Psychiatry & Psychosocial Medicine: General Practice: The Integrative Approach Series

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At the medical centre, GPs work together with physiotherapists, a midwife, a dietician, a social worker and a psychologist. The medical centre is situated in a deprived area of a large city in the east of the Netherlands. In September , the medical centre started the Eureka project. Its goal was early identification of child and adolescent psychological or social problems, short-term treatment within primary care where possible, and targeted referral in good time to secondary care as necessary.

The Eureka project provides facilities to help the GP carry out comprehensive assessments of children and adolescents who are presumed to have mental health problems, consult familiar youth mental health specialists and to provide short-term treatment. The Eureka project consists of the following parts:. The routine procedure is as follows: GPs at the Eureka practices see children at their surgeries whom they suspect may have a mental health problem.

If they include the child in the Eureka project, they either plan an extended youth consultation or involve the YMHPN directly. The outcome of the extended youth consultation may be an end of the Eureka intervention, further involvement of the YMHPN or referral to pedagogic care, primary youth mental healthcare both also available in the medical centre or specialized mental healthcare. Throughout the Eureka intervention, youth mental health specialist consultants may be involved.

Participating practices received a lump sum for each child treated within the Eureka protocol. Referrals are not included.

Introduction

The target population consists of children aged between 4 and 18, visiting the GP and in whom the GP suspects psychological or social problems. Approximately children in this age category are registered with the medical centre. This system records all diagnoses as assessed by the GP , treatments, medication prescriptions and referrals. We used data from GP practices that were comparable with the GP practices at the medical centre involved in the experiment in terms of the level of urbanization and being located in a deprived area. Thirty-three GP practices from urban areas took part, six of which were in deprived areas.

All data is collected and handled according to the data protection guidelines of the said Authority. Conforming these guidelines, patients are publicly informed about the participation of the practice in NIVEL Primary Care Database with a possibility to opt out. As Dutch law allows the use of anonymized electronic health records for research purposes under certain conditions, we did not need informed consent or approval by a medical ethics committee for this study Dutch Civil Law, Article 7: The period of measurement was 1 January to 31 December The Eureka project started in September To test pre-test versus post-test, data from was compared with data from For the comparison between the practices in the experiment and the control practices, data from was compared between the practices concerned and the control practices.

We analysed the number of children with diagnoses falling under chapters P Psychological and Z Social. Descriptive analyses were used to calculate the number of children with a psychological or social problem, the number of contacts with these children, and the numbers of prescriptions and referrals. We used t-tests and one-way analyses of variance ANOVA to compare the number of children with psychosocial and social problems, treatments, prescriptions and referrals pre-test and post-test. We also compared these numbers for the GP practices at the medical centre concerned and control GP practices.

About one third of the children with a psychological or social problem entered the Eureka programme. For the other two thirds, Eureka was not considered as being indicated; they got usual care from the GP. The Eureka protocol was used for children in the period between October and December About two thirds of the children who were treated within the Eureka protocol were seen by the YMHPN, for an average nearly four sessions.

Sometimes information was exchanged with schools or with an organization against child abuse. The practice nurse had contacts with the child psychiatrist or the family therapist about one third of the children included in the Eureka protocol. Identification of psychosocial problems within the four practices before the introduction of the Eureka protocol in was compared with the identification rate in , when the practices could use the Eureka protocol.

In , 87 children per aged 4 to18 got a psychological diagnosis and 15 per a social one. In , significantly more children were diagnosed with psychological and social problems by the participating GPs than in , before the start of the Eureka project. In , GPs in the medical centre identified more children with psychosocial problems than GPs in control GP practices. This difference is especially large when compared with control GP practices in deprived areas.

Differences between pre-test and post-test and between Eureka practices and control practices are mainly due to an increase of identified problems in the age category 11 to It also shows symptoms and diagnoses for control practices from deprived and non-deprived urban areas.

There was a significant increase in the number of GP consultations per child with a psychosocial problem in the first year after the start of the project an average of 3. In the second year after the start of the project, a child with a psychosocial problem had on average 2. In , children with psychosocial problems in the GP practices from the experiment had significantly more consultations with their GP than in children from the control GP practices. Numbers of children with a psychological or social diagnosis who received psychopharmacological prescriptions in Eureka practices, before and during intervention.

Numbers of children with a psychological or social diagnosis who received psychopharmacological prescriptions in Eureka practices and control practices in Although there was an increase in the number of children with identified psychosocial problems in the first year after the start of the Eureka project , the number of prescriptions remained low: In control practices from non-deprived areas, more prescriptions for psychostimulants were observed.

If the psychosocial problems of the child were regarded as too severe to treat at the medical centre, GPs referred the cases to facilities outside the medical centre. The proportion of children referred hardly changed after the start of the Eureka project. In the year before the start of the project, 63 out of children with a psychosocial diagnosis 29 were referred, compared to 65 out of 30 in the year after the start of the project and 68 out of 20 a year later.

Referrals to mental healthcare primary mental healthcare and specialized mental healthcare combined involved 38 18 , 40 16 and 51 19 respectively of children with a psychosocial diagnosis. The specific settings to which children with psychosocial problems were referred to showed some changes Fig. In each period, most children were referred to secondary mental healthcare, but after the start of the Eureka project, relatively more children were referred to primary mental healthcare.

The number of referrals to medical specialists decreased after the start of the Eureka project. In , when the Eureka project was running, practices referred relatively few children, compared to control practices in deprived areas: We studied an intervention that allows GPs to comprehensively assess child and adolescent psychological and social problems, and that provides opportunities for short-term treatment or quick, focused referral. The intervention led to an increased identification rate for psychological and social problems, more GP contacts because of such problems, a restricted psychopharmacological approach and a small change in the emphasis of referral destinations from secondary care to primary mental healthcare.

In a representative Dutch study conducted in in 82 general practices [ 24 ] with a registered population of 73, patients aged 0 to 18, GPs recorded psychological symptoms and diagnoses in 6. When we compare the Eureka project with this Dutch representative study, we find higher recognition rates, lower prescription rates and a referral rate to primary mental healthcare and specialized mental healthcare for Eureka that is lower than the average in the Netherlands.

In this respect the aim of the project to recognize and treat more child mental health problems within general practice is fulfilled. Compared to control practices, the Eureka intervention appears to be especially directed at specific behavioural problems, anxiety and relational problems with parents. This is more prevalent in control practices in deprived areas than in other control practices and in the Eureka practices. The question may arise if the lump fee, to be received for any patient included in the Eureka protocol, may not act as a reward to identify more possible mental health problems.

This study cannot answer that question. It should be possible, however, to account for the several modules of the Eureka intervention, actually used, afterwards and calculate with insurers a reasonable lump fee on a yearly basis. These results show that the Eureka protocol may contribute to the early detection and treatment of psychosocial problems among children and adolescents.

It provides general practices with opportunities to spend more time on and pay more attention to psychosocial problems with relatively mild symptoms. The increased detection rate was not accompanied by an increase in psychopharmacological treatments, nor by fewer children being referred to more specialized treatment. In this respect, there was a modest switch from specialized to primary mental healthcare.

Psychiatry, Addiction Medicine, Mind-Body Medicine

This may be attributable to the fact that more specific and specialized competencies were added to the general practice by the deployment of the YMHPN and by the frequent consultations with the psychiatrist, family therapist and psychologist. The Eureka protocol has an impact on all the barriers to psychological treatment in general practice that were mentioned in the introduction. Our study design was exploratory. Eureka has been implemented by GPs who also developed the project, so selection bias is plausible. Nevertheless, no significant differences could be found in the identification of psychosocial diagnoses before Eureka compared with the control practices, suggesting that GPs in the medical centre did not tend to identify more psychosocial problems before the start of the project.

Contrary to controlled randomly designed effect studies, we were only able to analyse routinely collected data before and after the implementation of the intervention and compare it with data routinely collected elsewhere. We cannot therefore report on the integrity of the intervention as a whole or the standardization of the assessments and therapies used. Given the exploratory character of the study and the lack of valid outcome measures, no conclusions can be drawn about the effectivity or cost-effectiveness of the project.

The comprehensive approach with consultations by experts and the using a youth mental health nurse has been proven to be feasible. It is not to be expected that referrals will decrease, as the project itself already increases the number of identified cases. Whether this extra assistance within general practice will be cost-effective in the long run should be the aim of a subsequent study. The authors would like to thank Manon Bouwman, practice assistant at Health Centre Eudokia and Marieke Eefting-Mensink, student-assistant, for their contribution to the data collection.

DW is one of the participating general practitioner. He designed the intervention and the health center in which he is working received on an experimental basis funding for this experiment. DW designed and described the intervention. PV and MZ designed the evaluation study. MvD collected data and performed statistical analyses.

PV and MvD drafted the text of the paper. All authors commented on the text. All authors read and approved the final manuscript. Peter FM Verhaak, Email: Marloes van Dijk, Email: National Center for Biotechnology Information , U. Published online Oct 9. Author information Article notes Copyright and License information Disclaimer. Received Feb 24; Accepted Oct 5. This article has been cited by other articles in PMC. Abstract Background Child and adolescent mental health problems are frequently not identified and properly treated within general practice.

Method The study is a naturalistic evaluation of Dutch general practices with pre-test and post-test comparison with controls based on data from Electronic Medical Records EMR. Results GPs in the intervention group were able to identify more emotional and behavioural problems after the integrated service had started. Conclusion An integrated mental healthcare approach within general practice may lead to an increase in detected psychosocial problems among children, and these problems can mainly be treated within the primary care setting.

The philosophy behind the experiment is the following: Has there been a shift in the identification, treatment and referral of children with psychological or social problems since the start of the Eureka project? Are there any differences in identification, treatment and referral of children with psychological or social problems between the participating GP practices and control GP practices that did not pay extra attention to youth mental health? Method Setting The medical centre that carried out the Eureka project consists of four general practices, in which there are six GPs. Data analysis also involved the reduction and synthesis of information, and the production of frequency of themes i.

Reports were produced to summarise pertinent results, which were read and discussed by all researchers. We also compared GP collaboration strategy for patients diagnosed with common mental disorders anxiety, depression and patients with serious disorders schizophrenia, bipolar disorder with or without concomitant disorders physical problems, substance abuse.

A new approach to child mental healthcare within general practice

Other pertinent data related to GP practice, extracted from the brief questionnaire, are presented in Table 2. Patients with mental disorders were generally managed by GPs in solo practice GPs working on their own whatever the setting who faced difficult access to mental health resources see interview quotes in Box 1. Parallel or sequential follow-up and communication with psychiatrists through consultation reports were the norm.

GPs identified psychosocial professionals, especially psychologists and psychiatrists, as their main partners in the management of mental disorders. Psychologists were reportedly quoted as playing a key role in helping patients facing challenging life events, thereby preventing accident and emergency department visits and hospitalisations. About half of GPs referred their patients with common mental disorders for psychotherapy either with psychologists in private practice for patients with private insurance or the public system HSSCs.

At least two-thirds of GPs considered joint psychotherapy and medication as the best treatment option for managing common mental disorders. I strongly recommend psychotherapy and pharmacotherapy. Once patients see the psychiatrist, I receive recommendations that assist me in the treatment of patients whose needs are more complex.

What influenced me in my workplace is that you can give patients the time they need and you have a multidisciplinary team that is close at hand with which you can easily have exchanges. So obviously, it gives me a lot of experience. You try powerful drugs, something that is more difficult to do in private practice. First, you gain confidence in this kind of medication, and then you gain experience in using them. This encourages me to take on more patients in my private practice.

Background

I find this more useful than going through the formal network. They do an assessment and they let us know if we are on the right track or not. Access to and communication with psychiatrists is very easy for my patients at hospital X. However, given that psychiatric services are regionalised, as soon as patients fall under the care of another hospital, I lose my contacts.

Waiting times are excessively long; telephone consultations for a quick opinion are also not possible. I believe that a special compensation package should be attached to the management of MD. We can provide follow-up care for stable serious mental disorders and we can deal with common mental disorders. We must have rapid access to a psychiatrist who can either see or support the patient during an acute episode or provide follow-up.

We must also have access to a multidisciplinary team that will take care of the patient and will not let him or her fall through the cracks. The patient should have access to various professionals on that team: There should even be a place for the integration of new professionals in the community who could accompany the patient daily in this process of change. I think it would be beneficial.

The few patients with serious mental disorders they managed see Table 2 were followed-up in conjunction with mental health professionals and psychiatrists e. Generally, GPs believed that they did not have sufficient skills to treat these patients alone. Because psychiatrists were so difficult to contact, some GPs established informal links with other GPs who specialised in mental healthcare. The latter had usually practised in HSSCs or psychiatric facilities, showed a keen interest in mental healthcare and saw more patients with mental disorders. Pharmacists were also mentioned as key partners, but GPs used them no differently than for other medical conditions, and communicated only occasionally with them, by fax or phone, to: Pharmacists practising in psychiatric facilities were particularly appreciated by GPs for their extensive knowledge of mental healthcare medication.

In addition, GPs had little knowledge of the voluntary sector or the detox centres, but believed HSSCs could act as a bridge. GPs cited few collaboration-enabling factors; however, they reported one key issue, namely, working in multidisciplinary practice settings, such as in HSSCs. Psychosocial professionals were present in a few private group clinics, but generally GPs were as isolated in these settings as in solo private practice.

Multidisciplinary practice settings were seen as favouring exchanges between professionals, prompt patient referral and joint patient assessment. In addition, GPs who worked or had practised in HSSCs or hospitals usually enjoyed stronger informal contacts — yet another collaboration-enabling factor.

Dr. Calderón

Cautiously, GPs avoided overusing informal networks, reserving them for crisis or complex situations. Almost a quarter of GPs claimed they had no informal networks. These included younger physicians who had not had time to establish them, and doctors mainly at HSSCs who appreciated their formal networks and saw no reason to look elsewhere. Half of GPs relied on informal networks: Most also had a list of private psychologists that they recommended to their patients. GPs favoured psychologists trained in cognitive—behavioural therapy who provided short-term and result-oriented therapies.

Access to private psychologist follow-up was immediate when patients had insurance. Private insurance also helped to relieve the financial worries of daily life, thereby further favouring patient recovery. However, it limited the number of psychotherapy sessions. GPs had to transfer patients whose insurance coverage had run out to HSSC single-access points for further psychotherapy sessions. Such occurrences did not favour robust therapeutic alliances and care continuity. Some patients even recovered on their own before receiving HSSC services, with GPs providing more assiduous follow-up in the interim.

Training that featured case discussion was considered doubly beneficial as it fostered networking and knowledge acquisition. GPs were particularly drawn to training offered at local networks, delivered by psychiatrists and involving multidisciplinary teams. Wherever implemented, ELMs and responding psychiatrists were seen as having a positive impact on access to psychiatric care, resulting in prompt psychiatric assessment and recommended treatment, with joint follow-up by GPs and psychiatrists as needed.

On the other hand, GPs cited numerous factors that hindered their management of patients with mental disorders, including: Also, HSSC single-access points — which co-ordinate care with mental healthcare teams and psychiatrists — were not considered to be sufficiently flexible. For instance, referral to specific psychiatrists was not permitted.

GPs also complained about: When access problems were resolved, GPs judged psychiatric care to be excellent and beneficial both for patient recovery and their own management of mental healthcare cases. Ideal care models identified by GPs included the following characteristics: Also favoured were adequate training, financial incentives, appropriate modes of compensation salary or hourly fees and wide access to care. GPs insisted on the importance of sharing responsibility for patient care.

Psychiatrists should be more readily available for difficult cases, crisis situations and destabilised patients. Irrespective of insurance coverage, psychologists should be universally affordable. In addition, sufficient psychotherapy sessions should be provided to meet the needs of patients with common mental disorders. Short reports from, or phone briefings with psychologists on treatment objectives, approaches and therapeutic planning would help GPs treat their patients more efficiently especially the more challenging cases.

Social workers were identified as key partners for serious mental disorders and highly disorganised patients. They — rather than nurses — would handle screening and follow-up of patients requiring more intensive psychosocial intervention. In addition, the voluntary sector would play a greater role, with nurses and social workers acting as brokers for patient referral. Some, however, were sceptical about reforms and doubted whether they could manage increased responsibility and heavier caseloads.

Reinforcing multidisciplinary approaches emerged as a solution for bolstering primary mental healthcare, including: HSSC single-access points, mental healthcare teams and shared-care initiatives were seen as major steps forward for reforming primary mental healthcare, but requiring consolidation before they could yield improved patient outcomes. Few management tools were utilised, e. In continuity with other studies, 9 , 10 this research highlighted the pivotal role GPs played in managing mental disorders, mainly common mental disorders. Studies indicate that most patients with common mental disorders are treated by GPs, without the latter having significant contacts with other mental healthcare providers.

However, referrals are a more common strategy, as shown in our study, as in others. GPs in our study were faced with all these challenges, and their recommendation of joint psychotherapy and medication suggested that they recognised the limited effectiveness of a pharmacology-only approach. Some patients resist taking drugs or prefer psychotherapy instead. In countries such as the UK and Australia, efforts have been made to enhance access to free psychotherapy, and co-ordinate GPs and psychologists more effectively.

Evidence-based psychological intervention is reported as cost-effective. In addition, comprehensive service provision that meets patient needs, and organisational, longitudinal and relational continuity of care have repeatedly been mentioned as key enabling factors for patient recovery — even more so for patients with recurrent or complex mental disorders. The serious shortage of nurses in the Quebec healthcare system as in many other jurisdictions would undoubtedly hamper efforts to foster their participation in mental healthcare.

International studies 9 , 12 have also shown that poor outcomes are associated with a substantial proportion of individuals suffering from mental disorders whose cases are managed in primary care, lending credence to current efforts to promote shared care, multifaceted interventions, and best practices. GPs see themselves as autonomous entrepreneurs. Guidelines defining joint roles and responsibilities must be clearly established. Other key elements for effective shared care, as per the literature, 47 , 48 include: Investments to improve co-ordination and extend the role of mental healthcare partners would relieve the burden of care for GPs and allow them to enhance their ability to treat patients with mental disorders and expand their caseloads.

First, this study may over-represent GPs who are more keenly interested in mental health, thereby accounting for a larger proportion of GPs paid by salary or hourly fees rather than fee-for-service in this sample, compared with GPs in Quebec as a whole. Second, GPs more driven by team practice may also be over-represented in this study.

Third, the study focused on Quebec; studies must be conducted in other jurisdictions to establish a basis for comparison.

The way primary care is organised depends on countries, but most follows the same challenges and trends for reform. This article illustrates the dynamics and key enabling factors and strategies to promote collaboration among GPs, psychiatrists and psychosocial professionals. It argues that increased efforts are needed to strengthen collaboration in the field of mental healthcare.

The final conceptual framework Figure 2 highlighted key issues that drive collaboration, and the study showed that most of them are lacking, resulting in GPs working mainly in solo practice. Although still in their infancy, reforms are underway to extend primary healthcare group practice and collaboration among GPs, psychiatrists and mental healthcare teams in most industrialised countries.

GPs in our study were strongly in favour of improving team practices. They strongly advocated extending access to psychologists for the treatment of common mental disorders, and to social workers for follow-up of serious mental disorders. Nurses can also play a more pivotal role in patient screening and follow-up, but only if the obstacles of insufficient mental healthcare expertise and personnel shortage are overcome.

Shared care, an extended role for psychosocial professionals, and more efficient mental primary care organisation should lead to expanded caseloads for GPs and better access to services for patients. We would like to thank the grant agencies: National Center for Biotechnology Information , U. Ment Health Fam Med. Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC.

Abstract Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. Introduction Mental disorder is a leading cause of morbidity worldwide.

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