In Ireland community mental health care consultations are provided by both primary care and specialised public mental health services. However, unlike the specialised public mental health service consultations, primary care service consultations are not currently free for the majority of Irish residents. Patients on the lowest end of the socioeconomic ladder qualify for state “medical or GP visit cards” which are a form of state health insurance that entitles the holder to receive free primary care consultations in addition to the universally free public specialist mental health consultations. All other patients including those with private health insurance pay for all primary care consultations which average around 60 dollars per consultation. A detailed description of the structure of both primary care and community mental health service provision in Ireland, as well as the proportions of patients with medical/GP visit cards and private health insurance and the packages received by these patients have been given in two related publications [
The delivery of mental health services presents several important challenges to health systems [
In 2003, the Government of Ireland commissioned an expert group to review Ireland’s mental health policy. The policy document produced by this expert group in 2006, entitled: “A Vision for Change,” recommends that links between specialist mental health services, primary care services, and voluntary groups that are supportive of mental health should be enhanced and formalised [
However, some studies have identified challenges including patients’ lack of confidence in GP care, GPs not being adequately trained to provide mental health care, and primary care not being adequately resourced with a multidisciplinary team to facilitate the care of patients with mental health difficulties, which cause some service users deemed to have relatively low clinical needs to remain within the specialist psychiatric service [
This study explores the preferences and views of patients attending a local community mental health clinic regarding their continuing care with primary care or specialist mental health services once they have been stabilised on their treatment.
As no prior questionnaire existed, a self-administered questionnaire of 20 items based on literature review and reflecting the objectives of our study was designed by the researcher. The questionnaire included questions on patients demographic and clinical characteristics such as age, sex, marital and employment status, possession of state or private medical insurance, frequency of attendance of psychiatric clinic, presence of medical comorbidity, registration with and frequency of attendance of general practice surgery, preference for receiving continuing care from primary care or specialised psychiatric services when mentally stable on treatment, and reasons for the choice. It was reviewed by a multidisciplinary group of six experts (two researcher and four psychiatrists) and pretested with five patients who were not included in the study sample. It took approximately 10 minutes to complete, and no financial incentive was offered to respondents. 150 consecutive psychiatric patients attending for outpatient review in a community mental health centre in Dublin were approached and asked to complete the questionnaire. The study received approval from the Research and Ethics Committee of the College of Psychiatry of Ireland.
After complete description of the study to the participants, written informed consent was obtained before they completed the survey forms. This cross-sectional survey was conducted between April and June 2009 and data were analysed using descriptive statistics and Chi-square test with SPSS version 17.
145 patients completed the questionnaire giving a response rate of 97%. The mean age for all respondents was 45.48 year (SD = 13.01 years) and the mean years for which patients had been attending the local specialised psychiatric service was 8.6 years (SD = 8.1 years). Table
Demographic and clinical characteristics of study population.
Variables | Total |
---|---|
Gender | |
Male | 75 (52%) |
Female | 70 (48%) |
Age group | |
≤45 | 75 (52%) |
≥46 | 70 (48%) |
Marital status | |
Single/divorced/separated/widowed | 36 (25%) |
Married/cohabiting | 109 (75%) |
Formal educational background | |
Primary | 48 (33%) |
Secondary | 62 (43%) |
Tertiary | 35 (24%) |
Employment Status | |
Employed | 45 (31%) |
Unemployed/retired | 100 (69%) |
Registered with a GP practice | |
Yes | 136 (94%) |
No | 9 (6%) |
Has a medical card | |
Yes | 84 (58%) |
No | 61 (42%) |
Has private health insurance | |
Yes | 26 (18%) |
No | 119 (82%) |
Diagnosis patients’ have been informed they have | |
by psychiatrist* | |
Depressive disorder | 81 (56%) |
Bipolar affective disorder | 22 (15%) |
Anxiety disorder | 61 (42%) |
Schizophrenia/schizoaffective disorder | 16 (11%) |
Alcohol dependency syndrome | 9 (6%) |
Drug/polysubstance abuse | 6 (4%) |
Other disorder | 16 (11%) |
Not been told of diagnosis | 22 (15%) |
Previous psychiatric inpatient treatment | |
Yes | 83 (57%) |
No | 62 (43%) |
Medical comorbidity | |
Yes | 41 (28%) |
No | 104 (72%) |
Overall, 42 (29%) patients reported that they had been stable on their medication for more than one year while 13 (9%) patients reported that they had been stable on their medication for between 6 months and one year. Again, 39 (27%) patients had had no changes made to their psychiatric medicines in over one year, 16 (11%) patients were on a depot injection, and 36 (25%) patients had a community psychiatric nurse assigned to them for follow-up visits. 45 (31%) patients reported that on the average, they attend the psychiatric clinic for review once every month, 48 (33%) said they attend about once every six weeks, 34 (23%) reported that they attend once every two months, and the rest said they attend once every 3 or more months. Within the previous three months, 71 (49%) patients reported that they have visited their GP between one and three times and 19 (13%) reported they had visited their GP more than three times for a medical review. Overall, 32 (22%) patients reported that they attended their GP regularly for review and prescriptions for chronic medical conditions. Of the 83 patients who have had previous inpatient psychiatric treatment, 57 (69%) reported that their inpatient treatment had been more than a year previously and the remainder had been within the last one year.
Overall, 29 (20%) patients indicated that they would prefer to attend their GP for their psychiatric care once they have been stabilised on their medication from specialised psychiatric services. 98 (68%) patients expressed a preference to continue attending specialised psychiatric services even if they are stable on their treatment and the remaining 18 (12%) patients expressed no preference for either primary care or specialised psychiatric services. I performed a Chi-square test to examine the association between the demographic and clinical variables (including gender, age group, relationship and employment status, possession of a medical card or private health insurance, and the presence of a medical comorbidity) and the expression of a preference to receive continuing care from primary care. I found no significant association between any of these demographic and clinical variables and the expression of a willingness to receive continuing psychiatric care from primary care (
The reasons given by patients who stated a preference for and against attending their GP for their psychiatric needs once they are stable on medication are as outlined in Tables
Reasons why some patients would prefer to attend their GP for their continuing psychiatric care.
Reason |
*Total |
---|---|
I am confident my GP can provide me with the same level of care I would receive from here | 18 (62%) |
It would be handy for me to attend my GP for both my physical and mental health problems | 13 (45%) |
It would take away the stigma often attached to attending psychiatric services | 9 (31%) |
I have a medical card and would attend my GP free of charge | 5 (17%) |
Other reasons | 4 (14%) |
*Total
Reasons why some patients would prefer not to attend their GP for their continuing psychiatric care.
Reason |
*Total |
---|---|
I would be worried about the quality of the psychiatric care from my GP | 67 (68%) |
I do not have a medical/GP visit card and cannot pay for GP consultations | 40 (41%) |
I do not have a GP | 9 (9%) |
Other reasons | 19 (19%) |
*Total
This study has established that the majority of Irish patients (98, 68%) would prefer to continue receiving mental health care from specialised psychiatric services rather than receive such care from primary care even if they become stable on their treatment. The majority of these patients (67, 68%) reported that they would be worried about the quality of the psychiatric care they would receive from their GP even if they are stable on their treatment. Many of these patients (40, 41%) also expressed that they did not have a medical or GP visit card and cannot afford to pay for GP consultations. In one multidisciplinary team’s retrospective review of the clinical notes of all patients attending a psychiatric outpatient clinic to determine the appropriateness of continuing to provide psychiatric services in a specialised mental health clinic rather than in a primary care setting, it was recommended that 35.2% of all the patients could be discharged back into primary care for continuing management [
Of the 29 (20%) patients who reported that they would prefer to attend primary care for their continuing mental health care once they are stable on their treatment, 18 (62%) stated that they had confidence in the care they would receive from their GP whilst 13 (45%) said it would be handy for them to attend their GP for both their physical and mental health needs. Again, 9 (31%) of these patients said that receiving continuing mental health care from primary care would take away the stigma often attached to attending psychiatric services.
Providing good generalist care which addresses both mental and physical health needs is recognised internationally as one of the benefits of primary care service involvement in the care of patients with mental health difficulties [
This study suggests that if a similar set of conditions exist in terms of the cost of consultations between primary care and specialised psychiatric services, and if GPs were adequately trained to provide continuing care for patients with enduring mental health difficulties, then the capacity of specialized psychiatric services to take on new referrals as well as care for acutely unwell patients would be greatly enhanced. Two previous surveys of GPs working in Ireland indicate that those GPs who undertook a psychiatric rotation as part of their GP training expressed significantly more confidence in their ability to recognise and manage psychiatric presentations in primary care compared with GPs who did not undertake such training [
The results of the study should be considered within the context of a number of limitations. Firstly, this study does not take into account the views of psychiatrists and GP’s which are described elsewhere [
Collaboration between GPs and community mental health teams can improve and expand access to care for people with mental illnesses. Most patients who attend specialised psychiatric services in Ireland prefer to continue attending specialized psychiatric services even when they are mentally stable on their treatment as opposed to attending primary care. The most reasons for this revolve around fears of inadequate psychiatric care from GPs and the cost of GP consultations relative to the free consultations they get from specialised psychiatric services. This can significantly restrict the capacity of specialised community mental health teams to take on new referrals from primary care. The Irish Government, the College of General Practitioners, and the College of Psychiatry of Ireland need to work collaboratively to remove the bottlenecks which hinder the active involvement of primary care in the management of patients with enduring mental health difficulties.
This study was presented as a poster at the 19th European Congress of Psychiatry, in Vienna, Austria on the 15th of March 2011.
The author has no conflict of interests to declare.
The author would like to express his profound gratitude to Professor Kevin Malone, Dr. Anthony McCarthy, Dr. Allys Guerandel, Dr. Freda O’Connell, and Ms. Leah Quinlivan all of St Vincent’s University Hospital in Dublin for their help in reviewing the questionnaire used in the study. The author would also like to thank all the Psychiatric Registrars who worked at St. Vincent’s University Hospital in Dublin between January and June 2009 for facilitating data collection and also Dr. B. Thekiso for his help in imputing that data into SPSS.