Jaffa Mental Health Clinic, Ministry of Health, Tel Aviv-Yafo, Israel.
Herzliya Mental Health Clinic, Hadar Street 2, 46290, Herzliya, Israel.
Isr J Health Policy Res. 2023 Jan 30;12(1):4. doi: 10.1186/s13584-023-00553-0.
Psychiatric morbidity is frequent in primary care, but a substantial proportion of these psychiatric problems appear to be neither recognized nor adequately treated by GPs. There exists a number of models of introduction of mental health services (MHS) into primary care, but little data are available on their effect on GPs' detection or management of mental disorders. The study aimed to measure the effect of referring patients to a psychiatrist within primary care (Shifted OutPatient model-SOP) or consultation of psychiatrists by the GPs (Psychiatric Community Consultation Liaison-PCCL) on the detection and treatment of mental disorders by GPs.
In six primary care clinics in Israel (three "SOP clinics" and three "PCCL clinics"), GP detection of mental disorders and treatment of GP-detected cases were evaluated before and after provision of 1-year MHS, according to GP questionnaires on a sample of primary care consecutive attenders whose psychological distress was determined according to the GHQ12 and psychiatric disorders according to the Composite International Diagnostic Interview.
After model implementation, a significant reduction in detection of mental disorders was found in SOP clinics, while no significant change was found in PCCL clinics. No significant change in detection of distress was found in any clinic. An increase in referrals to MHS for GP-diagnosed depression and anxiety cases, a reduction in GP counselling for GP-detected cases and those with diagnosed anxiety, an increased prescription of antidepressants and a reduced prescription of antipsychotics were found in SOP clinics. In PCCL clinics, no significant changes in GP management were observed except an increase in referral of GP-diagnosed depression cases to MHS.
MHS models did not improve GP detection of mental disorders or distress, but possibly improved referral case mix. The SOP model might have a deskilling influence on GPs, resulting from less involvement in treatment, with decrease of detection and counselling. This should be taken into consideration when planning to increase referrals to a psychiatrist within primary care settings. Lack of positive effect of the PCCL model might be overcome by more intensive programs incorporating educational components.
精神疾病在初级保健中很常见，但相当一部分精神问题似乎既未被全科医生识别，也未得到充分治疗。有许多将精神卫生服务（MHS）引入初级保健的模式，但关于这些模式对全科医生识别或管理精神障碍的效果的数据却很少。本研究旨在衡量将患者转介至初级保健中的精神科医生（转介门诊模式-SOP）或由全科医生咨询精神科医生（精神科社区咨询联络-PCCL）对全科医生识别和治疗精神障碍的效果。
在以色列的六个初级保健诊所（三个“SOP 诊所”和三个“PCCL 诊所”）中，根据 GP 对初级保健连续就诊者样本的问卷评估 MHS 提供前后的 GP 对精神障碍的识别和 GP 识别病例的治疗情况，这些就诊者的心理困扰根据 GHQ12 确定，而精神障碍则根据综合国际诊断访谈确定。
在实施模型后，SOP 诊所中精神障碍的识别率显著下降，而 PCCL 诊所中则无显著变化。任何诊所的困扰识别率均无显著变化。在 SOP 诊所中，GP 诊断为抑郁和焦虑的病例中，转介至 MHS 的人数增加，GP 对 GP 识别病例和诊断为焦虑的病例的咨询减少，抗抑郁药的处方增加，抗精神病药的处方减少。在 PCCL 诊所中，除了 GP 诊断为抑郁的病例转介至 MHS 的人数增加外，GP 管理未见明显变化。
MHS 模式并未改善 GP 对精神障碍或困扰的识别，但可能改善了转诊病例的组合。SOP 模式可能由于治疗参与度降低，导致 GP 技能下降，从而减少识别和咨询。在计划增加在初级保健环境中转介至精神科医生的人数时，应考虑这一点。PCCL 模式缺乏积极影响，可能需要更强化的项目，包括教育内容。
