Early Intervention Services (EIS) for psychosis have yielded superior outcomes for young adults by prioritizing early illness detection and phase-appropriate treatment (Correll et al., 2018; McGorry and Mei, 2018; Nolin et al., 2016). Despite the demonstrated effectiveness of EIS, significant delays in accessing these services are common (Anderson et al., 2013; MacDonald et al., 2018) and most patients are referred to EIS through urgent care services (e.g., emergency departments, inpatient psychiatry) while experiencing acute illness (Anderson et al., 2013; Jones et al., 2021; MacDonald et al., 2018). By necessity, these referrals frequently involve involuntary hospitalization and law enforcement intervention (Anderson et al., 2013; MacDonald et al., 2018), experiences widely described as negative and highly distressing for service users (Anderson et al., 2013; Jones et al., 2021; Loyal et al., 2023; MacDonald et al., 2018).

It has been suggested that negative initial experiences with healthcare, including referral processes, may increase young adults' risk for several adverse outcomes (Anderson et al., 2013; Jones et al., 2021). For example, initial experiences that include involuntary hospitalization, are associated with more negative views towards healthcare (Jones et al., 2021). Additionally, a systematic review and meta-analysis in early phase psychosis patients indicated the prevalence of PTSD symptoms and PTSD directly attributable to experiences in a recent psychotic episode, to be 42% and 30% respectively. Interestingly, the prevalence of PTSD diagnosis in those with prior involuntary hospitalization was two times greater compared to those without, with authors suggesting adverse experiences with healthcare as a potential cause (Rodrigues and Anderson, 2017). Furthermore, related research in samples of those living with severe mental illness, has demonstrated an association between PTSD symptoms and increased psychotic symptom severity, as well as decreased satisfaction and engagement in treatment (Minsky et al., 2015). Although these results suggest those with referral pathways to EIS involving urgent services may be more likely to disengage from services, prior research examining this relationship has shown mixed results (Anderson et al., 2013; Compton, 2005; Weiss et al., 2021). Furthermore, despite being raised as a potential consequence of referral via urgent services, limited research to date has examined the relationship between young adults’ referral source/experiences and negative clinical outcomes downstream including poorer functioning, relapse, and subsequent use of crisis healthcare services.

To address this gap, this study used a retrospective cohort design to examine the relationship between patients’ referral source and subsequent urgent healthcare utilization two-years after their acceptance to EIS. While controlling for illness severity and functioning, we hypothesized that individuals referred to EIS from urgent services would have an increased rate of urgent service use during follow-up compared to other referral pathways. Further understanding of the relationship between referral experiences and clinical outcomes is valuable as it could inform improvements in service delivery, including an early focus on addressing any potential negative outcomes from the referral pathway.