Abstract
Background: Waiting lists in mental health are a growing problem. This study analyzes their impact on attendance and early dropout from treatment in the Santander health area of the Spanish National Health System. Method: A retrospective observational study was conducted with 2,765 patients referred from Primary Care to four Mental Health Units during 2021. Logistic regressions were applied to analyze the influence of waiting times on attendance at the first appointment and early dropout, and ROC curves were used to identify optimal cut-off points. Results: The median waiting time was 51 days for the first appointment and 35 between the first and second. A total of 84.6% attended their first session, with higher attendance in women, older individuals, those with work-related disability, and shorter waiting times. Early dropout (15.8%) was associated with longer time between appointments, being male, and being younger. The discriminative power of the cut-off points was poor. Conclusions: Waiting times exceed recommended standards and negatively affect treatment continuity. Structural reforms and more human resources are needed to improve access to and the effectiveness of psychological care.
References
Alonso-Gómez, R. A., Reina, L. L., Méndez, I. F., García, J. M., & Briñol, L. G. (2019). El psicólogo clínico en los centros de salud. Un trabajo conjunto entre atención primaria y salud mental [The clinical psychologist in health centers. A joint work between primary care and mental health]. Atención Primaria, 51(5), 310–313. https://doi.org/10.1016/j.aprim.2018.08.012
Benítez-Ortega, J. L., Venceslá-Martínez, J. F., López-Pérez-Díaz, Á G., Rodríguez-Gómez, A., Gómez-Gómez, V., Martínez-Cervantes, R. J., Romero-Gamero, R., & Vázquez-Morejón, A. J. (2021). Calidad asistencial de la psicología clínica en el Servicio Andaluz de Salud evaluada por los facultativos [Quality of care of clinical psychology in the Andalusian Health Service as assessed by professionals]. Apuntes de Psicología, 39(3), 143-158. https://doi.org/10.55414/ap.v39i3.910
Benjet, C., Borges, G., Orozco, R., Aguilar-Gaxiola, S., Andrade, L. H., Cia, A., Hwang, I., Kessler, R. C., Piazza, M., Posada-Villa, J., Sampson, N., Stagnaro, J. C., Torres, Y., Viana, M. C., Vigo, D., & Medina-Mora, M. (2022). Dropout from treatment for mental disorders in six countries of the Americas: A regional report from the World Mental Health Surveys. Journal of Affective Disorders, 303, 168-179. https://doi.org/10.1016/j.jad.2022.02.019
Cano-Vindel, A., Muñoz-Navarro, R., Moriana, J. A., Ruiz-Rodríguez, P., Medrano, L. A., & González-Blanch, C. (2022). Transdiagnostic group cognitive behavioural therapy for emotional disorders in primary care: The results of the PsicAP randomized controlled trial. Psychological Medicine, 52(15), 3336–3348. https://doi.org/10.1017/S0033291720005498
Clark, D. M., Canvin, L., Green, J., Layard, R., Pilling, S., & Janecka, M. (2018). Transparency about the outcomes of mental health services (IAPT approach): An analysis of public data. The Lancet, 391(10121), 679-686. https://doi.org/10.1016/s0140-6736(17)32133-5
Clarkin, J., Heywood, C., & Robinson, L. J. (2024). Are younger people more accurate at identifying mental health disorders, recommending help appropriately, and do they show lower mental health stigma than older people? Mental Health & Prevention, 36, 200361. https://doi.org/10.1016/j.mhp.2024.200361
Cuellar-Flores, I., Garzón, L. F., Félix-Alcántara, M. P., Olivares, B. M., De la Vega Rodríguez, I., González, M. F., Albarsanz, M. L. P., Rivera, S. V., & Belmonte, M. J. M. (2022). Indicadores asistenciales y estándares de calidad asistencial para la psicología clínica en los centros de salud mental del Sistema Madrileño de Salud evaluados por sus profesionales [Care indicators and care quality standards for clinical psychology in mental health centers assessed by clinical psychologists of Madrid Health System]. Apuntes de Psicología, 40(2), 71-86. https://doi.org/10.55414/ap.v40i2.1414
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Noma, H., & Furukawa, T. A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta‐ analysis. Acta Psychiatrica Scandinavica, 144(3), 288-299. https://doi.org/10.1111/acps.13335
Díaz, J., Díaz-De-Neira, M., Jarabo, A., Roig, P., & Román, P. (2017). Estudio de derivaciones de atención primaria a centros de salud mental en pacientes adultos en la Comunidad de Madrid [Study of primary care referrals to mental health centers in adult patients in Madrid Region]. Clínica y Salud, 28(2), 65-70. https://doi.org/10.1016/j.clysa.2017.03.001
Duro-Martínez, J. C. (2021). ¿Sabemos cuántos profesionales especialistas en Psicología Clínica trabajan en el Sistema Nacional de Salud español? [Do we know how many professionals specialists in clinical psychology work in the Spanish National Health System]. Papeles del Psicólogo, 42(2), 81-93. https://doi.org/10.23923/pap.psicol.2955
Erekson, D. M., Bailey, R. J., Cattani, K., Klundt, J. S., Lynn, A. M., Jensen, D., Merrill, B. M., Schmuck, D., & Worthen, V. (2022). Psychotherapy session frequency: A naturalistic examination in a university counseling center. Journal of Counseling Psychology, 69(4), 531-540. https://doi.org/10.1037/cou0000593
Erekson, D. M., Lambert, M. J., & Eggett, D. L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology, 83(6), 1097- 1107. https://doi.org/10.1037/a0039774
Fan, Y., Fan, A., Yang, Z., & Fan, D. (2025). Global burden of mental disorders in 204 countries and territories, 1990–2021: results from the global burden of disease study 2021. BMC Psychiatry, 25(1). https://doi.org/10.1186/s12888-025-06932-y
Fenger, M., Mortensen, E. L., Poulsen, S., & Lau, M. (2011). No-shows, drop-outs and completers in psychotherapeutic treatment: Demographic and clinical predictors in a large sample of non-psychotic patients. Nordic Journal of Psychiatry, 65(3), 183–191. https://doi.org/10.3109/08039488.2010.515687
Fernández-García, X. (2021). Situación de la psicología clínica en el Sistema Nacional de Salud (SNS) y perspectivas de crecimiento [Situation of clinical psychology in the Spanish National Health System and growth perspectives]. Ansiedad y Estrés, 27(1), 31-40. https://doi.org/10.5093/anyes2021a5
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316-340. https://doi.org/10.1037/pst0000172
Gallucci, G., Swartz, W., & Hackerman, F. (2005). Impact of the wait for an initial appointment on the rate of kept appointments at a mental health center. Psychiatric Services, 56(3), 344-346. https://doi.org/10.1176/appi.ps.56.3.344
Garcia-Pedrajas, C., Bayona, E. M., Ibáñez, O. P., Guerre, S. O., & Fornas, C. V. (2018). Longitudinal descriptive study of diagnostic concordance between primary care and psychology support program in primary care. Anales de Psicología, 34(1), 23-29. https://doi.org/10.6018/analesps.34.1.251451
Gaudiano, B. A., & Miller, I. W. (2013). The evidence-based practice of psychotherapy: Facing the challenges that lie ahead. Clinical Psychology Review, 33(7), 813-824. https://doi.org/10.1016/j.cpr.2013.04.004
Goñi-Sarriés, A., De Jalón Aramayo, E. G., González, N. L., & Urra, E.L. (2008). Análisis de las derivaciones desde atención primaria a salud mental [Analysis of referrals from primary care to mental health]. Anales de Psiquiatría, 24(2), 83-88. https://dialnet.unirioja.es/servlet/articulo?codigo=2578508
González‐Blanch, C., Muñoz‐Navarro, R., Medrano, L. A., Moriana, J. A., Ruiz‐Rodríguez, P., & Cano‐Vindel, A. (2021). Moderators and predictors of treatment outcome in transdiagnostic group cognitive‐ behavioral therapy for primary care patients with emotional disorders. Depression and Anxiety, 38(7), 757-767. https://doi.org/10.1002/da.23164
González-Blanch, C., Barrio-Martínez, S., Priede, A., Martínez-Gómez, S., Pérez-García-Abad, S., Miras-Aguilar, M., Ruiz-Gutiérrez, J., Muñoz-Navarro, R., Ruiz-Rodríguez, P., Medrano, L. A., Prieto-Vila, M., Carpallo-González, M., Aguilera-Martín, Á., Gálvez-Lara, M., Cuadrado, F., Moreno, E., García-Torres, F., Venceslá, J. F., Corpas, J., . . . Cano-Vindel, A. (2023). Cost-effectiveness of transdiagnostic group cognitive behavioural therapy versus group relaxation therapy for emotional disorders in primary care (PsicAP-Costs2): Protocol for a multicentre randomised controlled trial. PLoS ONE, 18(3), e0283104. https://doi.org/10.1371/journal.pone.0283104
González-Blanch, C. (2025). Algunas prevenciones más: una crítica sobre la prevención cuaternaria en salud mental [Some further considerations: A critique of quaternary prevention in mental health]. Papeles del Psicólogo/Psychologist Papers, 46(2), 118–124. https://doi.org/10.70478/pap.psicol.2025.46.15
Hanevik, E., Røvik, F. M. G., Bøe, T., Knapstad, M., & Smith, O. R. F. (2023). Client predictors of therapy dropout in a primary care setting: A prospective cohort study. BMC Psychiatry, 23(1), 358. https://doi.org/10.1186/s12888-023-04878-7
Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9-16. https://doi.org/10.1037/a0022186
Instituto Nacional de Estadística. (2025). Spain Health Survey (SHS): Year 2023 [Press release]. https://www.ine.es/dyngs/Prensa/en/ESdE2023.htm
Institute for Health Metrics and Evaluation. (2022). Global Health Data Exchange (GHDx). https://vizhub.healthdata.org/gbd-results/
Jeitani, A., Fahey, P. P., Gascoigne, M., Darnal, A., & Lim, D. (2024). Effectiveness of stepped care for mental health disorders: An umbrella review of meta-analyses. Personalized Medicine in Psychiatry, 47, 100140. https://doi.org/10.1016/j.pmip.2024.100140
Kirkbride, J. B., Anglin, D. M., Colman, I., Dykxhoorn, J., Jones, P. B., Patalay, P., Pitman, A., Soneson, E., Steare, T., Wright, T., & Griffiths,
S. L. (2024). The social determinants of mental health and disorder: evidence, prevention and recommendations. World Psychiatry, 23(1), 58–90. https://doi.org/10.1002/wps.21160
Lau, B., Victor, M., & Ruud, T. (2016). Sickness absence and presence among employees in treatment for common mental disorders. Scandinavian Journal of Public Health, 44(4), 338-346. https://doi.org/10.1177/1403494815621418
Loumidis, K. S., & Shropshire, J. M. (1997). Effects of waiting time on appointment attendance with clinical psychologists and length of treatment. Irish Journal of Psychological Medicine, 14(2), 49-54. https://doi.org/10.1017/s0790966700002986
Marquina-Márquez, A., Olry-de-Labry-Lima, A., Bermúdez-Tamayo, C., Ferrer, L. I., & Marcos-Marcos, J. (2022). Identifying barriers and enablers for benzodiazepine (de)prescription: A qualitative study with patients and healthcare professionals. Anales del Sistema Sanitario de Navarra, 45(2), e1005. https://doi.org/10.23938/assn.1005
Martín-Jurado, A., De la Gándara Martín, J., Carbajo, S. C., Hernández, A. M., & Sánchez-Hernández, J. (2012). Análisis de concordancia de las derivaciones de atención primaria a salud mental [Concordance analysis of referrals from primary care to mental health]. Medicina de Familia SEMERGEN, 38(6), 354-359. https://doi.org/10.1016/j.semerg.2011.12.005
McGorry, P. D., & Mei, C. (2021). Clinical staging for youth mental disorders: Progress in reforming diagnosis and clinical care. Annual Review of Developmental Psychology, 3(1), 15–39. https://doi.org/10.1146/annurev-devpsych-050620-030405
Ministerio de Sanidad. (2022). Estrategia de Salud Mental del Sistema Nacional de Salud. Período 2022-2026 [Mental Health Strategy of the National Health System 2022 - 2026]. https://www.sanidad.gob.es/areas/calidadAsistencial/estrategias/saludMental/
Ministerio de Sanidad. (2024). Aspectos relevantes del informe anual del Sistema Nacional de Salud 2023 [Relevant aspects of the annual report of the National Health System 2023]. https://www.sanidad.gob.es/estadEstudios/estadisticas/sisInfSanSNS/tablasEstadisticas/InfAnualSNS2023/ASPECTOS_RELEVANTES_2023.pdf
Miranda-Chueca I, Peñarrubia-María MT, García-Bayo I, Caramés-Durán E, Soler-Vila M, Serrano-Blanco A. (2003). ¿Cómo derivamos a salud mental desde atención primaria? [How do we refer to mental health from primary care?]. Atención Primaria, 32(9), 524-530. https://doi.org/10.1016/S0212-6567(03)70782-3
Moratalla, B. G., & Lobo, A. O. (2002). Ausencias en las primeras consultas de un centro de salud mental: Un estudio controlado [No attendance to initial appointments in a mental health centre: a controlled study]. Revista de la Asociación Española de Neuropsiquiatría, 22(83), 27-36. https://doi.org/10.4321/s0211-57352002000300003
Nam, S. K., Chu, H. J., Lee, M. K., Lee, J. H., Kim, N., & Lee, S. M. (2010). A meta-analysis of gender differences in attitudes toward seeking professional psychological help. Journal of American College Health, 59(2), 110-116. https://doi.org/10.1080/07448481.2010.483714
National Institute for Health and Care Excellence. (2011). Generalised anxiety disorder and panic disorder in adults: Management (NICE guideline No. CG113). https://www.nice.org.uk/guidance/cg113
National Institute for Health and Care Excellence. (2022). Depression in adults:Treatment and management (NICE guideline No. NG222). https://www.nice.org.uk/guidance/ng222
Patel, R., Shetty, H., Jackson, R., Broadbent, M., Stewart, R., Boydell, J., McGuire, P., & Taylor, M. (2015). Delays before diagnosis and initiation of treatment in patients presenting to mental health services with bipolar disorder. PLoS ONE, 10(5), e0126530. https://doi.org/10.1371/journal.pone.0126530
Peipert, A., Krendl, A. C., & Lorenzo-Luaces, L. (2022). Waiting lists for psychotherapy and provider attitudes toward low-intensity treatments as potential interventions: Survey study. JMIR Formative Research, 6(9), e39787. https://doi.org/10.2196/39787
Pfefferbaum, B., & North, C. S. (2020). Mental Health and the Covid-19 Pandemic. New England Journal of Medicine, 383(6), 510-512. https://doi.org/10.1056/nejmp2008017
Punton, G., Dodd, A. L., & McNeill, A. (2022). ‘You’re on the waiting list’: An interpretive phenomenological analysis of young adults’ experiences of waiting lists within mental health services in the UK. PLoS ONE, 17(3), e0265542. https://doi.org/10.1371/journal.pone.0265542
Reichert, A., & Jacobs, R. (2018). The impact of waiting time on patient outcomes: Evidence from early intervention in psychosis services in England. Health Economics, 27(11), 1772-1787. https://doi.org/10.1002/hec.3800
Roos, J., & Werbart, A. (2013). Therapist and relationship factors influencing dropout from individual psychotherapy: A literature review. Psychotherapy Research, 23(4), 394-418. https://doi.org/10.1080/10503307.2013.775528
Santomauro, D. F., Herrera, A. M. M., Shadid, J., Zheng, P., Ashbaugh, C., Pigott, D. M., Abbafati, C., Adolph, C., Amlag, J. O., Aravkin, A. Y., Bang-Jensen, B. L., Bertolacci, G. J., Bloom, S. S., Castellano, R., Castro, E., Chakrabarti, S., Chattopadhyay, J., Cogen, R. M., Collins, J. K., . . . Ferrari, A. J. (2021). Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. The Lancet, 398(10312), 1700-1712. https://doi.org/10.1016/s0140-6736(21)02143-7
Sharf, J., Primavera, L. H., & Diener, M. J. (2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy, 47(4), 637-645. https://doi.org/10.1037/a0021175
Steinert, C., Stadter, K., Stark, R., & Leichsenring, F. (2017). The Effects of waiting for treatment: A meta-analysis of waitlist control groups in randomized controlled trials for social anxiety disorder. Clinical Psychology & Psychotherapy, 24(3), 649–660. https://doi.org/10.1002/cpp.2032
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–559. https://doi.org/10.1037/a0028226
Swift, J. K., Whipple, J. L., & Sandberg, P. (2012). A prediction of initial appointment attendance and initial outcome expectations. Psychotherapy, 49(4), 549-556. https://doi.org/10.1037/a0029441
Tejedo-García, A. (2018). Análisis comparativo de las derivaciones desde atención primaria de salud a salud mental: Atención psicológica y atención psiquiátrica [Comparative analysis of referrals from primary health care to mental health: Psychological care and psychiatric care]. Informaciones Psiquiátricas, 233, 23-50. https://dialnet.unirioja.es/servlet/articulo?codigo=6983196
van Dijk, D., Meijer, R., Van Den Boogaard, T., Spijker, J., Ruhé, H., & Peeters, F. (2023). Worse off by waiting for treatment? The impact of waiting time on clinical course and treatment outcome for depression in routine care. Journal of Affective Disorders, 322, 205-211. https://doi.org/10.1016/j.jad.2022.11.011
Vellisca, M. Y., Latorre, J. I., Orejudo, S., Gascón, S., Nolasco, A., & Villanueva, V. J. (2014). Patrón asociado a la inasistencia a la primera consulta de un centro de salud mental [Pattern associated with non- attendance to first appointment at a mental health center]. Revista de Psicopatología y Psicología Clínica, 19(2), 141-146. https://doi.org/10.5944/rppc.vol.19.num.2.2014.13064
Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., Bruffaerts, R., De Girolamo, G., De Graaf, R., Gureje, O., Haro, J. M., Karam, E. G., Kessler, R. C., Kovess, V., Lane, M. C., Lee, S., Levinson, D., Ono, Y., Petukhova, M., . . . Wells, J. E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet, 370(9590), 841-850. https://doi.org/10.1016/s0140-6736(07)61414-7
Wang, P. S., Berglund, P. A., Olfson, M., & Kessler, R. C. (2004). Delays in initial treatment contact after first onset of a mental disorder. Health Services Research, 39(2), 393-416. https://doi.org/10.1111/j.1475-6773.2004.00234.x
World Health Organization (2017). Depression and other common mental disorders: Global health estimates. World Health Organization. https://iris.who.int/handle/10665/254610
World Health Organization. (2022). Mental health and COVID-19: Early evidence of the pandemic’s impact [Scientific brief]. World Health Organization. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1-eng