Impact of Opt-Out Therapy Appointments on Resident Physicians’ Mental Health, Well-Being, Stigma, and Willingness to Engage Open Access

In recent years, high rates of depression, sleep impairment, and burnout among health care workers¹  have raised concerns of a worsening mental health baseline among health professionals^2,3  compounded by delays or avoidance in care seeking.⁴  Mental health opt-out appointments are one way to increase mental health services engagement and reduce barriers of access, stigma, and convenience.^5,6  A default option in an opt-out approach is that an individual participates unless direct action is taken to decline. Like other opt-out health strategies, such as immunizations, opt-out counseling can convey messages of normalcy. Prior work with medical residents has suggested a favorable view of opt-out services,⁶  but engagement is variable⁷  despite a call for more broad adoption of mental health opt-out counseling.^8,9 

The objective of this study was to contribute additional evidence of the utility of opt-out appointments on mental health service utilization among resident physicians. The primary theoretical framework is that, in creating an opt-out program, routine mental health service use is normalized. The study hypothesized that opt-out appointments would increase mental health service utilization, demonstrate institutions’ value of wellness, and decrease mental illness stigma.

During the 2020-2021 academic year, resident physicians at a large academic training hospital were offered an opt-out appointment with a licensed mental health professional. To participate in this initiative, programs were required to offer protected work time for the visit. A total of 29 training programs were offered opt-out appointments; 8 expressed interest, and 7 were included in the final sample. At the time of enrollment, programs were allowed to enroll all residents regardless of postgraduate year (PGY). Most programs offered opt-out appointments to interns only. One program offered appointments to all residents because of high suicidal ideation among its residents, as identified in an internal research study.

Participants were sent an email from their program coordinator or chief resident asking if they wanted to “opt out” of a mental health check-in appointment. If they didn’t respond to the email, they were scheduled an appointment during work hours with the Graduate Medical Education (GME) Wellness Office. All opt-out appointments were held virtually and typically occurred at the end of shift. During these appointments residents were asked about various mental health and wellness concerns. Additional appointments were scheduled as needed and tracked through the end of the 2020-2021 academic year. To maintain confidentiality, programs were not informed which resident physicians attended appointments.

To ascertain acceptability, satisfaction, value, and attitude toward mental health services, all participants received a survey within 2 weeks of their opt-out appointment, which is included as online supplementary data. The survey was developed by 2 authors (TK and RD) and refined with a panel of professionals associated with the training hospitals’ GME program. The survey consisted of Likert scale questions and free-text response fields. Surveys were administered through REDCap, and participation was voluntary. Analysis of results included simple statistics computing mean responses to ascertain value and attendance.

Estimates of full-time equivalent (FTE) required to deliver centralized opt-out mental health appointments were calculated based on the number of total visits that occurred during the study period.

The study design and survey were acknowledged by the University of Utah Institutional Review Board as quality improvement nonhuman subject research.

While 8 programs expressed interest in the initiative, only 7 were able to offer protected time for opt-out appointments; thus, 7 of 29 training programs, consisting of 153 residents, were included in the study. Of the 153 residents offered opt-out appointments, 62 (40%) opted out of the appointments. The final sample consisted of 91 residents who attended appointments (59% of 153 residents offered appointments). Participants self-identified as predominantly male and White (n=50, 55% male; n=66 73% White). Demographic and specialty characteristics of the residents are shown in Table 1.

Survey response rate was 57% (52 of 91). Respondents reported high satisfaction (96%, 50 of 52), felt the appointment was worth their time (96%, 50 of 52) and demonstrated their training program cared about well-being (94%, 49 of 52). Nearly all residents (98%, 51 of 52) recommended appointments be offered to future cohorts. Most respondents (80%, 42 of 52) indicated that appointments increased their willingness to engage in mental health services. Survey findings are summarized in Table 2.

Free-text responses showed that many residents already possessed a high willingness to engage in services but indicated that appointments reduced stigma toward mental health services and increased their willingness to engage in future mental health services.

Of the 91 trainees who attended opt-out appointments, 31 (34%) attended additional appointments. Residents attended between 1 and 10 additional appointments. Trainees who continued in therapy were shown to be equally distributed by gender, predominately White (80%), and heterosexual (84%).

A portion of participants (27) were already enrolled in services with the GME Wellness Office prior to being offered their opt-out appointment; 21 opted out of their opt-out appointment.

Approximately 10% (91 of 944) of mental health visits during the study period were opt-out appointments and represented 0.15 FTE. The increase in appointments was absorbed into the regular duties of the Wellness Office without hiring additional FTE or adding material costs.

Findings of the present study suggest that opt-out appointments can help address resident physician mental health needs. Residents reported that their opt-out appointment demonstrated their institutions care for them and increased positive attitudes toward future mental health services. In the present study, overall utilization of mental health opt-out appointments was 59%, with about one-third of participants attending additional appointments. These findings support previous research that mitigation of barriers can increase mental health engagement^5,6  and adds further evidence regarding the positive effect that increased familiarity of available services through opt-out appointments may have on resident well-being and future engagement in mental health services.

The present study also provides evidence for the efficacy of opt-out appointments delivered through virtual or telehealth platforms. While the present study was not aimed to assess the influence of a virtually delivered opt-out program, this finding is particularly relevant given the significant shift from traditional service delivery methods during the COVID-19 pandemic. Offering opt-out appointments through a virtual platform may further reduce common barriers to mental health utilization, such as lack of convenience.

Finally, this study has limitations. First, the survey used was developed by the authors and was not tested for evidence of validity, so respondents may have interpreted questions differently than intended. Furthermore, our sample consisted of resident physicians across multiple years of training (PGY-1 through PGY-7). Previous experience with the GME Wellness Program through wellness surveys, presentations, or utilization of opt-out appointments prior to the present study may have also influenced participation in the 2020-2021 academic year opt-out initiative. Future work with opt-out initiatives should include surveying residents who opt-out of appointments, provide additional follow-up to ascertain long-term value, and isolate appointments to first-year residents to clarify their effect on future mental health service use.

The present study found that opt-out appointments increased resident willingness to engage in mental health services, positive attitudes toward future mental health services, and perception of the training program’s care about their well-being. They also reduced perceived mental illness stigma. Finally, residents were satisfied with their appointments and recommended that opt-out appointments be offered to future cohorts.

The online version of this article contains the questionnaire used in the study.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented as a poster at the American Conference on Physician Health, October 7-9, 2021, Scottsdale, Arizona, USA.