Rates of treatment of schizophrenia by general practitioners. A pilot study

Treating body, treating mind: The experiences of people with psychotic disorders and their general practitioners - Findings from the Australian National Survey of High Impact Psychosis

OBJECTIVES

To describe from the perspective of people living with psychotic illness their use of general practitioner services over a 12-month period and the experiences, attitudes and challenges general practitioners face providing health care to this population.

METHODS

A two-phase design was used. Phase 1, screening for psychosis, occurred in public specialised mental health services and non-government organisations within seven catchment sites across Australia. In Phase 2, 1825 people who were screened positive for psychosis were randomly selected for interview which included questions about frequency and reason for general practitioner contact in the 12 months prior to interview. General practitioners (1473) of consenting participants were also surveyed.

RESULTS

Almost all (90.3%) survey participants had consulted a general practitioner in the 12-month period, on average 8.9 times, and 28.8% of attenders had consulted 12 times or more. The majority (83.5%) attended one general practitioner practice. Most (77.6%) general practitioners wanted to be involved in the mental health care of their patient. Although 69.1% said the management of their patient was not problematic for their practice, one in five general practitioners reported issues related to patient non-compliance with treatment and non-attendance at scheduled appointments; time constraints; and lack of feedback from treating mental health services.

CONCLUSION

People with psychotic disorders consult general practitioners, some very frequently. Most Australian general practitioners believe they have a responsibility to review the physical and mental health of their patients. Improved communication between general practitioners and mental health services, and easier access to mental health support, may help general practitioners manage the complex mental, physical and social problems of their patients.

Health behaviours of community-treated patients with psychosis

OBJECTIVE

To assess physical health self-reports and health utilization behaviours of community dwelling persons with persistent psychosis.

METHOD

A cross-sectional survey was conducted of 106 patients with persistent psychosis. Using self-reported measures, the prevalence of smoking, alcohol consumption and exercise, and body mass index were determined. Health utilization behaviour, especially with respect to general practice, was assessed. Data was compared with that derived from the general population and longitudinally with a historical cohort.

RESULTS

Compared with the general population, those with psychosis were more likely to be smokers, overweight or obese, and less likely to be non/ex-smokers. Compared with previous studies, smoking and obesity persisted as major modifiable risk factors. Over 7 years, some risks such as smoking increased, whereas moderating factors such as light exercise, improved. Three-quarters of patients would visit their GP if they had a physical illness but a third reported not having visited their GP or other doctor in the previous 12 months.

CONCLUSIONS

Patients with persistent psychosis have increased rates of cardiometabolic risk yet seek medical attention infrequently. These findings have not improved despite an increased awareness of the enhanced risk of developing metabolic disease in this group.

Variables associated with general practitioners' knowledge about and diagnostic skills for schizophrenia

OBJECTIVE

This study investigated the level of knowledge about schizophrenia of primary care doctors working in the city of Brescia, Italy, and variables associated with better information.

METHOD

The study design was devised after 2 joint meetings with leading figures of the Italian College of General Practitioners. A cross-sectional evaluation of 215 general practitioners was performed (June 2002). A random subgroup was selected to participate in a 4-month retest session in order to evaluate the reliability of the schedule (October 2002). The setting was the local health unit of Brescia, which involves 706 primary care doctors working in the city and its province. Of these, 30.5% took part in the study. A structured self-report questionnaire (SAKS) was devised for this study. General practitioners were also asked to rate videotaped cases of 5 patients with different DSM-IV diagnoses. The main outcome measures were the scores from subscales measuring knowledge of schizophrenia symptoms and signs, knowledge of antipsychotics and their adverse events, and correct diagnoses of 5 videotaped cases.

RESULTS

Primary care doctors identified positive (79.0%), negative (72.6%) and general (72.1%) symptoms of schizophrenia (p < .001). Of the 5 cases on videotape, they correctly rated a mean of 3.1 cases. The mean percentage of anti-psychotics correctly identified was 34.1% (older) and 51.2% (novel) (p < .001). Better answers were given by doctors who knew the diagnostic criteria, had read books on psychiatry, and had attended previous courses.

CONCLUSION

More teaching on the diagnosis of schizophrenia and clinical psychopharmacology should be given to general practitioners.

Characteristics of smokers with a psychotic disorder and implications for smoking interventions

Despite high rates of smoking among people with psychotic disorders, and the associated health and financial burden, few studies have investigated the characteristics of this group of smokers. This paper reports data from 298 smokers with an ICD-10 psychotic disorder residing in the community (56.7% with schizophrenia or schizoaffective disorder), including an examination of their demographic and clinical characteristics, smoking behaviours, severity of nicotine dependence, stage of change, and reasons for smoking and for quitting. Standardized self-report instruments were used, in conjunction with structured interviews, as part of the first phase of a randomized controlled trial. On average, participants smoked 30 cigarettes per day, commenced smoking daily at about 18 years of age (5 years before illness onset), and had made 2-3 quit attempts in their lifetime. Higher levels of nicotine dependence and concurrent hazardous use of alcohol or cannabis were associated with a younger age at smoking initiation. The present sample was also more likely to report stress reduction, stimulation and addiction as reasons for smoking, compared to a general sample of smokers. Males, precontemplators and participants with concurrent hazardous substance use cited fewer reasons for quitting smoking. These and other subgroup differences in smoking characteristics are used to illustrate potential implications for the nature and timing of smoking interventions among people with a psychotic disorder.

How do general practitioners manage subjects with early schizophrenia and collaborate with mental health professionals? A postal survey in South-Western France

OBJECTIVE

This study was conducted to explore how general practitioners (GPs) manage subjects with early psychosis and collaborate with psychiatrists in the care of such patients.

METHODS

Survey questionnaires exploring practice in patients with early psychosis were mailed to all GPs in South-Western France (n=3,829).

RESULTS

The response rate was 23.6%. Half of GPs responding to the survey had actually diagnosed a possible case of schizophrenia during the previous year. In such cases, the most frequent decision was to refer the patient to a psychiatrist, despite the difficulties of convincing the patient and obtaining a rapid referral. According to GPs' answers, the relationships between primary care and the mental health team were characterised by a lack of communication: less than one out of three GPs had regular contact with a mental health team, and a large majority reported that they never or rarely had information about the diagnosis and treatment of subjects referred for early schizophrenia. Having regular contacts with mental health services had a major impact on GPs' management of subjects with early schizophrenia, in particular on reducing delays to obtain a psychiatric consultation and on level of information on diagnosis and treatment after referral.

CONCLUSION

Promotion of networking between primary care and mental health services is required to reduce delayed access to care in subjects with early schizophrenia.

General practitioners and schizophrenia: results from a Swiss survey

BACKGROUND

General practitioners (GPs) have an important role in the care of patients with chronic schizophrenia and of those in the early phases of this disorder.

AIMS

To obtain information about the number of patients in the early and chronic stages of schizophrenia seen in general practice; the needs and attitudes of GPs, their diagnostic knowledge concerning early phases of schizophrenia and their knowledge and practice concerning treatment of patients with first-episode and multi-episode schizophrenia.

METHOD

A postal survey was conducted among randomly selected GPs in Switzerland.

RESULTS

A total of 1089 GPs responded to the survey. Early psychosis had a low prevalence in general practice, and GPs expressed a wish for specialised, low-threshold referral services. Diagnostic and treatment knowledge showed inconsistencies. Most GPs said they would treat first-episode schizophrenia with antipsychotics, but only a third recommended maintenance treatment after a first episode of schizophrenia that would conform with international recommendations.

CONCLUSIONS

Easily accessible, low-threshold referral services are pivotal in supporting GPs in the management and treatment of emerging schizophrenia in primary healthcare patients.

Assessing cost-effectiveness of drug interventions for schizophrenia

OBJECTIVE

To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

METHOD

Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

RESULTS

Replacing oral typicals with risperidone or olanzapine has an incremental cost-effectiveness ratio (ICER) of 48,000 Australian dollars and 92,000 Australian dollars/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of 80,000 Australian dollars. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at 20,000 Australian dollars. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at 42,000 Australian dollars or 23,000 Australian dollars/DALY respectively. The least cost-effective intervention is to replace risperidone with olanzapine at 160,000 Australian dollars/DALY.

CONCLUSIONS

Based on an 50,000 Australian dollars/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Overcoming barriers to reintegration of patients with schizophrenia: developing a best-practice model for discharge from specialist care

Many people with schizophrenia are in regular contact with their general practitioners. GPs commonly play a sentinel role in management, but may require support from Area Mental Health Services (AMHSs). The CLIPP (Consultation and Liaison in Primary-care Psychiatry) shared-care model of patient management combines a collocated consultation/liaison service for managing referrals from GPs to specialists with a carefully structured approach to long-term care of patients transferred from AMHS care to GPs. The CLIPP model uses the concept of a "relapse signature", involving recognition of early warning signs of relapse, to simplify clinical monitoring of patients with schizophrenia.

Comparisons between schizophrenia patients recruited from Australian general practices and public mental health services

OBJECTIVE

To examine differences between samples of schizophrenia patients recruited from general practice and public mental health services.

METHOD

Demographic, psychosocial, disability and 12-month service utilization data are reported from a multicentered survey of psychotic disorders and an associated study of schizophrenia in general practice. Patients with schizophrenia from three recruitment sources (in-patient, community services, general practice) were compared.

RESULTS

General practice patients had fewer symptoms, better functioning, lower service use, but comparable substance abuse, to patients from mental health services. They were generally similar to community mental health patients, with the exception of family support, premorbid work adjustment, negative symptoms and disability. Service contact models are also reported which demonstrate that general practitioners deal with schizophrenia patients across the range of illness severity and acuity.

CONCLUSION

Recruitment source impacts in schizophrenia research need to be more carefully considered during sample selection and better accounted for in the interpretation of results.