Referral of patients with depression to mental health care by Dutch general practitioners: an observational study

<p>Abstract</p> <p>Background</p> <p>Depression is a common illness, often treated in primary care. Guidelines provide recommendations for referral to mental health care. Several studies investigated determinants of referral, none investigated guideline criteria as possible determinants.</p> <p>We wanted to evaluate general practitioner's referral of depressed patients to mental health care and to what extent this is in agreement with (Dutch) guideline recommendations.</p> <p>Methods</p> <p>We used data of primary care respondents from the Netherlands Study of Depression and Anxiety with major depressive disorder in the past year (n = 478). We excluded respondents with missing data (n = 134). Referral data was collected from electronic patient files between 1 year before and after baseline and self report at baseline and 1-year follow-up. Logistic regression was used to describe association between guideline referral criteria (e.g. perceived need for psychotherapy, suicide risk, severe/chronic depression, antidepressant therapy failure) and referral.</p> <p>Results</p> <p>A high 58% of depressed patients were referred. Younger patients, those with suicidal tendency, chronic depression or perceived need for psychotherapy were referred more often. Patients who had used ≥2 antidepressants or with chronic depression were more often referred to secondary care. Referred respondents met on average more guideline criteria for referral. However, only 8-11% of variance was explained.</p> <p>Conclusion</p> <p>The majority of depressed patients were referred to mental health care. General practitioners take guideline criteria into account in decision making for referral of depressed patients to mental health care. However, other factors play a part, considering the small percentage of variance explained. Further research is necessary to investigate this.</p

A qualitative study of referral to community mental health teams in the UK: exploring the rhetoric and the reality

<p>Abstract</p> <p>Background</p> <p>Generic community mental health teams (CMHTs) currently deliver specialist mental health care in England. Policy dictates that CMHTs focus on those patients with greatest need but it has proved difficult to establish consistent referral criteria. The aim of this study was to explore the referral process from the perspectives of both the referrers and the CMHTs.</p> <p>Methods</p> <p>Qualitative study nested in a randomised controlled trial. Interviews with general practitioner (GP) referrers, CMHT Consultant Psychiatrists and team leaders. Taping of referral allocation meetings.</p> <p>Results</p> <p>There was a superficial agreement between the referrers and the referred to on the function of the CMHT, but how this was operationalised in practice resulted in a lack of clarity over the referral process, with tensions apparent between the views of the referrers (GPs) and the CMHT team leaders, and between team members. The process of decision-making within the team was inconsistent with little discussion of, or reflection on, the needs of the referred patient.</p> <p>Conclusion</p> <p>CMHTs describe struggling to deal with GPs who are perceived as having variable expertise in managing patients with mental health problems. CMHT rhetoric about defined referral criteria is interpreted flexibly with CMHT managers and Psychiatrists concentrating on their own capacity, roles and responsibilities with limited consideration of the primary care perspective or the needs of the referred patient.</p> <p>Trial Registration number</p> <p>ISRCTN86197914</p

Uptake of health services for common mental disorders by first-generation Turkish and Moroccan migrants in the Netherlands

Abstract Background Migration and ethnic minority status have been associated with higher occurrence of common mental disorders (CMD), while mental health care utilisation by non-Western migrants has been reported to be low compared to the general population in Western host countries. Still, the evidence-base for this is poor. This study evaluates uptake of mental health services for CMD and psychological distress among first-generation non-Western migrants in Amsterdam, the Netherlands. Methods A population-based survey. First generation non-Western migrants and ethnic Dutch respondents (N = 580) participated in structured interviews in their own languages. The interview included the Composite International Diagnostic Interview (CIDI) and the Kessler psychological distress scale (K10). Uptake of services was measured by self-report. Data were analysed using weighting techniques and multivariate logistic regression. Results Of subjects with a CMD during six months preceding the interview, 50.9% reported care for mental problems in that period; 35.0% contacted specialised services. In relation to CMD, ethnic groups were equally likely to access specialised mental health services. In relation to psychological distress, however, Moroccan migrants reported less uptake of primary care services (OR = 0.37; 95% CI = 0.15 to 0.88). Conclusion About half of the ethnic Dutch, Turkish and Moroccan population in Amsterdam with CMD contact mental health services. Since the primary purpose of specialised mental health services is to treat "cases", this study provides strong indications for equal access to specialised care for these ethnic groups. The purpose of primary care services is however to treat psychological distress, so that access appears to be lower among Moroccan migrants

Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care

<p>Abstract</p> <p>Background</p> <p>Medically unexplained physical symptoms (MUPS) are common in general practice (GP), and are even more problematic as they become persistent. The present study examines the relationship between persistent MUPS in general practice on the one hand and quality of life, social conditions, and coping on the other hand. Additionally, it is examined how patients with persistent MUPS evaluate the quality of GP-care.</p> <p>Methods</p> <p>Data were used from a representative survey of morbidity in Dutch general practice, in which data from the electronic medical records were extracted. A random sample of patients participated in an extensive health interview and completed self-reported measures on social isolation, coping and the quality of GP-care. Patients with persistent MUPS (N = 192) were compared with general practice patients not meeting the criteria for persistent MUPS (N = 7.314), and with a group of patients that visited the GP in comparable rates for medical diagnoses (N = 2.265). Multiple logistic regression analyses were used to control for relevant socio-demographic variables and chronic diseases.</p> <p>Results</p> <p>After adjustment for demographics and chronic diseases, patients with persistent MUPS reported more psychological distress, more functional impairment, more social isolation, and they evaluated the quality of GP-care less positive than the other two patient groups. Although the majority of MUPS patients were positive about the quality of GP-care, they more often felt that they were not taken seriously or not involved in treatment decisions, and more often reported that the GP did not take sufficient time. The three groups did not differ with respect to the statement that the GP unnecessarily explains physical problems as psychological ones.</p> <p>Conclusion</p> <p>Strengthening MUPS patients' social network and encouraging social activities may be a meaningful intervention in which the GP may play a stimulating role. To further improve MUPS patients' satisfaction with GP-care, GPs may pay extra attention to taking sufficient time when treating MUPS patients, taking the problems seriously, and involving them in treatment decisions.</p

Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders

BACKGROUND: General Practitioners spend a disproportionate amount of time on frequent attenders. So far, trials on the effect of interventions on frequent attenders have shown negative results. However, these trials were conducted in short-term frequent attenders. It would be more reasonable to target intervention at persistent frequent attenders. Typical characteristics of persistent frequent attenders, as opposed to 1-year frequent attenders and non-frequent attenders, may generate hypotheses regarding modifiable factors on which new randomized trials may be designed. METHODS: We used the data of all 28,860 adult patients from 5 primary healthcare centers. Frequent attenders were patients whose attendance rate ranked in the (age and sex adjusted) top 10 percent during 1 year (1-year frequent attenders) or 3 years (persistent frequent attenders). All other patients on the register over the 3-year period were referred to as non-frequent attenders. The lists of medical problems coded by the GP using the International Classification of Primary Care (ICPC) were used to assess morbidity.First, we determined which proportion of 1-year frequent attenders was still a frequent attender during the next two consecutive years and calculated the GPs' workload for these patients. Second, we compared morbidity and number of prescriptions for non-frequent attenders, 1-year frequent attenders and persistent frequent attenders. RESULTS: Of all 1-year frequent attenders, 15.4% became a persistent frequent attender equal to 1.6% of all patients. The 1-year frequent attenders (3,045; 10.6%) were responsible for 39% of the face-to-face consultations; the 470 patients who would become persistent frequent attenders (1.6%) were responsible for 8% of all consultations in 2003. Persistent frequent attenders presented more social problems, more psychiatric problems and medically unexplained physical symptoms, but also more chronic somatic diseases (especially diabetes). They received more prescriptions for psychotropic medication. CONCLUSION: One out of every seven 1-year-frequent attenders (15.4%) becomes a persistent frequent attender. Compared with non-frequent attenders, and 1-year frequent attenders, persistent frequent attenders consume more health care and are diagnosed not only with more somatic diseases but especially more social problems, psychiatric problems and medically unexplained physical symptoms

Management of patients with persistent medically unexplained symptoms: a descriptive study

Background: In 2013 the Dutch guideline for management of medically unexplained symptoms (MUS) was published. The aim of this study is to assess medical care for patients with persistent MUS as recorded in their electronic medical records, to investigate if this is in line with the national guideline for persistent MUS and whether there are changes in care over time. Methods: We conducted an observational study of adult primary care patients with MUS. Routinely recorded health care data were extracted from electronic medical records of patients participating in an ongoing randomised controlled trial in 30 general practices in the Netherlands. Data on general practitioners’ (GPs’) management strategies during MUS consultations were collected in a 5-year period for each patient prior. Management strategies were categorised according to the options offered in the Dutch guideline. Changes in management over time were analysed. Results: Data were collected from 1035 MUS consultations (77 patients). Beside history-taking, the most frequently used diagnostic strategies were physical examination (24.5%) and additional investigations by the GP (11.1%). Frequently used therapeutic strategies were prescribing medication (24.6%) and providing explanations (11.2%). As MUS symptoms persisted, GPs adjusted medication, discussed progress and scheduled follow-up appointments more frequently. The least frequently used strategies were exploration of all complaint dimensions (i.e. somatic, cognitive, emotional, behavioural and social) (3.5%) and referral to a psychologist (0.5%) or psychiatrist (0.1%). Conclusions: Management of Dutch GPs is partly in line with the Dutch guideline. Medication was possibly prescribed more frequently than recommended, whereas exploration of all complaint dimensions, shared problem definition and referral to mental health care were used less

What makes people decide who to turn to when faced with a mental health problem? Results from a French survey

<p>Abstract</p> <p>Background</p> <p>The unequal use of mental health care is a great issue, even in countries with universal health coverage. Better knowledge of the factors that have an impact on the pathway to mental health care may be a great help for designing education campaigns and for best organizing health care delivery. The objective of this study is to explore the determinants of help-seeking intentions for mental health problems and which factors influence treatment opinions and the reliance on and compliance with health professionals' advice.</p> <p>Methods</p> <p>441 adults aged 18 to 70 were randomly selected from the general population of two suburban districts near Paris and agreed to participate in the study (response rate = 60.4%). The 412 respondents with no mental health problems based on the CIDI-SF and the CAGE, who had not consulted for a mental health problem in the previous year, were asked in detail about their intentions to seek help in case of a psychological disorder and about their opinion of mental health treatments. The links between the respondents' characteristics and intentions and opinions were explored.</p> <p>Results</p> <p>More than half of the sample (57.8%) would see their general practitioner (GP) first and 46.6% would continue with their GP for follow-up. Mental health professionals were mentioned far less than GPs. People who would choose their GP first were older and less educated, whereas those who would favor mental health specialists had lower social support. For psychotherapy, respondents were split equally between seeing a GP, a psychiatrist or a psychologist. People were reluctant to take psychotropic drugs, but looked favorably on psychotherapy.</p> <p>Conclusion</p> <p>GPs are often the point of entry into the mental health care system and need to be supported. Public information campaigns about mental health care options and treatments are needed to educate the public, eliminate the stigma of mental illness and eliminate prejudices.</p