Variables associated with general practitioners taking on serious mental disorder patients

In light of efforts to improve healthcare efficiency, enhancing the integration of primary care within the mental healthcare system is strongly recommended [1‐3]. It has been reported that in countries with more fully developed primary care, the healthcare system is more effective with regard to service accessibility, service continuity and patient outcomes [4‐7]. The trend toward extending primary mental health care is related to the community-based movement in mental health whose objective is to promote patient recovery [8‐10]. Over the past 40 years, deinstitutionalization has returned individuals with mental disorders to the community. Accordingly, general practitioners (GPs) are increasingly viewed as major partners in the mental healthcare system [1, 11].

In recent years, many primary care models have proliferated, favouring collaboration, care continuity, and best-practices for the management of patients with chronic and complex problems (e.g., Wagner's Chronic Care Model; the patient-centered medical home approach) [12, 13]. In Canada, two such examples in mental health are shared-care [14, 15] and integrated service network models [15‐17], which aim at improving care co-ordination among GPs, psychiatrists and multidisciplinary mental health providers, or within the healthcare system as a whole. These models usually include a broad spectrum of integration strategies and best practices such as clinical guidelines, electronic medical records, case management, capitation and performance incentives for GP remuneration, and patient self-management support [14, 16, 18]. In the province of Quebec, multidisciplinary group practices such as "family medicine groups" involving several GPs working closely together with nurses responsible for patient screening, follow-up, referral and patient registration are other innovations designed to improve service continuity and patient outcomes. It has been shown that these innovative integrated models not only improve care continuity but also more appropriately meet the needs of mental health patients living in the community [19, 20].

Compared to specialized care, services provided primarily by GPs for patients with mental disorders are found to be more accessible, less stigmatizing and more comprehensive, since physical problems are managed along with mental disorders [21]. As the main entry point into the healthcare system [22, 23], GPs play a pivotal role in screening, detecting and treating mental disorders [24, 25]. In the course of a single year, about 80% of the population consults a GP, and between 20 and 40% of visits are related to mental health [26, 27]. In Canada, of all patients with a mental disorder seeking help, 45% consult a GP while 25% consult other healthcare practitioners [22, 25]. About 25% of patients with chronic psychosis see only their GPs [27]. Depression and anxiety are the predominant common problems in mental health patients seen by GPs [24, 28, 29]. In the context of current reforms designed to promote patient recovery and further deinstitutionalization, GPs are increasingly being asked to play a pivotal role with regard to stabilized serious mental disorder (SMD) patients (e.g., schizophrenia). This is a trend not only in Canada, but in most countries [2, 30].

Although current reforms encourage GPs to manage more SMD patients, few studies have been published as yet on this subject [19, 31, 32]. Most studies involving GPs focus on common mental disorders (e.g. depression and anxiety), examine best practices for treatment and assess outcomes for various types of intervention and programs [12, 14]. In the other hand, studies on SMD patients examine almost exclusively the mental health network, rarely including GPs' care [11]. To our knowledge, no prior study has investigated variables that promote or hinder the involvement of GPs with SMD patients, which is a prerequisite for the development of optimal integrated care models for these patients. Accordingly, this study is designed to test the association of GPs taking on SMD patients and multiple correlates such as GPs' socio-demographic profile, clinical practice, perceived inter-professional relationships and quality of care, and patient characteristics. Although based on the Quebec/Canada context, the findings from this study should be of wider relevance since primary mental health care in most of the industrialized countries share similar reform objectives (e.g., optimizing GPs' role, accessibly and continuity of care), and organizational and practice features (e.g., United Kingdom, Australia, Ireland) [33].

As found in other studies [28, 32, 37, 39], our research findings showed that only a minority of SMD patients are managed primarily by GPs. Three sets of variables were associated with GPs taking on SMD patients: (1) their level of expertise toward treating those patients; (2) their inter-professional relationship feature; and (3) their clinical practice profile. Those three sets of variables, especially the first one that contains the most strongly associated variable in the model, should be considered as significant hindering or enabling factors for optimizing primary mental healthcare service planning.

Consistent with our findings, various studies have cast doubt on the ability of GPs to detect and treat more complex forms of mental disorders, particularly major depression with suicidal tendencies, schizophrenia, and bipolar disorders [28, 40, 41]. They have also highlighted GP discomfort with such patients. GPs either consider these disorders too specialized for routine primary care, deeming their skills and experience inadequate for effective diagnosis and treatment, or they position themselves as complementary to specialized care, treating essentially physical problems [19, 23]. All of these conditions encourage GPs to transfer SMD patients to specialized care (i.e., psychiatric departments of acute-care or psychiatric hospitals, or emergency rooms).

Nevertheless, when GPs practice in integrated primary care models such as in shared-care or a patient-centered medical home approach, they are reportedly more at ease with managing patients with mental disorders [12, 14, 42]. This is confirmed by our findings: joint follow-up with other resources and involvement in post-hospital follow-up were found to be the second and third most important variables associated with GPs taking on these patients. Research showed that when SMD patients are successfully managed and stabilized by psychiatrists, GPs are more comfortable following them in the community with medication and/or supportive therapy, jointly with mental health teams, as required [43‐46]. SMD patients generally need continuous community follow-up of varying intensity over time. They usually have numerous bio-psycho-social needs that require teamwork to avoid relapse and help adapt to a recovery-oriented life [47, 48].

Along with the need for psychiatric team assistance, GPs who offer medication and supportive therapy follow-up and have a greater volume of SMD patients were also found, in our study, to be more likely to take on SMD patients. This is consistent with previous research [12, 23, 32] highlighting links between mental health knowledge and training, and the ability of GPs to manage these patients. Conversely, lack of both knowledge and training are major factors resulting in the transfer of patients by GPs to specialized care. A higher volume of SMD patient consultations would be expected to result in greater GP willingness to take them on. This further leads us to hypothesize that some GPs may specialize in the follow-up of these patients, being more able to manage both patient medication follow-up and supportive therapy. When all conditions favour SMD patient management by GPs, our findings also show that GPs apparently offer good continuity of care, seeing these patients on average six times a year. Half the time, SMD patients were followed-up by GPs either solely for their physical problems or for both physical and mental health problems

There are many reasons explaining why only a minority of GPs take on SMD patients. Such patients are deemed to require more care and time, more frequent visits, and be more difficult to treat [46, 49]. Often, they have concurrent diagnoses (e.g., substance abuse) and interrelated physical or social problems [50‐52]. As for GPs, their poor collaboration with psychiatry services, their busy schedules and the competing demands of other patients are other impending factors [7, 14, 53]. The historical separation between psychiatry and primary care [11], and GPs' limited training or experience with effective team practice [21] may also explain their reluctance to take on these patients – especially if they consider hospital psychiatric teams to be more appropriate. But none of this would suggest GPs' removal from the treatment equation of those patients. SMD patients are in great need of adequate physical care and mental health follow-up as they face higher risks of interrelated morbidity. Moreover, as psychiatric teams are usually concentrated more in urban settings, GPs are often the sole available source of care. This is the case in Quebec where almost half of the psychiatrists practice in the Montreal metropolitan area, and where in more remote regions, specialized care is scarce [54].

While our model yields various strong and interesting associations, the study has certain limitations. First, it has a cross-sectional design, which does not permit causal inference as in experimental or longitudinal studies. Second, as the data collected are from GP self-reporting, the results must be viewed as an approximation of actual GP practice. Third, our questionnaire was complex, which may have discouraged some GPs from participating. As a result, the response rate was limited, but was not substantially lower than that reported in other surveys involving GPs [36, 46, 55]. Finally, no data was collected on GPs' adequacy in treating mental-disorder patients, which is considered a major issue giving rise to conflicting results in the literature [12]

In the context of current reforms designed to enhance healthcare efficiency and support SMD patients' integration in the community, our findings sustain the development of integrated care models favouring service co-ordination, exchange of expertise between bio-psycho-social professionals and healthcare lines of services, and reinforcement of GPs' mental-health training. Our data show that GPs currently follow up only a minority of SMD patients on a continuous basis, and far fewer for both their physical and mental health problems. However, GPs may play a pivotal role in taking on patients with stable SMDs, if they have psychiatrists' and mental health team support. Lack of expertise in mental healthcare was also found to be a strong impediment. Without psychiatrists' and mental health team support or sufficient expertise in mental health, GPs are likely to transfer SMD patients to specialized care.

In the Canadian context of high GP shortages, increasing the development of mental-health integrated care models could nevertheless be a major challenge. Patients with stable SMDs ought to have the same care access as the general population, however, and services that are the least stigmatizing. Group practice models such as family medicine groups with nurses working closely with GPs to assist in patient screening and follow-up could serve as the basis for more refined integrated care models in Quebec's mental healthcare system. Improvements in access to direct communications with psychiatrists or shared-care initiatives, for diagnostic and therapeutic consultations, and to mental health teams, for patient case management of various intensities, should also be considered. For managing chronic and complex illnesses such as SMDs, various studies [18, 56] have indicated the major positive impact of comprehensive and continued multimodal strategies (e.g. clinical guidelines, electronic medical records, financing incentives, medical education sessions), which should be further encouraged.