Our study confirms that multiple, complex factors contribute to treatment delay for first episode psychosis, including not attributing problems to mental illness, stigma-related concerns, lack of knowledge about where to go for help and unhelpful health service responses. Our results concur with previous studies [16, 25] in suggesting that a crisis point or overtly socially unacceptable behaviour is often the catalyst to seeking help, despite considerable prior distress for both the individual experiencing symptoms and their family. Mixed findings from previous research regarding whether family members' involvement promotes  or impedes  prompt help-seeking are also reflected in our interviews, which typically reflect real concern from families but describe family responses experienced as both helpful and unhelpful. As in the comparison of carers' and service users' experience of the onset of psychosis by DeHaan and colleagues [15, 28], our study found recognition of psychosis and the need to seek help often came sooner among family members and other involved people than for the person experiencing symptoms. Our study helps validate these findings for a diverse, urban UK setting.
The descriptions in our study of responses to early psychotic symptoms help to understand these findings. The vague nature of many early psychotic experiences creates difficulties, especially for those without specialist training, in distinguishing illness symptoms from other motivational or developmental problems. A substantial number of service users (but not carers) remained unconvinced that they had a substantial problem up to the point of contact with mental health services. These problems of recognition of psychosis were sometimes exacerbated by people experiencing psychosis deliberately masking symptoms. GPs in particular were presented with vague, or physical rather than mental, symptoms, illustrating why it is difficult for them to identify early psychosis.
As well as consolidating previous knowledge, this study adds to it in the following ways:
The role of community organisations
Engagement of the wider community in identifying and seeking help for psychosis has been advocated for early intervention services recurrently by experts  and in government policy [7, 30]. To our knowledge, this is the first UK study to focus on the role of non-health organisations in help-seeking for a first episode of psychosis. A number of barriers to workers in community organisations promoting contact with mental health services were identified: these included non-disclosure or active masking of problems by the person experiencing psychosis, failure to recognise problems as psychosis, an insufficiently close relationship or a clearly defined, limited role with the person with psychosis, and preference for a wait and see approach. However, our interviews also revealed that people working in community organisations frequently were willing to intervene and did either seek help directly or encourage the young person or their family to do so. In some instances, community groups also played a valuable role in providing a social identity and support for both service users and their carers throughout the period of developing and recovering from psychosis.
Pathways to care
Participants in this study typically reported significant service delays in pathways to care once help-seeking had been initiated. In our sample, these mostly related to the response of GPs and primary care, rather than secondary mental health services.
The experience of different ethnic groups
We purposively sampled participants to reflect the ethnic diversity of the local catchment area. Similarities in participants' experiences were more outstanding than differences: we did not find differences between ethnic groups regarding stigma concerns, reservations about mental health services or experiences of service responses. Encouragingly, we found no evidence suggesting discriminatory practice. Our study suggests potential for effective intervention across the whole target population to address the problems of stigma and mistrust of services, rather than clearly indicating tailored initiatives for specific social or ethnic groups.
The limitations of this study relate to sampling issues and the retrospective nature of the data collected. In common with previous studies of people with psychosis , lower recruitment of carers than service users was achieved: not all CIEIS service users have involved carers, and reluctance to revisit distressing experiences and time pressures may have impeded carer recruitment. Women from white ethnic groups were over-represented in our small carer sample of nine, reflecting who we were able to recruit. Although small samples are often sufficient to achieve theme saturation in qualitative research , a larger sample would increase confidence that our results reflected a full range of carers' experiences.
Our service user sample had similar duration of untreated psychosis to CIEIS service users in general, but deliberately over-represented those in contact with community groups during illness onset, in order to explore the role of these groups in help-seeking. This divergence from the general CIEIS population, and socio-demographic differences between the client base of CIEIS and early intervention services in other parts of the UK may limit the applicability of our findings to a wider first episode psychosis population. Finally, experiences of the onset of illness and first contact with mental health services were reported retrospectively, creating possible lacunae or distortions through recall bias.
This study describes multiple barriers to prompt treatment for people with first onset psychosis both before help-seeking is initiated and after first contact with services. It supports the conclusion of a recent review  that initiatives to reduce DUP should be multi-focused and not (as for instance, GP education campaigns are) limited to reducing service delays. Our study suggests that a very significant component of delay is attributable to difficulties in recognising early symptoms as psychosis and reluctance by young people and their carers to act at the earliest opportunity to signals of a potential threat of psychosis. Help is frequently not sought until a crisis point has been reached. Without a strategy to address these delays, the hope of achieving an optimal reduction in DUP is unlikely to be realised. Further research regarding the most effective means to promote help-seeking for early psychosis is required.
Previous Canadian research has found that the involvement of people working in non-health service community organisations during pathways to care is common  but can be associated with treatment delay . Our study suggests some degree of willingness among UK non-health professionals such as teachers, faith group leaders and organisers of social or cultural groups to be involved in helping young people with psychosis or their families to access treatment. However, it also suggests that these people may not always recognise early psychosis, lack knowledge about how to access appropriate services and hold reservations about the benefits of contact with mental health services for young people with whom they work. The crucial question of whether early detection initiatives can overcome these barriers requires further research. There is a need to design interventions targeting community professionals who are in contact with young people during their first onset of psychosis, and to evaluate whether these can improve their effective involvement in help-seeking and play a significant role in reducing DUP.
The interviews in this study reflect the difficulties for all involved in recognising early psychosis. An alternative early detection approach from focusing narrowly on psychosis would be a stepped strategy: first, seeking to improve access to assessment and treatment for distressed young people with a range of mental health problems and associated deterioration in functioning; then second, seeking to improve detection and assessment for early psychosis from within this group. Comparison of the effectiveness and cost effectiveness of broader and more focused strategies to enhance early detection merits investigation.
This study indicates there is probably value in routine monitoring in early intervention services of pathways to care and components of DUP. This could illuminate major contributors to DUP and agencies involved in helping people access treatment, which may vary across cultures and between local service systems and so inform priorities for local initiatives to reduce DUP. The MiDATA Project in the UK  provides one means by which this information can be collected.
The median DUP for the service user sample in this study was fairly short, coming close to achieving the World Health Organisation 3-month target . Even so, a minority experienced very long DUP and most service users and carers described considerable distress and disruption to their lives following the onset of psychosis. This supports UK government advice that early intervention services should prioritise early detection and education of the wider community about psychosis [7, 35].
Interviewees in our study reported not knowing where to get help. Carers also expressed uncertainty about what to do if the person experiencing psychosis was reluctant to accept help. Even in the absence of resources for concerted early detection initiatives, early intervention services may be able to reduce these barriers to accessing treatment through modest changes to service organisation and practice. Feasible and potentially useful actions include: providing direct telephone access to the service; offering advice to concerned family members or involved community professionals, even if a referral cannot be made straight away. With sufficient resource allocation, more concerted campaigns are desirable. Ways to seek prompt referrals for people with first episode psychosis which have been used in large-scale early detection initiatives [36, 37] include: establishing regular links between the local early intervention service and GPs and large community organisations, public lectures in schools, colleges or community groups, "open house" events and promotional leaflet distribution. The experience of broader mental health initiatives [38, 39] suggests that prominent service user involvement in early detection initiatives, emphasising the stories and experiences of people who live with mental health problems may be an effective means to normalise psychosis and reduce stigma-driven reluctance to contact services. Internet and social networking forums also hold promise as mechanisms through which to reach young people: input from social marketers regarding the most effective media to reach target audiences could usefully inform future initiatives.