Psychologists’ Experiences Who Managed Waitlists in Mental-Health Services During the COVID-19 Lockdown

The phenomenon of excess referral rates, commonly known as a “waitlist” (OECD, 2020), poses a challenge to mental healthcare services worldwide (Bernado et al., 2021; OECD, 2020). Long waiting lists have been identified as a barrier to mental-health services in many European countries, where rates of depression and anxiety among the general population are high, with 4% of the population being diagnosed with depression and 5% with anxiety disorders (OECD, 2020). Current aspects of the COVID-19 pandemic, such as the economic impact, physical distancing measures, and changes to care access, are also likely to have increased the rates of mental health difficulties among the general population (O’Connor et al., 2021).

These changes in mental healthcare access have also increased the referral rates to mental-health services. Increased referral rates to Adult Mental Health Services (AMHS) have been recently amplified because of the profound impact of the COVID-19 pandemic on public mental health (Chong et al., 2021; Gloster et al., 2020; Neto et al., 2021), potentially posing a severe strain on already pressured AMHS and the healthcare professionals who deal with that matter (Byrne et al., 2021; World Health Organization, 2020). Hence, the pandemic and the lockdown have increased the demands for mental-health services, further increasing the waitlist rates in countries with a traditionally high rate of mental-health problems, such as in Ireland (18.5%; 3 out of 36 EU countries) (OECD/European Union, 2020). For some countries, including Ireland, the management of waitlists is thus becoming an issue of a public-health emergency (O’Connor et al., 2021).

Relevant literature indicates that the waiting time for mental healthcare can both harm clients’ referral problems and also exacerbate other psychosocial problems (Biringer et al., 2015; Redko et al., 2006; Reichert & Jacobs, 2018), such as unemployment, financial restrictions, and relationships (Dorling, 2009; Fitch et al., 2011; We Need To Talk Coalition, 2010). Clients who face lengthy waits may additionally be less motivated to enter treatment when the time comes (Brown et al., 1989), leading to higher unattended scheduled appointments or dropout rates (Carter et al., 2012) and further exacerbating the efficiency of the services. To lower waitlists, mental-health services have implemented various practices.

Screening appointments can help identify case severity and the clinical needs of the clients before treatment begins (Pumariega et al., 1997). This can empower individuals by highlighting their current strengths and coping mechanisms (Ní Shiothcháin & Byrne, 2009) and help reduce waiting times and nonattendance rates (Clemente et al., 2006; Parkin et al., 2003). Psychologists may also use an opt-in approach (Stallard & Sayers, 1998), requesting clients to respond by phone or mail on whether they want their offered appointment. In cases of “no response,” the client is automatically removed from a waitlist (Hawker, 2007). Such practice, a meta-analysis shows, has the potential to free up space on waitlists (Hawker, 2007). Additionally, providing clients with evidence-based bibliotherapy and temporary coping skills could facilitate self-management during the waiting time (Foster, 2006). However, for most AMHS, waitlist management practices are not standardized and take place on an ad-hoc basis. This practice may be attributed to a lack of organization and fairness (Brown et al., 2002), which can then create an extra burden for staff members, potentially lowering the overall efficacy of AMHS.

The existing difficulties clients face in timely accessing mental-health services under COVID-19 restrictions present a significant opportunity for permanent organizational changes in how healthcare services manage and address long waitlists. To ensure that future interventions lead to successful improvements in that matter, providers must understand the phenomenon from those who deal with it daily. Without such knowledge, decision-makers may fail to provide suggestions that can have a direct impact on the service and its users. Therefore, developing effective solutions for long waitlists may be facilitated by better understanding the experiences of healthcare professionals, such as staff psychologists in community AMHS.

This mixed-method service evaluation study had two aims: (1) to examine what practices had been used by staff psychologists working in a community mental-health service in Ireland during the second lockdown period (February and April 2021), and (2) to explore the experiences of psychologists from the application of such practices. We hypothesized that during the second lockdown staff psychologists used multiple nonspecified waitlist practices based on their needs. We also hypothesized that the management of these practices had created an extra burden for staff psychologists in their already excessive workload.

Materials and Method

Study Design

We employed a convergent, concurrent mixed method design (Creswell et al., 2011) to gather data through an online form, consisting of both quantitative and qualitative questions. Because of the COVID-19 restrictions, we followed a pragmatic stand with both quantitative (survey-based questionnaires) and qualitative (open-text responses) data, collected in parallel, analyzed separately, and then integrated (Maarouf, 2019) (see Figure 1). The rationale for this approach was that the quantitative data and analyses provided a descriptive indication of the research problem (i.e., practices used in waitlists), whereas the qualitative analyses served to explore and understand participants’ experiences in the context where the problem exists (Creswell et al., 2011). Before any research activity, the study was approved by University College Cork’s (UCC) School of Applied Psychology, Clinical Psychology Research Ethics Committee (CPREC). Participants were provided with an information statement outlining the purpose of the project, their participation, possible risks and benefits, issues of confidentiality, and the right to withdraw. All participants were asked to provide informed consent before taking part.

Results

We present the results in four sections: participants’ characteristics; findings from the quantitative strand (descriptive statistics); findings from the qualitative strand (three main themes derived from the textual data); and finally a mixed-method interpretation (convergence of the mixed methods).

Quantitative Strand: Practices Used by Staff Psychologists

Initial Information Gathered About Referrals

The number of referrals participants had received in the past 24 months ranged from 12 to 200 (M = 66.63, SD = 54.18). Most participants (n = 13) reported using both electronic and paper-based systems to manage their waitlists.

Practices Used to Address Waitlists

As Figure 2 shows, half of the participants (n = 10) reported using an opt-in approach to estimating the number of ongoing cases. Only few reported using screening appointments to determine the severity of cases and the nature of clinical needs before intake. From those screenings offered (84 in total) in the past 24 months (M = 16.8, SD = 10.28), the attendance rate was 83% (M = 14.00, SD = 7.65).

Five participants reported prioritizing clients based on two criteria: a service placement issue (e.g., staff rotation) or a discharge from a recent psychiatric hospitalization. Some participants (n = 5) mentioned using onward referrals, following a screening appointment, to other mental-health services or groups (online stress control, group self-help-based interventions).

Results showed that individuals who requested mental-health services had an estimated waiting period between 0 and 12 months for an initial assessment appointment (M = 5.22, SD = 3.58). Almost half of the participants (n = 9) reported using evidence-based bibliotherapy and temporary coping strategies with individuals on waitlists. A similar number of participants (n = 10) reported simply informing their clients of the estimated time for their intake appointment. Very few participants (n = 3) reported having maintained regular contact with their clients to update them regarding the likely waiting time for their appointments. Finally, participants found the opt-in approach as the most useful practice, followed by screening appointments, bibliotherapy provision, and waiting-time information (see Figure 3).

Waitlist and the Personal Impact

The level of stress concerning the waitlist management task was found to be moderate (n = 17, M = 2.76, SD = 0.64; on a 1–5 Likert-type scale); qualitative inputs below corroborate with this.

Qualitative Strand: Staff Psychologists’ Reported Experiences from Waitlist Management Practices

We present the three generated themes with direct quotes (textual data). Table 1 illustrates additional quotations, to support the interpretations and explanations of each theme. We then attempted a synthesis of qualitative and quantitative results in a mixed-method interpretation approach, following a joint display graph.

Table 1 Identified themes and quotations

Themes	Additional quotations
Appropriate referrals	• I think it might help to have clearer or more consistent guidelines across, e.g., the CHO area, as most referrals come from NCHDs who rotate between different sectors and areas every 6 months, and I think there is a lot of variation in how referrals are managed.
	• Clearer team guidelines on acceptable versus inacceptable referrals.
	• In cases where clients do not opt-in, I think it also promotes further consideration by referring agents as to who might be suitable for referral to psychology.
	• Discussion of all referrals for suitability, motivation to engage, and which service may meet their needs.
	• Referral agents, particularly NCHDs, need to discuss potential referrals to psychology in the MDT meetings with psychology present.
	• Communication is important, so people know what’s happening.
Challenges and the personal impact	• There is a feeling of responsibility/holding for clients awaiting psychology, and it is difficult not to be able to respond to the need because of a lack of resources – particularly once you have met a client at the screening and formed a relationship and have a felt-sense of their distress.
	• Don’t be afraid to have clear boundaries and discharge clients when they need to be discharged. We can’t afford to feel guilty and hold onto clients. That would stop us from being able to pick up new cases.
	• Managing the team’s expectations around responsiveness by psychology to referrals can be difficult.
Resource issues	• Sending opt-in letters, arranging screenings, sending bibliotherapy info, and communicating with people on the list are time-consuming but useful ways to manage the waiting list effectively. But this all eats into clinical time.
	• Increased resourcing (more psychology staff), perhaps introducing a psychology consultation role, i.e., not necessarily agreeing to see a client directly but offering a specific formulation/consultation staff to other team members (referrers).
	• Increased admin or assistant psychology support to manage the admin tasks of a senior and free up more time for groups and individual sessions.

Table 1 Identified themes and quotations

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Appropriate Referrals

Appropriate referrals to mental-health services were identified as an important practice. This should be followed by “clear” and “specific” referral guidelines that will be “discussed at multidisciplinary team (MDT) meetings,” so that even when rotated members of teams leave (e.g., psychiatrists), new members are well informed. The team should understand “what psychology provides and does not provide” to ensure appropriate referral (e.g., cognitive behavioural therapist or addiction counselor). Participants believe that a client’s “past compliance” or a current and previous engagement with the service (i.e., “one-to-one nursing support or CBT”) should be acknowledged by the referrer and discussed at an MDT before the referral is made to the Psychology Service. Clients should be informed about the referral, so that they can reject or approve it before this occurs, thus avoiding unnecessarily increasing the waitlist.

Challenges and the Personal Impact

Participants have felt pressured to deal with the external pressure of waitlists to manage their waiting list can be internalized by individual psychologists as something they must “fix” or “we are doing the best we can.” For those who have used the practice of screening appointments, anxiety in the form of “personal agonies” is experienced: They build a therapeutic rapport with the clients, as they gain an insight into their distress yet then have them wait to get full services. Participants also find the practice of providing information about the estimated wait time “stressful” and “uncomfortable,” coupled with a busy caseload; they also feel stressed for managing “the team’s expectations around responsiveness.”

Lack of Resources

Staff shortages, a need for more support, and “psychologists working at capacity” were some of the resource issues raised regarding waitlist management. While some participants acknowledged that clients are “being maintained relatively well” while awaiting care, most mentioned that increased resourcing is necessary for staff members to manage waitlists more efficiently. Participants who noted clients required lengthy treatment recognized the usefulness of waitlist management practices but also emphasized the time they needed for these practices – time that otherwise could have been used for clinical work. In services in whöch “demand always exceeds supply,” there was a feeling that some of the waitlist management strategies would only increase the “administrative burden” and create “further admin work.” Some participants reported that additional support staff (e.g., assistant psychologists) would be helpful in managing these administrative duties, implementing various waitlist management practices, or simply freeing up time for clinical work.

Integration of Quantitative and Qualitative Findings

Figure 4 shows that, during the second lockdown period in Ireland, psychologists had various practices at their disposal to manage their waitlist, and that these practices had a modest impact on their emotional well-being. Psychologists reported a moderate stress level from dealing with waitlist practices; a quantitative finding was further reported in qualitative responses. Synthesis of the mixed-method conclusions indicates that psychologists experienced this stress as a practical and emotional “burden”: The practical burden arose because of an increase in staffs’ administrative duties in underresourced services; the emotional burden reflected a compassionate concern about psychologists’ future therapeutic work or how the waiting time might have negatively impacted the therapeutic relationship with their clients. Further, while reducing the rate of unsuitable referrals to Psychology Services may help shorten waitlists, psychologists ultimately felt that additional resources (i.e., staff) are necessary to effectively manage lengthy waitlists.

Discussion

The high prevalence of mental-health issues because of the ongoing worldwide COVID-19 pandemic has increased the demand for mental-health services (Bernado et al., 2021; O’Connor et al., 2021; OECD, 2020). This consequently increased the waitlists for these services (Byrne et al., 2021; Chong et al., 2021; Gloster et al., 2020; Neto et al., 2021; World Health Organization, 2020), putting both the undersourced mental-health services and the healthcare professionals who deal with them under further strain (Byrne et al., 2021; World Health Organization, 2020). This mixed-method research examined how psychologists managed and experienced waitlists during COVID-19 restrictions. Given the dearth of knowledge on that matter, findings from this research can offer practical solutions that can be rapidly adjusted and implemented by psychologists working in similar services. Also, it can bring advocacy actions and inform relevant management policies that can leverage permanent organizational changes, informed by those who deal with the problem (mostly mental health practitioners).

This study showed that the most frequently used practices by psychologists were the opt-in systems: informing clients of the waiting time and providing evidence-based bibliotherapy. Screening appointments was found to be a less common practice. This corroborates with other research, showing that the screening appointment practice is less favorable (Clemente et al., 2006; Parkin et al., 2003) because it is time-consuming, often requiring from psychologists adherence to multiple clinical and administrative protocols (e.g., reporting on the case, following-up, etc.). Psychologists consensually agreed that the waitlist practice is an overall useful method to manage new cases and to keep clients informed. They also believed that they could increase clients’ motivation and support them during the wait time until they finally offered an appointment. However, they also believed that waitlists overall add workload and may not be the best choice for some clients who may not always adhere to them. Findings showed that, for some clients, providing evidence-based bibliotherapy and information may seem inappropriate, pointing to the potential utility of tailoring approaches within services. For instance, for some clients psychologists should first assess their readiness and acceptability before implementing any chosen practice.

Above all, psychologists highlighted the lack of resources as the main source of frustration, showing that the current waitlist management practices alone may not be enough to tackle the problem of long waitlists. Further, findings highlight the need for developing a system of referral within services built on a system where suitable, clear, and specific referrals of only motivated individuals be in place, and where referrals come from colleagues who know where to refer and for which professional (e.g., addiction counselors or CBT therapists). Applied in this way, these practices can potentially lower waitlists by maximizing referrals being delivered in appropriate services.

Most psychologists reported using an opt-in approach to manage their waitlists. They generally rated this approach as very useful, practical, and acceptable, while also acknowledging that, for some clients (e.g., younger clients) or those with specific needs (e.g., cognitive impairment), the opt-in system may not always be responsive, and they may still need psychological input. These findings corroborate with previous research showing that an opt-in system increases service efficiency (Hawker, 2007; Stallard & Sayers, 1998), but that this efficacy can be optimized if in-house administrative support deals with the opt-in system daily (Stallard & Sayers, 1998). Below, we expand the discussion with data-driven practical, organizational, and policy-based recommendations

In terms of practical recommendations, our findings propose three evidence-based parameters to be considered when developing and implementing an effective management process of new referrals. These include providing clear and up-to-date information about how specific psychology services prioritize new cases, creating lists with the referral criteria employed by each service, and including details about the capacity and expertise of the psychologists. In terms of organizational recommendations, our study underscores the need for an ongoing data gathering process pertaining to waiting times and examining the impact of waiting times on staff, clients, and service provision efficacy. Additionally, waitlist management practices should be standardized instead of occurring on an ad-hoc basis to promote better organization and fairness (Brown et al., 2002). Further, for services that are not currently using any of the aforementioned waitlist-management practices, a context-specific assessment of the staff’s needs and preferences should precede the implementation of practices, followed by a pilot audit of the practices’ efficacy, before further putting refinements in place. Finally, in terms of policy-based recommendations, our findings underscore the need for additional funding resources for psychological services. Extra funding for implementation research allows services to detect barriers and facilitators of waitlist management practices and provide adequate evidence and an up-to-date picture of the cost-effectiveness of these practices. This makes requests for extra funding to governmental bodies meaningful, particularly when health board committees’ goal is to further improve the effectiveness of the services.

This study has several limitations. First, because of restrictions on social contact, we gathered data only through online forms and from two community settings, so that the number of clinicians surveyed was small. Correspondingly, the study had a low response rate, with only half of the invited professionals (around 80 psychologists) completing the survey. Speculatively, and based on the study findings, we attribute the low response rate to the increased overload of staff psychologists during the second lockdown, which essentially left very little time for their participation in research. Also, we can assume that the online form of data collection might have been perceived as extra digital work for the psychologists who had already entirely switched their work from “in-person” to “online” modes. Future work should involve in-depth qualitative interviews or focus groups with clinicians and online surveys. Additionally, collecting data from multiple community centers and under a thorough recruitment plan that involves key stakeholders within the clinical settings, to encourage participation or provide incentives, might reduce the high attrition rate observed in this study. Second, the current study did not gather information about the geographical location or specific service delivery, making it difficult to account for referral rate variations or waitlist management initiatives across services. Future research should explore the benefits of waitlist management practices regarding service efficiency. Including multiple community centers and deductive data analysis, such as that based on priorities about waitlists set by health board units (i.e., the recommendations provided by Ní Shiothcháin & Byrne, 2009), can provide more breadth in scope and implementation suggestions. Adopting a multisite data collection would also reduce the self-selection bias that occurred to a certain degree in this study, because of the data collection in a specific context. Likewise, by expanding the data collection across units and communities, one could highlight differences and similarities or effective initiatives in waitlist management practices used in specific services, and they could be used in other units, too.

Another limitation lies in the selection of the measure employed to measure participants’ distress. We used a single item rather than a well-validated scale to reduce the number of time participants would take to complete the survey. We made this decision following recommendations proposing practices to reduce new environmental stressors, such as digital fatigue (Sharma et al., 2021). Future research should include a brief validated measure to more reliably capture psychological constructs. Finally, the generalizability of the present study findings cannot be warranted, though recommendations can be applied to a similar in scale and scope of services. Our findings described herein can be formulated under the “Plan-Do-Study-Act” (PDSA) approach for quality improvement in healthcare (Leis & Shojania, 2017), meaning that services that attempt to improve waitlist practices can follow an iterative approach when developing their waitlist management practices; they can break down their tailored needs, apply the new policy of waitlist implementation practices, evaluate the outcome from the application of these practices, and update them based on this evaluation.

In conclusion, our study indicates several issues and opportunities for improvement of waitlist management practices, particularly for large-scale AMHS, covering densely populated geographical areas. Developing, implementing, and evaluating contextually-specific waitlist management practices that account for various factors that interact and influence the services’ efficacy can lower the burden psychologists experience and increase their productivity. Tailoring to service needs may yield added benefits when developing specific protocols for waitlist management practices as different service users (e.g., early psychosis, developmental disabilities, etc.) may have different needs that should be considered.

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