GPs' responses to adolescents presenting with psychological difficulties: a conceptual model of fixers, future planners, and collaborators

General practitioners' everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands

BACKGROUND

Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in detecting and intervening in such problems, it is clinically necessary to improve our insight into their clinical decision-making (CDM). The objective of this study was to explore which mechanisms underlie GPs' everyday CDM and their options for management or referral.

MATERIAL AND METHODS

This was a mixed methods study in which qualitative (interview substudy) and quantitative (online survey substudy) data were collected from GPs. Using a question framework and vignettes representative of clinical practice, GPs' CDM was explored. GPs were selected by means of an academic research network and purposive sampling. Data collection continued in constant comparison between both substudies. Using grounded theory, data from both substudies were triangulated into a flowchart consisting of mechanisms and management/referral options.

RESULTS

CDM-mechanisms were divided into three groups. GP-related mechanisms were GPs' primary approach of the problem (somatically or psychosocially) and their self-assessed competence to solve the problem based on interest in and knowledge about youth mental health care. Mechanisms related to the child and its social context included GPs' assessment whether there was psychiatric (co)morbidity, their sense of self-limitedness of the problem and assessed complexity of the problem. Whether GPs' had existing collaboration agreements with youth care providers and how they experienced their collaboration were collaboration-related mechanisms.

CONCLUSION

The current study contributes to a relatively unexplored research area by revealing GP's in-depth thought processes regarding their CDM. However, existing research in this area supports the identified CDM mechanisms. Future initiatives should focus on validating CDM mechanisms in a larger population. If confirmed, mechanisms could be integrated into GP training and may offer guidelines for regulating proper access to mental health care services.

Clinical decision support methods for children and youths with mental health disorders in primary care

BACKGROUND

Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs).

OBJECTIVES

This review aimed to identify CDSMs in the literature and describe their functionalities and quality.

METHODS

In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols.

RESULTS

Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories.

CONCLUSION

Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.

GP follow-up after first diagnosing psychological problems among adolescents: a nationwide register-based study

BACKGROUND

Psychological problems are common among adolescents. Many GPs consider these problems challenging, even after diagnosis.

AIM

To explore how Norwegian GPs follow-up patients after a first diagnosis of a psychological problem at age 15-16 years.

DESIGN AND SETTING

Nationwide longitudinal, register-based study using claims data for all GPs in the national list patient system, and for adolescents born in 1993 and 1994 (n = 129 499).

METHOD

National databases and registers were used to determine how many adolescents received a first diagnosis of a psychological problem in a GP consultation at age 15 or 16 years. Further consultations, collaborative contacts in primary care, and referrals to secondary care during the year after diagnosis were then identified and used as outcomes in regression analyses to investigate associations with initial diagnosis, parental education, and GP characteristics.

RESULTS

In total, 6809 (5.3%) adolescents received a first diagnosis of a psychological problem in a GP consultation at age 15 or 16 years. Internalising problems constituted 50.5% of initial diagnoses among females and 28.8% among males. Behaviour and attention problems accounted for 21.3% for females and 45.0% for males. In total, 46.6% of females and 39.9% of males had ≥1 follow-up consultation, and 32.8% of females and 27.0% of males were referred to secondary care. GPs reported primary care collaboration for 22.1% of females and 19.1% of males. GPs with larger patient lists had higher referral rates, but collaborated less within primary care. Males with a male GP had more follow-up consultations than males with a female GP.

CONCLUSION

GP follow-up after diagnosing psychological problems among adolescents is limited, but predominantly comprised referrals and some multidisciplinary cooperation. GP follow-up consultations should be studied more thoroughly, and the role of GPs warrants further policy discussions.

Role of the general practitioner in providing early intervention for youth mental health: a mixed methods investigation

INTRODUCTION

Youth suicide in Ireland is now the second highest in the European Union. General practitioners (GPs), as the health-care professional most often consulted by young people, have a central role in early detection of youth mental health problems. However, evidence regarding the perspectives of young people and health-care workers towards screening and treatment for such issues in primary care in Ireland is lacking.

AIM

This study aimed to examine the role of GP in providing early intervention and treatment for youth mental health problems.

METHODS

A mixed methods study that involved qualitative interviews with health-care workers from primary care, secondary care and community agencies (n = 37) and young people (n = 20) in two of Ireland's most socioeconomically disadvantaged areas and a national cross-sectional survey of GPs (n = 175) were carried out.

RESULTS

GP satisfaction rates were low in regard to postgraduate training received in child and adolescent mental health (17%) and substance use (21%). Key barriers to treatment included the attitude of patients/families, lack of specialist staff, poor service availability and time. Access to services (66%), knowing which interventions can be initiated in primary care (44%), having appropriate time and space (47%) and access to a youth worker (42%) were the interventions most commonly identified that would facilitate screening and treatment.

CONCLUSION

The research outlined potential implications for clinical practice, research and education such as promoting awareness of mental health and the role of the GP in helping these issues, education of practitioners and improving access to psychological treatments.

GPs' experiences of children with anxiety disorders in primary care: a qualitative study

BACKGROUND

Anxiety disorders have a median age of onset of 11 years and are the most common emotional disorders in childhood; however, a significant proportion of those affected do not access professional support. In the UK, GPs are often the first medical professional that families see so are in a prime position to support children with anxiety disorders; however, currently there is little research available on GPs' perspectives on and experiences of supporting children with these disorders.

AIM

To explore the experiences of GPs in relation to identification, management, and access to specialist services for children (<12 years) with anxiety disorders.

DESIGN AND SETTING

Twenty semi-structured interviews were conducted with GPs in primary care throughout England.

METHOD

GPs reflected a diverse group in relation to the ethnic and socioeconomic profile of registered patients, GP age, sex, professional status, previous engagement with research, and practice size and location. Purposive sampling was used to recruit GPs until theoretical saturation was reached. Data were analysed using a constant comparative method of thematic analysis.

RESULTS

Data from 20 semi-structured interviews were organised into three themes: decision making, responsibility, and emotional response, with an overarching theme of GPs feeling ill equipped. These themes were retrospectively analysed to illustrate their role at different stages in the primary care process (identification, management, and access to specialist services).

CONCLUSION

GPs feel ill equipped to manage and support childhood anxiety disorders, demonstrating a need for medical training to include greater emphasis on children's mental health, as well as potential for greater collaboration between primary and specialist services.

Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners' perceptions

BACKGROUND

Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face.

AIM

To ascertain primary care practitioners' perceptions of the barriers that prevent effective management of child and adolescent mental health problems.

DESIGN AND SETTING

A systematic review of qualitative and quantitative literature in a primary care setting.

METHOD

A database search of peer-reviewed articles using PsycINFO, MEDLINE(®), Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers.

RESULTS

A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions.

CONCLUSION

The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services.

Patterns of engagement between GPs and adolescents presenting with psychological difficulties: a qualitative study

BACKGROUND

Psychological difficulties are common in adolescence with general practice attendees having higher rates than reported in community surveys. Yet GP identification of common mental health problems in this age group is limited. Anxiety and uncertainty around professional practice have been found among GPs and they vary in their degree of engagement with adolescents presenting with psychological difficulties.

AIM

To explore which factors influence the degree of GP engagement.

DESIGN AND SETTING

Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.

METHOD

Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.

RESULTS

In total 19 GPs were recruited: 10 were female, the age range was 29-59 years, with a modal range of 40-49 years. The participants collectively described a sense of their professional competence being challenged, yet reacted with varying degrees of engagement. Three themes appeared to shape a GP's response: performance in the clinical encounter; view of adolescents and their health needs; and the GP's own preferred epistemological framework.

CONCLUSION

The findings suggest that better patterns of engagement between GPs and adolescents are supported by medical education which includes input and feedback from adolescents; education about the science and psychology of adolescence; more effective working across disciplinary boundaries; and recognition of the importance of addressing psychological difficulties early.