Delivery and delay of guideline pharmacological, psychological, and social interventions for adults with complex psychosis in Dutch inpatient rehabilitation units: A retrospective study

Background: People with complex psychosis admitted to inpatient mental health rehabilitation units (IMRU) constitute a low volume, high need, high cost group with a complicated recovery process. Aims: To generate hypotheses regarding successful delivery of guideline care to patients with complex psychosis in IMRUs, based on clinical profiles and (historical) patterns of care delivery. Method: A retrospective passive consent chart study of patients with complex psychosis in IMRUs in The Netherlands, mapping sociodemographic and clinical profiles, care trajectories and delivery of pharmacological (focusing on clozapine delay), psychological and social guideline interventions. We assessed relationships between non-delivery of psychological and social interventions, delay in clozapine treatment, and current symptom severity. Results: The 62 included patients had a mean illness duration of 21.6 years (SD 9.4); 89% were diagnosed with a schizophrenia spectrum disorder. They exhibited severe symptoms (GAF-s: mean 33, SD 12.2), substantial functional impairment (GAF-f: mean 32, SD 9.5), a history of physical violence (74%) and/or severe substance use problems (61%), and limited or absent insight (87%). Care trajectories showed long-term instability of living environment, and frequent current compulsory care (76%). Of 54 patients with a clozapine treatment indication, 65% currently used it, of whom 94% started in IMRU setting, and 43% had one or more earlier aborted trials. Support in developing day activities was accepted by 87% of total sample, including patients without a day activity goal on beforehand. 66% developed day activities. We found associations between symptom severity, clozapine delay, declining psychological treatment, and not having day activity goals. Conclusions: For some people with complex psychosis, clozapine treatment and psychosocial interventions may only materialize in specialized, long term, high structure settings offering continuity of care. Support in developing day activities may present a pathway to collaborative engagement. Early identification of those in need remains a challenge.