Self-referral System Research Articles

Clinical effectiveness and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK

Depression and anxiety are increasingly prevalent in adolescents. The Brief Educational Workshops in Secondary Schools Trial investigated the effectiveness of a brief accessible stress workshop programme for 16-18-year-olds. We aimed to investigate the clinical effectiveness and cost-effectiveness of the DISCOVER cognitive behavioural therapy (CBT) workshop on symptoms of depression in 16-18-year-olds at 6 months compared with treatment-as-usual. We conducted a multicentre, cluster randomised controlled trial in UK schools or colleges with sixth forms to evaluate clinical effectiveness and cost-effectiveness of a brief CBT workshop (DISCOVER) compared with treatment-as-usual. We planned to enrol 60 schools and 900 adolescents, using a self-referral system to recruit participants. Schools were randomised in a 1:1 ratio for participants to receive either the DISCOVER workshop or treatment-as-usual, stratified by site and balanced on school size and index of multiple deprivation. Participants were included if they were 16-18 years old, attending for the full school year, seeking help for stress, and fluent in English and able to provide written informed consent. The outcome assessors, senior health economist, senior statistician, and chief investigator were masked. People with lived experience were involved in the study. The primary outcome was depression symptoms measured with the Mood and Feelings Questionnaire (MFQ) at 6-month follow-up, in the intention-to-treat population of all participants with full covariate data. The trial was registered with the ISRCTN registry (ISRCTN90912799). 111 schools were invited to participate in the study, seven were deemed ineligible, and 47 did not provide consent. Between Oct 4, 2021, and Nov 10, 2022, 933 students at 57 schools were screened for eligibility, seven were not eligible for inclusion, and 26 did not attend the baseline meeting and assessment, resulting in 900 adolescents participating in the study. The DISCOVER group included 443 participants (295 [67%] female and 136 [31%] male) and the treatment-as-usual group included 457 participants (346 [76%] female and 92 [20%] male). 468 (52%) of the 900 participants were White, and the overall age of the participants was 17·2 years (SD 0·6). 873 (97%) adolescents were followed up in the intention-to-treat population. The primary intention-to-treat analysis (n=854) found an adjusted mean difference in MFQ of -2·06 (95% CI -3·35 to -0·76; Cohen's d=-0·17; p=0·0019) at the 6-month follow-up, indicating a clinical improvement in the DISCOVER group. The probability that DISCOVER is cost- effective compared with treatment-as-usual ranged from 61% to 78% at a £20 000 to £30 000 per quality-adjusted life-year threshold. Nine adverse events (two of which were classified as serious) were reported in the DISCOVER group and 14 (two of which were classified as serious) were reported in the treatment-as-usual group. Our findings indicate that the DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools. Given the importance of addressing mental health needs early in this adolescent population, additional research is warranted to explore this intervention. National Institute for Health and Care Research Health Technology Assessment Programme.

Barriers and facilitators to help-seeking for mental health problems in prison: A qualitative interview study with incarcerated males in Northern Norway.

IntroductionThe prevalence of mental disorders is considerably higher among incarcerated individuals than in the general population, but this burden is not matched by a proportional use of mental health services. Studies have found that incarcerated males are reluctant to seek help for mental health problems. Gaining knowledge of factors that influence incarcerated individuals to access or avoid professional help for mental health problems is important for tailoring interventions to address the mental health needs of this population. Promoting mental health service utilization among people in prison has the potential to reduce prison suicide rates and increase institutional functioning, thereby providing safer conditions for peers and staff, promoting rehabilitation, and reducing recidivism upon release.ObjectivesThis study explores personal, interpersonal, and systemic aspects that motivate incarcerated individuals to approach or avoid seeking help for mental health problems. While prior studies have primarily focused on barriers to help-seeking, this study also sheds light on facilitators for seeking professional help for people in prison.MethodsIndividual in-depth interviews were conducted with sixteen incarcerated males from three prisons in Northern Norway. The data analysis was inspired by Grounded Theory.ResultsThe majority of participants shared positive personal perspectives related to professional help-seeking, whereas the barriers were predominantly perceived to be of an interpersonal and systemic nature. Aspects that encouraged help-seeking were: regarding mental health treatment as necessary for successful rehabilitation, sufficient knowledge of when and how to contact mental health services, support from peers, having a higher ranking in the prison hierarchy, health services that are out-reaching, and prior positive experiences with professional help. The barriers to professional help-seeking were: lack of information about when and how to access mental health services, challenges with the self-referral system, perceived unavailability of services, confidentiality issues, and a prison climate that favoured a tough appearance.ConclusionsThe participants appeared to be more positive to seeking professional help for mental health problems than reported in previous studies with incarcerated individuals. Interpersonal and systemic aspects were emphasized by the participants as barriers to accessing mental health services; some participants even perceived these services to be unavailable to them. The results are relevant for designing interventions to promote help-seeking for mental health problems among people in prison.Disclosure of InterestNone Declared

Association between Primary Care Utilization and Emergency Room or Hospital Inpatient Services Utilization among the Middle-Aged and Elderly in a Self-Referral System: Evidence from the China Health and Retirement Longitudinal Study 2011-2018.

With rapid economic growth and aging, hospital inpatient and emergency services utilization has grown rapidly, and has emphasized an urgent requirement to adjust and optimize the structure of health service utilization. Studies have shown that primary care is an effective way to reduce inpatient and emergency room (ER) service utilization. This study aims to examine whether middle-aged and elderly individuals who selected primary care outpatient services in the last month had less ER and hospital inpatient service utilization than those who selected hospitals outpatient services via the self-referral system. Data were obtained from four waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS). We pooled respondents who had outpatient visits and were aged 45 years and above. We used logistic regressions to explore the association between types of outpatient and ER visits or hospitalization, and then used zero-truncated negative binomial regression to examine the impact of outpatient visit types on the number of hospitalizations and the length of hospitalization days. A trend test was used to explore the trend of outpatient visit types and the ER or hospital inpatient services utilization with the increase in outpatient visits. Among the 7544 respondents in CHARLS, those with primary care outpatient visits were less likely to have ER visits (adjusted OR = 0.141, 95% CI: 0.101–0.194), hospitalization (adjusted OR = 0.623, 95% CI: 0.546–0.711), and had fewer hospitalization days (adjusted IRR = 0.886, 95% CI: 0.81–0.969). The trend test showed that an increase in the number of total outpatient visits was associated with a lower hospitalizations (p = 0.006), but a higher odds of ER visits (p = 0.023). Our findings suggest that policy makers need to adopt systematic policies that focus on restructuring and balancing the structure of resources and service utilization in the three-tier healthcare system.

Women’s experiences of self-referral to an abortion service: qualitative study

BackgroundGuidelines from the UK recommend that women should be able to self-refer to abortion services. In 2016, a self-referral system was introduced to the abortion service in Edinburgh, Scotland, as...

Safeguarding Trainee Health: A Call for an Annual Opt-Out Mental Health Screening

Back to table of contents Previous article Next article CommentaryFull AccessSafeguarding Trainee Health: A Call for an Annual Opt-Out Mental Health ScreeningPeriel Shapiro, M.D., Seth Barishansky, B.A.Periel ShapiroSearch for more papers by this author, M.D., Seth BarishanskySearch for more papers by this author, B.A.Published Online:6 Jun 2019https://doi.org/10.1176/appi.ajp-rj.2019.140603AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail There is an alarmingly high prevalence of depression among medical trainees. A 2016 meta-analysis of data from 122,356 medical students found that nearly a third were depressed (1). Another meta-analysis of data from 17,560 residents, published in 2015, found a similarly high rate of depression, with a prevalence estimate of 28.8% (2).In 2017, the Accreditation Council for Graduate Medical Education (ACGME) instituted a requirement that training programs provide a "confidential, affordable mental health assessment" (3). In fulfilling the ACGME mandate, many institutions offer access to university counseling centers or community providers for a mental health evaluation.Institutions that rely on self-referral to establish access to care are likely to miss many individuals in need. In one survey of house staff at Northwestern University, 110 residents and fellows felt that they would benefit from mental health care (4). Yet fewer than half of those trainees sought an evaluation. In another survey of 183 medical students at Yale University, 24.5% reported increased mental health needs during medical school, but fewer than half of those students increased their help-seeking behaviors (5). Many trainees may not self-refer because of stigma, manifesting as a fear of appearing weak or of facing professional consequences if discovered seeking care. Time and cost are also cited as barriers; programs may require that trainees seek an evaluation during their free time and pay out of pocket for services (4, 5).An annual opt-out mental health screening, included among other annual health care interventions, may mitigate issues associated with a self-referral system. By providing access to a no-cost evaluation in the same location and contiguous with workday time slots appointed for general health care needs, such as the influenza vaccine and tuberculin test, trainees will not have to sacrifice their limited personal time and funds in order to obtain an evaluation. An annual evaluation for every trainee would frame mental health care as a routine matter of health maintenance for all future physicians. A positive screen in the mainstreaming context of routine health maintenance may spur trainees to accept help before a crisis occurs.Mental health is a prerequisite for optimal medical training. An annual mental health assessment for trainees, embedded among well-established trainee health care requirements, would serve both to minimize the barriers associated with a self-referral system and to reduce the stigma associated with mental health care.Dr. Shapiro is a first-year psychiatry resident, and Mr. Barishansky is a fourth-year medical student, at Robert Wood Johnson Medical School, Rutgers University, New Brunswick, N.J.

How can we successfully recruit depressed people? Lessons learned in recruiting depressed participants to a multi-site trial of a brief depression intervention (the \u2018CLASSIC\u2019 trial)

BackgroundThere are enormous problems in recruiting depressed people into randomised controlled trials (RCTs), with numerous studies consistently failing to recruit to target (Sully et al., Trials 14:166, 2013). Given the high prevalence of—and disability associated with—depression, it is important to find ways of effectively recruiting to RCTs evaluating interventions. This study aimed to test the feasibility of using a self-referral system to recruit to a brief intervention in a multi-site trial, the CLASSIC trial of self-confidence workshops for depression. In that trial, participants referred themselves to a depression intervention with a positive non-diagnostic title of ‘self-confidence’, given the close relationship of depression and self-esteem (Horrell et al., Br J Psychiatry 204:222–233, 2014).MethodWe analysed uptake and retention rates by recruitment to the study, attendance at the workshops and follow-up rates. However, because of the rapid rate of recruitment, we decided to pause the trial and revise our original single-site research protocol in months 5–6. We report findings under three main headings: recruitment rates for the 12 months of the project before and after the pause; data regarding attendance at the workshops before and after the pause; and the follow-up rates before and after the pause.ResultsWe recruited 459 participants within 12 months, representing 38 participants recruited per month. Improved uptake of the intervention and retention after the development of multi-site research protocols are reported.DiscussionBased on previous evidence from RCT recruitment among depressed participants, our recruitment rate demonstrates that a self-referral system using a non-diagnostic title of self-confidence is a successful recruitment method. The implications of rapid recruitment using a self-referral system are described, including the impact on uptake of the intervention as well as participant retention. Because of the potential for recruiting many participants quickly, research teams need to be adequately resourced and the oversight committees prepared to meet at shorter intervals with RCTs of brief interventions.Short conclusionSelf-referral to a brief intervention for depression with a non-diagnostic title can be a very effective way of recruiting depressed people into trials. However, there are also some challenges.Trial registrationISRCTN, ISRCTN26634837. Registered on 10 June 2010.

Short time effect of a self-referral to inpatient treatment for patients with severe mental disorders: a randomized controlled trial.

BackgroundService user participation is a central principle in mental healthcare, and the opportunity to self-refer to inpatient treatment is used to increase service user involvement and activation. The aim of this study was to investigate the short-term effect of a self-referral system in an inpatient rehabilitation unit at a community mental health center on patient activation and recovery in individuals with severe mental disorders.MethodsA randomized controlled study including 53 patients (41 % females, mean age 40 years). Twenty-six patients in the intervention group were given a contract for self-referral to inpatient treatment, limited to maximum 5 days and a quarantine time of 14 days between each stay. The control group (27 participants) received treatment as usual, and was offered the intervention after 1 year. The Patient Activation Measure was the primary outcome and secondary outcome was the Recovery Assessment Scale. Mixed models were used to assess group differences.ResultsDuring the 4 months period, 15 (58 %) of 26 participants in the intervention group used the contract of self-referral to inpatient treatment. The intervention group had more admissions than the control group but both groups had a similar total use of inpatient days and out-patient consultations. The self-referral to inpatient treatment counted for 11 % of all inpatient days for the intervention group. There were no significant differences in the outcome between the groups on patient activation (estimated mean difference 2.7, 95 % confidence interval = −5.5 to 10.8, p = 0.52) or recovery (estimated mean difference 0.01, 95 % confidence interval = −0.3 to 0.3, p = 0.92).ConclusionsGiving persons with severe mental disorders the possibility to self-refer to inpatient treatment did not change their level of patient activation and recovery after 4 months and did not lead to increased use of health services. The cost-effectiveness and long-term effect of self-referral to inpatient treatment should be investigated further.Trial registrationNCT01133587, clinicaltrials.gov.

Factors Affecting Acceptance of a Web-Based Self-Referral System

With the growing availability of health information on the Web, people are becoming more knowledgeable on their health conditions and treatment options, and more patients seek specialists by themselves. To aid patients in requesting self-referrals, we have developed and evaluated a web-based self-referral system in three specialty clinics at the University of Washington. Two clinics adopted the system for routine clinical use, while the third clinic decided not to. A major difference between these two groups was in how fast online requests from patients were handled, which significantly influenced patients' satisfaction. Clinic's preparedness for handling the temporarily increased workload due to the introduction of a new health information system played a role as well. Also, we noticed that the physician leadership/championship made a difference in the acceptance of our system.

Can a self-referral system help improve access to psychological treatments?

Referrals for psychological treatment have been problematic for many years. Even though GPs have attempted to limit access into the small psychological treatment services, long waiting lists have developed which have deterred referrals and deferred psychological care. GPs have understandably been frustrated. In addition, the consultation rate for psychological problems is low when compared with the rate of identified mental health problems in population surveys. Possible reasons include patients' failure to recognise the problem as psychological and thus not consulting one's GP, and/or the problem not being detected by the GP. While a self-referral system may be seen as a way of trying to allow non-consulters to receive treatment, this has been viewed with some scepticism since it may allow the 'worried well' to access already limited services. However, a study has shown that those self-referring to advertised psychological workshops had high levels of psychological morbidity and also were more representative of the population, in terms of ethnicity, than GP referrals. The government has set up the Increasing Access to Psychological Therapies (IAPT) programme to address some of the service shortfalls by expanding the provision of psychological therapists. Notably, the IAPT programme is allowing self-referrals such that any member of the public can access the service directly, bypassing general practice. Although not available at all the sites, this represents a radical shift from the present system in which access to talking therapy is generally only available through direct referral by the GP. The implications of this new development are discussed.

Flystrike in New Zealand: An overview based on a 16-year study, following the introduction and dispersal of the Australian sheep blowfly, Lucilia cuprina Wiedemann (Diptera: Calliphoridae)

A summary and analysis have been carried out on data from over 6000 instances of flystrike in sheep in NZ, over a 16-year period, using a self-referral system where farmers submitted larvae and related information. The study covered a period of establishment and subsequent countrywide spread of the exotic blowfly, Lucilia cuprina. Comparisons are drawn between flystrike as it was perceived by surveys carried out before the 1940s, and the current situation with L. cuprina as an added major impediment. Briefly, the main differences are an increase in the prevalence of flystrike, changes in the representation and relative influence of individual primary blowfly species, an extension of the flystrike ‘season’, and an apparent increase in the importance of footrot as a factor predisposing to flystrike. Otherwise, flystrike is still primarily a disease of ewe lambs that are struck predominantly around the tail and perineum, mainly because of faecal staining.

Soldier Peer Mentoring Care and Support: Bringing Psychological Awareness to the Front

Since the Persian Gulf War of 1990-1991, the operational tempo for soldiers has steadily increased, whereas the numbers of soldiers available to fulfill these missions has decreased. As a result, soldiers and their families are experiencing increased levels of stress that continue to manifest in ways that can often be destructive for the soldiers, their families, and the Army community. Current mitigation and identification support systems such as the Chain of Command, noncommissioned officer leadership, chaplains, and family support systems have all provided critical services, but may not be expected to optimally perform necessary early risk management assessment. Behavioral health care as a self-referral system is often still perceived as career ending, shameful, or even culturally unacceptable. Our allies have also experienced similar family, operational, and combat concerns. In 1996, at the direction of their Commandant General, the British Royal Marines developed and instituted a peer-driven risk management and support system that has experienced a high degree of success and acceptance among its forces-enough so that the Royal Navy is now in the process of implementing a similar program. The Soldier Peer Mentoring and Support program, as part of the proposed deployment Cycle Support Program, is a model for peer group assessment based on the British Royal Marines psychological risk management and support system. This article presents and describes this project, which has been considered for use within the U.S. Army, as a potential augmenter of existing behavioral health support assets as a culturally acceptable, company-level support program in deployment and home stations.

Are self-referrers just the worried well?

Reluctance to seek formal help has been seen as a major problem in trying to reduce the prevalence of anxiety and depression. The aims of this study were to assess the psychiatric status of those self-referring to psycho-educational Stress and Self-Confidence community workshops using a cognitive behavioural therapy (CBT) approach. Cross-sectional analysis of 196 people who referred themselves to community workshops was carried out using the Clinical Interview Schedule (CIS-R) psychiatric interview and the Beck Depression Inventory (BDI) and Spielberger Trait Anxiety Inventory (STAI-T) scale self-report assessments. Over 70% of all self-referrers had an ICD-10 diagnosis. Those without diagnoses had experienced recurrent significant psychological problems and 29.7% had never consulted their General Practitioner (GP) for anxiety/depression problems. Total CIS-R scores and white ethnic group best predicted previous GP consultation. Setting up a self-referral system can enable those with diagnosable psychiatric problems, who may otherwise be reluctant to seek help, to come forward. This may have significant public mental health implications.

An Audit of a New System of Self–Referral in the Management of Multiple Sclerosis

A random sample of the referral notes of 35 multiple sclerosis patients experiencing relapse and referred via the current general practitioner (GP) system was reviewed. The time between receipt of the referral and assessment/admission (lead time) was examined. The mean value was obtained and a self referral system was initiated and monitored for a period of five months. The mean referral times were compared. The patients' disability status before and after treatment was measured using the Expanded Disability Status Scale (EDSS) and Functional Independence Measure (FIM), and we invited the patients' opinions about the self-referral system. The goals of the newly implemented self-referral system were to reduce lead time to less than 6.5 days, improve patient disability, and avoid inappropriate referral; the new system was also to be “user friendly.” The new system reduced referral times by a statistically significant amount (P = 0.0016). There was a significant objective improvement in patients' disability as measured by the EDSS and FIM scores (P = 0.031 and P = 0.04, respectively). There was a subjective improvement, and patients expressed a preference for the new system. There were no inappropriate referrals. These findings suggest that the self-referral system is efficient and effective and should be further evaluated. (Int J MS Care. 2002; 4: 10–12)

Patient Self-referral to Physiotherapy in General Practice - A Model for the New NHS?

This paper describes the changes which have occurred for GPs in access to physiotherapy services, and the benefits of GP paractice based physiotherapy services. Method : An innovative study is described in which physiotherapy was made available to the public at Carnoustie Health Centre by means of a patient self-referral system. The self-referral service was evaluated over 12 months. Results : The average number of referrals each month was 23.5; only four referrals were considered by the physiotherapist to be inappropriate. The number of GP referrals made to the existing physiotherapy service, which had been in operation for eight months when the study began, continued to increase over the 12-month study period, from 32 to 40 per month. The conditions being referred were of the same distribution as those from the GPs. Discussion : Patient self-referral has thus been shown to be feasible at a local health centre. Further studies to evaluate the benefits, such as reductions in waiting time for treatment, number of GP consultations, nuber of consultant referrals made by GPs, cost of prescriptions, and non-attendance at physiotherapy are indicated. It is proposed that patient self-referral within GP practice physiotherapy departments may be the model for some physiotherapy services within the new NHS.