|Year : 2022 | Volume
| Issue : 1 | Page : 54-59
Dropout rates and its correlates among the elderly patients attending a community health center
Aseem Mehra, Sandeep Grover, Ajit Avasthi
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||03-Jul-2022|
|Date of Decision||07-Jul-2022|
|Date of Acceptance||10-Jul-2022|
|Date of Web Publication||03-Aug-2022|
Dr. Aseem Mehra
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Aim: The current study aimed to evaluate the dropout rates and the reasons for dropouts among elderly patients presenting with mental health problems to a community health centre. Methodology: This naturalistic, longitudinal, follow-up study was carried out in the Outpatient Setting of a community health centre in North India. The study included 169 patients, aged ≥ 60 years diagnosed with mental health problems. They were assessed at the baseline and then followed for a period of 1 year. Those who dropped out from the outpatient clinic were contacted over the phone to evaluate the reasons for dropout from treatment. Results: The mean age of the participants was 67.6 years and the mean number of years of education was 2.9. Most of the patients were female, married, Hindu, unemployed, from lower socioeconomic status, and non-nuclear families. The most common diagnosis was that of depression (42.6%), and this was followed by somatoform disorder (11.2%). The mean age of onset of psychiatric disorder was 62.2 years, with a mean duration of illness being 30.3 months. Nearly half (53.3%) of the patients dropped out of treatment after their first visit and 90% dropped out by 1 year. Overall the most common reason of drop out was complete relief of symptoms, and this was followed by the presence of family problems, and farming-related work. Among the very early drop out (never returned to clinic after the first visit) the most common reason for dropout was complete relief in symptoms, followed by inability to follow up due to family problems, no relief in symptoms, and farming-related work. Among those who dropped out within 6 months, the most common reason was complete relief of symptoms followed by lack of time due to personal reasons. When the reason for “late” dropout (dropout between 6 to 12 months) was evaluated, the most common reason was complete relief of symptoms followed by an inability to follow up due to problems in the family. Conclusion: A significant number of elderly patients with mental health-related problems drop out of treatment prematurely. Psychoeducation about the illness, outcome, and course of illness should be done at each step, and prevailing psychosocial issues need to be evaluated to reduce the rate of dropout among elderly patients with mental health-related problems attending the community health centre.
Keywords: Elderly, drop out, mental health problems, community health centre
|How to cite this article:|
Mehra A, Grover S, Avasthi A. Dropout rates and its correlates among the elderly patients attending a community health center. J Geriatr Ment Health 2022;9:54-9
|How to cite this URL:|
Mehra A, Grover S, Avasthi A. Dropout rates and its correlates among the elderly patients attending a community health center. J Geriatr Ment Health [serial online] 2022 [cited 2022 Sep 26];9:54-9. Available from: https://www.jgmh.org/text.asp?2022/9/1/54/353166
| Introduction|| |
All the countries worldwide are in the midst of the longevity revolution or demographic changes. As per the United Nations, it is projected that by 2050, one in six people will be aged >65 years, in contrast to 1 in 11 in 2019. It is estimated that there will be 300 million elderly people in India by 2050.
The elderly populations are more prone to psychological disorders and physical diseases. It is evident in various studies that the health care needs of the elderly are different due to a higher prevalence of neuropsychiatric and noncommunicable diseases compared to the adult population. In terms of mental health issues, older adult brings unique challenges such as social isolation, bereavement, and loneliness, besides the high prevalence of depression, dementia, or anxiety disorders. Different studies from India have estimated the prevalence of psychiatric morbidity in the elderly to vary from 5.87% to 42.8%.,,, Elderly patients with psychiatric disorders also have been found to have poor medication and treatment adherence.
Adherence to clinical appointments and treatment is an important area to investigate in the field of psychiatry, specifically among elderly patients with psychological problems. Adherence can be understood as “the extent to which a person's behavior, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health-care provider.”
Poor adherence to appointments in psychiatry is not an exception. It has been reported that the rate of missed appointments in general adult people with mental health problems varies from 14% to 64%, with an average rate of 31.7%.,,, It is seen that the dropout rate is much higher after the initial appointment with the clinician, with an average rate of poor adherence of 50%.,, Even the data from India suggests that the rate of poor adherence after the first contact with the hospital is varying from 50% to 59%.,,,, The factors which are associated with dropout can be patient-related such as being male, coming from a long distance from the clinic and rural area having longer duration of illness, poor motivation for treatment, poor satisfaction with treatment, or long waiting time.,,
Although there are a number of studies that evaluated the dropout rate among the general adult patient with psychiatric illnesses, only a few studies have focused on dropout rates and treatment nonadherence among elderly patients with mental disorders.,,, To the best of our knowledge, only two studies evaluated the reason for dropout among the elderly population, but the major limitation of these studies is that they were limited to patients with depression attending a tertiary center., A study from North India evaluated the dropout pattern of 1422 elderly patients attending the psychiatry walk-in clinic and reported that 28.55% of patients dropped out from the treatment.
None of the studies have evaluated the drop rate and reason of dropout rate among the elderly patient with mental health-related problems visiting a community health center in India. In this background, the current study aimed to evaluate the dropout rates and reason for dropouts among elderly patients presenting with mental health problems to a community health center.
| Methodology|| |
This naturalistic, longitudinal, follow-up study was carried out in the outpatient setting of a community health center in North India. The institutional ethic committee approved the study. All the patients were recruited after obtaining written informed consent. The psychiatric outpatient clinic is run by the department of psychiatry on a fixed day, i.e., every Wednesday at the community health center in the Nariangarh sub-district of Haryana. Patients can walk-in directly to the psychiatric outpatient clinic on their own or are referred by other specialists working in the same setting. Health workers working in the village also refer patients to the clinic. Those patients who were registered for psychiatric services are examined in detail by a qualified psychiatrist. Based on the available information from patients, their caregivers, or reliable informant, and mental state examination, the diagnosis is made as per the International Classification of Diseases, Tenth Revision (ICD-10). Based on the diagnosis, the patients are started on psychotropics, nonpharmacological treatment, or combination of both as per the need. After the initial evaluation, patients are given a follow-up date for the next visit, usually between 1 week to a month. For seeking consultations, patients have to pay a registration fee of rupees 2 only, which is valid for 1 month. All the medications are provided free of cost to the patient.
In this study, consecutive new patients aged ≥60 years, seen in the community clinic for the first time between January 2018 and November 2019, were approached and explained about the nature of the study. They were explained that they are supposed to follow up regularly if advised to do so.
Those who did not attend the psychiatry services beyond 1 month of the scheduled appointment were considered dropout and were contacted telephonically after 3 months of dropout and reasons for not coming for follow-up were asked. For this, patients/their primary caregivers who accompanied the patient to the outpatient clinic at the initial visit were asked an open-ended question, and their responses were noted down.
| Results|| |
The mean age of the participants was 67.6 (standard deviation [SD]: 7.7) years, with a mean number of years of education was 2.9 (SD: 4.5). Females (58.0%) outnumbered the males. The majority of the patients were married (71.6%), Hindu (87.0%) by religion, currently unemployed (88.2%), from lower socioeconomic status (73.1%), and were from nonnuclear families (76.9%).
The majority of the patient visited the clinic after coming to know about the clinic from patients who received treatment (16.6%), relatives of other patients (20.1%), or fellow villagers (27.2%) [Table 1].
As per the ICD-10 criteria, the most common diagnostic category was that of affective disorder (49.1%), followed by neurotic and somatoform disorder (30.8%) [Table 2]. In terms of individual disorders, depression emerged as the most common diagnosis (42.6%), followed by somatoform disorder (11.2%), anxiety not otherwise specified (10.1%), and dementia (8.3%) [Table 2]. The mean age of onset of psychiatric disorder was 62.2 years (SD-11.2), with a mean duration of illness of 30.3 (SD-61.0) months. Hypertension was the most common physical morbidity, followed by the presence of both hypertension and diabetes mellitus. A family history of psychiatric disorder was present in only 4.7% of patients [Table 2].
About three-fourths (78.7%) of the patients were prescribed antidepressants, one-fifth (21.2%) were prescribed antipsychotic medication, and two-thirds (63.2%) were prescribed benzodiazepines. Escitalopram was the most commonly prescribed antidepressant, quetiapine was the most commonly prescribed antipsychotic medication, and clonazepam was the most commonly prescribed benzodiazepine [Table 3].
When the pattern of the dropout was evaluated, about half (53.3%) of the patients dropped out after the very first visit. By 6 months of registration with the clinic, another one-fourth (24.9%) of the patients dropped out. By the end of 1 year of registration with the clinic, 90% of the patients dropped out of treatment [Table 4].
When the patients were contacted to understand the reasons for dropout from the service, the most common reason for very early dropout was complete relief in symptoms (13.6%), followed by inability to follow up due to family problems (13.0%), no relief in symptoms (12.4%), and farming-related work (10.1%). Among those who dropped out within 6 months of registration with the clinic but visited at least once after the very first visit reported the most common reason as complete relief of symptoms (8.3%), followed by lack of time due to personal reasons (6.5%). When the reason for “late” dropout was evaluated, the most common reason was complete relief of symptoms (7.7%), followed by inability to follow up due to problems in the family (4.7%). Overall, the most common reason of dropout was complete relief of symptoms (29.6%), followed by the presence of family problems (21.8%) and farming-related work (17.7%) [Table 5].
| Discussion|| |
The present study attempted to evaluate the dropout rates and the follow-up pattern of elderly attending the psychiatry services in the community health center. The sociodemographic profile of the present study sample is more or less similar to the previous studies from India and other countries.,, In the present study, most of the patients were brought to the clinic after coming to know about the same from relatives or neighbors about the clinic. These findings suggest that in rural areas patients receiving treatment from the rural clinic can act as ambassadors to spread information about the services. Hence, the involvement of patients and caregivers already receiving treatment in the awareness about mental health issues can be helpful in bringing the persons with mental illness to the treatment net and reducing the mental health gap.
The most common diagnostic category was affective disorder (49.1%), followed by neurotic and somatoform disorder (30.8%). As per the ICD-10 criteria, the most common diagnostic category was that of affective disorder (49.1%), followed by neurotic and somatoform disorder (30.8%). In terms of individual disorders, the most common diagnosis was depression (42.6%), followed by somatoform disorder (11.2%), anxiety not otherwise specified (10.1%), and dementia (8.3%). This profile is supported by the findings of the previous studies that report depression and neurotic disorders to be the most common mental health-related problems among elderly attending different mental health settings.,,,,,, These findings suggest that there is an urgent need to increase awareness of the physicians working in the primary care center to identify depression in the elderly and manage the same. This will also facilitate timely referral of patients to mental health professionals.
In the present study, hypertension was the most common physical morbidity, followed by hypertension with comorbid diabetes mellitus and diabetes mellitus only. Earlier studies that have evaluated the comorbid medical illness among patients with psychiatric disorders attending the psychogeriatric clinic have also reported similar findings. Accordingly, it can be said that mental health problems attending the elderly population should be routinely screened these patients for hypertension and diabetes mellitus.
In the present study, about three-fourths (78.7%) of the patients were prescribed antidepressants, one-fifth (21.2%) were prescribed antipsychotic medication, and two-thirds (63.2%) were prescribed benzodiazepines. This profile is possibly influenced by the diagnostic profile. In terms of specific medications, escitalopram was the most commonly prescribed antidepressant, quetiapine was the most commonly prescribed antipsychotic medication, and clonazepam was the most commonly prescribed benzodiazepine. This prescription profile is similar to that reported for patients attending the tertiary care center.
In the present study, half (53.3%) of the patients dropped out after the very first visit. By 6 months of registration with the clinic, another one-fourth (24.9%) of the patients dropped out. By the end of 1 year of registration with the clinic, 90% of the patients dropped out of treatment. When we look at the existing data from tertiary care centers on dropout patterns among the elderly, it can be said that there are certain similarities and differences. A previous study defined “dropout” as a lack of at least 1 follow-up in the subsequent 6 months after initial registration and reported the dropout rate to be 28.55%. Another study that focused only on patients with depressive disorder attending outpatient services reported a dropout rate of 41.4% after the first visit. When we compare our findings with this study, it can be said that the early dropout rates for the elderly attending the rural clinics are about twice that seen in tertiary care. There could be many reasons for the same. First, the outpatient clinic in the tertiary care center runs for 6 days a week, whereas in the primary care center, the services are available only once a week. It is quite possible that this could have contributed to the higher dropout rates. Second, patients presenting to the tertiary care center would have more severe symptoms and hence by nature of the illness had to follow up more regularly. In contrast to this, patients presenting to the primary care center could be having symptoms of lesser severity and hence would have opted not to follow-up further. Another factor that could have contributed to the high dropout rate among primary care patients could be the stigma. It is quite possible that these patients and their caregivers agreed to attend the psychiatry services once, but on seeing the known people coming to the hospital to seek treatment, felt stigmatized, and refused to follow up. It would be interesting to assess these aspects in future studies. However, it is interesting to note that at the end of 1 year, the study focusing on patients with depressive disorder reported a dropout rate of 90%, as seen in the present study. This finding suggests that by 1 year of the initial visit and the dropout rates are similar in the primary care and tertiary care centers.
In the present study, the most common reason for dropout from treatment was complete relief in the symptoms. Previous studies from India have also reported complete relief or first dose effect to be associated with an early dropout of treatment.,, The proportion of patients who dropped out, citing the reason for complete relief, increased with time. This finding possibly reflects the lack of knowledge among the patients and caregivers about the need for regular follow-up. Hence, it is of paramount importance that mental health professionals catering to elderly patients with mental health issues in primary care spend adequate time with the patient and the family to explain the need for regular follow-up.
Limitation of the study
The indexed study has certain limitations. It was conducted in a community health center that provided mental health services once a week. Hence, the findings cannot be generalized to other settings. The study has a small sample size. The present study evaluated the reasons of dropout by asking an open-ended question, and no specific validated instrument or checklist was used to evaluate all the reasons of dropout. The study did not evaluate other confounding variables such as clinician-related variables and stigma toward mental illness among the patient and their caregivers. The study also did not evaluate the past experience of patients and their caregivers with a psychiatrist or their knowledge about mental illness. Future studies must attempt to overcome these limitations.
To conclude, the present study shows that elderly patients seeking mental health services at the primary care center most commonly have affective disorder (especially depression), followed by neurotic and somatoform disorders. The present study also shows that about half (53.3%) of the elderly patients dropout of treatment after the very first visit, and by the end of 1 year of registration with the clinic, 90% of the patients dropout of treatment. The most common reason for dropout of treatment is complete relief in symptoms, followed by inability to follow up due to family problems and farming-related work. Accordingly, it can be said that there is a need to actually develop mental health services that can cater to the elderly at their home to improve their mental health outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]