Prevalence and management of psychosocial problems in primary care in Flanders Lena Vannieuwenborg, Jan De Lepeleire, Frank Buntinx Department of General Practice, KU Leuven, Belgium
Project Description • Objective • To assess the prevalence, presentation and handling of psychosocial problems in primary care in Flanders • Background • Data on prevalence and handling psychosocial problems are widespread and sparse • Shortcoming of a global picture • Need for a frame that can comprehend the data available • The question is: what happens in primary care to intercept the psychosocial problems that are presented?
Methodology (1) • Mixed method • ‘Fishbone diagram’ • visualise the main (problem) areas and challenges • Literature study • various search engines and (official) databases • medicine, psychology and psychiatry journals • (research) data and/or databases available within the different organizations we approached
Methodology (2) • Semi-structured interviews • n = 21 • health care and welfare professionals in primary care • Focus groups • n = 2 (Nov 2012 and Jan 2013) • Duration approx. 2h • 6 and 7 participants respectively
Research (sub)questions • Main research questions: • how and how frequently psychosocial problems are presented in primary care? • by who (patients) and with whom (care givers)? • what what happens in primary care to intercept the psychosocial problems that are presented? • what are the results? • Split up into 3 areas: • presentation • handling/approach • course
Key FindingsConceptualisation and inventarisation of psychosocial problems (1) • Uniform definition of the concept of ‘psychosocial problems’? • Great dissension and indistinctness in literature and within the practice of the different health care professionals • Construction of our own operational definition
Operational definition of psychosocial problems Psychosocial problems include the broad spectrum of everything that is not strictly medical-somatic. They affect the functioning of the patient in daily life, and concern his environment and/or biography. On the one hand, it concerns different psychological problems such as: feeling anxious/nervous/tense, (posttraumatic or acute) stress, depression and feeling depressed, burn out, loneliness, irritability, sleep disorder, sexual problems, tics, alcohol abuse, tobacco abuse, drug abuse, memory problems, behavior problems, learning difficulties, phase of life problems, fear of mental illness, psychoses, schizophrenia, anxiety(disorder), somatization disorder, suicide/suicidality, neurasthenia/surmenage, phobia/obsessive compulsive disorder, personality disorder or identity problem, hyperkinetic disorder, intellectual disabilities, relation problems (with friend, family and/or partner), medical unexplained symptoms and eating disorders. On the other hand, it concerns different social problems such as: poverty/financial problems, housing problems, problems with food/water, social-cultural problems, problems with work or unemployment, school problems, problems with social security, with health care, legal problems, adjustment problems, loss/death of family/partner and educational problems.
Key FindingsConceptualisation and inventarisation of psychosocial problems (2) • objective and interpretable data very hard to find • Especially when searching for data on non-medical disciplines • Some possible reasons: • In Belgium, specific research or registration concerning interventions by (primary care) psychologists virtually absent • Nature of the data acquisition • (Still) prevailing (self-)stigma • Emotions are not measurable or objectifiable
Key FindingsPresentation of psychosocial problems in primary care (1) • Integrated (prevalence) data concerning psychosocial problems across the different primary care disciplines are missing • (Research) data are mostly found within the seperate disciplines • Different presentation of the same problem → different labeling and/or registration • ‘Proto-professionalization’ • ‘Attributional style’ of patients in regard to their problems
Key FindingsPresentation of psychosocial problems in primary care (2) • General practitioner (GP) as a very important gateway to primary care • Involved in 60-80% of the cases • In most cases, GP is first care giver to be consulted • Of these cases, majority remains with GP for follow-up • Data on consultation within the welfare → (strong) regional differences
Key FindingsHandling of psychosocial problems in primary care (1) • Assistance (still) too much ‘supply-driven’ • Data on approach of the (primary care) psychologist- and psychiatrist, social workers and nurses still sparse compared to data on approach of GP • No (official) recognition of the profession of primary care psychologist • Data on the approach of psychiatrists mostly concern secondary care • Data on the approach of social workers are spread and arise from registrations within the seperate branches of authorities • Ways of registration and reporting are not standardized
Key FindingsHandling of psychosocial problems in primary care (2) • Drug treatment remains popular • As only treatment, or in combination with non-pharmacological treatment • In Belgium, the use of psychotropic drugs is frequent and seems to increase even further • Use of tranquillizers and sleep medication seems to remain constant • Increase in prescription of antidepressants ≠ increase in number of (declared) depressions
Key FindingsHandling of psychosocial problems in primary care (3) • When it comes to referrals... • GP’s help 90% of the patients with psychosocial problems • Referral for psychotherapy is a time asking process, often spread over time • Financial implications can constitute a barrier • When GP’s refer → danger of losing sight of patient • Having a psychologist working in the general practice facilitates referrals to them • The process of referral to secondary care sometimes gets stuck
Key FindingsHandling of psychosocial problems in primary care (4) • Multiculturality asks for different or adapted approaches • Important topic in Belgium • Current care may not be sufficiently and/or appropriately adapted to the differences • Person of the caregiver important for effectivity of treatment • Rather than discipline-related or bound by theory • Nonspecific elements seem to be of particular importance • consolidation, containement, ‘a place to talk’,... • Demand for a larger and more continuous accessibility of professionals from psychiatry • Especially in crises • ‘Red Phone’ • ‘Help on the spot’
Key FindingsCourse of care program / treatment (1) • Need and demand for more multidisciplinary colaboration • Due to evolutions in primary and secondary (mental health) care • More information exchange between the different authorities and between primary and secondary care • Experience of limitations and practical considerations in care program by care givers ≠ by care takers • Care givers sometimes experience more barriers than patients • Consequences for further course of treatment • Slower progress, late/slow/no referrals, drug treatment when non-pharmacological help may be more appropriate
Key FindingsCourse of care program / treatment (2) • Great uncertainty among professionals in primary care about signaling function and -operationalization • Figures virtually untraceable • How professionals can signal psychosocial problems they notice in patients or families? • Financial and digital gap makes position of the deprived extra weak • Not aware of the (different) ways to help, their rights, how to obtain their rights,...
Conclusion • In (primary care in) Flanders: • No tradition of multidisciplinary research • Lack of integrated data on psychosocial problems across different disciplines • Distortion of (prevalence) data • Definition of ‘psychosocial problems’? • Different labeling (of problems)/(nature of) registration • In case of psychosocial problems: • GPvery important gateway to primary care • Person of caregiver important for effective treatment • Great need and demand for more and better cooperation, communication and coordination between actors involved in health care and welfare