Service disengagement in schizophrenia spectrum disorders

Abstract

Disengagement from mental health services by patients with schizophrenia spectrum disorders is an important issue. Most research in this area has been focused on studying the patients’ demographic and clinical characteristics that may be related to disengagement. However, research on patients’ perspective in regard to their decision of disengagement has been limited. An assessment tool developed based on an in--‐‑depth understanding of patients’ subjective experiences may capture other crucial factors. This may widen our scope of understanding of this phenomenon. Therefore, a mixed research method was employed in this thesis and three independent studies with distinctive research aims were carried out. The first study was a qualitative study which aimed at exploring reasons and factors that patients perceived influential to their decision of disengagement. Six ever--disengaged male patients aged between 18 and 28 with schizophrenia spectrum disorder were interviewed as a purposive sample after a thorough subject identification procedure. A thematic analysis of the data yielded seven themes which grouped into three domains: service (patient--‐‑clinician communication, service orientation, clinic operation); patient (psychological response, perception of illness); and medication (side effects and uncertain efficacy). A 16--‐‑item self--‐‑administered questionnaire, the Patient’s Perception of Psychiatric Service (PPPS) questionnaire, was developed. The construction of PPPS was based entirely on the themes identified from the first qualitative study. This questionnaire measured the subjective perception of the patient about the service and patient--clinician communication. Validation of the PPPS questionnaire was conducted in the second study by recruiting 50 patients with a diagnosis of a schizophrenia spectrum disorder from a psychiatric outpatient clinic. Results demonstrated that the PPPS questionnaire has good internal consistency, test-retest reliability, and convergent validity. The Singh O'ʹBrien Level of Engagement Scale (SOLES), Client Satisfaction Questionnaire (CSQ), and an internalized stigma scale were also translated and validated in this study for use in the third study.

The third study explored the relationship between disengagement and the patient’s perception of service, using PPPS, level of engagement (SOLE), satisfaction with service (CSQ), and other factors including clinical characteristics and service utilization. One hundred and fifty patients with schizophrenia spectrum disorder were recruited from two specialized outpatient clinics. In view of local clinical observation, patients who had more than one disengagement episode and each lasted more than two weeks were classified into the severe--‐‑disengagement group. In a forward stepwise regression model, results suggested that PPPS and length of service predict severe disengagement. In this thesis, the use of mixed study methods showed that it was pertinent to incorporate patients’ first person experience into an assessment tool. Measuring patients’ perception of service, by using PPPS, can effectively identify patients with severe disengagement history. PPPS as a patient--‐‑rated self--‐‑administered questionnaire can be used in clinical settings to enhance the understanding of a patient’s appraisal of the service and thus proactive measures can be taken to reduce service disengagement.