Abstract
It has been estimated that in 1997 over three million Australian adults experienced a psychological disorder [1], [2]. The Australian burden of disease study suggested psychological disorders make up 15% of the country's total burden of disease [3]. Anxiety alone accounting for 32.4 million person-days out of role among Australian adults [2]. This burden is likely to increase over the next 20 years [4].
While high prevalence of psychological disorders is of concern, so is their low level of treatment. In 1997, twothirds of people in the community with a mental disorder did not seek professional help. Of the third who used a health service, three-quarters saw a general practitioner (GP) and half of these saw no other health professional [1].
While only 35% of people with a psychological disorder seek help for their psychological problem [1], 71% of the community think that if they sought professional help for depression they would first turn to a GP [5]. During any one year approximately 82% of Australians will see a GP [6], placing GPs in a position to identify and manage those with a psychological disorder, some of whom, to date, have not had the problem professionally recognized [7]. As Andrews says: ‘the GP is the key to treatment for most people with mental disorders’ [1].
In the past decade, reforms have shifted mental health care toward primary care in Australia [8]. In 2001 these reforms culminated in the Better Outcomes in Mental Health Care initiative [9]. Under this scheme, GPs undergo training to improve diagnostic and management skills in mental health. They can then claim special Medicare item numbers for longer consultations using evidenced-based interventions or for provision of a 3-step mental health care plan involving assessment, a case management plan and patient review.
While these steps are positive, measuring the impact of these reforms on GP management of psychological problems requires a baseline measure prior to their introduction. Unfortunately, few studies have examined GP management of psychological problems in the broader sense.
The National Survey of Mental Health and Wellbeing [10], the most comprehensive study into psychological problems in the population, examined prevalence of psychological disorders and its relationship to gender, age, education, employment, comorbidity and service usage. Substance abuse was more prevalent in men, while anxiety and affective disorders were more prevalent in women. Women with a psychological problem were more likely to seek help from a GP (36.6%) than men (21.6%) and such help-seeking behaviour was more likely in people with depression (40.5%) than in those with a substance use disorder (7.8%) [10].
Research into GP management of psychological problems has mostly concentrated on the detection and management of depression and anxiety [11], [12]. The most recent study, the Somatic and Psychological Health Report (SPHERE) looked for ways to improve GPs' detection and management of psychological problems, particularly the more common ones (depression, anxiety and somatoform disorders) [12].
The study found that patients who have their psychological problems managed when attending GPs are more likely to be female, middle-aged and Australian-born. GPs who were more likely to manage a patient's psychological disorder were over 35 years of age, working in small practices and in regional centres [13].
The most recent paper examining all psychological problems (not just the more common ones) managed in Australian general practice [14] was based on a secondary analysis of data from the Australian Morbidity and Treatment Survey (AMTS), a national study of general practice activity, conducted in 1990–1991 [15]. This study investigated the rate of management of psychological problems and methods used to manage these problems. In the early 1990s the most common psychological problems managed were depression, sleep problems, anxiety and substance abuse disorders [14].
Over the past decade community awareness of psychological disorders has increased [5], which may have led to an increase in their treatment rate in general practice. The pharmacological treatments available for some disorders has also vastly improved, for example the release of the selective serotonin reuptake inhibitors and atypical antipsychotic medications [16], [17]. The advent of new treatments may be followed by an increase in diagnosis and subsequent management of the problem.
The Bettering the Evaluation and Care of Health (BEACH) program [6], a similar study to the AMTS, is representative of the (approximately) 100 million GP– patient encounters each year across the country. It has been suggested as a means by which GP behaviour in the management of psychological disorders may be tracked [8]. BEACH provides an opportunity to describe current GP management of psychological problems, giving a baseline against which the impact of recent government interventions in this area might be measured in the future. It also allows us to compare current GP management of psychological problems with their management a decade ago.
Method
The first section of this study examines current GP behaviour. This is a secondary analysis of data from the BEACH program, a continuous national study of general practice activity in Australia. Each year approximately 1000 active, recognized GPs participate, recruited from a random sample of Health Insurance Commission data drawn by the Australian Department of Health and Ageing. Participating GPs record details about 100 doctor–patient encounters (of all types); they also provide information about themselves and their practice. Data elements include GP characteristics, patient characteristics and encounter details (including problems managed by the GP and management techniques utilized).
The information is recorded on structured paper encounter forms. The methods have been described in detail elsewhere [18]. The BEACH data period for this study is April 2000 to March 2002 inclusive and includes data pertaining to 198 200 GP–patient encounters from 1982 GPs.
Problems were classified according to the International Classification of Primary Care – Version 2 (ICPC-2) [19] but were coded more specifically in ICPC-2 PLUS, an extended set of terms drawn from general practice in Australia [20]. The psychological problems managed at the encounters were regrouped from ICPC-2 PLUS into ICD 10 Australian modification (ICD 10 AM) [21], in order to provide results comparable to previous research and because it was thought that the readership would be more familiar with ICD 10 AM.
The second section examines changes in GP management of psychological problems over the past decade. Comparisons are made between BEACH data and a secondary analysis of the AMTS data [15]. Prior to BEACH, the AMTS was the most recent national survey of morbidity managed and treatments provided in Australian general practice [15]. Some of the authors of this paper were involved in the AMTS and the data are held by the Family Medicine Research Centre, allowing the application of more sophisticated statistics to the data than was possible in the early 1990s.
There were 495 GPs in the AMTS the random sample being selected in the same manner as in BEACH, except it was stratified by state. Post-stratification weighting corrected for over-representation of smaller states to provide national estimates. The participating GPs recorded all consultations occurring in the surgery or the patient's home for two periods of one week, six months apart. This led to a national dataset of 98 796 patient encounters [15].
The AMTS and BEACH encounter forms are similar. However, in BEACH more detailed information is captured on management. In the comparative analysis, some steps were taken to ensure comparability between surveys. The BEACH dataset was reduced to exclude indirect encounters, aged care facility encounters and medications advised for over-the-counter purchase, as these were not recorded in the AMTS.
Statistical methods that take into account the single stage cluster design in both surveys have been incorporated into the analyses through SAS V. 8.2 [22]. Where specific comparisons are made, statistical significance has been determined by non-overlapping 95% confidence intervals.
Results
General practice 2000–2002
In 2000–2002, there were 21 562 psychological problems managed at 198 200 encounters (a management rate of 11.5/100 encounters). Female patients had a higher rate of psychological problem management (12.0/100) than males (10.9/100). The management rate initially increased with patient age, peaking in the 25–44 years group (15.5/100 encounters), then decreased significantly at encounters with patients of 65–74 years (9.6/100). There was no difference in management rates between encounters with patients living in rural and metropolitan areas.
The management rate increased steadily with GP age, from 9.3 per 100 encounters with those under 35 years to 12.3 per 100 with those 55 years and over. The rate increased as size of practice decreased, GPs in solo practice having the highest rate (13.5/100 encounters). The rate was higher for GPs who had graduated in Australia. Female GPs managed more psychological problems than male GPs but the difference was only marginally significant (Table 1).
Rates of psychological management by general practitioner and patient characteristics
The psychological problems most often managed were mood disorders (4009/100 000 encounters), stress related disorders (2582), behavioural syndromes (1739) and disorders due to psychoactive substance use (1413) (Table 2).
Total management rates of psychological problems and sex specific management rates (BEACH 2000–2002)
The most common individual problems managed were depressive disorder (3842/100 000 encounters), anxiety disorder/feeling anxious (1729), sleep disturbance (1618), acute stress reaction (601), drug abuse (586), schizophrenia (448), dementia (425), tobacco abuse (409), alcohol abuse (365) and affective psychosis (145) (results not tabled).
Psychological problems more frequently managed for women were: mood disorders (4682/100 000 encounters c.f. 3065 for men); stress related disorders (2919 c.f. 2101); and organic mental disorders (497 c.f. 347). Those managed more often for men were: psychoactive substance abuse disorders (2002/100 000 encounters c.f. 1006 for women); schizophrenia, schizotypal and delusional disorders (639 c.f. 397); disorders of psychological development (42 c.f. 9); and disorders in children (243 c.f. 78) (Table 2).
Pharmacological management was the most common type of management with medications being prescribed, supplied or advised at a rate of 69.5 per 100 contacts with psychological problems. Nonpharmacological treatments were given at a rate of 51.3 per 100 contacts, the majority being clinical treatments (50.0/100) (Table 2). Referrals were given at a rate of 7.6 per 100 contacts (95% CI = 6.0–9.2), mainly to a specialist (4.3/100 contacts) or to an allied health professional (3.3/100) (results not tabled).
The group of problems for which medications were most frequently prescribed/advised/supplied was schizophrenia, schizotypal and delusional disorders with 95.6 medications per 100 contacts, the majority of these being antipsychotic medications (73.6/100). This was followed by behavioural syndromes with 89.8 medications per 100 contacts, sedatives and anxiolytics being the most frequent (62.8 and 13.8/100, respectively). Mood disorders followed with 76.9 medications per 100 contacts, of which 80.0% (61.5/100) were antidepressants. Contacts with psychoactive substance abuse disorders generated 62.9 medications per 100 contacts with opioid dependency drugs, antidepressants and anxiolytic medications commonly used. Contacts with neurotic and stress-related disorders generated 56.3 medications per 100 contacts, anxiolytic and antidepressant medication being most common. Medication rates for disorders in children were low at 23.4 per 100 contacts, a large proportion being stimulants.
Clinical treatments were most often provided for psychoactive substance abuse disorders (66.3/100 contacts), followed by neurotic and stress related disorders (59.8), mood disorders (54.9), unspecified mental disorders (48.1) and disorders in children (47.2).
Overall, mood disorders generated the highest rate of treatment actions (medications ++ clinical treatments) and mental retardation the lowest. While schizotypal disorders and behavioural syndromes generated high rates of medication, both had low clinical treatment rates. In contrast, contacts with disorders in children generated more clinical treatments than medications (Table 2).
Changes over the last decade
In this section the BEACH data set has been reduced to one comparable to the AMTS (see Method) and so the BEACH rates differ from those reported earlier. All differences reported are statistically significant.
Table 1 demonstrates that the relative management rate of psychological problems increased over the decade from 9.7 per 100 encounters in 1990-1991 to 11.6 in 2000–2002. The management rate for both male and female patients significantly increased with female patients having a consistently higher management rate in both studies. The relative rate of management rose for young adults (15–44 years) and decreased for older patients (65 years and older). There was a large increase (over one-third) in the rate of psychological problem contacts with rural patients (8.8/100 encounters c.f. 12.1).
The rate of psychological problem contacts in small and solo practices increased over the decade. In both studies, GPs who were 55 years or older had a higher management rate of psychological problems than GPs who were aged less than 35.
Table 3 shows the management rate of mood disorders almost doubled (from 2266/100 000 encounters in 1990-1991 to 4096 in 2000–2002) and tests and treatments tripled (from 102 to 371). In contrast there was a decrease in management rates of neurotic and stress-related disorders (from 3305/100 000 in 1990-1991 to 2631 in 2000–2002), organic mental disorders (348 c.f. 235) and mental retardation (43 c.f. 13).
Management rates of psychological problems, rates of medication and clinical treatment use in 2000–2002 and 1990–1991
However, in the AMTS the problem label ‘anxiety/depression’ was classified as a stress disorder, while in BEACH it was coded more specifically and classified as a mood disorder. Additional analysis of the BEACH data, reclassifying ‘anxiety/depression’ as a stress disorder eliminated the apparent decrease in the rate of stress disorder contacts but the increase in mood disorder contacts remained significant (results not tabled). The removal of the aged care facility visits from the BEACH data in Table 3 halved the rate of organic mental disorders when compared with the unadjusted data in Table 2.
Prescription rates per 100 psychological problem contacts increased significantly from 63.3 in 1990-1991 to 69.1 per 100 contacts in 2000–2002. This was particularly reflected in prescriptions for psychoactive substance abuse disorder (40.8/100 contacts in 1990–1991 and 61.2 in 2000–2002). No other significant changes were found in prescription rates for specific psychological disorders.
Clinical treatments provided per 100 psychological problems increased by nearly 50% over the decade (36.0/100 contacts in 1990–1991 c.f. 53.1 in 2000–2002). This was reflected in increased rates of clinical treatments provided for organic mental disorders, disorders due to psychoactive substance use, schizophrenia and schizotypal disorders, mood disorders, behavioural syndromes and neurotic, stress-related disorders.
Discussion
This study shows there have been changes in both the rate and methods of management of psychological problems in Australian general practice across the last decade and provides a baseline for measurement of future change. In 2000–2002 the rate of psychological management of 11.5 per 100 encounters extrapolates to psychological problems being managed on 12 million occasions at the 103 million GP–patient encounters in Australia in each of these years [23].
The increase in management rate may reflect an increase in prevalence of psychological problems in the population, increased community awareness of psychological problems [5] the shift from hospitalized care to primary care for psychological problems, improvement in GPs' detection of psychological problems or availability of better methods of management. However, it is likely due to a combination of all these factors.
Female patients having higher management rates of psychological problems, specifically mood and anxiety disorders and male patients having higher management rates of psychoactive substance abuse disorders are consistent with findings of the Mental Health and Wellbeing [10] and SPHERE [13] studies.
We found no difference in management rates between rural and metropolitan areas. In contrast, the SPHERE study suggested higher management rates in rural areas [13] and an earlier study using BEACH data demonstrated higher management rates in regional centres [13]. In the current study the comparison was between all rural and all metropolitan areas. This broader categorization of rural and metropolitan may be hiding specific differences between regions. However, the large increase (< 30%) in management rates of psychological problems in rural encounters is notable when compared with only a 13% rise at encounters in metropolitan areas.
As would be expected from the SPHERE study, GPs who were older managed more psychological problems. The increase in management rates by GPs in small and solo practices meant that by 2000–2002 solo practitioners managed relatively more psychological problems than those in large practices. There has been a shift away from solo practice over the past decade in favour of larger practices and GPs who are in solo practice tend to be older than GPs in larger practices (unpublished BEACH data). One wonders whether those GPs who are in solo practice offer more stable one-to-one relationships with patients and that this is attractive to patients with psychological problems.
The increase in the rate of psychological contacts in young adults (15–44 years) is not surprising considering the increased awareness of psychological problems in this age group [5]. The demonstrated decrease in management rates in older patients (≥ 65 years) requires more detailed investigation. The halving of the rate of organic mental disorders management when aged-care facility encounters are removed suggests a high rate of dementia in the patient population in aged-care facilities.
Our results highlight the wide range of psychological problems managed by GPs. While depression and anxiety remain frequent, GPs also often manage sleep disorders, schizophrenia, dementia and child-related psychological disorders. However, the significant increase in mood disorders is notable.
In the management of psychological problems, GPs still rely on the use of medication more often than clinical treatments, such as counseling. However, this seems to be changing, with a 50% increase in clinical treatments compared with a small increase in medication rates over the decade. It is pleasing that GPs preferred to use clinical treatments such as counseling for children's psychological problems more often than medication. The high use of stimulants in managing these children would be due to the management of attention deficit disorder.
This study shows that prior to the introduction of the Better Outcomes in Mental Health initiative, changes had already occurred in rates and management of psychological problems in general practice. It also provides a baseline from which future research can measure the impact of the recent reforms in mental healthcare. It highlights that apart from mood and anxiety disorders, GPs manage a broad scope of psychological problems. This study supports the concept that in Australia ‘the GP is the key to treatment for most people with mental disorders’ [1].
Footnotes
Acknowledgements
Thanks to the GP participants; the research funding from the Australian Department of Health and Ageing; Astra Zeneca Pty Ltd (Australia); Aventis Pharma Pty Ltd; Janssen-Cilag Pty Ltd; Roche; Merck Sharp & Dohme (Australia) Pty Ltd; Jan Charles and Joan Henderson for their comments and Stephanie Knox for assistance with statistical analysis.