University of Manchester and Lancashire Care NHS Trust, Preston, UK
Institute of Psychiatry, Section of Epidemiology, London, UK
Medical School University of Belgrade, Institute of Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia & Montenegro
University Hospital Center "Mother Teresa", Clinic of Psychiatry, Tirana, Albania
University Hospital Dubrava, Department of Psychiatry, Zagreb, Croatia
Counselling Department, Institute for Neuropsychiatry "Dr Laza Lazarevic", Belgrade, Serbia & Montenegro
Psychiatric Department, University Hospital "Alexandrovska", Medical University Sofia, Sofia, Bulgaria
Clinical Hospital of Psychiatry "Al. Obregia", Bucharest, Romania
University of Medicine and Pharmacy, Tg. Mures, Romania
Department of Psychiatry and Health Psychology, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Department of Psychiatry and Health Psychology, University Hospital of Psychiatry "Socola", Iasi, Romania
Charite-University Medicine of Berlin, Psychiatric Department, Berlin, Germany
Universities of Prague and Zagreb, and University of London, UK
Correspondence: Dr R. Gater, The Lantern Centre, off Watling Street Road, Fulwood, Preston PR2 8DY, UK. E-mail: richard.a.gater{at}manchester.ac.uk
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ABSTRACT |
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Aims To improve understanding of prior care-seeking and treatment of new patients seen at mental health services.
Method Pathways diagrams were drawn showing the routes of care-seeking for 50 new patients in eight centres. Patterns of care-seeking, durations and previous treatments were compared for ICD-10 diagnostic groups.
Results The diagnoses varied according to the organisation of services. Major pathways included general practitioners, direct access and hospital doctors. General practitioners have a limited role as gatekeeper in centres in Albania, Croatia, Macedonia, Romania and Serbia-Montenegro, and rarely prescribed treatment, except sedatives, for mental disorders.
Conclusions Findings highlight areas that require attention if aspirations for community-oriented mental health care are to be realised, particularly integration of mental health into primary care.
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INTRODUCTION |
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METHOD |
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Those eligible were interviewed using an encounter form, which was previously used in a study coordinated by the World Health Organization (Gater et al, 1991). The form gathers information on socio-demographic characteristics of participants and sources of care before reaching the mental health service. The encounter form was translated into Albanian, Bulgarian, Croatian, Macedonian, Romanian and Serbian. The psychiatrist in charge completed the questionnaire, which took 5-10 min. An instruction and coding manual was supplied to each psychiatrist who took part in the fieldwork.
The routes taken by participants from each centre were combined in a
pathways diagram. The proportion taking each route was marked on
the pathways diagram. The time intervals between onset of problem, first
seeking care and arrival at the mental health services were compared between
centres and diagnostic groups. Comparisons according to individual diagnostic
groups were made by groups of centres with sufficiently large numbers of
cases. Diagnostic groups were based on ICD-10 categories
(World Health Organization,
1992): mental and behavioural syndromes associated with
psychoactive substance misuse (F10-19), schizophrenia, schizotypal and
delusional disorders (F20-29), mood disorders (F30-39) and neurotic,
stress-related and somatoform disorders (F40-49). Schizophrenia, schizotypal
and delusional disorders were further divided into schizophrenia or
schizoaffective disorder (F20 and F25) and other psychotic disorders. Other
diagnoses did not occur in sufficient numbers for meaningful analysis.
Categorical data were analysed using the 2-test. Continuous
variables (such as duration of problem) were highly skewed; therefore average
values are presented as medians; analysis employed Kruskal-Wallis analysis of
variance.
Participating centres
The participating centres share a number of important characteristics. All
are in transition from predominantly institutional to community-based care,
but at present the mental health services are almost entirely hospital based.
Although in most centres primary care is widely distributed and accessible,
general practice has yet to establish its place in mental healthcare.
Communications between general practitioners and psychiatrists are rare at an
individual, institutional and guild (professional society) level. In most
countries involved, regulations require that a psychiatrist recommends an
antidepressant before the general practitioner can prescribe; there are a
limited number of psychotropic medications on the positive list
(available without charge), whereas others on the negative list
have to be paid for.
In Belgrade, where there are about ten psychiatrists per 100 000 population, participants were recruited at a large general psychiatric hospital. This is a state institution and all costs of treatment are covered by regular insurance. In Bucharest individuals were seen in the emergency and out-patient wards of the largest general psychiatric hospital in Romania. There are about 8.3 psychiatrists per 100 000 population and all public psychiatric services are covered by the regular medical insurance. Those in Iasi were seen in the University Hospital of Psychiatry, which is a state institution where costs are covered by insurance. There are 8.5 psychiatrists per 100 000 population. The service in Sofia is a private medical centre, replacing a former polyclinic (community primary and secondary care clinic), which receives donations from the local municipality and state. There are four psychiatrists per 100 000 population. Since this psychiatric service was only recently established, a substantial number of those with severe mental illness continue to receive psychiatric services elsewhere. In Strumica, an out-patient clinic and ward provide the only mental health service in the region, with 3.3 psychiatrists per 100 000 population. These are state institutions and the National Health Insurance Fund covers treatment costs. At the University Psychiatric Clinic of Tirgu Mures costs of treatment are covered by regular insurance. There are 5.4 psychiatrists per 100 000 population. In Tirana, participants were seen at the University Clinic of Psychiatry. There are 1.2 psychiatrists per 100 000 population. In Zagreb, the study was carried out in the emergency service of a large general psychiatric hospital. This is a state institution where national insurance covers admission and treatment costs, and there are about ten psychiatrists per 100 000 population.
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RESULTS |
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The most frequent diagnoses in all centres combined were mood and neurotic disorders (23% each), followed by schizophrenia (16%), other psychotic disorders (15%) and mental disorders due to substance misuse (11%). However, this distribution does not reflect the situation in any of the individual centres, which varied significantly (P<0.001) (Table 1). These differences are most likely to reflect differences in the mental health services and should not be interpreted as differences in the prevalence of mental illness. Between 28 and 38% of new patients from most centres had a previous psychiatric history but higher rates were found in Iasi (64%) and Tirgu Mures (46%) (P<0.01).
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The suggestion to first seek care most often came from family or friends for those initially presenting with psychotic symptoms (70%), violent, aggressive or other disturbed behaviour (100%) and attempted suicide (90%). Family members first suggested psychiatric care more frequently than either previous carers or individuals themselves for all diagnostic groups.
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Entry to psychiatric care in Tirana is almost exclusively through hospital doctors and direct access, with a few patients arriving via community/specialist nurses and native or religious healers (Fig. 3). General practitioners are not shown in Fig. 3 because they were involved with only 2% of participants.
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First carers varied between centres for schizophrenia (P=0.001), mood disorder (P<0.01) and neurotic disorder (P<0.01). More than two-thirds of those with schizophrenia in Bucharest and Strumica went directly to the psychiatric services compared with about half of those in Iasi and Zagreb. In Zagreb half of those with schizophrenia first went to a general practitioner compared with only 10% in Iasi and Strumica. Police were the first source of care for 15% of those with schizophrenia in Iasi and 13% in Strumica.
Those with mood or neurotic disorders often visited general practitioners first in Belgrade and Sofia, whereas in Tirana the most frequent first carers were hospital doctors or the psychiatric services. Police were rarely involved with those with mood or neurotic disorders.
In all centres combined, the median total durations of time from the onset of main problem to arrival at the psychiatric service were shorter for those with schizophrenia and other psychotic disorders compared with neurotic disorders and substance misuse (P<0.001) (Table 3). For individual diagnostic groups, the total duration of problems did not differ significantly between centres. There were significant differences between centres for duration before seeking care for those with other psychotic disorders (P<0.05; shortest durations in Zagreb and Bucharest) and for mood disorders (P<0.05; shortest durations in Iasi and Strumica).
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The median time between first seeking care and arrival at the psychiatric services was 3 weeks or less for all diagnoses. Those who had seen a general practitioner or hospital doctor were typically referred to the psychiatric services within a median of 2 or 3 weeks. In Belgrade there was a tendency towards a longer median duration after seeing a general practitioner (6 weeks) but this was not statistically significant.
The most common initial presenting problems to the first carer were psychotic (24%), depressive (19%), somatic (17%) and anxiety (12%) symptoms. This pattern had changed by the time individuals presented to the mental health services, with a greater proportion of psychotic (31%) and fewer somatic (10%) symptoms. Interpersonal problems and suicide attempts were infrequent at all centres (6% or less).
In all centres combined, approximately half of the new patients had been offered a treatment by their general practitioner, most often a sedative or hypnotic. Those with schizophrenia or other psychotic disorders were more likely to have been offered a treatment by their general practitioner than those with other diagnoses. This treatment was most often an antipsychotic medication (24%) or a sedative (20%). Nevertheless, 40% had not been offered any treatment by the general practitioner.
Mood, neurotic and substance misuse-related disorders had similar previous treatment profiles in all centres combined: over half had received no treatment from the general practitioner and 20-33% had been prescribed sedatives or hypnotics. Antidepressants were seldom prescribed to those with mood disorders (5%) and neurotic disorders (8%); they were prescribed almost equally to those with schizophrenia and other psychotic disorders (4%).
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DISCUSSION |
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Pathways
The study has demonstrated that three models, determined by the extent to
which general practitioners, hospital doctors and direct access are used, can
represent pathways to psychiatric care in Eastern Europe. Direct access was
the route for more than one-third of new patients in six centres. Irrespective
of diagnosis, general practitioners played a limited role in the pathways to
psychiatric care. A small proportion of patients consulted general
practitioners; the only treatment provided by general practitioners was
sedatives and hypnotics. Many factors contributed to this and included: lack
of training and experience in psychiatry in primary care, absence of
incentives, poor communications between the general practitioners and
psychiatrists, availability of medication and regulations limiting the
autonomy of general practitioners in managing mental disorders. If mental
health is to be integrated into primary care, then an educational approach is
more likely to succeed if this broader complex of factors is also addressed
through the formal inclusion of mental health as a component of primary care
and the further development and implementation of evidence-based national
programmes for mental health. Factors limiting the integration of mental
healthcare into general healthcare and interventions to overcome them have
been described by Sartorius
(1999).
Family involvement
Families and friends most often suggested seeking care, particularly if
there were psychotic problems or behavioural disturbance with a risk to self
or others. Families appear to be willing to help those with an illness but
seek help when socially disturbing symptoms become prominent. If community
mental healthcare is planned, then it will be important to realise the
potential positive role of families through public education and partnership
between mental health professionals and the families of people with mental
illness.
Variations between centres
Organisational differences account for much of the variation in proportions
of mental disorders between centres. The out-patient-based service in Sofia
was established recently and most individuals with severe mental illness
continue to attend the City State Psychiatric Dispensary; hence the low rates
of schizophrenia and other psychotic disorders. In contrast, other centres
such as Bucharest, Iasi and Zagreb recruited new admissions to acute
psychiatric wards with relatively high rates of schizophrenia and low rates of
neurotic disorders. In Strumica, general practitioners are
gatekeepers for patients with neurotic disorders, and relatively
few are referred to the psychiatrist; in Belgrade there are psychotherapeutic
treatments available which attract such referrals. In the three Romanian
centres there are no special units for alcohol dependence, which is treated in
psychiatric hospitals. Primary care is not involved in care-seeking pathways
in Tirana, and therefore the mental health service itself manages a relatively
high proportion of patients with mood and neurotic disorders (78%). The
pathways in some centres included routes that reflect their individual
circumstances. Native healers are popular in Strumica, particularly among the
rural population. Bucharest retains six mental health laboratories from the
communist period, and psychiatrists from these public institutions may refer
to the study psychiatrists (hence the 30% recursive pathways due to mental
health laboratory psychiatrists as the previous carers). In the east of
Romania, people are more religious and more often seek care from a priest,
whereas in the west there is a mixture of cultures, including Romanian,
Hungarian, German and Romas.
Durations and previous treatment
The time between first seeking care and arrival at mental health services
for mood and neurotic disorders was generally short, so there was insufficient
time for first-line treatments to be tried. General practitioners were more
likely to prescribe sedatives or hypnotics than other treatments.
Antidepressants were prescribed to very few participants and were almost as
likely to be given to those with schizophrenia as those with depression. This
pattern may arise in part from the constraints imposed by prescribing
regulations and by the limitations imposed by the positive list;
there may also be reservations of both patients and doctors to the use of
strong medicines (such as antidepressants or antipsychotics),
with connotations of severe mental illness, in favour of mild
medicines (such as sedatives or hypnotics), which are less taboo. These
patterns of prescribing are not unique; they do not differ greatly from those
reported from several centres in the original World Health Organization
pathways study (Gater et al,
1991).
In Bucharest, the longer duration before first seeking care for substance misuse may be related to the increasing numbers of drug users, especially of a younger age. There is also a negative attitude towards illegal drug use, which the authorities consider to be a criminal issue, and this renders treatment services less likely to be available or used.
A key strength of this study was that it used the same methodology and standard encounter form in all centres. Trained and experienced psychiatrists completed the encounter forms and made diagnoses using the ICD-10 classification. However, diagnoses were not based on a standardised diagnostic interview and algorithm. The sample size of 50 participants per centre is modest, but sufficient to give a representation of pathways to care and some inter-centre differences. The response rate was high in all centres, so minimising selection bias. Recall bias might have occurred as all information was based on self-report, and defining the onset of the main problem could be influenced by cultural factors, including the strong stigma associated with mental illness.
Conclusions
Although the sample and its size restrict the extent to which firm
conclusions can be drawn from this study, there are clear indications for
areas of further research. These include questions about the most effective
and efficient target disorders for the specialist mental health services and
the balance between hospital and community care. More apparent are questions
about the role of primary care in mental healthcare in both the detection and
management of mental disorders, and the barriers and solutions to
incorporating mental health into primary care. The police and traditional
healers could be trained to recognise mental illness in some centres.
The study has highlighted the important role of family and friends and suggests a significant impact of the stigma associated with mental disorders. These factors suggest the development of a public mental health approach and exploration of the best ways to collaborate with families. The pathways study has posed many questions, but if further progress is to be made there needs to be a shift to a more evidence-based culture and a reduction of the stigma associated with mental illness. We recommend that consideration be given to the inclusion of a research and development agenda in the national programmes of mental health.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication May 18, 2004. Revision received October 14, 2004. Accepted for publication October 18, 2004.