Introduction

Common psychiatric illnesses like anxiety and depressive disorders are highly prevalent all over the world. Estimates from 2001 ranks depression among the top ten causes of disability worldwide[1]. Depression is projected to become the second leading cause of disability in the world while the foremost cause in the underdeveloped countries by the year 2020[2]. The mounting burden of such disorders presents more of a challenge for the developing world, where only a minor percentage of the gross domestic product is allocated to health care.

The role of family physicians is fundamental in managing common psychiatric illnesses. Several studies have shown that the prevalence of psychiatric illnesses among patients visiting primary health care providers is high. The prevalence of psychiatric morbidity in Pakistan ranged from 10% to 25% for men and 25% to 57% for women in an analysis of 20 community based studies[3]. Sabooh et al reported the prevalence of common psychiatric illnesses in primary care settings to vary from 17% to 30%[4].

The prescription of psychopharmacological medications plays a major role in the management of common mental disorders. In Pakistan, there are currently only 350 psychiatrists for a population of 150 million[5]. The high prevalence of psychiatric illnesses in primary care clinics often leads to hasty diagnostic and therapeutic decisions. Evaluation and diagnosis of common mental disorders like anxiety and depression involves a challenge to the clinical ability, knowledge and experience of the family physicians. Due to the dearth of psychiatrists, most patients with psychiatric illnesses are being managed by family physicians[6]. Therefore it is imperative to know how they fare when it comes to prescribing psychopharmacological medications and if adequate information about the disease is being provided. Providing adequate information about the disease and its management is of special importance in the treatment of patients with mental illnesses. There is evidence that adequate information helps improve patient cooperation, medication compliance, tolerance to unwanted effects and the efficacy of medications and reduce the rate of unwanted drug effects[7].

The purpose of our study was to determine if patients who were prescribed psychopharmacological drugs by family physicians at a reputable community health center in Karachi, Pakistan receive adequate education about their disease and its management.

Methods

We carried out a cross-sectional study among patients attending the family medicine clinics at the Community Health Centre (CHC) at the Aga Khan University Hospital (AKUH), Karachi. Karachi is the largest city of Pakistan with an estimated population of 18 million[8]. AKUH is a privately managed tertiary care, university hospital, located in the centre of the city. The CHC provides primary health care services within AKUH premises and it serves patients from all socio-economic backgrounds. It comprises of 10 clinics which are conducted by trained family physicians that are certified by local or foreign examination boards. According to current estimates, the CHC has an average daily turnover of 250 patients. This number includes adults and children attending family medicine clinics, as well as specialty clinics and those coming in for brief surgical and medical procedures.

Results

We approached a total of 368 patients aged 18 and above over a period of 3 days, out of which 354 participated in our study with a response rate of 96.2%. Of the total participants, 251 (70.9%) were married, and 220 (62.1%) were unemployed. There were a total of 230 females which comprised 65.0% of the participants. The mean age of the participants was 38.8 years (SD 15.3). Of the participants, 130 (36.8%) were illiterate or had received primary education only. 54.5% had come in for a follow-up visit and 71.5% were financing their own healthcare. All patients who were interviewed had received a prescription from their family physician, either in the form of therapeutic or symptomatic medication. Prescription of psychopharmacological medications was found among 73 (20.6%) of the participants. Table 1 presents the differences in demographic profiles of the patients receiving psychotropic medications versus those receiving other medications. Among the patients prescribed psychopharmacological medications, 35 (47.9%) received Selective Serotonin Reuptake Inhibitors (SSRI), 23 (31.5%) received Tricyclic Antidepressants (TCA) and 15 (20.5%) received Benzodiazepines (BDZ).

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Table 1. Demographic profile of the patients receiving psychopharmacological medications and patients receiving other medications (n = 354).

https://doi.org/10.1371/journal.pone.0004620.t001

For all aspects of education, patients prescribed psychopharmacological medications knew less as compared to those patients that were prescribed other medications. As shown in Table 2, among the patients receiving psychopharmacological medications, 50.7% did not know their diagnosis compared to 27.9% of patients with other medications (p-value<0.001); 68.5% (versus 48.4%) of the participants were not explained the disease process in layman terms (p-value = 0.002); 71.2% (versus 56.2%) of the participants were not counseled about alternative treatments (p-value = 0.020); 86.3% (versus 77.7%) of the participants were not explained the adverse effects of the drugs (p-value = 0.107); 32.9% (versus 23.3%) were not aware of the duration of treatment (p-value = 0.093) and with 82.2% (versus 74.9%) of the participants an appropriate referral had not been discussed (p-value = 0.192).

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Table 2. Teaching of patients prescribed psychopharmacological medications vs. those who were prescribed other medications (n = 354).

https://doi.org/10.1371/journal.pone.0004620.t002

Discussion

Questions have been raised about the relevance of psychopharmacological prescriptions in primary health care practice[10]. These drugs can have serious side effects and some of them, especially the benzodiazepines have an addictive potential. Therefore, their prescription and use should be monitored by a healthcare professional. Also, the treatment of mental disorders entails more than just prescription of medicines; it also requires the doctor to develop a strong bond with the patient, and to counsel the patients regarding alternative treatment options. In this context, several of our findings were distressing.

Almost 51% of the patients with psychopharmacological medications did not know their diagnosis. Several factors could be responsible for this. Most of the psychopharmacological medicines in our study were antidepressants and it is possible that doctors were hesitant to tell patients that they were suffering from depression. Further, patients may have refused the diagnosis due to the social stigma associated with psychiatric diseases, or they may have been unable to understand the diagnosis due to cognitive disability associated with psychiatric illnesses. At the same time it can also be argued that the doctors were unable to effectively explain the diagnosis to their patients because they themselves were unclear about it.

With almost 71% of the patients no alternative treatment options were discussed. This issue must be addressed because addition of non-pharmacological treatment options can be helpful in augmenting the treatment of common mental disorders like anxiety and depression, and in milder cases these may be the only forms of treatment required[11], [12]. This finding can also be interpreted as a sign of over dependence on medications on the part of family physicians when it comes to managing such disorders, given that often there are several pharmacological and non-pharmacological treatment options.

Adverse effects of the drugs had not been explained to almost 86% of the patients being prescribed psychopharmacological medications. SSRIs have fewer side effects, but TCAs and benzodiazepines have significant ill-effects which should be discussed with the patients before initiating therapy. In general, most patients attending primary care services want to know the adverse effects of the treatment being prescribed to them[13]. Although, most patients knew about the duration of treatment, a third did not. This can prove hazardous as prolonged treatment with benzodiazepines can lead to dependence[14], [15], while stopping antidepressants before time is likely to lead to relapse[16].

With almost 82% of the patients no referral plan was discussed. This complements the findings of a previous study which showed that only 3% of the patients in a psychiatry clinic had been referred by primary care physicians[6]. The low rate of referral makes it all the more important for the physicians at first level of care to be well versed in the management of mental illness. In a developing country like Pakistan mental illnesses make up a significant proportion of the total disease burden and trained psychiatrists are few. Consequently, correct identification and effective management of common psychiatric disorders by family physicians becomes essential[17].

The most common psychopharmacological medicines prescribed were antidepressants with relatively fewer prescriptions of benzodiazepines. This pattern differs from other studies which show benzodiazepines rather than antidepressants as being the most commonly prescribed psychopharmacological medicine[18], [19]. This is an encouraging finding as benzodiazepines have a high potential for addiction and should be used judiciously. The doctors in our study were trained, local or international board certified family physicians who had been exposed to psychiatric patients during their training and were therefore able to make a more informed decision about benzodiazepine prescription. This may explain the low prescription rate of benzodiazepines. It may be worthwhile to carry out a similar study among primary care physicians without specialized training to know how they fare when prescribing psychopharmacological medications. Postgraduate training of family physicians in treating common psychiatric disorders has been suggested to protect patients against unnecessary prescription of psychopharmacological medications [20].

On the whole, all aspects of providing information to patients receiving psychopharmacological prescriptions were inadequate. This is a cause of concern as the doctors involved in our study were trained family physicians, whereas most primary care doctors in Pakistan receive no such training. A recent study showed that although there are very few formal training programs for family medicine in Pakistan, they are of international standards. However, very few doctors go through these training programs and most of them venture into family practice right after their house jobs without any continued training[21]. There is no reason to believe that their performance would be any better, in fact it is our belief that it would be worse. Given that the quality of mental health care provided by untrained family physicians and self-proclaimed medical workers (“quacks” and “hakims”) in Pakistan is not known, there is a need to assess how less specialized health care providers fare when managing patients with suspected psychiatric illnesses.

At the same time, measures are needed to improve the performance of existing trained and untrained family physicians, and to educate them about the importance of providing information to patients receiving psychopharmacological medications. This can be done by enrolling them in Continuous Medical Education seminars or special courses and workshops throughout the country Such interventions have been suggested and proven beneficial in other countries too[22], [23].

However, additional factors might be responsible for the inadequate practice of patient education seen in our sample. As shown in Table 1, the study participants who received psychopharmacological drugs differed from other patients with regards to gender, mean age, marital status and educational level. There were more illiterate or less educated individuals, and less college graduates and postgraduates. This suggests that these patients were adequately educated about their disease by the physicians but had a poor retention or comprehension of the counseling session due to their lower educational status. Similarly, the group of patients receiving psychopharmacological drugs had a higher proportion of females (82.2%) as compared to those with other medications (60.5%). Females in Pakistan generally have a lower educational status, and the lower quality of counseling reported by females might be a reflection of their poor understanding and comprehension secondary to lower education.

The patients with psychopharmacological medication were also older than those receiving other medications (43.3 years vs 37.6 years, p-value 0.005). A greater number of elderly patients in one group might have had cognitive defects leading to poor comprehension of the information provided by the physician. Also, the family physicians might have had problems in communicating with the elderly patients.

It is also possible that a quantity driven and profit oriented clinic setting makes it difficult to adequately counsel patients due to practical constraints like lack of time. In a previous study it was speculated that market influences were a possible reason for poor prescribing practices, as physicians in Pakistan participate in a market where consultations including patient education and medications are bought and sold[24]. Such constraints might be overcome to some extent if standardized patient leaflets were used to facilitate communication. Further, it is possible that only “difficult” or chronic patients received psychopharmacological medications due to feelings of helplessness on part of the physician. This might have led to a poorer quality of patient education in these cases as a clear plan for the treatment was not present. It has also been argued that the poor level of mental health literacy among patients could be a reason for the inadequate management of psychiatric illnesses in the country[25]. It was not our objective to pin-point the specific reasons behind this inadequate counseling but to merely determine if it is an issue of concern or not.

There were certain limitations to our study. Our data was collected from 2 sources i.e. the patients' prescriptions and the questionnaire based interviews. As regards the interview, some participants had been diagnosed with common mental disorders like anxiety and depression, or were taking psychopharmacological medications. This might have introduced an element of information bias in our study as both these factors are known to cause cognitive impairment. Also, our study was a cross-sectional survey and we recruited patients consecutively. It is an inherent limitation of the study that we cannot comment on the representativeness of the patients recruited during the three days. While all prescribing CHC doctors were trained and accredited family physicians, this setting cannot be generalized to the general practitioners throughout the country which comprise mostly of untrained doctors. The fact that there were multiple interviewers could also have led to an element of interviewer bias. However, we strived to eliminate this by designing a standard questionnaire and all interviewers read out the same standard set of questions during the interview.