Introduction: Since the Australian Government introduced the “Better Access to Mental Health Services” program in 2006, psychiatrists, psychologists and general practitioners (GPs) have become increasingly involved in service provision for people seeking help with mental health problems. The aim of this research was to a) explore psychologists’ perceptions of difficult to treat depression (DTTD) and b) explore what they thought about the GPs’ role in managing these patient given that most patients are referred to psychologist by GPs. Methods: A previously developed semi-structured interview schedule comprising six questions was used. Seven psychologists participated in a focus group held in Melbourne. Data were analysed using the framework method. Findings, including Discussion: While psychologists understood the term DTTD it was suggested that using different terms may limit understanding between health professionals. Rather than diagnosing, psychologists were more likely to conduct further assessment contextually to confirm GPs’ diagnosis. Communication with GPs was important, particularly when managing “long-term” and suicidal patients. Management included cognitive and behavioural interventions and referring to other mental health services, psychiatrists and/or other allied health professionals. Referral to psychiatrists could be difficult because of limited availability and for some patients, prohibitive costs. Although psychologists discussed non-pharmacological and/or complementary treatment options with patients, they were more likely to rely on GPs to discuss/prescribe these options. Conclusion: While generalisability may be limited, this study is the first to document some understanding of psychologists perceptions of DTTD and the importance of GPs and other health professionals’ role in managing this patient cohort.
Mental health and mental illnesses are determined by multiple and interacting social, psychological and biological factors [
These reforms resulted in a change in service provision with a greater emphasis on care within the community rather than institutions and/or hospitals [
In Australia, for the majority of people seeking help with mental health problems, the first point of contact is the GP [
While evidence suggests that the uptake of the better access initiative has been high [
In 2011-2012, there were an estimated 1858 (full-time-equivalent) registered psychologists practising [
A search of the literature found a study published in 2004 describing the benefits of a collaborative model of mental health care involving GPs and clinical psychologists for patients with common mental disorders who sought help via primary care health providers [
Thus the absence of literature suggests the importance of conducting exploratory work to gain an understanding of psychologists’ perceptions, and at the same time, adding to the exploration of GPs’ [
The aims of this research were a) to explore psychologists’ perceptions of DTTD and b) to explore what they think about the GPs’ role in managing patients diagnosed with DTTD.
As the DSMV [
A convenience sample was recruited via an email forwarded to psychologists with links to the Monash Medical Centre, a public hospital in Melbourne, Australia. When potential participants responded and agreed to participate, they provided their contact details (email) to the research team for the purpose of the research team advising time, date and venue for the focus group [
A semi-structured interview schedule comprising six headings was used; this schedule was previously developed and used when interviewing and/or conducting focus groups with GPs [
All data were collected in Melbourne; a focus group was held with seven psychologists (five females, two males) which lasted approximately one-and-a-half-hours, was audio-taped and transcribed verbatim. At the time of the focus group, all described themselves as clinical psychologists with experience in both the public (including hospitals) and private sector. No other demographic data were collected.
Data were analysed using the framework method [
Ethics approval to conduct the study was obtained from Monash University Human Research Ethics Committee (MUHREC).
Findings and discussion are reported under the interview schedule’s six sub-headings.
Question 1: Understanding of the term difficult-to-treat depression (DTTD).
Whilst GPs’ understanding of the term DTTD varied [
1. What is your understanding of the term difficult-to-treat-depression (DTTD)? | ||
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2. What is your understanding of other terms; viz: treatment-resistant depression (TResD) treatment-refractory depression (TRefD), treatment-resistant major depressive disorder (TRMDD) and major depressive disorder (MDD)? | ||
3. What are your experiences of diagnosing DTTD? | ||
4. What are your experiences of managing DTTD? | ||
5. Does your management of these patients include: | ||
a. using an illness management model or a chronic illness model [ | ||
b. communication with GPs; | ||
c. referring the patient to other allied health professionals; and | ||
d. suggesting/prescribing other non-pharmacological and/or complementary treatment? | ||
6. If “no” to any of Question 5, have you ever considered using any of these options/other comments? | ||
We start with an assessment, actually working out what were the presenting problems. (P1) I think there’s also an element that you aren’t able to engage the person in any level of responsiveness in self-management or anything like that, minimum insight. (P7) | ||
Question 2: What is your understanding of other terms viz: treatment-resistant depression, treatment- refractory depression, treatment-resistant major depressive disorder, and major depressive disorder (MDD)?
There was agreement that the terms could be used inter-changeably, thus may have different meanings for health professionals and/or patients. It was also suggested that different terms may be tied to medical expectation and/or medication (P7):
The variance of psychologists’ understanding of the terms when compared to the GPs’ [
Question 3: What are your experiences of diagnosing DTTD?
Whilst all GPs had diagnosed patients with DTTD, similar to GP trainees and psychiatrist registrars, psychologists’ experiences varied. The majority of psychologists agreed that if a client was referred with a diagnosis of DTTD, then they would not spend time confirming the diagnosis or otherwise (P3), rather, would do a further assessment contextually. One suggested starting a discussion about personality issues to check if that was the overriding or prime problem and that their [patient’s] low mood was sort of secondary to a different problem rather than being the primary issue (P1). Another suggestion was that if they [the psychologists] were unsure of the diagnosis as indicated in the referral provided, they would take the query back to the referring GP, particularly to check whether different medication had been tried (P3).
Whilst there was agreement that a change in medication may be helpful for some patients because some respond to some medications and not to others (P1), no-one would change medication, rather, the matter would be referred back to the referring GP:
The last comment moved the discussion from medication changes to unanticipated suicide. Whilst all had heard of another health professional having to deal with a suicide, no one in this group had that experience, but two had dealt with uncompleted attempts (P1, P2). In addition to dealing with uncompleted attempts, several GPs had dealt with completed suicide [
Question 4: What are your experiences of managing DTTD?
All started managing the patient with an assessment to work out what the presenting problems were by looking at the psychological aspects. In a hospital, the psychologist tends to use more of a clinical interview rather than a checklist, but when there is a workcover claim, or the patient is in the private health system, there are requirements for the psychologist to use outcome measures such as K10 or BECK [
As part of management, psychologists and GPs [
Question 5: Does your management of these patients include: a) using an illness management model [
a) Using an illness management model
Along with GP trainees [
b) Communication with GPs
General consensus was that, generally, people are now more willing to acknowledge and address mental health issues and seek help, initially from GPs. All participants had communicated with GPs and agreed with the GPs comments that navigating the various aspects of the mental health system could be difficult. This sometimes resulted in GPs using mental health treatment items [
One psychologist had worked in the country in a large rural centre and like the GPs who worked in rural Australia, found it “tough” to get services, albeit mental health support is more accessible in recent years because of the Medicare rebates and psychologists and social workers working in the community (P4).
c) Referring to other allied health professionals
Referring to other allied health professionals was limited, but it was generally agreed that it was difficult when referring to a multi-disciplinary team because “no one works on the same day” (P1):
Challenges were also experienced when endeavouring to deal with a crisis using the Crisis Assessment Team (CAT):
Whilst referral patterns differed between groups, general consensus was that, regardless of availability of resources or cost, the relationship between the patient and professional was particularly important [
d) Suggesting/prescribing non-pharmacological and/or complementary treatment
According to the Australian Psychological Society, psychologists spearheaded the development/use of non- pharmacological treatments [
Similarly, GPs felt that non-pharmacological, complementary and/or lifestyle options have a role in managing DTTD [
Question 6: If no to any of Question 5, have you ever considered using any of those options/other comments?
The discussion concluded by returning to the importance of “knowing the system” and any subsequent impact on health professionals and patients: most participants felt the referral process is difficult and “you have to be pretty assertive and then that can be misinterpreted” (P3). Some services have criteria which are understandable, but there is also the stigmatising issue:
Making referrals for someone with difficult to treat depression, was described as more difficult if the person’s not particularly receptive to accepting service:
This paper is the first to contribute to understanding psychologists’ perceptions of DTTD and at the same time, adding to the exploration of GPs [
These psychologists demonstrated a clear understanding of DTTD, insight into various terms and their professional role and relationship with GPs in diagnosing and managing patients diagnosed with DTTD. Although the Australian government’s initiatives had improved access to psychologists, particularly via GP referrals, concerns were expressed about the difficulty GPs and psychologists experienced when endeavouring to access services and also the cost of services for those who were unable to access services via Medicare funding options.
Opinion on communication varied; while referrals were made by GPs to psychologists as part of the diagnosis and management process, these referrals could be hampered initially by limited access/availability of psychologists and other health professionals, then, during the management process when these health professionals endeavoured to hold multi-disciplinary team discussions. After-hours services such as Crisis Assessment Teams were also described as difficult to access, resulting in people who were mentally unwell having to attend already overloaded emergency department in local hospitals.
While the generalisability of this study may be limited because of the small number of participants who were all from metropolitan Melbourne, this study is the first to contribute to the literature about psychologists’ experiences and perceptions of DTTD, what psychologists think about the GPs’ role in managing patients with this diagnosis and drawing some comparisons between the various health professionals’ experience in diagnosing and managing with DTTD.