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Psychiatric screening in primary care: What do patients really want?
Journal of Psychosomatic Research, Voh 42, No. 2, pp. 167 175, 1997 Copyright © 1997 Elsevier Science Inc. All rights reserved. 0022-3999/97 $17.00 + .00
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P S Y C H I A T R I C S C R E E N I N G IN P R I M A R Y CARE: W H A T D O PATIENTS R E A L L Y W A N T ? J E N N I F E R D. LISH,*II M A R Y A N N K U Z M A , t D A V I D T. L U S H , t G A R Y P L E S C I A , * N E l L J. F A R B E R t $ and M A R K Z I M M E R M A N § (Received 11 April 1995; accepted 8 May 1996)
Abstract--Psychiatric disorders are common in primary care, but underdiagnosed. U.S. physician reluctance to diagnose psychiatric illnesses is partly attributable to the belief that patients do not want their primary care physician to assess mental health. Six hundred one patients in a U.S. general internal medicine practice completed the SCREENER, a self-report questionnaire which screens for 15 psychiatric disorders, and another questionnaire about the SCREENER. Patients were predominantly female, unmarried, black, high school graduates. Only 3% thought that their physician should never evaluate their mental health. More than 60% desired periodic mental health screening, and one third wanted psychiatric assessment only when a problem was suspected. Attitudes toward questionnaire screening were less positive than toward physician interview. Patients were more likely to want screening if they were female, unmarried, young, had a history of mental health treatment, reported psychiatric symptoms, or were in fair-poor subjective physical or mental health. Copyright© 1997 Elsevier Science Inc. Keywords:
Mental disorders; Primary care; Patient satisfaction; Screening.
INTRODUCTION Psychiatric disorders are c o m m o n in p r i m a r y care patients [ 1 4 ] , and are associated with substantial morbidity, mortality, and cost [5-9], but are u n d e r d i a g n o s e d by U.S. p r i m a r y care physicians [10-13]. Main and colleagues [14] found, in a survey of m e m b e r s of the U.S. A m b u l a t o r y Sentinel Practice N e t w o r k , that the belief that p r i m a r y care patients do not want their physicians to investigate depression explained one third of the variance in physician reluctance to diagnose depression. A U.S. national survey of family practitioners f o u n d that the majority r e p o r t e d enc o u n t e r i n g resistance f r o m patients to psychiatric diagnosis [15]. P r i m a r y care physicians r e p o r t that s o m e patients are "insulted" by "pejorative labels," such as depression; therefore, physicians either fail to m a k e the diagnosis, diagnose only one s y m p t o m , or substitute destigmatized e u p h e m i s m s such as "limbic system dysfunction" to e n h a n c e acceptance of the diagnosis and of t r e a t m e n t [14, 16-18]. Main (personal c o m m u n i c a t i o n , 8/12/94) f o u n d that only 50% of p r i m a r y care physicians * Department of Psychiatry and tDivision of General Medicine, Medical College of Pennsylvania, Philadelphia, PA, USA. Department of Medicine, Philadelphia Veterans' Affairs Medical Center, Philadelphia, PA, USA. § Department of Psychiatry, Brown University, Providence, RI, USA. II Compass Information Services, Inc., King of Prussia, PA, USA. Address correspondence to: Jennifer D. Lish, Compass Information Services, Inc.. Suite 410, 1060 First Avenue, King of Prussia, PA 19406, USA. Tel: (610)-992-7060: Fax: (610)-992-7070. 167
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stated that they "disagree" with the statement "My patients do not want me to investigate depression problems"; although no physicians stated that they "agree" with this statement, 50% gave ratings for this statement that were intermediate between "disagree" and "agree." Thus, half of this sample of primary care physicians believes that their patients are not wholly supportive of them performing mental health evaluations. It is unclear whether primary care physician's perceptions that patients do not want them to diagnose psychiatric illnesses are accurate. Studie~ of primary care patients provide some evidence to the contrary. Frowick and colleagues [19] found that more than 90% of patients of family practitioners wanted their physician to provide care for mental health problems that presuppose a psychiatric diagnosis. For depression, nervousness and tension, alcoholism, long-term emotional illness, suicide attempt, or drug problems, 7% or fewer wanted their physician not to be involved, and more than half wanted him to provide "expert help." Brody and colleagues found that 24% of patients wanted "stress counseling" from their physicians, and were less satisfied with their visit if they did not receive it [20]. A majority of patients (57-78%) want their family physicians to treat their psychosocial problems [21]. A m o n g primary care patients who have a psychiatric disorder, those in whom it is correctly identified by their physician are more likely to feel that they were very much "helped by seeing the doctor" than those in whom it is missed [22]. Chronically ill (hypertensive, diabetic) adults are more satisfied with their medical care if their physician discusses psychosocial issues [23], and express a desire for physicians to become more involved with psychosocial issues [24]. Over 85% of primary care patients state that they want their doctor to ask about life events, such as a family divorce or death, but that their doctor does not ask [25]. Although evidence shows that patients want care from their primary care physician that presupposes his diagnosing psychiatric disorders, no study, to our knowledge, has directly asked patients specifically whether they want their physician to perform a psychiatric diagnostic evaluation of them. We therefore surveyed patients in a primary care setting regarding whether their physician should periodically interview them and/or have them complete self-report screening questionnaires to diagnose psychiatric disorders. In addition, we examined whether patient attitudes were associated with their current state of mental health and their history of mental health treatment.
METHOD This study was approved by the institutional review board. A consecutiveseries of 658 outpatients attending the facultygeneral internal medicinepractice at the Medical Collegeof Pennsylvaniawere asked to participate in a research study involving the completion of two questionnaires. Patients were approached after they had registered and been escorted into a physician'sexaminingroom. A receptionist introduced a research assistant, who explained the purpose of the study to the patient. Patients were assured of anonymity, and told that the questionnaires would not be reviewed by their physicians. Informed consent was obtained. We approached every patient except hospital employees and medical students. Ninety-one percent (601 of 658) of the patients agreed to participate in the study. The most frequent reasons for nonparticipation were patient refusal (n = 16), lack of reading glasses (n = 17), and insufficient time to complete the questionnaires (n = 15). Nonparticipantswere significantlyolder (47.4 - 14.9 vs. 39.4 -+ 15.2 years, t = 3.8,p < 0.001) and less well educated (11.7 ___1.9 vs. 12.6 --- 2.1 years, t = 3.0, p < 0.01).
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Study participants completed the SCREENER, and the Patient Acceptability Questionnaire (PAQ). The SCREENER is a self-administered questionnaire which was designed to screen for 15 DSM-IV Axis I disorders in five areas selected because of their demonstrably high prevalence in primary care-depression, anxiety, substance use, somatoform disorders, and eating disorders. All SCREENER questions are answered yes or no. The SCREENER scales have demonstrated good internal consistency, and convergent and divergent validity [30]. The diagnostic validity of the SCREENER in comparison to a definitive, "gold standard" psychiatric diagnosis (e.g., the Structured Clinical Interview for DSM-IV [26] has not been established. The average patient can complete the SCREENER in approximately l0 minutes. The Patient Acceptability Questionnaire (PAQ) [27] is a 13-item questionnaire which includes questions about patients' attitudes about screening for psychiatric disorders. One question on the PAQ was "How often should your doctor ask a few questions about emotional or nerve problems as part of their evaluation?," with response options of "every time I see the doctor," "on yearly check-ups," "only when an emotional, nerve, drug, or alcohol problem is suspected," and "not at all." Another question on the PAQ was "How often should you be given a brief questionnaire on emotional, nerve, drug, and alcohol problems when visiting your medical doctor?," with the same response options. The PAQ also included four questions assessing the degree to which the patients were annoyed, embarrassed, upset, or uncomfortable with the questions on the SCREENER (very much, somewhat, a little, not at all). The PAQ also contained questions about whether the SCREENER was too long, too short, or just right; whether the SCREENER was easy or difficult to complete; and about whether it would be easy or difficult to talk to the primary care physician about an emotional, nerve, drug, or alcohol problem. Finally, the PAQ included questions about lifetime history of "mental health care (counselor, psychiatrist, psychologist)," frequency of primary care visits, and self-rated global evaluations of current physical and emotional health. We dichotomized the global health ratings into excellent or good vs. fair or poor, as have other investigators [28]. No data are available regarding the reliability or validity of the PAQ. Because of missing data, the sample size varied by analysis. Comparison of categorical variables used the X2 statistic, or Fisher's exact test when the expected value in one or more cells of the 2 × 2 table was less than 5. We calculated Pearson correlation coefficients between continuous scales, and Spearman correlation coefficients between dichotomous scales and continuous scales. Significance tests were twotailed. Statistics were calculated using SPSS-PC.
RESULTS T a b l e I p r o v i d e s t h e d e m o g r a p h i c c h a r a c t e r i s t i c s o f the s a m p l e . T h e m a j o r i t y o f t h e p a t i e n t s w e r e f e m a l e , u n m a r r i e d , b l a c k , high s c h o o l g r a d u a t e s . T h e d e s i r e d f r e q u e n c y o f m e n t a l h e a l t h s c r e e n i n g v a r i e d d e p e n d i n g o n which question patients were answering. Regarding the question, "How often should your d o c t o r ask a few q u e s t i o n s a b o u t e m o t i o n a l o r n e r v e p r o b l e m s as p a r t o f t h e i r e v a l u a t i o n ? , " 37.8% (217 o f 573) r e s p o n d e d " e v e r y t i m e I see t h e d o c t o r , " 25.1% (144 o f 573) " o n y e a r l y c h e c k - u p s , " 34.4% (197 o f 573) " o n l y w h e n an e m o t i o n a l , n e r v e , d r u g , o r a l c o h o l p r o b l e m is s u s p e c t e d , " a n d o n l y 2.6% (15 o f 573) " n o t at all." R e g a r d i n g t h e q u e s t i o n , " H o w o f t e n s h o u l d y o u b e given a b r i e f q u e s t i o n n a i r e on e m o tional, n e r v e , drug, a n d a l c o h o l p r o b l e m s w h e n visiting y o u r m e d i c a l d o c t o r ? , " 10.7% (61 o f 569) r e s p o n d e d " o n e a c h visit," 41.7% (237 o f 569) " a t y e a r l y c h e c k ups," 2 9 % (166 o f 569) " o n l y w h e n a n e m o t i o n a l , n e r v e , drug, o r a l c o h o l p r o b l e m is s u s p e c t e d , " a n d 18.5% (105 o f 569) " n e v e r . " Thus, 6 3 % o f p r i m a r y c a r e p a t i e n t s feel t h a t t h e i r d o c t o r s h o u l d p e r f o r m m e n t a l h e a l t h s c r e e n i n g p e r i o d i c a l l y , e i t h e r a n n u a l l y o r at e a c h visit, a n d o n l y 2 . 6 % t h i n k t h a t he s h o u l d n e v e r i n q u i r e a b o u t m e n t a l h e a l t h . A p p r o x i m a t e l y o n e t h i r d o f t h e p a t i e n t s w a n t t h e i r p h y s i c i a n to b e vigilant a n d m a i n t a i n s o m e i n d e x o f s u s p i c i o n r e g a r d i n g p s y c h i a t r i c illness, a n d to ask if he s u s p e c t s a p r o b l e m , r a t h e r t h a n c o n s i d e r i n g it o u t s i d e o f his p r o f e s sional d o m a i n . F i f t y - t w o p e r c e n t o f p a t i e n t s feel t h a t t h e i r d o c t o r s h o u l d use a q u e s t i o n n a i r e to p e r f o r m m e n t a l h e a l t h s c r e e n i n g p e r i o d i c a l l y , e i t h e r a n n u a l l y o r at e a c h visit, a n d
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Table l.--Demographic characteristics of 601 primary care patients* Gender, % (no.) Male Female Marital status, % (no.) Single Married Separated Divorced Widowed Education Mean _+ so, years High school graduates, % (no.) Age Mean - SD, years />60, % (no.) Race, % (no.) White Nonwhite
18.7 (ll0) 81.3 (477) 49.6 (283) 32.5 (185) 5.8 (33) 7.5 (43) 4.6 (26) 12.6 _ 2.1 81.9 (476) 39.4 _+ 15.2 12.9 (76) 13.5 (78) 86.5 (499)
* Sample size varied for each variable because of missing data as follows: gender, n = 587; marital status, n = 570; education, n = 581; age, n = 588; and race, n = 577; 485 of the 499 nonwhites were black, and 14 were Hispanic or Asian.
18.5% think that he should never use a questionnaire to evaluate their mental health. Patients' attitudes toward mental health screening are m o r e positive if it is to be accomplished by brief physician interview than by questionnaire. Because the responses regarding desire for periodic evaluation differed according to the proposed m e t h o d of assessment, we examined the effect of patient characteristics on desired frequency of evaluation separately for each of the two assessment methods. For the purpose of these analyses, we dichotomized the patients into those who wanted their physician to evaluate them at every visit or annually versus those who wanted evaluation only when the physician suspected a problem or never. This dichotomization compares patients who think their physician should have a program of periodic screening of apparently asymptomatic patients to patients who think that he should not. G e n d e r and race had no effect on preferred frequency of screening by physician interview (Table II). Patients with a history of mental health treatment, approximately a quarter of the sample, were m o r e likely to r e c o m m e n d regular evaluation, as were patients who screened positive for at least one psychiatric disorder, and patients with fair or p o o r subjective mental health, or subjectively fair or p o o r physical health. Patients who were unmarried were m o r e likely to prefer regular evaluation. Patients who desired regular physician evaluation were significantly younger (38.2 ± 14.5 vs. 41.1 __+ 15.8, t = -2.19, p < 0.05), and had reported m o r e psychiatric symptoms on the S C R E E N E R (10.9 ± 9.8 vs. 8.0 ± 7.7, t = -3.96, p < 0.001). The predictors of wanting regular screening by questionnaire were similar (Table III). Women, patients who screened positive for at least one disorder on the S C R E E N E R , and patients with a history of mental health treatment were more likely to r e c o m m e n d regular screening. Patients who felt that a brief screening questionnaire should be given annually, or at each visit, were significantly younger than patients who did not (37.3 ± 13.6 vs. 41.5 _+ 16.5, p < 0.01), and had reported m o r e
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Table II.---Predictors of primary care patient desire for periodic mental health screening by physician interview Desire periodic screening Gender, % (no.) Male Female Marital status, % (no.) Married Not married Race, % (no.) White Nonwhite Education, % (no.) >12 years <12 years Subjective physical health, % (no.) Good-excellent Fair-poor Subjective mental health, % (no.) Good-excellent Fair-poor History of mental health treatment, % (no.) No Yes Screener No disorders One or more disorders
Do not desire periodic screening
56.6 (60) 64.0 (293)
43.4 (46) 36.0 (165)
54.9 (96) 66.7 (250)
45.1 (79) (p<0.01) 33.3 (125)
64.9 (50) 62.1 (296)
35.1 (27) 37.9 (181)
62.7 (289) 64.9 (63)
37.3 (172) 35.1 (34)
60.1 (252) 70.8 (109)
39.9 (167) (p<0.05) 29.2 (49)
61.3 (301) 73.2 (60)
38.7 (190) (p<0.05) 26.8 (22)
58.8 (264) 78.2 (97)
41.2 (185) (p<0.001) 21.8 (27)
54.4 (123) 68.6 (238)
45.6 (103) (p<0.001) 31.4 (109)
psychiatric symptoms on the S C R E E N E R (10.4 _+ 9.1 vs. 8.9 _ 8.3, t = -2.00, p < 0.05). The relationships between these various predictors of desiring regular screening were not such that all of the variation could actually be attributed to a single variable. Patients who had a disorder on the S C R E E N E R were slightly younger, more likely to consider themselves in poor mental and physical health, and more likely to have had mental health treatment. However, women were not significantly more likely to have had mental health treatment or to consider themselves in poor mental health, nor were unmarried or younger persons. There was no significant correlation between how frequently patients felt they should be assessed by questionnaire and how annoyed (r = 0.03, NS), embarrassed (r = 0.04, NS), or uncomforl:able (r = 0.02, NS) the S C R E E N E R made them feel, and only a trivial correlation (r = 0.09, p < 0.05) with how upset it made them feel, indicating that patients' opinions as to how often they should be screened were not based on how much negative affect was evoked by completing the S C R E E N E R . DISCUSSION
The patients in this study overwhelmingly indicated that their physician should evaluate them for the presence of psychiatric illnesses either regularly, or at least
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J. D. LISH et aL Table III.--Predictors of whether primary care patients desire periodic mental health screening by questionnaire
Gender, % (no.) Male Female Marital status, % (no.) Married Not married Race, % (no.) White Nonwhite Education, % (no.) >12 years <12 years Subjective physical health, % (no.) Good-excellent Fair-poor Subjective mental health, % (no.) Good-excellent Fair-poor History of mental health treatment, % (no.) No Yes Screener No disorders One or more disorders
Desire periodic screening
Do not desire periodic screening
39.2 (40) 55.0 (252)
60.8 (62) 45.0 (206) (p<0.01)
48.0 (84) 54.2 (201)
52.0 (91) 45.8 (170)
52.1 (38) 52.8 (252)
47.9 (35) 47.2 (225)
52.6 (241) 50.0 (48)
47.4 (217) 50.0 (48)
53.1 (220) 50.3 (78)
46.9 (194) 49.7 (77)
51.9 (254) 55.0 (44)
48.1 (235) 45.0 (36)
50.0 (224) 61.2 (74)
50.0 (224) (p<0.05) 38.8 (47)
45.5 (101) 56.8 (197)
54.5 (121) (p<0.001) 43.2 (150)
when he suspects that they may have a disorder. The majority of patients indicated that their doctor should have a program of regular screening. Patients appeared to be more positive toward such a program if it would be performed by physician interview rather than by questionnaire. Although patients did not experience significant discomfort from completing a self-report screening questionnaire, more patients recommended regular screening if it would be done by the physician himself. This may indicate that patients feel more comfortable revealing personal information to a physician with whom they have an ongoing relationship to recording it in writing, and/or that they think the symptoms covered by the S C R E E N E R are important health matters that warrant their physician's time and personal attention. One caveat regarding this interpretation of our data is that the questions on the P A Q regarding screening by questionnaire and by physician were inadvertently worded differently. That is, the question about screening by questionnaire referred to "emotional, nerve, drug or alcohol problems," whereas the question about physician interviewing referred only to "emotional or nerve problems." It is possible that patients' less positive responses to the latter question were not because of the mention of a questionnaire rather than an interview but because it mentioned drug and alcohol problems, which might be more stigmatized than "emotional or nerve problems." On the other hand, it is possible that the more positive responses regarding physician interview are because patients would prefer physician interview to ques-
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tionnaire screening. Our inadvertent confounding of these two issues is a limitation of this study. Another limitation is that all of the patients had been confronted with an actual screening questionnaire, whereas patients may or may not have been exposed during the same visit to a brief physican interview regarding mental health. It is possible that some patients who responded positively to a hypothetical physician interview might have responded more negatively to an actual physician interview. The major limitation of this study is that it was limited to a single, urban, hospitalbased group practice. The respondents were predominantly female, black, unmarried high school graduates, and thus not representative of the population of U.S. primary care patients. While primary care practice samples invariably contain more women, this sample has an unusually low number of men. Another limitation of this study is that a relatively large number of analyses were performed, raising the chances of a type I error (incorrectly rejecting a true null hypothesis). The most important point regarding this study is that our findings are not at all consistent with U.S. primary care practitioner beliefs that patients do not want their doctors to evaluate them for the presence of psychiatric disorders. Fully 62% of patients believe that their physician should maintain periodic surveillance of the mental health of apparently asymptomatic patients, and fewer than 3% believe that their physicians should never evaluate them psychiatrically. Patients appear to have a significantly more positive attitude than physicians believe they have toward mental health evaluation by primary care physicians. Our findings show that a minority of patients will experience some discomfort when a doctor asks questions about psychiatric symptoms or substance abuse. Nonetheless, nearly all patients, and most of those who experience discomfort, do want their physician to perform this uncomfortable procedure. This implies that, with mental health screening as with other discomforting medical procedures such as flexible sigmoidoscopy, patients feel they should and can tolerate the slight discomfort or inconvenience of a screening procedure applied to all, in return for the potential benefit to their health if they should be found to be one of the patients with the disorder being screened for. Increased primary care practitioner diagnosis of depression is advocated by the U.S. Agency for Health Care Policy and Research [29], and increased primary care practitioner diagnosis of a broader range of psychiatric disorders is extremely desirable on public health and economic grounds which have been adequately articulated elsewhere [30]. However, a mistaken belief on the part of some U.S. primary care physicians that patients do not want their psychiatric illnesses to be diagnosed apparently functions as a barrier to the achievement of this important public health goal. There are many formidable barriers to primary care physician diagnosis of psychiatric disorders, including physician time constraints, inadequate physician education and training, prejudicial physician attitudes toward mental illness, inadequate physician compensation for mental health evaluation and treatment, inadequate mental health treatment resources, and discriminatory health insurance coverage for mental illness [14, 31-35]. However, patient disinclination to be psychiatrically diagnosed by their primary care physicians does not, in fact, appear to be an important obstacle.
REFERENCES 1. SchulbergHC, Burns BJ. Mental disordersin primarycare: epidemiologic,diagnostic,and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.
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2. Katon W, Schulberg HC. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992;14:237-247. 3. Sato T, Takeichi M. Lifetime prevalence of specific psychiatric disorders in a general medicine clinic. Gen Hosp Psychiatry 1993;15:224-233. 4. Von Korff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic. Arch Gen Psychiatry 1987;44:152-156. 5. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry 1993;54:405-418. 6. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;B2:914-919. 7. Coryell W, Noyes R, Clancy J. Excess mortality in panic disorder: a comparison with primary unipolar depression. Arch Gen Psychiatry 1982;43:701-703. 8. Weissman MM, Klerman GL, Markowitz JS, Ouellette R. Suicidal ideation and attempts in panic disorder. N Engl J Med 1989;321:1209-1214. 9. Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL. Quality of life in panic disorder. Arch Gen Psychiatry 1989;46:984-992. 10. Zung WWK, Broadhead E, Roth M. Prevalence of depressive symptoms in primary care. J Fam Pract 1993;37:337-344. 11. Rost K, Smith GR, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333-337. 12. Linn LS, Yager J. Recognition of depression and anxiety by primary physicians. Psychosomatics 1984;24:593~00. 13. Keller MB. Depression underrecognition and undertreatment by psychiatrists and other health care professionals. Arch Int Med 1990;150:946-948. 14. Main DS, Lutz LI, Barrett JE, Matthew J, Miller RS. The role of primary care clinician attitudes, beliefs, and training in the diagnosis and treatment of depression: a report from the Ambulatory Sentinel Practice Network Inc. Arch Fam Med 1993;2:1061-1066. 15. Orleans CT, George LK, Houpt JL, Brodie HKH. How primary care physicians treat psychiatric disorders: a national survey of family practitioners. Am J Psychiatry 1985;142:52-57. 16. Reynolds RD. Practice commentary [editorial]. Arch Fam Med 1993;2:84. 17. Parchman ML. Physician's recognition of depression. Fam Pract Res J 1992;12:431-438. 18. Broadhead WE. Misdiagnosis of depression: physicians contribute to the stigmatization of mental illness. Arch Fam Med 1994;3:319. 19. Frowick B, Shank JC, Doherty WJ, Powell TA. What do patients really want? Redefining a behavioral science curriculum for family physicians. J Fam Pract 1986;23:141-146. 20. Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care 1989;27:1027-1035. 21. Hansen JP, Bobula J, Meyer D, Kushner K, Pridham K. Treat or refer: patients' interest in family physician involvement in their psychosocial problems. J Fam Pract 1987;24:499-503. 22. May S. Patient satisfaction and the detection of psychiatric morbidity in general practice. Fam Pract 1992;9:76-81. 23. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32:175-181. 24. Marvel MK. Involvement with the psychosocial concerns of patients: observations of practicing family physicians on a university faculty. Arch Fam Med 1993;2:629-633. 25. Yaffe M J, Stewart MA. Patient's attitudes to the relevance of nonmedical problems in family medicine care. J Fam Pract 1986;23:241-244. 26. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-IV (SCID). Washington, DC: American Psychiatric Association 1993. 27. Zimmerman M, Farber NJ, Hartung J, Lush DT, Kuzma MA. Screening for psychiatric disorders in medical patients: a feasibility and patient acceptance study. Med Care 1994;32:603--608. 28. McHorney CA, Ware JE, Raczek A. The MOS 36-item short form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993;31:247-263. 29. Depression Guideline Panel. Depression in primary care: detection, diagnosis and treatment. Quick reference guide for clinicians, no. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research 1993. 30. Zimmerman M, Lish JD, Farber NJ, Hartung J, Lush DT, Kuzma MA, PlesciaG. Screening for depression in medical patients: is the focus too narrow? Gen Hosp Psychiatry 1994;16:388-396. 31. Rost K, Humphrey J, Kelleher K. Physician management preferences and barriers to care for rural patients with depression. Arch Fam Med 1994;3:409-414.
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32. Marks JN, Goldberg DP, Hillier VF. Determinants of the abilities of general practitioners to detect psychiatric illness. Psychol Med 1979;9:337-353. 33. Domenici PV. Mental health care policy in the 1990's: discrimination in health care coverage of the seriously mentally ill. J Clin Psychiatry 1993;54:5-6. 34. MacGruder-Habib K, Zung WWK, Feussner JR. Improving physicians' recognition and treatment of depression in general medical care. Med Care 1990;28:239-250. 35. Epstein, D. Treating patients for depression: is primary care the appropriate first stop? Am Coll Phys Observ 1994;14:1.
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P S Y C H I A T R I C S C R E E N I N G IN P R I M A R Y CARE: W H A T D O PATIENTS R E A L L Y W A N T ? J E N N I F E R D. LISH,*II M A R Y A N N K U Z M A , t D A V I D T. L U S H , t G A R Y P L E S C I A , * N E l L J. F A R B E R t $ and M A R K Z I M M E R M A N § (Received 11 April 1995; accepted 8 May 1996)
Abstract--Psychiatric disorders are common in primary care, but underdiagnosed. U.S. physician reluctance to diagnose psychiatric illnesses is partly attributable to the belief that patients do not want their primary care physician to assess mental health. Six hundred one patients in a U.S. general internal medicine practice completed the SCREENER, a self-report questionnaire which screens for 15 psychiatric disorders, and another questionnaire about the SCREENER. Patients were predominantly female, unmarried, black, high school graduates. Only 3% thought that their physician should never evaluate their mental health. More than 60% desired periodic mental health screening, and one third wanted psychiatric assessment only when a problem was suspected. Attitudes toward questionnaire screening were less positive than toward physician interview. Patients were more likely to want screening if they were female, unmarried, young, had a history of mental health treatment, reported psychiatric symptoms, or were in fair-poor subjective physical or mental health. Copyright© 1997 Elsevier Science Inc. Keywords:
Mental disorders; Primary care; Patient satisfaction; Screening.
INTRODUCTION Psychiatric disorders are c o m m o n in p r i m a r y care patients [ 1 4 ] , and are associated with substantial morbidity, mortality, and cost [5-9], but are u n d e r d i a g n o s e d by U.S. p r i m a r y care physicians [10-13]. Main and colleagues [14] found, in a survey of m e m b e r s of the U.S. A m b u l a t o r y Sentinel Practice N e t w o r k , that the belief that p r i m a r y care patients do not want their physicians to investigate depression explained one third of the variance in physician reluctance to diagnose depression. A U.S. national survey of family practitioners f o u n d that the majority r e p o r t e d enc o u n t e r i n g resistance f r o m patients to psychiatric diagnosis [15]. P r i m a r y care physicians r e p o r t that s o m e patients are "insulted" by "pejorative labels," such as depression; therefore, physicians either fail to m a k e the diagnosis, diagnose only one s y m p t o m , or substitute destigmatized e u p h e m i s m s such as "limbic system dysfunction" to e n h a n c e acceptance of the diagnosis and of t r e a t m e n t [14, 16-18]. Main (personal c o m m u n i c a t i o n , 8/12/94) f o u n d that only 50% of p r i m a r y care physicians * Department of Psychiatry and tDivision of General Medicine, Medical College of Pennsylvania, Philadelphia, PA, USA. Department of Medicine, Philadelphia Veterans' Affairs Medical Center, Philadelphia, PA, USA. § Department of Psychiatry, Brown University, Providence, RI, USA. II Compass Information Services, Inc., King of Prussia, PA, USA. Address correspondence to: Jennifer D. Lish, Compass Information Services, Inc.. Suite 410, 1060 First Avenue, King of Prussia, PA 19406, USA. Tel: (610)-992-7060: Fax: (610)-992-7070. 167
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stated that they "disagree" with the statement "My patients do not want me to investigate depression problems"; although no physicians stated that they "agree" with this statement, 50% gave ratings for this statement that were intermediate between "disagree" and "agree." Thus, half of this sample of primary care physicians believes that their patients are not wholly supportive of them performing mental health evaluations. It is unclear whether primary care physician's perceptions that patients do not want them to diagnose psychiatric illnesses are accurate. Studie~ of primary care patients provide some evidence to the contrary. Frowick and colleagues [19] found that more than 90% of patients of family practitioners wanted their physician to provide care for mental health problems that presuppose a psychiatric diagnosis. For depression, nervousness and tension, alcoholism, long-term emotional illness, suicide attempt, or drug problems, 7% or fewer wanted their physician not to be involved, and more than half wanted him to provide "expert help." Brody and colleagues found that 24% of patients wanted "stress counseling" from their physicians, and were less satisfied with their visit if they did not receive it [20]. A majority of patients (57-78%) want their family physicians to treat their psychosocial problems [21]. A m o n g primary care patients who have a psychiatric disorder, those in whom it is correctly identified by their physician are more likely to feel that they were very much "helped by seeing the doctor" than those in whom it is missed [22]. Chronically ill (hypertensive, diabetic) adults are more satisfied with their medical care if their physician discusses psychosocial issues [23], and express a desire for physicians to become more involved with psychosocial issues [24]. Over 85% of primary care patients state that they want their doctor to ask about life events, such as a family divorce or death, but that their doctor does not ask [25]. Although evidence shows that patients want care from their primary care physician that presupposes his diagnosing psychiatric disorders, no study, to our knowledge, has directly asked patients specifically whether they want their physician to perform a psychiatric diagnostic evaluation of them. We therefore surveyed patients in a primary care setting regarding whether their physician should periodically interview them and/or have them complete self-report screening questionnaires to diagnose psychiatric disorders. In addition, we examined whether patient attitudes were associated with their current state of mental health and their history of mental health treatment.
METHOD This study was approved by the institutional review board. A consecutiveseries of 658 outpatients attending the facultygeneral internal medicinepractice at the Medical Collegeof Pennsylvaniawere asked to participate in a research study involving the completion of two questionnaires. Patients were approached after they had registered and been escorted into a physician'sexaminingroom. A receptionist introduced a research assistant, who explained the purpose of the study to the patient. Patients were assured of anonymity, and told that the questionnaires would not be reviewed by their physicians. Informed consent was obtained. We approached every patient except hospital employees and medical students. Ninety-one percent (601 of 658) of the patients agreed to participate in the study. The most frequent reasons for nonparticipation were patient refusal (n = 16), lack of reading glasses (n = 17), and insufficient time to complete the questionnaires (n = 15). Nonparticipantswere significantlyolder (47.4 - 14.9 vs. 39.4 -+ 15.2 years, t = 3.8,p < 0.001) and less well educated (11.7 ___1.9 vs. 12.6 --- 2.1 years, t = 3.0, p < 0.01).
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Study participants completed the SCREENER, and the Patient Acceptability Questionnaire (PAQ). The SCREENER is a self-administered questionnaire which was designed to screen for 15 DSM-IV Axis I disorders in five areas selected because of their demonstrably high prevalence in primary care-depression, anxiety, substance use, somatoform disorders, and eating disorders. All SCREENER questions are answered yes or no. The SCREENER scales have demonstrated good internal consistency, and convergent and divergent validity [30]. The diagnostic validity of the SCREENER in comparison to a definitive, "gold standard" psychiatric diagnosis (e.g., the Structured Clinical Interview for DSM-IV [26] has not been established. The average patient can complete the SCREENER in approximately l0 minutes. The Patient Acceptability Questionnaire (PAQ) [27] is a 13-item questionnaire which includes questions about patients' attitudes about screening for psychiatric disorders. One question on the PAQ was "How often should your doctor ask a few questions about emotional or nerve problems as part of their evaluation?," with response options of "every time I see the doctor," "on yearly check-ups," "only when an emotional, nerve, drug, or alcohol problem is suspected," and "not at all." Another question on the PAQ was "How often should you be given a brief questionnaire on emotional, nerve, drug, and alcohol problems when visiting your medical doctor?," with the same response options. The PAQ also included four questions assessing the degree to which the patients were annoyed, embarrassed, upset, or uncomfortable with the questions on the SCREENER (very much, somewhat, a little, not at all). The PAQ also contained questions about whether the SCREENER was too long, too short, or just right; whether the SCREENER was easy or difficult to complete; and about whether it would be easy or difficult to talk to the primary care physician about an emotional, nerve, drug, or alcohol problem. Finally, the PAQ included questions about lifetime history of "mental health care (counselor, psychiatrist, psychologist)," frequency of primary care visits, and self-rated global evaluations of current physical and emotional health. We dichotomized the global health ratings into excellent or good vs. fair or poor, as have other investigators [28]. No data are available regarding the reliability or validity of the PAQ. Because of missing data, the sample size varied by analysis. Comparison of categorical variables used the X2 statistic, or Fisher's exact test when the expected value in one or more cells of the 2 × 2 table was less than 5. We calculated Pearson correlation coefficients between continuous scales, and Spearman correlation coefficients between dichotomous scales and continuous scales. Significance tests were twotailed. Statistics were calculated using SPSS-PC.
RESULTS T a b l e I p r o v i d e s t h e d e m o g r a p h i c c h a r a c t e r i s t i c s o f the s a m p l e . T h e m a j o r i t y o f t h e p a t i e n t s w e r e f e m a l e , u n m a r r i e d , b l a c k , high s c h o o l g r a d u a t e s . T h e d e s i r e d f r e q u e n c y o f m e n t a l h e a l t h s c r e e n i n g v a r i e d d e p e n d i n g o n which question patients were answering. Regarding the question, "How often should your d o c t o r ask a few q u e s t i o n s a b o u t e m o t i o n a l o r n e r v e p r o b l e m s as p a r t o f t h e i r e v a l u a t i o n ? , " 37.8% (217 o f 573) r e s p o n d e d " e v e r y t i m e I see t h e d o c t o r , " 25.1% (144 o f 573) " o n y e a r l y c h e c k - u p s , " 34.4% (197 o f 573) " o n l y w h e n an e m o t i o n a l , n e r v e , d r u g , o r a l c o h o l p r o b l e m is s u s p e c t e d , " a n d o n l y 2.6% (15 o f 573) " n o t at all." R e g a r d i n g t h e q u e s t i o n , " H o w o f t e n s h o u l d y o u b e given a b r i e f q u e s t i o n n a i r e on e m o tional, n e r v e , drug, a n d a l c o h o l p r o b l e m s w h e n visiting y o u r m e d i c a l d o c t o r ? , " 10.7% (61 o f 569) r e s p o n d e d " o n e a c h visit," 41.7% (237 o f 569) " a t y e a r l y c h e c k ups," 2 9 % (166 o f 569) " o n l y w h e n a n e m o t i o n a l , n e r v e , drug, o r a l c o h o l p r o b l e m is s u s p e c t e d , " a n d 18.5% (105 o f 569) " n e v e r . " Thus, 6 3 % o f p r i m a r y c a r e p a t i e n t s feel t h a t t h e i r d o c t o r s h o u l d p e r f o r m m e n t a l h e a l t h s c r e e n i n g p e r i o d i c a l l y , e i t h e r a n n u a l l y o r at e a c h visit, a n d o n l y 2 . 6 % t h i n k t h a t he s h o u l d n e v e r i n q u i r e a b o u t m e n t a l h e a l t h . A p p r o x i m a t e l y o n e t h i r d o f t h e p a t i e n t s w a n t t h e i r p h y s i c i a n to b e vigilant a n d m a i n t a i n s o m e i n d e x o f s u s p i c i o n r e g a r d i n g p s y c h i a t r i c illness, a n d to ask if he s u s p e c t s a p r o b l e m , r a t h e r t h a n c o n s i d e r i n g it o u t s i d e o f his p r o f e s sional d o m a i n . F i f t y - t w o p e r c e n t o f p a t i e n t s feel t h a t t h e i r d o c t o r s h o u l d use a q u e s t i o n n a i r e to p e r f o r m m e n t a l h e a l t h s c r e e n i n g p e r i o d i c a l l y , e i t h e r a n n u a l l y o r at e a c h visit, a n d
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Table l.--Demographic characteristics of 601 primary care patients* Gender, % (no.) Male Female Marital status, % (no.) Single Married Separated Divorced Widowed Education Mean _+ so, years High school graduates, % (no.) Age Mean - SD, years />60, % (no.) Race, % (no.) White Nonwhite
18.7 (ll0) 81.3 (477) 49.6 (283) 32.5 (185) 5.8 (33) 7.5 (43) 4.6 (26) 12.6 _ 2.1 81.9 (476) 39.4 _+ 15.2 12.9 (76) 13.5 (78) 86.5 (499)
* Sample size varied for each variable because of missing data as follows: gender, n = 587; marital status, n = 570; education, n = 581; age, n = 588; and race, n = 577; 485 of the 499 nonwhites were black, and 14 were Hispanic or Asian.
18.5% think that he should never use a questionnaire to evaluate their mental health. Patients' attitudes toward mental health screening are m o r e positive if it is to be accomplished by brief physician interview than by questionnaire. Because the responses regarding desire for periodic evaluation differed according to the proposed m e t h o d of assessment, we examined the effect of patient characteristics on desired frequency of evaluation separately for each of the two assessment methods. For the purpose of these analyses, we dichotomized the patients into those who wanted their physician to evaluate them at every visit or annually versus those who wanted evaluation only when the physician suspected a problem or never. This dichotomization compares patients who think their physician should have a program of periodic screening of apparently asymptomatic patients to patients who think that he should not. G e n d e r and race had no effect on preferred frequency of screening by physician interview (Table II). Patients with a history of mental health treatment, approximately a quarter of the sample, were m o r e likely to r e c o m m e n d regular evaluation, as were patients who screened positive for at least one psychiatric disorder, and patients with fair or p o o r subjective mental health, or subjectively fair or p o o r physical health. Patients who were unmarried were m o r e likely to prefer regular evaluation. Patients who desired regular physician evaluation were significantly younger (38.2 ± 14.5 vs. 41.1 __+ 15.8, t = -2.19, p < 0.05), and had reported m o r e psychiatric symptoms on the S C R E E N E R (10.9 ± 9.8 vs. 8.0 ± 7.7, t = -3.96, p < 0.001). The predictors of wanting regular screening by questionnaire were similar (Table III). Women, patients who screened positive for at least one disorder on the S C R E E N E R , and patients with a history of mental health treatment were more likely to r e c o m m e n d regular screening. Patients who felt that a brief screening questionnaire should be given annually, or at each visit, were significantly younger than patients who did not (37.3 ± 13.6 vs. 41.5 _+ 16.5, p < 0.01), and had reported m o r e
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Table II.---Predictors of primary care patient desire for periodic mental health screening by physician interview Desire periodic screening Gender, % (no.) Male Female Marital status, % (no.) Married Not married Race, % (no.) White Nonwhite Education, % (no.) >12 years <12 years Subjective physical health, % (no.) Good-excellent Fair-poor Subjective mental health, % (no.) Good-excellent Fair-poor History of mental health treatment, % (no.) No Yes Screener No disorders One or more disorders
Do not desire periodic screening
56.6 (60) 64.0 (293)
43.4 (46) 36.0 (165)
54.9 (96) 66.7 (250)
45.1 (79) (p<0.01) 33.3 (125)
64.9 (50) 62.1 (296)
35.1 (27) 37.9 (181)
62.7 (289) 64.9 (63)
37.3 (172) 35.1 (34)
60.1 (252) 70.8 (109)
39.9 (167) (p<0.05) 29.2 (49)
61.3 (301) 73.2 (60)
38.7 (190) (p<0.05) 26.8 (22)
58.8 (264) 78.2 (97)
41.2 (185) (p<0.001) 21.8 (27)
54.4 (123) 68.6 (238)
45.6 (103) (p<0.001) 31.4 (109)
psychiatric symptoms on the S C R E E N E R (10.4 _+ 9.1 vs. 8.9 _ 8.3, t = -2.00, p < 0.05). The relationships between these various predictors of desiring regular screening were not such that all of the variation could actually be attributed to a single variable. Patients who had a disorder on the S C R E E N E R were slightly younger, more likely to consider themselves in poor mental and physical health, and more likely to have had mental health treatment. However, women were not significantly more likely to have had mental health treatment or to consider themselves in poor mental health, nor were unmarried or younger persons. There was no significant correlation between how frequently patients felt they should be assessed by questionnaire and how annoyed (r = 0.03, NS), embarrassed (r = 0.04, NS), or uncomforl:able (r = 0.02, NS) the S C R E E N E R made them feel, and only a trivial correlation (r = 0.09, p < 0.05) with how upset it made them feel, indicating that patients' opinions as to how often they should be screened were not based on how much negative affect was evoked by completing the S C R E E N E R . DISCUSSION
The patients in this study overwhelmingly indicated that their physician should evaluate them for the presence of psychiatric illnesses either regularly, or at least
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J. D. LISH et aL Table III.--Predictors of whether primary care patients desire periodic mental health screening by questionnaire
Gender, % (no.) Male Female Marital status, % (no.) Married Not married Race, % (no.) White Nonwhite Education, % (no.) >12 years <12 years Subjective physical health, % (no.) Good-excellent Fair-poor Subjective mental health, % (no.) Good-excellent Fair-poor History of mental health treatment, % (no.) No Yes Screener No disorders One or more disorders
Desire periodic screening
Do not desire periodic screening
39.2 (40) 55.0 (252)
60.8 (62) 45.0 (206) (p<0.01)
48.0 (84) 54.2 (201)
52.0 (91) 45.8 (170)
52.1 (38) 52.8 (252)
47.9 (35) 47.2 (225)
52.6 (241) 50.0 (48)
47.4 (217) 50.0 (48)
53.1 (220) 50.3 (78)
46.9 (194) 49.7 (77)
51.9 (254) 55.0 (44)
48.1 (235) 45.0 (36)
50.0 (224) 61.2 (74)
50.0 (224) (p<0.05) 38.8 (47)
45.5 (101) 56.8 (197)
54.5 (121) (p<0.001) 43.2 (150)
when he suspects that they may have a disorder. The majority of patients indicated that their doctor should have a program of regular screening. Patients appeared to be more positive toward such a program if it would be performed by physician interview rather than by questionnaire. Although patients did not experience significant discomfort from completing a self-report screening questionnaire, more patients recommended regular screening if it would be done by the physician himself. This may indicate that patients feel more comfortable revealing personal information to a physician with whom they have an ongoing relationship to recording it in writing, and/or that they think the symptoms covered by the S C R E E N E R are important health matters that warrant their physician's time and personal attention. One caveat regarding this interpretation of our data is that the questions on the P A Q regarding screening by questionnaire and by physician were inadvertently worded differently. That is, the question about screening by questionnaire referred to "emotional, nerve, drug or alcohol problems," whereas the question about physician interviewing referred only to "emotional or nerve problems." It is possible that patients' less positive responses to the latter question were not because of the mention of a questionnaire rather than an interview but because it mentioned drug and alcohol problems, which might be more stigmatized than "emotional or nerve problems." On the other hand, it is possible that the more positive responses regarding physician interview are because patients would prefer physician interview to ques-
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tionnaire screening. Our inadvertent confounding of these two issues is a limitation of this study. Another limitation is that all of the patients had been confronted with an actual screening questionnaire, whereas patients may or may not have been exposed during the same visit to a brief physican interview regarding mental health. It is possible that some patients who responded positively to a hypothetical physician interview might have responded more negatively to an actual physician interview. The major limitation of this study is that it was limited to a single, urban, hospitalbased group practice. The respondents were predominantly female, black, unmarried high school graduates, and thus not representative of the population of U.S. primary care patients. While primary care practice samples invariably contain more women, this sample has an unusually low number of men. Another limitation of this study is that a relatively large number of analyses were performed, raising the chances of a type I error (incorrectly rejecting a true null hypothesis). The most important point regarding this study is that our findings are not at all consistent with U.S. primary care practitioner beliefs that patients do not want their doctors to evaluate them for the presence of psychiatric disorders. Fully 62% of patients believe that their physician should maintain periodic surveillance of the mental health of apparently asymptomatic patients, and fewer than 3% believe that their physicians should never evaluate them psychiatrically. Patients appear to have a significantly more positive attitude than physicians believe they have toward mental health evaluation by primary care physicians. Our findings show that a minority of patients will experience some discomfort when a doctor asks questions about psychiatric symptoms or substance abuse. Nonetheless, nearly all patients, and most of those who experience discomfort, do want their physician to perform this uncomfortable procedure. This implies that, with mental health screening as with other discomforting medical procedures such as flexible sigmoidoscopy, patients feel they should and can tolerate the slight discomfort or inconvenience of a screening procedure applied to all, in return for the potential benefit to their health if they should be found to be one of the patients with the disorder being screened for. Increased primary care practitioner diagnosis of depression is advocated by the U.S. Agency for Health Care Policy and Research [29], and increased primary care practitioner diagnosis of a broader range of psychiatric disorders is extremely desirable on public health and economic grounds which have been adequately articulated elsewhere [30]. However, a mistaken belief on the part of some U.S. primary care physicians that patients do not want their psychiatric illnesses to be diagnosed apparently functions as a barrier to the achievement of this important public health goal. There are many formidable barriers to primary care physician diagnosis of psychiatric disorders, including physician time constraints, inadequate physician education and training, prejudicial physician attitudes toward mental illness, inadequate physician compensation for mental health evaluation and treatment, inadequate mental health treatment resources, and discriminatory health insurance coverage for mental illness [14, 31-35]. However, patient disinclination to be psychiatrically diagnosed by their primary care physicians does not, in fact, appear to be an important obstacle.
REFERENCES 1. SchulbergHC, Burns BJ. Mental disordersin primarycare: epidemiologic,diagnostic,and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.
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2. Katon W, Schulberg HC. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992;14:237-247. 3. Sato T, Takeichi M. Lifetime prevalence of specific psychiatric disorders in a general medicine clinic. Gen Hosp Psychiatry 1993;15:224-233. 4. Von Korff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic. Arch Gen Psychiatry 1987;44:152-156. 5. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry 1993;54:405-418. 6. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;B2:914-919. 7. Coryell W, Noyes R, Clancy J. Excess mortality in panic disorder: a comparison with primary unipolar depression. Arch Gen Psychiatry 1982;43:701-703. 8. Weissman MM, Klerman GL, Markowitz JS, Ouellette R. Suicidal ideation and attempts in panic disorder. N Engl J Med 1989;321:1209-1214. 9. Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL. Quality of life in panic disorder. Arch Gen Psychiatry 1989;46:984-992. 10. Zung WWK, Broadhead E, Roth M. Prevalence of depressive symptoms in primary care. J Fam Pract 1993;37:337-344. 11. Rost K, Smith GR, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 1994;3:333-337. 12. Linn LS, Yager J. Recognition of depression and anxiety by primary physicians. Psychosomatics 1984;24:593~00. 13. Keller MB. Depression underrecognition and undertreatment by psychiatrists and other health care professionals. Arch Int Med 1990;150:946-948. 14. Main DS, Lutz LI, Barrett JE, Matthew J, Miller RS. The role of primary care clinician attitudes, beliefs, and training in the diagnosis and treatment of depression: a report from the Ambulatory Sentinel Practice Network Inc. Arch Fam Med 1993;2:1061-1066. 15. Orleans CT, George LK, Houpt JL, Brodie HKH. How primary care physicians treat psychiatric disorders: a national survey of family practitioners. Am J Psychiatry 1985;142:52-57. 16. Reynolds RD. Practice commentary [editorial]. Arch Fam Med 1993;2:84. 17. Parchman ML. Physician's recognition of depression. Fam Pract Res J 1992;12:431-438. 18. Broadhead WE. Misdiagnosis of depression: physicians contribute to the stigmatization of mental illness. Arch Fam Med 1994;3:319. 19. Frowick B, Shank JC, Doherty WJ, Powell TA. What do patients really want? Redefining a behavioral science curriculum for family physicians. J Fam Pract 1986;23:141-146. 20. Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care 1989;27:1027-1035. 21. Hansen JP, Bobula J, Meyer D, Kushner K, Pridham K. Treat or refer: patients' interest in family physician involvement in their psychosocial problems. J Fam Pract 1987;24:499-503. 22. May S. Patient satisfaction and the detection of psychiatric morbidity in general practice. Fam Pract 1992;9:76-81. 23. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32:175-181. 24. Marvel MK. Involvement with the psychosocial concerns of patients: observations of practicing family physicians on a university faculty. Arch Fam Med 1993;2:629-633. 25. Yaffe M J, Stewart MA. Patient's attitudes to the relevance of nonmedical problems in family medicine care. J Fam Pract 1986;23:241-244. 26. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-IV (SCID). Washington, DC: American Psychiatric Association 1993. 27. Zimmerman M, Farber NJ, Hartung J, Lush DT, Kuzma MA. Screening for psychiatric disorders in medical patients: a feasibility and patient acceptance study. Med Care 1994;32:603--608. 28. McHorney CA, Ware JE, Raczek A. The MOS 36-item short form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993;31:247-263. 29. Depression Guideline Panel. Depression in primary care: detection, diagnosis and treatment. Quick reference guide for clinicians, no. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research 1993. 30. Zimmerman M, Lish JD, Farber NJ, Hartung J, Lush DT, Kuzma MA, PlesciaG. Screening for depression in medical patients: is the focus too narrow? Gen Hosp Psychiatry 1994;16:388-396. 31. Rost K, Humphrey J, Kelleher K. Physician management preferences and barriers to care for rural patients with depression. Arch Fam Med 1994;3:409-414.
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32. Marks JN, Goldberg DP, Hillier VF. Determinants of the abilities of general practitioners to detect psychiatric illness. Psychol Med 1979;9:337-353. 33. Domenici PV. Mental health care policy in the 1990's: discrimination in health care coverage of the seriously mentally ill. J Clin Psychiatry 1993;54:5-6. 34. MacGruder-Habib K, Zung WWK, Feussner JR. Improving physicians' recognition and treatment of depression in general medical care. Med Care 1990;28:239-250. 35. Epstein, D. Treating patients for depression: is primary care the appropriate first stop? Am Coll Phys Observ 1994;14:1.