Presenting prevalence and management of psychosocial problems in primary care in Flanders

Conceptualization of psychosocial problems

An important finding was that the concept of psychosocial problems is poorly defined
and therefore difficult to operationalize. Both literature and health care professionals
use vague concepts. There is no consensus on definitions:

1. In literature as well as in our focus groups and interviews with professional care
providers, we noted disagreement whether or not to include somatic components of a
psychosocial complaint in the definition. Some authors or care providers define somatic
elements within the ‘medical-somatic’ field. However, patient complaints do not always
allow for a strict division between ‘psychological’ and ‘somatic’ problems. Strictly
medical problems will usually also have consequences for the patient’s physical, psychological,
as well as social functioning, and vice versa 14].

2. In literature, there is also disagreement about whether or not to categorize psychiatric
diagnoses under the ‘psychosocial’ heading 14],15]. Some authors claim psychiatric disorders do not belong in the category of psychosocial
problems because of their biological component and/or because psychiatric problems
nearly always cause psychosocial problems. Psychosocial problems are thus interpreted
as resulting from psychiatric disorders, rather than being part of them. Others disagree
with this statement.

3. In daily practice, psychosocial diagnostic labels often reveal more about the way
a caregiver intervenes than about the diagnosis of the patient. For example, caregivers
sometimes use different terms for the same problem over time, depending on treatment
success following initial diagnosis. Even the definition of ‘a problem’ was not straightforward.
For this study, a psychosocial problem was defined as a problem for which professional
care was sought and which was labelled as a mental health problem and/or a social
problem by one of the partners (caregiver or patient/client).

Operational definition

We here propose an operational definition of psychosocial problems, based primarily
on the literature and interviews with individual professional caregivers. This definition
was presented at the beginning of both focus groups and further refined based on the
resulting feedback and discussions:

Psychosocial problems include the broad spectrum of all complaints which are not strictly
medical or somatic. They affect the patient’s functioning in daily life, his or her
environment and/or life events.

On the one hand, it concerns various psychological problems such as: anxiousness,
nervousness, tenseness, (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, relational problems (with friend, family and/or partner),
medically unexplained symptoms and eating disorders.

On the other hand, it concerns various social problems such as: poverty/financial
problems, housing problems, lack of adequate nutrition or 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.

Inventory and collection of data

Objective and interpretable data were difficult to find, in literature as well as
in daily practice-based registrations or research results. In non-medical disciplines
(psychologists, nurses, social workers) the problem is even more apparent. For instance,
Belgian primary care psychologists are not officially recognized as a licensed profession,
which means research or registration are virtually absent. Furthermore, because psychological
care costs are not reimbursed, there is no registration by health insurance agencies
of psychologist interventions.

Data acquisition and registration pose additional problems. Procedures for registration
and processing of the available data are neither similar across the various disciplines,
nor within the separate instances and settings. Especially overall data on contacts
with welfare workers (social work, home nursing) for psychosocial problems were difficult
to find. In Belgium or Flanders there is no general, unambiguous registration and/or
processing by the combined welfare agencies. Therefore national or regional data are
unavailable. However, cities and towns do provide data. Data structure and registration
mode show strong regional differences, which makes comparisons difficult. Moreover,
registration possibilities by care professionals frequently appear to be limited.
In some health insurance instances the number of categories with regard to a type
of contact is limited to two. Hence, counselors will prefer to register the practical
aspects of the consultation (arrangement of papers and documents,…) rather than any
psychosocial aspects (emotional support,…).

Presentation of psychosocial problems in primary care in Flanders

Flemish primary care does not have a tradition of multidisciplinary psychosocial research.
Integrated data concerning psychosocial problems across the different primary care
disciplines are missing.

Furthermore, the same psychosocial problem may receive different labeling and/or registration
according to discipline or setting. Patient or social factors can contribute to this,
as one problem is sometimes presented differently by the patient/client to different
care givers or disciplines, and may therefore also be labeled or registered under
a different name. Some possible reasons for this shortcoming can be:

Proto-professionalization16],17]. Patients formulate their problem or their request for help differently depending
on the nature of the caregiver consulted. This can result in different labels by different
caregivers for the same problem.

Patient attributional style18]-21]. Patients usually attribute their psychosocial problems to certain factors, e.g.
to external or situational factors (e.g. marital problems), or to psychological causes
(e.g. depression). Different studies show that patients with mental health problems
often present their problems somatically and/or often do not bring up psychological
or social components themselves.

(Self-)stigma. Many people still seem to have difficulties admitting or indicating that
they are struggling with mental health or financial problems. Other research also
reports psychiatric patients continues to be stigmatized, even among professional
caregivers 22].

General practitioner (GP) as an important gateway to primary care

The GP appears to be an important gateway to primary care for patients with psychosocial
problems, illustrated by the fact that GPs appear to be involved in 60-80% of consultations
for emotional problems 23],24]. Moreover, they appear to be the first caregivers to be consulted and the majority
of these cases remains with their GP for follow-up even after being referred 25]. Especially for socially disadvantaged groups (poorly educated and people with lower
income), the GP acts as a driving force in addressing mental health problems 26].

Within our focus groups and interviews, it was noted that the medical mandate of the
GP may break down barriers, since patients do not feel under any pressure to bring
up possible social or psychological problems with their GP. However, this can also
become a disadvantage, particularly when a patient continues to focus too much on
his medical-somatic problems and shows little or no openness to discuss the psychological
components of his complaint(s).

Management of psychosocial problems in primary care in Flanders

In line with our findings concerning data on prevalence and presentation of psychosocial
problems in primary care, we found that data on the approach of the (primary care)
psychologist- and psychiatrist, social workers and nurses are sparse and less elaborate
compared to data on the approach of GPs. From family medicine, a lot of specific research
is available with both international and specifically Flemish data 18],27]-31]. However, there is a lack of more general, reliable and easily interpretable data
on the management and care supply of other disciplines.

A number of factors can play a role in this. Data on the management by psychiatrists
often focus on secondary care, even though they are often also involved in primary
care. Data from welfare are geographically spread and registered differently by (different
branches of) authorities. These factors prevent an overall view of primary care interventions
for psychosocial problems.

General trends

Despite these limitations we can derive some general trends from research available
in Flanders, our interviews, and the focus groups.

Supply versus need

Based on the information that we obtained from the interviews and focus groups we
notice that assistance to patients with psychosocial problems still seems to be overly
‘supply-driven’. Assistance is based on what can be offered, rather than on patient
needs.

Drug treatment remains popular

Based on our review of the literature and research available in Flanders, we find
that a pharmacological approach remains popular in the treatment of people with mental
health problems, whether or not in combination with non-pharmacological treatment.
Also, many patients who do not meet the criteria for a mental disorder, but are treated
for emotional problems, are prescribed medication 23].

Furthermore, data on the use of psychotropic drugs show an increase in the already
frequent use of antidepressants, stimulants, and antipsychotics 1],32]. The use of tranquillizers and sleep medication remains constant 1]. Despite recent efforts to reduce the use of these potentially addictive products,
there is an increase in the prescription of antidepressants in Flanders compared to
10-15ys ago. Moreover, this increase does not match an increase in the number of diagnosed
depressions 33]. The chronic use of this medication once prescribed, as well as the prescription
of antidepressants for other conditions and problems (for example chronic pain, sleeping
problems in the elderly, etc.) could be possible explanations.

Referral of patients within primary care or to secondary care

There are some considerations concerning referrals for psychosocial problems. GPs
help 90% of the patients with psychosocial problems themselves 28]. GPs offer psycho-education and (psychotherapeutic) counseling, but in many studies
this frequently used approach is not clearly recorded as opposed to the pharmacological
approach that may also be used.

Referral for psychotherapy does not seem to be obvious. It is a time-consuming process,
often spread over time, which needs to be run through together with the patient 34]. Patients do not always (immediately) agree with advice for referral. Associated
financial implications or stigma may constitute a barrier for the patient. Having
a psychologist working in the general practice appears to lower the threshold for
referring patients 35]. Among all the different disciplines, there is a great need for more collaboration
and considerable advantages are to be expected from the growing emergence of multidisciplinary
practices.

Based on the experiences of interviewed professionals, we noted that the process of
referral to secondary care was sometimes hampered because of various reasons. Patients
may refuse because they have multiple problems (practical, financial, stigma,…). Furthermore,
there are usually long waiting lists. Finally, intake procedures can impede the course
of care. Patients sometimes have to talk to a number of caregivers, on different occasions,
before they are finally referred to a permanent caregiver for further treatment. This
can lead to a decrease in the patient motivation or to non-compliance.

GPs referring patients may lose sight of the patient’s further development. The patient
is followed up elsewhere and does not always return to the GP. A possible explanation
given by professionals in the focus groups is the fact that once a patient enters
psychiatry or a specific care project, he is not referred back to the GP soon enough
and/or patients are held in psychiatric care for too long, also when this is no longer
required. Specific advice from psychotherapeutic care about subsequent treatment of
the patient by the GP or other care providers is very rare.

The aspect of multiculturality

Based on the information from the interviews and focus groups, we notice that multiculturalism
appears to take an increasingly important place within primary care. It does not only
involve different countries of origin, but also important socio-demographic differences
(specific care of the elderly or youth, underprivileged populations, etc.). Different
cultures have different languages, understandings, reactions, expectations of care,
support systems, etc. The current care offered may not be sufficiently and/or appropriately
adapted to these differences. Hence, caregivers encounter difficulties. We noticed
growing frustration among caregivers and some were in danger of losing interest or
of giving up.

The person of the caregiver

Treatment effectiveness in psychosocial problems seems to more related to the person
of the caregiver than to a specific discipline, theory or type of treatment. For example,
a psychotherapeutic approach by the GP may have the same effect as drug treatment
in patients with depression. In literature as well as within our focus group sessions
we also found that short-term therapy or psychological interventions in patients with
depression can be carried out not only by psychotherapists, but also by GPs or nurses
without loss of efficacy 36]-39].

Different caregivers mentioned that non-specific elements (such as consolidation,
acceptance, containment, explanation, a place to ‘speak out’,..) seem to be of particular
importance in the treatment of psychosocial problems. These non-specific elements
are cross-disciplinary and were already described more than fifty years ago 40]. Especially important seems to be a good personality match between caregiver and
patient.