Variability and predictors of mental disorder rates and medical practitioner responses across Australian general practices

Co-occurring depression and alcohol misuse is under-identified in general practice: A cross-sectional study

Depression and alcohol misuse are common co-occurring conditions. This study aimed to determine the accuracy of general practitioner identification of depression and alcohol misuse. Participants from 12 Australian general practices reported demographic and health risk behaviour data. General practitioners were asked to indicate the presence or absence of six health risk factors for individual patients. Accuracy of general practitioner identification was low at 21 per cent. Those with severe alcohol misuse, no chronic diseases and lower education levels were more likely to be identified. Routine screening prior to patient appointments may be a simple and efficient way to increase identification rates.

Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research

OBJECTIVE

There has been at least 40 years of active research on screening for depression and distress in primary care. Both successes and failures have been documented. The purpose of this focussed narrative review was to summarise this research and present the key lessons for clinicians and researchers working in psychosocial oncology.

METHODS

We searched for studies assessing the utility of screening in primary care in seven electronic bibliographic databases (CENTRAL, CINAHL, Embase, HMIC, Medline, PsycINFO, Web of Knowledge) from inception to December 2010. Results were reviewed and summarised into key areas.

RESULTS

We found that research could be distilled into the following key learning points. (1) Primary care is an important partner in psychosocial care. (2) Both over and under detection are problematic. (3) Barriers to identification involve patient and clinician factors. (4) Acceptability of screening is critical to implementation. (5) Underserved groups need special attention in screening. (6) Patient-clinician trust is an important modifiable variable. (7) Greater contact influences detection. (8) Clinician confidence/skills influence screening success and subsequent action. (9) Training may improve confidence but effects upon long-term outcomes are modest. (10) Screening is generally ineffective without aftercare.

CONCLUSIONS

Primary care has shown largely what does not work in relation to screening. Namely relying on clinicians' unassisted judgement without infrastructural support, using over-complex scales with low acceptability, looking for depression alone, using screening without linked treatment, treating in the absence of follow-up and failing to engage patients in their own care. These pitfalls can and should be avoided in psychosocial oncology.

General practice management of psychological distress in patients with sexually transmissible infection

This paper investigates general practitioners’ (GP) self-reported practices for psychologically distressed patients with sexually transmissible infections (STI). A cross-sectional postal survey was conducted among a 15% random sample of GP practising in New South Wales. The main outcome measures were self-reported strategies to deal with psychologically distressed STI patients, priority of counselling, and perceived need for training in counselling. The great majority (82%) of GP reported that they extended their consultation time to deal with psychologically distressed patients, whereas 49% reported being likely to refer distressed patients to a counsellor. Just over half (54%) considered counselling to be a high priority in STI care, whereas 49% acknowledged benefits of further training in counselling. Overseas medical graduates were more likely to refer patients in distress to counsellors compared with Australian graduates (odds ratio = 1.80, P = 0.008). Female and metropolitan GP were more likely to consider counselling a high priority in STI care (odds ratio = 1.56, P = 0.038; odds ratio = 1.62, P = 0.028, respectively). GP appreciate the need to deal with psychological distress of STI patients; however, referral to counselling services is not a widespread priority. Further research is needed to examine practitioners’ actual practice in caring for psychological distress among STI patients and barriers to referral for counselling.

General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia

OBJECTIVE

Previous Australian research suggests there is very little difference in the prevalence of mental health disorders across rural, remote and metropolitan areas. However, mental health specialists are particularly scarce in rural and remote areas and some researchers have argued that non-metropolitan residents rely heavily on general practitioners (GPs) for mental health care. This article investigated rates of GP services for psychological problems across rural, remote and metropolitan areas.

METHOD

The Bettering the Evaluation and Care of Health (BEACH) program, Medicare and Pharmaceutical Benefits Scheme data were used in this report. Data included all psychological, depression and anxiety problems reported as managed by GPs and prescriptions for mental health medications (written and filled). Problem and medication rates are given per 100 patient encounters and per 1000 population.

RESULTS

Only a few regional differences were evident in the rate of psychological problems and prescriptions for mental health medications per 100 GP-patient encounters. However, rural and remote residents visited GPs less frequently than their metropolitan counterparts. Lower rates of GP encounters for psychological problems were evident for residents of most non-metropolitan areas (per 1000 population). Additionally, GPs prescribed mental health medications at half the rate for residents of remote areas than capital cities.

CONCLUSIONS

General practitioners provide fewer mental health services per capita in non-metropolitan areas. This difference could represent completely untreated psychological problems or fewer follow-up consultations. While non-metropolitan residents have limited access to specialists, rates of GP encounters for psychological problems are also very low.

Why wait? Reasons for delay and prompts to seek help for mental health problems in an Australian clinical sample

BACKGROUND

The initial delay to seek treatment accounts for a significant proportion of the unmet need for treatment of common psychiatric conditions. This study aimed to examine the barriers to initial help-seeking and factors that facilitate help-seeking for anxiety and depression.

METHODS

Help-seeking history was retrospectively self-reported by 233 patients at a specialist anxiety clinic, all of whom had delayed seeking professional treatment for at least one month. Data gathered included age at onset, age at help-seeking, primary reason for the delay, prompt to seek help and first professional contacted.

RESULTS

The most frequently endorsed reasons for the delay related to lack of knowledge about mental illness or available treatment. Increasing illness severity or disability was the primary prompt to seek help for the majority of respondents. Reason for the delay showed some relationship with length of the delay, but prompt to seek help did not. A general medical practitioner (GP) was the first professional contacted in 71 % of cases.

CONCLUSIONS

Lack of public 'mental health literacy' contributes to slow problem recognition. Increasing illness severity eventually facilitates problem recognition and prompts help-seeking. Structural barriers to initial help-seeking are relatively unimportant within the Australian health care system. General practitioners play an important role as gate-keepers to appropriate mental health care.

Barriers to the effective management of depression in general practice

OBJECTIVE

The aim of this study was to investigate the effects of prior general practice training in mental health and practice location on general practitioner (GP) attitudes toward depression, self-confidence in assessing and treating depressed patients, identification of doctor, patient and practice barriers to the effective care of depressed patients in general medical practice and GP-reported current clinical practice.

METHOD

Fifty-two (out of 123) Divisions of General Practice that responded to an invitation to participate in the study distributed 608 anonymous surveys to a representative sample of GPs; 420 (69%) were returned. The questionnaire focused on current clinical practice, perceived barriers to care of depressed patients and doctors' self-efficacy for assessing and treating depressed patients. It also consisted of two scales, based upon previous research, designed to assess doctors' attitudes towards depression and depressed patients.

RESULTS

General practitioners who had undertaken mental health education and training more often used non-pharmacological treatments (p=0.00), as did female GPs (p=0.00). Male GPs (p=0.00) and those in rural settings (p=0.01) more often prescribed medication for depression. Those without mental health training more often identified incomplete knowledge about depression as a barrier to its effective management (p=0.00). Urban-based GPs (p=0.04) and those with prior mental health training (p=0.00) were more confident in the use of non-pharmacological treatments. Female GPs without mental health training were the least confident in the use of these methods (p=0.01). Overall, GPs with mental health training were more positive in their attitudes toward depression and their treatment of these patients (p=0.00). Female GPs appeared more positive in their attitudes toward depression than male GPs (p=0.01), although the results were not entirely consistent.

CONCLUSIONS

Participation in mental health training by GPs appears to be related to their attitudes toward depressed patients and to their confidence and abilities to diagnose and manage the common mental disorders effectively.