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Care for patients with severe mental illness: the general practitioner's role perspective

Care for patients with severe mental illness: the general practitioner's role perspective Background: Patients with severe mental illness (SMI) experience distress and disabilities in several aspects of life, and they have a higher risk of somatic co-morbidity. Both patients and their family members need the support of an easily accessible primary care system. The willingness of general practitioners and the impeding factors for them to participate in providing care for patients with severe mental illness in the acute and the chronic or residual phase were explored. Methods: A questionnaire survey of a sample of Dutch general practitioners spread over the Netherlands was carried out. This comprised 20 questions on the GP's 'Opinion and Task Perspective', 19 questions on 'Treatment and Experiences', and 27 questions on 'Characteristics of the General Practitioner and the Practice Organisation'. Results: 186 general practitioners distributed over urban areas (49%), urbanised rural areas (38%) and rural areas (15%) of the Netherlands participated. The findings were as follows: GPs currently considered themselves as the first contact in the acute psychotic phase. In the chronic or residual phase GPs saw their core task as to diagnose and treat somatic co-morbidity. A majority would be willing to monitor the general health of these patients as well. It appeared that GP trainers and GPs with a smaller practice setting made follow-up appointments and were willing to monitor the self- care of patients with SMI more often than GPs with larger practices. GPs also saw their role as giving support and information to the patient's family. However, they felt a need for recognition of their competencies when working with mental health care specialists. Conclusion: GPs were willing to participate in providing care for patients with SMI. They considered themselves responsible for psychotic emergency cases, for monitoring physical health in the chronic phase, and for supporting the relatives of psychotic patients. Page 1 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 drugs can also result in overweight and diabetes mellitus Background Severe mental illnesses (SMI), especially the schizophre- [20-23]. nia spectrum and affective psychotic disorders present themselves in a wide variety of clinical signs and symp- GPs seem not to be aware of the high rate of physical ill- toms. The common denominator of these disorders is the ness in patients with severe mental illnesses, nor do they loss of contact with reality and people of importance to pay specific attention to monitoring and treating somatic them. Therefore these patients demand specific attention co-morbidity in this group of patients [24]. Internation- for their wellbeing and health problems. ally, it is currently acknowledged by psychiatrists that gen- eral health-care needs in patients with severe mental For treatment, a crucial distinction between the acute illness are neglected. Also, that the integration of general phase and the chronic phase must be made. During the somatic and psychiatric care services is less than optimal acute phase, when positive symptoms and reality distor- [25,26]. However, there is a lack of consensus as to which tion prevail and a psychotic crisis arises, GPs are often the health care professionals should be responsible for the first to offer medical assistance. Their role is to recognize prevention and management of co-morbid somatic ill- the signals of a developing psychosis and to start appro- nesses in SMI patients [27]. Psychiatrists think that the priate treatment immediately [1,2]. This usually results in monitoring of metabolic disorders as a possible side-effect a referral to an emergency psychiatric consultation and, of antipsychotic drug is their responsibility [27-29], but less often, the prescription of an antipsychotic drug [3]. not necessarily the medical treatment. The updated UK guideline for schizophrenia states that for people with In the chronic phase, the role of the GP is less well- schizophrenia, just as for other high-risk groups, regular defined. Psychiatric treatment is more or less restricted to physical checks and health advice are an essential primary infrequent medication checks by the psychiatrist and to care contribution to their treatment and management the support by a community psychiatric nurse with regard [30]. Adherence to the guideline on monitoring risk fac- to self care, daily structure and activities and reintegration tors in patients taking second-generation antipsychotics, of the patient in the community. appears to be low [31]. Long term chronic psychotic disorders are often accompa- Dutch GPs have no specific management policy in the nied by a loss of cognitive abilities, such as disturbances guidance of SMI patients; their current multidisciplinary in perception, retardation, and executive functions. Psy- guidelines on schizophrenia do not give them a sufficient chotic patients may not be able to recognise certain phys- directive [32]. ical phenomena as a symptom of a co-morbid disease [4], and they often find it difficult to communicate their phys- Qualitative research on opinions of experienced GPs iden- ical needs and problems and to arrange appointments for tified the factors which influenced their attitudes to pro- themselves [5-7]. As a consequence, they seek help at a rel- viding care for patients with psychotic disorders [11]. atively late stage. These facts underscore the importance Patient behaviour factors like aggression and drug abuse that care provided by GPs should be easily accessible. Fur- were perceived as being as difficult to manage and some- thermore, the GP should be alert on somatic co-morbid- times threatening, while involvement with the patient's ity, and pay specific attention to the differential diagnosis family was a stimulus for the GP to do as much as he combined with the patient's physical condition [8]. could. Also a good collaboration with acute psychiatric services was indispensable for GPs to feel competent in Not only patients with SMI, but also their carers experi- managing a psychotic crisis. ence a lot of stress. They visit their GPs with their concerns as well [9,10]. GPs are aware of this and they feel that pro- In order to check current practice among GPs and the need viding support for families of patients is one of their core for a set of guidelines, we posed the following questions: tasks [11]. Mental health education for family members appears to be an effective intervention in the treatment of 1. What part of the health care should be provided by psychosis [12,13]. GPs for patients with severe mental illnesses, both in the acute and the chronic phase? Patients with a chronic psychosis often suffer from somatic co-morbidities [14-16], and have a higher death 2. Do GPs consider themselves sufficiently equipped risk [17]. Disease-related factors including chronic stress, to provide this care, and if not, in which areas do they smoking, drug abuse, life-style habits and lack of exercise need more training? contribute to this as well [18,19]. The use of antipsychotic Page 2 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 3. How do GPs manage their care for patients with SMI database of Netherlands Institute for Health Service in practice, and how close is their collaboration with Researche (NIVEL). mental health services? Data analysis The data were processed using the software programme Methods The survey instrument SPSS 14.0; which was also used for the statistical analysis. After reviewing the literature [32-40] a questionnaire was The answers on the ordinal five-level Likert scale were developed regarding the GP's role perspectives, his treat- translated into a three point scale, measuring either a pos- ment of SMI patients, his personal details and his practice itive or a negative response to a statement. The answers to organisation. the questions on 'Opinion and Task Perspective' and on 'Treatment and Experiences' were subjected to a factor The term 'Severe Mental Illness' was confined to patients analysis. The factors found were correlated with personal with psychotic symptoms related to the schizophrenia details and treatment aspects of GPs using multivariate and affective psychotic spectrum. analysis. A division was made between 'Providing Emergency Care' Results and 'Providing Care in the Chronic Phase'. Questions A total number of 186 completed questionnaires was about GP's attitude to periodic health checks were divided returned (27%). Nine questionnaires were undeliverable. into three aspects: physical health, psychosocial well- Of the respondents, 62% were male, the average work being and psychiatric symptoms. experience was 18 years (minimum 2 years, maximum 35 years) and the average age was 49 years. 22% worked sin- The draft questionnaire was reviewed by an expert panel gle-handed, 32% worked in two-man practice, 29% in a and was tested in a pilot study by interviewing four expe- group practice and 17% in a primary health care centre. rienced general practitioners. The purpose of this was to These data are consistent with the national figures on test for ambiguity, the relevance of the questions, and the Dutch GPs from NIVEL. difficulties in answering them. The revised questionnaire was divided into three sections: Section 1: 'Opinion and Of the respondents, 52% of GPs worked part-time. 40% Task Perspective', Section 2: 'Treatment and Experience' were also GP trainers, and 31% had psychiatric work expe- and Section 3: 'Personal Details of the GP and Practice rience. 61% had easy access to a community psychiatric Organisation'. nurse, whose main task was to advise the patient on prob- lem solving. They rarely supervised patients with severe An ordinal five-level Likert scale with variations between mental illnesses (13%). The average number of patients in positive and negative statements was used for answering a GP practice who were thought to be susceptible to psy- eleven questions on 'Opinion and Task Perspective', five chosis was about 20 (minimum 0, maximum 200). The of the questions on 'Treatment and Experiences', and six mean size of a Dutch GP practice covers 2350 inhabitants. questions on 'Characteristics of the GP'. The other 43 Concerning practice location: 49% was located in an questions were multiple choices, except for the questions urban area, 38% in an urbanised rural area, and 15% in a on age of the respondent and an estimate of the number rural area. of registered patients who were susceptible to psychosis. Opinion and Task Perspective (table 1) The secretary of the Medical Ethics Committee of the Uni- In the acute phase of psychosis, GPs viewed themselves as versity Medical Centre Groningen stated upon being con- the first contact. They also felt responsible for the long sulted that it was not necessary to obtain the consent of term care in the chronic stage: monitoring somatic co- the committee. morbidity and taking care of repeat prescriptions. Regard- ing periodic physical checks, 80% of GPs considered this The questionnaire was distributed in June 2007. It took their task: 55% annually, 34% once half-yearly. Mental 20–30 minutes to complete the questionnaire. Participa- functioning should be monitored by a community psychi- tion was voluntary and anonymous. All GP's received a atric nurse and periodically checked by a psychiatrist reminder four weeks after the distribution. belonging to the mental health service. The GPs felt it their task to support the family and provide information The sample on the patient's condition. The research was conducted among GPs who provided continuous care, i.e. established GPs and GPs in service of Not all of the respondents felt capable of making contact established GPs. Locum GPs were excluded from the with the patient during a psychotic crisis, whereas they research. A random sample of 700 GPs was taken from the were confident making contact with the family. Neverthe- Page 3 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 Table 1: Opinion and Task Perspective (N = 186) Agree Neutral Disagree Tasks in the acute and long term phase For acute confusion, the GP is the first contact 74% 19% 7% I feel responsible for the care for chronic psychiatric patients in my practice 58% 23% 19% I think it is my job to check on psychiatric patients' ability to take care of themselves 37% 30% 33% I think I should monitor somatic co morbidity in chronic psychiatric patients 81% 13% 6% Care for family I think it is my job to support the family of a chronic psychotic patient 74% 17% 9% I think it is my job to provide information on the clinical picture to the family of a chronic psychotic patient 58% 26% 16% Self-experienced competencies I feel competent in making contact with the patient in a psychotic crisis 46% 35% 19% I feel competent in communicating with the family in a psychotic crisis 85% 11% 4% I feel competent in intervening in a crisis situation 52% 33% 15% I feel powerless in a psychotic crisis 18% 28% 54% I feel unsafe near an acute psychotic patient 16% 35% 49% Need for continual professional development training (CPD training) I need CPD training on guiding of and communicating with psychotic patients 55% 27% 18% I need CPD training on interventions in a psychotic crisis 63% 20% 17% I need CPD training on antipsychotic pharmacotherapy 54% 24% 22% less, most GPs felt reasonably well-able to intervene in a to a mental health service. A minority (39%) of GPs pre- crisis situation. A minority felt powerless or unsafe. GPs scribed an antipsychotic drug themselves, of which 53% did indicate they needed further training in this area. concerned a restart of previously prescribed drugs. Most GPs (60%) made follow-up appointments and contacted Practice experiences the family regularly (68%). At times, the GP would do a A majority of respondents (59%) had seen a patient con- physical check (35%) or request lab checks (28%). cerning psychosis in the previous 6 months, and 78% had seen one in the last 12 months. These contacts included: Experiences with specialised mental health services (table first episode psychosis (21%), psychotic depression 2) (23%), schizophrenia (29%), bipolar disorder (18%), In emergency cases, 61% of GPs stated they were able to reach mental health care services easily, and they felt taken psychosis resulting from drug abuse (3%) and the remain- ing category were: second episode of psychosis, organic seriously as the referring party. However, there was no col- psychosis and delirium. laboration with mental health care providers in the organ- isation of long term care. GPs were not included in the Of these patients, 62% had been in contact with mental development of treatment plans, and did not receive reg- health services previously. Most cases (84%) were referred ular information on the patient's status during treatment. Table 2: Experiences with specialised mental health services (N = 186) Agree Neutral Disagree It does take a lot of effort to consult a psychiatrist in an emergency psychotic crisis 30% 9% 61% My information is taken seriously by the psychiatrist 60% 25% 15% The mental health services involve me, as GP, in the treatment plan 12% 20% 68% The mental health services keep me informed on a regular basis 19% 29% 52% I feel supported by the collaboration with the mental health services 38% 39% 23% Page 4 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 Multivariate analysis which was consistent with actual figures: 1% of the popu- A factor analysis of the answers to the questions of the sec- lation is susceptible to psychosis. A broader role perspec- tion 'Opinion and Task Perspective', the questions on col- tive is associated with a higher job satisfaction in the laboration with MHS, and the questions on personal guidance of psychiatric patients. This group of GPs made details with regard to attitude and need for training iden- use of the community psychiatric nurse more often, if tified the following four independent factors: available. - self-experienced competencies in the acute phase of No significant relation was found between practice char- psychotic illness acteristics and experience with mental health services. - task perspective in the chronic phase of psychotic ill- Discussion ness The GPs responding to the questionnaire agree on their role in the acute phase: having assessed the patient's con- - experience with mental health services dition, they refer the patient to a mental health centre and/or prescribe an antipsychotic drug. In addition, the - need for continual professional development train- GPs support the family members. GPs consider the collab- ing (CPD) oration with mental health services as adequate in this phase. Not surprisingly, inexperienced GPs feel the need Relationship between the four domains and GP (practice) for training in dealing with crisis situations. characteristics (table 3) and treatment aspects of GPs (table 4) In the chronic phase, the responding GPs differ in their GPs who felt competent in the acute phase of a patient's opinion as to what care they should provide. These differ- psychotic illness suffered less from feelings of helplessness ences are explained by different task perspectives, experi- or fear than GPs who were not familiar with problems of ence with regional mental health services, and their patients with SMI. More often than not, these GPs had perceived need for specific training. gained work experience in a psychiatric institute and felt less need for extra training. They had diagnosed a patient Many GPs do feel involved in this stage, but they find the with acute psychosis more often in the last six months, psychosocial problems associated with it quite difficult. and conducted physical checks more often. Also, they Currently, GPs tend just to diagnose and treat somatic co- made follow-up appointments with patients more often, morbidity, but a majority would be willing to monitor and considered periodic checks on a patient's self-neglect physical health in the future. They also want to be respon- a part of the GP's responsibility. sible for repeat prescriptions, but they lack expertise in the effectiveness and side effects of antipsychotic drugs. GPs with a broader role perspective on the care for psy- chotic patients often had a smaller practice list and were GPs feel reluctant to inquire about the patient's self-care, more often GP trainers. They estimated that they had a and therefore they are unable to assess the risk of neglect. higher prevalence of psychotic patients in their practice, Possibly they are not aware of the fact that a better physi- Table 3: Significance of the relationship between the four domains and GP (practice) characteristics Domains 1 234 gender GP .082 .355 .573 .624 type of practice .704 .999 .704 .124 part time – fulltime .397 .988 .247 .335 GP trainer .493 .014 .488 .723 urbanization .109 .059 .406 .767 work experience in psychiatry .002 .266 .945 .045 work experience as GP .066 .724 .936 .790 volume of practice list .091 .044 .777 .102 registration of SMI in electronic patient records .345 .121 .548 .806 estimated number of patients susceptible to psychosis .111 .003 .996 .890 *statistically significant relations (p ≤ 0.05) are printed in bold 1 = self-experienced competencies in the acute phase 2 = task perspective in the chronic phase 3 = experience with mental health services 4 = need for CPD training Page 5 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 Table 4: Significance of the relationship between the four domains and GP's treatment aspects Domains 12 3 4 most recent treatment concerning psychosis .021 .748 .625 .026 referral patient to mental health services .661 .206 .270 .658 start pharmacotherapy .446 .243 .187 .771 follow-up appointment with patient .184 .013 .642 .758 follow-up appointment with family .279 .093 .977 .341 physical check .032 .319 .332 .050 lab diagnostics .093 .940 .466 .231 *statistically significant relations (p ≤ 0.05) are printed in bold 1 = self-experienced competencies in the acute phase 2 = task perspective in the chronic phase 3 = experience with mental health services 4 = need for CPD training cal condition improves the psychiatric symptoms and the In the chronic phase of a psychotic illness, GPs are willing quality of life [5]. to be part of the care system surrounding a psychotic patient. Most GPs consider assessing the patient's physical GPs that have a broad role perspective tend to monitor the condition and detecting and monitoring somatic co-mor- patient in the chronic phase and experience a higher job bidity as their responsibility. Risk management and the satisfaction in the guidance of their patients than those treatment of somatic co-morbidity are part of the GP's who do not. As these GPs often have a smaller practice list, expertise, as is giving support and information to the it is assumed that this enables the GP to know and under- patient's family. However, such judgment requires an stand his patients better. active, outreaching attitude on the GP's part. When com- municating with chronic psychotic patients, it is necessary The collaboration between GPs and mental health spe- for GPs to take the patient's possible cognitive handicaps cialists in chronic cases leaves much to be desired. There is into account [43]. no cohesion in the care given. This problem appears to be universal [4,41,42]. The GP is not included in the devel- The majority of the GPs, however, experience the need for opment of treatment plans and is not informed about the training in counselling in the chronic phase, specifically in patient's status during treatment. This finding was not pharmacotherapy, including topics like side-effect and associated with specific practice characteristics. interactions. Strengths and weaknesses The collaboration with mental health services is less than Although the response rate to the questionnaire was low, optimal and should be improved. With regard to the the responding GPs were comparable with the total group patients' perspective [44], the concept of continuity of of Dutch GPs in gender, age, type of practice and location. care refers also to the firm inclusion of the GP within com- This low response rate may have been due to different prehensive multidisciplinary care. The GP deserves a cen- causes. First, the questionnaire comprised several items tral position especially with respect to somatic co- on practice routines in relation to the last patient seen. morbidity and (psycho)pharmacological interactions. This type of question put a demand on the GP's memory and might take some time in retrieving the necessary Psychiatrists, like most specialists [45], consider "refer- details. Secondly, it is feared that GPs who lacked affinity ring" to be the GP's primary task. They do not consider with severe mental illnesses, simply did not answer the GPs as co-consultants in the care system surrounding a questionnaire. Nevertheless, the range of responses was patient with SMI. GPs may be able to change this, through quite wide. Perhaps the responders have sketched too pos- focusing more on the health condition of chronic psychi- itive image of primary health task perspectives. The find- atric patients, and describing their tasks in a set of guide- ings however offer concrete possibilities to improve the lines [46]. actual care for patients with severe mental illness. Recommendations It is recommended that the responsibilities and tasks for Conclusion The responding GPs find themselves capable of providing GPs dealing with severe mental illness should be devel- adequate care in the acute phase. As crisis situations are oped within multidisciplinary guidelines. These guide- relatively rare, most of them feel a need for continual pro- lines should be consistent with GPs' competences, fessional development training. especially those of monitoring and treating somatic co- Page 6 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 trial of family psycho education for schizophrenia. 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Care for patients with severe mental illness: the general practitioner's role perspective

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References (57)

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Springer Journals
Copyright
Copyright © 2009 by Oud et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
eISSN
1471-2296
DOI
10.1186/1471-2296-10-29
pmid
19419547
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Abstract

Background: Patients with severe mental illness (SMI) experience distress and disabilities in several aspects of life, and they have a higher risk of somatic co-morbidity. Both patients and their family members need the support of an easily accessible primary care system. The willingness of general practitioners and the impeding factors for them to participate in providing care for patients with severe mental illness in the acute and the chronic or residual phase were explored. Methods: A questionnaire survey of a sample of Dutch general practitioners spread over the Netherlands was carried out. This comprised 20 questions on the GP's 'Opinion and Task Perspective', 19 questions on 'Treatment and Experiences', and 27 questions on 'Characteristics of the General Practitioner and the Practice Organisation'. Results: 186 general practitioners distributed over urban areas (49%), urbanised rural areas (38%) and rural areas (15%) of the Netherlands participated. The findings were as follows: GPs currently considered themselves as the first contact in the acute psychotic phase. In the chronic or residual phase GPs saw their core task as to diagnose and treat somatic co-morbidity. A majority would be willing to monitor the general health of these patients as well. It appeared that GP trainers and GPs with a smaller practice setting made follow-up appointments and were willing to monitor the self- care of patients with SMI more often than GPs with larger practices. GPs also saw their role as giving support and information to the patient's family. However, they felt a need for recognition of their competencies when working with mental health care specialists. Conclusion: GPs were willing to participate in providing care for patients with SMI. They considered themselves responsible for psychotic emergency cases, for monitoring physical health in the chronic phase, and for supporting the relatives of psychotic patients. Page 1 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 drugs can also result in overweight and diabetes mellitus Background Severe mental illnesses (SMI), especially the schizophre- [20-23]. nia spectrum and affective psychotic disorders present themselves in a wide variety of clinical signs and symp- GPs seem not to be aware of the high rate of physical ill- toms. The common denominator of these disorders is the ness in patients with severe mental illnesses, nor do they loss of contact with reality and people of importance to pay specific attention to monitoring and treating somatic them. Therefore these patients demand specific attention co-morbidity in this group of patients [24]. Internation- for their wellbeing and health problems. ally, it is currently acknowledged by psychiatrists that gen- eral health-care needs in patients with severe mental For treatment, a crucial distinction between the acute illness are neglected. Also, that the integration of general phase and the chronic phase must be made. During the somatic and psychiatric care services is less than optimal acute phase, when positive symptoms and reality distor- [25,26]. However, there is a lack of consensus as to which tion prevail and a psychotic crisis arises, GPs are often the health care professionals should be responsible for the first to offer medical assistance. Their role is to recognize prevention and management of co-morbid somatic ill- the signals of a developing psychosis and to start appro- nesses in SMI patients [27]. Psychiatrists think that the priate treatment immediately [1,2]. This usually results in monitoring of metabolic disorders as a possible side-effect a referral to an emergency psychiatric consultation and, of antipsychotic drug is their responsibility [27-29], but less often, the prescription of an antipsychotic drug [3]. not necessarily the medical treatment. The updated UK guideline for schizophrenia states that for people with In the chronic phase, the role of the GP is less well- schizophrenia, just as for other high-risk groups, regular defined. Psychiatric treatment is more or less restricted to physical checks and health advice are an essential primary infrequent medication checks by the psychiatrist and to care contribution to their treatment and management the support by a community psychiatric nurse with regard [30]. Adherence to the guideline on monitoring risk fac- to self care, daily structure and activities and reintegration tors in patients taking second-generation antipsychotics, of the patient in the community. appears to be low [31]. Long term chronic psychotic disorders are often accompa- Dutch GPs have no specific management policy in the nied by a loss of cognitive abilities, such as disturbances guidance of SMI patients; their current multidisciplinary in perception, retardation, and executive functions. Psy- guidelines on schizophrenia do not give them a sufficient chotic patients may not be able to recognise certain phys- directive [32]. ical phenomena as a symptom of a co-morbid disease [4], and they often find it difficult to communicate their phys- Qualitative research on opinions of experienced GPs iden- ical needs and problems and to arrange appointments for tified the factors which influenced their attitudes to pro- themselves [5-7]. As a consequence, they seek help at a rel- viding care for patients with psychotic disorders [11]. atively late stage. These facts underscore the importance Patient behaviour factors like aggression and drug abuse that care provided by GPs should be easily accessible. Fur- were perceived as being as difficult to manage and some- thermore, the GP should be alert on somatic co-morbid- times threatening, while involvement with the patient's ity, and pay specific attention to the differential diagnosis family was a stimulus for the GP to do as much as he combined with the patient's physical condition [8]. could. Also a good collaboration with acute psychiatric services was indispensable for GPs to feel competent in Not only patients with SMI, but also their carers experi- managing a psychotic crisis. ence a lot of stress. They visit their GPs with their concerns as well [9,10]. GPs are aware of this and they feel that pro- In order to check current practice among GPs and the need viding support for families of patients is one of their core for a set of guidelines, we posed the following questions: tasks [11]. Mental health education for family members appears to be an effective intervention in the treatment of 1. What part of the health care should be provided by psychosis [12,13]. GPs for patients with severe mental illnesses, both in the acute and the chronic phase? Patients with a chronic psychosis often suffer from somatic co-morbidities [14-16], and have a higher death 2. Do GPs consider themselves sufficiently equipped risk [17]. Disease-related factors including chronic stress, to provide this care, and if not, in which areas do they smoking, drug abuse, life-style habits and lack of exercise need more training? contribute to this as well [18,19]. The use of antipsychotic Page 2 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 3. How do GPs manage their care for patients with SMI database of Netherlands Institute for Health Service in practice, and how close is their collaboration with Researche (NIVEL). mental health services? Data analysis The data were processed using the software programme Methods The survey instrument SPSS 14.0; which was also used for the statistical analysis. After reviewing the literature [32-40] a questionnaire was The answers on the ordinal five-level Likert scale were developed regarding the GP's role perspectives, his treat- translated into a three point scale, measuring either a pos- ment of SMI patients, his personal details and his practice itive or a negative response to a statement. The answers to organisation. the questions on 'Opinion and Task Perspective' and on 'Treatment and Experiences' were subjected to a factor The term 'Severe Mental Illness' was confined to patients analysis. The factors found were correlated with personal with psychotic symptoms related to the schizophrenia details and treatment aspects of GPs using multivariate and affective psychotic spectrum. analysis. A division was made between 'Providing Emergency Care' Results and 'Providing Care in the Chronic Phase'. Questions A total number of 186 completed questionnaires was about GP's attitude to periodic health checks were divided returned (27%). Nine questionnaires were undeliverable. into three aspects: physical health, psychosocial well- Of the respondents, 62% were male, the average work being and psychiatric symptoms. experience was 18 years (minimum 2 years, maximum 35 years) and the average age was 49 years. 22% worked sin- The draft questionnaire was reviewed by an expert panel gle-handed, 32% worked in two-man practice, 29% in a and was tested in a pilot study by interviewing four expe- group practice and 17% in a primary health care centre. rienced general practitioners. The purpose of this was to These data are consistent with the national figures on test for ambiguity, the relevance of the questions, and the Dutch GPs from NIVEL. difficulties in answering them. The revised questionnaire was divided into three sections: Section 1: 'Opinion and Of the respondents, 52% of GPs worked part-time. 40% Task Perspective', Section 2: 'Treatment and Experience' were also GP trainers, and 31% had psychiatric work expe- and Section 3: 'Personal Details of the GP and Practice rience. 61% had easy access to a community psychiatric Organisation'. nurse, whose main task was to advise the patient on prob- lem solving. They rarely supervised patients with severe An ordinal five-level Likert scale with variations between mental illnesses (13%). The average number of patients in positive and negative statements was used for answering a GP practice who were thought to be susceptible to psy- eleven questions on 'Opinion and Task Perspective', five chosis was about 20 (minimum 0, maximum 200). The of the questions on 'Treatment and Experiences', and six mean size of a Dutch GP practice covers 2350 inhabitants. questions on 'Characteristics of the GP'. The other 43 Concerning practice location: 49% was located in an questions were multiple choices, except for the questions urban area, 38% in an urbanised rural area, and 15% in a on age of the respondent and an estimate of the number rural area. of registered patients who were susceptible to psychosis. Opinion and Task Perspective (table 1) The secretary of the Medical Ethics Committee of the Uni- In the acute phase of psychosis, GPs viewed themselves as versity Medical Centre Groningen stated upon being con- the first contact. They also felt responsible for the long sulted that it was not necessary to obtain the consent of term care in the chronic stage: monitoring somatic co- the committee. morbidity and taking care of repeat prescriptions. Regard- ing periodic physical checks, 80% of GPs considered this The questionnaire was distributed in June 2007. It took their task: 55% annually, 34% once half-yearly. Mental 20–30 minutes to complete the questionnaire. Participa- functioning should be monitored by a community psychi- tion was voluntary and anonymous. All GP's received a atric nurse and periodically checked by a psychiatrist reminder four weeks after the distribution. belonging to the mental health service. The GPs felt it their task to support the family and provide information The sample on the patient's condition. The research was conducted among GPs who provided continuous care, i.e. established GPs and GPs in service of Not all of the respondents felt capable of making contact established GPs. Locum GPs were excluded from the with the patient during a psychotic crisis, whereas they research. A random sample of 700 GPs was taken from the were confident making contact with the family. Neverthe- Page 3 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 Table 1: Opinion and Task Perspective (N = 186) Agree Neutral Disagree Tasks in the acute and long term phase For acute confusion, the GP is the first contact 74% 19% 7% I feel responsible for the care for chronic psychiatric patients in my practice 58% 23% 19% I think it is my job to check on psychiatric patients' ability to take care of themselves 37% 30% 33% I think I should monitor somatic co morbidity in chronic psychiatric patients 81% 13% 6% Care for family I think it is my job to support the family of a chronic psychotic patient 74% 17% 9% I think it is my job to provide information on the clinical picture to the family of a chronic psychotic patient 58% 26% 16% Self-experienced competencies I feel competent in making contact with the patient in a psychotic crisis 46% 35% 19% I feel competent in communicating with the family in a psychotic crisis 85% 11% 4% I feel competent in intervening in a crisis situation 52% 33% 15% I feel powerless in a psychotic crisis 18% 28% 54% I feel unsafe near an acute psychotic patient 16% 35% 49% Need for continual professional development training (CPD training) I need CPD training on guiding of and communicating with psychotic patients 55% 27% 18% I need CPD training on interventions in a psychotic crisis 63% 20% 17% I need CPD training on antipsychotic pharmacotherapy 54% 24% 22% less, most GPs felt reasonably well-able to intervene in a to a mental health service. A minority (39%) of GPs pre- crisis situation. A minority felt powerless or unsafe. GPs scribed an antipsychotic drug themselves, of which 53% did indicate they needed further training in this area. concerned a restart of previously prescribed drugs. Most GPs (60%) made follow-up appointments and contacted Practice experiences the family regularly (68%). At times, the GP would do a A majority of respondents (59%) had seen a patient con- physical check (35%) or request lab checks (28%). cerning psychosis in the previous 6 months, and 78% had seen one in the last 12 months. These contacts included: Experiences with specialised mental health services (table first episode psychosis (21%), psychotic depression 2) (23%), schizophrenia (29%), bipolar disorder (18%), In emergency cases, 61% of GPs stated they were able to reach mental health care services easily, and they felt taken psychosis resulting from drug abuse (3%) and the remain- ing category were: second episode of psychosis, organic seriously as the referring party. However, there was no col- psychosis and delirium. laboration with mental health care providers in the organ- isation of long term care. GPs were not included in the Of these patients, 62% had been in contact with mental development of treatment plans, and did not receive reg- health services previously. Most cases (84%) were referred ular information on the patient's status during treatment. Table 2: Experiences with specialised mental health services (N = 186) Agree Neutral Disagree It does take a lot of effort to consult a psychiatrist in an emergency psychotic crisis 30% 9% 61% My information is taken seriously by the psychiatrist 60% 25% 15% The mental health services involve me, as GP, in the treatment plan 12% 20% 68% The mental health services keep me informed on a regular basis 19% 29% 52% I feel supported by the collaboration with the mental health services 38% 39% 23% Page 4 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 Multivariate analysis which was consistent with actual figures: 1% of the popu- A factor analysis of the answers to the questions of the sec- lation is susceptible to psychosis. A broader role perspec- tion 'Opinion and Task Perspective', the questions on col- tive is associated with a higher job satisfaction in the laboration with MHS, and the questions on personal guidance of psychiatric patients. This group of GPs made details with regard to attitude and need for training iden- use of the community psychiatric nurse more often, if tified the following four independent factors: available. - self-experienced competencies in the acute phase of No significant relation was found between practice char- psychotic illness acteristics and experience with mental health services. - task perspective in the chronic phase of psychotic ill- Discussion ness The GPs responding to the questionnaire agree on their role in the acute phase: having assessed the patient's con- - experience with mental health services dition, they refer the patient to a mental health centre and/or prescribe an antipsychotic drug. In addition, the - need for continual professional development train- GPs support the family members. GPs consider the collab- ing (CPD) oration with mental health services as adequate in this phase. Not surprisingly, inexperienced GPs feel the need Relationship between the four domains and GP (practice) for training in dealing with crisis situations. characteristics (table 3) and treatment aspects of GPs (table 4) In the chronic phase, the responding GPs differ in their GPs who felt competent in the acute phase of a patient's opinion as to what care they should provide. These differ- psychotic illness suffered less from feelings of helplessness ences are explained by different task perspectives, experi- or fear than GPs who were not familiar with problems of ence with regional mental health services, and their patients with SMI. More often than not, these GPs had perceived need for specific training. gained work experience in a psychiatric institute and felt less need for extra training. They had diagnosed a patient Many GPs do feel involved in this stage, but they find the with acute psychosis more often in the last six months, psychosocial problems associated with it quite difficult. and conducted physical checks more often. Also, they Currently, GPs tend just to diagnose and treat somatic co- made follow-up appointments with patients more often, morbidity, but a majority would be willing to monitor and considered periodic checks on a patient's self-neglect physical health in the future. They also want to be respon- a part of the GP's responsibility. sible for repeat prescriptions, but they lack expertise in the effectiveness and side effects of antipsychotic drugs. GPs with a broader role perspective on the care for psy- chotic patients often had a smaller practice list and were GPs feel reluctant to inquire about the patient's self-care, more often GP trainers. They estimated that they had a and therefore they are unable to assess the risk of neglect. higher prevalence of psychotic patients in their practice, Possibly they are not aware of the fact that a better physi- Table 3: Significance of the relationship between the four domains and GP (practice) characteristics Domains 1 234 gender GP .082 .355 .573 .624 type of practice .704 .999 .704 .124 part time – fulltime .397 .988 .247 .335 GP trainer .493 .014 .488 .723 urbanization .109 .059 .406 .767 work experience in psychiatry .002 .266 .945 .045 work experience as GP .066 .724 .936 .790 volume of practice list .091 .044 .777 .102 registration of SMI in electronic patient records .345 .121 .548 .806 estimated number of patients susceptible to psychosis .111 .003 .996 .890 *statistically significant relations (p ≤ 0.05) are printed in bold 1 = self-experienced competencies in the acute phase 2 = task perspective in the chronic phase 3 = experience with mental health services 4 = need for CPD training Page 5 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 Table 4: Significance of the relationship between the four domains and GP's treatment aspects Domains 12 3 4 most recent treatment concerning psychosis .021 .748 .625 .026 referral patient to mental health services .661 .206 .270 .658 start pharmacotherapy .446 .243 .187 .771 follow-up appointment with patient .184 .013 .642 .758 follow-up appointment with family .279 .093 .977 .341 physical check .032 .319 .332 .050 lab diagnostics .093 .940 .466 .231 *statistically significant relations (p ≤ 0.05) are printed in bold 1 = self-experienced competencies in the acute phase 2 = task perspective in the chronic phase 3 = experience with mental health services 4 = need for CPD training cal condition improves the psychiatric symptoms and the In the chronic phase of a psychotic illness, GPs are willing quality of life [5]. to be part of the care system surrounding a psychotic patient. Most GPs consider assessing the patient's physical GPs that have a broad role perspective tend to monitor the condition and detecting and monitoring somatic co-mor- patient in the chronic phase and experience a higher job bidity as their responsibility. Risk management and the satisfaction in the guidance of their patients than those treatment of somatic co-morbidity are part of the GP's who do not. As these GPs often have a smaller practice list, expertise, as is giving support and information to the it is assumed that this enables the GP to know and under- patient's family. However, such judgment requires an stand his patients better. active, outreaching attitude on the GP's part. When com- municating with chronic psychotic patients, it is necessary The collaboration between GPs and mental health spe- for GPs to take the patient's possible cognitive handicaps cialists in chronic cases leaves much to be desired. There is into account [43]. no cohesion in the care given. This problem appears to be universal [4,41,42]. The GP is not included in the devel- The majority of the GPs, however, experience the need for opment of treatment plans and is not informed about the training in counselling in the chronic phase, specifically in patient's status during treatment. This finding was not pharmacotherapy, including topics like side-effect and associated with specific practice characteristics. interactions. Strengths and weaknesses The collaboration with mental health services is less than Although the response rate to the questionnaire was low, optimal and should be improved. With regard to the the responding GPs were comparable with the total group patients' perspective [44], the concept of continuity of of Dutch GPs in gender, age, type of practice and location. care refers also to the firm inclusion of the GP within com- This low response rate may have been due to different prehensive multidisciplinary care. The GP deserves a cen- causes. First, the questionnaire comprised several items tral position especially with respect to somatic co- on practice routines in relation to the last patient seen. morbidity and (psycho)pharmacological interactions. This type of question put a demand on the GP's memory and might take some time in retrieving the necessary Psychiatrists, like most specialists [45], consider "refer- details. Secondly, it is feared that GPs who lacked affinity ring" to be the GP's primary task. They do not consider with severe mental illnesses, simply did not answer the GPs as co-consultants in the care system surrounding a questionnaire. Nevertheless, the range of responses was patient with SMI. GPs may be able to change this, through quite wide. Perhaps the responders have sketched too pos- focusing more on the health condition of chronic psychi- itive image of primary health task perspectives. The find- atric patients, and describing their tasks in a set of guide- ings however offer concrete possibilities to improve the lines [46]. actual care for patients with severe mental illness. Recommendations It is recommended that the responsibilities and tasks for Conclusion The responding GPs find themselves capable of providing GPs dealing with severe mental illness should be devel- adequate care in the acute phase. As crisis situations are oped within multidisciplinary guidelines. These guide- relatively rare, most of them feel a need for continual pro- lines should be consistent with GPs' competences, fessional development training. especially those of monitoring and treating somatic co- Page 6 of 8 (page number not for citation purposes) BMC Family Practice 2009, 10:29 http://www.biomedcentral.com/1471-2296/10/29 trial of family psycho education for schizophrenia. 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