The Perspective of General Practitioners about Mental Illness: A Cross-sectional Observational Study from a Tertiary Care Centre, Pakistan

Objectives: To assess the general practitioner's perspective on mental illness in a tertiary health care setting. Study Setting and Duration: Online seminar in March 2020, Jinnah Postgraduate Medical Centre, Karachi. Study Design: Cross-sectional, Observational study Methodology: A total of 152 general practitioners were enrolled in the study. All house officers, psychiatric specialists, staff members, and patients were excluded from the study. An online survey Original Research Article Afridi et al.; JPRI, 33(43B): 42-49, 2021; Article no.JPRI.73700

instrument was used to collect data from general practitioners through social media. The questionnaire was related to the biodata of the physicians and their perspective on mental health disorders. Data was analyzed by using SPSS Version 26. Results: A total of 152 general practitioners participated in the study. The mean age of participants was 39.76 (11.540) years. The majority of them were male and married with an average experience of 12.80 (10.90) years. According to the participants, the most common symptoms experienced by patients with mental disorders were loss of appetite, hopelessness, and the loss of interest in day to day activities. The majority of the doctors confessed they find the treatment and management of psychiatric illnesses the hardest. Most of the participants were aware of the diagnostic criteria used for common mental health disorders. Over a hundred (66.4%) participants considered mental health disorders to be a medical disorder while 16 (10.5%) assumed it is the possession by supernatural creatures. 65 (42.7%) of the doctors confessed that they would not feel comfortable having a coworker or befriending a person with a diagnosed mental health issue. Conclusion: Our findings suggest that general physicians had good knowledge about common mental illnesses; however they found the management of these patients difficult. Mental health awareness and training intervention tools are needed to help improve the perspective of health care professionals towards patients with suspected mental illnesses.

INTRODUCTION
Almost 10 to 13 % of Global burden of diseases is because of Mental Health Disorders; especially in low and middle income countries [1]. In Pakistan only; 10-16% of population, especially women is affected by Mental Health Disorders [2]. Mental disorders are managed first and foremost by a general practitioner in a primary care unit, where 40% of all reported mental health cases are received in developing countries [3]. Patients often present to a primary care center due to ease of accessibility, where the general practitioner assesses physical as well as mental disorders. Almost 10% of their daily practice comprise of cases with mental disorders [4]. General practitioners often connect patients with specialists after a complete patient assessment and evaluation. To facilitate general practitioners in the effective evaluation of psychiatric illnesses, many strategies, instruments, and guidelines have been developed. Models for more holistic and collaborative care have been introduced, such as psychometric diagnostic tools, continuous training, and strategies to facilitate closer coordination with other healthcare professionals. Psychiatric illnesses often present with a wide range of symptoms, which makes it difficult for a general practitioner to simply determine a diagnosis and commence treatment. A higher degree of comorbid conditions in patients of psychiatric illnesses complicates its management. The practitioners must make an accurate diagnosis, to avoid treatment which is not required and avoid adverse impacts on patient health [5]. For the provision of the best healthcare, diagnosis is an essential requirement on which treatment, prognosis, and patient education are based. However, in the field of psychiatry, diagnosis is perceived in a very critical manner and is often questioned [6]. It is therefore essential that the general practitioners apply evidence-based psychological practice and integrate the collected patient data and their expertise for the accurate diagnosis of psychiatric illnesses [7][8].
For the assessment of psychiatric symptoms, the general practitioner must be able to identify the underlying disorder and perform a comprehensive psychopathological evaluation [8][9][10][11]. The general practitioner should have the skill required to associate the psychiatric symptoms with the patient's neurodevelopmental impairments.
There is limited data on the perspective of general practitioners on mental health illnesses in Pakistan therefore; the current study was conducted at JPMC -the largest public sector hospital in Karachi, Pakistan.

MATERIALS AND METHODS
A cross-sectional survey was conducted over an online seminar in March 2020 at Jinnah Postgraduate Medical Centre (JPMC), Karachi. All consenting (152) general practitioners working around the country participated in the study. Their practice type was divided in two, one who practice within a hospital and the others who own their private clinic where patients paid a fee for their service. All house officers, interns, or students were excluded from the study.
After going through the previous studies, a questionnaire was developed regarding the general practitioners' perspectives regarding mental health illnesses [12][13]. The draft questionnaire was critically appraised by an expert panel of general practitioners and was also tested in a pilot study to ensure nonambiguity and non-coherence in the questions. The patients with psychotic disorder, with prevalence of less than 1%, usually report directly to emergency department due to their grave nature of presentation. Therefore that was not included in the study.
The revised final study instrument included socio-demographic information, training in psychiatry or rotation during house job, the questions exploring the perspective of general practitioners regarding mental health issues. The online survey took 20-30 minutes to fill. Participation was voluntary and anonymous. No personal identifiers were included in the questionnaire.
The data was collected and processed through SPSS Version 26. The categorical variables were presented as frequency and percentages while all continuous variables were presented as mean and standard deviation. The data was presented in tabular forms.

RESULTS
A total of 152 general practitioners participated in the study. The mean age of participants was 39.76 (11.540) years. The majority of them were male and married with an average experience of 12.80 (10.90) years.
According to the participants, the most common symptoms experienced by patients with mental health comorbidity were loss of appetite, hopelessness, and the loss of interest in day to day activities. The majority of the general physicians confessed they find the treatment and management of psychiatric illnesses the hardest. Most of the participants were aware of the diagnostic criteria used for common mental health disorders. Over a hundred (66.4%) participants considered mental health disorders to be a medical disorder while 16 (10.5%) assumed it is the possession by supernatural creatures. 65 (42.7%) of the doctors confessed that they would not feel comfortable having a coworker or befriending a person with a diagnosed mental health issue. See Table 2 for details.

DISCUSSION
Patients with mental health disorders throughout the world suffer a substantial degree of stress because they are subjected to discrimination and prejudice against them [13][14][15]. In our study, the general practitioner's perspective was highlighted regarding mental health disorders. Only six percent of doctors assumed that mental health disorders were more prevalent in men while more than half the doctors knew that psychiatric health issues are more prevalent in women compared to men.
In a study, evaluating the gender differences in major depressive disorder, it was revealed that the majority (62.8%) were women. However, the help seeking behavior was not very common among women [16]. In our society, the majority of the women do not have proper access to health care or education. Both are significant factors when seeking professional help.
In a study, the attitudes and health seeking behavior of Arab Muslim women from Israel, Jordan and the United Arab Emirates (UAE) towards mental health illness were compared. The study revealed that marital status of the women and age was significantly associated with a positive attitude towards seeking help [17].
Lack of education and support from families is a major factor dissuading the patient from seeking or continuing the treatment for their mental health illness. In our study, about two-fifth of the doctors claimed that mental health disorders are not a legitimate medical issue or they were not sure if it were. Approximately one-fifth of them even claimed that mental health disorders are just the lack of willpower. Whereas, about ten percent thought it is the possession by the supernatural beings (jinnat).
Almost half the population was not comfortable working with a coworker or befriending a person who has been diagnosed with a mental illness. Some doctors even suggested that the families should keep the mental illness secret in order to avoid societal shame and embarrassment instead of seeking professional help. Stigma and negative attitude among general practitioners is detrimental to the prognosis of those with mental health problems. In a 2016 study, The Community Attitudes towards Mental Illness (CAMI) scale was used to measure stigma and negative attitudes among doctors and the general population [18]. It was revealed that both groups had high stigma scores on CAMI. However, the stigma and negative attitude about mental illness was more drastic among the general population compared to the health care professionals [18].
About two-fifth of the general practitioners also believed that patients with suspected mental health disorders are violent and dangerous. These are some of the unfortunate findings of the study highlighting the negative perception of general practitioners regarding mental health disorders.
Stigmatization of psychiatric disorders in the society manifests itself in a negative perception of psychiatric patients. In a study from Peshawar, assessing the attitude of doctors about the psychiatric illness, it was revealed that only 26.7% supported the notion that the management of mental health issues is a medical responsibility [19].
A Japanese study by Okagami on community attitude toward mental illness showed that over half of the community residents being surveyed perceived the behavior of people with mental illness as unpredictable, dangerous, and not likely to make a social readjustment [20].
A study conducted at Aga Khan University hospital assessed the perception about schizophrenia -a Only 30% of the participants attributed 'mental illness' as the main cause of psychotic symptoms while a large number thought of 'God's will' (32.3%), 'superstitious ideas' (33.1%), 'loneliness' (24.8%) and 'unemployment' (19.3%) as the main cause. Mental illness as the single most important cause was reported by only 22%. As far as management is concerned, only 40% reported psychiatric consultation to be the single most important management step. Other responses included spiritual healing (19.5%) and Social changes (10.6) while 14.8% of respondents said that they would do nothing [21].
After so many years of effort to reduce the level of stigma attached to mental disorders, the current situation in Pakistan is far from satisfactory. General practitioner is the first professional help a patient may seek -and if he dismisses the signs and symptoms of psychiatric illness or invalidates their feelings because of his/her own beliefs and perception regarding the subject, it may lead to a delayed diagnosis and a worse prognosis for the patient.
The majority of the doctors suggested that as a community we should create awareness about mental health issues, encourage those with mental health issues to seek help while avoiding discrimination against those with diagnosed psychiatric illnesses and include them in societal activities.
Recent studies in primary care highlight the importance of patients' beliefs and emotional responses to their illness as being important in influencing their satisfaction with the consultation, reassurance following negative medical testing and future healthcare use [22][23]. Illness perceptions have associations with a number of outcomes in chronic illness including self-management behaviours and quality of life. Integrated health modules are needed to train general physicians in tackling common mental health issues and improve their perceptions towards patients with suspected psychiatric disorder subsequently improving health outcomes.

CONCLUSION
Our study indicates that the general practitioners had an adequate amount of knowledge about the common mental illnesses; however, a minority of them has negative perceptions regarding the psychiatric diseases. Mental health awareness and training intervention tools are needed to help improve the perspective of health care professionals towards patients with suspected mental health illness.

LIMITATIONS
The study has few limitations and that should be kept in mind before interpreting the results. First being study design which limits us from exploration of practitioners' perspective. Second, the practitioners were asked about their view on mental disorders, we didn't know if their assessment was correct.
Being descriptive design and opinion based questionnaire were used to make cooperation with the practitioners and desensitizing them about mental illnesses.

CONSENT AND ETHICAL APPROVAL
After obtaining the ethical approval from the Institutional Review Board (IRB), the instrument was distributed among the general practitioners through social media including whatsapp, facebook, and email. All those who gave electronic consent to take part in the study were referred to an online survey.