Non-attendance at a psychiatric clinic

ness and treatment may provide valuable insight into reasons for not attending. This consumer orientated approach could enable clinicians not only to improve clinic attendance but to assess their treatment efficacy. The aims of this study were: (a) to assess the rate of non-attendance at a psychiatric out-patient clinic (b) to compare personal and demographic characteristics of the non-attenders with those of the attenders (c) to identify possible contributory factors for non-attendance.

High attrition rates in psychiatric out-patient depart ments are well documented in the literature (Baekeland & Lundwall, 1975;Gillis & Egert, 1973).Non-attenders' attitudes and beliefs about their ill ness and treatment may provide valuable insight into reasons for not attending.This consumer orientated approach could enable clinicians not only to improve clinic attendance but to assess their treatment efficacy.
The aims of this study were: (a) to assess the rate of non-attendance at a psychiatric out-patient clinic (b) to compare personal and demographic characteristics of the non-attenders with those of the attenders (c) to identify possible contributory factors for non-attendance.

The study
This was a prospective study carried out for three months at the West Wales General Hospital, Carmarthen.Clinic attenders were asked to fill in a questionnaire which had been devised to elicit demo graphic, clinic, transport and personal factors.It also assessed patient satisfaction and self-rated symptom severity.All non-attenders were sent a similar ques tionnaire.Any new or follow-up patients who failed to turn up for a clinic appointment without making a cancellation were considered non-attenders.The overall non-attendance rate for the study period was calculated.
Characteristics of attenders and non-attenders were compared and the differences between them analysed using the x: test.

Findings
Over the study period there were 217 clinic attend ances and 46 non-attendances, the overall nonattendance rate being 17.5%.Most out-patients seen were follow-ups.The response rates to the question naires were 53% for non-attenders and 61% for attenders.In the non-attendance group, nonresponders did not differ significantly from the responders in sex, age and distance lived from the clinic.The following findings apply to the responders.Comparing the demographic character istics of attenders and non-attenders, age was the only significant differentiating factor.Younger patients were more likely not to attend than those over 35 years (x2= 6.4, d.f.= 2, P < 0.05).Distance of the patient's home from the clinic was not a signifi cant factor but the mode of transport was (x2= 4.18, d.f.= 1, P < 0.05) with almost twice as many nonattenders as attenders relying on public transport (although a private car was, or would have been, the commonest mode of transport for both groups).The only other significant difference was the number of days prior to the clinic patients received their appointment cards (x2= 7.09, d.f.= 2, P< 0.05).Most patients received their cards more than three days before the clinic, but significantly more nonattenders received less than 48 hours notice.
More attenders than non-attenders identified themselves as the one who wanted the clinic appoint ment, and more non-attenders identified their family, friends or family doctor as wanting the appointment.A relatively high percentage of both non-attenders (72.2%) and attenders (55.5%) identified the hospi tal doctor as wanting the appointment.However, more attenders than non-attenders felt that their GPs wanted them to attend clinic.Most attenders felt that the appointment was necessary (81.1%).Among the non-attenders an equal number felt that the appoint ment was necessary (39.1%) as felt that it was unwarranted.
The patients' perception of the necessity of their appointment was a significant differentiating factor between attenders and non-attenders (x: = 28.36,d.f.= 2, P<0.001).
Most of the non-attenders and attenders were sat isfied with the clinic, but the level of satisfaction was significantly higher among attenders (x:=14.6,d.f.= 2, P< 0.001).Symptom severity was not a significant differentiating factor.
The most commonly cited reason for not attending the clinic was that there was no longer any problem requiring psychiatric intervention.The next most common reply was that the patient felt that clinic attendance would not be helpful.A relatively much smaller number of patients did not attend due to family reasons, transport difficulties, and work commitments.Only one respondent forgot the appointment.

Comments
Apart from age, demographic variables did not appear to have any predictive power in discriminat ing between attenders and non-attenders.Shah & Lynch ( 1990)in addition found that diagnosis did not differentiate between attenders and non-attenders.
The fact that more non-attenders than attenders relied on public transport in travelling to the clinic may be particularly important as nearly all out patients paid for transportation themselves, despite many being unemployed or retired.It also appeared that non-attendance was not just due to a forgotten appointment.Interestingly, both attenders and nonattenders identified the hospital doctor rather than themselves as wanting the appointment.This suggests that patients may not be aware of the importance of follow-up, with attenders not wishing to displease the doctor.From the results one can only surmise that family and friends seem to have little influence on attendance whereas GPs may be more influential.It is apparent that non-attenders are a heterogeneous group in terms of symptom severity.However, levelof clinic satisfaction was significantly lower among nonattenders.As far as we know, this aspect of attendance has not been studied previously.
The most commonly cited reasons for not attend ing, that is, there was no longer a problem and clinic attendance was not perceived as helpful, suggest that we need to ensure that patients fully understand the importance of clinic attendance, continuity of care and the need for follow-up.It is also important that their expectations of the clinic are appreciated and appointments are made when necessary and appro priate.It seems from our study that GPs influence patient attendance and therefore they should empha sise the importance of attending clinics as well as Thapar and Ghosh giving adequate explanation.This has been shown in a study of paediatric out-patients (Morgan, 1988).The role of the GP and the community psychiatric nurse in improving clinic attendance merits further study.
Family and work seemed to take precedence over clinic attendance.Flexibility and discussion with patients prior to setting up clinic appointments, as well as providing more information about the entitle ment and procedure for reimbursement of travelling costs, might improve clinic attendance.Nonattendance, apart from reducing clinic efficiency, represents an interruption or premature cessation of psychiatric treatment.
The poor response rate we obtained from nonattenders in returning the questionnaire was not sur prising; further evaluation of this group remains a priority.(Non-response among the attenders was primarily due to administrative difficulties rather than refusal to fill in a questionnaire.)

A cknowledgemen ts
Our thanks to Drs H. Edwards and H. Bevan Jones for allowing us to study their patients, to Mrs T. Bollimi for helping with the literature search, and to Mrs J. Anscombe for distributing the questionnaires.