Given the potential for adverse consequences of treatment dropout, as described above, it is important for mental health treatment systems and providers to develop and implement strategies to increase treatment engagement and decrease dropout, particularly for those at greatest risk of disengaging from care. In this section, we will review interventions that have research support for reducing dropout from treatment among individuals with schizophrenia and other serious mental illnesses. Of note, the focus of this article is on interventions that have been shown to impact the proximal outcome of increased engagement in mental health treatment. Although a few of the more intensive interventions (discussed below) have also been shown to favorably affect important distal outcomes, including functioning, quality of life, and use of hospital and crisis services, these outcomes are not discussed in detail in this article.
Interventions to increase treatment engagement occur along a spectrum of intensity, from low-intensity interventions, such as appointment reminders, that can be applied universally, to high-intensity interventions, such as assertive community treatment (ACT), that are reserved for those at highest risk for adverse consequences of treatment dropout. Low-intensity interventions that can be applied widely are typically implemented at periods of high risk for treatment dropout, such as following an emergency room or hospital discharge or the time of entry into outpatient treatment.
With regard to low-intensity interventions used at periods of increased risk of dropout, Klinkenberg and Calsyn25
describe a number of “system responsiveness” variables that have been found to be associated with increased rates of aftercare following hospital or emergency room discharge. These include minimizing wait time to the first appointment, having inpatient staff clarify expectations about the role of aftercare, making appointments for clients with the aftercare agency, using “reaching out” techniques (eg, having the aftercare agency contact clients before the appointment, telephone prompts, reminder letters, and use of referral coordinators), and discussing or providing medications at the outpatient visit.25
Boyer et al10
evaluated linkage strategies aimed at increasing attendance at outpatient appointments following hospital discharge and found that the most common linkage strategy that was significantly associated with clients keeping their first appointment after discharge was a discussion about the discharge plan between the inpatient staff and outpatient clinicians. Other strategies that increased attendance at appointments following discharge included having the patient meet with outpatient staff and visit the outpatient program prior to discharge.10
Rossotto et al14
describe the development of a “community reintegration” curriculum aimed at helping hospitalized patients develop skills in symptom identification, medication management, relapse prevention, and the making and keeping of appointments. The curriculum is delivered in group format in the inpatient unit prior to discharge and in the outpatient setting following discharge. A small pilot study found the community integration curriculum to be a promising strategy for enhancing treatment adherence following hospital discharge.14
There are a number of individuals with serious mental illnesses for whom these low-intensity interventions are not adequate to establish a firm linkage to ongoing mental health care but for whom the risk of dropout is not so great as to merit more intensive approaches such as ACT. Such individuals may benefit from a medium-intensity approach to treatment engagement such as critical time intervention (CTI). CTI is a time-limited psychosocial model that aims to strengthen individuals’ ties to services providers and social networks and to provide emotional support and practical assistance during a time of transition. CTI was initially developed with the goal of decreasing return to homelessness among mentally ill homeless men being discharged from a shelter into the community26
but has since been adapted in other transitional settings, including upon discharge from acute psychiatric inpatient units. For example, Dixon et al3
adapted CTI for individuals with schizophrenia and other serious mental illnesses who were being discharged after psychiatric hospitalization within the VA health-care system and were at risk for treatment dropout. In this study, the population defined as at risk for treatment dropout included individuals with a co-occurring substance use disorder, a history of medication nonadherence, and/or an inpatient admission during the 2 years prior to the current admission, followed by a readmission, an emergency room visit, or no outpatient visits within 30 days after discharge. The CTI intervention was provided for 3 months by CTI clinicians, who chose among 9 focal areas that were either risk factors for treatment disengagement or potential mediators of engagement specific to each client. Areas of focus included systems coordination, engagement in psychiatric services, sustaining motivation in substance abuse treatment, medication adherence, social support network, life skills training, integration of medical care, establishing of community linkages, and practical needs assistance. CTI is provided in phases, with decreasing intensity over time. Initially CTI workers work very closely with clients, developing a trusting, collaborative relationship. As treatment linkages are established, the CTI worker steps back to observe the functioning of the client's support network and ultimately assists in the transition from CTI to community supports. In a randomized controlled trial, CTI recipients had fewer days to their first outpatient service following hospital discharge, were more likely to have an outpatient visit, had more total mental health and substance abuse visits following discharge, and had greater continuity of outpatient care than individuals receiving usual care.3
Service use was measured for 6 months following the index hospitalization. For participants in CTI, this includes 3 months of follow-up following the completion of the intervention. This study also examined quality-of-life outcomes and found that certain quality-of-life indicators (satisfaction with safety and greater frequency of social contacts) were improved among those who received CTI, although there were no differences in other quality-of-life variables, including satisfaction with living situation, daily activities and functioning, family relations, finances, work and school, and health.
Individuals at highest risk for treatment dropout and its adverse consequences may require more intensive and/or longer term intervention to facilitate treatment engagement. Case management programs can provide the consumer with assistance in coordinating care and navigating the challenges of participating in basic services. Case management extends the CTI model over a longer period of time that permits the case manager to provide concrete help for a greater range and severity of problems. The main goals of case management are to keep people in contact with services, to reduce the frequency and duration of inpatient admissions, and to improve outcomes with a particular focus on social functioning and quality of life. A Cochrane review of studies of case management interventions found that receipt of case management services increases the number of consumers remaining in contact with mental health treatment services.27
ACT is a highly intensive outpatient intervention in which community-based clinical treatment is provided by a multidisciplinary team to individuals who have had difficulty engaging in traditional treatment services. Though ACT has similar goals to case management, its practice is quite different. ACT teams serve as team-operated, community-based service providers, providing treatment services directly in clients’ homes. ACT teams assertively and consistently try to engage clients, not accepting initial client refusal as the endpoint of treatment. A Cochrane review of ACT demonstrated that individuals receiving ACT are more likely to remain in contact with services than people receiving standard care.28
ACT was shown to decrease hospital admissions and decrease homelessness among individuals receiving ACT services27
and is generally regarded as an evidence-based practice.1,2
As noted previously, a co-occurring substance use disorder significantly increases the risk of treatment dropout among people with schizophrenia and other serious mental illnesses. Given the high prevalence of co-occurring substance use and psychiatric disorders and the role that the comorbidity plays in increasing the risk of dropout, it is particularly important to target interventions to increase treatment engagement to this group. Providing integrated mental health and substance use treatment has been shown to increase retention in treatment29
and increase active engagement in treatment30
as compared with nonintegrated treatment. Other interventions, including home visits, flexible hours, short waiting lists, frequent contact with a single worker, and short gaps between hospital discharge and the first appointment have been found to increase engagement among individuals with substance use disorders.16
Another important group to target for interventions aimed at increasing treatment engagement and decreasing treatment dropout is individuals who have been newly diagnosed with a psychotic illness. As indicated above, younger age has been consistently found to be associated with treatment dropout. In addition, the initial period of treatment has been found to be the most likely time for dropout to occur. Therefore, this group of young, newly diagnosed consumers is at particular risk for treatment dropout, and efforts to enhance treatment engagement are particularly important. The data regarding early interventions for individuals with psychotic illnesses are limited, although there are some indications that early interventions may improve treatment adherence. For example, Petersen et al31
tested an integrated treatment model that included ACT, family involvement, and social skills training. This intervention found differences in treatment retention after 2 years but not after 5 years.31
Another early intervention program for psychosis, the Lambeth Early Onset (LEO) Team, found lower rates of treatment discontinuation in the group that received more intensive and specialized support.16
The LEO Team was a United Kingdom–based multidisciplinary team that provided assertive outreach and evidence-based interventions, including antipsychotic medication, cognitive behavioral therapy, family counseling, and vocational strategies to individuals presenting for the first time with a nonaffective psychotic disorder.32
Further research is needed to determine which individuals are not in need of ongoing treatment and which strategies are most successful in promoting treatment engagement among those with first-episode psychotic illnesses.