Abstract
Objective
To examine the barriers and incentives that may exist for Australian general practitioners (GPs) to screen for and detect individuals at risk of developing schizophrenia and to participate in studies aimed at assessing screening procedures.
Method
Examination of literature, existing procedures in general practice, informed by experience in the GP Integration Support, Evaluation and Resource Unit during 1995–1999 and the General Practice Integration Research Programme and the reports arising from this.
Results
The attitudes and responses of GPs to research proposals and to working with researchers will be influenced by their overall relationship with mental health services. As the average GP will only have a small caseload of patients with schizophrenia, it is important to provide some incentive to encourage GP involvement in schizophrenia prevention studies. Key incentives include: the availability of specialist support from mental health practitioners; systems development in general practice; inclusion in the research team; and Quality Assurance points.
Conclusions
General practitioners have shown willingness to engage in a diversity of research projects, including mental health research. Divisions of General Practice are increasingly interested in evaluation and research and may be a useful entry point for approaching GPs as a group.
The attitudes and responses of general practitioners to research proposals and working with researchers will be influenced by their overall relationship with mental health services. As clinicians, the foremost of their concerns will be how the problems that might be identified are going to be dealt with. How, for example, will the anxieties of patients, families and general practitioners themselves be dealt with? This is quite apart from the other problems, such as depression, suicidal ideation and drug and alcohol problems that accompany schizophrenia.
Eighty-seven per cent of the general population see a GP at least once a year [1], slightly more than the 81% of those afflicted with schizophrenia, as seen recently in Australia [2]. This proportion is a little lower for the 15–24-year-old age group [1], which comprises 4% and 6%, of male and female GP patients, respectively [3]. Patients with schizophrenia often present for other problems, such as contraception, injuries or respiratory infections. While mental illness is exceedingly common among GP patients [4], only a small proportion of patients with mental illness have schizophrenia. The average GP will have three or four patients with schizophrenia at any one time, but might expect to be involved in the diagnosis of only four or five patients with schizophrenia in their careers. Onset of schizophrenia is quite a rare event in individual general practices. General practitioners also provide care to other family members who may report concerns about some of the prodromal features and early signs of schizophrenia. This is quite an important opportunity to support the family and make a diagnosis. However, we need to recognise that continuity of care in general practice is decreasing in Australia as a result of the increasing mobility of patients between practices. Young people, in particular, may have several GPs for different purposes.
General practitioners provide the bulk of care for mental illness in the community but provide less of the care for schizophrenia. There are five factors that influence the effectiveness of GPs in managing and detecting mental illness:
Their general communication and interview skills.
Their preconceptions about the likelihood of illness within their practice or their community and preconceptions about severity.
Their patient load (the higher the patient load the shorter the consultation time and the less likely they are to detect these problems).
Remuneration.
The availability of and access to specialist support.
GPs are likely to be less concerned about detecting new cases of schizophrenia if the ones they already have cannot be appropriately managed.
GPs may be reluctant to use screening tools. This is not only related to the time involved in using a screening tool, but also the time involved in explaining it and managing the problems that are identified. You can have an extremely short screening tool but when a GP finds a ‘positive’ there is the inevitable dilemma of the need for in-depth care to be provided, while the time to deal with these is extremely limited. In a study, obtaining consent and providing information for the patient often involve a lot of time. Even if it is a relatively brief intervention, informed consent is required.
The prodromal features of schizophrenia that may present in general practice include social withdrawal, substance abuse, mood swings, sleep disorders, suspiciousness, anger, educational problems and loss of appetite and energy. These are exceedingly common in the adolescent and early adulthood age groups and they are exceedingly common in general practice. This is a real challenge. These features are often reported by parents who are concerned with their adolescents. The GPs may not actually see the adolescent themselves. They see a parent and try to sort out whether it is just normal adolescent behaviour, an anxious parent or something more serious.
The lack of back-up mental health services creates a real problem for GPs in the early detection of schizophrenia or its prodromal symptoms. General practitioners may resort to inappropriate drug therapy such as sedatives, antidepressants and amphetamines for behavioural disorders. Some GPs also have difficulty linking with other services, particularly those GPs who are not well linked with community health services.
Thus, the concerns that GPs have may influence their likelihood of detecting the illness early. They may lack skills in diagnosis and management, partly because it is such a rare event. They may have concerns about the reaction of the family and the patient and how they are going to handle these. They may have concerns about the disruption of the practice. Ethical concerns and legal liabilities may also be of concern to GPs. They may have concerns about the time needed to manage these patients and about the availability of specialists and support in times of crisis, which are real problems.
Beyond this, we need to think about what incentives might be available to support GP involvement in such research. There are several important types of incentive. First, the availability of specialist support and advice is a key incentive for GPs. That does not necessarily mean a psychiatrist but may mean other mental health workers or even a community health nurse within the practice. Someone who can help, share the load and provide some advice and support. Systems development in general practice may be another incentive, such as helping the practice to set up systems to improve their practice management. This is often required in order to conduct any kind of research in general practice and involves working with the practice manager or the receptionist as much as with the GP. Last, GPs appreciate being acknowledged and included as part of a research or academic team. Many GPs, for example, are keen to have students in their practices for long periods of time with no payment.
Of course, Quality Assurance (QA) points help as well. If it is constructed properly, involvement in research may attract QA points. This needs to be worked out in conjunction with the Continuing Medical Education and QA program of the Royal Australian College of General Practitioners. Essenially, it should help in assessing a practice against specified standards. The audit cycle involves the GP in auditing of care, reviewing the practice, setting standards and then repeating the audit. We have found that the non-financial rewards, such as Quality Assurance points and the relationship with the university, professional recognition, access to services and support are often more attractive than financial rewards.
In Australia, Divisions of General Practice provide a way of approaching GPs as a group. They cover most of Australia and most GPs are members [4]. They are independently incorporated bodies. Many divisions have shared mental health-care programs but have encountered difficulties in establishing partnerships with mental health services. This has, in part, been because of a lack of integration within the mental health services themselves, especially between community and inpatient services [5,6]. It also reflects the different priorities of general practice, in which the predominant mental health problems are anxiety and depression, and mental health services, which are principally concerned with the management of chronic illnesses such as schizophrenia.
Divisions have moved recently from project funding to block funding based on achieving outcomes, including mental health outcomes, in general practice. Mental health must compete for priority with other programs and research in cardiovascular disease, diabetes, injury prevention, asthma and other diseases. Like GPs, the interest a division has in participating will be influenced by their relationships with mental health services. They may also be concerned about the resource implications, legal and ethical issues and the demands placed upon their members. Despite these reservations, divisions are also increasingly interested in evaluation and research and are potential research partners in research into the early detection and prevention of schizophrenia.