Pathways to care
What are pathways to care?
The help-seeking efforts made by an individual and their families when symptoms of psychosis are apparent, and the clinical services made available as a result of these efforts, are collectively known as ‘pathways to care’. Pathways to care can also encompass service structures that have not been actively sought by the individual. Understanding pathways to care may improve early intervention strategies and contribute to reducing the duration of untreated psychosis.
What is the evidence for pathways to care?
Moderate to low quality evidence suggest young people have around three contracts before receiving specific services for first-episode psychosis. General practitioners are the most common first contact, followed by psychiatrists or specialised services, emergency or inpatient units, family or friends then social workers. Contacts with counsellors or courts led to longer duration of untreated psychosis, which was shortest following referrals from emergency services or general practitioners. Contact with the criminal justice system, emergency or inpatient units were associated with poor patient experiences, disengagement and high costs, despite sometimes resulting in reduced treatment delays.
Moderate quality evidence suggests having a sense of being different or not normal and characterising this difference negatively leads to fewer pathways to care for people with first-episode psychosis or at-risk mental states. Anticipating and experiencing negative reactions from self or others, employing strategies to avoid these negative reactions (such as nondisclosure of symptoms), lack of awareness and understanding of mental illness, and having a negative opinion of services also impacts on pathways to care. Perceived stigma is associated with more negative help-seeking attitudes towards treatment, and service-related stigma is a reason for opposing psychiatric treatment. Shame is the main reason for nondisclosure of symptoms. Care-givers’ concern that loved ones experiencing first-episode psychosis would be labelled as ‘mad’ was a frequent reason for relatives not contacting psychiatric services.
Moderate to high quality evidence suggests having a diagnosis of a psychotic disorder was associated with more involuntary than voluntary psychiatric admissions, which was a stronger association than for bipolar disorder or organic disorder. Being unemployed, on welfare, single, and having previous involuntary admissions were all related to a higher risk of involuntary admissions.
Moderate quality evidence shows a small effect of more involuntary psychiatric admissions in migrant groups compared to native groups. Compared to white ethnic groups, there were small effects of increased compulsory psychiatric admissions in Black Caribbean, Black African, South Asian, East Asian, and other minority groups. Authors report that the most common explanations for the increased risk of detainment in these groups included psychotic symptoms, perceived risk of violence, having police contact, absence of or mistrust of general practitioners, and ethnic disadvantages. Black people in the U.K. may be more likely to have had compulsory hospital admissions than white people in the U.K, particularly those of African Caribbean or Black African ethnicity. Black people in the UK are also less likely to be hospitalised on first presentation, or to be referred to specialist services, and police are more likely to have been involved during admission. There may be fewer compulsory admissions for Asians with first-episode psychosis in Canada than for Whites, Blacks, or those of other ethnic backgrounds.
Moderate quality evidence suggests the worldwide voluntary admission rate is around 62%, while the worldwide involuntary admission rate is around 43%.
Green - Topic summary is available.
Orange - Topic summary is being compiled.
Red - Topic summary has no current systematic review available.