Mental health knowledge and attitudes of general practitioners and pediatricians toward persons with psychiatric disorders prior to the integration of mental health into primary care – A research proposal

19 09 2013

Below please find is a research proposal entitled ‘mental health knowledge and attitudes of general practitioners and pediatricians toward persons with psychiatric disorders prior to the integration of mental health into primary care’. Since I think that this issue is very important and relevant to the Israeli health system and due to the fact that I do not have the time to promote it, I encourage you to use it and to study this highly important issue. Good luck!

 

Title

Mental health knowledge and attitudes of general practitioners and pediatricians toward persons with psychiatric disorders prior to the integration of mental health into primary care

Abstract

Scientific Background: Israel is currently promoting a reform aimed to improving the accessibility, availability, and efficiency of mental health services. As part of this reform, mental health integration into primary care will take place over the next couple of years.

Objectives: the main objective is to investigate whether, and to what extent, general practitioners and pediatricians, have the adequate knowledge and attitudes that are required to effectively assess, diagnose, treat, support and refer people with psychiatric disorders.  The findings of this proposed study may provide valuable information for policy makers concerning the current knowledge and attitudes of GPs and pediatricians in the mental health field while indicating whether there is a need to promote mental health training among these populations.

Working hypotheses: Overall, general practitioners and pediatricians do not have the adequate knowledge and attitudes to provide evidence based health services to children and adults with psychiatric disorders. Pre-service education and training in mental health, years of practice, participant’s country of origin country of medical studies and post graduate training, current workplace, familiarity with persons with psychiatric disorders, geographic location of the clinic and gender will impact the participant’s mental health knowledge and attitudes.

Methods of Data Collections: a cross-sectional quantitative research of general practitioner and pediatricians using case vignette questionnaires, demographic questionnaire and Level of Contact questionnaire

Methods of Data Analysis: Differences in socio-demographic characteristics across vignette groups will be analyzed using chi-square tests and one-way analysis of variance (ANOVA). The responses the questionnaires will be examined using one-way ANOVA tests, followed by posthoc Mann–Whitney U-tests for overall significance at the P < 0.05 level. ANOVAs followed by confirmatory ordinal logistic regressions will be used for interactions between the moderating variables and participants’ knowledge and attitudes towards the patients in the four vignettes.

 

  1. Scientific background:

About 450 million of people worldwide are affected by psychiatric disorders. The World Health Organization (WHO) estimates that 154 million people are affected by depression and 25 million people from schizophrenia; 91 million people are affected by alcohol use disorders and 15 million by drug use disorders (WHO, 2004, 2006). With regard to children, the literature indicates that approximately one in five children have a psychiatric disorder (WHO, 2005). Disorders regularly seen within this population include attention-deficit/hyperactivity disorder, conduct disorder, generalized anxiety disorder, depressive disorders, post traumatic stress disorder, and separation anxiety disorders (WHO, 2006; Korczak & Goldstein, 2009; Polanczyk, de Lima, Horta, Biederman and Rohde, 2007).

 

Psychiatric disorders are both prevalent and highly disabling conditions. Measured by years lived with disability and by premature death (DALYs), psychiatric and neurological conditions accounted for over 13% of the global disease burden in the year 2001 need more recent  (WHO, 2004). Among individuals age 15–44, unipolar depression is the second leading contributor of DALYs, with alcohol-related disorders, schizophrenia, and bipolar disorder among the top 10 disorders. Approximately, 33% of all years lived with disability (YLD) are imputed to psychiatric conditions. Of the 10 leading causes of YLD in the world among individuals of all ages, four are psychiatric conditions, with unipolar depression being the leading cause. These figures are rising. By 2030, in high-income countries, depression will become the single highest contributor to the overall disease burden (Mathers CD, Loncar, 2006). Psychiatric disorders also affect, and are affected by, chronic diseases such as cancer, cardiovascular diseases, diabetes and HIV/AIDS. Hence, when untreated, psychiatric disorders can contribute to unhealthy behavior, non-adherence to prescribed medical regimens, diminished immune functioning, poor prognosis and early dead (Miller, Paschall and Svendsen, 2006; Nakash, Shemesh, Nagar and Levav, 2012).

 

Despite the potential to successfully moderate the effect of psychiatric disorders, only a small minority of those in need receive adequate mental health care (World Health Organization and World Organization of Family Doctors (Wonca), 2008). The report of the US Surgeon General emphasized the critical role of stigma on the public’s willingness to seek help and to receiving mental health services (U.S. Department of Health and Human Services, 1999). Furthermore, it highlighted the fact that the separation of treatment care systems (i.e. mental health system – physical health system) increases the stigma of mental health disorders and care and decrease the accessibility to treatment, while maintaining the wide treatment gap.  As a result, many countries have recently sought to integrating mental health services into primary care to reduce the treatment gap while enhancing the access of mental health services (WHO & Wonca, 2008). In this process, those countries tried to assure that primary care workers hold the knowledge, which is required to effectively assess, diagnose, treat, support and refer to the specialized services people with mental disorders. Nonetheless, the professional literature indicates that in many parts of the world, primary care workers fail to detect psychiatric disorders, and for a range of reasons they also fail to provide evidence-based treatment to persons they do identify in need of care (Üstün & Sartorius, 1995).  While there are many reasons why psychiatric disorders are under-detected and undertreated in primary care (e.g., patient factors, health system factors, and societal and environmental factors) (WHO & Wonca, 2008), the role of the health care workers is crucial. Research suggests that many health workers do not receive adequate training on mental health issues or developed frank stigmatic attitudes. In most countries, primary care worker training ranges from a few hours to a maximum of one or two weeks. Misunderstandings about the nature of mental health problems, prejudice against people with mental disorders, and inadequate time to evaluate and treat psychiatric disorders in clinical settings are other contributing factors. For example, a recent study indicates that 98.5% general practitioners providing mental health services care in a primary care setting feel the need to be properly trained and oriented in the management of patients with psychiatric disorders to improve the overall quality of health care (Chaundhary & Mishra, 2012).  Furthermore, 79% of the primary care providers in their sample did not know any psychiatric illness diagnosis criteria neither have they any exposure to training to deal with psychiatric conditions. Hence, they treat their patients based on their “own intuitions” (Chaundhary & Mishra, 2012, p. 23).

 

While formal education in the mental health field can lead to better evidence based practice it may lead to positive attitudes toward persons with psychiatric illness. Research on health-related attitudes largely indicates that overall, one’s professional knowledge about psychiatric illness and disability, as well as one’s positive contacts and interactions with people who psychiatric disorders, positively affect the individual’s attitudes toward them, both in an absolute sense and in comparison to the views of the general public (Penny, Kasar, & Sinay, 2001; Whal & Aroesty-Cohen, 2010; Yamauchi Semba, Sudo, Takahashi, Nakamura, Yoshimura, Koyama et al, 2011). For example, in their recent review of the literature, Whal and Aroesty-Cohen (2010) found that 14 of the 19 studies investigated (published between the years 2004-2009) reported general positive attitudes among mental health professionals toward people with psychiatric illness, whereas only five showed predominantly negative attitudes. Nevertheless, students and professionals in the health field are not immune to the influence of negative attitudes and discrimination (e.g., Nordt, Rossler, & Lauber, 2006; Tervo & Palmer, 2004). In fact, the professional literature suggests that negative attitudes on the part of health professionals is most toxic, since their attitudes related to the prognosis, recovery and social inclusion of people with illnesses may have a crucial impact on the lives of their patients (Corrigan, 2007; Li, Comulada, Wu, Ding, & Zhu, 2011). For example, in a survey of 1073 mental health professionals and 1737 members of the general public, researchers found that psychiatrists held more negative attitudes toward people with psychiatric illness than the general public. Moreover, mental health professionals of all types were three times more likely to support restrictions for people with psychiatric illness than the general public (Nordt, Rossler, & Lauber, 2006). Another study found that general practitioners were less happy to have a patient with schizophrenia on their practice list and reported that patients with schizophrenia are more likely to be violent than most patients (Lawrie, Martin, McNeill, et al, 1998).

Israel is currently promoting a reform in its mental health system aimed to integrating mental health services into primary care settings. The main purposes of this reform are to (1) improving the link between mental and physical care by enhancing primary care physicians’ capacity to diagnose and treat psychiatric disorders; (2) strengthening the consultation and referral relationships between the primary care providers and mental health specialists; (3) and to improving availability and access of mental health services (Rosen,Nirel, Gross, Bramali and Ecker, 2008). Furthermore, the implementation of this reform is expected to facilitate help-seeking strategies, and improve early detection and intervention that that may increase the chances of quicker recovery and better long-term outcomes. Following the experiences of other countries (WHO and WONCA, 2008), one of the main factors that may determine the success of this reform is the degree to which primary care providers would have adequate knowledge and positive attitudes that would improve their practice, including their willingness to consult and be supervised by mental health experts. Hence, as will be elaborated in the next section, the main goal of this proposed research is to investigate the current diagnostic and treatment knowledge, attitudes and practices among general practitioners (GPs) and pediatricians.

 

  1. Objectives

General objective:

  1. To investigate mental health knowledge and attitudes of general practitioners and pediatricians (heretofore: participants), in primary care settings, in the pre integration era.
  2. To investigate mental health attitudes in general and attitudes toward persons with psychiatric disorders in particular among study participants.
  3. To investigate the association of participants’ age, gender,  country of origin, personal familiarity with persons with psychiatric disorders, country of medical studies and post graduate training,  current workplace (the health plan that the participate work with), mental health pre-service education; years of practice, geographic location of the site of current practice and, on mental health knowledge and attitudes.

 

  1. Working Hypotheses

Base on past research, we expect the following:

  • Overall, general practitioners and pediatricians do not have the adequate knowledge and attitudes to provide evidence based health services to children and adults with psychiatric disorders.
  • Pre-service education and training in mental health, years of practice, participant’s country of origin country of medical studies and post graduate training, current workplace, familiarity with persons with psychiatric disorders, geographic location of the clinic and gender will impact the participant’s mental health knowledge and attitudes. 

 

  1. Comprehensive description of study design and methodology:

This is a cross-sectional research of general practitioners and pediatricians using a case vignette questionnaire aimed to investigate 1) the degree to which the participants have the adequate knowledge on psychiatric diagnosis and treatments; 2) to explore the participants’ attitudes toward psychiatric disorders and patients with psychiatric disorders. Furthermore, the impact of pre-service education and training, country of medical studies and post graduate training, participants’ country of origin, years of practice, gender, geographic location of their clinic and personal familiarity with persons with psychiatric disorders, on their mental health knowledge and attitudes will be ascertained as well.

Participants: A convenient sample of 500 general practitioners and 200 pediatricians will be recruited for the present study. These figures were selected following a power analysis that was conducted using the G*Power 3 program (Faul, Erdfelder, Lang, & Buchner, 2007) to determine the sample size. With alpha set at 0.05 and power at 0.80 that a minimum sample of 180 participants was needed to detect a significant medium effect (f = 0.25) using one-way ANOVA with four [vignettes] groups.

Recruitment. This proposed research will approach all the registered GPs (around 5000) and pediatricians (around 2000) via an email message that will include a cover letter with the purposes and importance of the study followed by the research questionnaires. Furthermore, we will collaborate with the four Israeli health plans and will seek to promote collaborations with the Israel Ambulatory Pediatric Association and with the Israel Association of Family Physicians in order to increase participation.  The cover letter and questionnaires will also be published in websites and social media that are aimed for general practitioners and pediatricians. Finally, the research assistances will attend professional conferences where they will encourage GPs and pediatricians to fill the questionnaires on site.

Research tools:

The present research will be based on case vignettes that will be followed by mental health knowledge questionnaire concerning psychiatric diagnosis and treatment and attitudes measurements. The case vignettes that will be developed for GPs will include a description of adults who experience symptoms of schizophrenia, unipolar depression, diabetes or no illness (i.e. good health). The case vignettes that will be developed for pediatricians will include a description of children who experience symptoms of Attention deficit-hyperactivity disorder (ADHD), separation anxiety, Asthma or no illness.

These vignettes will be followed by a questionnaire that will be developed for this research aimed to assess the participants’ knowledge ability to diagnose and tailor a treatment (including referring the potential patient to a mental health expert) for the person described in the vignette. In addition, based on the study of Lawrie et al. (1998), which measured mental health attitudes among primary care providers, participants will be asked to report their level of agreement with 13 statements based on the vignette using a 7-point Likert scale (e.g., you would be happy to have this patient on your list, this person is likely to take up a lot of time, this patient is more likely to be violent than most patients, and this patient is unlikely to comply with advice or treatment given). In addition, a socio-demographic questionnaire will be distributed. In this questionnaire, participants will be also asked to report with what health plan they are working. Moreover, participants will be asked to answer a modified Level of Contact questionnaire (Holmes, Corrigan, Williams, et al, 1999) that include a lists 12 situations of varying degrees of intimacy that involve persons who have psychiatric illness and diabetes. The reason for asking of previous contact between the participants and persons with psychiatric illness and diabetes is based on the contact hypothesis (Allport, 1954) which demonstrated that contact under certain conditions is highly effective in alleviating negative attitudes and prejudice directed toward out-group members, including persons with psychiatric illness and other health conditions (Corrigan, Roe and Tsang, 2011; Wright, 2009). Finally, a questionnaire regarding the participants’ pre-service education will be developed. The aim of this questionnaire is to investigate to what extent, medical school, internship and residency programs impact the mental health knowledge, attitudes and practice of the participants.

 

Analysis

Analyses will conduct using the Predictive Analytics SoftWare (PASW, Version 18.0). All data will be dual entered. Differences in socio-demographic characteristics across vignette groups will be analyzed using chi-square tests and one-way analysis of variance (ANOVA). The responses to the mental health knowledge and attitudes across the four groups will be examined using Kruskal–Wallis one-way ANOVA tests, followed by posthoc Mann–Whitney U-tests for overall significance at the P < 0.05 level. ANOVAs followed by confirmatory ordinal logistic regressions will be used for interactions between the following variables and participants’ knowledge, skills and attitudes towards the patients in the four vignettes:

1. Preserves medical education and training in the mental health field

2. Workplace (i.e. the health plan that the participant work with).

3. Years of practice

4. Country of origin and country of medical studies and post graduate training

5. Contact with persons with psychiatric disorders

6. Gender

7. Geographic location of the clinic

 

Procedure:

At the first stage the vignettes and questionnaires developed for this study will be reviewed by a panel of experts. The questionnaire will be distributed among 10 GP experts and 10 pediatric experts. They will be asked to provide feedback concerning the validity and clarity of the vignettes and the questions and their relevance to the research objectives. The panelists will not serve as study participates. After the validation phase, vignettes and the questionnaires will be uploaded to a research website. Then, study participant will be recruited by the research assistances (see the recruitment section). The vignettes will be then randomly allocated and a cover letter which describe the aim of the research and that states that all responses would be anonymous,  with a link to the website will then be sent to study participates. Moreover, they will be informed that their participation is entirely voluntary. A follow up reminder will be sent to participants will be sent a month after.

 

Possible biases and research limitations

The qualifications of the study are those characteristics of the design or methodology that set parameters on the application or interpretation of the results of the study, that is, the constraints on the generalizability and utility of the findings established by internal and external validity. With regard to external validity, the proposed research needs to be examined in light of several limitations. First, the fact that the proposed research relies on a convenience sample, rather than a representative sample, reduces the ability to draw inferential conclusions from the sample data about the general population. However, the findings of this proposed research may provide important information can lead to further research among a representative sample of GPs and pediatricians in Israel. A second limitation relates to response rates. In this project, the main problem is the difficulty to reach the participants who may be loaded with their daily work and not see the importance of filling in a questionnaire for research purposes. Therefore, multiple recruitment strategies will be employed in order to assure that most participants will indeed answer the questionnaires. Finally, social desirability is treated as a factor that can contaminate commonly used self-report measures and thus lower reliability and validity of the results. This is mostly relevant to attitudes questionnaires. The proposed study will be anonymous and that may significantly reduce the social desirability bias.

5. Significance of the Proposal:

Over the past two decades, the State of Israel is preparing to transfer legal responsibility for mental health care from the government to the country’s four, competing, non-profit health plans. This reform seeks to improve the health and well-being of the persons with psychiatric disorders by establishing a legal right to care, increasing the level of government funding for mental health care, and improving the accessibility, availability, and efficiency of services. Nowadays, where the mental health integration into primary care is about to come to realization, there is a need to assess whether primary care providers, which will serve as the main gatekeepers for mental health conditions, have the adequate mental health knowledge and attitudes. Learning from the experience of countries that conducted similar mental health reforms without ensuring that the primary care providers have the needed mental health knowledge and attitudes to provide adequate mental health services (WHO and Wonca, 2008), the present study seeks to provide information about the current mental health knowledge and attitudes of primary care providers; information that may assist to better implement this important reform.

 

References

 

Allport, G. W. (1954). The nature of prejudice. Cambridge, MA: Perseus Books.

 

Corrigan. P.W., (2007). How Clinical Diagnosis Might Exacerbate the Stigma of Mental Illness. Social Work, 52 (1), pp. 31-39.

 

Faul, F., Erdfelder, E., Lang, A.G., and Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social ,behavioral, and biomedical sciences. Behavior Research Methods, 39, 175-191.

 

Lawrie, S. M., Martin, K.,  McNel, G. J., Drife, J. Chrystie, P., Reid, A.,  P. Wu, P., nammary, S., and J. Ball (1998). General practitioners’ attitudes to psychiatric and medical illness. Psychological Medicine, 28, pp 1463-1467.

 

Li, L., Comulada WS, Wu Z, Ding Y, Zhu W. (2011). Providers’ HIV-related avoidance attitude and patient satisfaction. Health Expectations. doi: 10.1111/j.1369-7625.2011.00705.x.

 

Mathers C.D., Loncar D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLos Medicine, 3:2011–2030.

 

Miller B.J., Paschall C.B., 3rd, Svendsen D.P., (2006). Mortality and medical comorbidity among patients with serious mental illness. Psychiatric Services;57(10):1482-7.

 

Nakash, O., Shemesh, A., Nagar, M., and Levav, I., (2012).  Cancer and common mental disorders in the community: Results of the Israel-World Mental Health Survey. European Journal of Psychiatry; 26 (3), 174-184.

 

Nordt, C., Rossler, W., and Lauber, C. (2006). Attitudes of Mental Health Professionals Toward People With Schizophrenia and Major Depression. Schizophrenia Bulletin. 32 (4): 709–714.

 

Penny, N.H.,  Kasar, J. and  Sinay, T (2001). Student Attitudes Toward Persons With Mental Illness: The Influence of Course Work and Level of Fieldwork. The American Journal of Occupational Therapy, 55 (2), 217-220.

 

Polanczyk G., de Lima M.S., Horta B.L, Biederman J, and Rohde L.A., (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis”. The American Journal of Psychiatry 164.

 

Rosen, B., Nirel, N., Gross,R.,  Bramali, S., and Ecker, N., (2008). The Israeli Mental Health Insurance Reform. The Journal of Mental Health Policy and Economics, 11, 201-208.

 

Tervo, R.C. & Palmer, G. (2004). Health professional student attitudes towards people with disability. Clinical Rehabilitation; 18(8), 908-915.

 

U.S. Department of Health and Human Services. (1999). Mental Health: A report of the Surgeon General. Rockville, MD: Author.

 

Üstün T.B., Sartorius N., (eds.) (1995). Mental illness in general health care: an international study. Chichester, Wiley.

 

Wahl, O.F. & Aroesty-Cohen, E. (2010). Professional Attitudes about Mental Illness: A Review of the Recent Literature. Journal of Community Psychology, 38 (1) 49–62.

 

World Health Organization (2004). Revised Global Burden of Disease (GBD) 2002 estimates. Geneva, World Health Organization. Can be retrieved at: http://www.who.int/healthinfo/bodgbd2002revised/en/index.html, accessed 31 March 2008 (

 

World Health Organization (2005). Child and adolescent mental health policies and plans. Geneva, World Health Organization.

 

World Health Organization (2006). Neurological disorders: public health challenges. Geneva, World Health Organization.

 

World Health Organisation, (2008). The Global Burden of Disease: 2004 Update. WHO, Geneva, Switzerland.

 

World Health Organization and World Organization of Family Doctors (Wonca) 2008. Integrating mental health into primary care: A global perspective. ISBN 978 92 4 156368 0; 206 pages. Available at: http://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf

 

Yamauchi T., Semba T., Sudo A., Takahashi N., Nakamura H., Yoshimura K., Koyama H., Ishigami S., and Takeshima T., (2011). Effects of psychiatric training on nursing students’ attitudes towards people with mental illness in Japan. International Journal of Social Psychiatry,  57 (6), 574-579.

 

 

 

 

 

 

 





The Psychiatric rehabilitation law in Israel

28 02 2012

In the past decades there have been substantial changes in the Israeli mental health field in general, and in the community based psychiatric rehabilitation in particular. These changes occurred both in policy making level and in practice level. Since 2001 the Israeli Ministry of Health has been in the process of developing community based psychiatric rehabilitation services as part of the implementation of the Rehabilitation in the Community of People with a Psychiatric Disability Law or “Psychiatric Rehabilitation Law”.

This law combines the rights of people with disability and the rights to dignity and liberty– in the psychiatric rehabilitation field prospective. The main goal of this law is “to work diligently for the rehabilitation and social inclusion of people with a psychiatric disability in order to allow them to achieve the maxim amount of independence and quality of life, while keeping their dignity according to the Basic Law: Human Dignity and Liberty” (2000).  Furthermore, this law emphasizes the importance of social inclusion of people with psychiatric disabilities as part of the rehabilitation process; and stated that all Israelis with a psychiatric disability will enjoy the right for community based psychiatric rehabilitation services provided by the country.

Nonetheless, while there are many developments in research and practice in this field in Israel, there are still many barriers that slow down the positive progresses in this field: the medical model approach is still dominant in policy and in budgets; the shift from the “protected” rehabilitation approach that encourages low functioning and social exclusion to “empowered” approach that encourages high functioning and social inclusion is slow; the passage from paternalistic attitude from many sectors in the system to a more self-definition attitude for the consumers and therapeutic practices and social attitude that maintain mental illness stigma and discrimination are still common; and still many people do not have access to psychiatric rehabilitation services.

For more information read these recent papers by Aviram, Ginat and Roe and by Drake, Hogan, Slade and Thornicroft.

For questions, clarifications and any other inquiries about this issue please feel free to contact me.

Have a great day!

 





Eating disorders

25 02 2012

Eating disorders… do we fully understand the reasons for these disorders? Do we fully acknowledge the dire consequences of anorexia, bulimia, and binge eating disorder? Do we really know how many people cope/suffer from these conditions? Are there enough professionals that know how to assist people with eating disorders to cope with the disorders symptoms? Are there enough resources for research, treatment and rehabilitation in this field? Well my friends, the answer for these questions is absolutely NO!

As part of my professional work I have been facing, more than once, with the lack of services for people with eating disorders in Israel. Personally, I had to deal with the tragedy of a very early dead due to an eating disorder (outside of Israel).

I call policy makers to recognise how prevalence and dangerous these health conditions are, and to allocate [much] more resources to reasearch and practice in this field.  Fortunately, Dr. Thomas R. Insel,  Director of the [American] National Institute of Mental Health (NIMH) is aware of the situation and is seeking to improve it.

Amir

 





The psychiatric services PARADOX

22 02 2012

“For consumers of all ages, early detection, assessment, and linkage with treatment and supports can prevent mental health problems from compounding and poor life outcomes from accumulating. Early intervention can have a significant impact on the lives of children and adults who experience mental health problems. Emerging research indicates that intervening early can interrupt the negative course of some mental illnesses and may, in some cases, lessen long-term disability. New understanding of the brain indicates that early identification and intervention can sharply improve outcomes and that longer periods of abnormal thoughts and behavior have cumulative effects and can limit capacity for recovery” (President’s New Freedom Commission on Mental Health)

Policy makers, clinicians and researcher highlight the importance of early intervention in the mental health field, as well as other medical areas. Furthermore, one of the main purposes of public awareness and anti stigma campaigns is to promote help seeking behaviors and treatment adherence among people who experience psychiatric symptoms. However, the call for early interventions and for help seeking behaviors is almost ironic in the present situation of psychiatric services (e.g., mental health departments/hospitals, ambulatory and community based rehabilitation services). For example, here in Israel, the situation of psychiatric services for children and teens is DIRE (!). In the same vein, most adults that need community based treatment and rehabilitation do not receive it due to lack of available services. So how can we call for people to go and get treatment when this treatment is not available for so many people?