 |
 |
 |
|
|
A worldwide tendency has developed for health services to be designed with a focus on primary care (1–3). In the mental health field, studies have shown that the prevalence of mental disorders in the community ranges from 13% to 29.5% (4–8) and that only a small portion (about 13%) of individuals with a mental disorder seek professional help (5,8–10). In fact, those who do, seek it at the primary care level (5,11). For these individuals, general practitioners (GPs) are often the first professionals consulted in the help-seeking process (9,12). Globally, they see most patients with mental disorders (13,14) and play an important role in the delivery of mental health care (15). GPs alone, however, cannot provide mentally ill individuals with all the care they need (16). Collaboration with other professionals—especially with psychiatrists —is widely recommended (16–19). Models of collaboration involving these physicians have been extensively outlined in the literature (20–23); some have been implemented in Ontario (24–29) and in Quebec (30). Key principles underlying models of collaboration have been identified (16,31,32). Still, only a few studies have considered the views of practitioners concerning collaboration. Strathdee studied the extent and the nature of collaboration between GPs and psychiatrists (33). She identified 3 main models of collaboration (shifted outpatient, consultation, and liaison-attachment), that were developed as a consequence of the initiative of particular GPs and psychiatrists. Physicians involved in closer working arrangements (the liaison-attachment model) were in the minority. Williams and Wallace surveyed both GPs and psychiatrists on how to improve written communication in a patient-referral process (34). The authors found a good degree of correlation between what psychiatrists expected and what they received in the referral letter. Conversely, the GP degree of correlation was small, and their needs from psychiatrists and psychiatric services were not being met. Studying GP working arrangements with mental health providers and their attitudes toward developing closer collaboration with psychiatrists in primary care settings, Barber and Williams found that GPs had primary care links with psychiatrists, psychologists, psychiatric nurses, and social workers (35). They also found that GPs held positive attitudes toward collaboration with psychiatrists in primary care settings. Despite GP openness to collaboration models, the authors suggested caution in the interpretation of these results, owing to the small study sample. One of these studies investigated only GP perceptions of collaboration with psychiatrists (35). The other 2 studies included the views of both GPs and psychiatrists. In one (33), however, only physicians involved in collaboration were recruited, and in the other (34), only 1 dimension of collaboration (written communication) was investigated. No study surveyed the views of both types of physicians with respect to specific strategies of collaboration, and no study involved random samples of physicians. For this reason, we designed a survey with 2 objectives. The first would collect the opinions of both GPs and psychiatrists practising in Montreal concerning strategies for improving collaboration at 3 levels: communication, continuing medical education (CME) for GPs in psychiatry, and on-site collaboration in primary care settings. The second objective was to identify demographic and practice characteristics of physicians associated with the acceptance of such strategies. MethodQuestionnaire Development First, we reviewed the literature on collaboration between GPs and psychiatrists. Second, we conducted 10 in-depth interviews and 1 focus-group session in a purposefully selected sample of 5 GPs and 5 psychiatrists. Third, we designed the first drafts of the questionnaire. The sources of the items were as follows: 1) the analyzed verbatim records of the interviews and focus group session; 2) the document, "Shared Mental Health Care in Canada" (16); and 3) other questionnaires (36,37). The items (53 in total) were grouped into 3 sections of strategies: communication (section A), CME (section B), and access to consulting psychiatrists (section C). Each item was the same for both psychiatrists and GPs and was measured through a 5-point Likert Scale (1 = strongly disagree, to 5 = strongly agree). Another section (section D) was also developed to collect demographic and practice-related data. It was specific to each group and included 15 variables: 1) sex; 2) age; 3) year of graduation; 4) years in practice; 5) place of practice (that is, hospital or community settings, including private practice, CLSC [community health centre], psychiatric outpatient clinic, rehabilitation centre and emergency room); 6) type of practice I (that is, solo or group practice); 7) type of practice II (that is, practice with appointment, without appointment, or both); 8) form of remuneration (that is, fee-for-service or fee-for-service combined with another form of remuneration, sessional fees, salary, or hourly fees); 9) teaching (yes or no); 10) research (yes or no); 11) administration (yes or no); 12) hours of work weekly; 13) for GPs only, residency training in family medicine (yes or no); 14) for GPs only, percentage of patients with mental health problems followed by GPs; and 15) for psychiatrists only,psychiatric clientele (that is, adult, child or adolescent, and the elderly). Then, when a preliminary version of the questionnaire was ready, we submitted it to the analysis of a professional group (3 GPs, 3 psychiatrists, and 1 psychologist) who are members of the Committee on Support of Psychiatric Shared Care from Régie régionale de Montréal-Centre. Although the basic structure (sections A, B, C, and D) of the questionnaire was the same, the suggestions of these advisors helped to improve the layout of the questionnaire and the wording of the items. (Some items were rewritten, others were deleted, and new items were added). Subsequently, the questionnaire was subjected to a pretest conducted with a small group of physicians (7 GPs and 6 psychiatrists). Following the pretest, the questionnaire and the survey proposal were submitted for the analysis and approval of the Ethics and Research Committee, Hôpital Louis-H Lafontaine, which is affiliated with the Université de Montréal.
|
||||||