Barriers to the Treatment of Mental Illness in Primary Care Clinics in Israel

The association between multiple sclerosis and early psychiatric background

BACKGROUND

The exact cause of Multiple Sclerosis (MS) is unclear. Since its definition in the late 19th century, researchers have repeatedly suggested a connection between the disease and mental state. Studies have shown that mental symptoms tend to precede the initiation of the disease by up to ten years. However, the hypothesis that psychiatric issues might precede MS onset by longer periods has not been empirically established. This study seeks to fill this research gap. The current matched cohort study investigated the possibility that psychiatric conditions may precede the initiation of multiple sclerosis by 15 years or more METHODS: A retrospective analysis utilizing the electronic database of Clalit Health Services (CHS), Israel's largest HMO, compared a group of 9,533 MS-diagnosed female and male individuals with 28,599 non-MS matched controls RESULTS: Logistic regression analysis revealed a significant association (p < 0.001) between MS diagnosis and prior psychiatric conditions, indicating a 93% increased likelihood of psychiatric history among those later diagnosed with MS compared with those who were not CONCLUSIONS: The heightened probability of mental health issues preceding the onset of MS by extended durations suggests a potential etiological role in the development of MS, rather than solely representing a component of the prodromal stage of the disease. Limitations include the retrospective design and the need for prospective studies to validate these associations.

Exploring the experiences of mental health nurses in the management of schizophrenia in the Upper East Region of Ghana: a qualitative study

OBJECTIVE

Schizophrenia is a chronic condition, of which the diagnosis and management require comprehensive care. The role mental health nurses play in this management cannot be overemphasised. In an effort to give their best, several challenges confront them which need to be sought and addressed. This study aimed to explore the factors that influence the management of schizophrenia by mental health nurses in the Upper East Region.

DESIGN AND PARTICIPANTS

A descriptive phenomenology design was used in this study. Individual in-depth interviews were conducted among 18 purposively sampled mental health nurses using a semistructured interview guide. Audio-recorded interviews were transcribed verbatim and analysed thematically using Colaizzi's approach.

SETTING

The study was conducted in five primary and secondary-level health facilities in the Upper East Region of Ghana.

FINDINGS

Five themes were deduced from the theoretical framework, which were as follows: individual factors, interpersonal factors, organisational factors, community-level factors, and policy-level factors. At the individual level, factors such as the condition of the patient at presentation, medication side effects, inadequate knowledge, and poor adherence were identified. Interpersonal factors identified were poor communication, lack of mutual respect, and poor communication, while organisational factors such as inadequate staff, inadequate infrastructure and logistics, and unavailability of antipsychotics were reported. Moreover, the study identified community-level factors such as stigma and cultural beliefs, while policy-level factors such as laws regarding suicide, patient rights, and non-inclusion of mental health services into the National Health Insurance Scheme were reported as factors influencing the management of schizophrenia by mental health nurses.

CONCLUSIONS

Addressing these factors is essential to ensure sustainable improvements and the effective management of schizophrenia. It is imperative to consider these factors when designing interventions and policies to optimise the management of schizophrenia by mental health nurses in Ghana.

A Cross-Sectional Study of the Prevalence and Determinants of Common Mental Health Problems in Primary Care in Switzerland

Objective: This study investigated the prevalence of the most common mental health symptoms in a large primary care patient population and characterized their determinants. Methods: Data came from a 2015-16 cross-sectional study of a primary care population in Switzerland. An investigator presented the study to patients in waiting rooms, and 1,103 completed a tablet-based questionnaire measuring stress in daily life, sleep disorders and anxiety and depressive symptoms. Diagnoses and treatments were recorded. Results: Moderate-to-high anxiety and depressive symptoms concerned 7.7% of patients; 27.6% felt stressed at least once a week; 17.2% had severe sleep disorders. Sociodemographic determinants were associated with psychiatric symptoms: female sex, young age, and frequency of consultations with a GP. Participants taking psychotropics had high levels of mental distress. Conclusion: Even though most patients were regularly monitored by their GP, a significant number of mental health problems were found. GPs should be provided with concrete tools to manage these patients better. Collaboration with mental health specialists should be encouraged in primary care settings.

Psychiatric consultation in general practitioners' daily practice: a qualitative study on the experience of consultation-liaison psychiatry interventions in primary care settings in French-speaking Switzerland

BACKGROUND

Mental disorders are frequent in primary care settings, which is challenging for primary care physicians. In Neuchâtel (Switzerland), a Consultation-Liaison psychiatrist integrated three primary care group practices, proposing both clinical interventions and supervisions/psychiatric training. Primary care physicians' experience regarding this collaboration was investigated.

METHODS

A qualitative study was conducted. Three focus groups were organized in each primary care group practice involved in the project (10 primary care physicians participated in focus groups). Data were analysed with thematic content analysis.

RESULTS

Six major themes emerged from our analysis, describing primary care physicians' collaboration with psychiatrists: 1) Impact on a difficult to reach and "reluctant to consult" population; 2) Fluidity of the intraprofessional collaboration; 3) Influence on the doctor-patient relationship; 4) Positive emotional experiences; 5) Psychiatric counselling and training; 6) Long-term prospects for the project.

CONCLUSIONS

Consultation-Liaison psychiatrist's presence came as a relief for participating primary care physicians, facilitating accessibility to mental healthcare, introducing a common culture of care, and offering "in-situ" psychiatric training. Primary care physicians felt that their relationships with patients benefited from such interventions, being better able to deal with complex emotional experiences and found patients more confident regarding proposed care. Models of psychiatric intervention provided in primary care must establish settings of collaboration that reinforce relationships between primary care physicians, psychiatrists, and patients.

Primary Care Providers' Perspectives on Prescribing Antidepressant Medication to Latino Immigrant Patients: A Preliminary Study

Latinos in the United States are less likely to take antidepressants than non-Latino whites, and more likely to prefer depression treatment in primary care. This preliminary study comprised focus groups (2) with primary care providers (12) serving uninsured immigrant Latinos regarding their experiences prescribing and counseling patients about antidepressants. Barriers and challenges included health literacy, language barriers, and illiteracy; perceived stigma; patients' concerns about addiction, polypharmacy, and adverse effects; time constraints of office visits; and difficulty discussing comorbid posttraumatic stress disorder. Messages providers try to share with patients included allowing time for medications to work, taking medications daily as prescribed, mechanisms of action, weighing risks versus benefits, and flexible options for treatment. Providers' recommendations for improving this process included better low-literacy, culturally appropriate written materials with pictures or videos discussing depression. More research is needed to understand patients' and providers' needs in optimizing counseling about antidepressants, particularly regarding underserved and at-risk US populations.

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study

BACKGROUND

There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center.

METHODS

Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results.

RESULTS

Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress.

CONCLUSIONS

General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers

Background

The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas.

Purpose

The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs).

Methods

This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC.

Results

Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care.

Conclusion

There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.

Knowledge and attitudes about mental health among older immigrants from the former Soviet Union to Israel and their primary care physicians

Previous studies have documented a high prevalence of psychological distress and mental illness among older immigrants from the former Soviet Union (FSU) in Israel. Yet, this population rarely seeks help from mental health providers. The present study aimed to identify beliefs and attitudes about depression and anxiety among older immigrants from the FSU treated in primary care, and among their primary care physicians, who were also FSU immigrants. The study used focus group (FG) interviews with primary care patients (n = 12) and physicians (n = 23). The interviews were transcribed and analyzed using open thematic coding. Three main themes were identified: a) avoidance of discussion of mental health and stigma regarding mental illness; b) expectations to control one's mental state; and c) limited opportunities to acquire knowledge about Western mental health. Primary care physicians recognized the barriers facing their older immigrant patients concerning mental health diagnosis and treatment. Yet, due to work overload, their ability to assist older immigrants was limited. The findings suggest that older immigrants from the FSU might benefit from mental health information and exchange of ideas about Western mental health.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework

Background

Uptake of clinical guideline recommendations into routine practice requires changes in attitudes and behaviors of the health care providers. The World Health Organization (WHO) has heavily invested in public health and health promotion globally by developing policy recommendations to guide clinical practice; however, clinical guidelines are often not applied. The success of the implementation of any guidelines depends on consideration of existing barriers and adequately addressing them. Therefore, exploring the context specific barriers and facilitators affecting the primary care providers (PCPs) in Mbarara district, Uganda may provide a practical way of addressing the identified barriers thus influence the PCPs action towards integration of mental healthcare services into PHC.

Methods

We adopted a theoretical model of behavior change; Capability, Opportunity and Motivation developed to understand behavior (COM-B). This was a cross-sectional study which involved using a semi-structured qualitative interview guide to conduct in-depth interviews with PCP’s (clinical officers, nurses and midwives).

Results

Capability - inadequacy in knowledge about mental disorders; more comfortable managing patients with a mental problem diagnosis than making a new one; knowledge about mental health was gained during pre-service training; no senior cadre to consultations in mental health; and burdensome to consult the Uganda Clinical Guidelines (UCG). Opportunity - limited supply of hard copies of the UCG; guidelines not practical for local setting; did not regularly deal with clients having mental illness to foster routine usage of the UCG; no sensitization about the UCG to the intended users; and no cues at the health centers to remind the PCPs to use UCG. Motivation - did not feel self-reliant; not seen the UCG at their health facilities; lack of trained mental health specialists; conflicting priorities; and no regulatory measures to encourage screening for mental health.

Conclusions

Efforts to achieve successful integration of mental health services into PHC need to fit in the context of the implementers; thus the need to adapt the UCG into local context, have cues to enforce implementation, and optimize the available expertize (mental healthcare providers) in the process.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3684-7) contains supplementary material, which is available to authorized users.

Psychiatrists role in primary health care in Greece: findings from a quantitative study

BACKGROUND

Although the need for integration of mental health services into primary care is well established little has been done. The outbreak of the recession found the Greek mental health system in transition. As a response to the crisis, governments implemented horizontal budget cuts instead of health reforms. This resulted in an unfavorable situation for mental health which was set once again on the sidelines of the health policy agenda. Previous studies suggest that the most prevalent disorders in the years of financial crisis in Greece are depression and anxiety while a general increase of the psychiatric morbidity is observed does not follow the population' needs.

METHODS

The present descriptive study was carried out between March and June of 2015. A convenience sample of 174 psychiatrists and psychiatry residents who met the inclusion criteria were finally selected to participate. Data were collected by using a 40-items questionnaire consisted of three sections: (a) nine questions about demographics, (b) nine questions pertaining to general aspects of administrative regulations related to primary care, (c) 22 questions about psychiatrists attitudes and perceptions towards their role in primary care. Quantitative variables are expressed as mean values, while qualitative variables as absolute and relative frequencies.

RESULTS

The vast majority of participants perceives the public primary care services and mental health services in their community as inadequate and considers psychiatrists' participation in primary care as important in order to improve the detection and management rates of people demonstrating mental health symptoms. They also believe that: (a) primary care practitioners' usually fail to detect the mental health conditions of patients; (b) their participation in primary care will decrease the social stigmatization for mental health conditions; (c) patients receiving pharmaceutical treatment for mental health problems by GPs and other primary care professionals usually fail to comply.

CONCLUSIONS

Respondents in the present study are receptive to participate in primary care. They believe that their inclusion to primary care will result to decreased social stigmatization for mental health problems, increased patient' access and improved detection and management rates for common mental health conditions.