Management Of Mental Health Problems Research Articles

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

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

How do GP registrars feel about dealing with mental health issues in the primary care setting? A qualitative investigation

The treatment of mental health problems is now a national priority in the UK. With a prevalence rate of 23% in the general population and 75% of the population visiting a GP each year, the role of primary care in the detection, management and treatment of mental health problems is pivotal. However, around 20% of mental health problems remain unidentified by GPs. Many reasons may contribute to this. One reason is cited as being the training received by GPs, although research into this has yielded inconclusive results. This study aimed to investigate qualitatively the attitudes of GP registrars, firstly towards dealing with mental health problems in primary care and secondly in relation to the training and support received. Sixteen semistructured interviews were conducted and analysed thematically. Results indicated that GP registrars in this study understood the psychosocial nature of mental health problems and felt confident in detecting these issues in their patients. However, they were less secure about the management of mental health problems due to a number of constraints such as inadequate time, lack of knowledge of referral pathways and local resources, and a limited understanding of the psychology of mental health problems. They appreciated the support provided by their trainers, the training practices and the vocational training scheme (VTS). They would benefit from additional input concerning assessment and management of psychological problems, and discussions around their new role as a GP, acknowledging its potentials and limitations.

Factors predictive of successful learning in postgraduate medical education.

To establish which personal and contextual factors are predictive of successful outcomes in postgraduate medical education. We performed a follow-up study of 118 doctors on a postgraduate occupational health training programme on the management of mental health problems. The following personal and contextual variables were measured as potential predictors of outcome: gender; age; years of experience as a doctor; university of graduation; learning style (Kolb); present employer (occupational health service), and educational format (problem-based or lecture-based). The main outcome measures were: scores on knowledge tests consisting of true/false and open answer questions, and performance in practice based on self-report and performance indicators. To determine the effect of potential predictive factors univariate analyses of variance and repeated measurement analysis of variance was applied. The mean scores of knowledge (P < 0.001) and performance (P = 0.001) of the participants increased after the educational programme. After multivariate analysis female gender was positively related to accruements in both knowledge and performance (both P < 0.05), independently of the influence of other factors. Accommodator learning style showed a relation with knowledge increase (P = 0.05), but had no influence on performance (P = 0.79). The problem-based educational format yielded a better performance outcome (P = 0.05), but had no influence on knowledge tests (P = 0.31). Gender and learning style were found to be related to an increase in knowledge. Gender was also found to be related to improvement in performance after a postgraduate medical education programme. We found no interactions with course design (i.e. problem-based or non problem-based learning formats), but further research could reveal other cues, suggesting practical consequences of student characteristics for course design in postgraduate training.

Child health in complex emergencies

Coordinated and effective interventions are critical for relief efforts to be successful in addressing the health needs of children in situations of armed conflict, population displacement, and/or food insecurity. We reviewed published literature and surveyed international relief organizations engaged in child health activities in complex emergencies. Our aim was to identify research needs and improve guidelines for the care of children. Much of the literature details the burden of disease and the causes of morbidity and mortality; few interventional studies have been published. Surveys of international relief organizations showed that most use World Health Organization (WHO), United Nations Children's Fund (UNICEF), and ministry of health guidelines designed for use in stable situations. Organizations were least likely to have formal guidelines on the management of asphyxia, prematurity, and infection in neonates; diagnosis and management of children with human immunodeficiency virus (HIV) infection; active case-finding and treatment of tuberculosis; paediatric trauma; and the diagnosis and management of mental-health problems in children. Guidelines often are not adapted to the different types of health-care workers who provide care in complex emergencies. Evidence-based, locally adapted guidelines for the care of children in complex emergencies should be adopted by ministries of health, supported by WHO and UNICEF, and disseminated to international relief organizations to ensure appropriate, effective, and uniform care.

Barriers to managing mental health in Western Australia.

To explore the views of community-care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Qualitative content analysis of semi-structured interviews. Community and mental health services in Esperance. One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n = 38). The views of community-care and mental health workers on barriers to the management of mental health, and how these could be addressed. Barriers included confusion about the role of mental health services, limited after-hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi-agency shared care with clinical streams for adults, those aged > 65 and children. This study revealed a number of barriers that are being addressed through a memorandum of understanding between services. Initiatives to foster collaboration between rural mental health services and general practitioners have not included other providers of primary care. We wished to explore the views of community-care and mental health workers on barriers to the management of mental health problems in rural Western Australia and how these could be addressed. We identified a number of barriers to collaboration between mental health and community-based services, including poor communication, difficulties with referral and cultural differences between services. Of all these themes, the most significant was the lack of communication at individual, case management and organisational levels.

Mental health in older adult recipients of primary care services: is depression the key issue? Identification, treatment and the general practitioner.

Mental health services for older people in primary care are relatively underdeveloped. This study has sought to determine the nature and extent of mental health problems in older people presenting to primary care and to compare this with the detection and management of mental health problems by the primary health care team (PHCT). Participants were patients aged 65 years and above attending a representative inner city general practice. Screening tools included the General Health Questionnaire (GHQ-28), Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE). The PHCT used a brief checklist to rate participants for the presence of mental health problems. Follow-up interviews using the Geriatric Mental State (GMSA), Cambridge Examination for Mental Disorders in the Elderly (CAMDEX)-cognitive subscale (CAMCOG), National Adult Reading Test (NART), were carried out. A high level of psychological morbidity was identified at screening (48.1%). There was a considerable degree of agreement between the HADS and GMSA, and the MMSE and GMSA at follow-up. Agreement rates between the PHCT and initial screening tools were low suggesting under-recognition of mental health problems at primary care level by the PHCT. Contributory factors included: short consultation times with a concentration on physical symptoms; few patients presenting explicitly with mental health problems; few decisions to treat or refer patients; and the general practitioners tended to monitor, or defer decisions. This study found lower levels of severe mental health problems, especially depression, than reported elsewhere, but higher prevalence of psychological distress. High levels of physical and mental health co-morbidity were found. These findings suggest that planning for primary care services needs to adopt a flexible assessment model. The development of effective, time-limited protocols and screening tools to assist the PHCT in improving their identification rates is recommended. This needs to be supported by the availability of appropriate treatments for the psychological distress.

Are we meeting the psychological needs of Black African HIV-positive individuals in London? Controlled study of referrals to a psychological medicine unit

The changing pattern of HIV infection in the UK includes an increase in the number of infections acquired as a result of heterosexual contact and Black African individuals represent a sizeable proportion of those affected. In most UK centres for the treatment of HIV infection, clinicians have limited experience in caring for Black African patients, and there is a dearth of information about the recognition and management of mental health problems in this patient group. In this investigation the proportion of Black African individuals looked after in a large centre for the care of HIV infection in London was compared with the proportion of such patients referred for specialist mental health help, the results revealing that Black Africans were almost three times less likely to be referred for specialist mental health care. A case control investigation of those referred to mental health services showed that Black Africans were more likely to be suffering from AIDS at the time of referral, be referred for assessment of possible organic brain disease, and more likely to be found to be suffering from major depression or organic brain disease. Reasons for the lesser likelihood of referral to the mental health service are considered, including the possible failure of staff to recognize psychological morbidity in Black Africans, or reluctance and fear on the part of patients to be referred to services that may be perceived as threatening.

Diagnosing Depression in Primary Care: Lessons from Developing Guidelines

One of my tasks on starting my part-time post at East Surrey Health Authority in spring 1999 was to develop guidelines for the management of depression in primary care. As a GP, I was aware of how common depressive symptoms were in the people that consulted me and there seemed to be a great deal of evidence that GPs could improve their practice by detecting more psychological disorders. Depression in primary care was considered to be an area ‘where current practice diverges from best practice providing significant gains in health’ (NHS Centre for Reviews and Dissemination, 1994). It was thought that the development of guidelines for the better management of mental health problems would benefit GPs and also fit in well with the Government’s modernisation agenda for mental health services (Department of Health, 1998). The guidelines were launched nearly 10 months later, in January 2000, to almost universally negative feedback from GPs who, contrary to our expectations, did not find them helpful in their day-to-day work. In retrospect it was noted that there had been very little participation by GPs during the development of the guidelines, and that there was not much evidence that PCGs were enthusiastic to develop mental health in primary care. Despite our best intentions we seemed to have hit a brick wall. So, what went wrong? Did we develop inappropriate guidelines? Were guidelines not the right tool to achieve change? Was it that GPs disagreed about our assumptions about depression in primary care and how it should best be managed?

Mental Health Promotion ‐ Re‐thinking the Evidence Base

The case for investing in mental health promotion is often debated in terms of whether it can or cannot contribute effectively to the prevention of mental illness. As it happens, it can; however, as Phil Barker points out, curing illness does not necessarily result in health (Barker, 2000). Indeed, the user/survivor movement shares with the disability rights movement ethical concerns about an agenda dominated by the struggle to eliminate all disorders of the mind. Organisations like the Manic Depression Fellowship, which has pioneered a self-management T approach to bi-polar disorder, and the Mental Health Foundation’s Strategies for Living initiative (Mental Health Foundation, 2000), demonstrate the extent of interest in alternative approaches, not only to the management of mental health problems, but to the way in which mental health (and mental illness) is conceptualised. The call for ‘mad pride’ is part of a growing self-confidence within the user/survivor movement, and a demand for acceptance which includes a recognition of the positive aspects of mental health problems (Curtis et al, 2000). This relationship between identity and diagnosis has been forged through the experience of discrimination and the conditions under which people with mental health problems have used mental health services. It is no coincidence that service users have been among the most vocal supporters of standard one, not only because of its explicit commitment to challenging discrimination, but because of the opportunity it offers to transform the terms of the debate about mental health. The requirement to ‘promote mental health for all’ (Department of Health, 1999) will mean talking openly about the mental health needs of the whole community and will help to dispel notions of ‘them and us’. Such a transition challenges the myth that people can be neatly divided into those who do and those who do not have mental health problems. It provides a framework for addressing how, as a society, our mental health needs are met, or not met: in our families, our schools, on the streets, at work – where we feel safe, involved, respected and valued, or in fear, marginalised and excluded. Addressing the public health potential of mental health promotion might help us to move beyond the current impasse, where we appear to be trapped in a discourse of cure, while all around us we are witnessing the erosion of, or disregard for, those features of society which promote

Psychosocial and health belief variables associated with frequent attendance in primary care.

The reasons for high use of primary care, and in particular the role of psychosocial factors, remain unclear. We identified and interviewed 236 frequent attenders and 420 normal users, matched by age and sex, of a public Health Centre in Granada, Spain. Users were questioned about mental health (GHQ-28), social support (Duke-UNC-11), family dysfunction (family APGAR) and health beliefs (health belief model, locus of health control and medical care expectations). We also measured a set of individual, social and illness variables. Multiple logistic regression analyses showed that mental health was the main factor associated with frequent attender status (odds ratio = 3.1; 2.4-3.9). The association was stronger than that between frequent attender status and perceived illness, and between the former and reported chronic illness. Family dysfunction and perceived susceptibility to and severity of disease were also significantly but more weakly associated with frequent attender status. Affective support was more strongly associated with FA status than was confidant support, but both associations disappeared when mental health and family function were controlled for. Our findings document the association of psychosocial factors and primary health care use. We suggest that the effective management of mental health problems from a family-based approach may reduce primary health care high use.

Improving research on primary care patients with mental health problems: observations from an investigator

BACKGROUND AND AIMS OF THE MANUSCRIPT: The purpose of this manuscript is to define under-recognized perspectives that the primary care research field needs to integrate into research initiatives, and to discuss practical strategies to ensure the successful implementation of these initiatives. METHODS: Perspectives and strategies were identified through personal experience, informal discussion with ten senior investigators in the field and a selected literature review. RESULTS: Research on improving treatment for the mental health problems of primary care patients will progress more rapidly if investigators explore the usefulness of a competing demands framework, integrate a readiness to change perspective in developing more individualized interventions for providers and patients, evaluate interventions for their effect on productivity and test alternative interventions particularly in patients who fail to benefit from currently accepted treatment. The implementation of these initiatives will be more successful if research teams define unique scientific agendas, invest energy in pursuing questions whose value is undisputed by multiple parties, increase the rate of inter-institutional exchange between senior and junior investigators, pilot test assumptions that affect project budget and timeline, build in a limited amount of slack time in early phases of project implementation and network effectively. IMPLICATIONS FOR FURTHER RESEARCH: Investigator efforts to define critical questions for the primary care management of mental health problems will be enhanced if they revisit the definition of their research agendas in the light of new perspectives that are emerging in the field. Similarly, the implementation of these agendas will be strengthened if investigators make conscious attempts to use one or more of the strategies suggested.

Improving research on primary care patients with mental health problems: observations from an investigator.

BACKGROUND AND AIMS OF THE MANUSCRIPT: The purpose of this manuscript is to define under-recognized perspectives that the primary care research field needs to integrate into research initiatives, and to discuss practical strategies to ensure the successful implementation of these initiatives. METHODS: Perspectives and strategies were identified through personal experience, informal discussion with ten senior investigators in the field and a selected literature review. RESULTS: Research on improving treatment for the mental health problems of primary care patients will progress more rapidly if investigators explore the usefulness of a competing demands framework, integrate a readiness to change perspective in developing more individualized interventions for providers and patients, evaluate interventions for their effect on productivity and test alternative interventions particularly in patients who fail to benefit from currently accepted treatment. The implementation of these initiatives will be more successful if research teams define unique scientific agendas, invest energy in pursuing questions whose value is undisputed by multiple parties, increase the rate of inter-institutional exchange between senior and junior investigators, pilot test assumptions that affect project budget and timeline, build in a limited amount of slack time in early phases of project implementation and network effectively. IMPLICATIONS FOR FURTHER RESEARCH: Investigator efforts to define critical questions for the primary care management of mental health problems will be enhanced if they revisit the definition of their research agendas in the light of new perspectives that are emerging in the field. Similarly, the implementation of these agendas will be strengthened if investigators make conscious attempts to use one or more of the strategies suggested.

Mental health practices of Ontario family physicians: a study using qualitative methodology.

To obtain descriptions of how family physicians detect and manage mental health problems commonly encountered in their practices and how they function in their role as mental health care providers. Also, to elicit their perceptions of barriers to the delivery of optimal mental health care. Focus groups with standardized questions were used to elicit descriptive data, opinions, attitudes, and terminology. Convenience samples of 10 to 12 physicians were chosen in each of Ontario's 7 health care planning regions, with a mixture of rural, urban, and university settings. Discussions were audiotaped, transcribed, analyzed, and recurring themes were extracted. Family physicians' descriptions of the range of problems commonly encountered and their detection and management highlight the unique nature of mental health care in the primary care setting. The realities of family medicine, the undifferentiated nature of presenting problems, the long-term physician-patient relationship, and the frequent overlap of physical and mental health problems dictate an approach to diagnosis and treatment that differs from mental health care delivery in other settings. Difficulties in the relationship with local psychiatric services--accessing psychiatric care (especially for emergencies), poor communication with mental health care providers, and cumbersome intake procedures of many mental health services--were consistently identified as barriers to the delivery of optimal mental health care. This study confirms the importance of the family physician in the detection and management of mental health problems. It offers insights into how family physicians function in their role as mental health care providers and how they deal with diagnostic and management challenges that are specific to primary care. It also identifies barriers to the optimal delivery of mental health care in the primary care setting, including difficulties at the clinical interface between psychiatry and family medicine. Further studies are needed to explore these issues in greater depth.

Clinical Management of Suicidal Behaviour in Children and Adolescents

Youth suicide has been recognized as a significant public health issue in Australia and internationally. Epidemiological evidence provides the imperative that strategies to deal with suicidal behaviour must be placed clearly in the context of appropriate assessment and management of mental health problems. Clinical management of suicidal children and young people is difficult. Staff reactions to young people who have attempted suicide may interfere with appropriate care. Those involved in dealing with these issues are encouraged to share their load with colleagues and to complement their clinical work with involvement in public health strategies.

The overuse of criminal justice dispositions: Failure of diversionary policies in the management of mental health problems

The overuse of criminal justice dispositions: Failure of diversionary policies in the management of mental health problems

On consultation

Consultation is a term that can have many different meanings. In this paper, it is used in the sense that Caplan (1964) defines as mental health consultation, to describe the interaction between a consultee and consultant who meet to facilitate some area of mental health work in which the consultee is involved. By working with workers instead of directly with clients, the consultant aims to offer a service to a greater number of people than would otherwise be possible and to have a preventive role with earlier detection and management of mental health problems.

Detection and management of mental health problems of older patients by primary care providers

Detection and management of mental health problems of older patients by primary care providers

Detection and Management of Mental Health Problems of Older Patients by Primary Care Providers

Evidence is accruing that older individuals receive little attention for mental health problems and that any attention that is given is most often within the primary care setting. A randomized clinical trial was carried out at a primary care clinic of The Johns Hopkins University, Baltimore, testing the ability of feedback of the results of a screening instrument (the General Health Questionnaire) to increase awareness in clinicians of the emotional and psychological problems of their patients. This report contrasts those aged 65 years and older with younger patients. Detection and management of mental morbidity were lower for older individuals, but the feedback intervention increased the likelihood of attention to these problems. This was not true for younger patients. Detection was significantly higher for older patients when screening data were made available, as was management, although the latter difference was not statistically significant. There was evidence as well that the intervention moved clinicians to greater congruence with their older patients in the perception that current mental health problems existed. These findings have important implications for primary care.

An algorithmic method for management of mental health problems in developing countries.

A new problem-oriented cross-cultural method has been developed to identify the appropriate management of mental health problems in primary-care settings. It is designed to be used by multipurpose health workers in out-patient clinics in many developing countries. Presenting mental health problems in many cultural settings can be placed into one or more of eight behaviourally determined categories. After this initial categorization an algorithmic process is used to determine the sequence of observations which must be made in order to identify the appropriate management. The system allows for variations in available resources and local constraints. We outline the design principles of this algorithmic method and the rules for using it, and describe a training programme developed to teach people to adapt it and use it effectively. The evaluation studies that have been done in different developing countries confirm that the method is acceptable and efficient, and gives management decisions with a high degree of repeatability.