Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Section of Epidemiology and General Practice, Institute of Psychiatry, London
Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London
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Correspondence: Dr Sube Banerjee, Section of Epidemiology and General Practice, Institute of Psychiatry, De Crespigny Park, London SE5 8AF
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ABSTRACT |
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Aims To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders.
Method Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained.
Results Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended.
Conclusions Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.
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INTRODUCTION |
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METHOD |
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Subjects were randomly selected by computer-generated random number with sampling fractions calculated on the basis of the previous six months' out-patient activity. The sampling fractions were: new patient non-attenders 1:1; new patient attenders 1:3; follow-up non-attenders 1:7; and follow-up attenders 1:12. Patients whose appointments were cancelled were not included in the study. Each subject was assigned to one of the four groups according to status at their first appointment during the study period. Subjects with more than one appointment in the study period were defined by their first appointment and excluded from consideration thereafter.
Recruitment
Recruitment is a particular problem when investigating those who by
definition have defaulted from their treatment plan. We therefore designed the
study to attempt to contact as many of the selected subjects as possible to
minimise non-response bias. We wrote to each subject with an appointment for a
home interview and a researcher (H.K.) visited them if they had not declined
consent. If contact was not made on this visit, then further telephone and
postal communication was attempted to reschedule the interview. If there was
still no response, we made a second home visit without an appointment.
Finally, a postal questionnaire was sent to subjects we had not managed to
interview.
Information collected
A clinical diagnosis was made from case note data using the ICD-10
(World Health Organization,
1992) for all those randomised for entry into the study. Age and
gender data were also collected on all subjects. A semi-structured interview
was completed with subjects who agreed to participate at which
socio-demographic data and past psychiatric history were gathered. Severity of
mental disorder was assessed using the Manchester Scale
(Krawiecka et al,
1977) which rates eight major psychiatric symptoms as either
absent (scoring zero) or present from a mild to a severe degree (scoring 1-4)
and may be particularly appropriate for people with psychosis. Level of social
disorganisation was assessed using the Social Adjustment Scale
(Marks, 1986). This rates
degree of impairment attributed to psychiatric problems in each of four areas
(home management, work, social leisure activities and private leisure
activities) on a scale from 1-8; the higher the score, the greater the
impairment.
In addition, new referrals were asked: who had referred them; whether the referrer had clearly explained the reasons for referral; whether their general practitioner (GP) had prescribed medication for the problem; the time from referral to receiving the appointment; and whether they had told anybody about the referral. Follow-up patients were asked about their current contact with the clinic and the grade of doctor they saw. Non-attenders were asked why they had missed their appointment.
Outcome data
Six and twelve months after recruitment, admission data and case notes were
examined to assess each subject's out-patient contact and whether they had
been admitted to hospital. Outcome data were collected on all subjects
randomised for entry into the study irrespective of whether they were
interviewed.
Statistical analysis
Statistical analysis was carried out using SPSS 7.0. Chi-squared and
Mann-Whitney U-tests were used to investigate differences between
attenders and non-attenders, new patients and follow-ups, with the P
value for statistical significance set at 0.05. Student's t-test was
used to examine differences in age between groups.
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RESULTS |
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Three hundred and sixty-five patients were randomly selected for entry into the study. Twelve (20%) new patient non-attenders and 15 (12%) follow-up non-attenders could not be traced despite exhaustive search. Their home addresses were boarded up or clearly uninhabited, or those living at the address had never heard of them and other sources (including their GP and social services) had no alternative address for them. Two hundred and twenty-four patients consented to participate (a response rate of 66% of those traceable and 61% overall) of whom 12 (5%) completed postal questionnaires. Recruitment and response rates are summarised in Table 1.
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Socio-demographic data
Of the 224 subjects interviewed, 173 (78%) described their ethnic group as
White European and the mean age was 39 years. The rate of unemployment in the
study population was 83% (95% confidence interval (95% CI) 78.1-88.0) compared
with 12% for the general population in North Camden. There was no
statistically significant difference between the four study groups in
socio-demographic characteristics. Twenty-four (14%) follow-up patients had no
social support other than from mental health professionals compared with only
one (2%) of the new patient group (2=5.61; d.f.=1,
P=0.018). There was no gender difference between non-responders
(including subjects who refused consent, those who were untraceable and those
who made no response) and subjects interviewed. However, non-responders were
younger than those who took part in the study (mean age 36 (s.d.=12)
v. 39 (s.d.=12) years, Student's t-test: P=0.005,
95% CI of the difference 6.23-1.09).
Primary diagnosis
There were marked differences between new patients and follow-up patients
in terms of diagnosis and severity of disorder. New patients predominantly had
primary diagnoses of depression and anxiety, whereas follow-up patients were
more likely than new patients to have a diagnosis of schizophrenia or bipolar
affective disorder (see Table
2). There were no statistically significant differences between
non-responders and those interviewed other than that there was a lower
prevalence of bipolar affective disorder among the follow-up non-responders
compared with those in the follow-up group who were interviewed (5 (5%)
v. 30 (18%); 2=8.91, d.f.=1, P=0.003).
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Mental state and social functioning
Table 3 presents details of
subjects' mental health as measured by the Manchester Scale and
Table 4 social functioning as
measured by the Social Adjustment Scale. Follow-up patients were more
psychiatrically ill than new patients (Mann-Whitney U-test,
P=0.046) and follow-up non-attenders scored significantly higher for
both mental disorder and social impairment than follow-up attenders
(Manchester Scale Mann-Whitney U-test, P=0.031; Social
Adjustment Scale Mann-Whitney U-test, P=0.018).
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New patients
Seventy-three per cent of new patients were referred by their GP and the
remainder by hospital doctors. More attenders had agreed to the referral
compared with non-attenders (25 (89%) v. 20 (69%),
2=3.54, d.f.=1, P=0.06). Most attenders (93%) and
non-attenders (86%) felt that the reason for referral had been clearly
explained to them. Attenders were more likely than non-attenders to have been
prescribed psychotropic medication by their GP prior to the referral (20 (71%)
v. 11 (38%),
2=6.44, d.f.=1, P=0.011). There
were no statistically significant differences between attenders and
non-attenders in having told somebody about the referral and in rates of
previous contact with psychiatric services. Non-attenders had waited no longer
for their appointment than attenders, with 73% of appointments occurring
within four weeks of referral.
Follow-up patients
Non-attendance was associated with a previous history of admission under
the Mental Health Act 1983 (38 (50%) v. 31 (34%),
2=4.34, d.f.=1, P=0.037). There was no statistically
significant difference between attenders and non-attenders in the length of
time they had been under the care of the out-patient department, who they were
seen by or how often they were seen.
Non-attenders
Forgetting the appointment (27%) and being too psychiatrically unwell (14%)
were the most common reasons given for non-attendance by the follow-up
patients, while being unhappy with the referral (17%), clerical error (14%)
and being too unwell (14%) were the most common reasons in the new patient
group. Further details are presented in
Table 5.
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Outcome at six and 12 months
Twelve months after recruitment into the study those follow-up patients who
had missed their appointment had a much higher chance of admission than those
who had attended the clinic at entry to the study (42 (33%) non-attenders
v. 27 (20%) attenders, 2=5.55, d.f.=1,
P=0.018). This difference was not apparent at the six-month follow-up
point (24 (19%) attenders v. 23 (17%) non-attenders,
2=0.13, d.f.=1, P=0.72).
Ninety-two (68%) follow-up attenders were still attending the clinic after
six months compared with 47 (36%) follow-up non-attenders
(2=25.9, d.f.=1, P<0.001) and by twelve months
these figures had barely altered (97 (71%) v. 46 (36%)).
At twelve months there were few admissions among the new patients (two
attenders and two non-attenders). At six months 18 (44%) new patient attenders
were still in contact with the clinic compared with four (7%) new patient
non-attenders (2=17.3, d.f.=1, P<0.001) and this
difference persisted at twelve months (19 (46%) attenders v. 8 (14%)
non-attenders). Outcome data for the four study groups are presented in
Table 6.
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DISCUSSION |
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Limitations
This study is the first to provide systematic, prospective data comparing
the nature of attenders and non-attenders at a psychiatric out-patient clinic.
However, since it was carried out in a single inner-city area there may be
limitations in generalising the results beyond similar populations with
similar models of service provision. Nevertheless, the inner city is of
particular clinical and policy interest since high morbidity, high need and
failures of community care have been identified
(Ritchie et al, 1994; Johnson & Lelliott, 1997).
The out-patient setting was chosen as it has less variability than other
elements of mental health service provision and remains the most common model
used for monitoring patients in the community.
The relatively low response rates detailed in Table 1 may have introduced non-response bias in the data obtained. Given that the study was of people who were non-adherent with their psychiatric management plan, non-response was predicted to be a potential problem from the start. We therefore sought to minimise this source of error by repeated attempts to contact the subjects and the use of face-to-face interviews. This approach seems to have had some success in that the response rates achieved here are higher than those reported for any other published study of mental health or non-mental health out-patient non-attendance we have located, for example, 40% for psychiatric attenders and non-attenders (Hills & Alexander, 1990) and 43% for non-attenders at ear, nose and throat, gastroenterology (Lloyd et al, 1993) and ophthalmology clinics (Potamitis et al, 1994). We were also able to collect basic socio-demographic data and full outcome data on all subjects from the case notes.
Follow-up non-attendance
The results of this study suggest that non-attendance at psychiatric
follow-up appointments is of important clinical significance. Those who failed
to attend were more unwell and more socially impaired than those who kept
appointments. Non-attendance at recruitment predicted further non-attendance,
drop-out from out-patient services and subsequent admission. There was no
evidence from the case notes that out-patient services were being substituted
for by other community psychiatric services for non-attenders. Our data
suggest that the first episode of non-attendance may be an important time to
intervene to attempt to prevent loss to follow-up of those with serious mental
illnesses and that sending repeat appointments to non-attenders may be an
insufficient response.
New referrals compared with follow-up patients
The data from this study confirm that new referrals for psychiatric
out-patient assessment have a different profile of mental disorder compared
with the follow-up population, with a predominance of non-psychotic disorder
of lower severity. These findings are in line with Johnson's
(1973) report that the majority
of new referrals have a diagnosis of depression or anxiety but that those who
remain under the care of psychiatric services have serious mental illness such
as schizophrenia and bipolar affective disorder. In contrast to previous
studies we found no evidence that those with diagnoses of personality disorder
and neuroses were less likely to attend
(Lister & Scott, 1988; Verbov, 1992), although our
study was not designed with sufficient statistical power specifically to
address this hypothesis.
Reasons for non-attendance
Despite exhaustive inquiries we were unable to trace a substantial number
of non-attenders (27/188, 14%). For new patients this might reflect
inappropriate referral, but the untraceable follow-up population is more
worrying as it may represent a mobile group with serious mental health
problems who are not receiving appropriate community psychiatric follow-up.
This finding suggests a high rate of inaccuracy of records in hospitals,
general practices and social services and that it might be useful to check
patients' addresses at each contact.
Twice as many of the follow-up non-attenders said that they had forgotten their appointment compared with the proportion reported by other medical out-patients (Verbov, 1992; Potamitis et al, 1994). Psychiatric out-patients might therefore benefit from a system of active reminding, a strategy which has been reported to improve attendance (Rusius, 1995). New referrals who do not agree to referral have been reported to be less likely to attend (Koch & Gillis, 1991; Grunebaum et al, 1996) and our data support this. As expected, we found a very high unemployment rate among all psychiatric out-patients; non-attendance was not, therefore, likely to be associated with difficulty in taking time off work. Clerical error has been shown to account for up to 45% of missed appointments in other hospital specialities (Verbov, 1992; Potamitis et al, 1994) but in our population it was reported to account for 12% of non-attendance at most.
This study suggests that the group of patients who are at particular risk of loss to follow-up and relapse are likely to have a diagnosis of schizophrenia, schizo-affective disorder or bipolar affective illness. They have more severe current disorder and are likely to be socially isolated, often with only professionals for support. Their psychiatric symptoms seem to suggest three main ways in which they might contribute to non-attendance: (a) active symptomatology such as paranoid delusions or feeling too depressed to get up; (b) negative symptoms such as apathy and reduced organisational skills; and (c) lack of insight.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Hillis, G. & Alexander, D. A. (1990) Rejection of psychiatric treatment. Psychiatric Bulletin, 14, 149-150.
Johnson, D. A. W. (1973) An analysis of outpatient services. British Journal of Psychiatry, 122, 301-306.[Medline]
Johnson, S. & Lelliott, P. (1997) Mental health services in London: evidence from research and routine data. In London's Mental Health (eds S. Johnson, R. Ramsey, G. Thornicroft, et al). London: King's Fund.
Jones, D. T. (1987) A survey of hospital outpatient referral rates, Wales, 1985. British Medical Journal, 295, 734-736.
Koch, A. & Gillis, L. S. (1991) Non-attendance of psychiatric out-patients. South African Medical Journal, 80, 289-291.[Medline]
Krawiecka, M., Goldberg, D. & Vaughan, M. (1977) A standardized psychiatric assessment scale for rating chronic psychotic patients. Acta Psychiatrica Scandinavica, 66, 299-308.
Lister, E. S. & Scott, J. (1988) Did not attend: characteristics of patients who fail to attend their first appointment at a psychiatric out-patient clinic. Health Trends, 20, 65-66.
Lloyd, M., Bradford, C. & Webb, S. (1993) Non-attendance at out-patient clinics: is it related to the referral process? Family Practice, 10, 111-117.[Abstract]
Marks, I. (1986) Work and Social Adjustment Scale, Behavioural Psychotherapy. Bristol: John Wright.
McGlade, K. J., Bradley, T., Murphy, G. J., et al (1988) Referrals to hospital by general practitioners: a study of compliance and communication. British Medical Journal, 297, 1246-1248.[Medline]
Potamitis, T., Chell, P. B., Jones, H. S., et al (1994) Non-attendance at ophthalmology out-patient clinics. Journal of the Royal Society of Medicine, 87, 591-593.[Abstract]
Ritchie, J. H., Dick, D. & Lingham, R. (1994) The Report of the Inquiry into the Care and Treatment of Christopher Clunis. London: HMSO.
Rusius, C. W. (1995) Improving out-patient attendance using postal appointment reminders. Psychiatric Bulletin, 19, 291-292.
Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People (1996) Report of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People. London: Royal College of Psychiatrists.
Verbov, J. (1992) Why 100 patients failed to keep an out-patient appointment - adult in a dermatology department. Journal of the Royal Society of Medicine, 85, 277-278.[Abstract]
World Health Organization (1992) International Classification of Diseases (ICD-10). Geneva: WHO.
Received for publication November 30, 1998. Revision received July 13, 1999. Accepted for publication July 27, 1999.