ABSTRACT : This study sought to determine factors associated with general practitioner (GP) recognition of emotional distress in Australian general practice. Methods: Twenty eight GPs completed a clinical audit in which they noted their identification of any emotional distress in their patients, while 868 of their patients completed the General Health Questionnaire (GHQ-28). The GHQ was scored with the conventional 4/5 cut-off. GP recognition was determined by a comparison of the GP record of emotional distress and the patient GHQ. Logistic regression was used to examine which patient and GP characteristics influenced correct recognition. Results: The GHQ identified 48% of all patients as probable cases. GPs identified 34% of their patients as having emotional distress, correctly recognizing 43% of GHQ cases. Overall, specificity was high (81%), though sensitivity was modest (43%). For individual GPs the rate of correct recognition varied considerably, from 4% to 100%. Correct recognition was associated with years experience as a GP, older age of patient and greater severity of distress. Conclusions: The data raise questions about the possible oversensitivity of the GHQ. The clinical skills associated with the recognition of mental illness and of emotional distress are obviously complex, and take time and experience to develop. Reassuringly, GPs are recognising most of the more severe depressions.
OBJECTIVES: Elderly persons suffer from high rates of psychological distress that are sometimes unrecognized by healthcare providers. Authors compared rates of psychological distress and physician detection among elderly and non-elderly primary-care patients and examined, among elderly patients, variables associated with distress and physician detection.
METHODS: This was a national survey of a sample of 2,325 Israeli primary healthcare recipients and 67 physicians. Patients completed the General Health Questionnaire (GHQ) and background questionnaires. Physicians completed forms indicating their diagnosis and treatment and their attitudes toward elderly patients.
RESULTS: Of those age 60 and over, 58.7% had a GHQ score reflecting distress, as did 49% of those age 40-59 and 30.4% of those age 18-39. There was no age-group difference in physician concordance on GHQ. In elderly patients, variables associated with GHQ psychological distress were being female, having more self-reported chronic diseases, poorer self-reported health, and more frequent primary-care clinic visits. Physician agreement with GHQ distress for elderly patients was best for female patients and patients who visited a physician more often. Physicians treated 71% of the instances of distress they noted in older patients and 42% of the GHQ-detected cases.
CONCLUSIONS: Physicians appear to detect distress no less accurately among older than younger patients. A majority of elderly primary-care patients are distressed, and many of them are neither diagnosed nor treated for distress. Increased attention by primary-care physicians to possible psychological distress among elderly patients who perceive their health status as poor and those patients who visit more frequently could improve detection of distress among these elderly patients.
BACKGROUND: In primary care the General Health Questionnaire (GHQ) is used to provide an independent assessment of probable caseness of psychological disorder against which to test the ability of the general practitioner (GP) to recognize patients with current emotional problems.
METHOD: The aim of the present study was to identify those clinical and psychosocial data on patients that increase the likelihood of GPs' attribution of emotional distress (GP model) and those that predict patients' emotional distress as defined by the GHQ-12 (GHQ model). The associations were explored using a classification tree technique (CHAID) and compared using bivariate logistic regression. Six GPs and 444 primary care patients took part.
RESULTS: The accuracy indices of the hierarchical GP and GHQ models were 72% and 69% respectively. The availability of information on patients' psychopharmacological and psychiatric/psychological treatment in the last year was the most important predictor of attribution. Occupational, financial and housing problems and life events of loss were the most important predictors of the GHQ-12 case definition. The overall accuracy of the bivariate model was 73%. Compared with the GHQ-12, GPs gave significantly more importance to psychiatric treatment, psychopharmacological drug use and chronic illness.
CONCLUSIONS: The findings suggest that to improve the detection of current emotional distress in primary care patients GPs should pay foremost and systematic attention to social problems and recent life events of loss. These problems are important clues for the possible presence of emotional distress, whereas critical patient data, in particular psychiatric history and psychopharmacological treatment, increase the probability of attribution errors.
OBJECTIVE: To compare general practitioner (GP) recognition of mental illness with cases identified by screening and diagnostic instruments.
METHOD: Cross-sectional survey (part of the Mental Health and General Practice Investigation [MaGPIe] study) set in the lower North Island of New Zealand. The study sample consisted of consecutive patients from a random sample of GPs who were screened using the General Health Questionnaire (GHQ-12). Based on GHQ scores a stratified random sample of patients was selected and invited to participate in an in-depth interview to assess their psychological health and a subsequent longitudinal study. GPs assessed patients' psychological health using a 5-point scale of severity. Patients completed the GHQ-12, Composite International Diagnostic Interview (CIDI), Somatic and Psychological Health Report (SPHERE-12) and World Health Organization's Disability Assessment Schedule Version II (WHODAS).
RESULTS: Seventy GPs (90% response) and 775 patients (70% response) were included in analyses. Overall, GPs recognized symptoms of psychological disorders in the past 12 months in 56.4% (95% CI=49.3-63.5) of patients. Agreement between GP rates of recognition of mental disorders and diagnostic or symptom rating instruments varied depending on the instruments used and was highest when there was concordance between several instruments and high levels of disability. Only 17.2% (95% CI=14.5-19.9) of the patients identified by at least one of the GHQ-12, CIDI or SPHERE, were identified by all three instruments.
CONCLUSIONS: In understanding rates of recognition of mental disorders by GPs, careful consideration needs to be given to the degree to which any single instrument can be utilized as a diagnostic 'gold standard'.
OBJECTIVE: Researchers have shown that primary care patients utilize global attribution styles to interpret ambiguous physical symptoms, diminishing the ability of practitioners to recognize psychological disorders. The present study examined the extent to which patients' specific beliefs about their presenting symptoms versus their global symptom attribution styles predict physician recognition of psychological distress and mental health treatment recommendations.
METHODS: Participants included primary care patients attending a five-physician medical practice. Patients completed surveys regarding their level of psychological distress, symptom attribution style, and perceptions of their presenting problems and medical consultations. Physicians completed brief assessments of each patient encounter.
RESULTS: Patient gender, age, severity of psychological distress, and beliefs about their presenting symptoms were reliable predictors of physician recognition and treatment recommendations. Global symptom attribution styles did not relate to these outcomes above and beyond the specific beliefs of patients.
CONCLUSION: Patients' specific beliefs about their presenting symptoms play an important role in predicting physician recognition and treatment of psychological distress.
In studies comparing the performance of psychometric instruments and general practitioners in the identification of psychological disorders, authors usually treat the psychometric instrument as the gold standard. Some patients may have no psychiatric diagnosis and normal scores on self-report measures of distress, but still benefit from detection and treatment of their psychosocial problems. However, physicians may be spending valuable time identifying problems in patients who have no disability. The extent and implications of the discrepancy between clinician assessment and standard instruments requires further exploration. Adult patients of 40 family physicians completed the General Health Questionnaire (GHQ-28) before their visit. Immediately following the visit, physicians, who were blind to the patient's GHQ score, indicated whether they had detected any signs or symptoms of anxiety, depression, somatization, or other psychosocial problems. Of the 1,011 primary care patients that participated, 439 had normal GHQ-28 scores. Physicians detected psychological problems in 177 (38.3%) of the 439. In bivariate analyses, poorer general and mental health (as measured by SF-36) was associated with higher detection rates. The patient's belief that there was a psychological component of his or her problem (OR=2.50), being in a marital relationship (OR=1.87), and the physician's perception of the seriousness of the problem (OR=1.84) were associated with detection. Detection was less frequent when the physician did not know the patient well (OR=0.69), and when the physician was a woman (OR=0.46). For the 28% of patients who themselves perceived a psychological element of their problem, physician detection was probably appropriate. However, it is unlikely that detection of the remaining patients was beneficial to the patients.
BACKGROUND: Recent research has shown the benefits of longer consultations in general practice. Approximately 40% of patients presenting to general practitioners (GPs) are psychologically distressed. Studies have shown that psychological morbidity increases with increasing socioeconomic deprivation. The combined effects of psychological morbidity and socioeconomic deprivation on consultation length are unknown. In addition, though it is known that doctors correctly identify half their distressed patients as such, the effect of consultation length on identification is unknown.
AIM: To examine factors associated with presentation and recognition of psychological distress in GPs' surgeries and the interaction of these factors with consultation length.
DESIGN OF STUDY: A cross-sectional study.
SETTING: Nine general practices in the West of Scotland, involving 1075 consultations of 21 full-time GPs.
METHOD: The main outcome measures were patient psychological distress (measured by General Health Questionnaire-12), doctors' identification of psychological distress, consultation length, and Carstairs deprivation category scores.
RESULTS: The mean consultation length was 8.71 minutes (SD = 4.40) and the prevalence of positive GHQ scores was 44.7%. Increasing GHQ (greater psychological distress) and lower deprivation category scores (greater affluence) were associated with longer consultations. Positive GHQ scoring increased with greater socioeconomic deprivation and also peaked in the 30 to 39 years age group. Recognition of psychological distress was greater in longer consultations (50% increase in consultation length associated with 32% increase in recognition).
CONCLUSION: Increasing socioeconomic deprivation is associated with higher prevalence of psychological distress and shorter consultations. This provides further evidence to support Tudor Hart's 'inverse care law' and has implications for the resourcing of primary care in deprived areas.
BACKGROUND: It is important that serious depressive illness be recognized and treated appropriately by primary care practitioners. This and the preceding article in this issue examine (a) factors responsible for older patients' decision to report depressive symptoms to their doctor and (b) general practitioners' (GPs') recognition of depression when it was present.
METHODS: A survey was conducted of a stratified sample of 1,021 patients aged 70+ years of 30 GPs in Melbourne, Australia, using the Canberra Interview for the Elderly, which generates rigorous ICD-10 research diagnoses.
RESULTS: GPs' ratings of depression were best predicted in descending order of importance by patients' past contact with a psychiatrist, the doctor's view that a patient did not have dementia, the number of current depressive symptoms, patients' disclosure of these symptoms, and current physical pain. Physicians' assessments of patients' mood concurred with research diagnoses in 23 of 35 (66%) cases of ICD-10 mild depressive episode and 23 of 26 (88%) cases of moderate or severe depressive episode. GPs were unaware, however, of many depressive symptoms and often rated patients as being depressed when they were not.
CONCLUSION: The use of a simple checklist of depressive symptoms would lead to a dramatic improvement in doctors' knowledge of patients' current psychiatric status.
BACKGROUND: Health inequalities exist for many disorders, but the contribution of deprivation to the prevalence and outcome of depressive symptoms in primary care populations has been infrequently studied.
AIMS: To examine the influence of Jarman under-privileged area (UPA) scores on the prevalence and outcome of depressive symptoms in general practice patients.
METHOD: 18 414 patients attending 55 representative practices completed the Hospital Anxiety and Depression Scale and a questionnaire for employment status. Outcome of those screening positive was assessed at 6 weeks and 6 months.
RESULTS: The UPA score accounted for 48.3% of the variance between practices in prevalence of depressive symptoms. Attending a high UPA score practice predicted persistence of depressive symptoms to 6 months.
CONCLUSIONS: The socio-economic deprivation of a practice locality is a powerful predictor of the prevalence and persistence of depressive symptoms.
