Psychiatric John
Referrals in General Practice
Hull, PhD
\s=b\ A major option available to the nonpsychiatric physician in dealing with patients who have psychiatric problems is to refer them to psychiatrists. A group of 93 nonpsychiatric physicians indicated that they have positive attitudes toward making such referrals where appropriate, and make extensive use of this mechanism with psychiatric patients. There are, however, great differences of opinion with respect to the appropriateness of psychiatric referrals for neurotic patients, those with alcohol and addiction problems, and those with other personal problems (marital, vocational, etc). (Arch Gen Psychiatry 36:406-408, 1979)
since World War in have been the target of numerous campaigns designed to increase their concern with "the whole man" or more specifically to increase their interest and competence in psychiatry as that branch of medicine that incorporates into its perspec¬ tive social and psychological factors in addition to physical
II, community physicians, Especially and, particular, general practitioners,
Numerous private, governmental, and quasigovernmental agencies and organizations including the American Psychiatric Association, the American Medical Associa¬ tion, the National Institute of Mental Health, and even the World Health Organization have been the sponsors of such ones.
A lengthy series of treatises, some of which have been described as "polemics" but that perhaps could more accurately be called exhortations, have appeared, encouraging community physicians to become more involved with the psychiatric problems of their patients. One major option available to the community physician is referring psychiatric cases to his specialist colleague, the
campaigns.
psychiatrist. To what extent do physicians exercise this option, and for what kinds of patients? Does a consensus exist among physicians as to the conditions under which a referral is appropriate? These are the issues that this article addresses.
METHODOLOGY AND DATA SOURCES To obtain relevant data, physicians practicing in four Chicago communities were interviewed with a 22-page questionnaire by interviewers from the National Opinion Research Center. Of the four communities, two were completely white and two completely black, and one of each was middle income while the other was lower income. The 93 physicians who were interviewed, all of whom engaged in some general practice, represented 62% of the 152 physicians practicing in the four communities. Respondents did not differ from nonrespondents in terms of sex distribution, the proportion who graduated from a school approved by the American Medical Association's Liason Committee for Medical Education (some physicians were quite elderly), and the propor¬ tion who were certified in a specialty, although there was a higher proportion of foreign-trained physicians among the respondents (24%) than among the nonrespondents (12%), and the respondents were slightly younger than the nonrespondents (mean age, 55 vs
60, respectively).
All of the physicians in the two white communities were white, whereas more than half of those in the black community were black (P < .01). The percentage of male physicians do not vary significantly, but the physicians in middle-income black communi¬ ty were significantly younger (P < .05) than those in the other three communities. Clearly, the physicians in their communities have a mean age higher than that for all practicing physicians, but they may not be significantly different from those practicing in communities in the inner cities of large urban areas.
RESULTS Accepted
publication Sept 5, 1978. Planning Support Services, Mental Health and Rehabilitative Services Directorate, Department of Health and Social Development, Province of Manitoba, Winnepeg. Reprint requests to Planning Support Services, Mental Health and Rehabilitative Services Directorate, Department of Health and Social Development, Province of Manitoba, 4-831 Portage Ave, Winnepeg, Manitoba R3G 0N6 (Dr Hull). for
From the
Downloaded From: by a Tulane University User on 01/16/2019
Before
turning to actual reported behavior with respect psychiatric referrals, it may be instructive to briefly examine the respondents' attitudes toward psychiatric referrals. They were asked to indicate whether they agreed or disagreed with the following three statements on the possible negative effects of making a psychiatric referral: to
(1) In recent years, patients seem much less annoyed or frightened at the suggestion that they should see a psychiatrist. (2) One should hesitate to make psychiatric referrals because it is a disadvantage for a patient to be labeled a "mental case." (3) One should hesitate to refer a patient for psychiatric advice because he may conclude that his symptoms are being regarded as imaginary. There was overwhelming agreement (93%) that patients have been much less annoyed or frightened in recent years when a psychiatric referral is suggested. There was also
substantial consensus that concern about the disadvan¬ tages of a psychiatric label (89% disagreed or strongly disagreed with the statement) or fears that patients may think their problems are being regarded as imaginary (83% disagreed or strongly disagreed with the statement) should not stand in the way of making a psychiatric referral. To obtain information on these trends, respondents were asked to indicate the percentage of patients in each diagnostic grouping whom they referred to psychiatrists. The diagnoses employed were those of the respondent. Of those respondents who had made at least one diagno¬ sis of psychosis in the past year, 64% indicated that they referred all such patients to psychiatrists. On the other hand, 7% said that they made no referrals and 12% treated 90% or more of these problems without a psychiatric referral. The remainder treated between 25% and 75% themselves. Of the 70 respondents who had encountered one or more problems in the past year, 31% indicated they made no referrals, 17% referred all such cases, and the remainder referred between 1% and 90%. Although the median was 10%, because of the somewhat skewed distri¬ bution, the mean was 30%. More than half (54%) of the respondents who had encoun¬ tered patients with addiction or alcohol problems in the preceding year said that they did not refer any of them to psychiatrists. The remainder, however, referred between 1% and 100%, with 7% indicating the latter figure. The mean reported rate was 16%, despite the fact that less than one tenth referred 30% or more of such problems. As might be expected, the modal and median percentage of patients referred to psychiatry for vocational, marital, and other personal problems was none. However, only 58% indicated that they never made psychiatric referrals for such problems, and 11% referred one half or more of persons with these problems to psychiatrists. COMMENT The findings with respect to the attitudes of the respon¬ dents concerning psychiatric referrals are interesting in the light of four British studies'"' that investigated some of the reasons physicians offered for not making psychiatric referrals. In these studies, 54%,' 60%,2 45%,3 and 51%4 of the physicians cited patients' dislike of such a referral as a major factor. In addition, a substantial proportion (21% to 36%) were also concerned about the disadvantage to patients of being labeled mental cases. There are no other North American studies with which to compare these results, but it is interesting that British physicians seemed to be more concerned about the consequences of labeling than the physicians in the current study. Turning to the reported rates of actual referral, we
Downloaded From: by a Tulane University User on 01/16/2019
of Physicians Referring Various of Patients to Psychiatrists, by Diagnostic
Percentage
% of
Physicians
Proportion of Patients Referred None 0.01 to 0.25 0.25-0.49 0.50-0.74 0.75 to 0.99 All
Psychoses 7 5 10
Neuroses 31
30 9
Proportions Category
Alcohol/ Addictions 54 22 10
Other Personal Problems 58 29
12 64
17
found that while there was agreement by almost two thirds of the respondents that all cases of psychosis should be referred, the remaining one third covered virtually the entire range of alternatives, indicating that there is not universal acceptance of the norm that psychotic patients should be referred to psychiatrists. In a study of medical patients admitted to a London hospital, Pritchard5 found that 60% of those with a diagnosis of a functional psychosis were referred to psychiatry, but only 18% of those with an organic psychosis were referred. Thirty-two percent of the physicians interviewed by Tsoi and Chia" would immedi¬ ately refer a schizophrenic patient to a psychiatrist, while 64% would try drugs and psychotherapy first, and if that was "unsatisfactory" would then make a referral to a psychiatrist. In summary, there does seem to be some agreement on the part of about two thirds of physicians that for the functional psychoses, one either makes an immediate referral or reserves referral as a highly proba¬ ble outcome in the treatment process, but there is obviously a minority who prefer to treat such problems themselves. The limited consensus that appeared with respect to the psychoses seems to be less apparent when physicians are asked about the use of psychiatric referral for neuroses. Although most would refer few such cases, 39% would refer more than a quarter and 17% would refer all such cases. Nevertheless, the results are not inconsistent with the findings of Tsoi and Chia," who reported that the vast majority (85%) of their respondents also would treat neurotic problems other than depression themselves rather than refer. However, of the hospitalized physically ill patients in Pritchard's5 study, some 34% of those who also had a diagnosis of neurosis were referred to psychiatry. This figure included those persons diagnosed as having neurotic depression, of whom 61% were referred, while 24% of persons given other neurotic diagnoses were referred. It seems probable that these high referral rates were influenced by the fact that all of the patients were inpatients at the time of the referral, and that ease of contact between physicians and between patients and specialists would increase the probability of referrals being made and followed through. Interestingly, a very high rate of referral was made for personality disorders (63%), particularly among males (78%). Those persons who had ever attempted suicide were also much more likely to be referred (71%) than were those who had not (24%)."' Surpris¬ ingly, Tsoi and Chia" found that while 37% of the physi¬ cians they interviewed would immediately refer a person
with
depression accompanied by
to a psychiatrist, if the depression was suicidal idea, the figure dropped to 28%, while under these circumstances 70% would attempt psychotherapy and drug therapy, only making a referral if these were not effective. Despite the differences, it is clear that most physicians prefer to treat the majority of neurotic patients themselves, without psychiatric refer¬ ral. The mean reported rate of referral for alcohol and addiction problems (16%) is similar to that of Pritchard,5 who found that 13% of persons with alcoholism and 23% of those with drug addiction were referred to psychiatrists, but again these inpatient referral rates are likely to be much higher than those for community practice. Other existing studies have not reported referral rates for other personal problems, but it is interesting that about one half of the respondents indicated that they will refer some patients with such problems to psychiatrists.
SUMMARY AND CONCLUSIONS The community physicians generally agreed that to refer a patient to a psychiatrist will not produce negative consequences for the patient. They also agreed that patients have seemed much more receptive to such refer¬ rals in recent years than they had in the past. Some two thirds of the physicians agreed that all cases of psychoses should be referred to psychiatrists, but the remaining one third covered the entire spectrum of alter¬ natives, indicating that there is not a norm for psychiatric
Downloaded From: by a Tulane University User on 01/16/2019
referral of psychotic patients. There was much less consensus about the use of referrals with neuroses. About one third made no referrals, one sixth referred all cases, and the remainder again covered the entire spectrum. More than half of the respondents did not refer any patients who had alcohol or drug problems, although 7% referred all such patients. Almost half of the respondents also made occasional psychiatric referrals for patients with marital, vocational, and other personal problems, and about one tenth referred one half or more of such patients. This study was supported in part by a grant from the Center for Health Administration Studies, University of Chicago. The Center and its director, O. W. Anderson, PhD, provided financial and other assistance. The Depart¬ ment of Health and Community Services, Province of Manitoba, also provided assistance.
References 1. Logan WPD, Cushion AA: Morbidity Statistics From General Practice: I. Studies on Medical and Population Subjects, No. 14. London, Her Majesty's Stationery Office, 1958. 2. Shepard M, Cooper B, Brown AC, et al: Psychiatric Illness in General Practice. London, Oxford University Press, 1966. 3. Mezey AG, Kellett JM: Reasons against referral to the psychiatrist. Postgrad Med J 47:315-319, 1971. 4. Fahy TJ, O'Rourke A, Wilson-Davis K: The Irish family doctor and psychiatry: A national survey of attitudes. J Ir Med Assoc 56:616-623, 1974. 5. Pritchard M: Who sees a psychiatrist? A study of factors related to psychiatric referral in the general hospital. Postgrad Med J 48:645-651, 1972. 6. Tsoi WF, Chia BH: General practitioners and mental illness. Singapore Med J 13:188-191, 1972.
Referrals in General Practice
Hull, PhD
\s=b\ A major option available to the nonpsychiatric physician in dealing with patients who have psychiatric problems is to refer them to psychiatrists. A group of 93 nonpsychiatric physicians indicated that they have positive attitudes toward making such referrals where appropriate, and make extensive use of this mechanism with psychiatric patients. There are, however, great differences of opinion with respect to the appropriateness of psychiatric referrals for neurotic patients, those with alcohol and addiction problems, and those with other personal problems (marital, vocational, etc). (Arch Gen Psychiatry 36:406-408, 1979)
since World War in have been the target of numerous campaigns designed to increase their concern with "the whole man" or more specifically to increase their interest and competence in psychiatry as that branch of medicine that incorporates into its perspec¬ tive social and psychological factors in addition to physical
II, community physicians, Especially and, particular, general practitioners,
Numerous private, governmental, and quasigovernmental agencies and organizations including the American Psychiatric Association, the American Medical Associa¬ tion, the National Institute of Mental Health, and even the World Health Organization have been the sponsors of such ones.
A lengthy series of treatises, some of which have been described as "polemics" but that perhaps could more accurately be called exhortations, have appeared, encouraging community physicians to become more involved with the psychiatric problems of their patients. One major option available to the community physician is referring psychiatric cases to his specialist colleague, the
campaigns.
psychiatrist. To what extent do physicians exercise this option, and for what kinds of patients? Does a consensus exist among physicians as to the conditions under which a referral is appropriate? These are the issues that this article addresses.
METHODOLOGY AND DATA SOURCES To obtain relevant data, physicians practicing in four Chicago communities were interviewed with a 22-page questionnaire by interviewers from the National Opinion Research Center. Of the four communities, two were completely white and two completely black, and one of each was middle income while the other was lower income. The 93 physicians who were interviewed, all of whom engaged in some general practice, represented 62% of the 152 physicians practicing in the four communities. Respondents did not differ from nonrespondents in terms of sex distribution, the proportion who graduated from a school approved by the American Medical Association's Liason Committee for Medical Education (some physicians were quite elderly), and the propor¬ tion who were certified in a specialty, although there was a higher proportion of foreign-trained physicians among the respondents (24%) than among the nonrespondents (12%), and the respondents were slightly younger than the nonrespondents (mean age, 55 vs
60, respectively).
All of the physicians in the two white communities were white, whereas more than half of those in the black community were black (P < .01). The percentage of male physicians do not vary significantly, but the physicians in middle-income black communi¬ ty were significantly younger (P < .05) than those in the other three communities. Clearly, the physicians in their communities have a mean age higher than that for all practicing physicians, but they may not be significantly different from those practicing in communities in the inner cities of large urban areas.
RESULTS Accepted
publication Sept 5, 1978. Planning Support Services, Mental Health and Rehabilitative Services Directorate, Department of Health and Social Development, Province of Manitoba, Winnepeg. Reprint requests to Planning Support Services, Mental Health and Rehabilitative Services Directorate, Department of Health and Social Development, Province of Manitoba, 4-831 Portage Ave, Winnepeg, Manitoba R3G 0N6 (Dr Hull). for
From the
Downloaded From: by a Tulane University User on 01/16/2019
Before
turning to actual reported behavior with respect psychiatric referrals, it may be instructive to briefly examine the respondents' attitudes toward psychiatric referrals. They were asked to indicate whether they agreed or disagreed with the following three statements on the possible negative effects of making a psychiatric referral: to
(1) In recent years, patients seem much less annoyed or frightened at the suggestion that they should see a psychiatrist. (2) One should hesitate to make psychiatric referrals because it is a disadvantage for a patient to be labeled a "mental case." (3) One should hesitate to refer a patient for psychiatric advice because he may conclude that his symptoms are being regarded as imaginary. There was overwhelming agreement (93%) that patients have been much less annoyed or frightened in recent years when a psychiatric referral is suggested. There was also
substantial consensus that concern about the disadvan¬ tages of a psychiatric label (89% disagreed or strongly disagreed with the statement) or fears that patients may think their problems are being regarded as imaginary (83% disagreed or strongly disagreed with the statement) should not stand in the way of making a psychiatric referral. To obtain information on these trends, respondents were asked to indicate the percentage of patients in each diagnostic grouping whom they referred to psychiatrists. The diagnoses employed were those of the respondent. Of those respondents who had made at least one diagno¬ sis of psychosis in the past year, 64% indicated that they referred all such patients to psychiatrists. On the other hand, 7% said that they made no referrals and 12% treated 90% or more of these problems without a psychiatric referral. The remainder treated between 25% and 75% themselves. Of the 70 respondents who had encountered one or more problems in the past year, 31% indicated they made no referrals, 17% referred all such cases, and the remainder referred between 1% and 90%. Although the median was 10%, because of the somewhat skewed distri¬ bution, the mean was 30%. More than half (54%) of the respondents who had encoun¬ tered patients with addiction or alcohol problems in the preceding year said that they did not refer any of them to psychiatrists. The remainder, however, referred between 1% and 100%, with 7% indicating the latter figure. The mean reported rate was 16%, despite the fact that less than one tenth referred 30% or more of such problems. As might be expected, the modal and median percentage of patients referred to psychiatry for vocational, marital, and other personal problems was none. However, only 58% indicated that they never made psychiatric referrals for such problems, and 11% referred one half or more of persons with these problems to psychiatrists. COMMENT The findings with respect to the attitudes of the respon¬ dents concerning psychiatric referrals are interesting in the light of four British studies'"' that investigated some of the reasons physicians offered for not making psychiatric referrals. In these studies, 54%,' 60%,2 45%,3 and 51%4 of the physicians cited patients' dislike of such a referral as a major factor. In addition, a substantial proportion (21% to 36%) were also concerned about the disadvantage to patients of being labeled mental cases. There are no other North American studies with which to compare these results, but it is interesting that British physicians seemed to be more concerned about the consequences of labeling than the physicians in the current study. Turning to the reported rates of actual referral, we
Downloaded From: by a Tulane University User on 01/16/2019
of Physicians Referring Various of Patients to Psychiatrists, by Diagnostic
Percentage
% of
Physicians
Proportion of Patients Referred None 0.01 to 0.25 0.25-0.49 0.50-0.74 0.75 to 0.99 All
Psychoses 7 5 10
Neuroses 31
30 9
Proportions Category
Alcohol/ Addictions 54 22 10
Other Personal Problems 58 29
12 64
17
found that while there was agreement by almost two thirds of the respondents that all cases of psychosis should be referred, the remaining one third covered virtually the entire range of alternatives, indicating that there is not universal acceptance of the norm that psychotic patients should be referred to psychiatrists. In a study of medical patients admitted to a London hospital, Pritchard5 found that 60% of those with a diagnosis of a functional psychosis were referred to psychiatry, but only 18% of those with an organic psychosis were referred. Thirty-two percent of the physicians interviewed by Tsoi and Chia" would immedi¬ ately refer a schizophrenic patient to a psychiatrist, while 64% would try drugs and psychotherapy first, and if that was "unsatisfactory" would then make a referral to a psychiatrist. In summary, there does seem to be some agreement on the part of about two thirds of physicians that for the functional psychoses, one either makes an immediate referral or reserves referral as a highly proba¬ ble outcome in the treatment process, but there is obviously a minority who prefer to treat such problems themselves. The limited consensus that appeared with respect to the psychoses seems to be less apparent when physicians are asked about the use of psychiatric referral for neuroses. Although most would refer few such cases, 39% would refer more than a quarter and 17% would refer all such cases. Nevertheless, the results are not inconsistent with the findings of Tsoi and Chia," who reported that the vast majority (85%) of their respondents also would treat neurotic problems other than depression themselves rather than refer. However, of the hospitalized physically ill patients in Pritchard's5 study, some 34% of those who also had a diagnosis of neurosis were referred to psychiatry. This figure included those persons diagnosed as having neurotic depression, of whom 61% were referred, while 24% of persons given other neurotic diagnoses were referred. It seems probable that these high referral rates were influenced by the fact that all of the patients were inpatients at the time of the referral, and that ease of contact between physicians and between patients and specialists would increase the probability of referrals being made and followed through. Interestingly, a very high rate of referral was made for personality disorders (63%), particularly among males (78%). Those persons who had ever attempted suicide were also much more likely to be referred (71%) than were those who had not (24%)."' Surpris¬ ingly, Tsoi and Chia" found that while 37% of the physi¬ cians they interviewed would immediately refer a person
with
depression accompanied by
to a psychiatrist, if the depression was suicidal idea, the figure dropped to 28%, while under these circumstances 70% would attempt psychotherapy and drug therapy, only making a referral if these were not effective. Despite the differences, it is clear that most physicians prefer to treat the majority of neurotic patients themselves, without psychiatric refer¬ ral. The mean reported rate of referral for alcohol and addiction problems (16%) is similar to that of Pritchard,5 who found that 13% of persons with alcoholism and 23% of those with drug addiction were referred to psychiatrists, but again these inpatient referral rates are likely to be much higher than those for community practice. Other existing studies have not reported referral rates for other personal problems, but it is interesting that about one half of the respondents indicated that they will refer some patients with such problems to psychiatrists.
SUMMARY AND CONCLUSIONS The community physicians generally agreed that to refer a patient to a psychiatrist will not produce negative consequences for the patient. They also agreed that patients have seemed much more receptive to such refer¬ rals in recent years than they had in the past. Some two thirds of the physicians agreed that all cases of psychoses should be referred to psychiatrists, but the remaining one third covered the entire spectrum of alter¬ natives, indicating that there is not a norm for psychiatric
Downloaded From: by a Tulane University User on 01/16/2019
referral of psychotic patients. There was much less consensus about the use of referrals with neuroses. About one third made no referrals, one sixth referred all cases, and the remainder again covered the entire spectrum. More than half of the respondents did not refer any patients who had alcohol or drug problems, although 7% referred all such patients. Almost half of the respondents also made occasional psychiatric referrals for patients with marital, vocational, and other personal problems, and about one tenth referred one half or more of such patients. This study was supported in part by a grant from the Center for Health Administration Studies, University of Chicago. The Center and its director, O. W. Anderson, PhD, provided financial and other assistance. The Depart¬ ment of Health and Community Services, Province of Manitoba, also provided assistance.
References 1. Logan WPD, Cushion AA: Morbidity Statistics From General Practice: I. Studies on Medical and Population Subjects, No. 14. London, Her Majesty's Stationery Office, 1958. 2. Shepard M, Cooper B, Brown AC, et al: Psychiatric Illness in General Practice. London, Oxford University Press, 1966. 3. Mezey AG, Kellett JM: Reasons against referral to the psychiatrist. Postgrad Med J 47:315-319, 1971. 4. Fahy TJ, O'Rourke A, Wilson-Davis K: The Irish family doctor and psychiatry: A national survey of attitudes. J Ir Med Assoc 56:616-623, 1974. 5. Pritchard M: Who sees a psychiatrist? A study of factors related to psychiatric referral in the general hospital. Postgrad Med J 48:645-651, 1972. 6. Tsoi WF, Chia BH: General practitioners and mental illness. Singapore Med J 13:188-191, 1972.
