Of the total sample of 494 patients included in the study carried out by Castillejos et al. [22], 259 were included. Therefore, the total sample in the present study consisted of 259 patients and 96 GPs. Regarding the patients included, the sociodemographic profile was as follows. The mean age at the beginning of the study was 43.88 years (range: 22‒80); 63.71% were male; 70.66% were single; 43.63% completed only primary school; 55.21% were living with their original family or other relatives; 37.84% were unable to work; 88.03% were living in urban areas; and 89.19% were living in non-socioeconomically-deprived areas. Most patients had a clinical diagnosis of schizophrenia (69.5%), 82.24% of whom had a low or medium global level of severity, 39.23% had at least one cardiovascular risk factor (type 2 diabetes mellitus, hypertension, hypercholesterolaemia, obesity and smoking), and 69.11% were taking antipsychotic medication (see Table 1).
Table 1
Characteristics of patients with schizophrenia and related disorders. Categorical variables (N = 259).
SOCIODEMOGRAPHIC CHARACTERISTICS
|
Patients
N (%)
|
Gender
Male
Female
|
165 (63.71%)
94 (36.29%)
|
Marital status
Single
Married/ Civil partnership/Cohabiting
Separated/Divorced/Widowed
|
183 (70.66%)
47 (18.15%)
29 (11.2%)
|
Educational level
No formal education and/or illiterate
Primary school
Secondary school
Higher education (Bachelor’s degree)
|
45 (17.37%)
113 (43.63%)
72 (27.8%)
29 (11.2%)
|
Living arrangements
Alone
Original family / other relatives or friends
Own family
Sheltered accommodation
Homeless
|
33 (12.74%)
143 (55.21%)
57 (22.01%)
23 (8.88%)
3 (1.16%)
|
Employment status
Employed
Unemployed
Student
Carer or househusband/housewife
Not working, receiving welfare benefits
Other
|
46 (17.76%)
49 (18.92%)
16 (6.18%)
14 (5.41%)
98 (37.84%)
36 (13.9%)
|
Type of Area
Urban
Rural
|
228 (88.03%)
31 (11.97%)
|
Within a socioeconomically deprived area
No
Yes
|
231 (89.19%)
28 (10.81%)
|
Primary care centre
Trinidad
Nueva Málaga
Miraflores
Palma-Palmilla
Ciudad Jardín
Capuchinos
Carlinda
Alameda Perchel
Victoria
Limonar
El Palo
Rincón de la Victoria
Colmenar
|
21 (8.11%)
7 (2.7%)
10 (3.86%)
17 (6.56%)
25 (9.65%)
8 (3.09%)
3 (1.16%)
26 (10.04%)
33 (12.74%)
30 (11.58%)
50 (19.31%)
28 (10.81%)
1 (0.39%)
|
CLINICAL CHARACTERISTICS
|
|
ICD-10 Clinical diagnosis
F20 Schizophrenia
F22 Persistent delusional disorders
F23 Acute and transient psychotic disorders
F25 Schizoaffective disorders
F21, F24, F28, F29 Schizotypal disorder, Induced delusional disorder, other non-organic psychotic disorders and unspecified non-organic psychosis
|
180 (69.5%)
26 (10.04%)
25 (9.65%)
17 (6.56%)
11 (4.25%)
|
Global level of severity
Level I (low severity)
Level II
Level III (high severity)
|
91 (35.14%)
122 (47.1%)
46 (17.76%)
|
Cardiovascular risk factors
No
Yes
|
156 (60.23%)
103 (39.77%)
|
Taking antipsychotic medication
No
Yes
|
80 (30.89%)
179 (69.11%)
|
Total
|
259 (100%)
|
Regarding characteristics of GPs, the mean age at the beginning of the study was 50.84 years old (range: 38‒63), 63.54% were women, about 50% had specialised training as a GP, 65.62% were not accredited training as a tutor, 63.16% had a residential training student, and 87.5% had training from mental health services. Moreover, it took 4‒11 years to finish their medical degree. The size of the patient list varied from 900 to 2,434 patients per GP. Regarding the perception of GPs on mental illness, they presented high punctuation in the level of satisfaction with their relationship with the community mental health centre, medium punctuation in the perception of their level of training in mental health, schizophrenia, and other psychotic disorders, and very low punctuation in erroneous beliefs and stigmatisation about mental illness (see Table 2).
Table 2
Characteristics of general practitioners. (N = 96).
Variable
|
N (%)
|
Minimum
|
Maximum
|
Mean
|
Median
|
Gender
Male
Female
|
35 (36.46%)
61 (63.54%)
|
|
|
|
|
Specialisation training as a General Practitioner (GP)
Yes
No
|
53 (56.38%)
41 (43.62%)
|
|
|
|
|
Accredited training as a tutor
Yes
No
|
33 (34.38%)
63 (65.62%)
|
|
|
|
|
Having any residential training student
Yes
No
|
60 (63.16%)
35 (36.84%)
|
|
|
|
|
Age
|
|
38
|
63
|
50.84
|
52
|
Time to complete the Medical degree
|
|
4
|
11
|
7.49
|
7
|
Size of patient list
|
|
900
|
2434
|
1603
|
1500
|
Relationship
|
|
7
|
15
|
12.71
|
13
|
Training
|
|
4
|
11
|
8.1
|
8
|
Beliefs
|
|
4
|
10
|
5.05
|
4
|
With respect to PCC variables, 69.2% of the directors of the PCCs agreed that PCCs received assistance visits from mental health services more than twice a month, and 46.2% of them agreed that PCCs received training sessions from mental health services once a month or more. Most of the directors (76.9%) agreed that there was training from mental health services to PCCs. In addition, most of the directors agreed that social workers (69.3%) play an active role in managing patients’ mental health, but nevertheless, 53.9% and 36.46% of them agreed with this role in GPs and nurses, respectively. Regarding communication between the PCC and community mental health centre, almost all directors interviewed (92.71%) agreed with it was good or very good. All of them agreed with the good communication between GPs and nurses, and only 38.5% agreed with the good communication between GPs and social workers (see Table 3).
Table 3
Primary care centre variables. N = 13
|
N (%)
|
Hometown
2,500–5,000 inhabitants
5,000–10,000 inhabitants
10,000–15,000 inhabitants
15,000–20,000 inhabitants
20,000–30,000 inhabitants
More than 30,000 inhabitants
|
1 (7.7%)
1 (7.7%)
1 (7.7%)
1 (7.7%)
6 (46%)
3 (23.1%)
|
Frequency of mental health care visits in primary care centres
Twice a month
More than twice a month
|
4 (30.8%)
9(69.2%)
|
Frequency of mental health training sessions in primary care centres
None
Once a year or less
Between 4 and 6 months
Every 2 months
Once a month
Twice a month
More than twice a month
|
3 (13.23.1%)
1 (7.7%)
1 (7.7%)
2 (15.4%)
4 (30.8%)
1 (7.7%)
1 (7.7%)
|
Training from mental health services
Yes
No
|
10(76.9%)
3(23.1%)
|
Primary care physicians play an active role in managing patients’ mental health
Neither agree nor disagree
Agree
Completely agree
|
6 (46.2%)
5(38.5%)
2(15.4%)
|
How would you rate the communications between the primary care centre and community mental health centre?
Neither good nor bad
Good
Very good
|
1 (7.7%)
6 (46.2%)
6 (46.2%)
|
How would you rate the communications of the centre’s primary care physicians and/or nurses?
Good
Very good
|
11 (84.6%)
2 (15.4%)
|
How would you rate the level of communication between primary care physicians and social workers?
Neither good nor bad
Good
Very good
|
3 (23.1%)
6 (46.2%)
3 (23.1%)
|
Nurses play an active role in managing patients’ mental health
Completely disagree
Neither agree nor disagree
Agree
Completely agree
|
1 (7.7%)
7 (53.8%)
2 (15.4%)
3 (23.1%)
|
Social workers play an active role in managing patients’ mental health
Disagree
Neither agree nor disagree
Agree
Completely agree
|
1 (7.7%)
2 (15.4%)
4 (30.8%)
5 (38.5%)
|
The mean number of patient contacts with their GPs during the study period was 13.53 (median = 11; range: 0‒69). The annual mean was 3.9 visits per patient.
The bivariate analysis showed that the patient factors associated with more contact with GPs were: being a woman (p ≤ .001), being married or with a partner (p = .0038), having no formal education (p = .011), having a schizoaffective disorder diagnosis (p = .0213), having any cardiovascular risk factor (p ≤ .001), and taking antipsychotic medication (p = .0011; see Tables 4 and 5).
Table 4
Bivariate analysis between dichotomous variables and number of contact with general practitioners.
|
W Wilconxon
|
P value
|
Patient gender
|
10172
|
p ≤ 0.001
|
Cardiovascular risk factors
|
5380
|
p ≤ 0.001
|
Taking antipsychotic medication
|
5352
|
0.0011
|
Type of area
|
4005.5
|
0.2284
|
Within a socioeconomically deprived area
|
3005
|
0.5413
|
General Practitioner gender
|
8797.5
|
0.0720
|
Specialisation training as a General Practitioner
|
9216.5
|
0.0718
|
Accredited training as a tutor
|
8662.5
|
0.0653
|
Having any residential training student
|
8697
|
0.1118
|
Training from mental health services
|
3166
|
0.1055
|
How would you rate the communications of the centre’s primary care physicians and/or nurses?
|
2343
|
0.8850
|
Table 5
Bivariate analysis between categorical variables with more than two categories and number of contact with general practitioners.
|
Chi squared
|
df
|
P value
|
Patient marital status
|
11.11
|
2
|
0.0038
|
Patient educational level
|
11.246
|
3
|
0.0110
|
Patient living arrangements
|
4.650
|
4
|
0.3251
|
Patient employment status
|
5.446
|
5
|
0.3639
|
Primary care centre
|
24.036
|
12
|
0.0201
|
ICD-10 Clinical diagnosis
|
11.518
|
4
|
0.0213
|
Global level of severity
|
0.689
|
2
|
0.7086
|
Hometown
|
4.6082
|
5
|
0.4655
|
Primary care physicians play an active role in managing patients’ mental health
|
5.874
|
2
|
0.0530
|
How would you rate the communications between the primary care centre and community mental health centre?
|
4.490
|
2
|
0.1059
|
How would you rate the level of communication between primary care physicians and social workers?
|
7.778
|
2
|
0.0508
|
Nurses play an active role in managing patients’ mental health
|
7.446
|
3
|
0.0589
|
Social workers play an active role in managing patients’ mental health
|
6.760
|
4
|
0.1491
|
In addition, the GP factors that were clearly associated with more contact with GPs were as follows: GP age was negatively associated, as older GPs were associated with less contact (p ≤ .001); and the training variables were also positively associated, such that GPs who had a perception of higher level of training in mental health received more contact (p = .0219; see Table 6).
Table 6
Bivariate analysis between continuous variables and number of contact with general practitioners.
|
ρ
|
p value
|
Patient age
|
0.098
|
0.1162
|
General practitioner age
|
-0.247
|
p ≤ 0.001
|
Time to complete the Medical degree
|
0.058
|
0.3504
|
Size of patient list
|
-0.060
|
0.3610
|
Relationship
|
0.053
|
0.3945
|
Training
|
0.124
|
0.0219
|
Beliefs
|
-0.111
|
0.0740
|
Lastly, there were statistically significant differences among the PCCs to which patients attended (p = .02). Colmenar (with a mean contact of 33), Trinidad (17.8), El Palo (17.5), and Carlinda (15) were the PCCs that presented more visits to the GPs (see Table 6). There were others PCC factors that almost reached statistical significance: GP and nurse roles in managing patients’ mental health, such that higher punctuation in GP role was positively associated with amount of contact (p = .053), but higher punctuation in nurse role was negatively associated (p = .0589); and communication between GPs and social workers was positively associated with amount of contact with GPs (p = .0508; see Table S2).
Regarding the multivariate analysis, based on the method explained previously in the data analysis, we achieved the model with the lowest OOB error with seven variables (see Fig. 1). Therefore, younger general practitioners, patients who were women, patients who were married, some primary care centres to which the patient belonged, taking antipsychotic medication, presenting any cardiovascular risk factor, and more frequency of mental health training sessions at the primary care centre were strongly associated with an increase in the number of visits to GPs in the multivariate analysis (see Fig. 2).