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The Need For Increased Collaboration Between Psychiatry and Primary Care
Several studies have addressed the need for improvements in the relationship between psychiatry and primary care. Craven and others (1996) conducted focus groups of family physicians across Ontario to identify issues at the clinical interface between psychiatry and family medicine. They found that family physicians in all areas of the province reported problems accessing psychiatric consultation in a timely fashion, poor communication between psychiatrists and family physicians, and poor continuity of care. The family physicians in this study also perceived that their psychiatric colleagues had little respect for their opinions, particularly when they called about a patient in crisis.
Similar complaints were reported by Falloon and others (1996) in their survey of New Zealand general practitioners (GPs). Of the 158 respondents, 64% felt that communication with psychiatrists was unsatisfactory, 69% indicated that they were not informed of changes to their patients treatment, 63% complained of long waiting times, 50% were not informed when their patient was admitted or discharged, 51% felt that they were not recognized as part of the treatment team, and 79% had difficulty with the time needed to provide services to patients with mental illness. Ninety-four percent of these GPs endorsed the value and importance of comanaging patients with mental health problems.
Goldberg and others (1993) surveyed 429 GPs in London, England. The 133 GPs who responded complained of long waits for outpatient appointments, poor liaison with the mental health teams, insufficient psychotherapy resources, and a high burden of caring for socioeconomically deprived persons with mental disorders. This study also consulted with mental health care consumers. This group highly endorsed the role of the GP as a mental health provider but identified a need for increased GP knowledge about mental health disorders, more time with patients, and greater communication and coherence between the GP and the mental health services.
Orleans and others (1985) surveyed 610 US family physicians about their mental health care practices and asked them about barriers and obstacles to providing care for their patients. Of the 350 respondents, 34% cited lack of coordination and lack of collaboration with mental health specialists as an obstacle.
Other studies support these surveys, citing a need for better communication (Bindman and others 1997; Nazareth and others 1995; Watters and others 1994; Lipkin 1997; Lang and others 1997; Toews and others 1996), difficulties with access to psychiatric consultation (Watters and others 1994; Lipkin 1997), discontinuity of care and problems in role definition (Lang and others 1997; Lipkin 1997; Bindman and others 1997), and concerns about patient stigma (Craven and others 1996; Barber and others 1996; Strathdee 1987).
Few articles address psychiatrist concerns about the relation between psychiatry and family medicine (Craven and others 1993; Strathdee 1987; Lipkin 1997). Among those that do, poor referral letters, inappropriate referrals, unrealistic expectations, inadequate evaluation of patients prior to referral, and family physician reluctance to follow patients after discharge are frequently cited.
These studies confirm a need for better working relationships between family physicians and psychiatrists and for the development of strategies to increase collaboration between them. Communication and referral issues are particularly problematic and will be reviewed in greater detail.
Why do family physicians refer to psychiatry, and what do they want? Morgan (1989) used qualitative methodology to conduct a detailed study of the circumstances preceding referral to psychiatry. Using analysis of referral letters and structured interviews with patients, their family members, and their GPs, he constructed an ethnography of the referral process for 74 patients referred to a British outpatient clinic. He found that 42% of patients were referred because their symptoms had failed to respond to treatment. In one-half of these cases, referral was actually triggered by a request from the patient or a relative. Fifteen percent were referred because of significant clinical deterioration, and 28% because of a breakdown in the therapeutic relationship. Only 20% were referred for a diagnostic opinion or advice about a specific aspect of the case.
In a study by Taylor and Wilkinson (1998), 52% of referrals were prompted by the disorders failure to respond to the GPs therapy. In contrast, Maguire and others (1995) found that Irish GPs cited failure to respond to treatment as the main reason for referral in only 20% of cases. In this study, the most commonly cited reason for referral was to access treatments not available in general practice (30%), primarily specific forms of psychotherapy. Ten percent of patients were referred for advice on how to treat them in general practice. In 14% of referrals, the GP was hoping to share the burden of a case where little could be done.
Coulter and others (1989) conducted an extensive prospective study of the reason for referral in more than 18 000 cases referred from Oxfordshire GPs to consultants in all specialties in 1983 and 1984. Of the referrals, 684 (3.6%) were to outpatient psychiatry clinics. There are some striking differences in the reasons for referral to psychiatry, compared with other specialties. In particular, only 7.1% of referrals to psychiatry were to establish a diagnosis (compared with a mean of 28% for all other specialties), 10.4% were for treatment (35.4% other specialties), 28.3% for advice on management (14.3% other specialties), and 46.6% to take over management (9.3% other specialties). The GPs desire for psychiatrists to take over management of care in so many cases is a striking finding and would seem to indicate that GPs experience specific difficulties in the care of psychiatric patients.
In contrast, Parker and others (1996) found that Australian family physicians did not consider willingness to take ongoing and total responsibility for patients with neurosis or schizophrenia to be important attributes in their psychiatric colleagues. These items ranked 28th and 36th respectively in a list of 36 psychiatrist behaviours and characteristics. In Parkers study, the 6 most important attributes of the consulting psychiatrist were as follows: psychiatrist being able to take urgent referrals; psychiatrist showing common sense and practical skills; psychiatrist trying their best with my referrals, irrespective of results; psychiatrist welcoming my calls if I have any difficulties with the patient; appointments being available within 1 to 2 weeks; and psychiatrist sending report at completion of treatment.
Several articles in this section report studies of the content of referral and consultation letters and the content items that psychiatrists and family physicians consider to be most important. Pullen and Yellowlees (1985) surveyed 80 Scottish GPs and 80 psychiatrists about the key items to include in referral and consultation letters. The psychiatrists identified main symptoms or problems, reason for referral, psychiatric history, medication, and family history as most important. GPs identified diagnosis, treatment, follow-up, prognosis, and a concise explanation of the patients condition as most important. Other studies (Kentish and others 1987; Cornwall 1993) have produced similar findings concerning key content items for child psychiatry consultation.
Studies examining how well referral and consultation letters meet these standards have produced widely varying results. Each of the studies reviewed examined different content items, making a summary or comparison among them difficult. Notable deficiencies were found in all the following categories in referral letters from family physicians: presenting problem (Kentish and others 1987), history of presenting problem (Cornwall 1993), reason for referral (Kentish and others 1987; Tanielian and others 2000), psychiatric history (Naik and Lee 1993; Tanielian and others 2000), medications (Pullen and Yellowlees 1985; Burbach and Harding 1997; Naik and Lee 1993), family history (Pullen and Yellowlees 1985; Burbach and Harding 1997), other agencies involved in the care of the patient (Kentish and others 1987; Cornwall 1993; Burbach and Harding 1997), the current mental state of the patient (Cornwall 1993), family dynamics (Cornwall 1993), medical history (Burbach and Harding 1997; Naik and Lee 1993). Only one of the studies reviewed referrals for indication of the degree of urgency: Burbach and Harding (1997) found reference to how urgent (or not) the case was in 19% of referral letters.
Two studies reviewed the content of psychiatrist consultation letters to family physicians. Pullen and Yellowlees (1985) found that 88% gave the diagnosis, 95% mentioned follow-up, 92% indicated what the treatment would be, 60% gave a concise explanation of the problem, and 27% mentioned prognosis. Kentish and others (1987) found that 72% of the letters they reviewed contained the psychiatrists understanding of the problem, 81% described the treatment, and 82% contained information about follow-up. A third study (Tanielian and others 2000), which surveyed US psychiatrists about their consultation practices, found that 79% reported often or always sending diagnostic and treatment information back to the referring physician. In 49% of cases, this was often or always in the form of a letter.
Very little attention has been devoted to identifying the format of referral or consult notes most acceptable to psychiatrists and family physicians. Pullen and Yellowlees (1985) included in their article recommendations for the content headings of referral and consult letters, together with an ideal example of each. Blaney and Pullen (1989) developed 6 sample referral letters from a fictitious GP and surveyed 90 psychiatrists about their preferred format. Most stated that they preferred a 1-page letter with 2 or 3 headings. The authors include in their article the version of the referral letter most popular with psychiatrists.
The referral and communication problems identified in these studies provide a compelling argument for more personal contact between family physicians and psychiatrists in the referral and discharge processes, particularly for more complex or urgent cases. They also suggest a need for more dialogue between hospital and academic departments and highlight opportunities to improve communication about patients through the development of locally designed, standardized referral forms and guidelines for consultation letters.
In studies that asked GPs and family physicians for their opinion about the value of formal arrangements designed to increase collaboration with mental health services, the response was almost uniformly positive. Several studies surveyed family physicians about their preferences for the shape that this increase in collaboration should take (Falloon and others 1996; Brown and Tower 1990; Stansfield and others 1992; Nazareth and others 1995; Barber and Williams 1996; Strathdee 1988; Toews and others 1996; Watters and others 1994) Three options that appear to be particularly attractive to GPs and family physicians are assessment by the psychiatrist with treatment by the GP, assessment and short term treatment by the psychiatrist, and advice on nonreferred patients (Strathdee 1988; Brown and Tower 1990; Barber and Williams 1996; Watters and others 1994). A few GPs and family physicians indicated a preference for transfer of responsibility for care to the psychiatrist or mental health service (Watters and others 1994; Barber and Williams 1996; Strathdee1988). One notable exception is a study by Kendrick and others (1995), who surveyed 507 London GPs about their care of those with long-term mental illness. Most GPs were prepared to take care of the patients physical needs, but only 59 of the 369 respondents were prepared to act as key worker, preferring the community psychiatric nurse to do this.
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