Introduction
Evidence has accumulated about ethnic inequalities in access to care and treatment for psychotic disorders. Compared with their White ethnic counterparts, people from Black and minority ethnic backgrounds are more likely to experience coercive treatment (Manuel et al., Reference Manuel, Pitama, Clark, Crowe, Crengle, Cunningham, Gibb, Petrović-van der Deen, Porter and Lacey2023; Morgan et al., Reference Morgan, Mallett, Hutchinson, Bagalkote, Morgan, Fearon, Dazzan, Boydell, McKenzie, Harrison, Murray, Jones, Craig and Leff2005; Oduola et al., Reference Oduola, Craig, Das-Munshi, Bourque, Gayer-Anderson and Morgan2019), more likely to receive long-acting antipsychotic medications (Das-Munshi, Bhugra, & Crawford, Reference Das-Munshi, Bhugra and Crawford2018; Williams, Harowitz, Glover, Tek, & Srihari, Reference Williams, Harowitz, Glover, Tek and Srihari2020), more likely to be placed on community treatment orders (Patel et al., Reference Patel, Matonhodze, Baig, Gilleen, Boydell, Holloway, Taylor, Szmukler, Lambert and David2011), and less likely to receive psychological therapies (Colling et al., Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017; Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023). Whilst antipsychotic medications are the mainstay treatment for psychotic disorders due to their efficacy in symptom reduction and treatment maintenance (Pacchiarotti et al., Reference Pacchiarotti, Tiihonen, Kotzalidis, Verdolini, Murru, Goikolea, Valentí, Aedo and Vieta2019), research has shown that augmenting pharmacological interventions with psychological and psychosocial interventions brings greater benefits to patients, including improved quality of life (Fusar-Poli et al., Reference Fusar-Poli, Frascarelli, Valmaggia, Byrne, Stahl, Rocchetti, Codjoe, Weinberg, Tognin, Xenaki and McGuire2015), increased therapeutic alliance (Bhui et al., Reference Bhui, Aslam, Palinski, McCabe, Johnson, Weich, Singh, Knapp, Ardino and Szczepura2015), improved social functioning (Morrison et al., Reference Morrison, Law, Carter, Sellers, Emsley, Pyle, French, Shiers, Yung, Murphy, Holden, Steele, Bowe, Palmier-Claus, Brooks, Byrne, Davies and Haddad2018), and better clinical outcomes (Morrison et al., Reference Morrison, Pyle, Maughan, Johns, Freeman, Broome, Husain, Fowler, Hudson, MacLennan, Norrie, Shiers, Hollis and James2020).
Current clinical guidance generally highlights the importance of offering psychological and psychosocial interventions for treating psychosis. In the UK, the National Institute for Clinical Excellence (NICE) recommends that people with first-episode psychosis should be offered psychological therapy (PT), such as cognitive behavioral therapy for psychosis (CBTp) and interventions involving the family (i.e. family intervention), along with antipsychotic medication (NICE, 2015). In the past decade, there has been a surge of interest in examining ethnic inequalities in receipt of psychological interventions among people with psychotic disorders. Evidence from the UK highlights pervasive inequalities in access to psychological therapy among ethnic minority people living with psychotic disorders. When surveying the National Clinical Audit of Psychosis data, Schlief et al. (Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023) found that compared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had lower adjusted odds of receiving CBTp. They also reported that people of Black African, Black Caribbean, non-African/Caribbean Black, non-British/Irish White, and of ‘any other’ ethnicity, also experienced lower adjusted odds of receiving family interventions (Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023). Colling et al. (Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017), in a sample of 2,308 patients with a diagnosis of schizophrenia disorders drawn from the electronic health records of a large mental health provider, showed that younger patients and white British patients were more likely to receive CBTp compared with people of Black ethnic groups (Colling et al., Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017).
These findings are echoed in the US. Oluwoye et al. (Reference Oluwoye, Stiles, Monroe-DeVita, Chwastiak, McClellan, Dyck, Cabassa and McDonell2018) employed data from the RAISE early treatment program to examine racial and ethnic differences in treatment outcomes among participants in a randomized controlled trial of an intervention for first-episode psychosis called NAVIGATE. They found that families of Hispanic participants in usual community care were less likely than non-Hispanic white families to receive family psychoeducation (Oluwoye et al., Reference Oluwoye, Stiles, Monroe-DeVita, Chwastiak, McClellan, Dyck, Cabassa and McDonell2018). Similarly, Heun-Johnson et al. (Reference Heun-Johnson, Menchine, Axeen, Lung, Claudius, Wright and Seabury2021) found in a sample of 3,017 privately insured patients that Black and Hispanic patients were less likely than White patients to receive psychotherapy from a behavioral health professional at FEP (Heun-Johnson et al., Reference Heun-Johnson, Menchine, Axeen, Lung, Claudius, Wright and Seabury2021).
Despite the growing evidence of ethnic inequalities in the offer of psychological therapies for psychosis, several methodological and clinical shortcomings need to be addressed. For example, a few of the previous studies have focused on populations of people with chronic forms of psychotic illness (Colling et al., Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017; Das-Munshi et al., Reference Das-Munshi, Bhugra and Crawford2018; Mercer, Evans, Turton, & Beck, Reference Mercer, Evans, Turton and Beck2019) and are consequently, biased toward those likely to have poor engagement with services. Others have used early intervention for psychosis as a proxy for first-episode psychosis (Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023), so it remains unclear whether and how the NICE-recommended treatment is being delivered to people with FEP during a first presentation to mental health services. In addition, most of the literature has been ‘silent’ regarding the influence of pathways to care and clinical characteristics during FEP on the offer of psychological therapy. For example, duration of untreated psychosis (DUP), usually defined as the time from the onset of frank psychotic symptoms (i.e. hallucinations or delusions) to the date of first contact with a mental health service for psychosis or the start of antipsychotic treatment (Singh, Reference Singh2007), and the speed at which psychotic symptoms develop (i.e. mode of onset) (Compton, Chien, Leiner, Goulding, & Weiss, Reference Compton, Chien, Leiner, Goulding and Weiss2008) are important indicators of illness prognosis. Indeed, a sizeable body of evidence has shown that a prolonged DUP is associated with poor clinical outcomes (Drake, Haley, Akhtar, & Lewis, Reference Drake, Haley, Akhtar and Lewis2000; Marshall et al., Reference Marshall, Lewis, Lockwood, Drake, Jones and Croudace2005), reduced social functioning, and poor quality of life (Craig et al., Reference Craig, Bromet, Fennig, Tanenberg-Karant, Lavelle and Galambos2000; Marshall et al., Reference Marshall, Lewis, Lockwood, Drake, Jones and Croudace2005). However, the extent to which DUP or mode of onset influences access to psychological therapy is unclear. To address these gaps, in this study, we used an epidemiologically derived cohort of first-episode psychosis patients to examine whether (a) ethnicity, pathways to care, and clinical characteristics influenced the offer of psychological therapies in an FEP sample, (b) there were ethnic and clinical differences in the offer, uptake, and type of psychological therapies, and (c) early intervention for psychosis service played a role in the offer and type of psychological therapies.
Methods
Settings, study design, data source, and participants
This study was carried out in the inner-city London boroughs of Lambeth and Southwark, served by the South London and Maudsley NHS Trust (SLaM). SLaM provides mental healthcare for the residents of five boroughs in south-east London, with a total population of 1.3 million (Perera et al., Reference Perera, Broadbent, Callard, Chang, Downs, Dutta, Fernandes, Hayes, Henderson, Jackson, Jewell, Kadra, Little, Pritchard, Shetty, Tulloch and Stewart2016). Adult services for patients with psychotic disorders in SLaM comprise community, outpatient, and inpatient teams.
Participants in this study were drawn from a large incidence study, namely the Clinical Record Interactive Search—First Episode Psychosis (CRIS-FEP) study (Oduola et al., Reference Oduola, Das-Munshi, Bourque, Gayer-Anderson, Tsang, Murray, Craig and Morgan2021b). Patients presenting for the first time with FEP (i.e. ICD F20–29, F30–33) to any adult mental health service in SLaM between May 2010 and April 2012 were identified. Data were obtained from the SLaM Biomedical Research Centre Clinical Records Interactive Search (CRIS) system (Perera et al., Reference Perera, Broadbent, Callard, Chang, Downs, Dutta, Fernandes, Hayes, Henderson, Jackson, Jewell, Kadra, Little, Pritchard, Shetty, Tulloch and Stewart2016; Stewart et al., Reference Stewart, Soremekun, Perera, Broadbent, Callard, Denis, Hotopf, Thornicroft and Lovestone2009), which provides fully de-identified access to all SLaM electronic clinical records. CRIS is a bespoke research database search and assembly tool which has supported several studies (Colling et al., Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017; Das-Munshi et al., Reference Das-Munshi, Chang, Dutta, Morgan, Nazroo, Stewart and Prince2017; Patel et al., Reference Patel, Oduola, Callard, Wykes, Broadbent, Stewart, Craig and McGuire2017). The clinical information documented in CRIS is available in structured fields (for diagnosis and demographic information) and unstructured free-text fields (for clinical notes and correspondence).
Procedure
Case identification
The approach for identifying cases in the CRIS-FEP study has been described and published previously (Oduola, Craig, Iacoponi, Macdonald, & Morgan, Reference Oduola, Craig, Iacoponi, Macdonald and Morgan2023; Oduola, Das-Munshi, et al., Reference Oduola, Das-Munshi, Bourque, Gayer-Anderson, Tsang, Murray, Craig and Morgan2021b). In summary, the Structured Query Language (SQL) (SQL – ANSI, 2011) was used to interrogate the structured and free-text fields in CRIS to retrieve the records of patients presenting to any adult mental health services between 2010 and 2012; then we applied defined search terms (e.g. ‘psychos*’; ‘onset’; ‘psychosis’; ‘voices’). This returned records of probable participants. Second, the research team screened each patient’s de-identified records for eligibility using the Screening Schedule for Psychosis (Jablensky et al., Reference Jablensky, Sartorius, Ernberg, Anker, Korten, Cooper, Day and Bertelsen1992) and the study inclusion/exclusion criteria.
Inclusion/exclusion criteria
Participants were included if they were residents in the London boroughs of Lambeth or Southwark, (b) aged 18–64 years old (inclusive) at presentation, (c) with a clinical diagnosis of a psychotic disorder (i.e. ICD F20–29, F30–33), and (d) were in first contact with mental health services for psychosis. Exclusion criteria were (a) evidence of psychotic symptoms with an organic cause, (b) transient psychotic symptoms resulting from acute intoxication, and (c) previous contact with services for psychotic symptoms.
Early intervention for psychosis and eligibility
Early intervention for psychosis services (EIS) are designed to identify and provide appropriate interventions as early as possible during an individual’s first episode of psychosis to reduce treatment delays and improve outcomes (Singh, Reference Singh2010). At the time of this study, FEP patients accessed mental health services at SLaM by two routes EIS and non-EIS depending on eligibility. The main eligibility criterion for accessing an EIS in SLaM at the time of our study was age, i.e. 18–35 years. This was before the introduction of the Access and Waiting Time Standard, i.e. April 1, 2016, when the upper age limit was extended to 65 years in England (NHS England, 2016). Therefore, our analyses relating to the role of EIS in the offer or type of PT were restricted to those aged 18–35 years. Early intervention psychosis services at SLaM typically offer a 3-year duration of treatment and support (Oduola et al., Reference Oduola, Craig, Iacoponi, Macdonald and Morgan2023).
Demographic characteristics
The procedure for extracting sociodemographic and clinical data for the CRIS-FEP sample has been reported elsewhere (Oduola et al., Reference Oduola, Craig, Das-Munshi, Bourque, Gayer-Anderson and Morgan2019; Oduola, Craig, & Morgan, Reference Oduola, Craig and Morgan2021a). In summary, the Medical Research Council Socio-demographic schedule MRC-SDS (Mallett, Reference Mallett1997) was used to capture data on demographic variables. Ethnicity was coded according to the 18 categories in the UK 2011 census (ONS, 2011). We collapsed the ethnic groups into seven categories for the purpose of analysis as follows: White British, Black Caribbean (Black Caribbean and Other Black), Black African, Asian (Indian, Pakistani, Bangladeshi, Chinese), White non-British (White Irish, White Gypsy, White Other), Other (Arab, Any Other Ethnic group), and Mixed (all Mixed ethnic groups). The ethnic characteristics of the sample in this study are representative of the study catchment areas, although there is heterogeneity when compared with England, as shown in Supplementary Table S1.
Clinical variables
Data relating to clinical and pathways to care characteristics, including duration of untreated psychosis (DUP), mode of onset of psychosis, and access to EIS, were collected using the Personal and Psychiatric History Schedule (PPHS) (WHO, 1996). Mode of onset of psychosis is defined as the speed at which psychotic symptoms develop, including an acute onset (within days or a week) or in a more gradual way, for more than a few months (Compton et al., Reference Compton, Chien, Leiner, Goulding and Weiss2008). This information was captured as a categorical variable in the PPHS. DUP was measured as a continuous variable (in days) from the date of onset of psychotic symptoms as recorded in clinical records to the date of first contact with SLaM for first-episode psychosis.
Outcome variables
The outcome data were the offer, uptake, and type of psychological therapy. Psychological therapy was defined as any formal therapy or psychosocial intervention, including CBTp, family intervention, group therapy, or counselling. Outcome data were collected from the study’s inception, from May 2010 until April 2014. Data on offer, acceptance, and type of psychological therapy were manually extracted from the electronic health records’ structured and free-text fields, using an adapted version of the Life Chart Schedule for case notes (Harrison et al., Reference Harrison, Hopper, Craig, Laska, Siegel, Wanderling, Dube, Ganev, Giel, An der Heiden, Holmberg, Janca, Lee, León, Malhotra, Marsella, Nakane, Sartorius, Shen and Wiersma2001). We operationalized the adapted Life Chart Schedule for data extraction from CRIS by first retrieving the clinical records of each patient in the CRIS-FEP study sample. Second, we interrogated the free-text fields of CRIS (including clinical assessment, correspondence, and discharge summaries) to determine whether the patient was offered and accepted a psychological therapy, both coded as binary variables: ‘yes’ or ‘no’ and the type of psychological therapy offered. Two researchers who have been trained in clinical records data extraction conducted the data collection. Inter-rater reliability was done on 20% of the sample on the offer of PT and type of PT variables between the two raters. Kappa scores of k = 0.97, p < 0.001 and k = 0.83, p < 0.001 were achieved, respectively between the raters, indicating a substantial agreement. Discrepant or ambiguous cases were resolved by consensus with research team members.
Statistical analysis
Stata version 15 was used to analyze the data (StataCorp, 2017). Descriptive statistics for the outcome and exposure variables were obtained as frequencies and percentages for categorical variables and mean (standard deviation [SD]) and median (interquartile range [IQR]) for continuous variables. We performed chi-square and Kruskal Wallis tests (as appropriate) to compare demographic and clinical characteristics between patients offered and not-offered PT. We performed univariable and multivariable logistic regression analyses to (a) examine associations between ethnicity, clinical, PtC factors, and offer of a PT in the whole sample; (b) assess associations between ethnicity, clinical factors, and offer of PT in the sample of patients aged 18–35 years who were eligible for an EIS; and (c) examine associations between the type of PT offered (CBTp versus no-CBTp), clinical characteristics, and ethnicity in those eligible for EIS. In all the multivariable regression models, we adjusted for a-prior confounders (age and gender) and other variables in the models. There were two missing data in the EIS variable, and those were removed from the analyses. We performed Bonferroni confidence interval adjustments (Curtin & Schulz, Reference Curtin and Schulz1998) for multiple comparisons when relevant.
Ethical approval
The Oxfordshire Research Ethics Committee approved the CRIS system as an anonymized dataset for secondary analysis (reference 23/SC/0257). We obtained local approval for this study via the CRIS Oversight Committee at the BRC South London and Maudsley NHS Foundation Trust (reference: 09–041). Under UK law, patient consent was not required for this study.
Results
Sample characteristics
Table 1 summarizes the patients’ characteristics. Five hundred and fifty-eight FEP patients were identified. The mean age was 33.6 (SD:10.6) years; there were more men (52.3%) and Black African people (26.3%) than other ethnic groups. Most of the patients did not access an EIS (58.1%), an insidious onset of psychosis is common (37.5%), and a median DUP of 93 (IQR: 19–447) days was observed.
Table 1. Sample characteristics
a 2 missing data
Offer, uptake, and type of psychological therapy
One hundred and ninety-five people were offered psychological therapy, of whom only two (1.6%) declined. Two types of PT were offered, namely CBTp (86.4%) and group therapy (13.6%) (Table 1).
Associations between demographic, pathways to care characteristics, and offer of any psychological therapy
We found that characteristics of the pathways to care and mode of onset of psychosis were associated with the offer of psychological therapy. Patients in the EIS were more likely to be offered a PT compared to those in the non-EIS group (EIS: 44.8% vs non-EIS 28.5%, p < 0.0001). This was reflected in the differences observed by age, in which those aged 18–35 years (37.6%) were more likely to be offered a PT than those aged 36–64 (30.6%; p = 0.08). We found that patients with an acute onset of psychosis were more likely to be offered a PT (PT offered: 44.0%) compared with a moderate onset (PT offered: 27.3%). There were no clear differences in the offer of PT by DUP or sex (Table 2).
Table 2. Demographic, clinical, pathways to care characteristics by offer of any psychological therapy (PT)
Associations between the offer of any psychological therapy and ethnic, clinical, and PtC characteristics
In the whole sample (n = 556), we found strong evidence that patients accessing EIS were twice as likely to be offered a PT (adj. OR: 2.24 [95%CI:1.39–3.59]) compared with non-EIS patients. We also found that patients with a moderate mode of onset of psychosis were less likely to be offered any PT (adj. OR: 0.52 [95%CI: 0.29–0.92]) compared with those with an acute onset. There was insufficient evidence of ethnic differences in the offer of any PT (Table 3).
Table 3. Unadjusted and adjusted odds ratios of associations between ethnicity, clinical, pathways to care and offer of any psychological therapy in the full sample (n = 556)
CI confidence interval
Model 1 unadjusted
Model 2 age, gender, ethnicity, DUP, mode of onset, EIS.
When we assessed ethnic differences in the offer of PT among patients who were eligible for an EIS, there was no evidence of associations. However, patients with a moderate onset of psychosis remained less likely to be offered any PT (adj. OR: 0.40 [95%CI: 0.19–0.82]) compared with those with an acute onset (Table 4). These results were held after Bonferroni corrections.
Table 4. Unadjusted and adjusted odds ratios of associations between ethnicity, clinical and offer of any psychological therapy (n = 340) in patients eligible for EIS
CI confidence interval
Model 1 unadjusted
Model 2 adjusted for age, gender, ethnicity, DUP, mode of onset.
Ethnic and clinical differences in the type of psychological therapy offered (i.e. CBTp versus non-CBTp) among patients eligible for early intervention services
In Table 5, we assessed ethnic variations in the type of PT offered to patients eligible for EIS. We focused on CBTp given it was the type of PT mostly offered. Multivariable logistic regression analyses showed strong evidence that Black African (adj. OR: 0.49 [95% CI: 0.25–0.94]) and Black Caribbean (adj. OR: 0.45 [95% CI: 0.21–0.97]) patients were less likely to be offered CBTp (relative to non-CBTp) compared with their White British counterparts. A moderate onset of psychosis was also associated with a reduced odds of being offered CBTp (adj. OR: 0.34 [95%CI: 0.15–0.73]). These results were held after Bonferroni corrections. We found no evidence of associations between the offer of CBT and DUP.
Table 5. Unadjusted and adjusted odds ratios of associations between ethnicity, clinical characteristics and offer of CBT in patients eligible for EIS (n = 340)
CI: confidence interval
Model 1: unadjusted
Model 2: adjusted for age, gender, ethnicity, DUP, mode of onset.
Discussion
Main findings
In this study, we investigated ethnic, PtC and clinical disparities in the offer, uptake, and type of psychological therapy during the first episode of psychosis. We assessed demographic, clinical, and pathways to care factors associated with being offered a psychological therapy and the type offered. Our sample is representative of people with psychotic illness who access and receive care from inner-city mental health services in the UK. We found that most patients offered a PT were those receiving care from an EIS, which is corroborated by the finding that younger patients aged 18–35 years were more likely to be offered a PT. It is noteworthy that EIS typically accepted patients aged 18–35 years at the time of our study. All but n = 2 of 195; (1.16%) patients accepted the offer of PT, suggesting there is a willingness to accept treatment. Patients were offered either CBTp or group therapy, with the majority being offered CBTp. Overall, we found insufficient evidence of ethnic differences in the offer of any psychological therapy. However, we found strong evidence of association between mode of onset of psychosis, indicating that patients with a moderate onset were less likely to be offered a PT. Initially, the multivariable analyses of patients eligible for an EIS (i.e. aged 18–35 years old) suggested there was no ethnic variation in the offer of PT among those eligible for EIS. However, when we assessed the associations by type of PT offered (i.e. CBTp versus non-CBTp), our analyses indicated large variations by ethnicity and clinical factors. We found that compared with White British patients, Black African and Black Caribbean patients were less likely to be offered CBTp. Patients with a moderate onset of psychosis were also less likely to be offered CBTp.
Methodological considerations
The findings need to be considered in the context of some methodological limitations. First, data were drawn from clinical records; therefore, reporting accuracy depends on the quality of clinicians’ documentation. Although clinicians are required to document treatment offered to patients, some patients may have been offered PT but not documented in the records. Second, our data were collected before the UK government introduced the Access and Waiting Time Standards (AWTS) (NHS England, 2016); despite this, our findings are comparable to more recent studies. Third, while we did not measure or adjust for socioeconomic factors when examining ethnic differences in the offer and type of PT, several lines of reasoning suggest this is unlikely to bias our findings. For instance, Schlief et al. (Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023) found lower odds of being offered CBTp among all minority ethnic groups after controlling for socioeconomic variables. Fourth, our findings in some ethnic groups, e.g. the ‘other’ and white non-British patients may not be generalizable owing to the heterogeneity of these ethnic groups. We included people of white Irish, white Gypsy/traveler, white non-British ethnicities in our white non-British, and people identifying as Arab and any other ethnic group were included in our ‘other’ ethnic group. Whilst we adjusted for several sociodemographic, PtC, and clinical factors, unmeasured factors, such as socioeconomic status, clinician bias, cultural stigma, systemic barriers, or cultural perceptions of therapy, may still confound the results.
Despite these limitations, our study has several methodological strengths. We used an epidemiologically derived cohort of people with first-episode psychosis assembled within the CRIS-FEP study (Oduola et al., Reference Oduola, Craig, Iacoponi, Macdonald and Morgan2023; Oduola, Das-Munshi, et al., Reference Oduola, Das-Munshi, Bourque, Gayer-Anderson, Tsang, Murray, Craig and Morgan2021b), providing a basis to determine the treatment trajectory at the start of the illness. We comprehensively reviewed the de-identified electronic health records of every CRIS-FEP patient for up to approximately 4 years to carefully determine their offer, type and uptake of PT. There were only two patients with missing data in our analysis in determining ethnic and clinical disparities in offer and type of PT, hence minimizing bias. Another strength is that our large sample size allowed us to categorize ethnicity according to the UK Census Ethnic Classifications, and the ethnic characteristics of our sample are representative of the base population (ONS, 2011). Furthermore, to our knowledge, this is one of the few studies that have considered the influence of pathways to care and clinical characteristics on the offer of PT during first-episode psychosis.
Interpretations of findings and relationship to previous studies
Our findings of ethnic variations in the type of PT (i.e. CBTp) align with many previous studies (Colling et al., Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017; Das-Munshi et al., Reference Das-Munshi, Bhugra and Crawford2018; Mercer et al., Reference Mercer, Evans, Turton and Beck2019; Oluwoye et al., Reference Oluwoye, Stiles, Monroe-DeVita, Chwastiak, McClellan, Dyck, Cabassa and McDonell2018; Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023). Specifically, the low offer of CBTp to the Black African (adj. OR:0.49 [95% CI: 0.25–0.94]) and Black Caribbean (adj. OR: 0.45 [95% CI: 0.21–0.97]) patients in our study has been shown in recent studies. For example, Schlief et al. (Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023) found adj. OR: 0.53 (95% CI: 0.47–0.59) and adj. OR: 0.59 (95% CI: 0.51–0.69) for CBTp among Black African and Black Caribbean patients, respectively. These findings were also echoed by Colling et al. (Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017). However, contrary to previous studies (Mercer et al., Reference Mercer, Evans, Turton and Beck2019; Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023), we did not find sufficient evidence of a reduced likelihood of the offer of any PT by ethnicity.
Considering pathways to care, DUP, and mode of onset of psychosis, we found that a high proportion of patients accessing early intervention services were offered a PT, and the majority accepted the treatment. This is not surprising, as a key treatment approach for FEP within early intervention for psychosis services is psychological therapy, according to the NICE guidelines (NICE, 2015). Our observation is also consistent with the National Clinical Audit of Psychosis (Royal College of Psychiatrists, 2022), which examined the rates of offer and receipt of therapy in early intervention for psychosis teams in England and found that an average of 86% of service users with psychosis were offered CBTp in 2021/22. However, the uptake of psychological therapy was greater in our study (98.4%) compared with 46% of service users taking up the offer of CBTp in the National Clinical Audit of Psychosis audit (Royal College of Psychiatrists, 2022).
We did not find evidence of associations between DUP and the offer or type of PT. However, we observed that an acute onset of psychosis is common among patients who were offered a PT, and conversely, those with a moderate onset were less likely to be offered any PT and more specifically CBTp. This observation may be explained by considering symptom recognition, i.e. frank psychotic symptoms are more recognizable in an acute presentation than in a moderate or more gradual onset of psychosis. Indeed, significant efforts have been spent in reducing treatment delays and improving outcomes of psychosis, and part of achieving this lies in recognizing the symptoms and initiating help-seeking. A recent systematic review of public health interventions, campaigns, and initiatives designed to improve pathways to care for individuals with psychotic disorders shows that interventions targeting multiple populations (general public and non-healthcare professionals) and those lasting >12 months show promise for reducing the duration of untreated psychosis (Murden, Allan, Hodgekins, & Oduola, Reference Murden, Allan, Hodgekins and Oduola2024). Therefore, we could argue that if patients are able to access specialist psychosis services quicker for treatment, i.e. shorter DUP, then they are more likely to access psychological therapy.
Furthermore, our data suggest that younger patients were more likely to be offered a PT in keeping with previous findings (Colling et al., Reference Colling, Evans, Broadbent, Chandran, Craig, Kolliakou, Stewart and Garety2017; Heun-Johnson et al., Reference Heun-Johnson, Menchine, Axeen, Lung, Claudius, Wright and Seabury2021; Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023). This may be linked to the age of onset of psychosis, which tends to occur in late teens and early adulthood (Oduola, Das-Munshi, et al., Reference Oduola, Das-Munshi, Bourque, Gayer-Anderson, Tsang, Murray, Craig and Morgan2021b). Additionally, we collected data for this study when the age of acceptance to early intervention for psychosis services was between 18 and 35 years; therefore, it is logical that younger people accessed EIS, which meant they were more likely to be offered a PT. Future study assessing variations in psychological therapy by age would be helpful. This is particularly important in the UK, given the implementation of the Access and Waiting Time Standards (NHS England, 2016), which recommends that EIS accept patients up to 65 years of age. Therefore, further research using post-AWTS data and the inclusion of older patients may provide insights into current practices and the uptake of PT. In contrast to previous studies (Das-Munshi et al., Reference Das-Munshi, Bhugra and Crawford2018; Schlief et al., Reference Schlief, Rich, Rains, Baldwin, Rojas-Garcia, Nyikavaranda, Persaud, Dare, French, Lloyd-Evans, Crawford, Smith, Kirkbride and Johnson2023), we found no patient was offered a family intervention. This is interesting, given the NICE guidelines and research demonstrating the benefits of family intervention in FEP populations (Claxton, Onwumere, & Fornells-Ambrojo, Reference Claxton, Onwumere and Fornells-Ambrojo2017).
Implications for clinical practice
Implications for clinical practice are highlighted in our results. We found significant under-presentation of Black African and Black Caribbean patients being offered CBTp. One possible explanation could be linked to the mismatch in the demographic characteristics of the patient population and the clinicians who deliver psychological therapies. It is well documented in clinical psychology that there is a lack of representation of Black and minority ethnic group people in the workforce (Turpin & Coleman, Reference Turpin and Coleman2010; Wood & Patel, Reference Wood and Patel2017). However, there is good evidence that in the dyad of patient-therapist matched on race/ethnicity, significant improvement in functioning was observed over time (Duong et al., Reference Duong, Zoupou, Boga, Kashden, Fisher, Connolly Gibbons and Crits-Christoph2024). Cooper and colleagues, in a qualitative study, reported that clinicians’ implicit racial bias was associated with Black patients’ perceptions of poorer communication and lower ratings of quality of care (Cooper et al., Reference Cooper, Roter, Carson, Beach, Sabin, Greenwald and Inui2012). Another important consideration is the notion of cultural sensitivity, which is the extent to which services and healthcare professionals are sensitive to people’s cultural identity or heritage, including ethnicity (Care Quality Commission, 2024). Previous studies have shown when healthcare professionals are curious about patients’ cultural identity, beliefs, and heritage, patients feel heard, accepted, and supported (Conneely et al., Reference Conneely, Packer, Bicknell, Janković, Sihre, McCabe, Copello, Bains, Priebe, Spruce and Jovanović2023; Gardner Reference Gardner, Oduola and Teague2024). There are calls for clinical psychologists to be more representative of the local population’s culture and personal identities that they serve (Mercer et al., Reference Mercer, Evans, Turton and Beck2019). In the UK, it is noteworthy that the Department of Health and Social Care aims to increase and improve the diversity of its workforce (NHS England, 2023). Nonetheless, it remains imperative that ethnic inequalities are explored and addressed to provide equitable healthcare for all.
Future research
This study provides important findings about demographic, clinical, and pathways to care factors associated with the offer, uptake, and type of psychological therapies during FEP within a diverse urban population. Future research across diverse catchment areas is warranted to validate these findings. For example, it would be beneficial for future research to investigate differences in access to psychological therapies in rural populations and gender minority groups, e.g. LGBTQ+ people. Additionally, understanding the mechanisms underlying the ethnic inequalities in accessing NICE-recommended treatment is critical. This could be achieved through qualitative approaches involving patients, carers, and clinicians, and, more importantly, such research could be co-produced with people with lived experience.
Conclusions
Our study shows that accessing an early intervention service during FEP increased the likelihood of being offered a PT. However, treatment inequalities remain by ethnicity and clinical characteristics. Our findings are relevant to international policymakers, clinicians, patients, and carers. Improving access to psychological therapies and targeting provision toward underserved groups are critical. Greater efforts are needed to ensure people at all stages of a psychotic illness receive treatment and interventions in an equitable manner, which in turn will improve outcomes.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/S0033291725101529.
Data availability statement
No additional data are available.
Acknowledgments
This paper represents independent research supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and, Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
Author contribution
All authors collected or supervised data collection. Study conception/design: SO, CM, TC, RM. Data analysis and manuscript preparation: SO. Interpretations and revisions of the manuscript: all authors.
Funding statement
CM was supported by UK Medical Research Council (Ref: G0500817), the Wellcome Trust (Grant Number: WT087417), and the European Union (European Community’s Seventh Framework Program (grant agreement No. HEALTH-F2–2009-241909) (Project EU-GEI)).
SO and CM are supported by the National Institute for Health Research [NIHR 207498]. The views expressed are those of the authors and not necessarily those of the funding bodies.
Competing interests
RM is Editor in Chief Psychological Medicine. He played no part the decision of this manuscript.
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