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Psychiatric disorders in primary care patients receiving complementary medical treatments
Psychiatric Disorders in Primary Care Patients Receiving Complementary Medical Treatments Jonathan R.T. Davidson, Hagen Rampes, Mark Eisen, Peter Fisher, Rebecca D. Smith and Mary Malik This study investigated lifetime and current rates of axis I diagnoses and the personality traits of neuroticism and extraversion in patients receiving complementary medical care in the United Kingdom and United States. Eighty-three patients were interviewed by means of the Structured Clinical Interview for DSM-III-R, and 78 completed the Eysenck Personality Inventory (EPI). Subjects were drawn from the Royal London Homoeopathic Hospital (n = 50) and a holistic family practice in North Carolina (n = 33). High rates of lifetime (68.7%) and current (39.8%) axis I disorders were found, with no substantial differences between the groups, apart from lifetime posttraumatic stress
disorder and current social phobia, which were higher in the US sample. The subjects were more introverted but not more neurotic as compared against normative population data with the EPI. The subjects were predominantly older women. We conclude that psychiatrists may need to be aware that patients with depressive or anxiety disorders are likely to seek out complementary treatments for a wide range of medical problems, and should inquire as to use of these in their patients. They may also need to cultivate greater awareness of the health beliefs of such patients.
N RECENT YEARS, there has been a marked growth of public interest in complementary medicine, which essentially covers those forms of medical practice that, in the past, have not generally been taught in medical schools, although it must be admitted that what is and is not taught in medical school always undergoes evolution.1 These treatment approaches have included homeopathy, acupuncture, osteopathy, anthroposophical medicine, and herbal medicine, among others. Of greater importance than the increase in public interest, however, is the increasing public consumption of such services, as shown by a recent survey.2 Complementary medicine, particularly in the form of homeopathy, and to a lesser extent anthroposophical medicine, has been available in the public sector under the National Health Service (NHS) in the United Kingdom since inception of the service in 1948, and is being increasingly used. Several studies have suggested that psychiatric disorders are heavily represented among patients seeking complementary medical care, e.g., surveys conducted in the United States, The Netherlands,
and Africa all provided some evidence to this effect. For instance, Jacobs and Crothers 3 reported a high rate of anxiety disorders in their homeopathic family practice in the US Northwest. Eisenberg et al. 2 noted that anxiety and depression were frequent among patients at complementary medical practices across the United States. A Dutch study recently reported a high frequency of psychoneurosis. 4 Hollifield et al. 5 studied panic disorder in Lesotho, Africa, and found that 23% of panic disorder patients attended traditional healers, i.e., those who practiced methods of treatment that were outside the mainstream and were not taught in medical school. In a San Antonio study, Katerndahl and Realini 6 also observed that 19% of panic disorder patients sought treatment from traditional healers. The implications of these findings are important, and suggest two lines of inquiry. The first of these might stimulate investigators to assess the effectiveness of complementary treatments. A second line of inquiry, the subject of this report, is to look more closely at the rates of specific psychiatric disorders in patients seeking complementary treatment in Western societies, by means of a structured clinical interview using standard diagnostic criteria. To our knowledge, this has not yet been undertaken. Furthermore, given that complementary medicine is practiced worldwide, we believe it to be of interest to include a transcultural comparison as part of the study. Accordingly, we undertook a survey of past and current psychiatric disorders in 83 patients receiving complementary medical treatment at The Royal London Homoeopathic Hospital (RLHH) NHS Trust, London, England, or at a
I
From Duke University Medial Center, Durham, NC; Barnet Healthcare National Health Service (NHS) Trust, London; and Royal London Homeopathic Hospital, NHS Trust, London, England. Supported by a grant (to J.R.T.D.) from the Boiron Foundation and Grant No. RlO-MH49339-OIA3 from the National Institutes of Health. Address reprint requests to Jonathan R.T. Davidson, M.D. Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Box 3812, Durham, NC 27710. Copyright © 1998 by W.B. Saunders Company 0010-440X/98/3901-0004503.00/0 16
Copyright© 1998by W.B. Saunders Company
Comprehensive Psychiatry,Vol. 39, No. 1 (January/February), 1998: pp 16-20
PSYCHIATRIC DIAGNOSES IN ALTERNATIVE MEDICINE
private practice in Chapel Hill, NC. The results are assessed as a whole and also for the two groups. METHOD
Subjects were obtained from two sites on the basis of consecutive acceptance. The London phase of the study was conducted during the months of July through September 1995, and the North Carolina component was obtained between September and December 1995. The study was approved by the Duke University Medical Center Institutional Review Board, and the subjects provided informed consent. The RLHH NHS Trust is a well-established institution that has provided homeopathic treatment for medical illness since 1840. It is an integral part of the UK NHS and is heavily used, with approximately 30,000 outpatient visits and 600 inpatient admissions annually. Patients were referred to the RLHH for a variety of medical problems, but psychiatric symptoms were rarely the reason for presentation. The North Carolina sample was recruited from a family practice (M.E.) specializing in anthroposophicaland homeopathic medicine. Anthroposophical medicine was established in Germany in the 1920s and is based on precepts articulated by Steiner, as outlined by Bott,7 It has spread throughout Europe, and is now available from the health services of several European countries. Subjects at the RLHH were interviewed by J.R.T.D. or H.R., and those in the US sample were interviewed by R.D.S. Data were obtained as to basic demographic information, lifetime and current psychiatric disorders according to the Structured Clinical Interview for DSM-III-R8 and personality measures of neuroticism and extraversion by the Eysenck Personality Inventory (EPI).9 After complete description of the study to the subjects, written informed consent was obtained in the US sample. Verbal consent was obtained in the UK sample in accordance with local requirements. RESULTS
Demographics A total of 50 subjects were interviewed at the R L H H in England and 33 in North Carolina, for a combined sample size of 83. The age (mean _ SD) for this combined sample was 50.3 _+ 16.2 years, with a mean age of 52.5 _+ 19.2 and 46.9 +_ 9.4 years for the R L H H and North Carolina samples, respectively (nonsignificant [NS]). Sixty-six of 83 subjects (79.5%) were women, and 17 (20.5%) were men. In the U K sample, 80% were women, compared with 78.8% in the US sample. The overall number of married subjects was 43 (51.8%), with U K and US rates of 35.7% and 66.7%, respectively (chi-square = 4.84, 1 df, P - = .02). Assessment of ethnic status showed that 72 (86.7%) were white, seven (8.4%) were Asian, and four (4.8%) were black. In the United Kingdom, 78.3% were white, as compared with 100% in the United States. In the U K sample, 13% were Asian and
17
8.7% were black (chi-square = 8.36, 2 df, P = .01). In the total sample, 61 (73.5%) had a high school diploma or an equivalent. Fifty-six percent of the U K sample had graduated from high school, and 100% had graduated from high school in the US sample (chi-square = 4.84, 1 df, P < .0001).
Lifetime Diagnoses Rates of lifetime diagnoses were assessed, and are shown in Fig 1. Overall, 68.7% of the combined sample met criteria for at least one lifetime psychiatric diagnosis, with major depression being the most common single diagnosis in the U K and US samples. No significant differences were found between the countries, except with respect to posttraumatic stress disorder, which was higher in the US versus the U K sample (33.3% v 10%, P < .008). Comparison between the US and U K samples indicated that some form of affective disorder was previously present in 50.6% of the sample, while 43.4% met criteria for a prior anxiety disorder. The mean number of disorders per person was 1.75 _+ 1.80.
Current Diagnoses Rates of current psychiatric disorder were also assessed (Fig 1). Thirty-three subjects (39.8%) in the sample exhibited at least one psychiatric disorder at the time of interview; 25.3% of the sample displayed criteria for at least one anxiety disorder, with simple and social phobia and generalized anxiety being the most common; and 12% exhibited an affective disorder, either major depression, bipolar disorder, or dysthymia. Social phobia was found significantly more often in the US sample (15% v 0%, P < .008). No other significant differences were found between the sites. The mean number of current diagnoses was 0.55 _+ 0.81 per person. Subjects with a current axis I disorder were compared with subjects without a disorder. Those with a current diagnosis were significantly younger than subjects without (46.0 +_ 15.4 v 53.1 _+ 16.2, F = 4.32, P = .04). No other significant differences were found with regard to any of the demographic variables.
Personality Assessments' The EPI was completed by 78 subjects of the sample (n = 45 and n = 33 in the U K and US samples, respectively). Mean extraversion scores
18
DAVlDSON ET AL
Percent 100 1
Lifetime Substance
Affectlve
Disorder
Anxiety I
150.6 44.6
I
I
Any
I
B
I
43.4
21.7
19.3
o
68.7
Use Disorder
Major Dysthyrnia Bipolar Depression
Any
13.z
lO.5
PTSO Social Phobia
GAD
13.3
Panic Simple Disorder Phobia
Alcohol Cannabis Any Axis 1 Disorder
Percent
1oo [
Current
50
1
o
Affective
Disorder
I
12.0
Any
Anxiety
I
I
I 39.8
25.3
~
6 6.0
"
Major Dysthymia Bipolar Depression
10.8
0 Any
PTSD
Social Phobia
were 1 0 . 0 _ 4.3, and mean neuroticism scores were 9 . 6 - 5.8. Transnational comparisons indicated extraversion scores of 9.3 _+ 4.2 and 11.0 ± 4.3 in the UK and US samples, respectively (NS). Neuroticism scores for the UK and US samples were 10.7 _ 5.8 versus 8.1 ± 5.6 t = 1.92, 76 df, P = .05). In comparing current axis I-positive (n = 31) with current axis 1-negative (n = 47) subjects, mean extraversion scores were 9.3 _+ 4.4 and 10.4 _ 4.2 (NS). Neuroticism scores were 13.3 ± 5.2 and 7.2 _ 4.9, respectively (t = 5.16, 76 df P = .00001). The neuroticism scores are not significantly different from the published EPI norms of 9.0 ± 4.8, although the extraversion score is significantly lower than the published score of 12.1 _ 4.4 (N = 193, t = 4.22, 388 df p < .0005). DISCUSSION
Our results indicate that among subjects receiving complementary medical care in both the United Kingdom and United States, there is a reasonable likelihood of exhibiting at least one psychiatric
GAD
10.8
Panic Simple Any Axis 1 Disorder Phobia Disorder
Fig 1. agnosis
Rates of psychiatric diin the total sample (N = 83). PTSD, posttraumatic stress disorder; GAD, generalized anxiety disorder.
disorder at the time of consultation. Twenty-five percent of the sample met criteria for an anxiety disorder, 12% met criteria for an affective disorder, and 39.8% were noted to have at least one psychiatric disorder. One weakness of our study is the lack of a matched control group, but we can provisionally compare our results with similar types of surveys in regular primary care settings. For example, Barrett et al. l° noted the occurrence of psychiatric disorder in 26% of subjects during the previous 15 months in a US population, and Goldberg and Blackwell ]1 reported a rate of approximately 20% for psychiatric disorder in a UK primary care population. In Holland, Tiemens et al. ]2 noted a 29% rate of current axis I disorder. With respect to depression, Barrett et al. 1° observed a 10% recent prevalence in primary care patients, and in European surveys, Blacker and Clare 13 observed a prevalence rate of 8% to 10%, and Tiemens et al. 12 found a 14% current prevalence rate for major depression or dysthymia. With respect to anxiety disorders in the US primary care population, Fifer et al. 14 reported a 10% prevalence rate and noted that only 44% had been recognized
PSYCHIATRIC DIAGNOSES IN ALTERNATIVE MEDICINE
19
and treated. Roy-Byrne15 reported a 6.4% prevalence rate for generalized anxiety disorder in primary care. In a recent French primary care study, Weiller et al.16 observed a current prevalence rate for social phobia of 4.9%. Tiemens et al. 12observed a prevalence rate of 10% for at least one definite anxiety disorder, noting generalized anxiety in 6.4% and panic disorder in 1.5%. Thus, our results are comparable, although the incidence of anxiety disorder or other current psychiatric disorder may be higher in this population. This is in keeping with other observations that diagnoses of anxiety disorder and psychoneurosis, in general, are featured highly on the list of diagnoses in subjects receiving homeopathic care.t,3 The study of psychopathology among homeopathic patients is limited, although one report by Amor and Todd 17 investigated whether homeopathic patients were conspicuously neurotic. They surveyed a population of patients attending the RLHH in the late 1980s and observed their sample to be predominantly female (79%) with a mean age of 51.7 years, figures remarkably similar to our own. They noted that the most neurotic patients in the sample were younger and tended to have a previous psychiatric history. They failed to find evidence for excessive levels of minor psychiatric morbidity in their population, observing that these were similar to the levels found in general practice. Amor and Todd concluded that homeopathic patients at the RLHH were not conspicuously neurotic as compared with a general practice sample, but recommended further research into the nature and needs of individuals who seek complementary medicine. Our results suggest a somewhat different picture, in that there was a substantial rate of psychiatric disorder, especially anxiety, in both populations. However, neuroticism as a whole was not elevated, although, as might be expected, levels were higher among subjects with a current axis I disorder. With respect to the cross-national comparison in our study, the samples did differ demographically. It is unlikely that such differences are a true
reflection of health-seeking patterns in the two countries; instead, they are more a function of the source of recruitment. The RLHH patient group represents both the Greater London community and beyond, and patients are referred by their primary care doctors for specialist evaluation and care. Consultation and testing are provided free to patients, of whom 80% are also exempt from the modest prescription fees imposed by the NHS. In the US component, patients were receiving regular family care in a midsize urban community and surrounding rural area. Despite the fact that the US and UK samples exhibited demographic and referral pattem differences, the two samples still seemed similar in terms of psychiatric disorder. In conclusion, we believe the study sheds light on a hitherto poorly researched question. With the growth of complementary medicine, systematic research on the topic is obviously needed, and this particular study perhaps made a contribution in the realm of psychopathology and its prevalence. There needs to be greater awareness of psychiatric illness in these patients who seek help from the complementary health care sector. Psychiatrists need to be aware that many of their patients might be attending a complementary practitioner or are thinking about doing so. Both complementary practitioners and psychiatrists need to remain aware of such findings, so that both may be able to provide the best possible service to their patients. Since complementary medicines are not necessarily without adverse reactions, it is important for the psychiatrist (or physician) to ask about any possible complementary, herbal, or homeopathic treatments that are perhaps being used. More broadly, we note a progressive pattern wherein medical schools are now beginning to include courses on complementary medicine as part of the curriculum in the United Kingdom and United States. This will inevitably result in greater awareness among practitioners as to complementary medicine, and perhaps also greater awareness as to patients' healthseeking behaviors and attitudes.
REFERENCES 1. Rampes H, Sharpies E Maragh S, Fisher E Introducing complementary medicine into the medical curriculum. J R Soc Med 1997;90:19-22. 2. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco T. Unconventional medicine in the United States. N Engl J Med 1993;328:246-252.
3. Jacobs J, Crothers D. Who sees homoeopaths? Br Homeopath J 1991;80:57-58. 4. Jansen GRHJ, Koster TGC. Complaints and diagnoses in homoeopathic practice. A tentative stock-taking. Br Homoeopath J 1995;84:40-143. 5. HoUifield M, Katon W, Spain D, Pule L. Anxiety and
20
depression in a village in Lesotho, Africa: a comparison with the United States Br J Psychiatry 1990; 156:343-350. 6. Katerndahl DA, Realini JP. Where do panic attack sufferers seek care? J Fam Pract 1995;40:237-243. 7. Bott V. Anthroposophical Medicine: Spiritual Science and the Art of Healing. Rochester, VT: Healing Arts Press, 1984. 8. Spitzer RL, Williams JBW. Structured Clinical Interview for DSM-III-R. New York, NY: Biometrics Research Department, New York State Psychiatric Institute, 1988. 9. Eysenck HJ, Eysenck SBG. Eysenck Personality Inventory. San Diego, CA: Educational and Industrial Testing Services, 1968. 10. Barrett JE, Barrett JA, Oxman TC, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 1988;45:1100-1109. 11. Goldberg DP, Blackwell B. Psychiatric illness in general practice: a detailed study using a new method of case identification. B M J 1970;2:439-443.
DAVIDSON ET AL
12. Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry 1996; 153:636-644. 13. Blacker CV, Clare AW. Depressive disorder in primary care. Br J Psychiatry 1987; 150:737-751. 14. Fifer SK, Mathias SD, Patrick DL, Maxonson PD, Lubeck OP, Buesching DP. Untreated anxiety among adult primary care patients in a health maintenance organization. Arch Gen Psychiatry 1994;5:740-750. 15. Roy-Byme PP. Generalized anxiety and mixed anxietydepression: associated with disability and health care utilization. J Clin Psychiatry 1996;57(7 Supply):86-91. 16. Weiller E, Bisserbe J-C, Boyer P, Lepine J-P, Lecrubier Y. Social phobia in general health care. An unrecognized undertreated disabling disorder. Br J Psychiatry 1996;168:169-174. 17. Amor T, Todd J. Are homoeopathic patients conspicuously neurotic? Psychiatr Bull 1989;13:84-85.
disorder and current social phobia, which were higher in the US sample. The subjects were more introverted but not more neurotic as compared against normative population data with the EPI. The subjects were predominantly older women. We conclude that psychiatrists may need to be aware that patients with depressive or anxiety disorders are likely to seek out complementary treatments for a wide range of medical problems, and should inquire as to use of these in their patients. They may also need to cultivate greater awareness of the health beliefs of such patients.
N RECENT YEARS, there has been a marked growth of public interest in complementary medicine, which essentially covers those forms of medical practice that, in the past, have not generally been taught in medical schools, although it must be admitted that what is and is not taught in medical school always undergoes evolution.1 These treatment approaches have included homeopathy, acupuncture, osteopathy, anthroposophical medicine, and herbal medicine, among others. Of greater importance than the increase in public interest, however, is the increasing public consumption of such services, as shown by a recent survey.2 Complementary medicine, particularly in the form of homeopathy, and to a lesser extent anthroposophical medicine, has been available in the public sector under the National Health Service (NHS) in the United Kingdom since inception of the service in 1948, and is being increasingly used. Several studies have suggested that psychiatric disorders are heavily represented among patients seeking complementary medical care, e.g., surveys conducted in the United States, The Netherlands,
and Africa all provided some evidence to this effect. For instance, Jacobs and Crothers 3 reported a high rate of anxiety disorders in their homeopathic family practice in the US Northwest. Eisenberg et al. 2 noted that anxiety and depression were frequent among patients at complementary medical practices across the United States. A Dutch study recently reported a high frequency of psychoneurosis. 4 Hollifield et al. 5 studied panic disorder in Lesotho, Africa, and found that 23% of panic disorder patients attended traditional healers, i.e., those who practiced methods of treatment that were outside the mainstream and were not taught in medical school. In a San Antonio study, Katerndahl and Realini 6 also observed that 19% of panic disorder patients sought treatment from traditional healers. The implications of these findings are important, and suggest two lines of inquiry. The first of these might stimulate investigators to assess the effectiveness of complementary treatments. A second line of inquiry, the subject of this report, is to look more closely at the rates of specific psychiatric disorders in patients seeking complementary treatment in Western societies, by means of a structured clinical interview using standard diagnostic criteria. To our knowledge, this has not yet been undertaken. Furthermore, given that complementary medicine is practiced worldwide, we believe it to be of interest to include a transcultural comparison as part of the study. Accordingly, we undertook a survey of past and current psychiatric disorders in 83 patients receiving complementary medical treatment at The Royal London Homoeopathic Hospital (RLHH) NHS Trust, London, England, or at a
I
From Duke University Medial Center, Durham, NC; Barnet Healthcare National Health Service (NHS) Trust, London; and Royal London Homeopathic Hospital, NHS Trust, London, England. Supported by a grant (to J.R.T.D.) from the Boiron Foundation and Grant No. RlO-MH49339-OIA3 from the National Institutes of Health. Address reprint requests to Jonathan R.T. Davidson, M.D. Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Box 3812, Durham, NC 27710. Copyright © 1998 by W.B. Saunders Company 0010-440X/98/3901-0004503.00/0 16
Copyright© 1998by W.B. Saunders Company
Comprehensive Psychiatry,Vol. 39, No. 1 (January/February), 1998: pp 16-20
PSYCHIATRIC DIAGNOSES IN ALTERNATIVE MEDICINE
private practice in Chapel Hill, NC. The results are assessed as a whole and also for the two groups. METHOD
Subjects were obtained from two sites on the basis of consecutive acceptance. The London phase of the study was conducted during the months of July through September 1995, and the North Carolina component was obtained between September and December 1995. The study was approved by the Duke University Medical Center Institutional Review Board, and the subjects provided informed consent. The RLHH NHS Trust is a well-established institution that has provided homeopathic treatment for medical illness since 1840. It is an integral part of the UK NHS and is heavily used, with approximately 30,000 outpatient visits and 600 inpatient admissions annually. Patients were referred to the RLHH for a variety of medical problems, but psychiatric symptoms were rarely the reason for presentation. The North Carolina sample was recruited from a family practice (M.E.) specializing in anthroposophicaland homeopathic medicine. Anthroposophical medicine was established in Germany in the 1920s and is based on precepts articulated by Steiner, as outlined by Bott,7 It has spread throughout Europe, and is now available from the health services of several European countries. Subjects at the RLHH were interviewed by J.R.T.D. or H.R., and those in the US sample were interviewed by R.D.S. Data were obtained as to basic demographic information, lifetime and current psychiatric disorders according to the Structured Clinical Interview for DSM-III-R8 and personality measures of neuroticism and extraversion by the Eysenck Personality Inventory (EPI).9 After complete description of the study to the subjects, written informed consent was obtained in the US sample. Verbal consent was obtained in the UK sample in accordance with local requirements. RESULTS
Demographics A total of 50 subjects were interviewed at the R L H H in England and 33 in North Carolina, for a combined sample size of 83. The age (mean _ SD) for this combined sample was 50.3 _+ 16.2 years, with a mean age of 52.5 _+ 19.2 and 46.9 +_ 9.4 years for the R L H H and North Carolina samples, respectively (nonsignificant [NS]). Sixty-six of 83 subjects (79.5%) were women, and 17 (20.5%) were men. In the U K sample, 80% were women, compared with 78.8% in the US sample. The overall number of married subjects was 43 (51.8%), with U K and US rates of 35.7% and 66.7%, respectively (chi-square = 4.84, 1 df, P - = .02). Assessment of ethnic status showed that 72 (86.7%) were white, seven (8.4%) were Asian, and four (4.8%) were black. In the United Kingdom, 78.3% were white, as compared with 100% in the United States. In the U K sample, 13% were Asian and
17
8.7% were black (chi-square = 8.36, 2 df, P = .01). In the total sample, 61 (73.5%) had a high school diploma or an equivalent. Fifty-six percent of the U K sample had graduated from high school, and 100% had graduated from high school in the US sample (chi-square = 4.84, 1 df, P < .0001).
Lifetime Diagnoses Rates of lifetime diagnoses were assessed, and are shown in Fig 1. Overall, 68.7% of the combined sample met criteria for at least one lifetime psychiatric diagnosis, with major depression being the most common single diagnosis in the U K and US samples. No significant differences were found between the countries, except with respect to posttraumatic stress disorder, which was higher in the US versus the U K sample (33.3% v 10%, P < .008). Comparison between the US and U K samples indicated that some form of affective disorder was previously present in 50.6% of the sample, while 43.4% met criteria for a prior anxiety disorder. The mean number of disorders per person was 1.75 _+ 1.80.
Current Diagnoses Rates of current psychiatric disorder were also assessed (Fig 1). Thirty-three subjects (39.8%) in the sample exhibited at least one psychiatric disorder at the time of interview; 25.3% of the sample displayed criteria for at least one anxiety disorder, with simple and social phobia and generalized anxiety being the most common; and 12% exhibited an affective disorder, either major depression, bipolar disorder, or dysthymia. Social phobia was found significantly more often in the US sample (15% v 0%, P < .008). No other significant differences were found between the sites. The mean number of current diagnoses was 0.55 _+ 0.81 per person. Subjects with a current axis I disorder were compared with subjects without a disorder. Those with a current diagnosis were significantly younger than subjects without (46.0 +_ 15.4 v 53.1 _+ 16.2, F = 4.32, P = .04). No other significant differences were found with regard to any of the demographic variables.
Personality Assessments' The EPI was completed by 78 subjects of the sample (n = 45 and n = 33 in the U K and US samples, respectively). Mean extraversion scores
18
DAVlDSON ET AL
Percent 100 1
Lifetime Substance
Affectlve
Disorder
Anxiety I
150.6 44.6
I
I
Any
I
B
I
43.4
21.7
19.3
o
68.7
Use Disorder
Major Dysthyrnia Bipolar Depression
Any
13.z
lO.5
PTSO Social Phobia
GAD
13.3
Panic Simple Disorder Phobia
Alcohol Cannabis Any Axis 1 Disorder
Percent
1oo [
Current
50
1
o
Affective
Disorder
I
12.0
Any
Anxiety
I
I
I 39.8
25.3
~
6 6.0
"
Major Dysthymia Bipolar Depression
10.8
0 Any
PTSD
Social Phobia
were 1 0 . 0 _ 4.3, and mean neuroticism scores were 9 . 6 - 5.8. Transnational comparisons indicated extraversion scores of 9.3 _+ 4.2 and 11.0 ± 4.3 in the UK and US samples, respectively (NS). Neuroticism scores for the UK and US samples were 10.7 _ 5.8 versus 8.1 ± 5.6 t = 1.92, 76 df, P = .05). In comparing current axis I-positive (n = 31) with current axis 1-negative (n = 47) subjects, mean extraversion scores were 9.3 _+ 4.4 and 10.4 _ 4.2 (NS). Neuroticism scores were 13.3 ± 5.2 and 7.2 _ 4.9, respectively (t = 5.16, 76 df P = .00001). The neuroticism scores are not significantly different from the published EPI norms of 9.0 ± 4.8, although the extraversion score is significantly lower than the published score of 12.1 _ 4.4 (N = 193, t = 4.22, 388 df p < .0005). DISCUSSION
Our results indicate that among subjects receiving complementary medical care in both the United Kingdom and United States, there is a reasonable likelihood of exhibiting at least one psychiatric
GAD
10.8
Panic Simple Any Axis 1 Disorder Phobia Disorder
Fig 1. agnosis
Rates of psychiatric diin the total sample (N = 83). PTSD, posttraumatic stress disorder; GAD, generalized anxiety disorder.
disorder at the time of consultation. Twenty-five percent of the sample met criteria for an anxiety disorder, 12% met criteria for an affective disorder, and 39.8% were noted to have at least one psychiatric disorder. One weakness of our study is the lack of a matched control group, but we can provisionally compare our results with similar types of surveys in regular primary care settings. For example, Barrett et al. l° noted the occurrence of psychiatric disorder in 26% of subjects during the previous 15 months in a US population, and Goldberg and Blackwell ]1 reported a rate of approximately 20% for psychiatric disorder in a UK primary care population. In Holland, Tiemens et al. ]2 noted a 29% rate of current axis I disorder. With respect to depression, Barrett et al. 1° observed a 10% recent prevalence in primary care patients, and in European surveys, Blacker and Clare 13 observed a prevalence rate of 8% to 10%, and Tiemens et al. 12 found a 14% current prevalence rate for major depression or dysthymia. With respect to anxiety disorders in the US primary care population, Fifer et al. 14 reported a 10% prevalence rate and noted that only 44% had been recognized
PSYCHIATRIC DIAGNOSES IN ALTERNATIVE MEDICINE
19
and treated. Roy-Byrne15 reported a 6.4% prevalence rate for generalized anxiety disorder in primary care. In a recent French primary care study, Weiller et al.16 observed a current prevalence rate for social phobia of 4.9%. Tiemens et al. 12observed a prevalence rate of 10% for at least one definite anxiety disorder, noting generalized anxiety in 6.4% and panic disorder in 1.5%. Thus, our results are comparable, although the incidence of anxiety disorder or other current psychiatric disorder may be higher in this population. This is in keeping with other observations that diagnoses of anxiety disorder and psychoneurosis, in general, are featured highly on the list of diagnoses in subjects receiving homeopathic care.t,3 The study of psychopathology among homeopathic patients is limited, although one report by Amor and Todd 17 investigated whether homeopathic patients were conspicuously neurotic. They surveyed a population of patients attending the RLHH in the late 1980s and observed their sample to be predominantly female (79%) with a mean age of 51.7 years, figures remarkably similar to our own. They noted that the most neurotic patients in the sample were younger and tended to have a previous psychiatric history. They failed to find evidence for excessive levels of minor psychiatric morbidity in their population, observing that these were similar to the levels found in general practice. Amor and Todd concluded that homeopathic patients at the RLHH were not conspicuously neurotic as compared with a general practice sample, but recommended further research into the nature and needs of individuals who seek complementary medicine. Our results suggest a somewhat different picture, in that there was a substantial rate of psychiatric disorder, especially anxiety, in both populations. However, neuroticism as a whole was not elevated, although, as might be expected, levels were higher among subjects with a current axis I disorder. With respect to the cross-national comparison in our study, the samples did differ demographically. It is unlikely that such differences are a true
reflection of health-seeking patterns in the two countries; instead, they are more a function of the source of recruitment. The RLHH patient group represents both the Greater London community and beyond, and patients are referred by their primary care doctors for specialist evaluation and care. Consultation and testing are provided free to patients, of whom 80% are also exempt from the modest prescription fees imposed by the NHS. In the US component, patients were receiving regular family care in a midsize urban community and surrounding rural area. Despite the fact that the US and UK samples exhibited demographic and referral pattem differences, the two samples still seemed similar in terms of psychiatric disorder. In conclusion, we believe the study sheds light on a hitherto poorly researched question. With the growth of complementary medicine, systematic research on the topic is obviously needed, and this particular study perhaps made a contribution in the realm of psychopathology and its prevalence. There needs to be greater awareness of psychiatric illness in these patients who seek help from the complementary health care sector. Psychiatrists need to be aware that many of their patients might be attending a complementary practitioner or are thinking about doing so. Both complementary practitioners and psychiatrists need to remain aware of such findings, so that both may be able to provide the best possible service to their patients. Since complementary medicines are not necessarily without adverse reactions, it is important for the psychiatrist (or physician) to ask about any possible complementary, herbal, or homeopathic treatments that are perhaps being used. More broadly, we note a progressive pattern wherein medical schools are now beginning to include courses on complementary medicine as part of the curriculum in the United Kingdom and United States. This will inevitably result in greater awareness among practitioners as to complementary medicine, and perhaps also greater awareness as to patients' healthseeking behaviors and attitudes.
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