Helpseeking Recognition and Referral

While many patients with an emerging psychotic illness present to a primary care professional (for example, a general practitioner, GP) before their eventual entry to treatment [43], help-seeking can be delayed for a number of reasons:

• Specific features of psychosis can include suspiciousness, persecutory ideas, social withdrawal and lack of insight.

• Young people may have difficulty understanding and interpreting psychotic experiences and mental health problems, and their adolescent cognitive bias of ''invulnerability'' can delay help-seeking.

• Lack of knowledge in the general community about psychosis, combined with the continuing stigma associated with seeking care for mental health problems, adds to the barriers. Shame is a key barrier to seeking help.

• Comorbid problems, such as substance use, depression and social anxiety, may interfere with a person's ability to recognize the need for assistance and to access mental health services.

• It is a fundamentally difficult step to trust a stranger to share and help with intensely personal problems. If this can be gradually overcome, management usually proceeds well.

Recognition of a problem by GPs, other primary health workers or care providers is a key step in the path to psychiatric care, but it depends partly on the skill, experience, knowledge and interest of the practitioner. The subtlety of symptoms in the early stages of psychosis, and distinguishing the symptoms from ''normal'' adolescent behaviour, can make recognition difficult even for skilled mental health professionals. A high index of suspicion assists recognition.

Even after a psychiatric disorder has been recognized, some patients are still not referred to an appropriate mental health service. Psychotic patients are more likely to be referred, usually because of the extent of behavioural changes and disability associated with psychosis, but this is not inevitable.

Once referred to a mental health service provider, young people with early psychosis can still be rejected, particularly if the service system is under-resourced. In such a situation, services are effectively rationed, with resources typically restricted to the existing case load of ''old friends'', those patients with chronic, established and clearly diagnosed illness, rather than focusing on the challenging and time-consuming referrals of obviously ill young people who nevertheless lack a clear diagnosis. This system behaviour is anti-preventive and demands chronicity and severity as criteria for initial and sustained access. Although a consequence of under-resourcing and rationing, it stands in stark contrast to service responses to cancer, diabetes and heart disease, where early intervention is held at a premium.

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