Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions

Aim In the current healthcare system primary care physicians (PCPs) have, in effect, become the primary psychiatric care physicians (PPCPs) for many of their patients. Being the PPCP in an already busy and stressful medical industry presents additional time management and treatment challenges to successfully manage patients' medical and psychiatric needs. The aim of the study was to ascertain PCPs' psychiatric assessment and treatment practices and to determine the extent to which PCPs have a need for using a structured psychiatric assessment tool.Method We sent 300 PCPs a survey to examine their psychiatric assessment and treatment practices. A one-page questionnaire was used to inquire about PCPs' psychiatric care practice habits including types of conditions treated, psychiatric medications prescribed, assessment methods used, interest in using a structured assessment tool and referral sources used. Sixty-eight usable surveys (23%) were returned.Results PCPs identify approximately one-third of their patients as mental health patients. They are treating a wide range of psychiatric conditions and prescribing a variety of psychiatric medications. The vast majority are using traditional clinical interviewing as their primary method of psychiatric assessment. However, the majority were willing to use a structured psychiatric assessment tool.Conclusion PCPs are serving a useful role in providing psychiatric treatment to many of their patients. Using a more structured psychiatric assessment method in practice could ultimately strengthen the assessment and treatment of psychiatric conditions in primary care settings.     

Optical coherence tomography for advanced screening in the primary care office

Optical coherence tomography (OCT) has long been used as a diagnostic tool in the field of ophthalmology. The ability to observe microstructural changes in the tissues of the eye has proved very effective in diagnosing ocular disease. However, this technology has yet to be introduced into the primary care office, where indications of disease are first encountered. We have developed a portable, handheld imaging probe for use in the primary care setting and evaluated its tissue site accessibility, ability to observe diseased tissue, and screening capabilities in in vivo human patients, particularly for pathologies related to the eye, ear and skin. Various stages of diabetic retinopathy were investigated using the handheld probe and early‐stage diabetic retinopathy was flagged as abnormal from the OCT images. At such early stages of disease, it is difficult to observe abnormalities with the limited tools that are currently available to primary care physicians. These results indicate that OCT shows promise to transform from being a diagnostic technology in the medical and surgical specialities to a screening technology in the primary care office and at the front‐line of healthcare. (© 2014 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Effects of an educational outreach campaign (IMPACT) on depression management delivered to general practitioners in one primary care trust

Objective An educational outreach initiative with general practitioners (GPs) within Walsall, led by pharmacists and aimed at delivering evidence-based guidance on stepped care management of clinical depression.Methods Standardised educational material was produced with key messages and contributions by experts on prescribing principles and management of clinical depression based on NICE guidance. The primary care pharmacists together with a psychiatrist or other professional delivered the training through initial face-to-face meetings with GP practices and carrying out follow-up visits.Evaluation Analysis of prescribing data (PACT) on antidepressants, which included prescribing of defined daily doses (DDD) and net ingredient cost (NIC) of commonly prescribed antidepressants for the whole of Walsall teaching Primary Care Trust (tPCT) and comparison with prescribing data for the West Midlands and for England during the period June 2000 to June 2006.Results The use of Fluoxetine increased slightly and the prescribing of Dosulepin continued to fall. The prescribing of Escitalopram, which had steadily increased prior to the launch of campaign, showed decline, resulting in savings of over ￡50K in the year 2005 to 2006. This was in comparison to a relative increase in the prescribing for Escitalopram for the same time period in the West Midlands and nationally. Prescribing of Dosulepin continued to fall. The total cost of prescribing for the four antidepressants fell and theses changes were sustained over the following year.Conclusions The educational outreach campaign successfully influenced prescribing behaviour in terms of adhering to NICE guidance and cost-effective prescribing, and also facilitated improved communication among clinicians at the primary-secondary care interface.     

Detecting psychogeriatric problems in primary care: factors related to psychiatric symptoms in older community patients

Objective The aim was to determine the relationship and influence of different variables on the psychiatric symptomatology of older people who reside in the community, as detected by family practitioners.Design A cross-sectional and multi-centre study.Setting Twenty-eight general practices and two psychiatric practices in Huesca, Spain, from 19 primary care health centres.Subjects A sample of 324 patients aged over 65 years, representative of the older people who reside in the community in the province of Huesca.Main outcome measures Symptoms of depression (Yesavage GDS), cognitive impairment (MMSE), anxiety (GADS), psychotic symptoms, obsessive symptoms and hypochondriacal ideas (GMS) were measured by family practitioner and were detected following specific questions from the Geriatric Mental State (GMS-B) examination, following DSM-IV criteria, being defined as 'concern and fear of suffering, or the idea of having a serious disease based on the interpretation of somatic symptoms'. Sociodemographic, physical and somatic, functional and social data were evaluated. Analysis was carried out in three phases: univariate, bivariate and multivariate with logistic regression.Results At the time of the study, 46.1% of the older people studied suffered from some psychiatric symptom; 16.4% had cognitive impairment, 15.7% anxiety, 14.3% depression, 6.1% hallucinations and delusions, 7.2% hypochondriacal ideas and 4.4% obsessive symptoms. Female gender was significantly associated with depression (prevalence ration (PR) 3.3) and anxiety (PR 3.9). Age was a factor associated with cognitive impairment (PR 4.4). Depression was significantly related to severity of the physical illness (PR 61.7 in extremely severe impairment). Isolation (PR 16.3) and being single (PR 13.4) were factors which were strongly associated with anxiety; living in a nursing home was associated with psychotic symptoms (PR 7.6).Conclusions Severity of physical illness, isolation, living in a nursing home and female gender, among others, are related to psychiatric symptoms in community-residing older people identified in primary healthcare centres.     

Prevalence of obese patients in a primary care setting

Objective: Previous research has addressed the relationship between BMI and chronic disease in primary care; however, little has been done with regard to the association between obesity and depression in primary care. The purpose of this paper is to assess the relationship between obesity and chronic conditions including depression. Research Methods and Procedures : Data from primary care patients seen at a university‐based family medicine clinic in the southeastern United States were extracted for the time between January 1, 1999 and January 1, 2002. Data extracted included most recent height and weight, age, ethnicity, pregnancy status, number of office visits, blood pressure, cholesterol, hemoglobin A_1C, current diagnoses, and medications. Results : A total of 8197 patients were included in the analysis. Sixty‐nine percent of patients seen in a 3‐year period were either overweight or obese. Comparing blood pressure, cholesterol, diagnoses, and medications between BMI groups found differences in virtually all categories. Diagnoses of high cholesterol, hypertension, diabetes, and depression significantly increased for obese patients. Discussion : Obese patients are over‐represented in primary care, and this over‐representation of obesity correlates with several diagnoses, including depression. Depression is a chronic disease that may interfere with health‐related behaviors and must be addressed within the health care system.     

Bereavement in the elderly: the role of primary care

Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members'' burden and suffering.     

Vaginal vault smears –''know more – do less'': a questionnaire survey of primary health care practitioners

BACKGROUND: The vaginal vault smear is a test for cellular atypia in women who have undergone a hysterectomy. In asymptomatic women the test has poor sensitivity and specificity. Current guidelines recommend: vault smears should not be used after hysterectomy for benign pathology; two vault smears (6 and 12 months postsurgery) should be taken when there is evidence of completely excised CIN II/III in the specimen. AIM: To describe primary health care professionals' self-reported knowledge and behaviour relating to the use of vault smears. DESIGN OF STUDY: Questionnaire. SETTING: South Birmingham. METHODS: Postal questionnaire survey to primary health care professionals (general practitioners and practice nurses, n = 424). Results: Response rate 80.0%, completed response rate 68.9%. Mean knowledge score was 7.3 out of possible 12 (SD 1.9); range 0-10. No significant differences were observed between GPs and practice nurses in knowledge scores, although differences were noted in the frequency of performing vault smears. An inverse relationship was observed between frequency of performing vault smears and level of knowledge about the test. There was a positive association between requesting further information and the 'knowledge score'. Only 11% correctly answered a question based on current guidelines. CONCLUSIONS: Knowledge of current guidelines was poor. Those who undertook fewest vault smears appeared best informed. This suggests that if all primary care professionals practised according to current guidelines, the number of vault smears performed may be reduced. Unnecessary vault smears may cause additional anxiety in women and have financial consequences for the NHS.     

Mental health in primary care for adolescent parents

Mental health care is important for everyone, especially teenagers. However, seeking mental health services may be challenging for teenagers, particularly when they are also parents. Offering mental health care in a safe, attractive and easily accessible manner, such as primary care, increases the chances that teenage parents will receive help. Comprehensive care models need to be established to address the many needs that at-risk young mothers and their children face. There are a number of programmes available to teenage mothers that either address healthcare and psychosocial needs or focus primarily on improvements in parenting skills; yet an integrated model that delivers medical, psychiatric and psychosocial care and facilitates positive parenting skills seems to be missing. Through a university–community partnership we have recently developed a model curriculum – the Mom Power (MP) group programme – at the University of Michigan which aims to close this gap in service delivery. We elaborate on core elements and key features of this 10-week group intervention programme for high-risk teenage mothers and their children, and present preliminary outcomes data. Analyses on the first 24 MP group graduates suggest that despite ongoing life trauma during the intervention period, teenage mothers show improvements in depression and post-traumatic stress disorder symptoms post intervention, and also self-rate as less guilty and shameful regarding their parenting skills after programme completion. Although preliminary, due to design and statistical limitations, these results show promise regarding feasibility and effectiveness of this integrated approach for teenage mothers with young children delivered through primary care.     

Optimising primary care for people with dementia

This review considers key areas in primary care regarding the diagnosis of dementia. Issues surrounding assessment, policy and incentives are considered. In addition, the relevance of non-medication approaches for dementia in primary care, which aim to enhance or maintain quality of life by maximising psychological and social function in the context of existing disabilities, is deliberated. Finally, key issues about primary care medication management are considered, and relevant therapeutic strategies with recommendation for a collaborative approach that improve outcomes by linking primary and secondary healthcare services – including general practice and pharmacy – with social care needs are weighed up. A key aspect of such a collaborative approach is to support informal carers in optimising medication.     

Brief cognitive behavioral therapy compared to general practitioners care for depression in primary care: a randomized trial

Background

Previous studies of acupuncture show favourable results for both subjective and objective outcomes of dry eye. However, firm conclusions could not be drawn from these studies because the quality of the trials was too low to establish concrete evidence. Therefore, this study was designed both to avoid the flaws of the existing trials and to assess the effectiveness, cost-effectiveness and qualitative characteristics of acupuncture treatment for dry eye.

Methods/design

One hundred fifty participants with dry eye will be recruited into three independent hospitals from different areas: Korea Institute of Oriental Medicine, DongGuk University Ilsan Oriental Hospital and Dongshin University Gwangju Oriental Hospital. The number of participants required was calculated from the data of a previous, relevant study. These patients will be randomly allocated into acupuncture treatment or artificial tear groups. Either 17 acupuncture points (bilateral BL2, GB14, TE 23, Ex1, ST1, GB20, LI4, LI11 and single GV23) will be used 3 times a week or disposable artificial tear drops (Refresh Plus^®, ALLERGAN) will be provided for use at least once a day for 4 weeks. The ocular surface disease index (OSDI), tear film break-up time (TFBUT), Schirmer I test, visual analogue scale (VAS) for self-assessment of ocular discomfort, general assessment (by both acupuncture practitioners and participants) and quality of life (QOL) through the Measure Yourself Medical Outcome Profile-2 (MYMOP-2) will be assessed for approximately 3-months for each study participant. In addition, qualitative study and cost-effectiveness of acupuncture treatment will be conducted.

Trial registration

ClinicalTrials.gov (Identifier: NCT01105221).     

Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec

Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed.Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation.Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients.Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.     

‘Can he have the test for bipolar,doctor? His dad's got it’: exploring the potential of general practitioners to work with children and young people presenting in primary care with common mental health problems – a clinical initiative

Background General practitioners (GPs) play a key role in assessing and managing adult mental health problems, but this input is not seen in their management of child and adolescent mental health. Mental health problems in 5–19-year-olds are common, yet detection rates in primary care are low. The symptoms of most adult diagnoses of mental health problems are present by mid-adolescence, yet the typical time from onset to diagnosis is 5–15 years. The role of general practice in this area has been underexplored.Aim This pilot study explores the potential of GPs to respond to common mental health problems in children and adolescents.Design Children and young people who would have ordinarily been referred to Child and Adolescent Mental Health Services (CAMHS) were seen in a GP setting. In a UK general practice surgery serving a disadvantaged population.Method Children and young people were seen for an initial biopsychosocial assessment and formulation of the presenting concerns. GP-based interventions were offered as appropriate or referred to CAMHS.Results Data from the first 50 children (2–19 years) are presented. Twenty younger children (10 years and under) and 30 older children (11 years and above) were seen. Eighteen referrals were made to CAMHS. GP interventions included watchful waiting, brief behavioural interventions, non-directive counselling, brief cognitive– behavioural therapy (CBT) and liaison with colleagues in education, CAMHS and the voluntary sector.Conclusion This clinical pilot demonstrates that with adequate time, access to supervision and practice support, children and young people experiencing emotional and behavioural problems associated with common mental health issues can be helped in primary care.     

Depression recovery from the primary care patient's perspective: 'hear it in my voice and see it in my eyes'

Purpose This paper aims to contribute to the discussion about the concept of recovery from depression from the patient perspective.Methods A structured, computer-assisted telephone interview of 576 participants from the Australian diamond cohort study who were asked, at the one year follow-up, how they would know if someone had recovered from depression. The responses were thematically analysed using a modified grounded-theory approach.Results Participants found the question challenging on a number of levels, relating to the definition of recovery, the subjective nature of getting better from depression, pessimism about the possibility of recovery and concerns that people hide how they really feel. Participants reported observation and human interaction as crucial to deciding if recovery had occurred. This led to three broad groups of indicators for recovery: a person's actions, their appearance and their thoughts and feelings.Conclusions Australian primary care patients with depressive symptoms report using observation and human interaction when trying to decide if someone is getting better from depression, leading to a broad range of indicators of recovery that include, but are not limited to, the traditional symptom-based definitions of depression remission. This data suggests that patients have a rich variety of ways of describing recovery, supporting a call for more patient-centred approaches to setting goals for depression recovery in the primary care setting.     

Integration of child mental health services to primary care: challenges and opportunities

In the first decade of this new millennium, health professionals are faced with a rapidly increasing need for child mental health services and changing models of service provision. This gives us a unique opportunity to make provision for services where it has not been available before, or to improve upon the existing services. This paper examines the challenges and opportunities while attempting to integrate child mental health services to primary care.     

Behavioural and psychological symptoms of dementia in primary care: a survey of general practitioners in Ireland

Background Management of neuropsychiatric symptoms is a challenging task in primary care. Aims To assess self-reported confidence and knowledge of general practitioners (GPs) regarding the identification and management of behavioural and psychological symptoms of dementia (BPSD).Methods A self-designed two-page paper questionnaire was sent to a random sample of 160 GPs practising in north Dublin. They were asked to evaluate their confidence and knowledge on several aspects of diagnosis and management of BPSD.Results Completed questionnaires were returned from 109 GPs (response rate = 68%), of which 106 were usable. In general, GPs were somewhat critical of their self-reported skills in diagnosing (76.4%) and managing (77.4%) BPSD, as well as in discriminating BPSD from other behavioural disturbances (71.7%). Many of them (67.9%) also encountered difficulty accessing specialist services. There was no correlation between demographic characteristics of GPs or patient caseload with respect to their responses to questionnaire items. Although many GPs (92.5%) highly valued the important role of non-pharmacological interventions in BPSD, none of them reported recommending these in their daily practice.Conclusions Despite the fact that GPs have a wealth of knowledge about BPSD, they are largely critical of their knowledge and management skills of these symptoms. Efforts should be focused on supporting GPs by means of educational interventions that consider all aspects of dementia, but additionally highlight the more challenging neuropsychiatric components of the illness. Health services need to be structured in a way that promotes collaboration between GPs and mental health professionals for a seamless delivery of care.     

Integrating mental health into primary care in Sverdlovsk

Introduction Mental disorders occur as frequently in Russia as elsewhere, but the common mental disorders, especially depression, have gone largely unrecognised and undiagnosed by policlinic staff and area doctors.Methods This paper describes the impact and sustainability of a multi-component programme to facilitate the integration of mental health into primary care, by situation appraisal, policy dialogue, development of educational materials, provision of a training programme and the publication of standards and good practice guidelines to improve the primary care of mental disorders in the Sverdlovsk region of the Russian Federation.Results The multi-component programme has resulted in sustainable training about common mental disorders, not only of family doctors but also of other cadres and levels of professionals, and it has been well integrated with Sverdlovsk's overall programme of health sector reforms.Conclusion It is possible to facilitate the sustainable integration of mental health into primary care within the Russian context. While careful adaptation will be needed, the approach adopted here may also hold useful lessons for policy makers seeking to integrate mental health within primary care in other contexts and settings.