TREATMENT OF PATIENTS DESIGNATED BY FAMILY

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1 This report examines the role of the family doctor as related to the treatment of mental and emotional disorders in medical group practice prior to the introduction of a mental health center. The findings provide a base line for later study of changes in the family doctor's role after the facility has been in operation two years. TREATMENT OF PATIENTS DESIGNATED BY FAMILY DOCTORS AS HAVING EMOTIONAL PROBLEMS Raymond Fink, Ph.D.; Sidney S. Goldensohn, M.D.; Sam Shapiro, B.S., F.A.P.H.A.; and Edwin F. Daily, M.D., F.A.P.H.A. Introduction AMONG the earliest stated goals of the community mental health center in this country is that of establishing a type of health facility "which will return mental health care to the mainstream of American medicine."' In achieving this goal it would be expected that the mental health center would influence the practices of persons and groups involvedain mental health care. Among those who might be most affected by the establishment of new mental health centers are family physicians. It has often been observed that an important part of family physician practice consists of patients with psychiatric disorders. There is, however, little information on what is done by family physicians for these disorders or on what changes occur when a psychiatric facility becomes available. This report describes a study designed to examine the role of the family doctor in a medical group practice as this relates to the treatment of emotional disorders seen by him in the course of his regular practice, and how these practices are influenced through the introduction of a mental health center readily available to him for patient care. An opportunity to study family doctor care for emotional problems was offered when, for the first time, psychiatric treatment became available in one of the medical groups of the Health Insurance Plan of Greater New York. In connection with this new psychiatric project, a program of research was begun to examine the impact of psychiatric treatment on medical care. This report is based on research conducted among family doctors of the medical group involved in the psychiatric program and among samples of their patients at a point in time immediately prior to the offering of psychiatric services on a large-scale basis. The findings reported here are intended to provide base line data for the examination of change in family doctor care for emotional problems resulting from the introduction of psychiatric care in the medical group with which he is associated. These base line findings may also be viewed as data from which speculation may be made on how these patterns of family doctor care might be VOL. 57. NO. 9. A.J.P.H.

2 MENTAL AND EMOTIONAL PROBLEMS influenced by those who are engaged in providing psychiatric care through a mental health center. There will be special emphasis in this report on the family doctor as a source of referral to the psychiatrist. This research is based on a study conducted in 1962 in the Health Insurance Plan of Greater New York on the role of the family doctor in providing medical care for patients' mental and emotional problems.2'3 Although this was a pilot study and predominantly methodological in purpose, it provided information on the significance of the family doctor in the detection of mental and emotional problems and in the treatment of these conditions. Among the observations coming from this pilot study was that, for many of those reported by family physicians as having emotional problems, the only professional treating these conditions was the family doctor himself. The findings of this pilot study pointed the way to this new investigation of the family doctor and his role in the treatment of mental illness. Study Setting The study is being conducted among patients of the Jamaica Medical Group, largest of the 31 medical groups of the Health Insurance Plan of Greater New York. The Jamaica Medical Group serves a total of 60,000 patients, almost all of whom live in the borough of Queens in New York City. HIP coverage provides its members with almost the entire range of diagnostic and therapeutic services. Until late 1965, psychiatric coverage included, visits to the psychiatrist only for consultative or diagnostic purposes rather than for psychiatric treatment. Medical care is received from family physicians, internists, and other specialists in the medical group center or doctor's office, patient's home, and in a hospital. Employee groups have been the pri- SEPTEMBER, 1967 mary source of enrollment, with more than half of the members coming into the program through contracts with the official agencies of New York City, including such departments as the Board of Education, Police, Fire, and Transit Authority. The largest source of enrollment next to this group are union health and welfare funds. Mental Health Center With grants from the New York Foundation and the United States Public Health Service, a Mental Health Center was established in late 1965 in association with the Jamaica Medical Group.4 The Mental Health Center was organized in connection with a demonstration project designed to gain experience in the HIP setting that could lead to the provision of psychiatric services as part of the medical coverage provided by HIP on a prepaid basis. Therapeutic service is provided in the center by a staff including psychiatrists, psychiatric social workers, and psychologists. The major focus and goal of the Mental Health Center is to use psychotherapeutic technics aimed toward the quick return of the patient to a functioning level and the prevention of family breakdown. Psychiatric service is being made available to all members of the medical group regardless of age. Prior to the opening of the Mental Health Center, visits to the medical group psychiatrist were limited to consultative or diagnostic purposes. Patients were seen by the group psychiatrist only on referral from a doctor in the medical group, usually a family doctor. With the new provision of psychiatric care, the old system of referrals to the psychiatrist by a medical group doctor has been retained. Patients continue to be referred to the psychiatrist by the group doctors for consultation. but now they are also screened for referral to the Mental Health Center for possible treatment. 1551i

3 Study Design The major objective of the study program is to examine the impact of the introduction of a psychiatric therapy service on patterns of medical care provided for emotional disorders. The study centers largely on the family physician and the medical care he provides for emotional disorders seen during his regular practice. The impact of the psychiatric therapy service will be measured with respect to changes in patterns of medical care provided for patients with emotional disorders; changes in the nature of those emotional conditions referred to the psychiatrist and those retained by the family physician; and differences in treatment provided for patients referred to the psychiatrist and those retained for family physician care. From the point of view of the patient, the study will examine the impact of the psychiatric service on: changes in patterns of medical care and other aid sought and received by those with emotional disorders; and social and psychological characteristics of patients as these relate to patterns of medical care for emotional disorders and changes in these patterns resulting from the introduction of 4sychiatric therapy. To achieve the research objectives, studies of family doctors and patients of the Jamaica Medical Group are being conducted at two points in time. The first point covers a period immediately prior to the offering of psychiatric care on a large-scale basis. The field work for this phase has been completed and is the basis for this report. The second study period is planned for a time in the future two years following the first time point. The basic study design for the second point in time is the same as the first. Sources of Data Experience with earlier research on the family doctor and treatment for mental illness has established the value of 1552 obtaining information through interviews with both doctors and patients. Consequently, information was obtained from the family doctor concerning his view of the nature and seriousness of the patient's emotional problem, the care for the problem provided both by himself and by others and what he regards as the possible future outcome of the emotional problem both if untreated and also if treated. Much of the information obtained from patients paralleled that gained from doctor interviews. Of particular interest here was information on care that might have been obtained for the emotional problem outside of the HIP setting that might have been unknown to the family doctor. Other information obtained from patients included: attitudes toward psychiatric care; social characteristics; and reports and symptoms which might indicate an emotional problem. Sample Selection The study population includes members of the Jamaica Medical Group 15 years of age and older who saw one of the group's 32 family physicians in his office during the three-month period from September 1 through November 30, In selecting the sample of respondents for interview it was possible to rely upon some of the special advantages offered by HIP's routine procedure of obtaining doctor reports on patient visits. For each patient visit the HIP physician fills in a line on a routine report form. The patient is identified by name, age, and sex. Information is also provided on the patient visit itself. This includes where the visit took place, that is, in the home, office, or hospital; the type of service given-whether an operation, examination, or treatment; and the tentative or final diagnosis. Two random samples of patients were selected from among those who were 15 years of age and older who saw a family physician during the three-month study VOL. 57. NO. 9. A.J.P.H.

4 MENTAL AND EMOTIONAL PROBLEMS period. The first of these was a sample of patients for whom the physician reported in the normal course of providing medical care, conditions classifiable according to the International Classification of Diseases as a "mental, psychoneurotic or personality disorder." This will be referred to as the "Psychiatric Diagnosis" sample. There was a total of 435 patients in this sample. The second sample was taken from among all other patients 15 years of age and older who saw a family physician during the study period. For these patients there was no indication of an emotional or psychiatric problem during this period. There were 521 patients in this sample of comparison patients. Physicians were further questioned about these comparison patients to determine whether or not some of them had, in fact, exhibited emotional problems either during or before the study period. Study findings for these patients are not reported in detail here. The analysis which follows centers instead on the Psychiatric Diagnosis sample. When the sample of patients had been drawn, arrangements were made to interview the 32 family physicians of the patients included in the sample. The interview with a physician was generally conducted within 90 days after the visit made by the patient, which was optimum considering the lag in gaining access to the reports. To maximize the accuracy of the physicians' reports, each was notified in advance of the interview and told the names of the patients about whom questions would be asked. It was requested that the physician have available during the interview the patient's medical chart for easy reference. In nearly every case the physician complied with the request. The bulk of patient interviewing was done from two to five months following the study visit. This greater lag was caused in part by the requirement that a patient not be interviewed until the interview with his doctor was completed, but largely because for administrative reasons patient interviewing could not begin until January, Study Findings During the three-month study period from September 1 through November 30, 1965, a psychiatric diagnosis was reported for 5 per cent of all patients seen by the family doctors of the Jamaica Medical Group. Of the 435 patients in the Psychiatric Diagnosis sample, there were 13 for whom the family doctor on interview felt he could not provide sufficient information. Thus, family doctor information reported here is based on the 422 psychiatric patients for whom adequate family doctor information is available. To provide perspective on patients in the psychiatric sample, a brief review of their personal characteristics as these relate to those of the Comparison Group is in order. Patients in the Psychiatric Diagnosis sample are predominantly women. Sixty-eight per cent of the psychiatric patients were women while 54 per cent of the Comparison patients were women. On other demographic variables differences between Psychiatric and Comparison samples were relatively small. Psychiatric Diagnosis patients were slightly less likely to be in the young adult age group under 30 years-14 per cent of this sample compared with 23 per cent of the Comparison sample was under 30 years. Patients in the Psychiatric Diagnosis sample were less likely than Comparison patients to be Catholic-40 per cent in the Psychiatric sample and 47 per cent in the Comparison sample. Psychiatric Diagnosis patients tended to have lower incomes than Comparison patients--42 per cent of the Psychiatric sample and 32 per cent of the Comparison sample had incomes under $8,000. Psychiatric patients were more likely to be married-83 per cent married versus SEPTEMBER,

5 75 per cent among Comparison patients. There were no differences of statistical significance on the following demographic variables: education, attendance at religious services, and native versus foreign born. At the time of interview, family doctors were asked if they had ever discussed with the patient the idea of the patient seeing an HIP psychiatrist. If such a discussion was reported by the doctor, he was further asked if such a referral had been made either by himself or by some other medical group physician. On the basis of these replies, patients in the Psychiatric sample were classified into three groups. The first, and largest, of these groups consists of those for whom there had never been any discussion of a referral to the HIP group psychiatrist. This group comprises 65 per cent of the Psychiatric Diagnosis sample (Table 1). The next group consists of those patients for whom the family doctor reports that although there had been a discussion of a psychiatric referral, no referral had ever been made. These were 9 per cent of the Psychiatric Diagnosis sample. Finally there were those who were referred to the group psychiatrist at some time either before, during, or after the threemonth study period. This group totals 26 per cent of the Psychiatric sample. It may be well to offer a reminder at this point of the nature of the psychiatric benefits available to Jamaica Medical Group patients during the study period. For about half of the three-month study period psychotherapeutic services were not yet available in the medical group. When services became available in the latter part of the study period, these were offered with little publicity and in a manner intended to minimize changes in family doctor referral practices. This was done not only for the purposes of this study but also because the staff of the Mental Health Center regarded it as desirable to limit patient 1554 intake at first in order to plan more effectively for future patient loads. As a consequence of this slow phasing in of psychiatric services, it is believed that both doctors and patients at the time of the study continued to regard psychiatric services as being limited to the purpose of consultation and diagnosis alone. Thus, in this report of referral patterns it is assumed that referrals were made at the time of the study for these purposes rather than for psychiatric therapy. A further understanding of the group who had only a discussion of referrals might also be useful at this point. From interviews with patients, it is evident that the psychiatric consultation was rejected by the patients with the reasons for rejection falling into two major categories. First, there were those who did not think their emotional condition serious enough to require the aid of a psychiatrist. The second major reason given was that such a visit would not be useful because at the time of the referral psychiatric treatment was not available. Family Doctor Description of the Emotional Problem and Referrals Some of the factors that entered into the family doctor's decision to offer psychiatric referral to patients who were judged by him to have an emotional problem follow. The referral decision and the family doctor's description of the emotional condition are considered first. For each patient, family doctors were asked "Do you regard this mental or emotional condition as acute or chronic?" If the reply was "Chronic,"' the family doctor was further asked "Is the problem at the present time an acute exacerbation?" For 41 per cent of the Psychiatric Diagnosis patients the condition was described as "Acute" (Table IA) - Thirty-three per cent were reported as having a chronic condition which was acute at the time of the study VOL. 57. NO. 9. A.J.P.H.

6 MENTAL AND EMOTIONAL PROBLEMS and 26 per cent as having emotional conditions which were chronic but not acute at the time of study. Patients with chronic emotional problems were about twice as likely as those with acute problems to receive a psychiatric referral. About a third of those with chronic conditions received a referral while only 17 per cent of those with acute conditions were referred to the psychiatrist. Family physicians were also asked to describe whether they thought the emotional condition they had diagnosed was of importance or not. Forty-three per cent of those with a psychiatric diagnosis had their conditions described by the family doctor as being of importance (Table 1B). Five of ten patients with emotional conditions so described were referred to the medical group psychiatrist, while an additional one in ten only discussed a referral with the phy- Table 1-Family doctor descriptions of patient's emotional condition and psychiatric referrals Physician reports of referral (per cent) % in Neitherdis- Discussed Family doctor description Sample each cussed nor referral Psychiatric Total of emotional condition size* categoryt referred only referral % Total (422) A. Acute vs. chronic Acute Chronic Acute at present Not acute at present B. Important or not important Important Not important C. Number of life activities with which patient's emotional condition interferes None One Two Three or more Don't know (all activities) D. Maximum interference in one or more of patient's life activities Great deal Somewhat \rery little or not at all Don't know (all activities) (167) (135) (104) (178) (235) (178) (74) (50) (86) (33) (126) (84) (178) (33) * The total of each of the distributions may not come to 422 due to the exclusion of "No Answers" and unclassifiable replies. "Don't Know" replies are not included in distributions where they totaled fewer than 20. t Per cent distributions are vertical and are based on the number of classifiable replies to the indicated items which may be fewver than the total respondent base of 422. SEPTEMBER,

7 sician. In contrast fewer than one in ten with emotional conditions described as "not important" were referred to the psychiatrist, and the family doctor discussed a referral with an additional 8 per cent of this group. Family doctors were asked about the extent to which the reported emotional condition interfered with the patient's work on a job, work around the house, family life, ability to get along with others, the patient's sex life, and his ability to enjoy himself during his free or leisure time. For each life activity the family doctor was asked if the degree of interference was a great deal, somewhat, very little or not at all. Each patient was scored according to the number of activities reported by his family doctor as being interfered with either "a great deal" or "somewhat." For half their patients, family doctors reported interference in one or more life activities. In general, the greater the number of activities in which the emotional condition interferes, the greater the likelihood of a psychiatric referral. Among patients having conditions interfering with no activities, only 10 per cent are referred to the medical group psychiatrist; 26 per cent of those with one life activity interfered with are referred. The proportion of referrals increases to about 40 per cent among those with two or more life activities in which their emotional problem is seen as causing some degree of interference (Table IC). The extent of the interference is also an important consideration in the referral process. Among patients who are reported by their family doctors as having emotional problems in which the extent of interference with life activities is "very little" or "not at all," only one in ten are referred to the psychiatrist. If there is "somewhat" interference in one or more activities, the likelihood of referral increases to one in four. For those reported by family physicians as experiencing "a great deal" of interfer ence with one or more life activities, half are referred to the psychiatrist (Table 1D). The relationships observed between interference with life activities as reported by the family doctors and the likelihood of a psychiatric referral are similar to those of Srole, et al., as reported in "Mental Health in the Metropolis."5 These investigators found a significant relationship between psychiatric impairment (as measured through psychiatrists' evaluation of household interview data) and whether or not respondents had ever had psychiatric care. Effectiveness of Family Doctor Care and Referrals The discussion has thus far concentrated on how the family doctor views the emotional problems found in his practice as these observations relate to the referral process. Yet we are aware that the care the family doctor may provide extends beyond this ability to refer to a group psychiatrist. In this section, two of the most common courses of treatment available to family physicians in caring for their patients' emotional problems will be reviewed as these relate to the referral process. These are the providing of psychotropic drugs and the use of doctor-patient discussions. According to family doctor reports, nearly eight out of ten patients with a psychiatric diagnosis at some time had drugs prescribed for this condition by the family doctor in the study. It is interesting to note that patients who did not have drugs prescribed were slightly more likely than those who did to be referred to the psychiatrist (Table 2A). Among those for whom drugs were prescribed, the likelihood of a psychiatric referral varied significantly with how the family doctor viewed the effectiveness of the drugs in treating the emotional problem. Among patients for whom the family doctor thought the drugs to be "very helpful," 18 per cent VOL. 57. NO. 9. A.J.P.H.

8 MENTAL AND EMOTIONAL PROBLEMS were referred to the medical group psychiatrists (Table 2B1). On the other hand, among patients for whom the family doctor considered the drugs to be of only "very little help" or "not at all helpful," 43 per cent were referred to the psychiatrist. Of particular interest is the role of doctor-patient discussions with regard to both the referral process and also the over-all treatment of patients with emotional problems. Earlier research has highlighted the importance of the fact that, for many with emotional problems, doctor-patient discussions are the most significant source of professional care for these problems. In planning psychiatric services it is recognized that patients already being effectively cared for by the family doctor might best remain in that care. It should be noted, however, that the implication does not follow that family doctor effectiveness is related to his rate of referral. Table 2-Family doctor care for patient's emotional condition and psychiatric referrals Physician reports of referral (per cent) Family doctor % in Neitherdis- Discussed reports of care and Sample each cussed nor referral Psychiatric Total helpfulness of care size category referred only referral % Total (422) A. Prescribing of drugs Drugs prescribed Drugs not prescribed B. Helpfulness of drugst Very helpful Somewhat helpful Very little or not at all helpful Don't know C. Number and length of doctor-patient discussions in past year Short discussions only or no discussions One discussion at length Two discussions at length Three or more discussions at length D. Helpfulness of discussionst Very helpful Somewhat helpful Very little or not at all helpful (330)* 78** (91) (119) (111) (42) (57) (158)* (96) (69) (96) (126) (152) (91) ** * Distributions are based on the entire sample of 422 Psychiatric Diagnosis cases excluding only "No Answers" and unclassifiable replies. "Don't Know" replies are not included in distributions where they totaled fewer than 20. t Excludes patients for whom no drugs were prescribed for an emotional condition. + Excludes patients for whom the family doctor reports no doctor-patient discussions about an emotional condition. ** Per cent distributions are vertical and are based on the number of classifiable replies to the indicated items which may be fewer than the total respondent base of 422. SEPTEMBER

9 Family doctors were questioned on both the total number of discussions held with the patient about his emotional problems and the number of these discussions which were held at length. About three out of five Psychiatric Diagnosis patients were reported by the family doctor to have had during the previous year at least one discussion at length about their respective problems (Table 2C). Those least likely to be referred to the psychiatrist were patients who had had one lengthy discussion about their emotional problem with the family doctor-15 per cent of these were referred. Those with more than one discussion at length were far more likely to be referred. Looking more directly at the relationship between doctor reports of the helpfulness of discussions with patients and likelihood of referral to the psychiatrist, an important relationship between the two is found. Among patients for whom such discussions have been found by the family doctor to be "very helpful," 19 per cent were referred (Table 2D). Where the doctor regarded such discussions as either of "very little" help or "not at all helpful," 39 per cent were referred. In order to establish more clearly the relationship between care provided by the family doctor, i.e., drugs and discussions, and the likelihood of a psychiatric referral, a special analysis was done which included only patients referred during the three-month study period or shortly thereafter. Including only these patients provided assurance that the referral decision could have come only after the family had had an opportunity to evaluate the effectiveness of drugs or doctor-patient discussions. Among these patients the relationship between the family doctor's view of the helpfulness of his care and the likelihood of a referral is a strong one. Where drugs were found to be "very helpful," 10 per cent of the patients were referred; among those for whom the drugs were of little or no help, 31 per cent were referred. In similar fashion where doctor-patient discussions were found to be "very helpful," only 11 per cent were referred; less helpful doctor-patient discussions were followed by the referral of 26 per cent of these patients. This relationship between the family doctor's view of the helpfulness of the care he provides his patients for their emotional problems and the referral decision highlights the importance of the family doctor in the therapy process. The impact of the mental health center on family doctor care may be reflected in several ways. An important part of the psychiatric demonstration program is a review with family doctors by the Mental Health Center's staff of selected case histories, including patient care received before referral for psychiatric screening. These reviews may serve in some cases to modify the family doctor's judgment of the care he has provided, and may in other cases cause him to modify his treatment of patients prior to a psychiatric referral. Future research will aim at measuring the nature and the direction of change in family doctor care for emotional problems. Finally, from the doctor's point of view we shall look at how his prognosis for the patient's emotional condition relates to the referral action taken. Doctors were asked how they regard the future course of the emotional condition first without professional care, and then with professional care. Thirty-eight per cent of all Psychiatric Diagnosis patients are reported by their family doctor as likely to improve without professional care, and only 12 per cent of this group are in fact referred to the psychiatrist (Table 3). Thirty-two per cent are expected to improve with professional care, and 41 per cent of these are referred to the psychiatrist. There are also those who the family doctor believes would not improve even with profes- VOL. 57. NO. 9. A.J.P.H.

10 MENTAL AND EMOTIONAL PROBLEMS sional help-these represent 16 per cent of the Psychiatric Diagnosis patients. Even with this negative prognosis, 26 per cent of this group are at some time referred to the medical group psychiatrist. In short, patients judged most likely to benefit from professional care for their emotional problems are also more likely to be referred to the group psychiatrist. It is recognized that these findings are the family doctor's view alone. Of considerable importance is the view coming from the patients. Do these observations hold in looking at data for which the patient is the source or are they at considerable variance with those of the patient? To answer this we must turn to the results of patient interviewing. Patien.t Interviewing Of the 422 Psychiatric Diagnosis patients for whom adequate doctor information was available, patient interviews were completed with 380, a completion rate of 90 per cent. Most of these were home interviews; 40 patients were interviewed at the time they were Table 3-Family doctor referral being seen for a psychiatric consultation at the medical group. The discussion which follows is based on data from these 380 patient interviews. Owing to the nature of the study it was of course essential that patients acknowledge discussion of an emotional or psychological problem with a physician. Without this acknowledgment, questions on drugs prescribed, referrals by a physician, and doctor-patient discussions could not be pursued. Patients were not informed that they had been described by their family doctor as having an emotional problem. Instead, patients were asked a series of questions designed to elicit a report of having been in contact with a physician about an emotional problem. In 86 per cent of the completed patient interviews, this kind of contact with a doctor was reported-in nearly every case the reported contact was with the study doctor who had been interviewed. An additional 5 per cent of the patients interviewed, while not acknowledging a physician contact because of an emotional problem, reported there were times when going somewhere or seeing someprognosis for patient's emotional problem and psychiatric Physician reports of referral (per cent) %o in Neitherdis- Discussed Family doctor Sample each cussed nor referral Psychiatric Total prognosis size* categoryt referred only referral % Total (422) Prognosis Improve without professional care (162 ) Improve with professional care (132) Stationary or progressive with professional care (65) Don't know (34) Other (26) * See footnote, Table 1. t See footnote, Table 1. SEPTEMBER,

11 one about such problems might have helped them. Nine per cent of the psychiatric patients did not acknowledge either doctor contact for an emotional problem or the need for seeing someone about this kind of problem. The tables and discussion which follow do not include the 9 per cent of the patients who report no doctor contact for an emotional problem nor need for such contact. However, because family doctor information on care provided these patients is available, we do know something about the care they received for their emotional problems. Thus, it should be noted here that these patients have half the rate of psychiatric referrals when compared with patients reporting an emotional problem. Relationship Between Patient Reports and Referrals Now let us look at how the patient viewed his emotional problem. Patients acknowledging an emotional problem were asked if they thought their problem was one that might bother them a long time or one that might go away soon. Among those who thought they might be bothered a long time, 38 per cent had had a psychiatric referral (Table 4A). In contrast, 24 per cent of those who thought the problem would go away soon or had already gone away had psychiatric referrals. Patients were also asked how often they have been bothered lately by their emotional problems. Among those who said they are bothered by their emotional problems "nearly all the time" six out of ten had received psychiatric referrals; among patients who were bothered less frequently, the rate of referral was about two in ten (Table 4B). In general, patients who described their emotional problems as serious were more likely than others to receive a psychiatric referral. This is seen in the relationship of psychiatric referral status to a number of patient-described emotional problems. Half the patients 1560 who reported they were bothered "a great deal" by their emotional problems had had psychiatric referrals, while about a fourth of those describing their emotional condition as of "somewhat" or "very little" bother were referred. Those who thought their condition to be "important" were twice as likely to be referred as those who thought it "not important" (Tables 4C and 4D). On questions dealing with the interference caused in life activity by the emotional condition, findings among patients paralleled those among the family doctors. For example, the greater the number of life activities the patient reports as interfered with, the greater the likelihood of referral. In addition, as was found in physician reports, among patients who indicate that the emotional problem interferes "a great deal" with one or more life activities the probability of a psychiatric referral is considerably greater than among other patients. Forty-seven per cent of those reporting a "great deal" of interference were referred to the psychiatrist and only 20 per cent of those with lesser or no interference (Tables 4E and 4F). These findings raised the question as to whether the patients' replies on the significance of their emotional problem might be colored by whether or not they were referred to the psychiatrist. It could be hypothesized that because a person is referred to the psychiatrist he might take a more serious view of his condition. In a separate analysis it was sought to determine whether or not the referral group had more serious emotional problems as measured by some outside criterion. The outside criterion used is a 22-item psychiatric symptom score developed for psychiatric screen. ing in survey interviews.6 Most of the 22 items ask about physical symptoms indicative of emotional problems, and their purpose is likely to be discernible only to the medically sophisticated. As a preliminary criterion measure of emotional problems, each of the 22 items VOL. 57, NO. 9. A.J.P.H.

12 MENTAL AND EMOTIONAL PROBLEMS Total Table 4-Patient descriptions of emotional condition and psychiatric referral Physician reports of referral (per cent) % in Neither dis- Discussed Patient description of Sample each cussed nor referral Psychiatric Total emotional condition size* categoryt referred only referral % A. How long will be bothered by problem Long time Go away soon or already gone Don't know Not now bothered B. How often bothered by problem Nearly all the time Some of the time Once in a while or not at all Not now bothered C. How much bothered lately by problem Great deal Somewhat Very little Not at all D. Important vs. not important Important Not important E. Number of life activities with which problem interfered None One Two Three Four or more (346) (91) (123) (76) (50) (62) (96) (136) (50) (75) (87) (134) (50) (199) (131) (152) (52) (42) (45) (56) F. Maximum interference in one or more life activities Great deal Somewhat Very little or not at all (110) (84) (152) * Sample includes Psychiatric Diagnosis patients who were interviewed and who indicated that at some time they had either discussed an emotional problem with a physician or had felt the need to discuss an emotional problem with a professional person. The total of each of the distributions may not come to 346 due to the exclusion of "No Answers" and unclassifiable replies. "Don't Know" replies are not included in distribution where they totaled fewer than 20. t Per cent distributions are vertical and are based on the number of classifiable replies to the indicated items which may be fewer than the total respondent base of 346. t The inclusion of only Psychiatric Diagnosis patients meeting the above criteria results in per cent distributions on referral status which differ in physician and patient reports. SEPTEMBER,

13 Table 5-Patient view of psychiatric referrals helpfulness of care provided for emotional problems and Physician reports of referral (per cent) % in Neitherdis- Discussed Patient report of Sample each cussed nor referral Psychiatric Total helpfulness of care size* categoryt referred only referral % Total (346) A. Helpfulness of medicine prescribed** Very helpful (107) Somewhat helpful (80) Very little or not at all helpful (47) B. Helpfulness of doctorpatient discussions No discussion held (44) a 100 Very helpful (108) Somewhat helpful (94) Very little or not at all helpful (72) * See footnote, Table 4. t See footnote, Table 4. 1 See footnote, Table 4. ** Includes only patients reporting having medicine prescribed for an emotional problem. was given a weight of one point and the score for each patient was based on the number of positive psychiatric replies. In comparing the three groups under study here it was found that the psychiatric referral group did in fact score higher than those not referred. Among Psychiatric Diagnosis patients for whom there had been neither a discussion of referral nor a referral, the average psychiatric score was 2.7; those for whom there had been only a discussion of referral had an average score of 3.1; those who were referred to the psychiatrist had an average psychiatric score of 5.8. Patient Reports of Effectiveness of Family Doctor Care and Referrals Like the family doctors, patients with a psychiatric diagnosis who received medication for their emotional condition were asked to evaluate the helpfulness of the drugs in treating their problem Among patients for whom drugs had been prescribed, 46 per cent found them "very helpful," 34 per cent "somewhat helpful," and 20 per cent found the drugs of "little or no help" (Table 5A). Twenty per cent of the patients who found the drugs "very helpful" were referred to the group psychiatrist, while 45 per cent of those who found the drugs of "very little" or no help were referred. In viewing the helpfulness of doctorpatient discussions, 34 per cent of those reporting an emotional problem found these discussions "very helpful"; 30 per cent found them "somewhat helpful," and 23 per cent found doctor-patient discussions about their emotional problems of "very little" or no help (Table 5B). Thirteen per cent indicated there had been no such discussions. The relationship between psychiatric referrals and patient evaluation of the effective. ness of doctor-patient discussions is not VOL. 57. NO. 9. A.J.P.H.

14 MENTAL AND EMOTIONAL PROBLEMS a strong one. Referrals went to 26 per cent of those who found these discussions "very helpful" and to 37 per cent of those who found the discussions of little or no help. When asked to comment on the future course of their emotional problem both with and without professional care, 45 per cent of the Psychiatric Diagnosis patients acknowledging an emotional problem felt that their problem would improve with professional care, and 30 per cent believed the problem would either get better without professional care or that they were no longer bothered with the problem (Table 6A). Patients who thought their emotional problem might improve through professional care were about twice as likely to be referred to the group psychiatrist as those who either believed they could get better without such care or who felt no longer bothered by the emotional problem. These findings, too, parallel those of the family physician. In summary, many of the patient characteristics described by family doctors as bearing a strong relationship to whether or not a referral is made are also found on interviewing patients. On each of several self-descriptive measures of seriousness or importance of their emotional problems it was found that patients who regard their emotional problems as serious in nature are more likely to receive a psychiatric referral. Further, patients who did not feel benefited by medication prescribed or doctor-patient discussions for their emotional problem were more likely to receive a referral than those who did feel benefited. Drugs and family physician patient discussions are for a significant number Table 6-Patient reports on psychiatric care and psychiatric referrals Physician reports of referral (per cent) % in Neither dis- Discussed Patient reports on Samiple each cussed nor referral Psychiatric Total psychiatric care size* categoryt referred only referral % Total (346) A. Patient prognosis for emotional problem Get better without professional care (50) Get better with professional care (156) Same or worse with professional care (54) Don't know (34) No longer bothered (50) B. Patient report on psychiatric treatment received outside of HIP Received psychiatric treatment outside HIP (55) No psychiatric treatment outside HIP (290) * See footnote, Table 4. t See footnote, Table 4. : See footnote, Table 4. SEPTEMBER

15 of the Psychiatric Diagnosis patients not the only care (other than psychiatric cvonsultation) they have received for their emotional problems. Sixteen per cent of the Psychiatric Diagnosis patients report that they had had psychotherapeutic care for an emotional problem outside of HIP (Table 6B). In at least two-thirds of the cases the care was received before the patient was referred to the HIP group psychiatrist. Patients who received psychiatric care outside of HIP were considerably more likely than those who did not to be referred to the HIP psychiatrist. Among those who had had outside treatment, 55 per cent were also referrals to the group psychiatrist. Twenty-four per cent of the patients with no outside treatment were referred. Conclusions Care provided by family doctors in HIP's Jamaica Medical Group for patients they view as having emotional conditions and their use of psychiatric referrals have been determined for a period prior to full operation of a newly established Mental Health Center. The center broadens psychiatric services in the group from consultation to treatment. In this "before" phase, it is evident that the manner in which the emotional condition is viewed by the family doctor is an important determinant of whether or not a referral is made. The referred patients tend to be those who have chronic emotional problems rather than those beset by an acute episode. Further, psychiatric referrals tend to go to those with conditions regarded by the family doctor as being of importance, and those conditions which interfere with life activities. Measures of differentials are available for comparison with the situation after the center has been in operation two years. Among the questions to be asked in later phases of this research are those touching on the manner in which the family physician may revise his perception of the emotional problems he sees. It will be of interest to see whether information fed back to him on his own patients referred to the group psychiatrist for screening alters the family doctor's distinguishing between "important" and "unimportant" emotional problems, and also whether family doctor referral practices vary with the program of the Mental Health Center. REFERENCES 1. Kennedy, John F. Message to Congress on Mental Health. (Feb.), Shapiro, S., and Fink, R. Methodological Considerations in Studying Patterns of Medical Care Related to Mental Illness. Milbank Mem. Fund Quart. XLI.4: (Part 1), Fink, R., and Shapiro, S. Patterns of Medical Care Related to Mental Illness. J. Health & Human Behavior 7:98-105, Goldensohn, S.; Daily, E. F.; Shapiro, S.; and Fink, R. Referral and Utilization Patterns in the First Year of a Mental Health Center in a Prepaid Group Practice Medical Program. Med. Care V,1 :36-43, Srole, L.; Langner, T. S.; Michael, M. K.; Opler, M. K.; and Rennie, T. A. C. Mental Health in the Metropolis. New York: McGraw-Hill, Langner, T. S. A Twenty-Two Item Screening Score of Psychiatric Symptoms Indicating Impairment. J. Health & Human Behavior 3: , Dr. Fink is associate director and Mr. Shapiro is director, Division of Research and Statistics, and Dr. Daily is medical director, Health Insurance Plan of Greater New York (625 Madison Ave.), New York, N. Y Dr. Goldensohn is director of the Jamaica Medical Group Mental Health Center. This paper was presented before the Mental Health Section of the American Public Health Association at the Ninety-Fourth Annual Meeting in San Francisco, Calif., October 31, It was revised and resubmitted in March, The project described was supported in part by research grant MH from the National Institute of Mental Health, Public Health Service VOL 57. NO. 9. A.J.P.H.

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