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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 2  |  Page : 148-160

Naturalistic study of “Adherence to Follow-Up” in the initial 1st year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework”


1 Formerly Professor, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Professor, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
3 Formerly Post-Graduate Junior Resident (Psychiatry), Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Submission04-Jun-2020
Date of Decision29-Jun-2020
Date of Acceptance20-Aug-2020
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Subhash Das
Department of Psychiatry, Government Medical College and Hospital, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_147_20

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  Abstract 


Background: There are very few specialised hospital with quality assurance services catering to the needs of the elderly with mental illness. The concept of 'Appointment adherence' has received little attention in the field of geriatric mental health from India. There is a need to study the pattern of 'drop-out' amongst geriatric patients. Method: An initial cohort of first 105 cases presenting to the clinic were followed up to explore their socio-demographic and clinical variables, overall functioning and satisfaction with the services. Adopting a 'naturalistic approach,' and using the 'service evaluation framework', at the assessment period of about 36 months, tools like socio-clinical profile, Hindi Mental State Examination (HMSE), Everyday Abilities Scale for India (EASI), Global Assessment of Function (GAF) scale, WHOQOL-BREF-Hindi version, Patient Satisfaction Scale (PAT-SAT) and 'Service Evaluation (SSS-16 and SSS-10 Practitioner Versions)' were administered. Result: 68 cases were available for assessment of functional outcome and satisfaction parameters were assessed for 78 of the cases. 75% had functional disorders and medical morbidity was present in more than 50% of cases. The mean score for WHOQOL-BREF and GAF were 44.4 (poor quality of life) and 72.91 (slight impairment in socio-occupational functioning) respectively. PAT-SAT score in all the sub-categories were above average. 'Organic' diagnosis patients had lower QoL on certain domains compared to 'functional' patients. Only 30.47% patients were coming for follow-up with 25.71% having died. Of the 32/68 (34.29%) cases who had dropped out, 50% were adherent to treatment in different ways. Additionally, GAF scores were lower in 'drop-out' group. Conclusions: There is a relatively high rate of 'drop-out' over a 3-year period. However, if patients keep coming for follow-up (i.e. do not 'drop-out'), they are more likely to show improvement in their level of social and occupational functioning.

Keywords: Dropout, elderly, geriatric, outpatient services, treatment


How to cite this article:
Gupta N, Das S, Kaur T. Naturalistic study of “Adherence to Follow-Up” in the initial 1st year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework”. Indian J Soc Psychiatry 2022;38:148-60

How to cite this URL:
Gupta N, Das S, Kaur T. Naturalistic study of “Adherence to Follow-Up” in the initial 1st year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework”. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 9];38:148-60. Available from: https://www.indjsp.org/text.asp?2022/38/2/148/349349




  Introduction Top


India is faced with a gradually increasing geriatric population as reflected from the recently concluded National Mental Health Survey.[1] The elderly tend to be afflicted with a myriad of physical, social, and psychological problems, insomuch that carrying out activities of daily living becomes challenging and lowers their quality of life (QoL) significantly.[2],[3]

The World Health Organization (WHO) has been working toward highlighting the need for developing appropriate and effective mental health-care services for the elderly across the globe for nearly a decade and a half,[4] most recently emphasizing on “developing age-friendly services and settings.”[4] In this context, various parameters (patient related, resource related, setting related, culture related, policy related, etc.) need to be taken into account and evaluated before any services can be deemed to be effective.

An important measure for “effective and/or appropriate” services is how the service user utilizes that particular service,[5] with one such parameter being “adherence.”[6] “Appointment adherence” is a sub-component of “adherence,” which is taken on a continuum; in the extreme form, it is conceptualized as dropout from follow-up (FU) after attending at least one session for assessment and/or treatment.[6]

Need for the study

Adherence to treatment, including meeting the doctor on scheduled appointment day, is important for continuity in treatment and care; poor “appoint adherence” results in poor health outcome and is actually a misutilization of a health infrastructure.[7] Though an important issue, “appointment adherence” has received little attention in the field of geriatric mental health from India; with only one retrospectively designed study available reporting approximately 29% of dropout rates from outpatient services.[6] Hence, there is a need to explore “appointment adherence” in the field of geriatric psychiatry, especially in the Indian context.

In addition, in the WHO Report on the effectiveness of old-age mental health services, various models of care were evaluated and two key points come across clearly, namely, hospital-based medical care in the form of outpatient geriatric services had not been evaluated rigorously, and most of the research was from the UK/Australia/North America with poor generalizability of implications for developing countries.[4] In keeping with this, there is a strong and acute need to develop evidence-based data for delivery of care to the elderly mentally ill in India. One way of developing a health-care facility is to assess its own facility from time to time, including getting feedback from the service users, and for this purpose “service evaluation framework” can be suitably utilized.[8]

Previously, we had published our results of the initial satisfaction with services by the first 105 patients (conducted between November 2016 and July 2017) attending the Geriatric Mental Health Clinic (GMHC) from our center by using a “service evaluation framework.”[8] The present study is on the same cohort and evaluates their naturalistic “FU” pattern by using the same “service evaluation framework.”[8]

However, in order to develop a better understanding of the methodology adopted, the results presented, and discussion thereafter, it will be pertinent to provide a detailed description of the SERVICE first itself, that is, The GMHC. The same has been described in detail earlier too.[8]

The service

Need for the service

The Department of Psychiatry, Government Medical College and Hospital, Chandigarh, has been providing tertiary mental health-care services since February 1994 to the union territory of Chandigarh. However, its catchment area also includes the neighboring states of Punjab, Haryana, Himachal Pradesh, extending up to New Delhi, and parts of Rajasthan, Uttar Pradesh, and Uttarakhand.

Apart from the regular outpatient clinics for adults, the department has developed and been running specialty outpatient clinics such as child guidance clinic (for children with mental health needs), de-addiction clinics (for substance abuse-related problems), and marital and psychosexual clinic (for sexual and marital issues).

In addition, though the institute had been providing generic services for the elderly in the form of a geriatric outpatient department (OPD) being run by the Department of Community Medicine since February 2012 (www.gmch.gov.in), yet these were geared toward addressing their physical health needs, and not their psychological, social, and mental health needs.

Keeping in view the WHO projection of increasing burden of elderly in future, the increased prevalence of morbidity (especially dementia and related disorders), and the need to provide integrated care for older populations in less resourced settings,[9] this unmet service need was addressed by the Department by initiation of a separate clinic for the elderly in January 2015.

Objectives of the service

The service was set up keeping in perspective the following objectives for the service users (i.e., patients and their caregivers), namely,

  1. There should be easy access for the service users
  2. The service should be able to deliver exclusive and specialized care in the way it has been envisaged
  3. Psychosocial support and holistic care to patients attending the clinic
  4. Appropriate guidance to care givers of the patients
  5. Consultation-liaison services with other specialties for delivering holistic and integrated care.


Details of service

Day and frequency

The clinic was named GMHC and was started on a once-a-week basis, that is, every Saturday. This day was specifically chosen as Saturday is a public holiday in government offices in Chandigarh and it would facilitate the attendance of the elderly by allowing their caregivers to bring/accompany them on that day, keeping in mind that a reasonable majority of young/middle-aged people residing in and around Chandigarh are from the public/government sector.

Personnel

The personnel included consultant psychiatrist (SD), consultant clinical psychologist, MD psychiatry trainee (by rotation), and M. Phil clinical psychology trainee (by rotation). There is an additional facility of referral to the psychiatric social work faculty placed in the OPD for assessment and management of psychosocial issues.

Referral process

Any new patient attending the psychiatry general outpatient clinic would be first screened by a senior resident (qualified psychiatrist; post MD) in terms of suitability of age for referral to GMHC (i.e., age above 60 years), followed by a detailed assessment using a specially designed socio-clinical pro forma (Instrument 1 under TOOLS), and making an initial working diagnosis based on ICD-10 (WHO) criteria, following which treatment and/or necessary investigations were advised accordingly. The senior resident makes the referral to the GMHC wherein the patient comes for the subsequent (i.e., 2nd) Follow-Up (FU) visit to the GMHC, is registered under the specialist clinic services, and is allocated a GMHC number.

Assessment process

In the 2nd visit, a detailed assessment is carried out wherein the MD trainee conducts a detailed clinical assessment involving history taking, physical examination, and mental status examination to arrive at a diagnosis as per ICD-10. In addition, a baseline assessment of cognitive function is done using the “Hindi Mental State Examination (HMSE),”[10] and the level of functioning is assessed with the help of “Everyday Abilities Scale for India (EASI)”[11] (Instruments 2 and 3 under TOOLS) by the M. Phil clinical psychology trainee under the direct supervision of the consultant clinical psychologist. A detailed case discussion is conducted with the consultant psychiatrist in-charge (I/C) of GMHC (SD) and by adopting such a multidisciplinary approach, the ICD-10 diagnosis (along with associated dysfunction) is confirmed or refuted.

Management and follow-up

In terms of management, patients were provided with appropriate pharmacological intervention in keeping with their psychiatric diagnosis and medical comorbidities. In addition, nonpharmacological strategies/packages were formulated (pure psychological, pure psychosocial, and mixed psychological and social) as per identified needs of the patient and caregiver, and attempts were made to deliver the same. Overall, the attempt was to deliver management in an integrated model adopting a judicious mix of pharmacological and nonpharmacological strategies as per the identified needs of both patients and their caregivers. FU of patients was provided/advised in a pragmatic manner in order to ensure convenience for both patient and his/her caregiver. This was generally done at a variable period ranging from once every 2 weeks to once every few months and was influenced by a host of variables – nature of illness, severity of illness, distance of patient's home from the hospital, functionality of patient, distress of caregiver, time constraints faced by caregiver, etc.

Aim

The aim was to carry out a naturalistic study of “adherence to FU” in the initial 1st year cohort of patients utilizing a tertiary hospital-based geriatric mental health-care service using the “Service Evaluation Framework.”

Objectives

  1. To outline the socio-clinical profile of patients presenting to the GMHC in the 1st year of its inception
  2. To determine the medium-term (36 months) functional and clinical outcomes of patients seen during the 1st year of the GMHC
  3. To compare the patients on various functional and satisfaction-related parameters on the basis of diagnosis, that is, by dividing them into broad categories of “organic” and “functional/nonorganic”
  4. To compare the patients on various functional and satisfaction-related parameters on the basis of their “adherence to appointments/treatment,” that is, by dividing them into broad categories of “drop-out” and “coming for FU.”



  Materials and Methods Top


Sample-cum-inclusion criteria

All consecutive elderly patients, that is, aged 60 years or more, who attended and were registered in the GMHC, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, over a period of 1 year, that is, from January 31, 2015, to January 30, 2016, were taken up for the study. Thereafter, this cohort of patients was followed up till July 2018.

Exclusion criteria

Patients not seen by the primary consultant I/C of the clinic (SD) and where data were incomplete or missing due to various reasons (patients could not be contacted, absence of baseline data, patient refused to participate, etc.) were excluded.

Assessment points and duration of follow-up

The first FU assessment of the patients and/or their primary caregivers for the purpose of the study was done between November 2016 and July 2017, that is, approximately within a range of 18–24 months, and with a view of keeping an average FU period of 18 months after first contact with the clinic services.

The second FU assessment was done between May and July 2018, which was within a range of 28–42 months, with the average FU period being 35 months (approximately 3 years).

Dropout

For the purpose of this study, all patients who had stopped coming to the GMHC in the preceding 12 months from the day of second FU assessment (i.e., between May and July 2018) during the study period were considered as dropouts.

Service evaluation parameters at second follow-up assessment

  1. Level of functioning (using Global Assessment of Functioning scale[12],[13] and EASI)
  2. QoL (using WHOQoL-BREF)[14]
  3. Satisfaction with the services (using PAT-SAT)[15]
  4. Service evaluation (SSS-16 and SSS-10 Practitioner Versions) questionnaire[16]
  5. Single question to determine the “reason for dropout.”


Procedure

As most of the elderly were frail with limited mobility with associated physical comorbidities, and many of them were from distant places, so it was jointly decided by the two principal authors (SD and NG) that the FU assessment would be conducted telephonically. This would also cause minimal inconvenience to the patients and further ensure uniformity in the procedure of data collection.

A final-year MD trainee in psychiatry (TK) was inducted into the study. TK was provided extensive training in the use of the assessment tools nos. 3–7 by SD and NG. Subsequently, TK administered tools 3–7 under the supervision of SD on ten admitted patients and their caregivers in order to familiarize herself with these instruments/scales. Thereafter, the same procedure was conducted by assessing ten patients and their caregivers telephonically. Verbal consent was taken from all these patients. Analysis of both sets of data by the supervising consultants revealed that there was near comparability in the assessment conducted across both settings and opined that assessment over phone can be done without major issues. Nevertheless, in order to ensure quality control, the first ten interviews by TK were again done under the supervision of NG. In addition, for all subsequent interviews, TK was randomly supervised during the interview process on a periodic basis. Hence, a robust system was put into place to ensure quality assurance for data collection.

TK would contact the patients telephonically and would explain the process to them in detail. Thereafter, verbal consent would be taken and recorded in the patient pro forma. In situations where the patient would not be in a position to provide consent or be interviewed or refuse interview or be unavailable due to any reason, then the primary caregiver would be interviewed. The primary caregiver was defined as an individual who had the responsibility of meeting the physical and psychological needs of the dependent patient, and also providing assistance or supervision in the daily activities of their patients with mental illness.[17] Caregivers were taken as adequate proxy measure of patients as there is reasonable body of evidence from our center/this area to support this methodological issue.[18],[19] The interviews were carried out at a time, which was convenient for the participants. The complete interview lasted for about an average time of 40 (range = 30–50) min. For any given participant, at least three attempts were made to establish contact with them. If after three attempts, no contact could be established, then such a case was excluded from the study and was not re-contacted.

Ethical considerations

Verbal consent was taken. Interviews were conducted as per the convenience of the participants. Anonymity and full confidentiality was ensured. Approval from the institute's ethics committee was not required as the study design and execution was done using the “service evaluation framework.”[20]

Tools

  1. Patient Intake Pro forma (for recording clinical and sociodemographic details): This specially designed pro forma, which is routinely used in the GMHC, contains patients' sociodemographic details such as name, age, gender, occupation, and address. In addition, it also contains information pertaining to clinical details such as comorbid physical illness, medications being used, family history of mental illness, past history of mental illness, substance use history, general physical and systemic examination, and mental status examination
  2. Hindi Mental State Examination (HMSE):[10] The HMSE is a 22-item scale, which tests different components of intellectual capacity. The items cover several areas of cognitive functioning such as orientation to time and place, memory, attention, and concentration; recognition of objects; language function; both comprehension and expressive speech; motor functioning; and praxis. It is relatively simple to administer and provides a quick brief index of the participant's current level of functioning. It is a modified and Hindi version of Mini–Mental State Examination[21] which can be used in Hindi-speaking Indian population and can even be administered on illiterate people. Its sensitivity and specificity of 81.3% and 60.2%, respectively, were reported from Ballabhgarh in North India.[22] This is used routinely in the GMHC during the initial detailed assessment and on FU visits
  3. Everyday Abilities Scale for India (EASI):[11] EASI is a 12-item uni-dimensional scale covering mobility, memory, and instrumental and personal care activities related to activities of daily living and can be used in Hindi-speaking Indian population. It is a brief assessment tool where information is gathered from caregivers and has sensitivity and specificity of 62.5% and 89.7%, respectively.[19] The higher the score, more is the dysfunction. This is used routinely in the GMHC during the initial detailed assessment and on FU visits
  4. Global Assessment of Functioning (GAF):[12],[13] The GAF is a 100-point scale divided into intervals or sections, each with 10 points. GAF covers the range from positive mental health to severe psychopathology, and is a global measure of how a patient is doing, and is intended to be a generic rather than diagnosis-specific scoring system. The 10-point intervals have anchor points (verbal instructions) describing symptoms and functioning that are relevant for scoring. The scale is provided with examples of what should be scored in each 10-point interval. The present GAF is found as Axis V of the Internationally accepted Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision
  5. WHO QoL -BREF (WHOQOL-BREF)[14] Hindi version: WHOQOL-BREF is an abbreviated 26-item version of the WHOQOL-100 and was developed using data from the field trial version of the WHOQOL-100. It has been developed cross culturally and is available in over twenty different languages. This instrument places primary importance on the perception of the individual. It is one of the best known instruments to measure the generic QoL. It is a self-administered scale that measures the following broad domains: physical health, psychological health, social relationships, and environment. The Hindi version was developed and validated and is widely used in various mental illnesses
  6. Patient Satisfaction Scale (PAT-SAT):[15] The scale comprises of 19 items subdivided into six domains, namely, trust, communication, exploration of ideas, body language, active listening, and miscellaneous. It is rated on a 5-point Likert scale (strongly agree, agree, do not know, disagree, and strongly disagree). The PAT-SAT is easily readable and understandable even for people with few years of education. The scale quantifies the complex and multidimensional relationship between the clinician and the patient seen from the patient's perspective. The PAT-SAT scale can be used without prior training for the practitioner and with a minimum of instructions to patients. It has been translated into Hindi by one of the authors (NG) and who had demonstrated that this scale can be used in the Indian setting, albeit judiciously, and can serve as proxy assessment for patients if administered on caregivers[19],[23]
  7. Service Evaluation Questionnaire (SSS-16 and SSS-10 Practitioner Versions):[16] SSS-16 is the briefer version of SSS-30. The scale comprises 16 items subdivided into four domains – manner and skill, perceived outcome, waiting, and information. The SSS-16 scale shows good reliability for mental health services
  8. A single question was asked to the respondents in the “dropout” group in order to ascertain the reason for dropout. The respondent was asked to mention the most important reason for “dropout” and this was recorded by TK.


It may be added here that tools such as HMSE, EASI, GAF, WHO-QoL BREF (Hindi version), PAT-SAT, SSS-16, and SSS-10 Practitioner's Versions are quite often used in different studies and are also suitable to be applied in the Indian population. All the former five tools have been already conveniently used in a previous study on the same cohort[8] and thus these same tools were used while following the cohort so as to reach the objectives of the study.

Statistical analysis

Statistical analysis was carried out using SPSS version 22.0 (IBM Corp, Armonk, NY, USA). Data were analyzed in which frequency generation, percentages, mean, and standard deviation were calculated. In addition, they were subjected to univariate analysis, where Chi-square analysis was done for nominal variables and Student's t-test (across-group comparison)/paired t-test (within-group comparison) for ordinal variables was carried out. For nonparametric comparison, Mann–Whitney-U analysis was conducted.

To test for homogeneity of variance among the sample, Levene's test of equality of variances was conducted before applying independent t-test across the comparison groups. This was necessitated due to the unequal sizes of the two comparison groups.

Cox regression and Kaplan–Meier survival analyses were conducted to determine the effect of “dropout” and “adherence to FU” over time on functioning. Statistical significance was kept at P < 0.05 for all tests.


  Results Top


Based on the inclusion and exclusion criteria, a total of 105 patients had comprised the sample for the study, of which 17 had died at the time of first FU assessment of the study period.[8] Hence, a total of 88 patients were available for contact.

On contact, nine were not contactable (as mentioned in “Methodology”) and one “refused consent.” Of the 78 patients so available for evaluation, 10 had further died. However, their immediate caregivers were willing to respond to “satisfaction-” related questions (PATSAT, SSS-16), hence were taken up as outlined in methodology earlier. Functional outcome assessments (EASI, GAF, and WHOQoL) were available, therefore, for 68 patients.

As shown in [Table 1], most of the cases (n = 88) were in the 60 to < 65 years' age group, were married, and males outnumbered females (male-to-female ratio being almost 2:1). Approximately one-half of the patients were illiterate/primary educated and Hindus, and a little over 40% were either homemakers or engaged in household work. Almost half of the patients stayed in a joint family setup, with majority being from urban areas, and only about 30% were from the union territory of Chandigarh.
Table 1: Sociodemographic profile of the whole sample evaluated for follow-up at 36 months (n=88)

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[Table 2] gives a description on the clinical variables at baseline of the overall sample (n = 88). About 3/4th of the cases had functional disorders such as depression and bipolar affective disorders. One-third of the cases had duration of illness for >5 years followed by about 28% who had illness duration of 0–6 months. Medical morbidity was present in more than half of the cases, with hypertension being the most common, and one-fifth of the cases were afflicted by it. Three-fourth of the cases did not have any positive history of mental illness in the family.
Table 2: Clinical profile of the whole sample evaluated for follow-up at 36 months (n=88)

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In the FU assessment at 36 months, [Table 3] shows that the mean scores for WHO-QOL BREF and GAF were 44.40 (suggesting poor QoL) and 72.91 (suggesting slight impairment in socio-occupational functioning), respectively. The mean PATSAT scores in all the sub-categories (PAT-SAT: D1, D2, D3, D4, D5, and D6, respectively, represents trust, communication, exploration of ideas, body language, active listening, and miscellaneous categories) were above average.
Table 3: Functional outcome and satisfaction scores on PATSAT of sample (n=78) obtained at follow-up of 36 months

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In addition, EASI score was 2.59 + 3.08, indicating higher degree of functional impairment. It will be pertinent to mention that the baseline mean EASI score was 1.77 + 0.42 (range being 0–12), suggesting that overall there was less functional impairment in the cases. The mean HMSE score was 26.27 + 6.38, suggesting that overall very few of the patients had cognitive impairment.

Thereafter, the whole study sample was subdivided into two groups: those with “organic” diagnosis (i.e., dementia, delirium) and those with “nonorganic/functional” (unipolar and bipolar affective disorders, anxiety disorders, etc.) mental disorders (organic and functional, respectively). Details of the findings are given in [Table 4]. On the 36-month FU assessment, the organic subgroup had significantly lower scores on WHOQOL domain scores of social relationships (WHOQOL-D3) and environment (WHOQOL-D4) and the domains of “waiting” of SSS-16 scale, but significantly higher score on the domain of “manner and skill” of SSS-16 compared to the functional subgroup.
Table 4: Comparison of “organic” versus “functional” cases on functional and satisfaction assessment parameters at 36-month follow-up

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Overall follow-up rates

At the outset, it is interesting to note that we had only 32 patients in active FU of the initial cohort of 105, giving an overall FU rate of 30.47%. Over the 3-year period, 27/105 (25.71%) had died, 36/105 (34.29%) were lost to FU, and 10/105 (9.52%) were not contactable.

Finally, the whole study sample was subdivided into two main groups as per the main focus of our service evaluation, that is, those who had dropped out (n = 36) and those who were coming for FU (n = 32). Both these groups were compared on various functional [Table 5] and satisfaction-related [Table 6] parameters. The “dropout” group had significantly lower scores on the PATSAT domain of “exploration of ideas/options” than the “FU” group, but comparable on all other parameters [Table 5] and [Table 6]. In addition, the most common and main reason for “dropout” was asked from each respondent in the “dropout” group [Table 7], in which 25% were actually showing treatment adherence (taking prescribed medication at home) and 14% were using coping strategies of “acceptance.”
Table 5: Comparison of the functional parameters between “follow-up” and “dropout” patients

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Table 6: Comparison of the satisfaction-related parameters between “follow-up” and “dropout” patients

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Table 7: Various reasons given by the respondents (n=36) for not coming for follow-up

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As the main aim of the study was to evaluate the naturalistic FU pattern of the initial study cohort, we conducted a survival analysis for the whole sample [Figure 1] and on the basis of a broad diagnosis of “organic” and “functional” by using GAF (a measure of social functioning) as the dependent variable [Figure 2] and [Figure 3]. There was a significant difference between the “dropout” and “FU” cases across the whole sample (n = 68), organic (n = 12), functional (n = 56).
Figure 1: Kaplan–Meier curve for the whole sample (n = 68)

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Figure 2: Kaplan–Meier curve for patients with “organic” diagnosis (n = 12)

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Figure 3: Kaplan–Meier curve for patients with “functional” diagnosis (n = 56)

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  Discussion Top


As was done in the first study reported from our center,[8] this study has also been planned using a “service evaluation framework;” the reasons being alluded to in our previous paper.[8] In the previous “service evaluation-based” study, we have already discussed in detail the reasons as to why this approach is more suited and appropriate than adopting the “more popular” research designs for the elderly.[8] In addition, it is important to emphasize that incorporation or focus on service user viewpoint has become of paramount importance in mental health outcome measurement;[24] hence, the approach adopted by us is not only “refreshing and innovative” in the Indian context but also extremely relevant as per the proposed trends in the current literature on assessing the outcomes of mental health interventions and developing services.[24]

Objective 1: To outline the socio-clinical profile of the FU patients (n = 88) presenting to the GMHC in the 1st year of its inception [Table 1] and [Table 2].

The first objective was to determine the profile of patients who were attending the GMHC in the 1st year of its inception and followed up at 36 months.

It the current study, most of the cases were in the age group of 60–64.9 years of age. Combining with the 65–69.9 years' age group, we get a cumulative percentage of 60% of cases. Majority of the cases in the present study were males. Nearly half of the sample was either illiterate or had just primary level of education. Similar findings were reported from a previous study conducted in Uttar Pradesh.[25] This finding holds significance as low level of education has been associated with dementia.[25] In our study, most of the patients were either engaged in household work or were homemakers, followed by people who were retired; this has already been discussed in our earlier study.[8]

In terms of psychiatric morbidity among the elderly in the current study, depressive disorder and bipolar affective disorder were the two leading mental illnesses and together they were present in more than half of the sample followed by dementia due to Alzheimer's disease. Detailed discussion on the clinical aspects (diagnosis, comorbidity, and its type) has been covered previously in the study by Gupta et al.[8]

Objective 2: To determine the medium-term (36 months) functional and clinical outcomes of patients seen during the 1st year of the GMHC [Table 3].

In our previous study of FU at an approximately mean duration of 18 months, it was observed that there was improvement in the overall functioning (on combined parameters of EASI and GAF) of the patients following treatment intervention.[8] However, because the current assessment at 36 months had a reduction of cases (n = 78) due to a combination of not assessed and having died, we were unable to compare like for like data. Nevertheless, the EASI scores had dropped from baseline (2.95 + 3.36) but were higher as compared to 18-month FU (1.64 + 2.57); correspondingly, a similar pattern was seen with social functioning using GAF wherein scores dropped from 78.77 + 16.92 (18-month FU) to 72.91 + 18.68 (36-month FU). Hence, this is reflecting deterioration in functioning; most likely due to loss of contact due to “dropout.” Though literature on the evaluation of outcome measures specifically related to geriatric mental health services is scanty, with fewer countries having specialized mental health care for the elderly, integrated and multidisciplinary effort including frailty-based programs in providing such care do seem to help the elderly; those in contact with our clinic too were eventually found to have a better outcome.[26]

The total WHOQoL score of 44.40 + 5.58 was comparable (not significant) to the previous FU score at 18 months (45.42 + 6.23), and reflective of a moderate degree of QoL.[8] Of interest is the findings from South India wherein near-similar values have been reported from rural and urban Tamil Nadu.[27],[28] Scores on all domains were comparable; a finding different from the studies from South India where the social domain values were highest in rural setting and physical domain values were highest in urban setting.[27],[28] However, it needs to be kept in mind that these studies were carried out on elderly population with physical ailments and not those afflicted with mental illness. Unfortunately, due to the inherent design of our study, we were unable to administer WHOQoL-BREF at baseline, due to which we are unable to comment upon the effect of the service as an intervention and its effect thereafter. Hence, one may only hypothesize that the moderate QoL reported in the cohort is contributed to by the intervention and contact with the GMHC thereof; the how and why remains unanswered at the moment!

We have continued with the trend of determining service user views related to their satisfaction with the consultant-I/C (SD) as was done previously at 18-month FU; for a detailed understanding of this concept, the reader can refer to previous literature.[8],[15] As was in the previous study, the scores obtained on each of the six domains of PATSAT were above 60% of the possible mean scores that could be obtained. This reflects that the patients (and/or their caregivers) were not dissatisfied, if not overly satisfied, with the services provided at 18 months of FU.[8] However, we are not in a position to carry out a detailed and critical analysis of the scores of each domain either cross-sectionally nor compare them with previous results, due to the fact that not only the current “n” is different but also the current cohort comprises of patients who have “dropped out” of FU.

Objective 3: To compare the patients on various functional and satisfaction-related parameters on the basis of diagnosis, that is, by dividing them into broad categories of “organic” and “functional/nonorganic” [Table 4].

The sample of 78 patients was divided into two sub-groups, namely “organic (comprising dementia, other dementias, delirium)” and “functional/nonorganic” (comprising schizophrenia and other psychosis, BPAD, depression-single/recurrent, anxiety disorder). Of the total sample of 78 patients, 59 cases (75.6%) were having functional disorders and the remaining 19 cases (24.4%) were having organic disorder.

During the interim period between 1st and 2nd FU, three cases of the former and seven cases of the latter had expired, the mortality being 5.1% and 36.8% in each group, respectively. Comparing with figures in the previous study at 18-month FU, there is no significant change (6.8% in functional and 37.5% in organic), which reflects a reasonably stable trend for mortality in both the groups across time. Another comparatively interesting observation is that although the “functional” group was performing functionally much better than the “organic” group at 18-month FU, both groups became comparable at the current assessment. On a closer look, it can be seen that this is due to a significant fall in the GAF score of the “functional” group, indicating a deterioration of functioning over the previous 18 months, which may indicate an inherent deterioration in the illness. However, the comparable EASI scores are not easy to explain. This is, in some ways, is on similar lines to the recent research wherein it has been pointed out over a reasonable period of time depression, which can lead onto dementia and death,[29],[30] but our FU period is too short to comment definitely upon the same, and neither our study design is geared to address this issue specifically.

Mixed results were also obtained on QOL; comparable overall, and on physical and environmental domains, but significantly lower scores on psychological domain and higher on social domain in “organic” subgroup. Lower scores on psychological domain in “organic” subgroup may be due to difficulty in managing the behavioral symptoms due to dementia/organicity; additionally, they require medications which may not be available or accessible due to a variety of factors (including dropout from FU). This issue will be seen in more detail in the last objective. Higher scores in the social domain are more likely than not reflective of the fact that the caregivers are more active and utilizing the “Manual on Caregiving” provided as part of routine treatment for patients with organicity (specifically dementia) and which has shown to be quite useful/helpful.[8] Unfortunately, no such manual has been developed for “functional” illnesses till date in GMHC.

Both groups were comparable on individual satisfaction measures (PATSAT), but the “organic” subgroup showed significantly higher satisfaction with services on the domain of “manner and skill satisfaction” and significantly lower satisfaction with services on “waiting/access satisfaction;” the reasons for these discrepant findings are unclear. Furthermore, it will be difficult and inappropriate to compare and discuss the findings of the various domains due to reasons alluded under Objective 2.

Objective 4: To compare the patients on various functional and satisfaction-related parameters on the basis of their “adherence to appointments/treatment,” that is, by dividing them into broad categories of “dropout” and “coming for FU” [Table 5],[Table 6],[Table 7] and [Figure 1],[Figure 2],[Figure 3].

Overall follow-up rates

Missing appointment in psychiatric services is not uncommon, and about 20% of patients may miss appointment and 50% of those who miss appointments, eventually drop out from treatment plan.[31] A study from Rohtak, in northern part of India, had found that at the end of 6 months, dropout rate from psychiatric services was as high as 75%. However, it comprised of patients across all age groups.[32] Our dropout rate was also quite similar and over a period of 3 years, we had only 32 patients in active FU of the initial cohort of 105, giving an overall FU rate of 30.47% only. This is significantly lower than that reported (71.45%) in a study from the same region with a near-similar catchment area.[6] In our study, over this 3-year period, 27/105 (25.71%) had died and 10/105 (9.52%) were not contactable. However, looking specifically at the “dropout” rates, 36/105 (34.29%) were lost to FU. This figure is actually comparable to that reported by Grover et al., that is, 28.55%, and make interesting findings as the study by Grover et al.[6] is retrospective in nature and also has used a different and less stringent definition of “dropout” (no FU after initial registration) and “FU” (at least once during 6 months after initial registration). Our study shows that over a long term, a significant proportion die (a not unexpected outcome in elderly, especially those suffering with mental with/without physical illnesses) and this can not only affect the outcome of the service so delivered but it should also make the service geared toward helping the family/caregivers to be able to address this inevitable outcome.

Additionally to achieve objective 4, we divided the available sample of alive patients (n = 68) into two subgroups, namely, “dropout” (n = 36) and “FU” (n = 32).

On the basis of diagnosis (organic/functional), both groups were comparable (dropout [5/31] vs. FU [7/25]; χ2 = 0.7435; P = 0.388); hence, the type of diagnosis made no impact on the tendency of the patient and/or his/her caregiver to drop out from the service. This is in contrast to that reported by Grover et al.[6] wherein “depressive disorders” were associated with lower dropout and “other” diagnosis with higher “dropout” rates.

Comparison on functional outcome parameters, that is, GAF, EASI, and QoL [Table 5], gave comparable results across both groups, which could be a reflection of the possibility that the “dropout” group was being able to maintain itself through a myriad of factors (seeking treatment closer to home, change of doctor, alternate pathway of care, additional coping strategies, etc.). On inquiry from the patients and/or caregivers in this subgroup [Table 7], the most common reasons that were put forth were 25% were actually showing treatment adherence (taking prescribed medication at home), 14% were using coping strategies of “acceptance,” and 11% were seeing a new doctor, that is, half of the patients were maintaining themselves through treatment adherence or positive psychological coping, thereby confirming our hypothesis. However, 25% reported accessibility issues and 25% reported being physically unwell, factors which remain beyond the control of our service but nevertheless not mitigiable as one can consider setting up of liaison and/or community-based linkages.[4]

On comparison of the satisfaction-related parameters, the only significant difference was on PATSAT domain of “Exploration of ideas/options;” “dropout” scoring lower. This is understandable from the concept that this domain measures those aspects of doctor–patient interaction in which direct face-to-face detailed discussion is required, whereas other domains look at only interpersonal communication patterns and interaction, which are not related to discussion about the illness per se. Hence, it may be possible that due to not being offered much in terms of intervention (qualitatively and/or quantitatively), the patients have dropped out. This remains speculative but nevertheless needs to be explored as nearly 50% gave reasons which were indicative of this phenomenon, and will help us to improve our service further.

Lastly, an attempt was made to understand if any difference is made by continuing to “FU” with the GMHC, especially if one considers the above finding of comparable functional outcomes. This will be more relevant if one considers the fact that a person presents with active phase of illness (whether organic or functional) receives intervention and then shows improvement (remission/recovery) in future. For this, we looked at the GAF scores between “dropout” group at 18 months (78.16 + 16.57) and 36 months (72.51 + 18.52); t + 2.798; P < 0.007; hence, the “dropout” group performed poorly at subsequent assessment. This indicates that without contact with GMHC, there is an actual and significant deterioration in the social functioning. To further check this out, a survival analysis was conducted for the whole sample and for either broad diagnostic category [Figure 1] and [Figure 3]. It was seen that at an approximate GAF score of 50, there was comparability. However, after that, the presence OR absence of FU started to make a difference, that is, patients who were in contact with GMHC were more likely to show a significantly higher improvement in GAF score, which would be reflective of their improvement in overall functioning (especially socio-occupational functioning).

Limitations

Despite being a service evaluation, numerous aspects still need addressing. To enumerate, the sample size was small; we were unable to conduct face-to-face interviews; evaluation of satisfaction with one's own doctor and the service can potentially introduce a lack of transparency in responses from patients;[19] PATSAT is not a completely culture-free instrument;[19] and mixed-methodology could have been a more appropriate methodology to address the main research question. Another way to improve upon this study would be to involve a completely different body to evaluate the facility at GMHC using the “Service Evaluation Framework” so as to minimize any bias. Nevertheless, it is pertinent to add here that the principal author of the study was not involved in the running of GMHC and was in a way a neutral observer.

Strengths

However, numerous strengths tend to balance out the above-mentioned limitations so pointed out, that is, a reasonably long period of FU of nearly 36 months, pragmatic in design, taking the patient and caregiver convenience into account, applying structured tools for assessment, assessing functional status and satisfaction with services in detail, etc.


  Conclusions Top


This study throws some interesting light on various key issues. It is probably the first of its kind study from India that focuses on the performance of a geriatric mental health service facility by using the “service evaluation framework” along with validated tools for such assessment. The methodology and findings from this study can thus act as a template for similar studies in future, which in turn could be very useful to the policymakers in developing geriatric services. The key finding from our study is that although there is a relatively high rate of “dropout” over a 3-year period, yet this is not surprising and is in keeping with that reported in literature. More importantly, it was seen that if patients keep coming for FU (i.e., do not “drop out”), they are more likely to show improvement in their level of social and occupational functioning. This finding assumes importance insomuch that irrespective of diagnosis, and irrespective of seeking treatment locally or elsewhere, the contact with GMHC (our service) is able to potentially bring about a significant change if “FU” can be ensured.

BUT-The question is how? Over the last 3 years, there has not been much increase in the available resources though the influx of patients has shown a significant increase by about 50%. In a resource-constrained, time-constrained setting, this puts a significant strain on the delivery of effectiveness and quality of services. Nevertheless, these reasons cannot be a justification for not trying to improve and implement changes. Ensuring FU is an essential component of any service and goes a long way in the development and sustenance of the service itself.

We are continuing to work toward this goal!

In the words of Sir Robert Frost,

“The woods are lovely, dark and deep,

But I have promises to keep,

And miles to go before I sleep,

And miles to go before I sleep”

(Taken from, Robert Frost's Stopping by Woods on a Snowy Evening from The Poetry of Robert Frost, edited by Edward Connery Lathem. Copyright 1923).

Acknowledgments

The authors would like to thank the patients and their family members and staff of GMCH, Department of Psychiatry, Government Medical College and Hospital, Chandigarh.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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