Psychological Reports, 1990, 67, 775-778. O Psychological Reports 1990
PSYCHOLOGICAL PROBLEMS WITH HAIR LOSS IN GENERAL PRACTICE AND THE TREATMENT POLICIES O F GENERAL PRACTITIONERS ' E. B. G . DE KONING, J. PASSCHIER
F. W. DEKKER
Department of Medical Psychology and Psychotherapy Erasmus University Rotterdam
Department of Family Medicine University of Lqden
Summary.-Scalp hair loss problems and the policies of general practitioners were studied by sending questiomaues to 374 physicians, of whom 21% responded. About 50% of the patients, accord~ngto their physicians, had psychological problems which predominantly comprised low self.esteern in the male patients and fear and anxiety in the female patients. The general practitioners followed the same p o k y for patients with psychological problems and for those without. The findings suggest that many alopecia patients need more psychological support from their phys~c~ans
The prevalence of alopecia androgenetica in the general population is 45% in men and 19% in women (Hamilton, 1951). Other kinds of alopecia are found much less frequently (Rook, Wilkinson, & Ebling, 1984). Given the relatively h g h number of inlviduals with alopecia, the prevalence of patients presenting to the general practitioner with complaints of alopecia is very low. In general practices in the Netherlands, figures have been recorded of 2.9 to 3.8 cases per year per 1000 patients (Lamberts, 1984). In this study we explored the nature of the hair problems, the possible presence of psychological problems, and the practitioners' treatment approaches using standard questionnaires. In addition, we studied whether the nature of the scalp hair problems and any existing psychological problems were dependent on the sex of the patient and whether the policy of the practitioner was dependent on the sex of the patient and the presence of psychological problems. -
~
Subjects and Procedure Two questionnaires were sent for completion to 374 general practitioners who were associated with one of four Sick funds which covered the western part of the Netherlands. After three weeks 78 practitioners (20.9%) had returned the questionnaires. Next, 86 nonrespondents were selected at random and politely reminded by telephone to answer the questions and two did so. This resulted in a response rate of 21.4%.
'.Sup orted by a grant From the Upjohn Company, Kalamazoo, Michigan and the Section ~ e n e f u x .Address correspondence to Dr. J. Passchier, Department of Medical Psychology and Psychotherapy, Erasmus University Rotcerdam, P O Box 1738, 3000 DR Rotterdam, The Netherlands.
776
E. B. G. DE KONING, E T A L .
Questionnaires Two questionnaires were sent to each general practitioner with identical questions referring to the last male and the last female patient who had consulted the physician about a scalp hair problem. The items were about the types of scalp hair problems. Next, it was asked whether psychological problems were present and, if so, we requested details about their nature. Finally, the physician was asked to describe treatment policy. Questions were asked in a truelfalse format with the possibility of adding alternative answers.
RESULTS The participants returned 76 and 71 completed questionnaires for the female and the male patients, respectively. Of these patients, 22 and 24 had visited their physicians more than once for scalp hair problems.
Scalp Hair Problems Twenty-eight percent of the men complained about diffuse hair loss and 48% about baldness. This tendency was reversed in the women: 68% of them complained about diffuse hair loss and 8% about baldness. These sex = 29.7, PS < .001). differences were significant (xI2= 22.9 a n d According to the physicians, 38 (50%) of the women and 33 (47%) of the men had psychological problems in addition to their hair problems. Those problems mentioned most frequently by the women were fear and anxiety (24% and 21%, respectively); the men mentioned "low self-esteem" in particular (26%). Depression was indicated for 5% of the women and 9% of the men. No frequencies of psychological problems were significantly different by chi squared between men and women.
Policy of General Practitioners Thirty-nine percent of the women and 58% of the men received information on baldness, a significant difference (x,Z = 4.91, p < .05). The next most frequently used policy was "referral to a dermatologist" (30% and 28%, respectively). Further, 30% of the men were prescribed minoxidil in comparison with only 5% of the women, which difference was significant (X,2 = 15.18, p < .001). O n the other hand, a significantly smaller percentage = 4.68 and of men were prescribed shampoo and vitamins than women (xL2 X,2 = 5.59, both p s < .05). Psychological advice was given to 18% of the women and 9% of the men. Policies which were seldom applied included referral to a psychiatrist or psychologist. No significant differences by chi squared in treatment policy were found between patients with and without psychological problems. DISCUSSION Our response rate was low (21 4%) so the data are interpreted tentatively. The present sample of participating general practitioners may be more
TREATMENT POLICIES: PSYCHOLOGICAL PROBLEMS IN HAIR LOSS
777
involved with scalp hair problems than the average population of general physicians.
Scalp Hair Problems The pattern of hair loss was different for male and female patients, which agrees with the literature on alopecia androgenetica (Hamilton, 1951). Whereas hair loss in men resulted in pattern baldness, that in women mostly had a diffuse character. About 50% of the male and the female patients had psychological problems too, according to their general physicians. For the male patients low self-esteem was mentioned most frequently, whereas in the female patients fear and anxiety prevailed. I n a previous study of male patients with alopecia androgenetica in which we investigated their motives for visiting their physicians, it was found that those who visited their physicians had more psychological problems than those who did not (Passchier, Rijpma, Dutrei-Meulenberg, Verhage, & Stolz, 1989). I n the former group, 15% were motivated for the visit to the general physician by the need for tallung about problems regarding hair loss. The physicians did not state explicitly what the fear and anxiety of the female patients was about. A recent study by our group (submitted) on the hair problems of a clinical sample of women with alopecia androgenetica showed that the focus of their emotion was, in particular, on the aggravation of the hair loss and its (negative) consequences for the appearance of the women. The women who reported that their (increasing) alopecia posed a threat to their marital and occupational status were only a few.
Policy of the General Physicians Several differences in the treatment policies regarding male and female patients were significant. Relatively more male patients received information on baldness and were offered rninoxidil treatment, whereas relatively more female patients were prescribed treatment by shampoo or vitamins. The prevalence of minoxidil treatment prescribed by the physicians for male patients was similar to that reported in our previous study (Passchier, et al., 1989). Minoxidil is primarily prescribed for cases with alopecia androgenetica. While 59% of our male patients were diagnosed by their physicians as having this type of baldness, only 5 % of our female patients received the diagnosis of alopecia androgenetica, which might explain the sex differences regarding prescription. Further, more information is available about alopecia androgenetica and its treatment by rninoxidil in men than in women. Despite the fact that about 50% of the patients had psychological problems according to their physicians, only a minority of them received psychological advice. Also, the number of patients who were referred to a psychologist or psychiatrist was very low (3%). No significant difference was observed in treatment policy between patients with psychological problems and those
778
E. B. G .
DE
KONING, ETAL.
without. Considering the lack of generally adequate medical treatment for hair loss, many of the patients who are also suffering from psychological problems seem to receive insufficient support in a psychological respect from their general physicians. REFERENCES HAMILTON,J. B. Pattern loss of hair in men; types and incidence. AnnaCc of the New York Academy of Sciences, 1951, 53, 708-711. LAMBERTS,H. M o r b i d i ~in general practice; diagnosis-related information from the monitoring project. Utrecht: Huisartsenpers, 1984. PASSCHLER,, RIJPMA,S. E., DUTR~E-MEULENBERG, R. 0. G. M., VERHAGE,F., & STOLZ,E. Wky men with hair loss go to the doctor PsychoIogical Peportx, 1989. 65. 323-330. ROOK,A. J., WIUCINSON,D. S., & EBLMG,F. J. G. (Eds.), Textbook of dermatology. Oxford, UK: Blackwell Scientific Publ., 1984. Pp. 1733-1824. Accepted Sep~ember25, 1390
PSYCHOLOGICAL PROBLEMS WITH HAIR LOSS IN GENERAL PRACTICE AND THE TREATMENT POLICIES O F GENERAL PRACTITIONERS ' E. B. G . DE KONING, J. PASSCHIER
F. W. DEKKER
Department of Medical Psychology and Psychotherapy Erasmus University Rotterdam
Department of Family Medicine University of Lqden
Summary.-Scalp hair loss problems and the policies of general practitioners were studied by sending questiomaues to 374 physicians, of whom 21% responded. About 50% of the patients, accord~ngto their physicians, had psychological problems which predominantly comprised low self.esteern in the male patients and fear and anxiety in the female patients. The general practitioners followed the same p o k y for patients with psychological problems and for those without. The findings suggest that many alopecia patients need more psychological support from their phys~c~ans
The prevalence of alopecia androgenetica in the general population is 45% in men and 19% in women (Hamilton, 1951). Other kinds of alopecia are found much less frequently (Rook, Wilkinson, & Ebling, 1984). Given the relatively h g h number of inlviduals with alopecia, the prevalence of patients presenting to the general practitioner with complaints of alopecia is very low. In general practices in the Netherlands, figures have been recorded of 2.9 to 3.8 cases per year per 1000 patients (Lamberts, 1984). In this study we explored the nature of the hair problems, the possible presence of psychological problems, and the practitioners' treatment approaches using standard questionnaires. In addition, we studied whether the nature of the scalp hair problems and any existing psychological problems were dependent on the sex of the patient and whether the policy of the practitioner was dependent on the sex of the patient and the presence of psychological problems. -
~
Subjects and Procedure Two questionnaires were sent for completion to 374 general practitioners who were associated with one of four Sick funds which covered the western part of the Netherlands. After three weeks 78 practitioners (20.9%) had returned the questionnaires. Next, 86 nonrespondents were selected at random and politely reminded by telephone to answer the questions and two did so. This resulted in a response rate of 21.4%.
'.Sup orted by a grant From the Upjohn Company, Kalamazoo, Michigan and the Section ~ e n e f u x .Address correspondence to Dr. J. Passchier, Department of Medical Psychology and Psychotherapy, Erasmus University Rotcerdam, P O Box 1738, 3000 DR Rotterdam, The Netherlands.
776
E. B. G. DE KONING, E T A L .
Questionnaires Two questionnaires were sent to each general practitioner with identical questions referring to the last male and the last female patient who had consulted the physician about a scalp hair problem. The items were about the types of scalp hair problems. Next, it was asked whether psychological problems were present and, if so, we requested details about their nature. Finally, the physician was asked to describe treatment policy. Questions were asked in a truelfalse format with the possibility of adding alternative answers.
RESULTS The participants returned 76 and 71 completed questionnaires for the female and the male patients, respectively. Of these patients, 22 and 24 had visited their physicians more than once for scalp hair problems.
Scalp Hair Problems Twenty-eight percent of the men complained about diffuse hair loss and 48% about baldness. This tendency was reversed in the women: 68% of them complained about diffuse hair loss and 8% about baldness. These sex = 29.7, PS < .001). differences were significant (xI2= 22.9 a n d According to the physicians, 38 (50%) of the women and 33 (47%) of the men had psychological problems in addition to their hair problems. Those problems mentioned most frequently by the women were fear and anxiety (24% and 21%, respectively); the men mentioned "low self-esteem" in particular (26%). Depression was indicated for 5% of the women and 9% of the men. No frequencies of psychological problems were significantly different by chi squared between men and women.
Policy of General Practitioners Thirty-nine percent of the women and 58% of the men received information on baldness, a significant difference (x,Z = 4.91, p < .05). The next most frequently used policy was "referral to a dermatologist" (30% and 28%, respectively). Further, 30% of the men were prescribed minoxidil in comparison with only 5% of the women, which difference was significant (X,2 = 15.18, p < .001). O n the other hand, a significantly smaller percentage = 4.68 and of men were prescribed shampoo and vitamins than women (xL2 X,2 = 5.59, both p s < .05). Psychological advice was given to 18% of the women and 9% of the men. Policies which were seldom applied included referral to a psychiatrist or psychologist. No significant differences by chi squared in treatment policy were found between patients with and without psychological problems. DISCUSSION Our response rate was low (21 4%) so the data are interpreted tentatively. The present sample of participating general practitioners may be more
TREATMENT POLICIES: PSYCHOLOGICAL PROBLEMS IN HAIR LOSS
777
involved with scalp hair problems than the average population of general physicians.
Scalp Hair Problems The pattern of hair loss was different for male and female patients, which agrees with the literature on alopecia androgenetica (Hamilton, 1951). Whereas hair loss in men resulted in pattern baldness, that in women mostly had a diffuse character. About 50% of the male and the female patients had psychological problems too, according to their general physicians. For the male patients low self-esteem was mentioned most frequently, whereas in the female patients fear and anxiety prevailed. I n a previous study of male patients with alopecia androgenetica in which we investigated their motives for visiting their physicians, it was found that those who visited their physicians had more psychological problems than those who did not (Passchier, Rijpma, Dutrei-Meulenberg, Verhage, & Stolz, 1989). I n the former group, 15% were motivated for the visit to the general physician by the need for tallung about problems regarding hair loss. The physicians did not state explicitly what the fear and anxiety of the female patients was about. A recent study by our group (submitted) on the hair problems of a clinical sample of women with alopecia androgenetica showed that the focus of their emotion was, in particular, on the aggravation of the hair loss and its (negative) consequences for the appearance of the women. The women who reported that their (increasing) alopecia posed a threat to their marital and occupational status were only a few.
Policy of the General Physicians Several differences in the treatment policies regarding male and female patients were significant. Relatively more male patients received information on baldness and were offered rninoxidil treatment, whereas relatively more female patients were prescribed treatment by shampoo or vitamins. The prevalence of minoxidil treatment prescribed by the physicians for male patients was similar to that reported in our previous study (Passchier, et al., 1989). Minoxidil is primarily prescribed for cases with alopecia androgenetica. While 59% of our male patients were diagnosed by their physicians as having this type of baldness, only 5 % of our female patients received the diagnosis of alopecia androgenetica, which might explain the sex differences regarding prescription. Further, more information is available about alopecia androgenetica and its treatment by rninoxidil in men than in women. Despite the fact that about 50% of the patients had psychological problems according to their physicians, only a minority of them received psychological advice. Also, the number of patients who were referred to a psychologist or psychiatrist was very low (3%). No significant difference was observed in treatment policy between patients with psychological problems and those
778
E. B. G .
DE
KONING, ETAL.
without. Considering the lack of generally adequate medical treatment for hair loss, many of the patients who are also suffering from psychological problems seem to receive insufficient support in a psychological respect from their general physicians. REFERENCES HAMILTON,J. B. Pattern loss of hair in men; types and incidence. AnnaCc of the New York Academy of Sciences, 1951, 53, 708-711. LAMBERTS,H. M o r b i d i ~in general practice; diagnosis-related information from the monitoring project. Utrecht: Huisartsenpers, 1984. PASSCHLER,, RIJPMA,S. E., DUTR~E-MEULENBERG, R. 0. G. M., VERHAGE,F., & STOLZ,E. Wky men with hair loss go to the doctor PsychoIogical Peportx, 1989. 65. 323-330. ROOK,A. J., WIUCINSON,D. S., & EBLMG,F. J. G. (Eds.), Textbook of dermatology. Oxford, UK: Blackwell Scientific Publ., 1984. Pp. 1733-1824. Accepted Sep~ember25, 1390
