Introduction
Methodology
Search strategy
Selection of relevant studies
Data extraction
Results
Study characteristics and settings
Study | Study objectives | Country | Population | Setting |
N
| Mean age (range) | (% male) | Instrument | Source of data |
---|---|---|---|---|---|---|---|---|---|
Addington et al. [22] | To determine the number of attempts it took before patients with FEP received adequate help, the signs or symptoms that led them to seek help and the people from whom they attempted to seek help | Calgary, Canada | First-episode psychosis | Early intervention for psychosis program | 86 | 24 (15–51) | 66.3% | Interview developed for the study | II + FI |
Anderson et al. [12] | To estimate the extent to which sociodemographic, clinical, and service-level factors were associated with negative pathways to care and referral delay | Montreal, Canada | First-episode psychosis | Early intervention for psychosis program | 324 | Median 22.6 (14–30) | 69.8% | CORS | II + FI + CR |
Anderson et al. [23] | To compare the pathways to care and duration of untreated psychosis for people of Black African, Black Caribbean, or White European origin with FEP | Toronto and Hamilton, Canada | First-episode psychosis | Early intervention for psychosis program | 171 | 21 (19–27) | 66.7% | WHO Encounter Form | II + FI + CR |
Archie et al. [24] | To examine ethnic variations in the pathways to care for persons accessing early intervention services in Ontario | Ontario, Canada | First-episode psychosis | Early intervention for psychosis program | 200 | 24.5 (16–50) | 78% | CORS | II + FI + CR |
Bakare [25] | To assess first points of contact and referral sources for a group of patients seen in a neuropsychiatric facility in South-Eastern Nigeria | Enugu, Nigeria | Any mental illness | Child and adolescent inpatient unit | 393 | 15.7 (3–18) | 55.7% | Interview developed for study | II + FI |
Bekele et al. [26] | To describe the routes taken by patients to reach psychiatric care, evaluate the time delay before seeking psychiatric care, and investigate the relationship between delays in the pathway to care and sociodemographic and clinical factors | Addis Ababa, Ethiopia | Any mental illness | Mental health hospital (inpatient and outpatient) | 1044 | 29 (2–85) | 62.2% | WHO Encounter Form | II + CR |
Bhui et al. [27] | To assess (1) which services or agencies are encountered by patients in their pathways to specialist psychiatric care; (2) which services or agencies and individual characteristics of patients were independently associated with the shortest DUP | East London, UK | First-episode psychosis | Specialist psychiatric service | 480 | 67.7% under 30, (18–64) | 61.3% | WHO Encounter Form | II |
Chadda et al. [28] | To study the help-seeking behaviour of patients visiting a mental hospital | Delhi, India | Any mental illness | Outpatient clinic | 78 | 50%+ under 30, (18–49) | 61.5% | Questionnaire developed for study | II + FI + CR |
Chesney et al. [29] | To describe the pathways to care for patients with FEP in Singapore | Singapore | First-episode psychosis | Early intervention for psychosis program | 900 | 27.1, (16–40) | 49.7% | Interview developed for study | II + CR |
Cheung et al. [30] | To estimate the public health costs of specific help-seeking pathways into an early intervention psychosis clinic | Edmonton, Canada | First-episode psychosis | Early intervention for psychosis program | 50 | 22.2 | 82.0% | Semi-structured interview (PCI) | II |
Chiang et al. [31] | To review the help-seeking pathways and reasons for delay for patients with FEP | Hong Kong | First-episode psychosis | Early intervention for psychosis program | 55 | 22.2 (16–30) | 60.0% | Interview developed for study | II + FI |
Chien and Compton [32] | To explore the possible effects of mode of onset on pathways to care | Atlanta, United States | First-episode psychosis | Hospital for FEP psychiatric units | 76 | Mean 23.2 | 77.6% | Interview developed for study | II |
Commander et al. [33] | To compare the experiences of people with non-affective psychoses from three broad ethnic groups, with respect to (a) pathways to care (b) the treatment received while in hospital (c) the delivery of care post-discharge | Birmingham, UK | First-episode psychosis | 4 hospital inpatient units | 120 | 65% under 35 (16–60) | 59.1% | WHO Encounter Form | II |
Compton et al. [34] | To examine the pathways to care and number of help-seeking contacts prior to hospitalization in first-episode patients of African–American background, and to ascertain the frequency of contact with primary care providers and police | Atlanta, United States | First-episode psychosis | Public sector hospital or crisis centre (inpatient) | 25 | 22.8 (18–32) | 76.0% | Symptom onset in schizophrenia inventory, CORS | II |
Cougnard et al. [35] | To describe the pathways to care between onset of psychosis and first admission | Bordeaux, France | First-episode psychosis | Acute wards of two psychiatric hospitals | 85 | 27.8 (17–45) | 63.9% | Questionnaire developed for study | II + FI + CR |
Del Vecchio et al. [36] | To explore the role of relatives in pathways to care of patients with a recent onset of psychosis | Naples, Italy | First-episode psychosis | Outpatient unit | 34 | 26 (18–35) | 64.7% | Pathways to care Form | II |
Ehmann et al. [37] | To examine the treatment delay associated with community and inpatient pathways into care for persons experiencing FEP | Vancouver, Canada | First-episode psychosis | Early intervention for psychosis service | 104 | 20.9 (15–37) | 67.3% | WHO Encounter Form | II + FI |
Etheridge et al. [38] | To assess whether duration of untreated psychosis in Rotherham reflected that reported nationally and internationally, and to identify potential obstacles to early identification and treatment | Rotherham, UK | First-episode psychosis | Early intervention for psychosis services (inpatient and outpatient) | 18 | 29.4 (15–50) | 61.1% | Questionnaire developed for study | II + FI |
Fridgen et al. [39] | To examine the help-seeking behaviour of individuals at risk for psychosis or with FEP in a low-threshold system with easy access to mental health care facilities, in which a specialized early detection clinic was newly established | Basel, Switzerland | First-episode psychosis | Early intervention for psychosis outpatient clinic | 61 UHR + 37 FEP | 28.4 (18+) | 59.0% | Basel interview for psychosis | II |
Fuchs and Steinert [40] | To examine patients’ help-seeking contacts and the delays on their pathways to psychiatric care in Germany | Ravensburg, Germany | First-episode psychosis | Admission in hospital for first-episode psychosis | 66 | Median 26 (14–51) | 59.0% | IRAOS + interview, adapted | II |
Giasuddin et al. [41] | To find out the referral patterns, delays to reach mental health professionals, and diagnoses and treatment received before reaching psychiatric care | Dhaka, Bangladesh | Any mental illness | Outpatient clinic | 50 | 25.8 (12–45) | 58.0% | WHO Encounter Form | II |
Hastrup et al. [42] | To document DUPs in Denmark and investigate associations of DUP with demographic characteristics, premorbid and illness-related factors and health-service factors | Denmark | First-episode psychosis | General population with FEP diagnosis | 1266 | 21 (15–25) | 55.5% | Danish Psychiatric Register | CR |
Hodgekins et al. [43] | To examine care pathways experienced by young people accessing a pilot specialist youth mental health service for those with non-psychotic, severe, and complex mental health conditions | Norfolk, UK | Any mental illness | Specialist mental health service | 94 | 18.3 (14–25) | 28.7% | Interview developed for study | II or FI + CR |
Jain et al. [44] | To evaluate the pathway to care of mentally ill patients attending a tertiary mental health facility in Jaipur, to highlight the difficulties of the mentally ill and their relatives in accessing appropriate care | Jaipur, India | Any mental illness | Tertiary mental health facility | 76 | 59% under 30 | 71.5% | WHO Encounter Form | II + FI |
Judge et al. [45] | To examine the duration of untreated psychosis in an FEP population, to describe precipitants of help-seeking attempts, and to identify barriers to obtaining appropriate treatment | North Carolina, USA | First-episode psychosis | Early intervention for psychosis clinic | 20 | 19.8 | 75.0% | Pathways to care interview (Perkins) | II |
Kurihara et al. [46] | To trace the help-seeking pathway of mental patients and to elucidate the role of traditional healing | Bali, Indonesia | Any mental illness | Admission to Mental Hospital | 54 | 30.6 | 48.0% | Interview developed for study | II + FI + CR |
Lahariya et al. [47] | To study the sociodemographic profile of psychiatric patients; to understand the pathways to care of the patients attending the facility, and to explore the interrelationships between pathways to care and sociodemographic variables | Gwalior, India | Any mental illness | Outpatient department of a psychiatric hospital | 295 | 16–45 | 68.8% | WHO Encounter Form + interview | II |
Lincoln et al. [48] | To gain an understanding of treatment delays in light of an initial episode of psychosis through examination of pathways to care | Melbourne, Australia | First-episode psychosis | Early intervention for psychosis program | 62 | 22.8 (16–30) | 64.5% | WHO Encounter Form | II |
McMiller and Weisz [49] | To determine whether African–American and Latino families were less likely than Caucasian families to seek help from agencies and professionals prior to contacting clinics for their child | California, USA | Any mental illness | Community mental health clinic | 192 | 11.4 (7–17) | 64.0% | Referral sequence and problems interview | II + FI |
Mkize and Uys [50] | To determine the pathways of care that clients with mental illness take, the effects of socio-cultural and economic factors on the pathways to mental health care and the satisfaction with different service providers consulted | Natal, South Africa | Any mental illness | Admission to a mental health institution | 15 | 67% below 29 (15–59) | 46.7% | Interview developed for study | II |
Naqvi et al. [51] | To systematically study the care and referral pathways taken by patients before they present to a psychiatrist at a university teaching hospital | Karachi, Pakistan | Any mental illness | Outpatient psychiatry clinic | 94 | 53% under age 30 | 55.3% | Interview developed for the study | II |
Neubauer et al. [52] | To investigate the duration of untreated illness and paths to first treatment in early vs intermediate vs late age of onset anorexia nervosa | Varied institutions, Germany | Anorexia | Specialized services for anorexia (inpatient and outpatient) | 140 | 22.3 | All female | Multiple choice questionnaire developed for study | II |
Norman et al. [53] | To examine and compare the extent of delay in individuals contacting health professionals and the delay in receiving treatment once such contact is made | London, Canada | First-episode psychosis | Early intervention for psychosis program | 110 | 26.2 (16–51) | 80.0% | CORS | II + CR + FI |
O’Callaghan et al. [54] | To establish if, when and where people seek help in the early phase of psychosis in a representative sample | Dublin, Ireland | First-episode psychosis | Community-based psychiatric services | 142 | 30.5 (16–64) | 62.0% | Beiser scale for DUP; interview for pathways | II |
Phillips et al. [55] | To summarize patterns of referral to one service providing clinical care for young people known to be at high risk of developing a psychotic illness | Melbourne, Australia | Ultra-high risk for psychosis | Specialized clinical service | 162 | 18.8 (14–30) | 61.0% | Interview developed for study | II + FI |
Platz et al. [56] | To obtain information about type of health professionals contacted by patients on their help-seeking pathways; number of contacts; type of symptoms leading to contacts; interval between initial contact and referral to a specialized service | Switzerland | First-episode psychosis, ultra-high risk for psychosis, help-seeking but not UHR or FEP | Specialized outpatient service for UHR | 104 | 22 (14–40) | 73.0% | Interview developed for the study | II |
Reeler [57] | To investigate pathways to care | Harare, Zimbabwe | Any mental illness | Psychiatric inpatient unit | 48 | 28.2 | 31.1% | WHO Encounter Form | II |
Reynolds et al. [58] | To explore the impact of a general practitioner training programme on referrals and pathways to care for people at high clinical risk of psychosis or with a first-episode psychosis | Southwark, UK | First-episode psychosis | Early intervention for psychosis program | 102 | 21.9(UHR) 24 (FEP) | 59%, (UHR), 75% (FEP) | Chart review methodology | CR |
Sharifi et al. [59] | To conduct a first study on the duration of untreated psychosis and pathways to care among patients with first-episode psychosis in Iran as a developing country | Tehran, Iran | First-episode psychosis | Admission to psychiatric hospital | 91 | 27.4 | 58.2% | Interview developed for the study | II + FRI + CR |
Shin et al. [60] | To examine patients’ help-seeking contacts in a context (Korea) where pathways to care had not been examined before | South Korea | Ultra-high risk for psychosis | Early intervention for psychosis programs | 18 | 15.8 (15–18) | 72.2% | Interview developed for the study | II + FI |
Stowkowy et al. [61] | To prospectively investigate the pathways to care of those at clinical high risk of developing psychosis | Toronto, Canada | Ultra-high risk for psychosis | Clinic for ultra-high risk of psychosis | 35 | 21 (14–30) | 71.4% | Pathways to care interview (Perkins) | II + FI |
Subramaniam et al. [62] | To create a typology of patients with first-episode psychosis based on sociodemographic and clinical characteristics, service use and outcomes using cluster analysis | Singapore | First-episode psychosis | Early intervention for psychosis program | 900 | 27.1 (15–41) | 49.6% | Chart review | CR |
Turner et al. [63] | To present the clinical and sociodemographic characteristics of patients referred to an early intervention for psychosis service and to describe their pathways to care | Christchurch, New Zealand | First-episode psychosis | Early intervention for psychosis program | 182 | 22.4 (16–30) | 72.5% | Interview developed for the study | II |
Graf von Reventlow et al. [64] | To acquire accurate knowledge about pathways to care and delay in obtaining specialized high risk care | Finland, Germany, Netherlands, UK | Ultra-high risk for psychosis | Early intervention for psychosis program | 233 | 23 | 54.9% | WHO Encounter Form, EPOS Form | II |
Wiltink et al. [65] | To investigate if the drop in rates of transition from ultra-high risk to FEP may be due to potential changes in patterns of referral to a large ultra-high risk clinic | Melbourne, Australia | Ultra-high risk for psychosis | Early intervention for psychosis program | 150 | 18.3 | 44.0% | Interview developed for the study | II + CR |
Healthcare system and organizational contexts
Study | Pathway to care definition | Pathway to care timeframe | Pathways to care (number of help-seeking contacts) | Treatment delays, in weeks | Notes on health system context |
---|---|---|---|---|---|
Addington et al. [22] | The number of individuals who were sought out for assistance with mental health concerns | From onset of psychosis to EI service | Pre-onset: mean 1.7, range 1–4 After onset: mean 2.3, range 1–6 | DUP mean 102, median 27, range 0–780 | Comprehensive program for individuals experiencing their first episode of psychosis. It is predicted that 80–90% of all new cases in Calgary are being referred to this specialized program |
Anderson et al. [12] | Type and sequence of contacts that the patient or family member sought help from | Lifetime until entry to EI service | Median 3 | DUI median 194.4, DUP median 16.4 Referral delay median 1 | Only specialized service for treatment of FEP within catchment area. Patients referred from any source |
Anderson et al. [23] | Series of help-seeking contacts made by patients and their family members in response to the symptoms of a mental illness | Onset of psychotic symptoms to contact with EI service | Median 6 (White Europeans); Median 4 (Black African and Black Caribbean) | Black Caribbean DUP median 69.5, White European DUP median 30.4, Black African DUP median 39.1 | Hospital and community-based early intervention services for FEP in two cities |
Archie et al. [24] | Sequence of all formal and informal supports contacted by participants seeking help | Onset of psychosis—entry to service | Mean 2.9 (SD = 2), median 3 | DUP mean 60.6, median 22.1, SD 11.2 | Specialized services within catchment area Referrals accepted from all sources (including self-referrals) |
Bakare [25] | Places where help was sought | Prior to presenting to hospital | NS | NS | Healthcare system is divided between primary, secondary, and tertiary care. Patients are free to access any tier of healthcare without referral |
Bekele et al. [26] | The routes taken by patients to reach psychiatric care | NS—(WHO Encounter Form uses previous 12-month timeframe)a | Range 0–4 contacts | Median 38, range: less than 1–45 years | Only mental hospital that provides outpatient and inpatient services for the full range of psychiatric disorders in the entire country. Patients can refer themselves directly to services |
Bhui et al. [27] | The services/agencies encountered by patients in their pathways to specialist psychiatric care | NS—(WHO Encounter Form uses previous 12-month timeframe)a | Range 0–3. 13% were in contact with psychiatric services at first contact; 73.33% at second contact, and 97.71% at third contact | Median 12, IQR 1–9.5 | The East London First Episode Psychosis Study was a large, population-based incidence study in three neighbouring boroughs |
Chadda et al. [28] | The various treatment services utilized by a group of psychiatric patients visiting a mental hospital | From onset of illness to mental health hospital | Range 0–3 | Median 78. Help-seeking median 52, range 4 days–20 years | Catchment area serving 30–40 million population. Facilities for psychiatric treatment are generally available in general hospital psychiatric units, mental hospitals and office-based practice. In India, mental hospitals remain one of the major service providers to the mentally ill |
Chesney et al. [29] | The individuals and organizations who are contacted by patients and their carers in order to seek help and receive treatment | Sources of help until referral to EI service | Mean 2.7 (SD, 0.9), median 3, range, 1–7 | Mean 53.6, median 20, range 0–204, SD 24.3 | The only state mental hospital in Singapore, single largest tertiary care facility in Singapore |
Cheung et al. [30] | Sequence of contacts with individuals and organizations in seeking help | Post-onset and up to 1 year prior to admission/intake at the early psychosis clinic | Mean 4.48 (inpatient pathways), mean 2.68 (outpatient pathways) | NS | Specialized FEP clinic within a public health service responsible for a region of approx. 1 million people |
Chiang et al. [31] | Help-seeking contacts before treatment in the EASY programme, a service for early psychosis | NS | Mean 1.06 | DUP mean 23.5 for GP first contact; mean 60 for private psychiatrist; mean 36.2 for helpline; mean 1.49 for ER | The programme accepts referrals of patients with FEP aged between 15 and 25 years, with an open referral system |
Chien and Compton [32] | The various help-seeking contacts made between the onset of illness and engagement in treatment | Onset of illness to engagement in treatment | Mean 2.2 (SD 1.5), range 1–8 | Mean 27.7 | Urban, public sector psychiatric units |
Commander et al. [33] | Past history of involvement with forensic and psychiatric services | 48 h prior to admission | 30% of Asian group, 45% of Black group, 10% of White, and 10% of White group had over 3 contacts | NS | Four hospitals providing most inpatient care in Birmingham |
Compton et al. [34] | Any help-seeking attempt initiated for the purpose of evaluating or treating either prodromal or psychotic symptoms | From the onset of prodromal symptoms until first hospital admission | Mean 3.3 (SD 2.0), range 1–8 | DUI mean 146.4, median 128, SD 151.3, range: 0.6–476.9. DUP mean 65.3, median 32.9, SD 89.1, range 0.4–337.7. Help-seeking delay mean 88.6 median 48.7, SD 48.7, range: 0.6–394.9 | Public sector outpatient services are available, though this sample focused on patients requiring hospital admission |
Cougnard et al. [35] | Number and profession of successive helping contacts, and the treatment and referral proposed by each contact | Between onset of psychosis and first admission | Median 2, range 1–7 | Help-seeking delay median 9. Median delay to first treatment 28. Median delay to admission 52 | Universal access to care with free access to private or public mental health professionals |
Del Vecchio et al. [36] | Pathways to psychiatric care | NS | Mean 0.8 (SD 0.8) | DUP mean 33.3 SD 54, DUI mean 145.4 SD 141.9. Help-seeking delay mean 17.6 SD 45. Referral delay mean 15.6 SD 29.9 | NS |
Ehmann et al. [37] | Help-seeking efforts leading up to referral to program’ | Onset of psychosis to referral to program | Mean 3.02 (SD 1.31), range 1–7 | Mean 92, median 30.5, SD 131, range 1–691 | Single EI program for psychosis within a defined catchment area; accepts referrals from any source |
Etheridge et al. [38] | Experiences of obtaining care when they first developed symptoms of psychosis | From when the illness started to referral | NS (service users), mean 3 (carers, on behalf of service users) | 67% had DUI less than 52, 22% between 52 and 156, 11% more than 1 | Swallownest Court Services, including the rehabilitation ward, assertive outreach service and day hospital |
Fridgen et al. [39] | Person contacted first along the help-seeking pathway and which persons or institutions were contacted subsequently | Any help-seeking attempt before coming to the early detection clinic | Mean 1.5, median 1, range 0–6 | DUI median 177, DUP median 52. Referral delay mean 165, median 39 | Psychiatrists in private practice and general practitioners, both with the possibility of referring to the university outpatient clinic |
Fuchs and Steinert [40] | Professional contacts | Before admission | 42% had more than 1 contact, range 1–5 | Mean 71; median 8 Help-seeking delay mean 5 | Sole psychiatric hospital in catchment area. Patients can consult outpatient psychiatric care without a referral |
Giasuddin et al. [41] | Initial and intermediate carers, and number of steps needed to reach mental health personnel | From symptom onset to arrival at a psychiatric service | Mean 2.7 | DUI mean 48, Median 25; Range 1–156. Help-seeking mean 13.8 | Direct access to specialized care is permitted |
Hastrup et al. [42] | Referral source was defined as general practitioner, emergency wards or other hospital services Contact leading to FEP diagnosis was reported as either with an inpatient or an outpatient unit | Interval from onset of psychotic symptoms to initiation of appropriate treatment (antipsychotic medication) | NS | 32.7% had a DUP below 26, 17.7% had DUP between 26 and 52. 32.8% had a DUP longer than 52 | Danish National Indicator Project (DNIP). In Denmark, it is mandatory for all psychiatric hospital units and relevant clinical departments to report data on all patients with schizophrenia to the registry |
Hodgekins et al. [43] | Sequence of help-seeking contacts with individuals and organizations | From date of onset | Mean 5.53 | Mean delay 195; Mean help-seeking delay 70.9; Mean referral delay 118.4 | Pilot specialist youth mental health service for young people aged 14 to 25 years with non-psychotic, severe and complex mental health conditions |
Jain et al. [44] | Sources of care used by patients before seeking help from mental health professionals and also the factors that modify it | From onset to visit with mental health professionals and to tertiary care centre | Total mean 5.3 (SD 10.7), median 2, range 0–67 Mean before reaching any mental health professional: 3.9 (SD 6.7), median 2, range 1–51 | Mean DUI 212, Median 56, Range 1–1042 | Patients allowed to seek help from any source of their choice and this includes faith healers. Government-run tertiary care centre providing free treatment to catchment area |
Judge et al. [45] | Each help-seeking attempt to whom participants turned for help | Onset of psychosis and administration of antipsychotic medicationa | Mean 5.1, range 1–15 | DUP mean 83.4, range 8–312 From onset to recognition = 33.8, from recognition to treatment = 63 | The only specialized psychotic disorders clinic in a catchment area, which ranges from suburban to rural |
Kurihara et al. [46] | All sources of care sought | Prior to visiting mental hospital | NS | DUI to hospital admission median 26 Help-seeking delay median 6 Referral delay to hospital median 12 | Access to both general practitioners and community health centres is readily available. In Bali, mental disorders are commonly considered ‘non- medical diseases’ thought to be the domain not of doctors, but of traditional healers |
Lahariya et al. [47] | A pathway a patient adopts to reach the appropriate treatment centre | NS (WHO Encounter Form uses previous 12-month timeframe)a | NS | DUI 45.6 | Outpatient department of a specialty psychiatric hospital affiliated with medical college in the city |
Lincoln et al. [48] | Range of people to whom individuals turn to for help | NS (WHO Encounter Form uses previous 12-month timeframe)a | Mean 4.9 SD 2.8, median 4.5, range 1–17 | DUP mean 38.8, median 17.2. Help-seeking delay mean 16, median 4.4 | Comprehensive and integrated community-based service for young people with FEP |
McMiller and Weisz [49] | Sequence of consultations and referrals preceding child clinic intake | Prior to contact with mental health clinic | NS | NS | NS |
Mkize and Uys [50] | Actions taken by individuals towards the early detection of mental illness. Specifically, steps or consultations taken by the client before being admitted to a mental health institution | Time of the onset of mental illness to the time of their admission to a mental health institution | NS | Range 26–130 | NS |
Naqvi et al. [51] | Care and referral pathway before presenting to a psychiatrist, including all professional and non-professional avenues | Since the onset of symptoms to appropriate care | Median 2 | Help-seeking delay mean 146, range 1–6 years Delay from first contact to psychiatrist mean 198 | Most mental health facilities are in urban areas, but are under-resourced. No referral system in operation |
Neubauer et al. [52] | Previous treatment facilities and paths to first treatment | Between onset and initiation of treatment | NS | Mean DUI = 109, SD, 160, range 0–843 | German healthcare system, details not specified |
Norman et al. [53] | All formal services, organizations or professional services consulted regarding any mental health/psychiatric problems experienced by the patient | Lifetime until entry to EI service | NS | Mean DUP 61.1, median 21, SD 100.8. Help-seeking delay mean 25.1, SD 58.5. Referral delay mean 44.6, SD 88.5 | EI service with open referral system within a public healthcare systema |
O’Callaghan et al. [54] | All previous contacts with health services, the police and the judiciary, and any treatment received | From 28 days prior to onset of prodrome to entry to EI service | Median 2, range 0–8 | Mean DUP 82; DUI 180. Delays evenly split between help-seeking and referral delays | Catchment area-based psychiatric services receiving referrals from general practitioners and emergency departments |
Phllips et al. [55] | Previous contacts made with health and allied services | Prior to referral | Mean 2.36, SD 1.32, range 1–7 | Total delay mean 127. Help-seeking delay mean 85.8, SD 132.71. First contact to treatment delay mean 41.4, SD 91.4 | Specialized clinical/research service for young people thought to be at high risk of developing a psychotic episode |
Platz et al. [56] | Professional groups that individuals had previously contacted for similar problems | Previous contacts | Mean 2.38, SD 1.4, median 3, range 1–8; no difference between UHR, FEP and help-seeking others | First contact to referral for UHR: mean 124, median 36, SD 217.1, range 1 day–7.6 years Referral delay median for UHR, FEP and help-seeking others = 28 Median help-seeking delay lower for FEP than for UHR and help-seeking others | Semi-urban catchment area of part of the only general psychiatric outpatient clinic. Patients can refer themselves directly to any public or private psychiatric facility and do not require referrals |
Reeler [57] | Various carers, kinds of treatment offered, and the times of various events | NS (WHO Encounter form 12 months) | NS | Help-seeking delay range 1–56.4; referral delay range 4.4–50.5 | Filter model of service, with stress on a primary care base |
Reynolds et al. [58] | Referrals and pathways to care to specialized early intervention service following trainings to general practitioners | NS | Range 1–5 | NS | Community-based team accepts referrals from any source |
Sharifi et al. [59] | Pathways that patients take to reach psychiatric care (admission to psychiatric hospital) | Any previous helping contacts and referrals | NS | Mean 52.3, median 11 | Care to patients with mental illnesses is delivered by public and private sectors. Patients and their families select their own care provider |
Shin et al. [60] | The contact process from when the illness is suspected until the first psychiatric treatment | From the initial suspected psychiatric illness until the first psychiatric help was noted | Median 0.7, range 0–4 | Mean 53.24, SD 50.28 DUI mean 56.49, range: 2 –156 | The Korean public health system does not provide a GP and therefore seeking psychiatric help is initiated by patients themselves. Each centre is main provider of psychiatric services in their area |
Stowkowy et al. [61] | All help-seeking activities collected in chronological order from onset of prodromal symptoms | For the period from the onset of prodromal symptoms to referral to clinic | Mean 1.7, range 1–4 | NS | UHR clinic accepting referrals from all sources |
Subramaniam et al. [62] | The sources of help sought in chronological order till the patients were referred | First contact to admission | Mean 3.2, range 1–7 | DUI mean 26, DUP mean 21.7 | Comprehensive, integrated, multidisciplinary and patient-centred program |
Turner et al. [63] | Patients’ contact with social agencies prior to entering EI service | 6 months prior | Mean 3.87 (SD 6.31), range 0–42 | DUP mean 17.14 for schizophrenia; DUP mean 4.14 for affective and other psychosis | The service available to all those with first-episode psychosis referred into the only early intervention for psychosis service in the Christchurch catchment area |
Graf von Reventlow et al. [64] | Number of help-seeking events from onset of at-risk criteria to receiving appropriate treatment | The period between the onset of frank psychosis and receiving an adequate treatment | Mean 2.9 | DUI mean 182.5, help-seeking delay mean 72.6. Referral delay mean 110.9 | Public sector mental health care (Finland, the UK) and private mental healthcare sector providing beds in psychiatric hospitals (Germany, the Netherlands) |
Wiltink et al. [65] | When a (health) service was first contacted, how many and which other services were contacted after that, and who made the referral | From onset to referral to clinic | Mean 1.93 | Total delay 46.5. Referral delay 6.5 | The catchment area-based program with open referral system |
Instruments and data sources
Timeframes
Pathways to care
Authors | Key pathway agents | Common first help-seeking contacts | Common referral sources |
---|---|---|---|
Addington et al. [22] | Most common: emergency services (33%), family physicians (23%) Other: psychologists, teachers/counsellors, psychiatrists, family, emergency services, police, clergy, social workers, and friends | Emergency services (52%), family physicians (18%), psychiatrists (18%) | |
Anderson et al. [12] | Over 45% of patients had contact with police or ambulance | Emergency services (62%) | Emergency services (74%) |
Anderson et al. [23] | Primary care physicians are most commonly used overall | Most common: primary care physicians | Most common: inpatient units |
Archie et al. [24] | Most common: emergency services and primary care physicians, family, doctors/walk-in clinics, clergy/homeopath/other non-medical contacts, psychologists, psychiatrists, school counsellors, psychiatric admissions | Family doctor/walk-in clinic (31%), emergency services (24%), clergy/homeopath (12%) | Psychiatric admissions (40.2%), family doctor/walk-in clinic (14.8%), emergency services (13.8%) |
Bakare [25] | Neuropsychiatric hospitals, prayer houses, other hospitals, traditional healers, patent medicine stores, roadside medical labs, specialized school for children | Psychiatric hospitals (48%), prayer houses (22%), other hospitals (21%) | Relatives, family, or friends. (92%), other hospitals (7%), prayer houses/faith healing centres (1%) |
Bekele et al. [26] | Priests, herbalists, nurses, doctors | Priests/holy water (31%), doctors (21.5%), herbalists (4.5%) | Self-referrals (41%) |
Bhui et al. [27] | Primary care physicians, emergency services, police, community-based health and social care agencies, prisons, psychiatric services, native or religious healers | Primary care physicians, emergency services, and criminal justice agencies | |
Chadda et al. [28] | Traditional healers, psychiatrists, non-psychiatric doctors, Ayurveda (Indian system of herbal medicine) | Psychiatrists (58%), religious faith healers (30%), physicians (12%) | |
Chesney et al. [29] | Medical specialists, psychiatrists, private psychiatrists, direct referrals, at-risk clinic, primary care physicians, health professionals, counsellors community health assessment team, police, employers and teachers, other, traditional or religious healers, courts, lawyers | Specialist care (59%), primary care (27%), police (12%) | Thirty patients (3%) were self-referred |
Cheung et al. [30] | Teachers, counsellors, police, psychologists, psychiatrists, family physicians, emergency services, public health, outpatient psychiatry, other | ||
Chiang et al. [31] | Self-referral, medical, non-medical and religious, alternative help | Social workers, primary care physicians | Telephone helpline, emergency services, primary care |
Chien and Compton [32] | Hospital/emergency services, police, outpatient service, family physicians | Psychiatric hospital and emergency (32%), psychiatrists, counsellors, or outpatient mental health clinics (26%), police (20%) | Psychiatric hospitals, psychiatric or general emergency services, police (25%), psychiatrists, counsellors, or outpatient mental health clinics (13.2%), emergency services (7.4%) |
Commander et al. [33] | Psychiatrists, social workers, police, emergency services, primary care physicians, community psychiatric nurses, other, self | ||
Compton et al. [34] | Most common: mental health professionals and psychiatric emergency services, general emergency department, primary care physicians, police, other | Mental health professionals (32%), psychiatric emergency services (24%), general emergency departments (20%) | Psychiatric emergency services (36%), mental health professionals (20%), general emergency departments (20%), police (20%) |
Cougnard et al. [35] | Primary care physicians (32%) | Primary care physicians (37%), psychiatrists | |
Del Vecchio et al. [36] | Primary care physicians, psychiatrists, neurologists, psychologists, relatives | Primary care physicians (28%), psychiatrists (30%), neurologists (21%) | |
Ehmann et al. [37] | Relatives/friends, schools, counsellors or crisis line, mental health teams, general physicians, private psychiatrists, hospitals, direct entry | Relatives/friends (52%), primary care physicians (16%), self-referrals (9%), counsellor or crisis line (8%), mental health teams (6%), psychologists (5%) | |
Etheridge et al. [38] | Primary care physicians, relatives, psychiatrists, teachers, hospitals | Most common by service users: relatives, primary care physicians, psychiatrists, teachers and hospitals Most common by family/carers on behalf of a service user: primary care physicians, school staff, police and emergency services | |
Fridgen et al. [39] | Friends, family, psychiatrists, primary care physicians, colleagues, partners, other physicians, psychologists, priests, alternative medicine | Family or friends (46%), private psychiatrists (14%), or primary care physicians (12%) | Outpatient departments, private psychiatrists, other physicians, self-referrals, family |
Fuchs and Steinert [40] | Most common: mental health professionals (46%), primary care physicians (20%), hospitals (18%), and psychosocial contacts (16%) | Primary care physicians (18%) | |
Giasuddin et al. [41] | Private practitioners, native or religious healers, other medical facilities, general hospitals | Private practitioner (44%), native or religious healer (22%), direct pathway (16%) | |
Hastrup et al. [42] | Primary care physicians, inpatient units, outpatient units, and emergency services, other medical specialists | Outpatient services (59%), hospital services (41%) | Emergency services (26%), primary care physicians (22%), hospitals (46%) |
Hodgekins et al. [43] | Primary care physicians, education services, emergency services, social care, other | Primary care physicians, educational settings | |
Jain et al. [44] | Faith healers, non-psychiatric allopath care providers, alternative medicine, direct entry, mental health professionals | Faith healers (40%), non-psychiatrist allopath care provider (29%), other psychiatrist (15%) | |
Judge et al. [45] | Relatives, emergency services | ||
Kurihara et al. [46] | Most common: traditional healers. Others: primary care physcians, hospital doctors, community health centres | Traditional healers (43%), primary care physicians (7%), direct entry (4%) | Traditional healers (67%), community health centres (17%), and primary care physicians (13%) |
Lahariya et al. [47] | Faith healers, psychiatrists, allopathic practitioners, traditional healers, other (friends and family) | Faith healers (69%), psychiatrists (9%) | Others (including previous patients), allopathic practitioners |
Lincoln et al. [48] | Mental health professionals (50%), primary care physicians (17%) | Primary care physicians (36%), psychiatric services (16%), police (12%) | |
McMiller and Weisz [49] | 52% of all contacts were ‘professional’ (56% for Caucasians, 47% for African–Americans and 42% for Latino) | 45% of first contacts were Healthcare professionals (53% for Caucasians, 32% African American, 30% Latino) | |
Mkize and Uys [50] | Traditional healers, faith healers, hospitals, police, mental health institutions, primary health care clinics | Primary care physicians (33%), faith healers (20%), traditional healers (20%) | |
Naqvi et al. [51] | Religious healers, primary care providers, specialists, hospitals doctors, psychiatric services | Self-referrals (49%), hospital or other specialists (20%), Primary care (2.9%) | |
Neubauer et al. [52] | Physicians, health professionals, mental health professionals, social networks, eating disorder clinics, day clinics | Inpatient treatment (55%), outpatient facility (39%), eating disorder-specific centre (4%) | |
Norman et al. [53] | Primary care physicians, community or school counsellors, psychologists, social workers, psychiatrists, hospitals, emergency services | Before psychosis: primary care physicians (40%), community or school counsellors (30%), psychologists or social workers (20%) After psychosis, hospital or emergency services (43%), primary care physicians (39%), community (13%) | Emergency services (49%), private psychiatrists or non-emergency hospital (26%), primary care physicians (15%) |
O’Callaghan et al. [54] | Primary care physicians, emergency services, counselling services, police, religious organizations, complementary and alternative medical services, and clinic website | Primary care physicians (59%), other, including emergency services (41%) | |
Phillips et al. [55] | Primary care physicians, private psychiatrists/psychologists, outpatient services, inpatient services, other | Youth access team, generic and mental health services, school and university counsellors and youth housing and employment workers | |
Platz et al. [56] | In-patient services, primary care physicians, alternative medical practitioners, non-medical counselling services, non-specified professionals | Primary care physicians (34.6%) | General practitioners, private psychiatrists/psychologists, psychiatric outpatient services |
Reeler [57] | Hospital doctors, traditional healers | Hospital doctors | Hospital doctors |
Reynolds et al. [58] | Primary care physicians, community-based teams, out of area teams, emergency services, police, prison, child and adolescent mental health teams, specialized services | Primary care physician (43%), emergency services (24%), police (11%) | Post training, 46% were referred by primary care physicians |
Sharifi et al. [59] | Psychiatrists, primary care physicians, other health professionals, traditional healers, other professional | Psychiatrist (25%), traditional healer (23%) or a primary care physician (18%) | Family (33%), health professionals (32%) and the legal system (17%) |
Shin et al. [60] | Most common: internet and family members (57%) Other: patients, teachers, physicians, specialized clinic, shelters | ||
Stowkowy et al. [61] | Primary care physicians, mental health clinics, psychiatrists and other individuals | Primary care physicians (29%), psychiatrists, mental health clinics and social workers, (14% each), Self-referral (11%) | |
Subramaniam et al. [62] | Primary care physicians, polyclinics, other primary care, hospitals, traditional or religious healers, direct entry, counsellors, police, courts, family, relatives, friends, other | Family, primary care physicians | Family |
Turner et al. [63] | Primary care physicians, school counsellors, religious ministers, psychiatric outpatient clinics, private psychiatrists, other, mental health services, other health services | Inpatient services (64%), emergency services (16%), general practitioners (7.7%) | |
Graf von Reventlow et al. [64] | Physicians, psychiatrists, psychologists, nurses, social workers, treatment teams, other counsellors, other healthcare professionals, other professionals | ||
Wiltink et al. [65] | Primary care physicians, teachers, counsellors, drug and alcohol services, accommodation services, youth health services, emergency services, public hospital, other |
Overall pathways
Key pathway agents
First contact
Referral sources
Treatment delays
Duration of untreated psychosis (DUP)
Duration of untreated illness (DUI)
Impact of pathways to care on treatment delays
Factors influencing pathways to care
Negative pathways to care
Costs
Conceptual frameworks
Quality appraisal
Study | Research question | Representativeness of participants | Non-participation rate | Adequacy of sample size | Adjustment for confounding factors | Definition of pathways to care | Ascertainment of pathways to care | Measurement of pathways to care | Method of ascertainment |
---|---|---|---|---|---|---|---|---|---|
Addington et al. [22] | + | ∙ | + | − | − | + | + | + | + |
Anderson et al. [12] | + | + | + | − | + | + | + | + | + |
Anderson et al. [23] | + | ∙ | + | − | + | + | + | + | + |
Archie et al. [24] | + | + | ∙ | − | + | + | + | + | + |
Bakare [25] | + | ∙ | − | − | ∙ | + | + | − | + |
Bekele et al. [26] | + | − | − | − | + | + | ∙ | + | + |
Bhui et al. [27] | + | ∙ | − | − | + | − | − | + | + |
Chadda et al. [28] | + | ∙ | − | − | + | − | − | + | + |
Chesney et al. [29] | + | ∙ | − | − | ∙ | + | + | − | + |
Cheung et al. [30] | + | + | − | − | ∙ | + | + | + | + |
Chiang et al. [31] | + | ∙ | ∙ | − | − | − | + | − | + |
Chien and Compton [32] | + | + | − | − | + | + | + | − | + |
Commander et al. [33] | + | + | + | − | ∙ | + | ∙ | − | + |
Compton et al. [34] | + | − | − | − | + | + | + | + | + |
Cougnard et al. [35] | + | ∙ | + | − | + | + | + | − | + |
Del Vecchio et al. [36] | + | ∙ | − | − | + | + | + | + | + |
Ehmann et al. [37] | + | ∙ | − | − | ∙ | + | + | + | + |
Etheridge et al. [38] | + | − | ∙ | − | ∙ | − | ∙ | − | + |
Fridgen al [39] | + | + | − | − | ∙ | + | − | ∙ | + |
Fuchs and Steinert [40] | + | ∙ | + | − | ∙ | − | ∙ | − | + |
Giasuddin et al. [41] | + | + | + | + | + | + | ∙ | + | + |
Hastrup et al. [42] | + | + | + | − | + | − | − | − | + |
Hodgekins et al. [43] | + | ∙ | − | − | ∙ | + | + | + | + |
Jain et al. [44] | + | ∙ | + | − | ∙ | + | + | + | + |
Judge et al. [45] | + | ∙ | − | − | ∙ | + | + | − | + |
Kurihara et al. [46] | + | ∙ | + | − | ∙ | + | + | + | + |
Lahariya et al. [47] | + | ∙ | + | − | ∙ | − | + | + | + |
Lincoln et al. [48] | + | ∙ | + | − | + | − | ∙ | + | + |
McMiller and Weisz [49] | + | ∙ | ∙ | − | − | + | ∙ | − | + |
Mkize and Uys [50] | + | − | − | + | + | + | ∙ | + | + |
Naqvi et al. [51] | + | + | − | − | − | − | ∙ | − | + |
Neubauer et al. [52] | + | ∙ | + | − | + | + | + | − | + |
Norman et al. [53] | + | ∙ | − | − | ∙ | + | + | + | + |
O’Callaghan et al. [54] | + | ∙ | + | − | + | + | ∙ | − | + |
Phillips et al. [55] | + | ∙ | ∙ | − | − | − | + | − | + |
Platz et al. [56] | + | + | − | − | − | − | + | − | + |
Reeler [57] | + | ∙ | − | − | − | + | ∙ | + | + |
Reynolds et al. [58] | + | ∙ | ∙ | − | + | + | − | − | + |
Sharifi et al. [59] | + | + | + | − | ∙ | + | + | − | + |
Shin et al. [60] | + | ∙ | − | − | ∙ | + | ∙ | − | + |
Stowkowy et al. [61] | + | ∙ | − | − | + | + | + | + | + |
Subramaniam et al. [62] | + | ∙ | − | − | + | + | ∙ | − | + |
Turner et al. [63] | + | ∙ | + | − | ∙ | + | ∙ | − | + |
Graf von Reventlow et al. [64] | + | + | + | − | + | − | + | + | + |
Wiltink et al. [65] | + | ∙ | ∙ | − | − | + | ∙ | − | + |