Beyond symptoms: Defining primary care mental health clinical assessment priorities, content and process

Whole person assessment for family medicine: a systematic review

OBJECTIVES

To identify and evaluate clinical approaches to whole person assessment (WPA) that are translatable to family medicine regarding feasibility, quality and alignment with theoretical models of whole person care (WPC).

DESIGN

Systematic literature review.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO and ATLA Religion databases were searched through 9 March 2020, with additional handsearches.

ELIGIBILITY CRITERIA

English language clinical assessments of multiple domains; which involve patient-clinician interaction and are translatable to general practice (GP); from the fields of medicine, allied health, nursing, mental health and pastoral care. Tools designed for single diseases or symptoms, for outcome rather than clinical assessment or with outdated classification systems were excluded.

DATA EXTRACTION AND SYNTHESIS

We appraised the quality of included papers using Johanna Briggs' Institute Checklists and Terwee's criteria for validation studies. Clinical assessments' alignment with theoretical WPC, feasibility for adaptation to GP and quality were examined. We analysed extracted data using framework synthesis.

RESULTS

Searches retrieved 7535 non-duplicate items. Fifty-nine were included after screening, describing 42 WPA methods and representing multiple disciplines, purposes and formats. All included assessments aligned partially with models of WPC, but most did not adequately encompass all aspects of WPC. Robustness varied significantly and was often inadequately described. We judged none of the identified assessments to be ideal as a multipurpose WPA in GP. Some could be used for specific purposes, such as elicitation of patient perspectives or complexity assessment.

CONCLUSIONS

While no WPAs were found that were sufficient for broad implementation in GP, some approaches may be suitable with adaptation and evaluation. Strengths of existing approaches could inform WPA development in future.

PROSPERO REGISTRATION NUMBER

CRD42020164417.

Screening, Monitoring, and Referral to Treatment for Young Adolescents at an Urban School-Based Health Center

BACKGROUND

This study describes the experience of implementing a screening, monitoring, and referral to treatment (SMARTT) initiative at an urban middle school school-based health center.

METHODS

Retrospective data were collected for adolescents screened with the Pediatric Symptom Checklist-17-Y. At-risk adolescents having unmet health needs were offered a mental health referral, and those that declined a mental health referral were offered a primary care monitoring (PCM) visit with the medical provider. Chi-square analyses were used to evaluate differences in screening and outcomes by age, sex, and race/ethnicity.

RESULTS

One out of four adolescents had a positive PSC-17-Y or negative screen with other identified concerns. Approximately half of these at-risk adolescents accepted a mental health referral, and 86% of those who declined agreed to the PCM visit. More than two-thirds of the PCM group did not need continued monitoring and support at follow-up, and 85.4% of youth who had a mental health assessment accepted mental health services.

CONCLUSIONS

The SMARTT initiative successfully demonstrated that co-located and integrated mental health services can enhance access and connection to mental health services for at-risk youth. In addition, PCM visits were found to be an effective option for youth who declined mental health referrals.

Long-term antidepressant use in general practice: a qualitative study of GPs' views on discontinuation

Background

There is considerable concern about increasing antidepressant use, with Australians among the highest users in the world. Evidence suggests this is driven by patients on long-term use, rather than new prescriptions. Most antidepressant prescriptions are generated in general practice, and it is likely that attempts to discontinue are either not occurring or are proving unsuccessful.

Aim

To explore GPs’ insights about long-term antidepressant prescribing and discontinuation.

Design and setting

A qualitative interview study with Australian GPs.

Method

Semi-structured interviews explored GPs’ discontinuation experiences, decision-making, perceived risks and benefits, and support for patients. Data were analysed using reflexive thematic analysis.

Results

Three overarching themes were identified from interviews with 22 GPs. The first, ‘not a simple deprescribing decision’, spoke to the complex decision-making GPs undertake in determining whether a patient is ready to discontinue. The second, ‘a journey taken together’, captured a set of steps GPs take together with their patients to initiate and set-up adequate support before, during, and after discontinuation. The third, ‘supporting change in GPs’ prescribing practices’, described what GPs would like to see change to better support them and their patients to discontinue antidepressants.

Conclusion

GPs see discontinuation of long-term antidepressant use as more than a simple deprescribing decision. It begins with considering a patient’s social and relational context, and is a journey involving careful preparation, tailored care, and regular review. These insights suggest interventions to redress long-term use will need to take these considerations into account and be placed in a wider discussion about the use of antidepressants.

Transdisciplinary Generalism: Naming the epistemology and philosophy of the generalist

BACKGROUND

Transdisciplinary research and generalist practice both face the task of integrating and discerning the value of knowledge across disciplinary and sectoral knowledge cultures. Transdisciplinarity and generalism also both offer philosophical and practical insights into the epistemology, ontology, axiology, and logic of seeing the 'whole'. Although generalism is a skill that can be used in many settings from industry to education, the focus of this paper is the literature of the primary care setting (i.e., general practice or family medicine). Generalist philosophy and practice in the family medicine setting highly values whole person care that uses integrative and interpretive wisdom to include both biomedical and biographical forms of knowledge. Generalist researchers are often caught between reductionist (positivist) biomedical measures and social science (post-positivist) constructivist theories of knowing. Neither of these approaches, even when juxtaposed in mixed-methods research, approximate the complexity of the generalist clinical encounter. A theoretically robust research methodology is needed that acknowledges the complexity of interpreting these ways of knowing in research and clinical practice.

METHODS

A conceptual review of literature to define the alignment between (a) the philosophy and practice of generalism in primary care and (b) both the practical (Zurich) and philosophical or methodological (Nicolescuian) schools of transdisciplinarity.

RESULTS

The alignment between generalism and transdisciplinarity included their broad scope, relational process, complex knowledge management, humble attitude to knowing, and real-world outcome focus.

CONCLUSION

The concurrence between these approaches to knowing is offered here as Transdisciplinary Generalism - a coherent epistemology for both primary care researchers and generalist clinicians to understand, enact, and research their own sophisticated craft of managing diverse forms of knowledge.

Nurse managed patient focused assessment and care: A grounded theory of qualified nurses in acute and critical care settings assessing the mental capacity of adult patients

AIMS

To explore processes used by qualified nurses in assessing mental capacity of acutely and critically ill hospitalised adult patients.

BACKGROUND

Mental capacity is the ability to understand, reason and make decisions. Acute and critical illness may impact upon the decision-making abilities of hospitalised adult patients but little is known about how qualified nurses across a range of acute settings assess the capacity of such patients in their care.

DESIGN

A qualitative grounded theory approach informed by the Corbin and Strauss (Basics of Qualitative Research (Third Edition). London, UK: Sage, 2008) methodological pathway.

METHODS

Data were collected through digitally recorded, semi-structured interviews to explore assessment of capacity processes used by 13 registered nurses employed in acute and critical care environments in a district general hospital in South Wales, UK. Data were analysed using iterative constant comparative processes leading to a core category and grounded theory. The study is presented in accordance with the COREQ checklist.

RESULTS

Informal, intuitive, holistic nurse-led processes were used to assess the mental capacity of patients which combined processes for the assessment of their physiological and mental capacity status, recognising the need to support their rights, dignity and autonomy. The assessment of mental capacity was not a lone process but one that contributed to a cyclical process in which multi-professional assessment was necessary and ongoing, and in which qualified nurses had a co-ordinating role. This led to the development of the theory, Nurse Managed Patient Focused Assessment and Care.

CONCLUSION

This theory provides a framework to explain processes and strategies used by qualified nurses in assessing mental capacity of, and caring for, adult patients with acute and/or critical illness.

RELEVANCE TO CLINICAL PRACTICE

This framework may inform related clinical practice and can serve as a basis of an assessment tool in what has been identified as a fundamental role of the qualified nurse.

Les médecins de famille et la santé mentale : une expertise en mal de reconnaissance ou une pratique différente de celle des psychiatres ?

Le système de santé au Québec a connu, dans la foulée du Plan d’action en santé mentale, des transformations majeures dans les services publics destinés à la santé mentale. Plusieurs patients, autrefois suivis en psychiatrie, se voient désormais orientés et traités en première ligne. Cette réforme fût mise en place alors qu’on connaissait paradoxalement assez peu la pratique et les besoins des omnipraticiens qui prodiguent les soins en santé mentale à une vaste proportion de la population. Les études évaluant leur pratique clinique démontrent une divergence dans l’application des guides de pratique par rapport aux psychiatres et concluent souvent à une compétence moindre sur le plan des compétences diagnostiques. L’objectif de cette étude est de comprendre la nature de la pratique des omnipraticiens en santé mentale, leurs besoins et surtout les limites perçues par eux-mêmes de leurs prises en charge. À l’aide d’une méthodologie qualitative d’analyse de contenu, nous avons analysé 57 demandes de consultation des omnipraticiens envers une équipe spécialisée en santé mentale. Les demandes analysées révèlent certaines particularités de cette pratique : l’incertitude liée au vaste spectre de la normalité, l’aspect longitudinal de la relation et la proximité du soma, et permettent de dégager certains axes autour desquels on peut d’ores et déjà articuler les efforts de collaboration, d’enseignement et d’organisation de soins en santé mentale de première ligne.

"You Never Know What Happens Next" - Young Adult Service Users' Experience with Mental Health Care and Treatment through One Year

Fragmented services are a well-known problem in the mental health sector. Mental health service users’ experiences of treatment and care can provide knowledge for developing more user-oriented continuity of care. We followed nine young adults with mental health illnesses and complex needs, conducting four interviews with each informant in the course of a year. The aim was to capture their experiences and views about treatment and care, focusing on (dis)continuities and episodes occurring through that year. The users’ experiences were affected by shifts and transitions between institutions, units and practitioners while their need was predictability and stability. A good and stable patient-provider relationship was considered highly useful but difficult to establish. The participants had a strong desire for explanation, adequate treatment and progress, but very different perceptions of the usefulness of diagnoses. Some felt rejected when they tried to tell the therapist about their trauma. Lack of user-involvement characterized many of the participants’ stories while they desired to become more engaged and included in important decisions concerning treatment and medication.

The participants’ experiences stand in contrast to key policy goals of coherent mental health services. The article discusses what may explain the gap between policy and reality, and how continuity of care may be improved.

Depression, patient characteristics, and attachment style: correlates and mediators of medication treatment adherence in a racially diverse primary care sample

Background

The depth and breadth of problems related to depressive symptomatology and optimal treatment outcomes, including medication treatment adherence, have long been documented in the literature. Missing are clear explanations as to what factors and patient characteristics may account for lack of medication treatment adherence.

Objectives

The two objectives of the current study were to examine the predictive strength of depression, patient characteristics, and patient attachment style regarding medication treatment adherence and to consider the extent to which attachment styles mediate the relation between depression and medication treatment adherence.

Method

Participants in the present study were 237 racially diverse American primary care patients with a diagnosis of hypertension who were participants in a clinical trial. Depression, patient characteristics, attachment style, and medication treatment adherence were assessed.

Results

Partly consistent with our four hypotheses, the following results were found: (a) Black American, younger, never married, and poorer patients had lower medication treatment adherence (b) depression was significantly associated with lower self-reported medication adherence; (c) insecure–dismissing attachment style was related to lower medication adherence; and (d) insecure–dismissing attachment style mediates the relation between depression and medication treatment adherence by exacerbating the negative association.

Conclusion

Physicians and other primary care providers should consider how depressive symptomatology, patient characteristics, and attachment style may inform the treatment plans they put forward and the extent to which patients may adhere to those treatment plans.

Quality of life, sense of coherence and experiences with three different treatments in patients with psychological distress in primary care: a mixed-methods study

Background

Psychological distress is associated with impaired health-related quality of life (HRQL) and poor sense of coherence (SOC). In a previous study, we found that therapeutic acupuncture (TA) and an integrative treatment that combined TA with person-centred approach in a salutogenic dialogue (IT) alleviated anxiety and depression significantly more than conventional treatment (CT) in primary care patients. Here, we report on secondary analyses regarding the HRQL and SOC from that previous pragmatic randomised controlled trial (RCT).

Method

Quantitative and qualitative design. One hundred twenty patients were referred for psychological distress. Quantitative analyses were performed at baseline and after 8 weeks of treatment using the SF-36 mental component summary (MCS), physical component summary (PCS) and the Sense of Coherence-13 (SOC) questionnaires. Qualitative manifest content analyses were based on open-ended questions—“Have you experienced any changes since the start of the treatment? Will you describe these changes?”

Results

No baseline differences were found. At 8 weeks, both the IT and TA groups had statistically better scores and greater improvement from baseline on the MCS and SOC than the CT group. The effect sizes were large. No significant differences were found between the IT and TA groups or in relation to the PCS. SOC was highly correlated with the MCS but not with the PCS. Dropout rates were low.

The experiences of the intervention resulted in four categories: Being heading back; Status quo; Feeling confirmed; and Feeling abandoned, with 13 related subcategories.

Conclusion

IT and TA seem to improve sense of coherence and mental health status in primary care patients with psychological distress, whereas CT appears to be less beneficial. IT and TA appear to be well-accepted and may serve as useful adjunct treatment modalities to standard primary care. Our results are consistent with much of the previous research in highlighting a strong relationship between SOC and mental health status. The written qualitative data described feeling confirmed and feeling increased self-efficacy, self-care and faith in the future. Those in the CT group, however, described feeling abandoned, missing treatment and experiencing increased emotional and physical problems. More research is needed.

Trial registration

ISRCTN trial number NCT01631500.

Mental ill health in the elderly: medical students' social representations in the United Kingdom

Objective This study aims to explore medical students' social representations of mental ill health in older adults. Method It comprises an exploratory and qualitative investigation based on the theory of social representations. Two focus groups with pre-clinical medics (group 1, N=4; group 2, N=4) and 10 individual interviews with clinical medical students were conducted. Thematic analysis at a latent level explored meanings and differences between groups. Results Three overarching themes reflect participants' representations of mental health problems in later life - mental ill health in old age, polarisation of care, and challenges to care. Primary health care appears as an important strategy to overcome barriers to mental health care in the community. Nevertheless, disqualifying representations, stigma and organization of services constitute the main challenges to quality mental health care in later life. Conclusion This paper highlights the need to address cultural and organizational barriers to promote quality care.