Psychological Medicine :: Research
The MaGPIe Study: The Mental Health and General Practice Investigation

Picture of PewWellington School of Medicine in conjunction with the World Health Organisation. A Centre Collaborating with the World Health Organisation's multi-centre study of Psychological Problems in Primary Care.

Director: Associate Professor John Bushnell
email john.bushnell@otago.ac.nz

 

Introduction

A research team from the Departments of General Practice, Psychological Medicine and Public Health is running a large study which will describe the prevalence, form, course and outcome of common mental disorders in New Zealand general practices. The study is collaborating with the World Health Organisation's project investigating Psychological Problems in General Health Care.

 

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Background

Throughout the world, mental disorders are a major public health problem. New Zealand is no exception to this. A study in Christchurch completed twelve years ago (the Christchurch Psychiatric Epidemiology Study (CPES)) found that 28% of adults in the general population experienced a diagnosable mental disorder in the past six months. The most frequently encountered disorders were: mood disorders (especially depression and dysthymia); substance use disorders (especially alcohol abuse and/or dependence); and anxiety disorders (especially phobias, panic disorder and generalised anxiety disorder). The CPES, consistent with research in other western countries, found that three quarters of those with a recent mental disorder had attended a health (mainly general practice) service, but only about a third had sought help for their mental health problem from any agency. One quarter of those who received treatment got it from specialist mental health or addiction services, and three quarters of the treatment for mental disorders which happened was delivered by GPs.

There are few New Zealand data, but studies in other western countries have found that common mental disorders such as anxiety, depression and alcohol disorders affect a substantial proportion of all general practice attenders. Estimates of that proportion vary from a quarter to half of those consulting a GP in the UK. The World Health Organisation (WHO) recently completed an international study, in 15 different centres in 14 countries. They found that 24% of general practice attenders had a current mental disorder reaching ICD-10 criteria and another 9% had a subthreshold disorder (clinically significant symptoms, but not meeting full criteria for ICD-10). The commonest ICD-10 diagnoses were depression, generalized anxiety disorder, neurasthenia and problems with alcohol.

These disorders are associated with significant physical and social disability and increased mortality. A World Health Organisation analysis of the global burden of disease has shown that mental disorders make up five of the ten leading causes of disability worldwide. The level of disability is similar to those experienced by people with chronic physical conditions. The emotional, social and financial impact on both the individual and society is huge in terms of direct costs of greater use of medical services, indirect costs resulting from days lost from work, and keeping people from usual activities due to feeling ill, and from the "intangible costs" to the individual in terms of the suffering and distress they experience.

GPs are in a unique position to identify and intervene with mental disorders. General practice management of common mental disorder includes accurate listening and identification of the issues, education, problem solving, and specific psychological interventions such as relaxation and anxiety management, or motivational interviewing for alcohol or drug use problems. Referral to specialist services is more likely to be successful where the GP has accurately identified the nature of the problem and is aware of the treatment approaches most likely to be helpful. Psychotropic medication (in particular anti-depressants, anxiolytics and hypnotics) may also play a role in the GP's response to the patient with a common mental disorder. Identification and management of common mental illnesses may be difficult to achieve in brief consultations in busy surgeries.

A small number of studies in New Zealand have described the nature of consultations in general practice, but none with a focus on mental health. Early studies of individual GPs or small groups of practitioners have described the nature of their caseloads. Larger scale studies with representative sampling have also been conducted: in 1981 in the Waikato (CoMedCa) and in Canterbury (PriMedCa) two similar surveys were conducted. In the CoMedCa study 3.1% of consultations were thought by the GP to be primarily psychological, somewhat less than the PriMedCa study, where 7.6% of consultations were primarily for psychological reasons. Ten years later, in 1991/2 another survey (WaiMedCa) was carried out in the Waikato. WaiMedCa found that the GPs rated the main reason for the visit as psychological in 4.4% of encounters.

The reason for such low prevalence rates in these studies of general practice is unclear. The international literature on psychological problems in primary care suggests that the rates might be about seven or eight times as high. Prevalence rates of mental disorder in the New Zealand general population are similar to European and North American countries in which many primary care studies have been undertaken. The difference may in part reflect the different emphasis of these studies, which focused on asking for one main reason for the consultation. This may not have allowed for the complexity of psychological problems, especially those which are presented as somatic concerns.

In summary, GPs already deliver the largest share of what mental health treatment is provided within the health system. The share is likely to increase rather than decrease in the foreseeable future. Very little has been known about meeting mental health needs of patients in a New Zealand primary care context, and this study has been designed to enable us to understand more about the role of the GP in the recognition and management of common mental disorders.

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Research Design

The project has recruited 70 randomly selected GPs, and carried out in depth interviews with 909 patients, who have been followed up with reinterviews at 3, 6, 9 and 12 months.

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Significance

This study has regional, national and international significance. It will describe the prevalence, form, course and outcome of common mental disorders, including alcohol disorder, in New Zealand general practices and determine the factors which influence identification and management of these disorders by GPs.

This study has a number of strengths over and above similar research conducted in other parts of the world.

  • The study will randomly sample GPs from the two regions in the lower half of the North Island, an area which covers urban, suburban, small town and rural areas with and without extensive community mental health services.
  • The number of GPs sampled will be sufficient to identify variables with moderate to large effect sizes.
  • Common mental disorders will be determined by the GP and by the use of a validated, standardised structured interview (CIDI).
  • The GPs characteristics and practice characteristics will be assessed.
  • Patient health service use, persisting disability, life events and psychological symptoms will be monitored by telephone interview every three months, and at the final interview of both patient and GP at one year.
  • The longitudinal design of the study will enable us to explore the impact of GP intervention on the subsequent management and outcome of common mental disorders.
  • The design of the study will make it possible to explore hypotheses relating to patient characteristics, as well as practice characteristics using analytic techniques such as Multi-Level/Structural Equation Modeling.

In a New Zealand health policy environment, where there is growing pressure for Primary Care Health Services to provide increasing amount of mental health care, this study will identify the nature and scale of common mental disorders in the primary care setting. With the information base which this study will provide, future policy initiatives may be targeted in such a way as to increase the likelihood of a professional response which is of most help to those patients who are experiencing a common mental disorder such as depression, substance use disorder, or anxiety disorder.

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Progress

Field work was completed in December 2001. Notification of publications will appear on this site as they become available. If you would like to be placed on a list for notification of pubished data, please email sramage@wnmeds.ac.nz

MaGPIe publications at 19 January 2005

Refereed Journal Articles
In preparation:

The MaGPIe Research Group. (Bushnell JA corresponding author) Recognition, treatment and outcome of mental health problems in primary care.

The MaGPIe Research Group. (McLeod D corresponding author) Barriers to treatment of mental health problems in primary care.

The MaGPIe Research Group. (Dowell AD corresponding author) General Practitioners do not under-treat Common Mental Health problems.

The MaGPIe Research Group. (Collings SCD corresponding author) The relationship between disability and General Practitioner recognition of mental disorder.

Published:

The MaGPIe Research Group. (Kljakovic M corresponding author) General Practitioner chartacteristics and attitudes influencing the identification of mental disorders in primary care. Australian Family Practice in press.

Dew, K., Dowell, A., McLeod, D. Collings, S. and Bushnell, J. This Glorious Twilight Zone of Uncertainty": Mental health consultations in general practice. Social Science and Medicine (in press)


The MaGPIe Research Group. (Bushnell JA corresponding author) Mental disorders among Maori people attending their general practitioner. Australian and New Zealand Journal of Psychiatry. (In Press)


The MaGPIe Research Group. (Dowell AD corresponding author) The effectiveness of screening for mental health problems in primary care. British Journal of General Practice. (In Press)

The MaGPIe Research Group. (McLeod D corresponding author) A comparison of general practitioner recognition of mental illness with cases identified by screening and diagnostic instruments. Australian and New Zealand Journal of Psychiatry. (In Press)


The MaGPIe Research Group. (Bushnell JA corresponding author) Frequency of consultations and general practitioner recognition of psychological symptoms. British Journal of General Practice, 54, 838-842, 2004

The MaGPIe Research Group. (Bushnell JA corresponding author) Psychological problems in New Zealand primary health care: a report on the Mental Health and General Practice Investigation (MaGPIe). New Zealand Medical Journal. 116(1171):U379, 2003 Apr 4.


The MaGPIe Research Group. (Bushnell JA corresponding author) Psychological problems in New Zealand primary health care: a report on the pilot phase of the Mental Health and General Practice Investigation (MaGPIe). New Zealand Medical Journal. 114(1124):13-6, (2001)

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Personnel

The following staff are (or have been) involved in the study.

Management Group

Stella Ramage (Project Supervisor)

Rowena Cave (Project Manager until March 2001)

Maria Zueva (Administrator until 2002)

John Bushnell (Clinical Psychologist)

Tony Dowell (General Practitioner)

Debbie McLeod (General Practice Research Manager)

Clare Salmond (Biostatistician)

Advisory Group

Lynn McBain (General Practitioner)

Marjan Kljakovic (General Practitioner)

Pete Ellis (Psychiatrist)

Sunny Collings (Psychiatrist)

(George Salmond (Health Services Researcher) and Karin Friedli (Health Services Researcher) were involved in the study in the early stages of planning.)

Field Team

Lee Lin Lim (Palmerston North)

Colleen Winn (Palmerston North)

Charlotte Bergman (Wellington)

Jo Bray (Wellington)

 

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Acknowledgements

This study is funded by the Health Research Council of New Zealand (grants 97/171 and 99/065) with additional support from the Alcohol Advisory Council (ALAC)

We are grateful to Murray Ball and Diogenes Design Ltd for permission to use "Pew".

 

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