Barriers and enablers to seeking help for mental health problems in the primary health care system of Hong Kong : a mixed methods study

Abstract

The need to enhance mental health care in primary care settings has been emphasized in recent years in response to the high prevalence of depression and anxiety disorders. Most of the help-seeking studies on mental health come from Western countries. A few Chinese studies are available, but they mainly focus on psychosis in specialist psychiatric settings. My study addressed a knowledge gap by investigating the barriers and enablers to seeking help for mental health problems in primary care settings in Hong Kong. The study explored the views and experiences of primary care physicians (PCPs), psychiatrists, and primary care attenders. A mixed methods design was adopted. Four focus group interviews were conducted with PCPs and psychiatrists, and nine focus groups plus six individual interviews with primary care attenders. The identified barriers and enablers were investigated in questionnaire surveys, which collected data from 516 PCPs, 83 psychiatrists, and 1626 primary care attenders in private and public settings. The survey found that while around 90% of PCPs and public psychiatrists supported the management of common mental health problems in primary care, it was supported by only two thirds of private psychiatrists. Factor analysis of the survey data from PCPs on barriers to mental health care suggested three major factors: their own clinical constraints (e.g. limited confidence in mental health care, time constraints), patients’ behaviors (e.g. reluctance to admit their psychological problems), and collaboration with psychiatrists. The numbers of mental health patients treated by the PCPs were mainly correlated with their own clinical constraints. Three barrier factors were also found in the primary care attenders. The top factor was worries about treatment, followed by uncertainties on PCPs’ role in mental health care, and patients’ limited knowledge on psychological distress and sources of help. The top enablers to mental health care reported by PCPs were being the patient’s regular doctor, arranging follow-up consultations, and family support. The primary care attenders placed stronger emphasis on personal factors including crisis and somatic symptoms caused by distress. Other important enablers were trust in doctors and encouragement from family or friends. Patients with a regular PCP were more likely to mention psychological problems to their PCP and to be treated. In the qualitative interviews, the PCPs shared many cases about their difficulties in managing psychosomatic complaints, including patients’ expectation for an explanation in physical terms and patients’ reluctance to discuss psychological problems. On the other hand, some PCPs reflected positive experiences in guiding the patients to recognize their psychological problems. The patient interviews also revealed that the patients trusted the professional knowledge of PCPs in general, although many were uncertain of the PCPs’ role in mental health care. The findings highlight the importance of enhancing the mental health training of PCPs, continuity of care, and collaboration with private psychiatrists. Public education in a Chinese context should target areas beyond mental health literacy, especially looking at reducing worries about treatment and uncertainties on PCPs’ role in mental health care.