Psychiatry Research
Volume 157, Issue 1 , Pages 53-65, 15 January 2008

What happens to patients seen only once by psychiatric services? Findings from a follow-up study

Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, 37134 Verona, Italy

Received 16 December 2005; received in revised form 20 March 2006; accepted 15 May 2006.

Article Outline

Abstract 

The aim of this study was to identify patient characteristics associated with once-only contact with a community-based mental health service (CMHS) and to re-evaluate these patients 3 months after the contact. A 33-month cohort of new episodes of care was followed up to identify and interview once-only contact patients. Of the 1101 patients who met the study criteria, 165 (15%) were discharged after the first contact, 87 (8%) dropped out after the first contact, 440 (40%) were low users and 409 (37%) were high users of the CMHS in the 90 days after the first contact. A higher score on the Global Assessment of Functioning scale, less severe psychiatric diagnoses and lower socioeconomic status were the factors most associated with once-only contact at baseline. At follow-up clinical conditions of patients who had only one contact (both discharged patients and drop-outs) had improved and, in most cases, they were in contact with other services. Drop-out patients, however, were more unwell and less satisfied with the initial contact. This dissatisfaction may have led these patients to seek help elsewhere. It is possible that some of these extremely low users are in need of a different or more specialized clinical treatment approach.

Keywords: Assessment, Mental health services, Low service use, Once-only contact, Patterns of care

 

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1. Introduction 

The goals of community-based mental health services are to identify people suffering from psychiatric problems and to provide them with appropriate care for as long as required. Therefore, the number of patients who do not return after the first visit could be considered as a key outcome indicator in this setting. Previous studies found that a substantial number of patients seen in psychiatric services have only one contact with those services. The studies that report data on this topic cover a period of about 30 years and have shown that service users of this type constitute between 9% and 63% of all those seen by a service (Baekeland and Lundwall, 1975, Henisz et al., 1977, Lavik, 1983, Trepka, 1986, Taube et al., 1988, Balestrieri et al., 1989, Sytema et al., 1989, Chen, 1991, Tansella et al., 1995, Morlino et al., 1995, Amaddeo et al., 1998, Rossi et al., 2005a, Rossi et al., 2005b). This wide range in the percentage of patients seen only once in a psychiatric setting could be due to differences in study design, patient populations, treatment settings and criteria used to define once-only contact. Furthermore, the proportion of once-only contact patients seems to have increased over time. In the last 25 years, in many developed countries there has been a gradual shift from hospital-centred to community-based mental health care. This trend, with increasing rates of once-only contact patients, may therefore be the result of improved access to out-patient and community-based mental health services (Tansella et al., 1998, Saraceno and Saxena, 2005). Intuitively, it is likely that once-only contact patients are quite different from patients who engage in treatment. Only a few of the studies reported above, however, have described the characteristics of such patients. In a study examining attrition among out-patients referred to clinical psychologists, it was found that patients who attended only once were more likely to belong to a lower social class and were more likely to have been referred by physicians with whom psychologists had poorer contact (Trepka, 1986). A recent 8-year retrospective cohort study found that compared with patients with more than one contact, patients who had once-only contact were more likely to be older, to be male, to be of lower socioeconomic status and to have a less severe psychiatric diagnosis. They were also more likely to be referred by consultation/liaison or emergency room services (Rossi et al., 2005a). In a subsequent comparative case register study carried out in South Verona and Western Australia, it was found that only clinical characteristics were significant determinants of this pattern of contact with services at both sites: the less severe the patient's diagnosis, the more likely the patient was to have a once-only contact (Rossi et al., 2005b). A limitation of these studies is that case register data only monitor the number of contacts with the service and do not provide reasons for the failure to follow up an initial contact. This limited information does not allow us to differentiate between patients with only one contact with the services because of a decision agreed with the clinician and those who dropped out of treatment. In this regard, it has been demonstrated that patients who inappropriately terminate contact with specialist services (drop-out) tend to be younger (Baekeland and Lundwall, 1975, Phillips and Ali, 1983, Tehrani et al., 1996, Chen, 1991, Young et al., 2000, Rossi et al., 2002, Edlund et al., 2002) and to be of lower socioeconomic status (Trepka, 1986, Chen, 1991, Baekeland and Lundwall, 1975). Moreover, no study has addressed the issue of what happens to once-only contact patients after the single contact with the service. It was considered that a follow-up study would reveal more about this.

The aims of this study are as follows:

1)to compare socio-demographic, clinical and contact characteristics among patients who dropped out after the first visit, patients who had been discharged after the first visit and patients with more than one contact with the South Verona CMHS;

2)to identify factors associated with these different types of service utilization; and

3)to evaluate clinical conditions, satisfaction with the service, utilization of other services and drug use in the group of once-only contact patients during the 3 months after the single contact.

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2. Methods 

2.1. Setting 

South Verona is a predominantly urban area on the southern outskirts of Verona, a city of about 260,000 inhabitants, located in northern Italy, halfway between Milan and Venice and on the route from Italy to central Europe. The total population of South Verona (that includes part of the city of Verona and four neighbouring small towns) is about 100,000 (population density 1073/km2).

In South Verona, in accordance with Italian Mental Health legislation (1978), mental health care is organized according to a district model, serves a geographically well-defined area and is supported by the National Heath Service (Tansella and Williams, 1987). The main agency providing psychiatric care for the adult population is the South Verona Community Mental Health Service (CMHS), which is run by the Section of Psychiatry and Clinical Psychology of the University of Verona. The CMHS supplies a wide range of well-integrated hospital and community services including an inpatient ward at the University General Hospital, a Community Mental Health Centre providing day care and rehabilitation, out-patient departments, scheduled domiciliary visits, a liaison service for psychiatric and psychological consultations for other departments of the General Hospital, a 24-hour accident and emergency department, a 24-hour staffed hostel, and sheltered apartments. Professionals involved in the clinical activities are psychiatrists, psychiatrists in training, psychologists, social workers and psychiatric nurses. With the exception of hospital nurses, all staff work both inside and outside of the hospital (single staff module). This ensures continuity of care through the different phases of treatment and across the various components of service provision.

2.2. 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 CMHS 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 are counted as contacts. The PCR also routinely records details of patients who leave the catchment area and those who die. Estimates of time spent for each outpatient 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.

2.3. Definition of once-only contact 

The most useful and accepted definition of the end of an episode of care in the field of psychiatric epidemiology, which has been tested using the case register data, is “90 days or more without any contact” (Tansella et al., 1995). Taking into account this definition, we decided to use this length of time to define a once-only contact patient. Based on the PCR, all patients who had their first-ever contact, or a new contact after at least 365 days without contacts with the South Verona CMHS (inclusion criteria), were followed-up for 90 days after their first contact, in order to identify those individuals who, during this period, had not had any successive contact with the service (once-only contact patients). As we could not exclude the possibility that the PCR may have missed some contacts, after having identified a patient as a once-only contact by means of the register, we double-checked with the clinician who made the first visit to be sure that the patient had not had any other contact over the follow-up period.

In a previous study, in order to assess the robustness of the results with respect to this definition of once-only contact, a sensitivity analysis was carried out using longer periods before re-contact (4, 5, 6, 12, and 24 months) (Rossi et al., 2005a). It showed the validity of this definition as the results did not change, despite increasing the length of time without contacts.

2.4. Study sample 

All patients seen in the South Verona out-patient department in the period between December 2001 and September 2004 who met the inclusion criteria of the study were included in the sample. According to local regulations, no formal approval by the local ethics committee was necessary for this study. At the conclusion of the initial meeting with each of these patients, the clinician recorded whether or a not a subsequent appointment with the patient had been fixed. We used information to divide patients into the following groups: (a) patients who dropped out after the first contact, (b) patients who had been discharged after the first contact and (c) patients with at least one contact with the service over the 90 days after the first visit (patients with more than one contact). Within the CMHS, after the first visit, a patient can be treated as an out-patient, in-patient or day patient, i.e. for a shorter or longer time within different settings. All settings and services are run by the same team. In order to obtain a cumulative measure of the consumption of service, Lavik (1983) proposed an index of total consumption of service (SCS) constructed using the following principles: one out-patient consultation=1 point; one contact in day care service=2 points, one day in in-patient service=3 points.

According to their SCS score, patients with more than one contact were then divided into two sub-groups: low users (1–3 index points) and high users (>3 index points). The cut-off score used to distinguish high from low service users was the median of the distribution.

2.5. Case register data collection 

According to previous studies and Andersen's Behavioural Model of Health Service use (Andersen and Newman, 1973), the use of health services is predicted by the combined effects of socio-demographic and clinical factors. The following data on patients' and contact characteristics were collected in relation to every contact that met the inclusion criteria over the study period:

1.Socio-demographic information: gender, age, marital status, living condition, educational level, employment status;

2.Type of contact (scheduled or unscheduled);

3.Type of referral: patient himself/herself, patient's family or neighbour, other specialists, general practitioners or South Verona CMHS staff (the latter are patients seen in consultation/liaison or in the emergency room and referred by a psychiatrist to the CMHS);

4.Whether the patient had previous contacts with the South Verona CMHS before this visit;

5.Length of the visit (number of minutes);

6.Presence/absence of physical illness;

7.Global Assessment of Functioning score.

Diagnoses were also collected according to the ICD-10 classification system, and then collapsed into six groups: 1) non-mental disorders; 2) schizophrenia and related disorders; 3) manic and bipolar disorders or depression with psychotic symptoms; 4) depression without psychotic symptoms; 5) anxiety-related and somatoform disorders; 6) personality disorders; 7) adjustment disorders; 8) substance-related disorders; and 9) organic mental disorders such as mental retardation and dementia.

2.6. Data collected at the follow-up 

Once a patient was identified as a once-only contact with the service, he or she was invited for an interview with one of the researchers. This invitation was via a letter posted to the patient where the research staff explained the purposes of the study, making it clear that participation was entirely voluntary and that participants would receive 15 Euros for their time. The patient was also invited to choose the venue, either at the Research Centre or at the patient's home. If a reply to the mailed letter was not received within 10 days, patients were called by telephone. Written informed consent was obtained from each patient who agreed to be interviewed. The following instruments were used: the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998); the General Health Questionnaire (GHQ-12) (Goldberg et al., 1997); the Verona Service Satisfaction Scale (VSSS) (Ruggeri and Dall'Agnola, 1993); the Global Assessment of Functioning (GAF) (Endicott et al., 1976) and an open question about the patient's reasons for terminating contacts with the services. All medical, psychiatric and informal cares received and drug utilization in the 90 days after the contact with the CMHS were recorded using the Italian version of the Client Services Receipt Interview (Amaddeo et al., 1996).

The reliability of the Italian versions of these instruments has been demonstrated (Ruggeri and Dall'Agnola, 1993, Piccinelli et al., 1993, Mirandola et al., 1999, Mirandola et al., 2000) apart from the MINI. We therefore undertook a study to evaluate the reliability of this instrument in its Italian version. The results indicated a very high interrater reliability of this version of the interview (Rossi et al., 2004).

2.7. Statistical analyses 

Three dependent variables were defined and separately analysed: (1) drop-out after the first contact vs. discharged after the first contact, (2) all once-only contact vs. low users, and (3) all once-only contact vs. high users.

Associations between dependent variables and socio-demographic and clinical characteristics were first analysed by two-way contingency tables. Fisher's exact test was used to test the null hypothesis of no association between the dependent variable and each explanatory variable. The strength of the association between categorical variables was measured by Cramer's V statistic (Agresti, 1996).

Multivariate analysis was performed by estimating a multiple logistic regression model. The selection of the set of variables to enter the model is a crucial and challenging step in the model-building procedure. Classical forward selection and backward elimination algorithms for automatic variable selection have a series of well-known disadvantages (Derksen and Keselman, 1992). The approach we adopted was to avoid relying on a single method alone, and instead to apply a set of selection algorithms: backward and forward selection together with bootstrapped stepwise selection (Austin and Tu, 2004) and random forests (Breiman, 2001). Variables chosen by at least one of these procedures were then used to build the multiple logistic model.

Goodness of fit of the model was assessed by the Hosmer and Lemeshow statistic (Hosmer and Lemeshow, 2000). The proportion of variance accounted for by the model was evaluated using Efron's R2 (Hosmer and Lemeshow, 2000).

Prospectively collected data were analyzed comparing patients who dropped out after the first visit with patients who were discharged after the first visit. These comparisons were conducted using Fisher's exact test for categorical variables (MINI diagnosis, service use and drug utilization) and the Wilcoxon rank sum test for continuous variables (GAF, GHQ and VSSS score). Univariate and multivariate analyses were undertaken using Stata 8.0 (StataCorp, 2001). Random forests were estimated by the software R (Ihaka and Gentleman, 2005) together with the varselRF package (Díaz-Uriarte and Alvarez de Andrés, 2005).

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3. Results 

During the study period, a total of 1101 new episodes of care met the inclusion criteria of the study. Of these, 165 patients (15%) were discharged after the first contact, 87 (8%) dropped out after the first contact, 440 (40%) were low users and 409 (37%) were high users of the CMHS in the 90 days after the index contact. The total number of patients was 1088; 13 of them entered the study two times. Between March 2002 and December 2004, an intensive effort was made to locate all the once-only contact patients using PCR data (patient's address and phone number when available), clinicians at the CMHS and, when necessary, the local council register of residents. Of the 252 patient with once-only contact, 100 (40%) agreed to be interviewed, 76 (30%) refused to participate and 76 (30%) were untraceable.

Table 1 presents the characteristics of the sample and the variables that were statistically significant. Table 2 presents the final logistic regression models selecting factors associated with these different types of service utilization (once-only contact, low users and high users). As the univariate analyses did not show any significant difference between patients who dropped out and those who were discharged after the first contact, we assumed that they represented a uniform group and, in the rest of the case register data analyses, we collapsed them into one group (all once-only contact patients).

Table 1. Socio-demographic, contact characteristics and clinical information for which differences were found between patients with once-only contact and patients with more than one contact with the South Verona CMHS
Independent variablesPatients with once-only contact (o.o.c.)Patients with more than one contactCramer's statistic (P by Fisher's exact test)
Discharged after the first contact (n=165) n (%)⁎Dropped out after the first contact (n=87) n (%) ⁎Low users (n=440) n (%) ⁎High users (n=409) n (%) ⁎o.o.c. discharged vs. o.o.c. drop-outAll o.o.c. vs. low usersAll o.o.c. vs. high users
Gender
Male72 (43.6)31 (35.6)176 (40.0)159 (38.9)0.070.010.02
Female93 (56.4)56 (64.4)264 (60.0)250 (61.1)(0.229)(0.822)(0.610)
Age (years)
<2511 (6.7)5 (5.7)44 (10.0)55 (13.4)0.110.110.22
25–4552 (31.5)36 (41.4)167 (37.9)198 (48.4)(0.399)(0.035)(<0.001)
45–6042 (25.4)22 (25.3)124 (28.2)83 (20.3)
>6060 (36.4)24 (27.6)105 (23.9)73 (17.8)
Median age (range), median test P52 (15–94)46 (18–87)46 (16–90)39 (15–89)0.1420.025<0.001
Marital status
Unmarried51 (31.3)24 (27.6)149 (34.2)158 (39.0)0.040.040.09
Married79 (48.5)43 (49.4)199 (45.7)176 (43.9)(0.789)(0.521)(0.056)
Widowed/separated/divorced33 (20.2)20 (23.0)87 (20.0)69 (17.0)
Living condition
Alone24 (14.8)11 (12.9)69 (16.0)48 (12.0)0.100.070.10
With partner or family127 (78.4)72 (84.7)350 (81.2)344 (86.0)(0.327)(0.226)(0.047)
In an institution11 (6.8)2 (2.3)12 (2.8)8 (2.0)
Educational level
Up to primary66 (42.9)27 (31.8)133 (32.2)75 (19.3)0.110.100.22
Secondary42 (27.3)26 (30.6)159 (38.5)157 (40.4)(0.219)(0.032)(<0.001)
Diploma/graduate46 (29.9)32 (37.6)121 (29.3)157 (40.4)
Employment status
Employed69 (43.4)46 (58.2)200 (47.4)199 (50.0)0.140.120.13
Unemployed8 (5.0)4 (5.1)52 (12.3)49 (12.3)(0.084)(0.007)(0.004)
Student/housewife/retired82 (51.6)29 (36.7)170 (40.3)150 (37.7)
Type of contact
Unscheduled6 (3.7)1 (1.2)19 (4.4)21 (5.1)0.07−0.04−0.05
Scheduled155 (96.3)82 (98.8)415 (95.6)387 (94.8)(0.428)(0.326)(0.165)
Type of referral
Patient56 (34.8)31 (37.3)175 (40.4)157 (38.6)0.120.100.14
Relative/neighbor14 (8.7)5 (6.0)38 (8.8)41 (10.1)(0.477)(0.157)(0.016)
Psychiatrist/other specialist23 (14.3)6 (7.2)48 (11.1)39 (9.6)
General practitioner57 (35.4)34 (41.0)125 (28.9)113 (27.8)
CMHS staff11 (6.8)7 (8.4)47 (10.8)57 (14.0)
Previous contacts with the South Verona CMHS
Yes38 (23.0)20 (23.0)121 (27.5)80 (19.6)0.0005−0.050.04
No (first ever patients)127 (77.0)67 (77.0)319 (72.5)329 (80.4)(1.000)(0.195)(0.288)
Length of the visit (number of minutes)
<45 min89 (56.3)46 (54.1)224 (52.0)185 (45.7)0.030.030.09
>45 min69 (43.7)39 (45.9)207 (48.0)220 (54.3)(0.684)(0.451)(0.03)
Diagnostic group
Non-mental disorders42 (29.6)15 (19.7)28 (8.0)14 (4.0)0.230.270.39
Schizophrenia and related disorders7 (4.9)3 (3.9)22 (6.3)35 (10.1)(0.120)(<0.001)(<0.001)
Manic and bipolar and depression with psychotic symptoms2 (1.4)2 (2.6)10 (2.9)21 (6.0)
Depression without psychotic symptoms44 (31.0)38 (50.0)159 (45.7)150 (43.2)
Anxiety and somatoform disorders19 (13.4)9 (11.8)66 (19.0)71 (20.5)
Personality disorders3 (2.1)2 (2.6)17 (4.9)25 (7.2)
Adjustment disorders6 (4.2)3 (3.9)20 (5.7)18 (5.2)
Substance related disorders8 (5.6)0 (0.0)5 (1.4)6 (1.7)
Organic mental disorders11 (7.7)4 (5.3)21 (6.0)7 (2.0)
Presence of physical illness
Yes71 (59.2)36 (57.1)207 (63.1)145 (49.5)0.02−0.050.09
No49 (40.8)27 (42.9)121 (36.9)148 (50.5)(0.875)(0.302)(0.056)
GAF score at contact
<5014 (9.2)8 (9.8)69 (16.6)70 (19.0)0.060.190.22
50–6038 (25.0)23 (28.0)139 (33.5)123 (33.3)(0.855)(<0.001)(<0.001)
60–7049 (32.2)28 (34.1)139 (33.5)122 (33.1)
>7051 (33.5)23 (28.0)68 (16.4)54 (14.6)
Median GAF (range), median test P65 (15–100)66 (38–98)60 (16–95)60 (9–99)0.643<0.001<0.001

⁎ Differences in simple size reflect of missing values.

Table 2. Logistic regression analyses of variables associated with once-only contact and continuation of contacts with the service by new episodes of care
Variables associated with the probability of being a patient with once-only contact as opposed of being a low user patient (N=692) Outcome variable coding: 1=once-only contact, 0=low userOdds ratioS.E.P95% CI
GAF score at the contact
<50Reference
50–601.860.730.1140.86–4.01
60–702.200.830.0421.03–4.61
>704.111.710.0011.82–9.29
Diagnostic group
Non-mental disordersReference
Schizophrenia and related disorders0.370.190.0590.13–1.04
Manic and bipolar disorders and depression with psychotic symptoms0.270.180.0510.07–1.03
Depression without psychotic symptoms0.300.09< 0.0010.17–0.53
Anxiety-related and somatoform disorders0.270.09< 0.0010.14–0.53
Personality disorders0.240.140.0150.07–0.76
Adjustment disorders0.260.130.0070.10–0.68
Substance-related disorders1.250.890.7590.31–5.10
Organic mental disorders0.700.330.4600.27–1.80
Educational level
Up to primaryReference
Secondary0.480.120.0030.29–0.78
Diploma/graduate0.860.210.5360.53–1.39
Variables associated with the probability of being a patient with once-only contact as opposed to being a high user patient (N=661) Outcome variable coding: 1=once-only contact, 0=high user
GAF score at the contact
<50Reference
50–602.581.130.0311.09–6.10
60–703.191.390.0081.35–7.52
>706.523.07<0.0012.59–16.43
Diagnostic group
Non-mental disordersReference
Schizophrenia and related disorders0.220.130.0090.07–0.68
Manic and bipolar disorders and depression with psychotic symptoms0.090.070.0010.02–0.37
Depression without psychotic symptoms0.160.06<0.0010.07–0.35
Anxiety-related and somatoform disorders0.160.07<0.0010.07–0.37
Personality disorders0.110.070.0010.03–0.40
Adjustment disorders0.210.120.0070.07–0.66
Substance-related disorders0.490.380.3540.10–2.23
Organic mental disorders1.060.730.9330.27–4.06
Educational level
Up to primaryReference
Secondary0.210.06<0.0011.12–0.38
Diploma/graduate0.270.08<0.0010.16–0.49
Referral
PatientReference
Relative/neighbor0.660.300.3650.27–1.61
Psychiatrist/other specialist1.250.470.5640.59–2.63
General practitioner1.410.360.1830.85–2.32
CMHS staff0.300.140.0100.12–0.75

3.1. Case register data analyses 

In the univariate analysis, the once-only contact and low users groups were significantly different in 5 of the 13 variables. Compared with the low users, once-only contact patients were older, less educated, less likely to be unemployed and more likely to be housewives or retired. The most significant factors, however, were clinical characteristics: patients with schizophrenia, affective disorders, and anxiety, personality and adjustment disorders were more likely to have more than one contact, while patients with substance-related disorders, organic mental disorders and, above all, patients without mental disorders were most likely to have once-only contact with the service. With regard to their GAF score, which is a measure of psychosocial ability to cope, once-only contact patients were coping better at the time of the first consultation than the low users. In the final logistic regression model, it was found that diagnostic group, GAF score and educational level were all associated with once-only contact with the service. In particular, our results show that compared with being a patient without a mental disorder, having depression without psychotic symptoms or anxiety, personality or adjustment disorders all decreased the odds of being a once-only contact patient. The other diagnostic categories were not statistically significant. Furthermore, a higher GAF score was associated with once-only contact with the service, as well as an educational level lower than secondary school. Hosmer and Lemeshow's goodness of fit test was not rejected (χ2=6.96, df=8, P=0.542). The proportion of variance accounted for by the model is small (Efron's R2=0.11). The area under the receiver operating characteristic (ROC) curve was 0.68.

In the comparison between once-only contact and high user patients, the univariate analysis identified eight variables in which they were significantly different: once-only contact patients were older, less educated, less likely to be unemployed and more likely to be housewives, retired or living in an institution. The contacts referred by the South Verona CMHS staff were significantly less likely to be “once-only”. The length of the first visit (measured in minutes) was greater for patients who then became high users. Regarding the clinical status, patients with a lower GAF score and diagnosis of schizophrenia, affective disorders, and anxiety and personality disorders were more likely to become high users, whereas patients with substance-related disorders, organic mental disorders and, above all, patients without mental disorders were most likely to have once-only contact with the service. In this comparison, the final logistic regression model revealed that the variables of diagnosis, GAF score, educational level and referral were significantly associated with once-only contact with the service. Compared with being a patient without mental disorders, all the psychiatric diagnoses (apart from substance-related and organic disorders) were associated with a high use of the service in the 3 months after the first contact. This logistic model also shows that having a higher GAF score was associated with once-only contact. On the contrary, having a higher level of education and being referred by the South Verona CMHS staff both decreased the probability of a once-only contact with the service. Also in this model Hosmer and Lemeshow's goodness of fit test was not rejected (χ2=4.89, df=8, P=0.769). The proportion of variance accounted for by the model was small (Efron's R2=0.25). The area under the ROC curve was 0.78.

3.2. Analyses of data collected at follow-up 

At the follow-up we were able to interview less than half (40%) of the once-only contact patients. Previous research (Young et al., 2000, Fisher et al., 2001) found that patients who are lost to follow-up in psychiatric studies were different at baseline from responders. They suggested that careful attention must be paid to the statistical analysis of the sample of patients being assessed, as biases can result from inadequate treatment of non-response. To assess this problem, we followed the suggestions of Hofler et al. (2005). We first compared the baseline socio-demographic and clinical characteristics of respondents and non-respondents by univariate and multivariate analyses. No statistically significant differences were found. The estimation of the sampling weights and the use of weighted data in the subsequent statistical analyses were therefore debatable because of the trade-off between bias reduction and increase in variance. Given that the two groups did not differ with respect to the set of explanatory variables considered, we preferred to use unweighted data.

Table 3 presents clinical and satisfaction with services variables for the 100 patients interviewed at follow-up. As we can see, 56% of the whole sample presented a mental disorder 3 months after the single contact (in this sub-group of patients, at baseline, the figure was 71%). Although the diagnoses received by the individuals in the two groups were not significantly different, those who left care against medical advice had received relatively more psychotic, anxiety and mood-related diagnoses than the discharged group, which contained a comparatively larger sample of persons without mental disorders. Both groups showed an improvement in the GAF score from baseline to follow-up.

Table 3. Comparisons of MINI grouped diagnoses, Global Assessment of Functioning (GAF) scale scores, General Health Questioners (GHQ) scores and Verona Service Satisfaction Scale (VSSS) scores between patients who dropped-out and those who were discharged after the first contact, interviewed 3 months after the contact
Independent variablesPatients with once-only contact, interviewed 3 months after the contact
Total sample (n=100)Discharged after the first contact (n=69) n (%)Dropped out after the first contact (n=31) n (%)P
Diagnosis at the follow-up
Non-mental disorders4433 (47.8)11 (35.5)0.664
Psychotic disorders85 (7.3)3 (9.7)
Mood disorders2013 (18.8)7 (22.6)
Anxiety disorders2616 (23.2)10 (32.3)
Substance-related disorders22 (2.9)0 (0.0)
Mean (S.D.)Mean (S.D.)Mean (S.D.)P
GAF at the first contact63.3 (20.3)63.5 (20.5)62.9 (20.2)0.893
GAF at the follow-up69.8 (13.1)68.6 (14.2)69.2 (11.8)0.803
GHQ total score at the follow-up2.8 (3.3)2.4 (3.0)3.8 (3.6)0.069
VSSS total score at the follow-up3.7 (0.7)3.8 (0.8)3.6 (0.6)0.046

No significant differences were found between the two groups regarding the GHQ score. However, the drop-out group had higher mean scores than the discharged patients, indicating a higher level of distress for the former group.

The VSSS is a questionnaire that measures satisfaction with psychiatric services. In this case the participants were asked to rate their overall feeling about the single contact that they had with the service. The total score of the VSSS lies within a 5-point Likert scale (1=“terrible”, 2=“mostly unsatisfactory”, 3=“mixed”, 4=“mostly satisfactory”, 5=“excellent”). Both groups had a level of satisfaction with the service near to “mostly satisfactory”. However, the drop-out group showed a tendency for less satisfaction, compared with the discharged group.

The type of services at which the once-only contact patients interviewed were seen in the 90 days after the single contact with the CMHS is shown in Table 4. The six variables reported represent the main health and social services (alternative to the CMHS) available in the studied area and, therefore, constitute a comprehensive set of categories against which the mental health services use made by once-only contact patients can be assessed.

Table 4. Comparisons of service use and drug utilization in the 3 months after the single contact with the South Verona CMHS between patients who dropped out and those who were discharged after the first contact
Independent variablesPatients with once-only contact, interviewed 3 months after the contact
Total sample (n=100)Discharged after the first contact (n=69) n (%)Dropped out after the first contact (n=31) n (%)P
Contacts with health services:
General practitioners7249 (71.0)23 (74.2)0.813
Mental health (MH) professionals157 (10.1)8 (25.8)0.067
Other specialists (not MH)6945 (65.2)24 (77.4)0.252
Accident and emergency126 (8.7)6 (19.3)0.182
Day care and admissions in other departments (not MH)1514 (20.3)3 (9.7)0.256
Contacts with social services:
Social workers, Self-help and voluntary groups and home help138 (11.6)5 (16.1)0.534
Psychotropic drugs
Antidepressants3120 (29.0)11(35.5)0.641
Anxiolytics3122 (31.9)9 (29.0)0.820
Antipsychotics76 (8.7)1 (3.2)0.431
Mood stabilizers00 (0.0)0 (0.0)NCa
Number of psychotropic drugs
No psychotropic drugs5438 (55.7)16 (51.6)0.523
1 psychotropic drug2213 (18.8)9 (29.0)
≥2 psychotropic drugs2418 (26.1)6 (19.3)
Other drugs5735 (50.7)22 (71.0)0.081

aNC, not calculable.

Although the pattern of service use did not reveal significant differences between the drop-out and discharged groups, contact rates were more frequent among individuals who dropped out (apart from day care and admissions in non-mental health departments). Table 4 also shows the rates of drugs used by individuals over the follow-up period, divided by main types of psychotropic drugs, amount used and use of other drugs. As we can see, in spite of termination of contacts with the CMHS, the use of psychotropic medications was common among these individuals: nearly half of them were using psychotropic drugs at the time of the follow-up interview. Although no significant differences were found between groups on any of the drug utilization measures, the total use of psychotropic medications was higher among the drop-outs. In particular, they used more antidepressants, while the discharged patients used more anxiolytics and, surprisingly, more antipsychotic medication. The drop-out group was also more likely to use other types of medications (non-psychotropic drugs). However, among individuals who used psychotropic drugs, those who had been discharged after the first visit were more likely to use a combination of two or more psychotropic medications.

Of the 31 drop-out patients, 29 gave a reason why they left care after the first visit. The most frequent reasons were: “dissatisfaction with the service and self-referral to other services” (11 patients or 38%), “problem was improved” (6 patients or 21%), “missed the appointment or lack of time to attend” (5 patients or 17%) or “because they were still in the waiting list” (4 patients or 14%). Finally, three of these patients (10%) did not come back because they felt they were beyond help.

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4. Discussion 

This study, combining routinely monitored data from a PCR with follow-up data, aimed to identify patient characteristics associated with once-only contact with a community-based mental health service (CMHS) and to re-evaluate these patients 3 months after the contact. As the study was conducted in a case register area, it was possible to operationalise the definition of once-only contact over a certain period of time (3 months), and to relate these PCR data to patients' measures of clinical condition, satisfaction with services, utilization of other services and drug use at the follow-up. In addition, unlike other studies on this topic, we were able to distinguish (among patients with once-only contact) between individuals who had a single contact with the service because of a decision made in agreement with the treating clinician that they did not require further psychiatric care and those who dropped out of treatment. A limitation of our study was that its generalisability may be limited since it was conducted at a single site.

4.1. Rates of once-only contact 

Among the 1101 new episodes of care included in the study, we found that 23% (252) consisted of only one contact with the service; this value is lower than the rate of once-only contact found in other studies carried out previously in the same service (30–37%) (Balestrieri et al., 1989, Sytema et al., 1989, Tansella et al., 1995, Amaddeo et al., 1998, Rossi et al., 2005a). In this study, however, to ensure that the patients included in the once-only contact group were only those who had discontinued contacts with the service after the first visit, we adopted a very stringent criterion, i.e. that no contact had taken place with any services reported to the case register for at least 90 days. In addition, we double-checked every once-only contact episode with the responsible clinician, to be sure that the patient had not had any other unrecorded contact with the service over this period. These may be the reasons for the lower value of once-only contact, compared with the other studies that relied exclusively on case register data. However, our finding is within the broad range of the percentages of once-only contact (9–63%) reported in the international literature.

We found that a small percentage of patients (8%) dropped out of treatment after the first visit. This drop-out rate after the first visit is similar to that of Bass et al. (2002) and may be explained by the fact that the South Verona service is designed to promote continuity of care, especially for severely mentally ill people (only 9 of the 102 patients with a major mental disorder dropped out after the first contact).

Among the 252 once-only contact patients, 165 (65%) were patients who had been assessed, but did not receive any psychiatric care. Checking the case notes for these patients, we found that 41% of them were referred to general practitioners and 16% to other specialists (not CMHS staff). The out-patient department (the setting of the first visit in the South Verona CMHS) is the first and most direct pathway to entry into the care system. According to the rules of the Italian National Health Service, patients can refer themselves to this facility without a previous consultation with their general practitioners. For this reason, a high number of patients could be appropriately referred to other services. On the other hand, the high permeability of this filter enables a greater accessibility to the service, and this is recognised as an indicator of good quality of care, as it helps to prevent individuals from slipping through the care net.

4.2. Case register variables associated with once-only contact 

The study did not find significant differences between individuals who dropped out and those who were discharged after the first visit, regarding case register variables. This finding is quite surprising as, intuitively, a higher level of distress in the first group might be expected. A possible explanation is that, as the assessment of a new patient often requires more than one visit to be completed, a further appointment after the first visit does not necessarily reflect the clinical judgment of the patient's level of distress but only the clinician's need for more time to evaluate the patient.

This study supports the findings of other studies (Henisz et al., 1977, Lavik, 1983, Rossi et al., 2005b) that there is a strong relationship between severe psychopathology and consumption of services. In both the comparisons, the multivariate analyses showed that clinical characteristics (GAF score and diagnosis) were the most significant determinants of service utilization: the more severe the patient's clinical status, the more contacts the patient had with the service. In the comparison between once-only contact and high users, in particular, the odds that a patient without mental disorders would have a once-only contact were between 5 to 10 times greater than the odds for a patient with a mental disorder (excluding substance-related and organic mental disorders who were not significant in this comparison). Analogously, the GAF score consistently decreased from the once-only contact patients to the high users.

Another important association was found between lower educational level and once-only contact with the service. In the univariate analysis we also found that once-only contact patients were older, more likely to be housewives or retired and to live in an institution. In common with previous research (Baekeland and Lundwall, 1975), it is possible that the lower socioeconomic individual puts much more emphasis on the present than on the future. Hence, it is not hard to understand why a form of treatment that emphasizes long-range goals may seem unnecessary and irrelevant to these persons once their symptoms have somewhat abated. In this respect, it should be kept in mind that non-specific initial symptom reduction with placebo is marked after the first interview (Frank et al., 1963). On the other hand, the average clinician's bias against lower socioeconomic patients is underscored by his being likely to see them as less attractive people, and more likely to assign them to a less intensive treatment (Flaskerud and Hu, 1992).

Finally we found that, compared with high users, once-only contact patients were less likely to be referred by the CHMS staff. This result is the opposite of what we found in a previous study carried out in the same service, that covered the period between 1992 and 1999 (Rossi et al., 2005a). In this respect, it could be that training programmes for psychiatrists carried out in this service over the last 4 years (Rimondini and Del Piccolo, 2002) have improved the capabilities of health professionals to provide information, support the patients and make more appropriate decisions regarding patient referral.

4.3. Information on the drop-out and discharged groups collected at the follow-up 

The information collected at the follow-up shows a clinical improvement in the once-only contact group between the first visit and the follow-up regarding characteristics that we could compare (diagnosis and GAF score). There are several possible explanations for this finding. Firstly, the most common diagnosis among once-only contact patients with a mental disorder at baseline was depression without psychotic symptoms (51%). According to DSM-IV-TR (American Psychiatric Association, 2000), an untreated episode of this disorder typically lasts 4 months (roughly the length of time between the first visit and the interview in our study) and, in the majority of cases, there is a complete remission of symptoms and functioning returns to premorbid level. Moreover, the vast majority of these patients had made contact with other health services (mostly general practitioners) after the single contact with the CMHS and, as reported in other studies, common mental disorders can be treated by primary-care-based services with no reduction in the quality of care (Goldberg et al., 1996, Goldberg, 2006).

In the comparison between discharged patients and drop-outs, we found a trend (NS) for a poorer clinical status (diagnosis and GHQ) in the drop-outs. For the VSSS total score a tendency was found for lower satisfaction scores in the drop-out patients and, when asked why they left care after the first contact, their main reason was “dissatisfaction with the service and self-referral to other services”. The last two findings may lead us to the tentative conclusion that dissatisfaction with the first contact may have played a role in the termination of treatment in this sub-group of patients.

Regarding the endorsed reasons for drop-out, the findings of this analysis were different from those of other studies. The top reason in our study was “dissatisfaction with the service” while “desire to handle symptoms on one's own” and “no need for services” were the top reasons, respectively, in the studies of Wang et al. (2000) and Pekarik (1983). However, these studies indicate that acceptability of treatment (including preference for self-management and perceived ineffectiveness of treatment) may play an important role in dropping out of mental health treatment. Our results suggest the usefulness of making regular checks of the percentage of drop-out patients, which could be used, together with other variables, as a proxy measure of the quality of care provided by CMHSs.

In conclusion, although there is no way of knowing the status of patients who could not be located, information from the people interviewed suggests that, for a group of patients predominantly without psychoses, dropping out of contact after the first visit is associated with being less satisfied with the services received at the initial contact. This dissatisfaction may have led these patients to seek help elsewhere. It is possible that for these patients, the CMHS does not offer treatment for their problems, but rather provides support during a period of time while the patient seeks treatment from a number of different services. Perhaps, some of these extremely low users are in need of a different or more specialized clinical treatment approach.

Future studies are needed to understand which other factors (i.e. early initiation of medications, entitlements, distance from the clinic and caregiver/parenting responsibilities) may influence patients' decision to return for treatment.

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Acknowledgements 

We thank those who participated in the follow-up study and the staff of the South Verona Community Psychiatric Service for their collaboration. We thank Alberto Porta and Lucia Grosso for their help in data collection. We thank Julia Jones for her revision of the paper. This study was funded by the Veneto Region, Ricerca Sanitaria Finalizzata 2001, with a grant to M.T.

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PII: S0165-1781(06)00176-4

doi:10.1016/j.psychres.2006.05.023

Psychiatry Research
Volume 157, Issue 1 , Pages 53-65, 15 January 2008

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