A study of the classification of mental ill-health in general practice

Complexity of GPs' explanations about mental health problems: development, reliability, and validity of a measure

BACKGROUND

How GPs understand mental health problems determines their treatment choices; however, measures describing GPs' thinking about such problems are not currently available.

AIM

To develop a measure of the complexity of GP explanations of common mental health problems and to pilot its reliability and validity.

DESIGN OF STUDY

A qualitative development of the measure, followed by inter-rater reliability and validation pilot studies.

SETTING

General practices in North London.

METHOD

Vignettes of simulated consultations with patients with mental health problems were videotaped, and an anchored measure of complexity of psychosocial explanation in response to these vignettes was developed. Six GPs, four psychologists, and two lay people viewed the vignettes. Their responses were rated for complexity, both using the anchored measure and independently by two experts in primary care mental health. In a second reliability and revalidation study, responses of 50 GPs to two vignettes were rated for complexity. The GPs also completed a questionnaire to determine their interest and training in mental health, and they completed the Depression Attitudes Questionnaire.

RESULTS

Inter-rater reliability of the measure of complexity of explanation in both pilot studies was satisfactory (intraclass correlation coefficient = 0.78 and 0.72). The measure correlated with expert opinion as to what constitutes a complex explanation, and the responses of psychologists, GPs, and lay people differed in measured complexity. GPs with higher complexity scores had greater interest, more training in mental health, and more positive attitudes to depression.

CONCLUSION

Results suggest that the complexity of GPs' psychosocial explanations about common mental health problems can be reliably and validly assessed by this new standardised measure.

What do patients want and not want to see about themselves on the computer screen: a qualitative study

OBJECTIVE

To explore patients' views about what they would or would not like to read on the computer screen, and how this might be managed.

DESIGN

A qualitative study using semi-structured interviews with patients who had recently consulted, and who were representative of the age-sex structure of our practice population.

SETTING

Primary health care, patients' homes.

PATIENTS

30 patients aged 18-89 years.

MAIN OUTCOME MEASURES

Patients were likely to state that information about lifestyle (e.g. smoking and drinking) might be helpful to read on condition that it had been provided by the patients themselves, and not by a third party. Most patients would not want to read personal comments. Nearly half of the patients expressed concern about seeing a serious illness on the screen, especially if it had not been fully discussed in advance. Over a third were concerned about seeing a mental illness listed. They suggested that these labels were subjective, confusing, and likely to be rejected by patients.

CONCLUSIONS

Doctors need to develop and evaluate ways by which patients gain access to reading about their problems on desk-top computers, and devise strategies whereby this can be integrated constructively with information exchange in the consultation.

Non-medical influences on medical decision-making

BACKGROUND

The influence of non-medical factors on physicians' decision-making has been documented in many observational studies, but rarely in an experimental setting capable of demonstrating cause and effect. We conducted a controlled factorial experiment to assess the influence of non-medical factors on the diagnostic and treatment decisions made by practitioners of internal medicine in two common medical situations.

METHOD

One hundred and ninety-two white male internists individually viewed professionally produced video scenarios in which the actor-patient, presenting with either chest pain or dyspnea, possessed various balanced combinations of sex, race, age, socioeconomic status, and health insurance coverage. Physician subjects were randomly drawn from lists of internists in private practice, hospital-based practice, and HMO's, at two levels of experience.

RESULTS

The most frequent diagnoses for both chest pain and dyspnea were psychogenic origin and cardiac problems. Smoking cessation was the most frequent treatment recommendation for both conditions. Younger patients (all other factors being the same) were significantly more likely to receive the psychogenic diagnosis. Older patients were more likely to receive the cardiac diagnosis for chest pain, particularly if they were insured. HMO-based physicians were more likely to recommend a follow-up visit for chest pain. Several interactions of patient and physician factors were significant in addition to the main effects.

CONCLUSIONS

The variability in decision-making evidenced by physicians in this experiment was not entirely accounted for by strictly rational Bayesian inference (the common prescriptive model for medical decision-making), in-as-much as non-medical factors significantly affected the decisions that they made. There is a need to supplement idealized medical schemata with considerations of social behavior in any comprehensive theory of medical decision-making.

Evaluating services for women with serious and ongoing mental health problems: developing an appropriate research method

Despite an increase in the literature on women with less disabling or transitory mental health problems, there is little relating to women with serious and ongoing difficulties. In considering the means by which the needs of this population might be studied, tension arises over methodology. Research comparing the clinical, functional and service use characteristics of women and men might demonstrate their different mental health problems but would neither elucidate women's particular needs nor examine the social reasons for this difference. A feminist methodology would, however, offer a means of exploring the experiences of women, a framework for understanding sex differences, and generate findings that would be beneficial to women. The present study gives an insight into ways in which the exploration of sex differences can be combined with a study of women for women without compromising the relevance and impact of the findings.

Philosophy and medicine: the Oxford connection

Three aspects of the approach to philosophy advocated by the Oxford philosopher J. L. Austin are outlined: his conception of the nature of philosophical problems, essentially as a mixed bag; his method of linguistic analysis, namely, clarification of our concepts by active observation of the ways in which they are actually used rather than by passive reflection on their meanings; and his views on the organisation of philosophical research, that in some areas it should be pursued rather as a science is pursued, as a corporate rather than merely individual venture. It is suggested that Austin's approach provides the basis for a potentially fruitful two-way relationship between philosophical theory and medical practice.

Consultation for physical illnesses by patients diagnosed and treated for psychiatric disorders by a general practitioner: 20 year follow up study

Patterns of consultation for physical illness were analysed in a body of consultation data covering a continuous 20 year period from a single general practitioner in south London. Three groups of adult patients were identified: patients with a psychiatric disorder and a new prescription for a psychotropic drug; patients with a psychiatric disorder but no new prescription for a psychotropic drug; and a control group without psychiatric disorder. The percentages of patients having one or more consultation for physical illnesses were stable over the years studied, being roughly 90%, 85%, and 60% respectively. For groups identified in 1972 their patterns of consultation for physical illness were examined in 1957, 1962, and annually from 1967 to 1976. In every year studied except 1957 the group with a psychiatric disorder and a new prescription for a psychotropic drug exceeded both other groups in the percentage of patients having one or more consultations for physical illnesses. Both groups with psychiatric disorders had an excess of consultations over the control group; this excess halved in about four years for the group with a new prescription and in about one year for the group without a new prescription. Mental health care by general practitioners for patients with psychiatric disorders does not seem to have an offset effect on general health care of these patients.

A comparison of psychiatric decision-making by trainee general practitioners and trainee psychiatrists using a simulated consultation model

A videotape-assisted simulated consultation model was used in a pilot study comparing range of assessment and treatment decisions made by trainee general practitioners and trainee psychiatrists in response to two cases representing women with depressive disorders. The doctors were studied individually in their consulting rooms or offices. In relation to the methods of analysis chosen, levels of agreement within and between the two groups of trainees were generally low. The findings are discussed in relation to previous similar work undertaken with experienced clinicians studied in groups.

Dimensions of neuroses seen in primary-care settings

This study uses methods of latent trait analysis to examine the relationship between psychiatric symptoms that constitute the common psychiatric disorders encountered in primary-care setting. Two highly correlated symptom dimensions of anxiety and depression are shown to underlie these disorders. Neurovegetative symptoms of depression are shown to be on the same dimension as psychic symptoms of depression, but to represent a more severe manifestation of depression.