ABSTRACT

The PhD study was conducted in general practice in Aarhus County in cooperation between the Research Unit for Functional Disorders, Aarhus University Hospital and the Research Unit for General Practice, Aarhus University.

The recognition of mental disorders in general practice is essential to promote mental health interventions. Attempts to improve the general practitioners (GPs) recognition of mental disorders using screening instruments have mainly focused on depression. Few studies have tried to evaluate the feasibility and usefulness of screening for a wider range of mental disorders in everyday practice.

This thesis addresses the following questions: 1) does a brief screening instrument improve the GPs recognition of common mental disorders, 2) does disclosure of the screening information to the GP affect management of the patients, 3) is the screening instrument a valid tool for use in general practice, and 4) how can a screening procedure be implemented in daily clinical practice?

The screening instrument was evaluated in a randomised controlled trial including 1785 consecutive patients age 18-65 years, who consulted 38 GPs with a new health problem. Patients were screened before the consultation using a one-page questionnaire including scales for somatisation, anxiety, depression and alcohol abuse. Patients were randomised to one of two groups: (I) 900 questionnaires were disclosed and scored by GPs and (II) 885 were blinded to GPs. After the consultation the GPs completed a questionnaire on their assessments and actions taken. Subsequently a stratified sub-sample of 701 patients was selected for a diagnostic interview (SCAN) to be used as the gold standard. All the participating GPs were invited to receive a 6 months follow-up visit by a project physician in order to facilitate and evaluate the implementation of the entire intervention.

Improved recognition rates and diagnostic accuracy was demonstrated among patients with high screening scores. However, the routine screening for common mental disorders demonstrated limited effectiveness. Patients with high screening scores may be identified by 1) reporting fair or poor self-rated health, 2) perceiving their problem as not simply physical, 3) presenting with many physical symptoms, and 4) making the GPs feel uncertain, annoyed or insufficient. Disclosure of positive screening results increased the GPs' overall registration of mental disorders, conversation on psychological subjects, and rates of planned follow-ups. The instrument was easy-to-use and the operational characteristics suggest that it may be valid for use in primary care settings. Adjustment of the scoring-procedure improved the diagnostic performances of subscales. By using structured follow-up visits additional information was produced concerning future implementation strategies.

There is a need for further validation and development of mental health screens in general practice. New such approaches may include the evaluation of specified screening-criteria and use of electronic questionnaire-versions.