Early Identification of People With Psychosis Linked to Educating Outpatient Providers

Early detection and intervention are known to be critical for the successful treatment of psychotic symptoms. But effectively implementing intervention programs requires a good understanding of the population trends—who is showing symptoms and where they are first presenting in the health care system.

To provide a clearer picture of first-episode psychosis prevalence and the settings where patients most commonly presented with these symptoms, researchers examined electronic health record data from five large health care systems (Group Health Cooperative of Washington State and the Colorado, Northern California, Southern California, and Northwest regions of Kaiser Permanente).

The analysis revealed the incidence of first-episode psychosis to be about 86 per 100,000 among people aged 15 to 29 and 46 per 100,000 among those aged 30 to 59; this translates to approximately 56,000 and 58,000 new cases of psychotic symptoms in the United States each year, respectively.

The study, published January 3 in Psychiatric Services in Advance, first compiled all the cases in which new psychosis symptoms were reported in patients aged 15 to 59 who attended one of the five health systems between January 1, 2007, and December 31, 2013; this resulted in 37,843 diagnoses of first-episode psychosis. (Older patients were excluded given the high occurrence of psychosis associated with dementia or other neurodegenerative disorders that might conflate the results.)

The researchers then selected 300 random diagnoses from the records of each of the five health care systems for a more detailed chart review to confirm reported symptoms. The percentage of confirmed cases, based on this chart review, was used to determine the final incidence rates.

Lead author Gregory Simon, M.D., M.P.H., a senior investigator at Group Health Research Institute in Seattle, told Psychiatric News that while the rates of first-episode psychosis identified (86 and 46 per 100,000) are slightly higher than some previous estimates, they are within the range of these reports.

“This is also not the first study to report that new-onset psychosis is common in older adults, but it’s still a prevailing idea that psychosis is a young person’s disorder,” he said. That misconception can be consequential when planning intervention strategies. “Programs that work for a 17-year-old will not necessarily work for someone who is 40.”

Still, Simon said he believes the more telling finding from the study is where the patients with first-episode psychosis were presenting. Only about one-third of diagnoses were made in emergency departments or mental health inpatient settings; the rest of the patients were diagnosed in outpatient settings.

“I think the findings speak to how we should define the problem of new-onset psychosis,” Simon said. “If you define it as symptoms that require someone to be admitted to a hospital, then you are missing a whole lot of patients.”

James Kirkbride, Ph.D., a Sir Henry Dale Fellow in the Psychiatry Department at University College London, commended the researchers’ detailed efforts to calculate and validate where people with first-episode psychoses are being identified in the United States.

Kirkbride recently completed a similar study, which appeared in the February issue of the American Journal of Psychiatry, looking at where people with new psychosis were presenting in eastern England.

Even with the rigorous design employed by Simon and his team, Kirkbride noted that many cases of psychosis were likely missed—most notably among the uninsured, homeless population.

While Simon acknowledged that the results—which were based entirely on presentations within an insured population—likely underestimate the full extent of first-episode psychosis, he said they highlight the importance of educating patients and providers at outpatient facilities about signs of psychosis.

Moving forward, “the big challenge will be striking the balance between identifying first-onset psychosis as early as possible and identifying it as accurately as possible,” Simon said. Regardless, educating providers in outpatient settings about the symptoms of early psychosis could help expand efforts to guide patients at high risk of psychosis to care or social support earlier, he said.

The study was supported by a grant from the National Institute of Mental Health. ■