Background
Methods
Sample
The Monash-Shenzhen Primary Healthcare Leaders Program
Recruitment and fieldwork
Interview guide
Patient profile
Analysis
Results
Demographics
Current practice (TDF Domains 1–5)
Awareness of depressive disorder, prevalence and symptom profile
1. Knowledge
|
1.1. Doctors are depression aware but do not actively diagnose |
1.2. Patients present with somatic symptoms of depression and do not talk about their feelings |
1.3. Key motivations for consultation are insomnia and desire for a “leave-from-work certificate” |
2. Optimism
|
2.1. Doctors perceive a sizable mental health treatment gap |
3. Beliefs about consequences
|
3.1. Depression is not considered to be a treatment priority in CHC |
4. Memory, attention and decision processes
|
4.1. No standardized guidelines for the management of depression at CHC |
4.2. Two systems share responsibility for depression care: CHC are focused on initial assessments, general counselling and patient education; Hospital is focussed on diagnosis and treatment |
4.3. Traditional Chinese Medicine plays a role in depression treatment |
5. Skills
|
5.1. Limited awareness and use of depression scales/screeners by CHC doctors |
5.2. Doctors are generally pessimistic about screener utility and effectiveness |
5.3. Doctors actively choose time appropriate tools to support diagnosis |
6. Beliefs about capabilities
|
6.1. Doctors receive limited professional development |
6.2. Doctors’ confidence in their ability to treat is low |
7. Social/professional role and identity
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7.1. Doctors are not psychiatrists |
7.2. Doctors protect patients from stigma by avoiding a depression diagnosis |
8. Emotion
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8.1. Doctors fear making treatment mistakes |
8.2. Doctors are not attuned to providing psychotherapy |
9. Environmental context and resources
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9.1. High volume of patients and short consultation times at CHC |
9.2. Limited trained mental health resource at CHC level |
9.3. Limited trained mental health resource at hospital level |
9.4. Patients lost to a developing referral system |
9.5. Poor CHC ability to follow-up patients |
9.6. No anti-depressants at CHC |
9.7. Doctors without access to anti-depressants are un-empowered to treat |
9.8. No private space/designated consultation room for mental health conditions |
10. Social influences
|
10.1. Poor general/community health literacy |
10.2. Chinese underlying culture: loss of face accentuates poor health seeking |
10.3. Intense stigma associated with the main speciality hospital |
10.4. Community induced isolation and discrimination |
10.5. Family members are important facilitators for patient care |
10.6. Poor family understanding of depression can lead to poor treatment outcomes |
10.7. Poor employer attitudes towards depression |
10.8. A climate of poor public-opinion and trust in the medical profession |
11. Behavioral regulation
|
11.1. Require depression-specific policies for patient reimbursement |
11.2. Require doctor incentivisation (like psychosis polices) |
11.3. “One psychiatric doctor per community health centre” facilitates passing down and cross-referral |
11.4. Establishment of dedicated mental health department at local hospitals |
11.5. Review of “five in one policy” |
11.6. Stronger health promotion on world mental health day |
11.7. Use of e-health to vitalize resource and reach more patients |
12. Reinforcement
|
12.1. Improved doctor training with special instruction in mental health |
12.2. Access to Western Medicine and improved consulting environment |
12.3. Improved mental health literacy |
13. Intentions and 14. Goals
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13.1. The care of depression patients to be more strongly prioritised |
13.2. Good psychological health is an important component for quality of life |
13.3. Timely management of depression prevents suicide |
Most community health service centres rarely diagnose depression, and our centre doesn’t diagnose it basically. We won’t diagnose the patient as depression even though we suspect it. (D14)
He won’t talk too much about the internal reasons. He will only tell the ones who he trusts; but to us he may feel (the doctor) is an outsider and he may not talk so deeply. (D01)
Patients come to see us directly not because of mental reason. They come to see us due to discomfort such as insomnia, fatigue and so on. (D07)
Perceived treatment gap for depressive disorder
We have very few psychologists with certifications. If general practitioners screen all these depression patients out, what should we do? I know that 20% people have depression, and the proportion of anxiety disorder is also very high. The reality is, where should we refer these patients to? As you see, there are 20 million people in Shenzhen and there is only one Kangning Hospital with only a dozen of physicians inside. You can calculate the number, 20% of 20 million. How should physicians deal with such a huge number of depression patients? (D09)
Status of depression treatment in CHC
There shouldn’t be any priority, since we treat all patients consistently. …. It can’t be that the patient who has mental problem comes and I’ll just need to give him special care. There is no such thing. (D06)
Doctors current approach to depression care
We spend much time communicating with patients to let them understand that depression is a common disease, which is just like cold. Besides, we need to let them know that some diseases can be cured via life style improvement, individual adjustment or psychological guidance. (D08)
If they come to see Traditional Chinese physicians on purpose, definitely, we prescribe Chinese medicine to them……In fact, there is acupuncture therapy for insomnia and headache, and we prescribe traditional Chinese medicine in combination with these therapies. (D16)
Current usage of mental health guidelines
We assess according to physician’s clinical experience. Therefore, community health service centers are not professional in terms of mental disease diagnosis currently. (D13)
Current usage of assessment tools
It’s not proper to take the scale to ask patients questions directly because they may feel disgusted. Basically, we talk with patients with some communication skills, not just asking questions rigidly. (D02)
However, we feel that the scale can’t represent the reality, as our patients are very smart, and they know what the scale is for… for instance, when they wish physicians to feel the severity of their disease, they tick the serious options; when they want to avoid negative outcomes, they select mild options. In a word, they tick answers according to their subjective wishes, rather than their real status. In later psychological consulting, physicians find that their status is not so severe as or more severe than the scale outcome. (D14)
…that’s why we use PHQ-2 very often. There are problems if the score of PHQ-2 is higher than 3, so we use PHQ-9 to make another evaluation…. As for mild patients, we ask them to visit us for several times when there are not many patients, as we have to control the counselling time for every patient when we are busy. (D10)
Doctors’ psychological response to providing depression care (TDF Domains 6–8)
Doctors personal beliefs about their capabilities
With respect to treatment… training about it is rare. Physicians are not so confident in treating patients like this, and don’t know what therapies are proper for the patients. (D11)
Doctors beliefs about their professional role and identify
I don’t want to first make this diagnosis, because after all I’m not a psychiatrist…Although I have the psychological counsellor certificate, in our country it requires…Class Two Psychological Counsellor in order to prescribe this medicine. (D03)
We are cautious for the diagnosis because it’s a taboo for some people, and they may feel embarrassed. We also don’t say it out easily when suspecting that it’s depression. Perhaps we’ll tell the patient euphemistically. Maybe I’ll tell patients that their pressure recently is somewhat great, and it will be possible for them to get depression if they don’t pay attention to it…..We don’t dare to recommend the specialized hospital dedicated to mental diseases, but recommend general hospitals because there is psychological department in large general hospitals. (D13)
Doctors underlying emotional influences
Doctors are also very afraid of patients who cause accidents! Like those mental health patients…(who) sometimes will fall ill, or don’t take medicine in time….and cause accidents at the slightest stimulation. It will be very troublesome!.. Many doctors…..are not specialized in this, and are not very familiar with this area … so they feel the pressure is big. (D05)
There is also a bit of personal factor which is I am not willing to develop in this direction…because the truth they reveal must be sometimes torture, domestic violence and other types of unpleasant things… If I come across too much of this kind of negative darkness…. I think my emotions will also be affected. So, I don’t want to be taken into the darkness by them. (D03)
External influences (Domains 9–10)
Health system and immediate work environment context
Firstly, there is deficiency in the aspect of depression finding, and perhaps patients with depression might be omitted. Commonly, we have too many patients, and perhaps we need to treat a patient every 2–3 min. We have no time to ask his medical history at all, and it’s also impossible to discern whether the patient has psychological problems or not. (D12)
Only a few physicians in community hospitals are able to deal with depression…..Most physicians don’t know how to diagnose depression or when to screen. (D10)
The psychological doctors….are very few…(but) the patients are packed over several floors. (D04)
When we feel that their status is somewhat severe, we refer them to hospitals, and we seldom trace them after the referral. If the referred hospital has confirmed the diagnosis of depression, patient information would be sent back to the community healthcare centre… Only under this circumstance would we trace them and follow them up. If their severity hasn’t met the diagnosis criteria, we don’t follow them up. (D17)
Currently, common drugs for anti-depression are managed as antipsychotics. Many leaders think community health service center should not have this kind of drugs. However, what our centre requires the most is these drugs. (D08)
Community healthcare center has no diagnosis capability and no corresponding drugs for them. Some patients haven’t even met the physicians here, so there is no face-to-face interaction. They get drugs at Kangning… therefore, some of them are unwilling to accept our management, as they feel it unnecessary. (D16)
However, the situation is rare because we have so many patients to see, and we need to arrange a room for them separately, and thus we only select one intractable patient from them. (D17)
Social influences
In Chinese society, common people consider psychological problems as psychiatric problems or mental illnesses. They don’t accept it! Moreover …. we don’t have many websites, newspaper, or free calls for consultation, so they don’t talk with others about their problem, which worsens the illness. (D09)
Chinese people are afraid of stigma!… Chinese people are like, let the household disgrace be buried inside the house. Usually they keep it to themselves. (D04)
When we want to refer (patients) to (specialist) hospitals, they don’t go there, as in Chinese culture, it’s a taboo to see psychiatrists or psychologists, as most people are afraid of being considered as a psycho. (D03)
When we go to the patient’s home for follow-up, nearby residents may pop their head out to see what happened and gossip because there are many people including policeman.3 They think the person we are visiting has committed a crime, which then increases the mental stress of the patient. (D12)
When you ask your employer for leave, he/she may ask you your problem. The employer may approve it rapidly if you say you have a fever or something else. However, if you tell him/her that you have had poor sleep or bad mood, he/she may advise you not to think too much and work harder. (D02)
I think they, because of the anxiety, should perform even better at work, such as complete tasks very quickly …… it hasn’t affected his work. So people around him might just feel he is a bit anxious, and there doesn’t exist that kind of (suspicion that the patient has mental problems). (D03)
If family members are all very positive, there is no problem. They encourage patients to see physicians because of anxiety or depression, as they feel that problems can be solved after taking medicine. If family members consider it as a scandal and keep it in secret, the status would worsen. (D09)
The family will say, don’t call me! I don’t have this (family member) with mental problems at home. He also feels if he has a family member who has such mental problems, this will be a very shameful thing. (D01)
Currently, the relationship between doctors and patients is somewhat tense. The public opinion makes people think it requires a high cost for getting medical treatment, and all the money is earned by doctors. (D07)
If the patient is positive, his/her compliance is high and he/she trusts me, it will be quite helpful, and the disease can be cured quicker relatively. If the patient doesn’t trust me or he/she doesn’t understand the disease well, or he/she rejects it subconsciously, I will have no way to treat it. This is the obstacle. (R08)
Doctor identified enablers and needs for improved depression care (Domains 11–12)
Health system policy enablers
Now we pay much attention to severe mental disorder, so there is corresponding policy support, and drugs for mental disorder are free after patients apply. However, there is no such policy for depression. (D10)
If the GP discovers one of these cases (schizophrenia), there will be certain money (reward) to encourage you to discover and report (more cases). (D04)
If the patient has already a confirmed diagnosis, … the diagnosed patient will be recorded in the system (by the hospital), then…our doctor in charge of psychiatric prevention (in the community centre) can also see this patient….We call that passing down to the doctor who is in charge of mental health. (D06)
Some doctors in our centre received training about psychological counselling before. For instance, if the patient is not familiar to me, and I’m not good at the treatment of the disease, I may ask my colleague for consultation …..(D02)
Now (the Group) has established a mental health department …..as well as some Wechat communication groups… When we come across some patients and do not know how to deal with it by ourselves, we can consult that Director in that chat group…. If we can’t solve it ourselves, we might …..make a referral up (to the Group), we can still have certain communication with the doctor who accepts the referral. (If) you make a referral to Kangning Hospital, you will have a hard time track that patient’s progress. (D05)
Why the policy of “five-in-one” is necessary? Firstly, physicians feel unsafe. Secondly, patients reject it themselves. They want to protect their privacy and don’t want others know that they have the disease. (D12)
Shenzhen has already been a leader in this field, as this city has established many policies, including screening children with autism, maternal depression and elderly depression. However, it’s the preparatory work of a program, and it hasn’t been conducted in clinical practice. (D09)
I have a friend, a nurse, she also holds the psychological counselling certificate, (and) she is an online psychological counsellor. She is paid online by virtual money…..Because ….her career is reaching its end and she doesn’t want to end up with no economic back up …. she’s thinking…..she could change career to become a psychological counsellor. So she’s doing that online. (D03)
Doctor identified needs for improvement to depression care
Firstly, some relevant training needs to be provided. Besides theoretical training, we also need role-play for better understanding about it. Actually, we learned relevant knowledge before, but it was extremely shallow. It will be the best for us if there is practical training. The integration of theory with practice is important. (D07)
It is the best if we can prescribe corresponding drugs, have enough time and a quiet consulting room. It’s impossible to work well with a lot of patients in the consulting room. (D17)
If the patient is aware of his illness, he can only have a search in Baidu. But much of the information in Baidu5 is useless. Trash information! There is no… professional information that could provide useful advice to the patient…or could help people realize that this is in fact a very common issue, and not a very embarrassing problem. I think this is an issue about public awareness of this disease. The key is the awareness. If everyone thinks it’s the same as having a cold or fever, ….. then everyone will be able to treat it normally. You have this, (and) I also have this, (and) there won’t be any discrimination. Hmm, there won’t be any discrimination, then people can be open to speak about such a thing. (D01)
Doctors’ desire to change (TDF Domains 13 and 14)
I think there should be a health priority. Patients like this get easily annoyed if they have to wait for the diagnosis for a long time or their attitudes towards physicians are not good or they are not well cared for. …. Perhaps it’s acceptable for general patients to wait for a long time, but patients with emotional disorder can’t wait for such a long time and then they may go away, which will cause the delay of disease. (D13)
In my perspective, we need to pay attention to patients’ psychological health, no matter whether they suffer anxiety or depression or not. We need to intervene when discovering such cases. I pay more attention to patients’ psychological health, as good psychological health is good for their quality of life. (D15)
Depression is a hidden disease and it will cause bad consequences if it’s not solved timely, and even cause tragedy. (D11)