Predictors of disengagement from treatment in an early psychosis program
Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Alberta, Canada. Schizophrenia Research
(Impact Factor: 3.92).
04/2012; 136(1-3):7-12. DOI: 10.1016/j.schres.2012.01.027
Disengagement from treatment is a major concern in psychiatry. This is of particular concern for those presenting for care at their first episode of psychosis (FEP). The purpose of this study is to determine the rate of disengagement from a three year FE treatment program and the predictors of disengagement.
We used a longitudinal cohort design. The cohort consisted of 286 FEP individuals. Measures included assessments of positive and negative symptoms, depression, substance use, premorbid and current functioning, cognition and duration of untreated psychosis. Disengagement from treatment was defined as leaving the program before the 30 months.
At 30 months after treatment, the estimated rate of disengagement from treatment was 31%. Predictors of disengagement were examined via Cox proportional hazards models which revealed that lower ratings on negative symptom scores at baseline (HR=0.946; CI=0.909-0.985), a shorter duration of untreated psychosis (HR=0.997; CI=0.994-0.999), and not having a family member involved in the program (HR=0.310; CI=0.196-0.490) contributed significantly to predicting disengagement from treatment. An examination of those who dropped out at different times revealed that those who dropped out prior to 6 months had significantly greater cannabis (p<0.05) and other drug use (p<0.01).
Engagement in early services may be helped by attending carefully to substance use to prevent early dropout, to those who may have had a short duration of untreated psychosis and to working with families to engage families in the program.
Available from: Emilie Leclerc
- "Factors associated with nonadherence to medication or psychosocial treatment (p f 0.05) Rabinovitch (2013) 54 Prospective cohort 152 6 months Medication -predictive: any lifetime substance use diagnosis at baseline Other associated factors: increase in family support Robinson (2002) 60 Prospective cohort 112 1 year Medication -predictive: poorer premorbid cognitive functioning Schimmelmann (2006) 37 Prospective cohort 157 18 months Psychosocial (disengagement) -predictive: lower severity of illness at baseline, higher global functioning at baseline, living without family at baseline Other associated factors: living without family during treatment, persistent substance use, lower global functioning at discharge Schimmelmann (2012) 50 Prospective cohort 99 18 months Medication: cannabis use Disengagement: persistent cannabis use (compared to baseline or decreasing use) Schö ttle (2012) 49 Retrospective longitudinal 134 18 months Medication: schizoaffective disorder diagnosis (compared to bipolar disorder) Segarra (2012) 42 Prospective cohort 577 1 year Global treatment nonadherence -predictive: low insight into need for treatment, low level of education Steger (2012) 52 Prospective cohort 301 6 months Medication -predictive: resolution of negative symptoms Others: no remission of positive symptoms Stowkowy (2012) 31 Prospective cohort 286 30 months Psychosocial (disengagement) -predictive: lower negative symptoms at baseline, shorter DUP, not having a family member involved in the program Early dropout (, 6 months): greater cannabis use, greater other drug use "
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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.
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Although there have been numerous studies on pathways to care in first-episode psychosis (FEP), few have examined the determinants of the pathway to care and its impact on subsequent engagement with mental health services.
Using a sample of 324 FEP patients from a catchment area-based early intervention (EI) program in Montréal, we estimated the association of several socio-demographic, clinical, and service-level factors with negative pathways to care and treatment delay. We also assessed the impact of the pathway to care on time to disengagement from EI services.
Few socio-demographic or clinical factors were predictive of negative pathways to care. Rather, service-level factors, such as contact with primary care providers, have a stronger impact on patterns of health service use across multiple indicators. Patients who were in contact with primary care had a reduced likelihood of negative pathways to care, but also had longer referral delays to EI services. Socio-demographic and clinical factors were more relevant for predicting subsequent engagement with EI services, and indicators of negative pathways to care were not associated with service disengagement.
Primary care providers may be an efficacious target for interventions aimed at reducing overall treatment delay. Increasing the uptake of primary care services may also reduce the likelihood of negative pathways to care. Our findings draw attention to the need for further investigations of the role that the primary care system plays in early intervention for FEP, and strategies for supporting service providers in this role.
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ABSTRACT: The quality of the therapeutic alliance is associated with engagement in- and thus important to the outcome of- treatment in schizophrenia. In non-psychotic disorders, general personality traits and individual patterns of interpersonal problems have been linked to the formation and quality of the therapeutic alliance. The role of these factors in relation to therapeutic alliance has not previously been explored in schizophrenia spectrum disorders.
To investigate associations between personality traits, interpersonal problems and the quality of the therapeutic alliance in early schizophrenia spectrum disorders.
Demographic and clinical characteristics including Positive and Negative Syndrome Scale (PANSS) scores were assessed in 42 patients. Personality traits and interpersonal problems were assessed with the NEO Five factor Inventory (NEO-FFI) and the circumplex model of the Inventory of Interpersonal Problems (IIP-64C). Therapeutic alliance was measured with the Working Alliance Inventory - short form (WAI-S).
Patient WAI-S scores were predicted by IIP-64C Submissive/Hostile interpersonal problems, age and PANSS excitative symptoms. Therapist WAI-S scores were predicted by NEO-FFI Agreeableness and the PANSS insight item.
Core traits of personality and dimensions of interpersonal problems are associated with both patients' and therapists' perceptions of the quality of the working alliance.
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