‘DNA’ or ‘did not attend’ will be a familiar phrase to clinicians in all areas including those working in psychological therapy services for common mental health problems. The latter being characterised by mild-moderate depression or anxiety disorders. In England, NHS psychological therapy services for such problems are modelled after the Improving Access to Psychological Therapy (IAPT) programme. Analyses of this data suggests around 40% of initial appointments are not attended (Davis et al, 2020). Non-attendance is a problem, not least because you cannot help someone if they don’t turn up, but also because it makes it harder to provide efficient services (Kheirkhah et al., 2015). Understanding the barriers to attending initial appointments could therefore be of value to those wanting to make their service or individual practice more efficient and helpful.
Sweetman and colleagues found a gap in the literature and so conducted a review to identify factors that influence attendance at initial appointments for common mental health problems within psychological therapy services. They wanted to find and synthesise different types of existing research to see what, if anything, could be done to influence attendance.
How the reviewers found and analysed the research
The reviewers provided a detailed account of how they searched for, evaluated and analysed research on this topic, including the use of guidance from the Cochrane Collaboration, Centre for Reviews and Dissemination and the PRISMA statement. They looked for studies about non-attendance at first and second appointments, excluding those cancelled in advance. Research on ‘drop-outs’ was also excluded unless it differentiated attendance at assessment from subsequent appointments.
Two of the reviewers screened research articles to increase reliability of the search process. They also tested this using a random sample and assessed with Cohen’s kappa. Information from selected articles was extracted by two reviewers using a standardised format.
The reviewers used narrative synthesis methods for the quantitative studies. This involved extracting headline factors and then grouping them based on similarity.
A thematic analysis was undertaken by the reviewers for the qualitative studies. This involved identifying themes within each study, looking for commonalities and making interpretations.
The quality of studies included in this review
To assess the quality of the research, two reviewers independently used appraisal tools from the Joanna Briggs Institute. The reviewers used this to inform their discussion of the findings, but did not exclude any studies on the basis of quality. The reviewers found that a minority of studies met all quality criteria. The reviewers noted how many of the studies did not sufficiently describe their designs to achieve a higher rating.
The reviewers whittled down thousands of records to a final 34 studies that were selected for inclusion. These consisted of 15 cohort studies, 9 cross-sectional, 9 qualitative and one mixed-methods. Most of these studies were based in Europe and North America between 2011 and 2019. Depression and anxiety were the most common disorders amongst participants.
The reviewers produced 11 factors that seemed to be influencing attendance at initial appointments. Some of these linked across several studies, whereas others in just one.
- ‘Presenting problem’: Anxiety diagnoses and more severe problems were associated with greater attendance than other conditions, including depression, and lower severity.
- ‘Beliefs relating to mental health symptoms and treatment’: A belief in the value of therapy was associated with greater attendance whilst stigmatising beliefs about mental health could be a barrier. In other words, patients who felt reluctant or doubtful about how a therapist could help, were less likely to attend.
- ‘Contact with services’: Attendance was improved for patients who had been introduced to the service by another professional and did not feel pressure to accept the referral.
- ‘Knowledge about services of treatment’: Understanding what would be offered was important to help patients attend. This was especially important to address misconceptions such as believing that they would only be offered medication or coerced into treatment.
- ‘Practical challenges’: Having sufficient money and time were important to facilitating attendance. Things like physical health problems and conflicting commitments presented a barrier for some patients.
- ‘Social support’: For some patients, social support may make attending an appointment less important since they have friends or family to help them. The presence of friends and family may also present a barrier for some patients when mental health difficulties are stigmatised.
- ‘Individual perceptions about mental health symptoms and accessing support’: People interpret their difficulties in a variety of ways and not all will conceptualise them as needing professional intervention. This may therefore make attendance seem less relevant. Furthermore, some people may not see their difficulties as a priority relative to other responsibilities in their life. Those with children may also worry that attending a service could have negative repercussions on their family such as being deemed an unfit parent.
- ‘Social and cultural influences’: Belonging to an ethnic, religious or cultural group seemed to influence attendance depending on the norms about mental health problems and services held by that group. For example, people from some groups may face greater stigma than others.
- ‘Experiences with services’: Having a bad experience with services may make some people reluctant to attend again. This included bad experiences with clinical staff, such as not being understood, as well as reception staff.
- ‘Route to accessing support’: Long waiting times or requiring conversations with multiple therapists could be a barrier to attendance for some patients. A perception that they’re being offered an appropriate treatment was also important, since some patients may be put off by being offered a small number of sessions that feels disproportionate to the severity of their difficulties.
- ‘Logistical issues’: Some patients faced practical challenges that reduced their ability to attend. This included a lack of information about the appointment, inaccessibility of public transport and appointments that conflicted with work or other commitments.
The reviewers concluded that:
“This review found that initial non-attendance was associated with a perceived mismatch between treatments offered and patient perceptions of the cause or severity of their problem, patient concerns about the consequences of engaging with mental health services, and a lack of confidence in the service or therapist offering treatment.”
They also suggest that appointment bookings should be prompt and accommodate patient circumstances such as childcare commitments, transport options and physical health conditions.
Strengths and limitations
This review makes a good starting place to understand what may influence non-attendance in a well-defined area of mental health. The reviewers presented a detailed overview of their process, which followed established guidelines and controlled for bias by using a team approach. The review incorporates experiences from 12,148 patients from across the globe within various settings. Such a large data set is of course difficult to synthesise, especially from a range of research designs, but the reviewers presented a concise and coherent list of factors that they link to the studies.
A review like this is, of course, limited by the quality of the constituent studies, but these were taken into account by the reviewers. This included paying attention to how factors coalesced or diverged between studies. The authors noted how studies described similar issues being important to early non-attendance, supporting the conclusions drawn about these factors.
Unfortunately the review risks being prematurely dated due to the COVID-19 pandemic, which is of course no fault of the reviewers. The studies included in this review were all published before 2020 and so there is little on the use of remotely provided appointments. This is important since, if my clinical experience is anything to go by, services will have dramatically changed how they provide appointments. This may quite radically redefine the meaning of services and appointments and so could limit the validity of the review.
Implications for practice
This review prompted me to think more about the mismatch between services and clients in perceptions of problems as a factor influencing attendance. This is a factor that seems unlikely to be influenced by changes such as remote appointments. Improving attendance may therefore depend on tailoring the information (or dare I say marketing) about services rather than standardising to the point of one-size-fits all.
The need to tailor psychological services in this way is further supported by the evidence for the importance of relational aspects of psychotherapy and client preferences about how their problems need to be resolved (e.g. Wampold, 2015; Duncan et al, 2009). In other words, ‘depression’ and it’s ‘treatment’ will mean quite different things amongst clients. Understanding how clients and their community perceive emotional problems, and responding to that, is likely to have the best outcome. This is in contrast to a model in which services present an authoritative definition of say, depression, and stipulate to clients how that should be treated. This has tangible implications for how services present written information on their websites or leaflets. For example, a list of treatments like CBT, DBT and so on may present a barrier to some groups whereas clear language about how to access the service, what actually happens in an appointment and who works there may be more helpful.
Statement of interests
Laurence is a clinical psychologist in specialist NHS psychology services for people with chronic physical health problems. He also runs a private psychology practice specialising in common mental health problems and sex and relationship difficulties.
Sweetman, J., Knapp, P., Varley, D., Woodhouse, R., McMillan, D., Coventry, P. (2021) Barriers to attending initial psychological therapy service appointments for common mental health problems: A mixed-methods systematic review. Journal of Affective Disorders 2021 284, 44-63.
Davis, Smith, Talbot, Eldridge and Betts. (2020) Predicting patient engagement in IAPT services: a statistical analysis of electronic health records (PDF). Evidence-Based Mental Health 2020 23(1) 8–14. Accessed Oct 2021.
Duncan, B., Miller, S., Wampold, F., Hubble, M. (2009) ‘The Heart & Soul of Change Delivering What Works in Therapy’. American Psychological Association.
Kheirkhah, P., Feng, Q., Travis, L.M., Tavakoli-Tabasi, S., Sharafkhaneh, A. (2016) Prevalence, predictors and economic consequences of no-shows (PDF). BMC health services research 2016 16, 1-6. Accessed Oct 2021.
Wampold, B. (2015) ‘The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work’. Routledge.