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RAISE and Other Early Intervention Services
Published Online: 31 March 2015

Engaging Immigrants in Early Psychosis Treatment: A Clinical Challenge

Abstract

Objective:

The study compared engagement in treatment and medication adherence of immigrants and nonimmigrants in early intervention services for persons with first-episode psychosis.

Methods:

This two-year longitudinal prospective cohort study recruited patients with first-episode psychosis who were entering early intervention services in Montreal, Canada (N=223). Data on sociodemographic characteristics, symptoms, and social functioning were collected annually.

Results:

At two years, immigrants had more than three times the odds of attrition than nonimmigrants after the analysis controlled for potential confounding factors (first-generation immigrants: odds ratio [OR]=3.11, 95% confidence interval [CI]=1.01–9.57, p=.049); second-generation immigrants: OR=3.65, CI=1.07–12.50, p=.039). Medication adherence was similar among those who remained in the programs.

Conclusions:

During the two years after entering a program for first-episode psychosis, immigrants were more likely than nonimmigrants to disengage from treatment. Further research is warranted to understand this phenomenon and to improve the ability of services to engage immigrants with first-episode psychosis.
Despite immigrants’ increased vulnerability to developing psychosis (1), they are less likely to use mental health services than residents of the host country (2,3). Although early intervention services for psychosis have been shown to improve young people’s engagement in treatment, most studies have not documented the immigration status of participants (4,5). The aim of this study was to assess whether early intervention services for psychosis are successful in engaging immigrants in treatment by comparing their service disengagement rates and medication adherence rates to those of nonimmigrants during the two years after they entered an early intervention program.

Methods

A two-year longitudinal prospective cohort study of individuals with first-episode psychosis was conducted from 2005 to 2012 in two five-year early intervention programs in urban catchment areas of Montreal, Canada. Both programs offer specialized treatment based on early psychosis intervention guidelines to all persons with first-episode psychosis in their defined catchment areas (6). [A description of the program is included in an online supplement to this report.] To be included, patients had to be between the ages of 18 and 30, to have a primary diagnosis of a psychotic disorder, and to have had no treatment or less than one year of treatment. Patients with a developmental disability and inadequate proficiency in French or in English were excluded. The study received institutional ethics and scientific committee approval, and written informed consent was obtained from each participant.
Data on sociodemographic characteristics, diagnosis, symptoms, and social functioning were collected annually by participant interviews and file reviews. Medication adherence was assessed by asking the participant and his or her case manager and psychiatrist and by reviewing medical files. To allow calculation of the attrition rate, two-year follow-up status was categorized as followed up, lost to follow-up, and transferred to other services or deceased. Immigration status was divided into nonimmigrants (including mixed second-generation immigrants (one immigrant parent and one nonimmigrant parent), first-generation immigrants, and second-generation immigrants. [Additional information on group categorization is presented in the online supplement.]
Analyses were performed with SPSS software, version 20. Baseline characteristics, attrition rate, and medication adherence for first-generation and second-generation immigrants were compared with those of nonimmigrants. Analysis of variance was used for group comparisons for continuous variables, and Pearson’s chi square tests were used for discrete variables. Logistic regression analysis was conducted for the attrition rate differences between nonimmigrants and immigrants (first generation and second generation) while taking into account potential confounding factors (baseline group differences).

Results

A total of 223 participants were enrolled in the study. First-generation immigrants (N=54), second-generation immigrants (N=37), and nonimmigrants (N=129) entering the early intervention programs had similar baseline sociodemographic, clinical, and functioning profiles. However, compared with nonimmigrants, second-generation immigrants were more likely to be living with their families and first-generation immigrants were less likely be male and to have a substance use disorder. Also, nonimmigrants were more likely to have a higher Global Assessment of Functioning (GAF) score (better functioning) and a lifetime history of homelessness [see figure and tables in the online supplement].
The attrition rates at one and two years were significantly higher in immigrant groups (Table 1). The difference remained when we excluded the nine mixed second-generation individuals from the nonimmigrant group (attrition rate at 12 months: nonimmigrants, 6%; immigrants, 18%; p=.009; at 24 months: nonimmigrants, 8%; immigrants, 22%; p=.005). To control for potential confounding, we tested three different outcome hypotheses for the participants transferred to other services (N=6): all were considered followed up, all were considered lost to follow-up, and all were excluded. Differences in attrition rates between immigrants and nonimmigrants remained significant in all three analytical scenarios, indicating that our results were robust despite the participants transferred to other services.
TABLE 1. Adherence, community treatment orders, and injectable medications among immigrants and nonimmigrants in first-episode psychosis programs
   Immigrants 
 Nonimmigrants (N=124)First generation (N=54)Second generation (N=37) 
Follow up and variableN%N%N%p
1 yeara       
 Attrition rate76815822.009e
 Medication adherence (>90%)b917934762690.318
 Community treatment orderc111071627.472e
 Injectable medication232061313.112e
2 yearsd       
 Attrition rate981325719.007
 Medication adherence (>90%)b908631822897.185
 Community treatment orderc1312924414.239e
 Injectable medication21201026414.731e
a
Participants excluded from analysis because of transfer to other services: nonimmigrants, N=3 (2%); immigrants, N=3 (3%). Deceased participants excluded from analysis: nonimmigrants, N=2 (2%)
b
Medication was taken as prescribed >90% of the time.
c
A court order by a judge that obliges the individual to take the prescribed medication because the patient is considered unable to consent to care
d
At two years the N of participants in each group was as follows: nonimmigrants, N=119; first generation, N=53; second generation, n=37. Participants excluded from analysis because of transfer to other services: nonimmigrants, N=8 (7%); immigrants, N=4 (4%). Deceased participants excluded from analysis: nonimmigrants, N=2 (2%)
e
Fisher’s exact test was used because of the small group.
The logistic regression model (including immigration status and variables with differences at admission: gender, GAF score, substance use disorder, history of homelessness, and living arrangement) showed that immigrants had more than three times the odds of attrition than nonimmigrants. The difference was statistically significant for first-generation immigrants (odds ratio [OR]=3.11, 95% confidence interval [CI]=1.01–9.57, p=.049) and for second-generation immigrants (OR=3.65, CI=1.07–12.50, p=.039). Language status could not explain the variance because attrition rates were similar among participants whose native language was French or English and those whose native language was not French or English (22% and 25%, respectively).
Although medication adherence remained relatively high, it was similar for the three groups throughout the two-year follow-up, as were rates of injectable long-acting antipsychotic prescriptions and treatment orders (Table 1).

Discussion

No association was found between immigration status and medication adherence among participants who remained in the early intervention programs. These findings are similar to those reported by Levy and colleagues (7). The overall high rate of medication adherence suggests that these services are effective in promoting medication adherence among participants regardless of their immigrant status.
The social context of immigration and its associated precariousness may influence an individual’s ability and willingness to request mental health services and to pursue treatment. Various hypotheses may explain the higher attrition rate among immigrants: different health belief models (8), experiences of discrimination and stigma (9), and increased mobility of immigrants and sequential migration (10) (especially among first-generation immigrants). After experiencing a first episode of psychosis in the host country, some immigrants may associate their new country with their problems and experience ambivalent feelings toward the host country. Support from people who share the same values and ethnic backgrounds is known to effectively buffer social stressors (11). Moving elsewhere or back to the homeland may be a help-seeking pathway, especially if recovery is not achieved within the first year, which can also lead to an inability to keep up with student and work visa requirements.
Some studies point to the relationship between perceived discrimination and incidence of psychosis (12). Immigrants with a first episode of psychosis may face a double stigma stemming from both immigration and psychosis. Family members may share some of the stigmatization because of their affiliation and kinship with the person with mental illness.
Even though early intervention services provide mental health care in a collaborative, nonjudgmental, and welcoming atmosphere, the ethnocultural knowledge of the care teams may be limited because ethnic and cultural differences are not taught in most clinical training. Therefore, the presence of other explanatory systems for the illness may not always be elicited by the care teams.
The therapeutic alliance, a cornerstone of medication adherence (13), may be harder to build when the therapist and the patient have different health belief models (14). Because immigrants in the first year of the early intervention programs quit treatment at a higher rate and earlier than nonimmigrants, the health care team may not have had the opportunity to build a strong therapeutic alliance to facilitate treatment retention.
Several limitations of this study must be considered. The exclusion of patients without a minimal mastery of the French or English language (less than 2% of the potential cohort) excluded a certain group of less integrated immigrants. Also, 20% of patients refused to participate in the study, which limits the conclusions and their generalizability; however, that proportion is similar to those in other studies of persons with first-episode psychosis (14). Immigrants are a very heterogeneous group (for example, number of years since immigration at the time of the study, age at immigration, reasons for immigration, and immigration processes); however, we had no data to capture this heterogeneity, and those factors probably had an important impact on outcome. Furthermore, medication adherence was assessed by self-report or clinician estimates, which are known to overestimate adherence (15).

Conclusions

Treatment attrition is a complex phenomenon. Documenting patients’ and families’ beliefs about health, systems of meaning, and discrimination could contribute to a better understanding of the reasons that patients leave services without notice and could be helpful in the development of programs to provide better care for this population.

Supplementary Material

File (appi.ps.201300284.ds001.pdf)

References

1.
Bourque F, van der Ven E, Malla A: A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants. Psychological Medicine 41:897–910, 2011
2.
Kirmayer LJ, Weinfeld M, Burgos G, et al: Use of health care services for psychological distress by immigrants in an urban multicultural milieu. Canadian Journal of Psychiatry 52:295–304, 2007
3.
Lindert J, Schouler-Ocak M, Heinz A, et al: Mental health, health care utilisation of migrants in Europe. European Psychiatry 23(suppl 1):14–20, 2008
4.
Norman RM, Manchanda R, Malla AK, et al: Symptom and functional outcomes for a 5 year early intervention program for psychoses. Schizophrenia Research 129:111–115, 2011
5.
Petersen L, Jeppesen P, Thorup A, et al: A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ331:602, 2005
6.
Australian Clinical Guidelines for Early Psychosis: A Brief Summary for Practitioners, 2nd ed. Melbourne, Orygen Youth Health, Early Psychosis Guidelines Writing Group, 2010
7.
Levy E, Pawliuk N, Joober R, et al: Medication-adherent first-episode psychosis patients also relapse: why? Canadian Journal of Psychiatry 57:78–84, 2012
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Whitley R, Kirmayer LJ, Groleau D: Understanding immigrants’ reluctance to use mental health services: a qualitative study from Montreal. Canadian Journal of Psychiatry 51:205–209, 2006
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Corrigan P: How stigma interferes with mental health care. American Psychologist 59:614–625, 2004
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Kirmayer LJ, Narasiah L, Munoz M, et al: Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Medical Association Journal 183:E959–E967, 2011
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Kirkbride JB, Jones PB: The prevention of schizophrenia—what can we learn from eco-epidemiology? Schizophrenia Bulletin 37:262–271, 2011
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Veling W, Susser E, van Os J, et al: Ethnic density of neighborhoods and incidence of psychotic disorders among immigrants. American Journal of Psychiatry 165:66–73, 2008
13.
Abdel-Baki A, Ouellet-Plamondon C, Malla A: Pharmacotherapy challenges in patients with first-episode psychosis. Journal of Affective Disorders 138(suppl):S3–S14, 2012
14.
Archie S, Akhtar-Danesh N, Norman R, et al: Ethnic diversity and pathways to care for a first episode of psychosis in Ontario. Schizophrenia Bulletin 36:688–701, 2010
15.
Velligan DI, Weiden PJ, Sajatovic M, et al: The Expert Consensus Guideline Series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry 70(suppl 4):1–46, 2009

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services

Cover: Gravesend Bay, by William Merritt Chase, 1888. Private Collection. Photo credit: Art Resource, New York City.

Psychiatric Services
Pages: 757 - 759
PubMed: 25828871

History

Received: 28 June 2013
Revision received: 9 October 2014
Accepted: 24 November 2014
Published online: 31 March 2015
Published in print: July 01, 2015

Authors

Details

Clairélaine Ouellet-Plamondon, M.D., F.R.C.P.C.
Except for Dr. Rousseau, the authors are with the Department of Psychiatry, Université de Montréal, Quebec, Canada. Dr. Rousseau is with the Department of Psychiatry, McGill University, Quebec. Send correspondence to Dr. Abdel-Baki (e-mail: [email protected]). This report is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section.
Cecile Rousseau, M.D., M.Sc.
Except for Dr. Rousseau, the authors are with the Department of Psychiatry, Université de Montréal, Quebec, Canada. Dr. Rousseau is with the Department of Psychiatry, McGill University, Quebec. Send correspondence to Dr. Abdel-Baki (e-mail: [email protected]). This report is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section.
Luc Nicole, M.D., F.R.C.P.C.
Except for Dr. Rousseau, the authors are with the Department of Psychiatry, Université de Montréal, Quebec, Canada. Dr. Rousseau is with the Department of Psychiatry, McGill University, Quebec. Send correspondence to Dr. Abdel-Baki (e-mail: [email protected]). This report is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section.
Amal Abdel-Baki, M.D., F.R.C.P.C.
Except for Dr. Rousseau, the authors are with the Department of Psychiatry, Université de Montréal, Quebec, Canada. Dr. Rousseau is with the Department of Psychiatry, McGill University, Quebec. Send correspondence to Dr. Abdel-Baki (e-mail: [email protected]). This report is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section.

Funding Information

The authors report no financial relationships with commercial interests.

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