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Brief Reports   |    
Pathways to Care for African Americans With Early Psychosis
Orlena B. Merritt-Davis, M.D.; Matcheri S. Keshavan, M.D.
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.7.1043

Research examining pathways to care among African Americans with recent-onset psychosis is limited but suggests that African Americans have more complex and less desirable routes into care compared with whites. Delays in treatment of psychotic illness contribute to increasing rates of hospitalization, lengths of stay, long-term functional disability, and poor outcomes. African Americans may be less likely to seek help than whites, which may be due partly to stigma and beliefs in the African-American community about causes of mental illness as well as to external obstacles, such as involuntary civil commitment. Because African Americans are more likely than whites to seek assistance in primary care, the general practitioner or family physician has a potentially greater role in the identification of psychotic illnesses among African Americans. Further research is necessary to evaluate the role of ethnicity in treatment delays among patients with recent-onset psychotic illnesses. (Psychiatric Services 57:1043-1044, 2006)

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Dr. Merritt-Davis is affiliated with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 2751 East Jefferson, Detroit, Michigan 48207 (e-mail, omdavis@med.wayne.edu). Dr. Keshavan is with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, and the Department of Psychiatry, University of Pittsburgh, Pennsylvania.

Differences in rates and patterns of mental health treatment have been observed between African Americans and whites. In the report titled Mental Health: Culture, Race, and Ethnicity (1), then-Surgeon General David Satcher highlighted the racial, ethnic, and cultural disparities in mental health services for African Americans. This population tends to be underrepresented in out-patient care and overrepresented in inpatient and emergency care. Failure to receive outpatient care early during episodes of mental illness contributes to increasing rates of hospitalization, lengths of stay, long-term functional disability, and poor outcomes among African Americans. Routes of access to psychiatric services are often less desirable among African Americans, with higher rates of involuntary civil commitment and police involvement. Moreover, when African Americans receive mental health care, the care is often of lower quality compared with the care that whites receive. Despite these and other well-documented disparities in mental health care for African Americans, little is known about the nature and extent of treatment delays for those who have psychotic illnesses. This article describes factors contributing to treatment delays among African Americans with psychotic illnesses and emphasizes the need for further research.

Psychotic illnesses cause significant disability and have devastating effects on the lives of affected individuals and their family, friends, and community. Studies of mostly non-African-American patients have revealed that delays in obtaining appropriate treatment in the course of psychotic illnesses are common and occur from the onset of the illness and first helper contact (2,3) and between the first helper contact and successful treatment (4,5). Not uncommonly, patients experience psychotic symptoms for one to two years before appropriate treatment is initiated (4,5). Research further suggests a link between the duration of untreated psychosis and treatment outcomes, with longer durations of untreated psychosis being associated with poorer short-term and long-term treatment outcomes (6,7). The interval between the onset of psychosis and treatment may also be a period of increased suicide risk—nearly 50 percent of patients in one study reported suicidal ideation during this period (8).

Although research examining the pathways to care for African Americans with psychotic symptoms is vastly undeveloped, treatment delays have been reported to be similar to findings among whites and other ethnic groups (9). However, contrary to findings for whites, findings for blacks of Caribbean and African origin show more complex and aversive pathways to the hospital (10). Compared with white patients who experience relatively straightforward pathways, few black patients are admitted for treatment after a single consultation, and many follow tortuous routes that often involve the police (10).

Among the providers who are reported to be most successful in obtaining treatment during the early course of a psychotic illness is the general practitioner or family physician (2). Involvement of the general practitioner also has been associated with more desirable routes to care, including less likelihood of police involvement and compulsory admission (11). Among patients with psychotic illnesses, there is evidence that African Americans are more likely than whites to make contact with a general practitioner but are less likely to be referred for psychiatric care (10). This finding is consistent with other findings in the mental health literature that suggest that the mental health needs of African-American patients do not receive adequate attention from primary care physicians (12).

Various cultural and ethnic factors influence help-seeking behaviors and thus affect the length of time to treatment for African Americans with psychotic illnesses. Knowledge about mental illness and mental health services and social attitudes and perceptions may be important mediators of help-seeking behavior among patients and families (13,14). Early psychotic symptoms have been attributed by African Americans to depression, lack of motivation, and relational stress, which may reflect insufficient knowledge of psychotic symptoms (9). African Americans also may exhibit higher distress thresholds, as decisions to seek help have been reported to hinge on the emergence of behaviors that are unbearable or that create a social disturbance (9). This apparent lessened tendency to seek help may be related to greater stigma in the African-American community, as mentally ill individuals are more likely to be viewed as morally inferior (15). African Americans more strongly endorse folk, supernatural, spiritual, or mystical beliefs as causes of illness, which have been associated with lower rates of mental health service use (15). They also are less likely to perceive themselves as having a mental health problem (10) and are more likely to fear mental health treatment (1).

Reducing treatment delays among African Americans with psychotic illnesses requires further examination of factors influencing the duration of untreated psychosis. Although existing studies suggest that treatment delays are common among African Americans (9), most investigations have been conducted with African-Caribbean patients in the United Kingdom (2,10,11), which raises the question of the translatability of these findings to African Americans residing in the United States. Given the higher than expected rates of schizophrenia diagnoses and other well-recognized disparities in access, treatment, and quality of mental health services for African Americans (1), further examination of the role of ethnicity in treatment delays among patients with recent-onset psychosis is warranted.

Efforts to engage African Americans in research must be undertaken to identify and minimize barriers to successful early intervention. Increasing the research base with African Americans will require community educational efforts, with particular attention to overcoming the reluctance and mistrust based on past research abuses and other negative historical experiences with the health care system. Initiatives to increase the public's mental health literacy and awareness of treatment interventions for early psychosis also warrant support. Finally, carefully designed educational interventions targeting emergency and general practitioners and family physicians are needed to improve knowledge of early psychosis and familiarity with local referral processes for mental health services. The specific content of these interventions must increase awareness of racial, ethnic, and cultural influences on health beliefs and behaviors.

Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2001
 
Addington J, van Mastrigt S, Hutchinson J, et al: Pathways to care: help seeking behaviour in first episode psychosis. Acta Psychiatrica Scandinavica 106:358-364, 2002
 
Norman RMG, Malla AK, Verdi MB, et al: Understanding delay in treatment for first-episode psychosis. Psychological Medicine 34:255-266, 2004
 
Loebel AD, Lieberman JA, Alvir JMJ, et al: Duration of psychosis and outcome in first-episode schizophrenia. American Journal of Psychiatry 149:1183-1188, 1992
 
Johannessen JO, Larsen TK, McGlashan TH: Duration of untreated psychosis (DUP): an important target for intervention in schizophrenia? Nordic Journal of Psychiatry 53:275-283, 1999
 
McGlashan TH: Duration of untreated psychosis in first-episode schizophrenia: marker or determinant of course? Biological Psychiatry 46:899-907, 1999
 
Keshavan MS, Haas G, Miewald J, et al: Prolonged untreated illness duration from prodromal onset predicts outcome in first episode psychoses. Schizophrenia Bulletin 29:757-769, 2003
 
Lincoln C, Harrigan S, McGorry PD: Understanding the topography of the early psychosis pathway: an opportunity to reduce delays in treatment. British Journal of Psychiatry 172:21-25, 1998
 
Compton MT, Kaslow NJ, Walker EF: Observations on parent/family factors that may influence the duration of untreated psychosis among African American first-episode schizophrenia-spectrum patients. Schizophrenia Research 68:373-385, 2004
 
Commander MJ, Cochrane R, Sashidharan P, et al: Mental health care for Asian, black and white patients with non-affective psychosis: pathways to the psychiatric hospital, in-patient and after-care. Social Psychiatry and Psychiatric Epidemiology 34:484-491, 1999
 
Cole E, Leavey G, King M, et al: Pathways to care for patients with a first episode of psychosis: a comparison of ethnic groups. British Journal of Psychiatry 167:770-776, 1995
 
Sleath B, Svarstad B, Roter D: Patient and psychotropic prescribing during medical encounters. Patient Education Counseling 24:227-238, 1998
 
Landrine H, Klonoff EA: Cultural diversity in causal attributions for illness: the role of the supernatural. Journal of Behavioral Medicine 17:181-193, 1994
 
Angermeyer MC, Klusmann D: The causes of functional psychosis as seen by patients and their relatives: I. the patients' point of view. European Archives of Psychiatry and Neurological Sciences 238:47-54, 1988
 
Alvidrez J: Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European young women. Community Mental Health Journal 35:515-530, 1999
 
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References

Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2001
 
Addington J, van Mastrigt S, Hutchinson J, et al: Pathways to care: help seeking behaviour in first episode psychosis. Acta Psychiatrica Scandinavica 106:358-364, 2002
 
Norman RMG, Malla AK, Verdi MB, et al: Understanding delay in treatment for first-episode psychosis. Psychological Medicine 34:255-266, 2004
 
Loebel AD, Lieberman JA, Alvir JMJ, et al: Duration of psychosis and outcome in first-episode schizophrenia. American Journal of Psychiatry 149:1183-1188, 1992
 
Johannessen JO, Larsen TK, McGlashan TH: Duration of untreated psychosis (DUP): an important target for intervention in schizophrenia? Nordic Journal of Psychiatry 53:275-283, 1999
 
McGlashan TH: Duration of untreated psychosis in first-episode schizophrenia: marker or determinant of course? Biological Psychiatry 46:899-907, 1999
 
Keshavan MS, Haas G, Miewald J, et al: Prolonged untreated illness duration from prodromal onset predicts outcome in first episode psychoses. Schizophrenia Bulletin 29:757-769, 2003
 
Lincoln C, Harrigan S, McGorry PD: Understanding the topography of the early psychosis pathway: an opportunity to reduce delays in treatment. British Journal of Psychiatry 172:21-25, 1998
 
Compton MT, Kaslow NJ, Walker EF: Observations on parent/family factors that may influence the duration of untreated psychosis among African American first-episode schizophrenia-spectrum patients. Schizophrenia Research 68:373-385, 2004
 
Commander MJ, Cochrane R, Sashidharan P, et al: Mental health care for Asian, black and white patients with non-affective psychosis: pathways to the psychiatric hospital, in-patient and after-care. Social Psychiatry and Psychiatric Epidemiology 34:484-491, 1999
 
Cole E, Leavey G, King M, et al: Pathways to care for patients with a first episode of psychosis: a comparison of ethnic groups. British Journal of Psychiatry 167:770-776, 1995
 
Sleath B, Svarstad B, Roter D: Patient and psychotropic prescribing during medical encounters. Patient Education Counseling 24:227-238, 1998
 
Landrine H, Klonoff EA: Cultural diversity in causal attributions for illness: the role of the supernatural. Journal of Behavioral Medicine 17:181-193, 1994
 
Angermeyer MC, Klusmann D: The causes of functional psychosis as seen by patients and their relatives: I. the patients' point of view. European Archives of Psychiatry and Neurological Sciences 238:47-54, 1988
 
Alvidrez J: Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European young women. Community Mental Health Journal 35:515-530, 1999
 
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