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|Year : 2012
: 54 | Issue : 4 | Page
|A study on patient satisfaction with psychiatric services
Prabhakar C Holikatti1, Nilamadhab Kar2, Ajaya Mishra3, Rajnikant Shukla3, Sarada P Swain3, Samrat Kar4
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh, India
2 Consultant Psychiatrist, Black Country Partnership NHS Foundation Trust, Steps to Health, Showell Circus, Low Hill, Wolverhampton, United Kingdom
3 Department of Psychiatry, Mental Health Institute, S.C.B. Medical College, Cuttack, Odisha, India
4 Department of Psychiatry, Mamta Medical College and Hospital, Khammam, Andhra Pradesh, India
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|Date of Web Publication||19-Dec-2012|
| Abstract|| |
Context: Patient satisfaction with psychiatric services is an important construct, which influences multiple areas including treatment adherance and outcome. There is paucity of studies from India in this area.
Aims: To measure satisfaction of psychiatric outpatients of Mental Health Institute, Cuttack, and to assess the relationship between demographic and clinical variables with different domains of patient satisfaction.
Settings and Design: In a cross-sectional study, patients of age 18-60 years receiving treatment for at least six months from outpatient department of Mental Health Institute, SCB Medical College, Cuttack, were assessed.
Materials and Methods: Participants (n=60) were selected randomly. Satisfaction was assessed by Patient Satisfaction Questionnaire-18 (PSQ-18) and the diagnoses were based on the Diagnostic and Statistical Manual-IV-TR. Severity of psychiatric disorder was measured using Clinical Global Impression-severity scale. The functioning level was assessed by Global Assessment of Functioning.
Statistical Analysis: Continuous variables compared using independent t-test or analysis of variance.
Results: Diagnostic break-up of the patients included anxiety disorder (36.6%), major depressive disorder (30.0%), bipolar disorder (16.6%), and schizophrenia (16.6%). Greatest level of satisfaction was noted in interpersonal aspects (71.4%) and time spent with doctors (62.4%). General satisfaction level was a little over 50% (57%). Differences between composite scores of PSQ-18 in the diagnostic categories were statistically significant; patients with depression had the highest score followed by those with anxiety disorder, bipolar, and the least was with schizophrenia patients. There was variability among the demographic and clinical groups regarding the various subscale score of PSQ-18.
Conclusions: Satisfaction of psychiatric outpatients was observed to be different in various clinical and demographic groups and across many domains of satisfaction.
Keywords: India, out-patient, patient satisfaction, psychiatry
|How to cite this article:|
Holikatti PC, Kar N, Mishra A, Shukla R, Swain SP, Kar S. A study on patient satisfaction with psychiatric services. Indian J Psychiatry 2012;54:327-32
| Introduction|| |
Patient satisfaction is an evaluation of quality of care, an outcome variable in its own right, and is an indicator of weaknesses in the service.  Studies indicate that global satisfaction is affected by many factors other than the quality of service delivery; it may include factors such as patients' demographics, , diagnosis, , treatment programme,  and chronicity of disease. Among demographic characteristics, age, health status, and race had a consistent, statistically significant effect on satisfaction scores and among the institutional characteristics, hospital size had a consistent and significant effect on patient satisfaction scores. 
Factors for high satisfaction
In a meta-analysis, greater patient satisfaction was found to be significantly associated with greater age, less education, being married, and having higher social status.  A study on patient satisfaction with outpatient psychiatric care showed a high general satisfaction with treatment.  Satisfaction was highest in areas of treatment planning/treatment design, treatment accomplishment, and relationship to staff. A somewhat lower level of satisfaction was noted concerning information and co-influence of the patient.  Level of satisfaction was not related to social and psychiatric background characteristics. Patients with longer time in therapy showed a higher level of satisfaction. 
Holcomb et al. found that severely ill inpatients who reported fewer symptoms, higher quality of life, and a higher level of functioning at admission tended to be more satisfied with their services. In addition, patients who were employed at admission, and therefore most likely functioning at a higher level in the community, rated their treatment more positively.  In a study of mental health services, the strongest and most consistent predictors of satisfaction were older age and better self-reported health.  Longer length of stay was also associated with greater satisfaction on a majority of subscales. Findings among female and minority veterans were mixed across measures.
A Finnish study on satisfaction of psychiatric inpatients found that, in general, patients were quite satisfied with their care. Of seven different satisfaction areas, they were most satisfied with staff-patient relationships and reported highest dissatisfaction in the areas of information, restrictions, compulsory care, and ward atmosphere/physical milieu. Younger and female patients were less satisfied with staff-patient relationships than older patients and men. 
A study by Ito et al. reported that older patients tend to be more satisfied with psychiatric care than younger patients.  Patients with schizophrenia and mood disorders rated the psychiatric care more positively, whereas patients with personality disorders rated negatively. Patients with neurosis rated the care positively in informed consent, but negatively in other items. In another study, patients with schizophrenia had higher levels of satisfaction with services and life than others, and a statistically significant relationship was found between life satisfaction and service satisfaction for schizophrenics, and those with affective and adjustment disorders. 
Focusing on modifiable service delivery factors, staff teaching efforts regarding medication, illness management, substance abuse, outpatient treatment, and living skills were significantly associated with greater levels of satisfaction with care, controlling for demographic and clinical variables.  This may reflect the value consumers place on staff time, attention, and communication.
Factors for low satisfaction
A meta-analysis conducted by Lehman et al. revealed that chronic patients express less satisfaction with their treatment as compared to non-chronic patients. No differences were found in rates of patient satisfaction between inpatient and outpatient programs.  In a study by Barker et al., patients with a diagnosis of a non-affective psychotic illness, particularly those who lacked insight were significantly less satisfied with their care.  Respondents were more satisfied with personal rather than professional qualities of the doctors, and less satisfied with their empowerment and doctors' availability. 
In a child psychiatric hospital, those who reported abusive behaviour were significantly less satisfied with the hospital experience than those who did not report abuse. The participants' perception of clinical improvement was weakly related to their satisfaction.  In a study by Gigantesco et al., the satisfaction with services expressed by psychiatric outpatients and their relatives was fairly good, with the exception of poor satisfaction with information about treatment and involvement in the treatment program. The satisfaction of inpatients and their relatives was significantly lower, with the issue of information giving by staff appearing particularly critical.  Among patients, variables associated with dissatisfaction were being an inpatient, having a diagnosis of psychosis, being in contact with services for more than six years, and being single.
In a study by Bjørngaard et al., satisfaction was associated with treatment outcome, better health as assessed using Health of the Nation Outcome Scales (HoNOS), being female, advanced age, and with having less psychiatric team severity indicated by the teams' mean Global Assessment of Functioning (GAF) score. Patients with a schizophrenia spectrum disorder were more satisfied when treated as inpatients and day patients, as compared with outpatient treatment. Patients in other diagnostic categories were less satisfied with day treatment. 
Negative correlations have been reported between patient satisfaction and personality pathology.  Patient satisfaction was significantly affected by symptom reduction and to some extent by personality pathology, while duration of the hospital stay, age, and sex contributed minimally.
Studies in India
There are very few studies in India that measure patient satisfaction with psychiatric services provided by the healthcare organizations.  A study on perception of satisfaction in a drug-dependence treatment center in India, more than 90% of the patients and their attendants appreciated the services provided. Most of them (90-94%) were satisfied with supply of drugs, good quality of clinical care, and cleanliness of the hospital.  The overall level of patient satisfaction achieved was about 65%.  Corruption appears to be highly prevalent and was the top cause of dissatisfaction among patients. Other important areas of hospital services contributing to patient dissatisfaction were poor utilities like water supply, fans, lights, etc; poor maintenance of toilets and lack of cleanliness; and poor interpersonal or communication skills.
| Materials and Methods|| |
The study sample was recruited from the patients attending outpatient department of Mental Health Institute, SCB Medical College, Cuttack, in eastern India. The department of psychiatry offers outpatient care in addition to the provision of short-stay 60-bed hospital, support by clinical psychologists, and social workers.
All patients aged 18-60 years, receiving psychiatric treatment for at least six months from the institute were considered for the study. Patients who were uncooperative, unable to spend time for the evaluation related to the study, having confusional states, and impaired cognition, who could not engage in conversation because of severity of disorders, and who did not give consent were excluded. Informed consent was obtained from all participants, and they were reassured regarding confidentiality. Institutional ethics committee approved the study.
From the log of pre-registered patients coming for follow-up on a given day, a random list was generated by random number tables. Among these patients, those who fulfilled the recruitment criteria were approached for the study. About 2-3 patients could be evaluated for the study in a day. The recruitment continued for one month.
Demographic variables were collected using a proforma used in the institute, which included: Age, sex, marital status, education, employment status, family pattern, and address of residence. A semi-structured interview schedule was used at Mental Health Institute to aid for psychiatric history taking. The diagnoses were based on the DSM-IV-TR criteria. We assessed the severity of psychiatric disorder using Clinical Global Impression (CGI) severity scale.  It has scores from 0 to 7; higher scores suggest greater severity.  The functioning level was assessed by GAF.  Higher scores of GAF indicate better functioning.
We used Patient Satisfaction Questionnaire-18 (PSQ-18) to assess satisfaction.  It was translated to the local language Oriya following translation-retranslation procedure.  It has seven subscales: General satisfaction (GS), technical quality (TQ), interpersonal aspects (IPM), communication (COM), financial aspects (FIN), time spent with doctor (TWD), and accessibility and convenience (AC), which give scores in these domains. A composite score (CS) is also calculated. Higher value indicates more satisfaction.
Continuous variables were compared using independent t-test or analysis of variance (ANOVA). Significance was set at standard 0.05. Statistical analyses were performed using SPSS-16 for windows. 
| Results|| |
The sample size was 60; out of 68 patients who were found eligible for inclusion and approached, 8 (11.7%) patients could not participate in the study interview considering the severity of symptoms and were excluded. The sociodemographic and clinical profile of the excluded patients were comparable to that of included sample. The study sample consisted of 30 females (50.0%); half were between 18-34 years of age; 60% (n=36) had less than 10 years of education, 50% were employed, 73.3% (n=44) were married, 63.3% (n=38) belonged to nuclear families, and most of them (66.6%, n=40) were from rural background. Proportions of different primary diagnoses as observed were anxiety disorder (n=22, 36.6%), major depressive disorder (MDD; n=18, 30.0%), bipolar disorder (n=10, 16.6%), and schizophrenia (n=10, 16.6%). The overall PSQ-18 scores of the whole sample are given in [Table 1].
Sociodemographic variables and patient satisfaction
Composite scores were comparable between genders, age groups, educational groups, employment groups, marital status, and type of family [Table 2]. Comparing the genders, subscale scores of general satisfaction was significantly more in female patients, and that of communication was more in males. Older group (age 35-60 years) compared to the younger group (18-34 years) had significantly higher scores in TQ, IPM, and TWD, whereas significantly lower score in financial aspects. Patients with less than 10 years of education reported significantly more scores on accessibility and conveyance than those with more years of education. Patients who were employed had significant higher scores in communication, but lower score in general satisfaction than those who were unemployed. Married patients had significantly higher score on TQ and AC, but lower score on financial aspects. There was no difference in subscale or composite scores based on type of family-extended or nuclear.
|Table 2: Mean scores of different domains and composite scores of PSQ-18|
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Clinical variables and patient satisfaction
Among the diagnostic categories, the difference between composite scores was statistically significant; patients with MDD had the highest, followed by those with anxiety disorder, bipolar, and the least was with schizophrenia patients. Subscale scores of TQ and IPM were highest in patients with MDD, FIN in patients with bipolar disorder, and AC in patients with anxiety disorder [Table 2]. Based on CGI, individuals with higher scores (3 or more) had significantly higher score on IPM. However, the composite scores were comparable. Considering the level of functioning, patients with higher GAF score (60 or more) had significantly higher score on TWD but lower score on IPM, with no difference in the composite score. There was no correlation between PSQ-18 total score with age or CGI severity.
| Discussion|| |
This study assessed the satisfaction level of the psychiatric patients who received at least six months of care from outpatient department of a hospital in Eastern India. It attempted to address, to an extent, the paucity of information on patient satisfaction on psychiatric services in an Indian set-up.
Sociodemographic variables and satisfaction
It was interesting to note that the composite patient satisfaction scores were not significantly different between any of the sociodemographic groups studied: Males and females, younger (18-34 years) and older (35-60 years) age groups, lower or higher educational groups, employed and unemployed, married and unmarried, and extended or nuclear family background are rural or urban background.
Interpersonal rapport and good doctor-patient relationship have been a cornerstone of higher patient satisfaction. Respondents were more satisfied with personal rather than professional qualities of the doctors.  In our study, the highest level of satisfaction was noted in interpersonal aspects (71.4%) and time spent with doctors (62.4%). General satisfaction level was a little over 50% (57%).
Variability was seen in the subscale scores in many demographic groups studied. Comparing the genders, even though subscale scores of general satisfaction was significantly more in female patients, the score for communication was significantly less than the males. It is important to improve the communication with patients, especially female patients. Often, the communication is directed to persons accompanying the female patients, and the information is discussed with others rather than the female patient directly. Communication with female patients needs specific attention, and it should be in a way they can understand and appreciate the information.
Older age group (35-60 years) compared to the younger age group (18-34 years) had significantly higher scores and lower scores in TQ, IPM, and TWD, whereas significantly less score in financial aspects. Patients with less than 10 years of education reported significantly higher scores on accessibility and conveyance than those with more years of education. Patients who were employed had significantly higher scores in communication, but lower score in general satisfaction than those unemployed. Married patients had significantly higher score on TQ and accessibility and conveyance but lower score on financial aspects. These observed differences in satisfaction scores in different subscales among various demographic groups suggest the complexities involved in the patients' perception of satisfaction.
Clinical variables and satisfaction
Among the diagnostic categories, the difference between composite scores were statistically significant; patients with MDD had the highest scores followed by those with anxiety and bipolar disorder, and the least score was with schizophrenia patients. In a previous study, variables associated with dissatisfaction included having a diagnosis of psychosis, being an inpatient, being in contact with services for more than six years, and being single.  In contrast to our finding, patients with a schizophrenia spectrum disorder were more satisfied when treated as inpatients and day patients, as compared with outpatient treatment.  Patients in other diagnostic categories were less satisfied with day treatment. 
Subscale scores of TQ and IPM were highest in patients with MDD, FIN in patients with bipolar disorder, and AC in patients with anxiety disorder [Table 2]. Appropriate TQ of care was significantly associated with higher levels of satisfaction in a different study.  Results of these analyses studying the causal relationship between patient-reported interpersonal and technical quality of care for depression indicated that patients who reported high satisfaction with care were more likely to receive higher technical quality depression care six months later as compared with those who are less satisfied. 
Based on CGI, persons with higher scores (3 or more) had significantly higher score on IPM. However, the composite scores were comparable. Considering the level of functioning, patients with higher GAF score (60 or more) had significantly higher score on TWD but lower score on IPM, with no difference in the composite score. Clinical severity and functioning level might not be directly influencing the overall satisfaction but they affect various components of it.
This study has few limitations. It considered only the outpatient population. Thus, the results cannot be generalized to inpatient populations. The sample size was small considering fewer patients in diagnostic categories.
| Conclusion|| |
Satisfaction with the psychiatric outpatient services in Cuttack was observed to be varied across diagnostic groups: Patients with schizophrenia were least satisfied, whereas patients with major depression had highest satisfaction with services. There was a difference in satisfaction levels among the demographic and clinical groups regarding various components of satisfaction. Patient satisfaction in psychiatry is a complex issue with various influencing factors. It is essential to study this further, as it has potential to improve clinical care.
| Acknowledgment|| |
The study was supported by Quality of Life Research and Development Foundation. The authors thank the patients, their relatives, and staff of Mental Health Institute, Cuttack.
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Prabhakar C Holikatti
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, (PGIMER), Sector-12, Chandigarh, 160 012, Punjab
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]