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Article Excerpt
General practitioners (GPs) in Australia typically do not refer clients to mental health care providers. Few systematic and referenced studies of the reasons for this lack of collaboration have been identified. The current research addresses this gap by investigating GPs' views on psychologists and the factors that determine patient referral. The research used a qualitative design consisting of semistructured in-depth interviews that were tape recorded, transcribed verbatim, and thematically analyzed. Participants were 12 Western Australian GPs from the Perth metropolitan area. The main findings were that GPs were satisfied with psychologists' capabilities but not their professional communications and were overwhelmingly dissatisfied with a mental health system that does not readily provide funding for patients in need of mental health care services. The findings suggest that GPs would like health care policies to be more inclusive of psychological services and are interested in collaborating with psychologists for better patient outcomes. Directions for further research are discussed.
Keywords: general practitioners, psychologists, mental health, collaboration, attitudes
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Approximately 82% of the Australian population will consult a GP during any given year (Harrison & Britt, 2004). This places GPs in a unique position with regard to identifying and managing psychological disorders, as they are the first professional contact for most Australians with mental health problems. It is reported that approximately 23% of Australians suffer with some mental disorder annually (Vines et al., 2004), and it has been suggested that psychological disorders make up 15% of Australia's total disease burden (Harrison & Britt, 2004).
The Australian health care system encompasses a public and a private sector. The public sector is funded through the taxation system via a Medicare levy (i.e., a percentage of income) collected from taxpayers (Commonwealth Department of Health & Aged Care, 2000). The Medicare system provides free or partial-payment health services in public hospitals and GP practices. The private sector is funded by private health insurance. In Australia, specialist medical treatment is only accessible on referral from a general practitioner (GP). Although the Australian health care system provides medical fee rebates for GP and medical specialist treatments, until recently Medicare rebates have not been available for treatments from allied health professionals such as psychologists. This meant that people with private health insurance were able to claim a rebate through their insurance fund, whereas those with no such insurance were liable for the full fee.
People with psychological problems usually seek help from their GP only when their problems are severe (King et al., 2002), and then only half consult any health professional other than their GP (Harrison & Britt, 2004). The most common psychological problems managed by Australian GPs in the early 1990s were mood and stress-related disorders such as depression and anxiety, sleep-related problems, and behavioral problems related to substance use (Harrison & Britt, 2004). Of the Australian patients presenting to GPs, it has been estimated that fewer than half of adults and one third of children receive appropriate mental health treatment (Vines et al., 2004). Indeed, when evaluating Australian GP recognition of mental disorders, GPs did not recognize 56% of patients' mental health problems (Hickie et al., 2001). Australian GPs are thus often obliged to take on the burden of mental health service provision regardless of their level of comfort or expertise because of the absence of, or patient financial difficulty in accessing, other mental health professionals (Winefield & Chur-Hansen, 2004).
In 2002-2003, Australian GPs referred 2.5% of total consultations to allied health workers including physiotherapists, podiatrists, chiropodists, dieticians, dentists, and psychologists. Fewer than 0.2% of consultations were referred to psychologists (Britt et al., 2003). Many factors have been identified that may determine GPs' referrals of clients to mental health professionals, such as GPs' attitudes toward mental health and mental health professionals; GPs' training, feelings of competence, comfort, understanding, and skill; professional relationships; support, accessibility, and time constraints; patient difficulty; and the affordability of psychological services for patients (Meyer, Fink, & Carey, 1988; Pryor & Knowles, 2001; Railton, Mowat, & Bain, 2000; Richards, Ryan, McCabe, Groom, & Hickie, 2004; Sahhar & O'Connor, 2004; Sigel & Leiper, 2004). Seeking to further explore the reasons behind GPs' low referral rates to psychologists, we first review the relevant literature and then report on an exploratory qualitative study that sought to identify GPs' views of psychologists and the factors that contribute to patient referral.
Strong evidence is presented in the literature showing that use of mental health care providers in collaborative practice is cost effective and in the best interests of patients (Hemmings, 2000; Huezenroeder et al., 2004; Hunsley, 2003; Lenihan & Iliffe, 2000; Vines et al., 2004; I. Wilson & Howell, 2004; J. Wilson & Read, 2001; Winefield & Chur-Hansen, 2004). Despite this, it appears that GPs are reluctant to refer patients who present with mental difficulties to psychologists (Britt et al., 2003; Meyer, Fink, & Carey, 1988; Sigel & Leiper, 2004; J. Wilson & Read, 2001).
BARRIERS TO COLLABORATION
Sigel and Leiper (2004) stated that health care professionals are often trained to work independently. This, in addition to differences in theoretical orientations, professional languages, interaction styles, and assumptions regarding treatment, may have an impact on effective interprofessional collaboration (Twilling, Sockell, & Sommers, 2000) and communication. In their professional interactions with psychologists, GPs found that communications from psychologists were not very informative (Sigel & Leiper, 2004). Pryor and Knowles (2001) found that although many GPs displayed favorable attitudes toward psychologists, they were generally unaware of their training. Also Herman, Trauer, and Warnock (2002) have suggested that professions have a tendency to interpret differences in training as deficiencies.
O'Connor, Clarke, and Presnell (1999) noted the lack of substantial educational exposure of Australian and New Zealander medical students to counseling, psychological therapies, mood and anxiety disorders, cognitive impairment, and substance use. According to O'Connor et al., the time devoted to mental health training should reflect the approximately 9% of consultations that GPs would expect to see relating to psychological and emotional problems. Sahhar and O'Connor (2004) found that GPs commonly used psychology-based treatments for mental health and reiterated that medical school training was deficient in basic psychological skills.
Similar to other studies (Pryor & Knowles, 2001; Richards et al., 2004), Sigel and Leiper (2004) found frequency of referrals to psychologists to be predicted in part by GPs' confidence in liaising with them. Other factors were found to be GPs' views of psychological problems and therapies, access to psychological services, patient suitability for psychological therapy, and the GPs' feeling that they had reached the limits of their own capabilities. GPs who believed that working with depressed patients was difficult were more likely to refer to psychologists because the time required to supportively deal with these patients was seen to tax GPs' busy schedules. GPs generally saw their role as one of containment that included ongoing support and monitoring of risks, even after referral.
In a Scottish study, Railton et al. (2000) found four main areas of impact on GPs' management of depressed patients: (a) organizational issues, including inadequate consultation times; (b) treatment and management issues, including a need for more GP mental health training; (c) stigma, including the detection and management of depression; and (d) referral and other service response issues, suggesting that the use of other professionals was influenced by the quality of professional relationships. Profound divisions were seen between GPs and other mental health professionals, particularly psychiatrists, who were seen to lack understanding of patients' social and family issues and to communicate ineffectively. Also noted was perceived lack of support from psychologists and psychiatrists. Feelings were, however, generally positive toward counseling services that were connected to practices. Overall, GPs saw themselves as serving a key role in the management of depressed patients.
Richards et al. (2004) suggested that factors affecting the diagnosis and management of mental health problems by GPs are practice factors (such as workload and time and financial constraints); patient factors (such as reluctance to accept diagnosis, somatic presentation, and treatment compliance); GP factors (such as confidence regarding diagnostic criteria, treatments, and assessment; attitudes toward mental health; and comfort in discussing mental health issues); and access to mental health specialist resources....
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