Family Practice Advance Access originally published online on July 29, 2005
Family Practice 2005 22(6):631-637; doi:10.1093/fampra/cmi080
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Do patients want to disclose psychological problems to GPs?
The MaGPle Research Group, including,
The MaGPIe (Mental Health and General Practice Investigation) Research Group, Wellington School of Medicine and Health Sciences, University of Otago, New Zealand.
Correspondence to Dr Deborah McLeod, Department of General Practice, Wellington School of Medicine, University of Otago, Box 7343 Wellington, New Zealand; Email: dmcleod{at}wnmeds.ac.nz
Received 29 January 2005; Accepted 6 July 2005.
The MaGPle Research Group, including Bushnell J, McLeod D, Dowell A, Salmond C, Ramage S, Collings S, Ellis P, Kljakovic M and McBain L, for the MaGPIe Research Group. Do patients want to disclose psychological problems to GPs? Family Practice 2005; 22: 631–637.
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Abstract |
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Background. GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored.
Objectives. To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care.
Methods. A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity.
Results. Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the ‘right’ person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%).
Conclusions. Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.
Keywords. General practice, mental disorders, patient disclosure, research.
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Introduction |
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Mental disorders such as anxiety, depression and substance abuse are a major health issue in New Zealand with 35.7% of general practice attenders having a diagnosable DSM-IV disorder in the previous 12-months.1 As is the case for many healthcare systems across the world, GPs in New Zealand act as gatekeepers to secondary and tertiary care, including mental health care, with the exception of crisis presentations. Primary care, including general practice, pharmacological and laboratory charges, is funded through a mix of public subsidy and patient fees, with greater subsidies for people on low incomes enrolled with primary health organisations serving predominantly low income populations, for children and for those aged over sixty-five. Other users pay the full costs of seeing their GP. Specialist mental health care is fully subsidised and currently serves 1.6% of the population.2 Psychological services for other patients are also available in the private sector and through non-governmental social and community groups.
Although identification of the symptoms of mental illness by New Zealand GPs is high amongst patients they have seen three or more times in the past 12 months, identification is lower for patients seen less frequently.3 Barriers to identification include GP factors such as actual or perceived lack of knowledge, skills or interest in or attitudes towards mental health care. While it is generally suggested that recognition of mental illness could be increased through GP training and the use of screening tools for mental illness4–7 there has been little attention to patient factors as a barrier to recognition.
Emphasis on GP education and screening is based on the assumption that patients consider identification and management of mental disorders in primary care is appropriate, and that failure to identify symptomatic patients can be understood by analysing the characteristics of practitioners and medical settings.8 In order to explore this assumption with patients in New Zealand the following question was included as part of the patient interview in the MaGPIe study: "Some people don't talk to doctors about problems with emotions, nerves, alcohol or drugs. Was there ever a time when you did not talk to your doctor, despite having problems like these?"9 This paper reports MaGPIe study participants' responses to this question and discusses implications for the provision of primary mental health care.
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Methods |
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Data were collected as part of the cross-sectional phase of the MaGPIe study, a study of the prevalence, outcomes and management of common mental disorders in New Zealand general practices. Methods are described in detail elsewhere.1
Seventy-eight GPs were selected at random from a list of all 299 known GPs in a geographical area in the lower North Island of New Zealand. The GHQ-12 was completed by 3414 consecutive eligible adult patients, approximately 50 from the practice of each participating GP. Patients were eligible to complete the GHQ-12 if they were 18 years old or over, read English well enough to understand and complete the GHQ-12, and were about to consult the sampled GP for their own health concerns. The GP completed a questionnaire for every patient aged 18 or over whom they saw over the study period. This questionnaire included rating scales of the extent to which the presenting symptoms were physical or psychological, and an assessment of the overall severity of the patient's physical and psychological disorders in the past 12 months.
Based on GHQ-12 strata, patients were invited to participate in a structured in-depth interview and subsequent 12-month longitudinal study. 150 of the 1834 patients with GHQ scores of 0 or 1 were invited to participate (an 8% chance of selection), 247 of 826 patients with scores of 2 to 4 (a 30% chance of selection) and all 754 patients with scores of 5 or more. The measures used in the in-depth interview were based on the World Health Organisation's Collaborative Study of Psychological Problems in General Health Care.10 Measurements relevant to this paper include a computerised interviewer-delivered version of the Composite International Diagnostic Interview version 2.1; the Somatic and Psychological Health Report (SPHERE)11 and the World Health Organisation's Disability Assessment Schedule-version II (WHODAS).12 Non-disclosure of psychological problems was determined by the following question "Some people don't talk to doctors about problems with emotions, nerves, alcohol or drugs. Was there ever a time when you did not talk to your doctor, despite having problems like these?" Open-ended responses to the question "What were the main reasons you did not talk to your doctor?" were recorded verbatim directly onto interviewers laptops. This question has been used previously in both New Zealand and the USA.9 Four trained female interviewers with backgrounds in nursing, counselling or psychology conducted the interviews. Audits and quality-control meetings were regularly performed during the data collection phase to ensure between-interviewer consistency.
The Wellington and Manawatu-Whanganui Ethics Committees approved the methods and procedures used in the study. Patient consent was provided at two levels: verbal consent to participate in the GHQ-12 screening stage and written consent to participate in the MaGPIe interview.
Outcome measures
For quantitative analyses patients were categorised into two groups based on whether or not they reported a time when they had avoided discussing an existing psychosocial problem with their GP. Reasons for not discussing psychological problems were grouped by theme. Themes were grouped after discussion amongst members of the research group.
Patients with current symptoms or symptoms in the last 12 months. Patients were defined as symptomatic if they were identified as cases using either the CIDI (over the past 12 months) or SPHERE (over the last 4 weeks). CIDI data were scored using WHO scoring algorithms to produce DSM-IV diagnoses from CIDI v2.1. SPHERE cases were either psychosomatic or psychological cases or both using the scoring framework described by Hickie et al.11 The remaining patients were described as ‘Patients with no mental health symptoms currently or in the past 12 months.’
GP recognition. There were three levels of GP identification of common mental disorders based on GP responses to the patient questionnaire: identification of sub-clinical psychological symptoms; identification of clinically significant emotional distress; and explicit diagnosis. Definition of levels of GP recognition is described in detail elsewhere.3
Disability. The WHODAS12 was used as an assessment of patient self-reported physical and psychological disability.
Ethnicity was determined by self-identification using the Statistics New Zealand question used in the 1996 census. M
ori were defined as any participants identifying themselves as Mori, solely or in combination with any other ethnic group.
Socio-economic deprivation. An individualised study-specific index of social and material deprivation was also created using similar constructs as NZDep2001, but using available deprivation data for each participant in the study. Participants were scored 1 for each of the following: if they were unemployed, had no educational qualifications, held a Community Services Card, had no car, or had no telephone. The count of these attributes was then used as the individualised social and material deprivation index.
Statistical methods
Statistical analyses were carried out using Statistical Analysis Software (SAS) version 8.02 and STATA/SE version 8.2. Data were weighted to adjust for differences in the probability of being sampled.13 Prevalence estimates were derived using the SAS procedure SURVEYMEANS, which adjusted rates and proportions for the probability of selection, and adjusted standard errors and 95% confidence intervals (CI) to allow for the effects of clustering within GP. Relative risks were calculated in STATA using a generalised linear modelling function with a binomial distribution and a log link. The iterative re-weighted least squares (IRLS) option was used; observations were weighted to account for probability of being sampled; confidence intervals were adjusted to allow for the effect of clustering within GP.
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Results |
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Seventy of the 78 (90%) randomly selected eligible GPs agreed to participate. GHQ screening questionnaires were completed by 3414 of 3687 (93%) patients. Data from subsequent interviews completed with 775 of 1132 eligible patients provides the basis for analyses in this paper.
Nearly 30% (29.8%; 95% CI 25.3–34.2) of all patients surveyed, approximately 20% (21.1%; 95% CI 13.8–28.5) of patients with no current or recent symptoms and nearly 40% (36.9%; 95% CI 31.6–42.2%) of patients with symptoms in the last 12 months said they had, at some time, chosen not to disclose psychological problems with a GP (Table 1). Non-disclosure of psychological problems was not differentially associated with a specific CIDI diagnosis, as 41.9% (95% CI 26.7–57.1) of patients reaching the DSM-IV threshold for depression, 45.9% (95% CI 36.1–55.6) of patients with anxiety and 42.5% (95% CI 33.6–51.5) of patients with substance use diagnoses in the 12 months prior to interview, reported not discussing psychological issues with a GP.
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Younger patients were nearly twice as likely to report non-disclosure than older patients (t = 12.37, P = 0.0065). Patients who were currently or recently symptomatic who had consulted three or four times and patients who had consulted five or more times in the previous 12 months were also more likely to report non-disclosure of psychological problems than patients who had not previously consulted in the last 12 months (RR 1.71 95% CI 1.01–2.87 and 1.97 95% CI 1.11–3.53, respectively) (Table 2). This finding does not take into account the increased opportunities for non-disclosure amongst patients who attend their general practice more frequently. Patients currently or recently symptomatic with psychological disability were also more likely to report non-disclosure than those without associated disability (RR 1.52 95% CI 1.06–2.17). This association remained significant after adjusting for age and the number of consultations in the previous 12 months (RR 1.44 95% CI 1.03–2.02).
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Patients were able to provide more than one reason for non-disclosure and 57 patients providing more than one reason were coded into different categories. Reasons given were grouped into five main categories: a belief that a GP is not the right person to talk to (33.8% 95% CI 24.2–43.3); a belief that mental health problems should not be discussed at all (27.6% 95% CI 8.7–36.5); a belief that the patient's own GP is not the right person for them to talk to (20.6% 95% CI 12.3–28.8); the stigma of disclosure and/or treatment (18.7% 95% CI 9.6–27.8); and structural system factors such as time and cost (8.4% 95% CI 2.2–14.5). Typical responses within each category and subcategory are shown in Table 3.
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GP identification of psychological symptoms was not significantly associated with non-disclosure (Table 4). The unadjusted RR was 0.75 (95% CI 0.49–1.14) and the RR adjusted for age, number of consultations and psychological disability was 0.82 (95% CI 0.57–1.17).
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Discussion |
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The data reported in this paper are drawn from a larger longitudinal study of the recognition and subsequent management of common mental disorders in general practice attenders; the MaGPIe Study. The key finding is that a substantial proportion of patients who were independently assessed as having a mental disorder reported a time when they had not talked to a doctor about their psychological problems. Their reasons for non-disclosure included unwillingness to discuss psychosocial problems with anyone at all; beliefs that a GP is not the appropriate person to talk to; and concerns about aspects of their relationship with their own GP.
As the GP is the most accessible person to discuss mental health problems with it is of concern that many patients did not see them as an appropriate resource. Addressing this would involve public education to enhance mental health literacy14 and to inform people about the role of the GP. Mental health literacy refers to ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’14 and includes knowledge and beliefs about professional help available and attitudes that facilitate recognition and appropriate help-seeking. Limitations in mental health literacy may cause problems in communicating with health practitioners and the presentation of psychological concerns as somatic disorders.15 Increases in mental health literacy have been achieved following public awareness campaigns in the US and UK.15
Approximately a quarter of the patients in this study with psychological symptoms reported feeling that mental health problems should not be discussed with anyone. In a UK study the majority of the public reported they would be embarrassed to consult a GP for depression because the GP may see them as unbalanced or neurotic.16 Stigma may extend to concerns about the questions asked in screening questionnaires.17 Strategies to increase mental health literacy are likely to also increase patients' willingness to seek help by addressing the stigma associated with mental disorders and increasing patients' recognition of their symptoms and understanding that discussing symptoms is acceptable.
In a US study only one fifth to one third of patients with mental disorders who believed it was appropriate to discuss psychosocial problems with GPs had actually discussed these problems with their GP.8 In the current study a fifth of patients who did not want to talk to their GP about their psychological problems gave reasons relating to the doctor–patient relationship or the doctor's perceived attitude.
There are three core components to all psychological treatments: establishing a positive therapeutic relationship where patients feel free to discuss emotional problems, developing a shared understanding of the problem (communication of a clear and appropriate conceptualisation of the patient's problems), and promoting a change in behaviour, thoughts or emotions.18 Concepts of mental disorders such as depression may also differ between patients and doctors with doctors attaching greater importance to somatic symptoms, medical and external causes.19 Empowering patients to press their treatment requests more successfully may address these issues especially if supported by GP training, modified practice arrangements and reimbursement policies.8
In the current study some patients were concerned about receiving pharmacological treatment if they talked to their GP. Although many mental disorders are minor or self-limiting some may progress to more severe illness and would benefit from intervention. Pharmacological intervention and counselling have both been demonstrated to be effective in the management of various high prevalence conditions.20 In reviewing the literature Jorm15 reports a negative belief about psychotropic medication, in contrast to evidence from metanalyses, as a consistent finding across many countries. These views contrast with patients' positive views about medication for physical disorders and psychological treatments such as counselling. If patients do not accept evidence based treatment recommendations they may seek other treatments.15
In this study only a minority of patients reported concern about structural aspects of the health system. A community-based sample may result in different findings, as in the current study the sample was drawn from patients who were attending a general practice, although not necessarily with the intention of discussing a mental health problem. The association between ethnicity and deprivation and non-disclosure should also be explored further in a community-based sample as the results may differ from those in the current study. Further research is also warranted to explore the extent to which patients in other countries avoid discussing mental health symptoms with GPs and whether they have similar reasons for not doing so as patients in New Zealand.
The high response rates of 90% from GPs and 70% from patients provide assurance that the findings of this study are broadly representative of patients attending New Zealand general practices. The data about non-disclosure of psychological problems is based on patients' beliefs that there had been a time when they had psychological problems but had not sought care for these problems. In this study independent assessment of whether or not a patient had symptoms of a mental disorder was also based on a different time frame (in the last 12 months) than self-reported non-disclosure (ever in the past). Therefore, it is possible that patients' current attitudes to non-disclosure may differ to their attitudes in the past. Findings from the current study do not link patient feelings and beliefs about seeking care with whether care was actually given, or their attitudes in the past to current symptoms. Nevertheless the findings contribute to understanding the identification of mental disorders in a primary care setting.
In conclusion, there are high rates of identification of psychological symptoms by New Zealand GPs amongst patients with whom they have an ongoing therapeutic relationship. Further education and the introduction of screening tools are unlikely to facilitate recognition (although screening tools may provide a mechanism for introducing discussion of psychosocial issues). However, there is the potential for education to facilitate patient disclosure and doctor–patient communication about psychological problems. Education of the general public is needed to address mental health literacy, to de-stigmatise mental illness and to promote the role of the GP in providing mental health care and the effectiveness of psychotropic drugs. Education targeting the GP is needed to increase awareness of patient perspectives of mental health and to improve strategies to establish an effective therapeutic relationship with patients with mental health disorders.
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Declaration |
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Funding: the Health Research Council of New Zealand funded the project with supplementary funds contributed by the New Zealand Alcohol Advisory Council.
Ethical approval:
Conflicts of interest: none.
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Acknowledgments |
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We are grateful for the support of the participating GPs and other practice staff, the patients who participated, and our research staff.
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Notes |
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The ‘MaGPIe’ (Mental Health and General Practice Investigation) research group consists of a management committee and an advisory committee. The management committee that undertook day-to-day oversight and management of this study consisted of John Bushnell, Deborah McLeod, Anthony Dowell, Clare Salmond, and Stella Ramage. The advisory committee consisted of Sunny Collings, Pete Ellis, Marjan Kljakovic, and Lynn McBain. 
This version published 22 August 2005
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References |
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1 The MaGPIe Research Group. The nature and prevalence of psychological problems in New Zealand primary health care: a report on Mental Health and General Practice Investigation (MaGPIe). NZ Med J 2003; 116(1171).
2 Mental Health Commission. Towards implementing the blueprint for mental health services in New Zealand. Wellington, New Zealand: Mental Health Commission; 2004. www.mhc.govt.nz/publications/2204/MHC_Reportonprogress.pdf.
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6 Hickie I, Davenport T, Naismith S, Scott E. Conclusions about the assessment and management of common mental disorders in Australian general practice. SPHERE National Secretariat. Med J Aust 2001; 175(Suppl): S52–55.
7 Goldberg D, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment in the outcome of major depression in primary care: a naturalistic study in 15 cities. Br J Gen Pract 1998; 48: 1840–1844.[Web of Science][Medline]
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11 Hickie I, Davenport T, Hadzi-Pavlovic D et al. Development of a simple screening tool for common mental disorders in general practice. Med J Aust 2001; 175 Suppl: S10–S17.
12 World Health Organisation. WHODAS-II Disability Assessment Schedule Training Manual: A guide to administration. Geneva: World Health Organisation; 2000.
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20 National Institute for Clinical Excellence. NICE guidelines to improve the treatment and care of people with depression and anxiety. London: National Institute for Clinical Excellence; 2004.
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