Diagnosis of alcoholism in a simulated patient encounter by primary care physicians

Although early detection and treatment of alcoholism have been shown to be efficacious, it is widely accepted that primary care physicians often fail to diagnose alcoholism. In this study, a computerized, simulated encounter with an alcoholic patient was used to assess the performance of a randomly selected sample of primary care physicians in diagnosing alcoholism. Of 95 physicians in this study, only 32 percent diagnosed alcoholism with maximal certainty. There was great variability among physicians in the threshold of information needed to diagnose alcoholism. One third of subjects misinterpreted symptoms of alcoholism and erroneously made other psychiatric diagnoses, chiefly anxiety or depression. Results of this pilot study were not associated with the physicians' age, sex, specialty, duration of training, or reported personal impact of alcoholism. This study provides further evidence of the need for additional education of primary care physicians if such physicians are to succeed in reducing the dramatic impact of alcoholism and alcohol abuse on public health.     

Do patient attitudes influence physician recognition of psychosocial problems in primary care?

Research has yielded consistent evidence of high levels of psychiatric morbidity and psychosocial problems among primary care patients, and recent studies have focused on improving physician recognition. These studies are based on the unexamined assumption that patients want their physicians to treat psychosocial disorders; thus, underrecognition is examined by analyzing characteristics of physicians and medical settings. Patient characteristics, particularly attitudes about the appropriateness of seeking help for psychosocial problems in primary care, have not been examined in relationship to underrecognition. This study directly focuses on patient attitudes about appropriateness of requesting care for psychosocial difficulties, the extent to which patients discuss difficulties with their physicians, and the degree to which physician recognition is explained by these patient characteristics. The study sample of 883 adult patients was drawn from 23 primary care practices. Over 70 percent of patients find it appropriate to turn to their primary care physicians for help with emotional distress, family problems, life stress, behavioral problems, and sexual dysfunction; however, only one fifth to one third of patients who have experienced difficulties have discussed these problems with their primary care providers. Attitudes about appropriateness are significantly related to physician recognition of psychiatric symptoms and family difficulties but account for limited variance in levels of recognition.     

Alcoholism,brief intervention and the institutional context: a focus-group study with French and Finnish general practitioners

The moral problem of heavy drinking has become medicalised. However, when taking into account the different levels of medicalisation, French alcohol policy and treatment organisation has traditionally gone further than Finnish policy, although physicians in both countries are now becoming more important in the treatment of alcoholism. General practitioners (GPs) are often the first to diagnose alcoholism and they are expected to apply brief interventions, which have been proven effective in reducing heavy alcohol consumption. Focus-group interviews were conducted in Finland and France using three film clips as a stimulus for discussion. The short vignettes show incidences of alcohol problems from scenes in international fictional movies, with themes of loss of control, harm of loved ones and cue dependency. Interviews were analysed for GPs’ narratives about alcohol problems and alcoholism, using the semiotic concept of focalisation. The influence of historical approaches to alcohol problems was evident in the French GPs’ focus on the suffering of the alcoholic in comparison with the Finnish GPs’ emphasis on the alcoholic's family misery and their obligation only in caring for the physical problems of the alcoholic. The organisation of primary health care is identified as one important factor for these differences in conceptualising heavy drinking. Implications are that the compatibility of brief interventions with institutional and cultural contexts of health care should be considered before implementation.     

Psychiatric malpractice: liability for suicide and attempted self-destruction

One of the many observations of changes in doctor-patient relationships is in regard to psychiatric problems. First, patients have become more sophisticated in their comprehension of these problems and have become more willing than previously to talk about these conditions and simultaneously to be managed for these problems by primary care physicians--sometimes in preference to a psychiatrist. Secondly, primary care physicians have changed their perceptions of patients' psychiatric problems. They have developed a greater comprehension of these problems--particularly as they relate to somatic complaints. One result of this has been that physicians are now able to detect these problems and to intervene before the problem reaches serious proportions. One of these psychiatric disasters is suicide, and it is to this subject that this article is devoted. Obviously, it is a subject as applicable and important to the primary care physician as it is to the psychiatrist, as both encounter patients in situations and with conditions that have the potential for leading to self-destruction.     

A study of the preferences of family practitioners and other primary care physicians in treating patients' psychosocial problems

Family medicine specialists claim that they treat patients' psychosocial problems as well as their biological problems. Forty-four family physicians and 130 other primary care physicians at two urban medical centers in a large city completed a questionnaire designed to identify if any differences existed in their preferred mode of treating patients' psychosocial problems. Seventy percent of the time, family physicians, like other primary care physicians, preferred referring patients with psychosocial problems to social workers and other mental health experts to treating psychosocial problems themselves. The study has implications for family medicine, social work, and health care planning in the United States.     

Alcoholism in the families of family practice outpatients

As part of a screening process for alcoholism, 147 patients at a university-based family practice center were each asked to complete two tests: the Michigan Alcohol Screening Test (MAST) concerning themselves and a modified MAST concerning their families. Charts of patients with positive results for family alcoholism were reviewed for presenting complaints, ongoing medical problems, and recognition or mention of family alcoholism by the physician. Over 34 percent (50) of patients had definite alcoholism problems in their families. Women were more likely than men to have a positive family MAST (37.7 percent women vs 24.4 percent men, P less than .001), whereas men were more likely to be alcoholic (34.1 percent men vs 10.4 percent women, P less than .001). Nearly 40 percent of patients with a positive family MAST had complaints that could be attributed to the family disruption of alcoholism, and another 20.8 percent had medical problems that might be exacerbated by stress, but use of alcohol by a family member was mentioned in only 12.5 percent (5/40) of charts reviewed.     

The Cuban immigration of 1980: a special mental health challenge

The 124,769 Cubans who entered the United States from Cuba in a boatlift in 1980 included a small minority of people who needed mental health care. Some had been taken involuntarily from psychiatric hospitals, mental retardation facilities, jails, and prisons. The National Institute of Mental Health, Public Health Service (PHS), was responsible for mental health screening, evaluation, and treatment of the Cuban Entrants. Bilingual psychiatrists and psychologists found that many Entrants given preliminary evaluations showed evidence of transient situational stress reactions, not psychiatric illnesses. Entrants who had not yet been sponsored were consolidated into one facility in October 1980, and about 100 of those with severe problems were transferred to an Immigration and Naturalization Service-PHS evaluation facility in Washington, DC. Between March 1, 1981, and March 1, 1982, a total of 3,035 Entrants were evaluated at both facilities. Among the 1,307 persons who presented symptoms, there was a primary diagnosis of personality disorders for 26 percent, schizophrenic disorders for 15 percent, adjustment disorders for 14.5 percent, mental retardation for 8.6 percent, chronic alcohol abuse for 8.6 percent, and major depression for 7.2 percent. Only 459 Cubans with symptoms were found to be in need of further psychiatric care. As of October 1984, many Entrants with psychiatric illnesses remained under inpatient or community-based halfway house psychiatric care as a direct Federal responsibility. A PHS program for further placement in community-based facilities is underway.     

Carbohydrate-deficient transferrin is elevated in catabolic female patients.

Serum carbohydrate-deficient transferrin (CDT) is currently widely used as a biochemical marker of alcohol misuse. However, various recent studies have questioned the diagnostic value of this parameter and reported low levels of both specificity and sensitivity, especially in women. Thus, we sought to identify sub-groups of female individuals in which CDT is elevated independently of alcohol consumption. Significantly increased CDT levels were found in catabolic disease states due to psychiatric disorders distinct from alcoholism. None of those patients reported frequent alcohol consumption. CDT therefore appears also to be increased by metabolic processes distinct from alcohol degradation. Possible biochemical mechanisms of this phenomenon are discussed. As a consequence of these findings, the measurement of CDT alone is not suitable to screen for alcohol misuse in catabolic subjects.     

Diagnosing depression among new patients in ambulatory training settings

A research-validated instrument, based upon the Diagnostic and Statistical Manual of Mental Disorders-III, is used as a "gold standard" to compare physician assessments of depression. Twenty-seven of 294 patients (9.2 percent) presenting to three primary care clinics for the first time met clinical criteria for a depressive disorder. Although the 27 depressed patients differed from the nondepressed patients on sociodemographic characteristics, prior service utilization patterns, and clinical variables, only 7 of the 27 were diagnosed as depressed by their primary care physicians. Factors associated with accurate assessment include comment in the patient's chart of a prior psychiatric history. Many depressed patients reporting high levels of dysphoria on a screening instrument had no mood symptoms recorded on their charts.     

Preemployment evaluations: dilemmas for the family physician.

Preemployment evaluations present primary care physicians with numerous medical, ethical, and legal dilemmas. These examinations are especially problematic for community-based primary care providers unaccustomed to standards used by physicians in occupational settings. In response to a mailed questionnaire, 255 family physicians and general practitioners described their current methods of performing these examinations. Forty percent reported that employers routinely provide no information about the job for which the prospective employee is being evaluated. Respondents differed according to number and type of laboratory tests routinely included as part of a preemployment evaluation and in the proportion of prospective employees disqualified on the basis of the examination. Twenty-four percent reported no disqualifications, and 34 percent disqualified 5 percent or more. The percentage reporting medical and psychological information also varied. One-half routinely reported alcohol and drug abuse to employers, and of these, only one-half obtained a waiver for the release of such information. Five of every 6 physicians believed that it was more important to "tell the truth to the employer" than to "protect the interests of the employee." Our findings show that no consensus exists among the primary care physicians in our survey about the performance of preemployment evaluations. Because this can have serious consequences to workers, employers, and physicians, we propose guidelines for primary care physicians who perform preemployment evaluations.     

From policy to practice: physicians' views on OBRA and mental health resources in long-term care

OBJECTIVES: The purpose of this national survey was to seek to clarify physician beliefs about nursing home mental health needs, understand the perceived effectiveness of OBRA legislation, determine physician exposure to OBRA PASARR Level II assessments, and understand the current role of community mental health interventions in the nursing home. DESIGN: A self-administered questionnaire. SETTING: Surveyed physicians were nursing home medical directors and/or attending physicians. PARTICIPANTS: The overall response rate for the 1000 physicians surveyed nationally, was 62% (n = 620). Fifty-nine percent (n = 361) of all responders were family physicians, and 41% (n = 250) were general internists. MEASUREMENTS/RESULTS: Only 48% (n = 291) of all respondents ever saw the recommendations from their patient's OBRA PASARR Level II assessment screening. Approximately one-third of all respondents viewed each discipline's recommendations as "very" or "somewhat" helpful. Thirty-seven percent (n = 228) of respondents viewed OBRA's psychotropic guidelines as only somewhat helpful. More than two-thirds (n = 412) believed OBRA regulations had not improved access to mental health care for their nursing home patients. CONCLUSIONS: This survey demonstrated that OBRA PASARR Level II assessments are not being viewed or valued by many physicians. In nursing homes, limited access to community mental health staff and psychiatric input may leave primary care physicians treating difficult behavioral problems themselves. Collaborating on helpful mental health interventions for nursing home patients is an ongoing critical issue in long-term care.     

Improving the detection of drug abuse,alcohol abuse,and depression in community health centers

Up to 35 percent of primary care patients suffer from substance abuse or mental disorders, and most of these patients receive care from general medical professionals rather than mental health specialists. Accumulating evidence suggests that primary care physicians often fail to recognize, diagnose, and treat their patients with mental and substance use disorders; only about 5 percent of primary care visits result in a mental or substance use diagnosis. The goals of this project were to evaluate the feasibility of screening for drug abuse, alcohol abuse, and major depression at two federally funded urban Community/Migrant Health Centers (C/MHCs), in Newark, New Jersey, and Bronx, New York, and to examine the effects of a clinical tool designed to guide primary care clinicians in the identification and treatment of substance use and depression, assess provider perceptions of the screening form, and determine the concordance between provider and patient reports of assessment and management.     

Perceptions of substance use,treatment options and training needs among Iranian primary care physicians

In order to be optimally effective, continuing training programmes for health-care professionals need to be tailored so that they target specific knowledge deficits, both in terms of topic content and appropriate intervention strategies. A first step in designing tailored treatment programmes is to identify the characteristics of the relevant health-care professional group, their current levels of content and treatment knowledge, the estimated prevalence of drug and alcohol problems among their patients and their preferred options for receiving continuing education and training. This study reports the results of a survey of 53 primary care physicians working in Iran. The majority were male, had a mean age of 44 years and saw approximately 94 patients per week. In terms of their patients' drug use, primary care physicians thought most patients with a substance use problem were male, women were most likely to use tobacco (52%), opium (32%) and marijuana/hashish and young people were most likely to use tobacco, alcohol, marijuana and heroin. Counselling and nicotine patches were the treatments most commonly provided. Although the majority (55%) reported referring patients to other services, more than a third did not. Most primary care physicians reported being interested in attending further training on substance abuse issues. The implications of these data for ongoing education and training of primary care physicians in Iran are discussed.     

Clinical competence of family physicians. The patient perspective.

OBJECTIVE: This study examines the attitudes and perceptions of patients regarding the clinical competence of family physicians. DESIGN: Telephone survey employing probability sampling (random-digit dialing). SETTING: A sample of adults living in Kentucky. PARTICIPANTS: Data come from a sample of 650 completed calls (64% response rate). MEASUREMENTS/MAIN RESULTS: Ninety-three percent of the patients reported having a physician who provides primary health care. Only 1% of those with a physician listed a specialist as their source of care. Patients generally agree that family physicians are clinically competent to handle common medical problems. Of 11 investigated conditions, depression and heart disease were the conditions with the lowest reported patient confidence. A stepwise logistic regression model indicated that the quality of care provided by one's primary care physician was the only significant predictor of patient confidence in the competence of family physicians. CONCLUSIONS: These results suggest that patients believe family physicians are competent to treat a wide variety of common medical problems.     

Styles of care provided to children in the United States: a comparison by physician specialty

This study was based on findings from a national survey of physicians that was conducted from 1975 to 1977. The data concern face-to-face encounters with children in the ambulatory care setting. Over one half of the practices of pediatricians consisted of infants and preschoolers, whereas well over 50 percent of the child patients of other types of physicians were 10 to 19 years old. The proportion of visits dealing with a problem already under care was consistently greater for specialists other than primary care physicians; the proportion of visits for preventive care was much lower in the practices of these specialists than in primary care practice. These findings suggest that other specialists are functioning in ways different from primary care physicians. As compared with family physicians, pediatricians performed more diagnostic tests for all diagnoses and more immunizations and counseling about growth and development, were more likely to have seen children previously for problems other than the one dealt with in the visit under consideration, and were more likely to report that no specific therapy was required (except for well-child care). However, family physicians did more counseling about family and sex matters than pediatricians, were much more likely to have seen musculoskeletal and skin problems among 10- to 19-year-old patients, and were much more likely to have administered cauterization, cryotherapy, or suturing for skin problems. Family physicians provided more counseling of all types and did more minor surgical procedures than general practitioners. These and other findings show the existence of systematic differences across specialties in the care of children, even for apparently similar problems.     

Psychiatry and general health care

The paper presents a study of psychiatric morbidity in the general health care program of a Health Maintenance Organization. Mental health services are built into the program as an integral component of primary care teams in internal medicine and pediatrics. The following were some of the findings: 15.7% of patients visiting the Health Center over a two-year period presented emotional problems; 72% were treated by primary care clinicians alone and 28% by mental health clinicians. Treatment by primary and mental health clinicians is broken down by diagnostic categories. A study of patients with chronic emotional problems revealed that they tended to be high utilizers of all Health Center services for both physical and emotional difficulties. Chronic patients represented 2% of all patients who visited in 1974; of these, 54% were seen by mental health clinicians and 46% by primary care clinicians. In the case of patients with non-chronic emotional problems, over a two-year period, there was an increase in the per cent seen by primary clinicians. The use of psychoactive drugs by primary physicians and the advantages and difficulties of developing a program of integrated health-mental services are described.     

Improving mental health practices in primary care: findings from recent research

This paper reviews restraints on the provision of mental health services in primary health care under the broad categories of physician profile, patient behavior, the nature of psychiatric illness as presented in primary care, and service system characteristics. An extensive research agenda is proposed toward improving mental health care in primary care settings. Research recommendations focus on the following types of issues: seeking a better understanding of the clinical decision making process when confronted with psychological or emotional problems, designing more focused mental health training for primary care physicians and nurses, providing patient education to encourage communication of psychosocial problems to medical providers, clarifying the nature and course of psychiatric disorder in primary care, designing innovative clinical interventions applicable to primary care, and examining organizational models for better coordination of health and mental health services.