Family Practice Advance Access originally published online on November 22, 2005
Family Practice 2006 23(1):53-59; doi:10.1093/fampra/cmi097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The treatment of common mental health problems in general practice
The MaGPIe Research GroupThe MaGPIe Research Group, Wellington School of Medicine, University of Otago, New Zealand
Correspondence to Professor Anthony Dowell, Department of General Practice, Wellington School of Medicine and Health Sciences, University of Otago, Box 7343 Wellington, New Zealand; Email: tonyd{at}wnmeds.ac.nz
Received 21 December 2004; Accepted 26 October 2005.
The MaGPIe Research Group. The treatment of common mental health problems in general practice. Family Practice 2006; 23: 53–59.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionDeclarationReferences |
|---|
Background. Previous studies report GPs under-treat mental health disorders, particularly depression, and treatments are non-specific and lack an evidence base. They conclude further training and education of GP's is required.
Objective. To describe the treatment of common mental health disorders in relation to the level and severity of psychological problems as defined by the GP and external assessment.
Methods. Cross sectional survey of General Practice attenders in New Zealand. Fifty consecutive adult patients were recruited from each practice of 70 randomly selected GP's. The psychological status of 773 respondents selected via the General Health Questionmaire (GHQ) was assessed, and details of management provided. Management options were compared with the level of psychological problem identified by the GP.
Results. Treatment varied depending on the level of problem identification, and frequency of consultation, from 93% given treatment when an explicit diagnosis was made to 22.3% in patients with subclinical symptoms. The most commonly given treatment with an explicit diagnosis was psychotropic medication [73% (95% CI 63.6–82.9)] while for those patients with subclinical symptoms the most common form of treatment was discussion and counselling [15.7% (7.1–24.2)]. Only 1.7% (0.3–3.0) of patients with subclinical symptoms received psychotropics.
Conclusion. There is a clear association between the level of psychological problem identified and treatment. In contrast to previous views that treatment often appears to be given regardless of diagnosis, these results provide a picture of general practice management of common mental disorders more in line with evidence-based practice than previously described.
Keywords. Primary health care, mental disorders.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionDeclarationReferences |
|---|
Mental disorders are recognized as a major public health problem1,2,3 and the management of mental health problems places an increasing burden on health services. A World Health Organisation (WHO) study of the global burden of disease assessed that mental disorders make up five of the ten leading causes of disability.4 Since the management of these problems takes place predominantly in general practice and primary care settings,5 it is important to determine the effectiveness of current treatment rationales.
There is continuing debate regarding the effectiveness of the management of common mental health problems in general practice settings. Many studies have reported that GPs under-diagnose and under-treat mental disorders, particularly depression.6–9 There is also concern that GPs are providing non-specific treatments2 that lack an evidence base, or treatments that may be inappropriate since they are given below previously accepted diagnostic thresholds.10,11 A common response to these findings has been suggestions that further training and education of practitioners is required as a remedy for this inappropriate treatment.12 Most previous studies however have used categorical definitions of disorders which may overstate the extent of the problem; it has been suggested that a dimensional approach aligning diagnostic and management strategies to perceived severity may be more appropriate.13 Assessing effectiveness is also important given the difficulty of applying treatment algorithms and guidelines in primary care settings,6,14 and the equivocal results so far of the work of some other mental health care professionals in general practice. The use of counsellors and facilitators in mental health has been explored with only partial success in improving diagnosis, and less in changes to management or outcome.15,16 Different diagnostic and treatment paradigms inform decision making in general practice compared to psychiatric practice in secondary care settings. Current diagnostic criteria for offering treatment were developed from a secondary care context17 and may not fit well with the environment of uncertainty that characterizes general practice. In this setting a ‘wait and see’ philosophy may be appropriate, particularly in cases where the clinician perceives less severe levels of morbidity.18 The frequency with which this ‘wait and see’ philosophy is adopted however is not clear, nor is the frequency with which GP's initiate treatment for perceived differing levels of clinical symptoms. Variation in the use of referral as a management option has been described using both quantitative19–22 and qualitative approaches23,24, but there is little information about relationship to levels of diagnosis or morbidity.
The use of further laboratory and physical investigations in the management of psychological disorders has also received little research attention in general practice settings.25
An observational cohort study of general practice attenders in New Zealand was used to explore these issues.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionDeclarationReferences |
|---|
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 illness in New Zealand general practice. Methods are described in detail elsewhere.26
GPs were randomly selected from a list of all 299 known eligible GPs in a geographical area in the lower North Island of New Zealand, yielding a mix of urban, small town and rural practices. GPs were eligible if they were currently practising at least half the time without restriction (e.g. due to ill health or compulsory supervision).
Fifty consecutive eligible adult patients were recruited from the practice of each GP. Stratified sampling of these patients identified a primary sample of 1151, of whom 788 consented to interview. Of these, 773 also consented to their GP disclosing information about their health status and data from these respondents form the basis of this paper.
Patients were eligible for screening if they were 18 years old or over, read English well enough to understand and complete the General Health Questionnaire (GHQ)-12 screening instrument, and were about to consult with the index GP for their own health concerns. The GP completed a questionnaire (the Encounter Form) for every patient aged 18 or over who was seen during the study period. The Encounter Form 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, 8% of patients with scores of 0 or 1, 22% of patients with scores of 2–4 and all patients with scores of 5 or more were invited to participate in an in-depth interview and subsequent 12-month longitudinal study. The measures used in the in-depth interview were based on the WHO's Collaborative Study of Psychological Problems in General Health Care27 and included a 12-month computerized interviewer-delivered version of the Composite International Diagnostic Interview (CIDI) version 2.1; the WHO's Disability Assessment Schedule-version II28 as an assessment of disability; the Somatic and Psychological Health Report (SPHERE-12)29 as a dimensional measure of severity; as well as a range of socio-demographic questions.
External comparison of psychological status
To provide comparison with GP assessment of psychological status, patients were classified in the following way: a patient defined as ‘Well’ was SPHERE-negative and neither CIDI 1m- nor CIDI 12m-positive; a ‘Subclinical’ patient was SPHERE-positive but neither CIDI 1m- nor CIDI 12m-positive. Results were also compared for those with a CIDI-diagnosed disorder within the last 12 months but not in the last month, and for those with a CIDI-diagnosed disorder within the last one month.
Levels of psychological problem recognized by general practitioner
GPs completed a more detailed patient management questionnaire about problems, history and current management for each patient selected for the in-depth interviews whom the GP considered had a psychological component to their presentation.
Levels of psychological problems recognized in the past 12 months were defined using data from two sources: the GP's Encounter Form rating of severity of psychological disorder and the GP's responses to the Patient Management Questionnaire about psychological disorders diagnosed in the past 12 months. ‘Any psychological symptoms’ was defined as any report of psychological symptoms, distress or disorder whatsoever. ‘Clinically significant psychological problems’ required identification as a mild, moderate or severe case of psychological disorder from the Encounter form, or reporting any definite psychological disorder on the Patient Management Questionnaire. ‘Explicit psychiatric diagnosis’ was defined as the GP reporting any named psychological disorder on the Patient Management Questionnaire.
Statistical methods
Statistical analyses were carried out using Statistical Analysis Software (SAS) version 8.2. Data were weighted to adjust for differences in probability of being sampled using the method of Kish.30 Weighted prevalence estimates were derived using the SAS procedure SURVEYMEANS, which also adjusted standard errors and 95% confidence intervals for the effects of clustering within general practitioner.
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionDeclarationReferences |
|---|
The relationship between the level of psychological problem identified by the GP and the type of treatment delivered, offered or planned is shown in Table 1. The proportion varies according to the level and severity as assessed by the GP.
|
When an explicit diagnosis was made treatment was given to 93% (89.5–96.7) of those patients, while when the patient presented with perceived subclinical symptoms only 22.3% of patients received treatment of any kind. The most commonly given treatment for those with an explicit diagnosis was psychotropic medication [73% (63.6–82.9)] while for those patients with subclinical symptoms the most common form of treatment was discussion and counselling [15.7% (7.1–24.2)]. There were very low levels of psychotropic prescribing for patients with subclinical symptoms only 1.7% (0.3–3.0).
Of the 98 patients with clinically significant symptoms but no explicit diagnosis a total of 29 received treatment of some kind. Although explicit diagnoses were not given for these patients the doctor indicated the nature of the clinically significant symptoms. The most common symptom clusters were those associated with adjustment disorders (11/29) and depression (10/29). Eight of the 29 patients had been prescribed night-time sedation, 14 had been prescribed antidepressants and only two had been prescribed anxiolytics. These patients account for a weighted estimate 16.9% of the general practice population who would receive treatment without an explicit diagnosis.
There are differences between the proportion of patients receiving different types of treatment according to these diagnostic groupings. While over 80% of patients received psychotropic medication when a diagnosis was made of either anxiety or depression, less than 70% received medication when the patient was given a diagnosis of substance use disorder by the GP.
There were high levels of further physical investigation [41.6% (11–72)] and referral to mental health professionals [68.9% (45.3–92.4)] when the GP made an explicit diagnosis of substance use disorder compared to either diagnosed anxiety or depression.
Table 2 shows the types of psychological treatment given by general practitioners to patients within different levels of external assessment (CIDI/SPHERE).
|
The data suggest that overall 29% of general practice attenders received psychological treatment, with the proportion varying according to the severity of their psychological problems. For patients who were ’well' (both SPHERE and CIDI negative) only 16% received treatment, while 31% of those who were ‘subclinical’ (symptoms reaching a SPHERE but not CIDI threshold) were treated. Of those who had a CIDI-diagnosed disorder in the last month 52% were treated. For each treatment modality there was a positive relationship between proportion treated and severity of disorder. Of those who were ‘well’ 7.7% received psychotropic medication compared to 33.7% of those with a diagnosable disorder in the last month.
The relationship between treatment and consultation frequency is shown in Table 3. If the patient had been seen once or not at all prior to the index consultation 16.4% received treatment of some kind. Among those seen three or more times in the previous year 35.4% were treated (Table 3).
|
Variation according to consultation frequency is also seen with different types of treatment (Table 3). Treatment was given to 9.6% of patients with a CIDI-diagnosed disorder seen once or not at all in the previous year but to 44.9% of patients who had been seen three times or more.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionDeclarationReferences |
|---|
By including information about levels of problem identification and consultation frequency we believe these results provide a picture of general practice management of common mental disorders more in line with evidence-based practice than usually described. In this study management and treatment decisions vary according to the level of psychological problem identified by the GP, a finding in agreement with work from the UK.10 There was also a positive association between treatment and the level of psychological problem identified by external assessment, (CIDI), a finding in contrast to Kendrick's study where nearly half the offers of antidepressant prescribing were to patients unlikely to be suffering from major depression.10 The likelihood of treatment being given was also positively associated with increasing consultation frequency. This clear association between level of disorder and treatment contradicts previous views that treatment often appears to be given regardless of diagnosis.3 When patients were given an explicit diagnosis by the GP over 90% received some form of treatment. The majority of these patients received psychotropic medication, with antidepressants being the most commonly prescribed medication. Treatment levels were lower when using externally assessed measures of disorder rather than GP recognition (52% receiving treatment with a CIDI-diagnosed disorder), aligning the results to some extent with other studies. In the ‘Sphere’ project in Australia 40% of patients identified by the GP as having a mental disorder received pharmacological treatment prompting concerns about unmet need and inadequate treatment.31 However debate continues about the validity of current diagnostic instruments when applied to primary care studies, particularly when categorical rather than dimensional perspectives are taken to identify a case.10,13,32 In the absence of a diagnostic ‘gold standard’ it is possible that overall levels of treatment may be appropriate to the type and severity of conditions seen in general practice settings. Our data suggest that treatment decisions are influenced by frequency of consultation in the last year. GP's were relatively cautious in their prescribing when the patient was not well known to the practice or practitioner. The overall level of prescribing in this study also needs to be considered in the context of media attention, in many countries, about ‘excessive’ prescribing of psychotropic medication to those with less severe forms of mental disorder.33,34 Levels of psychotropic prescribing were much lower when patients did not have an explicit diagnosis or subclinical symptoms only, and for those patients without an explicit diagnosis more of the management was delivered by discussion and counselling rather than psychotropic medication. The fact that not all patients with a diagnosis received treatment may well be appropriate given the primary care context of the study.
In this study patients without explicit diagnoses were given treatment. Empirical treatment is used as a management option for patients without an explicit diagnosis in all general practice disciplines, and mental health problems are no exception to this. It is reassuring however to note the very low levels of anxiolytic prescribing in those patients, in keeping with current guidelines and best practice recommendations.
Discussion and counselling were provided to over half of those given an explicit diagnosis, and this was often combined with sources of practical support (17%), such as advice about benefits or social networks. Debate continues about the effectiveness of forms of treatment such as counselling and the provision of practical support to patients14,16 and their widespread use would seem to warrant further evaluation of these aspects of the consultation.
In this study 22% of those with an explicit diagnosis given by the GP were referred to a mental health professional. While this level is comparable to other reported studies19,20 the high cost of referral and the relative lack of published literature highlight a need for further work about appropriate levels of referral. Without further evidence of the impact of referral and subsequent treatment in general practice attenders it is unclear whether this should be source of concern or reassurance.31
This study provides a cross-sectional view of treatment provided to general practice attenders in New Zealand and has a number of limitations. The number of patients in some treatment categories are small (e.g. GP-diagnosed substance use disorder) and subject to wide confidence intervals. Although the study provides details about the levels of different treatment options we are unable to draw conclusions about the effectiveness or appropriateness of the treatment for individual patients from cross-sectional data. While the prescribing of psychotropic medication for depression would accord to many current guidelines, longitudinal data is required to assess the impact of treatment. We have identified the formulation of an explicit diagnosis and frequency of consultation as important predictors of the level of treatment provided but accept that a strategy in all branches of medicine to legitimize treatment options is to make an explicit and ‘post hoc’ diagnosis. In New Zealand however there is a relative lack of psychological services outside of the private sector and in many cases at significant cost to the patient of a psychotropic prescription.35 In these conditions there are fewer incentives for GPs to offer treatment unless there is a diagnostic imperative for doing so. While it is also possible that the GP's were attempting to be on their best diagnostic and treatment behaviour, we feel the fact that the GP participants were randomly selected militates against a Hawthorne effect.
While we believe that the results from this study provide further insights into patterns of treatment for common mental disorders there remain unresolved questions over the effectiveness of these strategies which may be answered by follow up of longitudinal patient cohorts and randomized controlled trials.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionDeclarationReferences |
|---|
Support: The Health Research Council of New Zealand funded the project (grant 99/065). Supplementary funds were also contributed by the Alcohol Advisory Council (ALAC).
Ethics committee approval: The Wellington and Manawatu-Whanganui Ethics Committees approved the methods and procedures used in the study.
Conflict of interest: None
|
Acknowledgments |
|---|
Authors: 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. Members of both committees were involved in the detailed planning of the study and have reviewed this paper. AD drafted and revised the paper. AD is the corresponding author. All authors are affiliated to the University of Otago at Wellington School of Medicine and Health Sciences, New Zealand.
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionDeclarationReferences |
|---|
1 Sartorius N, Ustun TB, Costa e Silva JA et al. An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on ‘Psychological Problems in General Health Care’. Arch Gen Psychiatry 1993; 50: 819–824.
2 Goldberg D, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment on 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]
3 Goldberg D, Gater R. Implications of the World Health Organization study of mental illness in general health care for training primary care staff [comment]. Br J Gen Pract 1996; 46: 483–485.[Medline]
4 Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study [comment]. Lancet 1997; 349: 1498–1504.[CrossRef][Web of Science][Medline]
5 Hornblow AR, Bushnell JA, Wells JE, Joyce PR, Oakley-Browne MA. Christchurch psychiatric epidemiology study: use of mental health services [see comment]. N Z Med J 1990; 103(897): 415–417.[Medline]
6 Klinkman MS. The role of algorithms in the detection and treatment of depression in primary care. J Clin Psychiatry 2003; 64(Suppl. 2): 19–23.
7 Peveler R, Kendrick T. Treatment delivery and guidelines in primary care. Br Med Bulletin 2001; 57: 193–206.
8 Paykel ES, Priest RG. Recognition and management of depression in general practice: consensus statement [see comment]. Br Med J 1992; 305: 1198–1202.
9 Davidson JR, Meltzer-Brody SE. The underrecognition and undertreatment of depression: what is the breadth and depth of the problem? J Clin Psychiatry 1999; 7: 4–9.
10 Kendrick T, King F, Albertella L, Smith P. GP treatment decisions for patients with depression: an observational study. Br J Gen pract 2005; 55: 280–286.[Web of Science][Medline]
11 Schwenk TL, Coyne JC, Fechner-Bates S. Differences between detected and undetected patients in primary care and depressed psychiatric patients. Gen Hosp Psych 1996; 18: 407–415.
12 Hickie IB, Davenport TA, Naismith SL, Scott EM, Hadzi-Pavlovic D, Koschera A. Treatment of common mental disorders in Australian general practice [comment]. Med J Aust 2001; 175(Suppl): S25–S30.
13 Thompson C, Ostler K, Peveler RC, Baker N, Kinmonth AL. Dimensional perspective on the recognition of depressive symptoms in primary care: the Hampshire Depression Project 3. Br J Psychiatry 2001; 179: 317–323.
14 Kendrick T. Why can't GPs follow guidelines on depression? We must question the basis of the guidelines themselves [see comment]. Br Med J 2000; 320: 200–201.
15 Bashir K, Blizard B, Bosanquet A, Bosanquet N, Mann A, Jenkins R. The evaluation of a mental health facilitator in general practice: effects on recognition, management, and outcome of mental illness. Br J Gen Pract 2000; 50: 626–629.[Web of Science][Medline]
16 Friedli K, King MB, Lloyd M, Horder J. Randomised controlled assessment of non-directive psychotherapy versus routine general-practitioner care [comment]. Lancet 1997; 350: 1662–1665.[CrossRef][Web of Science][Medline]
17 Dowrick, C. Case or continuum? Analysing general practitioners ability to detect depression. Prim Care Psychiatry 1995; 1: 255–257.
18 Klinkman MS, Schwenk TL, Coyne JC. Depression in primary care—more like asthma than appendicitis: the Michigan Depression Project. Can J Psych—Revue Canadienne de Psychiatrie 1997; 42: 966–973.
19 Ashworth M, Clement S, Sandhu J, Farley N, Ramsay R, Davies T. Psychiatric referral rates and the influence of on-site mental health workers in general practice. Br J Gen Pract 2002; 52: 39–41.[Medline]
20 Carr VJ, Lewin TJ, Walton JM, Faehrmann C, Reid AL. Consultation-liaison psychiatry in general practice [see comment]. Aust N Z J Psych 1997; 31: 85–94.[Medline]
21 Verhaak PF, van de Lisdonk EH, Bor JH, Hutschemaekers GJ. GPs' referral to mental health care during the past 25 years. Br J Gen Prac 2000; 50: 307–308.[Web of Science][Medline]
22 Falloon IR, Ng B, Bensemann C, Kydd RR. The role of general practitioners in mental health care: a survey of needs and problems. N Z Med J 1996; 109: 34–36.[Medline]
23 Nandy S, Chalmers-Watson C, Gantley M, Underwood M. Referral for minor mental illness: a qualitative study [comment]. Br J Gen Pract 2001; 51: 461–465.[Web of Science][Medline]
24 Lucena RJ, Lesage A. Family physicians and psychiatrists. Qualitative study of physicians' views on collaboration. Canadian Family Physician 2002; 48: 923–929.
25 Madsen AL, Aakerlund LP, Pedersen DM. [Somatic illness in psychiatric patients]. Ugeskrift for Laeger 1997; 159: 4508–4511.[Medline]
26 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). N Z Med J 2003; 116: U379.[Medline]
27 Ustun T, Sartorius N. Mental illness in general health care. England: Wiley; 1995.
28 World Health Organisation. WHODAS-II Disability Assessment Schedule Training Manual: A guide to administration. Geneva: World Health Organisation; 2000.
29 Hickie IB, Davenport TA, Hadzi-Pavlovic D, et al. Development of a simple screening tool for common mental disorders in general practice.[comment]. Med J Australia 2001; 175(Suppl): S10–17.
30 Kish L. Survey sampling. New York: Wiley; 1965.
31 Hickie IB, Davenport TA, Naismith SL, Scott EM. Conclusions about the assessment and management of common mental disorders in Australian general practice. SPHERE National Secretariat. Med J Australia 2001; 175(Suppl): S52–55.
32 The Mental Health General Practice Investigation (MaGPI) Research Group. General practitioner recognition of mental illness in the absence of a ‘gold standard’. Australian & N Z J Psych 2004; 38: 789–794.
33 Hollinghurst L, Kessler D, Peters TJ, Gunnell D. Opportunity cost of antidepressant prescribing in England: analysis of routine data. BMJ 2005; 330: 999–1000.
34 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel S. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Pub Health Med 2001; 23: 262–267.
35 Dew K, Dowell AC, McLeod DM, Collings S, Bushnell JA. ‘This glorious twilight zone of uncertainty’ mental health consultations in general practice in New Zealand. Soc Sci Med 2005; 61: 1189–1200.[CrossRef][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  C. Dowrick, G. M Leydon, A. McBride, A. Howe, H. Burgess, P. Clarke, S. Maisey, and T. Kendrick Patients' and doctors' views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study BMJ, March 19, 2009; 338(mar19_1): b663 - b663. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. E Newman, S. C Kippax, L. Mao, G. D Rogers, D. C Saltman, and M. R Kidd Features of the management of depression in gay men and men with HIV from the perspective of Australian GPs Fam. Pract., February 1, 2009; 26(1): 27 - 33. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||