Interventions specific to first episode psychosis have become a significant focus in community mental health. However, programs directed at early intervention and identification are unable to impact treatment progress if clients are not engaged. In general, disengagement from mental health services is problematic.  Approximately 30% of individuals with first episode psychosis disengage from treatment, which is consequently associated with poorer outcomes (Casey et al., 2016; Robinson et al., 2002).  Thus, identification of factors related to disengagement becomes necessary to influence treatment outcomes.
As cited in Casey et al. (2016), research identifying predictive factors related to disengagement and first episode psychosis has been equivocal. For instance, Singh and Burns (2006; as cited in Casey et al., 2016) found conflicting evidence for disengagement between minority ethnic groups. Ouellet-Plamondon et al. (2015; as cited in Casey et al., 2016) found immigrant populations were more likely to disengage from treatment.  Clients with a history of childhood physical abuse, alcohol use, violence, and psychopathic traits were also associated with disengagement (Spidel et al, 2010; as cited in Casey et al., 2016). Though dated, Baekeland and Lundewall (1975; as cited in Casey et al, 2016) found no consistent relationship between engagement and gender, age, living status, marital status, SES, or educational level. Additionally, little is known about disengagement and the impact of the emergence or chronology of psychosis, as well as symptom attribution or one’s beliefs about mental illness (Casey et al., 2016).  The literature has found conflicting results regarding levels of engagement and the duration of untreated psychosis (Casey et al., 2016).  More recent studies found the strongest association of disengagement is impacted by symptom severity at baseline, duration of untreated psychosis, insight, comorbid substance use, and family support (Doyle et al., 2014). Doyle et al. (2014) indicated that individuals entering a first episode psychosis program without family support and those who maintain persistent substance use are at higher risk for disengagement.
Casey et al. (2016) found that the level of education predicted levels of engagement; where as higher engagement scores were associated with lower levels of education. Duration of untreated illness (greater than 1220 days) was also a significant predictor for engagement. In this study, duration of untreated illness was defined as the time period of prodromal onset to treatment compliance (p. 205). Beliefs about mental illness were also a significant predictor, in that individuals with the belief that social stress is a cause of mental illness and that odd thoughts are associated with mental illness had higher engagement scores. Though not a predictor, patients living with others had significant higher engagement scores.
Overall, Casey et al. (2016) emphasized interventions specific to understanding patient beliefs about mental illness and discussing such beliefs in a non-judgmental manner regarding symptom attributions. Additionally, initiatives targeted at individuals with higher educational levels were also recommended.  Awareness of these factors will provide clinicians with an understanding of the characteristics likely associated with disengagement. Thus, outreach may need to reflect more active strategies for engaging individuals with these characteristics. As recommended by Heinssen, Goldstein, and Azrin (2014), for individuals with first episode psychosis “assertive outreach, efficient enrollment, and hopeful messages are critical at the time of intake” (p. 8). First contacts are critical.  Clinicians should be supportive, reassuring, and focus on learning about the individual’s experience of symptoms, the impact of these symptoms on daily life, and how psychosis has impacted family members (Heinssen, Goldstein, & Azrin, 2014). In addition, establishing a youth friendly environment, offering ongoing education and support, as well as giving consideration to providing services separate from the larger clinic, (if possible with a separate entrance and waiting room) may help positively impact levels of engagement. Due to the poorer outcomes associated with disengagement, as well as the progressive course of a psychotic illness, every effort should be considered to increase engagement in services.
References
Casey, D., Brown, L., Gajwani, R., Islam, Z., Jasani, R., Parsons, H.,…Singh, S. P. (2016). Predictors of engagement in first-episode psychosis. Schizophrenia Research, 175, 204-208.
Doyle, R., Turner, N., Fanning, F., Brennan, D., Renwick, L., Lawlor, E., & Clarke, M. (2014). First-episode psychosis and disengagement from treatment: A systematic review. Â Psychiatric Services, 65(5), 603-611.
Heinssen, R. K., Goldstein, A. B., & Azrin, S. T. (2014). Evidence-based treatments for first episode psychosis:Â Components of coordinated specialty care. Retrieved from http://www.nimh.nih.gov/health/topics/schizophrenia/raise/nimh-white-paper-csc-for-fep_147096.pdf
Robinson, D. G., Woerner, M. G., Alvier, J. M. J., Bilder, R. M., Hinrihsen, G. A., & Lieberman, J. A. (2002). Predictors of medication discontinuations by patients with first-episode schizophrenia and schizoaffective disorder. Schizophrenia Research, 57, 209-219.
Dannie S. Harris, MA
WKPIC Doctoral Intern