Date of Award

January 2018

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Vinod H. Srihari

Second Advisor

Sarah R. Kamens

Abstract

PART I. MEASURING PATHWAYS TO CARE IN FIRST-EPISODE PSYCHOSIS: THE STEP PATHWAYS TO CARE SCALE

Reduction of the duration of untreated psychosis (DUP) has become a priority of psychiatric services for individuals experiencing a first episode of psychosis (FEP). Efforts to reduce DUP can be informed by a better understanding of the sources of delay along individuals’ pathways to care. A major barrier to understanding pathways is the lack of a standardized tool to measure them. The aim of this thesis is to describe the feasibility and validity of the STEP Pathways to Care Scale, which has been adapted from the Pathways to Care Interview previously developed by Perkins et al. The STEP Pathways to Care Scale has been designed to systematically gather information about local pathways to care as part of an ongoing Early Detection study for FEP. This manuscript demonstrates how the scale can be used to gain a better understanding of regional pathways within a defined catchment area, including descriptions of the data that the scale obtains and examples of possible useful analyses. This is followed by an exploration of how this information could be used by Early Intervention services to tailor interventions that modify local sources of delay, thus aiding attempts to reduce DUP in their respective regions.

PART II. PHENOMENOLOGY OF NEGATIVE PATHWAYS TO CARE IN FIRST- EPISODE PSYCHOSIS

In the first-episode psychosis (FEP) literature, duration of untreated psychosis (DUP) is often studied alongside pathways to care. The term “negative pathways” has been used to refer to pathways that involve contacts such as emergency services, psychiatric inpatient units, and the police or criminal justice system, which may be experienced as distressing or coercive. This study was designed to investigate first-episode service users’ subjective experiences of negative pathways and to assess whether these experiences are related to their interest in treatment services and desire to seek help in the future. Semi-structured qualitative interviews were conducted with ten individuals enrolled in first-episode services (FES) in an urban area of Connecticut, and the data was analyzed using a modified version of Giorgi and Wertz’s phenomenological methods. All participants reported experiencing multiple types of negative pathways and were hospitalized prior to FES. The majority also encountered emergency services and/or the police. Participants generally described these experiences as distressing; however, some also identified helpful aspects of these pathways, particularly the inpatient unit. The experiences shared also reflected changes in perceptions of the hospital and FES over time. Our findings support that negative pathways are experienced as distressing and coercive, that individuals are often dissatisfied with services, and that this can lead to reluctance to seek treatment in those settings in the future. Multiple service users viewed agreement to FES as a means of reducing the length of hospital stays, and future work might explore ways to enhance internal motivation and perceived agency for these individuals.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 06/25/2100

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