The Utility of Diagnostic Schemata when Diagnosing Mental Illness in General Practice

Abstract

Background: Those with mental health problems are much more likely to be seen by a general practitioner than a specialist psychiatrist. A large body of research over many years has highlighted the poor detection rate of mental illness by general practitioners in those who attend. There is inference that the poor detection rate results from either not using or inappropriately using diagnostic schemata such as ICD-10 or DSM-IV (or their primary care versions). However, there is little data that seeks to understand why diagnostic systems have such poor uptake in general practice. Aim of research: This research sought to understand the utility of diagnostic schemata for general practitioners as well as understanding what features would be required in order to increase their usefulness. Methodology: A two stage process was used for this research. A qualitative stage comprising nine focus groups of 34 general practitioners was initially undertaken with the purpose of understanding the relevant issues in depth. A quantitative second stage based on the results of the qualitative stage was then initiated. The second stage was a survey of 1,000 vocationally registered general practitioners in New Zealand with 41.4% return rate. Results: The survey confirmed that general practitioners infrequently use diagnostic schemata, 82% replying never or rarely. Poor knowledge and little experience of schemata was reported (75%). Other reasons were complexity (66%), rigidity (57%), not reflecting mental illness seen in general practice (51%), lack of management focus (49%) and poor reliability (44%). When making a diagnosis of mental illness, the stated principal purpose was assistance with choice of pharmaceutical treatment (70%). Other reasons cited were communication with colleagues (67%), assisting with decisions regarding referral iii (55%), providing a patient with a label for their symptoms (52%), assessing safety of the patient or others (48%) and documentation (36%). The utility of new schemata could be improved if they could assist with choice of pharmacological intervention (94%), increased sensitivity of diagnosis (92%), increased specificity of diagnosis, referral decisions to secondary care (85%) and informing prognosis (78%). Integration of diagnostic schemata with existing computerised clinical notes systems was considered important. Conclusion: Low uptake of diagnostic systems in general practice represents lack of both a shared language and shared understanding of psychiatric disease between specialty psychiatry and general practice. It is unlikely that significant gains can be in the efficient and effective recognition and treatment of mental illness in primary care until there are solutions to these problems.