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A STUDY OF A PSYCHIATRIC FOLLOW-UP

OUT-PATIENT CLINIC

by

AJIT K. SHAH MBChB, MRCPsych.

Consultant in Psychiatry of Old Age, West London Healthcare NHS Trust

SUMMARY

A study of the characteristics of attenders and non-attenders at a psychiatric follow-up clinic is reported. Twenty-one percent of the patients failed to attend the clinic. Patients with physical illness were more likely to attend the clinic, probably because they were more used to attending hospital clinics and may be referred by other hospital specialists. The strongest predictor of non-attendance was a previous history of non-attendance. The associations between non-attendance, increased length of psychiatric history and greater number of previous admissions suggest that these patients may have had severe illness without insight. Formal evaluation of educational strategies to improve insight and attendance rates is suggested.KEY WORDS Psychiatry, out-patients, clinic, non-attendance.

INTRODUCTION

Over 80% of psychiatric out-patient visits in England are for follow-up (Department of Health, 1991). With the contemporary emphasis on community psychiatry, the role of the out-patient clinic is becoming more refined and less prominent (Shah & Lynch, 1990). Several studies have reported predominantly on new out-patient clinics (Kessel & Hassall, 1971; Johnson, 1973; Huws, 1991; Thapar & Ghosh, 1991; Baggaley, 1993; Woods, 1992; Hillis, 1990).Amongst new psychiatric out-patients the commonest diagnosis is depressive illness (up to 42%) followed by personality disorder (up to 30%) (Johnson, 1973; Kessel & Hassall, 1971). Neurosis other than depressive disorders account for up to 26% of the out-patients (Johnson, 1973; Kessell & Hassall, 1971). Significantly, no psychiatric morbidity was detected in almost 10% of new out-patients (Johnson, 1973; Kessel & Hassall, 1971). Amongst new out-patients, diagnosis of personality disorder, neurosis and no psychiatric disorder are commonest in the younger age groups, diagnosis of depression and schizophrenia in the middle aged and organic psychosyndromes in the elderly (Johnson, 1973). Sex ratio of new out-patients favours women, particularly with a diagnosis of depressive illness (Johnson, 1973; Kessel & Hassall, 1971).Studies of new out-patients missing their out-patient appointments have shown that the socio-demographic factors are not important (Thapar & Ghosh, 1991; Baggaley, 1993; Frankel et al., 1989), although younger patients are less likely to keep their appointments (Thapar & Ghosh, 1991). Psychiatric diagnosis appears not to discriminate between patients who keep their appointments and those who do not. Administrative factors and other factors independent of the patient are thought to be more relevant (Thapar & Ghosh, 1991; Baggaley, 1993; Frankel et al., 1989). Patients not keeping their appointments tended to have received their appointments at relatively short notice (Thapar & Ghosh, 1991), tended to rely on public transport for attending the hospital (Thapar & Ghosh, 1991) and tended to perceive the appointment as being organised to please the doctor rather than themselves (Thapar & Ghosh, 1991). In the cases of some patients who missed appointments, their psychiatric illness had improved between the referral and the appointment (Thapar & Ghosh, 1991).Factors that may improve attendance rates include reassurance and allaying fears about psychiatry (Skuse, 1975), providing the patient with an adequate explanation about the nature and purpose of the referral at the time of the referral, providing patients with information on social service or hospital funding of transport to/from the hospital (Thapar & Ghosh, 1991). It has been suggested that if psychiatric out-patient clinics are held in general practice health centres, as opposed to hospitals, the attendance rates are likely to be higher (Woods, 1992; Shah, 1991).

Although there is a wealth of information about the characteristics of new psychiatric out-patients, only one pilot study has reported on the characteristics of follow-up psychiatric out-patients (Shah & Lynch, 1990). This study, with a small sample size, reported that the majority of follow-up patients have a diagnosis of schizophrenia or manic-depressive illness, and they attended the clinic for monitoring of their mental state and prescription of psychotropic drugs. The majority of these patients had only limited access to social service facilities, such as day centres, in the community. Thirty-eight percent of the patients failed to keep their appointments at this clinic and the only predictor of non-attendance was a previous history of non-attendance. With this in view, a study with the following aims was undertaken: to describe the characteristics of follow-up psychiatric out-patients, to identify factors associated with patients who miss their follow-up appointments, and avenues likely to improve attendance rates.

METHOD

The study was performed in a general psychiatry out-patient follow-up clinic at a London teaching hospital. The psychiatric department catered for general psychiatry and had specialist services for eating disorders and psychogeriatrics. It had 60 inpatient beds and two day hospitals.

1. SAMPLE

All patients scheduled to attend the clinic for a prospective six month period were included.

2. DATA COLLECTION

An itemised questionnaire (Shah & Lynch, 1990) was completed with the aid of case-notes, interview with the patient (for attenders only) and personal knowledge of the patients. Data on age, sex, marital status, employment, diagnosis, previous psychiatric history, previous admissions, previous deliberate self-harm, drug or alcohol misuse, psychotropic prescription, attendance at day centres, registration with a general practitioner, presence of physical illness, accommodation and previous history of non-attendance were collected. Previous psychiatric history was defined as any contact with psychiatric services prior to attending the clinic.

3. COMPARISON OF ATTENDERS AND NON-ATTENDERS

RESULTS

During the study period 57 patients had appointments to attend this clinic. The characteristics of these patients are illustrated in Table 1. The most notable features are that almost 90% (n=51) of the patients had a diagnosis of either manic-depressive illness (46%) or schizophrenia (44%), almost 90% had a previous psychiatric history and over 80% were receiving psychotropic drugs. It is also of significance that only 3.5% (n=2) of the patients were attending day centres. 

TABLE 1: The characteristics of patients given appointments for follow-up psychiatric clinics.Median age (Range) years: 49 (20 - 77)

Twenty-one percent of the patients (n=12) failed to keep their appointments. The characteristics of attenders and non-attenders are shown in Table 2. There were no statistically significant differences between patients who kept their appointments and those who did not in terms of age, sex, marital status, diagnosis, family psychiatric history, psychotropic medication, employment, attendance at a day centre, follow-up by other health care providers, accommodation, alcohol or substance misuse and deliberate self-harm. Patients who missed their appointment had a longer psychiatric history (Wilcoxon’s rank test, P<0.04) and a greater number of hospital admissions (Wilcoxon’s rank test, P<0.003). Also, the number of patients with hospital admission was over-represented among the patients who missed their appointment (X2=4.72, 1d.f., P<0.03). Previous history of non-attendance was associated with non-attendance (X2=4.49, 1d.f., P<0.04).

TABLE 2: Characteristics of patients who keep their appointments and those who do not.

NS = Not significant* X2=4.5, 1d.f., P<0.04**X2=23, 1d.f., P<0.0001***Wilcoxon’s rank test, P<0.04

****Wilcoxon’s rank test, P<0.003

DISCUSSION

The characteristics of patients in this clinic were similar to those reported in a previous study of a teaching hospital follow-up clinic (Shah & Lynch, 1990) and this was not surprising, as both clinics were in the inner city London area. The majority of the patients had schizophrenia or manic-depressive illness. Patients with either diagnosis are liable to chronicity and recurrent relapse, and this explains the previous psychiatric history in 90% of patients. In contrast, among new out-patients, depression and personality disorder account for majority of the diagnosis (Johnson, 1973). Patients with schizophrenia and manic depressive illness are more likely to be on medication and hence attend the clinic for supervision of the medication. This is supported by the high rate of psychotropic drugs being prescribed. A surprising finding was that only 3.5% of patients attended day centres (47% were employed). This probably reflects relatively poor provision of such facilities in the catchment area of the hospital and has previously been demonstrated in London (Shah & Lynch, 1990).The association between patients who keep their appointments and physical illness may be explained by the assumption that physically ill patients are used to attending hospitals and may have been referred by other hospital doctors. The strongest predictor of non-attendance was a previous history of non-attendance which is consistent with previous studies in psychiatric follow-up (Shah & Lynch, 1990) and new (Frankel et al., 1989) patient clinics. A significant number of patients (21%) failed to keep their out-patient appointments. This clearly is inefficient and as the non-attended appointment also has to be funded it is very expensive. In the current era of budgetary cut-backs, strategies to use this scarce resource more efficiently should be developed. One suggestion is to over-book appointments (Baggaley, 1993). However, this would be difficult to implement in practice as non-attendance is variable from clinic to clinic and difficult to predict in advance (Baggaley, 1993). The association between patients who fail to keep appointments and length of psychiatric history and the number of previous admissions suggests that these patients may have severe illness with reduced insight. Allaying fears about psychiatry (Skuse, 1975), reassurance about the nature and purpose of the appointment (Thapar & Ghosh, 1991) and general education about mental illness may be valuable here in improving attendance among such patients. Health service policy makers should commission research evaluating the efficacy of such strategies in improving attendance rates.

This study did not address factors not directly related to the patients (such as availability of transport to/from hospital, when they received the appointment, and convenience of the appointment time). This is an important area for further study and policy makers should commission such research. An alternative approach for monitoring patients who do not keep their appointments is follow-up at home by the psychiatrist or other mental health workers like community psychiatric nurses. Many of the advantages of such home visits have been described elsewhere (Shah, 1992; Shah & Ames, 1994) and home visits are routinely used in some psychogeriatric services (Shah, 1992 , Shah & Ames, 1994). One estimate suggests they are only slightly more expensive than out-patient visits (Shah, 1992). However, prospective evaluative studies measuring the efficacy of out-patient clinic follow-up with home visits are required before unequivocally advocating them. Any research in this area should include cost-effectiveness analysis.

REFERENCESBaggaley M. Improving the attendance for new psychiatric out-patient referrals. Psychiatric Bulletin. 1993; 17: 347-348.Department of Health. Health and Personal Social Services Statistics for England 1991. London: HMSO. 1991Frankel S, Farrow A, West R. Non-attendance or non-invitation? A case control study of failed out-patient appointments. British Medical Journal. 1989; 298: 1343-1345.Hillis G. Rejection of psychiatric treatment. Psychiatric Bulletin. 1990; 14: 149-150.

Huws R. Non attenders at a marital and psychosexual difficulties clinic. Psychiatric Bulletin. 1991; 15:8-9.

Daw J. An analysis of out-patient services. British Journal of Psychiatry. 1973; 22: 301-306.Kessel WIN, Hassall C. Evaluation of the functioning of the Plymouth Nuffield Clinic. British Journal of Psychiatry. 1971; 118: 305-312.Shah A. K, Lynch S. Characteristics of patients in a psychiatric follow-up clinic. Psychiatric Bulletin. 1990; 14: 153-154.Shah A. K. An aspect of community psychiatry training: a senior registrar’s experience. Psychiatric Bulletin. 1991; 15: 424-425.

- - - - Home visits by psychiatrists. British Medical Journal. 1992; 304: 780.

Shah A. K., Ames D. Developing and planning psychogeriatric services. International Review of  Psychiatry. 1994; 6: 15-27.Skuse D. Attitudes to the psychiatric out-patient clinic. British Medical Journal. 1975; 3: 469-471.Thapar A, Ghosh A. Non-attendance at a psychiatric clinic. Psychiatric Bulletin. 1991; 15: 205-206.

Woods J. Can psychiatrists predict which new referral will fail to attend? Psychiatric Bulletin. 1992; 16: 18-19.

Correspondence

Dr Ajit Shah John Connolly UnitWest London Healthcare NHS TrustUxbridge Road, SouthallMiddlesex UB1 3EU

Telephone: (UK) 0181 967 5045 Facsimile: (UK) 0181 967 5798 E-mail: a.k.shah@ic.ac.uk

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