International studies have shown that the average length of time from the onset of psychotic symptoms to first treatment (duration of untreated psychosis; DUP) ranges between 364 and 721 days  with recent meta-analyses reporting an association between long DUP and poor outcome at 6 and 12 months, for both symptoms and quality of life. Drake et al.  suggest that the point at which DUP exceeds three months, defines a critical point after which the likelihood of poorer outcome begins to increase, and several studies indicate that accessing treatment within the first 6 months of onset is a key indicator of outcome, specifically in terms of treatment response [3–8].
Evidence for the efficacy of initiatives to reduce DUP, however, is mixed ; the ‘TIPS’ study in Norway has had the greatest success. Their prospective trial in a defined health care region, incorporating the introduction of an early detection program alongside a public health awareness campaign, achieved significant results in comparison with parallel health care areas without an early detection program. DUP was significantly shorter and associated with better clinical status and reduced suicide risk at baseline and negative symptoms at 12 months, with positive effects on clinical and functional status maintained at 5 year follow-up . However, similar public health initiatives in Australia  and Canada  have failed to demonstrate any impact on DUP.
Implementation of a TIPS style intervention in UK healthcare settings, however, may prove ineffective as the care pathway delays experienced by young people with first-episode psychosis in UK may not be directly comparable to those experienced in Norway. Rogaland County is a dispersed population centred around the predominantly Caucasian (95%) city of Stavanger ; approximately 60% of the population living in urban areas . In contrast, Birmingham, UK is the second most populous city in Britain (1.05m) and the ‘youngest city in Europe’ with 40% of its population under the age of 20. It has a high degree of cultural and religious diversity, including 68% White British residents, 20% residents of Asian or Asian British heritage and 7% Black or Black British, and includes the highest number of residents from the Muslim faith in any UK local area for whom help-seeking can include imams at the family mosque; indeed, our recent study showed that religious construction of psychosis is common .
In the UK, the widespread adoption of early intervention in psychosis teams (EIS) have not led to a reduction in DUP [16, 17]; this is, perhaps, not surprising since these teams are not resourced or equipped with any community focused early detection function. Birmingham, UK, was the setting of the first early intervention service in the UK, yet despite this it continues to experience long DUP . Our cluster randomized trial to improve early detection of psychosis focusing on primary care  did not achieve reductions in DUP; further analysis revealed that the main sources of delay occurred elsewhere in the care pathway, in particular, within mental health services themselves and in help-seeking delay 16; 18. A recent systematic review of interventions to reduce DUP  concluded that greater focus on the sources of delay within care pathways, (which will vary between healthcare settings) is needed to achieve sustainable reductions in DUP.
Recent data from the UK National EDEN study  has confirmed that there are two primary sources of delay: delay in help-seeking among both patients and carers and delays within mental health services. The first referral point to mental health services was found to have the greatest impact on DUP: where the first point of contact was for acute crisis (admission, home treatment), delay within the mental health service was low; where access was via a Community Mental Health Team (CMHT), delays were greatly extended. These findings suggested that whilst improvements in help-seeking behavior are necessary, significant improvements within mental health services themselves would be essential to reduce DUP. In Birmingham, as part of the present study, a youth access pathway into the mental health service has been developed within the CMHT , providing a single referral point and ensuring that first episode cases of psychosis are managed in a youth sensitive framework and guarantee direct access to the specialised service.
The primary hypothesis to be tested is whether implementation of a psychosis public health campaign in addition to the youth access pathway for first episode psychosis, will significantly reduce DUP.