Barriers to initial outpatient treatment engagement following first hospitalization for a first episode of nonaffective psychosis: a descriptive case series.
ABSTRACT Due to the increasingly recognized importance of adequate treatment early in the course of schizophreniform disorder and schizophrenia, this report addresses the dearth of hypothesis-generating case series describing facilitators and barriers to engagement in initial outpatient care. This case series included six single, African-American first-episode patients. Narratives describing the initial hospitalization and the first outpatient appointments in an urban community mental health setting are presented. Several barriers to outpatient treatment engagement emerged from this relatively homogenous series of first-episode patients. Apparent barriers included inadequate remission of paranoia, impaired insight, and involvement with the criminal justice system between hospital discharge and the first outpatient appointment. Good family support appeared to be an important facilitator of treatment engagement during the first several months of outpatient treatment. A variety of other potential barriers, such as involuntary status at the time of hospital discharge, are considered. Though these are preliminary findings from a small case series, further research, based at least in part on the hypotheses generated here, is warranted. Many factors, at the level of the patient, the family, and the system of care, likely affect treatment engagement early in the course of schizophreniform disorder and schizophrenia. Clinicians should give special attention to this issue when caring for first-episode patients.
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ABSTRACT: We sought to systematically review the literature on ethnic differences in the likelihood of general practitioner (GP) involvement, police involvement, and involuntary admission on the pathway to care of patients with first-episode psychosis (FEP). We searched electronic databases and conducted forward and backward tracking to identify relevant studies. We calculated pooled odds ratios (OR) to examine the variation between aggregated ethnic groups in the indicators of the pathway to care. We identified seven studies from Canada and England that looked at ethnic differences in GP involvement (n = 7), police involvement (n = 7), or involuntary admission (n = 5). Aggregated ethnic groups were most often compared. The pooled ORs suggest that Black patients have a decreased likelihood of GP involvement (OR = 0.70, 0.57-0.86) and an increased likelihood of police involvement (OR = 2.11, 1.67-2.66), relative to White patients. The pooled ORs were not statistically significant for patients with Asian backgrounds (GP involvement OR = 1.23, 0.87-1.75; police involvement OR = 0.86, 0.57-1.30). There is also evidence to suggest that there may be ethnic differences in the likelihood of involuntary admission; however, effect modification by several sociodemographic factors precluded a pooling of these data. Ethnic differences in pathways to care are present at the first episode of psychosis.Acta Psychiatrica Scandinavica 02/2014; 130(4). DOI:10.1111/acps.12254 · 4.86 Impact Factor
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ABSTRACT: Of the studies that focus on the course of therapy of patients in the early stages of psychosis, several have brought to light such problems as missed appointments, abandonment of treatment and noncompliance with medication. Yet the way in which differences in the perspectives of patients, their loved ones and their care providers may influence and structure clinical encounters remains largely unexplored. Bearing in mind the range of current knowledge, we explore this issue through a set of interviews conducted with people in these three categories of people. We examine the respective positions occupied by their knowledge and their voices during the clinical encounter, as well as the way in which the relationships among them are established. Our data bring out the ambiguity in the meaning of the therapeutic process and the importance of uncertainties about its nature. The analysis underscores the impact of the context of the encounter, which implies an imbalance in the participants’ positions that is related to their differences in terms of experience and expertise. This invites to consider thoroughly the clinical scope of what the various participants may perceive, construe and express from their own frame of reference and within the context of their interaction.L &E cute volution Psychiatrique 10/2008; 73(4):639-654. DOI:10.1016/j.evopsy.2008.09.004 · 0.13 Impact Factor