ABFM, FFCM (KFU)
Family & Community Consultant,
Supervisor of Primary and Community
Mental Health Program, Eastern Province,
Saudi Arabia (S.A)
A. Rahim, Ph.D.,
Professor, Department of Psychiatry,
King Faisal University, S.A
was an Associate Professor, Department
of Family and Community Medicine,
King Faisal University, S.A
S. AbuMadini, MBBS, DPM, BC Psych.
Professor and the Chairman and Psychiatry
Department, King Faisal University
Dukhail Al Khathami
King Fahad Hosp. of the University
measure the effect of mental health
training program on the ability of
PHC physicians to detect and manage
Method: It is
an intervention study carried out
in Dammam Sector, Saudi Arabia. The
course was implemented in June 1999,
and ran over 4 days. A random sample
of 31 PHC physicians was selected.
The area of study was divided into
five clusters, from which ten physicians
were selected randomly to evaluate
their skills in diagnosis and pattern
of managementsof mental disorders
in PHC settings. File audit was used
through the period of six months prior,
and six months after the course, in
order to evaluate the training effect
on the physicians' performance. Every
physician acted as his/her own control.
total number of psychiatric cases
detected by the ten physicians during
the first 6-month period was 20 cases
out of about 60,000 PHC patients.
Following the course, during the last
six-month period, 21 psychiatric cases
were detected (3.5 cases in every
10,000 patients). According to the
results, the trained physicians were
able to diagnose more generalized
anxiety disorder, social phobia, and
sexual disorder, at the expense of
non-specified mental disorders. The
majority of cases were referred to
shorter-term mental health-training
program didn't enable PHC physicians
to detect the minor mental health
problems. There is a need for an advanced
and long-term mental health-training
course, focusing on the practical
application of identifying mental
illness among PHC patients.
Key Words: Mental
illness, training course, File audit, evaluation,
PHC physicians, Saudi Arabia
Mental illness is frequent
in the primary health care (PHC) setting;
about 20-40% of PHC patients suffer from
diagnosable mental disorders (1,2). A similar
percentage was found among Saudi PHC patients3.
Most of these are cases of depression, anxiety,
or somatoform disorder (4,5). They mostly
present with more physical than with psychological
complaints (6,7) and are usually associated
with a significant degree of disability
There is evidence suggesting
that, despite the high prevalence of these
mental illness, they frequently pass unrecognized
by the PHC physicians (2,4,9). Higgins (1994)
conducted a meta-analysis of extensive literature
over 25 years performed in PHC settings
to find that 33-79% of mentally ill patients
had not been recognized by their physicians10.
A study conducted in Al-Khobar showed that
21.7% of adult male PHC patients suffered
from some mental illness, of which 80% were
undetected5. Another in Riyadh also showed
low identification index of the PHC physicians
Experience shows that
brief training programs can substantially
upgrade the PHC physicians' knowledge and
attitudes towards these disorders (12,13).
Most studies consider programs of two weeks
or more are cost effective and appropriate
(14,15). Recognition of such patients is
vitally important in order to reduce the
suffering of individuals and the futile
consumption of public resources (16).
The aim of the present
study was to measure the change in PHC physicians'
skills resulting from a short mental training
course for the detection and management
of common mental disorders in PHC settings.
This is an intervention
study carried out in Dammam Sector, Eastern
Province, Saudi Arabia. The course was implemented
in June 1999, and ran over four days. A
random sample of 31 PHC physicians out of
191 physicians working in 111 PHC settings
was selected. All the recruits had no previous
exposure to post-graduate training in psychiatry
and never worked as a physician in any psychiatric
To evaluate the PHC physician's
skills, the area of study was divided into
four clusters. Dammam and Khobar each represented
a cluster, Qatif and Safoa, as a cluster.
Ras-tanoora, Jubail and Bqaq represented
the fourth cluster. Thirty-three percent
from each cluster was randomly selected
as the representative sample of 10 physicians.
The course was structured accordant with
the national program to improve the PHC
physicians' skills in the field of mental
health care. It contained assessment and
management of the common mental health problems
in the community e.g. depression, anxiety,
somatization, as well as mental problems
in children and young people, the basic
psychiatric medication, and the referral
system. A variety of teaching methods were
employed, including brief lectures/demonstrations,
videotapes, small group workshops, discussions
and role-play. The workshops were facilitated
by experienced psychiatrists and were conducted
in small groups.
All files of presumably
mentally ill patients were evaluated, of
whom each 10 physicians had seen during
the six months prior to the course and six
months after the course and register in
the registration books. File audit was used
to estimate the detection rate and patterns
of management before and after the training
intervention. Every candidate acted as his/her
own control. The difference between the
quantity and quality of management achieved
by each candidate in the Post-intervention
from those obtained in the Pre- intervention
periods would be the outcome product of
the training course on that particular subject.
At the end of the intervention
course, a self-administered questionnaire
was distributed to the trainees, consisting
of seven questions. For each question, the
responses were made on a five-point scale
ranging from completely unfavorable (scoring
one) to completely favorable (scoring five).
The study sample was
composed of 31 PHC physicians. Of these
16 (51.6%) were men and 15 (48.4) were women.
Twenty (64.5%) were Saudi, 6 (19.4%) from
other Arab countries, and 5 (16.1%) were
non-Arabs. Their ages ranged from 26 to
49 years with a mean + SD of 34.24+ 7.47.
Their professional service in PHC settings
ranged from 1 to 20 years (mean 4.81+ 5.19).
Six of the trainees (19%) were not exposed
to undergraduate psychiatric training. Twenty
percent had been exposed to 4 weeks or less,
and 71% of them exposed to more than 4 weeks.
Ten PHC physicians (30%) of the trainees
were selected to evaluate their practical
performance; 4 were men physicians (40%)
and 6 women (60%).
Each PHC physician saw
an average 40 patients per working day.
Roughly he/she was seeing 12,000 cases per
year. The total number of psychiatric cases
detected by all the ten physicians during
the 6-month period proceding the course
was just 20 cases out of about 60,000 PHC
patients (3.3 cases out of 10,000 patents).
This detection rate has not been affected
by the training course, for the total number
of detected cases during 6-month period
following the courses was almost the same
1 shows the recorded different psychiatric
diagnosis before and after the intervention.
The trained PHC physicians were able to
diagnose more of generalized anxiety disorder,
social phobia and sexual disorder, at the
expense of less of non-specified mental
disorders. They diagnosed 17 cases out of
the all-detectable cases (85%) before the
intervention and diagnosed 20 cases (95%)
after the intervention.
Most of the diagnosed patients were referred
to psychiatric clinics. A small proportion
of the patients were referred to non-psychiatric
clinics e.g. medical or pediatric clinics.
The management forms were reassurance and
non-psychiatric medication. These were given
to 20% of the mentally ill patients in the
pre-program period and 24% in the post-program.
Psychiatrists prescribed all anti-depressive
drugs previously. In the pre-course period
no patient had a follow-up appointment at
PHC settings, but after the post course
two patients had follow-up with their PHC
All physicians who took
part in the sample felt that it was necessary
to have a mental training program. Thirty-two
percent of them felt that they were average
in psychiatric knowledge before the intervention.
After the intervention only 3.2% of the
trainees had the same feeling, while the
rest had the feeling that their level had
improved (see Table 2).
Despite the high prevalence
of mental illnesses in PHC settings, physicians
were not able to detect most of these cases.
Each physician discovered on average only
two cases annually. Moreover, there are
a number of physicians who had never diagnosed
any case, neither before nor after the training.
This means that most mentally ill patients
do not get real benefit from their visits
to PHC settings. This is deplorable in view
of the fact that, most of these minor psychiatric
morbidity cases if detected and identified
early could be appropriately managed by
PHC physicians, if only they are given a
little instruction in this field.
None of these physicians
had adequate undergraduate or postgraduate
encounters with psychiatric patients. Many
of them may be wary of becoming involved
in mentally ill patients' care, preferring
to adopt a minimalist role and deal only
with physical complaints. As most patients
usually present with physical symptoms,
somatically oriented physicians are more
likely to miss the concomitant psychological
features. Besides the stigma of mental illness,
which is still so strong in this culture
might influence the physicians' readiness
to label their patients as such. Whereas
the PHC physicians have in their pharmacies
a wide a range of drugs for treating somatic
symptoms, they are offered no psychotropic
drugs whatsoever. Presumably, their reluctance
to document psychiatric diagnosis in their
registration books is partly due to the
strength of habit, or the presence of co-morbidity
with a more chronic medical condition to
which they are more equipped to offer help.
Although the studied
PHC physicians did not diagnose significantly
more psychiatric cases after their course,
they became more definite about the diagnosis
than before . Additionally, some began to
give appointments for follow-up. These findings
indicated that if theses courses were modified
in quality and quantity, they could provide
a good out-come. This is supported by Joukamaa
et al findings that the ability of PHC physicians'
detection for psychiatric cases was significantly
associated with postgraduate long-term psychiatric
training and qualification as a specialist
in general practice (Family Medicine)2.
So, short the training period of the course,
lack of psychiatric medication, and the
absence of continuous medical education
might play a role in the failure of the
However, many psychiatric
training programs for PHC physicians were
able to improve the trainees' ability to
diagnose and manage mentally ill patients
(18-20). When we compare our findings with
that achievement, there were very important
differences in the methodology of the evaluation
process; they had used screening tools i.e.
General Health Questionnaire (GHQ) before
the intervention, not file audit, and asked
the PHC physicians to assess in advance
the patients' emotional status (17,18).
This design could increase the doctors'
awareness of mental illness and make them
ask their patients about related symptoms
and signs. Also, the distribution of the
GHQ to the patients before the interview
may alert the patient to psychological complaints
which he or she might not have otherwise
discussed with the doctors spontaneously.
In some studies the participants had already
been exposed to mental health training before
the intervention, despite that they recommended
the requirement to further training in the
basic skill set (19).
A shorter-term mental
health-training program didn't enable PHC
physicians to detect and manage mental health
problems. It appears that there is a need
for an advanced program, preferably a long-term
mental health-training course that focuses
on practical application of correctly identifying
mental illnesses. Also, we recommend further
efforts to lift the physicians' skills such
as to establish a referral clinic with specialists
who are interested in primary mental health
care within PHC settings. Hoping to build
good communications between the PHC physicians
and the specialists through consultations,
may promote primary mental health care.
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