پیش بینی عدم مشارکت درمان در یک برنامه روان پریشی زودرس

Background Disengagement from treatment is a major concern in psychiatry. This is of particular concern for those presenting for care at their first episode of psychosis (FEP). The purpose of this study is to determine the rate of disengagement from a three year FE treatment program and the predictors of disengagement. Method We used a longitudinal cohort design. The cohort consisted of 286 FEP individuals. Measures included assessments of positive and negative symptoms, depression, substance use, premorbid and current functioning, cognition and duration of untreated psychosis. Disengagement from treatment was defined as leaving the program before the 30 months. Results At 30 months after treatment, the estimated rate of disengagement from treatment was 31%. Predictors of disengagement were examined via Cox proportional hazards models which revealed that lower ratings on negative symptom scores at baseline (HR = 0.946; CI = 0.909–0.985), a shorter duration of untreated psychosis (HR = 0.997; CI = 0.994–0.999), and not having a family member involved in the program (HR = 0.310; CI = 0.196–0.490) contributed significantly to predicting disengagement from treatment. An examination of those who dropped out at different times revealed that those who dropped out prior to 6 months had significantly greater cannabis (p < 0.05) and other drug use (p < 0.01). Conclusions Engagement in early services may be helped by attending carefully to substance use to prevent early dropout, to those who may have had a short duration of untreated psychosis and to working with families to engage families in the program.

It is well known that disengagement from treatment is a major concern in psychiatry. A review of the literature suggests that as many as half of all individuals with schizophrenia that require ongoing treatment are not currently receiving care (Kreyenbuhl et al., 2009). This is of particular concern for those presenting for care at their first episode of psychosis (FEP) as it has been demonstrated that long term treatment can improve symptoms and functioning in individuals experiencing a FEP (Addington et al., 2003b) as well as reduce the likelihood of relapse (Schimmelmann et al., 2006 and Miller et al., 2009). Reported rates of disengagement among FEP individuals vary throughout the literature, however, most studies have reported the number of those who disengage to be between 23% and 30% (Schimmelmann et al., 2006, Turner et al., 2007 and Conus et al., 2010). The importance of disengagement for service delivery was emphasized when it was identified as one of 24 evidence supported performance measures as essential for evaluating the quality of first episode psychosis services (Addington et al., 2005a). Disengagement is a useful performance measure which can be readily measured and is typically recorded in routine administrative data bases. A comparison of two Canadian First Episode Psychosis treatment services using a set of performance measures found one year discontinuation rates of 28% and 26% (Addington et al., 2009). In a recent comprehensive review it was reported that individuals with schizophrenia who disengage from treatment tend to be younger, are male, belong to an ethnic minority, have low social functioning, have an early onset of psychosis, are socially isolated and typically have a co-occurring substance use disorder and/or additional psychiatric illness (Kreyenbuhl et al., 2009). Research on individuals experiencing a FEP has revealed somewhat similar trends as those displayed in schizophrenia research, however, there is very little research published to date on this topic. To the best of our knowledge four different groups have investigated disengagement with FEP individuals. In a comprehensive chart review from the EPPIC program in Melbourne in a sample of over six hundred patient files it was reported that low severity of illness, forensic history before treatment, having a persistent substance use disorder and living without family were the strongest predictors of disengagement (Conus et al., 2010). Interestingly, consistent results were reported in a subsample of adolescents aged 15–18 which showed that lower severity of illness at baseline, living without family, and having persistent substance abuse during treatment were the strongest predictors of disengagement (Schimmelmann et al., 2006). Secondly in a FE sample (N = 236) from New Zealand it was reported that unemployment, substance abuse, good health, good social functioning, and higher mean GAF scores were the strongest baseline predictors of service disengagement. They also found that longer duration of untreated psychosis and lower symptom scores were significant univariate factors associated with disengagement ( Turner et al., 2007 and Turner et al., 2009). One study investigated specifically the impact of cannabis use on treatment drop out, and found that independent of age, race, SES and gender, cannabis use significantly impacted disengagement from treatment ( Miller et al., 2009). Lastly, a Canadian study which looked at medication adherence and service engagement in patients enrolled in a program, found that a history of physical abuse, agreeableness, and poor alliance with the therapist were significant characteristics of poor service engagers ( Lecomte et al., 2008). Thus, research to date has suggested a range of different predictors of disengagement from treatment among individuals experiencing a FEP. Not all studies examined the same potential predictors but there were still inconsistencies, for example low severity of illness did not consistently contribute to disengagement. On the other hand substance use in varying degrees consistently played a role in disengagement. Limitations with existing studies are that data was obtained via chart review, samples were small and the programs may have only lasted for 18 months or less and enrolled different diagnostic groups. With the increased attention to early intervention, understanding predictors of disengagement may have important implications for the development of specialty programs for this young population. The purpose of this study is to determine the rate of disengagement from a three year comprehensive treatment program for individuals with a FE of psychosis and identify predictors of disengagement. Potential predictors to be considered will include a range of demographic factors, positive and negative symptoms, general psychopathology, diagnosis, substance use, social functioning, cognition and having a family member involved in treatment. The study will address some of the limitations of current research by using a large FE sample that was attending a three year specialized treatment program and will rely on data from prospective assessments. For the purposes of this study ‘disengagement’ will be defined as dropping out of treatment before 30 months in treatment.