Treatment Continuation and Discontinuation in Young Adults Following Psychiatric Hospitalization

Background: Approximately 1.6 million young adults experience a serious mental illness (SMI: bipolar, major depression, or a psychotic disorder) each year. Yet, they are less likely to use mental services than older adults and are at increased risk for discontinuation when they do seek help. Young adults remain the most frequent users of emergency departments, which are costly, crisis-oriented and provide an opportunity to engage young adults into outpatient care. Unfortunately, many fail to follow-up after discharge. This study examined adherence to treatment after discharge using a mixed methods approach to examine intentions and perceptions about illness and treatment while in the hospital, then follow-up two months later to identify factors that influenced adherence.

Methods: Young adults (ages 18-25) voluntarily admitted to a public psychiatric hospital were screened by their psychiatrists and referred to the study. Youth with an SMI diagnosis, currently stabilized in hospital with discharge plans for outpatient treatment were eligible. Following consent, participants were interviewed using a mixed-methods interview while inpatient, then again 60 days later in the community. Of 26 youth enrolled and interviewed, 14 were located for the follow-up interview and used in the current analysis. Analysts reviewed structured quantitative interview data and qualitative interview transcripts at each time point. Data were abstracted using a case extraction form, then transferred into a matrix for analysis. Two analysts met to compare/contrast cases to identify common themes and key barriers and facilitators to continuation.

Results: While all participants stated the intention to seek treatment after discharge only 7 were currently involved in mental health services Treatment and medication continuation or discontinuation was the result of a combination of intersecting factors. For those that discontinued, circumstances such as relocation, homelessness, low resources, and life chaos contributed to losing medications or inability to refill prescriptions. Perceptions of illness and the effectiveness of treatment also contributed, with those that had discontinued reporting less belief in possessing an illness (“I don’t really think I’m mentally ill, I think I’m just a little bit unwell.”) compared to those who continued talking more about having an illness that needs to be managed (“I have to deal with an illness … you have to rely on meds.”) Social supports was key in facilitating both continuation and discontinuation. Decisions to stop treatment also occurred in the context of alternatives, most prominently marijuana and alcohol, which were perceived as cheaper, more tolerable, less stigmatizing, and more effective than psychiatric medications.

Implications: Results reach beyond simple confirmation of low adherence with treatments following psychiatric hospitalization for this high-risk population, to highlight potential avenues for improving follow-up. For example, families played a key role in treatment continuation, and youth discharged to unstable housing faced particular challenges with treatment continuation. Discharge planning should target key supports and planfully address housing situations to promote continuity of treatment. Youth perceptions of illness and treatment including their understanding of symptoms and the role of treatments in addressing them, require greater intergration into care planning at discharge and in follow-up appointments.