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Pathways to care, DUP, and types of interventions over 5 years following psychosis onset: findings from a naturalistic study conducted in routine generalist mental health services

  • Elisabetta Miglietta
  • Antonio LasalviaEmail author
  • Chiara Bonetto
  • Carla Comacchio
  • Doriana Cristofalo
  • Sarah Tosato
  • Katia De Santi
  • Sara Petterlini
  • Gioia Zanatta
  • Carla Cremonese
  • Luana Ramon
  • Mirella Ruggeri
  • The PICOS Veneto Group
Original Paper
  • 18 Downloads

Abstract

Purpose

To describe pathways to care, duration of untreated psychosis (DUP), and types of interventions provided to first-episode psychosis (FEP) patients by routine Italian mental health services over 5 years since the first service contact.

Methods

Naturalistic study conducted in Veneto, within the context of the Psychosis Incident Cohort Outcome Study (PICOS). A comprehensive set of measures was used, including schedules designed to collect information on referrals to psychiatric services and on psychological and pharmacological treatments at 1, 2, and 5 years since first service contact.

Results

Overall, 397 patients were assessed. Most engaged with services with the help of family members (47.4%) and through emergency routes (60.3%). Those referred by clinicians were more likely to access care in a non-emergency way. Mean DUP was 5.62 months (SD 11.8) and longer DUP was associated with poorer functioning at 2 and 5 years. Interventions provided over 5 years were mainly constituted by antipsychotic medications (95.4% at 1 year; 85.8% at 2 years; 80.6% at 5 years), whereas a lower percentage (69.1% at 1 year; 61.5% at 2 years; 44.9% at 5 years) also received some forms of psychological interventions, mainly consisting of unspecific support sessions. Other structured interventions, such as CBT or family interventions, were seldom provided at each time-point.

Conclusions

Mental health services in Veneto seem effective in engaging FEP patients within a short time since illness onset. However, type of care provided does not meet quality standards recommended by treatment guidelines, especially regarding psychological interventions.

Keywords

First-episode psychosis (FEP) Pathways to care Patterns of care Psychological interventions Duration of untreated psychosis (DUP) 

Notes

Acknowledgements

This study was partially supported by Fondazione Cariverona with the grant “Disabilità cognitiva e comportamentale nelle demenze e nelle psicosi. Sotto-obiettivo A.9. Basi morfofunzionali cognitive e genetiche delle psicosi maggiori: uno studio integrato longitudinale” to M. Ruggeri and S. Tosato.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interest.

Ethical approval

The PICOS was approved by the ethics committee of the coordinating center—Azienda Ospedaliera di Verona (N. prog. 1103, 27.10.2004) and of the local collaborating sites.

References

  1. 1.
    National Institute for Clinical Excellence (NICE) (2014) Psychosis and schizophrenia in adults: prevention and management, http://www.nice.org.uk/CG178. Accessed 1 Aug 2019
  2. 2.
    American Psychiatric Association (APA) (2004) Practice guideline for the treatment of patients with schizophrenia, Second Edition. Am J Psychiatry 161(supplement):1–56Google Scholar
  3. 3.
    Galletly C, Castle D, Dark F et al (2016) Royal Australian and New Zealand college of psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry 50(5):410–472.  https://doi.org/10.1177/0004867416641195 CrossRefGoogle Scholar
  4. 4.
    De Masi S, Sampaolo L, Mele A et al (2008) The Italian guidelines for early intervention in schizophrenia: development and conclusions. Early Interv Psychiatry 2:291–302.  https://doi.org/10.1111/j.1751-7893.2008.00091.x CrossRefGoogle Scholar
  5. 5.
    Norman RM, Malla AK (2001) Duration of untreated psychosis: a critical examination of the concept and its importance. Psychol Med 31(3):381–400CrossRefGoogle Scholar
  6. 6.
    Perkin DO, Gu H, Boteva K, Lieberman JA (2005) Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 162(10):1785–1804.  https://doi.org/10.1176/appi.ajp.162.10.1785 CrossRefGoogle Scholar
  7. 7.
    Penttila M, Jaaskelainen E, Hirvonen N, Isohanni M, Miettunen J (2014) Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry 205(2):88–94.  https://doi.org/10.1192/bjp.bp.113.127753 CrossRefGoogle Scholar
  8. 8.
    Albert N, Melau M, Jensen H et al (2017) The effect of duration of untreated psychosis and treatment delay on the outcomes of prolonged early intervention in psychotic disorders. NPJ Schizophr 3(1):34.  https://doi.org/10.1038/s41537-017-0034-4 CrossRefGoogle Scholar
  9. 9.
    Anderson KK, Fuhrer R, Malla AK (2010) The pathways to mental health care of first-episode psychosis patients: a systematic review. Psychol Med 40(10):1585–1597.  https://doi.org/10.1017/S0033291710000371 CrossRefGoogle Scholar
  10. 10.
    O’Callaghan E, Turner N, Renwick L et al (2010) First episode psychosis and the trail to secondary care: help-seeking and health-system delays. Soc Psychiatry Psychiatr Epidemiol 45(3):381–391.  https://doi.org/10.1007/s00127-009-0081-x CrossRefGoogle Scholar
  11. 11.
    Bhui K, Ullrich S, Coid JW (2014) Which pathways to psychiatric care lead to earlier treatment and a shorter duration of first-episode psychosis? BMC Psychiatry 14:72.  https://doi.org/10.1186/1471-244X-14-72 CrossRefGoogle Scholar
  12. 12.
    Volpe U, Fiorillo A, Luciano M et al (2014) Pathways to mental health care in Italy: results from a multicenter study. Int J Soc Psychiatry 60(5):508–513.  https://doi.org/10.1177/0020764013501648 CrossRefGoogle Scholar
  13. 13.
    MacDonald K, Fainman-Adelman N, Anderson KK, Iyer SN (2018) Pathways to mental health services for young people: a systematic review. Soc Psychiatry Psychiatr Epidemiol 53(10):1005–1038.  https://doi.org/10.1007/s00127-018-1578-y CrossRefGoogle Scholar
  14. 14.
    Breitborde NJ, Moe AM, Ered A et al (2017) Optimizing psychosocial interventions in first-episode psychosis: current perspectives and future directions. Psychol Res Behav Manag 10:119–128.  https://doi.org/10.2147/PRBM.S111593 CrossRefGoogle Scholar
  15. 15.
    Fusar-Poli P, McGorry PD, Kane JM (2017) Improving outcomes of first-episode psychosis: an overview. World Psychiatry 16:251–265.  https://doi.org/10.1002/wps.20446 CrossRefGoogle Scholar
  16. 16.
    Ehmann TS, Tee KA, MacEwan GW et al (2014) Treatment delay and pathways to care in early psychosis. Early Interv Psychiatry 8(3):240–246.  https://doi.org/10.1111/eip.12051 CrossRefGoogle Scholar
  17. 17.
    Cabassa LJ, Piscitelli S, Haselden M et al (2018) Understanding pathways to care of individuals entering a specialized early intervention service for first-episode psychosis. Psychiatr Serv 69(6):648–656.  https://doi.org/10.1176/appi.ps.201700018 CrossRefGoogle Scholar
  18. 18.
    Lasalvia A, Tosato S, Brambilla P et al (2012) Psychosis Incident cohort outcome study (PICOS). A multisite study of clinical, social and biological characteristics, patterns of care and predictors of outcome in first-episode psychosis. Background, methodology and overview of the patient sample. Epidemiol Psychiatr Sci 21(3):281–303.  https://doi.org/10.1017/s2045796012000315 CrossRefGoogle Scholar
  19. 19.
    Jablensky A, Sartorius N, Ernberg G et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A world health organization ten-country study. Psychol Med Monogr Suppl 20:1–97CrossRefGoogle Scholar
  20. 20.
    World Health Organization (1992) Schedules for Clinical Assessment in Neuropsychiatry (SCAN), version 1.0. World Health Organization: GenevaGoogle Scholar
  21. 21.
    Kay SR, Fiszbein A, Opler LA (1987) The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 13(2):261–276CrossRefGoogle Scholar
  22. 22.
    American Psychiatric Association (APA) (1994) Diagnostic and statistical manual of mental disorder, 4th edition (DSM-IV). American Psychiatric Association, WashingtonGoogle Scholar
  23. 23.
    Priebe S, Huxley P, Knight S et al (1999) Application and results of the manchester short assessment of quality of life (MANSA). Int J Soc Psychiatry 45(1):7–12.  https://doi.org/10.1177/002076409904500102 CrossRefGoogle Scholar
  24. 24.
    Cocchi A, Meneghelli A, Erlicher A et al (2013) Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy. Soc Psychiatry Psychiatr Epidemiol 48(12):1905–1916.  https://doi.org/10.1007/s00127-013-0736-5 CrossRefGoogle Scholar
  25. 25.
    Del Vecchio V, Luciano M, Sampogna G et al (2015) The role of relatives in pathways to care of patients with a first episode of psychosis. Int J Soc Psychiatry 61(7):631–637.  https://doi.org/10.1177/0020764014568129 CrossRefGoogle Scholar
  26. 26.
    Anderson KK, Fuhrer R, Schmitz N et al (2013) Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis. Soc Psychiatry Psychiatr Epidemiol 48(1):125–136.  https://doi.org/10.1007/s00127-012-0571-0 CrossRefGoogle Scholar
  27. 27.
    Singh SP, Brown L, Winsper C et al (2015) Ethnicity and pathways to care during first episode psychosis: the role of cultural illness attributions. BMC Psychiatry 15:287.  https://doi.org/10.1186/s12888-015-0665-9 CrossRefGoogle Scholar
  28. 28.
    Tarricone I, Braca M, Allegri F et al (2014) First-episode psychosis and migration in Italy (PEP-Ita migration): a study in the Italian mental health services. BMC Psychiatry 14:186.  https://doi.org/10.1186/1471-244x-14-186 CrossRefGoogle Scholar
  29. 29.
    Marshall M, Lewis S, Lockwood A et al (2005) Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 62(9):975–983.  https://doi.org/10.1001/archpsyc.62.9.975 CrossRefGoogle Scholar
  30. 30.
    Amaddeo F, Barbui C, Tansella M (2012) State of psychiatry in Italy 35 years after psychiatric reform. A critical appraisal of national and local data. Int Rev Psychiatry 24(4):314–320.  https://doi.org/10.3109/09540261.2012.694855 CrossRefGoogle Scholar
  31. 31.
    Tansella M, Amaddeo F, Burti L et al (2006) Evaluating a community-based mental health service focusing on severe mental illness. The Verona experience. Acta Psychiatr Scand Suppl 429:90–94.  https://doi.org/10.1111/j.1600-0447.2005.00724.x CrossRefGoogle Scholar
  32. 32.
    Keating D, McWilliams S, Schneider I et al (2017) Pharmacological guidelines for schizophrenia: a systematic review and comparison of recommendations for the first episode. BMJ Open 7(1):e013881.  https://doi.org/10.1136/bmjopen-2016-013881 CrossRefGoogle Scholar
  33. 33.
    Muller H, Laier S, Bechdolf A (2014) Evidence-based psychotherapy for the prevention and treatment of first-episode psychosis. Eur Arch Psychiatry Clin Neurosci 264(suppl 1):17–25.  https://doi.org/10.1007/s00406-014-0538-0 CrossRefGoogle Scholar
  34. 34.
    Cocchi A, Meneghelli A, Preti A (2008) Programma 2000: celebrating 10 years of activity of an Italian pilot programme on early intervention in psychosis. Aust N Z J Psychiatry 42(12):1003–1012.  https://doi.org/10.1080/00048670802512032 CrossRefGoogle Scholar
  35. 35.
    Ghio L, Natta W, Peruzzo L et al (2012) Process of implementation and development of early psychosis clinical services in Italy: a survey. Early Interv Psychiatry 6(3):341–346.  https://doi.org/10.1111/j.1751-7893.2012.00340 CrossRefGoogle Scholar
  36. 36.
    Bertelsen M, Jeppesen P, Petersen L et al (2008) Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Arch Gen Psychiatry 65(7):762–771.  https://doi.org/10.1001/archpsyc.65.7.762 CrossRefGoogle Scholar
  37. 37.
    Gafoor R, Nitsch D, McCrone P et al (2010) Effect of early intervention on 5-year outcome in non-affective psychosis. Br J Psychiatry 196(5):372–376.  https://doi.org/10.1192/bjp.bp.109.066050 CrossRefGoogle Scholar
  38. 38.
    McGorry PD, Ratheesh A, O’Donoghue B (2018) Early intervention- an implementation challenge for 21st century mental health care. JAMA Psychiatry 75(6):545–546.  https://doi.org/10.1001/jamapsychiatry.2018.0621 CrossRefGoogle Scholar
  39. 39.
    Malla A, Joober R, Iyer S, Norman R, Schmitz N, Brown T (2017) Comparing three-year extension of early intervention service to regular care following 2 years of early intervention service in first-episode psychosis: a randomized single blind clinical trial. World Psychiatry 16(3):278–286.  https://doi.org/10.1002/wps.20456 CrossRefGoogle Scholar
  40. 40.
    Bird V, Premkumar P, Kendall T et al (2010) Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J Psychiatry 197:350–356.  https://doi.org/10.1192/bjp.bp.109.074526 CrossRefGoogle Scholar
  41. 41.
    Lally J, Ajnakina O, Stubbs B et al (2017) Remissionand recovery from first-episode psychosis in adults: systematic review and meta-analysis of long-term outcome studies. Br J Psychiatry 211(6):350–358.  https://doi.org/10.1192/bjp.bp.117.201475 CrossRefGoogle Scholar
  42. 42.
    Gustavson K, Von Soest T, Karevold E et al (2012) Attrition and generalizability in longitudinal studies: findings from a 15-year population-based study and a Monte Carlo simulation study. BMC Public Health 12:918.  https://doi.org/10.1186/1471-2458-12-918 CrossRefGoogle Scholar
  43. 43.
    Register-Brown K, Hong LE (2014) Reliability and validity of methods for measuring the duration of untreated psychosis: a quantitative review and meta-analysis. Schizophr Res 160(1–3):20–26.  https://doi.org/10.1016/j.schres.2014.10.025 CrossRefGoogle Scholar
  44. 44.
    Singh SP, Grange T (2006) Measuring pathways to care in first-episode psychosis: a systematic review. Schizophr Res 81(1):75–82.  https://doi.org/10.1016/j.schres.2005.09.018 CrossRefGoogle Scholar
  45. 45.
    Cocchi A, Cavicchini A, Collavo M et al (2015) Implementation and development of early intervention in psychosis services in Italy: a national survey promoted by the associazione Italiana interventi precoci nelle psicosi. Early Interv Psychiatry 12(1):37–44.  https://doi.org/10.1111/eip.12277 CrossRefGoogle Scholar
  46. 46.
    Selick A, Durbin J, Vu N, O’Connor K, Volpe T, Lin E (2017) Barriers and facilitators to implementing family support and education in Early Psychosis Intervention programmes: a systematic review. Early Interv Psychiatry 11(5):365–374.  https://doi.org/10.1111/eip.12400 CrossRefGoogle Scholar
  47. 47.
    Weck F, Kaufmann YM, Höfling V (2017) Competence feedback improves CBT competence in trainee therapists: a randomized controlled pilot study. Psychother Res 27(4):501–509.  https://doi.org/10.1080/10503307.2015.1132857 CrossRefGoogle Scholar
  48. 48.
    Jolley S, Onwumere J, Bissoli S et al (2015) A pilot evaluation of therapist training in cognitive therapy for psychosis: therapy quality and clinical outcomes. Behav Cogn Psychother 43(4):478–489.  https://doi.org/10.1017/S1352465813001100 CrossRefGoogle Scholar
  49. 49.
    Barbui C, Papola D, Saraceno B (2018) Forty years without mental hospitals in Italy. Int J Ment Health Syst 12:43.  https://doi.org/10.1186/s13033-018-0223-1 CrossRefGoogle Scholar
  50. 50.
    Csillag C, Nordentoft M, Mizuno M et al (2018) Early intervention in psychosis: from clinical intervention to health system implementation. Early Interv Psychiatry 12(4):757–764.  https://doi.org/10.1111/eip.12514 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Elisabetta Miglietta
    • 1
  • Antonio Lasalvia
    • 1
    • 2
    Email author
  • Chiara Bonetto
    • 1
  • Carla Comacchio
    • 1
  • Doriana Cristofalo
    • 1
  • Sarah Tosato
    • 1
    • 2
  • Katia De Santi
    • 1
    • 2
  • Sara Petterlini
    • 1
  • Gioia Zanatta
    • 1
  • Carla Cremonese
    • 3
  • Luana Ramon
    • 4
  • Mirella Ruggeri
    • 1
    • 2
  • The PICOS Veneto Group
  1. 1.Department of Neurosciences, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
  2. 2.Unit of Psychiatry, Azienda Ospedaliera Universitaria Integrata (AOUI) di VeronaVeronaItaly
  3. 3.Psychiatric Clinic, Department of NeuroscienceUniversity of PaduaPaduaItaly
  4. 4.Department of Mental HealthNHS, Local Health Authority Portogruaro (VE)PortogruaroItaly

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