Kalina waited until she was eighteen to tell her GP about her depression. She had planned the visit carefully for years. If she was of legal age, she couldn’t be referred to a pediatrician or asked for her parents’ approval. 

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As part of her planning, she felt she had to make up a more convincing reason for her depression in order to be taken seriously. So when Kalina finally saw her GP, she told her it was because of her grandfather’s death. In reality, she had been continuously sad and tired since she was twelve and wasn’t quite sure why.

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“Before my second check up with a psychiatrist, I went back to my GP for a referral,” says Kalina. “She looked at me and said, “You’ve already been there twice. Aren’t you over it already?” That’s why I never went back.”

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Bulgaria’s health system puts GPs at the source. A referral from them is the integral first step to being seen by a psychiatrist, but their training is lagging behind. Mistakes on their part, from incorrect referrals to stigmatization, are what often stops people from seeking any further help.

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THE NUMBERS

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When the National Centre for Public Health (NCPH) submitted an analysis last year of the country’s psychiatric services, it showed that only a fifth of people with mental illnesses seek some form of help. Out of them, most people only end up speaking to their GP. Kalina is part of the rare few who then go on to see a specialist.

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People usually consult their GPs about physical symptoms, such as fatigue, sleeplessness, and difficulty breathing, not about specific mental illnesses. Because of the overlap between these symptoms and other physical diseases, most GPs first refer people to other specialists, such as cardiologists and endocrinologists, to eliminate other possible triggers. 

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This delay in referring people to a psychiatrist can sometimes be fatal. According to the NCPH analysis, 70% of people who attempted suicide in Bulgaria had contacted their GP in the past two weeks but had been referred to the wrong specialists until it was too late.

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ACTING AT THE SOURCE

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Realising the importance of GPs in this process, the National Centre for Public Health founded the project “Improved Services for Mental Health”. In it, more than 2,000 GPs and social workers undergo a two-stage training programme to better recognise mental illnesses and speed up the referral process.

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“We know that most people look at GPs for help, so we decided to target our efforts at them,” says Dr. Zahari Zarkov, one of the founders of the project and head of Psychiatry at the NCPH.

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 “Whether it’s because of stigma, low health culture or other unknown reasons to us, people don’t seem to take symptoms like insomnia and stress for something unnatural. They don’t realize that they decrease their quality of life.”

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The project is the first of its kind in the country and works on a self-registration basis on the online platform. Alongside improving GPs’ recognition of mental illnesses, the project aims to improve and digitalise the collection of suicide statistics, which today is still sent by post.

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EXPECTING A VISIBLE DROP

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GPs are showing interest but struggling to find the time to go through the full training. Half of the participants Dr. Zarkov has spoken to reach the registration to the online platform but don’t complete it.

At this stage, however, more than 2,000 people have completed both stages of the programme - the online training and practical training at university clinics.

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Two regions in the country are not currently participating in the project. These regions will be used as control groups to compare the effects of the project in two years’ time. What the team hopes to see is a 10% decline in suicides in regions that have taken part in the project.

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“We want to see if this form of intervention is effective,” adds Dr. Zarkov. “Measuring effectiveness in this branch is almost impossible, especially when the information is so delicate and differs from one source to another.

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“We need to make sure that what we are doing is working, so we can incorporate it into the system and hopefully make it a permanent part of it.”

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"GPs DON'T MISSPEAK"

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While most GPs admit they carry a big responsibility in the mental health process, some are not convinced this initiative is needed. Dr. Tanislava Govedarova, a practicing GP for over 25 years, says she doesn’t think there will be any noticeable effect from the project.  

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“I think it’s all a matter of experience. A good GP should just be able to recognise the symptoms. It’s not difficult, especially in young people.

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“If someone was, up to a few weeks ago, living a normal life, going to work or university and suddenly cant function the same way because he feels suffocated or too tired, it’s usually obvious that it’s a mental illness.”

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GPs argue that when they put patients through different medical tests and send them to various specialists, they are doing their job by eliminating the possibility of a more serious disease.

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This training, however, also aims to better prepare GPs for tackling the issue of mental health in order to eliminate stigma on their part that might become a barrier on the road to a specialist.

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“I don’t think there are cases when GPs misspeak or create stigma,” insists Dr. Govedarova.

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OLD DOG, NEW TRICKS

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While not everyone experiences misunderstanding on a GP's part, most people expect it when it comes to mental health. When Violeta sought out help for her depression, she was ashamed of telling her GP because she expected her to call her spoiled.

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She links the issue to a more looming stigma that has simply become part of the older generation’s way of thinking. Twenty years ago, health culture in Bulgaria was even weaker than it is today and mental health did not even exist socially as a term.

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“Bulgarians still don’t seem to take mental illness for a real problem,” adds Violeta. “They think you just can’t handle your problems. If you can’t point to an obvious reason why you are depressed, they make you feel guilty for feeling the way you do – even if it is out of your control.

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“Bulgaria raised me into thinking this was something that didn’t happen in Eastern Europe. This was just some virus that struck the Western Countries.”