Predicting Initial Aftercare Appointment Adherence and Rehospitalization for Individuals with Serious Mental Illness Discharged from an Acute Inpatient Stay A Thesis Submitted to the Faculty of Drexel University by Petra Kottsieper in partial fulfillment of the requirements for the degree of Doctor of Philosophy May 2006 ii Acknowledgments Completing this project is the final chapter of a dream and goal that I could not have reached without the help, support, and encouragement from many people. I would like to first thank Dr. Kirk Heilbrun, for his knowledge, mentorship, and feedback during not only the dissertation process, but my entire graduate career. I also would like to thank my committee members, Drs. James Herbert, Michael Lowe, Mark Salzer, and Jeffrey Draine for their thoughtful contributions to this project. I want to especially thank Drs. Draine and Salzer, for their continued mentorship and support throughout my graduate training. I am very grateful for the time and effort of the following graduate and undergraduate students without whom I could not have completed this project: Samantha Corrato, Jacey Erickson, Greg Kramer, and especially Rachel Kalbeitzer, who held it all together. I am grateful to the PMCU; its director Carol Boylan, and the staff who all welcomed the research project onto the unit. I’m also grateful to Michael Lewis at CBH for helping to make the CBH data available to me. Thank you all so much for your interest and commitment to this project. I would also like to thank Dr. Robert Archer at EVMS for his interest and support during the final stages of this project. Finally, I wanted to say thank you to my family, and my friends. To Brendan and the Keenan’s, your encouragement and support was vital in my pursuit of my dream in the first place. Thank you to all of you who helped me get through my first year of graduate school during a very difficult time in my life. To my dearest friends, thank you for your friendships and being understanding when I had no time, needed encouragement, and for all the motivation I received. To my mom, Christel, dad, step-dad, and my sister, iii Silke, thank you for your love and encouragement from across the ocean. To Tony (aka measles), thank you for your love, support, laughter, taking care of the doggles, and just about everything else. Lastly, thanks to Hazel and Daisy, who often told me that they thought of maybe going back to college too, before once again drifting off to sleep nuzzled against me. iv Table of Contents LIST OF TABLES .............................................................................................. viii LIST OF FIGURES .............................................................................................. ix ABSTRACT.............................................................................................................x 1. INTRODUCTION ............................................................................................1 1.1 The Importance of Treatment Adherence ................................................2 1.2 The Relationship between Medication Adherence and Appointment Adherence .................................................................................................4 1.3 The Scope of Adherence/Non-Adherence.................................................5 1.3.1 Psychiatric Medication Adherence .....................................5 1.3.2 Non-adherence Rates: Initial Psychiatric Appointment ......7 1.3.3 Non-adherence Rates: Ongoing Psychiatric Clinical Appointments ......................................................................8 1.3.4 Non-adherence Rates: Aftercare following Hospital Discharge ...........................................................................9 1.4 Models of Medical/Health Decision Making .........................................12 1.4.1 Overview............................................................................12 1.4.2 Rational for HBM and TTM..............................................14 1.4.3 Health Belief Model...........................................................15 1.4.4 Transtheoretical Model of Change.....................................17 1.5 Factors Affecting Adherence and Non-Adherence in Individuals With Mental Illness or Co-occurring Disorders .....................................19 1.6 Empirical Evidence on Clinical Appointment Adherence and Medication Adherence ...........................................................................21 v 1.6.1 Patient Characteristics .......................................................21 1.6.1.1. Individual Static Characteristics ...............................21 1.6.1.2. Individual Dynamic Characteristics and the Health Belief Model..................................................23 1.6.1.3. Individual Dynamic Characteristics, Motivation, and TMM ..................................................................27 1.6.2 Social Factors ....................................................................30 1.6.3 Illness/Clinical Determinants.............................................32 1.6.3.1. Diagnosis, Symptom Severity, and other features of the Illness..............................................................32 1.6.3.2. Characteristics of the Treatment Regimen................33 1.6.4 Institutional and Cultural Determinants.............................35 1.6.5 Provider Determinants .......................................................37 1.6.5.1. Clinical Setting..........................................................37 1.6.5.2. The Relationship between Health Care Provider and Patient.................................................................39 1.7 The Measurement of Treatment Adherence ...........................................39 1.8 Aims of the Current Study ......................................................................41 2. METHODS .....................................................................................................43 2.1 Participants .............................................................................................43 2.2 Procedure ................................................................................................45 2.3 Measures .................................................................................................48 2.4 Outcome Measures..................................................................................54 2.5 Analytic Strategies and Statistical Methods ...........................................56 2.5.1 Power Analysis ....................................................................5 vi 2.5.2 Statistical Methods.............................................................57 3. RESULTS ........................................................................................................60 3.1 General Background Information ...........................................................60 3.2 Background Characteristics Rehospitalization .......................................60 3.2.1 Insurance ...........................................................................61 3.2.2 Number of Previous Psychiatric Hospitalizations ............61 3.2.3 Mental Health Diagnosis at Discharge ..............................61 3.3 Background Characteristics Aftercare Adherence .................................62 3.3.1 Case Management Services ..............................................63 3.3.2 Length of Index Hospitalization ........................................63 3.4 Health Beliefs, Rehospitalization, and Aftercare Adherence .................63 3.5 Motivational Beliefs, Rehospitalization, and Aftercare Adherence .......65 3.6 Mutivariate Analyses ..............................................................................65 3.6.1 Missing Data ......................................................................65 3.6.2 Predicting Aftercare Adherence.........................................66 3.6.3 Predicting Rehospitalization ..............................................73 4. DISCUSSION .................................................................................................79 4.1 Aftercare Adherence.................................................................................79 4.1.1 Risk Factors ......................................................................80 4.1.2 Motivational Variables ......................................................83 4.1.3 Health Belief Variables......................................................86 4.2 Clinical Implications.................................................................................91 4.3 Hospital Recidivism ...................................................................................9 vii 4.3.1 Risk Factors ......................................................................93 4.3.2 Motivational Variables.......................................................95 4.3.3 Health Belief Variables......................................................95 4.4 Clinical Implications ................................................................................98 4.5 Limitations................................................................................................99 4.6 Directions for Future Research...............................................................102 4.7 Conclusions.............................................................................................107 LIST OF REFERENCES ....................................................................................110 APPENDIX A: ILLUSTRATION OF THE HEALTH BELIEF