Elsevier

Schizophrenia Research

Volume 210, August 2019, Pages 122-127
Schizophrenia Research

The association between community and service level factors and rates of disengagement in individuals with first episode psychosis

https://doi.org/10.1016/j.schres.2019.05.037Get rights and content

Abstract

Introduction

Individuals who experience a first episode of psychosis require early intervention and regular follow-up in order to improve their prognosis and avoid long-term negative outcomes. However, approximately 30% of individuals accessing support will end up disengaging from early intervention (EI) services. Although we know that individual factors can impact rates of disengagement, less is known about potential service and community level factors.

Methods

Data were gathered from a cohort of individuals attending a specialist youth mental health service in Melbourne, Australia between 1st January 2011 and 7th September 2014. Data were collected from clinical files and electronic medical records using a standardised audit instrument. Cox regression analysis was used to identify whether community level factors were predictors of disengagement.

Results

Data were available for 707 young people experiencing a first episode of psychosis. Individuals residing in neighbourhoods of higher social deprivation were at a higher relative risk of disengaging, with 4.7% increase in engagement for each increase in decile of deprivation. The introduction of a new clinic was not significantly associated with a difference in the proportion of individuals disengaging from the service and distance to service was not significantly associated with disengagement rates.

Discussion

Developing strategies focused on engaging young people with first episode psychosis who reside in more deprived areas may address the higher rates of disengagement these individuals experience. These finding suggest that location may not be a barrier to engagement, however services should be resourced in-line with the population demographic in their specific location.

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.

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