The European Journal of Psychiatry

GP mental health care in 10 European countries: patients' demands and GPs' responses

Background: There is a large variation between different countries regarding the presentation of psychological symptoms, their diagnosis and treatment in general practice. A possible explanation for such variation might be the conditions of the health care system in different countries. A gate-keeping function might be facilitating the recognition and treatment of mental disorder. Furthermore, the payment system and insurance system are considered of importance. Method: To test these hypotheses, data were collected in 10 European countries with different health care systems. 25 - 43 GPs in each country collected data on 20 consecutive doctor-patient contacts, including videotaped consultations, patient and GP questionnaires per contact and a general GP questionnaire. Results: There are differences, not related to health care system characteristics, between countries concerning the prevalence of mental distress among patients visiting their GP. Only a minority of distressed patients presented psychological symptoms. Although GPs did not limit their psychological diagnoses to patients presenting with psychological symptoms, they also diagnosed only a minority of distressed patients with a psychological diagnosis. In general, psychological presentation and diagnosis in gate-keeping countries and in Switzerland (where GPs were remunerated for psychological diagnosis and treatment) was more frequent than in other countries. Especially in Eastern European countries Estonia, Poland and Rumania the presentation of psychological symptoms by distressed patients was very uncommon. Psychological treatment was not related to gate-keeping. In case of Switzerland, remuneration seemed an effective incentive. Conclusion: Overall prevalence of mental distress cannot be explained by gate-keeping function of the GP, payment system, remuneration system or differences between Eastern and Western Europe. However, a gate-keeping system appears to lower the threshold for help seeking and diagnosis. Gate-keeping has no clear impact on treatment of mental disorder in general practice. In this case, remuneration is observed to be effective.

Improving the quality of mental health care in primary care settings: a view from the United Kingdom

Background and objectives: In the forty years since 'general practice' became a focus for research in psychiatry the UK there have been considerable developments in policy, practice and research. The aim of this paper is to review recent research and policy developments concerned with improving quality of mental health in primary care settings. Methods: Narrative review of the literature. Results: Disappointing results from large scales trials in the last decade have led to a move towards more exploratory studies and attempts to understand more about contextual factors. Policy initiatives such as the NICE (National Institute of Health and Clinical Excellence) guidelines have set clear standards for the delivery of care, but considerable variation in quality of care persists in primary care settings. The Medical Research Council of the UK has suggested a sequential model for future randomised trials of complex interventions. Conclusion: Major outstanding challenges are the difficulties in recruiting GPs (General Practitioners) into research studies who are not particularly interested in mental health and linking research and policy such that the findings of such studies are effectively implemented in everyday practice.

Improving the Classification of Medically Unexplained Symptoms in Primary Care

Background: Many patients in primary care complain of physical symptoms not attributable to any known conventionally defined disease, i.e. medically unexplained symptoms (MUS). Objectives: This paper aims to present the problems with our current classification of MUS in general practice and propose new criteria for the classification of Medically Unexplained Symptoms in a future edition of the International Classification of Primary Care (ICPC). Methods: Discussion of European classification systems in relation to current evidence about MUS in primary care. Results: At present, clinical care and research are hampered by the lack of a valid and reliable diagnostic classification of MUS. A particular problem in primary care is that the diagnostic category of somatoform disorders only includes persistent cases and therefore offers no opportunity for the classification of many patients with MUS in general practice. We propose new diagnostic criteria for MUS that can easily be integrated in a future edition of the ICPC. The criteria introduce mild to moderate MUS into the chapter of general and unspecified health problems if the patient has at least three MUS during an episode of care, whereas severe conditions are kept in the psychological chapter under the diagnoses applied until now. Conclusion: A diagnosis and classification of MUS is essential for the prediction of prognosis and the choice of appropriate care for these patients in general practice. It remains to be evaluated in epidemiologic research whether the proposed classification criteria fulfil this purpose.

Improving long-term outcome of depression in primary care: a review of RCTs with psychological and supportive interventions

Background and objectives: Depression is often a recurrent or persistent disorder. Since the majority of depressed patients are treated in primary care, it is clear that to improve long-term outcomes more effective treatments in this setting are needed. The goal of this study was to review the strategies used for improvement of routine treatment in terms of their effects on patient outcome. Methods: We conducted a systematic literature search to identify improvement strategies tested in randomized controlled trials in primary care, reporting at least six months effects on depression course and outcome. Results: Four strategies were identified: (1) training primary care physicians (PCPs) - this appears ineffective (2) supporting PCPs by other professionals - this produces better short term outcomes but does not prevent recurrence (3) organisational quality improvement - this shows improved outcomes at 6 months, and there is some evidence of longer term effectiveness; and (4) recurrence - and chronicity prevention strategies - these have not been shown to be effective. Conclusion: Since effects of the reviewed strategies generally do not seem to persist over time and no clear superiority over usual care has been demonstrated, we conclude that for improving long-term outcome of depression in primary care new directions or even a novel paradigm is needed.

Do mail-shots improve access to primary care for young men with depression?

Background: Young men with mental health problems often do not present to traditional primary care services. Novel methods to engage this population need to be explored. Between April and July 2005, Croydon Primary Care Trust developed a depression service for men aged 18 to 35 years. Part of this service was a mail-shot to all men in this age group registered with two general practices. The mail-shot informed them of the symptoms of depression, the importance of seeking help and where to obtain help. The objective of this research was to determine whether this mail-shot influenced the number of young men presenting to primary care with depression. Method: This was a before and after study. The quarterly incidences of depression in men aged 18 to 35 years was calculated from January 2000 to June 2005. Incidence risk ratios were calculated to compare pre-mail-shot incidence with the post mail-shot incidence. The cost of the mail-shot was calculated. Results: There were 148 new cases of depression diagnosed between January 2000 and June 2005 across the practices. There was a statistically significant increase in depressed young men contacting the two participating general practices in the quarter after the mail-shot compared with previous quarters (IRR 2.57; 95% CI 1.59-4.17; p < 0.001). The cost of the mail-shot was £1.00 per registered man aged between 18 and 35 years, or £297 (450 ) per case of depression detected. Conclusion: Mail-shots may be a cost-effective way to encourage this traditionally 'hard-to-reach' group to consult primary care professionals for depression treatment.

Mental Health Problems in Primary Care: Progress in North America

Background and Objectives: Research in the last decade has acknowledged that primary care plays a pivotal role in the delivery of mental health services. The aim of this paper is to review major accomplishments, emerging trends, and continuing gaps concerning mental health problems in primary care in North America. Methods: Literature from North America was reviewed and synthesized. Results: Major accomplishments include: the development and adoption of a number of clinical guidelines specifically for mental health conditions in primary care, the acceptance of the chronic care model as a framework for treating depression in primary care, and the clear adoption of pharmacologic approaches as the predominant mode for treating depression and anxiety. Emerging trends include: the use of non-physician facilitators as care managers in the treatment of depression in primary care, increasing use of technology in the assessment and treatment of mental health conditions in primary care, and dissemination and implementation of integrated mental health treatment approaches. Lingering issues include: the difficulty in moving beyond problem identification and initiation of treatment to sustaining evidence-based treatments, agreement on a common metric to evaluate outcomes, and the stigma still associated with mental illness. Conclusion: Though there now exists a solid and growing evidence base for the delivery of mental health services in primary care, there are still significant challenges which must be overcome in order to make further advances.

General practitioners are bearing an increasing burden of the care of common mental disorders in France

Introduction: In France, general practice is playing an increasing role in the management of common mental disorders. This is due to a variety of factors, among which the way general practice and specialised mental health services have evolved over time. Methods: A description of the status quo in France, with a comparison between France, the UK and the Netherlands. A review of reasons for the present position. Results: The general practitioner (GP) is often the only medical carer to be contacted in cases of psychological distress and over 80% of psychotropic medications are prescribed in this setting. Although most common forms of mental disorder can be managed at the primary care level, GPs need to be able to refer patients rapidly to specialised mental health services. Yet there are delays for consultations with both private and public psychiatrists along with difficulties in finding beds for full-time hospitalisation. The situation is predicted to get worse with the reduction in the number of psychiatrists and GPs forecasted for the coming years. 'Psychiatric sectorisation' has led to a substantial development of community mental health care services, yet this has not compensated fully for the reduction in full-time hospital beds. Furthermore, community mental health care services remain relatively isolated from other community health services with very limited exchanges with general practice. Conclusion: GPs report an urgent need for training in mental health. Along with improving their ability to accurately detect and treat mental disorders, it is crucial also to improve communication between GPs and psychiatrists and increase shared case-management. Structural changes are also necessary to ensure a quicker and easier access to specialised mental health care services.

Somatic and psychiatric co-morbidity in Primary Care patients in Spain

Background: There is limited information on the subject of co-morbidity of general medical conditions (GMCs) and general psychiatric disturbance in primary care (PC). Methods: A representative sample (n = 1559) of adult PC patients was examined in a two-phase screening. Standardized screening instruments were used, including the Standardized Polyvalent Psychiatric Interview (SPPI). ICD-10 research criteria were used for psychiatric diagnosis, and ICPC-2 for medical diagnosis. Results: Most co-morbidity cases had depressive (120 cases, 28.1%) or anxiety/neurotic disorders (217 cases, 50.9%). In support of the working hypothesis, the proportion of patients with several medical diagnoses was significantly higher among the cases, and logistic regression showed that the probability of being a psychiatric case increased with each medical diagnosis done by the primary care physician (OR = 2.46; IC 1.66-3.66, p < 0.001). Moderate/severe cases were significantly more frequent among the depressed group (91 cases, 75.9%), but were also common in the anxiety/neurosis group (52 cases, 24%), the between groups differences in disability being non-significant. The distribution of both affective and neurotic disorders by specific ICPC-2 categories suggests preferential associations. Conclusion: In PC, the probability of having a co-morbid psychiatric diagnosis doubles with each medical diagnosis. Anxiety/neurotic disorders, and not only depressive disorders, are relevant co-morbid psychiatric categories in this setting.

Models of collaboration between general practice and mental health services in Italy

Background and objectives: Anxiety and Depressive disorders represent an important public health problem, which involves not only the mental health services, but the General Practice as well. This paper examines models of Collaboration between General Practice and Community Mental Health Services developed in Italy. Methods: Different Consultation -Liaison activities are presented. For every Collaboration model advantages and disadvantage are discussed. Results: The structured Consultation Liaison Service is based on supplying diagnostic consultation and therapeutic interventions in support of General Practitioners (GPs). The service could be based in either a Community Mental Health Centre (CMHC) or externally. Diagnostic evaluation can be followed by brief and focal therapeutic interventions, in support of the GP's therapeutic plan. The spontaneous collaboration in small centres are frequent in rural areas where the contained dimensions of the services and the direct acquaintance between psychiatrists and GPs encourage the personalization of the collaboration. The model of Liaison and Group-Training focuses on direct contact between consultant and GPs. In the course of regular meetings, the consultant gives the GPs supervision and education, and they can discuss the therapeutic plans for patients requiring specialist intervention. Conclusion: The empiric classification presented should be considered an attempt to represent a complex reality. Every service, in fact, carries out activities that are necessarily wider than abstract typologies and that overlap with other models' activities.