Summary of qualitative barriers and facilitators by diagnosis/treatment phase
| Recognition and diagnosis | Management | Referral | |
|---|---|---|---|
| Confidence | Reluctance to ask ‘deeper’ questions48 Lack of clarity of diagnostic criteria, issues around potential comorbidity, parental discrepancies,49 children’s inability to express themselves well: ‘[mental health problems] don’t come to light so easily’,48 lead to issues with confidence | Difficulties ‘establishing a rapport, finding the right words and tone to use and dealing with silence’50 with younger patients Reluctance to broach the issue [of mental health] for fear of provoking ‘defensiveness and anxiety’ in the young person51 | Uncertain where to refer52,53 — ‘Long, unhelpful letters from specialists’52 Uncertainty regarding ‘the lack of clarity’ about how other services are structured and governed led to lack of confidence51 |
| Knowledge and skills | Lack of emphasis on mental health in medical training49,52,54,55 ‘[re: hyperactivity] you have to learn all about these diseases that have a prevalence of about one in a million, and this relatively common problem is hardly ever mentioned’52 Lack of skills;48 it was suggested routine screening could increase | Lack of training:52,54,57 ‘My paediatric residency didn’t include adequate training for the amount of paediatric mental health problems there [are] in the world!’ 56 | |
| Prioritisation of mental health problems | Lack of time to carry out exploratory screening51,57 More time needed for evaluation49 Increased reimbursement possible facilitator that could increase ‘behavioural health’ diagnoses49 Insurance policies that restrict the number of visits per patient51 hamper recognition Difficulties gaining insurance reimbursement for mental health diagnoses56 Physical health may sometimes be prioritised as mental health problems are not seen as a ‘chief complaint’51 | Lack of time to deal with such [mental health] issues as it is ‘too complicated and difficult’ for the time allowed54 | Lack of care available from insurance policies56 Lack of psychiatrists provided by insurance companies58 Limitations on the number of funded therapy visits57 Occasional difficulty choosing whether to refer in short appointment times48 |
| Resources | Lack of tools.48,49,51,53,54 Lack of tools in this area is in contrast to the more extensive availability of tools in the adult mental health field48 and for organic illnesses53 | Desire for more support from other disciplines,54 including psychologists, schools, counsellors Collaborating with other groups described as communicating into a ‘void’,58 which results in a separation from available resources | Lack of providers and resources49,56,57 with practitioners sometimes becoming the ‘“de facto” mental health provider’ as there ‘simply wasn’t anyone else available’ 57 Extensive waiting times for specialists services50,54,56,58,59 Distance to resources was a barrier for rural practitioners56 Lack of communication led to a disconnect between primary and secondary care56 and ‘contributed to primary care practitioners’ perceptions of poor effectiveness of therapy’ 57 Desire for increased communication,48 information,59 and feedback on referrals60 Dislike of long letters Desire for telephone communication59 Frustration with frequent rejection of referrals50 Desire for clearer referral criteria — Child and Adolescent Mental Health Services criteria were described as a ‘mystery’ 48 ‘Greater assistance from mental health providers’ was a desired facilitator49,56 |
| Family issues | Increased parental awareness of mental health problems was endorsed as a facilitator49,51 | ‘A longstanding relationship with the family strengthened the [practitioner’s] commitment’ and provided the advantage of contextual knowledge57 | |