Family Practice Vol. 18, No. 1, 95-100
© Oxford University Press 2001
Psychological Problems |
Lack of mental well-being in 15-year-olds: an undisclosed iceberg?
Department of Child and Adolescent Psychiatry and
a Department of General Practice, University of Glasgow, Glasgow, UK.
Correspondence to Mrs ML Gillies, Room 3, Trust Management Corridor, Yorkhill NHS Trust, Glasgow G3 8SJ, UK.
Potts Y, Gillies ML and Wood SF. Lack of mental well-being in 15-year-olds: an undisclosed iceberg? Family Practice 2001; 18: 95–100.
Received 14 February 2000; Revised 13 June 2000; Accepted 5 September 2000.
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Abstract |
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Background. Young people suffer from psychiatric symptoms and illness, and the frequency of both may be higher than currently is recognized. The frequency with which young people consult GPs with emotional problems is not established.
Objective. The purpose of this study was to identify the number of 15-year-olds who consult their GP directly or indirectly with psychiatric symptoms or illness.
Methods. A two part survey was carried out involving (i) general practice casenote review; and (ii) questionnaires self-report. The subjects comprised all adolescents aged 15 years from 34 randomly selected general practices and a randomly selected subsample of these adolescents. The main outcome measures were a purpose-designed data collection sheet, General Health Questionnaire (GHQ-12) and a purpose-designed self-report questionnaire.
Results. In phase 1, the general practice casenotes of 2359 adolescents were examined. Five per cent of subjects were identified as attending the GP with mental health problems; 1% had attempted suicide during the year. In phase 2, 99 subjects returned completed self-report questionnaires. Although over a quarter (26%) were rated as GHQ-12 ‘cases’ and approximately half reported having felt ‘sad, unhappy or low’ or ‘anxious or worried’ in the previous year, only one subject reported attending his/her GP with any of these concerns.
Conclusions. Fifteen-year-olds rarely consult their GP about their emotional well-being, yet, with the GHQ-12, the self-reported rate of psychiatric morbidity was nearly seven times greater than that suggested by these same subjects' medical records. Although the majority of adolescents consult their GP throughout the course of a year, those with mental health problems, including those who attempt suicide, are indistinguishable in the frequency of their GP consultations from adolescents without mental health problems.
Keywords. Adolescents of 15 years, attendance at general practice, casenotes, mental health.
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Introduction |
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The risk of developing a mental health problem during adolescence has increased in the last decade. Adolescents aged 14–15 years are more likely to have emotional and conduct disorders in comparison with children aged 10–11 years. There is an even greater number of adolescents who cannot be diagnosed as suffering from a mental illness but do suffer from psychiatric symptoms. Psychiatric illness in these adolescents may not be identified because a diagnosis such as depression requires the presence of five or more depressive symptoms, whereas 60% or more adolescents suffer from at least one depressive symptom.1 The frequency with which young people consult GPs with emotional problems is not established.
The principal aim of this study was to identify the number of 15-year-olds who were consulting their GP directly or indirectly with psychiatric symptoms or illness. The research questions were:
- (i) How often do 15-year-olds consult their GP over a 1-year period and what are their reasons for doing so?
- (ii) What psychological intervention or referral to specialist services do these young people receive at primary care level?
- (iii) How easy do 15-year-olds find consulting their GP with a mental health or physical problem?
- (iv) What proportion of 15-year-olds have symptoms of mental health problems, as identified by the General Health Questionnaire?
- (ii) What psychological intervention or referral to specialist services do these young people receive at primary care level?
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Methods |
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Sample selection
The general practice casenotes of 2500 young people were to be reviewed in the first phase. Fifteen-year-olds were chosen because the ages at which young people were referred most frequently for psychiatric assessment were 14 and 15 years (National Audit Database); in addition, an attempt was made to allow comparison with the West of Scotland 11–16 sample2 whose most recent assessment (in 1999) was at 15 years. General practices (n = 101) were selected randomly from the same geographical area, the Central Clydeside Conurbation, a predominantly urban area in and around Glasgow. For the second phase of the study, 20% of 15-year-olds participating in phase 1 were selected randomly, with the aim of achieving an overall response rate of 10% to a postal survey. Random selection was conducted before the casenotes were examined, thus avoiding bias.
Procedure
Following consent, the general practice records of all 16-year-olds were identified using G-PASS or VAMP software. Consultations for the full year that the individual was aged 15 were examined, and information about gender, postcode, and date(s) and reason(s) for consultation were obtained. Correspondence was reviewed and information regarding attendance at mental health services or suicide attempts was noted.
In phase 2, the randomly selected 20% of subjects (n = 500) and their parent or guardian were mailed a letter and pre-paid envelope, via their GP, explaining the purpose of the research and requesting the consent of each young person and of one parent or guardian. Those agreeing were then mailed the General Health Questionnaire (GHQ-12) and a brief purpose-designed self-completion questionnaire with a pre-paid envelope. This questionnaire was designed to elicit information about the subjects' consultations with their GP in the previous year, their reasons for doing so and consultation satisfaction.2 Those who had not attended their GP in the previous year completed the section of the questionnaire asking about their physical and mental well-being. The GHQ-12 is a self-administered screening tool which is easy to complete and quick to score. It is aimed at detecting psychiatric disorders in settings including primary care.3 Non-respondents were each followed-up on two occasions at fortnightly intervals.
Statistical analysis
Data from each phase were coded and entered into SPSS for Windows. GHQ-12 data were scored 0 or 1 to maintain consistency with the West of Scotland 11–16 and 20–07 studies.2,4 GHQ-12 cases were identified as those with scores of three or more out of a possible 12, in accordance with A Users' Guide to the General Health Questionnaire, where the total misclassification is reported to be 13.3% using the best threshold score.3 Analysis of the data was primarily descriptive but also incorporated proportions, cross-tabulations and chi-squared analysis.
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Results |
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In phase 1, 34 GPs (35%) agreed to participate, 53 (52%) failed to respond and 14 (14%) declined to take part. There is no obvious single reason for this level of response. It is perhaps worth noting that several research projects (some also involving casenote review) were being conducted at the same time in general practices in the Central Clydeside Conurbation. In some instances, practices had difficulty in providing accommodation for the research assistant.
The casenotes of 2359 16-year-olds were examined, providing information on 5425 consultations which had occurred at age 15 years. Of the 137 subjects who agreed to participate in phase 2 of the study, only 99 (72% of those originally selected) returned a complete set of questionnaires, i.e. 4% of those whose casenotes were examined in phase 1.
Attendance
Subjects consulted their GP on average 2.3 times per year (SD = 2.82), females consulting more than males (3:2). The distribution of attendance shows that 30% of the sample had not consulted their GP throughout the year studied (Table 1
); of those, 5% had not been seen in general practice for 2 years and 3% had not attended for 3 years. Thirteen per cent of questionnaire respondents reported that they had felt like seeing their doctor but had not made an appointment.
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Reason for attendance
The most commonly reported symptoms were sore throats, upper respiratory tract infections and tonsillitis. Mental health concerns were reported less frequently: 4% of patients consulted their GP for the mental health problems represented in Table 2
and only 3% of all casenotes contained information concerning discussion about emotional or mental well-being.
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Information in the GP casenotes identified 116 subjects (5%) with definite mental health problems such as stress, eating disorders, depression or attempted suicide. Possible mental health problems were identified in a further 1% of casenotes. In total, 70 subjects (3%) had attended mental health services when aged 15 years. Of those identified as having definite or possible mental health problems at this age, 60% had been referred to mental health services.
Parasuicide
One per cent of subjects (n = 26) had attempted suicide at age 15 years (two females: one male), one in five of these on more than one occasion. Just over half (n = 14) had received psychiatric assessment following their suicide attempt.
GHQ-12 results
Adolescents who scored <3 are referred to as GHQ-12 negative and those with a score of 
33 as GHQ-12 positive (i.e. having a number of symptoms). Twenty-six subjects (26%) were rated as GHQ-12 positive. Analysis of the distribution of scores for ‘rather more’ or ‘much more than usual’ responses revealed that 40% of subjects had ‘felt constantly under strain’ whilst 26% had been ‘feeling unhappy and depressed’. Although a few subjects who were GHQ negative attended their GP more frequently than GHQ-positive subjects (Table 3), a higher proportion of GHQ cases (58%) than non-cases (33%) had been seen more than twice, i.e. more than the average number of consultations (chi-squared = 7.699, d.f. = 1, P = 0.006). This suggests that 15-year-olds with possible mental health problems are more likely than those without such problems to be frequent attenders at general practice. However, only 35% of those identified from their medical notes as having possible mental health problems, and 54% of those who had attempted suicide, had attended their GP more than the average number of times.
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Postal questionnaire results
Adolescents (n = 99) regarded their health as ‘good’ (67%) or ‘fairly good’ (33%); the option ‘not so good’, was never chosen. One quarter of subjects reported that they had a long-standing illness, the most common being asthma (n = 9). Over half of the subjects had felt ‘sad, unhappy or low’ and 48% reported feeling ‘anxious or worried’ in the previous year (Table 4
). A higher proportion of adolescents with these symptoms had consulted their GP when compared with those who had not seen their doctor (Table 5), and only one subject reported specifically attending his/her GP with such problems.
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Satisfaction with GP consultations
One in five subjects reported that they would prefer to see someone other than a doctor about their problems, the most popular alternative being a friend, followed by their mother. Two-thirds of subjects (n = 62) responded to the question asking about satisfaction with consultations; 24% of these were dissatisfied, but only half had acted on this.
Possible somatic symptoms
The majority of adolescents with mental health problems did not consult their GP for what could be somatic symptoms, e.g. abdominal pain. Table 4
, however, shows that over one-third of subjects reported experiencing ‘tummy problems’, yet only 3% reported attending their GP with this problem. A further 6% of 15-year-olds with mental health problems or who had attempted suicide had attended their GP with abdominal pain or headaches.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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General practice casenotes revealed that 15-year-olds rarely consult their GP about their emotional well-being. However, when the GHQ-12 was completed, the total self-reported rate of psychiatric morbidity was nearly seven times greater than that suggested by these same subjects' medical records. Only 3% of those described as GHQ-12 positive were identifiable from their general practice casenotes as having a possible mental health problem. This suggests that 15-year-olds may find it difficult to consult their GP with mental health concerns. Possibly, as a result of this, referral to psychiatric services was infrequent; however, this was also true for those who had attempted suicide.
It is interesting to compare the results from this study with those of the West of Scotland 11–16 study, which has corresponding samples from the same geographical area. In this study, 57% of 15-year-old respondents reported feeling ‘sad, unhappy or low’ in the preceding year, whereas 40% of 13-year-olds and 35% of 11-year-olds reported similarly in two separate sweeps of the West of Scotland 11–16 study.2,4 Analysis of the 15-year-old sweep of the West of Scotland 11–16 study currently is in progress.
Despite almost half of the subjects in this study reporting emotional problems in the previous year, very few had discussed such concerns with their GP, including most of those who had attempted suicide. It could be argued that adolescents are not bringing their mental health concerns to the attention of their GP. Alternatively, it is possible that GPs do not pick up and respond to affect-laden comments and non-verbal cues from adolescents. Such problems have already led to the development of new training programmes for GPs to improve interview skills and patient–doctor interaction.6,7 If most adolescents prefer to talk to their GP about their problems yet only a few of those who experience mental health problems do consult their GP, the question arises as to why they do not talk to their GP about emotional problems. Understanding why adolescents do not communicate their feelings is essential to the reduction of suicidal behaviour as those who rarely or never communicate suicidal ideation have more chance of completed suicide.8 Further research in this area is urgently needed.
Previous research suggests that most psychiatric morbidity in adolescents can be found amongst frequent attenders at general practice,9 suggesting that paying more attention clinically to frequent attenders may reduce hidden psychiatric morbidity. The present study contradicts this theory as approximately half (42–62%) of those whose casenotes indicated definite mental health problems, including those who had attempted suicide, had consulted their GP less than the average number of times per year. Adolescents with mental health problems did not attend their GP more often than those without. Headaches are reported in the literature to be the most common somatic symptom,10 with recurrent abdominal pain second.11 However, when the general practice casenotes of three groups (those who had attempted suicide, those identified as having possible mental health problems and GHQ-12 cases) were compared with the remaining sample, there was little difference in frequency of consultation for headaches and abdominal pain. This suggests that adolescents with mental health problems do not consult their GP with somatic symptoms. In summary, it appears that adolescents with mental health problems, including those who attempt suicide, are indistinguishable in the frequency of their GP consultations from adolescents without mental health problems. This contradicts Beautrais et al.12 who reported that adolescents who attempt suicide have a life time history of contact with health services for psychiatric reasons.
Implications for the NHS
Unpublished local data have demonstrated that adolescents report not knowing how to talk about mental health issues and are concerned that admitting a problem will make them different.13 This study has shown that adolescents are aware of their emotional problems and although many claim that they would talk to their GP about these problems, the majority do not. If psychiatric morbidity in adolescents is to be reduced, this apparent contradiction needs to be addressed. One way to encourage adolescents to discuss their problems with GPs may be to introduce education for them about mental well-being, explaining that the majority of young people and adults have emotional concerns at some time but that this does not mean that they have psychiatric illness. Alternatively, education could be aimed at parents, who may not recognize mental health problems in their children,2,5 and it is also known that parents do not perceive GPs as a source of help for children's emotional problems.14 Changing this belief, therefore, may prevent this opinion from being passed on to adolescents.
The GHQ-12 detected nearly seven times more adolescents with emotional problems than was apparent from general practice casenotes. In addition, in a randomized controlled trial conducted in Scotland, the GHQ-30 was found to be associated with a significant increase in the detection of emotional distress in patients over 14 years.15 There is evidence to suggest that adolescents find it easier to disclose emotional concerns in the GHQ rather than in their GP consultations. It may, therefore, be beneficial for all adolescents to complete the GHQ-12, a one-page questionnaire, whilst in the GP waiting room.
It is essential that further research addresses the so far undisclosed iceberg of psychiatric symptoms and illness in young people, without any further delay.
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Acknowledgments |
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This research was funded by a Mini-Grant from the Chief Scientist Office of the Scottish Office Health Department. The content of the paper is the view of the authors alone and not necessarily the view of the funding body or the journal.
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References |
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2
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