The elusive population: characteristics of attenders versus non-attenders for community mental health center intakes

A multicenter randomized controlled trial of aftercare services for severe mental illness: study protocol

BACKGROUND

Severe mental illness is responsible for a significant proportion of burden of diseases in Iranian population. People with severe mental illnesses are more likely to have high rates of non-attendance at follow-up visits, and lack of an active follow-up system, particularly in the country's urban areas that has resulted in the revolving door phenomenon of rehospitalizations. Therefore, there is an increasing need for implementation of effective and cost-effective aftercare services.

METHOD/DESIGN

This is a randomized control trial with the primary hypothesis that aftercare services delivered to patients with severe mental illnesses in outpatient department and patient's home by a community care team would be more effective when compared to treatment as usual (TAU) in reducing length of hospital stay and any psychiatric hospitalization. Patients were recruited from three psychiatric hospitals in Iran. After obtaining informed written consent, they were randomly allocated into aftercare intervention and control (TAU) groups. Aftercare services included treatment follow-up (through either home care or telephone follow-up prompts for outpatient attendance), family psychoeducation, and patient social skills training that were provided by community mental health teams. Patients were followed for 12 months after discharge. The primary outcome measures were length of hospital stay and any hospitalization in the 12 month follow-up. Secondary outcome measures included patients' clinical global impression, global functioning, quality of life, and patient's satisfaction. The trial also allowed an assessment of direct cost-effectiveness of the aftercare services.

DISCUSSION

This paper presents a protocol for an RCT of aftercare services delivered to patients with severe mental illnesses within patients' home or outpatient department. The findings of this study can influence policy and program planning for people with severe mental illnesses in Iran.

TRIAL REGISTRATION

IRCT201009052557N2.

A study of attendance and filling in of pre-appointment questionnaires in an outpatient clinical psychology service

This study looked at whether filling in pre-appointment questionnaires was related to attendance in an adult clinical psychology out-patient service. Comparisons were made between attenders who filled in forms, attenders who did not fill in forms, non-attenders who filled in forms and non-attenders who did not fill in forms. The variables compared were: age, source of referral, reason for referral, gender, Health Authority, ethnic origin, marital status, level of anxiety (BAI), level of depression (BDI) and severity of symptoms (SCL-90). Attendance was much higher in those who filled in pre-appointment questionnaires (75% v. 35%). In addition, non-attenders who filled in questionnaires were younger than most of the other groups; attendance rates were raised with consultant referrals; GP referred clients were less likely to fill in questionnaires; and, among form fillers, non-attenders were more likely to be single. The results are discussed with reference to their service implications.

Does an encouraging letter encourage attendance at psychiatric out-patient clinics? The Leeds PROMPTS randomized study

BACKGROUND

The aim was to reduce non-attendance for first-time consultations at psychiatric out-patient clinics.

METHOD

The study was a pragmatic randomized controlled trial; the setting was seven inner-city UK out-patient clinics in Leeds. The participants were 764 subjects of working age with an appointment to attend a psychiatric out-patient clinic for the first time. The intervention was an 'orientation statement' letter delivered 24-48 h before the first appointment compared with standard care. The primary outcome measure was attendance at the first appointment; secondary outcomes included hospitalization, transfer of care, continuing attendance, discharge, presentation at accident and emergency and death by 1 year.

RESULTS

Follow-up was for 763 out of 764 subjects (>99%) for primary and for 755 out of 764 subjects (98.8%) of secondary outcome data. The orientation statement significantly reduced the numbers of people failing to attend [79 out of 388 v. 101 out of 376 subjects, relative risk 0.76, 95% confidence interval (CI) 0.59-0.98, number needed to treat 16, 95% CI 10-187].

CONCLUSIONS

Prompting people to go to psychiatric out-patient clinics for the first time encourages them to attend. Pragmatic trials within a busy working environment are possible and informative.

The effects of preparing parents for child psychotherapy on accuracy of expectations and treatment attendance

This study used an experimental design to evaluate the effectiveness of two procedures designed to inform parents about the workings of child therapy, increase the accuracy of their expectations for their child's treatment, and thereby improve their attendance rates. The informational materials explained the importance of parental involvement, how play is used in therapy, confidentiality, and the importance of persisting with treatment until goals are met. Participants were 149 parents or primary caretakers of children aged 3-10 years old. The findings were that: (1) The combination of a brochure and videotape increased the accuracy of parental expectations; (2) the brochure alone had no effect; (3) parents with more accurate expectations had higher rates of treatment utilization on 2 of 7 indices of attendance; and (4) the preparation procedures did not improve attendance rates. Implications for understanding and improving parental utilization of child therapy services are discussed.

Prompts to encourage appointment attendance for people with serious mental illness

BACKGROUND

Prompts to encourage attendance at clinics are often used in day-to-day practice by diligent carers of people with mental health problems. These may take the form of telephone prompting, financial incentives or issuing a copy of the referral letter to the appointee.

OBJECTIVES

To estimate the effects of simple prompting by professional carers to encourage attendance at clinics for those with serious mental illness.

SEARCH STRATEGY

Methodical searches of Biological Abstracts (1985-2000), CINAHL (1982-2000), Cochrane Schizophrenia Group's Register (June 2000), Cochrane Library (Issue 2, 2000), EMBASE (1980-2000), MEDLINE (1966-2000) and PsycLIT (1887-2000) were undertaken. These were supplemented by searching of reference lists, personal contact and hand searching of high yield journals.

SELECTION CRITERIA

All relevant randomised (or quasi-randomised) studies comparing the addition of 'prompts' to standard care for those with serious mental illnesses such as schizophrenia. Prompts had the stated purpose of encouraging attendance or contact with mental health teams and could be text-based, electronic, by telephone call, by personal visit, or could employ financial or other rewards.

DATA COLLECTION AND ANALYSIS

Studies and data were independently selected and extracted. For homogeneous dichotomous data the random effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data the reviewers calculated weighted mean differences.

MAIN RESULTS

Only three relevant trials were identified (total n=597). It is not clear whether there is any real difference between attendance of those prompted by telephone one or two days before the appointment, and those given the standard appointment management system (2 trials, n=457, RR missed appointment 0.84 CI 0.7 to 1.1). Text-based prompts, a few days before the appointment day, did increase clinic attendance when compared with no prompt (2 trials, n=200, RR missed appointment 0.6 CI 0.4 to 0.9, NNT 6 CI 2 to 14). Only one small study (n=61) reported data on the combination of telephone and text-based prompts versus no prompt (RR missed appointments 0.7 CI 0.4 to 1.2). When telephone prompts were compared with text-based prompts (1 trial, n=75), the latter, in the form of an 'orientation statement' (a short paragraph, taking about 30 seconds to read, explaining the programme of care, the fee system, and providing gentle encouragement) may be somewhat more effective than the telephone prompt (RR missed appointments 1.9 CI 0.98 to 3.8). One last study (n=120) compared a standard letter prompt with a letter 'orientation statement'. Overall, results tended to favour the orientation statement approach rather than the simple letter prompting attendance but the results did not reach conventional levels of statistical significance (RR missed appointments 1.6 CI 0.9 to 2.9).

REVIEWER'S CONCLUSIONS

There is evidence that a simple prompt to attend clinic, very close to the time of the appointment may encourage attendance, and a simple orientation-type letter, 24 hours before the clinic appointment, may be more effective than a telephone prompt. This simple intervention could be a more cost effective means of encouraging compliance at first attendance, but supplementing these data with the results of large, well designed, conducted and reported randomised studies would be desirable.

Predictors of receiving aftercare 1, 3, and 18 months after a psychiatric emergency room visit

This study used logistic regression to predict the receipt of aftercare within one, three, and eighteen months of an emergency room visit for individuals with a severe mental illness. Two psychiatric history variables (had previous psychiatric admissions and was currently receiving outpatient treatment) and one system responsiveness variable (was not admitted at the index emergency room visit) predicted receiving aftercare at all three points in time. In general, variables measuring a client's psychiatric history and the responsiveness of the treatment system appear to be better predictors of the receipt of aftercare than client background variables.