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What Impedes General Practitioners' Identification of Mental Disorders at Outpatient Departments? A Qualitative Study in Shanghai, China.

ABSTRACT: Background:Mental disorders endanger people's health and lives. General practitioners (GPs) play a valuable role in identifying and treating mental disorders in outpatient clinical settings. However, there are obstacles for GPs' identification in developing countries. Objective:This study's aim was to identify the related obstacles and to propose optimized strategies. Methods:We conducted qualitative interviews with 26 GPs from seven randomly sampled community healthcare centers in Shanghai, China. The interview guide was based primarily on the items from mental status evaluation. After transcribing, coding, condensing, and categorizing talking content, we summarized the theme structure and results. Findings:GPs lacked the confidence and skills to conduct psychiatric evaluation and seldom conducted it. Patients' behaviors also influenced whether evaluations were conducted. The GPs expressed that they were short of strategies and wished to be well trained and have sufficient practice. We found that two major reasons impeded GPs' identification. First, the GPs had difficulty making a diagnosis: they lacked diagnostic ability and confidence, they had misunderstandings about diagnoses, and they had unclear qualifications for making psychiatric diagnoses. Second, the GPs lacked skills for evaluation and reevaluation: their evaluation had inadequacies of contents and subjects; they lacked mental state examination evaluation, communication, and severity assessment skills and knowledge. Conclusions:This study found that it is difficult for GPs in developing countries to become competent in the diagnosis and systematic evaluation of mental disorders without external help. Unclear qualification also limited GPs' diagnoses of mental disorders. We proposed that optimized strategies to overcome these challenges lie in support of changes in policy, programs, and utilizing effective tools, such as the mhGAP, GMHAT/PC, BVC, Grille's assessment tool, and telemedicine.

SUBMITTER: Zhang H

PROVIDER: S-EPMC6857524 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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What Impedes General Practitioners' Identification of Mental Disorders at Outpatient Departments? A Qualitative Study in Shanghai, China.

Zhang Hanzhi H Yu Dehua D Wang Zhaoxin Z Shi Jianwei J Qian Jie J

Annals of global health 20191111 1

<h4>Background</h4>Mental disorders endanger people's health and lives. General practitioners (GPs) play a valuable role in identifying and treating mental disorders in outpatient clinical settings. However, there are obstacles for GPs' identification in developing countries.<h4>Objective</h4>This study's aim was to identify the related obstacles and to propose optimized strategies.<h4>Methods</h4>We conducted qualitative interviews with 26 GPs from seven randomly sampled community healthcare ce ...[more]

PMID: 31799127

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Project description:BackgroundEmergency Department attendance is increasing internationally, of which a significant proportion could be managed in general practice. In England, policies backed by substantial capital funding require such patients attending Emergency Departments be directed or 'streamed' to General Practitioners working in or parallel to Emergency Departments. However, evidence for streaming is limited and the processes of streaming patients attending Emergency Departments to General Practitioners lacks exploration.ObjectivesThis paper explores streaming to General Practitioners in and alongside Emergency Departments at ten sites across England. It highlights positive streaming practice, as well as issues that may contribute to poor streaming practice, in order to inform future service improvement.MethodsA longitudinal qualitative study was conducted with data collected between October 2017 and December 2019 across 10 case study sites throughout England as part of a broader mixed methods study. 186 non-participant observations and 226 semi-structured interviews with 191 health professionals working in Emergency Departments or related General Practitioner Services were thematically analysed in relation to streaming processes and experiences.ResultsSix interconnected themes influencing streaming were identified: implementing and maintaining structural support; developing and supporting streaming personnel; implementing workable and responsive streaming protocols; negotiating primary/secondary care boundaries; developing and maintaining interprofessional relationships and concerns for patient safety. Streaming was considered central to the success of General Practitioners in/parallel to Emergency Departments. The importance of the skills of streaming nurses in delivering an optimal and safety critical service was highlighted, as was the skillset of General Practitioners and interprofessional relationships between streamers and General Practitioners. There was no distinct streaming model or method associated with good streaming practice to General Practitioners in/alongside Emergency Departments, instead factors for success were identified and key recommendations suggested. 'Inappropriate' streaming was identified as a problem, where patients streamed to General Practitioners in or parallel to Emergency Departments required Emergency Department management, or patients suitable for General Practitioner care were kept in the Emergency Department.ConclusionDespite adopting differing methods, commonalities across case sites in the delivery of good streaming practice were identified, leading to identification of key recommendations which may inform development of streaming services.Study registrationISRCTN51780222. Tweetable abstract: Workplace culture and the skillset of streamers and General Practitioners is crucial to streaming of patients to General Practitioners in Emergency Departments.

Project description:BackgroundPrimary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.MethodsThis study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.ResultsAt least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.ConclusionsTo improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.

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Project description:BACKGROUND:For a decade, experts have suggested integrating mental health care into primary care to help bridge mental health Treatment Gap. General Practitioners (GPs) are the first port-of-call for many patients with mental ill-health. In Indonesia, the WHO mhGAP is being systematically introduced to its network of 10,000 primary care clinics as an add-on mental health training for pairs of GPs and Nurses, since the end of 2015. In one of 34 provinces, there exists an integrated care model: the co-location of clinical psychologists in primary care clinics. This trial evaluates patient outcomes among those provided mental health care by GPs with those treated by clinical psychologists in primary care. METHODS:In this partially-randomised, pragmatic, two-arm cluster non-inferiority trial, 14 primary care clinics were assigned to receive the WHO mhGAP training and 14 clinics with the co-location framework were assigned to the Specialist arm. Participants (patients) were blinded to the existence of the other pathway, and outcome assessors were blinded to group assignment. All adult primary care patients who screened positive for psychiatric morbidity were eligible. GPs offered psychosocial and/or pharmacological interventions and Clinical Psychologists offered psychosocial interventions. The primary outcome was health and social functioning as measured by the HoNOS and secondary outcomes include disability measured by WHODAS 2.0, health-related quality of life measured by EQ-5D-3L, and resource use and costs evaluated from a health services perspective, at six months. RESULTS:153 patients completed the outcome assessment following GP care alongside 141 patients following Clinical Psychologists care. Outcomes of GP care were proven to be statistically not inferior to Clinical Psychologists in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Economic analyses indicate lower costs and better outcomes in the Specialist arm and suggest a 50% probability of WHO mhGAP framework being cost-effective at the Indonesian willingness to pay threshold per QALY. CONCLUSION:General Practitioners supported by nurses in primary care clinics could effectively manage mild to moderate mental health issues commonly found among primary care patients. They provide non-stigmatising mental health care within community context, helping to reduce the mental health Treatment Gap. TRIAL REGISTRATION:ClinicalTrials.gov NCT02700490.

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What Impedes General Practitioners' Identification of Mental Disorders at Outpatient Departments? A Qualitative Study in Shanghai, China.

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What Impedes General Practitioners' Identification of Mental Disorders at Outpatient Departments? A Qualitative Study in Shanghai, China.

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