Investigators of a study published in the American Journal of Psychiatry examined the various healthcare services used by patients between the ages of 15 and 29 years in the months before first diagnosis of a psychotic disorder. Those diagnosed with a psychotic disorder were much more likely to have had mental health inpatient care, mental health emergency department care, or a diagnosis of bipolar disorder in the year before diagnosis.

A random sample of 1000 potential cases was selected for review from 5 healthcare systems participating in the National Institute of Mental Health-funded Mental Health Research Network. Reviewers included patients with at least 1 reported symptom of psychosis 60 days before or after diagnosis, plus documentation of at least 1 symptom more than 60 days before diagnosis. Cases in which symptoms could be attributed to another medical condition or an adverse effect of medication were excluded.

The study defined psychosis according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, which lists features of psychosis as hallucinations, delusions, disorganized speech, and disorganized or catatonic behavior.

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The study population included patients who had received a first diagnosis of schizophrenia spectrum disorder (17%; n=105), mood disorders with psychotic symptoms (12%; n=78), or other psychotic disorders (71%; n=441). Each of these cases was matched with 3 cases of unipolar depression diagnoses and 3 general population cases.

In general, the types of care and rate of use were moderately comparable among patients with psychotic disorder diagnoses compared with those diagnosed with unipolar depression. However, patients diagnosed with a psychotic disorder were 2.96 times more likely to have received mental health inpatient care and 3.74 times more likely to have received mental health emergency department care in the year before diagnosis. A previous diagnosis of bipolar disorder was 8 times as likely.

“Most people receiving a first diagnosis of a psychotic disorder have had some indication of mental health need in the previous year,” the researchers wrote. “General use of primary care or mental health services, however, does not clearly distinguish people who later receive a diagnosis of a psychotic disorder from those who later receive a diagnosis of unipolar depression. Use of acute care mental health services (inpatient or emergency department care) is a more specific indicator of risk.”

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The investigators noted that their method of analysis emphasized first diagnosis of a psychotic disorder, not the first occurrence of symptoms. Thus, it is possible patients could have first experienced symptoms months or years before receiving care. In addition, only cases of patients who had been continuously enrolled in each health system for at least 12 months were considered.

Disclosures: Dr Simon has received research grant funding from Novartis and Otsuka and royalties from UpToDate. Dr Yarborough has received grant support from the Kaiser Permanente Community Benefit Initiative, the Kaiser Permanente Center for Safety and Effectiveness Research, the National Institute of Diabetes and Digestive and Kidney Diseases, National Institute on Drug Abuse, National Institute of Mental Health, Purdue Pharma, and the Industry PMR (a consortium of companies conducting FDA-required postmarketing studies assessing risks related to extended-release, long-acting opioid analgesics). Dr Penfold has received research funding from Janssen.


Simon G, Stewart C, Hunkeler E, et al. Care pathways before first diagnosis of a psychotic disorder in adolescents and young adults [published online January 24, 2018]. American Journal of Psychiatry. doi:10.1176/appi.ajp.2017.17080844