The American Journal of Managed Care February 2009
"No-Shows": Who Fails to Follow Up With Initial Behavioral Health Treatment?
Patients who obtained authorization but did not get initial mental health treatment needed treatment as much as or more than patients who presented for care.
Objective: We sought to determine what demographic and clinical factors are associated with receipt of initial mental health treatment.
Study Design and Methods: A total of 1177 patients completed structured clinical interviews (Michigan Screening for Treatment and Research Triage) when they called to authorize mental health benefits. Measures included age, sex, alcohol use, drug use, anxiety, depression, medical history, behavioral health treatment history, psychosocial stressors, functioning, and suicidality. Multivariate analyses determined the association between these variables and a behavioral health claim within 90 days of the interview.
Results: Among those completing interviews, 85% attended initial mental health treatment. Factors significantly associated with increased odds of treatment initiation were good self-rated health (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.15, 2.50), support of family or friends (OR = 1.71; 95% CI = 1.11, 2.65), previous outpatient mental health visits (OR = 1.56; 95% CI = 1.11, 2.19), and recent alcohol use (OR = 1.41; 95% CI = 1.00, 1.97). Factors associated with decreased odds of treatment initiation were recent period of total disability (OR = 0.62; 95% CI = 0.45, 0.87), any previous suicide attempt (OR = 0.56; 95% CI = 0.36, 0.87), 6 or more physician visits for medical reasons this year (OR = 0.64; 95% CI = 0.44, 0.92), and legal problems (OR = 0.31; 95% CI = 0.16, 0.61). In multivariate analyses, family support, history of medical visits, and recent alcohol use were no longer significant predictors.
Conclusions: Most individuals in this insured population who completed an initial telephone assessment had an initial behavioral health claim. However, patients with greater health or social service needs were at higher risk for not obtaining treatment, suggesting the need for greater outreach and attention by providers and insurers.
(Am J Manag Care. 2009;15(2):105-112)
In this analysis of 1177 patients who completed a structured clinical screening interview (Michigan Screening for Treatment and Research Triage) to obtain authorization for behavioral health benefits, we found that:
- 85% of patients completing the telephone screening had an initial behavioral health clinic claim.
- Patients without a behavioral health claim were less likely to have good self-rated health and previous outpatient mental health care. They were more likely to have periods of disability, a previous suicide attempt, greater use of medical services, and legal problems.
- Clinicians may assume that patients who do not show up for initial treatment are in as much or greater need of treatment as patients who do present for care.
- Development of targeted interventions to assist patients with treatment engagement appears warranted.
In addition to clinicians remaining alert for symptoms of mental health disorders, using formal screening tools to identify patients who manifest symptoms, and diagnosing those who meet criteria, patients must recognize a need for treatment, make the initial contact, attend the first visit, and adhere to a recommended course of action before they can benefit from treatment.3 Patients who have made initial contact to receive mental health services have progressed in this treatment-seeking pathway; however, many do not take the next step in obtaining needed care—completing an initial behavioral health visit. Prior studies have reported that among patients attempting to access care in community mental health settings, approximately 25%-40% do not show up for their first appointment.4-7 These prior studies focused largely on community mental health settings, often serving a predominately seriously mentally ill population. Frequently, these studies also were limited by small sample sizes and lack of key patient information, such as symptom burden, family support, and current levels of functioning, which bear on the need for mental health treatment.
In this study, we used data from a standardized telephone intake interview routinely conducted by a managed behavioral healthcare organization affiliated with a university medical center. The standardized interview, which was used as a component of the organization’s routine triage and referral activity, included detailed information on patients’ mental health symptoms, home and work environments, suicidal ideation, and substance use, allowing us to examine demographic and clinical factors associated with patients’ initial behavioral health treatment. Identifying factors that predict failure to follow up with behavioral health treatment may lead to targeted interventions to improve engagement in care.
The study population consisted of patients initially assessed for treatment by a managed behavioral healthcare organization associated with a large Midwestern university between January 1, 2003, and March 31, 2006. Patients routinely completed a telephone-based assessment interview (Michigan Screening for Treatment and Research Triage [M-START]) when they called to request authorization for services. All patients who called to authorize their benefits were approved to initiate care. The care management system tracks interview dates, and assessments are not completed more than once in a 1-year period. Furthermore, all participants were continuously enrolled for the duration of the study, and no participants completed more than 1 interview.
We examined whether patients had a behavioral health claim within the 90 days after their M-START interview. Although wait times may be associated with not showing up for treatment,4-6 we chose a 90-day window for 2 reasons: (1) this time window is a standard metric used by the National Committee for Quality Assurance to evaluate effectiveness of acute treatment for depression among managed care organizations8 and (2) this time window was sufficient for all patients to be able to be seen by the behavioral health provider (ie, all members should have been able to be seen within 90 days if they chose to do so).
The M-START interview is a comprehensive telephonebased, computer-assisted structured interview, consisting of triage and need-relevant measures of psychiatric symptoms that allow for referral to appropriate specialties as needed, health and functional assessments, and psychosocial supports. M-START is administered by trained clinical social workers and takes approximately 10-15 minutes to complete. The interview includes stem questions from validated and reliable clinical instruments (eg, the Patient Health Questionnaire [PHQ-9]9 for depression, the Structured Clinical Interview for DSM-III-R [SCID]10 for mood and anxiety disorders, the CAGE11 for alcohol use). Additional items were generated from the expert opinion of 23 clinicians and researchers. The Delphi method12 was used to ask the experts to narrow down an initial list of potential items into a brief interview designed to identify patient treatment needs by indicating their rankings of importance of individual items.
In particular, patients are asked about their age, alcohol use, anxiety, behavioral health treatment history, depression symptom severity (using PHQ-99), drug use, sex, psychosocial issues in their environment (eg, family and relationships, significant loss, legal problems), medical history, functional impairment (eg, inability to work or carry out normal activities), and suicidality.
Patient M-START interview data then were linked to outpatient behavioral health claims from the managed care organization that administered the interviews. Behavioral health claims were identified based on Current Procedural Terminology codes 90801-90911.13
We first conducted bivariate analyses using t tests (for continuous measures) and Χ2 tests (for categorical or dichotomous measures), comparing patients who had a behavioral health claim within 90 days of their M-START interview with those who did not have a claim during that time period. As we conducted 48 bivariate tests, we used the false discovery rate14 to adjust for multiple comparisons. In this case, our adjusted P values for significance were ([n + 1]/[n*2])*0.05 = (49/96)*0.05 = 0.026. All predictors identified as potential significant predictors of behavioral health claims at the P ≤.026 level were used in multivariable analyses. Next, we used stepwise logistic regression analysis to evaluate which factors influenced whether a patient had a behavioral health claim within the 90-day period. We removed predictors that were no longer significant in the full model, with the exception of age, sex, and PHQ-9 score, which were left in regardless of significance because of their relevance as demographic and clinical factors associated with behavioral health treatment.
Between January 1, 2003, and March 31, 2006, 1177 patients completed an M-START interview. Of those, 1006 (85%) had an outpatient behavioral health claim within 90 days after their M-START interview. Baseline characteristics of the population completing interviews are presented in Table 1.
In univariate analyses, the following characteristics were associated with increased odds of behavioral treatment initiation: good self-rated health (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.15, 2.50), having support of family or friends (OR = 1.71; 95% CI = 1.11, 2.65), having made any outpatient mental health treatment visits in the past 2 years (OR = 1.56; 95% CI = 1.11, 2.19), and having consumed alcohol in the past 3 months (OR = 1.41; 95% CI = 1.00, 1.97). Conversely, the following characteristics were associated with decreased odds of treatment initiation: functional impairment (being totally unable to work or carry out normal activities for any days in the past 30 days [OR = 0.62; 95% CI = 0.45, 0.87]), having ever made a suicide attempt (OR = 0.56; 95% CI = 0.36, 0.87), having had 6 or more doctor visits for medical reasons this year (OR = 0.64; 95% CI = 0.44, 0.92), and having legal problems (OR = 0.31; 95% CI = 0.16, 0.61).
In multivariate analyses (presented in Table 2, model 3), factors that continued to increase the odds of treatment initiation included good selfrated health (OR = 1.55; 95% CI = 1.01, 2.37) and having any mental health outpatient visits in the last 2 years (OR = 1.82; 95% CI = 1.27, 2.60). Alternatively, factors that decreased the odds of behavioral treatment initiation included functional impairment (being totally unable to work or carry out normal activities for any days in the past 30 days [OR = 0.65; 95% CI = 0.45, 0.94]), having ever made a suicide attempt (OR = 0.61; 95% CI = 0.38, 0.98), and having legal problems (OR = 0.30; 95% CI = 0.15, 0.61). Family support was no longer a significant predictor in fully adjusted analyses. In fully adjusted models containing both medical visits and self-rated health, neither was a significant predictor as a result of the strong relationship between the 2 factors (Χ2 = 266.3, P <.0001, or in correlational terms, r = -0.48 with P = .032). For this reason and given the ubiquity of the selfrated health measure in research and clinical settings, the “medical visits” measure was dropped from the final model (see Table 2).
This study presents new findings regarding demographic and clinical factors that are associated with showing up for initial outpatient behavioral health treatment among privately insured individuals. In this population, the large majority of the patients who called to initiate treatment subsequently had a behavioral health claim. This finding differs from those of previous studies that have reported higher no-show rates, although most of these studies were conducted in community mental health populations.4-7
Interestingly, our follow-up rates were similar to those found in a study conducted in a community mental health center in the Netherlands. That study also found long waiting times, lack of motivation, and resolution of the problem as the primary reasons why patients did not follow through with initial treatment. The authors concluded that measures to reduce the no-show rate may be counterproductive by discouraging active coping.15
Unfortunately, in the present study, patients who did not have a behavioral health claim appeared to be those who were most functionally impaired. Although one would expect that patients with more psychiatric illnesses or greater symptom severity would be in greater need of treatment, the presence of psychiatric symptoms from a variety of disorders (depression, anxiety, panic, posttraumatic stress disorder, obsessivecompulsive disorder) and the severity of depressive symptoms as measured by PHQ-9 did not appear to affect the likelihood of following through with a behavioral health visit. More troubling, patients with poor selfrated health, difficulty functioning at work and in other activities, past suicide attempts, or with legal problems were less likely to initiate behavioral healthcare. Conversely, patients who had prior experience with the mental health system were more likely to engage in care.