Predictors of engagement in first-episode psychosis

https://doi.org/10.1016/j.schres.2016.04.030Get rights and content

Abstract

Engagement with psychiatric services is critical for ensuring successful outcomes in patients experiencing a first episode of psychosis (FEP). However, it is not known how sociodemographic factors and patient beliefs about the causes of mental illness affect engagement. This study explored predictors of engagement in a cohort of 103 FEP patients presenting to an early-intervention service. Beliefs that mental illness is caused by social stress or thinking odd thoughts predicted higher engagement scores. Patients with no qualifications were found to have higher engagement scores than those educated to a higher level. Ethnicity, gender, age and socioeconomic factors were not significantly correlated with engagement scores. Duration of untreated illness (DUI) significantly predicted higher engagement scores, but only for values > 1220 days. Duration of untreated psychosis (DUP) was not a significant predictor of patient engagement scores. Patient beliefs about the causes of mental illness are an important factor to be taken into consideration and may represent a target of interventions to increase engagement in FEP.

Introduction

Disengagement from psychiatric care represents a major problem for mental health services. Recent reviews suggest that approximately 30% of patients eventually disengage from care (Kreyenbuhl et al., 2009, O'Brien et al., 2009a). The problem is particularly severe for patients experiencing a first-episode of psychosis (FEP), where early disengagement is associated with poor patient outcomes (Robinson et al., 1999, Robinson et al., 2002, Ruggeri et al., 2007, Schimmelmann et al., 2006, Turner et al., 2009). Hence, identification of the factors which determine whether a patient engages or disengages is essential to improve therapeutic relationships and treatment outcomes.

Several factors have been identified as predictors of engagement in FEP, but most are in contention. There is conflicting evidence regarding levels of disengagement amongst black and minority ethnic (BME) groups (Singh and Burns, 2006). Whilst some studies have found greater disengagement and less satisfaction with services (McGovern and Cope, 1991, McCreadie et al., 1997, Wang, 2007), others have found no difference or greater engagement amongst BME groups (Bindman et al., 2000, Goater et al., 1999, Takei et al., 1998, Raleigh et al., 2007). Recent work suggests that immigrants are more likely than nonimmigrants to disengage from treatment (Ouellet-Plamondon et al., 2015). Childhood physical abuse, alcohol, a history of violence and a psychopathic traits have been associated with poor engagement (Spidel et al., 2010). There is contradictory evidence regarding the effect of other sociodemographic factors on levels of engagement (O'Brien et al., 2009a). There is no consensus on the effects of gender, age, living status, marital status, socioeconomic status or level of education on engagement (Baekeland and Lundwall, 1975). Moreover, it is not known how the emergence and chronology of emerging psychosis affects levels of engagement. Whilst some have found an association between duration of untreated psychosis (DUP) and engagement (Conus et al., 2010), others have not (Macbeth et al., 2013). Furthermore, little is known about how symptom attribution and patients' beliefs about the causes of mental illness impacts upon engagement.

Previous studies have also had some limitations. Firstly, engagement and disengagement were poorly conceptualized and defined, and patient populations and service settings were heterogeneous and diverse (O'Brien et al., 2009a). Secondly, the most common measure of disengagement used is drop-out, which is an unsuitable proxy for a construct as complex as engagement (Catty, 2004). This also means we have little direct data about which factors influence engagement levels when patients first present to services. Apart from measures of contact, unvalidated scales are often employed to measure engagement (Zheng et al., 2013). In addition, despite the existence of robust statistical methods, all studies in the field of engagement research to date have used conventional techniques alone, which have are less able to detect real differences between groups (Wilcox et al., 2013).

We used the validated Singh-O′Brien Level of Engagement Scale (SOLES) to measure engagement in FEP (O'Brien et al., 2009a) We sought to identify sociodemographic predictors of engagement, exploring the role of beliefs, attributions, and ethnicity on engagement. In addition, we examined the correlation between the chronology of psychosis onset and engagement. We employed non-parametric statistical techniques along with conventional methods.

Section snippets

Participants

A total of 103 FEP patients were recruited from the Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) early intervention services over a 2-year period. Invitations to participate in the study were extended to all patients attending the Birmingham early intervention service, as the Solihull early intervention service had not yet been established at the time of study initiation. Each patient's community psychiatric nurse (CPN) was approached to ascertain whether the potential

Sociodemographic predictors of engagement

See Table 1 for summary statistics for the sample and mean SOLES scores.

Discussion

Any intervention is only as effective as the willingness of those who need it choosing to engage with it. Disengagement from mental health care is a major concern for services. Within EIS, there is a specific focus on therapeutic engagement, and disengagement is considered a performance measure for the quality of service provided (Singh et al., 2005). For ethnic minority groups, disengagement from metal health care is a particular cause of concern (Singh et al., 2007). About 30% patients with

Role of funding source

This study was based on work funded by the ENRICH programme grant. Funders had no role in the design, analysis or interpretation of this study.

Contributors

SP and DC conceptualized the study, analyzed the data and drafted the manuscript. All authors interpreted results and contributed to the manuscript.

Conflict of interests

The authors have no conflict of interests to declare.

Acknowledgements

Data used in the preparation of this article were obtained from the ENRICH project. This article presents independent research funded by the National Institute for Health Research under its Programme Grants for Applied Research programme (RP-PG-0606-1151). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. Dr D.C. holds a Pathfinder Fellowship Award from the Royal

References (36)

  • J. Catty

    “The vehicle of success”: theoretical and empirical perspectives on the therapeutic alliance in psychotherapy and psychiatry

    Psychol. Psychother.

    (2004)
  • M.J. Edlund et al.

    Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario

    Am. J. Psychiatry

    (2002)
  • N. Goater et al.

    Ethnicity and outcome of psychosis

    Br. J. Psychiatry

    (1999)
  • C. Helman

    Culture, health and illness

    (2007)
  • M. Jellinek

    Referrals from a psychiatric emergency room: relationship of compliance to demographic and interview variables

    Am. J. Psychiatry

    (1978)
  • J. Kreyenbuhl et al.

    Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: a review of the literature

    Schizophr. Bull.

    (2009)
  • A. Macbeth et al.

    Service engagement in first episode psychosis: clinical and premorbid correlates

    J. Nerv. Ment. Dis.

    (2013)
  • R.G. McCreadie et al.

    Nithsdale, Nunhead and Norwood: similarities and differences in prevalence of schizophrenia and utilisation of services in rural and urban areas

    Br. J. Psychiatry

    (1997)
  • Cited by (18)

    • Digital technology for addressing cognitive impairment in recent-onset psychosis: A perspective

      2022, Schizophrenia Research: Cognition
      Citation Excerpt :

      First, on average, antipsychotics are associated with negligible benefits for cognition (Karson et al., 2016), and may in fact adversely affect cognitive function (MacKenzie et al., 2018). Second, low engagement levels and non-adherence are a long-standing challenge in ROP treatment (Casey et al., 2016). Technological advancement brings new possibilities for research and treatment (Rus-Calafell and Schneider, 2020) that can address these challenges.

    • Engagement with online psychosocial interventions for psychosis: A review and synthesis of relevant factors

      2021, Internet Interventions
      Citation Excerpt :

      While females are typically more help-seeking than males, findings between gender and engagement with psychosocial treatments for psychosis have been mixed (Thompson et al., 2016). Many studies found gender was not associated with service engagement (Alvarez-Jimenez et al., 2009; Anderson et al., 2013; Casey et al., 2016; Conus et al., 2010; Gurak et al., 2017; Kim et al., 2019; Kukla et al., 2014; Lincoln et al., 2014; Ma et al., 2012; Schimmelmann et al., 2006; Thomas et al., 2018; Turner et al., 2007). However, male gender was associated with increased risk of dropout in meta-analytic examination (Villeneuve et al., 2010), and lower rates of engagement amongst individuals with both early psychosis and schizophrenia (Lecomte et al., 2008; Tsang et al., 2010).

    • Development and validation of the client engagement and service use scale: A pilot study

      2018, Schizophrenia Research
      Citation Excerpt :

      Engagement with care is particularly important for individuals experiencing a first episode of psychosis (FEP), as FEP represents a critical window for both vulnerability to morbidity and mortality (Schoenbaum et al., 2017) as well as responsiveness to intervention (Kane et al., 2016). Although specialized FEP services seek to promote engagement by making services more practically accessible and developmentally targeted to youth and young adults (Becker et al., 2016), many FEP patients do not access available services, or access them only briefly or with superficial engagement (Casey et al., 2016). Poor engagement with care and inconsistent adherence to medications leads to poorer outcomes, with higher likelihood of relapse, rehospitalization, and chronic disability (Conus et al., 2017; Winton-Brown et al., 2017), while good engagement and treatment adherence is associated with greater improvements in psychosocial functioning, symptom severity, and re-hospitalization rates (Chien et al., 2015).

    • Cultural factors in first episode psychosis treatment engagement

      2018, Schizophrenia Research
      Citation Excerpt :

      Despite their diagnoses, many of these individuals never engaged in outpatient treatment over the following year: 62% filled no outpatient prescriptions, and 41% received no individual psychotherapy (Schoenbaum et al., 2017). For those who do seek outpatient care, engagement is critical to outcomes in FEP, as longer duration of untreated psychosis, drop-out from mental health services, and poor medication adherence all predict worse treatment response and higher likelihood of symptom recurrence (Casey et al., 2016; Conus et al., 2017). As we recognize the importance of treatment engagement, we must prepare to address it more rigorously within psychosis and schizophrenia research.

    View all citing articles on Scopus
    View full text