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There is a large variation between different countries regarding the presentation of psychological symptoms, their diagnosis and treatment in general practice. A possible explanation for such variation might be the conditions of the health care system in different countries. A gate-keeping function might be facilitating the recognition and treatment of mental disorder. Furthermore, the payment system and insurance system are considered of importance. Method: To test these hypotheses, data were collected in 10 European countries with different health care systems. 25 - 43 GPs in each country collected data on 20 consecutive doctor-patient contacts, including videotaped consultations, patient and GP questionnaires per contact and a general GP questionnaire. Results: There are differences, not related to health care system characteristics, between countries concerning the prevalence of mental distress among patients visiting their GP. Only a minority of distressed patients presented psychological symptoms. Although GPs did not limit their psychological diagnoses to patients presenting with psychological symptoms, they also diagnosed only a minority of distressed patients with a psychological diagnosis. In general, psychological presentation and diagnosis in gate-keeping countries and in Switzerland (where GPs were remunerated for psychological diagnosis and treatment) was more frequent than in other countries. Especially in Eastern European countries Estonia, Poland and Rumania the presentation of psychological symptoms by distressed patients was very uncommon. Psychological treatment was not related to gate-keeping. In case of Switzerland, remuneration seemed an effective incentive. Conclusion: Overall prevalence of mental distress cannot be explained by gate-keeping function of the GP, payment system, remuneration system or differences between Eastern and Western Europe. However, a gate-keeping system appears to lower the threshold for help seeking and diagnosis. Gate-keeping has no clear impact on treatment of mental disorder in general practice. In this case, remuneration is observed to be effective.
