Mental Health Service Use Decision-Making Among Young Adults at Clinical High-Risk for Developing Psychosis

Background and Purpose: Research has shown that young adults at clinical high-risk (CHR) for developing psychosis have the capacity to both recognize they have a problem and seek mental health services, yet considerable underutilization of mental health services exists among this population. There is a paucity of theory-based research that examines the decision-making process among these young people. This is concerning, as the longer the duration of untreated psychosis (DUP) the worse the outcomes. The purpose of this qualitative study was to explore how youth at CHR make decisions about staying engaged in services through the application of the Unified Theory of Behavior (UTB) (Jaccard et al., 2002), a decision-making framework.

 Methods:  Purposive sampling was utilized to recruit 30 CHR participants, ages 18 to 30 from a specialty research and treatment clinic for young people at CHR. Face-to-face interviews were conducted with semi-structured questions eliciting responses regarding constructs from the UTB (i.e., behavioral beliefs, social norms, self-concept/social image, emotions, self-efficacy, knowledge, environment, salience of behavior, and habits) in order to understand engagement with services. Example questions included, “What do you see as the advantages/ disadvantages of seeking help from the clinic?", and “How would you describe the type of person your age that may use/not use mental health services at the clinic?” Three analysts engaged in content analysis, utilizing constant comparison, and the development of a taxonomy of the most salient responses.

 Results: Sample demographics included mean age 23 (SD=3.41), 60% male, 34% White, 23% Black, 20% Hispanic, 20% Bi-Racial, 3% Asian. Behavioral beliefs, image considerations, and emotions were the most salient UTB constructs reported in the data. Most participants reported advantages of remaining engaged with services such as “helps you get out of the funk”, and “being around people with experience.” They described the type of person their age that may use the clinic as “actively interested in getting help”, and as being at “potential deep risk of psychotic breakdown.” By comparison, the type of person their age who would choose not to access the clinic “in denial”, and “internalized fear of medication and being mentally ill.” Participants described emotional reactions when thinking about attending the clinic that included positive “hopeful”, negative “anxious”, and mixed emotions “shame initially but turns to feeling glad that I am doing it.” Differences in UTB responses emerged depending on whether a participant was engaged in clinical services and research at the time of the interview or just research.

 Conclusions and Implications: Attention has been paid to youth experiencing a first-episode of psychosis. Comparatively, those at CHR have not been a focus. This study provides an important examination of what is salient to keeping those at CHR connected to care. Future research can use these data to enhance treatment engagement strategies in order to raise the low rates of service utilization among young adults at CHR and ultimately reduce the DUP.