title: General practitioners' management of mental disorders: a rewarding practice with considerable obstacles.
abstract: BACKGROUND
  Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.
  
  
  METHODS
  This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.
  
  
  RESULTS
  At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.
  
  
  CONCLUSIONS
  To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.
authors.affiliation: Department of Psychiatry, McGill University, Montreal, Canada. flemar@douglas.mcgill.ca
authors.forename: Marie-Josée
authors.initials: MJ
authors.lastname: Fleury
authors.forename: Armelle
authors.initials: A
authors.lastname: Imboua
authors.forename: Denise
authors.initials: D
authors.lastname: Aubé
authors.forename: Lambert
authors.initials: L
authors.lastname: Farand
authors.forename: Yves
authors.initials: Y
authors.lastname: Lambert
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence / Q000592:standards* / Q000706:statistics & numerical data; D039721:Diagnostic and Statistical Manual of Mental Disorders; D019468:Disease Management; D018588:Fee-for-Service Plans / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D058005:General Practitioners; D006123:Group Practice / Q000706:statistics & numerical data; D006302:Health Services Research; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods / Q000592:standards; D010353:Patient Education as Topic / Q000379:methods; D010818:Practice Patterns, Physicians'; D015995:Prevalence; D011331:Private Practice / Q000706:statistics & numerical data; D011792:Quebec / Q000453:epidemiology; D019035:Rural Health Services / Q000191:economics; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D019037:Urban Health Services / Q000191:economics