Factors associated with treatment attrition for Medicaid-enrolled youth with serious emotional disturbances

Premature discontinuation from treatment is a significant problem that undermines the delivery of effective mental health services and increases the risk for relapse and poor outcomes. However, factors associated with treatment attrition in children and adolescents are not well understood. This retrospective longitudinal cohort study examines factors associated with attrition for Medicaid-enrolled youth, aged 5 to 17 with “new episodes” of ICD-9-CM diagnosed serious emotional disturbance (N = 43,122). Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Multilevel modeling was used to assess the association between individual and contextual-level variables and attrition. Of the 43,122 youth in the study sample, 4056 (9.4%) discontinued treatment. The odds of treatment attrition were significantly higher for youth who were male (OR = 1.16, p < 0.001), black compared to white (OR = 1.19, p < 0.001), had a co-occurring substance abuse disorder (OR = 1.35, p = 0.01), and lived in a county with a larger percentage of minorities (OR = 1.02, p = 0.01). In contrast, youth diagnosed with bipolar and depressive disorders compared to ADHD (OR = 0.78, p < 0.001 and OR = 0.87, p = 0.01, respectively), with comorbid psychiatric (OR = 0.74, p < 0.001) and medical disorders (OR = 0.82, p < 0.001), and a prior history of two or more psychotropic medications compared to no medications (OR = 0.76, p < 0.001) had lower odds of attrition. Residence in a county with a larger number of pediatricians and psychologists also reduced the odds of attrition (OR = 0.97, p = 0.05 and OR = 0.99, p = 0.03 respectively). Overall, this study suggests that a combination of individual factors, demographic and clinical, and contextual factors impact attrition in children's mental health outpatient treatment.