Improving the accuracy of patients' expectations of the psychiatric out-patient consultation

Aims and method. To investigate the impact of a video to improve the accuracy of patients' expectations of their first out-patient appointment. An intervention study was conducted in which patients watched a video before their appointment. The video provided information about the content of the consultation, the psychiatrist's role and types of treatments. Results. The intervention increased the accuracy of patients' expectations but had no impact on satisfaction or anxiety. The video was popular as a means of preparing patients for the consultation. Clinical implications. This could be offered routinely to patients attending services for the first time.

Interventions to improve the accuracy of patients' expectations of mental health services have resulted in improved attendance and satisfaction and decreased anxiety (Skuse. 1975;Spector, 1988;Webster, 1992). Of the different interventions studied, video has been found to be the most effective (Tinsley et al 1988). Videos have been used successfully to prepare patients for psychotherapy (Deane et al, 1992) and the transition from in-patient to out patient services (Hagan et al, 1983).

The study
Patients were recruited from a general adult clinic at an inner city hospital. To identify the issues to be included in the video, 19 patients were asked a series of open-ended questions about their expectations of the consultation, the psychiatrist's role and types of treatment. Three psychiatrists were asked about the format and content of their consultations at the clinic and for their views about patients' expectations and any misconceptions.
Patients expressed a range of expectations. There was confusion about the psychiatrist's role, whether psychiatrists are medically quali fied and the difference between psychiatrists and psychologists. Many patients expected a short interview (15-30 minutes) and did not expect to be asked about their background, relationships or past medical history. The most commonly expected treatment was talking therapy, rather than medication. Patients expressed concerns about confidentiality, the stigma of mental ill ness and whether the referral implied that they were going mad.
A 10-minute video was produced that included a series of simulated clips of the initial consulta tion with points highlighted by a presenter. The main points included are given in Table 1 (a copy of the full script is available from the author upon request).
The study was a randomised comparison between patients viewing this video or a control video (attention placebo control). The control was a 10-minute video called The Meal Ticket' produced by the National Dairy Council in 1992, which provided information about healthy eating. A video unrelated to mental health issues was chosen to ensure a neutral impact. All new patients available to take part con sented. The 48 patients were predominantly male (63%), single (63%), Caucasian (88%) and unemployed (44%), with an average age of 36 years and a diagnosis of depression (52%); 63% had seen a psychiatrist previously, 38% had been admitted to a psychiatric hospital and 48% had a relative who had seen a psychiatrist. There were no significant differences between the experimental (n=24) and control (n=24) groups.
A measure of patients' expectations was devised to assess the impact of the video (Table  2).
Before watching either video, patients com pleted the State-Trait Anxiety Inventory (Spielberger et al, 1983) and the expectations questionnaire.
After watching the video, the experimental group completed the State Anxiety Inventory, the expectations questionnaire and a question about the usefulness of the video. After their consultation, both groups completed the Client Satisfaction Questionnaire (CSQ-8; Larsen et al 1979). The experimental group were also asked a question about the helpfulness of the video.

Findings
There was no significant difference between the experimental (mean 7.9, s.d.=1.3) and control groups ( Most patients found the experimental video useful (16/24) and felt that it had prepared them for the consultation (15/24).
Several patients said that the video was helpful in providing information and confirming the expectations already held. The clarification about confidentiality was highlighted as being particularly helpful. Of the 10 patients who had previously seen a psychiatrist, seven commented that the video would be particularly helpful for patients who had never had contact with psychiatric services.

Comment
The video improved the accuracy of patients' expectations. Although it did not significantly reduce anxiety or improve satisfaction, it did not have an adverse effect on either. Patients found the video helpful and this intervention could be offered routinely to new patients.
It was difficult to recruit patients due to nonattendance, and it was not possible to include only patients who had never had contact with psychiatric services. The patients who attended had reasonably accurate expectations. It may be that those who may have benefited most did not attend. This indicates that an intervention before attending could be beneficial (c.f. Skuse, 1975).
No established measure of patients' expecta tions of psychiatric services could be identified from the literature.
Although the measure Table 2. Patient Expectations Questionnaire The patient was asked to circle 'Yes' or 'No' in response to the following 10statements to indicate what they expected to happen in the appointment: 1. The psychiatrist will ask me about my upbringing 2. The psychiatrist will not wish to know my opinions about the cause of my problems 3. The psychiatrist will not ask me about any physical illnessesI have had 4. The psychiatrist will ask me about any emotional problems I have 5. The psychiatrist will not be interested in any current relationships I have 6. My interview with the psychiatrist will be confidential 7. The psychiatrist will ask me about any medicines I am currently taking 8. The psychiatrist will write back to my family doctor after my appointment 9. I will definitely be given medication 10. The psychiatrist will have decided on the best treatment plan for me by the end of the first appointment devised was based on information from patients and psychiatrists, its reliability and validity were not empirically tested. A ceiling effect was observed, possibly due to patients' previous experience with psychiatric services. A ceiling effect was also observed in satisfac tion, which is not unusual (Elbeck & Fecteau, 1990;Jones & Lodge, 1991). Conceptual and methodological issues in the assessment of patient satisfaction have been highlighted re cently and recommendations have been made for alternatives to traditional questionnaires (Uys et al 1997).
Research with larger samples is needed to establish the effectiveness of a video in preparing new patients for their first consultation. of clients with schizophrenia who express uncertainty or uncertainty about continuing treatment with depot neuroleptlc medication. Archines  Nursing. 11. 238-248. CLINTON. D. N. (1996)