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Publication - Dr Sarah Sullivan

    Association of Primary Care Consultation Patterns With Early Signs and Symptoms of Psychosis


    Sullivan, S, Hamilton, W, Tilling, K, Redaniel, T, Moran, P & Lewis, GH, 2018, ‘Association of Primary Care Consultation Patterns With Early Signs and Symptoms of Psychosis’. JAMA Network Open, vol 1.


    Primary care is an important part of the care pathway for
    patients with psychosis; therefore, primary care physicians need to be
    able to accurately identify those at clinical high risk of psychosis.
    The difficulty of this task is increased because clinical high-risk
    symptoms are frequently nonspecific to psychosis.

    To determine whether the consultation patterns for a
    prespecified set of symptoms can be used to identify primary care
    patients who later developed a psychotic illness.

    Design, Setting, and Participants 
    This nested case-control study used primary care consultation
    data collected from 530 primary care practices in 13 UK regions from
    January 1, 2000, through September 30, 2009. Participants included
    11 690 adults with a diagnosis of psychosis and 81 793 control
    participants who did not have a diagnosis of psychosis individually
    matched by age group, sex, and primary care practice. Data were analyzed
    from July 1, 2015, through June 2, 2017.

    Prespecified symptoms selected from literature included
    attention-deficit/hyperactivity disorder–like symptoms, bizarre
    behavior, blunted affect, problems associated with cannabis, depressive
    symptoms, role functioning problems, social isolation, symptoms of
    mania, obsessive-compulsive disorder–like symptoms, disordered personal
    hygiene, sleep disturbance, problems associated with cigarette smoking,
    and suicidal behavior (including self-harm).

    Main Outcomes and Measures 
    Case (diagnosis of psychosis) or control (no diagnosis of
    psychosis) status. Conditional logistic regression was used to
    investigate the association between symptoms and case-control status in
    the 5 years before diagnosis. Positive predictive values (PPVs) were
    calculated using the Bayes theorem for symptoms stratified by age group
    and sex. Repeated-measures Poisson regression was used to investigate
    symptom consultation rate.

    Of the total sample of 93 483 participants, 57.4% were female
    and 40.0% were older than 60 years (mean [SD] age, 51.34 [21.75] years).
    Twelve symptoms were associated with a later psychotic diagnosis (all
    prespecified symptoms except disordered personal hygiene). The strongest
    association was with suicidal behavior (odds ratio [OR], 19.06; 95% CI,
    16.55-21.95). Positive predictive values were heterogeneous across age
    and sex. The highest PPVs were for suicidal behavior (33.0% in men 24
    years or younger [95% CI, 24.2%-43.2%] and 19.6% in women aged 25-34
    years [95% CI, 13.7%-27.2%]). Pairs of symptoms were associated with an
    increase in PPV. Consultation rates were higher in cases and increased 3
    months before diagnosis.

    Conclusions and Relevance 
    Most of the preselected nonspecific symptoms were associated
    with a later psychotic diagnosis, particularly among young men
    consulting for suicidal behavior, especially if consulting with
    increasing frequency. These symptoms should alert physicians to patients
    who may benefit from a further assessment of psychotic symptoms.

    Full details in the University publications repository