Introduction
While attrition rates are often omitted from research reports (Ladouceur, Gosselin and Laberge, Reference Ladouceur, Gosselin and Laberge2001), failure to attend and drop-out are everyday problems for clinicians, e.g. Gilbert, Barkham, Richards and Cameron (Reference Gilbert, Barkham, Richards and Cameron2005). Self, Oates, Pinnock-Hamilton and Leach (Reference Self, Oates, Pinnock-Hamilton and Leach2005) found a strong relationship between social deprivation and attrition from psychotherapy. In particular, clients from deprived backgrounds were more likely to default from first appointment and the early stages of therapy. While a range of ways of improving attendance has been reported (e.g. Lefforge, Donohue and Strada, Reference Lefforge, Donohue and Strada2007), having a highly skilled therapist sitting waiting for patients who do not appear is a poor use of a scarce resource.
STEPS is the primary care mental health team in South East Glasgow. The area has significant levels of deprivation. Since 2005, we have been offering a six-level service for those with common mental health problems. The levels are: individual therapy; groups/classes; single contacts; non face-to-face interventions; working with others; population level. Information about the service can be found in White (Reference White and Bennett-Levy2010).
Between 2005 and 2008 all levels of the service, e.g. groups, classes and self-help were accessed via self-referral. Access to individual CBT or person-centred therapy (PCT) required a written referral from a GP or a mental health clinician. By operating a “buddy system”, we divided South East Glasgow (population: 130,000) into quadrants, with one CBT and one PCT “buddy” in each quadrant. GPs chose whether to refer to either CBT or PCT by ticking a box on the referral form. Individuals were sent an opt-in letter (with pre-paid envelope) asking them to tick a box if they wanted an appointment. They were also given a one page information sheet on the appropriate therapy. Throughout the period in question, there were no waiting times for CBT and a wait of up to 6 weeks for PCT. Service users were made aware of this and that therapy would consist of up to 6–8 sessions.
In this paper, we present referral data for individual therapy from 1 January to 30 April 2008, along with attendance/attrition rates. We were interested in comparing the figures for CBT and PCT and also assessing the impact of deprivation on attendance rates.
Method
Procedure
Individual therapy case files were reviewed by assistant psychologists and at the initial appointment, assessment information was extracted such as whether or not the individual was triaged to another service at initial appointment, completion rates, type of therapy offered, and demographic information, including Scottish Index of Multiple Deprivation (SIMD) information. SIMD designates each postcode with a value between 1 and 10 where 1 represents the most affluent and 10 the most deprived households (Scottish Executive, 2006).
We adopted a stringent criterion for a “completer”. If a patient failed to attend an appointment agreed at the previous meeting by both therapist and patient and then subsequently failed to contact the service, that patient was designated a non-completer, even if it was anticipated by the therapist that it would be the final appointment following a course of therapy. Therapy sessions usually took place in the same building as patients’ GPs were based.
Results
Referrals
Four hundred and ninety-seven referrals for individual therapy were received in the 4-month period; 174 to PCT, 323 to CBT; 62% were female, 38% male. Mean age was 37 (range 17–81).
SIMD data
Patients’ SIMD data were consistent with the demographic profile of the south-east area, with 40% of those referred from SIMD 10, the highest deprivation category. There were no differences between CBT and PCT in terms of distribution of SIMD values.
Opt-in
Overall, 338 individuals (68%) opted-in; 114 (66%) and 224 (70%) of those referred to PCT and CBT respectively opted-in. Of those, 75% were female, 25% male. Mean age was 39 (range 17–79). A review of the presenting problems outlined by GPs did not identify obvious differences between those opting-in and those who did not. We did not have the information on employment status for those who did not opt-in to allow comparison to be made on this demographic.
The “therapy journey”
Figure 1 shows a flowchart of people using the service: from referral, opt-in, attendance at first appointment, those triaged at first appointment, to those completing individual therapy. Almost one-third of individuals were lost at the opt-in stage, with another quarter of those who had opted-in then failing to attend first appointment. Relatively few individuals were found to be unsuitable for either CBT or PCT but 48% were assessed to be more suited to other options; 92% of these were referred to other STEPS groups and classes, with the Stress Control class by far the most popular destination. The remaining 8% were referred to secondary care mental health services or social or voluntary services. Of those who attended first appointment and were offered individual therapy, 34% subsequently dropped-out. Comparison between CBT and PCT did not reveal any differences other than CBT therapists being much more likely to refer the individual to other STEPS services following the assessment appointment.
Flowchart showing total number of referrals, opt-in rates, and attendance rates at initial appointment, numbers triaged at initial appointment, and completion rates for those offered individual therapy
We conducted 2 × 2 chi-square tests to compare the proportions of opt-ins, attendance rates and completion rates among those allocated to CBT and PCT. There were no significant differences in the opt-in rates (X2 (1, N = 497) = 0.60, p = .44), the attendance rates at first appointment (X2 (1, N = 338) = 0.42, p = .26) or in the completion rates (X2 (1, N = 114) = 0.28, p = .30).
The effect of deprivation
We were interested to see if deprivation influenced attrition. In order to assess this, we divided individuals into three groups, based on SIMD categories: low deprivation (SIMD 1 – 5), mid deprivation (SIMD 6 – 9) and, by far the largest single category, high deprivation (SIMD 10). Using 3 × 2 chi square tests, we then compared the three groups in terms of numbers of individuals who opted-in to the service, and numbers of individuals who, having opted-in, attended their first appointment. A significant difference between groups in terms of opt-ins was observed (X2 (2, N = 497) = 0.11.6, p < .01). This showed that individuals in the high deprivation group were significantly less likely to opt-in to the service than those in the low and mid deprivation groups. However, no significant differences were observed between the groups in terms of attendance at first appointment (X2 (2, N = 338) = 2.11, p = .35).
Discussion
Despite no waiting times for CBT and only minimal waits for PCT, attrition rates are high at all stages of the process. When we omit those who were triaged at first appointment and those not suitable for the service, the completion rate for individuals who opted-in to individual therapy was 37%. When we take into consideration those who failed to opt-in, the completion rate falls to 21%.
Although the opt-in system is clearly an efficient way of handling large numbers of referrals and potentially weeding out those who, otherwise, would have failed to appear if offered an appointment, there is a concern that it may stop suitable individuals from seeking help as they may feel that, for example, other people deserve an appointment more than they do or that nothing could be done to help them in any case. Thus there may be an ethical issue to the use of this system.
Previous research (e.g. Self et al., Reference Self, Oates, Pinnock-Hamilton and Leach2005) suggested a link between social deprivation and attrition rates, particularly at first appointment. The findings from this study do not lend full support to this. Although individuals from deprived areas (i.e. those with a higher SIMD score) were more likely to fail to opt-in, there was no evidence that they were more likely to fail to attend their first appointment or drop-out during therapy than those from more affluent areas.
Although referrals across SIMD categories closely match the south-east Glasgow demographic profile, we should have received significantly more referrals from the more deprived areas, given the strong link between deprivation and prevalence of common mental health problems. It may be, however, that those in the most deprived areas do not think therapy is the answer to their psychosocial difficulties and failing to opt-in reflects an informed decision.
No significant differences were observed between CBT and PCT. It is likely that the majority of our service-users were not psychologically-minded to the extent that they would have strong views about CBT or PCT and simply went wherever the GP sent them.
This paper suggests that the service needs to look at improving the “stickability” of individual therapy once people are referred (Lefforge et al., Reference Lefforge, Donohue and Strada2007). However, it also suggests that people should be offered more say in the process rather than being passively referred into a system many obviously do not connect with. A future paper will look at the way the STEPS service has developed to better meet these needs.
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