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| Journal of the New Zealand Medical Association,
04-April-2003, Vol 116 No 1171
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The nature and prevalence of psychological problems in New
Zealand primary healthcare: a report on Mental Health and General Practice
Investigation (MaGPIe)
The MaGPIe Research Group
Mental disorders are increasingly recognised as a major
public health problem.1,2 A World Health
Organization (WHO) study of the global burden of disease has shown that mental
disorders make up five of the ten leading causes of
disability.3 The provision of appropriate and
effective mental healthcare is an important and challenging priority for New
Zealand, especially in view of some measures of poor performance such as the
rate of suicide among young people.4
While the general practice and primary care sectors provide
an appropriate context for the detection and management of mental disorders,
there is relatively little information about rates of presentation to primary
care in New Zealand. There is no local research exploring how general
practitioners and patients make decisions about diagnosis, management or
referral of psychological problems.
In the general population of New Zealand, as in other
Western countries,5 over one quarter of the
population have had a diagnosable mental disorder in the last six months. Three
quarters of those with a recent mental disorder have attended a health (mainly
general practice) service, but only about one third have sought help for their
mental health problem from any agency.6 One
quarter of those who received any treatment got it from specialist mental health
or addiction services, while GPs delivered three quarters of the treatment for
mental disorders.7
In general practice, most studies of mental health have
found that about one quarter of patients have had a diagnosable mental disorder.
The WHO study of general practice attenders, conducted in 15 different centres
across 14 countries,8 found that 24% of general
practice attenders had a current mental disorder reaching ICD-10 criteria, and
another 9% had a sub-threshold disorder (clinically significant symptoms, but
not meeting full criteria for ICD-10). The most common diagnoses were
depression, generalised anxiety disorder, neurasthenia, and problems with
alcohol.9 Compared with the high prevalence of
disorders in the general population,10 only a
small proportion of patients in New Zealand general practice settings present
mental health problems to their doctor as the main reason for their
consultation. Four studies have found that between 3.1% and 7.6% of patients had
a mental health problem as the main presentation at the
consultation.11–14 The apparently low
rate of presentation of common mental disorders to general practitioners may
reflect a problem of access to healthcare by those with mental disorders
resulting from New Zealand’s fee-for-service system for access to general
practice and other primary care
services.15
The overall aims of this study were to describe the
prevalence and nature of common mental disorders among patients attending New
Zealand general practices, and to determine the degree of associated disability
and other factors influencing recognition, management, course and outcome of
these disorders. This paper describes the methods used in the study and reports
selected key findings about the nature and prevalence of the psychological
problems from the first phase of the MaGPIe study.
MethodsSetting
and sampling
Participants were 70 randomly selected GPs in the Wellington, Kapiti and Manawatu areas of the North Island, New Zealand. Fifty eligible consecutive adult patients were recruited from the practice of each participating general practitioner.
*At the time the study began, the 12-month version of
CIDI was not available using the WHO ISHELL programme, so the lifetime version
was adapted to assess the presence of the disorder in the last 12
months.
†DSM-IV applies a diagnostic hierarchy, such that if criteria for a ‘lower’ disorder are met at the same time as a ‘higher’ disorder, and these symptoms may occur as part of the ‘higher’ disorder, then the ‘lower’ disorder is not separately diagnosed. Because less common disorders such as organic mental disorder, schizophrenia, and bipolar disorder were not assessed in the version of the CIDI used in this study, only those hierarchical rules applying within anxiety disorder, depression and substance use could be applied. Measures
The measures used (Table 1) were based on the World Health Organization’s Collaborative Study of Psychological Problems in General Health Care.8 The main modifications to this model were: the use of a 12-month version of the Composite International Diagnostic Interview (CIDI) version 2.1, with additional components added to determine syndromes common in primary care; the use of the World Health Organization’s Disability Assessment Schedule (WHODAS) version II to determine disability;16 use of the Somatic and Psychological Health Report (SPHERE-34)17 as a dimensional measure of severity; and adaption of other sections, such as the demographics, general practitioner questionnaire, and encounter form, to fit them to the New Zealand context. Procedures Ethical approval The Wellington and Manawatu-Whanganui Ethics Committees approved the methods and procedures used in the study. Recruitment of general practitioners GPs were selected at random from a list of all 299 known eligible general practitioners in a geographical area encompassing the administrative health districts around and between Wellington City and Palmerston North. Proportionality of selections from Wellington City, Palmerston North and small town/rural regions was maintained. Seventy GPs were recruited, 15 in Palmerston North, 16 in the small town/rural group, and 39 in Wellington City. GPs were eligible if they were currently practising a minimum of 0.5 full time equivalent per week, working in the geographical area for which they were selected, and working without restriction (eg, due to ill-health or compulsory supervision). After initial telephone contact, the Project Manager visited each practitioner to seek written consent to proceed, and arranged for data collection by the field interviewers to begin. GP participation in the study attracted a reimbursement of $1000, $800 payable after the initial data collection phase and a further $200 after the 12-month follow-up phase. Involvement in the study qualified doctors for at least 10 Maintenance of Professional Standards (MOPS) points and up to 30 MOPS points if they used the study as a self-audit activity. Characteristics of general practitioners Participating GPs completed a questionnaire outlining their own demographic details, background, and experience with mental health issues. Phase 1a: recruitment of patients/index consultation The aim was to screen 50 eligible patients per participating GP using the GHQ-12 as a screening instrument. Usually this took two to three working days, but was continued for a maximum of ten days. There were four practices with fewer than 50 persons screened after ten days. Patients were eligible for screening if they were 18 years old or over, read English well enough to understand and complete the GHQ-12 screening instrument, and were about to consult with the index GP (ie, not just accompanying someone else, seeing the nurse or seeing a different GP). During the appointed surgery days, the field interviewer approached consecutive patients until 50 eligible patients had been recruited. Reception staff assisted in this procedure. A record was kept of reasons for ineligibility or refusal. Patients were primarily selected for interview and follow up by GHQ-12 score. Each field interviewer was supplied with a numbered sequence of 50 GHQ-12 forms per GP. The interviewer would introduce themself to the patient, briefly explain the study and ask if they would fill out the GHQ. On completion, the interviewer would score it and determine if the patient was selected for follow up by comparing the patient’s score to a cut-off value pre-printed on the form headers in order to yield the following sampling strata: 100% of those with high GHQ scores of 5 or more were selected; those with medium scores (2–4) had a 30% probability of selection; while those with low scores (0–1) had an 8% probability of selection. If selected, a follow-up appointment time was made immediately, or by phone as soon as possible. An Encounter Form was completed by the GP for every patient aged 18 or over who was seen that day. The Encounter Form included an assessment of psychological health. In addition to those selected by GHQ screening as described above, a random 50% of those not selected by GHQ but whom the GP had identified on the Encounter Form as having psychological problems, were also selected. Patients selected for follow up by this method were then contacted by telephone to arrange an interview. For each patient who was selected for follow up and consented to participate, the GP was also asked to complete a more detailed questionnaire covering their care and treatment over the previous 12 months. Phase 1b: first MaGPIe patient interview Responses to the structured patient interview were entered by the interviewer directly into a laptop computer using the World Health Organization’s ISHELL software. The interview was usually carried out in the patient’s home, but occasionally at another site selected by the patient. Before beginning the interview, the interviewer gave detailed verbal and written information about the study and gained written consent from the participant. Phase 2: longitudinal phase of the MaGPIe study Follow-up telephone interviews with patients were conducted every three months and a second face-to-face interview was conducted at 12 months. The GP was also re-interviewed at 12 months, and GP notes for each selected patient audited to determine diagnosis, management and referral. Statistical methods All statistical analyses were carried out using Statistical Analysis Software (SAS) version 8.2. Data were weighted to adjust for differences in probability of being sampled using the method of Kish.18 Weighted prevalences were derived using the SAS procedure ‘surveymeans’, which adjusted standard errors for the effects of clustering within GPs. ResultsOf the 78 eligible GPs approached, 70 (90%) agreed to
participate.
Patient response
rates
GHQ screening questionnaires were completed by 3414 of 3687
eligible general practice attenders (93%). Of the 1334 selected for interview,
357 refused further contact, 27 became ineligible for the more demanding
interview (because of limited language skills or worsening illness), 37 were not
traceable, and 3 were lost through operational error, yielding 910 interviews.
This represented a response rate of 70% for completion of the initial MaGPIe
interview. Two interviews were lost after completion, leaving 908. During the
year of follow up, a further 62 respondents became ineligible, with 696
completing the final interview – 82% of those undertaking the first
interview.
Characteristics of general
practitioners
Fifty six of the randomly selected GPs were male (80%), and
their mean age was 48.1 years (SD 8.9). Nearly two thirds identified themselves
as New Zealand European/Pakeha (64.3%), one was Maori (1.4%), 18.6% were from
Europe, and the remainder mainly from India or China, with a smaller number from
other parts of Asia or South Africa. Most had trained in New Zealand (73%), with
smaller numbers training in UK and Eire (12%), South Africa (9%), or Asia
(5%).
Mean length of time practising as a GP was 17.5 years (SD
9.0, range 1–43 years). Forty three GPs (62%) were Fellows of the Royal
New Zealand College of General Practitioners, 29% were Associate Members, and 9%
did not belong to the College.
One third of the GPs (33%) had worked in posts in mental
health services, most commonly as house officers for periods of less than a
year. In the previous two years, 20 GPs (29%) had undertaken a training course
in mental health, most commonly as part of a programme organised by their
independent practitioners association. Just over half the GPs (54%) had no
specific education or training about mental health since their undergraduate
degree.
Table 2. Age and gender of patients attending New
Zealand general practices
*SE adjusted
for clustering within GPs
Characteristics of
patients
Demographic
characteristics
Almost two thirds of the general practice attenders were
women, and the age distribution is shown in Table 2. Sociodemographic
characteristics of the participating patients are shown in Table 3. Six people
out of ten lived with a partner, and two thirds had one or more children. Eight
out of ten had some school or post-school educational qualification and half
were in paid employment. Seven per cent were unemployed for health reasons and
four out of ten had a community services card.
*estimated for the population by weighting the sample
according to probability of selection;
†SE
adjusted for clustering within general practitioners;
‡n= 907 because of missing data;
§n=312 because of missing data
Psychological health
status
Figure 1 shows that half of general practice attenders
currently experienced psychological symptoms, and about one in five had GHQ
scores of 5 or greater.
 Figure 1. Distribution of GHQ-12 scores for the
first-stage sample
Frequency of
consultations
One third of male and 42% of female patients had five or
more consultations in the year preceding the index consultation. These
proportions increased with the age of the patient: among patients aged 65 or
over, half the men and nearly two thirds of the women had attended five or more
times (Table 4).
General practitioner
assessment of severity of psychological disorder
GPs recognised that about half their patients had
experienced psychological problems in the past year, although they considered
that these were moderate or severe in about only one in ten of their patients.
GPs reported that another one in ten patients had a mild psychological disorder
and, furthermore, more than one quarter of all age groups were thought to have
psychological distress but at a ‘sub-clinical’ level of severity
(Table 5).
Table 4. Number of general practice consultations in
last 12 months
*percentages are unweighted rates based on n=3414
pre-selection sample minus 41 with incomplete data;
†SE
adjusted for clustering within GPs;
‡frequency
of consultations
Table 5. General practitioner opinion about severity of
psychological disorder in last 12 months among general practice
attenders
*percentages are unweighted rates based on n=3414
pre-selection sample minus 54 with incomplete data;
†SE
adjusted for clustering within general practitioners;
‡severity of psychological
disorder
NB: percentages in [ ] should be interpreted with caution as standard error is high (mean +/- (SE * 1.96) <0 or >100) CIDI-DSM-IV disorder
overall
Over one third of patients had experienced a DSM-IV
diagnosable disorder in the 12 months prior to the consultation. One in five had
experienced an anxiety disorder, nearly one in five a depressive disorder, and
more than one in ten a substance use disorder (Table 6).
Table 6. Twelve-month overall prevalence of mental
disorder among general practice attenders
*DSM-IV disorder assessed by CIDI v2.1;
†n varies from 910 interviewed because of
incomplete data; ‡rates of disorder are
estimated for the population by weighting the sample according to probability of
selection; §SE adjusted for clustering
within GPs
Specific CIDI-DSM-IV
disorders by gender
Substance use disorders were twice as common among males as
females (16.6% vs 8.2% in the last year); anxiety disorders twice as common
among females as males (25.7% vs 12.2%), and depression also much more common in
females than males (21.6% vs 12.1%). Among both male and female GP attenders,
over half of those under the age of 44 had one or more mental disorders. Those
over the age of 65 had the lowest rates of disorder of any age group (Table
7).
Table 7. Twelve-month prevalence of groups of mental
disorder among general practice attenders by age and gender
*DSM-IV disorder assessed by CIDI v2.1;
†rates
of disorder are estimated for the population by weighting the sample according
to probability of selection;
‡SE
adjusted for clustering within GPs;
§n=(n-1), and
║n=(n-2) because of incomplete
data
NB: prevalence figures in [ ] should be interpreted with caution as standard error is high (mean +/- (SE * 1.96) <0 or >100) Most substance use disorders were related to alcohol
consumption, with disorders related to cannabis much less frequently
encountered. The majority of the depression was represented by a single episode
of moderate or severe intensity. Phobic anxiety disorders were extremely common
in women and the prevalence of generalised anxiety disorder was also high (Table
8).
Table 8. Twelve-month prevalence of specific mental
disorders among New Zealand general practice attenders by gender
*disorders determined using DSM-IV criteria by CIDI
v2.1; †rates of disorder are estimated
for the population by weighting the sample according to probability of
selection; ‡SE adjusted for clustering
within GPs; §n=(n-3),
║n=(n-1),
¶n=(n-2), **n=(n-4) because of missing or
incomplete data; ††bulimia assessed
only among 131 women aged 18–30 years; PTSD in 573 women, 306 men, n=879
overall
NB: prevalence figures in [ ] should be interpreted with caution as standard error is high (mean +/- (SE * 1.96) <0 or >100) Comorbidity of CIDI-DSM-IV
disorder
There was considerable overlap of DSM-IV disorders. More
people with anxiety disorders had a comorbid depression than had an anxiety
disorder alone. Similarly, depression without anxiety was less common than
depression with a diagnosable anxiety disorder. Substance use with either
depression or anxiety disorder was as common as substance use alone (Figure
2).
Figure 2. Comorbidity of anxiety, depression and
substance use disorders in the last 12 months among New Zealand general practice
attenders
 NB: percentages are estimates of proportion of general
practice attenders with these characteristics, weighted for probability of
selection. Disorders were determined by CIDI v 2.1 using DSM-IV
criteria
Discussion
The response rate from the randomly selected GPs is higher
than achieved in comparable research, and provides some assurance of the
representativeness of the practices sampled. However, some aspects of the
setting for this study may limit its use to make generalisations: it includes
the more affluent areas of Wellington City, and the study has a greater
proportion of New Zealand educated doctors than found elsewhere in the country.
The acceptable response rate from patients suggests data from this study provide
a reasonably representative picture of psychological morbidity in New Zealand
general practice.
More than one third of people attending their GP had a
diagnosable mental disorder during the previous 12 months. The most common
disorders identified by accepted and well-validated psychological instruments
were anxiety disorders, depression, and substance use disorders. There was high
comorbidity of these three groups of disorder, with the experience of mixed
pictures as common as disorders occurring alone.
Many of the patterns of disorder varied with age and gender.
The high prevalence of mental disorder in both males and females under the age
of 44 years highlights the difficulty facing the GP who has most frequent
contact with those with the lowest rates of disorder and less frequent contact
with the age groups with highest rates of disorder.
Strategies to improve treatment of mental disorders in
primary care should include an appropriate consideration of not just GP
behaviour but a wider consideration of the patient, the doctor and the health
system.19 Relatively high direct costs to the
patient may be a barrier to consultation about symptoms of mental disorder,
especially when those symptoms may not be identified by patient or doctor as
requiring medical attention. Time pressure on GPs within consultations may limit
the scope for the lengthier assessments required for mental health issues.
However, this paper challenges some accepted views about low rates of
identification of mental disorders in primary
care.20–24 In fact, GPs thought that
about half their patients had some type of psychological problems in the past
year, although they considered that these were moderate or severe in about only
one in ten of their patients. We anticipate that further analysis of MaGPIe
study data will provide important information about relationships between the
nature and severity of disorder and disability, and between recognition of
disorder, management and outcome. This will provide a sound basis for
discussions of future service developments in a wider context, considering the
patient, the doctor and the health system as a whole, rather than individual,
unrelated elements.
Author information:
The MaGPIe (Mental Health and General Practice Investigation) research group at
Wellington School of Medicine, University of Otago consists of a management
committee and an advisory committee. The management committee, which undertook
day-to-day oversight and management of this study, consisted of John Bushnell,
Deborah McLeod, Anthony Dowell, Clare Salmond, Stella Ramage and Rowena Cave.
The advisory committee consisted of Sunny Collings, Pete Ellis, Marjan Kljakovic
and Lynn McBain. Members of both committees were involved in the detailed
planning of the study and have reviewed this paper. John Bushnell drafted and
revised the paper and is the corresponding author. Two former members of the
research group Karin Friedli and George Salmond were involved with early
planning for the study but not its execution.
Acknowledgements: We
thank the participating general practitioners and other practice staff, the
patients who participated, and our research staff Maria Zueva, Li Lin Lim,
Charlotte Bergman, Jo Bray, Colleen Winn and Kirsten McMurray. The Health
Research Council of New Zealand funded the project (grant 99/065). Supplementary
funds were also contributed by the Alcohol Advisory Council (ALAC).
Correspondence:
Associate Professor John Bushnell, Director, MaGPIe Research Group, Wellington
School of Medicine, University of Otago, Box 7343, Wellington. Fax: (04) 389
5725; email: bushnell@wnmeds.ac.nz
References:
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