1. Introduction

A significant increase in the number of mentally ill people in general somatic institutions indicates the relevance of creating a system of specialized care for these populations. At the same time, at present we can talk not only about a serious lag in this form of medical care, not only about low quality, but in a number of issues – about its absence at all [1,2]. The current situation is fraught with the danger of untimely identification of numerous mental disorders, which is reflected in an increase in the number of cases “neglected” in terms of diagnosis and treatment, decreased ability to work, deterioration in quality of life, and unjustified economic costs of the health service [3,4].

Despite numerous attempts to develop and implement various organizational models of psychiatric care in a general somatic network, undertaken in Western countries, there is currently no common understanding of the ways and forms of implementing this task [5]. At the same time, when using foreign experience in improving mental health services, it is necessary to exercise some caution, having a good understanding of the relativity of numerical indicators, calculations and organizational charts, which, as a rule, are not comparable with the specific health conditions of countries [6,7].

Difficulties in organizing specialized care for patients with mental disorders in the general somatic network are caused by a number of circumstances. The most common, “classical” models of psychiatric institutions - a psychiatric hospital and a psychoneurological dispensary - do not create favorable conditions for solving diagnostic and treatment problems for patients with erased, somatized, masked mental disorders. At the same time, models for integrating psychiatric services with various branches of medicine in healthcare have not been developed. The consequence of this is the limited information and professional contacts between doctors of general somatic institutions (territorial clinics, medical units, multidisciplinary hospitals, etc.) and specialists of psychiatric clinics, dispensaries and hospitals. The lack of integration of psychiatric and general medical services is also manifested by the increasing lack of demand for psychiatric care in its official, normative forms [8,9,10].

The purpose of our study was to study the characteristics of the routes of movement of the examined patients in search of help. The frequency of visits and hospitalizations of patients to medical institutions, the duration of visits and treatment activities outside the hospital of the somatic clinic (before admission to the somatic hospital) were analyzed.

2. Materials and Methods

To find out the reasons for late visits of patients to a psychiatrist/psychotherapist for mental disorders against the background of somatic diseases, it was undertaken to examine patients at a regional multidisciplinary hospital. The study group included 1066 patients (815 men, 851 women) with various somatic diseases, against the background of whose somatic pathology mental disorders developed. The average age of the examined patients was 50.3±15.7. During the study, the following methods were used: clinical interviewing, questioning using a special questionnaire compiled by us. The choice of research methods implied the possibility of conducting a comprehensive study of all factors that cause or contribute to the formation of mental disorders and interdependencies with somatic pathology, and therefore, first of all, clinical and epidemiological approaches were used for interdisciplinary research. All types of examination, diagnosis and treatment of patients were carried out personally by the author, in close cooperation with internists. The clinical method involved examining each patient to obtain a qualified psychopathological assessment of the patient's health status.

In addition to analyzing the data obtained during interviews with patients and collecting anamnestic information, clinical observation of the subjects was carried out and a description of their mental status was carried out. The clinical examination included anamnestic data, patient complaints, and questionnaires. The main attention was paid to the timeliness of detection of mental disorders in patients with somatic pathology, the quality and effectiveness of treatment, both the underlying disease and the mental state of the patient himself.

3. Results and Discussions

Until now, the problem of psychological competence of somatic doctors and their awareness of the issues of diagnosis and treatment of mental disorders have not been studied in domestic medicine. In connection with the above, a study was undertaken of the professional competencies of doctors of the general somatic network in assessing the mental health of patients with various forms of somatic pathology and concomitant mental disorders.

The information obtained upon admission was supplemented by observation during hospitalization, which made it possible to trace the dynamics of the mental state. Indicators of direct examination of patients were considered taking into account the entire complex of data obtained according to medical documentation. During the clinical examination, a comparison was made between the qualification of mental pathology established by the internists with the diagnosis established as a result of a subsequent psychopathological examination by a psychiatrist; Accordingly, the timeliness, adequacy, and completeness of diagnosis of mental disorders by interns in the absence of qualified psychiatric care were comparatively assessed. A comprehensive assessment of the effectiveness of prescribed psychotropic therapy was carried out. In order to verify the characteristics of the somatic condition, a full clinical and instrumental examination was carried out by an internist in accordance with modern standards to confirm the presence of a somatic disease (with an assessment of syndromes, degree/stage) or its absence.

The study examined the ability of internists to recognize mental disorders in a somatic patient (table 1); assessment of doctors’ attitude towards additional study of psychiatry and possible forms of training, their readiness for it; a study of the level of doctors’ ideas about the spectrum of mental disorders in patients with somatic diseases and about methods of their treatment; studying problematic situations in the work of internists that arise when caring for patients with mental disorders.

Table 1. Psychopathological symptom complexes identified by internists in somatic patients

According to the results of this table, doctors at a somatic hospital, during dynamic observation, were able to diagnose certain mental disorders only in 1/6 of the cases. Although the above disorders do not always meet the diagnostic criteria of ICD-10. Among the diagnoses that were kind of concomitant, the dominant ones were: astheno-neurotic syndrome in different variations (9%), anxiety-depressive (4.5%), the next position was occupied by dementia syndrome (3.2%).

However, during the survey, somatic doctors stated that in 50-65% of cases various forms of somatic pathology are combined with mental disorders, as a result of which their influence on the course of the underlying disease is established. Despite this, the level of knowledge of doctors of somatic specialties in the diagnosis and treatment of mental disorders, and their possession of interpersonal communication skills are not always sufficient to provide high-quality medical care that meets the condition and needs of patients.

During the study, only 68% of somatic hospital doctors confirmed their readiness to undergo additional training in psychiatry. The most common reasons doctors cited for not being ready to study were lack of time, as well as administrative obstacles.

According to our research, doctors in the general somatic network quite often prescribe psychopharmacological agents.

Figure 1. Group of psychopharmacological drugs according to the list of prescriptions prescribed by attending physicians

An analysis of psychopharmacological drugs according to the list of prescriptions prescribed by attending physicians according to selected medical documentation showed that the share of these prescriptions was almost 1/4, the vast majority of which were nootropic drugs (18%), and the next group was prescribed by internists without any particular concerns, were antidepressants (6%), a minority were prescribed antipsychotics (2%). These drugs were prescribed in complex treatment in short courses, without further maintenance regimen of psychotropic therapy. In all cases, psychopharmacotherapy was carried out without consulting a psychiatrist.

It should also be noted that if the patient, in addition to a somatic illness, also suffers from mental disorders that arose as a result of a somatic illness, especially in the initial stages of therapy and in non-severe, subacute conditions, preference was given treatment from general somatic doctors and not to contact psychiatrists. In some cases, the patient even refused to consult a psychiatrist. This is due to the fact that in addition to a trusting attitude towards a specialist in a somatic clinic, the absence of stigmatizing aspects associated with contacting a psychotherapist or psychiatrist plays an important role.

To determine the degree of significance of certain clinical characteristics in the occurrence of mental disorders, the following parameters were studied: the patient’s previous visits to medical institutions and/or other institutions, the effectiveness of diagnosis and treatment of a somatic disease when combined with a psychopathological disorder, the primary or repeated hospitalization of the patient in a somatic clinic...

Of the examined patients, about 32.3% were hospitalized in a somatic hospital with a verified somatic diagnosis initially; in the remaining patients, the case of somatic disease was registered again (fig. 2).

Figure 2. Primary/repeated hospitalization rates among the examined patients

A previous somatic illness is a definite risk factor for the development of mental disorders, so among patients with psychopathological symptoms there are on average 2.2 times more patients with repeated somatic illness (p < 0.001).

It can be assumed that the fact of repeated somatic illness affects both the frequency of occurrence of mental disorders and their severity and the formation of a protracted course of the disease.

The study examined the presence of patients' visits to psychiatrists/psychotherapists before hospitalization in a somatic hospital. The type of previous visits of patients in the general sample regarding mental disorders, as well as the number and patient’s assessment of the results of visits are shown in table 2.

Table 2. Patient requests before admission to the somatic clinic

As follows from the data presented, patients with somatic diseases and concomitant mental disorders, 81.5% of the examined patients, positively evaluate the result of treatment by a psychiatrist (psychotherapist). This indicator correlates with a fairly high compliance of patients seeking help during treatment by a psychiatrist/psychotherapist. In 51 observations (out of 74 observations) there were multiple visits to the office of a psychiatrist or psychotherapist. In 74.6% of observations, they negatively assessed their experience of visiting internists, although in 84 observations (out of 187 observations) repeated visits to a somatologist were noted. At the same time, 32.4% of the examined patients positively assessed the result of treatment by a local doctor or general practitioner. According to the data received, it is 61.6%. Moreover, in 165 observations (out of 239 observations), the local doctor repeatedly provided medical assistance to patients who applied.

Many patients from the study group with concomitant mental disorders visited psychologists, tabibs, and healers before going to the psychotherapeutic office of the clinic. 8.3% of the examined patients sought help from psychologists, while 75.0% of them were dissatisfied with the treatment results obtained. In 11.8% of cases, simultaneous contact with several facilities was noted with the hope of obtaining a quick improvement in health, but only 12.3% of them indicated a positive result. 16.2% of the examined patients turned to healers for help. The result was assessed positively by 21.0% of patients who applied.

The results of treatment were also analyzed from the treatment measures taken to the patient’s admission to the somatic hospital (figure 3).

Figure 3. Effectiveness of previous treatments as assessed by patients (%)

The indicators shown in the figure indicate that in most cases, patients did not notice a sufficient effect from the treatment measures received. Relatively positive reviews from patients were received when using antidepressants (amitriptyline, Mirtel, depres, adep...) (23.9%), sedatives that were representatives of various pharmacological groups (sedavit, persen, somnol, barboval, novopassit...) (23, 9%), non-medicinal methods in the form of reflexology, manual therapy, physiotherapy, TMS (trancranial magnetic stimulation), psychotherapy (19.5%).

To study the interaction between primary care physicians and psychiatrists, the presence and frequency of referral of patients to a psychotherapist/psychiatrist by various specialists before inpatient treatment in a somatic clinic was examined (table 3).

Table 3. Referral to a psychiatrist (psychotherapist) if there has been previous treatment (n=74)

The results presented in the table indicate that local therapists most often refer people for consultation to a psychotherapist (32.4%). Doctors of other specialties recommend consultation with a psychotherapist much less frequently (12.2%). The second most important is self-referral (26.7%). In some cases, requests were made because of relatives or friends of the patient.

It is also important to point out that a fairly large contingent of patients (52.7%) did not consult a psychiatrist (psychotherapist) for a long time, despite the presence of symptoms of mental disorders. This group included mainly elderly patients, often with higher or incomplete higher education. It was noted that they had a desire to independently cope with the symptoms of a mental disorder, in particular, through self-medication. During numerous conversations with patients, it was found that a large group of them, when the first symptoms of a mental disorder appeared, were looking for ways to independently overcome the problems that arose. At the same time, support for this was found in the family, from friends, or from healers, tabibs.

If the use of these resources was ineffective, people with mental disorders turned to doctors at the clinic, primarily to local therapists. This stage was largely decisive for the patient’s subsequent route. If the patient was sent for numerous examinations and additional consultations, the route was lengthened and the time frame for receiving qualified psychiatric care increased. In cases where local therapists actively consulted with a psychiatrist (psychotherapist), the patient quickly received the necessary help.

The study also examined the fact of effective diagnosis of mental disorder in the population surveyed (table 4).

Table 4. Distribution of the total sample according to the primary diagnosis of a current mental disorder

When analyzing this table, it is important to note that in more than half of the cases (58.9%), the patient's mental status was initially determined by a psychiatrist or by including a consultation with a psychiatrist. In almost 1/10 of the patients who applied, specialized endocrinologists and therapists discovered psychopathological conditions at the time of application and referred them to a psychiatrist. Low results were shown by a neurologist, general practitioner, cardiologist and surgical doctors (7.2%, 6.8%, 5.6% and 3.0%, respectively).

4. Conclusions

1. Thus, an analysis of the practical activities of somatic doctors who provide medical care to somatic patients with mental disorders shows that the greatest difficulties arise when qualifying combined (mental and somatic) pathology; assessing the patient’s condition and establishing a verified diagnosis with the appropriate criteria according to ICD-10. At the same time, the choice (if psychopharmacotherapy is necessary) of psychotropic drugs adequate to the mental state, taking into account their effect on the somatic state, and their compatibility with somatotropic drugs, requires high professional competence and training from a specialist in a general somatic clinic.

2. Thus, the presence of the above-mentioned problems indicates the need to change the methodology, organization, and structure of psychiatric (psychotherapeutic) care in primary health care. This circumstance indicates the need to increase the competence of clinic doctors in the field of diagnosing mental disorders, the advisability of earlier referral of patients for consultation with a psychiatrist (psychotherapist).

3. It is necessary to provide primary care doctors with knowledge and skills in diagnosing psychopathological syndromes and the basics of psychopharmacotherapy. The independent professional competencies of a primary care physician should also include communication skills.

4. It is advisable to empower doctors who are not psychiatrists, after special training, for example, as part of advanced training, to make a preliminary medical opinion on the state of mental health of the patients they supervise (syndromic diagnosis), and, if necessary, prescribe them psychopharmacological treatment.

5. The low level of provision of psychiatric/psychotherapeutic care to patients in the primary and general medical networks is largely due to the insufficient number of psychotherapeutic rooms and psychiatrists working in them, as well as the low level of interaction between internists and psychiatrists / psychotherapists.