Extending access to mental healthcare for vulnerable people

Doctors have a golden rule for addressing first-episode psychosis: treat it early. “For most mental disorders, onset occurs before age 25 ^— the earlier you intervene, the easier it is and the better the response,” notes Dr. Amal Abdel-Baki, a clinical professor in the Department of Psychiatry and Addiction at Université de Montréal.

Early intervention helps psychotics function in society, alleviates their symptoms and reduces the need to be hospitalized or go to the emergency room. And among these patients, some immigrants are especially vulnerable, coming from difficult and sometimes traumatic backgrounds that put them at greater risk of experiencing a psychotic episode.

“It’s important to consider how we can better meet their needs – if we can get them into treatment, the benefits are as great as for people without their sociodemographic vulnerabilities,” said Ines Boujelben, an UdeM psychiatry resident and master’s student who with Abdel-Baki has analyzed access to mental healthcare for racialized people and immigrants.

Based on an extensive five-year longitudinal study, their findings were published last month in Schizophrenia Research.

More likely to disengage

Previous studies have found that racialized and immigrant youth often have difficulty getting treated for first-episode psychosis and, if they do get it, are more likely to disengage afterwards. “These studies seem to indicate that we’re losing them,” said Boujelben. “It’s an important issue because when patients disengage, there’s a significant risk that the benefits of treatment will be lost.”

Boujelben investigated the reasons for disengagement using data from a longitudinal observational study of 567 adults between the ages of 18 and 30 who were admitted for first-episode psychosis between 2005 and 2013 to two sites in Montreal: the UdeM-affiliated CHUM hospital clinic for young adults with psychotic disorders, known as the JAP, and the first-episode psychosis program at UdeM’s Institut universitaire en santé mentale de Montréal.

Boujelben and her research team found that first-generation racialized immigrants were more likely to come to these early intervention services through “adverse pathways” (law enforcement or ambulance) than non-racialized non-immigrants and even second-generation racialized immigrants. Across all groups, individuals brought in by police or paramedics were more likely to subsequently disengage from treatment than those brought by a relative, referred by a professional, or who came to a walk-in clinic on their own.

More likely to leave Montreal

Breaking down the data by racial and immigrant status also provided added nuance to previous findings. For example, first-generation immigrants are more likely to leave Montreal and return to their country of origin, which may falsely appear as treatment abandonment.

“We had the impression that we weren’t able to keep these vulnerable young people in treatment, but actually those who stayed in Montreal generally continued to be engaged throughout the five-year follow-up period,” said Boujelben. “People leave the Montreal area for all kinds of reasons and aren’t necessarily disengaging from care.”

To dig deeper into the results, the researchers intend to follow up their quantitative work with a qualitative study. “The qualitative component will help us understand the reasons for the overrepresentation we see,” said Abdel-Baki. “This will help us set improvement targets and provide guidance for responders, clinics, police, paramedics and policymakers,” Boujelben added.

“Once we have the qualitative results, we plan to share them with police and ambulance services,” Abdel-Baki said. 

With the number of marginalized and vulnerable people growing in the metropolis, more consideration must be given to how their specific needs can be met more effectively, the researchers believe.

“Immigrants and racialized people are at greater risk of experiencing a psychotic episode,” said Boujelben. “But if we can get them into treatment, the benefits for the individual in terms of symptom remission and for society as a whole are the same as for any group.”

“It’s a question of equity in access to care,” Abdel-Baki concluded.

An approach that works

The Équipe d’intervention intensive de proximité (EQIIP SOL) at Université de Montréal’s teaching hospital, the CHUM, is an outreach team that offers intensive specialized treatment to street youth dealing with incipient psychosis and associated substance use. It began as a pilot project in 2012.

“After the successful pilot project, the program was permanently implemented in the healthcare system,” said UdeM psychiatry professor Amal Abdel-Baki.

The program includes intensive follow-up several times a week to deliver mental healthcare and other social services to young people with a range of vulnerabilities including drug use, homelessness, incipient psychosis. Over the years, the model has proven its effectiveness.

“Young people exit homelessness much faster with EQIIP SOL,” said Abdel-Baki. At the CHUM’s JAP clinic for young people with psychotic disorders, patients achieve housing stability – finding and staying in a fixed residence – within an average of 14 months; with EQIIP SOL, it takes seven months.

To find out whether housing stability was sustained over time, the research team tracked over three years the 177 young people who were in the EQIIP SOL program between 2012 and 2020. The study’s findings were published in April in Social Psychiatry and Psychiatric Epidemiology.

“Approximately 80 per cent of the subjects permanently exited homelessness,” said Abdel-Baki. Despite their precarious circumstances, the young people remained engaged with treatment when it was adapted to their needs, and many returned to school or found work.

“The fact that a very high proportion of these young people are able to get off the street, recover and become productive when they receive support gives us hope,” Abdel-Baki said.

This intensive intervention approach yields significant benefits, she noted. To begin with, it reduces the use of emergency and hospital services, and “visits to the ER and hospitalization are what cost society the most.”

Furthermore, said Abdel-Baki, “early intervention for psychosis reduces the likelihood of accidental death or suicide by three-quarters in the two years following diagnosis. That’s a huge difference. It shows how important it is to act early.”

About these studies

“Pathways to early intervention services involving police or ambulance and disengagement rates in racialized and immigrant youth compared to the White majority,” by Ines Boujelben, Amal Abdel-Baki et al., was published in the June 2025 issue of Schizophrenia Research.

“Addressing the complex needs of homeless youth with early psychosis and comorbid substance use: a naturalistic longitudinal study of 10 years’ experience with EQIIP SOL’s specialized outreach service,” by Amal Abdel-Baki et al., was published April 21, 2025 in Social Psychiatry and Psychiatric Epidemiology.