A sample of 333 participants (N=168 in Chennai, Montreal; and N=165 in Montreal, Canada) with first-episode psychosis was enrolled. Participants’ characteristics at their time of entry to services are shown in Table 1.
Table 1 Baseline sociodemographic and clinical characteristics
Variable
|
Montreal (N = 165) Mean ± SD / N (%)
|
Chennai (N = 168) Mean ± SD / N (%)
|
Statistical test
|
p value
|
Age at entry (years)
|
24.1 ± 5.3
|
26.6± 5.2
|
t(331) = -2.47
|
<0.001
|
Gender N (%)
|
|
|
χ2(2) = 12.37
|
0.002
|
Men
|
110 (66.7)
|
82 (48.8)
|
Women
|
54 (32.7)
|
86 (51.2)
|
Transgender
|
1 (0.6)
|
0
|
Total
|
165
|
168
|
Education (years)
|
12.24 ± 2.63
|
11.75 ± 3.9
|
t(293.94) = 1.34
|
0.182
|
Education
|
|
|
χ2(1) = 0.03
|
0.868
|
Less than high school
|
44 (27.2)
|
47 (28)
|
High school or more
|
118 (72.8)
|
121 (72)
|
Total
|
162
|
168
|
Occupation Status
|
|
|
χ2(3) = 30.0
|
<0.001
|
Student
|
40 (29.0)
|
24 (14.4)
|
Paid employment
|
35 (25.3)
|
25 (15.0)
|
Homemaker
|
7 (5.1)
|
40 (24.0)
|
Unemployed
|
56 (40.6)
|
78 (46.7)
|
Total
|
138
|
167
|
Marital Status
|
|
|
χ2(2) = 50.51
|
<0.001
|
Single
|
149 (90.9)
|
95 (56.5)
|
Married/Common law
|
13 (7.9)
|
62 (36.9)
|
Separated/divorced/widowed
|
2 (1.2)
|
11 (6.5)
|
Total
|
164
|
168
|
Living Situation
|
|
|
χ2(3) = 22.95
|
<0.001
|
Alone
|
16 (10.0)
|
2 (1.4)
|
With family
|
125 (78.1)
|
140 (96.6)
|
With friend/roommate
|
16 (10.0)
|
2 (1.4)
|
In residence, group home or homeless
|
3 (1.9)
|
1 (0.7)
|
Total
|
160
|
145
|
SCID diagnosis
|
|
|
χ2(1) = 26.29
|
<0.001
|
Schizophrenia-spectrum psychosis
|
109 (67.3)
|
150 (90.4)
|
Affective psychosis
|
53 (32.7)
|
16 (9.6)
|
Total
|
162
|
166
|
Substance use diagnosis (SCID)
|
|
|
χ2(1) = 32.9
|
<0.001
|
Yes
|
54 (37.8)
|
17 (10.2)
|
No
|
89 (62.2)
|
149 (89.8)
|
Total
|
143
|
166
|
Age at onset (years)
|
23.41 (5.67)
|
25.81 (5.22)
|
t(318)=3.94
|
<0.001
|
SAPS (baseline)
|
34.5 ± 14.9
|
19.9 ± 9.9
|
t(259.56) = 10.19
|
<0.001
|
SANS (baseline)
|
22.7 ± 12.6
|
21.6 ± 15.7
|
t(295.56) = 0.67
|
0.505
|
SCID = Structured Clinical Interview for DSM-IV-R, Research version.
SAPS = Scale for the Assessment of Positive Symptoms. SANS = Scale for the Assessment of Negative Symptoms.
Patients in Chennai were likelier to be women, married, and older than those in Montreal. While most participants at both sites were living with families, this was particularly true in Chennai (96.6%). Almost all Montreal patients were single (91%) unlike in Chennai (57%). This was mainly due to the low proportion of single women in Chennai (36%) relative to Montreal (85%) and may reflect the greater social emphasis on marriage in India. While the proportion of people identified as unemployed was similar at the two sites upon entry, a quarter of patients in Chennai were homemakers compared to a small minority in Montreal (5%). Montreal patients had a higher level of baseline positive symptoms than Chennai patients.
In terms of religious affiliation, most Chennai patients were Hindu (81%), with Christianity (16%) and Islam (3%) also being represented. In Montreal, 38% of patients did not respond to the religious affiliation question, 26% were Roman Catholic, and 13% stated they were agnostic, atheist, non-practising or had no religion. Forty-two percent of the Montreal sample were from a visible minority.
Differences in DUP: Primary hypothesis
Overall DUP [Chennai mean=32.8 ± 61.1 weeks; Montreal mean=40.8 ± 88.5 weeks] and help-seeking DUP [Chennai mean=21.6 ± 53.0 weeks; Montreal mean=26.1 ± 63.1 weeks] were not significantly different at the two sites [t(287.33) =-1.22; p=0.224; t(300.14) =-1.31; p=0.191, respectively]. However, Chennai patients had a significantly shorter referral DUP [Chennai mean=12.0 ± 34.1 weeks]; than those in Montreal. [Montreal mean=13.2 ± 28.7 weeks; t(302.57)=4.40; p<.001].
First contact
The type of first contact following the onset of psychosis varied widely between the sites (see Table 2). At both sites, the first contact for a large proportion of patients was a medical source (72% in Chennai, 88% in Montreal). Further, the role of traditional or faith healers was prominent in Chennai, making up almost 25% of all first contacts (n=40). Finally, a stark difference was found in the number of patients who had a first contact with the early intervention itself [44% in Chennai (n=72) versus 5% in Montreal (n=8)].
Table 2 First contacts on the pathway to early intervention for psychosis
Variable
|
Montreal N (%)
|
Chennai N (%)
|
Statistical test
|
p value
|
First contact- Type
|
Medical
|
140 (88.1%)
|
117 (71.8%)
|
χ2(2) = 50.2
|
< 0.001
|
Non-medical: Psychologists/ counsellors/social workersa
|
19 (11.9%)
|
5 (3.1%)
|
Non-medical: Traditional or Faith healersb
|
0%
|
40 (24.7%)
|
Total
|
159
|
162
|
First Contact - subcategories
|
Medical
|
|
|
|
|
ER
|
83 (52.2%)
|
2 (1.2%)
|
General practitioner, any doctor
|
10 (6.3%)
|
5 (3.1%)
|
Psychiatrist
|
12 (7.5%)
|
19 (11.7%)
|
Walk-in clinic
|
4 (2.5%)
|
9 (5.6%)
|
EI service
|
8 (5.0%)
|
72 (44.4%)
|
Hospital outpatient
|
13 (8.2%)
|
9 (5.6%)
|
Hospital inpatient
|
10 (6.3%)
|
2 (1.2%)
|
Psychologists/counsellors/social workers
|
|
|
|
|
Psychologist
|
10 (6.3%)
|
3 (1.9%)
|
School counsellors
|
6 (3.8%)
|
1 (0.6%)
|
Counsellor or social worker
|
3 (1.9%)
|
1 (0.6%)
|
Traditional or faith healers
|
|
|
|
|
Temple
|
0%
|
16 (9.9%)
|
Clergy
|
0%
|
15 (9.3%)
|
Other faith healer (e.g., remover of evil spirits)
|
0%
|
4 (2.5%)
|
Astrologer
|
0%
|
3 (1.9%)
|
Alternative medicine (e.g., homeopathy)
|
0%
|
2 (1.2%)
|
a Standardized residuals = 2.1, significantly higher proportion of Montreal patients’ first contact was a psychologist, counsellor or social worker
b Standardized residuals = 4.4, significantly higher proportion of Chennai patients’ first contact was a traditional or faith healer
Source of referral
The sites differed significantly with respect to the main source of referral (see Table 3).. As predicted, Montreal patients entered the early intervention service through various medical services, with half the patients entering through hospital emergency services and only a small fraction (6%, n=5) coming directly from families or being self-referred. In Chennai, a majority of patients were brought by family or friends or were self-referred (64%, n=104). Notably, a significantly higher proportion of Montreal patients were hospitalised at program entry (36%, n=60) compared to Chennai (0.06%, n=1; Χ(1) = 71.2, p<0.001).
Table 3 Sources of referral on the pathway to early intervention for psychosis
Source of Referral - Type
|
Medical
|
151(92.6%)
|
53 (32.5%)
|
χ2(1) = 125.8
|
< 0.001
|
Non-medical
|
12 (7.4%)
|
110 (67.5%)
|
Total
|
163
|
163
|
Source of Referral - Subcategories
|
Medical
|
|
|
|
|
ER
|
81 (49.7%)
|
0%
|
Hospital outpatient
|
21 (12.9%)
|
52 (31.9%)
|
Hospital inpatient
|
19 (11.7)
|
0%
|
Ultra-high risk for psychosis service
|
15 (9.2%)
|
0%
|
Community medical services
|
11 (6.7%)
|
0%
|
Psychiatrist or GP
|
4 (2.5%)
|
1 (0.6%)
|
Non-medical
|
|
|
|
|
Family
|
9 (5.5%)
|
60 (36.8%)
|
Self
|
0%
|
44 (26.9%)
|
Church
|
0%
|
4 (2.5%)
|
College or school
|
0%
|
2 (1.2%)
|
Psychologists/counsellors/social workers
|
3 (1.8%)
|
0%
|
Number of contacts
The total number of contacts from the onset of the psychotic episode until entry into early intervention services varied significantly, with Montreal patients having significantly more overall contacts [mean 2.3 ± 1.5 contacts] than the Chennai sample [mean 0.8 ± 0.8 contacts].
A first contact with a psychologist/counsellor/social worker was linked to more contacts [mean 2.4 ± 1.7 contacts] than a first contact with a medical professional [mean 1.4 ± 1.5 contacts] or a traditional/faith healer [mean 1.6 ± 0.8 contacts]. In Chennai, a first contact with a healer resulted in significantly more total contacts [mean 1.6 ± 0.8 contacts] than any other kind of first contact [mean 0.5 ± 0.7 contacts] (see Table 4).
Table 4 Total contacts and duration of untreated psychosis by first contact and source of referral
Variable
|
Total contacts
|
Total DUP* (weeks)
|
Help-seeking DUP* (weeks)
|
Referral DUP* (weeks)
|
First contact (both sites combined)
|
Medical
|
|
|
|
|
Mean ± SD
|
1.38 ± 1.5
|
31.8 ± 68.8
|
23.6c ± 59.1
|
9.2f ± 25.5
|
Median (Range)
|
-
|
9.9 (0-684.3)
|
5.6 (0-532.1)
|
2.6 (0-215.1)
|
Psychologist/counsellor/ social worker
|
|
|
|
|
Mean ± SD
|
2.43a ± 1.7
|
94.2b ± 116.7
|
56.4d ± 79.8
|
34.5 ± 53.7
|
Median (Range)
|
-
|
43.5 (2-421.4)
|
14.1 (0-260.9)
|
8.9 (0.29-172.7)
|
Healer
|
|
|
|
|
Mean ± SD
|
1.62 ± 0.8
|
23.7 ± 39.5
|
6.6e ± 12.9
|
21.0 ± 41.6
|
Median (Range)
|
-
|
10.3 (2-220.9)
|
2.0 (0-54.3)
|
7.1 (0.43-218.9)
|
Test; p
|
F(2,308) = 5.57; .004
|
F(2,307) = 11.06; < .001
|
F(2,314) = 10.39; < .001
|
F(2,313) = 19.35; < .001
|
Referral source (Chennai only)
|
Medical
|
|
|
|
|
Mean ± SD
|
0.94 ± 0.8
|
33.8 ± 55.6
|
17.6 ± 37.2
|
17.2 ± 44.3
|
Median (Range)
|
-
|
12.7 (0.29-223.0)
|
6.4 (0-223.0)
|
4.1 (0-218.9)
|
Non-medical
|
|
|
|
|
Mean ± SD
|
0.7 ± 0.9
|
32.2 ± 64.8
|
23.2 ± 59.9
|
9.5 ± 28.0
|
Median (Range)
|
-
|
11.3 (0.43-518.7)
|
5.7 (0-518.7)
|
0.3 (0-181.1)
|
Test; p
|
t(154) = 1.71; .09
|
t(153) = 0.26; .794
|
t(154) = -0.44; .660
|
t(156) = 2.20; .029g
|
First contact (Chennai only)
|
Healer
|
|
|
|
|
Mean ± SD
|
1.63 ± 0.8
|
23.7 ± 39.4
|
6.6 ± 12.9
|
21.0 ± 41.6
|
Median (Range)
|
-
|
10.3 (2-220.9)
|
2.0 (0-54.3)
|
7.1 (0.43-218.9)
|
Other
|
|
|
|
|
Mean ± SD
|
0.5 ± 0.7
|
35.8 ± 66.5
|
26.6 ± 59.9
|
8.9 ± 30.7
|
Median (Range)
|
-
|
12.6 (0.29-518.7)
|
8.6 (0.29-518.7)
|
0 (0-215.1)
|
Test; p
|
t(159) = 8.98; <.001
|
t(88.75) = -0.20; .819
|
t(159) = -4.85; < .001
|
t(160) = -5.54; < .001
|
First contact (Chennai only)
|
Early intervention service
|
|
|
|
|
Mean ± SD
|
N/A
|
33.5 ± 74.9
|
32.4 ± 74.8
|
0.8 ± 6.2
|
Median (Range)
|
|
8.6 (0.3-518.7)
|
7.3 (0.3 – 518.7)
|
0 (0-52.1)
|
Other
|
|
|
|
|
Mean ± SD
|
N/A
|
32.3 ± 47.8
|
13.1 ± 22.0
|
19.8 ± 42.5
|
Median (Range)
|
|
13.7 (1.0-220.9)
|
4.3 (0-123.9)
|
6.6 (0.1-218.9)
|
Test; p
|
N/A
|
t(158) = -1.81; .072
|
t(159) = 2.93; .004
|
t(120.13) = -14.75; < .001
|
*log DUP used for all analyses, +1 constant added to all dup values
a LSD significantly more contacts before date of entry if psychologist/counsellor/social worker is first contact
b LSD psychologist/counsellor/social worker significantly longer than medical and healer
c,d,e LSD each type of contact significantly different from the other
f LSD medical significantly shorter than psychologist/counsellor/social worker and healer
g Not significant after Bonferroni correction for multiple tests
Figure 1 presents the pathways to care for the 40 SCARF patients whose first contact was a healer. Twenty-two of them went to a healer first and then sought help from SCARF without further stops. Of these, four were referred to SCARF by the concerned faith healer (in these cases, the church). Thirteen went to a healer first, followed by one to two formal pathways (e.g., doctor) and then reached SCARF. Five went first to more than one healer before reaching SCARF.
Influence of first contact and referral source on duration of untreated psychosis
The route into the service influenced DUPs, with those whose first contacts were psychologists/counsellors/social workers (n=24) having significantly longer DUPs than those whose first contacts were with medical professionals (n=257) or healers (n=40) (see Table 4). The three routes of entry were associated with significant differences in help-seeking DUPs, with those whose first contact was a healer having the shortest help-seeking DUP [mean 6.6 weeks] and those whose first contacts were psychologists/counsellors/social workers having the longest [mean 56.4 weeks]. For systemic delay (from first contact to entry to the early intervention service), having a medical first contact resulted in a significantly shorter referral DUP [mean 9.2 weeks] than contacting a psychologist/counsellor/social worker or healer first.
Our hypothesis that first contacts with healers would lengthen DUPs proved relevant only to Chennai, because no Montreal patient first consulted a healer. In Chennai, too, where a fourth of patients had consulted healers, there was no difference in overall DUP for those whose first contact was a healer compared to those whose first contact was a medical professional or a psychologist/counsellor/social worker (see Table 4). Those whose first contact was a healer (n=40) had a shorter help-seeking DUP [mean 6.6 weeks] than those who first sought help elsewhere [n=122, mean 26.6 weeks]. However, they had a significantly longer systemic/referral delay [mean 21.0 weeks] than those who sought help elsewhere [mean 8.9 weeks].
In the Chennai sample, there was no difference in total, help-seeking or referral DUPs for those whose referral source was medical (n=53) vs. non-medical (n=110) (see Table 4). As the early intervention service was the first and only contact for a substantial number in Chennai (n=72), we compared DUP and its components for this subsample with those who had other contacts before accessing early intervention (see Table 4). While their overall DUPs were similar, those whose first contact had been the early intervention service itself had a significantly longer help-seeking DUP [mean 32.4 weeks] and shorter referral DUP [mean 0.8 weeks] compared to those who first sought help elsewhere [n =90; help-seeking DUP mean 13.1 weeks; referral DUP mean 19.8 weeks].