Effect of implementation of mental health services within primary care on GP detection and treatment of mental disorders in Israel.

BACKGROUND: Psychiatric morbidity is frequent in primary care, but a substantial proportion of these psychiatric problems appear to be neither recognized nor adequately treated by GPs. There exists a number of models of introduction of mental health services (MHS) into primary care, but little data are available on their effect on GPs' detection or management of mental disorders. The study aimed to measure the effect of referring patients to a psychiatrist within primary care (Shifted OutPatient model-SOP) or consultation of psychiatrists by the GPs (Psychiatric Community Consultation Liaison-PCCL) on the detection and treatment of mental disorders by GPs. METHODS: In six primary care clinics in Israel (three "SOP clinics" and three "PCCL clinics"), GP detection of mental disorders and treatment of GP-detected cases were evaluated before and after provision of 1-year MHS, according to GP questionnaires on a sample of primary care consecutive attenders whose psychological distress was determined according to the GHQ12 and psychiatric disorders according to the Composite International Diagnostic Interview. RESULTS: After model implementation, a significant reduction in detection of mental disorders was found in SOP clinics, while no significant change was found in PCCL clinics. No significant change in detection of distress was found in any clinic. An increase in referrals to MHS for GP-diagnosed depression and anxiety cases, a reduction in GP counselling for GP-detected cases and those with diagnosed anxiety, an increased prescription of antidepressants and a reduced prescription of antipsychotics were found in SOP clinics. In PCCL clinics, no significant changes in GP management were observed except an increase in referral of GP-diagnosed depression cases to MHS. CONCLUSIONS: MHS models did not improve GP detection of mental disorders or distress, but possibly improved referral case mix. The SOP model might have a deskilling influence on GPs, resulting from less involvement in treatment, with decrease of detection and counselling. This should be taken into consideration when planning to increase referrals to a psychiatrist within primary care settings. Lack of positive effect of the PCCL model might be overcome by more intensive programs incorporating educational components.

Mental disorders in primary care in Israel: prevalence and risk factors.

OBJECTIVE: Psychiatric morbidity is common among patients in primary care services and leads to disability and increased use of medical services. Comparison of primary care and community prevalence data is of interest in relation to the health services planning for mental disorders. The aim of the present study was to measure prevalence of mental disorders in six primary care clinics in Israel and to assess risk factors for these disorders. METHOD: Prevalence of mental disorders was measured in a sample of 2,948 primary care consecutive attendees, using two-stage stratified sampling with the General Health Questionnaire 12 (GHQ-12) and the Composite International Diagnostic Interview (CIDI). RESULTS: A high rate (46.3%) of current mental disorders was found, with rates of current depressive episode, generalized anxiety disorder, somatization disorder, and neurasthenia being relatively high in comparison with rates in other countries. Low education was a risk factor for all categories of disorders, unemployment a risk factor for depressive disorders, and parenthood was protective for most categories of disorders. CONCLUSIONS: High rates of mental disorders were found in this Israeli primary care sample as compared to other countries, while in the community the rates were midrange as compared to other countries, pointing to a relatively higher use of primary care services by patients with mental disorders in Israel than in other countries.

Involvement of GABAA receptor modulating neuroactive steroids in patients with social phobia.

Dehydroepiandrosterone (DHEA) and its sulfate ester (DHEA-S), neurosteroids synthesized in the brain, are weak gamma-aminobutyric acid (GABA) A receptor allosteric antagonists that may be involved in anxiety disorders. In the present study we measured the circulatory [corrected] levels of DHEA, DHEA-S, pregnenolone and cortisol in [corrected] untreated patients (n=26) diagnosed with social phobia (SP) compared with sex- and age-matched healthy controls (n=21). No significant differences in neurosteroids were observed in [corrected] untreated SP patients and [corrected] compared with healthy controls. The findings may reflect an absence of involvement of the GABA(A) modulators DHEA, DHEA-S and pregnenolone in SP.

Platelet vesicular monoamine transporter density in untreated patients diagnosed with social phobia.

The vesicular monoamine transporter (VMAT2) is important in the storage and release of monoamines. Platelet VMAT2 was characterized using high-affinity [(3)H]dihydrotetrabenazine ([(3)H]TBZOH) binding in untreated social phobia (SP) patients (n=20) compared with sex- and age-matched healthy controls (n=15). No significant differences in VMAT2 density (B(max)) and affinity constants (K(d)) were observed.