How long can a waiting list be?

Access to child developmental assessment services in culturally and linguistically diverse metropolitan Sydney: a retrospective cohort analysis

BACKGROUND

Despite the increasing prevalence of neurodevelopmental disorders (NDD), data regarding access to child development services have remained limited globally. Long wait times are a major barrier to developmental assessments, impacting on care and outcomes. The aim is to retrospectively analyse the demographic profile and prioritisation of patients seen at a child developmental assessment service (CDAS) in a vulnerable region of Sydney, and explore factors affecting wait times.

METHODS

Data was collated and analysed for 2354 patients from 2018 to 2022. Socio-Economic Indexes for Areas (SEIFA) were collated from the Australian Bureau of Statistics. Descriptive statistics were used for demographic data and various statistical methods were used to analyse the relationships and impact of factors likely to affect wait lists.

RESULTS

The median age was 51 months (IQR41-61) and males comprised 73.7% of the cohort. 64% of children were from culturally and linguistically diverse backgrounds (CALD) and 47% lived in the most disadvantaged suburbs. The median wait time was 302.5 days (IQR175-379) and 70% of children were seen within 12 months. CALD patients and children over 5-years had shorter wait times. Most children with Global Developmental Delay (GDD) were from the lowest four SEIFA deciles and waited longer for an appointment. 42.6% were seen within the priority allocated time or sooner. Children with ASD and/or severe GDD were prioritised to be seen earlier. Overall, the study could not demonstrate any difference in the wait times according to the prioritisation groups.

CONCLUSION

This study provides insights into the profile, prioritisation processes and wait lists of children seen by CDAS in South Western Sydney with high rates of social vulnerability and presents an argument to discuss benchmarking targets with service providers. It identifies the need to prioritise children living in suburbs with socioeconomic disadvantage and refine prioritisation and data collection processes to improve wait times.

Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada

PURPOSE

A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work.

METHODS

We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature.

RESULTS

Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups.

CONCLUSION

We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

[Cross-sectoral therapeutic concepts and innovative technologies: new opportunities for the treatment of patients with mental disorders]

Mental disorders are widespread and a major public health problem. The risk of developing a mental disorder at some point in life is around 40%. Therefore, mental disorders are among the most common diseases. Despite the introduction of newer psychotropic drugs, disorder-specific psychotherapy and stimulation techniques, many of those affected still show insufficient symptom remission and a chronic course of the disorder. Conceptual and technological progress in recent years has enabled a new, more flexible and personalized form of mental health care. Both the traditional therapeutic concepts and newer decentralized, modularly structured, track units, together with innovative digital technologies, will offer individualized therapeutic options in order to alleviate symptoms and improve quality of life of patients with mental illnesses. The primary goal of closely combining inpatient care concepts with innovative technologies is to provide comprehensive therapy and aftercare concepts for all individual needs of patients with mental disorders. Last but not least, this also ensures that specialist psychiatric treatment is available regardless of location. In twenty-first century psychiatry, modern care structures must be effectively linked to the current dynamics of digital transformation. This narrative review is dedicated to the theoretical and practical aspects of a cross-sectoral treatment system combined with innovative digital technologies in the psychiatric-psychotherapeutic field. The authors aim to illuminate these therapy modalities using the example of the Central Institute of Mental Health in Mannheim.

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation

BACKGROUND AND OBJECTIVE

Unipolar depression is the most common form of depression and demand for treatment, such as psychotherapy, is high. However, waiting times for psychotherapy often considerably exceed their recommended maximum. As a potentially less costly alternative treatment, internet-based cognitive behavior therapy (ICBT) might help reduce waiting times. We therefore analyzed the cost-utility of ICBT compared to face-to-face CBT (FCBT) as an active control treatment, taking differences in waiting time into account.

METHODS

We constructed a Markov model to simulate costs and health outcomes measured in quality-adjusted life years (QALYs) for ICBT and FCBT in Germany. We modeled a time horizon of 3 years using six states (remission, depressed, spontaneous remission, undergoing treatment, treatment finished, death). The societal perspective was adopted. We obtained parameters for transition probabilities, depression-specific QoL, and cost data from the literature. Deterministic and probabilistic sensitivity analyses were conducted. Within a scenario analysis, we simulated different time-to-treatment combinations. Half-cycle correction was applied.

RESULTS

In our simulation, ICBT generated 0.260 QALYs and saved €2536 per patient compared to FCBT. Our deterministic sensitivity analysis suggests that the base-case results were largely unaffected by parameter uncertainty and are therefore robust. Our probabilistic sensitivity analysis suggests that ICBT is highly likely to be more effective (91.5%), less costly (76.0%), and the dominant strategy (69.7%) compared to FCBT. The scenario analysis revealed that the base-case results are robust to variations in time-to-treatment differences.

CONCLUSION

ICBT has a strong potential to balance demand and supply of CBT in unipolar depression by reducing therapist time per patient. It is highly likely to generate more QALYs and reduce health care expenditure. In addition, ICBT may have further positive external effects, such as freeing up capacities for the most severely depressed patients.

Patients' preferences for the treatment of anxiety and depressive disorders: a systematic review of discrete choice experiments

Introduction: Matching available mental health services to patients' preferences, as well as is possible, may increase patient satisfaction and help increase adherence to certain treatments. This study systematically reviewed discrete-choice experiments (DCEs) on patients' preferences for treatment of depressive and anxiety disorders and assessed the relative importance of outcome, process and cost attributes to improve the current and future treatment situations.Methods: A systematic literature review using PubMed, EMBASE and PsychInfo was conducted to retrieve all relevant DCEs published up to 15 April 2019, eliciting patient preferences for treatment of depressive and anxiety disorders. Data were extracted using an extraction sheet, and attributes were classified into outcome, process and cost attributes. The relative importance of each attribute category was then assessed, and studies were evaluated according to their reporting quality, using validated checklists.Results: A total of 11 studies were identified for qualitative analysis. All studies received an aggregate score of 4 on the five-point PREFS checklist (Purpose, Respondents, Explanation, Findings and Significance). Most attributes were outcome related (52%), followed by process (42%) and cost (6%) attributes. Comparing the attribute categories and summing up the relative importance weights for each category within the studies, process attributes were ranked as most important, followed by cost and outcome attributes.Conclusions: In this systematic review, heterogeneous results were observed regarding the inclusion and framing of different attributes across studies. Overall, patients considered process and cost attributes to be more important than outcome attributes. Outcomes and process are important for patients, and thus clinicians should be particularly aware of this and take patients' preferences into account, although the attribute importance may depend on chosen attributes and related levels.

Increasing initial attendance at mental health out-patient clinics: opt-in systems and other interventions

Out-patient appointments which are missed without prior notice are a major contributor to wasted resources in planned mental healthcare services. It is not unusual that a quarter to a third of patients referred to a service will miss their first appointment (Hoare et al, 1996). Non-attendance rates for second and subsequent appointments are lower. Early non-attendance predicts attrition later in treatment (Goode, 1997; Aubrey et al, 2003), leading to further wasted resources, with most first-time non-attenders never attending subsequent appointments.

Why wait? The effect of wait-times on subsequent help-seeking among families looking for children's mental health services

Placement on a wait-list may increase families' help-seeking efforts, leading them to contact more than one children's mental health (MH) agency/professional. Two issues were examined in the current study: 1) Does time on a wait-list for families impact the time to contact a new agency for children's MH services? 2) What are the effects of predisposing (e.g., child age), need (e.g., child psychopathology), and enabling/system-level factors (e.g., parent treatment history) on the length of time parents wait before they contact a new agency for help with their child's MH problems? A total of 273 families seeking help for their child (64% boys, M = 10.7 years old, SD = 3.3) were asked about their contact with MH agencies/professionals during the previous year. Survival analyses, modeling time from initial wait-list placement to when a new agency was contacted, were conducted separately for families who did (n = 114), and those who did not (n = 159), receive help prior to contacting a new agency. Almost half of wait-listed families contacted a new agency by the end of the study period. Longer wait-time was associated with a greater likelihood of seeking help at a second agency with 25% of families contacting a new agency within the first month of being wait-listed. Parents with previous treatment experience and families living in areas with more agencies contacted a new agency sooner. Subsequent help-seeking behaviour suggests parents' intolerance for lengthy treatment delays may result in disorganized pathways to care. These findings suggest a highly fragmented service delivery system.

How Long Do Adolescents Wait for Psychiatry Appointments?

Appointment wait times are a neglected dimension of children's access to psychiatry. We systematically examined how long an adolescent waits for a new patient appointment with a psychiatrist for routine medication management. From state directories, we identified 578 providers of adolescent psychiatric care in Ohio. Researchers posing as parents telephoned randomly selected offices, seeking care for a hypothetical 14-year-old patient under different scenarios. Overall, we measured 498 wait times at 140 unique offices. The median wait time was 50 days (interquartile range = 29-81 days). In adjusted models, adolescents with Medicaid waited longer than those with private insurance, especially during the spring (geometric mean = 50.9 vs. 41.9 days; p = 0.02). Wait times also varied markedly by region, with geometric means ranging from 22.4 to 75.1 days (p < 0.01). This study demonstrates that adolescents often experience lengthy wait times for routine care. This methodology represents a useful approach to real-time monitoring of psychiatric services.

'Did not attends' in children 0-10: a scoping review

Patients who do not attend ('DNA') health appointments have been identified as a service problem incurring significant costs to the NHS. In order to explore the causes, effects and costs of child DNAs, we carried out a scoping study to map the literature and identify gaps in the research. Given the breadth of issues underpinning DNAs, a scoping study, including research studies, audits, policy documents and conference abstracts, was the most useful way to map the field. To foster public and patient participation, we sought advice from parents participating in the National Children's Bureau's Family Research Advisory Group. From a pool of 1997 items, we found few UK studies with non-attendance of 0-10 year olds as a primary focus, though many more incidentally reported DNA rates. Overall, four topics predominated: the conceptualization of DNAs; the correlates of non-attendance; initiatives to reduce non-attendance; and the relationship between non-attendance and safeguarding. The Family Research Advisory Group identified broadly similar issues, but with a stronger emphasis on communication and practical matters. While there may be circumstances where failing to attend appointments makes little or no difference to a child (or even benefits them) it is likely that there are children whose health or well-being are compromised as a result of failing to attend appointments. Both 'over' and 'under'-attendance can be a source of anxiety to health professionals. Areas where further work is needed include robust evaluation of the effectiveness, cost-effectiveness and maintenance of measures to reduce DNAs and a better understanding of the relationship of safeguarding to non-attendance.

Tackling a long waiting list in a child and adolescent mental health service

Objective: Long waiting lists have a negative impact on client satisfaction, staff moral and referrer's opinion of the service. The aim of this project was to decrease a waiting list from a maximum wait of more than one year to a wait of no more than six weeks.

Method: We introduced three simultaneous initiatives to decrease a long waiting list; (i) an individually led triage system (ii) setting-up an attention deficit hyperactivity disorder (ADHD) specialist team and (iii) division of the residual waiting list between team members. These initiatives were introduced and analysed over a ten month period. The study period ran from 1/3/2004 to 31/12/2004.

Results: The waiting time to first appointment was significantly reduced. At the beginning of the study there were 62 people waiting to be seen and each had waited an average of 122 days with a waiting time range of 0-449 days. At the end of the study, there were 19 people waiting with a mean waiting time of 19 days and a range of 0-168 days.

Conclusions: The single most powerful intervention was the triage system. The ADHD clinic allowed referrals to be streamlined in a very structured and efficient way. The division of the residual waiting list was not as onerous as it first appeared. The service saw more referrals then ever during the study period. Referrers and families appreciated being seen more quickly. By removing the burden of the waiting list from staff the potential for creative thinking around further development of the service increased.

The effect of waiting time on youth engagement to evidence based treatments

Prolonged waiting times to receive mental health services are common and may have negative consequences. This study examines the relationship between waiting time and treatment engagement among 2,054 youth referred to an evidence based treatment (EBT). Findings indicate that families are more likely to refuse services if they face longer waiting times. Families exposed to a prolonged waiting time were also more likely to drop out prematurely from Functional Family Therapy, but this relationship was not significant among youth receiving Multisystemic Therapy. Implications for EBT implementation and strategies for engaging families are discussed.

Active waiting list management: potential usefulness in a community eating disorders service

We explored the usefulness of an initiative for managing a treatment waiting list in a community eating disorders service. We sent 108 patients awaiting treatment an opt-in letter and, if necessary, a reminder 3 weeks later. Those who opted in were compared with those who did not. Of those receiving the letter, 67.6% opted in and did not differ significantly from those who opted out on measures of eating disorder pathology and general functioning. However, they had waited less time. Opt-in letters may help to identify those who no longer want to access services, thereby allowing resources to be directed towards those who still want treatment.

Clinical intake of child and adolescent consumers in a rural community mental health center: does wait-time predict attendance?

This study examines the clinic variable of wait-time as a predictor of intake attendance in a rural community mental health center (CMHC) serving child and adolescent consumers. Data from 1,317 contacts seeking services for a child or adolescent (ages 2-17) were examined. In logistic regression analysis, wait-time between initial consumer contact and intake appointment was identified as a significant predictor of appointment attendance, even after accounting for consumer variables. The impact of wait-time on the likelihood of intake appointment attendance was not moderated by the urgency of consumer need. Findings elucidate the odds of intake attendance versus non-attendance associated with each day of wait-time and clarify the impact of this clinic variable on pre-intake attrition above and beyond more often studied consumer variables. These results provide information that can assist rural CMHCs in assessing the costs and benefits of steps to reduce wait-time or its impact.

Introduction of a child and adolescent mental health link worker: education and health staff focus group findings

Policy guidance suggests that outcomes for adolescents with mental health problems can be improved by secondary education services (SES) and child and adolescent mental health services (CAMHS) working more closely. This study reports on staff experiences of the introduction of a mental health link worker (MHLW). The findings of two focus groups are presented, conducted with staff from CAMHS and SES. These focus groups formed part of the overall wider evaluation of the MHLW role. The groups explored staff perceptions and experiences following the introduction of the MHLW, and elicited their views on the effectiveness of this innovative role. Qualitative methods were employed, and analysis was conducted using the principles of grounded theory and the constant comparative method. The findings revealed that the MHLW was well received by both groups, despite the identification of potential barriers. A number of key themes emerged, which included the ability of the link worker to improve communication and to encourage mutual understanding between services. The issues raised by these themes are discussed and recommendations are made for future practice and research.

The clinical effectiveness of a brief consultation and advisory approach compared to treatment as usual in child and adolescent mental health services

A brief consultation and advice (BCA) approach to dealing with routine referrals was introduced into a child and adolescent mental health service (CAMHS) over an 18-month period. This is a time-limited, client-centred and solution-focused approach to dealing with common non-complex referrals. The model proposes that all families are seen for an initial 'consultation' appointment followed by a maximum of two further appointments. A randomized controlled study compared the clinical effectiveness of BCA treatment with treatment as usual (TAU) over a 6-month period. The parents of children referred to CAMHS were eligible to participate if their child was deemed 'non-complex'. Ethical approval was granted by the relevant ethics committee. Families who consented to participate in the study were randomly allocated to either the BCA or TAU group. Sixty children enrolled in the study. Both groups showed improvements on a number of variables at 3 months post treatment, but only those receiving BCA showed continued improvement at 6 months. Participants in both groups showed high levels of satisfaction with the treatment received. Participants in the TAU group expressed dissatisfaction with long waiting times and had a higher drop out rate than the BCA treatment group. During the time frame studied, the introduction of the BCA approach did not lead to a decrease in overall mean waiting time. These results and the usefulness of a BCA model are discussed.

The Establishment of a Triage System in a Child and Adolescent Psychiatry Clinic in Hong Kong

BACKGROUND

  The problems of long waiting time and non-attendance prompted the implementation of a triage procedure in a child and adolescent psychiatry clinic in Hong Kong.

METHOD

  A two-stage triage procedure was set up, incorporating an initial screening by the Strengths and Difficulties Questionnaire, followed by a semi-structured telephone triage interview scored according to pre-set criteria. Results from the triage interview were compared with clinicians' rating of urgency.

RESULTS

  The procedure was successful in identifying cases that were in need of urgent assessment, whose waiting time was shortened substantially. The non-attendance rate also improved.

CONCLUSIONS

  The triage procedure helped to streamline the service in a grossly under-resourced clinic, but further refinement is still needed.

Reducing Waiting Times: Using an Opt-In System and Changing Prioritisation Criteria

BACKGROUND

  The Highland Clinical Psychology Service for Children and Young People, faced with excessive waiting lists, a large geographical remit, and only three psychologists, sought to change waiting list management to improve services.

METHOD

  An opt-in appointment system and outcome research were used to inform waiting list management. Referrals with the characteristics of cases where psychological interventions are helpful were prioritised over cases that had characteristics of poor outcomes.

RESULTS

  Attendance at first appointments was significantly increased and waiting times were significantly reduced.

CONCLUSIONS

  The success of the opt-in system replicated research in other CAMHS. It is also hypothesised that the new waiting list prioritisation criteria had an effect, although this needs further research. Issues associated with the change in waiting list prioritisation are discussed and it is suggested that prioritising treatable cases over complex cases is an appropriate, effective and ethical use of scarce resources.

Evaluation of a Waiting List Initiative in a Child and Adolescent Mental Health Service

BACKGROUND

  The aim of the study was to evaluate Initial Assessment (IA), a new system for managing referrals. The system is designed to: reduce waiting times, reduce 'did not attend' (DNA) rates, and improve multi-disciplinary team working and team morale, compared to the existing referral procedure.

METHOD

  A comparison was made between a child mental health service using IA and a second centre using the existing system over a 6-month period, based on administrative records, a child functioning measure, staff and user questionnaires.

RESULTS

  The Initial Assessment system was associated with a significantly shorter average waiting time for the first appointment (9 weeks) and a lower DNA rate (10%) in the intervention centre. The populations seen under the new and existing systems were similar in terms of the severity of cases. Staff reported a positive impact overall on team working and team morale, despite a reported individual increase in time pressure; users reported acceptance of the system.

CONCLUSIONS

  Findings suggest that the increase in team morale and support from colleagues associated with the new system may have mediated against any negative impact of the increased time pressure. Substantial cost savings to the NHS are indicated.

A Triage Clinic in a Child and Adolescent Mental Health Service

AIMS

To determine whether non-urgent referrals can be adequately assessed in a triage clinic, to determine the service outcome of these referrals, and whether triage was acceptable to families, referrers and CAMHS clinicians.

METHOD

Families, CAMHS clinicians and GPs were surveyed to ascertain the acceptability of triage. Non-attendance and outcome of triage were recorded.

RESULTS

Ninety-two cases were included and the DNA rate fell by one-third.

CONCLUSIONS

Overall, clinicians and families reported high rates of satisfaction with triage (93.7% and 95.2%) and multidisciplinary working improved.