Classification of mental disorder in primary care

Which patients do GPs refer to which professional

Referral rates to three groups of mental health professionals working In primary care were compared. All patients referred over an 18-month period at two health centres in an outer London borough were assessed by case-note review and data were collected on 181 consecutive referrals. In general, younger, more socially-stable patients were referred to the psychologist and older patients were seen by the CPN. The psychologist saw most new patients; patients previously seen by a psychiatrist were most likely to be referred again to a psychiatrist. Patients requesting referral to a mental health professional were most likely to be referred to the psychologist. Patients with a diagnosis of psychosis were seen mainly by the psychiatrist and the CPN; the psychiatrist saw most patients with a personality disorder. A high proportion of patients were seen for assessment only. In general, all interventions were brief. There was evidence of selection by GPs in the referral of patients to each mental health professional.

A comparative study of diagnostic practice in psychiatry in Northern Norway and Northwest Russia

BACKGROUND

The co-operation between psychiatrists in Norway and Russia is increasing. The object of this study was to find out whether there were differences in diagnostic practice of psychiatrists in both countries, to look at the nature of the differences and to examine whether these differences affected diagnostic quality.

METHOD

Thirty medical doctors working at psychiatric hospitals in both countries diagnosed 12 clinical case vignettes selected from a wide spectre of psychiatric disorders.

RESULTS

The Russian clinicians used a larger range of diagnoses than the Norwegians. The Russians tended to diagnose schizophrenia and schizophrenia-like disorders in cases that presented psychotic syndromes, and somatoform disorders in cases that presented agoraphobia. The Norwegians tended to evaluate affective aspects in preference to psychotic symptoms in the case of schizoaffective disorder and overestimate the degree of depression. In general, the Russians had lower total score of correct answers than the Norwegians.

CONCLUSION

In spite of the limitations due to minor differences in the data collection phase in the two countries, the study clearly demonstrates differences in diagnostic practice between the countries.

Mental illness in a general hospital's family medicine clinic in Taiwan

There has been a paucity of evidence-based information regarding mental illness in general medical settings among the Chinese population. Aims of the present study are to investigate the patterns and distribution of mental disorders among family medicine clinic attenders, illness behavior of attenders with such disorders, and the recognition and management given by family physicians for them. A random sample (n = 200) of patients attending a family medicine clinic in a medical center in Taiwan, received a standardized psychiatric assessment using the semistructured Clinical Interview Schedule (CIS) after they had seen the family physician. A total of 12 family physicians, who were blind to the psychiatric status of their patients, were then asked to assess the physical and psychological condition of the subjects. Of all study subjects, 51% had at least one psychiatric diagnosis based on the CIS assessment, and the corresponding figure was 21.5% from family physicians. While the specificity of psychiatric case identification among family physician was high (91%), the sensitivity was very low (30%), especially for depressive disorders and alcohol-related disorders. Because the same magnitude of psychiatric morbidity and similarly low detection rates by general medical physicians were found in other developing countries, the improvement in psychiatric education for medical students and family physicians is highly implicated there.

Diagnosis of depression by primary care physicians versus a structured diagnostic interview. Understanding discordance

In this paper, false-negative and false-positive cases of depressive illness are examined, differentiating levels of disagreement between a primary care physician's diagnosis and a standardized research diagnosis. Two stratified random samples of primary care patients in Seattle, USA (N = 373) and Groningen, The Netherlands (N = 340) were examined with the Composite International Diagnostic Interview-Primary Health Care Version (CIDI-PHC). Physician's severity ratings and diagnosis of psychological disorder were obtained. Three levels of disagreement between physician and CIDI diagnosis were distinguished: 1) complete disagreement about the presence of psychiatric symptoms (true false-negative and true false-positive patients); 2) disagreement over severity of recognized psychological illness (underestimated or overestimated); and 3) disagreement over the specific psychiatric diagnosis among those given a diagnosis (misdiagnosed or given another CIDI diagnosis). All three levels of disagreement were common. Only 27% of the false-negative cases were due to complete disagreement (true false-negatives), and 55% of the false-positives were due to complete disagreement (true false-positives). The true false-negative patients were younger, more often employed, rated their own health more favorably, visited their doctor for a somatic complaint and made fewer visits than the underestimated, misdiagnosed, and concordant positive patients. Complete disagreement in depressive diagnoses between the primary care physician and research interview is not as frequent as indicated by an undifferentiated false-negative/ false-positive analysis. Differentiating levels of disagreement does more justice to diagnostic practice in primary care and provides guidance on how to improve the diagnostic accuracy of primary care physicians.

Linking epidemiology and disability measurement with mental health service policy and planning

OBJECTIVE

This article reviews the extent to which epidemiology and disability measurement can contribute to mental health and service policy and planning.

METHODS

The review explores the information required for local, mental and international policy and planning in a variety of settings.

RESULTS

Epidemiology and disability measurement are essential to underpin policy and planning that are responsive to local needs, together with information on service inputs and processes and health outcomes.

CONCLUSIONS

Epidemiology and disability measurement should be an integral part of the policy and planning process to support the development of service, and service processes and the measurement of health outcomes for not only specialist mental health services, but also activities in primary care, schools and workplaces.

Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model

The objective of this study was to evaluate the effect of a short cognitive behavioural group therapy programme for somatization disorder in primary care. The treatment model was focused on patient education and stress relaxation. A controlled and prospective study design was used with repeated assessments of the patients' perception of their psychosocial problems, psychological distress and medication usage. The results were analysed up to 6 months after treatment and showed the treated patients to be moderately but significantly improved with respect to physical illness and somatic preoccupation, hypochondriasis, and medication usage. In a control group of untreated patients no such improvements were observed. In summary, the short group treatment programme used in this study may be beneficial for patients with somatization disorders. With some modifications it might be useful to practitioners in primary care for the management of psychosomatic disorders.

Consequences of mental distress recognition in general practice in Italy: a follow-up study. Italian Cooperative Group on Mental Distress in General Practice

Many reports have been recently published on the accuracy of mental distress detection by general practitioners. Recognition of 'caseness', irrespective of its accuracy, nevertheless determines the implementation of therapeutic interventions. This paper reports the results of a naturalistic study describing the consequences for the patients of being identified as 'cases' in the general practice (in terms of referral strategies at recruitment and outcome 3 months and 1 year later), in the context of care provision generated by the 1978 Italian psychiatric reform. Sixty-eight GPs recruited 878 'cases' according to implicit criteria. Overall 20% of the patients were referred the psychiatric setting; only half of these for psychiatric care. After 3 months and 1 year from recruitment respectively 12% and 23% of the subjects were no longer 'cases'. The factors contributing to predict the outcome at three months were age, symptom duration, comorbidity, presence of social context risk factors and prior psychiatric history (or presence of 'major' symptoms); after one year the predictors of caseness were caseness status at 3 months, and clinical severity, symptom duration and presence of somatization at recruitment. GPs remain the main care providers in the short- and long-term. The results of the study indicate the need for a reappraisal of the emphasis to be put on caseness recognition and on the development of standardized instruments for the identification of mental distress. Non-clinical variables concurring in the definition of caseness in general practice, and the factors influencing physicians' decision-making in the implementation of alternative intervention strategies should be further clarified by ad hoc studies.

A triaxial classification of health problems presenting in primary health care. A World Health Organization multi-centre study

Over the past two decades, research in a variety of countries and settings has revealed the extent to which psychological morbidity and social problems constitute an important proportion of primary health care contacts, either in their own right or in association with physical ill-health. The development of appropriate responses, medical and non-medical, to such problems is, in part, hindered by the relatively low level of awareness concerning the significance of such problems and by currently inappropriate methods of describing and classifying health care problems in the primary care setting. There is a pressing need for an appropriate, relatively simple and flexible classification or list of problems presenting in primary care. This study describes the development, under WHO auspices and in an international setting, of a triaxial classification of health problems and the testing and modification of the classification by means of an international case vignette rating exercise. A psychological problem list and a social problem list, together with detailed glossaries, suitably modified in the light of experience derived from the study, are described, and proposals enumerated of possible ways in which these lists might be further developed and used in research and clinical undertakings in primary care.

A three-year follow-up of psychiatric morbidity in urban and rural primary care

Follow-up by examination of medical and psychiatric records was carried out on 357 patients with conspicuous psychiatric morbidity in two general practices three years after clinical and personality assessment using structured interview schedules. One practice was an inner-city urban one and the other was rural. Full follow-up data over the 3-year period was available for 301 patients (84.3%). After three years patients with personality disorder and those in the urban practice had greater morbidity, more contacts with all levels of the psychiatric service and more psychotropic drugs, particularly benzodiazepines. Despite this increased morbidity, the number of consultations with the general practitioner for psychiatric illness was no higher in the urban group and those for medical illness were significantly higher in the rural one. The implications of the findings are discussed with particular reference to developments in community psychiatric care.

Educating the psychiatrist of the 21st century

Psychiatry is under threat from developments within mental health care. In educating future psychiatrists, more emphasis should be placed upon: collaborative research; integrated teamwork, without interprofessional rivalry; work in primary care; the non-scientific components of psychiatry, centred upon relationships with patients; less dogmatic attitudes for or against psychoanalysis: psychiatry as a branch of medicine; and modern management and audit methods. Younger psychiatrists should be encouraged to take responsibility for shaping the future of the profession.