Detecting mental disorders in primary care

Abstract

Managing mental health problems of people around the world is a major challenge for health workers as well as for policy makers. It is a particular problem for low- and middle-income countries for many reasons, especially due to lack of recourses.

A computer-assisted interview, the GMHAT/PC (Global Mental Health Assessment Tool – Primary Care) has been developed to assist general practitioners and other health professionals to make a quick, convenient, and comprehensive, standardised mental health assessment. It has proved to be a reliable and valid tool in various studies. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings more effectively. The article outlines the development and potential use of the GMHAT/PC

Introduction

Mental health problems are one of the leading causes of disability in the world.^1,2 A vast majority of people with mental disorders, including those with severe mental illness, view primary care as the cornerstone of their healthcare system.³ A large proportion of people with mental disorders around the world fail to receive appropriate help in spite of developments in new treatments for mental illnesses (psychological and social as well as medicinal), and as a consequence suffer in silence. In developed countries this may be due to the stigma attached to mental illness, leading to reluctance to ask for help for any kind of mental health problem. Another important reason could be primary care health services providing inadequate training and poor skills for detecting and treating people with mental health problems. Research studies have highlighted the lack of time and training available to general practitioners (GPs) and primary care workers for assessing the mental health of their patients.^4,5

The National Health Service in the UK has received a significant boost in funding allocation for primary mental health care in recent years.^6,7 Any such additional resource is a welcome move, but only an efficient use of existing and new resources will make any demonstrable impact on mental health services in primary care.⁸

A poor provision of mental health care in low- and middle-income countries is often blamed on a lack of resources. It takes about six years to train a doctor, and a further three years to train as a psychiatrist. These countries therefore have few doctors and fewer psychiatrists, because of the high cost of medical education. A high proportion of these professionals emigrate to high-income countries. In a number of African countries there are no psychiatrists and in some only one or two. There is no foreseeable answer to this problem. As a result, many thousands of mentally ill people remain untreated, unable to work, and in poverty or in mental institutions.

Early and accurate detection of mental health problems followed by an appropriate treatment and management plan directed towards recovery and return to work would help to reduce the global burden on health and social care systems caused by mental disorders. Work in the field of psychotic disorders has clearly shown that early intervention not only helps towards quick and full recovery, but also leads the person to better re-integration into society.⁹ Our emphasis should therefore be to establish systems in every corner of the world to help identify people with mental health problems at the earliest opportunity and provide appropriate interventions. One way to approach this problem is to take advantage of modern technology such as computer-assisted methods to scale up human resources available in the area of health and social wellbeing, particularly in low- and middle-income countries.

We have developed with primary care workers a computer-assisted package, the Global Mental Health Assessment Tool (GMHAT/PC),^10,11 already translated into a number of languages (Spanish, Dutch, German, Hindi, Chinese and Arabic, with French, Portuguese and Tamil versions in preparation). The package is an innovative way to address this problem. Firstly this method aims to improve the recognition of mental illness in primary care and the initiation of appropriate treatments by empowering primary care workers. Secondly, by developing a more comprehensive mental health assessment tool (GMHAT- full). This provides computer-assisted differential psychiatric diagnosis consistent with ICD-10 (International Classification of Diseases and Related Health Problems) criteria, pathways of care, quality of life, needs, and risk assessment. That will be more useful in secondary care settings. These methods have been developed by primary care physicians and psychiatrists and have proved to be effective so far in the UK, India and Abu Dhabi. The use of computers could be a restriction to general use, but we are developing the program to be installed on a touch-screen PDA, making it easy to use anywhere and where the results could be communicated by mobile phone. These methods, which have so far taken seven years to adapt and develop are based on many years of developing and using computer-assisted research diagnostic tools. In our studies, so far, non-medically trained health professionals used the GMHAT/PC successfully. They needed about half a day's training before administering it. We believe that in developing countries, non-medically qualified health workers will be able to use the GMHAT/PC as long as they receive a training package that we are developing at present. The use of GMHAT/PC in India, Abu Dhabi and Singapore by nurses and psychologists is very encouraging. A brief description of the GMHAT/PC is as follows:

The Global Mental Health Assessment Tool (GMHAT/PC)

The GMHAT/PC is a computerised clinical assessment tool developed to assess and identify mental health problems in primary and general health care. The assessment program starts with basic instructions giving details of how to use the tool and rate the symptoms. The following screens consist of a series of questions leading to a comprehensive yet quick mental state assessment, focusing sequentially on the following symptoms or problems: worries; anxiety and panic attacks; concentration; depressed mood, including suicidal risk; sleep; appetite; eating disorders; hypochondriasis; obsessions and compulsions; phobia; mania/hypomania; thought disorder; psychotic symptoms (delusions and hallucinations); disorientation; memory impairment; alcohol misuse; drug misuse; personality problems and stressors. One question at a time appears from these respective subsections. The questions proceed in clinical order along a tree-branch structure. For each of the major clinical disorders there are key screening questions. When the patient has no symptoms based on the key items of a subsection, the interview moves on to the next subsection. At the end of the interview, the screen asks for the interviewer's details and his/her clinical diagnosis if available. The screen then proceeds to a summary report of symptoms and their scores and presents the GMHAT/PC diagnosis. The main computer diagnosis is derived using a hierarchical model and designed around ICD-10. The diagnostic program takes account of severity of symptoms (moderate to severe). It also generates alternative diagnoses and co-morbid states based on the presence of symptoms of other disorders. In addition, it includes an assessment of risk of self-harm. The program also contains management guidelines for these disorders.

For services where there is no adequate psychiatric secondary care service available, the secondary care model, GMHAT/FULL, using the new ALL-AGECAT differential diagnostic program is now undergoing validity trials.

GMHAT/PC studies

The GPs and nurses successfully used the GMHAT/ PC in primary care.^10,11 The reliability, sensitivity and specificity proved to be satisfactory in these studies. We have extended its use in the general health setting.¹² The physicians and nurses in the general health settings found GMHAT/PC useful. Further studies which are near completion include liaison settings in Perth (Australia) and Singapore; general health settings (epilepsy and respiratory disorders) in Jaipur (India), and an acute care setting in Rotterdam.