Mental Health in Family Medicine

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ISSN 1756-834X

Publications in this journal

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    ABSTRACT: Objective: Little is known about how primary care providers (PCPs) approach mental health care for low-income rural women. We developed a qualitative research study to explore the attitudes and practices of PCPs regarding the care of mood and anxiety disorders in rural women.Method: We conducted semi-structured interviews with 19 family physicians, internists, and obstetrician-gynaecologists in office-based practices in rural central Pennsylvania. Using thematic analysis, investigators developed a coding scheme. Questions focused on 1) screening and diagnosis of mental health conditions, 2) barriers to treatment among rural women, 3) management of mental illnesses in rural women, and 4) ideas to improve care for this population.Results: PCP responses reflected these themes: 1) PCPs identify mental illnesses through several mechanisms including routine screening, indicator-based assessment and self-identification by the patient; 2) Rural culture and social ecology are significant barriers to women in need of mental healthcare; 3) Mental healthcare resource limitations in rural communities lead PCPs to seek creative solutions to care for rural women with mental illnesses; 4) To improve mental healthcare in rural communities, both social norms and resource limitations must be addressedConclusion: Our findings can inform future interventions to improve women's mental healthcare in rural communities. Ideas include promoting generalist education in mental healthcare and expanding access to consultative networks. In addition, community programs to reduce the stigma of mental illnesses in rural communities may promote healthcare seeking and receptiveness to treatment.
    Mental Health in Family Medicine 12/2013; 10(4).
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    ABSTRACT: Background Recruitment rates of general practitioners (GPs) to do research vary widely. This may be related to the ability of a study to incorporate incentives for GPs and minimise barriers to participation. Method A convenience sample of 30 GPs, ten each from the Sydney intervention and control groups Ageing in General Practice 'Detection and Management of Dementia' project (GP project) and 10 GPs who had refused participation, were recruited to determine incentives and barriers to participating in research. GPs completed the 11-item 'Meeting the challenges of research in general practice: general practitioner questionnaire' (GP survey) between months 15 and 24 of the GP project, and received brief qualitative interviews from a research GP to clarify responses where possible. Results The most important incentives the 30 GPs gave for participating in the project were a desire to update knowledge (endorsed by 70%), to help patients (70%), and altruism (60%). Lack of time (43%) was the main barrier. GPs also commented on excessive paperwork and an inadequate explanation of research. Conclusions While a desire to update knowledge and help patients as well as altruism were incentives, time burden was the primary barrier and was likely related to extensive paperwork. Future recruitment may be improved by minimising time burden, making studies simpler with online data entry, offering remuneration and using a GP recruiter.
    Mental Health in Family Medicine 09/2013; 10(3):163-73.
  • Mental Health in Family Medicine 09/2013; 10(3):125-7.
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    ABSTRACT: Dementia is a major cause of disability and has immense cost implications for the individual suffering from the condition, family caregivers and society. Given the high prevalence of dementia in China with its enormous and rapidly expanding population of elderly adults, it is necessary to develop and test approaches to the care for patients with this disorder. The need is especially great in rural China where access to mental healthcare is limited, with the task made more complex by social and economic reforms over the last 30 years that have transformed the Chinese family support system, family values and health delivery systems. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for discussion of innovative approaches in the management of dementia in rural China, with particular focus on its implementation in the primary care system.
    Mental Health in Family Medicine 09/2013; 10(3):133-41.
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    ABSTRACT: Introduction Elderly patients occupy up to 65% of acute hospital beds and a significant proportion of them present with a comorbid psychiatric condition such as depression, delirium or dementia. Liaison old age psychiatry (LOAP) services have been developed to provide psychiatric consultation in medical and surgical settings, improving at the same time the knowledge and expertise of general ward staff. Objective The aim of this study is to evaluate clinical characteristics across different psychiatric disorders among elderly patients in medical wards. Method A prospective observational study was developed between October 2011 and January 2013, which involved 107 subjects aged 65 years or older that were hospitalised in the Department of Internal Medicine and referred to the LOAP service. Psychiatric diagnostic was assessed using the Confusion Assessment Method, the Geriatric Depression Scale, the Mini-Mental State Examination and the Clinical Global Impression Scale. Results Delirium (40.6%), depression (22.4%) and dementia (20.4%) were the most common psychiatric diagnoses. Patients with delirium were significantly older, had more severe psychiatric symptomatology (mean CGI = 5.35) and presented infectious processes as acute medical conditions more frequently than the other patients. Conclusion Psychiatric disturbances occurring in elderly inpatients in medical wards are highly prevalent and complex. A LOAP service may play an important role in effectively reducing the overutilisation and consumption of health resources through early recognition of these conditions, effective management and prevention of adverse outcomes, and effective communication with out-patient clinics, community mental health teams and day-care centres.
    Mental Health in Family Medicine 09/2013; 10(3):153-8.
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    ABSTRACT: This review considers key areas in primary care regarding the diagnosis of dementia. Issues surrounding assessment, policy and incentives are considered. In addition, the relevance of non-medication approaches for dementia in primary care, which aim to enhance or maintain quality of life by maximising psychological and social function in the context of existing disabilities, is deliberated. Finally, key issues about primary care medication management are considered, and relevant therapeutic strategies with recommendation for a collaborative approach that improve outcomes by linking primary and secondary healthcare services - including general practice and pharmacy - with social care needs are weighed up. A key aspect of such a collaborative approach is to support informal carers in optimising medication.
    Mental Health in Family Medicine 09/2013; 10(3):143-51.
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    ABSTRACT: Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members' burden and suffering.
    Mental Health in Family Medicine 09/2013; 10(3):159-62.
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    ABSTRACT: Appropriate management of advanced dementia requires it to be recognised as a terminal condition that needs palliative care. Interventions during this stage should be carefully chosen to ensure the improvement or maintenance of the quality of life of the person with dementia. Advanced care planning is an important aspect of dementia care. Carers and relatives should be educated and encouraged to actively participate in discussions related to artificial nutrition, cardiopulmonary resuscitation (CPR) and other medical interventions.
    Mental Health in Family Medicine 09/2013; 10(3):129-32.
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    ABSTRACT: Context Medically unexplained physical symptoms (MUPS) are frequently encountered in family medicine, and lead to disability, discomfort, medicalisation, iatrogenesis and economic costs. They cause professionals to feel insecure and frustrated and patients to feel dissatisfied and misunderstood. Doctors seek answers for rather than with the patient. Objectives This study aimed to explore patients' explanations of the medically unexplained physical symptoms that they were experiencing by eliciting their own explanations for their complaints, their associated fears, their expectations of the consultation, changes in their ideas of causality, and the therapeutic approach that they considered would be useful. Methodology A qualitative analysis was under-taken of interviews with 15 patients with MUPS in a family medicine unit, 6 months after diagnosis. Results Experience is crucial in construction of the meaning of symptoms and illness behaviour. Many patients identify psychosocial causes under-lying their suffering. These patients received more medication and fewer requests for diagnostic examinations than they had expected. Normalisation is a common behaviour in the clinical approach. Normalisation without explanation can be effective if an effective therapeutic relationship exists that may dispense with the need for words. Listening is the procedure most valued by patients. Diagnostic tests may denote interest in patients' problems. The clinician's flexibility should allow adaptation to the patient's phases of acceptance of the significance of their physical, emotional and social problems. Conclusion Patients with MUPS have explanations and fears associated with their complaints. The patient comes to the consultation not because of the symptom, but because of what he or she thinks about the symptom. The therapeutic relationship, therapeutic listening, and flexibility should be the basis for approaching patients with MUPS. Patients do not always expect medication, although it is what they most often receive. Diagnostic tests, although used sparingly, can be a way to maintain and build a relationship. Drugs and tests can be a ritual statement of clinical interest in the patient and their symptoms.
    Mental Health in Family Medicine 06/2013; 10(2):67-79.
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    ABSTRACT: The findings reported here form part of a larger research project that examined non-compliance with medication among the mentally ill patients attending public clinics in a specific parish in Jamaica. The aim of the research was to explore the perceptions of caregivers about caring for the mentally ill at two outpatient psychiatric clinics. Caregivers involved in looking after their relatives with mental illness played a vital role in mental health promotion. This study sought to examine the caregivers' perception of mental illness, including how they thought the illness was best controlled, the reasons why their relatives found it difficult to take their medication as instructed, and the coping skills that they employed when caring for their relatives. There were two focus groups, consisting of four individuals each, at two psychiatric clinics. The results revealed the following about the majority of the caregivers. First, it was recognised that caregivers have a good knowledge (and awareness) of medication usage inferred by either the absence or the presence of their relatives' symptoms. Secondly, they sometimes felt sad and hopeless as a result of being the victims of violent attacks by those for whom they provided care. Thirdly, they highlighted issues of cost, accessibility and availability of medications as being problematic. Fourthly, in some cases they received little or no assistance from other family members.
    Mental Health in Family Medicine 06/2013; 10(2):113-21.
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    ABSTRACT: Objectives Somatoform disorders are common in international primary care settings, but have been little studied in the developing world. The objective of this study was to determine the prevalence of severe undifferentiated somatoform disorder, and its relationship to depression and anxiety, among patients attending walk-in clinics in Trinidad. Methods The study participants, who were all aged 18 years or older and attending walk-in clinics at 16 randomly selected health centres, were surveyed between May and August 2007 using the PRIME-MD questionnaire. Results There were 594 participants (the response rate was 92%), of whom 72.7% were female. Their ages ranged from 18 to 93 years, and 54.5% were over 50 years of age. In total, 37.2% were married and 25.9% were single. Indo-Trinidadians represented 43.1% and Afro-Trinidadians represented 36% of the study sample; 56.5% of the participants reported that their income was less than US$ 400 per month, and 65.7% were unemployed. At walk-in clinics in Trinidad, the estimated prevalence of severe undifferentiated somatoform disorder was 10.3% (95% CI: 7.86-12.74), that of hypochondriasis was 28.5% (95% CI: 24.9-32.1), and that of body dysmorphic disorder was 15.8% (95% CI: 11.9-18.7). Severe undifferentiated somatoform disorder was statistically significantly associated with gender and ethnicity but not with age, level of education, employment status or income. Chi-square testing found significant associations between the presence of severe undifferentiated somatoform disorder and both depression and anxiety (P < 0.05), between hypochondriasis and both anxiety and depression (P < 0.05), and between body dysmorphic disorder and depression (P < 0.05) but not anxiety. Regression analysis suggested that the demographic features that predicted severe undifferentiated somatoform disorder were being female or Indo-Trinidadian. Conclusions Walk-in clinics in Trinidad that serve older patients on a lower income have a high proportion of patients with somatoform disorders as measured by the PRIME-MD scale. These patients exhibit many features of anxiety and depression. These findings have implications for medical training and service delivery.
    Mental Health in Family Medicine 06/2013; 10(2):81-8.
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    ABSTRACT: Background General practitioners often encounter patients with medically unexplained symptoms. These patients share many common features, but there is little agreement about the best diagnostic framework for describing them. Aims This study aimed to explore how GPs make sense of medically unexplained symptoms. Design Semi-structured interviews were conducted with 24 GPs. Each participant was asked to describe a patient with medically unexplained symptoms and discuss their assessment and management. Setting The study was conducted among GPs from teaching practices across Australia. Methods Participants were selected by purposive sampling and all interviews were transcribed. Iterative analysis was undertaken using constructivist grounded theory methodology. Results GPs used a variety of frameworks to understand and manage patients with medically unexplained symptoms. They used different frameworks to reason, to help patients make sense of their suffering, and to communicate with other health professionals. GPs tried to avoid using stigmatising labels such as 'borderline personality disorder', which were seen to apply a 'layer of dismissal' to patients. They worried about missing serious physical disease, but managed the risk by deliberately attending to physical cues during some consultations, and focusing on coping with medically unexplained symptoms in others. They also used referrals to exclude serious disease, but were wary of triggering a harmful cycle of uncoordinated care. Conclusion GPs were aware of the ethical relevance of psychiatric diagnoses, and attempted to protect their patients from stigma. They crafted helpful explanatory narratives for patients that shaped their experience of suffering. Disease surveillance remained an important role for GPs who were managing medically unexplained symptoms.
    Mental Health in Family Medicine 06/2013; 10(2):101-11.
  • Mental Health in Family Medicine 06/2013; 10(2):65-6.
  • Mental Health in Family Medicine 06/2013; 10(2):63-4.
  • Mental Health in Family Medicine 01/2013; 10(1):1-2.
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    ABSTRACT: Background and objectives The purpose of this paper is to describe the use of resident performance on an observed structured clinical examination (OSCE) as a tool to refine a mood disorders curriculum, and to disseminate a mood disorders OSCE for use in other residency settings. Methods A depression-focused OSCE and a direct observation evaluation tool were developed and implemented. A total of 24 first-year family medicine residents (PGY1) participated in the OSCE, and their performance was used to direct changes in a mood disorders curriculum. Results Residents performed well on general interview behaviours, and 67% were able to uncover depression in a patient presenting with headaches. Less than 50% of the residents asked about suicidal ideation and recreational drug use. Curriculum was added that addressed the latter deficiencies. Conclusions Tracking of resident performance on specific behaviours during OSCE sessions can be used for curriculum evaluation purposes. The mood disorders curriculum in additional family medicine residency programmes can now be evaluated using our depression-focused OSCE and Clinical Performance Checklist.
    Mental Health in Family Medicine 01/2013; 10(1):45-51.
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    ABSTRACT: Background Slovenian psychiatry is predominantly hospital based. A programme for the development of general community psychiatric services was proposed to improve access to and quality and comprehensiveness of psychiatric care according to the modern standards of delivery of psychiatric services. Aim The aim of the paper is to present the programme for developing community services that was proposed to the Slovenian government, and to describe the barriers to its implementation that were encountered, as well as the errors made by the programme authors, that contributed to the rejection of the programme last year. Conclusions There are historical, political, professional and service organisation characteristics that impede the development of community psychiatry in Slovenia. These are to be addressed through coordinated action involving primary care professionals, non-government organisations with service users and carers, the Health Insurance Agency and politicians involved in the planning of health services.
    Mental Health in Family Medicine 01/2013; 10(1):23-8.