First-Episode Psychosis Incidence Higher Than Earlier Estimates

Pam Harrison

January 18, 2017

The incidence of first-episode psychosis is higher than previous estimates indicate, new electronic health record (EHR) data show.

Using a large population-based sample, investigators at Group Health Research in Seattle, Washington, found that when their analysis took into account data for patients presenting in all healthcare settings, the incidence of first-episode psychosis was higher than is usually reported, and it was even higher among patients aged 30 to 59 years than it was for younger patients.

"No previous research has characterized the proportion of first presentation with psychotic symptoms across all treatment settings (inpatient settings, emergency departments, mental health or chemical dependency outpatients clinics, and primary care or general meeting settings)," the investigators, led by Gregory Simon, MD, MPH, write.

"When all care settings were included, incidence of first-onset psychotic symptoms was higher than previous estimated based on surveys or inpatient data," they add.

The study was published online January 3 in Psychiatric Services.

EHRs Shed New Light

EHRs from the National Health–funded Mental Health Research Network were used to capture the incidence of psychosis in both older and younger age groups. Billing or diagnoses records were used to capture all first-time diagnoses of psychotic symptoms from January 2007 to December 2013. Illnesses included schizophrenia spectrum disorder, mood disorders with psychotic symptoms, and other psychoses.

"Across all health care systems, electronic health records and insurance claims identified 109,687 individuals with first diagnoses of any psychotic disorder during the study period," the investigators report.

When restricted to patients aged 15 to 29 years, the sample size was reduced to 56,470, they note.

The investigators randomly selected approximately 300 patients at each of the five participating healthcare systems to confirm that they had not received a diagnosis of or were being treated for psychosis prior to study entry.

"We were also interested in identifying middle-aged people [with first symptoms of psychosis] along with younger people between 15 and 29 years of age," Dr Simon told Medscape Medical News.

The researchers estimate that the rate of first presentation of psychotic symptoms was lower, at approximately 86 per 100,000 person-years, among patients aged 15 to 29 years than for those aged 30 to 59 years, for whom the rate was about 46 per 100,000 person-years.

Dr Simon explained that although the rate of new-onset psychotic symptoms is about twice as high in people between the ages of 15 and 29, "since there are twice as many people aged 30 to 59 as those between 15 to 29 years, half as high a rate [of first-episode psychosis] times twice as many people equals about the same number of people with new-onset psychotic symptoms in the older age group," Dr Simon said.

Table. Crude Incidence of First Psychosis Diagnoses in Different Healthcare Settings

Age Group and Setting Number of First Recorded Diagnoses, 2007-2013 Annual Incidence Rate per 100,000
Age 15 to 19 Years    
Inpatient or ED 2837 27
Outpatient mental health specialty 5876 56
Other outpatient facility 4391 42
Age 30 to 59 Years    
Inpatient or ED 5806 25
Outpatient or mental health speciality 8511 37
Other outpatient facilities 10,422 45

ED, emergency department

Therapeutic Implications

The finding that first-episode psychosis does not occur disproportionately in younger patients has important therapeutic implications. First, said Dr Simon, psychotic symptoms are a frightening and isolating experience.

"It's important for people to feel that they are not alone and that other people have recovered from similar problems, so peer support is likely to be most helpful when it comes from 'people like me,' " he said. "And the life challenges or goals of a 40-year-old are certainly different from those of a 17-year-old."

He also emphasized that if physicians hope to identify people with symptoms of new-onset psychosis as early possible, "we need to understand where the very first presentations occur," he said.

"We certainly can't limit ourselves to hospitals or emergency departments, or even to specialty mental health clinics. We need primary care providers to understand the importance of early intervention," Dr Simon added.

He cautioned that for any type of prevention or early intervention, there is tension between wanting to intervene as early as possible and wanting to avoid intervention that is unnecessary or even harmful.

"Some of the components of early intervention programs for psychotic symptoms, like family-oriented psychotherapy and vocational/educational rehabilitation, are certainly not harmful. But we'd probably want to be more cautious about very early prescription of antipsychotic medication," said Dr Simon.

No Treatment at All

Asked by Medscape Medical News to comment on the study, John Kane, MD, adjunct clinical professor of psychiatry and behavioral sciences, Albert Einstein School of Medicine, New York City, told Medscape Medical News that this is another study that supports the fact that many people are suffering from psychotic illness without receiving any treatment at all.

"In our study that you previous covered, the median duration of untreated psychosis was 1.5 years," Dr Kane said.

"So this study again underscores that there is a tremendous amount to be done."

For example, healthcare professionals in general need to be able identify people in need of mental health and addictive services, owing to the large, unmet community needs in this regard.

"We also need to make a concerted effort not just with health professionals but with educators and with lay public to do a better job at identifying mental illness — what we refer to as 'mental health literacy,' " Dr Kane added.

Moreover, people who theemselves suffer from mental illness do not know how to go about seeking help once they recognize that they do need help.

"This paper is a valuable contribution to the literature in that it helps us understand that first-episode psychosis does occur more frequently than we thought in older people, and it also helps us from a public health standpoint to appreciate that we need to reach out to more than just psychiatric hospitals and clinics. We need primary care providers to understand how important it is to cast as broad a net as possible and to plan our services so they are oriented to middle-aged people and not just young people as well," said Dr Kane.

Dr Simon and coinvestigator Christine Stewart, PhD, has received grant funding from Novartis Pharmaceuticals and Otsuka Pharmaceuticals. Dr Kane has been a consultant for or has received honoraria from Alkermes, Eli Lilly, EnVivo Pharmaceuticals (Forum), Forest (Allergan), Genentech, H. Lundbeck, Intracellular Therapeutics, Janssen Pharmaceutica, Johnson and Johnson, Neurocrine, Otsuka, Pierre Fabre, Reviva, Roche, Sunovion, Takeda, and Teva and grant support from Otsuka and Janssen. He has participated in advisory boards for Alkermes, Intracellular Therapies, Lundbeck, Neurocrine, Otsuka, Pierre Fabre, Takeda, and Teva and is a shareholder in MedAvante, Inc, Vanguard Research Group, and LB Pharmaceuticals, Inc.

Psych Serv. Published online ahead of print January 3, 2017. Abstract


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