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The Seriously Mentally Ill (SMI)
Although relatively low, the prevalence of serious mental illness in primary care is unevenly distributed, with inner-city family physicians and those practising near a psychiatric hospital tending to have more of these patients in their practices than do suburban or rural family physicians. In a Canadian survey by Toews and others (1996), 54% of Alberta family physicians estimated that they saw 1 to 2 patients with schizophrenia monthly, 20% indicated that they saw 3 to 5 patients monthly, and 7% saw more than 6 patients monthly. Kendrick and others (1991) surveyed GPs in a large health region in England and asked them to estimate the number of patients with long-term mental illness on their registers. Of the 369 GPs who responded, 33% estimated that they had 6 to 10 patients with long-term mental illness in their practice, 27% estimated that they had 11 to 16 such patients, and 28% estimated they had 5 or fewer (12% were unable to estimate). GPs who practised in Greater London or within 3 miles of a psychiatric hospital reported higher numbers. These figures suggest that there may be opportunities to target practices with high numbers of SMI patients to develop specialized shared care programs.
The role of the family physician in caring for this population is an important one, but it remains ill-defined. When family physicians are asked what they think their role should be in the care of patients with serious mental illness, responses vary. Bindman and others (1997) found that 57% of Inner London GPs were unclear about their role, and 71% saw themselves as providing mainly repeat prescriptions for psychotropic drugs. Kendrick and others (1991) found that 82% of the London GPs surveyed agreed or strongly agreed with the statement that patients with long-term mental illness discharged into the community should be the primary responsibility of the psychiatric team. At the same time, 90% agreed or strongly agreed that care should be shared between the psychiatrist and the GP. In a survey by Nazareth and others (1995), London GPs reported that they treated at least 25% of patients with new-onset psychosis themselves at the first encounter. Toews and others (1996) found that 59% of Alberta family physicians refer such patients to a psychiatrist for assessment and treatment but continue to monitor the patient in their practice.
In some cases, the GP may be the only consistent care provider. (Lang and others 1997; Kendrick and others 1994). In Kendrick and othersstudy, 93% of patients with long-term mental illness had been seen by their GP in the preceding 12 months, but only 63% were currently in contact with a psychiatrist or a community psychiatric nurse. More than one-third of patients had had no contact with psychiatric services during the preceding 12 months. It is not surprising, given these statistics, that family physicians are eager for more links with mental health services and more backup from consulting psychiatrists.
Patients with serious mental illness have complex needs and tend to consult their GP or family physician more frequently than other patients. Kendrick and others (1994) established case registers of patients with long-term mental illness in 16 London practices and then examined their attendance rates and the care they received over a 12-month period. The average number of GP visits was 8 per patient yearly, which was significantly greater than the 2.1 visits yearly in the nonpsychiatric control group. Nazareth and King (1992) found that schizophrenia patients in London visited their family physicians on average 9.5 times yearly, compared with 2.1 visits yearly for other patients.
Many of these visits are for physical problems (Kendrick and others 1994; Lang and others 1997; Nazareth and others 1993), which may take precedence over the patients chronic mental illness in terms of the GPs focus. Nazareth and others found that the index disorder was more often assessed in patients with chronic physical diseases than in those with schizophrenia and that the latter received little management specific to their mental health problems. Lang and others (1997) reviewed the records of 131 British patients with schizophrenia who had consulted their family physicians in the previous 6 months; they found that less than one-half had notes on their mental state recorded. Moreover, although GPs are frequently responsible for repeat prescribing for patients with long-term mental illness (Bindman and others 1997; Nazareth and others 1995), they may be reluctant to make changes or to adjust drug dosages (Nazareth and King 1992).
Observations such as these have led to calls for more structured assessments of SMI patients in primary care and for the development of tools to facilitate their use. (Nazareth and King 1992; Lang and others 1997). In a pilot study in 16 group practices in London, GPs were taught how to use a structured assessment tool, and their use of the tool was monitored over a 2-year period. Compared with a group of control GPs, intervention GPs were significantly more likely to make changes in prescriptions for antipsychotic drugs and were significantly more likely to make referrals to community psychiatric nurses. GPs assessments of the usefulness of the tool were less than enthusiastic. Most found the structured assessment easy to use and acceptable to patients, but about one-half thought it was sometimes too time-consuming for routine consultation, and, paradoxically, most did not consider that it led directly to changes in treatment.
A similar lack of enthusiasm greeted investigators who attempted to introduce patient-held management cards similar to those in use for antenatal care. Essex and others (1990) developed and piloted shared care records for patients with chronic psychosis in an area of Southeast London. The records contained diagnoses, medication details, services working with the patient, the responsibilities of individual care providers, brief follow-up notes about the patients clinical status, and information designed to support the patient in the management of the illness. They found that patients liked the records but that both psychiatrists and GPs were reluctant to use them. Many psychiatrists doubted the ability of the GPs to manage such patients in the community. Some regarded shared care as a challenge to their authority, and others did not like making notes that patients could view. GPs were more positive about the benefits of the shared record, but many felt that they were a low priority. A similar study by Warner and others (2000) in Manchester found that the use of shared care cards was low by both patients and care providers and that the shared records did not have any significant effect on mental status, satisfaction with care, likelihood of being admitted, or clinic attendance.
Programs that have enhanced direct communication between GPs and psychiatrists or mental health services appear to have been more successful at engaging care providers and meeting their needs and the needs of patients. Wilkinson and others (1995) established 4 primary care-based mental health teams in Buckinghamshire, England, to determine whether the treatment of individuals with long-term mental illness could be maintained successfully in a shared care model in a predominantly rural setting. Interdisciplinary teams were fully integrated into existing general practices, with readily available on-site access to team members, weekly team meetings, and shared case notes. The GP retained an active role in patient treatment. After 2 years, significant improvements were found in clinical global impressions (CGI) ratings, and in informants ratings of symptoms and social functioning. Both patients and GPs were satisfied with the service.
In Australia, Meadows (1998) established a collaborative care program that included a component directed specifically at SMI patients. In addition to providing consultation on any patient referred by family physicians, it also identified patients with long-term mental illness who were being cared for in traditional outpatient services but who were felt to be sufficiently stable to be transferred to shared care. Specially trained psychiatric nurses reviewed each patients file, prepared a detailed summary and treatment plan, and then arranged for a bridging meeting for the patient, the family physician, and the psychiatrist who would provide ongoing backup. Patients were then reviewed every 6 to 12 months by the psychiatrist, with the GP monitoring their status in between. The advantages of this model are that it addresses concerns that shared care tends to focus on the less severely ill (Low and Pullen 1988), it works actively to promote flow through the larger mental health system, and it is better integrated into that system.
An innovative Canadian program has also successfully developed a shared care approach to patients with psychotic disorders (Hobbs 1999). This Hamilton, Ontario, program provides intensive early treatment and education for patients with new-onset psychotic disorders in a traditional outpatient clinic. In addition, it offers an enhanced ongoing relationship with the patients primary care provider. Once stabilized, the patient is discharged back to the family physician, but regular, planned follow-up visits also occur in the outpatient clinic. If deterioration or a crisis occurs between visits, the patient and the family physician have rapid access to the psychiatry team, who will offer advice and support or reassume care and restabilize the patient. The advantage of this model is that it can be implemented by any existing outpatient program with few additional resources.
Some authors have outlined suggested key components of shared care for
SMI patients and have attempted to specify the respective roles of psychiatrists
and GPs. Strathdee (1994) lists the elements of shared care for an individual
patient and then proposes a 6-stage plan to improve the mental health
care of all SMI patients in primary care, with goals and suggested responsibilities.
Keks and others (1997) review the potential benefits of collaborative
care and outline the components of a coordinated care agreement between
a GP and an area mental health service for a patient with chronic psychosis.
They also provide case examples and discuss issues relevant to rural settings.
Three fundamental prerequisites for success identified in these articles
are the need to be able to identify SMI patients in a family practice
population; the need for the family physician and psychiatrist or mental
health service to have frequent, personal contact; and the need to specify
clearly who is responsible for which aspect of patient care at each stage.
Thus, case registers of SMI patients are seen to be key to the success
of collaborative care for this group, as are increased personal contact
and enhanced communication between psychiatrists and family physicians,
along with processes that encourage regular case reviews.
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