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ORIGINAL ARTICLES

Training Russian family physicians in mental health skills

, , &
Pages 19-22 | Published online: 11 Jul 2009

Abstract

Objective: This paper describes the setting up of training for family physicians in mental health skills, with the results obtained for the first 75 doctors who attended the course, in the city of Ekaterinburg, Russian Federation. Methods: Instruction was by lectures, discussion groups, and role-plays, initially using the World Psychiatric Association's (WPA) training materials on mental health skills for general medical practitioners, dubbed into Russian. This represented the first time that formal teaching on depression and unexplained somatic symptoms (USS) had been offered to these doctors. Teaching was initially by English teachers, but is now led by a Russian family physician using videotaped recordings of local doctors speaking in Russian. All doctors were tested for both knowledge and clinical practice before the course and 3 months after the course was completed. Results: Older doctors started the course from a lower knowledge base than younger doctors, but acquired more knowledge. Theoretical knowledge of both depression and USS increased dramatically, and great changes occurred in the way that these patients are managed.

Conclusion: Mental health skills training has been provided to Russian family physicians with a positive impact on theoretical knowledge and self-reported management. The course has now been expanded, and more Russian teachers are involved.

Introduction

Primary care in Russia was previously carried out in polyclinics, each containing an assortment of subspecialists, whose basic medical education had included very little instruction concerning common mental disorders. In 1992, the policy of the Ministry of Health in the Russian Federation was to move to one of general practice Citation[1], and training courses were set up both for those who had previously worked in the polyclinics and for younger general practitioners (GPs) in training Citation[2], Citation[3].

A WHO survey showed that public satisfaction with doctors is not as good in the Russian Federation as in three other European countries, with the lowest numbers of patients rating their doctors as having good medical skills, and high numbers expressing dissatisfaction with their doctor as a person and with medical communication skills such as providing enough information, spending enough time on the consultation, and taking problems seriously Citation[4]. Qualitative research carried out with Russian family physicians has revealed that they would like training in behavioural medicine—specifically in the diagnosis and treatment of depression, anxiety disorders, and substance abuse as well as for lifestyle changes, patient–doctor communication, and physician self-care Citation[5]. Historically, the old specialist-based mental health system combined with stigmatization of mental specialities has resulted in mental health issues being avoided by both doctors and patients.

The present training course was undertaken as a small part of a project funded by the Department for International Development of the UK government, aimed at normalizing mental health care and moving the location of care from large institutions to community settings. It took place in Ekaterinburg, a medium-sized industrial city in the Urals in the Sverdlovsk Oblast from 2002 to 2005 Citation[6].

The aim of this paper is to describe the process of introducing skills-based training, and to report the effects of the training on the doctors who have so far attended the courses.

Methods

In the first year of the project, two of us gave a series of lectures and workshops on depression and unexplained medical symptoms, accompanied by videotapes of British GPs managing these disorders and demonstrating particular therapeutic skills. These tapes had been dubbed into Russian by Dr Nikolai Kornetov of Tomsk. After each demonstration, the doctors arranged themselves into groups of three—“patient”, doctor, and observer—and practised the skills they had just seen in a role-play. All materials had been translated into Russian, and the task of the observer was to obtain feedback from the other two, and make his or her own comments about the demonstration, including pointing out any skills that had not been demonstrated. During this visit, local psychiatrists were identified to contribute to the training and to provide backup to the trainer in family practice.

In the second year, a trainer from the Department of Family Medicine took over some of the tasks of the teachers, and was given feedback about her own teaching from her British colleagues. In the third and fourth years, she was entirely responsible for teaching, and had visited the UK and watched GPs being trained using the same methods in London and Manchester. Training was gradually extended to cover anxiety disorders and alcohol misuse in addition to the original disorders. By the fourth year, the English videotapes had been replaced with those made locally in Russian, and a second Russian trainer became involved in the teaching.

Doctors completed a questionnaire dealing with their present practices concerning depressed patients and medically unexplained symptoms, and their knowledge of the relationship between psychological disorders and physical disease. Some of the “knowledge” items dealt with possible advantages to the patient in treating depression (for example, “Treating depression in patients with advanced physical disease may improve their quality of life”), while others dealt with the quality of the interaction between doctors and patients (for example, “It does not matter how a doctor speaks to a patient, provided that he or she prescribes the correct medical treatment”).

The questionnaires were completed on the first day of their training, and repeated 3 months later after they had returned to their usual place of work. Scores were assigned to the knowledge part of the questionnaire by giving 1 point for a correct answer, −1 for an incorrect answer, and 0 for not known. Other variables were dichotomized as never/sometimes versus usually/always or none versus some for questions on the number of depressed patients seen. McNemar's test was applied to the dichotomized variables, and a paired t test was applied to the total knowledge scores, to test for changes before and after training. The change scores of the older- and younger-doctors groups (year of graduation before 1988, and 1988 and after) were compared with an independent t test.

Results

The Department of Family Medicine has now trained 75 staff and delivered six courses of instruction, each one lasting a total of 26 hours. As the course has progressed, it has become more elaborate, so that it now includes instruction in 10 different areas. Co-operation has also grown between the departments of psychiatry and family practice, with opportunities to discuss shared clinical cases and challenge resistance to change.

Overall ratings: Knowledge items

There were significant gains in knowledge for all doctors (overall improvement score 4.41, 95% confidence interval [CI] 3.21–5.61, p<0.001). There was a significant difference in the improvement scores for older and younger doctors (p=0.009): older doctors started from a lower baseline and gained more points (see ).

Table I.  Effect of age (median split on year of graduation) on knowledge scores.

Depression

Training improved the doctors’ scores for understanding that it was more than general appearance that should suggest depression, and doctors no longer thought that there was only a chance relationship between depression and physical illness, more of them understood that some depressions remit without medical treatment, and that antidepressants targeting different neurotransmitters produce similar effects. They no longer thought that psychiatrists were the only doctors who could treat depression, and that medically treated depressions do not recur.

Effects on practice

Training had the effect of allowing doctors to recognize depression, and they were much more likely to tell patients if they thought they were depressed. Use of antidepressants increased dramatically. Doctors were also more likely to discuss patients’ personal problems, to ask them to come back to report progress, and to arrange to see the patient themselves.

Medically unexplained somatic symptoms

After training, the doctors were more likely to understand that acute life stress can produce abdominal pain that mimics appendicitis, and can also present as backache, that most patients do not exaggerate their symptoms, and that emotional distress may affect the course of physical diseases (see ).

Table II.  Patients with depression in primary care: effects on knowledge and clinical practice.

Effects on practice

As a result of training, the doctors were less likely to say that they never saw cases of USS, and when they did so, they discussed personal problems further and were more likely to assess the patient for depression. They were less likely to tell the patients that their problems were due to “nerves”, and more likely to explain the links between distress and somatic symptoms. They more often prescribed antidepressants as part of their treatment package, and arranged for the patient to return and report progress (see ).

Table III.  Patients with medically unexplained symptoms: effects on knowledge and clinical practice.

Discussion

We have not reported changes in items that almost all of the doctors answered correctly at the start of their training, as there was no possibility of significant improvement in these items. As the doctors worked in widely dispersed locations, it was not practicable to observe their practice directly after their return to work, and it is a limitation of the study that the doctors may have given responses that they thought were desirable in terms of their teacher's standards, rather than changes in their actual practice.

We were very pleased that Russian versions of our teaching materials had been prepared on our last visit, and that the training had been expanded to include other common disorders such as alcohol misuse, anxiety disorders, and dementia. For the older doctors, this was the first time that they had received formal training in the diagnosis and management of common mental disorders, and this may account for the large changes seen in our evaluation.

Our findings confirm the considerable need for such training among family physicians in Russia, and help to explain some of the findings of previous cross-national comparisons of treatment for depression Citation[7]. However, there are considerable challenges in bringing about change in the Russian system. These include not only the resistance to change from specialists working within the old polyclinic system of provision Citation[8] (some of whom were keen to retain the sole rights of psychiatric services to prescribe free antidepressant medication), but also the wider bureaucratic problems which make such change difficult to achieve in the Russian healthcare system Citation[9].

Conclusions

We have demonstrated that mental health training can be provided to Russian family physicians with positive impact on theoretical knowledge and self-reported management. The challenge is now not only to ensure that such training both continues and is disseminated across training programmes within Russia, but also to demonstrate positive impacts on health outcomes.

Acknowledgements

Professor Olga Lesnyak encouraged us to undertake the study in her department, and the work was part of a larger attempt to modernize mental health services in the Russian Federation under the guidance of Professor Rachel Jenkins. We are indebted to Professor Nikolai Kornetov for dubbing the WPA tapes into Russian, and to Dr Dimitri Maximov for his assistance.

References

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