Psychosomatics 48:123-127, March-April
doi: 10.1176/appi.psy.48.2.123
© 2007 Academy of Psychosomatic Medicine
Perceived Effectiveness of Mental Health Care Provided by Primary-Care Physicians and Mental Health Specialists
JianLi Wang, Ph.D., and
Scott B. Patten, M.D., Ph.D.
Received January 8, 2006; revised February 28, 2006; accepted March 8, 2006. From the Depts. of Psychiatry and Community Health Sciences, Faculty of Medicine, Univ. of Calgary. Send correspondence and reprint requests to JianLi Wang, Rm. 127, Heritage Medical Research Building, 3330 Hospital Dr. NW, Calgary, Alberta, Canada T2N 4N1. e-mail: jlwang{at}ucalgary.ca
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ABSTRACT
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The authors used data from the Canadian Community Health Survey: Mental Health and Well-Being to estimate and compare perceived effectiveness of mental health care provided by general practitioners/family doctors (GP/FDs), by mental health specialists among those who visited GP/FDs, and by mental health specialists-only in the past 12 months (N=2,859). The authors found that, in Canada, perceived effectiveness of mental health care provided by GP/FDs did not significantly differ from that provided by mental health specialists. Using services from both GP/FDs and mental health specialists and taking psychotropic medication improved perceived effectiveness of care.
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INTRODUCTION
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Mental disorders are prevalent in the general population, and they impose significant burden on society.1 Patients with mental disorders who seek treatment are often first seen by general practitioners/family doctors (GP/FDs). However, the rate of mental health services use is relatively low.2,3 Furthermore, among those who use mental health services, adherence to psychiatric treatment is low in both general practice and specialty mental-health services.4
Many factors may affect mental health service use and adherence to psychiatric treatment. According to the Health Belief Model, perceived effectiveness is a major factor facilitating or impeding contact and/or compliance, given the acceptance of personal susceptibility to a condition.5 Because perception of the effectiveness of care is of interest to consumers and vital to maintaining high-quality healthcare delivery systems,6 it has been widely regarded as an important health system performance indicator.6,7
Patients with mental disorders who seek treatment may be seen by a GP/FD and/or by a mental health specialist, that is, a psychiatrist or a psychologist.2,3 In Canada, mental health services are largely publicly funded. Individuals with mental health problems are often first seen by GP/FDs. Some may be referred to mental health specialists by the GP/FD. However, it is not clear how people perceive the effectiveness of the mental health services they received from these professionals and whether demographic and clinical factors affect perceived effectiveness of care. We conducted this analysis to 1) estimate the proportion of patients perceiving psychiatric care to be effective when provided by GP/FDs and by mental health specialists in a general-population sample; and 2) identify factors associated with perceived effectiveness of mental health services.
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METHOD
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Population and Sample
We used the data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS–1.2). The methodology of the CCHS–1.2 was described by Gravel and Beland.8 In brief, the CCHS–1.2 is the first Canadian national mental health survey. It was conducted by Statistics Canada between the years 2002 and 2003. The target population of the survey consisted of household residents age 15 years or older. Excluded from the target population were those living in the three territories, on Indian Reserves and Crown lands, clientele of institutions, full-time members of the Canadian Forces, and residents of some remote areas. Members of the Canadian Forces were part of a separate survey component conducted parallel to the CCHS–1.2. Participants were selected by use of multi-staged, stratified random sampling procedures. The final sample of the CCHS–1.2 consisted of 36,984 participants, with a response rate of 77%. Face-to-face interviews were carried out among 86% of the participants by interviewers hired and trained by Statistics Canada; 14% of the interviews were completed by telephone because travel was prohibitive or the respondent refused to have the interview conducted in person. Informed consent was obtained by interviewers from Statistics Canada. In this analysis, we included those who had visited GP/FDs and mental health specialists in the past 12 months for emotional, mental, and alcohol-use problems (N=2,859). Among the 2,859 participants, 2,237 received mental health services from GP/FDs, and 622 received mental health services from mental health specialists-only.
Key Measures
Participants who visited a health professional in the past 12 months for mental health problems were asked to specify the type of health professional (GP/FD, psychiatrist, psychologist, nurse, social worker) from whom they received help for emotional, mental health, or substance-use problems. For each type of health professional, they were asked, "In general, how much would you say the (health professional) helped you?" The following response options were provided: A Lot; Some; A Little; Not At All. We considered an answer of "A Lot" as indicative of perceived effectiveness of psychiatric care. In this analysis, we focused on perceived effectiveness of services provided by a GP/FD, services provided by a mental health specialist, and services provided by both.
Depressive and anxiety disorders were assessed with the Canadian adaptation of the Composite International Diagnostic Interview (WMH–CIDI), based on DSM-IV criteria.8 Alcohol and illicit-drug dependence were determined by the CIDI Short Form, based on DSM-III-R criteria.9 The CCHS–1.2 participants who passed the screener for psychiatric symptoms were administered the Sheehan Disability Scale10 to assess the extent to which a particular mental disorder interfered with functioning in work, household, relationships, and social roles in the worst month of the past year. Responses were scored with a 0-to-10 visual-analog scale. Statistics Canada defined functional impairment as having a score of 4-or-more on the scale.11 The CCHS–1.2 used the Non-Specific Psychological Distress Scale (K10) developed and validated by Kessler and colleagues.12 The total possible score of the K10 was 40, with a higher score indicating a higher level of psychological distress. On the basis of Kessler and colleagues’ work,12 a score of 20-or-higher was defined as indicating significant distress. Also, participants were asked whether they had taken antidepressants, mood stabilizers, or medications to reduce anxiety.
Statistical Analysis
In this analysis, the proportions of respondents perceiving the care provided by a GP/FD, a mental health specialist, and any of these health professionals to be effective were estimated overall and by type of health professional. We used logistic-regression modeling to identify demographic (gender, age, marital status, educational level, family income) and clinical (specific mental disorders based on the CIDI, severe psychological distress, functional impairment, long-term medical conditions, visiting a mental health specialist, and psychotropic medication use) factors associated with perceived effectiveness of mental health care provided by any health professional. Because the CCHS–1.2 used a complex study design, the estimates and associated 95% confidence intervals (CI) were weighted to account for sampling and design effects. The analysis was performed by use of STATA 8.0.13
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RESULTS
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The demographic and clinical characteristics of the participants who had visited a mental health specialist-only, who had visited a GP/FD-only, and who had received mental health services from both a GP/FD and a mental health specialist in the past 12 months are presented in Table 1. Participants who visited a GP/FD-only were more likely to be women, older, married, and have  13 years of education than those who also visited a mental health specialist. They were less likely to report low family income, having a long-term general medical condition, mental disorders according to the CIDI, severe psychological distress, functional impairment, and having taken psychotropic medication than participants who had received serviced from both types of health professionals. Compared with those who had received services from both GP/FD and mental health specialists, participants who visited a mental health specialist-only were less likely to report low family income, chronic general-medical conditions, mental disorders (except substance-use disorders) on the basis of the CIDI, severe psychological distress, and the use of psychotropic medications.
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TABLE 1. The Demographic, Socioeconomic, and Clinical Characteristics of Those Who Used and Who Did Not Use the Services From Mental Health Specialists Among Participants Who Visited GP/FDs for Mental Health Problems in the Past 12 Months, Percent, 95% Confidence Intervala
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Among selected participants, the proportion reporting perceived effectiveness of mental health services provided by GP/FDs, mental health specialists, or any of these health professionals was 55.9%, 51.4%, and 62.0%, respectively (Table 2). There was no difference between those who visited a GP/FD-only (57.2%) and those who also visited a mental health specialist (51.4%) in perceived effectiveness. However, the proportion perceiving effectiveness of mental health care in those who visited both a GP/FD and a mental health specialist (71.5%) was greater than that in those who visited a GP/FD alone (57.2%). The proportion of perceived effectiveness of mental health treatment in participants who visited mental health specialists-only was 53.5% (95% CI: 48.9–58.1).
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TABLE 2. Proportions of Patients’ Perceived Effectiveness of Mental Health Services; Percent, 95% Confidence Intervala
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In multivariate logistic-regression modeling, only having visited a mental health specialist (odds ratio [OR]: 2.08; 95% CI: 1.55–2.78) and the use of psychotropic medications (OR: 1.46; 95% CI: 1.10–1.94) were positively associated with perceived effectiveness of mental health care. Specific types of mental disorders, as delineated in the CIDI, functional impairment, and severity of psychological distress, were not associated with perceived effectiveness of mental health care in this model.
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DISCUSSION
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In Canada, over 50% of those who received mental health care from GP/FDs and/or mental health specialists considered the services to be very helpful. This is in contrast to the general public’s view that only 8% believed that a psychiatrist would be helpful.14 This particular result reflects differences between the general public and those who have actually used the services, and it is a positive message for the general public, physicians, and educators. Nevertheless, the data indicate that there is room for improvement.
In the unadjusted analysis, there were no significant differences in perceived effectiveness of care provided by GP/FDs and by mental health specialists. Participants who visited a mental health specialist reported more comorbid mental disorders, more severe symptoms, and more functional impairment than those who visited a GP/FD alone. It was possible that the mental health specialists were seeing people who had more severe and/or chronic psychiatric symptoms. As a result, the symptoms of those who were seen by specialists may have been more difficult to treat. If these clinical characteristics translated into less-effective treatment, this could lead to a lower rating of perceived effectiveness as a result of confounding of provider type with illness severity or chronicity.
In a largely publicly funded mental health system, those who had only visited mental health specialists appeared to be unique, as compared with others who had contacted both GP/FDs and mental health specialists. They might have seen mental health specialists directly in several ways. They might be treated by a mental health specialist in a hospital emergency room. Also, some might have accessed private psychologists or psychiatrists through special health insurance provided by their employers. These individuals differed in socioeconomic and clinical characteristics from others who received services from both GP/FDs and specialists. However, perceived effectiveness of mental care in these two populations resembled each other.
There may be many ways to improve people’s perception of mental health care, including adherence to clinical guidelines, increased intensity and frequency of visits,15 and shared mental health care.16 This is consistent with the findings of the current analysis: that seeing a mental health specialist and taking psychotropic medications predict overall perception of effectiveness. The more favorable perceptions held by those subjects who had consulted both with GP/FDs and mental health specialists provide some general support for the idea that care should be effectively coordinated between these different categories of health professionals. However, since a similar level of satisfaction was reported by subjects that had only consulted mental health professionals, the data presented here cannot confirm that better coordination will lead to improved satisfaction. Improved care may be achieved either by shared care arrangements, where mental health professionals spent time in the primary-care environment, or by disease-management strategies, whereby care provided by GP/FDs and specialists is coordinated by a case-manager.
This analysis had several limitations. First, because the CCHS–1.2 was a cross-sectional survey, a temporal relationship could not be established. It is not clear whether seeing a mental health specialist will subsequently improve perceived effectiveness of mental health care. It is possible that better perceptions of care led to more effective care-seeking, rather than the opposite direction of effect. Second, the CCHS–1.2 relied on self-reporting of healthcare utilization. Thus, reporting and recall biases were possible. Perceived effectiveness of treatment was assessed by a general question in the CCHS–1.2. On the basis of this question, it was not possible to determine the extent to which the mental health care adhered to clinical practice guidelines. Finally, large-scale surveys can provide a great deal of information about populations, but, by necessity, must use brief measurement instruments. In this analysis, we used a global measure of satisfaction in relation to broad categories of care in the general population. Different study designs and more detailed measures would be needed to study more subtle determinants of perceived effectiveness, such as the relationship between specific aspects of the doctor–patient relationship and perceived effectiveness of care. It will also be interesting for future studies to determine the extent to which perceived effectiveness is related to the effectiveness of treatment as evaluated by more objective measures or according to clinician assessment. However, this analysis provides important information about perceived effectiveness of mental health care, which may be used as a benchmark for quality-improvement initiatives.
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ACKNOWLEDGMENTS
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The research and data analysis in this work used the data from Statistics Canada. However, the opinions and views expressed do not represent those of Statistics Canada.
JianLi Wang is supported by a New Investigator Award from the Canadian Institutes of Health Research. Scott B. Patten is a Health Scholar with the Alberta Heritage Foundation for Medical Research and a fellow with the Institute of Health Economics.
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REFERENCES
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ABSTRACT
INTRODUCTION
