Unplanned first contact as a predictor of future intensive use of mental health services

The scheduled appointment system, widely used in most mental health services, has never been evaluated. This study attempts such an evaluation within a community-based mental health service that permits unplanned access to specialist care, by comparing further service use of first-episode patients who come unannounced to seek psychiatric care with that of patients with a planned (scheduled) initial appointment. All patients with first lifetime psychiatric contact who contacted psychiatric services reporting to the South-Verona Psychiatric Case Register between 1 January 1982 and 31 December 1989 (n = 1261) were identified. A total of 1056 patients entered the study and were followed for 2 years. Poisson regression with the generalised estimating equation (GEE) method (to take into account both overdispersion of contacts between subjects and correlation between contacts within subjects) was used to evaluate the effects of the type of first-ever contact (defined as planned or unplanned according to whether or not a regular appointment was previously arranged) and of other selected variables, including sociodemographic characteristics, on the annual rate of planned and unplanned care in the follow-up period. Thirty-six percent of first-ever contacts were unplanned. Patients who began with unplanned contact, as compared with others, were more often widowed, separated or divorced, unemployed and with a diagnosis of schizophrenia or organic psychosis. Moreover, they had, in the following 2 years, significantly higher rates of both unplanned and planned community care, as well as more in-patient care (higher admission rate and a longer mean length of stay). These results at follow-up were confirmed when the rates for the type of first-ever contact were adjusted for all other clinical and sociodemographic variables at initial contact. Step-down Poisson multiple regression analysis showed that the rates of both unplanned and planned contacts in the follow-up period were significantly and independently associated with: type of first-ever contact, diagnosis and type of service first contacted. Unplanned cases at initial contact require particular attention and are confirmed as at risk for placing higher demands on mental health services in the following 2 years. The results of the present study may also have implications for other, non-psychiatric health services.