Predictors of disengagement from Early Intervention in Psychosis services

The problem of missing data for learning health systems focused on first-episode psychosis

BACKGROUND

A Learning Health System (LHS) requires data to improve care.

DESIGN

Data are from the ESPRITO LHS that includes 13 US clinics providing coordinated specialty care (CSC) for first-episode psychosis. Causes of missing data examined were: clinic patients not enrolling in ESPRITO, participants prematurely disengaging from treatment and missing patient-reported outcomes.

RESULTS

ESPRITO informed consent used a verbal opt-out format. This resulted in a high participant agreement rate (83.5 %) but limitations on data sharing within ESPRITO. During a 6-month period, 15.4 % of ESPRITO participants prematurely terminated treatment. An exploratory analysis revealed factors associated with increased premature termination likelihood: being homeless or having unstable housing, not being prescribed a long-acting injectable antipsychotic and factors associated with decreased premature termination likelihood: having commercial insurance, longer duration of CSC treatment, better scores on the Global Functioning: Social Scale and reporting higher likelihood to attend on the Intent to Attend scale. Examining patient-reported outcomes, rates of missing data with participants still in treatment on the Questionnaire about the Process of Recovery were 26.5 % at first major assessment rising up to 59.8 % on later assessments.

CONCLUSIONS

Missing data are a substantial problem for first-episode psychosis-focused LHS. LHS designs should consider factors that may influence LHS data participation and a LHS research priority should be developing interventions to decrease missing data. LHS data analyses should also consider potential differential characteristics of individuals who are versus who are not included in LHS data sets.

Care coordinator delivered Method of Levels therapy for people reporting first-episode psychosis: Experiences and views of service user, care coordinator, and team manager participants of the CAMEO trial

BACKGROUND

Without effective and timely support, psychosis can lead to negative personal, economic, and societal outcomes. Care coordinators play a key role in the delivery of early intervention in psychosis services, which aim to improve outcomes and promote recovery for people experiencing first-episode psychosis. Enhancing the support offered by care coordinators could improve outcomes and reduce levels of service user disengagement. This study aimed to understand participants' views on the acceptability of a transdiagnostic talking therapy, called Method of Levels (MOL), delivered by care coordinators in early intervention in psychosis services. It also sought to understand participants' experiences of the MOL training and supervision programme, and to identify any barriers that might impact on the implementation of the approach in routine practice.

METHODS

Semi-structured interviews and focus groups were conducted with service users (n = 14), care coordinators (n = 6), and team managers (n = 6) from early intervention in psychosis services. Interviews and focus groups were transcribed and reflexive thematic analysis was used to analyse the data.

RESULTS

Three themes were identified: 'Digging deeper to find my own solutions'; (2) 'Prepared for practice?'; and (3) 'Levels of implementation'. Participants described how the use of MOL enabled service users to explore problems in greater depth and generate their own solutions to these. Care coordinators generally reported feeling ready to deliver the intervention after attending MOL training and were able to integrate the approach into their practice in a flexible way. High workloads limited care coordinators' capacity to attend MOL supervision regularly, reducing their overall confidence in delivering the approach. This impacted on the degree to which care coordinators used MOL in their practice.

CONCLUSIONS

Findings suggest that MOL delivered by care coordinators could be a helpful approach for people experiencing first-episode psychosis. Care coordinators found it difficult to attend clinical supervision, however, which represents a barrier to implementation. This issue will need to be addressed before care coordinator delivered-MOL for first-episode psychosis can be evaluated in a larger study or implemented in practice.

Care coordinator delivered method of levels therapy to improve engagement and other outcomes in early psychosis (CAMEO): protocol for a feasibility cluster-randomised controlled trial

BACKGROUND

Rates of disengagement from early intervention in psychosis (EIP) services are high. Care coordinators make up the largest staff group in EIP services and have the most frequent and sustained contact with service users. The quality of relationships between service users and care coordinators plays a central role in determining the effectiveness of EIP services. Care coordinators, however, are not routinely offered training in psychosocial interventions that could enhance the therapeutic impact of their role. Method of levels (MOL) is a flexible, transdiagnostic cognitive therapy with potential advantages over previously evaluated approaches. Training care coordinators in MOL could make their routine contacts with service users more helpful and improve outcomes such as recovery rates and levels of engagement.

AIMS

This study aims to assess the feasibility of training care coordinators in EIP services to deliver MOL, to understand whether this approach might improve service user engagement and recovery from psychosis compared to treatment as usual, and to assess the feasibility of conducting a cluster-randomised controlled trial (C-RCT) with clustering at the level of teams. Specific feasibility outcomes relate to the recruitment and retention of participants, care coordinators' level of engagement with the MOL training and supervision programme, implementation of MOL in practice, and the acceptability of the intervention amongst participants.

METHODS

A feasibility parallel group cluster-randomised controlled trial (C-RCT) designs with two arms: (1) treatment as usual (TAU) or (2) TAU plus support from a care coordinator who has received training in MOL. Randomisation will take place at the level of EIP teams with an allocation ratio of 1:2 in favour of the intervention arm. Our recruitment target is 12 EIP teams, 24 care coordinators working in participating EIP teams, and up to 96 service users working with participating care coordinators. Outcomes will be collected at baseline, 3 months, and 6 months. Qualitative methods will be used to understand participants' experiences of the study, MOL training programme, and MOL intervention.

DISCUSSION

This is the first study that aims to evaluate the feasibility of training EIP care coordinators to deliver MOL in their routine practice. Training care coordinators in MOL could enhance the quality of relationships between care coordinators and service users and improve outcomes for people experiencing early psychosis. Results will be used to determine the appropriateness of progressing to a larger evaluation trial.

TRIAL REGISTRATION

This study was prospectively registered with the ISRCTN Registry (14082421).

What happens after early intervention? Mapping early intervention in psychosis care pathways in the 12 months after discharge

AIM

Early intervention services are the established and evidence-based treatment option for individuals with first-episode psychosis. They are time-limited, and care pathways following discharge from these services have had little investigation. We aimed to map care pathways at the end of early intervention treatment to determine common trajectories of care.

METHODS

We collected health record data for all individuals treated by early intervention teams in two NHS mental health trusts in England. We collected data on individuals' primary mental healthcare provider for 52 weeks after the end of their treatment and calculated common trajectories of care using sequence analysis.

RESULTS

We identified 2224 eligible individuals. For those discharged to primary care we identified four common trajectories: Stable primary care, relapse and return to CMHT, relapse and return to EIP, and discontinuity of care. We also identified four trajectories for those transferred to alternative secondary mental healthcare: Stable secondary care, relapsing secondary care, long-term inpatient and discharged early. The long-term inpatient trajectory (1% of sample) accounted for 29% of all inpatient days in the year follow-up, with relapsing secondary care (2% of sample and 21% of inpatient days), and Relapse and return to CMHT (5% of sample, 15% of inpatient days) the second and third most frequent.

CONCLUSIONS

Individuals have common care pathways at the end of early intervention in psychosis treatment. Understanding common individual and service features that lead to poor care pathways could improve care and reduce hospital use.

Demographic predictors of lack of current mental health treatment among university students with a schizophrenia spectrum disorder

AIM

To identify the demographic predictors of lack of current mental health (MH) treatment among university students with a schizophrenia spectrum disorder (SSD).

METHODS

Adult university students with a self-identified diagnosis of an SSD (schizophreniform, schizophrenia, schizoaffective disorder) were identified from the 2019-2020 Healthy Minds Study survey. In this study, pertinent demographic factors included age, race/ethnicity, sex assigned at birth, gender identity, sexual orientation, parental education, financial stress, and employment. Multivariable modelling was used to investigate the demographic predictors of lack of current psychotherapy treatment, no current antipsychotic use, and lack of any MH treatment (defined as concurrent lack of psychotherapy and antipsychotic treatment).

RESULTS

Of the 135 included students with a SSD, the median age was 23 years old and 79 (58.5%) were assigned female at birth. Fifty-five participants (40.7%) lacked any current MH treatment. In fully adjusted models, lack of current MH treatment was associated with working more than 20 h per week (OR 2.9 [1.2-7.1], p = 0.02). No current antipsychotic use was associated with Hispanic/Latino race/ethnicity (OR 4.2 (1.2-14.5), p = 0.04). Lack of current psychotherapy treatment was associated with cisgender male identity (OR 5.5 [2.0-15.2], p < 0.01), working greater than 20 hours per week (OR 6.5 [2.2-19.2], p < 0.01), and having one or more structural or attitudinal barriers to care (OR = 4.6 [1.5-13.9], p < 0.01).

CONCLUSIONS

The demographic predictors of lack of current MH treatment varied between psychotherapy and antipsychotic use, suggesting university health centres should consider interventions targeting several at-risk populations to increase treatment use among students with a SSD.

Neglecting the care of people with schizophrenia: here we go again

Specialist early intervention teams consider clinician-patient engagement and continuity of care to be a driving philosophy behind the treatment they provide to people who have developed schizophrenia or a related psychotic illness. In almost all countries where this service model has been implemented there is a dearth of available data about what is happening to patients following time-limited treatment. Information on discharge pathways in England indicates that some early intervention specialists are discharging most of their patients from all psychiatric services after only 2 or 3 years of input. Some ex-patients will be living in a state of torment and neglect due to an untreated psychosis. In the UK, general practitioners should refuse to accept these discharge pathways for patients with insight-impairing mental illnesses.

Clinical insights: Preventing psychosis treatment disengagement

Many patients with schizophrenia spectrum disorders disengage from treatment, with negative impacts on prognosis and recovery. This commentary provides an overview of common reasons underlying treatment dropout and strategies for overcoming obstacles and enhancing patient engagement. Basic clinical skills such as open-ended questions and reflective listening can be powerful tools in unmasking structural and attitudinal barriers to psychosis care.

Polysubstance use in young people accessing residential and day-treatment services for substance use: substance use profiles, psychiatric comorbidity and treatment completion

BACKGROUND AND AIMS

People with substance use disorders (SUDs) frequently present to treatment with polysubstance use and mental health comorbidities. Different combinations of substance use and mental health problems require different treatment approaches. Our study aimed to: (i) identify the shared substance use classes among young people at treatment admission, (ii) determine which mental health symptoms, quality of life (QoL) and service types were associated with the identified substance use classes, and (iii) prospectively determine which substance use classes and service types were more likely to complete treatment.

DESIGN

Cross-sectional and prospective study using service and outcome data.

SETTING

Substance use treatment services in Queensland and New South Wales, Australia.

PARTICIPANTS

De-identified service and outcome measure data were extracted from the files of 744 clients aged 18-35 years (48% male) admitted into seven residential and four day-treatment programmes.

MEASUREMENTS

Substance use and severity among tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, opioids, sedatives and inhalants. Other variables included: depression, anxiety, post-traumatic stress and psychotic symptoms, as well as QoL.

FINDINGS

Latent class analysis identified three polysubstance use classes: wide-ranging polysubstance users (WRPU; 22.45%), primary amphetamine users (56.45%) and alcohol and cannabis users (21.10%). The WRPU class had higher odds of psychotic symptoms than the alcohol and cannabis use class [odds ratio (OR) = 1.30; 95% confidence interval (CI) = 1.11-1.11]; and double the odds of residential programme enrolment than those in the amphetamine use class (OR = 2.35; 95% CI = 1.50-3.68). No other class differences on mental health or QoL variables were found. Clients enrolled in day-programmes had higher odds of completing treatment.

CONCLUSIONS

There appear to be high levels of polysubstance use among young people entering substance use treatment in Australia. Wide-ranging polysubstance users were more likely to report psychotic symptoms and be enrolled into a residential programme than primary amphetamine users and alcohol and cannabis users.

The transition from adolescence to adulthood in patients with schizophrenia: Challenges, opportunities and recommendations

Schizophrenia is a severely debilitating neurodevelopmental disorder that requires continuous multidisciplinary treatment. Early onset schizophrenia (EOS, onset before 18) is associated with poorer outcomes than the adult-onset type. The transition from adolescent to adult mental healthcare services (AMHS) poses various challenges for maintaining continuity of care. The heterogeneous availability of specialized mental health services and resources for people with schizophrenia across Europe and the inadequacy of training programs in creating a shared culture and knowledge base between child and adult mental health professionals are major challenges at the policy level. More flexible and individualized transition timing is also needed. While changes in the relationship between patients, caregivers and mental health professionals at a time when young people should acquire full responsibility for their own care are challenges common to all mental health disorders, these are particularly relevant to the care of schizophrenia because of the severe associated disability. This Expert Opinion Paper examines the main aspects of transitioning of care in schizophrenia with the aim of identifying the challenges and the potential approaches that could enhance continuity of care.

Rates and Predictors of Disengagement and Strength of Engagement for People With a First Episode of Psychosis Using Early Intervention Services: A Systematic Review of Predictors and Meta-analysis of Disengagement Rates

Disengagement is a problem in early intervention for psychosis services; identifying predictors is important to maximise mental-health care.

Aim

To establish the average disengagement rate, time to disengage, and predictors of disengagement or strength of engagement.

Methods

Papers were identified from 5 databases and citation searches; chosen if they reported dis/engagement in early intervention services, discarded if they didn't give a clear definition of disengagement. The studies were rated for quality and a systematic review identified predictors of engagement; meta-analysis established the average disengagement rate. Meta-regression evaluated associations between disengagement and year of study or length of follow up.

Results

26 papers were reviewed comprising over 6800 participants, meta-analysis of 15 eligible cohorts found that the average disengagement rate was 15.60% (95% confidence intervals 11.76%-20.45%), heterogeneity was considerable, important to note when reporting as a global average. Higher disengagement rates were associated with earlier studies and length of follow up; causal factors are unclear due to the lack of data and complex interaction between clinical and methodological issues. Robust predictors of disengagement were substance use, contact with the criminal justice system, medication non-adherence, and lower symptom severity.

Conclusions

Disengagement rates have declined although the cause is not clear partly due to methodological variation, we suggest a guide for defining disengagement. Underpinning reasons for disengagement could include people who struggle to engage (substance users), don't want to engage (medication non-adherence) or feel they don't need to engage (lower symptomology). Future research should focus on minority status, education/employment during treatment, and digital technologies.

Structural Disadvantage and Culture, Race, and Ethnicity in Early Psychosis Services: International Provider Survey

OBJECTIVE

Little is known about provider perspectives on programmatic responses to structural disadvantage and cultural differences within early intervention in psychosis (EIP) services, programs, and models. The primary objective of this study was to investigate providers' perspectives on the impacts of disadvantage and minority race, ethnicity, and culture and to describe current practices and perceived gaps and concerns.

METHODS

An online survey of specialized EIP providers was disseminated in the United Kingdom, United States, Canada, Australia, and Chile. A total of 164 providers, representing 110 unique sites, completed the survey. Closed-ended questions gathered demographic and program data, including information on formal assessment of trauma or adversity, integration of trauma-informed care, integration of formal cultural assessment tools, training focused on culture, programmatic changes to address culture-related issues, and consultation with cultural insiders. Open-ended questions addressed the demographic mix of the program's client population; the perceived role and influence of trauma, structural disadvantage, and cultural differences; and concerns and needs related to these topics. Frequencies were examined for closed-ended items; open-ended responses were systematically coded.

RESULTS

Overall, survey findings suggested low levels of implementation of a variety of assessment and support practices related to cultural diversity in EIP programs. Coding of open-ended responses revealed numerous concerns regarding the impacts of disadvantage and cultural difference on clients and perceived gaps in policy and implementation.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the disadvantage- and culture-related needs of young people with early psychosis and their families should be a priority for the field.

Disengagement From Early Intervention Services for Psychosis: A Systematic Review

OBJECTIVE

Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.

METHODS

A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.

RESULTS

Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.

CONCLUSIONS

Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.

Tailoring cognitive behavioural therapy to subtypes of voice-hearing using a novel tabletised manual: a feasibility study

BACKGROUND

Cognitive behavioural therapy for psychosis (CBTp) is a recommended treatment for psychotic experiences, but its effectiveness has been questioned. One way of addressing this may be to tailor therapy materials to the phenomenology of specific psychotic experiences.

AIM

In this study, we investigated the acceptability of a novel treatment manual for subtypes of 'voice-hearing' experiences (i.e. auditory verbal hallucinations). An uncontrolled, single-arm design was used to assess feasibility and acceptability of using the manual in routine care for people with frequent voice-hearing experiences.

METHOD

The manual was delivered on a smart tablet and incorporated recent research evidence and theory into its psychoeducation materials. In total, 24 participants completed a baseline assessment; 19 started treatment, 15 completed treatment and 12 participants completed a follow-up assessment (after 10 sessions of using the manual).

RESULTS

Satisfaction with therapy scores and acceptability ratings were high, while completion rates suggested that the manual may be more appropriate for help with participants from Early Intervention in Psychosis services rather than Community Mental Health Teams.

CONCLUSION

Within-group changes in symptom scores suggested that overall symptom severity of hallucinations - but not other psychosis features, or beliefs about voices - are likely to be the most appropriate primary outcome for further evaluation in a full randomised controlled trial.

Personality disorder in an Early Intervention Psychosis cohort: Findings from the Social Epidemiology of Psychoses in East Anglia (SEPEA) study

AIM

Personality Disorders (PD) often share clinical and phenomenological overlap with psychotic disorders, especially at onset. However, there is little research on comorbid PD among people experiencing first episode psychosis. We examined the prevalence of PD recording and its sociodemographic and clinical correlates in people accepted to Early Intervention in Psychosis (EIP) services.

METHODS

Participants were aged 16-35, accepted into 6 EIP services for suspected psychosis, as part of the Social Epidemiology of Psychoses in East Anglia (SEPEA) study. PD was recorded by clinicians according to ICD-10. Multilevel logistic regression was performed.

RESULTS

Of 798 participants, 76 people (9.5%) received a clinical diagnosis of PD, with emotionally unstable PD (75.0%, N = 57) the most common subtype. In multivariable analysis, risk factors for PD included female sex (odds ratio [OR]: 3.4; 95% CI: 2.0-5.7), absence of psychotic disorder after acceptance to EIP (OR: 3.0; 95% CI: 1.6-5.5), more severe hallucinations (OR: 1.6; 95% CI: 1.2-2.1), and lower parental SES (OR: 1.4; 95% CI: 1.1-1.8). Compared with the white British, black and minority ethnic groups were less likely to receive a PD diagnosis (OR: 0.3; 95% CI: 0.1-0.7). There was no association between PD and neighbourhood-level deprivation or population-density.

CONCLUSIONS

Recording of a PD diagnosis was three times more common amongst participants later found not to meet threshold criteria for psychotic disorder, implying phenomenological overlap at referral which highlights difficulties encountered in accurate diagnostic assessment, treatment and onward referral. People with PD experienced more individual-level, but not neighbourhood-level social disadvantage in an already disadvantaged sample.

Predictors of study drop-out and service disengagement in patients at clinical high risk for psychosis

PURPOSE

Study drop-out during follow-up and service disengagement frequently occur in patients at clinical high risk for psychosis (CHR-P). However, little is known about their predictors. Therefore, we aimed to analyze the rate and reasons for drop-out and service disengagement in CHR-P patients and investigate their sociodemographic and clinical predictors.

METHODS

Data from 200 patients of the prospective Früherkennung von Psychosen (FePsy) study were analyzed with competing risks survival models, considering drop-out and transition to psychosis as competing events. To investigate whether symptoms changed immediately before drop-out, t tests were applied.

RESULTS

Thirty-six percent of patients dropped out within 5 years. Almost all drop-outs also disengaged from our service. Hence, study drop-out was used as a proxy for service disengagement. Patients with more severe baseline disorganized symptoms and a late inclusion into the study were significantly more likely to disengage. Immediately before disengagement, there was significant improvement in negative symptoms only.

CONCLUSION

A considerable proportion of CHR-P patients disengaged from our clinical study and service. Patients who were included during a later study period with more assessments disengaged more often, which might have been due to more frequent invitations to follow-up assessments and thereby increasing participation burden. Hence, our study provides a cautionary note on high-frequency follow-up assessments. Larger-scale studies evaluating predictors on multiple domains would help to further elucidate drop-out and disengagement.

Early Intervention in Psychosis Treatment Components Utilization in Patients Aged Over 35

Early Intervention in Psychosis (EIP) services have been youth-focused since their inception. In England, recent National Institute for Health and Care Excellence (NICE) guidelines and new National Health Service (NHS) Standards for EIP recommend the expansion of the age acceptability criterion from 14-35 to 14-65. In the Cambridgeshire and Peterborough EIP service (CAMEO), we ran a service evaluation to assess the initial impact of this policy change. It aimed to elicit EIP treatment components utilization by patients with first-episode psychosis (FEP) aged over 35, in comparison with those under 35. We found that the over-35s required more contacts from EIP healthcare professionals, especially from care coordinators (coefficient = .239; Robust SE = .102; Z = 6.42; p = 0.019) and social workers (coefficient = 18.462; Robust SE = .692; Z = .016; p < 0.001). These findings indicate that FEP patients aged over 35 may present with more complex and sustained clinical/social needs. This may have implications for EIP service development and commissioning.

The rates and determinants of disengagement and subsequent re-engagement in young people with first-episode psychosis

BACKGROUND

A core component of treatment provided by early intervention for psychosis (EI) services is ensuring individuals remain successfully engaged with the service. This ensures they can receive the care they may need at this critical early stage of illness. Unfortunately, rates of disengagement are high in individuals with a first episode of psychosis (FEP), representing a major barrier to effective treatment. This study aimed to ascertain the rates and determinants of disengagement and subsequent re-engagement of young people with FEP in a well-established EI service in Melbourne, Australia.

METHOD

This cohort study involved all young people, aged 15-24, who presented to the Early Psychosis Prevention and Intervention Centre (EPPIC) service with FEP between 1st January 2011 and 1st September 2014. Data were collected retrospectively from clinical files and electronic records. Cox regression analysis was used to identify determinants of disengagement and re-engagement.

RESULTS

A total of 707 young people presented with FEP during the study period, of which complete data were available for 700. Over half of the cohort (56.3%, N = 394) disengaged at least once during their treatment period, however, the majority of these individuals (85.5%, N = 337) subsequently re-engaged following the initial episode of disengagement. Of those who disengaged from the service, 54 never re-engaged, representing 7.6% of the total cohort. Not being in employment, education or training, not having a family history of psychosis in second degree relatives and using cannabis were found to be significant predictors of disengagement. No significant predictors of re-engagement were identified.

CONCLUSION

In this study, the rate of disengagement in young people with first-episode psychosis was higher than found previously. Encouragingly, rates of re-engagement were also high. The concept of disengagement from services might be more complex than previously thought with individuals disengaging and re-engaging a number of times during their episode of care. What prompts individuals to re-engage with services needs to be better understood.