Patient determinants of mental health interventions in primary care

Background. A large proportion of a general practitioner's (GP's) caseload comprises patients with mental health problems. It is important to ensure that care is provided appropriately, on the basis of clinical need. It is therefore necessary to investigate the determinants of the use of mental health care in the primary care sector and, in particular, to identify any non-clinical characteristics of patients that affect the likelihood of their receiving appropriate care. Aim. To identify and compare the influence of non-clinical patient factors on GPs' acknowledgement of mental problems and on their provision of mental health care. Method Cross sectional study of adults aged 16 to 65 years old (n = 802) attending one of eight practices (20 GPs in total) in inner west London. Results. Multivariable analysis showed that the combination of factors that best predict GPs' acknowledgement of the presence of mental problems are general health questionnaire (GHQ) scores (odds ratio [OR] = 1.10 per unit increase in score, 95% confidence interval [CI] = 1.07 to 1.13), previous mental symptoms (OR = 7.5 95% CI = 4.3 to 129), increasing age (OR = 1.03 per one-year increase, 95% CI = 1.01 to 1.04) and physical health status (OR = 0.98 per unit increase in short form-36 (SF-36) score, 95% CI = 0.96 to 1.00). Multivariable analysis showed that the combination of factors that best predict intervention (prescription for psychotropic medication; return visit to GP; referral to psychiatric inpatients/outpatients; referral to other [specified] health professionals, or social services) are previous symptoms (OR = 7.4, 95% CI = 3.8 to 14.4), white ethnic group (OR = 2.2 95% CI 0.9 to 55); and not owning a property (OR = 2.1, 95% CI = 1.1 to 4.0). Life events influenced intervention only in the presence of low GHQ scores (OR = 8.1, 95% CI = 2.7 to 24.0). Conclusions. Mental problems are common in primary care and their acknowledgement is a necessary but not a sufficient condition for intervention. Our results show that GPs' decisions about mental health interventions can be influenced by non-clinical patient factors, regardless of patients' clinical needs. The results suggest that current practice may not always be equitable, and point to the need for better understanding of the basis of these potential inequalities and for focused training.