Randomized trial of reattribution on psychosocial talk between doctors and patients with medically unexplained symptoms.

BACKGROUND: In reattribution, general practitioners (GPs) request psychosocial information directly and explain medically unexplained symptoms (MUS) using psychosocial information in the consultation. We explored whether reattribution training (RT) increased the communication of psychosocial information and decreased communication about somatic intervention between GPs and their MUS patients. METHOD: A cluster randomized controlled trial (RCT) of RT versus usual treatment in GPs from 16 practices and 141 patients with MUS on audio-recorded and transcribed doctor-patient communication in an index consultation. In a secondary data analysis, the Liverpool Clinical Interaction Analysis Scheme (LCIAS) was applied by an experienced rater to each turn of speech in the transcript from the index consultation blind to treatment allocation. RESULTS: After RT, patients were more likely to disclose and discuss psychosocial problems, and propose psychosocial explanations for symptoms; around 25% of patients discussed psychosocial information extensively. In the RT group, GPs did not seek new psychosocial disclosure but they reduced advocacy for somatic intervention. After RT, GPs suggested, on average, two utterances of psychosocial explanation and six utterances of somatic intervention. CONCLUSIONS: After RT, some patients discussed psychosocial issues extensively but GPs did not probe underlying psychosocial issues. They gave mixed psychosocial and somatic messages about MUS, which may have increased patients' concerns about their health. GPs should actively seek the disclosure of underlying psychosocial problems and give clear, unambiguous messages to MUS patients when they are willing to discuss psychosocial issues.

How do stakeholder groups vary in a Delphi technique about primary mental health care and what factors influence their ratings?

BACKGROUND: While mental health is a core part of primary care, there are few validated quality measures and little relevant internationally published research. Consensus panel methods are a useful means of developing quality measures where evidence is sparse and/or opinions are diverse. However, little is known about the dynamics of consensus techniques and the factors that influence the judgements and ratings of panels and individual panelists. OBJECTIVES: (1) To describe differences in panel ratings on the quality of primary mental health care services by patient, carer, professional and managerial panels within a Delphi procedure; and (2) to explore why different panels and panelists rate quality indicators of primary mental health care differently. DESIGN: Two round postal Delphi technique and exploratory semi-structured interviews. PARTICIPANTS: 115 panelists across 11 panels. Eleven panelists were subsequently interviewed. RESULTS: 87 of 334 indicators (26%) were rated face valid by all 11 panels. There was little disagreement within panel ratings but significant differences between panels. The GP panel rated the least number of indicators valid (n = 138, 41%) and carers the most (n = 304, 91%). The way in which panelists interpreted and conceptualised the indicators and their definition of quality of mental health care affected the way in which participants made their ratings. CONCLUSIONS: Stakeholders in primary mental health care have diverse views of quality of care and these differences translate into how they rate quality indicators. Exploratory interviews suggest that ratings are influenced by past experience, expectations, definitions of quality of care, and perceived power relationships between stakeholders.

Quality indicators for primary care mental health services.

OBJECTIVES: To identify a generic set of face valid quality indicators for primary care mental health services which reflect a multi-stakeholder perspective and can be used for facilitating quality improvement. DESIGN: Modified two-round postal Delphi questionnaire. SETTING: Geographical spread across Great Britain. PARTICIPANTS: One hundred and fifteen panellists representing 11 different stakeholder groups within primary care mental health services (clinical psychologist, health and social care commissioner, community psychiatric nurse, counsellor, general practitioner, practice nurse/district nurse/health visitor, psychiatrist, social worker, carer, patient and voluntary organisations). MAIN OUTCOME MEASURES: Face validity (median rating of 8 or 9 on a nine point scale with agreement by all panels) for assessing quality of care. RESULTS: A maximum of 334 indicators were rated by panels in the second round; 26% were rated valid by all panels. These indicators were categorised into 21 aspects of care, 11 relating to general practices and 10 relating to health authorities or primary care groups/trusts. There was variation in the total number of indicators rated valid across the different panels. Overall, GPs rated the lowest number of indicators as valid (41%, n=138) and carers rated the highest number valid (91%, n=304). CONCLUSIONS: The quality indicators represent consensus among key stakeholder groups in defining quality of care within primary care mental health services. These indicators could provide a guide for primary care organisations embarking on quality improvement initiatives in mental health care when addressing national targets and standards relating to primary care set out in the National Service Framework for Mental Health for England. Although many of the indicators relate to parochial issues in UK service delivery, the methodology used in the development of the indicators could be applied in other settings to produce locally relevant indicators.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance.

OBJECTIVES: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care. DESIGN: Qualitative case studies using semi-structured interviews and documentation review. SETTING: Twelve purposively sampled PCG/Ts in England. PARTICIPANTS: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members. MAIN OUTCOME MEASURES: Participants' perceptions of the role of clinical governance in PCG/Ts. RESULTS: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment). CONCLUSION: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Teaching front-line health and voluntary workers to assess and manage suicidal patients.

BACKGROUND: To devise and evaluate the retention of a new brief training package for non-psychiatrically trained multidisciplinary staff to assess suicide risk and manage suicidal patients, including referral of patients at significant risk to psychiatric staff. METHOD: 8 h of interview skills training, using role play with modelling and video feedback, was taught to 33 health and voluntary workers. Evaluation used a controlled before and after training design. Performance of the interview skills was assessed blindly by raters using predetermined criteria from videotaped role played interviews with actors. Self-rated questionnaires (SIRI-2 and visual analogue scales) were used to assess the clinical skills and confidence respectively of the front-line workers. RESULTS: Suicide risk assessment and management skills such as problem solving, future coping and provision of immediate support were significantly improved at 1 month after training. Training did not significantly improve general interview skills, combating hopelessness nor the removal of lethal weapons. Performance on the SIRI-2 and confidence significantly improved after training. The assessment procedure itself did not improve clinical skills nor confidence. LIMITATIONS: Performance among individual health disciplines was not assessed. Design was not a randomised controlled trial with short follow up and no patient outcome data. CONCLUSIONS: A brief training package is available which is effective in teaching suicide risk assessment and clinical management skills.

Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.

New telecommunications technologies promise to profoundly change the spatial and temporal relationship between health professional and patient. This paper reports results from an ethnographic study of the introduction of a videophone or 'telemedicine' system intended to facilitate faster and more convenient referral of patients with anxiety and depression in primary care, to a community mental health team. We explore the reasons for contest over the telemedicine system in practice, contrasting professionals' critique of the technology in play with a more fundamental problem: the extent to which the telecommunications system threatened deeply embedded professional constructs about the nature and practice of therapeutic relationships.

The treatment of somatization: teaching techniques of reattribution.

Patients commonly present to general practitioners with somatic symptoms for which no adequate physical cause can be found, which are accompanied by the symptoms of an anxiety state or a depressive illness. These illnesses pose a major public health problem, but little is known about optimal management. A three stage model is proposed to encourage patients to reattribute these symptoms, and relate them to psychosocial problems. These stages are; feeling understood; changing the agenda; and making the link. A videotaped learning package is described suitable for use with vocational trainees in general practice, consisting of demonstrations of component parts of the model followed by micro-teaching, as a preliminary to video-feedback of actual interviews with such patients.

The treatment of somatization: evaluation of a teaching package with general practice trainees.

A teaching package is described which aims to improve the management of somatization by general practice trainees. The package comprises a training videotape in which a model (described in the preceding paper) is demonstrated, together with material for paired role-play of new skills and small group videofeedback of consultations. Evaluation of the teaching package reveals that the skills can be effectively learned.

Impact of a national campaign on GP education: an evaluation of the Defeat Depression Campaign.

BACKGROUND: The Defeat Depression Campaign, which was run by the Royal College of Psychiatrists and the Royal College of General Practitioners (RCGP) from 1992 to 1996, aimed to educate general practitioners (GPs) to recognize and manage depression. AIM: To measure the educational impact on GPs of the Defeat Depression Campaign. METHOD: A postal survey using a structured questionnaire was distributed to 2046 GPs obtained by systematically sampling 1 in 14 GPs from alphabetical lists from family health services authorities (FHSAs) in England and Wales. The questionnaire covered awareness of the campaign, awareness and use of campaign materials, and ratings of the usefulness of the campaign in relation to other educational activities. RESULTS: Two-thirds of GPs were aware of the campaign and 40% had definitely or possibly made changes in practice as a result of it. Impact of materials was highest for a consensus statement on the recognition and management of depression in general practice and for guidelines derived from it, each of which had been read in detail by about one quarter of responders and was known of by an additional one third. Impact was low for the other materials. The campaign had the highest impact among younger GPs, members of the RCGP, and (less strongly) among those who had undertaken a six-month post in psychiatry, those who were working in larger practices and fundholding practices, and women; 56% of GPs had attended a teaching session on depression in the past three years. CONCLUSION: A national campaign of this kind can have a useful impact, but it needs to be supplemented by local and practice-based teaching activities.

Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners.

BACKGROUND: Patients with mental disorder presenting with medically unexplained symptoms (somatized mental disorder) are common in primary care, difficult to treat, and function poorly in their daily lives. AIM: To examine the effects on patient outcome and satisfaction of a training package for somatized mental disorder delivered to general practitioners (GPs). METHOD: A prospective study of a before-and-after training study of different cohorts of patients attending eight GPs who acted as their own controls. Patients were stratified according to their belief that the presenting medical symptom had either a partial or completely physical cause. RESULTS: One hundred and three patients in the cohort before training, and 112 patients in the cohort after training, were diagnosed with somatized mental disorder by the study GPs. After training there were significant improvements in interview-rated psychiatric disorder (P = 0.032) at one month, self-rated psychiatric disorder (P = 0.024), and global function (P = 0.020) at three months in patients who believed their symptoms to have a partial physical cause. Training at one-month follow-up reduced depressive symptoms in patients with major depression but did not significantly change any other outcome in patients who believed their symptoms had only a physical cause. There was no overall change in patient satisfaction. CONCLUSION: Training GPs clinically benefited patients with somatized mental disorder who believe that their symptoms have a partial physical cause.

Domains of consultation research in primary care.

The consultation is increasingly viewed as a crucial aspect of general practice medicine, but a variety of methods of conceptualising, describing and modifying its structure and content have been described. This article describes the historical background to the current interest in the consultation, and describes four qualitatively distinct approaches (or 'domains') to understanding the consultation: the psychodynamic; clinical-observational; social-psychological; and sociological. Four key dimensions along which the domains can be differentiated are described. These concern whether the critique of medical practice inherent in the domain is internal or external to the discipline of general practice; whether the focus of the domain is on the consultation participants' identities or activities; whether the key research methodology is quantitative or qualitative in character; and the degree to which the objective of research within the domain is to describe current practice or prescribe ways of conducting the consultation. Methods of encouraging work across domains are discussed.

Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective.

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

Telepsychiatry evaluation in the north-west of England: preliminary results of a qualitative study.

A telepsychiatry referral service for patients suffering from anxiety and depression was evaluated from a user perspective. Low-cost video-phones linked a psychiatrist to two general practices in the north-west of England. Quantitative data were collected using a semistructured interview schedule. Twenty-two patients and 13 doctors were interviewed after a video-link consultation. Some users were very positive about the service and recognized its potential benefits, while others were more ambivalent. Patients saw the service as a means of obtaining additional 'expert' advice. General practitioners felt that the service might adversely affect the doctor-patient relationship in psychiatry. Both patients and clinicians recognized that the video-link modified normal interaction. Users need to adapt to this form of communication. An induction session is recommended for both patients and clinicians.

Factors influencing the evaluation of telehealth interventions: preliminary results from a qualitative study of evaluation projects in the UK.

We have carried out a qualitative study of factors that influence the evaluation of telehealth. The study concerned six telehealth projects that are being tracked over two years. In the first 12 months of the study we carried out semistructured interviews and made observations of the participants in the projects. Each case study involved 5-15 subjects, many of whom were interviewed several times. The results indicate that important issues affecting telehealth evaluation include developing and maintaining the technology, reorganization of clinical and administrative duties, professional dynamics, and the difficulty of integrating service provision and evaluation. The findings suggest that the evaluation of telehealth interventions is highly complex, and that this complexity is often underestimated in the design and conduct of evaluation studies.

A program designed to monitor the course and management of depressive illness across the primary/secondary interface.

Information Technology (IT) is an increasingly important area for all aspects of life in the twenty first century. Computers have an impact on both our home life and our work life with information on many aspects of our lives being held on computer systems, some of which we are unaware. Despite this universal progression towards IT, certain areas within the National Health Service are still considered to be somewhat old fashioned in their tendency to resolutely adhere to recording information on paper. One of these areas is that of the mental health services, which perhaps given the nature of having a number of care sites makes it well suited to having the use of a well designed computer system capable of collating and co-ordinating all aspects of patient's management. This paper describes the development and implementation of a computer system designed to hold information on patients with depressive disorder across all mental health sites within both primary and secondary care. Data were manually input from patients' case notes onto a specially designed system at all sites and were then merged onto a master database by use of a patient's NHS number. Ultimately the master database held data on the entire course and management of 914 patients who suffered from depressive disorder that came within the two general practice catchment area. Professional perceptions of the usefulness of the database are discussed along with suggestions for promoting the implementation of such a system within mental health services nationwide.

Psychiatry by videophone: a trial service in north west England.

In this paper we report on the use of a video link between two general practices and a hospital based mental health team in North West England to provide a trial telepsychiatry service for individuals with depression and anxiety related disorders. Patients (n = 16) took part in an evaluation of the service by both structured questionnaire and semi-structured interview. The results of the evaluation study suggest that patients may be highly critical of telemedicine systems and that they do so not simply on the grounds of the technical quality of video links, but also because the remote link increases the difficulty that the patient faces in expressing deep scated emotional and existential problems. It is not, therefore, simply a matter of technical quality in the link, but also a question of the quality of interpersonal relations perceived by the patient.

Mental health. Past tense--future imperfect.

Experience from total purchasing sites suggests that commissioning mental health services in primary care will be difficult to achieve. Health authorities and trusts are concerned about maintaining adequate services for severely mentally ill people, who are rarely the focus of primary care innovations. Conflict between the competing priorities of primary and secondary services seems likely to remain. Evidence from total purchasing sites suggests it is more difficult to bring about change in mental healthcare than other services.

Person-centred mental health care: the challenge of implementation.

Within mental health care, 'person-centredness' has been generally interpreted to convey a holistic approach with an attitude of respect for the individual and his/her unique experience and needs. Although it has been possible to demonstrate that professionals can acquire such skills through training, the impact on clinical outcomes has been more difficult to demonstrate in randomized controlled trials. Indeed what is becoming increasingly apparent in the literature is the need to acknowledge and address the degree of complexity that exists within the health care system that militates against achieving satisfactory implementation and outcomes from person-centred mental health care. In addressing this, we must develop and work with more sophisticated and three-dimensional models of 'patient-centredness' that engage with not only what happens in the consulting room (the relationship between individual service users and healthcare professionals), but also addresses the problems involved in achieving person-centredness through modifying the way that services and organizations work, and finally by engaging families and communities in the delivery of health care. A truly meaningful concept of 'people-centredness' encompasses how the views of the population are taken into consideration not only in healthcare but also in health and social care policy, and wider society too.

Training teachers to teach mental health skills to staff in primary care settings in a vast, under-populated area.

Background The Arkhangelsk Oblast is an area the size of France with a sparsely distributed population. The existing primary care staff have had very little training in the management of mental health disorders, despite the frequency of these disorders in the population. They requested special teaching on depression, suicide, somatisation and alcohol problems. Methods An educational intervention was developed in partnership with mental health and primary care staff in Russia, to develop mental health skills using established, evidence-based methods. After a preliminary demonstration of teaching methods to be employed, a 5-day full-time teaching course was offered to trainers of general practitioners and feldshers. Results The findings are presented by providing details of improvements that occurred over a 3-month period in four areas, namely depression in primary care, somatic presentations of distress, dealing with suicidal patients, and alcohol problems. We present preliminary data on how the training has generalised since our visits to Archangelsk. Conclusions Teachers who are used to teaching by didactic lectures can be taught the value of short introductory talks that invite discussion, and mental health skills can be taught using role play. The content of such training should be driven by perceived local needs, and developed in conjunction with local leaders and teachers within primary care services. Further research will be needed to establish the impact on clinical outcomes.

Help Seeking and Access to Primary Care for People from "Hard-to-Reach" Groups with Common Mental Health Problems.

Background. In the UK, most people with mental health problems are managed in primary care. However, many individuals in need of help are not able to access care, either because it is not available, or because the individual's interaction with care-givers deters or diverts help-seeking. Aims. To understand the experience of seeking care for distress from the perspective of potential patients from "hard-to-reach" groups. Methods. A qualitative study using semi-structured interviews, analysed using a thematic framework. Results. Access to primary care is problematic in four main areas: how distress is conceptualised by individuals, the decision to seek help, barriers to help-seeking, and navigating and negotiating services. Conclusion. There are complex reasons why people from "hard-to-reach" groups may not conceptualise their distress as a biomedical problem. In addition, there are particular barriers to accessing primary care when distress is recognised by the person and help-seeking is attempted. We suggest how primary care could be more accessible to people from "hard-to-reach" groups including the need to offer a flexible, non-biomedical response to distress.