Rate and predictors of service disengagement in an epidemiological first-episode psychosis cohort

Département Universitaire de Psychiatrie Adulte, Université de Lausanne, Clinique de Cery, Switzerland.
Schizophrenia Research (Impact Factor: 3.92). 03/2010; 118(1-3):256-63. DOI: 10.1016/j.schres.2010.01.032
Source: PubMed

ABSTRACT To assess the prevalence and predictors of service disengagement in a treated epidemiological cohort of first-episode psychosis (FEP) patients.
The Early Psychosis Prevention and Intervention Centre (EPPIC) in Australia admitted 786 FEP patients from January 1998 to December 2000. Treatment at EPPIC is scheduled for 18 months. Data were collected from patients' files using a standardized questionnaire. Seven hundred four files were available; 44 were excluded, because of a non-psychotic diagnosis at endpoint (n=43) or missing data on service disengagement (n=1). Rate of service disengagement was the outcome of interest, as well as pre-treatment, baseline, and treatment predictors of service disengagement, which were examined via Cox proportional hazards models.
154 patients (23.3%) disengaged from service. A past forensic history (Hazard ratio [HR]=1.69; 95%CI 1.17-2.45), lower severity of illness at baseline (HR=0.59; 95%CI 0.48-0.72), living without family at discharge (HR=1.75; 95%CI 1.22-2.50) and persistence of substance use disorder during treatment (HR=2.30; 95%CI 1.45-3.66) were significant predictors of disengagement from service.
While engagement strategies are a core element in the treatment of first-episode psychosis, particular attention should be paid to these factors associated with disengagement. Involvement of the family in the treatment process, and focusing on reduction of substance use, need to be pursued in early intervention services.

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Available from: Charles Bonsack, Jun 16, 2015
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    • "Prospective cohort 98 8 years* Medication: family history of psychosis, lower functioning, lower levels of depressive symptoms, more alcohol use, involuntary first admission to hospital Coldham (2002) 22 Prospective cohort 200 1 year Medication: younger age, earlier age at onset, poorer premorbid functioning, no family member involved in treatment, more positive symptoms, more relapses, more alcohol and cannabis use, reduced insight, poorer quality of life Conus (2010) 36 Retrospective longitudinal 660 18 months Psychosocial (disengagement) -predictive: lower premorbid functioning, forensic history before treatment, shorter duration of prodrome, no work or school, living without family, lower severity of illness at baseline, higher baseline functioning, diagnoses other than schizophrenia spectrum or bipolar disorder Associated: persistence of substance use disorder, living without family at discharge, higher severity at discharge, lower functioning at discharge Fanning (2012) "
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    ABSTRACT: To conduct a comprehensive review of current evidence on factors for nonadherence to treatment in individuals with first-episode psychosis (FEP). MEDLINE, LILACS, PsycINFO, and SciELO databases were searched with the keywords first episode psychosis, factor, adherence, nonadherence, engagement, disengagement, compliance, and intervention. References of selected studies were consulted for relevant articles. A total of 157 articles were screened, of which 33 articles were retained for full review. The factors related to nonadherence were: a) patient-related (e.g., lower education level, persistent substance use, forensic history, unemployment, history of physical abuse); b) environment-related (e.g., no family involved in treatment, social adjustment difficulties); c) medication-related (e.g., rapid remission of negative symptoms when starting treatment, therapeutic alliance); and d) illness-related (e.g., more positive symptoms, more relapses). Treatment factors that improve adherence include a good therapeutic alliance and a voluntary first admission when hospitalization occurs. The results of this review suggest that nonadherence to treatment in FEP is multifactorial. Many of these factors are modifiable and can be specifically targeted in early intervention programs. Very few studies have assessed strategies to raise adherence in FEP.
    Revista Brasileira de Psiquiatria 05/2015; 37(ahead). DOI:10.1590/1516-4446-2014-1539 · 1.77 Impact Factor
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    • "Likewise, Schimmelmann et al. [36] demonstrated that FEP adolescents who stopped using cannabis had better outcomes (CGI-S, GAF, remission of positive symptoms) than those who continued to use cannabis, although non-adherence did not explain the association between persistent cannabis use and worse outcomes. Persistent substance abuse is also a significant predictor of service disengagement [38], adding to the growing evidence that reduction of substance use should be a major focus of treatment in FEP patients. "
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    ABSTRACT: This study aimed to examine factors associated with treatment adherence in first-episode psychosis (FEP) patients followed up over 8 years, especially involuntary first admission and stopping cannabis use. This prospective, longitudinal study of FEP patients collected data on symptoms, adherence, functioning, and substance use. Adherence to treatment was the main outcome variable and was categorized as 'good' or 'bad'. Cannabis use during follow-up was stratified as continued use, stopped use, and never used. Bivariate and logistic regression models identified factors significantly associated with adherence and changes in adherence over the 8-year follow-up period. Of the 98 FEP patients analyzed at baseline, 57.1% had involuntary first admission, 74.4% bad adherence, and 52% cannabis use. Good adherence at baseline was associated with Global Assessment of Functioning score (p = 0.019), Hamilton Depression Rating Scale score (p = 0.017) and voluntary admission (p < 0.001). Adherence patterns over 8 years included: 43.4% patients always bad, 26.1% always good, 25% improved from bad to good. Among the improved adherence group, 95.7% had involuntary first admission and 38.9% stopped cannabis use. In the subgroup of patients with bad adherence at baseline, involuntary first admission and quitting cannabis use during follow up were associated with improved adherence. The long-term association between treatment adherence and type of first admission and cannabis use in FEP patients suggest targets for intervention to improve clinical outcomes.
    BMC Psychiatry 12/2013; 13(1):326. DOI:10.1186/1471-244X-13-326 · 2.21 Impact Factor
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    • "A similar chart review of patients in the Early Psychosis Prevention and Intervention Centre service identified individuals considered to have disengaged from services. Significant predictors of disengagement were forensic history , lower illness severity, living outside the family unit, and persistent substance misuse (Conus et al., 2010). Both these studies were constrained by reliance on case note data rather than clinical interview. "
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    ABSTRACT: Engagement can be understood as a multifactorial process, incorporating acceptance of treatment, therapeutic rapport, and collaboration in a shared goal of clinical and functional recovery. Difficulties in engagement with clinical services represent a risk factor for treatment discontinuation in first episode psychosis. The current study explored the associations between engagement, clinical, and preonset variables. We report the cross-sectional data on a Scottish sample with first episode psychosis, characterized in terms of psychotic symptoms, premorbid adjustment, duration of untreated psychosis, and clinician-rated engagement. Poorer clinician-rated engagement was associated with greater positive and negative symptoms, greater general psychopathology, and poorer premorbid social adjustment. In a regression analysis, only severity of negative symptoms predicted engagement. The study highlights the role of negative symptoms and impairments in social functioning as factors associated with poorer engagement with clinical services. The value of detailed assessment of social and premorbid functioning is highlighted.
    The Journal of nervous and mental disease 04/2013; 201(5). DOI:10.1097/NMD.0b013e31828e0e19 · 1.69 Impact Factor
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