Early Detection Strategy for First-Episode Psychosis

The early detection strategy (ED) will target all residents of a designated geographic catchment contiguous with the Connecticut Mental Health Center (CMHC) in which STEP is located. This includes the 8 towns of Bethany, Orange, Woodbridge, Hamden, New Haven, East Haven, West Haven and North Haven, with a total population of 323,285 (Census, 2010) and for which we estimate an annual incidence 40–70 cases of schizophrenia-spectrum disorders. The catchment was chosen based on feasibility of travel for care at STEP. The intensive approach to ascertainment of new onset cases from across the catchment will include public messaging and targeted outreach to all major treatment centers. Also measurement of DUP will be undertaken at one other major community mental health center that draws from this catchment zone. At this community ‘sentinel’ site, in addition to the usual outreach, clinical records will be reviewed on a regular basis to determine the prognostic profile and DUP of patients who were not successfully referred to STEP for initiation of treatment. The control site, PREP^R is based in the Jamaica Plains area of Boston and while it draws from a much larger metropolitan population of more than 4 million (Census 2010), the demographic and prognostic profile of usual recruits over the past 5 years have been broadly comparable to that of STEP (see section Choice of Control site below).
The focus of early intervention after the onset of a psychosis is to improve the outcomes of individuals with schizophrenia-spectrum disorders. The reality, embraced by all exemplar early intervention programs, is that an accurate diagnosis is often difficult to make at the time of symptom onset [42 (link)]. Thus a ‘first-episode’ psychosis sample will necessarily include patients who will, on longitudinal follow-up, turn out to have less severe illnesses such as major depression with psychotic features, brief psychotic disorder or bipolar disorder (with psychotic features). The study population is thus expected to be diagnostically heterogeneous in the service of identifying, with as much sensitivity as possible, those who are likely to develop chronic psychotic illnesses.
We will thus use criteria that are simple to communicate and apply, to minimize delays in determining eligibility:

Inclusion Criteria: 16–35 years old, must live within catchment of interest (For PREP^R: greater Boston metropolitan area; for STEP: 8 town catchment) and must have had their first-episode of psychosis within the past 3 years.

Exclusion Criteria: Established diagnosis of Affective psychosis (i.e. non-ambiguous Bipolar d/o or MDD with psychotic features) or Psychosis secondary to substance use or a medical illness, unable to communicate in English, eligible for DDS (Department of Developmental Services), legally mandated to enter treatment, unable to reliably determine DUP, unstable serious medical illness. We will exclude from this study, those patients who converted to psychosis while being followed and cared for in prodromal clinics (i.e. DUP of 0), which exist at both sites. We will also exclude those who have previously received care at another FES.

Reasons for exclusion and patient refusal will be recorded for all referrals. DUP will be estimated for refusers who are otherwise eligible, to gauge the impact of sampling bias on the relationship between DUP reduction and early outcomes.
Written informed consent for participation in the study will be obtained from all adult participants. For those participants under 18 years of age, written consent will be obtained from a parent or legal guardian in addition to written assent from the participant. All procedures are in compliance with the Helsinki Declaration and have received ethics approval from the Yale University Human Investigation Committee (Protocol Number: 1310012846).