophrenia-related information on Facebook; (2) study how this index differed across demographic groups and how it correlated with complementary Web-based (Google Trends) and non–Web-based variables about population well-being (mental health indicators and infrastructure), and (3) examine the relationship of Facebook derived schizophrenia index with other types of online activity as well as offline health and mental health outcomes and indicators.

Methods

Data from Facebook’s advertising platform was programmatically collected to compute the proportion of users in a target demographic group with an interest related to schizophrenia. On consultation with a clinical expert, several topics were combined to obtain a single index measuring schizophrenia awareness. This index was then analyzed for differences across US states, gender, age, ethnic affinity, and education level. A statistical approach was developed to model a group’s awareness index based on the group’s characteristics.

Results

Overall, 1.03% of Facebook users in the United States have a schizophrenia-related interest. The schizophrenia awareness index (SAI) is higher for females than for males (1.06 vs 0.97, P<.001), and it is highest for the people who are aged 25-44 years (1.35 vs 1.03 for all ages, P<.001). The awareness index drops for higher education levels (0.68 for MA or PhD vs 1.92 for no high school degree, P<.001), and Hispanics have the highest level of interest (1.57 vs 1.03 for all ethnic affinities, P<.001). A regression model fit to predict a group’s interest level achieves an adjusted R²=0.55. We also observe a positive association between our SAI and mental health services (or institutions) per 100,000 residents in a US state (Pearson r=.238, P<.001), but a negative association with the state-level human development index (HDI) in United States (Pearson r=−.145, P<.001) and state-level volume of mental health issues in United States (Pearson r=−.145, P<.001).

Conclusions

Facebook’s advertising platform can be used to construct a plausible index of population-scale schizophrenia awareness. However, only estimates of awareness can be obtained, and the index provides no information on the quality of the information users receive online.

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

BACKGROUND

Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP.

AIMS

To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

METHOD

The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale.

RESULTS

Mean (±standard deviation ( SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors.

CONCLUSION

Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors.

Impact of online resources and social media on help-seeking behaviour in youth with psychotic symptoms

AIM

The objective of the study was to explore the content of existing online resources available to information-seeking youth as psychotic symptoms first emerge and determine how these resources may influence initiation of care.

METHODS

Using 18 hypothetical search terms, developed by the Early Treatment Programme (ETP) staff, we searched three of the most popular websites used by the youth (Google, Facebook and Twitter) and extracted the first five hits from each. Sites were categorized into those that encouraged help seeking, those that potentially contribute to treatment delay, those with an undetermined impact and those that were unrelated to treatment.

RESULTS

An alarmingly few of the first five hits from the top three online resources encourage potentially psychotic youth to seek professional evaluation. The majority of our search results yielded unmonitored chat forums that lacked a unified message. The remainder promoted stigma, normalized potentially psychotic experiences or were completely unrelated to mental health.

CONCLUSION

We must develop innovative, easy-to-access and youth-focused online and social media experiences that encourage symptomatic youth to seek care.

Patterns and Determinants of Treatment Seeking among Previously Untreated Psychotic Patients in Aceh Province, Indonesia: A Qualitative Study

Immediate treatment of first-episode psychosis is essential in order to achieve a positive outcome. However, Indonesian psychiatric patients often delay accessing health services, the reason for which is not yet fully understood. The current study aimed to understand patterns of treatment seeking and to reveal determinants of the delay in accessing psychiatric care among first-time user psychotic patients. Qualitative interviews were conducted with sixteen family members who accompanied the patients to a psychiatric hospital. Many families expressed beliefs that mental illness appertains to village sickness and not hospital sickness; therefore, they usually take the patients to traditional or religious healers before taking them to a health professional. They also identified various factors that potentially delay accessing psychiatric treatment: low literacy and beliefs about the cause of the illness, stigmatisation, the role of extended family, financial problems, and long distance to the psychiatric hospital. On the other hand, the family mentioned various factors related to timely help seeking, including being a well-educated family, living closer to health facilities, previous experience of successful psychotic therapy, and having more positive symptoms of psychosis. The findings call for mental health awareness campaigns in the community.

Reduced duration of untreated illness over time in patients with schizophrenia spectrum, mood and anxiety disorders

AIMS

Psychiatric disorders represent highly impairing conditions, often underdiagnosed and undertreated, with a conspicuous duration of untreated illness (DUI). Given that social and cultural factors influence the DUI and assuming that progress in diagnosis and treatment determines a reduced latency to pharmacotherapy, we assessed and compared DUI and related variables in a large sample of psychiatric patients (n = 562) whose onset occurred within three different a priori-defined epochs.

METHODS

Two temporal cut-offs were established - the year 1978, when Law 180 (redefining standards for mental care) was introduced in Italy, and the year 2000 - in order to divide patients into three subgroups: onset before 1978, onset 1978-2000 and onset after 2000.

RESULTS

A significant difference in terms of age at onset, age at first diagnosis and age at first treatment was observed in patients with onset 1978-2000 and in those with onset after 2000. In addition, a significant reduction of the DUI was found across epochs (onset before 1978: 192.25 ± 184.52 months; onset 1978-2000: 77.00 ± 96.63 months; and onset after 2000: 19.00 ± 31.67 months; P < 0.001). Furthermore, the proportion of patients with onset-related stressful events, use of benzodiazepines and neurological referral was found to be significantly different between the three epochs (χ(2) = 23.4, P < 0.001; χ(2) = 9.92, P = 0.007; χ(2) = 16.50, P = 0.011).

CONCLUSIONS

Present data indicate a progressive, statistically significant reduction of latency to treatment and other related changes across subsequent epochs of onset in patients with different psychiatric disorders. Future studies will assess specific changes within homogeneous diagnostic subgroups.

Access and latency to first antipsychotic treatment in Italian patients with schizophrenia and other schizophrenic spectrum disorders across different epochs

BACKGROUND

The duration of untreated illness (DUI) is a measure to express the latency to first psychopharmacological treatment: it differs among psychiatric disorders, being influenced by several illness-intrinsic and environmental factors. The present study aimed to assess differences in DUI and related variables in patients with schizophrenia (SKZ) versus other schizophrenic spectrum disorders (SSDs) across different epochs.

METHODS

101 SKZ or SSD patients were assessed with respect to DUI and related variables through clinical interview and questionnaire.

RESULTS

Patients with SKZ showed earlier ages of onset, first diagnosis and first antipsychotic treatment compared with patients with other SSDs (F = 11.02, p < 0.001; F = 12.68, p < 0.001; F = 13.74, p < 0.001, respectively) who showed an earlier access to benzodiazepines than SKZ patients (F = 6.547; p < 0.05). Dividing the total sample by the epoch of onset (before 1978; between 1978-2000; after 2000) showed a significantly later age of onset in patients with onset within the two most recent epochs (F = 7.46; p < 0.001) and a reduced DUI across epochs (from 144 to 41 to 20 months, on average; F = 11.78, p < 0.001).

CONCLUSION

Schizophrenic patients showed earlier onset and longer DUI compared with patients with other SSDs. Data on the total sample showed a later age of onset and a reduced DUI across epochs.

The Experience of Childhood Trauma and Its Influence on the Course of Illness in First-Episode Psychosis: A Qualitative Study

Persons with schizophrenia spectrum disorders often report high levels of childhood trauma, which often exacerbates symptoms and impede the process of recovery. However, little is known about how these traumas are experienced by service users and how they are integrated in their life stories. To examine this, we conducted in-depth interviews with 15 service users with a diagnosis of a first-episode nonaffective psychosis who had reported 1 or more childhood traumas in self-report measures. There was an unexpected discrepancy between the number of traumas reported in self-report measures and in semistructured interviews, and many of the traumas did not seem integrated in their personal narratives. The analyses further revealed that although participants often described complicated and traumatic childhood environments, they still felt supported by their families; they reported a range of ways in which they tried to cope with and gain control of their psychotic disorder, and they described a general optimistic view of the future.

Does ethnicity have an impact on duration of untreated psychoses: A retrospective study in Singapore

BACKGROUND

Some studies have suggested ethnicity as being one of the causes leading to a longer duration of untreated psychosis (DUP) in first episode psychosis.

AIM

We sought to investigate this issue, in a large cohort of patients with a first episode of psychosis, in Singapore.

METHOD

In this naturalistic retrospective study, 794 patients accepted into Early Psychosis Intervention Programme (EPIP) services in Singapore were recruited. Diagnosis was made based on SCID 1 (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Axis I Disorders). Information about DUP and sociodemographic characteristics was collected from patients and relatives. Positive and Negative Symptom Scale (PANSS) and Global Assessment of Functioning (GAF) Scale were used as tools to assess the severity of symptoms and functioning of the patient, respectively, at baseline, 3, 6, 12 and 24  months.

RESULTS

The mean and 50th quantile (median) of DUP for this sample were 14.2 and 6, respectively. The mean and median DUP were higher among Indians than in the other ethnic groups. After adjusting for demographic variables, Indian ethnicity was significantly associated with higher median and 75th Percentile DUP than Chinese. Secondary and tertiary education and diagnosis of affective psychosis and brief psychotic disorder (vs. schizophrenia spectrum and delusional disorder) were also significantly associated with lower mean, median and 75th percentile DUP symptoms. Increase in age was significantly associated with higher mean, median and 75th percentile DUP while married and separated/divorced (vs. single) was significantly associated with lower mean and 75th percentile DUP.

CONCLUSION

This study found a positive correlation between certain ethnic groups and DUP. Indian ethnicity, older age, single, lower education and patients diagnosed with schizophrenia spectrum and delusional disorders were more likely to be associated with longer DUP.

The Help-Seeking Experiences of Parents of Children with a First-Episode of Psychosis

The objective was to understand the experiences of parents as they sought psychological and specialized medical services for a loved one having a first episode of psychosis. The research method was qualitative and the data gathering was done through semi-structured interviews. Eleven parents of eight adolescent or young adult children consented to be interviewed. Data from these interviews were coded and sorted. Parents reported that many of their encounters resulted in delays in accessing treatment. These encounters were characterized by misattributions of the child's behavior, poor advice, misdiagnosis, disbelief in the seriousness of the child's condition, and an unwillingness to share information. But parents also reported that encounters with other individuals were characterized by helpful advice, emotional support, and suggestions as to how to access early intervention services. Encounters with many professionals were generally not helpful to parents. These encounters served as roadblocks to accessing proper treatment for their child. More publicity, outreach, and education are recommended in the professional community.

The role of relatives in pathways to care of patients with a first episode of psychosis

AIMS

To explore the role of relatives in pathways to care of patients with a recent onset of psychosis.

METHODS

A total of 34 consecutive patients and their relatives from the Department of Psychiatry of the University of Naples SUN participated in the study. Pathways to care were retrospectively evaluated by administering the Pathways to Care Form and the Nottingham Onset Schedule (NOS) to patients, relatives and treating physicians. Relatives were addressed with the Family Involvement in Pathways to care Schedule (FIPS).

RESULTS

Duration of untreated illness (DUI) and duration of untreated psychosis (DUP) were 145.4 (±141.9) and 33.3 (±54.0) weeks, respectively. Help-seeking delay was 17.6 (±45.0) weeks. The first request for help was made by relatives in 76% of cases. Among health professionals, general practitioners were those most frequently contacted, followed by psychiatrists, neurologists or psychologists. Stigma and wrong attribution of psychotic symptoms were the main reasons for help-seeking delays.

CONCLUSIONS

Relatives play a crucial role in pathways to care of patients with psychosis. DUI and DUP could be reduced by interventions aimed at increasing knowledge of early symptoms in the general population, and by the provision of psychiatric consultations in non-stigmatizing settings for young people with psychological distress.

The Stigma Complex

Since the beginning of the twenty-first century, research on stigma has continued. Building on conceptual and empirical work, the recent period clarifies new types of stigmas, expansion of measures, identification of new directions, and increasingly complex levels. Standard beliefs have been challenged, the relationship between stigma research and public debates reconsidered, and new scientific foundations for policy and programs suggested. We begin with a summary of the most recent Annual Review articles on stigma, which reminded sociologists of conceptual tools, informed them of developments from academic neighbors, and claimed findings from the early period of "resurgence." Continued (even accelerated) progress has also revealed a central problem. Terms and measures are often used interchangeably, leading to confusion and decreasing accumulated knowledge. Drawing from this work but focusing on the past 14 years of stigma research (including mental illness, sexual orientation, HIV/AIDS, and race/ethnicity), we provide a theoretical architecture of concepts (e.g., prejudice, experienced/received discrimination), drawn together through a stigma process (i.e., stigmatization), based on four theoretical premises. Many characteristics of the mark (e.g., discredited, concealable) and variants (i.e., stigma types and targets) become the focus of increasingly specific and multidimensional definitions. Drawing from complex and systems science, we propose a stigma complex, a system of interrelated, heterogeneous parts bringing together insights across disciplines to provide a more realistic and complicated sense of the challenge facing research and change efforts. The Framework Integrating Normative Influences on Stigma (FINIS) offers a multilevel approach that can be tailored to stigmatized statuses. Finally, we outline challenges for the next phase of stigma research, with the goal of continuing scientific activity that enhances our understanding of stigma and builds the scientific foundation for efforts to reduce intolerance.

Family members' experience of seeking help for first-episode psychosis on behalf of a loved one: a meta-synthesis of qualitative research

AIM

Family members often play a vital role in seeking help for loved ones experiencing first-episode psychosis. Understanding this experience is crucial in facilitating the help-seeking process. Qualitative research offers valuable insight into the lived experience of family members who seek help on behalf of a loved one experiencing first-episode psychosis.

METHOD

The current research presents a systematic review of qualitative studies exploring the family member experience of seeking help for first-episode psychosis.

RESULTS

A meta-synthesis of 13 qualitative studies has revealed four themes relating to family members' experience of seeking help for first-episode psychosis. These include a sense of not knowing, the reaching of crisis point, the impact upon the family member and the mediating role of interactions with others. A further synthesis of translation captures the interaction of these themes within this experience.

CONCLUSIONS

The findings provide a novel insight into this experience, suggesting implications for clinical practice. These include a focus upon the facilitation of early positive interactions with family members and for first-episode psychosis to be presented to families in a normalizing manner. The need for future research that examines the experience of those who do not seek help from health services is discussed.

School-based approaches to reducing the duration of untreated psychosis

Students with emerging psychosis often experience delays in diagnosis and treatment that impact mental health and academic outcomes. School systems have tremendous potential to improve early identification and treatment of adolescent psychosis. As a community-based resource, schools can support outreach, education, and screening for adolescents with psychosis and engage identified students and their families for treatment. The concept of duration of untreated psychosis (DUP; the gap between symptom onset and treatment initiation) in adolescent psychosis and the potential role of schools in reducing DUP are reviewed. Future directions for clinical care and research needed to support school-based interventions are proposed.

The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis

Although the family has an important role in the early detection and intervention of first-episode psychosis (FEP), there are few findings reporting associations between family strengths and early treatment-seeking experiences. This study aimed to investigate, within the framework of the resiliency model of family stress, adjustment, and adaptation, the association between family coping strategies, resource management factors and duration of untreated psychosis (DUP) in Iranian families with one adult child with FEP. Hundred and seven individuals referred to three medical centers in Tehran and diagnosed with FEP participated in this study. Caregiver-perceived DUP was measured via semi-structured interviews administered to primary caregivers. They also completed two questionnaires regarding family resources of stress management and family coping strategies. Data analysis indicated that the Family Inventory of Resources of Management (FIRM) total scale score did not significantly explain the variance of caregiver-perceived DUP, but one of the FIRM subscales, the Extended Family Social Support, and the Family Crisis-Oriented Personal Evaluation scale (F-COPES) total score and one its subscales, the Acquiring Social Support, explained a significant amount of the variance of caregiver-perceived DUP. The results suggest that higher family resiliency, especially social support, facilitates the family's appropriate adaptive reaction (i.e., treatment-seeking), with the consequent decrease of DUP.

Recent advances in cross-cultural measurement in psychiatric epidemiology: utilizing 'what matters most' to identify culture-specific aspects of stigma

BACKGROUND

While stigma measurement across cultures has assumed growing importance in psychiatric epidemiology, it is unknown to what extent concepts arising from culture have been incorporated. We utilize a formulation of culture-as the everyday interactions that 'matter most' to individuals within a cultural group-to identify culturally-specific stigma dynamics relevant to measurement.

METHODS

A systematic literature review from January 1990 to September 2012 was conducted using PsycINFO, Medline and Google Scholar to identify articles studying: (i) mental health stigma-related concepts; (ii) ≥ 1 non-Western European cultural group. From 5292 abstracts, 196 empirical articles were located.

RESULTS

The vast majority of studies (77%) utilized adaptations of existing Western-developed stigma measures to new cultural groups. Extremely few studies (2.0%) featured quantitative stigma measures derived within a non-Western European cultural group. A sizeable amount (16.8%) of studies employed qualitative methods to identify culture-specific stigma processes. The 'what matters most' perspective identified cultural ideals of the everyday activities that comprise 'personhood' of 'preserving lineage' among specific Asian groups, 'fighting hard to overcome problems and taking advantage of immigration opportunities' among specific Latino-American groups, and 'establishing trust among religious institutions due to institutional discrimination' among African-American groups. These essential cultural interactions shaped culture-specific stigma manifestations. Mixed method studies (3.6%) corroborated these qualitative results.

CONCLUSION

Quantitatively-derived, culturally-specific stigma measures were lacking. Further, the vast majority of qualitative studies on stigma were conducted without using stigma-specific frameworks. We propose the 'what matters most' approach to address this key issue in future research.

Implementing a mental health ministry committee in faith-based organizations: the promoting emotional wellness and spirituality program

Social workers have successfully collaborated with African-American faith-based organizations to improve health outcomes for numerous medical conditions. However, the literature on Faith-Based Health Promotion for major depression is sparse. Thus, the authors describe a program used to implement a Mental Health Ministry Committee in African-American churches. Program goals are to educate clergy, reduce stigma, and promote treatment seeking for depression. Key lessons learned are to initially form partnerships with church staff if there is not a preexisting relationship with the lead pastor, to utilize a community-based participatory approach, and to have flexibility in program implementation.

Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy

PURPOSE

This study set out to investigate the patterns of referral in a sample (n = 206) of patients having first-time access to an Italian comprehensive program that targets the early detection of and early intervention on subjects at the onset of psychosis. The primary goal of the study was to investigate the duration of untreated illness (DUI) and/or the duration of untreated psychosis (DUP) in the sample since the implementation of the program.

METHOD

Data on pathways of referrals prospectively collected over a 11-year period, from 1999 to 2010; data referred to patients from a defined catchment area, and who met ICD-10 criteria for a first episode of a psychotic disorder (FEP) or were classified to be at ultra-high risk of psychosis (UHR) according to the criteria developed by the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne. Changes over time in the DUI and DUP were investigated in the sample.

RESULTS

Referrals increased over time, with 20 subjects enrolled per year in the latter years of the study. A large majority of patients contacted a public or private mental health care professional along their pathway to treatment, occurring more often in FEP than in UHR patients. FEP patients who had contact with a non-psychiatric health care professional had a longer DUP. Over time, DUP and DUI did not change in FEP patients, but DUI increased, on average, in UHR patients.

CONCLUSIONS

The establishment of an EIP in a large metropolitan area led to an increase of referrals from people and agencies that are not directly involved in the mental health care system; over time, there was an increase in the number of patients with longer DUI and DUP than those who normally apply for psychiatric services.

Childhood onset schizophrenia and early onset schizophrenia spectrum disorders

The clinical severity, impact on development, and poor prognosis of childhood onset schizophrenia may represent a more homogeneous group. Positive symptoms in children are necessary for the diagnosis and hallucinations are more often multimodal. In healthy children and children with a variety of other psychiatric illnesses, hallucinations are not uncommon and diagnosis should not be based on these alone. Childhood onset schizophrenia is an extraordinarily rare illness that is poorly understood but seems continuous with the adult onset disorder. Once a diagnosis is affirmed, aggressive medication treatment combined with family education and individual counseling may defer further deterioration.

Female families' experiences of caring for persons with schizophrenia

The caring experiences of female families of persons with schizophrenia were described through exploring the families' descriptions of their experiences. Focus group interviews were conducted with 11 family caregivers. According to content analysis, the experiences revealed five major themes: early family experiences, family perceptions of illness and relatives with schizophrenia, family burden and suffering, family attitudes toward relatives with schizophrenia, and family thoughts about society and mental health resources. Also, the families had strength to overcome considerable adversity. It is needed for professionals to listen to family caregivers' narratives carefully and improve the support by focusing on accepting their experiences and histories with persons with schizophrenia.

Clinical risk of stigma and discrimination of mental illnesses: Need for objective assessment and quantification

Stigma and discrimination continue to be a reality in the lives of people suffering from mental illness, particularly schizophrenia, and prove to be one of the greatest barriers to regaining a normal lifestyle and health. Research advances have defined stigma and assessed its implications and have even examined intervention strategies for dealing with stigma. We are of the opinion that stigma is a potential clinical risk factor. It delays treatment seeking, worsens course and outcome, reduces compliance, and increases the risk of relapse; causing further disability, discrimination, and isolation even in persons who have accessed mental health services. The delay in treatment due to stigma causes potential complications like suicide, violence, harm to others, and deterioration in capacity to look after one's physical health. These are preventable clinical complications. In order to deal with the impact of stigma on an individual basis, it needs to be (i) assessed during routine clinical examination, (ii) assessed for quantification in order to obtain measurable objective deliverables, and (iii) examined if treatment can reduce stigma and its impact on individuals. New and innovative anti-stigma programs are required that are clinically driven in order to see the change in life of an individual by removing potential risks. The basic requirement for dealing with an individual's stigma perception/experience is its proper assessment for origin and impact in both a qualitative and quantitative manner. We further argue that quantification would allow for regular assessment and offer more effective intervention for patients. It will also be helpful in identifying modifiable social factors to enhance quality of care planning for management in hospitals and communities. The objective of quantification is to facilitate developing an approach to bring the assessment of stigma into clinical work and formulating customized strategies to deal with stigma at the patient level. It would be expected that the assessment of stigma would become a part of routine clinical assessment to identify barriers to outcome. This article discusses the need for quantification of patients' experiences of mental illness stigma.

Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework

The duration of untreated illness (DUI), meaning the latency to the pharmacological treatment, has been increasingly investigated in the last decade as a predictor of outcome across different psychiatric conditions, particularly in psychotic disorders. DUI is essentially computed by subtracting the age of onset of a specific disorder from the age at which the first adequate pharmacological treatment is administered. Assessment of the latency to treatment represents one of the first steps in planning early interventions. This review examines the role of the DUI in psychotic and affective disorders, focusing on neuropathological, epidemiologic, clinical and prognostic factors related to a longer latency to treatment. Through a Medline and Cochrane Library search, relevant studies up to June 2011 and other pertinent articles including meta-analyses, randomized controlled trials, naturalistic studies and clinical reviews were identified. Converging evidence indicates that a prolonged DUI negatively influences the outcome of first-episode psychosis and schizophrenia in different ways, and increasing data point toward a similar conclusion in affective disorders. Even though methodological limitations related to investigation of the DUI need to be considered, research and interventions aimed to reduce latency to treatments are object of increasing implementation worldwide. The assessment of the DUI represents one of the most important parameters to consider in this perspective, in order to quantify different latency to treatment in specific disorders and to plan related, targeted interventions.

Pharmacotherapy challenges in patients with first-episode psychosis

The first episode of a psychotic disorder typically occurs in late adolescence or young adulthood, a critical time of development with respect to personality, social role, education, and vocation. The first few years of psychosis appear to be a critical period during which intervention needs to be initiated before the consequences of psychosis become more severe. Early intervention is therefore crucial in maximizing outcomes. Although response rates to antipsychotic medication in first-episode psychosis (FEP) are good, there is a relatively high risk of relapse. The greatest challenges that physicians face in treating FEP and preventing relapse are engaging patients in treatment and preventing non-adherence to therapy. Overall rates of non-adherence to antipsychotic medications for FEP patients are estimated to be at or higher than 50% within the first year of treatment, suggesting that malleable factors linked to non-adherence need to be targeted in interventions provided. Factors influencing adherence can be categorized into four groups: (1) environment-related, (2) patient-related, (3) medication-related, and (4) illness-related. This paper will review the factors associated with adherence and discuss solutions to optimize engagement, adherence to medication, and treatment in order to prevent relapse. Factors like social and family support, therapeutic alliance, attitudes and beliefs toward illness and medication, insight, substance use disorders, medication efficacy, tolerability, and accessibility will be discussed. Solutions, such as early psychosis specialized services integrating psychosocial therapies and careful selection of appropriate antipsychotic medication, will be proposed.

"There are too many steps before you get to where you need to be": help-seeking by patients with first-episode psychosis

BACKGROUND

There has been substantial research on pathways to care in first-episode psychosis (FEP); however, few studies have used a qualitative research paradigm or have been done from the perspective of the person experiencing the psychotic episode.

OBJECTIVE

We sought to describe the experiences of patients with FEP on their pathway to care and to identify factors that help or hinder help-seeking efforts.

METHODS

Using a qualitative descriptive approach, we conducted semi-structured interviews with 16 patients recruited from an early intervention program. Data were analyzed using content analysis to organize the findings into themes.

FINDINGS

Self-stigma and a pervasive lack of knowledge regarding the symptoms of psychosis and availability of services were barriers to help-seeking. Participants highlighted the crucial role of significant others in initiating the help-seeking process. Participants typically described a complex series of contacts along the pathway to care which resulted in feelings of being misunderstood and losing control, but many individuals identified unexpected benefits of their experience.

CONCLUSIONS

Our findings suggest a shift in the philosophy and orientation of service delivery towards the creation of services that address these concerns and are relevant to the young people who utilize them.

Reducing treatment delay for early intervention: evaluation of a community based crisis helpline

BACKGROUND

A limited number of studies have assessed the pathways to care of patients experiencing psychosis for the first time. Helpline/clinic programs may offer patients who are still functional but have potential for crisis an alternative that is free from judgment.

METHODS

In this study we report on patient calling a round-the-clock crisis helpline for suicide prevention supported by psychiatric facilities in Mumbai, India. Chi-square and test of mean differences were used to compare outcomes between first-episode patients and those with a previous history.

RESULTS

Within five years, the helpline received 15,169 calls. Of those callers, 2341 (15.4%) experienced suicidal ideation. Two hundred and thirty four patients opting for counseling lasting 12 months agreed to a psychiatric assessment. Of those, 32 were fist time psychosis sufferers, whereas, 54 had previously been psychotic. Of all psychiatric assessments, the clinic received 94 patients with 'first-episode psychosis'. We found that the duration of illness was significantly shorter (17 vs. 28 months) and suicide attempts were fewer (16 vs. 21) in first-time psychosis sufferers compared to those with a treatment history.

CONCLUSIONS

We conclude that some first-episode patients of schizophrenia and other disorders do access services by using helplines. We also argue that helplines may be somewhat immune to stigma, allowing patients a safe alternative when finding help.

Stigma of Mental Illness-1: Clinical reflections

Although the quality and effectiveness of mental health treatments and services have improved greatly over the past 50 years, therapeutic revolutions in psychiatry have not yet been able to reduce stigma. Stigma is a risk factor leading to negative mental health outcomes. It is responsible for treatment seeking delays and reduces the likelihood that a mentally ill patient will receive adequate care. It is evident that delay due to stigma can have devastating consequences. This review will discuss the causes and consequences of stigma related to mental illness.

Constructing illness: how the public in eight Western nations respond to a clinical description of "schizophrenia"

According to classic and contemporary social theory, the community is crucial to how individuals respond to the onset of health problems. Cultural response to symptoms provides the foundation for lay diagnosis; offers a gauge for marking individual and societal health literacy; and reflects the cultural embeddedness of modern medical knowledge. Using data collected between 2004 and 2007 from the Stigma in Global Context - Mental Health Study (SGC-MHS) on the recognition of schizophrenia from vignettes describing individuals meeting DSM-IV criteria, we examine the nature and correlates of lay diagnosis. Focusing on Western societies in the SGC-MHS, we ask three questions regarding problem recognition in Bulgaria (N = 255), Cyprus (N = 253), Germany (N = 382), Hungary (N = 352), Iceland (N = 291), Spain (N = 327), Great Britain (N = 289), and the United States (N = 449): (1) What is the cross-national variation in recognition of schizophrenia as a mental illness? (2) Is lay diagnosis associated with individuals' socio-demographic characteristics and/or their evaluation of underlying causes? (3) Are lay diagnoses likely to shape the nature and direction of the illness career? We find lay diagnosis of "mental illness" to be high across these Western nations with some, though modest, difference across countries. Variation for the more specific diagnosis of "schizophrenia" is greater, though fairly consistent in country ordering. Lay diagnoses are shaped most consistently by attributions, inconsistently by socio-demographics, and generally associated with respondents' treatment recommendations and expected outcomes. In light of assumptions about public beliefs and knowledge that often underlie research, community efforts, clinical programs, and health policy, these findings suggest that a greater understanding of the complexities of lay diagnosis is warranted.

Labeling of mental disorders and stigma in young people

Mental disorders are common in young people, yet many do not seek help. The use of psychiatric labels to describe mental disorders is associated with effective help-seeking choices, and is promoted in community awareness initiatives designed to improve help-seeking. However these labels may also be coupled with stigmatizing beliefs and therefore inhibit help-seeking: lay mental health or non-specific labels may be less harmful. We examined the association between labeling of mental disorders and stigma in youth using data from a national telephone survey of 2802 Australians aged 12-25 years conducted from June 2006 to August 2006. Label use and stigmatizing beliefs were assessed in response to vignettes of a young person experiencing depression, psychosis or social phobia. Logistic regressions examined the association between a range of labels commonly used, including psychiatric labels, and a range of stigma components. There were no significant associations between label use and the stigma components of "stigma perceived in others", "reluctance to disclose" and for the most part "social distance". Most mental health labels were associated with seeing the person as "sick" rather than "weak" and accurate psychiatric labels had the strongest effect sizes. However, for the psychosis vignette, the "dangerous/unpredictable" component was predicted by the labels "schizophrenia/psychosis", "mental illness" and "psychological problem", and the accurate psychiatric label showed the strongest association. For all vignettes, generic lay labels were not associated with stigma, but also rarely had a counter stigma effect. These findings suggest that the use of accurate psychiatric labels by young people is seldom associated with stigma and may assist young people by reducing perceptions of weakness. However, community education that promotes accurate labeling of psychosis should proceed with caution and address beliefs about dangerousness and unpredictability.

Implications of weight-based stigma and self-bias on quality of life among individuals with schizophrenia

Obesity has been associated with significant stigma and weight-related self-bias in community and clinical studies, but these issues have not been studied among individuals with schizophrenia. A consecutive series of 70 obese individuals with schizophrenia or schizoaffective disorder underwent assessment for perceptions of weight-based stigmatization, self-directed weight bias, negative affect, medication compliance, and quality of life. The levels of weight-based stigmatization and self-bias were compared with levels reported for nonpsychiatric overweight/obese samples. Weight measures were unrelated to stigma, self-bias, affect, and quality of life. Weight-based stigmatization was lower than published levels for nonpsychiatric samples, whereas levels of weight-based self-bias did not differ. After controlling for negative affect, weight-based self-bias predicted an additional 11% of the variance in the quality of life measure. Individuals with schizophrenia and schizoaffective disorder reported weight-based self-bias to the same extent as nonpsychiatric samples despite reporting less weight stigma. Weight-based self-bias was associated with poorer quality of life after controlling for negative affect.

Evidence-based practice problems: form and focus

Health care reform poses major challenges for psychiatric mental health care. Foremost among the challenges is a mandate for reimbursement based on performance-based outcomes. Clinicians can increase the efficiency of evidence-based practice searches by using the correct form of PICOT (population, intervention, comparator, outcome, time frame) question to focus the search, based on (a) diagnosis, (b) treatment, (c) prognosis, (d) etiology, (e) prevention, and (f) meaning. The correct form of a PICOT question focuses the literature search by requiring a minimum of sorting to find relevant studies. Quickly and effectively locating the critical evidence will help meet the performance standard mandates required by new health care reform legislation.

The period of untreated psychosis before treatment initiation: a qualitative study of family members' perspectives

AIM

This study used a qualitative research methodology to explore common themes pertaining to the period of untreated psychosis before treatment initiation in hospitalized, urban, African American, first-episode psychosis patients.

METHODS

Twelve family members of 10 patients were interviewed at length to gather detailed narrative accounts of factors related to untreated psychosis and treatment delay. Using qualitative analysis, verbatim transcripts were reviewed by 2 researchers to identify prominent themes useful for generating future research hypotheses.

RESULTS

Four themes emerged as informative of the period of untreated psychosis before treatment initiation: (1) misattribution of symptoms or problem behaviors (eg, depression, drug use, and adolescent rebellion), (2) positive symptoms causing unusual or dangerous behaviors that served as a catalyst for initiating treatment, (3) views about personal autonomy of an adult or nearly adult patient, and (4) system-level factors (eg, unaffordability of health care and inefficiency on the part of health care providers).

CONCLUSIONS

Family members encountered numerous barriers when seeking treatment, including their own misattributions, the nature of the patient's symptoms, financial issues, and system-level delays. The themes uncovered in this formative analysis merit further exploration with additional qualitative and quantitative research.