Family Practice Advance Access published June 20, 2015

Family Practice, 2015, 17

doi:10.1093/fampra/cmv044

Health Service Research

Managing common mental health problems:

contrasting views of primary care physicians
and psychiatrists
Kai SingSuna, Tai PongLama,*, Kwok FaiLamb and Tak LamLoa,c
Department of Family Medicine and Primary Care, bDepartment of Statistics and Actuarial Science, The University
of Hong Kong, Hong Kong and cKwai Chung Hospital, Hong Kong, China.
a

*Correspondence to Tai Pong Lam, Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap
Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China; E-mail: tplam@hku.hk

Abstract
Background. Recent studies have reported a lack of collaboration and consensus between primary
care physicians (PCPs) and psychiatrists.
Objective. To compare the views of PCPs and psychiatrists on managing common mental health
problems in primary care.
Methods. Four focus group interviews were conducted to explore the in-depth opinions of PCPs
and psychiatrists in Hong Kong. The acceptance towards the proposed collaborative strategies
from the focus groups were investigated in a questionnaire survey with data from 516 PCPs and 83
psychiatrists working in public and private sectors.
Results. In the focus groups, the PCPs explained that several follow-up sessions to build up trust
and enable the patients to accept their mental health problems were often needed before making
referrals. Although some PCPs felt capable of managing common mental health problems, they
had limited choices of psychiatric drugs to prescribe. Some public PCPs experienced the benefits of
collaborative care, but most private PCPs perceived limited support from psychiatrists. The survey
showed that around 90% of PCPs and public psychiatrists supported setting up an agreed protocol
of care, management of common mental health problems by PCPs, and discharging stabilized
patients to primary care. However, only around 5467% of private psychiatrists supported different
components of these strategies. Besides, less than half of the psychiatrists agreed with setting up
a support hotline for the PCPs to consult them.
Conclusions. The majority of PCPs and psychiatrists support management of common mental
health problems in primary care, but there is significantly less support from the private psychiatrists.
Key words: Health care system, mental health, primary care, psychiatrists, referral.

Introduction
In recent years, the WHO has called for integration of mental health
into primary care in response to the high prevalence of common
mental disorders, such as depression and anxiety disorders (1). Many
studies have shown that the general public tends to visit primary care
physicians (PCPs) in their initial contact with mental healthcare (2).
Experiences from Australia, USA and UK showed positive outcomes,

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including increased accessibility, patient satisfaction, continuity of

care and efficiency of services (1,3).
Apart from the patients help seeking behaviours, the attitudes
of the healthcare providers are crucial in determining the service
outcomes. Trials reported successful models of collaborative care
which commonly involved a PCP, a mental health professional and
a case manager (4,5). Collaborative care was often included as a

Family Practice, 2015, Vol. 00, No. 00

2
component of the stepped care model which started with the least
intensive intervention required and the patient could step up or
down the pathway according to treatment outcome (6). However,
some studies showed limited benefits perceived by the collaborating members in their everyday practice (7), and their predilection
to collaborative care could vary a lot (8). The participating mental
health professionals were often psychiatric nurses, psychologists or
social workers instead of psychiatrists (4,7,9). Some psychiatrists
perceived a lack of time and remuneration to sustain their regular visits to primary care settings (10,11). Furthermore, for some
stepped care interventions, access to collaborative care was restricted
and reserved for a small proportion of patients meeting specific criteria (12). In fact, in many countries, the major help seeking pathway
remained that the psychiatrists acted as secondary care providers
and were accessed via referrals from PCPs (1315). Integration of
mental health into primary care is at the stage of infancy in most
places. Recent studies still reported a lack of collaboration (16,17)
and consensus on protocol of care (18,19) between PCPs and psychiatrists. This can lead to significant barriers in the provision of mental
healthcare service. It is therefore important to understand the views
of the PCPs and psychiatrists, who are the key players of mental
healthcare provisions. Their strengths and limitations, opinions on
referrals, intention for collaboration as well as group interests (20)
would affect their acceptance of policy strategies.
In line with the WHO perspective, adequate provision of mental health service is considered central to the future primary care
model in Hong Kong. Similar to USA and most Asian countries (21),
the healthcare system of Hong Kong is pluralistic (mixed mode of
public-private financing) (22). The public doctors are paid a regular
monthly salary according to their ranks while the private doctors
are paid on a fees-for-service basis. The general public can consult
any private doctors including specialists regarding any health issues.
There are currently 312 specialist psychiatrists (Specialist Register,
2014) serving 7.15 million people in Hong Kong. In other words,
there are 4.4 psychiatrists/100 000 people, which is at an intermediate level by international standard. Being the major healthcare
service providers to the community, the 5000 PCPs are expected to
play a pivotal role in caring for patients with common mental health
problems. Postgraduate mental health training for PCPs has been
made available since 2002 (23). Besides, collaborative care involving PCPs, psychiatrists and other healthcare professionals, named
as the Integrated Mental Health Program (IMHP), has been started
in some government general outpatient clinics (GOPCs) since 2010.
However, over 75% of the PCPs work in the private setting, with the
majority as solo practitioners or in group practices similar to health
maintenance organizations. Their collaboration with psychiatrists
largely depends upon the referral system. In contrast to primary care,
only about 30% of the specialist psychiatric services are provided by
the private sector. The fees charged range from about HK$500 to
$2000 (US$64 to $258) per consultation. Most patients attend the
public psychiatric services with a very low charge [HK$100 (US$13)
per consultation] but often requiring a lengthy waiting time which
may take 1month to 1year, except for urgent cases. Aformal referral from PCPs or other specialists is mandatory.
This study was part of a large project investigating the facilitators
and obstacles for PCPs to managing mental health patients. The findings regarding the PCPs obstacles are published elsewhere (24). The
identified obstacles included consultation time constraint, patients
reluctance to accept diagnosis of mental health problems and to be
referred to psychiatrists (e.g. more stigmatization effects), as well
as a lack of feedback from psychiatrists after referrals. The current
article focuses on comparing the views of PCPs and psychiatrists on

managing common mental health problems in primary care and the

strategies for collaboration under a pluralistic health care system.
This will address a research gap in Hong Kong and the findings will
be useful for international reference.

Methods
A combined qualitative and quantitative approach was adopted for
this study. Ethics approval was obtained from the local Institutional
Review Board of The University of Hong Kong/Hospital Authority
Hong Kong West Cluster (UW 09-326).

Qualitative approach
We started with focus group interviews to explore in-depth opinions
of the PCPs and psychiatrists on the study topic. We purposively
recruited participants from both public and private settings with
a wide range of characteristics and experience. We contacted the
honorary teachers (including PCPs and psychiatrists who normally
work outside the university but appointed to provide teaching on an
honorary basis) of the Department of Family Medicine and Primary
Care of the University of Hong Kong to recommend participants for
the interviews based on their professional network. Invitation letters were sent to them and followed by telephone contacts. We conducted four focus group interviews of 610 participants each. There
were two focus groups for PCPs with one group working in public
setting and another group in private setting; and same arrangement
was adopted for two focus groups for psychiatrists. Questions on
participants views towards management of mental health patients
in primary care, referrals and collaboration strategies were raised
and discussed in the interviews. We aimed to avoid presumption of
attitudes of the participants who were encouraged to share their
opinions freely but an interview guide (see Appendix) was used to
ensure relevant questions were covered.
A facilitator experienced in focus group led the 90-minute
interviews which were audio-taped and then transcribed verbatim.
Field notes were prepared by another observer to record any nonverbal responses during the interviews. The facilitator and one of
the authors (TPL) checked the accuracy of the transcriptions. Using
the conventional content analysis approach described by Hsieh and
Shannon (25), coding categories were inductively derived from the
text data. The data were coded independently by two investigators
of the research team who are experienced in qualitative research.
The coding consistency between the two sets was checked and the
majority of the codes were consistent. Inconsistencies were resolved
by discussion between the two investigators to reach an agreement
for a common theme. The key themes on the major collaboration
strategies between PCPs and psychiatrists identified from the focus
group findings were incorporated in the design of a questionnaire for
quantitative survey.

Quantitative approach
Sample
For the PCPs, we invited all members of Hong Kong College of
Family Physicians and graduates of the Postgraduate Diploma in
Community Psychological Medicine (PDCPM) to complete a structured questionnaire. The target population comprised 1394 College
members and 198 PDCPM graduates. The contact details of the
graduates were available from our Department, whilst the College
members were reached with the help of the College. To avoid duplication, 85 PDCPM graduates who were also affiliated with the
College were removed from the mailing list of the College. All 275

Managing common mental health problems

psychiatrists on the list of the Medical Council (Specialist Register,
2012) were invited to complete another version of the structured
questionnaire. Their addresses were available from the gazette published by the government. Atotal of three rounds of invitations were
sent to both PCPs and psychiatrists.
Questionnaire
The questionnaire itself was anonymous but coded with a unique
reference number to identify the respondent for subsequent rounds
of reminders. The code was known to one research assistant only and
not available to members of the research team. The questionnaire
was sent with an invitation letter which asked for consent of the
subject to fill in the questionnaire. The questionnaire, which mainly
asked for descriptive facts and views, was tested for its face- and
content-validity with 10 PCPs and 6 psychiatrists with minor modifications made. Questions about collaboration strategies based on
our focus group findings are examined in this article, while questions
for other themes have been reported elsewhere (24). A4-point Likert
scale (1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly
agree) was adopted for the questions about views, while options of
Yes/No, numbers and percentages were used for questions about the
personal background and practice characteristics.
Statistical Analysis
The quantitative data were analyzed using SAS 9.3. We summarized
the responses from PCPs and psychiatrists by frequencies and percentages. Fishers exact test was used to test for the difference in
response distributions between the respondents in private and public
settings. AP-value < 0.05 is considered statistically significant.

Results
Participants recruited
Focusgroups
Four focus groups comprising 17 PCPs and 13 psychiatrists from
private and public settings were held between November 2011
and January 2012. Among the participants, 80% were males. The
mean (SD) years after graduation from medical school was 18.5
(11.17).
Questionnairesurvey
There were 599 respondents with 516 PCPs and 83 psychiatrists
after three rounds of mailing from June 2012 to December 2012.
Excluding 10 PCPs and 10 psychiatrists with invalid addresses,
the response rates were 34.5% (516 /1497) for PCPs and 31.3%
(83/265) for psychiatrists. The details of their personal and practice
characteristics are shown in Table1.

Views of the focus group participants

Opinions on referrals
The PCPs discussed their views about referrals. They needed to
consider the timing of referrals, and they took time facilitating
the patients to realize their mental health problems. Several more
follow-up sessions to build up trust were often needed to enable a
successful referral. Good communication skills are indispensable in
convincing the patients.
Most of them do not present because of their mental illness. We
are the ones who notice [their mental problem] and further dig
into it. The patients are not ready to consult about it. Therefore if
we have to manage these patients, we would need to let them real-

3
Table 1. Personal and practice characteristics of survey respondents during JuneDecember 2012
PCPs, n=516
Gender
Male
Female
Work setting
Hospital
Community
Work sector
Public
Private
Type of practice
Group
Solo
Years since graduation
Mean SD

Psychiatrists, n=83

337 (65.6%)
177 (34.4%)

60 (74.1%)
21 (25.9%)

62 (12.3%)
443 (87.7%)

53 (66.3%)
27 (33.8%)

224 (43.9%)
286 (56.1%)

56 (69.1%)
25 (30.9%)

284 (58.8%)
199 (41.2%)

61 (75.3%)
20 (24.7%)

20.0 (12.56)

22.4 (9.42)

Some data in the categories were missing due to respondents refusal to

answer or invalid response.

ize and understand that this is a [mental] problem so a successful

referral can be made. I would take a note and follow up with
the patients when Isee them again. Then they would place more
trust in me. If the patients proactively visit for mental illness, they
would be cooperative. (P1, public PCPsgroup)
Sometimes they want to seek our advice, or they would like to
obtain a referral to see a psychiatrist. Occasionally when we have
to refer the patient to psychiatric service right from the beginning,
the patient would query why having poor sleep is a mental illness.
What we need to do is to match their expectations. (P6, public
PCPsgroup)
If the patients with severe condition feel reluctant to visit a
psychiatrist, Iwould frankly advise them that their condition is
quite severe, and that they may need further extensive treatment
and assessment. I may also tell them that the current sleep loss
should in fact be managed by a psychiatrist; many patients with
sleeping problems would call for a psychiatric consultation. (P4,
public PCPs group)

When asked about the appropriate timing for referrals, some public
psychiatrists felt that it would be best for the patients to enter the
specialist system at a later time point, after they had gone through
the management of the PCPs. The same perspective was shared by
somePCPs.
Psychiatrists working in the public sector prefer patients to consult them at a later time. It is possible that they wish to handle
cases that are more severe in order to bring their expertise into
full play. (P9, public PCPs group)

However, some private psychiatrists commented that the expectation of referrals at a later time point was due to resource availability
rather than the best benefits for the patients. Despite the difference
in opinions, a portion of both public and private psychiatrists supported the management of common mental health problems by
PCPs, provided that there was appropriate collaboration and understanding of their limitations. Some of them pointed out that the decision and timing for referral should be flexible.
In an ideal system, more could be done by the PCPs, particularly
mental problems. Psychiatrists should have more collaboration
with PCPs and discuss cases together. In other words, the boundaries [of care] between [psychiatrists and PCPs] should be flexible.
(P4, public psychiatristsgroup)

Family Practice, 2015, Vol. 00, No. 00

4
Many PCPs are gradually finding something that they are
incapable of handling nowadays, and sometimes they want to
consult specialists opinions. (P6, private psychiatrists group)

The relationship between us is not mutual. [Internal medicine]

Physicians would assist and support us, but Ithink psychiatrists
dont feel like to provide support to PCPs to handle this kind of
problem in the community. (P2, private PCPs group)

Strengths and limitations of PCPs in thesystem

The PCPs offered their views on why many patients preferred to
consult them first, instead of psychiatrists. Apart from less stigmatization effect to consult a PCP, the long term doctor- patient relationship facilitated the patients to express their psychological problems
more comfortably.

They expressed a strong need to strengthen the collaboration with

psychiatrists. They suggested setting up hotline and feedback mechanism for their communication with psychiatrists.

The patient has been consulting you since young age and hence
the patient would be more willing to disclose more to you. The
patient would refuse to do so if it is an unfamiliar doctor. That is,
if he has confidence in you, he would tell you a lot. (P6, private
PCPs group)

Another major reason was that many patients consulted the PCPs
for diagnosis to see if their problems had a psychiatric cause before
seeing psychiatrists. This could save extra cost andtime.
Patients would come to us first to determine if their problem
should be handled by a psychiatrist; refer only if it is. Also, some
of the patients have got used to consulting us, especially the
elderly. We know their problems, such as chest pain and dizziness.
We are familiar with these patients. We know the symptoms are
not caused by organic disease but something that should be managed by a psychiatrist. (P5, private PCPs group)

The limitations of PCPs in the system were also discussed. For those
who felt capable of managing common mental health problems, they
often had limited choices of psychiatric drugs to prescribe, especially
in the public setting (e.g. availability of tricyclic antidepressants only
while no or few selective serotonin reuptake inhibitors being available for patients with depression). Apublic psychiatrist gave the following comment.
The public PCPs were probably under some pressure not to prescribe sedatives; they tried to handle the case for a while, and
without many choices on medicine they would then refer the
patients to us. In fact if they had a higher degree of freedom on
medicine prescription, they should be able to handle more cases.
This is an unresolved issue because they are not permitted to prescribe some of the drugs. They can at most give out some soothing medicines. Afew are even reluctant and dare not prescribe
anything. (P3, public psychiatrists group)

Views in strengthening the collaboration between

PCPs and psychiatrists
The PCPs expressed their opinions of strengthening their collaboration with psychiatrists. The public PCPs acknowledged the benefits
of the IMHP in theGOPCs.
Indeed the cooperation works better than before, because we
now have IMHP which seems building the bridge that connects
GOPC) and the psychiatric department. Severe patients are to be
referred to psychiatrists, whereas those who are not as severe are
to be referred to IMHP. The psychiatric department has monthly
meeting with IMHP. Also, there are appointed time slots when
psychiatrists would need to be on duty in IMHP or GOPC. If a
patient is living near IMHP or having a stable condition, the psychiatric department would refer the patient to IMHP. (P7, public
PCPs group)

However, PCPs working in the private setting perceived limited support from the psychiatrists. Some doubted the psychiatrists willingness to helpthem.

We may find a doctor from the psychiatric service whom we can

contact directly when theres a special need. At least we would be
able to inquire to make ourselves comfortable by letting us and
the patient know more. (P3, private PCPsgroup)
For example, if I refer a patient whom I cant manage to a
specialist, and he subsequently writes me a reply letter after the
patient has been seen, then Ican learn from the case. (P1, private
PCPs group)

Findings of the survey on PCPs and psychiatrists

The survey respondents were asked about their views on the major
strategies shared by the focus group participants. The responses
from PCPs and psychiatrists are compared in Table 2. Almost all
PCPs and public psychiatrists supported the establishment of a feedback mechanism to notify the PCPs when the referred patients had
consulted the psychiatrists. Around 90% of PCPs and public psychiatrists supported setting up an agreed protocol of care, management
of common mental health problems by PCPs, and discharging stabilized patients to primary care. However, only around 5467% of
private psychiatrists supported these strategies. Besides, while 79%
of public PCPs and 87% of private PCPs wanted to set up a support
hotline for them to consult psychiatrists, only about 45% of public
and private psychiatrists agreed withthis.
Overall, except the responses on setting up an agreed protocol
of care, the private PCPs were more likely to agree strongly on all
suggested strategies than the public PCPs. Significant differences
(P<0.05) between the responses from private and public PCPs were
observed for the strategies on setting up a support hotline, establishing a feedback mechanism and encouraging PCPs management
of common mental health problems. When comparing the public
and private psychiatrists, there were significant differences in their
responses regarding setting up a protocol, encouraging PCPs management and discharging stabilized patients to primary care. Among
all groups of respondents, the public psychiatrists had a distinctly
high percentage of strongly agree responses (46%) for the strategy
on discharging stabilized patients.

Discussions
The qualitative findings of this study explained how the PCPs and
psychiatrists saw the need and timing for referral. Both consensus and
conflicts in their views were observed. The private PCPs perceived
very limited support from the psychiatrists and expressed the need
for stronger collaboration. The survey results showed that while PCPs
and public psychiatrists generally supported management of common
mental health problems in primary care, only two-third of private psychiatrists supported it. This signified the difference in group-interest
between the public and private sectors, probably due to financial
consideration. AFrench study had found that PCPs and private psychiatrists were similar but different from public psychiatrists for the
proportion of mental health patients with anxiety or depressive disorders (70% versus 65% versus 38%) (26). The PCPs and psychiatrists
in the private sector may be interpreted as market competitors to some
extent. On the other hand, they have an interdependent relationship.

Managing common mental health problems

Table2. Comparison of survey responses between PCPs and psychiatrists on collaboration strategies
Public PCPs, n=224

Private PCPs, n=286

Public Psy, n=56

Private Psy, n=25

To set up a support hotline for

PCPs to consult psychiatrists

Strongly disagree
Disagree
Agree
Strongly agree
Fishers exact test

3 (1.4%)
43 (19.4%)
148 (66.7%)
28 (12.6%)
P=0.018*

2 (0.7%)
34 (12.0%)
189 (66.8%)
58 (20.5%)

5 (8.9%)
26 (46.4%)
24 (42.9%)
1 (1.8%)
P=0.163

4 (16.0%)
10 (40.0%)
8 (32.0%)
3 (12.0%)

To set up an agreed protocol

of care with psychiatrists

Strongly disagree
Disagree
Agree
Strongly agree
Fishers exact test

0 (0.0%)
12 (5.4%)
154 (68.8%)
58 (25.9%)
P=0.683

2 (0.7%)
19 (6.8%)
191 (68.2%)
68 (24.3%)

1 (1.8%)
5 (8.9%)
43 (76.8%)
7 (12.5%)
P=0.029*

1 (4.2%)
8 (33.3%)
14 (58.3%)
1 (4.2%)

To establish a feedback
mechanism to notify the PCP
when the referred patient is
seen by the psychiatrist the
first time

Strongly disagree
Disagree
Agree
Strongly agree
Fishers exact test

0 (0.0%)
2 (0.9%)
165 (73.7%)
57 (25.4%)
P=0.010*

1 (0.4%)
3 (1.1%)
173 (61.1%)
106 (37.5%)

0 (0.0%)
1 (1.8%)
47 (83.9%)
8 (14.3%)
P=0.398

0 (0.0%)
2 (8.0%)
20 (80.0%)
3 (12.0%)

To encourage management
of common mental health
problems (e.g. depression,
anxiety) by PCP

Strongly disagree
Disagree
Agree
Strongly agree
Fishers exact test

0 (0.0%)
10 (4.5%)
163 (72.8%)
51 (22.8%)
P=0.013*

1 (0.4%)
7 (2.5%)
180 (63.2%)
97 (34.0%)

0 (0.0%)
7 (12.5%)
31 (55.4%)
18 (32.1%)
P=0.006*

0 (0.0%)
8 (33.3%)
15 (62.5%)
1 (4.2%)

To discharge stabilized
patients to primary care

Strongly disagree
Disagree
Agree
Strongly agree
Fishers exact test

0 (0.0%)
20 (9.0%)
165 (74.0%)
38 (17.0%)
P=0.054

0 (0.0%)
18 (6.4%)
192 (68.1%)
72 (25.5%)

0 (0.0%)
4 (7.1%)
26 (46.4%)
26 (46.4%)
P<0.001**

0 (0.0%)
11 (45.8%)
11 (45.8%)
2 (8.3%)

Psy, psychiatrists. Fishers exact test for the difference in responses between public and private sectors.
*P<0.05.
**P<0.001.

The private psychiatrists are partially dependent on private PCPs for

referral of patients (27). In fact, given the large unmet needs for treatment for common mental health problems (28), both groups can play
a significant role in the system. Some focus group participants pointed
out that the psychiatrists wanted to utilize their specialty to manage
more severe cases. They also explained the strength of PCPs in initial
management of the patients in the help seeking pathway. This echoed
the concept of stepped care. These factors may be the driving forces
which still prompted over half of the private psychiatrists encouraging
the PCPs management of common mental health problems in this
study. As supported by two-third of private psychiatrists, an agreed
protocol of care should be set up by the policy makers. Besides, providing more opportunities such as clinical meetings and training courses
for the private PCPs and psychiatrists to come closer may enhance
their mutual understanding and relationship (23,27).
Despite the supportive attitudes towards PCPs, over half of both
public and private psychiatrists disagreed with the proposed strategy
of setting a support hotline for the PCPs to consult them. The psychiatrists might regard this strategy as a burden on them. This suggested
the gap between their attitudes and behaviours. Although related experience from Australia also showed that proposals to promote more
telephone-based consultation services by psychiatrists to PCPs were
not supported (29), telephone call was identified as the most common
mode of communication between PCPs and psychiatrists in USA. It
was reported that 35 % of the US psychiatrists often received information by this means (30). Different from the suggestion of hotline,
over 90% of our psychiatrist respondents supported establishing a
feedback mechanism after referral. The policy makers should facilitate

the implementation of this mechanism. This is what had been done in

USA that about 80% psychiatrists often sent diagnostic and treatment
information back to the referring physician (30). This mechanism is
important to check if the referred patients show up at psychiatric clinics and reduce lost to follow-up (31). Besides, as pointed out by our
PCP focus group participants, the feedback would improve their diagnostic knowledge and also relationship with psychiatrists.
This study had some limitations. Firstly, the response rate of the
survey was 34.5% for PCPs and 31.3% for psychiatrists. It is not
high compared with the 3050% response rate reported by relevant
surveys of similar sample sizes in other countries (16,19,32,33), but
is already much higher than most other surveys among doctors in
Hong Kong (34,35). The results of the survey are able to show the
overall pattern of the similarities and differences among the four
groups. Secondly, this study investigated the views of the doctors
only. Further studies are needed to explore the views of the patients.
Thirdly, the survey was more likely to recruit PCP respondents with
an interest in looking after patients with mental health problems.
Besides, the proportion of PCP survey respondents from the public
service sector (43.9%) was higher than the corresponding proportion in the actual healthcare system (around 25%). This might reflect
that the public PCPs were more interested in the study topic.

Conclusions
The majority of PCPs and psychiatrists support management
of common mental health problems in primary care, but there
is significantly less support from the private psychiatrists. For a

6
successful referral, several follow-up sessions by PCPs to build
up trust and enable the patients to recognize their mental health
problems first were often required. Some public PCPs acknowledge the benefits of collaborative care, but most private PCPs perceived limited support from psychiatrists. Despite the support for
a feedback mechanism after referral, over half of the psychiatrists
disagreed with setting a support hotline for the PCPs to consult
them.

Acknowledgements
We are grateful to Miss Chan Hoi Yan for the English translation of the focus
group quotes.

Declaration
Funding: Committee on Research and Conference Grants of The University of
Hong Kong (10401224).
Ethical approval: Institutional Review Board of The University of Hong Kong/
Hospital Authority Hong Kong West Cluster (UW 09-326).
Conflict of interest none.

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Managing common mental health problems

Appendix

For Psychiatristgroups

Relevant questions of the interviewguide

1. How do patients get to come to see you as a psychiatrist?

2. Would you consider suggesting your patients to seek help from a
PCP for their mental health problems? If yes, what would be the
factors to encourage you to do so?
3. What are the possible factors to discourage you from suggesting
your patients to seek help from a PCP for their mental health
problems?
4. How would you evaluate the present collaboration with PCPs in
offering help to mental health patients? How can it be strengthened?

For PCPgroups
1. How often have you come across patients with mood/mental
health problems, and what would you usually do?
2. What do you think are the factors that may make mental health
patients seek help from a PCP?
3. What are the possible factors which might have discouraged mental health patients to seek help from a PCP?
4. What factors may hinder or facilitate you to recognize and treat
these patients? Is there any real case you can share?
5. How would you evaluate the present collaboration with psychiatrists in offering help to mental health patients? How can it
be strengthened?