Why don't patients attend their appointments? Maintaining engagement with psychiatric services

Abstract

Patients miss about 20% of scheduled appointments for mental health treatment, almost twice the rate in other medical specialties. Up to 50% of patients who miss appointments drop out of scheduled care. Many who miss appointments because of slips and lapses later rearrange their appointments without adverse consequences. Those that do not are at risk of further deterioration, relapse and hospital readmission. Predictors of non-attendance are complex and linked with the predictors of missed medication. Service barriers and administrative errors are common but are often overlooked in the absence of feedback from patients. Of prime importance are the therapeutic alliance and degree of ‘helpfulness’ of the clinician but again these are rarely measured routinely. Useful markers of engagement include patient-rated trust, satisfaction and degree of perceived participation in treatment decisions. Much can be done to improve attendance in most services. Simple measures such as offering prompt, convenient appointments, offering reminders and augmenting with telephone contact have a reasonable evidence base. Scales to assess therapeutic alliance are now available. Complex interventions need to be evaluated carefully in order that the overall benefits outweigh costs. We suggest that clinicians consider accessibility, discharge policies and patient feedback when examining local rates of non-attendance.

Correlates of attendance in mental health services for individuals with psychotic disorders: A critical review

“…Studies also frequently did not clearly operationalize their attendance terms (Operationalized dropout/attendance terms in Table 2), making it difficult first for readers to understand exactly what is being measured, and second, for researchers to replicate the research design. As has been discussed before (Doyle et al, 2014;Mitchell & Selmes, 2007;Nose et al, 2003;O'Brien et al, 2009), this issue runs rampant in the attendance literature, and presents a barrier to furthering this research in a replicable, robust manner.…”

“…Their review found 23 different predictors to be associated (in at least four studies) with adherence. Mitchell and Selmes (Mitchell & Selmes, 2007) also speak to this conundrum. In their review of attendance in psychiatry, they highlighted several additional areas which can impact engagement, including perceived benefits of care, perceived costs of care, barriers to care, doctor-patient factors, illness factors, and cues to act.…”

“…As Mitchell and Selmes (2007) note, attendance is often not measured in a nuanced fashion, but evidence indicates there may be distinctions in what predicts attendance for patients at varied levels of engagement (e.g., disengaged, low attendance, good attendance, etc.). O'Brien and colleagues (2009) discussed the difficulty in defining disengagement in general, and that terminology is often used interchangeably (such as attendance and engagement) when there may be important nuanced differences in what these terms imply; this issue is also of concern in the growing literature on treatment for first-episode psychosis (Doyle et al, 2014).…”

How Psychiatrists Recommend Treatment and Its Relationship with Patient Uptake

“…A great deal of attention has focused on methods to persuade patients to adhere to treatment decisions, without sufficient acknowledgement that avoidance of sometimes complex, costly, and unpleasant regimens may be entirely rational (Mitchell, 2007). By providing a more holistic picture – mapping a range of practices psychiatrists use to initiate decisions in naturally occurring consultations – support for this perspective is offered here.…”

“…They may distrust people when they are experiencing paranoia, experience attention deficits (Hamann et al, 2006) or have poor awareness of their illness leading to resistance of medication. Psychiatrists may then use methods to persuade patients to adhere to their treatment (Mitchell & Selmes, 2007). …”