Pruebas de Hermeticidad en Sistema de Alcantarillado

There are two important factors at the ‘conspicuous psychiatric morbidity’ level (Level 3) which impinge on this study. The first is the treatment provided by the general practitioner and the second is the outcome for patients with a mental illness.

3.8.1 Why treat m ental disorders?

Shepherd and his colleagues (1966) found that "no treatment recorded", sedatives and reassurance were the most common treatments (p. 153) and that the type of treatment was related to the age and sex of the patient. Hence, the rather critical conclusion that 'Treatm ent of minor psychiatric disorders in general practice is often haphazard and inadequate" (Shepherd et al, 1966, p. 175). The second point relates to the outcome for patients with psychiatric disorders seen in general practice. Why is it worthwhile detecting mental disorders in the general

practice setting? Johnstone & Goldberg (1976) demonstrated that recognition of

‘hidden’ psychiatric illnesses did reduce the length of the emotional disorder and detection significantly reduced the length of the disorder in more severe cases. But Hoeper and his colleagues (1984) when screening with the GHQ were unable to repeat this finding. The primary care physicians’ identification of disorders was not influenced by the patient’s GHQ score. They did not alter their attitude toward patients with high GHQ scores. However, Goldberg (1990) (and Goldberg & Williams, 1988) suggested that there were flaws in the design of the study and that the patient would not benefit unless the general practitioner used the knowledge of a high GHQ score in a constructive way. For example, symptoms

were not discussed with or assistance offered to the patients with high scores. In addition, Freeling et al (1985) demonstrated that undetected depressive illness tended to last longer than detected depressive illness. These authors felt that the failure to recognise depression was not related to skills or attitudes but rather to the general practitioners knowledge of depressive symptoms.

In a review of depression in the elderly, Hendrie & Crossett (1990) cited evidence which suggested that if treatment was well after the onset of symptoms, the prognosis was the worst and "that early intervention could be effective in reducing chronicity".

The use of prescribed drugs increased with the age of the patient, whilst advice, reassurance, psychotherapy by the general practitioner or psychiatric referral became less likely with advancing age (Shepherd et al, 1966).

3.8.2 The decision to refer

The effect of the general practitioners’ treatment on mentally disturbed patients who have been identified (second filter) is critical within the model as it determines whether or not the general practitioner refers a patient to specialist mental health care (third filter). Surveys (reviewed by Goldberg & Huxley, 1980) suggest that only 1% of up to 15%, diagnosed as a psychiatric case, were referred to a psychiatrist and that they were more likely to be chronic than acute cases. In Shepherd and his colleagues’ (1966) study on psychiatric illness in general practice, they found at least 15% of the patients who consulted over a period of 12 months had consulted, at least once, for a disorder diagnosed as primarily psychological. However, only 5% (of the 15%) of these patients were referred to

a mental health specialist.

Some possible reasons for non-referral are that general practitioners: are dissatisfied with the lack of collaboration with

psychiatrists;

are aware of long delays for consultations (Langsley, 1982);

are of the view that the patients would not like to be referred; and

feel that the care of the mentally disturbed is their function (Shepherd et al, 1966).

There is evidence to suggest that there may be some justification to the last point. Findings by Hopkins and Cooper (1969) in a study of psychiatric referral patterns and outcomes in London found that the majority of patients did not keep their first appointment with a specialist or did not continue attending. In addition, at the termination of hospital care, a small proportion (8%) were considered to have recovered, a third were considered to be ‘relieved’ but almost 60% were considered to be unimproved.

It is also possible that some general practitioners avoid patients with psychological disorders and refer them to a psychiatrist. In an attitudinal survey of general practitioners and specialists carried out in New York, over half of the general practitioners avoided psychiatric patients because they lacked knowledge and patience or were unable to understand emotional suffering. It was suggested that such attitudes could be related to personality factors (Krakowski, 1973).

3.9 Summary

This chapter has examined the underlying principles and factors relating to the role and performance of general practitioners in the detection of psychological disturbances. The evidence confirms that general practitioners are the gatekeeper for mental health care (that is, they are in the optimal position open the gate at Level 2 to facilitate entry to the second filter) but that there are limitations to their ability to detect psychological disturbances. Many factors which inhibit entry to the second filter have been presented. Perhaps the most positive and pragmatic approach to improvement is to further develop general practitioners’ communication and consultation techniques and in so doing enhance their performance.

It is not until patients have passed the second filter that treatment or referral can be obtained. General practitioners treat the majority of patients before they reach the third filter as relatively few patients are referred to a mental health specialist. Thus it is imperative that patients with ‘conspicuous psychiatric morbidity’ are treated seriously and appropriately by general practitioners. With a commonly agreed diagnostic schema for primary care, decisions on diagnosis would become more accurate, and treatment and referral would become more standardised.

3.9.1 The future o f general practice

"General practitioners in the years ahead will be servicing a more demanding and discerning population with far more competition both from within the profession and without." (Andersen et al, 1986, p. 115) This statement is true

for people of all ages but particularly so in relation to our ageing population. They will be more demanding and discerning for a range of reasons: for example, they will probably be better educated, be more financially secure, more economically and physically independent than previous generations. And so it would be true to say that "...the ultimate survival of general practice in Australia will depend on the capacity of the individual general practitioner to project an attitude of caring whilst attending to the needs of individuals and families." (Andersen et al, 1986, p. 115)

Research on the detection of psychological disorders in the consulting population has shown that there is room for improvement in general practitioners’ accuracy at identification. In order to improve the detection rate, general practitioners must first be convinced that the time spent in diagnosing and then treating a psychological disturbance is worth it in terms of their patient’s recovery and their monetary return. Training in techniques which have been demonstrated to improve detection of psychological disorders (for example, Gask et al, 1987, 1988) will be successful only when general practitioners have been convinced that the detection of psychological disorders, especially in their elderly patients, is worthwhile.

CHAPTER 4

GENERAL PRACTITIONERS AND