GPs' role in the detection of psychological problems of young people: a population-based study (original) (raw)

Abstract

Background

Among young people, about one in three females and one in five males report experiencing emotional distress but 65–95% of them do not receive help from health professionals.

Aim

To assess the differences among young people who seek help and those who do not seek help for their psychological problems, considering the frequency of consultations to their GP and their social resources.

Design of study

School survey.

Setting

Post-mandatory school.

Method

Among a Swiss national representative sample of 7429 students and apprentices (45.6% females) aged 16–20 years, 1931 young people reported needing help for a problem of depression/sadness (26%) and were included in the study. They were divided into those who sought help (n = 256) and those who did not (n = 1675), and differences between them were assessed.

Results

Only 13% of young people needing help for psychological problems consulted for that reason and this rate was positively associated with the frequency of consultations to the GP. However, 80% of young people who did not consult for psychological problems visited their GP at least once during the previous year. Being older or a student, having a higher depression score, or a history of suicide attempt were linked with a higher rate of help seeking. Moreover, confiding in adults positively influenced the rate of help seeking.

Conclusion

The large majority of young people reporting psychological problems do not seek help, although they regularly consult their GP. While young people have difficulties in tackling issues about mental health, GPs could improve the situation by systematically inquiring about this issue.

Keywords: access to health care, adolescence, mental health, physician–patient relationship

INTRODUCTION

Among young people, about 35% of females and 20% of males report suffering from psychological problems,1,2 and the prevalence of mood or affective disorders reaches 5–7% when using specific tests.3–5 Although these problems can hamper everyday functioning and wellbeing, only a small minority of these young people receive professional help, with rates of unmet needs varying between 65% and 95%.6–12

Research has highlighted several barriers affecting the utilisation of mental health services. In the US, disparities concerning insurance status, closely linked to socioeconomic status, significantly influence access to mental health care for adolescents and children.6,7 In European countries where health insurance is compulsory in most cases, the association between socioeconomic status, and help seeking for psychological problems is strongly debated.8,9,11,13 Nevertheless, studies reveal high rates of unmet needs (72–87%). These studies highlight differences between young people seeking help or not, showing, for example, that those seeking help are less likely to have parents living together and more likely to have concomitant health or school problems. Informal resources, such as support of the family, other adults, or friends, also influence help seeking.8,11 Furthermore, young people themselves have identified several barriers affecting the utilisation of mental health services, such as being aware of the availability of local services, social visibility, and lack of anonymity.14,15 Even though patients in Switzerland can consult mental health professionals without being referred by their GP, in view of the perceived barriers to mental health care, GPs could play an important role in helping young people with psychological problems by assessing their needs and accompanying them towards more specialised care if needed. However, many young people do not consult their GP for such problems, thinking that it would be inappropriate and unhelpful because of beliefs that GPs deal exclusively with physical illness.12

There is evidence that 75–90% of young people consult their GP at least once a year, in most cases for somatic complaints.1,15,16 Thus, the question that arises is: are young people who do not seek help part of the minority of young people who do not consult their GP, or do they consult without expressing their distress? A small number of studies have tackled this question, reporting that the more contact young people have with their GP, the better the odds of consulting mental health services for psychological problems.8,13 This issue is worth addressing in depth because if young people not seeking help for psychological problems nevertheless have regular contacts with their GP, opportunities for discussing this issue as part of a regular consultation do exist.

The aim of this study is to assess, among young people who feel a need for help for psychological problems, the differences between those who seek medical help and those who do not. The frequency of consultations with their GP and their social resources will be taken into account, and potential confounders will be controlled for.

The research hypotheses are that among young people with psychological problems who seek help and those who do not, both regularly consult their GP;17 and that young people with more support from peers, family, or other adults will be more likely to seek medical help for their problems.18

METHOD

Data were drawn from the Swiss Multicenter Adolescent Survey on Health 2002 (SMASH02) database, which is based on data from a cross-sectional survey using a self-administered anonymous questionnaire of health determinants, status, behaviour, and healthcare utilisation, performed among a nationally representative sample of 7429 young people (weighted number) aged 16–20 years, attending post-mandatory school.

How this fits in

About one in four young people report needing help for psychological problems, but the majority of them do not consult for it even though most young people consult their GP at least once a year. Brief questioning by GPs could enable them to detect problems, help many of the young people consulting, and tackle the taboo issues around mental health.

In Switzerland, after mandatory school, about 30% of young people enter high school (students), 60% start an apprenticeship (apprentices attend class 1 or 2 days per week and work in a company the rest of the time), and 10% interrupt or delay their education, and therefore are not included in this study. The methodology of the survey has been described elsewhere.1

From the 7429 participants included in SMASH02 (45.6 % females), the present research only used a subsample of 1931 young people (26%) who answered positively to the question: ‘Do you currently need help for a problem of depression or sadness?’ (hereafter referred as ‘psychological problems’).

Dependent variable

The sample was divided into those who consulted a GP, a psychologist/psychiatrist, or another health professional for psychological problems (n = 256; 13.3%) and those who did not (n = 1675; 86.7%). (In Switzerland, patients can consult specialists without being referred by a GP.)

Independent variables

The main independent variable was the frequency of consultation with the GP during the previous year (none, 1–2 times, >2 times). Other independent variables, described as potential confounding factors in the literature,13,14,18 included:

• sociodemographic factors: age, sex, nationality, residence, academic track (student/apprentice), and socioeconomic status. Parents' education level was used as a proxy for socioeconomic status, and it was considered to be low when both parents' education level was mandatory school or less;
• social support and resources: family structure (parents living together/not); who the young people talk to when they encounter psychological problems (family, other adults, friends, boy/girlfriend, education professional, nobody); parent–young person relationship; school climate; and relationship with friends. The quality of the parent–young person relationship (1 = good to 4 = poor) was assessed using a six-item inventory. Five items were taken from the Inventory of Parent and Peer Attachment,19 and the last item was created about young people's perception of how much their parents trust them (Cronbach's α: 0.85). School climate (1 = good to 4 = poor) was measured with five items used in earlier studies (Cronbach's α: 0.61).20,21 Relationship with friends was measured (from 1 = good to 4 = poor) using the Inventory of Parent and Peer Attachment19 (Cronbach's α: 0.89); and
• mental and physical health: health perception (good/poor); having a chronic illness and/or handicap; history of suicidal attempt during the previous year; aggressive behaviour during the previous year (attacking an adult, carrying a weapon or using it in a fight); antisocial behaviour during the previous year (vandalism, theft, starting a fire intentionally); a history of sexual abuse; having been a victim of physical violence during the last year; substance abuse including alcohol misuse (>2 drunkenness episodes during the last month), cannabis use (>2 times during the last month), and use of other illegal drugs (at least once during the last month). Depression was measured with the Depressive Tendencies Scale (1 = low to 4 = high), a validated instrument containing eight items (Cronbach's α: 0.89).22,23

Statistical analysis

First, a bivariate analysis was performed to compare the two groups, using χ2 for categorical data and _t_-test for continuous data. Results are given as percentages or means with 95% confidence intervals. Next, a binary logistic regression was used. Standard procedures for automatic variables selection in regressions are known to produce unstable and non-reproducible results.24 Thus the explanatory variables to be included were selected using a bootstrap procedure. Ten thousand bootstrap samples were generated and a backward selection procedure was applied on each of them. Variables retained in at least 60% of the replications were included in the final model.25 Besides these selected variables, the study also controlled for sex, as it is a significant confounder. Stata (version 9.2) was used for bivariate analyses and logistic regressions. Matlab (version 7.5) was used for the bootstrap variable selection.

RESULTS

Overall, 34% of females and 19% of males reported that they needed help for psychological problems. Their background characteristics are described in Table 1. Results of the bivariate analysis are shown in Table 2. A high rate of young people who had not sought help was found (1675 of 1931, 87%). However, 78% of them had seen their GP at least once during the previous year. Among the 13% of young people reporting psychological problems who consulted for that reason, 45% sought help from a GP, 41% from a psychologist/psychiatrist, and 14% from another health professional.

Table 1.

Demographics of young adults reporting psychological problems (n = 1931).

Table 2.

Bivariate analysis comparing young adults with psychological problems who consulted with those who did not.

The multivariate analysis (Table 3) shows that older young people and students were more likely to consult for psychological problems, while sex was not associated with consultation rate.

Table 3.

Binary logistic regression with variables retained in at least 60% of replications in bootstrap analysis (sex added as important confounding factor).

The frequency of consultation with a GP was positively associated with seeking help for psychological problems: consulting once or twice a year was associated with a twofold increase in seeking help, and consulting three times or more with almost a fourfold increase. Confiding psychological problems in an education professional showed the strongest association with seeking help, with an adjusted odds ratio (aOR) of 5.0, while confiding in a family member or another adult showed an aOR of 2.0, and confiding in peers had no influence. Young people reporting psychological problems with factors of seriousness, such as a higher score on the depression scale or a history of suicide attempt, were more likely to consult, with an aOR of 2.1 and 3.5, respectively. Other concomitant physical or mental problems, such as having a chronic condition, substance abuse, or behaviour disorders, did not have any impact.

DISCUSSION

Summary of main findings

It was found that only 13% of young people who needed help for psychological problems had consulted a health professional (whether a GP or not) for this reason, and this rate was positively associated with the frequency of consultation with the GP. However, almost 80% of young people who did not consult for psychological problems had visited their GP at least once during the last year. Young people were more likely to consult for psychological problems if they were older or students, and if signs of seriousness were present (higher depression score, history of suicide attempt). Moreover, young people who talked about their psychological problems with adults were more likely to seek help from health professionals, especially if the adult was an education professional.

Strengths and limitations of the study

The main strength of this study is that a nationally representative sample was used. Additionally, there has been little research focusing on the association between help seeking for psychological problems and the frequency of consulting a GP, taking into account the influence of informal resources.8,11,26

The research also has limitations worth mentioning. First, the cross-sectional setting did not allow assessment of causality considerations or of temporal aspects of help for psychological problems. It is not possible to exclude that such problems could be linked to the mood of the day for some young people. Second, the results may also be limited because of self-reported data. However, the literature suggests that self-administered anonymous questionnaires encourage reporting the truth, especially concerning sensitive topics.27,28 Third, the study only took into account young people who recognised having psychological problems and needing help. It can therefore be considered that they had performed the first step to seeking help by admitting that they needed it,29 and so the proportion of young people not seeking help is probably underestimated. Finally, among the 10% of young people not included in the study who have interrupted or delayed their education, the rate of psychological problems is probably high, as a Swiss study reported that these young people were more depressed and carried out more suicide attempts than others.30 Therefore, the true rate of psychological problems among Swiss adolescents is probably higher than reported.

Comparison with existing literature

The rate of unmet needs in this study is consistent with the literature.6–12 Older young people were more likely to consult, maybe because they are more mature and consequently have a better insight as to their need for help for psychological problems. This association has already been described, although there is no conclusive evidence.13,18 While many studies reported that females were more likely to seek help than males,13,18,31,32 no significant sex association was found in the present study. Saunders et al found, in line with the present results, that females were more likely to identify a need for help but that there was no sex difference in obtaining help.26

In accordance with other studies, it was found that the more frequently young people see their GP, the more likely they are to consult for psychological problems.8,11 It is interesting to note that potential confounding factors, like having a poor health perception or a chronic condition, that are known to influence help seeking9–11,18 are not associated with it in the final analysis of the present study. Studies that have taken into account formal and informal resources have reported results similar to the present ones.8,26 Furthermore, it was found in the present study that most young people with psychological problems but not seeking help consult their GP at least once a year. These findings, consistent with those of Zwaanswijk et al,17 confirm the study assumption that young people with unmet needs for psychological problems are not out of the healthcare system. As most young people in both groups have contacts with their physician, differences between them are probably linked with both the patients' and the GPs' characteristics. A friendly attitude and systematically including questions on this issue during the consultation might increase the number of young people disclosing their psychological problems.

When young people confide their psychological problems to adults, this positively influences the rate of consultations for psychological problems. Gasquet et al also highlighted this difference between peers and adults, but found that young people talking to parents had no impact, while confiding in peers reduced the likelihood of consulting for a psychological problem.8 It can be hypothesised that adults understand the contribution of medical help and the seriousness of psychological problems better than young people. This finding confirms the importance of young people being supported by adults. Furthermore, Gasquet et al also found that education professionals have more impact than other adults.8 They are in a good position to detect psychological problems among young people, as they spend many hours with them and probably have more distance and objectivity than parents. It can be added that young people confiding in an education professional decide to speak about their problems outside the private circle, and consulting a GP requires a similar approach. The fact that secondary schools in Switzerland have a school nurse with a good network of health professionals to refer to if needed surely plays a role in the study findings.

Finally, young people with higher scores on the depression scale, or a history of attempted suicide in the previous year, were more likely to seek help. These two signs of seriousness increase the likelihood of consulting, either spontaneously or encouraged by family or friends.9,26 Although studies reported a similar influence of other concomitant psychological problems, such as behaviour disorders (antisocial, aggressive), substance abuse, or problems following sexual or physical abuse,9,13,18 no significant associations were found in the present study.

Implications for clinical practice

While young people have difficulties in seeking help for psychological problems, GPs could improve the situation by including questions in their medical history which can help them not only detect psychological problems but also tackle taboo issues about emotions and feelings. Through this approach, young people would receive the message that discussing such issues is also part of the GP's role. Moreover, such a practice could reveal occult symptoms of depression, which are frequently present among adolescents.33

This study focused on young people reporting the need for help for psychological problems. It found that 26% of young people reported this problem, a prevalence that was higher than that reported for mood disorders among young people (5–7%) when using specific tests.3–5 Consequently, it can be assumed that only some of these young people would have criteria for a psychiatric diagnosis and that attentive listening and counselling by a GP would be sufficient in some cases, while others could be referred to a specialist. Moreover, some of these young people probably do not need help from a physician and the GP's role is obviously not to treat all of them. The aim would be that young people appreciate that GPs are potential sources of help for psychological problems.

Finally, lack of time and training are often mentioned by GPs as major barriers to a comprehensive psychosocial anamnesis.34,35 However, a recent study performed in an emergency department showed that asking only two questions was a sensitive and specific way to detect depressive symptoms among 12–17 year-olds.36 Such quick and simple tools could also be used by GPs. Concerning training, Kraus et al reported that about 60% of Swiss GPs were interested in obtaining training for treating adolescents' depression and anxiety.37 Consequently, there is room for improvement and solutions to overcome these barriers.

Acknowledgments

The survey was performed within a multicenter multidisciplinary group from the Institute of Social and Preventive Medicine, University of Lausanne (F Narring, MD, MSc (principal investigator); V Addor, RN, MPH; C Diserens, MA; A Jeannin, MA; G Van Melle, PhD; P-A Michaud, MD); the Institute for Psychology, University of Bern (F Alsaker, PhD; A Bütikofer, MA; A Tschumpfer, MD); and the Sezione Sanitaria, Dipartimento della sanità e della socialità, Canton Ticino (L Inderwildi Bonivento, MA).

Funding body

The SMASH02 survey was carried out with the financial support of the Swiss Federal Office of Public Health (contract 00.001721/2.24.02.-81) and the participating cantons. The funding bodies had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review or approval of the manuscript

Ethics committee

The study protocol was approved by the ethics committee of the University of Lausanne's medical school, Switzerland

Competing interests

The authors have stated that there are none

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