1) Policies and protocols.

The theme Policies and Protocols considers national policies and protocols related to screening and management practices. Participants indicated that the focus of the national health policies and protocols for managing comorbid MI and CPI emphasized the role of PCPs. Health policymakers (HPMs) referred to the current Jamaican National Strategic Plan for Non-Communicable Diseases [14] that identifies that PCPs are responsible to screen for MI in people with CPI:

“A part of that process (primary health care) is to ensure that persons with chronic illnesses, they should be screened for mental illnesses… and once persons are identified…the protocol is for them to be referred to the mental health team to ensure that they’re getting that kind of specialized care …So the primary care physician does not generally manage severe mental illnesses. So they are trained to manage depression and mild (mental) conditions and if they are unable to manage the cases adequately then persons are referred to the mental health team for further care.” (HPM #1)

The policies and protocols outlined for PCP specify them as the first point of contact and mental health practitioners (psychiatrists and mental health nurses) as secondary contacts:

“Actually what I would say that it’s more primary care physician who would have to be the one who’s on the front line to pick up either physical or mental issues because they are the ones who see more regularly and they are the first point of contact into the primary care system. Yes, the mental health practitioner would have to make sure in their clinic when they are seeing patients for mental illnesses they remember that there may also be physical disorders that may develop with time that they need to look out for but I think the primary care physicians are the ones who will naturally see most of the patients and be the first point of contact…” (HPM #2).

Although there was an acknowledgment of mental health practitioners (Psychs and MHNs) needing to recognise patients’ physical illness, participants were unaware of any clear policy directive related to their role in screening and management of CPIs. This was noted as an area of a significant policy gap as it represents a loophole for patients who do not access PCPs as their first point of contact. Consequently, the core of the policy issues expressed by participants was the need for a comprehensive and inclusive assessment policy that involves all relevant health practitioners in the screening and management of comorbid mental and chronic physical illnesses:

“My stance is that there should be a policy that looks at both physical health and the mental health of the person as a part of the comprehensive assessment… the comprehensive approach is what is needed for all patients”. (HPM #2)

Despite the recognised gap in national directives for mental health practitioners in the management of CPIs for their patients with MI, a few Psychs referenced international guidelines that guide their practice. These guidelines were developed to help mitigate the increased risk people with SEMI face of developing CPIs due to being treated with psychotropic drugs:

“Well initially according to international guidelines you should be taking a detailed history to again check if they are predisposed or have a strong family history or if they themselves have a personal history by just being obese or having a sedentary lifestyle. So we really should be exploring the benefits vs the risks at the beginning before prescribing medication and then if it is that this is the absolute last resort, then we’re supposed to be monitoring them so that we have routine investigations that will monitor their blood pressure, weight, height, waist circumference among others. So there are guidelines…” (Psych #1)

Another area of concern noted by several participants was the absence of national policy guidelines and protocols on the routine screening and management of substance use problems from both the Jamaican National Strategic Plan for Non-Communicable Diseases and the drafted National Mental Health strategic plan. PCPs and mental health practitioners expressed a lack of detailed screening or active dialogue about substance use with their patients. They also expressed a lack of knowledge about resources available for assisting clients with substance use issues:

“I don’t think primary care doctors are trained enough to know, how, when, and who to refer them (patients) to for substance abuse disorders…if you stop any clinician and ask them what do you do with somebody who has a substance abuse problem they’re going to look up in the sky and scratch their head, I promise you.” (PCP #5)

As it relates to the management of patients with comorbid MI and CPI, participants explained that the organisation of the community primary healthcare system involves the co-location of curative and mental health clinics. This aspect of the health system response is advantageous in helping streamline services and improve patient access to care. However, there was an absence of national-level guidelines related to how clinic administrators can strategise offering services in ways that best meet the needs of patients. For example, in some settings, mental health clinics are held on different days from the curative clinic. This presented a gap in the operational protocols:

“One of the good things though, the mental health service is also offered in primary care so it’s not necessarily a referral into the secondary care system. So even though the person is referred to another service, that person is still given an appointment within the chronic care clinic or the mental health clinic for follow-up and I suppose that’s where the gap is… How do we ensure that we have both services available on the same day so that persons just take one day and get holistic care for those conditions?” (HPM # 1)

This was of particular concern as HPMs discussed issues related to social determinants of health and recognised that people with comorbid MIs and CPIs who access the public health service often lack financial and social resources to attend clinics on multiple days. This lack of coordination between clinics was seen as diminishing some of the advantages of co-location and creating additional barriers to accessing care.

Furthermore, this created a barrier to what participants described as co-management as PCPs and mental health practitioners may not meet due to different clinic dates. Health policymakers suggested co-management is an important aspect of the collaborative care model. Nevertheless, clinicians and HPM were unaware of specific national guidelines or protocols related to how co-management should occur. PCPs were clear that they had a responsibility to manage CPIs, screen for MIs, and refer patients to mental health services. Yet, their role in follow-up and engagement after referral to the mental health team was not articulated. Similarly, mental health practitioners expressed varying views about their responsibility in the management of CPIs, referral, and follow-up.

2) Clinical practices.

The theme of Clinical Practices involved discussion around participants’ perception of the prevalence of comorbid MI and CPIs, and the application of prescribed policies and protocols in screening for and managing these illnesses. Participants engaged in clinical practice were asked about their perception of the prevalence of co-occurring MI and CPI. Primary Care Physicians estimated that between 5–25% of their patients had comorbid MI and CPI, commonly involving Schizophrenia, Major Depressive Disorder, Bipolar Disorder with, Hypertension, and/or Diabetes Mellitus. Mental health practitioners estimated that between 10–60% of their patients had comorbid MI and CPI, involving Schizophrenia, Schizoaffective Disorder, Bipolar Disorder accompanied by Hypertension and/or Diabetes Mellitus.

Primary care physicians and mental health practitioners outlined their experience of the screening process in clinical practice as shown in Fig 3.

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Fig 3. Screening and management process for patients with MIs and CPIs in primary care.

https://doi.org/10.1371/journal.pone.0290975.g003

Primary care physicians reported a lack of consistency in screening approaches for MIs across clinicians and clinic sites. Most PCPs reported that depression was the only mental illness screened for in a standard way. At some health centres, there were clear protocols for depression screening:

“At one health centre… they developed mandatory questions for us to ask those patients (with CPI) to screen them for depression… the nurse would stamp the two criteria questions for depression (Patient Health Questionnaire-2) in the patient’s docket before the doctor would see the patient and then they will be screened for depression before the doctor would continue with their visit with the patient.” (PCP #3)

While in other settings, depression screening was done at the discretion of the PCP’s clinical suspicion of the presence of a MI in a specific patient.

“We will go through their history on what the presenting complaint is… particularly patients who you might now be suspecting (of mental illness)” (PCP #6)

Screening tools were reportedly used by most PCPs to assist in their assessment of common MIs. These tools included the Patient Health Questionnaire two or nine [27, 28], the General Anxiety Disorder Assessment [29] and the Mental Status Examination or mini-mental status examination. One PCP also reported using the Hamilton Depression Rating Scale [30]. Other mental illnesses were identified based on clinical observation of patient presentation and history taking:

“We would have that patient assessed in terms of a risk evaluation and then would have that patient actually worked up to rule out other medical causes, you know of what symptoms the patients are presenting with… then having done that and finding no medical cause that would explain the symptoms we would then would refer to Psychiatry clinic, but if it’s a case that the patient has been evaluated as having somewhat elements of suicidal or homicidal thoughts, or intentions, then (we) would refer that patient to a critical-care/accident and emergency unit.” (PCP #5)

It is noteworthy that PCPs reported that most of their patients with MIs were previously diagnosed and treated by the mental health service, and referred to the curative clinic for screening and management of physical health problems.

Additionally, screening for alcohol and other drug use was not a standard part of the practice for most PCPs. Less than half of PCPs reported any screening practice and for those who did report screening, it was at the point of the initial interview for history taking but was not routinely monitored or treated:

“If it’s a new patient that we don’t know anything about then we would ask about, you know, alcohol or drug use, but otherwise, there wasn’t any screening, you know for the regular follow-up patients we didn’t really screen that often for substance use.” (PCP #3)

As it relates to screening practices for CPIs among mental health practitioners, most did not routinely screen for CPIs but indicated they did screen if they felt it was warranted. Clinical observation and patient reports of symptoms were used to guide when further investigations into physical health concerns were needed:

“…you should not dismiss what the person will say just because he had a mental illness. So if due diligence is done and you see that okay, this is actually possible, then it kind of prompts you to investigate further”. (Psych #5)

Mental health practitioners who engaged in screening for CPIs explained that:

“We usually would fully assess, do a physical examination, take a full history and the next step from there would be to make a referral as I said to be Internal Medicine service. We tend to take off the blood works that we need to do, prior to making the referral, just so that it facilitates the speed of them being seen in the other service.” (Psych #9)

However, a few psychiatrists expressed the view that screening for CPIs did not fall within their purview, for them there was a clear delineation of their role to treat MIs and not CPIs:

“We’re not really checking them for (blood) pressure and so if they come for mental illness, that’s it. They go to another doctor for their pressure (blood pressure) and sugar (glucose levels)… so we refer them to the appropriate physician or appropriate doctor to deal with that”. (Psych #10)

Additionally, mental health practitioners indicated that the screening process for CPIs was complex because it was dependent on the patient’s ability to articulate physical health concerns. There were varying viewpoints about the ability of patients with serious mental illnesses to report on physical health problems. While a few mental health practitioners reported that patients with severe and enduring mental illnesses are capable of reporting on physical health concerns, the majority believed patients might not be able to explain their symptoms:

“It’s not easy for them (people with SEMI)…some of them are kind of out of touch with their whole body system and so on and it really not, I would say a majority of them don’t know. A few will know but for the majority, it is not so easy to recognize.” (MNH #4)

In cases where patients had difficulty articulating their symptoms, mental health practitioners emphasised the important role family or supporters play in sharing their observations and advocating for the patient:

“A lot of times you’d find that when a patient has a severe mental illness, it’s the relatives that are the ones that are pushing for their treatment in the mental health aspect and they may be the ones that are pushing for the treatment on the physical health aspect as well. So it really depends on whether or not they have a good support system as it relates to that.” (Psych #2)

Despite this, mental health practitioners reported that some physical health problems that were not readily observable through an external examination could be missed due to poor access to resources such as equipment (e.g. scales or blood pressure machines), adequate support staff, and patient load on clinic days at some clinic sites. In addition, COVID-19 has further complicated the screening for CPIs among this population, for example, some routine checks were temporarily discontinued to limit the use of the equipment and the potential spread of infection:

“For you to be sanitized and so, you know your blood pressure machine on everybody, after two or three persons, it is going to be soaked. So we took the decision of not doing this. However, it is available for persons who we suspect might have need, once we see any physical issues…it is there that we can pop out and say we’re going to do that (blood pressure check)”. (MNH #3)

Mental health practitioners emphasised that to mitigate the potential of missing CPIs in the mental health clinics, they encourage patients to do a complete physical health check-up annually with their PCPs.

Another consideration affecting adequate screening and management practices for patients related to communication between clinical teams. Although the services of the curative clinic and mental health clinic were co-located, PCPs and mental health practitioners expressed mixed views related to ease of communication within the public health primary care system. In some clinics, co-location provided better access to medical records held at clinics within the same facility and referral of patients. A few PCPs reported good engagement and communication across curative and mental health teams. However, most participants reported that engagement of clinicians across clinics was limited or non-existent and the system relied heavily on patients to carry messages from physicians:

“Not much of a process in terms of the public system. Most of the time it’s the patient that comes and says ‘I went to that other doctor and this is what they gave me or this is the prescription’… in the public system, you don’t usually get any correspondence from the colleague, it’s the patient that’s the means of communication. They’ll come back and say well that doctor told me X or Y. The process itself needs some improvement.” (Psych #9)

Likewise, some PCPs described their engagement with the mental health service as generally uncoordinated, with poor collaboration, little communication, and no follow-up after patients were referred:

“It’s basically like two people managing separately, we don’t sit and talk and say, ‘let’s talk about Anna Jones, how is Anna Jones doing?’…not much of a collaboration around managing patients and I understand because there are a lot of patients and for the most part, although it is a team effort, we do our own thing- I take care of the (blood) pressure- you take care of the schizophrenia- it is not we take care of her together”. (PCP #4)

Although communication was potentially enabled through co-located patient records, there was no system to share medical records outside of the co-located services, including with hospitals or other health services. There was also a noted absence of a computerised system or database to access and store patient medical records. This resulted in patients being asked to courier letters and information between clinicians and/or being requested to present with their written prescriptions or medications. Some clinicians and health policymakers reported this method to be ineffective, as patients often provided incomplete information and forgot the names of their prescriptions or medications. It was recommended that these processes be addressed in both policy and practice:

“We need to… really reorient and re-educate our practitioners to understand the whole concept of NCDs and mental disorders being closely intertwined and that they need to address both aspects of the patient is very critical for the overall outcome… we don’t (need to) have separate silos where the doctors that deal with mental illness are over that side and the doctors that deal with curative illnesses are over that side… but there is collaboration through maybe case conferences or consultation to deal with the patient so that both sides can get comfortable dealing with physical illnesses and dealing with mental illnesses.” (HPM #2)

That observation was elucidated by the finding that most PCPs did not consider they had a significant responsibility to manage MIs outside of mild to moderate depression. Even then, some PCPs shared their observation that they had encountered PCPs who did not do this and automatically referred symptomatic patients to the mental health clinic without any treatment intervention:

“They (some PCPs) refer everybody…if you say you’re not sleeping, they didn’t want to ask you why you’re not sleeping-sometimes they refer them (patients) without even doing blood work investigations. This is how quick they refer them.” (PCP # 5)

However, for those PCPs who engaged in the management of MIs, this mainly took the form of prescribing antidepressant medication and providing basic counselling. Medication management involved prescribing anti-depressants and paying close attention to possible medication interactions for co-morbid CPIs. Primary care physicians discussed that patients who reported not feeling any notable improvement in symptoms by the second visit were referred to the mental health clinic. Patients deemed to need urgent medical intervention were referred for critical care through the accident and emergency department at general hospitals.

Among mental health practitioners, there was some discrepancy in the views of psychiatrists and mental health nurses as it related to their role in managing CPIs in their patients. Most psychiatrists stated that the management of CPIs was the responsibility of the PCPs, despite their acknowledgment of the role that psychotropic drugs play in the development of CPIs among patients with severe and enduring mental illnesses:

“…some of the newer medications do predispose them (patients) to get diabetes or hypertension, which are two of the common ones that we really have and obesity as well as the fact that their mental illness could also lead them to have poor physical health as well. So it’s a combination of things it’s hard to say which one but whatever it is, there is a correlation between the two in terms of the physical illnesses and a mental illness.” (Psych #1)

For these psychiatrists, management of CPIs involved mainly screening and then referring; some would initiate management depending on the nature of the illness and then refer to the relevant clinic for follow-up. In contrast, mental health nurses mostly believed the management of CPIs was their responsibility based on the level of engagement and follow up they have with the patients:

“Well, it’s the nurses (responsibility to manage CPIs), because the doctor will diagnose them and give them their prescription and you have the nurse to do the education… I have to try to ensure that I do my follow-up and get them to keep to the appointment… the nurses are there from 8 am giving the patient’s a promotional talk every time… you do their blood pressure, their weight check. You counsel them. Because even after the doctor has spoken to them, they come right back to you, the nurse, for clarification. You also take out the medication and show them and give them explanations…” (MHN #1)

All mental health practitioners and some PCPs supported the promotion of a healthy lifestyle as a critical to the management of patients with these comorbidities as well as to mitigate the physical health risks associated with psychotropic drugs. Healthy lifestyle promotion was done through individual, family, and group health talks, referrals to dietitians or nutritionists, and focused on raising awareness about diseases, self-care tips, and encouraging appropriate diet, rest and physical activity.

3) Personnel.

The theme of Personnel outlines findings related to clinician characteristics or staffing issues that affect screening and management practices. A number of personnel challenges were noted across participant groups that were believed to affect clinicians’ ability to conduct routine comprehensive screening of patients with comorbid MI and CPI.

Clinicians expressed that insufficient staff in curative and mental health clinics negatively affected the management of comorbid MI and CPI in patients. The quality of care offered to patients is often compromised as the time allotment for each patient is reduced to enable staff to see all attending patients:

“As I say the shortage of staff is my problem. Sometimes when I could spend a little more time talking with a patient, as talk therapy helps more than the medication. But that had to be reduced to 3–5 minutes now, as I have over 35 patients in one day now, and I am alone. Also, if they wait too long they (patients) will leave this clinic and go away. You can’t afford that because when they go away, sometimes you don’t find them.” (MHN #2)

Staff shortage coupled with large patient volume greatly hindered mental health practitioners’ ability to adhere to protocols related to mitigating risks associated with psychotropic drugs:

“Most of the time they’re not adhered to (guidelines for mitigating risk of psychotropic drugs) and that’s the honest truth because in the clinic setting in the public system, we are limited, in that we don’t have the nursing staff at times to assist with taking the measurements that we may need. Again, the clinic numbers may be large. Patients are outside getting frustrated, so you want to try to move them through as quickly as you can. So there are limitations. So oftentimes no, the guidelines are not adhered to as strictly as they should be”. (Psych #9)

In some settings, Psychs and PCPs were absent and MHNs and psychiatric nursing aides routinely oversaw the clinic activities including performing the necessary vital checks and encouraging patients to follow up with their PCP for any CPIs:

“There are a few clinics now that we don’t have any doctor in as in working in Psychiatry…(in these cases) we encourage them (patients) to maintain their follow because we’re aware that they were already following up, sometimes in the same Health Center where we are”. (MHN # 1)

The issue of staff shortage and large patient volume were also of notable concern to PCPs. They shared that the sheer volume of patients that access clinic services rendered it very difficult to engage in a collaborative care approach. High patient volume instead resulted in reduced time with patients, limited available time for clinicians to collaborate, discuss and follow up on individual patients:

“Clinics are too busy and too packed, because for you to pick up the phone and call whoever it is- and remember (mental health) clinic is only one day for the week- because the mental health team has a lot of all that stuff doing, they have home visits, they have emergency calls, they have clinic at the hospital. They have clinics on different days and at different facilities.” (PCP #5)

Additionally, some participants linked the strain experienced by clinicians to the heavy focus of the health system response to the role of medical staff such as doctors and nurses. Only a few participants noted the presence, albeit limited, of psychologists and social workers. However, these professionals were not referred to in the standard process of screening or management of patients with comorbid MI and CPI. Several participants spoke to the need for multidisciplinary allied health teams that can help clinicians to better manage patients with comorbid MIs and CPIs as these professions could provide talk therapy and social interventions for patients.

Some clinicians felt that allied health professionals could help alleviate some of the pressure placed on the medical staff as well as help to address other social determinants of health that may be negatively affecting patients and contribute more than just medication management:

“Some of them (patients) need occupational therapies, social workers, and psychologists. (These professionals) are needed to help to mobilise these persons manpower and resources are lacking and if we had them we would see a vast improvement in the welfare of these clients and so we could see a support system that could help them have a better life…” (MNH #5)

Furthermore, the role of clinicians’ previous training, direct experience and attitude towards screening and management for MI and/or CPIs was noted to be important to their clinical practice. Among PCPs, those who had undertaken additional training or who had experience working with people with MI argued that providing medical care for people with comorbid MI and CPI was the ‘same’ as any other group. These PCPs also indicated they enjoyed the work:

“I would say that it was fine for me (working in the clinic with patients with MI) because I had some background. I had worked 4 months as a SHO (Senior House Officer) assigned to mental health, so I had some background (in mental health), so it wasn’t really very challenging for me.” (PCP #3)

Further, this small group of PCPs expressed care by spending ‘more time’ with this population, listening to their concerns, offering support, educating patients, initiating treatment, and taking time to explain treatment and referrals in plain language:

“(PCPs) are you willing to take the time to educate them (patients)?…if you give them the chance and empower them…(talk to them) in a language that they can understand and you work with them and make them feel safe then they will come back and you don’t have to teach them that much”. (PCP #7)

These PCPs also referenced ‘holistic care’ and the need for a multidisciplinary approach, which they believed, should involve psychologists and social workers. They described good working relationships, which included regular dialogue and collaboration with Psychs via telephone or in-person. All participants who reported a good relationship with the mental health team had additional training or experience in mental health:

“If I am suspicious of this patient being depressed or having schizophrenia, then I consult the psychiatrist. I always, always involve my psychiatrist because first of all, that I do have some experience in the area but I am not the specialist…so it’s always a collaborative effort for me and you know collaborative team approach.” (PCP #8)

This difference was even observable to some mental health practitioners. They noted that patient-centered PCPs tended to be more motivated to engage them:

“(Engagement) is still dependent on the motivation of the particular physician. So depending on the particular setting that I’m in, some physicians are just very thorough and they’re very patient-centred. So they will initiate contact with me as much as I will initiate contact with them, but then there are other settings where they just don’t have that same drive or motivation. So you will not have that sort of engagement.” (Psych #4).

In contrast, PCPs without additional training and experience tended to describe the population as ‘challenging’ and said they were ‘uncomfortable’ treating this group of patients. Primary care physicians in this group framed this in terms of limited professional confidence, exacerbated by a sense that psychotic patients are irrational and unstable. Consequently, this group of PCPs argued that the management of patients with MI was not their responsibility. They also reported that they immediately referred people who demonstrated psychiatric symptoms to the mental health service without detailed investigation or intervention. They reported a sole focus on the CPI aspect of care for patients with MI:

“If it’s severe depression, no we don’t deal with that… we just see them for their chronic disease, and we don’t address the mental illness…some (PCPs) are not comfortable with it… I am fine with depression, to be honest, the ones who are diagnosed with schizophrenia or psychotic disorder, I am a little hesitant, I will see them but when they are unstable I am hesitant…they can be unpredictable…they can be irrational. If they are in front of me and stable I am fine but if I pick up on any sign of instability I am uncomfortable.” (PCP #4)

Among mental health practitioners there were mixed views and practices. Mental health nurses expressed overall comfort managing the CPIs of patients as guided by practitioners, however, and this was different for psychiatrists. Psychiatrists who reported extensive experience in general medical practice or who expressed comfort and confidence in their ability to treat physical illnesses favoured holistic care:

“…it (treating comorbid patients) keeps my clinical skills up to scratch, current. It allows me to not just be limited to just Psychiatry. It gives me that opportunity to treat as a whole. And for me to utilize all other aspects of my training in dealing with these patients. It just allows me to be able to use my medical knowledge on a whole and treat them as well.” (Psych #6)

These psychiatrists tended to report thorough physical examinations, investigation of physical health complaints, initiating management of CPIs, follow-up with PCPs and patients about CPIs, more careful mitigation measures against the risks of psychotropic drugs, and involving the family or support persons in care and collaboration:

“I tend to make my assessment as psychiatric management …and I then tend to communicate that information to his primary physician or the person who made the referral, simply because, this allows the primary care physician to be aware of what (the) working diagnosis is, what medications you think are necessary, but also gives the primary physician a second opinion of the chronic medical issue that they may have been treating in the first place and help to possibly streamline (care)… So if you’re able to streamline that (care) what you find is you give the patient a better chance of dealing with both types of ailments.” (Psych #5)

In contrast, Psychs who lacked current knowledge on the treatment of physical illnesses reported focusing on MI rather than physical concerns. They saw their role as one of encouraging the patient to follow up with their PCPs for CPI care and to take the medication prescribed to them:

“Oftentimes the concept that if you’re a physician you should be able to manage everything, but some things go beyond the expertise of Specialists. So I wouldn’t bring it upon myself to manage somebody’s asthma and somebody’s diabetes because I didn’t think that that would be a disservice to the patient because that’s not what I have expertise in and other Physicians have expertise.” (Psych #2)