Key words: attitude, recognition, anxiety, depression

About 50% of general practitioners working in Abu Dhabi come from other Arab countries (North Africa and Middle East) and the other 50% from the Indian Subcontinent (India, Pakistan and Bangladesh)[1]. This complex set up of different languages, cultures and health beliefs complicates the provision of care at all levels, especially primary care which is the interface between patients and the health system.

Mental health is an important area in primary care where, according to W.H.O., at least 24% of patients suffer some sort of mental disorder[2] . The most common are anxiety and depression. In order that GPs can properly recognize anxiety and depression, they need to be aware of the prevalence to give it proper attention. The few studies conducted in the UAE were in the neighbouring area of Al-Ain where the Faculty of Medicine is situated. They showed a total prevalence of minor psychiatric disorders of 31.9% in women and 20.3% for men. The commonest diagnosis was depression 55%, anxiety –depressive states 13.3% and anxiety 11.7% .

There are different and complex barriers to recognizing anxiety and depression in primary care [4,5,6]. These are usually classified into patient, physician and health system factors. The patient may consider the symptoms as non-medical in nature and think that the GP cannot help. He/she thinks the problem is simple and can be handled by self bearing in mind the stigma of mental illness[4]. Physician factors include negative attitude toward mental illness, deficient knowledge, lack of good communication and interviewing skills, medicalisation of symptoms and fear of offending the patient. This is complicated by co-morbidity with a medical condition and negative false perception about treatment, in addition to personal factors like discomfort in dealing with emotional and interpersonal issues[4]. Health system factors include time constraints, limitation on third party coverage, limited treatment resource availability, restriction on access to particular treatment and fragmentation of care [4].

This was a quantitative, cross-sectional, descriptive study. Current GP knowledge of, and attitude towards, recognition of anxiety and depression was determined using a questionnaire constructed specially for the study. The study was approved by both Monash University Ethics Committee and Ministry of Health Ethics Committee in Abu Dhabi. All GPs working in Abu Dhabi primary care centers were invited to participate in this study. They were all Ministry of Health employees. A copy of the questionnaire (Appendix 1) was sent to GPs by routine mail in April 2004. Participants were requested to complete it and return it to the researcher in a reply paid envelope.

Development of the study questionnaire

The study questionnaire was designed to assess the GPs’ knowledge and attitude toward anxiety and depression. It consisted of three parts exploring the demographic characteristics including specialty and interest in psychiatry, knowledge of anxiety and depression and management issues and attitude toward anxiety and depression. The knowledge questions consisted of 18 items related to anxiety and depression, nine for anxiety and nine for depression and two items on drug interaction. These two items were included because, although GPs do not prescribe antidepressants, they see patients who use them from the psychiatric hospital but consult their GP for other illness. Thirteen questions comprise a simpler form of some questions available online from Membership of the Royal College of Psychiatry (MRCP Psych) Part I & Part II . The other seven were formulated by the researcher after gaining knowledge on the subject from the Oxford Textbook of Psychiatry and literature review.

The ten attitude items were selected after careful review of The Depression Attitude Scale , The Physician Belief Scale and McCall attitude questionnaire taking into consideration local factors in Abu Dhabi.

Each item was rated on a Likert scale of four ranging from strongly agree to strongly disagree. The four point scale was chosen to avoid jeopardising the result with a neutral response if it were selected by many participants, as it forces participants to choose. While this solves the problem of those who tend to choose neutral all the time, it forces them to either a positive or a negative end.

Most GPs were in the age group (46-55) years with an almost equal number of male (47.8%) and female GPs (51.1%). Arabic speaking GPs constituted about 65% of GPs and 10% had a family medicine specialty. About half of GPs (51.1%) said that they referred more than three patients to the psychiatrist per year and 45.6% referred one to three patients per year. Only 2.2% did not refer any patients to the psychiatrist per year.

The result of attitude items showed that a large number of GPs agreed with five of the items, which reflect negative attitude towards psychosocial aspects.

On the questions regarding anxiety disorders 54.4% of GPs were able to recognize the type of anxiety and only 42% recognized sleep deprivation as a cause of hallucination. Only 20% recognized the correct features of phobia and 42% identified the correct presentation of obsessive-compulsive disorder.

As for the questions on depression, only 33.3% of GPs were able to determine the correct type of depression. About 54% of GPs were aware of the correct relationship of depression to drugs and other diseases and 45.6% properly recognised the features of depression in the elderly. Only 56.7% were able recognise the presentation of postpartum depression. The question about factors that increase the risk of suicide in patients with depression warrants special notice. It was the least correct answer with 13.3% of GPs identifying insomnia as a factor which increases the risk of suicide. The review of all answers showed that 42 (56%) of the 75 GPs who answered incorrectly thought that suicidal ideas, increases the risk of suicide.

About 60% of GPs could not identify the discriminating feature between depression and anorexia and 85% did not recognise that cold cures interact significantly with antidepressants. More than 50% of the questions received a low percentage of correct answers. This shows that GPs lack important information required for anxiety and depressive disorders.

The comparison of the results of GPs according to sex, first language and specialty revealed a significant difference between the groups on few items. There was a statistically significant difference in attitude according to gender in the two items concerning GP perception of their role (first & fourth items in the table). For the first t=2.61, df=86, p=0.01) and second (t=2.49, df=87, p=0.02).

A significant difference existed on the same items regarding specialty between GPs with no prior training and family medicine specialty (t=-2.38, df=39, p=0.02 and t=-4.86, df=39, p=<0.01), and between GP with family medicine specialty and other specialty with significance (t=1.95, df=54, p=0.05), and (t=5.34, df=55, p=<0.01). There was no such difference due to first language.

Detailed examination of knowledge questions showed a significant difference according to first language (Arab/Non-Arab) in question 36 on discriminating features between major depression and primary anorexia nervosa, t=-3.01, df=82,p=<0.01). Regarding specialty there was a significant difference between GPs with no prior training and GPs with other specialty in one knowledge question (no 31) on elderly depression, (t=2.25, df=75, p=0.03). A second difference existed between GPs with family medicine specialty and other specialty on two knowledge questions. Question (18) on the types of anxiety was answered better by family specialty with significance (t=1.99, df=55, p=0.05). The other question [21] about phobia with significance (t=2.02, df=54, p=0.05). There was no significant difference on knowledge questions according to gender.

The study had a high response rate (81.8%). The relatively small number of GPs in Abu Dhabi (126) and continuous mobility between primary care centers, made all GPs acquainted with the researcher. Most GPs were aged 45 years. This is due to the fact that more than 95% of the GPs are expatriates. They require certain years of experience before they can apply for the license of medical practice in Abu Dhabi. There were almost equal numbers of male and female GPs unlike many western countries where male GPs outnumber females in full practice. The National depression study in Australia showed that more than half were male GPs . GPs who speak Arabic as a first language constitute about two thirds of GPs, which was not the case 10 years ago when Non-Arabic doctors represented the majority. This reflects the current policy of employing more Arab doctors for better communication especially with local patients. GPs with no prior training constituted one third of all working GPs. More than half of them were in the age group (46-55) and two thirds of them were females. About half of GPs said they referred more than three patients to a psychiatrist per year and only 2% said they referred none per year. This reflects the difference between what GPs think they do and what they actually do, as a previous pilot study using audit showed that no patient was referred to psychiatrist over a period of two years in one of the health centres.

Regarding attitude toward anxiety and depression in primary care, the majority of GPs disagreed with the statement that they cannot make a difference to patients with anxiety and depression and more than two thirds agreed that these patients should be referred to a psychiatrist. This showed that although GPs feel they can make a difference to patients with anxiety and depression, they do not consider it as a major role and that these patients should primarily be managed by psychiatrist.

The majority of GPs were more comfortable treating physical illness than emotional disorders, but less than one third said they felt frustrated exploring psychological issues with the patients. One possible explanation is the effect of medical school teaching which reflects the biomedical approach and the GPs comfort in dealing with physical illness, which they know best. GPs attitude towards competence, comfort or frustration in dealing with mental disorders raises the issue of GPs sensitivity towards issues that question their credibility and competence. More than two thirds of GPs said that they are too pressed for time to investigate psychological issues and that there are many issues to consider in the consultation. While this is true in busy primary care centers where GPs see 70-80 patients within seven hours, this is hardly the case in other centers where GPs see 20-25 patients within the same time range. On looking at all the attitude items the mean of all answers rated around ‘agree’ pointing to a possible response bias. This raises a lot of questions on whether the GPs put the scores as what they actually think, or what they are expected to think. Another factor which needs consideration is the unfamiliarity of GPs in UAE with surveys, especially those which need a rating on a scale.

The knowledge questions were structured in a simple direct way to explore basic knowledge in the area of anxiety and depression. However, more than half the questions were answered incorrectly by 50% or more of the GPs. The questions which received low correct percentage were those on the different types of anxiety, causes of hallucination, general features of phobia, presentation of obsessions in obsessive compulsive disorders, assessing the degree of depression and drugs that may cause it, depression in the elderly and postpartum depression, factors which may increase suicidal attempts, differentiation between depression and anorexia nervosa and depression and drugs which interact significantly with tricyclic antidepressants.

The simple form of the question construction lessens the doubt that questions were confusing or difficult to understand. The basic nature of the required information does not need extra expertise in the area of psychiatry, in fact this basic information can be found in medical books and they could have looked items up as the survey was done at a time and place convenient to them. This deficiency in GPs’ knowledge raises a lot of concern.

It will strongly affect GPs ability to recognise anxiety and depression and provide proper management even when these disorders are recognised. There were no previous studies in UAE exploring GPs knowledge and attitudes towards anxiety and depression to the best of the researcher’s knowledge. International studies showed that GPs knowledge and skill in the area of anxiety and depression is inadequate, however the depth with which such studies were conducted is variable. On comparing this study to an international one, the Australian study by McCall, only three out of 23 questions were answered incorrectly by more than 50% of participating GPs in the pre-course questionnaire. This result showed that GPs had a good knowledge level and answered most of the questions correctly (86.9%) even before attending the course in psychiatry. However they maybe a biased group already interested in psychiatry or knew they needed to improve their knowledge.

GPs in Abu Dhabi lack important knowledge, which is needed for recognition and management of anxiety and depression. A proportion of GPs lack confidence in diagnosing anxiety and depression. GPs perceive that they have a role towards patients with anxiety and depression, but do not know what it is exactly. This means that a large proportion of patients suffering from anxiety and depression, who attend primary care clinics, will not be recognised and therefore do not get the required treatment.

Training courses for GPs in primary care psychiatry are crucial to improve GPs’ knowledge and skills. These courses should meet GPs learning needs and upgrade their skills, and should be designed according to the most effective evidence-based strategies.

Click here to view Table 1

Special thanks to my local mentor Professor Greg Papworth who encouraged me to do the Masters degree and our continuous discussion enlightened me on the chosen topic.

Lastly, I thank my family who tolerated my frustration during my study and had faith that I can succeed in achieving my goals.