ABSTRACT

Objective

To examine the clinical and sociodemographic characteristics and treatment approaches of patients with psychotic spectrum disorders receiving services from a community mental health center.

Methods

This cross-sectional study included 203 patients diagnosed with psychotic spectrum disorders who were registered at a community mental health center and consented to participate. Data were collected through face-to-face interviews conducted by the clinician. Patients diagnosed by a clinician according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria provided written and verbal informed consent. The sociodemographic data form and the Positive and Negative Syndrome Scale were administered to all participants. Prior to the commencement of the study, ethical approval was obtained from the Yalova University Ethics Committee and institutional permission was granted by the Provincial Directorate of Health (approval no: 2025/330, date: 25.06.2025).

Results

In our study, the majority of patients were male (66.5%). Mental disorders were more frequently observed among first- and second-born children within households. A psychiatric disorder was present in the first-degree relatives of 88 patients (43.3%). Additionally, a history of legal issues was identified in 55 (27.1%) patients, and tobacco use was reported by 114 (56.2%) patients. Regarding treatment, 45 patients (22.2%) were receiving long-acting injectable paliperidone palmitate (3-month formulation), and 28 patients (13.8%) were receiving long-acting injectable aripiprazole.

Conclusion

This study is one of the few investigations in Türkiye examining the clinical and treatment characteristics of patients with psychotic spectrum disorders who receive services from a community mental health center. Therefore, we believe that our study makes a significant contribution to the existing literature.

INTRODUCTION

Psychosis is a syndrome characterized by impaired reality testing, delusions, hallucinations, disorganized thoughts and speech, marked behavioral disturbances, including catatonia, and negative symptoms (such as affective flattening, alogia, and avolition). The category of “psychotic disorders” includes schizophrenia, schizophreniform disorder, schizoaffective disorder, substance/medication-induced psychotic disorder, psychotic disorder due to a general medical condition, among others (1). Psychotic spectrum disorder (PSD) is a severe mental illness characterized by early onset, recurrent episodes, and a chronic course. Psychotic disorders, which significantly impair cognitive and social functioning, place a considerable burden on both families and society. Schizophrenia, the most common psychotic disorder, affects approximately 24 million people worldwide and has a lifetime prevalence of approximately 1% (2). Psychotic disorders are significant because of the negative impacts they have on individuals, families, and society throughout the course of the illness. The lifetime prevalence of encountering any legal issues for individuals with PSD has been reported as 21% (3). The main contributing factors to legal problems or violent behavior include psychotic episodes, positive symptoms, nonadherence to treatment, history of violence, and alcohol or substance abuse (4, 5). For these reasons, regular follow-up and treatment of patients with PSD are critically important.

Mental health services can be categorized as community-based and hospital-based service-delivery models. Since the 1960s, because of inadequacies in prevention and follow-up care and serious violations of human rights, nearly all developed countries have shifted from a hospital-based model to community-based services (6). In Türkiye, the foundation for the transition to a community-based model was established by the National Mental Health Policy Directive prepared in 2006. In line with this, the Ministry of Health of Türkiye decided to establish Community Mental Health Centers (CMHCs) in April 2009 and began implementing related projects (7, 8). Prior to the adaptation studies initiated at the CMHC in Bolu, mental health services for individuals with mental disorders in Türkiye were limited to psychiatric outpatient clinics located in hospitals or day hospitals (9). CMHCs have broad and significant responsibilities. These include informing patients with severe mental illness and their families who live within the geographic area of the CMHC, providing outpatient treatment and follow-up, enhancing patients’ psychosocial skills through therapy-based interventions, facilitating their participation in occupational therapy according to their interests, offering psychoeducation and rehabilitation services, collaborating with psychiatric clinics, and conducting home visits through mobile teams (7).

The aim of this study is to examine the clinical and sociodemographic characteristics and treatment approaches of patients diagnosed with PSD who receive services from a CMHC.

METHODS

Study Design

This study had a cross-sectional design.

Population and Sample

The study population consisted of all registered patients diagnosed with PSD who were followed and treated at a CMHC. A total of 203 patients diagnosed with PSD who voluntarily agreed to participate in the study were included.

Study Site and Duration

The study was conducted between August 15 and September 30, 2025, at a CMHC affiliated with the Provincial Health Directorate in a city in the Marmara Region.

Data Collection Tool

Sociodemographic Data Form

A semi-structured questionnaire developed for the purpose of this study to collect data on patients’ age, gender, marital status, educational level, employment status, family history of mental illness, alcohol and tobacco use, and current treatment modalities.

The Positive and Negative Syndrome Scale (PANSS) is a semi-structured interview comprising 30 items designed to assess seven positive symptoms, seven negative symptoms, and 16 general psychopathology symptoms, each rated on a seven-point severity scale (9). The 7-point scale in each item reflects increasing levels of psychopathology severity: 1=absent, 2=very mild, 3=mild, 4=moderate, 5=moderate/severe, 6=severe, 7=extreme. The validity and reliability of the Turkish version of the scale were assessed by Kostakoğlu et al. (10).

Ethics

The study was designed in accordance with the principles of the Declaration of Helsinki, the Patient Rights Regulation, and ethical standards. Ethical approval was obtained from the Yalova University Ethics Committee and institutional permission was granted by the Provincial Directorate of Health (approval no: 2025/330, date: 25.06.2025). Written informed consent was obtained from all participants in the study.

Implementation

Interviews were conducted in a private consultation room, ensuring that no third party was present with the patient. The purpose of the study and the confidentiality of personal information were explained in detail to the patients. Patients were asked whether they wished to participate, and those who volunteered were included in the study. The sociodemographic data form was completed by the clinician through face-to-face interviews with the patients. The PANSS was administered by the clinician to patients included in the study who were diagnosed with a PSD, and the patients’ treatment protocols and illness characteristics were assessed. The sociodemographic and clinical characteristics of the patients were examined in two sections. The first section focused on sociodemographic characteristics such as gender, educational status, marital status, employment status, family history of psychotic disorders, and age at onset of illness. The second section examined clinical features related to the illness, including tobacco use, alcohol use, and substance misuse; history of legal issues after illness onset; and treatment protocol.

Data Collection

The data obtained in the study were analyzed using SPSS for Windows, version 21.0 (Statistical Package for the Social Sciences). Descriptive statistical methods (mean, standard deviation, frequency, and percentage) were employed to evaluate the data.

RESULTS

A total of 203 patients participated in the study. Among them, 8.8% (n=18) were diagnosed with schizoaffective disorder and 91.2% (n=185) with schizophrenia. Of the participants, 66.5% (n=135) were male and 33.5% (n=68) were female. In terms of marital status, 81.8% (n=166) were single and 18.2% (n=37) were married. A family history of psychotic disorders was reported in 43.3% (n=88) of participants, while 56.2% (n=114) had tobacco use disorder. Comorbid physical illnesses were observed in 42.9% (n=87) of the participants. When examining the age distribution, the majority of participants were between 50 and 59 years of age (n=66; 30.0% of the sample). Additionally, age at illness onset was most frequently reported as 21-29 years, accounting for 37.9% (n=77) of cases (Table 1).

With respect to birth order, 26.1% (n=53) were first-born children, 30.0% (n=61) were second-born, 15.3% (n=31) were third-born, 9.9% (n=20) were fourth-born, and 18.7% (n=38) were fifth-born or later. Educational status was as follows: illiterate, 2.0% (n=4); literate, 6.4% (n=13); primary school, 29.1% (n=59); secondary school, 22.7% (n=46); high school, 30.0% (n=61); university, 9.9% (n=20). The number of psychiatric hospitalizations was reported as follows: none: 12.3% (n=25); 1-5 times: 73.4% (n=149); 6-10 times: 7.9% (n=16); 11 times or more: 6.4% (n=13) (Table 1).

Employment Status

Employment prior to illness onset: employed: 47.8% (n=97), unemployed: 52.2% (n=106); employment after illness onset: employed: 29.1% (n=59), unemployed: 70.9% (n=144). History of legal issues was reported in 27.1% (n=55) of the participants. Electroconvulsive therapy (ECT) had been administered to 31.0% (n=63), while 69.0% (n=140) had not undergone ECT. Clozapine use was observed in 34.0% (n=69) of the patients, whereas 66.0% (n=134) were not using clozapine (Table 1).

Use of long-acting antipsychotics (LAIs) was distributed as follows: no LAI medication: 38.4% (n=78), risperidone LAI: 1.0% (n=2), paliperidone palmitate LAI (monthly formulation): 19.2% (n=39), paliperidone palmitate LAI (3-month formulation): 22.2% (n=45), haloperidol LAI: 3.9% (n=8), zuclopenthixol depot: 1.5% (n=3), aripiprazole maintena: 13.8% (n=28) The mean total PANSS score was found to be 72.4±13.2 (Table 1).

DISCUSSION

In this study, the clinical and sociodemographic characteristics and treatment approaches of patients with PSD receiving services from a CMHC were examined.

In our study, 66.5% (n=135) of the patients were male. The overall prevalence of psychosis is higher in males than in females, and males are more likely to seek treatment (11). A study conducted in Türkiye reported that the proportion of early psychosis cases in CMHCs was 60.7% (12), and another study by Yıldız and Yıldırım (13) indicated that the proportion of male patients was 66.5%.

In our study, 81.8% of PSD patients were single, consistent evidence that marriage or partnership rates are significantly lower among individuals with severe mental disorders than in the general population. This finding is also supported by national CMHC data. In a large-scale registry study from a CMHC in the Black Sea Region (n=640), the proportions of single and married individuals were 61.3% and 35.5%, respectively; among the schizophrenia subgroup, the rate of single individuals was 65.2% (14). Similarly, at another comparative study conducted at a CMHC, the marriage rate among patients with schizophrenia was 22.9%, while the proportion of single patients was 54.3%, further demonstrating the relatively low prevalence of marriage among patients with psychosis receiving community-based services (15). In contrast to our findings, Şahpolat (16), in a comparative study conducted at a CMHC, reported that 52.2% of patients were married. This discrepancy may stem from the inclusion of different patient populations and regional cultural differences.

43.3% of participants had a first-degree relative diagnosed with another psychiatric disorder. In a study conducted by Belli et al. (17) involving patients with schizophrenia (n=463), the rate of psychotic disorder among relatives of these patients (regardless of degree of kinship) was 26%. Tang et al. (18) reported rates of psychotic disorders among relatives of patients with schizophrenia: 11% in males and 14% in females (n=542).

In our study, comorbid physical illnesses were observed in 42.9% of patients. In a Turkish adaptation study of the health improvement profile, physical health problems were detected in 57.1% of participants (19), which is higher than that observed in our study. This difference may be attributed to factors such as age/gender composition, measurement methods (diagnostic records vs. symptom screening), and healthcare access.

In terms of age distribution, 30% of the participants were in the 50-59 age range. In Turkish CMHC cohorts, the mean age is generally reported to be in the mid-40s, indicating that community-based follow-up often clusters around middle-to-older-age groups (20). Murat and Kutlu (19) also reported that the mean age of patients was in the 40s. In our sample, The high concentration of chronic cases in the 50-59 age group may reflect a shift toward an older age distribution.

Legal histories were present in 27.1% of patients, suggesting that individuals with serious mental illness have a higher frequency of contact with the criminal justice system than the general population (21). Indeed, large-sample studies report that 20-40% of individuals with PSD experience at least one arrest or detention over the long term; for schizophrenia alone approaches 39% (22). Yıldız et al. (23) reported that 11% of psychotic patients had a forensic history. A separate study of hospitalized patients in Türkiye reported a rate of 18% (24). Wallace et al. (3) reported a 21% prevalence of legal history and associated it with substance use. Our findings appear consistent with the literature.

Examination of the treatments received by patients in our study showed that rates of LAI use were as follows: no medication, 38.4% (n=78); risperidone, 1.0% (n=2); monthly paliperidone, 19.2% (n=39); 3-month paliperidone, 22.2% (n=45); haloperidol, 3.9% (n=8); zuclopenthixol, 1.5% (n=3); and aripiprazole, 13.8% (n=28). Non-adherence to antipsychotic treatment is a major issue among patients. Depot antipsychotics, developed in the 1960s to improve adherence, have been shown to reduce rates of relapse and hospitalization significantly (25, 26). Some studies suggest that atypical antipsychotics are more effective than conventional ones in improving adherence and preventing relapse (27, 28). Despite the advantages of long-acting depot antipsychotic injections for many patients with chronic psychotic disorders, the proportion of patients treated with these formulations worldwide—varying across national, regional, and local contexts—has been reported to be as low as 15% (16, 29, 30). In our study, the utilization rate of long-acting injectable antipsychotics was 25.1%. This relatively higher rate may reflect a more severe clinical profile among patients with psychotic disorders who seek services from CMHCs than among the broader population of individuals with psychotic disorders.

Study Limitations

There are several limitations to our study. First, the study was conducted at a single center. Secondly, the province where the study was conducted has a relatively small population, which may cause its demographics to differ from those of other regions. Moreover, the findings of this study should be interpreted with caution, taking into account the limitations inherent in its cross-sectional design.

CONCLUSION

In conclusion, among patients with PSD receiving services from a CMHC, the male predominance, the high proportion of single individuals, the frequent presence of psychiatric disorders among first-degree relatives, and the considerable burden of comorbid physical illness are notable. The age distribution, concentrated in the 50-59 age, suggests a chronic and progressive course of illness, while the presence of a legal history in one in four patients highlights the persistence of associated social risks. The rate of LAI use suggests a level supportive of treatment adherence but also indicates room for improvement relative to international benchmarks. From the perspective of mental health services, strengthening gender-sensitive psychoeducational programs, family- and community-based interventions, and routine physical health monitoring at the CMHC level is recommended. In terms of pharmacotherapy, enhancing access to and acceptance of LAIs antipsychotics is encouraged. Initiatives aimed at improving the quality and standards of care provided within the scope of CMHC services should be prioritized. To this end, particular emphasis should be placed on enhancing the scope and quality of in-service training in CMHCs, especially for specialist psychiatric nurses, in collaboration with psychiatrists and clinical psychologists. further studies are recommended to assess the effectiveness of care and services provided to patients.