Disengagement from mental health services: A literature review

Division of Mental Health, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
Social Psychiatry (Impact Factor: 2.54). 12/2008; 44(7):558-68. DOI: 10.1007/s00127-008-0476-0
Source: PubMed


This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

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    • "This was in contrast to several previous studies and meta-analyses (Baekeland & Lundwall, 1975; Barrett et al., 2008; Baruch et al., 2009; Berghofer et al., 2002; Chiesa et al., 2003; Clarkin & Levy, 2004; Issakidis & Andrews, 2004; Johnson et al., 2008; McCabe, 2002; Killaspy et al., 2000; McMuran et al., 2010; Meresman et al., 1995; Mohr et al., 2006; O'Brien et al., 2009; Pekarik, 1985; Perry, Bond & Roy, 2007; Richmond, 1992; Smith, "
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    ABSTRACT: Objective: To explore the association between the stability or instability of services' organizational structure and patient- and therapist-initiated discontinuation of therapy in routine mental health. Method: Three groups, comprising altogether 750 cases in routine mental health care in eight different clinics, were included: cases with patient-initiated discontinuation, therapist-initiated discontinuation, and patients remaining in treatment. Multilevel multinomial regression was used to estimate three models: An initial, unconditional intercept-only model, another one including patient variables, and a final model with significant patient and therapist variables including the organizational stability of the therapists' clinic. Results: High between-therapist variability was noted. Odds ratios and significance tests indicated a strong association of organizational instability with patient-initiated premature termination in particular. Conclusions: The question of how organizational factors influence the treatment results needs further research. Future studies have to be designed in ways that permit clinically meaningful subdivision of the patients' and the therapists' decisions for premature termination.
    Full-text · Article · Feb 2014 · Psychotherapy Research
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    • "This is comparable to previously reported rates involving mental health care delivered in the community [14]. More recently, a review of the literature involving disengagement from different mental health settings yielded similar rates, approximately 30% from the majority of services [11]. It should be noted however that studies reviewed by Simmonds et al. [14] involved an urban population where access was easier and distances shorter than in our catchment area. "
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    ABSTRACT: Objectives. Treatment of psychotic disorders is impended by high rates of disengagement from mental health services and poor adherence to antipsychotic medication. This study examined the engagement rates of psychotic patients with a community mental health service during a 5-year period. Methods. The Mobile Mental Health Unit of Ioannina and Thesprotia (MMHU I-T) delivers services in remote, rural, mountainous areas using the resources of the primary care system. Clinical and demographic information for patients with a diagnosis of schizophrenia and related psychoses was obtained from the medical records of our unit. Results. A total of 74 psychotic patients initially engaged in treatment with our unit. In half of cases treatment was home-based. With the exclusion of patients who died or discharged, engagement rates were 67.2%. Statistical analysis was performed for 64 patients, and no differences were found between engaged and disengaged patients regarding clinical and demographic parameters. All engaged patients regularly refilled their antipsychotic prescriptions. Conclusion. Engagement rates in our study were comparable to previous research, involving urban settings and shorter follow-up duration. Community mental health teams may ensure treatment continuation for psychotic patients in deprived, remote areas. This is important for low-income countries, affected by economic crisis, such as Greece.
    Full-text · Article · Oct 2013
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    • "Even if a professional supports participation in treatment programmes, the clients themselves may consider participation irrelevant (Drake et al., 1996; Naegle, 1997; O’Brien et al., 2009; Rogler & Cortes, 1993). Also, service providers may miss clients due to ineffective working methods or inadequate assessment. "
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    ABSTRACT: Mothers with a co-occurring mental illness and substance abuse (dual diagnosis) use numerous different services. Help-seeking and engagement are complex processes which have not yet been sufficiently conceptualized. A descriptive phenomenological approach was used to explore these experiences from different service contexts and to describe the decisions in and structure of help-seeking over a 13-year period. Four in-depth interviews were conducted and data were analysed with a descriptive phenomenological method developed by Giorgi. The essential meaning structure is an inner conflict within the client, including a realization that change starts from within. The essential meaning structure combines the other meaning structures: disbelief of receiving help and admitting the need for help, keeping up the perfect façade and the risk of total collapse, being given and making own choices regarding care and being forced to use services and inner emptiness and search for contentment in life. It is possible that clients in the help-seeking process do not always recognize they have a need for care. If the client experiences inner powerlessness as emptiness and resistance to being helped, it is probably not possible to create relationships with care providers. Clients may have several ambiguous inner processes which prevent them from accepting the need for care. Theoretically and empirically a long-term approach is crucial, since the inner transformative processes take time. The services can contribute new experiences to the personal level of understanding and decision-making, if they consider the experiential level of their clients.
    Full-text · Article · Aug 2013 · International Journal of Qualitative Studies on Health and Well-Being
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