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Sarah Cruddas BSc MSc1*

Research Assistant, Greenwood Institute of Child Health, Leicester, UK.

*Corresponding Author:
Sarah Cruddas
Research Assistant, Greenwood Institute of Child Health
Westcotes House, Westcotes Drive, Leicester LE3 0QU, UK.
Tel:
+44 (0)116 225 2885
fax: +44 (0)116 225 2881
email: [email protected]
 
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Ghali et al highlight the benefits of early intervention in psychosis, as longer periods without treatment have been related to a poorer prognosis. Based on this, the authors sought to examine the duration of untreated psychosis (DUP) among different ethnic groups in the UK, with a specific focus on routes into care. They refer specifically to the initiation of psychopharmacology with regard to early intervention in psychosis. The suggestion that extended DUP is related to poor prognosis as a result of delayed initiation of drug treatment has been criticised, as early intervention was thought to have a positive effect on psychosis prior to the development of antipsychotic drugs (Warner, 2013). However, the study assessed the period leading to the initiation of antipsychotic drugs and also the time taken to refer patients into early intervention services. When confounding variables were controlled for, the white other, South Asian, black British and black African groups experienced significantly shorter periods of referral to services compared with the white British group. In terms of initiation of drug treatment, the South Asian, black Caribbean and black African groups experienced shorter periods.

Ghali et al suggest that the differences in DUP exhibited by the various ethnic groups may be influenced by differing routes into care. The study found that white British participants were more likely to access care via a GP compared with white other, black British and black Caribbean groups, whereas the latter groups were more likely to contact the emergency services. Furthermore, all of the black groups were more likely to access care via a criminal justice agency. Alternatively, when controlling for confounding variables, the differences in pathways to care via GPs only remained significant for black British participants, indicating the complexity of factors affecting routes into care. Ghali et al speculate that routes into care via GPs may be popular among white British patients, due to an increased likelihood of being registered with a GP, higher levels of confidence in primary care services, and greater interest in understanding the symptoms of psychosis. In contrast, treatment may be avoided until crisis point is reached by individuals who hold negative beliefs about the services. For example, black patients are highlighted as being more likely to present to the accident and emergency services once crisis point has been reached.

Alternatively, differences in DUP may be related to the mode of onset of psychosis, such that early intervention is associated with an increased likelihood of experiencing brief psychosis with a better prognosis (Warner, 2013). However, acute psychosis may be more common in black and minority ethnic groups, and their need for care may be noticed earlier through attention from police and emergency services, leading to reduced DUP. Ghali et al do briefly refer to the possibility that the differences between groups are associated with mode of onset, as insidious psychosis may be related to increased DUP. They also mention that this may constitute a confounding effect, as white British groups may experience a more insidious onset of the disorder. In addition, the study found that longer DUP was related to the GP route to care, whereas it was shorter for both other routes. According to the authors, this slower referral from GPs may indeed be explained by the possibility that they are approached by less acute or high-risk cases, potentially associated with delays in seeking intervention and reduced likelihood of starting medication. Alternatively, they suggest that GPs may either lack the skills to recognise early psychosis, or be uncertain how to approach patients who decline most help and are resistant to referral to mental health services. It may also reflect a less clear clinical picture. However, the reasons for the observed differences in routes to care may be more complicated than they first appear and therefore require further investigation, as previous research suggests that other factors may be involved. For example, Fearon (2013) has highlighted the fact that black Caribbean family members are more likely to call the police than to involve other services over concerns about their relative’s behaviour.

Ghali et al highlight the importance of reducing delays in routes to services via primary care for white British patients, and suggest that education and encouragement of swift referral for GPs may be beneficial. Different recommendations were provided depending on ethnicity, with a focus on reducing coercive routes to care for members of black ethnic groups, which may serve to increase engagement with services and treatment. Raising public awareness through education, combined with direct access to services, was also highly recommended for reducing DUPin general. Although at first sight this seems like a sensible approach to reducing DUP and potentially improving prognosis, increasing knowledge of early psychosis symptoms may result in people seeking care unnecessarily. This is particularly important as experiences commonly associated with psychosis, such as paranoia and hearing voices, are also present in the general population, indicating that clinical psychosis symptoms and psychosis-like experiences may exist on a continuum with ‘normality’ (van Os et al, 2009). This suggests that individuals differ in terms of the severity of their experiences and related distress, rather than in the types of experience. Therefore greater knowledge may lead to unnecessary concern and help seeking due to the potential for brief anomalous experiences to be mistaken for psychotic symptoms. Furthermore, some cases resolve without intervention involving drug treatments (Calton et al, 2008), which some authors have argued may exacerbate long-term outcomes (Warner, 2013). Education and increased help seeking in response to very early signs or symptoms may therefore also expose people to unnecessary antipsychotic drug treatment.

Ghali et al have made an important contribution to the literature, as this is the first UK study on ethnic differences in routes into early intervention care for psychosis. However, the study failed to differentiate between South Asian ethnic groups, due to its limited sample size, so participants who identified their ethnicity as Bangladeshi, Pakistani or Indian were combined to form a general South Asian ethnic group. Therefore differences in routes into care for the individual groups within this category were not assessed and remain unknown. Furthermore, data were collected mainly from inner-city areas, which have been associated with an increased risk of developing psychotic disorders (Kelly et al, 2010). This possible association was not statistically controlled for, and may also explain some of the variance among the data. Despite this, the study has been acknowledged for its contributions to current knowledge about DUP in a relatively large UKsample of early intervention service patients, the routes to these services for various ethnic groups, and possible factors which may improve or impede access to early intervention services (Fearon, 2013).

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