مسیری برای روان پریشی: رفتار راهنماجویانه در فاز علائم اولیه بیماری

Background Knowledge of pathways to care by help-seeking patients prior to the onset of psychosis may help to improve the identification of at-risk patients. This study explored the history of help-seeking behavior in secondary mental health care services prior to the onset of the first episode of psychosis. Method The psychiatric case register in The Hague was used to identify a cohort of 1753 people in the age range of 18–35 at first contact who developed a psychotic disorder in the period from 1 January 2005 to 31 December 2009. We retrospectively examined the diagnoses made at first contact with psychiatric services. Results 985 patients (56.2%) had been treated in secondary mental health services prior to the onset of psychosis. The most common disorders were mood and anxiety disorders (N = 385 (39.1%)) and substance use disorders (N = 211 (21.4%)). Affective psychoses were more often preceded by mood/anxiety disorders, while psychotic disorder NOS was more often preceded by personality disorder or substance abuse. The interval between first contact and first diagnosis of psychosis was approximately 69 months in cases presenting with mood and anxiety disorders and 127 months in cases presenting with personality disorders. Discussion This study confirms the hypothesis that the majority of patients with psychotic disorders had been help-seeking for other mental disorders in the secondary mental health care prior to the onset of

Many risk factors contribute to the development of psychotic disorders. Some are distant, such as genetic and other pre- and perinatal risk factors (Harrison and Weinberger, 2005 and Keshavan et al., 2005). Others are more proximal, such as cannabis abuse in adolescence (Moore et al., 2007). The development of psychopathology has in many cases been found to be a prodromal sign for the development of psychotic disorders. Social decline, depression and anxiety problems, sleeping problems, cognitive disturbances and psychotic-like experiences (PLEs) often precede the onset of psychosis (Häfner, 2000, Klosterkötter et al., 2001, Häfner et al., 2005b, Krabbendam and Van Os, 2005, Yung et al., 2005 and Velthorst et al., 2010). Retrospectively, PLEs almost always precede frank psychosis, but prospectively only 8% of new cases with PLEs in the general population develop a psychosis within 24 months (Hanssen et al., 2005). PLEs do not differ in intensity in patients compared with non-patients, but both groups do differ in their need for care (Stip and Letourneau, 2009) and in the distress associated with the symptoms (Yung et al., 2006). Need for care and distress are important determinants of help-seeking behavior, and seeking help for disorders other than psychosis might be an important pathway to psychosis. It is also shown that people who report sub-clinical psychosis are more help-seeking than those subjects who do not report sub-clinical symptoms (Murphy et al., 2010). The combination of risk factors does raise the odds of developing a psychotic disorder. For instance, in a population-based study (NEMESIS) two or more sub-clinical psychotic symptoms with depressed mood result in a forty percent chance of developing a psychosis within 24 months (Hanssen et al., 2005). A review by Anderson et al. (2010) found help-seeking behavior in 33–98% of patients who experienced a first psychotic episode. Some of the studies included in the review found that patients contacted their GPs before the onset of schizophrenia psychosis (Norman et al., 2004). Only two studies have explored help-seeking behavior during the prodromal stage in more detail. In a retrospective study in a cohort of 24 schizophrenia patients, 19 patients (75%) sought help prior to the onset of psychosis (Bota et al., 2005). Of these patients, 14 were diagnosed with an Axis I diagnosis and 15 were prescribed medication or had a psychological intervention. Another retrospective study found evidence for prodromal disorders in 80% of 86 first-episode (schizophrenia) patients of whom 40% showed prodromal help-seeking behavior for these disorders (Addington et al., 2002). These proportions of help-seeking behavior (40 and 75%) are based on small sample sizes, and a more accurate estimate of the prevalence of help-seeking behavior in larger populations entering the secondary mental health services before the onset of the disorder would be helpful. Does help-seeking in secondary mental health services result in the detection of frank psychosis at a much earlier stage? Apparently it does not. Researchers found that the delay in secondary mental health care services was associated with a duration of untreated psychosis that was seven times longer than a direct referral to a first-episode psychosis department. They concluded that intervention is required in secondary as well as primary care services to reduce the duration of untreated psychosis (Brunet et al., 2007 and Boonstra et al., 2008). Health care professionals do not seem to detect the development of psychosis when treating other disorders, or perhaps they are convinced that the psychotic symptoms are secondary to other problems. If a substantial proportion of patients who are likely to develop psychosis in the future do seek help in secondary mental health services, then screening for sub-clinical psychotic symptoms might be a strategy to prevent a lengthy period of untreated psychosis. Targeted intervention might even postpone or prevent a first psychotic episode. An important question remains: what proportion of people with a first psychotic episode has been help-seeking in health services at the prodromal stage? In this study prodromal help-seeking behavior and diagnoses over time were retrospectively explored in all consecutive cases with a psychotic disorder recorded in a psychiatric case register during five years in a well-defined urban catchment area. Additionally, we examined the time between first contact and first diagnosis of psychotic disorder.

The majority of people who have developed a psychotic disorder had been help-seeking for other mental disorders in the prodromal period. Not all those with mental problems will develop a psychosis, but a selection of people with, for example, depression and PLEs probably have an elevated risk of developing a psychosis in the near future. The findings of this study encourage the identification of patients at risk of developing a psychotic disorder in a help-seeking population in secondary mental health care.