Needs Analysis Paper

TEACHING, TRAINING AND FURTHER EDUCATION

How well do Australian medical schools prepare general practitioners to care for patients with mental disorders?
Deborah Sahhar and Daniel O’Connor

TEACHING, TRAINING and FURTHER EDUCATION

Objective: The purpose of the present paper was to map the mental health workloads of general practitioners (GPs) , and to determine GPs’ views of the adequacy of their undergraduate training in psychiatry. Methods: Twenty-nine GPs who had graduated since 1980 from an Australian medical school provided data on 339 consecutive adult patients with conspicuous psychological disorders. After listing their patients’ problems and management plans, doctors rated the value of their undergraduate teaching in preparing them for this task. Results: Depression, anxiety and substance abuse accounted for 71% of reported cases. Virtually all patients were given some psychologically orientated treatment. Only half were prescribed a psychotropic medication. Nineteen of the 29 doctors wished that they had received more training in counselling. Conclusions: In an earlier survey it was found that Australian and New Zealand medical school curricula focused largely on the diagnosis and pharmacological management of psychosis and depression. The GPs in the present study most commonly applied psychologically orientated treatments of anxiety, depression and substance abuse. It is proposed that medical schools provide tuition to medical students in counselling. Key words: counselling, medical school, mental disorder, primary care, university.

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Australasian Psychiatry • Vol 12, No 1 • March 2004
Deborah Sahhar Consultant Psychiatrist, Caulfield General Medical Centre, Melbourne, Vic., Australia. Daniel O’Connor Professor of Psychiatry of Old Age, Department of Psychological Medicine, Monash University, Melbourne, Vic., Australia. Correspondence: Professor Daniel O’Connor, Kingston Centre, Warrigal Road, Cheltenham, Vic. 3192, Australia. Email: [e-mail]

ental disorder is common. In the recent National Survey of Mental Health and Well-being, nearly one in five adult Australians had experienced an anxiety, depressive or substance abuse disorder in the previous 1 year. More specifically, 10% had met criteria for an anxiety disorder, 8% for a substance abuse disorder and 6% for depression.1

General practitioners (GPs) provide far more care to such patients than specialists. In the same survey, 49% of persons with a depressive disorder had consulted their GP for a mental health problem in the last year compared with 12% who consulted a psychiatrist.2 Mental disorder accounts therefore for a substantial proportion of GPs’ workloads. In an earlier study of Australian GP morbidity patterns, psychological problems arose at least once in 9% of all consultations and accounted for 7% of all registered problems.3 If undergraduate and postgraduate educational programmes are properly targeted and effective, young GPs should possess the necessary knowledge and skills to meet this challenge. But do they?

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In an earlier study, we reported that in 1996 Australian and New Zealand medical students received an average of 353 h (range: 279–454 h) of tuition from departments of psychiatry, mostly in the form of clinical attachments.4 With respect to content, psychotic illness accounted for 23% of formal teaching hours, depression for 26% and substance abuse for 35%. Psychological therapies were covered in an average of only 7 h (range: 1–17 h). The therapies taught included an eclectic mix of counselling, relaxation training, cognitive therapy and family therapy, depending on tutors’ interests and skills. These observations prompted us to enquire if recently graduated Australian GPs believed that their undergraduate education had equipped them adequately for the kind of psychological disorders they encountered in day-to-day practice. To address this, we questioned 29 local doctors about their mental health workload, management plans, referral patterns, and views of medical school tuition.

phrenia and other psychotic disorders).5 We asked for a brief, one-paragraph summary of each patient’s complaint to check on diagnostic validity. Both authors reviewed these summaries and noted if we agreed or disagreed with the doctor’s diagnosis. To minimize demands on time, most questions required just a tick against predetermined options. Doctors listed whether they managed a problem themselves or referred, or planned to refer, to a psychiatrist, psychologist or other help agency. The GPs’ own treatments were categorized as watchful waiting, reassurance, practical advice, information sharing, psychological treatment and/or psychotropic medication. Doctors who nominated psychological treatment were asked to classify their approach very generally as counselling, cognitive behaviour therapy, relaxation training, meditation, psychotherapy or other modalities. Finally, doctors checked the most and least useful components of their undergraduate teaching in psychiatry (lectures, clinical attachments, demonstrated interviews and other formats) and what topics they believed were taught too much and too little.

METHODS
Subjects We sought to identify 30 GPs who had qualified in an Australian medical school since 1980 and were currently employed in Melbourne’s inner and middle south-eastern suburbs. Each week, we sent letters explaining the study’s aims and requirements to 15 randomly selected members of two local GP divisions. These letters were followed by telephone calls and visits to the surgery if possible. This process continued until 30 doctors were enrolled. Study demands were high and we knew from the outset that take-up rates would be low. To compensate doctors for their efforts, one of us (DS) visited participating doctors later to discuss issues concerning their patients. The study was approved by the local Health Research Ethics Committee and the Royal Australian College of General Practitioners, who awarded practice assessment points. Instruments Participating doctors completed a brief questionnaire covering their age, year and place of graduation, other qualifications, type of practice (solo or group) and postgraduate experience in psychiatry. They then completed a de-identified clinical summary of up to 15 consecutive patients aged 18 years and over who presented (in their judgement) with a predominantly psychological or psychiatric disorder. Information was sought about patient’s age and sex, psychiatric history (if known), current psychiatric diagnoses, and actual or proposed management plans. Diagnostic categories were kept deliberately broad using Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) chapter headings (e.g. mood disorder, substance-related disorders, schizo-

RESULTS
Doctors We approached 103 eligible GPs to find 30 (29%) who agreed to participate. One of the 30 withdrew later, leaving 29 doctors. Sixteen of the 29 (55%) were female and their ages ranged from 29 to 54 years (average 35 years). The mean time since graduation was 10.4 years (range: 6–17 years). Twenty had graduated from Monash University, eight from the University of Melbourne and one from the University of Tasmania. Fourteen were Fellows of the Royal Australian College of General Practitioners and 12 had postgraduate diplomas. All but two worked in group practices. Only eight had worked in psychiatry as residents. Doctors who chose not to participate were broadly similar: 53% were female and 89% worked in group practices. The commonest reason for non-participation was pressure of work and the study’s unusually high demands. Clinical summaries We asked each of the 29 doctors to contribute summaries of 15 patients presenting consecutively with a psychological disorder. This was an easy task for some. Others found it more difficult, with the result that return rates ranged from three to 15 cases, giving a total of 339 out of a possible 435 summaries (78%). Most doctors with low return rates were women who worked part-time. Two-thirds of the 339 patients were female. The ages of the patients were as follows: 18–35 years (40%),

Australasian Psychiatry • Vol 12, No 1 • March 2004

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36–65 years (44%) and 66 years or over (16%). Twofifths (41%) had consulted a psychiatrist at some point and 24% had received inpatient psychiatric treatment. The GPs’ primary diagnoses are listed in Table 1. Depression, anxiety and substance abuse accounted for 71% of all cases. Another 64 patients (19%) were given a secondary diagnosis. These diagnoses were all consistent in both authors’ views with doctors’ brief clinical summaries. Management The GPs’ existing or proposed management plans are listed in Table 2. Some kind of psychological treatment was applied in almost every instance. More specifically, doctors said that they provided counselling in 223 cases (66%); cognitive behaviour therapy in 40 cases (12%); psychotherapy in 32 cases (9%); relaxation training in 25 cases (7%); and meditation training in six cases (2%). Half of all patients were prescribed a psychotropic medication. More than one medication was prescribed in 16 cases (5%). Referral rates were high: 126 patients (37%) were referred to a psychiatrist for treatment of the current problem, 43 (13%) were referred to a psychologist and 27 (8%) were referred elsewhere (e.g. to a counselling service or self-help group).

Views of tuition With respect to medical school experiences, GPs rated the most useful types of teaching as lectures (14%), clinical attachments (45%) and interview demonstrations (41%). Fifteen doctors (52%) stated that psychosis was taught excessively. By contrast, 19 (66%) thought that counselling skills were covered inadequately. Doctors nominated a number of other gaps in teaching: anxiety (41%), depression (17%), substance abuse (14%), personality disorder (14%) and psychopharmacology (14%). These categories are not mutually exclusive.

DISCUSSION
Our study was run with slender resources by one of the authors (DS) as part of her advanced training in psychiatry. It reflects the treatment by a modest number of inner-urban GPs of a relatively small number of patients and we cannot be certain that our findings reflect practice throughout the whole of Australia. Despite this, we know of no similar studies and our findings will be of interest to GPs, general practice tutors and psychiatrists. We were not surprised by our low recruitment rate of 29% of local divisional members. The study was particularly onerous; many College members had their full quota of practice assessment points, and non-College members gained no extra benefit. Although the doctors who participated were broadly similar to those who did not, it is likely that they had a greater than average interest in psychological issues and wished to learn more about themselves and their patients. This was not an impediment because psychologically minded doctors will speak authoritatively and insightfully on the degree to which their undergraduate training prepared them for work in primary care. The mix of GPs’ diagnoses fitted well with the finding in the recent National Survey of Mental Health and Well-being that anxiety, depression and substance abuse accounted for the majority of cases of mental disorder in Australia.1 The patients described here were therefore reasonably representative of those perceived by doctors as needing psychological or psychiatric support. Admittedly, they represented a small proportion of all those who meet rigorous research criteria for mental disorder, many of whom go unrecognized in a busy primary care setting.6,7 This was not an obstacle; we wanted to know what GPs actually offered their patients and how well their undergraduate training equipped them in their view for this task. General practitioners are the preferred port of call for people troubled by anxiety, depression and substance abuse.2 Psychotropic medications have a place but

Table 1: Patients’ primary presenting diagnoses (n = 339) Diagnosis Depression Anxiety Substance abuse Adjustment disorder Schizophrenia Bipolar disorder Organic disorder Personality disorder Eating disorder Other n 133 69 42 34 22 12 9 9 4 5 % 39 20 12 10 6 4 3 3 1 1

Australasian Psychiatry • Vol 12, No 1 • March 2004

Table 2:

GPs’ management plans (n = 339) n 33 147 172 % 10 96 51

Management Watchful waiting Psychological support Psychotropic medication
Treatments are not mutually exclusive.

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most patients prefer to ventilate their concerns to a trusted professional who listens empathically and responds non-judgementally. Few GPs have time for formal psychotherapy but even 15 min consultations leave scope for psychological understanding and support. In our study, virtually all patients with a conspicuous mental disorder were offered some kind of psychological help, most commonly labelled as counselling. We do not know what form this treatment took, but doctors perceived it as more than giving advice and reassurance. The fact that 72 treatments were labelled as cognitive behaviour therapy or insight-orientated psychotherapy suggests a seriousness of purpose. Our findings fit well with those from two other Australian studies. In the SPHERE national survey, 386 GPs reported using non-drug treatments twice as often as pharmacological ones for patients they perceived as having a mental disorder,8 and 91% of the 872 GPs questioned in another survey endorsed counselling as an appropriate treatment of depression.9 In the UK, counselling was positively evaluated by GP patients,10 and cognitive therapy worked as well as antidepressant medication in this setting.11 The Commonwealth Government, through its National Action Plan for Depression, has acknowledged the critical role of GPs in detecting and treating depression and other common mental disorders12 by boosting Medicare rebates for suitably qualified GPs to conduct mental health assessments, formulate care plans and monitor patients’ progress. Approved training courses include material on counselling, stress management, family therapy and other psychological treatments.13 Now that motivated GPs have access to such courses, is there still a place for teaching psychological therapies in medical school? Two-thirds of the doctors in the present study would have valued it, but is it feasible and desirable, would medical schools make room for it, and would students perceive it as useful? Most medical schools teach communication skills but psychological treatment consists of more than openended questioning, information sharing and the like. Psychological treatment can be defined very generally as a sustained, deliberate attempt to ease distress and promote resilience usually, but not exclusively, by means of empathic discussions of patients’ emotions, thoughts, behaviours and relationships. Counselling is one of many such approaches and its key components – listening, reflecting and exploring – are widely known and endorsed by many GPs.9 We were astounded to learn in an earlier study that Australian and New Zealand medical schools in 1996 devoted only 7 h on average to teaching psychological treatments, mostly in the form of lectures and tutorials on the principles of psychotherapy and its

various categories.4 None of the schools taught treatment as a skill to be observed and practised under supervision. We see no reason why basic skills in psychological understanding and treatment cannot be taught to medical students by means of observed interviews and role plays using patients, volunteers or actors. ‘Selectives’, in which small groups of motivated students devote several hours a week to a course of study, are ideally suited to this purpose. Such an approach was mooted in a recent World Psychiatric Association forum on psychiatry in medical education but has not, to our knowledge, been adopted by any medical school.14 We welcome a debate on this topic by GPs, psychiatrists and medical educationalists. It is timely because many Australian medical schools are presently re-designing their undergraduate curricula. Further research in this area might include studies of the practicality and efficacy of teaching psychological therapy to medical students as well as more finegrained analyses of what constitutes psychological therapy in primary care, perhaps by means of interviews with GPs and patients regarding the nature, purpose and content of psychotherapeutic consultations. ACKNOWLEDGEMENTS
We thank participating GPs and the Central Bayside and Monash Divisions of General Practice.

REFERENCES
1. Henderson S, Andrews G, Hall W. Australia’s mental health: an overview of the general population survey. Australian and New Zealand Journal of Psychiatry 2000; 34: 197–205. 2. Parslow RA, Jorm AF. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Well-being. Australian and New Zealand Journal of Psychiatry 2000; 34: 997–1008. 3. Pearse P, Neary S. Psychological problems: how are they managed in general practice? Australian Family Physician 1994; 23: 443–451. 4. O’Connor DW, Clarke DM, Presnell I. How is psychiatry taught to Australian and New Zealand medical students? Australian and New Zealand Journal of Psychiatry 1999; 33: 47–52. Australasian Psychiatry • Vol 12, No 1 • March 2004 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington DC: APA, 1994. 6. O’Connor DW, Rosewarne R, Bruce A. Depression in primary care 2: general practitioners’ recognition of major depression in elderly patients. International Psychogeriatrics 2001; 13: 367–374. 7. Hickie IB, Davenport TA, Scott EM et al. Unmet need for recognition of common mental disorders in Australian general practice. Medical Journal of Australia 2001; 175 (Suppl.): S18–S24. 8. Hickie IB, Davenport TA, Naismith SL et al. Treatment of common mental disorders in Australian general practice. Medical Journal of Australia 2001; 175 (Suppl.): S25–S30. 9. Jorm AF, Korten AE, Jacomb PA et al. Beliefs about the helpfulness of interventions for mental disorders: a comparison of general practitioners, psychiatrists and clinical psychologists. Australian and New Zealand Journal of Psychiatry 1997; 31: 844–851.

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10. Scott AIF, Freeman CPL. Edinburgh primary care depression study: treatment outcome, patient satisfaction, and costs after 16 weeks. British Medical Journal 1992; 304: 883–887. 11. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. British Medical Journal 1995; 310: 441–445.

12. Commonwealth Department of Health and Aged Care. National Action Plan for Depression. Canberra: Mental Health and Special Programs Branch, 2000 13. Royal Australian College of General Practitioners. Level One GPMHSC Approved Courses. Melbourne: RACGP, 2003. http://www.racgp.org.au/document.asp?id=6769 14. Gelder MG. A core curriculum in psychiatry for medical students. Current Opinions in Psychiatry 1998; 11: 491–492.

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Australasian Psychiatry • Vol 12, No 1 • March 2004

References: 1. Henderson S, Andrews G, Hall W. Australia’s mental health: an overview of the general population survey. Australian and New Zealand Journal of Psychiatry 2000; 34: 197–205. 2. Parslow RA, Jorm AF. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Well-being. Australian and New Zealand Journal of Psychiatry 2000; 34: 997–1008. 3. Pearse P, Neary S. Psychological problems: how are they managed in general practice? Australian Family Physician 1994; 23: 443–451. 4. O’Connor DW, Clarke DM, Presnell I. How is psychiatry taught to Australian and New Zealand medical students? Australian and New Zealand Journal of Psychiatry 1999; 33: 47–52. Australasian Psychiatry • Vol 12, No 1 • March 2004 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington DC: APA, 1994. 6. O’Connor DW, Rosewarne R, Bruce A. Depression in primary care 2: general practitioners’ recognition of major depression in elderly patients. International Psychogeriatrics 2001; 13: 367–374. 7. Hickie IB, Davenport TA, Scott EM et al. Unmet need for recognition of common mental disorders in Australian general practice. Medical Journal of Australia 2001; 175 (Suppl.): S18–S24. 8. Hickie IB, Davenport TA, Naismith SL et al. Treatment of common mental disorders in Australian general practice. Medical Journal of Australia 2001; 175 (Suppl.): S25–S30. 9. Jorm AF, Korten AE, Jacomb PA et al. Beliefs about the helpfulness of interventions for mental disorders: a comparison of general practitioners, psychiatrists and clinical psychologists. Australian and New Zealand Journal of Psychiatry 1997; 31: 844–851. 29 10. Scott AIF, Freeman CPL. Edinburgh primary care depression study: treatment outcome, patient satisfaction, and costs after 16 weeks. British Medical Journal 1992; 304: 883–887. 11. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. British Medical Journal 1995; 310: 441–445. 12. Commonwealth Department of Health and Aged Care. National Action Plan for Depression. Canberra: Mental Health and Special Programs Branch, 2000 13. Royal Australian College of General Practitioners. Level One GPMHSC Approved Courses. Melbourne: RACGP, 2003. http://www.racgp.org.au/document.asp?id=6769 14. Gelder MG. A core curriculum in psychiatry for medical students. Current Opinions in Psychiatry 1998; 11: 491–492. 30 Australasian Psychiatry • Vol 12, No 1 • March 2004