Introduction 1 2 5 3 6 1 Method Recruitment strategy In August 2002, a specialised, low-threshold outpatient service for the assessment of patients considered at-risk for psychosis was established in a semi-urban catchment area of North Western Switzerland (population = 300.000). This “prodromal clinic” is part of the only general psychiatric outpatient clinic of the catchment area and is associated with a public psychiatric hospital. As is the case all over Switzerland, patients can refer themselves directly to any public or private psychiatric facility and do not require referral to mental health systems via gate-keeping GPs. Patients can also be referred by any other source such as GPs, school counsellors, paediatricians or social workers. n n 7 8 In our study, sensitised primary and secondary health care providers were encouraged to contact the outpatient clinic whenever one of their patients showed sustained decline in social functioning in a still relatively asymptomatic state; if they showed attenuated or brief intermittent positive psychotic symptoms; or if they suspected that “something odd had been going on” for some time in their patients. The research protocol was approved by the “Ethikkommission beider Basel”. It was designed to obtain data on help-seeking pathways and to collect longitudinal information about progression of symptoms and social as well as neuropsychological functioning, and was not a treatment trial. Patient sample As of January 1st 2003, patients could be referred to our prodromal clinic. Consenting patients were included in the study. Each individual was fully informed about the research protocol. Written informed consent was obtained from all patients, and additionally from the parents if under 18. Patients were considered ineligible for further assessment within the study if they presented a history of a past psychotic episode, traumatic brain injury, epilepsy or other known neurological disorder; other significant medical conditions considered to affect cognitive performance and self-perception; an IQ of below 70; or patients below the age of 18 in the first year and below the age of 14 years in the second year of the present study. Symptom ratings 9 10 11 12 13 14 15 10 11 Group assignment 16 Assessment of help-seeking pathways and of symptoms at prior contacts After symptom assessment, patients were asked which other professional groups they had previously contacted for similar problems. Further, timing and number of contacts as well as type of symptom leading to each single prior contact were recorded and, whenever possible, corroborated with information from family members. These data were assessed using a semi-structured interview that was designed for this study. However, no information was collected whether referrals to mental health services were voluntary or involuntary. Analysis t χ 2 Results Sample characteristics 1 Table 1 Socio-demographic characteristics  First episode At-risk Controls Total Significance values Number of patients 28 50 26 104  Mean age 23.4 21 22.1 22 χ P Gender     m (%) 22 (79) 31 (62) 23 (88) 76 (73) χ P     f (%) 6 (21) 19 (38) 3 (12) 28 (27) Marriage status     Unmarried (%) 26 (93) 45 (90) 25 (96) 96 (92) χ P Children     No children (%) 28 (100) 48 (96) 25 (96) 101 (97) χ P Living situation     Alone (%) 5 (18) 7 (14) 6 (23) 18 (17) χ P     With partner or friends (%) 5 (18) 5 (10) 8 (31) 18 (17)     With parents or relatives (%) 18 (64) 36 (72) 10 (39) 64 (62) City size     >200,000 (%) 5 (18) 5 (10) 4 (15) 14 (14) χ P     10,000–200,000 (%) 7 (25) 12 (24) 6 (23) 25 (24)     <10,000 (%) 16 (57) 33 (66) 16 (62) 59 (62) School education     None completed (%) 1 (4) 1 (2) 2 (8) 4 (4) χ P     Obligatory school (%) 19 (68) 36 (72) 18 (69) 73 (70)     Maturity (%) 5 (18) 4 (8) 4 (15) 13 (13)     Still in education (%) 3 (11) 9 (18) 2 (8) 14 (13) Professional training     None (%) 9 (32) 22 (44) 8 (31) 39 (38) χ P     Apprenticeship (%) 12 (42) 18 (36) 12 (46) 42 (40)     Academic education (%) 5 (18) 1 (2) 1 (4) 7 (7)     Still in training (%) 2 (7) 9 (18) 5 (19) 16 (15) Work situation     No occupation (%) 12 (43) 19 (38) 10 (39) 41 (39) χ P     At work (%) 10 (36) 11 (22) 6 (22) 27 (26)     In training (%) 6 (21) 20 (40) 10 (39) 36 (35) Number of contacts and professionals contacted χ 2 P 2 χ 2 P χ 2 P χ 2 P Table 2 Distribution of professionals contacted  FE AR PCo Total (n) % of total (66) 26.7 (125) 50.6 (56) 22.7 (247) 100 General practitioners 21.2% (14) 21.6% (27) 37.5% (21) 25.1% (62) Private Psychiatrists/Psychologists 21.2% (14) 24.8% (31) 21.4% (12) 23.1% (57) Psychiatric out-patient services 30.3% (20) 25.6% (32) 16.1% (9) 24.7% (61) Psychiatric in-patient services 19.7% (13) 7.2% (9) 16.1% (9) 12.6% (31) Other professionals 7.6% (5) 20.8% (26) 8.9% (5) 14.6% (36) Percentages (and absolute numbers) of contacts made with professional groups at any stage of the help-seeking pathway 1 χ 2 P χ 2 P χ 2 P Fig. 1 n n  Symptoms at prior presentations 3 Table 3 Frequency of presented symptoms  FE AR PCo Total Number of contacts 66 125 56 247 Positive symptoms   Ideas of reference (%) 15 (23.1) 2 (<5.0) 1 (<5.0) 18 (7.7)   Unusual contents of thought (%) 36 (55.4) 18 (14.8) 1 (<5.0) 55 (23.5)   Hallucinations (%) 13 (20.0) 11 (9.0) 2 (<5.0) 26 (11.1)   Perceptual disturbances (%) 5 (7.7) 21 (17.2) 0 26 (11.1)   Alienation or derealisation (%) 16 (24.6) 29 (23.8) 0 45 (19.2) Negative symptoms   Deterioration of social functioning (%) 32 (49.2) 54 (44.3) 16 (34.0) 102 (43.6)   Social withdrawal (%) 32 (49.2) 42 (34.4) 14 (29.8) 88 (37.6)   Avolition (%) 9 (13.8) 26 (21.3) 12 (25.5) 47 (20.1) Cognitive symptoms   Impaired concentration (%) 13 (20.0) 29 (23.8) 1 (<5.0) 43 (18.4)   Impaired attention (%) 7 (10.8) 12 (9.8) 1 (<5.0) 20 (8.5)   Impaired memory (%) 10 (15.4) 5 (<5) 2 (<5.0) 17 (7.3)   Formal thought disorders (%) 17 (26.2) 25 (20.5) 0 42 (17.9) Other symptoms   Depression (%) 24 (36.9) 74 (60.7) 38 (80.9) 136 (58.1)   Anxiety (%) 14 (21.5) 27 (22.1) 9 (19.1) 50 (21.4)   Lack of impulse-control (%) 2 (<5.0) 14 (<5.0) 11 (23.4) 27 (11.5) Absolute numbers (percentages) of presented symptoms. Percentage values do not add to 100% due to multiple symptoms recorded for most contacts χ 2 P χ 2 P χ 2 P 4 χ 2 P Table 4 Positive vs. non-positive symptoms presented to professional groups  General practitioners Psychiatrists psychologists Out-patient services In-patient services Other xprofessionals Total Number of contacts 59 55 61 30 34 239 Contacts made with positive symptoms 37.3% (22) 40% (22) 67.2% (41) 70% (21) 55.9% (19) (125) Contacts made with non-positive symptoms 62.7% (37) 60% (33) 32.8% (20) 30.0% (9) 44.1% (15) (114) Percentages (absolute numbers) of symptoms presented to professional groups. Percentage values do not add to 100% due to multiple symptoms recorded for most contacts 3 3 Duration from initial contact to referral z P n n z P z P z P Discussion To the best of our knowledge, this is the first study to investigate the help-seeking pathways of a patient cohort, which was referred to a prodromal clinic for a suspected at-risk state for psychosis. We were able to confirm the important role of GPs along the help-seeking pathways of patients with emerging psychosis. Furthermore, GPs were contacted in particular by those patients who presented insidious features. It was these patients that showed the longest delays in referral to our specialised outpatient service. The importance of GPs along the early pathways 1 17 18 2 5 19 The challenge of detecting the insidious symptoms 1 3 20 21 7 22 6 23 24 25 23 Delays in referral 7 22 17 18 Number of contacts and duration of help-seeking pathways 1 1 5 2 3 Weaknesses of this paper 26 27 Conclusions 28 29