General practice in Ireland: are we equipped to manage mental health?

Abstract

General practice plays a key role in the detection, assessment and treatment of mental health problems in Ireland. A recent report indicated that 25% of patients attending their general practitioner (GP) had a mental health problem and over 95% of these problems were dealt with in primary care.1 Additionally, urban Ireland has been found to have the highest prevalence of depressive disorder in Europe.2 The World Health Organisation is predicting that by 2020 depression will constitute the second most burdensome health problem after coronary heart disease.3 However, there has been insufficient research in Ireland to look at how primary care is coping with this growing problem. Research in other countries has consistently shown that general practice is not adequately equipped to deal with the burden of mental health problems. In particular, it is estimated that half of the patients presenting with depressive symptoms are missed on their first consultation.4;5 Of those, some will spontaneously improve and others will be detected later, but even at three-year follow up 18% remained undetected.6 Even in those detected, management in general practice may be inadequate with subsequent poor outcomes.7 GPs have, in the past, been shown to prescribe inadequate doses of antidepressants and, more recently, been advised to prescribe fewer antidepressants in mild depression.8 It is not surprising that GPs may be feeling bruised over criticism of their management of mental health problems. The question then arises as to how this situation can be improved. The research evidence is not encouraging. The routine administration and feedback of simple questionnaires measuring depression or quality of life has no impact on the recognition, management, or outcome of depression in nonspecialist settings. Detection rates of depression can be increased when a practice nurse or administrative assistant deliver and score a questionnaire and feed back positive results. However, there is no evidence that this actually influences clinical practice or clinical outcome.9 Simple educational strategies to improve the recognition and management of depression by general practitioners, when given alone, have minimal impact on clinical practice and the outcome of depression.9 Psychiatric placements for GP trainees may also fail to meet the needs of GPs.10 The lengthy psychiatric interviews used in hospitals do not translate easily into ten-minute GP appointments. In addition and probably most importantly, the types of mental health problems seen in hospital psychiatry are largely different from those seen in the community. Ireland has particular issues that contribute towards the deficiencies in the management of mental health problems in general practice. There is a clear lack of mental health capacity in the community. Many GPs do not have the knowledge or skills to deal with the common primary care mental health problems. In combination with the lack of a ‘primary care team’ with easy access to primary care based counseling, psychology, social work, psychotherapy and cognitive behavioural therapy, this has contributed towards a medicalisation of mental health problems. There is also inequitable access to counseling and psychological therapies, with GMS patients needing referral to psychiatry for these services. The subsequent stigmatization of patients with a mental health problem in being referred to psychiatry discourages further referrals. The discrepancies between hospital-based psychiatry and general practice mental health problems have led to attitudinal problems in the way GPs and psychiatrists view each other and consequently hindered shared learning and working practices. Poor communication about patients between psychiatric services and general practice and the difficulty experienced by GPs in referring patients due to sectorisation of psychiatric services have further contributed to a service that does not provide optimal care for the patient. There is further evidence that simple information is not readily accessible to GPs concerning mental health services such as voluntary agencies and self help groups. In spite of all this, primary care is ideally situated for the prevention, detection and management of the majority of mental health problems. It is clear that the improvement of the management of mental health problems in general practice is similar to other chronic disease management and is complex. Provision of education and guidelines for GPs is necessary, but not enough. Practices must adopt active management strategies that continue contact with patients by monitoring treatment and patient status. Thus, responding promptly to patient concerns and need for treatment modification. There is a variety of strategies, ranging from quality improvement and case management to collaborative care and other complex models that improve patient outcomes. Integrated quality improvement programmes involving combinations of clinician and patient education, nurse case management, enhanced support from specialist psychiatric services, and monitoring of drug concordance have been shown to be clinically and cost effective in the shorter term, but this effect disappears in longer term follow-up. Simple telephone support, counseling, and medication monitoring