Determinants of once-only contact in a community-based psychiatric service

Abstract Background This study examined variables associated with patients who had a once-only contact with the out-patient department of a Community Mental Health Service (CMHS). Methods Using the South-Verona Psychiatric Case Register (PCR), an 8-year cohort of patients who had a new episode of care with the out-patient department of the South Verona CMHS was followed up for 3 months after the first contact, to identify those patients who had no further contact with the service. Potential determinants of once-only contact were analysed. Results A total of 2,446 new episodes of care met the inclusion criteria of the study. Of those, 734 (30%) were once-only contacts with the service. Compared to patients with more than one contact, patients who had a once-only contact were older, more likely to be male, had a lower socio-economic status and less severe psychiatric diagnosis. They were more likely to be referred by consultation/liaison or emergency room. Conclusions Multivariate analysis revealed that having a less severe psychiatric diagnosis was the most significant determinant of once-only contact with a CMHS. The results suggest that the behaviour of referring agents in selecting patients and preparing them for treatment merits further investigation.     

Patterns of psychiatric care in south Verona and Groningen. A case-register follow-up study

The pattern of utilization of mental health services in south Verona (Italy) and in Groningen (the Netherlands) was studied. The local psychiatric case registers were used to select patients aged 15 years or more who had at least one contact in 1982 and no contacts in the previous 365 days. Each patient was followed for 36 months after the first contact in 1982. The 2 cohorts differed in size (373 in south Verona and 590 in Groningen), age, diagnosis and pattern of care, whereas the sex distribution was similar. The cohort in Groningen was characterized by a higher number of elderly people, suffering from organic psychoses. Drug dependence prevailed in south Verona, while alcohol dependence was predominant in Groningen. The pattern of care was classified according to 2 basic measures, the gross duration of care and the net duration of care. In south Verona single consulters were almost 3 times more common than in Groningen. In general, patients in Groningen tended to depend more on the mental health services. Linear regression analysis was used to determine the extent to which the pattern of care was predicted by the sociodemographical and clinical characteristics of the patients. Only the site where the contacts were made (south Verona or Groningen) and the diagnosis were significantly associated with the pattern of care.     

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

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.     

The use of a case register to evaluate the costs of psychiatric care

The aim of this study was to show the usefulness of adding cost information to a routine data collection provided by a case register for analysing the association between patients' characteristics and the direct costs of the psychiatric care actually provided. All patients (n= 706) who in 1992 had at least one contact with services which report to the South Verona psychiatric case register and who received an ICD-10 diagnosis were included in the study. The costs of specialist psychiatric care provided during the 365 days following the first contact in 1992 were calculated using a unit cost list. A bespoke software, linked to the case register, was designed to produce the individual information on costs directly. For each patient, costs were categorized as in-patient costs, sheltered accommodation costs, day-care costs, out-patient costs and community costs. All costs, grouped by service type, were found to differ significantly (P<0.01) between diagnostic groups (affective disorders, neurotic and somatoform disorders, schizophrenia and related disorders, and other diagnoses). The multivariate analyses showed that costs are significantly higher for patients with a diagnosis of schizophrenia and related disorders than for patients belonging to the other diagnostic groups. However, only 6% of the variation could be explained by diagnostic group alone. On the other hand, between 40 and 50% of the costs of mental health care was predicted by patients' personal characteristics and other measures recorded on the case register. The results of the present study show that, where service use is monitored regularly, the base from which decisions on community provision and placement are made can be informed by careful analysis of routinely or easily available data on direct costs.     

The effect of previous psychiatric history on the cost of care: a comparison of various regression models

OBJECTIVE: Many studies conducted in Europe have reported high variance of costs estimated at the individual level. The objectives of the present study were to estimate costs of patients and to evaluate the performance of various regression models. METHOD: All patients who in the period 1992-1995 had at least one contact with the psychiatric services in South Verona were included in the study and were followed for 1 year after the index contact (n = 1725). Four different groups, classified on the basis of their previous services utilization, were analysed. RESULTS: First-ever patients and patients with a new episode of care after 3 years were less costly than patients with an ongoing episode of care and patients having a new episode, after an interval between 3 months and 3 years. CONCLUSION: The regression models allow us to predict cost for a patient with a given set of characteristics. Great care in the interpretation of the values of the individual coefficients should be taken in order to have a broader understanding of the expenditure dynamic.     

Level of caregiver burden among relatives of the mentally ill in South Verona.

Identifying the burden of care on relatives of the mentally ill remains an integral part of research in community psychiatric services. The present study aimed to assess the level and extent of burden on relatives in South Verona (northeast Italy). The South Verona catchment area provides a comprehensive, community-based psychiatric service with minimal reliance on the hospital. Patients were selected from the South Verona Psychiatric Case Register and 40 of their relatives were interviewed using structured assessments measuring objective burden, patient behaviour, coping strategies, satisfaction and needs for services. Both positive and negative aspects of burden were apparent, 92% of relatives continued to maintain contact with friends/relatives, 72% had no change to their family income, and 52% could manage any household disruptions during a crisis. The main negative effects for relatives included reduced leisure activities (57%) and psychological problems (67%). The greatest burden was on relatives of patients who were male (P = 0. 016), unemployed (P = 0.013) and diagnosed with psychosis (P = 0. 041). The implications of employment for patients and its association with lower levels of caregiver burden are discussed.     

The Nordic Comparative Study on Sectorized Psychiatry: patients who use only psychiatric in-patient care in comprehensive community-based services — a 1-year follow-up study

In the present paper a sample of patients using psychiatric in-patient care only is characterized and analysed with regard to characteristics of the psychiatric services. This paper forms part of the Nordic Comparative Study on Sectorized Psychiatry, designed to investigate contact rates and use of psychiatric care by new patients in 7 catchment areas in 4 Nordic countries during a 1-year follow-up. One-year treated incidence cohorts were used. The logistic regression analysis revealed that the variable ‘psychiatric service’ was one of the statistically significant determinants of using only in-patient care during the follow-up. The diagnostic groups with the highest probability of using only in-patient care were dependencies and functional psychoses. The following factors were associated with a high risk of using only in-patient care: older age, being referred by another psychiatrist, having received previous psychiatric in-patient care, male sex, being retired, and not living with one's parents or a partner. Patients who used only inpatient care had fewer admissions and days in in-patient care than others during the 1-year follow-up period. Lack of 24-hour emergency services in out-patient care correlated positively with the use of only in-patient care.     

Outcome of patients dropping out from community-based mental health care: a 6-year multiwave follow-up study

OBJECTIVE: To test three hypotheses: i) is dropping out of community mental health care due to dissatisfaction? ii) Do those who appropriately interrupt mental health care need any more help? iii) Do those who need treatment continue to receive it? METHOD: A cohort from a Community Mental Health Service in Verona, Italy, was followed up for 6 years, interviewing patients at follow-up who are both in contact and not in contact with the service. RESULTS: The main reason for dropping out was service dissatisfaction. Patients still in contact with the service were more often psychotic. Many patients no longer in contact had mild-to-moderate problems, especially anxiety and depression and some social disability. Patients out of contact rarely sought help from other agencies. CONCLUSION: Comprehensive community mental health services seem to offer good continuity of mental health care to patients with psychosis, but dedicate less attention to patients with less severe problems. Some of these patients will go on experiencing a burden of symptoms and disability, over the years.     

Factors associated with clinicians’ dispositions in an out-patient psychiatric department

AIM: This cross-sectional study attempted to identify factors associated with clinicians' dispositions of patients after the first visit in an out-patient psychiatric department. METHODS: Over a 33-month period, all new episodes of care with the department were included in the study. For each patient, socio-demographic, clinical information and contact characteristics were prospectively collected in relation to the first visit, as was information on case disposition. Factors associated with clinicians' disposition were analysed. RESULTS: Of the 1,138 patients who met the study criteria, 848 (75%) were followed up by the department, 150 (13%) were referred to other services and 140 (12%) were discharged. Suffering from a major psychiatric disorder, being younger and not living in an institution influenced clinicians' disposition to follow-up patients. Older age increased the chances of being referred to other services rather than discharged. CONCLUSIONS: Examining decision-making behaviour in out-patient psychiatric departments is a worthwhile endeavour because this setting represents the main entry point of modern and accessible community-based systems of care. The findings confirmed the importance of psychiatric determinants in the dispositional process and contribute to make clinicians more aware of other factors related to their decision-making.     

Comparison of patient satisfaction with community-based vs. hospital psychiatric services

OBJECTIVE: Previous work suggests that psychiatric patients are more satisfied with community-based than with hospital-based services, but it is not clear how far these findings can be generalized to routine services. The aim of this study was to compare the satisfaction of patients with psychosis between a hospital-based service in London, UK and a community-based service in Verona, Italy. METHOD: The Verona Service Satisfaction Scale (VSSS) was used to measure satisfaction among patients with psychosis in Nunhead (London) and South Verona. RESULTS: Satisfaction across all dimensions was higher in South Verona than in Nunhead. Sociodemographic and service use differences between the two groups were insufficient to explain this difference. CONCLUSION: This study suggests that experimental findings that patients prefer community-based to hospital psychiatric services can be generalized to routine services.     

Ethnic matching of clients and clinicians and use of mental health services by ethnic minority clients

OBJECTIVES: Research in the United States has indicated that matching clients from a minority group with clinicians from the same ethnic background increases use of community mental health services and reduces use of emergency services. This study assessed the effects of matching clients from a non-English-speaking background with bilingual, bicultural clinicians in a mental health system in Australia that emphasizes community-based psychiatric case management. METHODS: In an overall sample of 2,935 clients served in the western region of Melbourne from 1997 to 1999, ethnic minority clients from a non-English-speaking background who received services from a bilingual, bicultural case manager were compared with ethnic minority clients who did not receive such services and with clients from an English-speaking background. The clients' engagement with three types of services-community care teams, psychiatric crisis teams, and psychiatric inpatient services-was assessed. RESULTS: Compared with ethnic minority clients who were not matched with a bilingual clinician, those who were matched generally had a longer duration and greater frequency of contact with community care teams and a shorter duration and lower frequency of contact with crisis teams. Clients born in Vietnam who were matched with a bilingual clinician had a shorter annual mean length of hospital stay and a lower annual mean frequency of hospital admission than Australian-born clients. CONCLUSIONS: The benefits of matching clients with psychiatric case managers on the basis of ethnic background include a lower level of need for crisis intervention and, for clients from some ethnic groups, fewer inpatient interventions. These Australian results support findings of the effectiveness of client-clinician ethnic matching in the United States.     

South Verona's psychiatric service: an integrated system of community care

Italy's mental health law of 1978 mandated the closing of state mental hospitals to new and former patients and the creation of comprehensive community-based service systems. The authors describe the organization, facilities and services, and treatment principles of one system created in accordance with the law--the South Verona Community Psychiatric Service, which serves a population of 75,000. Case register data for South Verona for the years 1978 to 1984 reflect the changes mandated by the law. They also indicate that despite an increase in admissions to the psychiatric ward in the general hospital following the closing of the state hospital, there was a substantial overall decrease in the number of hospital beds occupied per day by South Verona residents after passage of the law, and that a substantial proportion of patients with functional psychosis were able to be treated as outpatients.     

Demographic,clinical, social and service variables associated with higher needs for care in community psychiatric service patients

BACKGROUND: Mental health services should be provided on the basis of need. This study investigated a representative sample of patients attending a community-based psychiatric service. The aim was to identify the profile of patients with higher needs for care, by considering a full range of potential demographic, clinical, social and service correlates. METHODS: A total of 268 patients using mental health services in South Verona, Italy, had cross-sectional assessments of their needs (using the Camberwell Assessment of Need), symptomatology, disability, functioning, quality of life, service use and satisfaction with care analysed using linear regression. RESULTS: A model comprising being male, being unemployed, having high symptomatology and disability, having low functioning and self-reported quality of life, and a high number of outpatient and community contacts accounted for 67% of the variance in total level of need. CONCLUSIONS: Patients who meet any of these criteria may be more likely to have higher needs, which has implications for clinical practice and audit. Assessment of needs for care by using the CAN provides a good overall measure of the number and the severity of a patient's problems in several key areas of everyday life.     

Care utilization and the incidence of suicide: suicide victims' contacts with primary health care and psychiatry in six psychiatric districts in the County of Stockholm from 1979 to 1990

The aim of this study was to ascertain whether suicide victims had ever been in contact with a primary health-care centre, a psychiatric out patient treatment centre or any form of institutional psychiatric care, and whether there had been any change in such patterns over time. The results show an increase in the number of suicide victims seeking help from the primary health-care centres. The transformation within psychiatry from hospitalized care to out-patient care resulted in a corresponding increase in the number of suicide victims who applied to psychiatric out-patient care services. The move towards non-institutional forms of care has probably contributed to the decrease in the total number of suicides observed during the study period.     

Use of mental health services in south Verona and Groningen. A comparative case-register study

A comparison was made of the utilization of mental health services in a psychiatric case register area in Italy (south Verona) and one in the Netherlands (Groningen). All residents living in these areas who contacted a mental health service in 1982 were traced and followed for a period of one year. The year prevalence rates differed considerably (110/10,000 in south Verona and 329/10,000 in Groningen). Rates of single consulters were similar in both areas, while those of chronic inpatients were more than 11 times higher in Groningen than in south Verona. After excluding both single consulters and chronic inpatients, when comparing service consumption according to fixed classes of scores, the category of highest service use accounted for 60% of care provided in Groningen as compared with less than 30% in south Verona. The proportion of total service consumption due to inpatient care was about the same in both areas, but brief admissions were more common in south Verona. Moreover, when service use was considered as a relative construct, about 10% of patients in both areas could be called high users. Finally, long-term patients were more prevalent in Groningen (26%) than in south Verona (13%).     

Continuity of contact with psychiatric services: immigrant and Australian-born patients

  Background: Under-representation of ethnic minority groups in psychiatric services has been widely reported in Western nations. The present study examined whether there were differences between immigrant and Australian-born patients in their maintenance of contact with a statewide psychiatric service system. Methods: Groups were selected on the empirical grounds that they are differently represented in this service system. Employing a form of case-control design, four groups of patients were compared: those born in Australia, the United Kingdom, Southern Europe, and South East/East Asia respectively (n = 79 for each). Groups were identically matched on sex, age, diagnosis (either schizophrenia or bipolar illness) and locality of service. The groups did not differ as to the timing of their first appearance in the 3-year period in which their psychiatric contact was examined. Results: Despite their different representation in the psychiatric service system, the four groups did not differ on measures of continuity of contact. Measures included number of contacts with mental health community services, number of admissions to inpatient wards, length of stay in hospital and the longest interval between any two successive service contacts. Conclusions: The commonly reported under-representation of immigrant groups in the psychiatric service system does not appear to be due to greater discontinuation of contact with services. If the assumption of equal community prevalence of disorder is made, then the observed under-representation may be due to differential rates of access to (that is, initial contact with) psychiatric services. Accepted: 16 August 2000     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

Unplanned first contact as a predictor of future intensive use of mental health services

The scheduled appointment system, widely used in most mental health services, has never been evaluated. This study attempts such an evaluation within a community-based mental health service that permits unplanned access to specialist care, by comparing further service use of first-episode patients who come unannounced to seek psychiatric care with that of patients with a planned (scheduled) initial appointment. All patients with first lifetime psychiatric contact who contacted psychiatric services reporting to the South-Verona Psychiatric Case Register between 1 January 1982 and 31 December 1989 (n= 1261) were identified. A total of 1056 patients entered the study and were followed for 2 years. Poisson regression with the generalised estimating equation (GEE) method (to take into account both overdispersion of contacts between subjects and correlation between contacts within subjects) was used to evaluate the effects of the type of first-ever contact (defined as planned or unplanned according to whether or not a regular appointment was previously arranged) and of other selected variables, including sociodemographic characteristics, on the annual rate of planned and unplanned care in the follow-up period. Thirty-six percent of first-ever contacts were unplanned. Patients who began with unplanned contact, as compared with others, were more often widowed, separated or divorced, unemployed and with a diagnosis of schizophrenia or organic psychosis. Moreover, they had, in the following 2 years, significantly higher rates of both unplanned and planned community care, as well as more in-patient care (higher admission rate and a longer mean length of stay). These results at follow-up were confirmed when the rates for the type of first-ever contact were adjusted for all other clinical and sociodemographic variables at initial contact. Step-down Poisson multiple regression analysis showed that the rates of both unplanned and planned contacts in the follow-up period were significantly and independently associated with: type of first-ever contact, diagnosis and type of service first contacted. Unplanned cases at initial contact require particular attention and are confirmed as at risk for placing higher demands on mental health services in the following 2 years. The results of the present study may also have implications for other, non-psychiatric health services. Accepted: 20 July 1997     

Italian psychiatric reform 20 plus years after

OBJECTIVE: To describe the current situation of mental health care in Italy and implementation of mental health reform legislation. METHOD: The current mental health care system and studies of the implementation of psychiatric reform are described. RESULTS: The 1978 reform law inaugurated fundamental changes in the care system (prohibiting admissions to state mental hospitals, stipulating community-based services, allowing hospitalization only in small general-hospital units). Uneven reform implementation was reported initially. However, in 1984 in- and out-patient services in the community were available to >80% of the population. There is a comprehensive network of in- and out-patient, residential and semi-residential facilities. Recently, services have been jeopardized by the managed-care revolution, and non-profit organizations supplement the public system (especially residential care, employment and self/mutual help). CONCLUSION: Implementation of the psychiatric reform law has been accomplished, and the year 1998 marked the very end of the state mental hospital system in Italy.     

Patterns of mental health care in two European areas: Mannheim, Federal Republic of Germany; and Groningen, The Netherlands

All consecutive cases entering the mental health services cooperating with the cumulative psychiatric case register of Mannheim between 1-31 July 1976 were followed up until the end of June 1978 and compared with the consecutive cases entering the mental health services cooperating with the psychiatric case register of Groningen between 1 January and 1 May 1979. Patterns of in-, day- and outpatient care delivered to these 2 cohorts of patients, who were greater than or equal to 15 years of age, and who had not been in contact with one of the services for at least 6 months prior to entry, were compared by diagnostic category. The most common episode of care was the relatively brief outpatient one. Mixed types of care and chronic cases were more common among patients with a psychosis or an addiction than in other diagnostic categories. Between 6 and 24 months after first contact 76% of the patients in Mannheim and 43% of the patients in Groningen had no more contacts. Between 18 and 24 months after the first contact the percentages had increased to 90 and 72% (respectively). In Groningen a higher percentage of patients received outpatient care only. Although a larger percentage of patients in Mannheim received inpatient care, the accumulation of "new chronic" patients was larger in Groningen, as a result of a greater length of stay in Groningen.