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Attitudes to referral to community mental health teams: a questionnaire study

  • P. Walker (a1), O.G. Haeney (a2) and P.C. Naik (a3)
Abstract
Aims and Method

There are no data or guidelines on who should be referred to community mental health teams (CMHTs), resulting in enormous variability in referral patterns. General practitioners (GPs) and psychiatrists were surveyed using a purpose-designed questionnaire to assess their attitudes regarding referral of individuals with different psychiatric disorders.

Results

There was consensus among GPs and psychiatrists that individuals with psychotic disorders, mania, severe depression and phobias should be referred to CMHTs. GPs were more likely to refer personality disorder, whereas the reverse was true for moderate depression and anxiety/ panic disorders. There was disagreement within groups about referral for acute stress reaction, mild depression and adjustment disorders.

Clinical Implications

Uncertainty about appropriate referral causes variability in referral patterns and service provisions. This needs resolution through the Royal Colleges of Psychiatrists and General Practitioners, to provide guidance leading to equality of care for all.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Department of Health (1999) A National Service Framework for Mental Health: Modern Standards and Service Models. London: Department of Health.
Double, D. (2002) The limits of psychiatry. BMJ, 324, 900904.
World Health Organization (1992) The ICD–10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Attitudes to referral to community mental health teams: a questionnaire study

  • P. Walker (a1), O.G. Haeney (a2) and P.C. Naik (a3)
Submit a response

eLetters

Who should be referred to Community Mental Health Teams?

Reena M Roy, Specialist Registrar in Psychiatry
21 June 2005

I read with interest the article by Walker,Heaney and Naik (Psychiatric Bulletin, June 2005,29,213-214). I think it raised some validissues that there is some uncertainty about who should be referred to Community Mental health Teams, and that due to this there is much variability in referral patterns.

However, I did feel that the method was flawed in a number of ways. Using the ICD 10 definitions of the ten common psychiatric disorders, and then asking GPs and General Adult Psychiatrists to decide whether each individual with each disorder would need referral to a CMHT does not relate to what should be current practice amongst doctors.

The ICD 10 definitions are used to make a diagnosis but it is not theonly tool we use to decide whether an individual needs to be referred to aCMHT. Most clinicians should take into account the individual patient's circumstances including his/her social and psychological needs. No matter what the diagnosis, if a patient was particularly vulnerable or was displaying a risk of harm to themselves or others, they would benefit fromthe multi-disciplinary and enhanced level of care that is provided by a CMHT. Many variables would need to be considered at an individual level before any doctor should decide to refer to a CMHT. It should never be a 'yes' or 'no' decision dependent on only the ICD 10 diagnosis.

Some patients prefer to have sole treatment from their GP possibly due to the reduced stigma and cope well. However, others with the same condition benefit from the 'Care Programme Approach' that is usually undertaken and audited by a CMHT. The benefits of having a 'care coordinator' that acts as an advocate and supervises the ongoing needs of the patient can be multiple. The patients's choice should always be considered when a referral is made to a CMHT.

I also noticed that dual diagnosis patients were not considered. Many patients may fit the criteria for several psychiatric conditions and this would surely influence their referral to a CMHT?

They state that the Royal College needs to research and provide guidance as to which patients should be referred to mental health services. I do not agree with this as I feel that the Royal College should be encouraging doctors to think laterally and to not rigidly followguidelines when it comes to important decisions about any individual person's care.

Reena Roy Specialist Registrar, Wickham Park House, Royal Bethlem Hospital, Beckenham, Kent, BR3 3BX, email: rroy@doctors.org.uktel:07944 734 679 fax:0208 776 4576
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Conflict of interest: None Declared

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Attitudes to Referral

Ross J Hamilton, Consultant Psychiatrist
16 June 2005

Sir: Walker and colleagues' questionnaire study (Psychiatric Bulletin, June 2005, 29,213-214) concerns attitudes to referral to a community mental health team (CMHT). The authors conclude that uncertaintyexists over appropriate referral criteria and this issue has been highlighted previously with respect to tension at the primary care/secondary care interface (Gask et al, 1997).

My own observations as a former general practitioner now a consultantpsychiatrist leading a CMHT lead to some hesitation in accepting the findings of such questionnaire surveys at face value. In a nutshell I feara significant Hawthorne effect comes in to play in such studies of referrers' and providers' views (Mays 1995). In my experience the responses elicited are as much a reflection of the responding clinicians' relationship with the institution inviting the response, as they are a true reflection on views of referral criteria. Within our own CMHT we arebombarded with so many questionnaires and surveys that our stock response is usually "who wants to know?".

Lest it be thought that we sit paralysed within this paranoid position we have introduced screening clinics for triage of new referralsto our CMHT in the face of ever increasing numbers of referrals from our general practice colleagues (Hamilton et al 2002).

GASK, L., SIBBALD, B. & CREED, F. (1997) Evaluating models of working at the interface between mental health services and primary care. British Journal of Psychiatry, 170, 6-11.

MAYS, N., & POPE, C. (1995) Qualitative Research: Rigour and qualitative research. British Medical Journal, 311, 109-112.

HAMILTON, R., GORDON, P. & NAJI, S. (2002) Service Innovation: The first year of a brief psychiatric screening clinic in primary care. Psychiatric Bulletin, 26, 218-22
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Conflict of interest: None Declared

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