“This glorious twilight zone of uncertainty”: Mental health consultations in general practice in New Zealand
Introduction
General practitioners (GPs) provide treatment for three quarters of the people with a diagnosable mental disorder in New Zealand (Andrews, 1994) but it has been reported internationally that GPs may not recognise a substantial minority or even the majority of common mental disorders (Coyne, Schwenk, & Fechner-Bates, 1995; Schwenk, Coyne, & Fechner-Bates, 1996; Goldberg, 1999). It has also been suggested that these assertions may not take into account the complexity of “recognition” or the fact that the GP does not employ the standard classification systems of psychiatric practice for detection and subsequent management of mental health problems (Schwenk, Klinkman, & Coyne, 1998; Rout & Rout, 1996; MaGPIe Research Group, 2004). The general practice consultation is complex and has led to a plethora of models which explain the dynamics of the consultation (Stott & Davis, 1979; Balint, 1986; Byrne & Long, 1976; Helman, 1981) or act as decision aids for clinical practice (Pendelton, Schofield, Tate, & Havelock, 1984; Neighbour, 1987; Stewart et al., 1995; Usherwood, 1999). Early work highlighted the roles played by the doctor and the patient in the consultation (Balint, 1986; Helman, 1981) and this has been built on to explore the components of the consultation and how the physician can utilise different skills in different contexts (Stott & Davis, 1979). In the 1980s and 1990s the patient centred approach (Stewart et al., 1995) and the concept of the reflective practitioner (Neighbour, 1987) have been important in refining understanding of the consultation. Mental health issues introduce additional complexity and uncertainty into the interaction between patient and doctor.
While many studies have recorded the details of general practitioner recognition of mental disorders (e.g. Ormel, Koeter, van den Brink, & van de Willige, 1991; Marks, Goldberg, & Hillier, 1979; Jencks, 1985) there is relatively little qualitative exploration to provide insight into the complexity of mental health consultations. This complexity affects both the recognition of problems and their management. Practitioners have been shown to take a particular perspective of mental health consultations with problems such as depression categorised as everyday problems of living, rather than as objective diagnostic categories, and unease at responding to patients living in socio–economically deprived environments (Chew-Graham, Mullin, May, Hedley, & Cole, 2002). Studies have also emphasised the sense of powerlessness that GPs express when faced with psycho–social presentations and the way that medically unexplained symptoms are explained unsatisfactorily as a mental health problem (Wileman, May, & Chew-Graham, 2002; Salmon, 2000; Dowrick, Ring, Humphris, & Salmon, 2004) and the conflict for primary care physicians caused by the contrast between medicalised understandings of depression and the recognition of the social context of depression (Thomas-MacLean & Stoppard, 2004).
Klinkman has advocated a dynamic model in which problem recognition and clinical decision-making are determined by competing demands within three overlapping spheres: the clinician, the patient, and the practice ecosystem, all operating within a policy environment that forms a fourth indirect sphere of influence (Klinkman, 1997). This paper builds on this schema and elaborates on these dynamic issues in the general practice mental health consultation.
The nature of the GP consultation may be clarified by consideration of the ways in which the role of the individual doctor and patient link with other systems and socio–cultural factors. Analysis of systems factors does not deny the impact of human agency and the motivations and orientations of practitioners, but outlines the structural factors and discursive practices that shape and constrain that agency. This approach may help to move the debate about primary mental health care beyond the initial perspective of practitioner rates of recognition towards practical implications for effective management, focusing upon systems issues and rather less on uni-dimensional approaches such as practitioner training.
At the time of this study general practice in New Zealand was a partially state-subsidised health system, predominantly funded by fee-for-services, financed by a combination of patient payments, tax funding and less commonly, insurance. Government funding covered the cost of most pharmaceutical and laboratory services, with a low level of user charge for such services. GPs are the gateway to secondary and tertiary care, through referrals to hospitals for specialist care, including elective care. New Zealand consultations are typically 12–15 min in length, and it is common to be able to see the practitioner of choice within 48 h (MaGPIe Research Group, 2004).
Section snippets
Method
The research reported in this paper is based on a qualitative study that was a follow up to a larger longitudinal cohort study known as the MaGPIe study (MaGPIe Research Group, 2003). The MaGPIe study explored the nature, form and outcome of mental health consultations in a New Zealand context. The study involved interviews with 910 patients of 70 randomly selected GPs in the lower North Island of New Zealand. Although results from this study will be referred to as appropriate in this paper,
Practice pressures
It has long been recognised that the consultation process is subject to many external influences. The participants identified the issue of time and the relationship between primary and secondary care as having a major impact on mental health consultations in general practice.
Time was an obvious and frequently mentioned constraint on the delivery of mental health care. The potential for a consultation associated with mental health issues to take longer conflicts with the requirement to avoid
Medico–legal factors
Two important medico–legal factors, identified by GPs and associated with labelling, influenced the way in which they diagnosed mental health problems. One was that to diagnose depression and place that diagnosis on the patient's notes could mean that the patient may have any life insurance premiums increased. GP5/1 noted that if the GP records “depression” then “now they’ve got a 50% load on their insurance as well”.
The other factor was patient access to notes:
One of the problems is that you
Socio–cultural factors
Socio–cultural factors include a range of issues that can influence the consultation. A commonly mentioned but infrequently elaborated factor is that of stigma. GPs thought that the reason patients themselves would not disclose mental health issues is that there was a stigma attached to mental health problems that was not similarly attached to physical problems. The issue of stigma was often related to the issue of labelling in that GPs were aware of the difficulties of giving a label where a
The consultation process
There are a number of aspects of the consultation process itself that influenced how GPs respond to mental health issues.
GP strategies
To cope with the conflicting demands placed upon them GPs described a range of strategies, with some adopting particular styles. GPs could potentially take a special interest in the topic of mental health or seek to avoid mental health consultations. They could focus on the goal of identifying specific evidence-based measures, or carefully select the cases they can deal with and refer others on. The role of talk and communication was emphasised by some, and others articulated a process of
Acknowledgement of limitations
The GPs acknowledged situations where boundaries had been reached to effective management, and the doctor would limit his or her engagement with mental health issues. At times mental health consultations had to be wound down: “I had several borderline personality people and I mean they’re distressed but there's no way you can actually help them often. The mental health people don’t want them and, you know, you do tend to wind those consultations down at times” (GP3/1).
In response to a vignette
Discussion
This study describes some aspects of the complex framework that shapes mental health work in general practice. The four themes of practice pressures, socio–cultural factors, medico–legal issues and the dynamic of the consultation itself form a network of influences to which a GP has to respond. GPs have a range of strategies available to them in response to these influences and the dynamics of the mental health consultation.
A number of important points can be drawn from these data in relation
Acknowledgements
The authors would like to thank the University of Otago for awarding the research team a grant to support this research and the general practitioners who volunteered their time and insights.
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