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 (8).

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 (33%) (11).

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 facility.

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 (21 cases).

Table 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 physician.

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 physicians' improvement.

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.

1. Sartorius N, Ustun B, Silva J, Silva J, Goldberg D, Lecrubier Y. et al. An International Study of Psychological Problems in Primary Care: Preliminary Report From the WHO Collaborative Project on 'Psychological Problems in General Health Care'. Arch Gen Psychiatry, 1993; 50: 819-824.
   
2. Joukamaa M, Lehtinen V, Karlsson H. The ability of general practitioners to detect mental disorders in primary health care. Acta Psychiatr Scand 1995: 91; 52-56.
   
3. Al-Khathami A, Ogbeide D. Prevalence Of Mental Illness Among Saudi Adult Primary-Care Patients In Central Saudi Arabia. Saudi Med J, 2002;23(6): 721-724.
   
4. Ormel J, Maarten W, Koeter J, Brink W, Williige G. Recognition, Management, and Course of Anxiety and Depression in General Practice. Arch Gen Psychiatry,1991;48: 700-6.
   
5. Al-Fakeeh A. Adult male psychiatric morbidity among PHC attendants in Al-Khobar [Dissertation]. King Faisal Univirsity, 1994.
   
6. Freeling P, Reo B, Paykel E, Sireling L, Burton R. Unrecognized depression in general practical. BMJ 1985; 290:1880-1883.
   
7. Rasmussen N, Avant R. Somatization disorder in family practice. Am Fam Physician, 1998;40(2):206-14.
   
8. Gureje O, Simon G, Ustun T, Goldberg D. Somatization in cross-cultural perspective: a WHO study in primary care. Am J Psychiatry, 1997;154(7);989-95.
   
9. Brown C, Schulberg H. The efficacy of psychosocial treatments in primary care. A review of randomized clinical trials. Gen Hosp Psychiatry 1995;17(6):414-24.
   
10. Higgins E. A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. Arch Fam Med 1994;3(10):908-17.
    
11. Faris E, Hamad A, Shammari S. Hidden and conspicuous psychiatric morbidity in Saudi primary health care (A pilot study). The Arab J of Psychiatry, 1995;6(2):162-175.
    
12. Khathami A, Mangoud A. Shiekh Iddris, AbuMedian M. Mental Health Training in Primary Care: Impact on Physicians Knowledge. Neuroscience J, 2003; Vol. 8 (2): 447-45.
    
13. Khathami A, Shiekh I, Mangoud A, Abu-Median M, Hanif M. Can A Short-Term Training Course Improve PHC Physicians Attitudes Toward Mental Health Problems? J. Family & Community Medicine, 2003; Vol10(3):19-24.
    
14. Higgins E. A review of unrecognized mental illness in primary care: Prevalence, natural history, and efforts to change the course. Arch Fam Med 1994; 3(10):908-917.
    
15. Qureshi NA, Al-Ghamdy YS, Al-Haddad NS, Abdelgadir MH, Tawfik MH. Integration of mental health care into primary care. Preliminary observations of continuing implementation phase. Saudi Med J 2001;22:899-906
    
16. World Health Organization. Recognition and management of patients with functional complaints. Regional Office for South-East Asia, New Delhi, 1989.
    
17. The Annual Bio-statistical Report. MOH, Eastern Province, 1999.
    
18. Steven A, Boker J, Brird J, Arthur M. Psychiatric Education for Primary Care: A Pilot Study of Needs of Residents. J Med Education , 1982; 57: 931-936.
    
19. Howe A. Detecting psychological distress: Can general practitioners improve their own performance. Br J of Gen Practice, 1996;46:407-410.
    
20. Al-Faris E, Al-Subaie A, Khoja T. Nasary L, Abdul-Raheem F, Hamdan N. et al. Training primary health care physicians in Saudi Arabia to recognized psychiatric illness. Acta Psychiatr Scan, 1997; 96:439-44.