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


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.
    Full-text · Article · May 2015 · Revista Brasileira de Psiquiatria
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    • "Those consistently refusing all medications from the outset were more likely to have a forensic history compared to those who became nonadherent later on [38]. Service disengagement was further predicted by moderate illness severity and a lack of significant treatment success until disengagement from both the entire sample and the adolescent subsample [37] [39]. "
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    ABSTRACT: Commonly conceptualized as neurodevelopmental disorders of yet poorly understood aetiology, schizophrenia and other nonorganic psychoses remain one of the most debilitating illnesses with often poor outcome despite all progress in treatment of the manifest disorder. Drawing on the frequent poor outcome of psychosis and its association with the frequently extended periods of untreated first-episode psychosis (FEP) including its prodrome, an early detection and treatment of both the FEP and the preceding at-risk mental state (ARMS) have been increasingly studied. Thereby both approaches are confronted with different problems, for example, treatment engagement in FEP and predictive accuracy in ARMS. They share, however, the problems related to the lack of understanding of developmental, that is, age-related, peculiarities and of the presentation and natural course of their cardinal symptoms in the community. Most research on early detection and intervention in FEP and ARMS is still related to clinical psychiatric samples, and little is known about symptom presentation and burden and help-seeking in the general population related to these experiences. Furthermore, in particular in the early detection of an ARMS, studies often address adolescents and young adults alike without consideration of developmental characteristics, thereby applying risk criteria that have been developed predominately in adults. Combining our earlier experiences described in this paper in child and adolescent, and general psychiatry as well as in both lines of research, that is, on early psychosis and its treatment and on the early detection of psychosis, in particular in its very early states by subjective disturbances in terms of basic symptoms, age-related developmental and epidemiological aspects have therefore been made the focus of our current studies in Bern, thus making our line of research unique.
    Full-text · Article · Sep 2014
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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.
    Full-text · Article · Dec 2013 · BMC Psychiatry
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