First Presentation With Psychotic Symptoms in a Population-Based Sample

Objective: Increasing evidence supports the effectiveness of comprehensive early intervention at first onset of psychotic symptoms. Implementation of early intervention programs will require population-based data on overall incidence of psychotic symptoms and on care settings of first presentation. Methods: In five large health care systems, electronic health records data were used to identify all first occurrences of psychosis diagnoses among persons ages 15-59 between January 1, 2007, and December 31, 2013 (N=37,843). For a random sample of these putative cases (N=1,337), review of full-text medical records confirmed clinician documentation of psychotic symptoms and excluded those with documented prior diagnosis of or treatment for psychosis. Initial incidence rates (based on putative cases) and confirmation rates (from record reviews) were used to estimate true incidence according to age and setting of initial presentation. Results: Annual incidence estimates based on putative cases were 126 per 100,000 among those ages 15-29 and 107 per 100,000 among those ages 30-59. Rates of chart review confirmation ranged from 84% among those ages 15-29 diagnosed in emergency department or inpatient mental health settings to 19% among those ages 30-59 diagnosed in general medical outpatient settings. Estimated true incidence rates were 86 per 100,000 per year among those ages 15-29 and 46 per 100,000 among those ages 30-59. Conclusions: When all care settings were included, incidence of first-onset psychotic symptoms was higher than previous estimates based on surveys or inpatient data. Early intervention programs must accommodate frequent presentation after age 30 and presentation in outpatient settings, including primary care.