Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Health Services Research Department, Institute of Psychiatry, King's College London, UK
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Correspondence: Dr Alberto Rossi, Department of Medicine and Public Health, Section of Psychiatry, Ospedale Policlinico, Piazzale L.A. Scuro 10, 37134 Verona, Italy
Declaration of interest Funding was received from the Fondazione Cassa di Risparmio di Verona Vicenza Belluno e Ancona, Progetto Sanità 1996-1997.
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ABSTRACT |
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Aims To identify patient and treatment characteristics associated with dropping out of contact with community-based psychiatric services (CPS).
Method A 3-month cohort of patients attending the CPS was followed up for 2 years, to identify drop-outs.
Results We identified 495 patients who had had at least one psychiatric contact of whom 261 had complete ratings for the Global Assessment of Functioning and the Verona Service Satisfaction Scale. In the year after the index contact, 70 terminated contact with the CPS; of these, 44 were rated as having inappropriate terminations (the drop-out group) and 26 had appropriate terminations of contact. Drop-outs were younger, less likely to be married and their previous length of contact with services was shorter. No drop-outs had a diagnosis of schizophrenia. Multivariate analysis revealed predictors of dropping out.
Conclusions In a CPS targeted to patients with severe mental illnesses, those who drop out of care are younger patients without psychoses who are generally satisfied with their treatment.
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INTRODUCTION |
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An episode of care can be simply defined as the time interval between a first service contact for a mental health problem and a last contact with the services. The most useful definition of last contact in the field of mental health care, which has been tested using case register data, is a contact, after which there is a gap of 90 days or more without any further contact (Tansella et al, 1995). This has been applied to the end of a single episode of care, but may not be a sufficiently long period of time without contact to establish that treatment has truly been terminated. By contrast, in this paper we define an illness episode as the time interval between the onset or recurrence of a mental health problem and its resolution or remission.
This perspective can be developed by considering the nature of terminations to service contact, where these can be seen as either appropriate or inappropriate. By appropriate terminations of contact, we mean those which occur when a clinical resolution or remission has taken place, or those cases when, for some other reason, staff and patient agree that treatment should be stopped. Inappropriate terminations are those which occur when there has not been a clinical resolution or an agreed termination, and they are referred to, in this paper, as drop-out cases. They are identified after excluding those patients who died or moved away from the local catchment area.
Previous research has shown that socio-demographic factors, such as age, marital status and living situation, may be important to predict such drop-outs (Trepka, 1986; Tehrani et al, 1996; Young et al, 2000). Other predictors of dropping out identified previously are: clinical setting, patient satisfaction (Pekarik, 1983; Tehrani et al, 1996; Young et al, 2000) and severity of clinical status (Robin, 1976).
Although it has been estimated, for example, that between 26% and 40% of patients may inappropriately leave out-patient follow-up care in a 1-year period (Pekarik, 1983; Tehrani et al, 1996; Young et al, 2000) and that this event is considered as an indicator of low quality of care (Grassi, 2000), until now, no studies have investigated those dropping out of care from an integrated community mental health service which aims to optimise continuity of care (Thornicroft & Tansella, 1999), nor have any used a comprehensive catchment area case register to ascertain cases and to evaluate their patterns of care.
The aim of this study is to identify patient and treatment characteristics associated with the likelihood of dropping out of contact with local community-based psychiatric services, so that services can identify the measures necessary to reduce inappropriate terminations of clinical contact.
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METHOD |
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The CPS supplies a wide range of well-integrated hospital and community services. With the exception of hospital nurses, all staff work both within and outside the hospital. This ensures continuity of care through the different phases of treatment and across the various components of service provision (Sytema et al, 1997). Two private in-patient units (with a total of 220 beds), an out-patient service for children and adolescents, an out-patient service for those with addictions and a small number of general hospital neurological wards also provide psychiatric care to the residents in the Province of Verona, a wider area that includes South Verona (Tansella et al, 1998).
The South Verona Psychiatric Case Register
The South Verona Psychiatric Case Register (PCR), which began in 1979,
records socio-demographic characteristics, past psychiatric and medical
history, clinical data, and contacts with psychiatrists, psychologists, social
workers and psychiatric nurses. The PCR collects information not only from the
South Verona CPS but also from all public and private psychiatric services of
the Province of Verona. Contacts with general practitioners (GPs),
psychiatrists and psychologists in private practice are not reported to the
PCR. Each attendance at an out-patient clinic and each home visit is counted
as a contact. The PCR also routinely records details of patients who leave the
catchment area and those who die. Estimates of time spent for each out-patient
contact and each domiciliary visit are routinely recorded by the professionals
providing care (Tansella et al,
1998), as are the types and numbers of professionals involved.
This information forms the basis for calculating costs of specialist mental
health care (Amaddeo et al,
1997).
Patients
This study is part of the South Verona Outcome Project, in which
cross-sectional standardised assessments of patients in contact with the South
Verona CPS have been made each year since 1994. Both first-ever patients and
patients already in contact with the service are assessed, using several
outcome measures, but in this study we report only the use of the Global
Assessment of Functioning Scale (GAF) and the Verona Service Satisfaction
Scale (VSSS) for all those seen by a psychiatrist or a psychologist. The
Outcome Project study excludes contacts which take place in the casualty
department or in the liaison psychiatry department because of logistical
difficulties in assessing patients in these settings. Full details of the
design of the Outcome Project are given in Ruggeri et al
(1998).
The official Italian versions of GAF and VSSS were used. The GAF is a measure of individual well-being in the previous month on a continuous scale, where 0 denotes extremely severe dysfunction and 90 extremely good function (Endicott et al, 1976). The VSSS consists of 54 items covering 7 dimensions of the patient's experience of mental health services in the previous year: overall satisfaction, the skills and behaviour of professionals, information, access, efficacy, type of intervention and involvement of relatives items are rated on a 5-point Likert scale (1=terrible; 5=excellent) (Ruggeri & Dall'Agnola, 1993; Ruggeri et al, 1994).
All key professionals were trained in the correct use of these standardised instruments. Interrater reliability for GAF scores was assessed during the project and was always higher than 0.70 (intraclass correlation coefficient). If necessary, the research team helped the patients to complete the VSSS and assessed their understanding of items and coherence of assessments; confidentiality was fully preserved. The test-retest reliability and the validity of the VSSS have been assessed previously and proved to be good (Ruggeri & Dall'Agnola, 1993; Ruggeri et al, 2000).
This study includes all first-ever and all previously treated patients who were seen in the cross-sectional assessment period between October and December 1994, and for whom both GAF and VSSS were completed. Using the PCR, each patient was followed-up for 2 years after his/her first contact during the 3-month assessment period. Patients who died or moved away from the catchment area during the first year after the index contact were excluded from the study.
Drop-out patients were defined as those who (a) had a period without psychiatric contacts lasting at least 365 consecutive days, either immediately after the index contact or after further occasional contacts occurring in the following year and (b) those whose termination of treatment was not rated as appropriate.
To rate appropriateness of termination of contact, we considered the reason. This was independently assessed from the case notes of the last recorded contact and rated by a psychiatrist. From these case records, a rating was made for each patient in the following categories who terminated contact: (a) clinical resolution of the episode, (b) termination agreed between patient and clinician for other reasons, (c) termination not agreed, or (d) referral to the GP. When the reason for termination of contact could not be assessed from the case notes, the psychiatrist used the case notes to make a GAF rating of the overall functional level of each patient during the month preceding the date of the last recorded contact. This rating was blind to all previous GAF ratings and to the status of the patient in terms of contact termination. This retrospective method of rating the GAF from case records has been shown to be highly reliable (Mirandola et al, 2000).
Using the information gathered in the steps outlined above, an appropriate termination of contact with services was defined as applying to: (i) those patients for whom the recorded reason of termination referred to categories (a), (b) or (d) above or (ii) those patients in which the clinical condition at termination showed only a minor degree of disability/symptom severity, as shown by a GAF score of 70, for the month preceding the date of termination of contact, indicating only a mild degree of disability.
Measures used
For each patient, the following data were collected in relation to the
index contact.
Statistical analysis
The probability of being a drop-out was assessed by logistical regression.
Since the study only included subjects (respondents) for whom
complete GAF and VSSS data were available, weights were applied to make the
sample representative of all the eligible patients (patients who had been seen
in the cross-sectional assessment in OctoberDecember 1994). The
dependent variable was patient status (drop-out or not drop-out). The
independent variables were: socio-demographic characteristics (gender, age,
marital status, living situation, education and employment status); clinical
characteristics (diagnosis and whether the patient had a severe mental illness
or not); length of contact with services before entry into the study; service
utilisation characteristics of the patients in the year preceding entry into
the study (days of admission to hospital, days of contact with day care,
number of contacts with out-patients or domiciliary care and total service
costs in the previous year); patient overall functioning at entry into the
study as rated by GAF score; and patient satisfaction characteristics at entry
into the study, as rated by the VSSS total score and the scores in the seven
VSSS dimensions.
Weights for non-response were proportional to the inverse probability of responding, estimated from a logistical regression on the whole group of eligible patients. The weights are greater for respondents with a lower response probability, who are therefore underrepresented in the analysed sample (Iannacchione et al, 1991). The independent variables were socio-demographic and clinical information available both for respondents and non-respondents, and the dependent variable was the response status. A missing at random mechanism for non-response is assumed, given the characteristics included in the logistical regression model (Brick & Kalton, 1996). All statistical analyses were performed using STATA Release 7.0 (STATA Corporation, 2000).
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RESULTS |
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Table 2 presents the comparison of socio-demographic, clinical and psychiatric history data between drop-out and other patients (univariate analysis). Significant demographic and clinical differences were found between patients who remained in treatment and the drop-out group. Compared with the other patients, drop-outs were younger (F=4.88, P=0.002), and were less likely to be married, (F=3.32, P=0.037). The length of contact with services before entry into the study was greater for patients who remained in contact (F=7.72, P=0.0005). No significant differences between groups were found for gender, living condition, educational level or employment status. There were significant differences between groups for diagnosis (F=5.58, P=0.0002). Compared with drop-outs, patients who stayed in care were more likely to have severe mental illnesses and less likely to suffer from anxiety and somatoform disorders. Of the 44 patients who left care inappropriately, none had schizophrenia and only 4 were classified as having severe mental illness.
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Table 3 shows the comparison of GAF and VSSS scores between drop-out patients and patients remaining in contact. Since there were no patients with a diagnosis of schizophrenia among the drop-outs, we divided those who remained in care into those suffering from schizophrenia and those who were not. Using a one-way analysis of variance (ANOVA), significant differences between these three groups were found for mean GAF scores (F=6.39, P=0.0002). Patients with schizophrenia remaining in contact had a lower mean score (52.5), whereas those without schizophrenia and drop-out patients had similar mean scores (62.1 v. 62.5). These differences are also clinically relevant because in the GAF, the range score from 50 to 60 is used to describe a moderate-to-severe level of impairment of symptoms and functioning, and the range from 60 to 70 is used to describe a mild-to-moderate level. For the VSSS total score and sub-scale scores, a trend was found only for lower satisfaction scores in drop-out patients.
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Table 4 compares service utilisation during the previous year by drop-out patients, patients without schizophrenia who remained in care and those with schizophrenia who remained in care (excluding first-ever patients who, by definition, had received no contact in the previous year).
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Table 5 shows the direct costs (Italian lire at 1999 prices) of care provided in the year preceding the entry into the study (weighted data). The drop-out group had received a much lower level of in-patient, sheltered residential, day and community care than those patients remaining in contact with services. The total costs for the drop-out group for the year preceding the index contact were much less than for patients with and without schizophrenia who continued contact over the follow-up period. Differences were statistically significant for day care, community care and total costs. Table 5 also strongly suggests that the clinical service is successfully targeted to patients with schizophrenia in terms of the balance of expenditure and clinical interventions.
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Predicting drop-out
All patients with schizophrenia remained in contact with services during
the study period, so the diagnosis of schizophrenia was a perfect predictor
for not dropping out. Table 6
shows the final logistic regression model calculated for the remaining 177
patients (excluding those with a diagnosis of schizophrenia, n=46). A
backward selection was performed, and in the initial model, socio-demographic
characteristics (living condition, working status, educational level, marital
status), clinical variables (diagnosis, GAF, length of contact, number of
contacts in the previous year), total costs and satisfaction with services
were introduced. The prediction formula used in
Table 6 and an example of a
prediction for a typical patient are shown in the Appendix.
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It was found that lower age, less use of day care, and less use of out-patient care in the previous year all increased the risk of dropping out of treatment. Premature termination of treatment was not associated with the other socio-demographic characteristics, psychiatric history or diagnosis (except schizophrenia), in-patient days or community care contact in the previous year.
No significant effect on dropping out was found for GAF score, VSSS total score and for total costs. Instead, associations were found between some aspects of patient satisfaction with services and dropping out: patients with greater satisfaction with the skill and behaviour of professionals had a greater probability of staying in contact, whereas those who were more satisfied with the type of intervention received were 5.9 times more likely to drop out.
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DISCUSSION |
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The decision to include information on disability/symptomatology and satisfaction with services as possible predictors of drop-out reduced the size of our sample from 495 (all 3-month period prevalent treated cases) to 261 (those for whom both GAF and VSSS were complete). However, a well-established weighting procedure (see Statistical analysis above) was used to ensure that the patient data included in the study were adjusted to be representative of all treated prevalent cases. This study extends previous work by drawing on case register data, using the types, amounts and costs of care received in the year prior to the index contact as potential predictor variables. This approach has the advantage of realistically categorising patients who end contact with care and who are relatively well (GAF > 70) as appropriate discontinuations, even if no formal agreement to discharge has been reached between clinician and patient, as in the study by Percudani et al (2002).
A limitation of our study was that it did not include follow-up details of patients who came under the treatment of private psychiatrists or private psychologists, or those who sought care from GPs without a transfer from the CPS. These limits are common to all studies using case registers, which do not usually include data from these sources.
Rate of inappropriate termination of contact (drop-out)
Among the 261 patients included in the cross-sectional South Verona Outcome
Project we found that 17% (44) had an inappropriate termination of contact
during the year after the index contact. Our findings are not consistent with
the results of other studies (Pekarik,
1983; Tehrani et al,
1996; Young et al,
2000), which estimated that between 26% and 40% of patients may
inappropriately leave out-patient care in a 1-year period. The lower drop-out
found in our study may be explained by several factors. First, the South
Verona service is designed to promote continuity of care, especially for
people with severe mental illness (none of the patients with schizophrenia
dropped out), which explains why only 27% (70 out of 261) of the total group
discontinued contact during the year after the index contact. Second, previous
studies have defined the concept of inappropriate termination of treatment
less stringently (Baekeland & Lundwall,
1975; Louks et al,
1989; Koch & Gillis,
1991; Mohl et al,
1991), relating dropping out to the number of out-patient visits
made or to the length of time in treatment
(Atwood & Beck, 1985;
Dworkin et al, 1986;
Axelrod & Wetzler, 1989;
Mohl et al, 1991). In
these investigations, a patient was considered to be a drop-out if he or she
terminated treatment before an arbitrary cut-off point, whether the clinician
agreed with the termination or not. By contrast, our definition distinguished
between appropriate and inappropriate termination. In addition, the
possibility that some of our drop-out patients did not, in fact, drop out of
contact with services, but rather transferred care to other providers not
reporting to the case register, would further reduce the proportion of cases
dropping out of care, and would increase the difference between our findings
and those of previous studies. In these respects, the South Verona CPS acts
more as an assertive outreach team than as a general adult mental health
service within the UK context (Department
of Health, 2001). This is because it has relatively fewer
referrals of patients with lesser disability than catchment area teams in
Britain (which often combine both consultation assessments at the request of
primary care practitioners and the treatment of a longer-term case-load of
patients with greater disability), as shown by previous UKItalian
comparative studies (Amaddeo et
al, 1995; Gater et
al, 1995).
Variables associated with dropping out of care
Our findings relating drop-out to younger age are consistent with the
results of Kline & King
(1973), Molnar & Pinchoff
(1993), Tehrani et al
(1996) and Young et
al (2000), although the
finding from the univariate analysis that drop-outs are more likely both to be
younger and unmarried must be interpreted with caution, as these two variables
are often associated in psychiatric datasets. In terms of clinical status, our
results show that there was a significant difference in the level of
disability between drop-out patients and patients who remained in contact.
These results are consistent with those of Robin
(1976). However, a recent
controlled prospective study at a psychiatric out-patient service in London
(without an outreach service) showed that those who missed appointments were
more unwell and had higher levels of disability than those who did attend
(Killaspy et al,
2000). This study, however, referred only to loss of contact with
the out-patient component of the service, rather than with any part of the
service, and therefore addressed a more restricted issue. In addition, our
results show that direct costs of patients who dropped out of treatment in the
previous year were significantly lower than those of patients both with and
without schizophrenia, who remained in contact.
Predictors of dropping out of care
For the multivariate analysis, we excluded the 46 patients with
schizophrenia because none of them dropped out of care in the year following
the index contact; the diagnosis of schizophrenia thus might be considered a
perfect predictor of non-drop-out. This is because the South Verona CPS is
deliberately targeted at those with severe mental illness and if such a
patient fails to attend for an appointment, the staff actively arrange to
visit them at home to ensure continuity of clinical contact.
Termination of treatment might be assumed to represent a behavioural sign of dissatisfaction, so a strong inverse relationship between inappropriate termination of treatment and satisfaction with care might be expected. Our use of a detailed service satisfaction scale allowed us to differentiate between different aspects of satisfaction. In terms of the bivariate analysis, we found a trend, but no significant differences, for lower satisfaction in drop-out patients (Table 3). However, when multivariate analyses were performed to identify predictors of dropping out, after excluding patients with a diagnosis of schizophrenia, satisfaction with type of intervention received became the most significant predictor. This sub-scale summarises ratings made on 17 items of the VSSS referring to patients' perceptions of a wide range of treatment and care received, from medication to sheltered work and advice on welfare benefits. This suggests that, for a group of patients predominantly without psychoses, dropping out of contact with services is strongly associated with being more satisfied with the interventions received in the period prior to the index contact and this implies that, from the perspective of these patients, the termination of contact was appropriate.
These results indicate that different criteria may be used by staff and by patients not suffering from schizophrenia when judging at which point to discontinue clinical contact, and that these different priorities may well warrant a more detailed investigation. This leads us to the tentative conclusion that a basis for planning a mutually agreed termination of treatment by clinicians should be open discussion with patients as to whether they are satisfied with the type and amount of treatment received, and when they feel that they have had sufficient care.
At the same time, as expected, patients who are less satisfied with the professional skills and behaviour (rating professionalism, competence and thoroughness of staff) are also more likely to drop out of care. Therefore, these aspects of satisfaction may also have important consequences for whether patients without a diagnosis of schizophrenia allow continuing clinical contact, and therefore potentially effective treatment, to take place at all. This also indicates a further avenue for research, namely the interrelationships between the processes and the outcomes of care, in this case where the processes are rated from a patient perspective.
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Clinical Implications and Limitations |
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LIMITATIONS
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APPENDIX |
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So, for a patient with:
and considering that the constant value of the logistic regression is equal
to -0.704:
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Thus, P<0.5. As P=0 is not drop-out and P=1 is drop-out, then the patient with these characteristics has a high probability of not dropping out of care.
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ACKNOWLEDGMENTS |
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REFERENCES |
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Amaddeo, F., Beecham, J., Bonizzato, P., et al (1997) The use of a case register to evaluate the costs of psychiatric care. Acta Psychiatrica Scandinavica, 95, 189-198.[Medline]
Amaddeo, F., Beecham, J., Bonizzato, P., et al (1998) The costs of community-based psychiatric care for first-ever patients. A case register study. Psychological Medicine, 28, 173-183.[CrossRef][Medline]
Atwood, N. & Beck, J. (1985) Service and patient predictors of continuation in clinic-based treatment. Hospital and Community Psychiatry, 36, 865-869.[Medline]
Axelrod, S. & Wetzler, S. (1989) Factors associated with better compliance with psychiatric aftercare. Hospital and Community Psychiatry, 40, 397-401.[Medline]
Baekeland, F. & Lundwall, L. (1975) Dropping out of treatment: a critical review. Psychological Bulletin, 82, 738-783.[Medline]
Brick, J. M. & Kalton, G. (1996) Handling missing data in survey research. Statistical Methods in Medical Research, 5, 215-238.[Medline]
Department of Health (2001) Policy Implementation Guidelines. London: Department of Health.
Dworkin, R., Adams, G. & Telshow, R. (1986) Cue of disability and treatment continuation of chronic schizophrenics. Social Science and Medicine, 22, 521-526.[CrossRef][Medline]
Endicott, J., Spitzer, R. L., Fleiss, I. L., et al (1976) The Global Assessment Scale. A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766-771.[Abstract]
Gater, R., Amaddeo, F., Tansella, M., et al (1995) A comparison of community-based care for schizophrenia in South Verona and South Manchester. British Journal of Psychiatry, 166, 344-352.[Abstract]
Grassi, G. (2000) Output standard in the mental health service of Reggio Emilia, Italy. Methodological issues. Epidemiologia e Psichiatria Sociale, 9, 56-69.[Medline]
Iannacchione, V. G., Milne, J. G. & Folsom, R. (1991) Response probability weight in adjustments using logistic regression. In Proceedings of the American Statistical Association, Section on Survey Research Methods, pp. 637-642. Alexandria, VA: American Statistical Association.
Killaspy, H., Banerjee, S., King, M., et al
(2000) Prospective controlled study of psychiatric
out-patient non-attendance. British Journal of
Psychiatry, 176,
160-165.
Kline, J. & King, M. (1973) Treatment dropouts from a community mental health centre. Community Mental Health Journal, 9, 354-360.[Medline]
Koch, A. & Gillis, L. (1991) Non-attendance of psychiatry out-patients. South African Medical Journal, 80, 289-291.[Medline]
Louks, J., Mason, J. & Backus, F. (1989) AMA discharges: prediction and treatment outcome. Hospital and Community Psychiatry, 40, 299-301.[Medline]
Mohl, P., Martinez, D., Ticknor, C., et al (1991) Early dropouts from psychotherapy. Journal of Nervous and Mental Disease, 179, 478-481.[Medline]
Mirandola, M., Baldassari, E., Beneduce, R., et al (2000) A standardised and reliable method to apply the Global Assessment of Functioning (GAF) scale to psychiatric case records. International Journal of Methods in Psychiatric Research, 9, 79-86.
Molnar, G. & Pinchoff, D. (1993) Factors in patient elopements from an urban state hospital and strategies for prevention. Hospital and Community Psychiatry, 44, 791-792.[Medline]
Pekarik, G. (1983) Improvement in clients who have given different reasons for dropping out of treatment. Journal of Clinical Psychology, 39, 909-913.[Medline]
Percudani, M., Belloni, G., Contini, A., et al
(2002) Monitoring community psychiatric services in Italy:
differences between patients who leave care and those who stay in treatment.
British Journal of Psychiatry,
180,
254-259.
Robin, A. (1976) Rationing out-patients: a defence of the waiting list. British Journal of Psychiatry, 129, 138-141.[Abstract]
Ruggeri, M. & Dall'Agnola, R. (1993) The development and use of Verona Expectations for Care Scale (VECS) and the Verona Service Satisfaction Scale (VSSS). Psychological Medicine, 23, 511-524.[Medline]
Ruggeri, M., Dall'Agnola, R., Agostini, C., et al (1994) Acceptability, sensitivity and content validity of VECS and VSSS in measuring expectations and satisfaction in psychiatric patients and their relatives. Social Psychiatry and Psychiatric Epidemiology, 29, 65-276.
Ruggeri, M., Biggeri, A., Rucci, P., et al (1998) Multivariate analysis of outcome of mental health care using graphical chain models. Psychological Medicine, 28, 1421-1431.[CrossRef][Medline]
Ruggeri, M., Leese, M., Thornicroft, G., et al
(2000) Definition and prevalence of severe and persistent
mental illness. British Journal of Psychiatry,
177,
149-155.
STATA Corporation (2000) STATA Statistical Software. Release 7.0. College Station, TX: Stata Corporation.
Sytema, S., Micciolo, R. & Tansella, M. (1997) Continuity of care for patients with schizophrenia and related disorders: a comparative South-Verona and Groningen case register study. Psychological Medicine, 27, 1355-1362.[CrossRef][Medline]
Tansella, M., Micciolo, R., Biggeri, A., et al (1995) Episodes of care for first-ever psychiatric patients. A long-term case-register evaluation in a mainly urban area. British Journal of Psychiatry, 167, 220-227.[Abstract]
Tansella, M., Amaddeo, F., Burti, L., et al (1998) Community-based mental health care in Verona, Italy. In Mental Health in our Future Cities (eds D. Goldberg & G. Thornicroft), pp. 239-262. Hove: Psychological Press.
Tehrani, E., Krussel, J., Borg, L., et al (1996) Dropping out of psychiatric treatment: a prospective study of a first admission cohort. Acta Psychiatrica Scandinavica, 94, 266-271.[Medline]
Thornicroft, G. & Tansella, M. (1999) The Mental Health Matrix. A Manual to Improve Services. Cambridge: Cambridge University Press.
Trepka, C. (1986) Attrition from an out-patient psychology clinic. British Journal of Medical Psychology, 59, 181-186.[Medline]
World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO.
Young, A., Grusky, O., Jordan, D., et al
(2000) Routine outcome monitoring in a public mental health
system: the impact of patients who leave care. Psychiatric
Services, 51,
85-91.
Received for publication June 15, 2001. Revision received April 15, 2002. Accepted for publication June 11, 2002.
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