How to care for patients with mental health problems

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In the European Union, more than one in four adults experienced at least one type of mental disorders in the past year (1). People suffering from mental health disorders have a reduced life expectancy (10–20 years lower) compared with the general population (2). Their poorer mental health status is often also associated with poorer physical health and social condition (1,3,4). Accordingly, these patients have complex care needs and need multidisciplinary health care.

By providing patients’ global health care in a holistic and patient-centred approach, GPs have the skills to meet their complex care needs (somatics, mental and social care) (5). As primary health care gatekeepers, they are the main front-line health providers for this population (6) and contribute to offering accessible, affordable, cost effective and less stigmatizing care (7). The literature has already demonstrated the central role of GPs in the management of patients with mental disorders (8–10). In the French health system, GPs have the task of the ‘médecin traitant’ (treating physician), introduced by the health law of 2005. Their role is to provide global and coordinated care for patients and promote prevention. They are the gatekeepers for the access to specialized care. Some specialized physicians, including psychiatrists, can still be directly reached without going through the ‘médecin traitant’s’ pathway. However, direct access to the psychiatrist is still unusual: As a general rule, patients visit a GP for mental health problems before seeing psychiatrists and psychologists (11). A large French study suggested that GPs were the only doctor consulted by a majority of depressive patients (12). A minority consulted a psychiatrist and very rarely without having consulted their GP first (12).

GPs face difficulties in caring for patients with mental disorders. Challenges include the accurate diagnosis of mental disorders, crisis management, the patient’s access to mental health care, the medication adjustement and effective collaboration between GPs and mental health providers (13–17).

This study aimed to better understand the GP’s views, atittudes and needs in the care of patients with mental disorders.

Methods

Study design

We conducted a qualitative study from June to July 2017, based on semi-structured interviews led on GPs working in Marseille (France). We chose this approach in order to get a better understanding of complex issues (human behaviours and communication’s strategies in a health care system).

Population and sampling

We included GPs working in various areas of Marseille (districts 7–9 that are the most high-income areas, districts 6–12 that represent middle-social incomes and districts 14–16 that represent a poorer area). We firstly randomized the GPs from an internet phone list area by area. Then, we contacted GPs in order to explain the study and ask for their willingness to participate. We collected data on gender, experience (number of years from qualification), office organization (solo practice or group practice), interest in mental health and exposure to mental disorders. We used a purposeful variation sampling method and progressively targeted inclusion to obtain a diversified sample on these data (18,19). We stopped the inclusions when saturation of data had been reached.

Data collection

Semi-structured interviews explored the views of GPs about the mental health care system, their practices and difficulties in managing patients with mental health disorders, their collaboration with mental health providers and their perceived keys for improvement. The interview guide is available on Supplementary Data (interview guide). We first led an ethnographic phase during which the investigator (DE, resident in general practice at this time) observed and recorded various situations by attending GP’s consultations. After three pilot tests, she (DE) conducted face to face interviews in the GPs’ office. Interviews were recorded and fully transcribed. Field notes were made during and after the interviews, about attitudes of GPs and unrecorded information. The researcher identified in a ‘logbook’ her emotions, the evolution of her views, her intellectual process and the results of her encounters with others actors.

Analyses

We performed an inductive thematic content analysis, using Excel® software. Two researchers (DE and OL) conducted two parallel content analyses and compared them. Then, a triangulation process for analysis carried about by two other authors of this work (JM and BE) on each step of the analyses: construction of the matrix, first content analysis and inductive process.

Ethical issues

Each GP received an information letter and provided signed consent for publishing the results. All interviews were anonymized as soon as they were concluded. This study was registered on the CNIL (French National Commission for Data Protection and Liberties) on n°2017-CIL-14 and was approved by the ethics committee of the Faculty of Medicine of Aix-Marseille.

Results

We invited 94 GPs to participate: 52 were not reachable and 20 others refused to participate (9 argued a lack of interest, 8 a lack of time, 3 other practical reasons). Ultimately, 22 GPs were interviewed. The interviews lasted for ~30 minutes. Characteristics of interviewed GPs are described in Table 1. Most GPs were interested in taking care of people with mental disorders and were exposed to mental disorders in their daily practice (11 of 22 estimated that >30% of their patients suffered from mental disorders).

Table 1.

Characteristics of the interviewed GPs (n = 22 GPs interviewed between June and July 2017)

Three predominant themes emerged from the analyses of GPs’ interviews: (i) the effect of the type of psychiatric symptoms on GP’s attitudes; (ii) GP’s opinion about mental health care system; (iii) ways to improve patients’ management.

Three categories of cases which led to three different attitudes by GPs

The GPs identified three main categories of patients with mental disorders:

• - the ‘minor cases’: the GPs identified as ‘minor cases’ mostly the patients they perceived as facing some difficult life events, with mainly anxious or depressive symptoms,

• - the ‘severe patients’: the GPs identified as ‘severe patients’ mostly patients with psychotic disorders,

• - the ‘crisis situations’: they were most of the time described by the GPs as cases of agitation, often with acute delusions.

The GPs had different attitudes depending on how they categorized their patients. For the ‘minor cases’, the GPs often perceived their role in screening and treating these disorders. They said they felt comfortable diagnosing and treating these types of patients. They explained that they often knew these patients for a long time, which created a good doctor–patient relationship that facilitated their care.

I saw them being born. I have a special relationship with my patients, they come to see me, have confidence. The minor cases are still 90% of our pratice… GPs have a place.

The GPs described a sympathetic understanding and a global approach to their care. They provided patients a constant support, with a mostly paternalistic relationship. They felt their interactions had a positive effect and was efficient. They didn’t feel that referring these patients to a specialist was necessary in most of the cases.

When the intensity of the disorders is not very high and I feel that I can bring them what they need then I can manage them alone.

Many GPs highlighted however their limits in the care of these patients: if the patient’s situation didn’t improve, they then referred them to a mental health specialist.

I delegate when the patient is in denial or blocking. If one month of treatment not work I delegate ... I do not let it drag.

In contrast, the ‘severe patients’ were perceived by GPs to be out of the mainstream of primary care. The global health care of these patients was perceived to be part of the psychiatrist’s responsibility: the GPs mostly expressed attitudes of disengagement in their care. They explained that they received these patients only occasionally, to treat acute infections, to prescribe treatment when the psychiatrist wasn’t there or to treat comorbidities in patients with chronic psychiatric problems.

For psychotic patients it’s different. The psychiatrist takes the lead’/GP N°11: ‘I’m unable to take care of them

But many GPs said they were often involved in supporting the families of these patients.

During one year the family was forgotten’, ‘they come to see us (the GPs) because we are accessible

The ‘crisis situations’ were perceived as rare but hard to manage for GPs. The GPs usually chose to refer them to emergency services, without initiating any treatment because there was no alternative means of accessing specialized care.

when there is a crisis, it’s difficult to contact someone who can advise you. So it goes often to emergency room.

A critical look at the mental health care system

The GPs’ expressed mostly negative views about the organization of the mental health system. They described the ‘psychiatric universe’ as an opaque and closed system. They pointed out a lack of communication with mental health specialists. They felt that the psychiatrists were difficult to contact and did not integrate them to the patients’ care.

Psychiatrists appear to function in secret…That they should not tell us anything and that we should not ask. As if we were not ourselves of this medical word […]. Sometimes we don’t know the patient’s disorder and we don’t have a letter from the psychiatrist. As if it was a secret.

Most of the GPs also expressed some dissatisfaction about the psychiatric’s care for their patients. They felt that hospitalizations were too long and that the restraint measures were too severe for these patients. They also felt that drug therapies took precedence over psychotherapy too frequently.

The biggest gangsters in the world after the ‘daltons’ are the psychiatrists [note: The Daltons are outlaws who regularly appear in the Lucky Luke comic book series] … I have patients hospitalized for 2 or 3 years… It’s terrible

I feel that as psychiatry becomes more molecular […]. We drown patients with molecules

The GPs expressed a variable level of access to psychiatrists, which depended on their personal network. They often regretted their lack of knowledge about existing mental health services. This seemed to complicate the patient’s referring to appropriate care.

Ways to improve the global care of patients with mental disorders: the GP’s perspective

The GPs identified solutions to improve the whole care for patients with mental disorders. The major focus was on improving the collaboration between mental health services (public or private) and general practice. GPs wanted to be more involved in the care of their patients with mental disorders. They wanted to be informed by mail or phone about the diagnoses and treatments performed by the psychiatrists. They also asked for facilitated access to mental health care and advice. Some of them proposed that informational gatherings between GPs and psychiatrists, with few participants, might help develop stronger links for a better collaboration. GPs also wanted to be better informed about mental health services that existed in their health area. They proposed the development of written documentation, with localization of services, skills, specialties and contacts. All interviewed GPs were interested in a ‘hotline’ operated by psychiatrists to help GPs with diagnosis, treatment and referring, for patients with mental disorders. Some GPs thought that a helpline could also be reserved for families to give them direct and specialized support.

Discussion

Main results

The GPs interviewed in this study seemed to assess the complexity of the cases and therefore their ability to deal with them, based on the nature of patient’s psychiatric symptoms. Patients with anxious and depressive symptoms were mostly perceived as ‘minor cases’, whereas patients with psychotic symptoms were perceived as ‘severe’. While they felt comfortable providing total care for their patients with anxiety and depression, they felt uncomfortable and poorly integrated in the care of patients with more sever psychiatric symptoms, as well as in situations identified as emergencies. They expressed difficulties in communicating with the mental health specialists and wished the collaboration with them to be improved.

Strengths and weaknesses of this study

This qualitative study provides a comprehensive approach and sheds light on collaboration gaps and difficulties of GPs caring for patients with psychiatric illness. As a result of the purposive sampling strategy used in this study, we obtained a good diversity of our sample with respect to our targeted criteria. Nevertheless, GPs who agreed to participate were probably more interested in taking care of patients with mental disorders than those who declined. Indeed, 11 GPs of the 22 interviewed said that >30% of their patients suffered from mental disorders, which is a little more than the national estimate (20,21). This may explain why the GPs were almost all supportive and asking for change and improvement in the care of these patients.

Qualitative methods involve some subjectivity of the investigator during the analysis of data process. The reflexing process of the researcher was improved by listening to opinions and experiences of other external participants during the whole process of data collection and a preliminary participant observation phase. Using a logbook also enhanced the rigor of the analyses (22,23). This study only provided the GP’s perspective and hypotheses about their attitudes and views.

The ‘severe patients’: a difficult role for GPs

When GPs had to manage the patients, they categorized as ‘severe burdensome patients’ (mostly patients with psychotic disorders), they felt that their role was often limited to intercurrent health problems. Many studies have shown that patients with severe mental disorders received poorer care (treatment as well as prevention) even though they are the most in need of multidisciplinary and coordinate care (1,4,24–26). The GPs described patients with psychotic disorders as being ‘out of the primary care system’, which is to say their global health care is either not provided at all or provided only by mental health specialists. These views can be explained by the perceived difficulties of GPs in the care of these patients and the lack of communication with mental health’s specialists. A (mental health care) training program for GPs in Canada also led to attitudes changes of GPs about their patients with mental health disorders. At the end of the training program, the GPs reported an increased confidence in diagnosing and treating their mental health patients, in developing care plans and in prescribing medications (27). Previous studies have shown that GPs were more involved in treating patients with mental disorder when they felt that the management was simple and experienced a good collaboration with mental health care, with availability of diversified services (28). Training for GPs in mental health and an improved collaboration with mental health specialists can be two key steps for improving the care of patients with severe mental disorders.

The ‘minor cases’: are they as easy to treat as they seem?

The patients with depressive disorders seemed to be mostly considered as ‘minor cases’, and GPs felt they could treat them longer than they would for another disorder before addressing to a specialist. If the GPs felt here competent in most of the cases, the literature identified that only 37.2% of the patients with major depression and who consulted only a GP were adequately treated (29). A low level of satisfaction about cooperation with mental health specialists may also lead GPs to prescribe too much antidepressant treatment without any psychotherapy for patients with depression (30). Even if GPs feel more comfortable in dealing with mental disorders when they perceive them as simple to manage (31), it’s necessary to give the GPs some guidance to help them to better consider the severity of mental health disorders and make an objective evaluation of their own capacity of treating mental disorders.

Improving the collaboration between GPs and mental health providers: a key answer to improve the global health care for patient with mental disorders?

The GPs expressed the need to improve their collaboration with psychiatrists. The dissatisfaction of GPs about their relationship with mental health specialists has already been expressed by French GPs: they regret the lack of communication, the difficulties of referral to a psychiatrist and mutual difficulties in understanding one another (32). In France, psychiatrists also expect an improved partnership between GPs and psychiatrists (33). Collaborative care has already been described to improve depression and anxiety treatment outcomes compared with usual care (34). Some models to improve the collaboration between GPs and mental health providers have been evaluated. The impact of co-located services between somatic and mental health providers is still controversial (35–37). Other studies argued the benefits of a team-based approach, with close collaboration between primary health providers, psychosocial professionals and psychiatrists (38). A shared care program developed in Ontario aimed to provide timely access to mentoring for GPs managing mental health care in the community. Communication was established via e-mail, telephone, fax, or listserv, or even face to face. This program helped GPs feel more confident in dealing with mental health concerns, but further evaluations were necessary (39).

Conclusion

If the GPs interviewed in this study felt at ease providing global care for their patients with anxious and depressive disorders, they felt uncomfortable with managing their patients with psychotic disorders, identified as ‘severe patients’. Improving the collaboration and communication with the mental health providers was perceived by GPs as a key answer. Regular contact by phone or mail and a phone ‘hotline’ held by psychiatrists for GPs were judged to be promising solutions, which need to be then evaluated.

Declarations

Funding: none.

Ethical approval: this study was approved by the ethic commitee of Aix-Marseille University on the reference N°2017-05-07-003.

Conflict of interest: none.

Acknowledgement

We are very grateful to Prof. John Detre for his help in language editing

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