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

Disengagement from mental health services can lead to devastating consequences for individuals with schizophrenia and other serious mental illnesses who require ongoing treatment. We review the extent and correlates of dropping out of mental health treatment for individuals with schizophrenia and suggest strategies for facilitating treatment engagement. Although rates vary across studies, reviews of the literature suggest that up to one-third of individuals with serious mental illnesses who have had some contact with the mental health service system disengage from care. Younger age, male gender, ethnic minority background, and low social functioning have been consistently associated with disengagement from mental health treatment. Individuals with co-occurring psychiatric and substance use disorders, as well as those with early-onset psychosis, are at particularly high risk of treatment dropout. Engagement strategies should specifically target these high-risk groups, as well as high-risk periods, including following an emergency room or hospital admission and the initial period of treatment. Interventions to enhance engagement in mental health treatment range from low-intensity interventions, such as appointment reminders, to high-intensity interventions, such as assertive community treatment. Disengagement from treatment may reflect the consumer's perspective that treatment is not necessary, is not meeting their needs, or is not being provided in a collaborative manner. An emerging literature on patient-centered care and shared decision making in psychiatry provides suggestive evidence that efforts to enhance client-centered communication and promote individuals' active involvement in mental health treatment decisions can also improve engagement in treatment.

[1]  M. Valenstein,et al.  Longitudinal Patterns of Health System Retention Among Veterans with Schizophrenia or Bipolar Disorder , 2008, Community Mental Health Journal.

[2]  Julie Kreyenbuhl,et al.  Practice guideline for the treatment of patients with schizophrenia , 1997 .

[3]  C. Charles,et al.  Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). , 1997, Social science & medicine.

[4]  D. A. Owens,et al.  Predictors of missed first appointments at community mental health centers after psychiatric hospitalization. , 2006, Psychiatric services.

[5]  F. Dickerson,et al.  The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. , 2010, Schizophrenia bulletin.

[6]  B. Cuffel,et al.  Predictive models and the effectiveness of strategies for improving outpatient follow-up under managed care. , 2002, Psychiatric services.

[7]  M. Stewart,et al.  The impact of patient-centered care on outcomes. , 2000, The Journal of family practice.

[8]  Klinkenberg Wd,et al.  Predictors of receipt of aftercare and recidivism among persons with severe mental illness: a review. , 1996 .

[9]  J. Kogan,et al.  Predictors of timely follow-up care among medicaid-enrolled adults after psychiatric hospitalization. , 2007, Psychiatric services.

[10]  M. Crawford,et al.  Providing continuity of care for people with severe mental illness , 2004, Social Psychiatry and Psychiatric Epidemiology.

[11]  M. Harrow,et al.  Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medications: A 15-Year Multifollow-Up Study , 2007, The Journal of nervous and mental disease.

[12]  John E. Ware,et al.  Expanding Patient Involvement in Care , 1985 .

[13]  W. D. Klinkenberg,et al.  Predictors of receipt of aftercare and recidivism among persons with severe mental illness: a review. , 1996, Psychiatric services.

[14]  J. R. Koch,et al.  The prevalence and correlates of untreated serious mental illness. , 2001, Health services research.

[15]  S. Normand,et al.  Evaluation of a Patient Activation and Empowerment Intervention in Mental Health Care , 2008, Medical care.

[16]  M. Stewart.  Effective physician-patient communication and health outcomes: a review. , 1995, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[17]  G. Dunn,et al.  The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis , 2004, BMJ : British Medical Journal.

[18]  C. Mowbray,et al.  Immediate outcomes of substance use treatment within a state psychiatric hospital , 2008, The journal of mental health administration.

[19]  F. Goodwin,et al.  Health care reform for Americans with severe mental illnesses: report of the National Advisory Mental Health Council. , 1993, The American journal of psychiatry.

[20]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[21]  H Killaspy,et al.  Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome. , 2000, The British journal of psychiatry : the journal of mental science.

[22]  S. Kaplan,et al.  Expanding patient involvement in care. Effects on patient outcomes. , 1985, Annals of internal medicine.

[23]  M. Birchwood,et al.  Predicting engagement with services for psychosis: insight, symptoms and recovery style , 2003, British Journal of Psychiatry.

[24]  J. Os,et al.  Results of a multinational, randomised controlled trial Results of a multinational, randomised controlled trial , 2004 .

[25]  P. Deegan.  The lived experience of using psychiatric medication in the recovery process and a shared decision-making program to support it. , 2007, Psychiatric rehabilitation journal.

[26]  R. Drake,et al.  Shared Decision Making in Antipsychotic Management , 2008, Journal of psychiatric practice.

[27]  Anita Everett,et al.  Promoting the value and practice of shared decision-making in mental health care. , 2007, Psychiatric rehabilitation journal.

[28]  Gina R Kruse,et al.  Factors associated with attendance at a first appointment after discharge from a psychiatric hospital. , 2002, Psychiatric services.

[29]  G. Krarup,et al.  A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness , 2005, BMJ : British Medical Journal.

[30]  M. Ruggeri,et al.  Outcome of patients dropping out from community‐based mental health care: a 6‐year multiwave follow‐up study , 2007, Acta psychiatrica Scandinavica. Supplementum.

[31]  M. Folstein,et al.  Prevalence of Treated and Untreated DSM‐III Schizophrenia Results of a Two‐Stage Community Survey , 1985, The Journal of nervous and mental disease.

[32]  T. Belin,et al.  Routine outcome monitoring in a public mental health system: the impact of patients who leave care. , 2000, Psychiatric services.

[33]  T. Schofield.  Patient-Centered Medicine: Transforming the Clinical Method , 1995 .

[34]  M. Tansella,et al.  How often do patients with psychosis fail to adhere to treatment programmes? A systematic review , 2003, Psychological Medicine.

[35]  M. Olfson,et al.  Identifying risk factors and key strategies in linkage to outpatient psychiatric care. , 2000, The American journal of psychiatry.

[36]  E. Susser,et al.  Preventing recurrent homelessness among mentally ill men: a "critical time" intervention after discharge from a shelter. , 1997, American journal of public health.

[37]  Patricia E Deegan,et al.  Best practices: a program to support shared decision making in an outpatient psychiatric medication clinic. , 2008, Psychiatric services.

[38]  F. Dickerson,et al.  The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. , 2004, Schizophrenia bulletin.

[39]  Aileen O'Brien,et al.  Disengagement from mental health services , 2009, Social Psychiatry and Psychiatric Epidemiology.

[40]  R. Rosenthal,et al.  A Prospective Study of Integrated Outpatient Treatment for Substance-Abusing Schizophrenic Patients , 1995 .

[41]  Lars Hansson,et al.  Structured patient–clinician communication and 1-year outcome in community mental healthcare , 2007, British Journal of Psychiatry.

[42]  R. Bentall,et al.  Predictors and profiles of treatment non-adherence and engagement in services problems in early psychosis , 2008, Schizophrenia Research.

[43]  J. Brown.  Patient-centred medicine: Transforming the clinical method , 1998 .

[44]  Robert E. Drake,et al.  Shared Decision-Making and Evidence-Based Practice , 2006, Community Mental Health Journal.

[45]  L. Dixon,et al.  Use of a critical time intervention to promote continuity of care after psychiatric inpatient hospitalization. , 2009, Psychiatric services.

[46]  J. Gunderson,et al.  The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome. , 1990, Archives of general psychiatry.

[47]  S. Kaplan,et al.  Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease , 1989, Medical care.

[48]  S. Priebe,et al.  Processes of disengagement and engagement in assertive outreach patients: qualitative study , 2005, British Journal of Psychiatry.

[49]  A. Gray,et al.  Case management for people with severe mental disorders. , 2011, The Cochrane database of systematic reviews.

[50]  D. Charney,et al.  Discovering the neural basis of human social anxiety: a diagnostic and therapeutic imperative. , 2004, The American journal of psychiatry.

[51]  L. Kohn,et al.  COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA , 2000 .