Department of Psychiatry, Hospital of Legnano, and Laboratory of Epidemiology and Social Psychiatry, Mario Negri Institute for Pharmacological Research, Milan
Department of Psychiatry, Hospital of Legnano, Milan
Laboratory of Epidemiology and Social Psychiatry, Mario Negri Institute for Pharmacological Research, Milan
Correspondence: Dr Corrado Barbui, Laboratory of Epidemiology and Social Psychiatry, Mario Negri Institute for Pharmacological Research, Via Eritrea 62, 20157 Milan, Italy. Tel: +39 0239014431; fax: +39 02 33200049; e-mail: barbui{at}marionegri.it
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ABSTRACT |
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Aims To estimate the long-term probability of leaving care in first-contact patients attending an out-patient service, and to identify patients most likely to drop out.
Method All patients who had a first contact with the community mental health centre of Magenta during a 1-year recruitment period were followed up for 24 months. Patients who failed to return after the last out-patient visit were regarded as drop-outs.
Results During the 1-year recruitment period 330 subjects were at their first contact. The 1-year incidence of first-contact patients was nearly 33 per 10 000 inhabitants. At follow-up, 46% of patients had dropped out. In comparison with patients with psychoses, subjects suffering from neurotic (P =0.004) and personality disorders (P=0.029) were more likely to drop out.
Conclusions In the Italian system of community psychiatric care nearly half of the patients are no longer in contact after 2 years. Those who stay in treatment are more likely to suffer from psychosis, suggesting a commitment of Italian out-patient facilities to tackling the needs of patients with more severe disorders.
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INTRODUCTION |
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The Italian psychiatric system gives high priority to out-patient care delivered by community mental health centres (CMHCs). Individuals with psychological and psychiatric problems in a specific catchment area are all followed by the CMHC for that area. Continuity of care is considered a basic quality requirement, essential for following patients in their own context of life for a long time (Tansella et al, 1995). To date, however, continuity of care has been investigated rarely in Italian CMHCs. Morlino et al (1995) explored the probability of leaving care in a university psychiatric out-patient clinic but this did not cover a specified catchment area, which might have influenced the overall drop-out rate (82% at 3 months). The present outcome study followed all patients who had a first contact with a CMHC during a 1-year period for 24 months; the purpose was to estimate the probability of leaving care and to identify subgroups of patients most likely to drop out.
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METHOD |
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The Magenta Community Psychiatric Service consists of one psychiatric ward in a general hospital, one psychiatric residential rehabilitative centre, two community mental health centres (the Magenta CMHC providing care to the Magenta residents, and the Abbiategrasso CMHC providing care to the Abbiategrasso residents) and two unstaffed apartments. The psychiatric ward in the Magenta general hospital is a 16-bed in-patient unit generally used for acute episodes. This ward offers acute in-patient care, liaison services to other hospital units and a 24-hour emergency service to both the Magenta and the Abbiategrasso residents.
The CMHCs are the operational units in charge of managing all psychiatric services provided to patients from their catchment areas. All but emergency cases are expected to have their first contact with public mental health care in these units. The CMHCs also are charged to act as the psychiatric interface of the network of general practitioners providing primary general care to all residents. The Magenta CMHC catchment area comprises various small towns located in a mainly rural territory. Population density is 772.75 inhabitants per square kilometre. The main economic activities are farming and traditional manufacturing. The CMHC serves 85 809 adult residents (total population is 101 045). Further details of routine clinical work and costs of this facility can be found elsewhere (Percudani et al, 1999; Fattore et al, 2000).
Study population
The study was carried out at the Magenta CMHC. In 1992 an administrative
database was developed to routinely collect service utilisation data
(Regione Lombardia Settore
Sanità e Igiene, 1992) as part of
the computerised psychiatric information system of the local regional health
authority. From this database socio-demographic and clinical information was
extracted on all patients who had had a first contact with the CMHC from
January to December 1994. All these patients were followed for 24 months.
Patients were grouped in six ICD-10 (World
Health Organization, 1992) diagnostic categories: schizophrenia,
schizotypal and delusional disorders (F2 diagnoses); mood disorders (F3
diagnoses); neurotic, stress-related and somatoform disorders (F4 diagnoses);
disorders of adult personality and behaviour (F6 diagnoses); mental
retardation (F7 diagnoses) (hereafter, learning disability); and other
diagnoses (patients not included in F2, F3, F4, F6 or F7).
Outcome
The total number of months of contact with the CMHC during the study period
was recorded. Patients who failed to return after the last out-patient visit,
even though a new appointment had been established, were regarded as having
dropped out. Patients who remained in contact with the out-patient service
during the whole study period were considered still followed up
and patients who discontinued the contact in agreement with the treating
psychiatrists were regarded as discharged.
Statistical analysis
Rates of first-contact patients by diagnosis were calculated by dividing
the total number who had had a first contact with the CMHC during the 12-month
recruitment period by the resident population. Rates of first-ever-contact
patients by diagnosis were calculated by dividing the number of patients with
no previous psychiatric contacts with any other mental health facilities who
had had a first contact with the CMHC during the 12-month recruitment period
by the resident population. Univariate comparisons between patients who
dropped out, were discharged by agreement and those who stayed
in treatment were performed using 2 statistics, and a
KaplanMeier curve estimated the survival probability (continuity of
care) over the 24-month follow-up. A Cox regression analysis was carried out
to determine the role of independent variables in the probability of
discontinuing contact with the out-patient service. All calculations were done
using Stata 4.0 (StataCorp,
1995).
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RESULTS |
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Characteristics of the 330 first-contact patients
The socio-demographic and clinical characteristics of the sample are
presented in Table 2. The
majority were female, only one-third were over 50 years of age, half were
married and a minority lived alone. Sixty-four had had previous psychiatric
contacts and the others were first-evercontact patients. Neurotic disorders
were the most common diagnoses, followed by affective disorder. Patients
suffering from psychotic disorders accounted for 7% of the total sample.
Nearly half of the patients received no prescription for psychotropic drugs at
first contact.
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Outcome
After 2 years of follow-up 46% of patients had dropped out, one-third were
still followed up, a quarter discontinued the contact in agreement with the
treating psychiatrists and two patients had died (of causes unrelated to the
psychiatric diagnosis) (Table
3).
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Differences between patients who dropped out, were discharged
by agreement and who stayed in treatment
The distribution of patients who dropped out, were discharged and who
continued treatment showed no significant differences in socio-demographic and
clinical variables (Table 4).
However, more continuing than discharged and drop-out patients were suffering
from psychotic disorders, and more drop-outs than continuing patients suffered
from neurotic and personality disorders. In addition, more continuing than
discharged and dropout patients were prescribed psychotropic drugs at first
contact. The survival probability of patients with and without a psychotic
disorder over the 24 months of follow-up showed that the former were less
likely to drop out (Fig. 1). A
multivariate Cox regression analysis was carried out to determine the
independent contribution of socio-demographic and clinical variables to the
probability of leaving care. Using patients with psychosis as a reference
category, patients with neurotic and personality disorders were more likely to
drop out (Table 5). In
addition, male gender was a risk factor for dropping out.
Table 6 presents the
distribution of drop-outs and patients continuing treatment by number of
contacts per month with the CMHC. There were no real differences.
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DISCUSSION |
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Annual rates of first-contact patients in the Magenta area were slightly higher than in other Italian catchment areas. We estimated that out of 10 000 inhabitants, 33 contacted the out-patient service in 1 year, compared with 20 in the Verona area (Balestrieri et al, 1992) and 26 in the Portogruaro area in 1990 (De Salvia & Rocco, 1992). These figures suggest that the Magenta CMHC is as accessible as other Italian community-oriented psychiatric facilities.
Drop-out rates in routine clinical practice
Continuity of care, considered a cornerstone of community psychiatry, has
been monitored rarely in the Italian context of psychiatric care. We found
that nearly half of the first-contact patients were no longer in treatment
after 2 years of follow-up. This is hardly comparable with figures from the
literature because we adopted a very naturalistic approach, avoiding any form
of patient selection and following all first-contact patients for a long time.
Depending on study design and definition, dropout rates in routine clinical
practice vary between 20 and 60% (Swett
& Noones, 1989; Mahneke
et al, 1993; Pang
et al, 1996; Tehrani
et al, 1996; Killaspy
et al, 1999), compared with estimates in experimental
studies of around 30% of patients leaving care
(Barbui & Hotopf, 2001).
Morlino et al (1995),
in a study conducted in Italy, estimated an overall drop-out rate of 82% at 3
months but the study setting was a university department with no particular
catchment area. In this rather special context of care many patients arrived
from far away, and this might explain the high drop-out rate. No association
was detected between diagnosis and continuity of care; in contrast, two
studies in the USA found that patients with schizophrenia
(Young et al, 2000)
and personality disorders (Cohen et
al, 1995) were more likely to drop out. The present study
indicated that in the Italian context of care, patients with psychosis are
more likely to stay in treatment, and patients with neurotic and personality
disorders are more likely to leave.
Study limitations
A first limitation of this study is the possibility of unreliability of the
mental health information system, which might have missed some data. Although
this possibility cannot be ruled out completely, the reliability of the
definition of drop-outs was checked externally by analysing each patient's
clinical chart and recording whether there was a failure to return after the
last out-patient visit, even though a new appointment was planned. This
double-check approach was adopted to be sure that the drop-out category
reflected people who failed contact with the psychiatric service, and not a
failure within the information system. A double-check approach, namely
information collected at the index contact and information from the
computerised system, was used also to identify first-contact patients.
First-ever-contact patients, however, were identified using only information
collected at the index contact, because the computerised system works in such
a way that each psychiatric service has access only to its own service
utilisation data.
A second limitation of this study comes from the lack of outcome data on patients who left care in comparison with those who stayed in treatment. Outcome data in our study would have provided an external check on the validity of the drop-out category and would have provided information on whether drop-out status is a matter of concern in the Italian context of psychiatric care. In fact, there is the possibility that some terminations of treatment might have been for good reasons, such as improvement in symptoms or moving out of the catchment area, and it is not easy to make a clear distinction between appropriate and non-appropriate terminations without following up all patients, including those who interrupted contacts. Young et al (2000) examined outcomes for continuing and drop-out patients and showed that average outcomes improved for both groups, and patients who left treatment and could be located for follow-up were less severely ill and showed the greatest improvement and the best outcomes. Killaspy et al (2000) assessed the outcome of attenders and non-attenders in a cohort of 365 UK psychiatric out-patients and found that those who failed to attend were more unwell and more socially impaired than those who kept their appointments.
Implications for practice
The finding that patients who stayed in treatment were more likely to
suffer from psychotic disorders might be explained by the strong commitment of
Italian CMHCs to providing care for people suffering from severe illness.
Frankel et al (1989),
in a UK out-patient facility, showed that patient factors were less important
than aspects of the service in explaining non-attendance at out-patient
appointments. In Italy, since the closure of mental hospitals, community
psychiatric services have implemented strategies, attitudes and specific
treatment plans to tackle the needs of patients with psychosis more than other
patients (Tansella et al,
1987,
1995). A comparison between
South Verona and Groningen showed that more patients in South Verona received
community care within 2 weeks after hospital discharge, suggesting better
continuity of care for severe cases in that specific system of care
(Sytema et al, 1997).
However, our data did not suggest that there was any selection of patients, at
least judging from the total number of contacts per month with the CMHC, which
was similar for patients who left care and those who stayed in treatment.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication April 9, 2001. Revision received September 14, 2001. Accepted for publication September 28, 2001.