General Practitioners (GPs) play a crucial role in the detection and referral of mental health problems in primary care (Borowsky et al. Reference Borowsky, Rubenstein, Meredith, Camp, Jackson-Triche and Wells2000; Copty, Reference Copty2004; Copty & Whitford, Reference Copty and Whitford2005; Bradley, Reference Bradley2008). In Ireland, this is highlighted by current mental health policy as outlined in A Vision for Change (Department of Health and Children, 2006), which further augments the role of the GP as a conduit for access to a broad range of mental health services both public and private. Primary care is considered a very important part of the mental health framework for two reasons. For the majority of patients, most mental health problems are dealt within primary care without referral on to specialist mental health services and the GP is the main access point to such services (Department of Health and Children, 2006). Furthermore, a large emphasis is placed on providing mental health services in so far as is possible, within a primary care setting and psychological therapies are identified as a fundamental component of these services. A Vision for Change (Department of Health and Children, 2006) reports a number of submissions, which call for ‘a comprehensive range of psychological therapies’ (p. 60) to be provided. However, it does not explicitly define the parameters of the term ‘psychological therapist’. We define psychological therapy to refer to a range of therapeutic approaches broadly derived from psychological principles and paradigms, which are used to treat psychological disorders. The term psychological therapist for the purposes of this paper therefore refers to providers of such therapy including Psychiatrists, Psychologists, Psychotherapists and Counsellors.
GPs play a key role in the detection and referral of mental health disorders. A HSE/National Suicide Research Foundation report found that that the vast majority of adults would seek help first from their GP if they felt they needed to address a mental health issue (National Office for Suicide Prevention, 2007). Copty & Whitford (Reference Copty and Whitford2005) found that half of GP respondents to their survey estimated the proportion of their patients with mental health problems in the range 15–32%. Hughes et al. (Reference Hughes, Byrne and Synnott2010) found that 33% of GP adult attendees exhibited some degree of psychological distress.
In spite of their key role as a first point of contact for many people who may need to access the mental health services, GPs have acknowledged their inadequate training and knowledge in the area of mental health (Funk & Ivbijaro, Reference Funk and Ivbijaro2008; Zakroyeva et al. Reference Zakroyeva, Goldberg, Gask and Leese2008). A study hosted by the Irish College of General Practitioners (ICGP) with the support of the Eastern Regional Health Authority (Copty & Whitford, Reference Copty and Whitford2005) reported that 68% of GPs had no specific training in mental health and 32% had between 3 and 9 months ‘on the job’ training and/or some training as part of a hospital rotation. Qualitative data from the same study revealed that at times GPs do not know where to refer their patients: ‘At the moment I’m referring to a psychiatrist, not because I particularly want the psychiatrist to see them, but because psychiatrists are the only gatekeepers in this area’ (p. 84). However, Copty (Reference Copty2004) also reported that 46% of Psychiatrists believed that at least 40% of patients referred to them should be treated in primary care. Jeffers (Reference Jeffers2013) reports that all psychiatrists involved in their research believed that at least 20% of the referrals they receive could be managed in Primary Care.
Both GPs and service users have expressed a desire for greater availability of psychological therapies. In A Vision for Change (Department of Health and Children, 2006), concern was expressed by service users over the perceived over-emphasis on drug treatments. Many felt that there were limited opportunities for discussion and resolution of their problems through psychotherapy and counselling (Dunne, Reference Dunne2006; Mannix-McNamara et al. Reference Mannix-McNamara, Carew-Eichloz, Vitale and Jourdan2012; Vitale & Mannix-McNamara, Reference Vitale and Mannix-Mc-Namara2013). This reflected a view reported in Copty (Reference Copty2004), which found general support among service users for more patient choice in treatment, with many of those service users expressing a preference for counselling or psychotherapy over medication. Additionally, there is increasing evidence that psychological interventions can be more cost-effective than optimal drug treatment, for example, CBT (Cognitive Behavioural Therapy) for depression has been shown to cost approximately a third less than pharmacological treatment (O’Shea & Kennelly, Reference O’Shea and Kennelly2008). Psychological therapy when combined with other treatments can reduce hospitalisations, medical expenses and work disability in patients with enduring mental health difficulties such as schizophrenia and bipolar affective disorder. Considering that the estimated cost of poor mental health in Ireland in 2006 was just over 3 billion (O’Shea & Kennelly, Reference O’Shea and Kennelly2008), the potential savings are significant and in the current economic climate, particularly relevant.
A Vision for Change (Department of Health and Children, 2006) identified a dearth of information on the functioning of current psychological therapy services, in terms of the number of individuals who avail of services, the types of interventions available or the effectiveness of interventions on offer. Furthermore, GPs identified the lack of direct access to counselling services as a major barrier to improving the treatment of mental health issues in primary care (Copty, Reference Copty2004). A range of views were reported on the ideal model for accessing psychological therapies in primary care. These included having a Clinical Psychologist or nurse counsellor on site in GP practices or alternatively area-based services, which could be accessed by direct referral. However, effective implementation of strategies to increase access to psychological therapies necessitates as a starting point information regarding current referral practices and protocols.
Furthermore, although some research has been conducted into the referral of patients with mental health difficulties to publicly funded services (Copty, Reference Copty2004; Copty & Whitford, Reference Copty and Whitford2005; Jeffers, Reference Jeffers2013) there is a dearth of research examining GP referrals to the full range of public and private psychological services available. A key barrier that GPs may experience in the referral of patients presenting with mental health difficulties is the lack of standardisation of training and qualification requirements across Psychological therapists. To date in Ireland, in the absence of statutory regulation there has been very little clarity around the use of titles such as ‘counsellor’, ‘psychotherapist’ and even ‘psychologist’. There are a variety of accrediting bodies with widely varying requirements for academic and supervision experience. This leads to a two-fold problem: on the one hand, referral agents such as GPs may have difficulty identifying an appropriately qualified practitioner. On the other hand, potential service users may be vulnerable to putting their trust in a psychological therapist with the most effective advertising rather than the most appropriate qualifications and experience.
This paper presents findings from an exploratory study, which aimed to understand the experience and practice of Irish GPs when seeking to refer patients with mental health difficulties for psychological therapies within their geographical area. It also aimed to survey what psychological therapies were available, and the education level of therapists, the range of therapies offered, accreditation, work sector, client groups and referral pathways.
Methods
A quantitative research design was adopted for this investigation. Postal surveys were developed based on existing literature with input from GPs, Psychological therapists and selected users of primary care services. Questionnaires were designed in order to assess GPs’ experience of referring mental health patients to Psychological Therapists (whether public or private services) and therapists experience of receiving such referrals.
Instruments
The General Practitioners’ Questionnaire consisted of a form for gathering demographic information and 21 items exploring referral processes organised in two sections. The first section aimed to assess GPs’ general experience of referring patients with mental health issues for psychological therapy. Questions included: What percentage of your adult patients do you estimate have presenting or underlying mental health issues? What percentage of your adult patients with mental health issues do you refer to other professionals? To whom do you refer? What factors influence your decisions to refer adult patients to psychological therapies? The second section focused on GP’s awareness of psychological therapists working in their area.
The Psychotherapist Questionnaire aimed to profile therapists working in the same geographical area as the targeted GPs. The form consisted of a bio-form and 19 items relating to referral sources, client profiles and information dissemination strategies. Questions included: What are the main presenting issues you accept referrals on? Where do you most typically receive referrals from? Have you presented yourself and information on what you do to GPs in your area? If a patient has been referred to you by another professional would the patient typically have a good understanding of what the therapy will involve, expected outcomes of therapy, previous client outcomes, your qualification as a therapist?
Access and recruitment of the samples
From the target area all General Medical Practitioner’s listed by the ICGP and all Psychological Therapists listed on publicly available sources such as websites of a variety of accrediting bodies were invited to take part in the study. The main therapist accrediting bodies referenced were as follows: Psychological Society of Ireland (PSI); Irish Association for Counselling and Psychotherapy (IACP); Irish Association of Humanistic and Integrative Psychotherapists (IAHIP); Irish Council for Psychotherapy (ICP) and Family Therapy Association of Ireland (FTAI).
Ethical considerations
Ethical approval was granted by the Mary Immaculate College Research Ethics Committee. All participants were informed about the aims and objectives of the study. They were also informed that their participation was voluntary, their data would be anonymous and confidential and that they had the right to withdraw at any time.
Procedures
All participants were surveyed by post. Each of them received in the following order: an invitation letter, a consent form, a questionnaire and a self-addressed envelope. They were instructed to complete the questionnaire and return it to the first author.
The response rate for the GP group was 33% (i.e. 97/298). This is lower than a mean response rate among doctors of 57.5% and 54% reported in systematic reviews of healthcare professional response rates by Asch et al. (Reference Asch, Jedrziewski and Christakis1997) and Cook et al. (Reference Cook, Dickinson and Eccles2009), respectively. However, recent studies have also noted that response rates by doctors in clinician surveys are declining (Wiebe et al. Reference Wiebe, Kaczorowski and MacKay2012). It was not possible to provide financial incentives, a factor that has been found to increase response rates (Edwards et al. Reference Edwards, Roberts, Clarke, DeGuiseppi, Pratap, Wentz, Kwan and Cooper2007). Factors that were found to increase response rates such as the use of personalised letters, a short survey instrument and inclusion of stamped return envelopes (Edwards et al. Reference Edwards, Roberts, Clarke, DeGuiseppi, Pratap, Wentz, Kwan and Cooper2007) were incorporated in the study design. The response rate for psychological therapists was higher at 45% (n=129/284).
Results
As indicated above in Table 1, male participation (53%) was slightly higher than female (47%). Participants’ age range varied, with the highest frequency in the 51–60-year age range (34%). Half of the sample (50%) worked with patients living in both urban and rural areas, 30% worked only with patients living in urban areas and 20% in rural areas.
Table 1 Overview of the GPs sample (n=97)
As indicated above in Table 2, most of the therapists were female (80%); the highest age range was between 51 and 60 years (43%). The most common qualification was ‘Undergraduate/Higher Diploma (66%); followed with much lower rates by Master Level (39%) and Doctoral Level (5%). The type of therapies provided varied and the most frequent were Counselling (39%), Integrative Therapy (28%), Psychodynamic (27%) and Cognitive Behavioural Therapy (24%). The largest proportion of therapists were accredited by the IACP (66%). Most worked in private practice (80%) and generally with adult populations (91%).
Table 2 Overview of the therapists sample (n=129)
Most of their referrals were from other clients (78%), followed by self-referral (74%); other psychotherapists (64%) and GPs (63%).
General findings on GPs’ referral of individuals presenting mental health difficulties
GPs’ estimation of the percentage of their patients who have presenting or underlying mental health issues was quite broad across the sample, with a mean of 22% and a standard deviation of 21. Furthermore, their estimation of the proportion of those patients presenting with mental health difficulties who are referred to psychological therapists was also quite broad; with a mean of 21% and a standard deviation of 22.
In addition, GPs were asked to indicate which of a list of psychological therapies and other relevant services they would consider for their referrals. They had the option to tick more than one option (see Table 3).
Table 3 Percentage of GPs who indicated they would refer patients with mental health difficulties to each of the service options
As indicated in Table 3, the psychiatrist was by far the most frequent referral option (94%) followed by Counsellors (69%) and Clinical Psychologists (60%). In terms of services, the outpatient services represented the most frequent referral option (50%) followed by in-patient mental health services (43%).
Specific finding on GPs’ referral s to psychological therapists
The second part of research aimed to gather specific information on the GPs’ referral of patients presenting with mental health difficulties to psychological therapists. A total of 65% indicated that they would check the qualifications and accreditation status of the therapist. The most frequently endorsed sources of such information were registers of professional or accreditation bodies (57%) and recommendations from other professionals (61%). Furthermore, 74% of the sample would consider the ‘goodness’ of fit between the therapeutic approach of the therapist and the presenting problem of the patient.
Participants were asked to list the type of information given to patients referred to specific psychological therapists in private practice. The results indicated that in 99% cases they would give the name and the address of the therapist; in 74% of cases they would give a brief explanation of the therapeutic approach; 37% indicated that they would inform patients of the possible outcomes; 28% would inform patients of the psychotherapists’ accreditations and qualifications; 13% would provide patients with a detailed explanation of the therapeutic approach.
Participants were asked to indicate their knowledge of specific psychotherapies by using a three-point scale (i.e. ‘in-depth knowledge’, ‘some knowledge’ and ‘very little knowledge’). The results are summarised below in Table 4.
Table 4 Participant GP’s knowledge of therapeutic approaches
As is possible to observe from Table 4, participants’ in-depth knowledge of the different types of psychotherapeutic approaches was quite low. CBT was the type of approach GPs were most familiar with, however, only 29% of the sample considered they had in-depth knowledge of this. Substantially more participants professed ‘some knowledge’ of the various approaches with the largest percentages being for CBT and Systematic/family therapy.
The results also indicated that most of the GP participants (89%) felt they did not have enough information on the number and type of psychological therapists available in their catchment area. These findings are consistent with findings from the psychological therapists’ data, which indicated that only 39% of the sample typically inform GPs that they are working in the same area. Out of those, 28% indicated that they would inform GPs on the type of therapy offered; 48% would include information on their qualifications; 20% on their professional training; 26% on their professional experience; 12% on their accreditation; and 38% on the types of mental health issues they dealt with.
Data from GPs endorsed the need for additional information from therapists on; their professional qualifications (50%), the kind of interventions provided (45%), the use of specific referral guidelines (26%), the costs (11%), the type of mental health issues they deal with (5%) and waiting time (4%).
Discussion
Several relevant findings emerged from the current study, which overall suggest a disconnect between GPs at the coalface of mental health problem recognition and referral, and providers of psychological therapies whether in the public (community mental health teams and inpatient services) or private services. The data also suggest some possible solutions in terms of enhanced education, communication and information sharing.
GPs’ estimation of the percentage of their patient population presenting with mental health problems alone or in concomitance with physical health problems averaged approximately one-fifth of their patients with large standard deviations. This finding reflects evidence from other studies (Copty, Reference Copty2004; Shaw et al. Reference Shaw, Clegg-Smith, Middleton and Woodward2005; Bradley, Reference Bradley2008; Cepoiu et al. Reference Cepoiu, McCusker, Cole, Sewitch, Belzile and Ciampi2008), which indicates that GPs find it difficult to identify mental health disorders among their patient populations. As Grembowski et al. (Reference Grembowski, Martin, Patrick, Diehr, Katon, Williams, Engelberg, Novak, Dickstein, Deyo and Goldberg2002) pointed out, the referral of patients with mental health disorders from primary to secondary care is a critically important yet poorly understood mechanism. This is particularly critical, given the fact that GPs have a unique position in the detection of mental health disorders (Gilbody et al. Reference Gilbody, Whitty, Grimshaw and Thomas2003; Copty, Reference Copty2004; Copty & Whitford, Reference Copty and Whitford2005).
Another relevant finding that emerged from the study is that GPs estimated that just over one-fifth (22%) of those patients presenting with mental health difficulties are referred for psychological therapy, again with significant standard deviation. This may support previous evidence, which indicated that identification of their patients’ mental health needs and the provision of effective and appropriate management represent a challenge for GPs (Copty, Reference Copty2004; Copty & Whitford, Reference Copty and Whitford2005; Shaw et al. Reference Shaw, Clegg-Smith, Middleton and Woodward2005). As Zastrow et al. Reference Zastrow, Faude, Seyboth, Niehoff, Herzog and Lowe2008) pointed out clinicians tend to overestimate or underestimate levels of distress of their patients. The underdetection of mental health disorders across the primary care population leads to patients not receiving optimal treatment. Previous studies for instance indicated that the detection of patients with depression in primary care is between 15% and 60% (Maginn et al. Reference Maginn, Boardman, Craig, Haddad, Heath and Stott2004). On the other hand, over-detection of mental health disorders among primary care patients can also lead to inappropriate treatment. For example, in the European study of the epidemiology of mental disorders (ESE MeD) about 13% of individuals presenting to GPs with symptoms of depression did not have any mental disorder (Alonso et al. Reference Alonso, Codony, Kovess, Angermeyer, Katz, Haro, Girolamo, De Graaf, Demyttenaere, Vilagut, Almansa, Lepine and Brugha2007) or as Druss et al. (Reference Druss, Wang, Sampson, Olfson, Pincus, Wells and Kessler2007) indicated, almost 40% of primary care patients received an intervention for depression without a proper diagnosis.
The findings also indicated that a very large percentage of GPs (94%) refer patients presenting with mental health problems to a psychiatrist with much lower percentages referring to other types of psychological therapists. This might reflect GPs’ adherence to the medical model of mental health disorders and suggests that much still needs to be done in order to promote a more holistic approach to mental health issues, in line with national and European mental health policy (Barclay et al. Reference Barclay, Todd, Finlay, Grande and Wyatt2002; World Health Organization. European Ministerial Conference on Mental Health, 2005; Department of Health and Children, 2006; World Health Organization, 2012). Furthermore, it does not reflect service users’ dissatisfaction with the overreliance on the medical approach to their mental health care (Copty, Reference Copty2004; Copty & Whitford, Reference Copty and Whitford2005; Dunne, Reference Dunne2006; Mannix-McNamara et al. Reference Mannix-McNamara, Carew-Eichloz, Vitale and Jourdan2012).
It could also be of course, that the GPs’ predominant choice to refer patients presenting with mental health disorders to psychiatrists might be due to a lack of awareness and networking with psychological therapists in their geographical area. The results of the current study clearly indicate that links between GPs and psychological therapists is very weak. Specifically, a total of 89% of GPs felt they did not have enough information on the number and type of psychological therapists available in their catchment area; on the other hand, only 39% of therapists stated that they inform local GPs about their practice. This might reflect findings from previous studies (Sigel & Leiper, Reference Sigel and Leiper2004), which indicated that GPs’ frequency of referrals to psychotherapists and psychologists in particular can be predicted in part by GPs’ confidence in liaising with them.
In the current study, GPs report relatively little knowledge of the different types of psychotherapeutic approaches and the therapists who may offer them. This lack of knowledge is very likely to impact on their choice of referral option. In Copty (Reference Copty2004), GPs report that their treatment and management of patients is based on three factors; whether the patient has a medical card, whether they have access to private psychiatric care if necessary, and whether they can afford to pay for counselling or other psychotherapy. The third option of private counselling or psychotherapy services is one that is overlooked in many studies but was specifically included in the research reported here. Interestingly, 63% of psychological therapists reported most typically receiving referrals from GPs but 74% most typically received referrals directly from clients themselves and 78% reported most typical referrals through previous clients. This may have important implications for the continuity of care of patients as well as for the integration of various elements of that care.
In July 2013, the HSE launched the Counselling in Primary Care (CIPC) initiative to provide short-term counselling/psychological therapy for medical card holders over 18 years old. The scheme is designed for people with mild or moderate conditions considered suitable for short term treatment. Patients are referred to the scheme by a member of the Primary Care Team (typically the GP). Once they have opted into the service they are scheduled for an appointment with a qualified and accredited Counsellor, Psychologist or Psychotherapist. On completion of a maximum of eight sessions, the Counsellor/therapist will communicate to the Primary Care Team that the service had been completed or if required recommend referral to Secondary Mental Health Services. This initiative responds to some of the needs identified in the Vision for Change report (as well as the current research) though data on its implementation is not yet publicly available. Dr Shari McDaid, Director of Mental Health Reform, the national coalition promoting improved mental health services, considers that ‘While the roll out of the CIPC service to medical card holders was a positive step, there is still a vast amount of unmet need. We are asking for funding for the CIPC service to be extended to more people with mild to moderate mental health difficulties and to increase the maximum number of sessions from eight to twenty’ (Mental Health Reform, 2014).
A limitation of the study is the low participation rate of GP’s in the study, which was lower than that of psychological therapists. It is not possible to gauge the representativeness of those GPs that chose to respond. It may be that GP respondents were more interested in psychological therapies or had patient cohorts with significant psychological needs. However, there are no grounds to assume that the sample was not representative of a broader GP sample.
In conclusion, the findings of the current study support the view that GPs have a need for further information and training around the issues of detection and identification and referral of psychological disorders. Furthermore, GPs would like to have a range of information made available to them about psychological therapists operating in their area. Specifically they would like information on the psychological therapists’ professional qualifications, type of populations they deal with, type of interventions provided, waiting time and costs of the treatment. Findings reported here suggest that there is a need for greater education and information-sharing between providers of psychological therapies and GPs, to increase knowledge on the types of therapies, the evidence base underpinning different psychological therapies, accreditation and costs. A Vision for Change (2006) reports that, in order to best benefit patients, psychological therapies should be an integral part of primary care medical services. There is much work remaining to be done to build bridges between primary care and psychological therapies.
Acknowledgements
This work was supported by the Mary Immaculate College Seed Funding Scheme. Research Assistants were Michelle O'Donoghue (MIC) and Paul O'Sullivan (UCC).
Financial Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of Interest
None.
