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In the last decade, there has been a growing interest in patient satisfaction as a measure of outcome and quality of care in psychiatry (1). Patient perspective in service evaluation is needed because objective outcome indicators in psychiatry are controversial (2). In addition, patient satisfaction is a factor in the care process (3), influencing intervention efficacy and consumer behaviour such as compliance and service utilization (4,5). Patient satisfaction is influenced by many factors, including patients’ clinical and socioeconomic characteristics (6,7), expectations (8), living conditions (9), and previous service experiences (10). In addition, satisfaction appears to depend on the quality of care, as indicated by waiting time for appointments (11); support and service organization (12); and the outcome of care (that is, problem improvement as identified by patients; 9). In a metaanalysis of literature on satisfaction with mental health services between 1955 and 1983, chronically ill patients were found to be less satisfied with treatment than were nonchronically ill patients (13). Further studies in the last 10 years have begun to investigate the relation between patient satisfaction and type of psychiatric diagnosis. Researchers in Denmark found patients diagnosed as suffering from affective and adjustment disorders or from reactive psychoses to be more satisfied than patients with schizophrenia or personality disorders. Patients receiving antidepressant treatment were particularly satisfied (7). Similarly, Canadian researchers found the greatest level of patient dissatisfaction and the lowest level of patient–therapist agreement in patients suffering from schizophrenia and other psychotic disorders. They linked their findings to therapists’ underestimation of nonbiological treatment aspects, such as social support (8). Both research groups recommended comparisons of treatment needs and quality among diagnostic groups. To our knowledge, no study comparing levels of patient satisfaction in nonpsychotic, nonsubstance-related, specific diagnostic categories, such as eating disorders and somatoform disorders, has been published. The correlation between patient satisfaction and objective treatment outcome, as assessed by the Symptom Checklist- 90-Revised (SCL-90-R), has been found to be low (14). This finding may be explained by the difference between actual and perceived change (2,9): a small change could make a great difference to the individual patient, while a significant change may be irrelevant in the patient’s perception. Sex differences have attracted particular interest regarding the determinants of health and the need for health care (15,16). Some authors urge using a typology of problems, goals, or foci for assessing the most relevant change domains (2,17). To our knowledge, the relation between patient satisfaction and outcome across different change domains has not been studied systematically. This study investigates the influence of diagnosis on patient satisfaction with psychiatric psychotherapeutic care provided by the psychiatric outpatient department of a university general hospital in a consecutive sample of patients with nonpsychotic, nonsubstance-related disorders. We further investigate the relation between type of treatment and perceived types of change on patient satisfaction. We address 3 questions. First, does patient satisfaction depend on psychiatric diagnosis? Second, with regard to satisfaction levels, do patients treated with psychotherapy alone differ from patients treated with a combination of psychotherapy and pharmacotherapy? Third, is there a relation between perceived type of therapeutic change and patient satisfaction? Methods and MaterialsThis study includes all outpatients who received 8 or more sessions of individual psychiatric–psychotherapeutic treatment at the psychiatric department of the University Hospital of Zurich, Switzerland, during the years 1999 and 2000. Patients were considered eligible if they were diagnosed with 1 of the following ICD-10 (18) diagnostic categories: F3 (mood or affective disorders), F4 (neurotic, stress-related, and somatoform disorders), F5 (behavioural syndromes associated with physiological disturbances and physical factors, mainly eating disorders), or F6 (disorders of adult personality and behaviour). We based our sample size estimation on the metaanalysis by Lehman and Zastowny (13), which found a mean difference of 0.49 standard deviations (SDs) in the satisfaction level of chronic and nonchronic patients for all analyzed studies. In outpatient health care programs, the mean difference was 1.19 SDs. We assumed an effect size (that is, mean difference divided by SD) of 1 as clinically significant for group comparisons. For a power of 80% in a t test (a = 0.05, 2-tailed), 17 patients per group were required. Informed by data regarding the quantity and characteristics of treatments provided by our clinic and assuming a response rate of 50%, we felt that a sample recruited from a 2-year intake of patients would suffice to address our research questions. Between 9 and 21 months following treatment, we contacted 161 patients by mail (that is, 65 patients in 1999 and 96 patients in 2000) and requested their study participation (that is, we asked patients to complete a self-report questionnaire). We sent a reminder to patients who did not respond after 3 weeks. Following this procedure, a total of 97 patients returned the questionnaire, for a response rate of 60.2%. We interviewed 41 of the 64 nonrespondents by telephone and asked all subjects for written informed consent to participate in the study. MeasuresWe registered patients’ demographic and administrative data and diagnoses at the beginning and at the end of treatment. Diagnoses were based on the first clinical interview, using ICD-10 diagnostic criteria (18). We assessed patient satisfaction using the 3-item short form of Larsen’s Client Satisfaction Questionnaire (CSQ) (19). The CSQ is one of the most widely used satisfaction measures in German-speaking countries (14). We chose the short form because research by Larsen and colleagues has shown there is only 1 underlying factor in their 8-item scale with a high degree of internal consistency (Cronbach’s alpha = 0.94 in a large follow-up assessment) (19). In our sample, Cronbach’s alpha = 0.89. The global satisfaction score (GSS) of the 3-item CSQ ranges from 3 to 12. We assessed therapeutic change as perceived by the patients, using a modified form of the Bern Inventory of Treatment Goals (BIT-C) (17). The 67 items of the inventory are preceded by the statement, “My therapy at the psychiatric outpatient clinic helped me to . . . . ” These 67 items can be subsumed under 21 change categories and 6 change types: P = coping with specific problems and symptoms (categories 1 to 10), M = medication issues (category 11), I = interpersonal changes (categories 12 to 16), W = well-being and functioning (category 17), E = existential issues (category 18), and G = personal growth (categories 19 to 21). Following the item list, we asked patients to record 3 most important changes. Further details of this modified form are available (20,21). Statistical Analyses ResultsThe average age of the 62 (63.9%) female patients and 35 (36.1%) male patients was 39.1 years (SD 14.1 years). Of the total patients, 32 (33.0%) were married, 55 (56.7%) were unmarried, 7 (7.2%) were separated, 1 (1.0%) was widowed, and 2 (2.1%) had missing data. Of these patients, 21 (21.6%) lived alone; 64 (66.0%) lived with parents, partners, or other persons; and the remaining 12 (12.4%) provided no data on their living arrangements. A total of 44 patients (45.4%) had full-time paid work, 15 (15.5%) had part-time paid work, 33 (34.0%) had no paid work or were unemployed, and 5 (5.1%) had missing data. Table 1 shows the diagnostic characteristics. Respondents and nonrespondents differed significantly among diagnostic categories (c2 = 11.8, df 5; P < 0.05), with more anxiety disorders and fewer eating disorders among respondents (see Table 1). Moreover, Swiss nationality was more prevalent in respondents, compared with nonrespondents (c2 = 14.8, df 1; P < 0.001). There were no significant differences regarding sex, age, education, and psychotropic medication.
Treatments comprised individual short-term therapies with supportive and interpersonal elements, with or without medication. All treatments were conducted by residents in their last years of specialization as psychiatrists, and in most cases, they were assisted by an external supervisor. The average number of therapy sessions was 17.5 (SD 12.3 sessions, range 8 to 70 sessions). Of these patients, a total of 53 (54.6%) received psychotherapy combined with psychopharmacological medication, and 44 (45.4%) received psychotherapy only. Of the patients treated with medication, antidepressants were prescribed for 73.6%, tranquilizers for 26.4%, and neuroleptics for 11.3%. Table 2 shows the GSS of patients with different psychiatric diagnoses. We found a statistically significant relation between satisfaction scores and diagnostic categories (Kruskal–Wallis test, c2 = 14.7, df 5; P < 0.05). The 70 patients with disorders following an episodic course (that is, affective, anxiety, or adjustment disorders) were significantly more satisfied (mean 9.8, SD 2.5) with treatments than the 27 patients with chronic disorders, such as somatoform, eating, and personality disorders (mean 7.9, SD 2.7 patients; Mann–Whitney U test = 533.5, P < 0.001).
Patients treated with a combination of psychotherapy and pharmacotherapy (n = 53, mean 9.7, SD 2.4) were numerically but not statistically more satisfied than patients treated with psychotherapy alone (n = 44, mean 8.8, SD 3.0; Mann–Whitney U test = 985.0, P = 0.19). The treatment with antidepressants in particular was also not associated with satisfaction. Table 3 shows the correlation between global satisfaction and most important types of change. In all patients, changes in coping with specific problems and symptoms and changes in the interpersonal domain were positively correlated with satisfaction. The experience of no change and changes in the handling of and confidence in medication were negatively linked to satisfaction. Sex appeared to have an influence on the relation between perceived changes and satisfaction. The positive correlation between changes in coping with specific problems and symptoms was significant in male patients but nonsignificant in female patients. However, in female patients, interpersonal changes were significantly correlated with satisfaction, whereas in male patients, this relation did not reach statistical significance. Further, the correlation coefficients for changes in well-being were markedly different, with opposed signs for female and male patients.
Table 4 shows the results of the multiple regression predicting global satisfaction. The factors sex, age, pharmacotherapy, number of treatment sessions, and days between treatment end and assessment did not have a significant effect on patient satisfaction. However, the presence of a chronic disorder was a significant predictor for dissatisfaction. Concerning the perception of most important outcomes, changes in coping with specific problems and symptoms and changes in the interpersonal domain were positive predictors of patient satisfaction. However, improvements in pharmacotherapy reported as one of the most important outcomes predicted dissatisfaction. The predictive model accounted for 33% of the variance in patient satisfaction.
DiscussionIn this explorative study, we assessed a consecutive sample of patients with nonpsychotic, nonsubstance-related disorders after psychiatric–psychotherapeutic treatment. Using self-report questionnaires, we investigated the relation between patient satisfaction and 1) diagnosis, 2) use of psychopharmacological medication, 3) important outcomes as reported retrospectively by patients. Several methodological shortcomings need to be addressed. Recruiting all patients after 8 or more treatment sessions provided a heterogeneous sample with regard to psychopathology and treatments. However, this methodology allowed us to make comparisons between diagnostic categories and between treatment modalities; the results may be generalized to similar clinical settings. Also, the response rate of 60% and the significant differences between respondents and nonrespondents reduced the external and internal validity of the investigation. We did not include data assessed by interview because satisfaction scores assessed by questionnaire and direct interview are not comparable (6). In fact, the satisfaction scores assessed by telephone interview in our study were higher than those assessed by questionnaire. Because of this study’s cross-sectional design, no inferences can be made about the direction of causality between our measures of change and patient satisfaction. We applied no standardized instruments for assessing health status before and after treatment; thus, patient satisfaction and patients’ reported change could not be compared with quantitative health measures. An analysis of variance revealed a relation between diagnostic categories and patient satisfaction. This result was confirmed by the final multiple regression showing a significant negative relation between the presence of a chronic psychiatric condition and patient satisfaction. The rather high level of satisfaction in subjects with affective and anxiety disorders and the rather low level of satisfaction in subjects with personality disorders confirms the results of previous studies (7,8); it supports the findings that patients with chronic psycho- somatic conditions, such as eating and somatoform disorders, tend to have low levels of satisfaction and that patients with adjustment disorders (that is, time-limited mild conditions) tend to have high levels of satisfaction. In summary, our results support the generalizability of the association between dissatisfaction and the course (13) and severity (10) of mental health conditions. Regarding different treatment aspects, we could not find a significant relation between the use of psychotropic medication and patient satisfaction, either by bivariate or by multivariate analyses. Therefore, we could not confirm the finding of the Danish researchers that “treatment with antidepressants is the most sensitive indicator of patient satisfaction” (7). However, our results are in line with studies showing that nonbiological aspects of treatment, such as social support, contribute significantly to patient satisfaction (8) and that potential effects of psychotropic medication, such as reduction of psychiatric symptoms, may not be related to patient satisfaction (9,14). Patient satisfaction was associated with the perception of important improvements in 2 specific outcome domains: coping with specific problems and symptoms and the interpersonal domain. This result consistently emerged both in bivariate and multivariate analyses. Although objective positive treatment outcome, measured as the difference in health status before and after treatment, does not necessarily produce patient satisfaction (24), our finding is in line with previous studies that found a strong relation between satisfaction and patients’ global reports of outcome (10). Moreover, we found a sex difference in the relation between satisfaction and perception of change. Among male patients, coping with specific problems and symptoms was associated with satisfaction, whereas among female patients, changes in the interpersonal domain were associated with satisfaction. These results must be interpreted with caution, because the sample was too small for more sophisticated statistics testing interactions among sex, patient-reported outcome, and satisfaction. This preliminary finding is intriguing, given that genetic and environmental factors causing psychiatric disorders may differ between the sexes (25,26). For example, male subjects were more sensitive to the depressogenic effects of work problems, while female subjects were more sensitive to problems socializing with individuals in their proximal network (26). Significant sex differences have also been shown in physiological responses to stress: male subjects showed significantly greater cortisol responses to achievement stress, while female subjects showed greater cortisol responses to social rejection challenges (27). Taken together, further research is warranted to test the hypothesis that treatment processes associated with positive outcome, including patient satisfaction, differ between the sexes. As expected, the perception of no therapeutic change was associated with dissatisfaction. Unexpected, however, was the finding that only dissatisfied male patients reported improvement in the handling of and confidence in medication as important outcomes. Multivariate statistics confirmed the association between medication issues perceived as an important change and dissatisfaction. According to our data, interpreting this finding was not easy, because pharmacotherapy was not related to dissatisfaction, and improvements in pharmacotherapy perceived as one of the most important outcomes were not associated with lack of important outcomes in other change domains. Finally, multiple regression analysis controlling for variables such as sex, age, and time between treatment end and assessment, which had shown weak effects on patient satisfaction in previous studies (10), did not change the primary results of this study. The direction of association between patient satisfaction and patient age, and between patient satisfaction and the interval between treatment end and assessment, was consistent with previous reports (6). We conclude that chronic psychiatric conditions, such as somatoform and eating disorders, must be considered when measuring and interpreting patient satisfaction. Future research is needed to clarify the relation between medication issues reported as important outcomes and dissatisfaction. Moreover, this study encourages investigations of the role of sex in generating patient satisfaction. References1. Svensson B, Hansson L. Patient satisfaction with inpatient psychiatric care. The influence of personality traits, diagnosis and perceived coercion. Acta Psychiatr Scand 1994;90:379–84. 2. Kazdin AE. The meanings and measurement of clinical significance. J Consult Clin Psychol 1999;67:332–9. 3. Ruggeri M. Patients’ and relatives’ satisfaction with psychiatric services: the state of the art of its measurement. Soc Psychiatry Psychiatr Epidemiol 1994;29:212–27. 4. Ware JE Jr, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. 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New York: HarperCollins; 1996. 24. El-Guebaly N, Toews J, Leckie A, Harper D. On evaluation patient satisfaction: methodological issues. Can J Psychiatry 1983;28:24–9. 25. Fanous A, Gardner CO, Prescott CA, Cancro R, Kendler KS. Neuroticism, major depression and gender: a population-based twin study. Psychol Med 2002;32:719–28. 26. Kendler KS, Thornton LM, Prescott CA. Gender differences in the rates of exposure to stressful life events and sensitivity to their depressogenic effects. Am J Psychiatry 2001;158:587–93. 27. Stroud LR, Salovey P, Epel ES. Sex differences in stress responses: social rejection vs achievement stress. Biol Psychiatry 2002;52:318–27. Author(s)Manuscript received February 2003, revised, and accepted February 2004. 1. Resident Psychiatrist, Psychiatric Department, Zurich University Hospital, Zurich, Switzerland. 2. Psychologist, Psychiatric Department, Zurich University Hospital, Zurich, Switzerland. 3. Postdoctoral Fellow, Mood and Anxiety Disorders Program, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland. 4. Senior Physician, Division of Psychosocial Medicine, Zurich University Hospital, Zurich, Switzerland. 5. Head, Division of Psychosocial Medicine, Zurich University Hospital, Zurich, Switzerland. 6. Head, Psychiatric Department, Zurich University Hospital, Zurich, Switzerland. Address for correspondence: Gregor Hasler, National Institutes of Health, National Institute of Mental Health, Mood, and Anxiety Disorders Program, 15K North Drive, Room 300C, MSC 2670, Bethesda, MD 20892 e-mail: g.hasler@bluewin.ch
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