Predictors of admission to an assertive outreach service for psychosis in Lebanon

Schizophrenia is a chronic and debilitating mental illness characterized by positive symptoms, negative symptoms, cognitive distortions, and disorganized behaviors [1]. The worldwide prevalence of schizophrenia is estimated at around 1%. With a typical age of onset in late adolescence and early adulthood, it leads to significant disability and reduction in quality of life over the years [2]. According to the Global Burden of Disease study, cases increased from 14.2 million in 1990 to 23.6 million in 2019. This contributes to 12.2% disability-adjusted life-years globally [3]. Untreated or under-treated schizophrenia often translates into a cascade of negative outcomes including reduced economic productivity, family instability, disrupted education, high medical morbidity, early mortality and homelessness [4]. In 2012, the worldwide economic burden of schizophrenia reached an estimated 56 billion dollars. This includes indirect costs, direct healthcare costs, direct non-medical costs, and social costs [5].

The effective treatment of schizophrenia faces multiple challenges, some of which are inherent to the disease. Additional complications include psychiatric comorbidities, such as substance use and mood disorders, known to worsen prognosis [6] and increase the risk of suicide [7]. Another concern is the ubiquity of medical comorbidity, particularly of a cardio-metabolic nature, which is responsible for morbidity and mortality. This necessitates that patients with schizophrenia receive regular medical monitoring and treatment [7]. Despite advances in psychopharmacology, a major challenge remains, namely medication non-adherence, primarily blamed for poor disease outcomes [8]. The rate of medication non-adherence ranges between 37% and 74% resulting in increased hospitalization rates, repeated relapses, and subsequent greater resource usage [9]. Therefore, close follow-up of patients with schizophrenia is deemed a priority to address poor prognosis [10].

Over the years, a number of interventions have been promoted with the aim to improve prognosis in schizophrenia. These include pharmacologic interventions such as the early use of LAI antipsychotics and psychosocial ones such as the implementation of shared-decision making programs in a recovery-oriented mental healthcare system [11]. Assertive outreach treatment (AOT) is a service level intervention that targets patients with severe mental illness (SMI) who do not engage effectively with traditional services [12]. This distinct model of care originated in the United States of America (USA) as early as 1967 under the Assertive Community Treatment (ACT) name to address identified gaps in the continuity of care of SMI patients following discharge from hospital [13]. It was subsequently adapted by other health systems while retaining the core elements and spirit. The American and Australian application focused on reduction in hospitalization and greater social inclusion for patients [14]. Australian studies showed conclusively that patients receiving assertive care had fewer hospitalizations, shorter hospital stays, and a better quality of life [15]. In the United Kingdom (UK), an additional measured outcome was risk reduction towards self and the public [14]. A variation on assertive community care dedicated to early psychosis resulted in more sustained contact with services and resulted in lower rates of symptomatic relapse and readmission rates [16].

In Lebanon, a low middle income country, the prevalence of schizophrenia is estimated at 50,000 individuals for a population of five million [17]. Mental health services are historically under-resourced, with an estimated 1.26 psychiatrists per 100,000 population [18], well below international recommendations [19]. Specialist inpatient, acute and residential, services consist respectively of 28.52 beds and 1.5 beds per 100,000 population with a 97% occupancy rate [18]. It is in this context that the first specialist community service for patients diagnosed with a psychotic disorder was established. The Psychosis Recovery Outreach Program (PROP), staffed by a multidisciplinary team that applies principles of early intervention and assertive outreach, was initiated in February 2016 at the American University of Beirut Medical Center (AUBMC) [17].

In our study, significant differences were noted in a number of demographic and clinical variables between patients under the assertive outreach model (PROP) versus those receiving standard outpatient care. PROP patients tended to be younger males with a diagnosis of schizophrenia and have a comorbid cannabis use disorder. They also were more likely to be prescribed a LAI antipsychotic and/or be prescribed more than one oral antipsychotic. Their use of services was higher, including attendance to the emergency department and admission to the psychiatry inpatient unit. These results seem to suggest that patients with the worst prognostic factors are being referred and included in the program. This is in line with its intended mission. As the literature supports, this group has the most to benefit from assertive community treatment programs [20, 21]. The young age at enrollment could be attributed to several factors. First, older adults with psychotic illnesses tend to have less severe active symptomatology. Indeed, some studies showed reduction in the number and intensity of positive symptoms in patients with schizophrenia over time due to the natural course of the illness [22]. Aging was associated with better psychosocial functioning, decreased positive psychotic symptoms, less substance use, lower psychiatric hospitalization rates, and improved overall mental health [23]. Some studies even looked at the need to decrease antipsychotic dosages or eventually discontinue medications in older adults with schizophrenia, due to their multiple side effects and possibly limited effectiveness in this population [22]. The apathy and amotivation associated with negative symptoms could explain why this group of patients were less likely to be enrolled in PROP despite referral. A systematic review published in 2019 on the longitudinal course of schizophrenia across the lifespan showed that negative symptoms tend to increase or remain relatively constant despite treatment [24]. Additionally, older adults with psychotic illnesses may shy away from seeking help due to stigma while clinicians and care providers may also be satisfied with maintaining some form of stability even at the expense of functionality. One study suggested that schizophrenia in older adults is associated with a double social stigma [25], with this population receiving less recognition, treatment, rehabilitation, and engagement in society [26].

Males were more likely to be enrolled in PROP than females, who are already under-represented in the overall sample. Research shows that schizophrenia and non-affective psychoses are more common in males who have a worse prognosis, poorer psychosocial functioning, and reduced response to treatment compared to females [27]. One can hypothesize that males with psychosis are more likely to require assertive outreach due to illness severity. Another angle is that both the manifestation of the disease in males and the social perception of it is also linked to gender roles expectations, such as economic productivity or the concern over more disruptive and even violent behavior. In more conservative societies, males tend to be the primary breadwinners and have a wider social network to preserve.

In terms of diagnoses, patients with a diagnosis of “other psychotic disorder” were less likely to be enrolled in PROP. Multiple studies have attempted to compare several outcomes between patients with schizophrenia and other psychotic disorders, whether affective or non-affective in nature. One study found that patients with schizophrenia had more severe impairments, specifically in instrumental work functioning, and showed more persistent psychopathology and problems in functioning than patients with other psychotic disorders [28]. Reaching a diagnosis of schizophrenia, especially within the first year of presentation, usually implies clinical certainty on the part of the treating psychiatrist that could be explained by active first-rank symptoms and a more severe illness course. The comorbidity of a cannabis use disorder was strongly associated with enrollment in PROP. Other substance use disorders were too rare in our sample to allow comparison. In a meta-analysis that looked at cannabis use in psychotic disorders, continued use after onset of psychosis predicted higher relapse rates, longer hospital admissions, and more severe positive symptoms [29]. The relative age of the population in treatment where cannabis use is prevalent may also account for this number.

Patients enrolled in PROP were more likely to be prescribed LAI antipsychotics than those in standard care. Non-adherence to antipsychotics is notoriously high in psychotic disorders and responsible for early relapse and poor prognosis [30–32]. One crucial contributing factor is the absence of insight inherent to the psychotic process [33]. LAI antipsychotics are gaining ground, in particular in early psychosis, due to advantages over oral formulations. These include more stable blood concentrations, consistent bioavailability, an improved pharmacokinetic profile, and predictable medication adherence [10]. A more assertive approach to treatment may indicate a general propensity to use LAI antipsychotics due to the evidence surrounding them. In parallel, patients enrolled in PROP possibly have a severe illness course and limited insight into their condition, limiting the efficacy of any oral medication. This second hypothesis is supported by the finding that they were also more likely to be prescribed more than one oral antipsychotic. Polypharmacy generally indicates either a more resistant illness or poor medication compliance often leading to the use of LAI [34]. In fact, despite all the measures put in place, patients enrolled in PROP were still more likely to use unscheduled mental health services, including visits to the emergency department and admission to the psychiatry unit. Several studies have shown that patients use unscheduled services due to illness exacerbations and the urgent need to follow up, [35]. For example, one study that looked at the use of unscheduled mental health services in a cohort of patients with psychotic disorders following up in outpatient clinics showed that despite regular follow ups with mental health providers, half of the patients had at least one unscheduled clinical contact over 12 months, including phone-based nursing services and visits to the emergency departments, and up to 1 in 10 patients was still admitted to the psychiatry unit [36].

Economic constraints in low- and middle-income countries (LMIC) challenge health care services to identify efficient and cost-effective methods of delivering mental health care. Few of these countries have implemented formal outreach community services for patients with severe mental disorders, which include psychotic disorders. Examples of such services are the community engagement mental health (CEMH) model in Jamaica [37], the “Care at Doorsteps” (CADS) initiative in India [38] and the Chinese Assertive Community Treatment (ACT) in China [39]. These outreach programs all share similarities with PROP; from adopting a task sharing model that shifts key elements of care delivery from the psychiatrist to trained nurse practitioners, psychiatry residents, psychologists, social workers, to shifting clinical interaction from the clinic to the community when possible [17, 37]. In addition, one common goal of these outreach programs is the emphasis on social functioning and inclusion as a primary outcome rather than symptom relief alone [37]. One similarity between Lebanon and China is the prominence of family support; in both countries, most patients live with their families and families are by default included in the community care model [39]. This stresses the importance of allocating resources for regular psychoeducation of families, which has been shown to help strengthen social support, improve adherence to antipsychotics and decrease admission rates [40, 41]. The assertive model of care demonstrated to be effective is expected to include a full range of accommodation arrangements, medication optimization, regular psychiatric evaluations, adequate in-patient support, rehabilitation activities, psychosocial support, and rapid crisis response [42]. The absence of a number of these elements is often a major limiting factor for effectiveness despite the therapeutic effort put forward by clinicians. Specialist outreach services in LMIC often struggle to incorporate them in care packages in the absence of effective integration of advanced health and social services. Until such integration is possible, an adapted model of assertive treatment is needed for fragile healthcare settings.