”You may wade through them without seeing them.” General Practitioners and Their Young Patients with Mental Health Problems Marit Hafting Center for Child and Adolescens Mental Health, University of Bergen København

Research Question What characterises, according to GPs, good medical service provided to children and adolescents with mental health problems by their GP?

Choice of scientific method Child and adolescent psychiatry in primary health care is scarcely investigated Inductive, qualitative approach Data collection: Focus group interviews Analysis: Phenomenological perspective

Data collection 4 focus groups (Bergen, Førde, Stavanger) 19 GPs 2 hours per group interview Strategic sample (variation in gender, age, length of time i practice, experience from clinical work in different areas and health care settings) Data: 4 transcribed tape recordings and 4 logs from the group settings

Interview questions What is good health service for these patients from their GP? What kind of children and adolescents with mental health problems do you see? What can the GP do for them? With whom do you collaborate to help these patients?

Analyses Aim: To elaborate new and systematically documented descriptions from this practice field seen from the GPs perspective Procedure: The text was broken down into meaning units during a thorough reading. To develop adequate and condensed categories the similarities and difference between the meaning units were evaluated and compared with the total material.

Results Two main perspectives: The management of children and adolescents with mental health problems in general practice (what patients did they see, assessment and interventions) Opportunities and limitations in the care for young patients with mental health problems within the framework of primary health care and general practice in Norway

What patients did the informants see? Patient and/or the parents who consult their GP directly: Young patients with internalising problems (depression, anxiety, psychosomatic problems) “You may wade through them without seeing them” When the patient/ the parents think that somatic disease can be a cause When the patient (adolescent) seek confidentiality

What patients did the informants see? continued The GPs get involved in the patient through multidisciplinary collaboration with preventive care, child-protection service, school etc: Externalising problems (behavioural problems) Children and adolescents living in conditions with risk of developing psychiatric problems (trauma and/or abuse, psychiatric diseased or addicted parents, bullying etc) When learning difficulties, disabilities or mental health problems interfere with social well-being and performance in school

Assessment in the informants office The GPs make a global assessment mainly based on: Knowledge over time of the patient/ the family A thorough history Clinical examination – and observation over time

Intervention in the informants office “Show interest, talk understandable and offer a new appointment” The main intervention was giving advice to the parents based on knowledge of normal development and common health problems in children Systematic therapeutic contact with these children directly is seldom except for short time talking sessions with adolescents Psychopharmacological treatment is seldom offered They used to a little extent instruments or interventions developed towards specific psychiatric problems

Opportunities Confidence – gained through management of everyday medical problems over time Acquired general clinical competence – ”Our competence consist of all the children we have met, a large normal sample” “This is the strength of the GP. She can see the difference between the cases that are serious and those that are not. The parents trust us, and we are in a position to observe.”

Limitations Family medicine – only partly Network: Often not included in the multidisciplinary collaboration in primary care. “Surely there is a lot of good collaboration going on, but I do not know about it.”

Method discussion Our sample did not include GPs who do not have young patients in their practice and/or do not think that their mental health problems shall be treated in general practice. We claim that our study give reliable and valid results about the opportunities interested GPs have to offer health services to young patients with mental health problems within the frameworks of general practice in Norway

Method discussion continued The material contained to a very little extent stories about clinical difficulties and ambiguity about offering these patients treatment in general practice. The focus group design and the fact that the researchers are well known specialists in child and adolescent psychiatry, may have created some distortion in the material.

Conclusions The GPs are in a good position to provide psychiatric care for these patients because of their knowledge about the families and the local communities. They have acquired skills from their unselected practice to recognise serious and abnormal conditions and they have the patients´ and/or parents´ confidence. If the GPs are not involved in multidisciplinary collaboration with preventive health care, child protection services and schools, they will to a lesser extent come in contact with patients with behavioural problems and in unfavourable living conditions.

Conclusions Their services might have been more efficient if they possessed more specific competence to recognize child and adolescent mental health problems, specially conditions with co- morbidity to psychosomatic conditions like OCD, anxiety and depression. It is important to gain further knowledge about best practice in the interface between general practice and specialist services

Publications Hafting M, Garløv I. Fastlegen og psykisk sykdom blant barn og ungdom. Tidsskr Nor Lægeforening 2006; 126: Hafting M, Garløv I. ”You may wade through them without seeing them.” The General Practitionar and Their Young Patients with Mental Health Problems. Nordic Journal of Psychiatry.