We identified multiple issues affecting desired health and personal outcomes at the patient, relational-societal and organizational levels. At the patient level, these issues included difficulties experienced due to psychiatric impairment, and low levels of functioning when trying to access appropriate health-care. Key themes at the relational-societal level included the patient-GP relationship, and stigmas associated with mental illness as key themes. Finally, issues identified at the organizational level included structural level impediments.
Patient level
Both parties emphasized the general requirement of an active role for the patients within the health-care system, in order to ensure that they can receive the appropriate health services. The active role includes the need to be aware of one’s health condition and needs; to seek timely medical health-care; to actively address related administrative procedures; to understand and follow the recommendations of one’s GP, and so on. Both parties indicated that the ability of patients with SMI to take on such multi-level tasks may be compromised due to the severity of their psychiatric symptoms, the occurrence of acute episodes, and their functioning levels. For example, one interviewee, diagnosed with bipolar disorder and married to a woman diagnosed with bipolar disorder, described his efforts to help his wife take a health test:
She is at home a lot. It is hard to get her out of the house. Last week, I took her for a stomach ultrasound, and it was very difficult. I had to set an alarm for 9 am, to wake her up and wash her and dress her, and to go out in the heavy traffic. It was raining, I had to find parking and find the place in the building and wait in line and [get to] the ultrasound room, and it was difficult, it was very difficult. (Mr. and Mrs. Hassan, both diagnosed with bipolar disorder)
Access to, and utilization of health services demanded significant effort on the part of the patients, especially when their psychiatric symptoms were active. If the illness was in its active phase, the degree to which the patient could advocate for his/her own needs was restricted. In addition, one’s state of mental health seemed to influence the nature of the responses received from GPs and other medical professionals. This can be seen in the following quote:
When I was in a poor mental state it was very difficult to deal with the procedure to fight for each pill, and sometimes they [pharmacists] insult you. Today I am more resilient (…) when you are insecure, not focused and with cognitive difficulties, you want to say a sentence and you are not sure what do you want to say. And then they shut you up, they shout and go. (Ms. Tavori, diagnosed with schizophrenia)
Relational-social level
Both parties described the importance of long-term, trusting relationships, to ensure that the health-care provided matched the patients’ mental status, needs, and abilities. Patients also emphasized the importance of having confidence in their GP, especially during periods when they experienced health and mental health crises. For example:
During my last [depressive] episode, I told her [my GP] ‘I’m falling’, and she said to me ‘You’ve come to the right place’. She kept in touch with me daily. (Ms. Cohen, diagnosed with schizophrenia)
In this example, the patient shared her experience of attending her appointment in a state of stress and turmoil, which she described with the words “I’m falling.” She felt that her GP recognized the intensity of her emotional crisis and responded to her immediate needs, “to make sure that I will not fall,” thus providing her with a sense of security. Though this example is particularly poignant, given the effort made by the GP remain in daily contact, other patients similarly emphasized the importance of feeling cared for by their GPs during periods of crisis.
A number of GPs noted that the doctor’s level of familiarity with the patient, as well as certain characteristics of the GP-patient relationship, are crucial in determining the extent to which the delivery of services to patients with SMI can be efficacious. For example:
I think that you need to be familiar with where the person is coming from; his family, what helps him to take his medications and remain stable, what knocks him off balance and… even to be a bit like a kindergarten teacher, to tell them, to ask them, to remind them, not to expect them to do it all alone. But also on the other hand, to give them autonomy, [to] give them autonomy and allow them to make decisions for themselves, give them the dignity as a person like anyone else, not to treat just the mental illness but see the person as a whole. (Dr. Gurevitch)
Thus, both parties stressed the importance of developing a caring relationship, with a high level of familiarity, such that the GP becomes intimately aware of the patient’s complex needs, resources and abilities. The value of such relationships is twofold. First, it allows patients to feel comfortable with the GP, sharing experiences and information that the GP must know, in order to help them. In addition, the doctor’s genuine sense of care towards the patient’s welfare can help patients feel accepted and understood, with regard to their condition and its potential repercussions. This further supports adherence to treatment. For example:
She [the GP] is nice, she is warmhearted and she is ok. She said to me also “why were there periods that you didn’t come to take the treatment?” She said to me “if it is about money, I will give you the money, don’t worry, we have a cashbox that will help you if you don’t have the money to buy medications.” (Mr. Bar, diagnosed with schizophrenia and PTSD)
This quote demonstrates that a GP operating in a holistic, person-centered role can be essential in identifying the additional barriers that prevent successful engagement with the patient. Other patients, without trusting relationships with their GPs, described multiple difficulties with negative implications for the quality of care received. For example, one patient described a distance in the patient-GP relationship, which she connected to the lack of attention to her medical needs:
She [the GP] has never taken an interest and asked me, “how do you feel?” Maybe there is a need for one less pill. She just prescribes the medication, and I take [the prescription] to the pharmacy. (Ms. Oron, diagnosed with schizophrenia)
Another problem mentioned by the patients was when the GP did not recognize the difficulties experienced by the patient:
Sometimes, I arrive at the last minute because it is urgent and I didn’t notice the time and then she [his GP] complains, “Why don’t you come on time? It’s impossible! I have a life too.” I don’t know, she is a bit [interviewee stutters] tough and not sensitive (…) when I come I worry, I am worried that she will send me away because it is as though I have come to disturb her. (Mr. Reshef, diagnosed with bipolar disorder)
From the perspectives of these patients, the two GPs discussed above were unable to recognize their patients’ needs and difficulties. The absence of trust on the part of the patient, therefore, reduces the chances that the patient will feel comfortable enough to provide a complete account of his/her health status. Notably, some of the patients did not attend subsequent appointments with their GPs, due to the uncomfortable nature of their relationships with their GPs. The patients believed that a main cause of such negative relationships was the stigma associated with SMI.
Stigma of SMI
GPs and patients discussed the prejudice manifested against people with SMI as a dominant norm, one negatively affecting patients’ motivation to utilize available health services. One manifestation of this prejudice was that of downplaying patients’ physical complaints, attributing their health conditions to an expression of their mental health status:
She thinks that if I see a psychiatrist then everything is… even if I come to her [i.e., the GP] then everything is a psychiatric [problem]. (Mr. Amos, diagnosed with schizophrenia)
Some of the GPs addressed this issue candidly:
I think that there is [a tendency] to put less effort in preventive medicine and also in the treatment of the psychiatric patient, to deal less with complaints and symptoms. It is easier to think that these complaints are not genuine – not genuinely physical – even though they are. That’s my general feeling. (Dr. Albez)
Thus, the at-times stigmatic notions of SMI emerge, affecting the treatment options and explanations offered to individuals with SMI by their GP, as well as how patients’ complaints are perceived by GPs.
Another form of impaired health-care provision was reflected in the limited provision of services and referrals. This tendency was driven by the widely held notion that patients with SMI find it difficult to take up and utilize available health services. To help them avoid the hardships and difficulties associated with approaching and accessing health services, physicians tended to refrain from suggesting certain medical procedures to their patients. For example:
Does it influence us that they are [mentally] sick? Does it affect our decision-making regarding their treatment? Sometimes maybe yes, because often these people are quite lonely and when you know that they…either will not be able to even book an appointment or will encounter difficulties and will not find the right address, or that they don’t have someone to accompany them and they will miss their appointment, then sometimes you even consider making as few referrals and examinations as possible. (Dr. Braun)
Here, Dr. Braun describes a vicious cycle, one in which physicians’ awareness of the difficulties experienced by SMI patients in utilizing available health services leads to GPs suggesting fewer services to those patients. Although many physicians may believe that they are acting in the best interests of their patients, their decisions deprive their patients of the opportunity to approach the services in the first place.
Organizational level
In addition to the above, two kinds of structural-level impediments were described by the GPs: the absence of continuous patient monitoring, and the lack of resources specifically dedicated for psycho-social interventions.
Monitoring
Lack of SMI patient health monitoring was referenced by the GPs as a significant shortcoming in current mental health-care protocols. Where implemented for physical illnesses (e.g., diabetes), patient health monitoring enables continuous and comprehensive health-care, while at the same time helping to verify that the health-care provision in question is both appropriate and timely.
It is even possible that you have in your list of patients, people with schizophrenia that you have never seen them… that… they do treatment in a psychiatric clinic or in the ministry of health and you never see them … then it is possible that chronic illness are hidden or maybe not… but you don’t even know of their [patients’] existence. (Dr. Brahman)
In common with other GPs, here Dr. Brahman describes patients who are registered but never visit the clinic. GPs also discussed how the lack of monitoring affected patient compliance and adherence, with regard to compliance with prescribed medications, and ongoing psychiatric and general health-care management.
Some GPs observed how the protocols for other health conditions included the creation and maintenance of electronic databases. Electronic databases provide periodic updates for physicians about their patients’ health-care, facilitating monitoring functions. Such electronic databases do not exist for the population of SMI patients.
There are, let’s say, diabetes reports, blood pressure reports, I can… see who are my diabetes patients and who did not do the test, this is very important to the management (…) But I don’t have a report of schizophrenic patients, so…but… there are indirect ways, if I have a patient who is both schizophrenic and diabetic and he didn’t do the test so… [I can say] “Ah! I really haven’t seen him for long time, let’s get his file and see what has happened.” (Dr. Gabay)
Drs. Gabay, and other GPs, imply that health system policy must first be changed so that people with SMI can be identified as part of a high-priority population, and so that their utilization of health-care services can be monitored.
Resources for psycho-social intervention
GPs acknowledged that they do not always know how to help their patients, as they do not understand the difficulties specific to their SMI, or how to overcome those difficulties. This scenario, in which the GPs feel that they lack the competence to help their patients, is a source of frustration for the doctors. Moreover, the GPs are wary not to subject their patients to unnecessary stress, are unsure of how to support patients’ life style changes, and are frustrated by what manifests as the patients’ lack of motivation. Most of all, however, GPs feel helpless when confronted with patients who regularly miss their appointments. Some GPs discussed the possibility of receiving supplementary assistance from professionals from other fields, in order to improve the treatment they can offer their patients:
In the past we thought that it will be good if we can have a psychiatrist in the clinic (…) I need to know how to treat him [a patient with SMI], and how to cope with him and so on. How to solve the mental together with the physical difficulties, how to cooperate with him better, this is the aim. (Dr. Braun).
A lot of responsibility and not enough tools, the main tool that is needed, of course, is time and second [tool is] availability, and direct contact with a psychiatric consultant. (Dr. Frith)
Drs. Braun and Dr. Frith both feel strongly that interdisciplinary consultation, in the form of psycho-social intervention, could help improve the levels of support they are able to offer their patients, and that the support of such professional intervention should be an integral responsibility of the health system. Currently, there is no systematic mechanism for supporting GPs’ attempts to improve the treatment they can provide to patients with SMI.
GPs and SMI patients alike note that more time needs to be devoted to doctor-patient interaction, and the importance of coordinating the treatment given the patient by the different professionals responsible for him/her –psychiatrists, social workers and family members, amongst others. But the establishment of collaborative partnerships with other professionals or with the patient’s family members demands time and effort. Physicians often cannot afford the time necessary to manage such complex interventions.