The association between community and service level factors and rates of disengagement in individuals with first episode psychosis
Introduction
It is well recognised that a first episode of psychosis (FEP) requires early intervention and appropriate sustained treatment to avoid poor clinical and functional outcomes (The Schizophrenia Commission, 2012). Disengaging from Early Intervention (EI) services has been associated with more severe psychopathology, an increased risk of relapse and hospital admissions, socio-functional decline, and poorer prognosis (Macbeth et al., 2013). Despite the established benefits of remaining under the care of an EI service, rates of disengagement from treatment are typically around 30% (Doyle et al., 2014a) with a range from 13% to 40% (Chan et al., 2014; Doyle et al., 2014b; Garety and Rigg, 2001). Understanding the factors that may contribute to disengagement could help to identify areas of intervention to improve the engagement of this population.
Previous literature on disengagement in FEP has focussed on individual and disorder specific factors that lead to disengagement with services, such as age, co-morbid substance abuse, duration of untreated psychosis (DUP), symptom severity at baseline, and level of family support (Doyle et al., 2014a). For example, we recently reported findings from a cohort of 707 young people experiencing FEP (Kim et al., 2019), concluding that individuals who; were not in employment, education or training (NEET); did not have a family history of psychosis in second degree relatives; and had co-morbid cannabis use were more likely to disengage. It was hoped that identifying individuals more likely to disengage would inform the development of targeted preventive strategies and treatment adaptations (Stowkowy et al., 2012). However there has been limited consensus between studies (Doyle et al., 2014a; Nose et al., 2003) making the development of such strategies to tackle disengagement a challenge. In addition, there is growing global evidence that mental disorders are socially determined (Lund et al., 2018), with social and economic factors directly influencing illness prevalence and severity. It stands to reason therefore that these societal factors may also influence disengagement from mental health service. Support for this comes from a study in the USA and Canada, which found that lower socio-economic status was associated with disengagement from general outpatient mental health services (Edlund et al., 2002). A more recent study from Canada found material deprivation predicted disengagement in second-generation immigrants with FEP (Maraj et al., 2017). In addition, a study from the UK found that individuals living in more deprived areas had higher rates of relapses of psychotic disorders (Puntis et al., 2018). It is plausible that if there are higher rates of disengagement in these areas, this could in part contribute to the risk of relapse and also potentially lengthen the time taken for the relapses to be identified and treated.
The importance of service and community level factors of disengagement from EI services have been proposed as potential new targets to inform service protocols aimed at reducing rates of disengagement (Lal and Malla, 2015; Smith et al., 2013). For example, the availability, type, and accessibility of EI services are variables that may be augmented to improve disengagement rates (Bechard-Evans et al., 2007). There is potential that by tailoring services to the communities they represent – by ensuring their accessibility, and considering how resources are allocated to populations most in need – could improve engagement (Kirkbride and Jones, 2013). To date however, no such empirical evidence exists. For example, location of services, and thus their accessibility, is often thought to be a global barrier to accessing and remaining engaged with healthcare providers (Ballon et al., 2004; Brown et al., 2016; Elliott and Larson, 2004; Myers et al., 2010) however this view typically comes from subjective data from questionnaires or interviews.
The present study aimed to look at the impact of a number of community and service level factors on rates of disengagement in a population of young people experiencing first episode psychosis. The factors we were able to examine were the impact of the neighbourhood, i.e. levels of social deprivation and social fragmentation, the distance to the EI service from the individual's place of residence, and whether establishing a clinic in a new location was associated with a change in disengagement rates.
Section snippets
Setting
This sample comprised a population-based cohort of individuals with FEP, consecutively admitted to the Early Psychosis Prevention and Intervention Centre (EPPIC) service in Melbourne, Australia between 1st January 2011 and 7th September 2014. The EPPIC service is a specialist youth mental health service that provides multi-disciplinary care for young people with FEP between the ages of 15 and 24 managed by Orygen Youth Health. Individuals are referred by multiple avenues such as local mental
Participant demographics
A total of 707 individuals presented with FEP between 1st January 2011 and 3rd September 2014. The mean age of the cohort was 19.3 years (SD ± 2.9), and 60.1% of the sample were male. Approximately 20% of the sample had a 1st degree family history of a psychotic disorder, with 20% also having a history in second degree relatives. A total of 37.4% (N = 262) had a diagnosis of schizophreniform disorder or schizophrenia at baseline assessment and 16.0% (N = 112) had a diagnosis of bipolar
Discussion
In this large, epidemiological cohort of young people with FEP, the overall rate of disengagement was 55.7%, with many of these individuals having multiple episodes of disengagement whereby they subsequently re-engaged and later disengaged again. Individuals residing in neighbourhoods of higher social deprivation were more likely to have an episode of disengagement. The introduction of a new clinic location did not have a significant impact on the rates of disengagement, but it was associated
Role of funding source
There are no funding sources associated with this project.
Declaration of Competing Interest
The authors do not have any conflicts of interest to report.
References (29)
- et al.
Determinants of help-seeking and system related components of delay in the treatment of first-episode psychosis
Schizophr. Res.
(2007) - et al.
Rate and predictors of disengagement from a 2-year early intervention program for psychosis in Hong Kong
Schizophr. Res.
(2014) - et al.
Rate and predictors of service disengagement in an epidemiological first-episode psychosis cohort
Schizophr. Res.
(2010) - et al.
Adolescents in mid-sized and rural communities: foregone care, perceived barriers, and risk factors
J. Adolesc. Health
(2004) - et al.
The rates and determinants of disengagement and subsequent re-engagement in young people with first-episode psychosis
Soc. Psychiatry Psychiatr. Epidemiol.
(2019) - et al.
Social determinants of mental disorders and the sustainable development goals: a systematic review of reviews
Lancet Psychiatry
(2018) - et al.
Disengagement in immigrant groups receiving services for a first episode of psychosis
Schizophr. Res.
(2018) - et al.
Neighbourhood-level socio-environmental factors and incidence of first episode psychosis by place at onset in rural Ireland: the Cavan–Monaghan First Episode Psychosis Study [CAMFEPS]
Schizophr. Res.
(2014) - et al.
Predictors of disengagement from treatment in an early psychosis program
Schizophr. Res.
(2012) - et al.
Youth help-seeking expectancies and their relation to help-seeking behaviours for substance use problems
Addict. Res. Theory
(2004)
Systematic review of barriers and facilitators to accessing and engaging with mental health care among at-risk young people
Asia Pac. Psychiatry
Suicide and parasuicide in London: a small-area study
Urban Stud.
First-episode psychosis and disengagement from treatment: a systematic review
Psychiatr. Serv. (Washington, D.C.)
First-episode psychosis and disengagement from treatment: a systematic review
Psychiatr. Serv.
Cited by (8)
Highlights
2019, Schizophrenia ResearchTobacco smoking in young people seeking treatment for mental ill-health: What are their attitudes, knowledge and behaviours towards quitting?
2021, Irish Journal of Psychological MedicineShort-term disengagement from early intervention service for first-episode psychosis: findings from the “Parma Early Psychosis” program
2023, Social Psychiatry and Psychiatric EpidemiologyRates and predictors of service disengagement in adolescents with first episode psychosis: results from the 2-year follow-up of the Pr-EP program
2023, European Child and Adolescent Psychiatry