MHBIS interventions, using a recoveryfocused approach, are based on the needs of patients, including education, monitoring of medication, counseling, strategies to enable change, and goal setting. If necessary, MHBIS will refer patients to other community services.
Previous annual surveys7 have indicated that most patients believed MHBIS aided their recovery by assisting them in developing behavioral strategies and in improving their lives. The intent of our study was to get the PCPs’ view of MHBIS: What kind of effect did they think it had on patient outcomes and their practice’s relationship with secondary services? Our main hypotheses were that MHBIS contributes to improving the mental health status of patients in primary care practices and enhances the interface between PCPs and SMHS by either facilitating referral as needed or averting the need for it in many instances.
Methods
We used mixed methods for this study to enable triangulation of data and to increase confidence in the research findings.8 We collected data using a questionnaire specifically designed for this study. To gain a more in-depth understanding of the impact of MHBIS on general practice, we also used a semi-structured interview format in 5 focus groups with a subset of participants. We extracted 6 months’ worth of data for 474 patient referrals from the MHBIS database, including the number of sessions attended, referrals to other services, and clinical and demographic information.
The total sample of 96 practitioners included the 39 physicians and 52 practice nurses (PNs) in the 28 general practice centres in the South Canterbury District Health Board and 5 MHBIS clinicians.
We coded the questionnaires so that responses could be directly entered onto Statistical Package for the Social Sciences (SPSS, version 16) for analysis. We thematically coded written responses in the free text sections of the questionnaires and from the transcribed focus groups to detect emerging themes, and recoded them until a saturation point was reached.9 We transformed emerging themes into quantitative variables and entered them into SPSS for further analysis.
Ethics approval was granted through the South Link Health Ethics Committee, the Upper South Regional Health and Disability Ethics Committee, and the Ngai Tahu Ethics Committee.
Completed questionnaires were returned by 54% of physicians (n=21), 44% of PNs (n=23), and 100% of MHBIS clinicians (n=5). Twenty-one members of the sample participated in the focus groups.
Of the 474 patients MHBIS saw between January 1 and June 30, 2008, 340 (72%) were female and 134 (28%) male (TABLE). Patients <18 years accounted for 4% of referrals; 18 to 24 years (16%); 25 to 44 years (40%); 45 to 64 years (28%); and ≥65 years (12%). Of referrals seen, 411 (86.7%) identified themselves as New Zealand European (NZE), 18 (3.8%) as Maori; 1 (0.2%) Pacific peoples, and 44 (9.3%) as “other” ethnicity.
Most patients were seen 1 or 2 times, with 25% using the allowable 4 visits. This would indicate that 4 visits are enough in most cases.
TABLE
Demographics of patients referred to and seen by MHBIS (n=474)
| Age group, years | Female | Male | NZE | Maori | Pacific peoples | Other |
|---|---|---|---|---|---|---|
| <18 | 15 | 5 | 15 | 3 | _ | 2 |
| 18-24 | 50 | 25 | 64 | 5 | _ | 6 |
| 25-44 | 139 | 52 | 162 | 7 | _ | 22 |
| 45-64 | 95 | 36 | 118 | 2 | 1 | 10 |
| ≥65 | 41 | 16 | 52 | 1 | _ | 4 |
| Total (%) | 340 (72%) | 134 (28%) | 411 (86.7%) | 18 (3.8%) | 1 (0.2%) | 44 (9.3%) |
| MHBIS, Mental Health Brief Intervention Service; NZE, New Zealand European. | ||||||
Results
All PCPs agreed that the MHBIS had assisted treatment and improved outcomes for patients, compared with PCP care alone. With MHBIS, patients returned less frequently, and, as described by one PCP, “they go away and … don’t bounce back.”
Physicians reported that access to MHBIS made a positive difference in the use of psychotropic medication: 67% wrote less prescriptions, 23% wrote the same number of prescriptions, and 5% prescribed more (5% of the sample did not respond to the question). In addition, 85% of physicians reported that they prescribed medications more effectively (based on their perception of “more effective”), and 76% reported greater patient compliance with medication regimens. One physician commented, “when MHBIS is seeing patients, issues are talked over and … the result [is that] they are more compliant with treatment.”
Deciding factors for PCPs making a referral to MHBIS were: presentation of symptoms, patient’s level of functioning and willingness to accept help, whether the patient presented in emotional distress, and office time pressures. All PCPs reported regularly receiving positive feedback from patients.
Interestingly, 81% of physicians reported an improvement in their relationship with SMHS and 33% used SMHS for medication reviews more frequently. Further-more, 71% of physicians reported that access to MHBIS resulted in decreased referrals to SMHS; 5% referred more, 5% the same, and 19% did not respond to the question. During the 6 months of the study, only 4% of patients seen by MHBIS were referred to SMHS. All PCPs reported that patients with a moderate mental illness preferred referral to MHBIS rather than to SMHS. Additionally, PCPs and PNs perceived that patients were more likely to attend a referral to MHBIS than a referral to another counselor in the community (91% PCPs, 96% PNs).