Vol. 9. No. 2 Printed in Great Britain
Family Practice © Oxford University Press 1992
Perceptions of Psychological Problems in General Practice: A Comparison of General Practitioners and Psychiatrists DAVID ARMSTRONG, JULIAN BIRD, JOHN FRY AND PAULINE ARMSTRONG
INTRODUCTION About 40% of patients consulting with their general practitioner have been shown to have some degree of emotional disturbance.1-1 However, a number of studies have shown that the ability of the average GP to identify these patients does not match that of standardized psychiatric instruments which have been validated against psychiatric interview.2"4 The reasons for this discrepancy are not clear. Marks et at.' found that one group of factors which explained why GPs detect or fail to detect psychiatric illness, were the 'demographic cues' offered by high-risk patients such as females, the unemployed, and those undergoing a marital break-up, and another was the GP's 'psychiatric focus'—that is the predilection of the GP to make psychiatric diagnoses. Even when primary care physicians prescribe treatments for psychological disturbances, they may still fail to make and record specific psychiatric diagnoses.3 The failure of individual GPs to identify psychiatric disturbance and make appropriate diagnoses may be due to the unsuitability of existing diagnostic
categories for the manifestations of psychological illness presenting in general practice.6 A corollary of this is that they may use more 'implicit' classification systems which are at variance with those promoted by psychiatrists. Such a classification system would be difficult to demonstrate without an 'ethnographic' investigation, but one means of approaching the problem would be to examine some of the background assumptions about psychological problems possessed by both GPs and psychiatrists. An opportunity to do so arose with the preparation of clinical guidelines for GPs in a health district. A survey was carried out to compare GPs' and psychiatrists' perceptions of the prevalence of psychiatric illness among consulting patients and their reported clinical management strategies. METHOD A structured questionnaire on the perceived prevalence of psychological disorders among consulting patients together with usual methods of management was sent to every GP in one health district using a numbered code system to ensure complete anonymity. In addition, a slightly amended questionnaire was sent to all consultant psychiatrists in the district: in this latter version the management questions asked for the psychiatrists' judgements on the appropriate answers
Department of General Practice, UMDS, London; Psychological Medicine, King's College Medical and Dental School, London; Beckenhim and Bromley LMC, UK. Address correspondence to: Dr D Armstrong, Department of General Practice, UMDS, Guy's Hospital, London SE1 9RT, UK.
173
Downloaded from http://fampra.oxfordjournals.org/ at Sheffield University on September 5, 2015
Armstrong D, Bird J , Fry J and Armstrong P. Perceptions of psychological problems in general practice: a comparison of general practitioners and psychiatrists. Family Practice 1992; 9: 173-176. All general practitioners and psychiatrists working in a single health district were sent a questionnaire on their perceptions of the prevalence of psychological problems among patients consulting in general practice. One hundred and twenty-one GPs (75%) and 10 (83%) psychiatrists responded. GPs and psychiatrists agreed that up to 20% of consulting patients were likely to be clinically depressed; they also agreed on the most appropriate management, although GPs tended to be more conservative than psychiatrists would advise on making use of hospital services. GPs, however, believed non-specific psychological problems to be significantly less common than did psychiatrists. This expectation may help explain the reported failure of GPs to diagnose all psychological problems identified by formal psychiatric instruments.
174
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
from a GP's viewpoint, e.g. "How long should a GP treat mild depression?". A second questionnaire was sent to those doctors who failed to respond to the first. The questionnaires were coded, punched and the data analysed using SPSS. The GPs' perceived prevalence of psychological problems and usual management was then compared with the views of the psychiatrists.
X of doctors SOX -f
50% --
40% --
30X --
20X --
10X --
-10
^M GPs FIGURE 2.
X of doctors 50X
-20 -30 % prevalence of depression
-40
tMtt Psychiatrists
Clinical depression: perceived prevalence
TABLE 1. Perceived prevalence of clinical depression in patients with other problems
-(•
GPs 40X
Patients with clinical depression
30X - -
20% - -
mean
Psychiatrists SD
mean
SD
Chronic physical illness
37
18
43
Parasuicide
69
26
31
14 NS 23»««
Alcoholics
50
22
44
21 NS
Mann-Whitney: NS = no significant difference ***P < 0.001
10% --
OX
-10
-20
-30
-40
-50
-60
-70
X prevalence
I M GPs FIGURE 1.
liH Psychiatrists
Psychological problems: perceived prevalence
Approaches to management were explored with three questions: how long a GP might treat a mildly depressed patient without drugs; how long a GP might wait before changing a prescribed drug if it produced no response; and how long a GP might wait before referring to a psychiatrist. Means and standard deviations for both GPs and psychiatrists are given in Table 2.
Downloaded from http://fampra.oxfordjournals.org/ at Sheffield University on September 5, 2015
RESULTS One hundred and twenty of 161 GPs replied, giving a response rate of 75%. Using FPC data on sex, age, country of qualification and partnership size, responders were compared with non-responders. There was no statistically significant difference between the two groups except that responders were more likely to come from practices with larger numbers of partners (Mann-Whitney: P < 0.05). However, none of the GP's perceptions reported below was found to correlate with practice partnership size. Twelve psychiatrists working in the health district were sent questionnaires and 10 replied, a response rate of 83%. No background information on psychiatrists was obtained. Figure 1 shows the perceived prevalence of 'psychological problems' among patients consulting in general practice; the psychiatrists thought that psychological problems were significantly more common than did GPs (Mann-Whitney U 278: P < 0.005). On the other hand there was no statistically significant difference between GPs and psychiatrists in their respective perceived prevalence of clinical depression, both
reporting it to be between 0 and 20"% of the consulting population (Figure 2). The mean and standard deviations of the perceived prevalence of clinical depression amongst various morbidity groups in the population are shown in Table 1. There was no difference between GPs and psychiatrists, except for parasuicides whom GPs believed were much more likely to be clinically depressed.
175
PERCEPTIONS OF PSYCHOLOGICAL PROBLEMS IN GENERAL PRACTICE TABLE 2.
Usual management of mild clinical depression
How many weeks would you treat a depressive
GPs
Psychiatrists
mean
SD
mean
SD
Without drugs?
3.7
1.4
3.7
1.5 NS
Without referral?
5.5
1.5
4.5
1.7*
Before changing drug (if no response)
4.1
1.4
3.7
1.6 NS
TABLE 4. Drugs used in the treatment ofdinical
In addition two case vignettes were used to compare management strategies. One asked for the most likely response to suicidal talk by a young woman who was distressed by social problems but whose history and examination were otherwise unremarkable. The other asked for the most likely response to suicidal talk by a recently widowed 65 year old man who lay awake in the early hours feeling worthless. Results are shown in Table 3. Treating the list of options as an ordinal scale of increasing levels of intervention, it can be seen that the psychiatrists opted for a greater hospital input than the GPs. For the depressed young woman, the psychiatrists were more in favour of an out-patient appointment compared with the GPs, but the greatest contrast was in the management recommendations for the suicidal elderly bereaved man. Eighty percent of psychiatrists said the GP should seek admission but only 24% of GPs chose this option. No psychiatrists said the GP should issue anti-depressants whereas 45% of GPs said they would do so. Finally, the questionnaire asked about usual management strategies. In treating a mildly depressed patient, GPs were willing to wait on average about 3 j weeks TABLE 3.
DISCUSSION The response rate of both GPs and psychiatrists in this study were relatively good: in part this may be due to the fact that the survey took place under the aegis of a research group sponsored by the GPs' Local Medical Committee and because they had previously participated in similar studies.
GPs (%) Dothiepin Amitriptyline Trimipramine Lofepramine Imipramine Mianserin Clomipramine Flupenthixol Nortryptilline Protriptyline Diazepam Lorazepam Lithium Trazodone Carbamazine Chlormethiazole Doxepin Phenelzine Propranolol
Listen Appointment Antidepress Outpatient Voluntary admission Compulsory admission
Mann-Whitney:
Psychiatrists (
Family Practice © Oxford University Press 1992
Perceptions of Psychological Problems in General Practice: A Comparison of General Practitioners and Psychiatrists DAVID ARMSTRONG, JULIAN BIRD, JOHN FRY AND PAULINE ARMSTRONG
INTRODUCTION About 40% of patients consulting with their general practitioner have been shown to have some degree of emotional disturbance.1-1 However, a number of studies have shown that the ability of the average GP to identify these patients does not match that of standardized psychiatric instruments which have been validated against psychiatric interview.2"4 The reasons for this discrepancy are not clear. Marks et at.' found that one group of factors which explained why GPs detect or fail to detect psychiatric illness, were the 'demographic cues' offered by high-risk patients such as females, the unemployed, and those undergoing a marital break-up, and another was the GP's 'psychiatric focus'—that is the predilection of the GP to make psychiatric diagnoses. Even when primary care physicians prescribe treatments for psychological disturbances, they may still fail to make and record specific psychiatric diagnoses.3 The failure of individual GPs to identify psychiatric disturbance and make appropriate diagnoses may be due to the unsuitability of existing diagnostic
categories for the manifestations of psychological illness presenting in general practice.6 A corollary of this is that they may use more 'implicit' classification systems which are at variance with those promoted by psychiatrists. Such a classification system would be difficult to demonstrate without an 'ethnographic' investigation, but one means of approaching the problem would be to examine some of the background assumptions about psychological problems possessed by both GPs and psychiatrists. An opportunity to do so arose with the preparation of clinical guidelines for GPs in a health district. A survey was carried out to compare GPs' and psychiatrists' perceptions of the prevalence of psychiatric illness among consulting patients and their reported clinical management strategies. METHOD A structured questionnaire on the perceived prevalence of psychological disorders among consulting patients together with usual methods of management was sent to every GP in one health district using a numbered code system to ensure complete anonymity. In addition, a slightly amended questionnaire was sent to all consultant psychiatrists in the district: in this latter version the management questions asked for the psychiatrists' judgements on the appropriate answers
Department of General Practice, UMDS, London; Psychological Medicine, King's College Medical and Dental School, London; Beckenhim and Bromley LMC, UK. Address correspondence to: Dr D Armstrong, Department of General Practice, UMDS, Guy's Hospital, London SE1 9RT, UK.
173
Downloaded from http://fampra.oxfordjournals.org/ at Sheffield University on September 5, 2015
Armstrong D, Bird J , Fry J and Armstrong P. Perceptions of psychological problems in general practice: a comparison of general practitioners and psychiatrists. Family Practice 1992; 9: 173-176. All general practitioners and psychiatrists working in a single health district were sent a questionnaire on their perceptions of the prevalence of psychological problems among patients consulting in general practice. One hundred and twenty-one GPs (75%) and 10 (83%) psychiatrists responded. GPs and psychiatrists agreed that up to 20% of consulting patients were likely to be clinically depressed; they also agreed on the most appropriate management, although GPs tended to be more conservative than psychiatrists would advise on making use of hospital services. GPs, however, believed non-specific psychological problems to be significantly less common than did psychiatrists. This expectation may help explain the reported failure of GPs to diagnose all psychological problems identified by formal psychiatric instruments.
174
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
from a GP's viewpoint, e.g. "How long should a GP treat mild depression?". A second questionnaire was sent to those doctors who failed to respond to the first. The questionnaires were coded, punched and the data analysed using SPSS. The GPs' perceived prevalence of psychological problems and usual management was then compared with the views of the psychiatrists.
X of doctors SOX -f
50% --
40% --
30X --
20X --
10X --
-10
^M GPs FIGURE 2.
X of doctors 50X
-20 -30 % prevalence of depression
-40
tMtt Psychiatrists
Clinical depression: perceived prevalence
TABLE 1. Perceived prevalence of clinical depression in patients with other problems
-(•
GPs 40X
Patients with clinical depression
30X - -
20% - -
mean
Psychiatrists SD
mean
SD
Chronic physical illness
37
18
43
Parasuicide
69
26
31
14 NS 23»««
Alcoholics
50
22
44
21 NS
Mann-Whitney: NS = no significant difference ***P < 0.001
10% --
OX
-10
-20
-30
-40
-50
-60
-70
X prevalence
I M GPs FIGURE 1.
liH Psychiatrists
Psychological problems: perceived prevalence
Approaches to management were explored with three questions: how long a GP might treat a mildly depressed patient without drugs; how long a GP might wait before changing a prescribed drug if it produced no response; and how long a GP might wait before referring to a psychiatrist. Means and standard deviations for both GPs and psychiatrists are given in Table 2.
Downloaded from http://fampra.oxfordjournals.org/ at Sheffield University on September 5, 2015
RESULTS One hundred and twenty of 161 GPs replied, giving a response rate of 75%. Using FPC data on sex, age, country of qualification and partnership size, responders were compared with non-responders. There was no statistically significant difference between the two groups except that responders were more likely to come from practices with larger numbers of partners (Mann-Whitney: P < 0.05). However, none of the GP's perceptions reported below was found to correlate with practice partnership size. Twelve psychiatrists working in the health district were sent questionnaires and 10 replied, a response rate of 83%. No background information on psychiatrists was obtained. Figure 1 shows the perceived prevalence of 'psychological problems' among patients consulting in general practice; the psychiatrists thought that psychological problems were significantly more common than did GPs (Mann-Whitney U 278: P < 0.005). On the other hand there was no statistically significant difference between GPs and psychiatrists in their respective perceived prevalence of clinical depression, both
reporting it to be between 0 and 20"% of the consulting population (Figure 2). The mean and standard deviations of the perceived prevalence of clinical depression amongst various morbidity groups in the population are shown in Table 1. There was no difference between GPs and psychiatrists, except for parasuicides whom GPs believed were much more likely to be clinically depressed.
175
PERCEPTIONS OF PSYCHOLOGICAL PROBLEMS IN GENERAL PRACTICE TABLE 2.
Usual management of mild clinical depression
How many weeks would you treat a depressive
GPs
Psychiatrists
mean
SD
mean
SD
Without drugs?
3.7
1.4
3.7
1.5 NS
Without referral?
5.5
1.5
4.5
1.7*
Before changing drug (if no response)
4.1
1.4
3.7
1.6 NS
TABLE 4. Drugs used in the treatment ofdinical
In addition two case vignettes were used to compare management strategies. One asked for the most likely response to suicidal talk by a young woman who was distressed by social problems but whose history and examination were otherwise unremarkable. The other asked for the most likely response to suicidal talk by a recently widowed 65 year old man who lay awake in the early hours feeling worthless. Results are shown in Table 3. Treating the list of options as an ordinal scale of increasing levels of intervention, it can be seen that the psychiatrists opted for a greater hospital input than the GPs. For the depressed young woman, the psychiatrists were more in favour of an out-patient appointment compared with the GPs, but the greatest contrast was in the management recommendations for the suicidal elderly bereaved man. Eighty percent of psychiatrists said the GP should seek admission but only 24% of GPs chose this option. No psychiatrists said the GP should issue anti-depressants whereas 45% of GPs said they would do so. Finally, the questionnaire asked about usual management strategies. In treating a mildly depressed patient, GPs were willing to wait on average about 3 j weeks TABLE 3.
DISCUSSION The response rate of both GPs and psychiatrists in this study were relatively good: in part this may be due to the fact that the survey took place under the aegis of a research group sponsored by the GPs' Local Medical Committee and because they had previously participated in similar studies.
GPs (%) Dothiepin Amitriptyline Trimipramine Lofepramine Imipramine Mianserin Clomipramine Flupenthixol Nortryptilline Protriptyline Diazepam Lorazepam Lithium Trazodone Carbamazine Chlormethiazole Doxepin Phenelzine Propranolol
Listen Appointment Antidepress Outpatient Voluntary admission Compulsory admission
Mann-Whitney:
Psychiatrists (
