- Email: [email protected]
WHO OUGHT TO SEE A PSYCHIATRIST ?
1092
Points of View WHO OUGHT TO SEE A PSYCHIATRIST ? M.B.
NEIL KESSEL Cantab., M.R.C.P., D.P.M.
ASSISTANT DIRECTOR, M.R.C. UNIT FOR RESEARCH ON THE EPIDEMIOLOGY ILLNESS, DEPARTMENT OF PSYCHOLOGICAL MEDICINE,
OF PSYCHIATRIC
UNIVERSITY OF EDINBURGH
WHO ought to receive psychiatric care in Britain today ? The processes by which people at present obtain it are devious and often arbitrary. Within the context of our semi-affluent health service it is pertinent to examine them. In some ways it is fortuitous to single out psychiatric care for similar considerations apply in other specialties. Our tripartite medical system creates a general problem. Patients often have to be transferred from family doctor to specialist, and the separate administration of the hospital service and general practice makes this more complex than it ought to be. In one respect, however, psychiatry is atypical. The limits of its competence are not agreed. Partly the psychiatrist has fixed them himself, to be followed, with tolerant reluctance, by other doctors. Partly they have been set by the importunity of a public none too critically informed. Lewis (1953) expressed this dichotomy when he wrote that the psychiatrist is " asked to investigate and treat disturbances of behaviour in children which can hardly be included within any warranted conception of illness.... It may be that there is no form of social deviation in an individual which psychiatrists will not claim to treat or prevent-the pretensions of some psychiatrists are extreme." Both psychiatrist and public contribute to the growing demand for psychiatric care. Thus some psychiatrists consider that the techniques they have developed can help people with a variety of human problems and overstep the traditional boundaries of medicine; while patients tend to ask for psychiatric attention because they have troubles and believe that psychiatry holds the answer. Usually these requests are made through the family doctor, who has little option but to arrange for a psychiatric consultation. Such is the case, for instance, where this is suggested by lawyers or by the courts. There is also a small but increasing demand for the right of self-referral. Many
patients already directly approach privately practising psychiatrists; and some groups, such as students (Read 1954) and people in industry (Jaques 1951), have direct access to a psychiatrist serving their organisation. Those who oppose these tendencies are in a weak position. Many people who are not medically qualified are capable of recognising that a condition is psychological-often better than some doctors. For this reason we number of direct referrals to increase.
can
expect the
CHOICE OF PATIENT
The largest number of referrals, however, still come from the family doctor. How does he decide when to obtain psychiatric care for patients who come to him with psychiatric conditions, overt or covert ? In a small series of patients who were recognised by their general practitioner as having conspicuous psychiatric morbidity but who had not been referred, two psychiatrists found clinical syndromes akin in type and severity to those with which they were daily familiar in psychiatric outpatient clinics (Kessel 1960). The general practitioners could not tell why these particular patients had not been referred nor, conversely, what were their criteria for
selection. Certainly selection was occurring, since only a tenth of the psychiatric patients were sent to a psychiatrist. Psychotics, for the most part, got themselves to psychiatric attention, but they were only a small proportion of the doctors’ case-load. Comparison of age-rates for neuroses in general practice and psychiatric outpatient clinics shows that young people are more likely to be referred (Kessel and Shepherd 1962). There are probably three reasons for this. The practitioner may have higher hopes for successful treatment of the less ingrained neuroses of young adults. There is more pressure on him to take action, because neuroses at this age are more eruptive and difficult for the family to contain. In older people neuroses somehow become linked to physical infirmities, and they are more likely to have bodily complaints which the doctor, feeling himself more secure, is inclined to accept at face value. If neurotic patients with somatic symptoms need specialist care, probably they will be sent to a nonpsychiatric clinic. Shepherd, Davies, and Culpan (1960) found that a large proportion of patients at general medical and surgical clinics suffer primarily from psychological disorders. Priest (1962), a general physician, described 1000 consecutive outpatients seen at his clinic. A sixth of them had neuroses and nothing else; psychosomatic conditions were excluded. Strangely enough he considered that this figure " did not imply any misuse of the hospital services". Davies (1958) has shown that the diagnosis of neurosis was often in the mind of the referring doctor who might, however, have wished to have physical disease excluded or to turn to therapeutic account the reassuring effect of careful examination and investigation in the prestige-laden atmosphere of the hospital. Whether such management has the intended therapeutic effect would be worth studying. Hopkins (1955) noted that some of these patients return to their own doctors bewildered because their symptoms persist though they had been told there was nothing wrong. Others continue to attend for investigation and treatment at the clinic, especially where the exclusion of a physical lesion is difficult. Physical-medicine departments are often reservoirs of neurotic patients. Referral-rates vary from doctor to doctor. Propinquity of the doctor’s surgery to the clinic leads to high referralrates (Hare 1959). Certainly supply of psychiatric services creates demand; whenever a new outpatient clinic is opened it is very soon fully used. Rawnsley and Loudon (1962a) considered that the wide range of referral-rates from six general practices in a South Wales mining valley could not be accounted for by social and demographic variations in the populations at risk, nor by selective recruitment of psychiatric patients to the list of certain practices. Nor was it related to variations in clinical severity or diagnosis of the patients referred. Fry (1959) cited five factors influencing referral-the doctor, the patient, the illness, the hospital, and the area. Rawnsley and Loudon (1962b) found that the doctor’s attitude to psychiatry and psychiatrists powerfully affected the number of people he referred. 3 out of the 8 doctors they interviewed also said that pressure from relatives influenced their decisions, and this is a sixth factor to be added to Fry’s five. Mowbray et al. (1961) found that most doctors did not refer patients on the basis of a diagnosis, but in their letters cited chiefly abnormalities of conduct, social
problems,
or
"
inappropriate
responses
to
medical
1093
Though abnormalities of conduct may be the other two items are not, unless matters, psychiatric positive psychological features are present. Richards (1960) discovered that, though over half a series of patients sent to a psychiatric outpatient department had been treated for their present illness by their general practitioner in only a third was failure of treatment the principal reason for referral. Indeed, some patients appeared to the doctor to have been helped by his treatment, but they were referred all the same. A third of the referrals had been instigated by the patient or his relatives. One must doubt whether this proportion would be as high in any other attention".
specialty. Clearly general practitioners are not using the correct criteria when selecting patients to send to a psychiatrist. Not diagnosis, not clinical severity, not failure of treatment are their reasons. Young adults are more likely to be referred than older people. -Pressure from the patient his relatives exerts considerable influence, and the doctor’s own attitude is important. Non-clinical considerations, in fact, are among the most weighty in the choice of patients. What is the reason for, this ? I suggest that it is because few general practitioners know what psychiatrists do. Unless they qualified recently, probably no part of their undergraduate training was pertinent to the management of neuroses. Many general practitioners have overcome this handicap in so far as their own psychiatric work is concerned, but they remain in ignorance of what psychiatrists do. or
THE PSYCHIATRIST AND HIS MYSTERIES
surrounded by an aura of mystery, of doings and this is entirely because few general magic even, attended a psychiatric outpatient have ever practitioners is the heart of the Here clinic. problem. During his will the student have training spent some time in the outof every other specialty, will learn patient department what happens there, and which cases may be profitably referred. But in psychiatry the mystique has been preserved and doctors enter practice lacking experience of whom to send to outpatients, and of the kinds of patient that psychiatrists can most appropriately handle there. It is less generally appreciated that this is also true of many psychiatrists; they too may have idiosyncratically invented their own ideas of the outpatient clinic transaction. Most psychiatrists have been trained in mental hospitals, not teaching centres, and their training has been almost exclusively in the management of the psychotic patients for whom these hospitals were designed. Outpatient clinics are a recent development in mental hospital practice. Originally most of them provided little more than aftercare of discharged inpatients. However, it has been estimated that nowadays about half the patients seen at these clinics have neuroses (Hare 1959, Kessel and Shepherd 1962). The psychiatrist’s time for clinic work is so restricted that to see all the patients sent to him he can often give them little longer than their own doctor, who may already know a good deal of their history. Moreover, any training in the management of outpatients that the psychiatrist has is likely to have been almost completely unsupervised. Only the patients and himself know what went on in those little offices. Carstairs and Bruhn (1962) mournfully relate: " Short term treatments with relatively brief interviews and much reliance on drugs is the rule.... British practice approximates rather closely to that of the busy doctor’s surgery-both in its concentration upon somatic These
are
symptoms and somatic remedies and in its tendency to neglect the time-consuming but vitally important task of taking a full social history and appraising the patient’s current personal problems." In 1946 Blacker could describe: "
practitioner is confronted with what is for him a difficult psychological ’ case ... and sends the patient up with a letter. Later, the patient returns with an unfavourable report on the clinic ... She was interviewed by a doctor who seemed td be in a hurry, asked her a lot of peculiar questions (and) did not examine her physically ... In due course the practitioner receives a short letter saying that the patient is suffering from an anxiety state with features of depression and that the possibility of schizophrenia must be borne in mind. He finds the letter quite unhelpful and the patient is no better for her visit to A
the clinic."
Is the position so very different today ? Of the 8 doctors interviewed by Rawnsley and Loudon (1962b), 4 had less confidence in psychiatric reports than in those from other specialties. 4 had little confidence in ,the physical therapies used by psychiatrists. Psychological treatments fared little better. These attitudes spring a failure to understand the purposes of from principally Yet where can doctors turn to learn a referring patient. these purposes ? THE BEST GUIDANCE WE HAVE
only British book devoted exclusively to in psychiatry general practice, Watts and Watts (1952) are cryptically oracular: " If the practitioner feels he has reached an impasse, he should refer the case to a In the
psychiatrist." Craddock (1958) suggests that a psychiatrist should be If consulted " immediately " for five types of patient: there is any real dread of killing or suicide ’as distinct from empty threats ’; if there is a phobia which does not yield easily; if the difficulties are deep-seated and evaluation has no effect; if a psychogenic cause for symptoms is suspected but cannot be found; if the condition is longstanding, particularly in older people." There is little help here for the practitioner seeking guidance. The categories are far too broad and vague. Pinsent (1953) considers that the practitioner should ask himself the following questions in deciding whether to advise a consultation. Is the patient aware of the nature of his condition ? Is he a danger to himself or to others ? Will the patient cooperate in treatment aimed at restoring "
him to normal ? Is he unable to manage his own domestic and other affairs ? Is there evidence of mental disability ? But surely these are questions to be asked if one is considering admission to mental hospital. There are other reasons for advising a consultation. What do the psychiatrists say? Guttmann (c. 1945) wrote: "
It is where no specific cause can be assigned to the patient’s illness or where the symptoms do not fit a pattern which can easily be related to the known circumstances of the case, that the need for referral on diagnostic grounds most usually arises. It is a sound rule to refer for diagnosis any patient who seeks advice for purely psychological symptoms such as fears, depression, convulsions, unless the doctor is able to spend sufficient time for a diagnostic interview himself. The same is true of patients worried or partially incapacitated by vague, somatic or psychosomatic symptoms for which the practitioner is puzzled to find a cause. Roughly the same rules apply to the chronic neurotic with an acute exacerbation of his symptoms." ...
Thus he would have the
number, possibly
a
general practitioner refer a great third, of his patients. Perhaps it was
with this in mind that Blacker warned that
a
"
descent
1094
in vast multitudes upon the psychiatric clinics of this country might be caused by nothing more than an alteration of standpoint among general practitioners ". Blacker
recognised three main groups of patients who are sent to the psychiatric clinic: those with disordered behaviour, those where the doctor wanted a diagnosis and guidance in management, and those where a course of needed which was outside the doctor’s There is, however, no guide to help the practitioner decide which patients fall into the last two treatment was resources.
groups.
Leigh and four general practitioners (Bodkin et al. 1953) recommend that psychotics, mental defectives, and the depressed patient should be referred. Of neurotics they say: " On the whole we have devoted our main energies to young, intelligent people who show good evidence of dealing with most facets of life on a realistic basis and whose neurotic symptoms are of recent origin. We have had no hesitation in rejecting for treatment cases which we have considered as falling into the category ...
of chronic neurosis."
Yet elsewhere in the
same
paper,
discussing psychoneurosis, they write: " The treatment of these patients is largely beyond the capacity of the general practitioner." So apparently the general practitioner cannot treat them and the psychiatrist will not. And what about
acute
neurotics who
are
neither young
nor
intelligent? Only Leigh and his colleagues give specific recommendations, simple to understand, and which take into account the limited psychiatric time available. But their defeatist position will not commend itself to many general practitioners. Psychiatrists themselves do not agree about who should be referred. One psychiatrist would like referrals limited to the insane or nearly so, while another believes that help should be offered to everyone seeking it, no matter what the condition. The views of rival schools cannot be The general practitioner, however, He wants cares little for such schismatic scholasticism. to know what sort of cases psychiatrists feel they can usefully treat, and he would like these to bear some relation to the patients he finds hard to manage.
readily reconciled.
general practitioner, for his part, often fails to pass the psychiatrist important pieces of relevant information. Almost invariably he does not tell the psychiatrist whether he is himself willing to manage a case if he is given advice. In general medicine the respective roles of the specialist and the family doctor are fairly clearly recognised, but in psychological medicine this is not so. Today this is being overcome by letting medical students watch psychiatrists at work and so learn their functions, but it is unnecessary to wait until the effects of educational progress make themselves widely felt. The
on to
Psychiatrists need to discuss what sorts of patients they wish to see. Should they urge general practitioners to send them more patients or fewer; patients freshly diagnosed or only those who have not responded to treatment ; easier cases that might be helped fairly simply and quickly, or more difficult cases needing protracted treatment ; only cases with psychological symptoms or patients with somatic complaints thought psychogenically determined ? Do psychiatrists want general physicians and surgeons to refer more of their neurotic patients ? Do psychiatrists want routine referral for certain behaviour such as attempted suicide or persistent truancy ? Do psychiatrists want to encourage lay bodies and individuals
psychiatric aid ? On the answers to such questions depends the proper planning of a psychiatric service.
to
seek
CONCLUSION
Partly because it has oversold itself, psychiatry has It is the mid-20th-century become oversubscribed. panacea, and some psychiatrists are far from educating the public otherwise. So long as treatment facilities remain limited, psychiatrists face a dilemma. They need to appraise and guard their therapeutic potential, so that those people most likely to benefit receive most of the available time. Yet psychiatrists are public servants and they cannot repudiate the role that the public awards them. Some resolution of this situation is possible. Psychiatrists will not be able to resist increasing public demand for their services, and indeed they should welcome it. General practitioners and specialists should be encouraged to refer patients freely when they want advice. They must be firmly dissuaded from allowing their practice to be influenced by their prejudices. For patients other than neurotics, the advice of Leigh and his co-authors may serve as a guide, bearing in mind that depression can wear a hundred disguises. In deciding whether to refer neurotic patients, his largest psychiatric group, the general practitioner should not stand upon niceties of diagnosis nor on length of history, but use two criteria for selection: first, clinical severity, judged both by the degree of distress that the illness is causing to the patient and by the amount of social disability that it engenders; and, secondly, failure to respond to treatment. At present many patients are referred before the family doctor has used his own therapeutic armoury or waited to see its effects. He must accept that his resources extend beyond the prescription pad and that it is as much his function to perform planned minor psychotherapy as planned minor surgery. At least for a transitional period, more patients are likely to be referred, though probably not as many as predicted by some’Cassandras. To meet this the psychiatric clinic will have to become more consultative than at present. Some patients will have no psychiatric disorder, and the psychiatrist must recognise them and state firmly that distress due to social difficulties is not synonymous with psychological illness. In many uncomplicated cases he should draw up plans for treatment, pharmacological or psychotherapeutic, clear enough for general practitioners to carry out. He must give a realistic prognosis and a treatment goal. The numbers of patients he need treat himself should not rise considerably, and the extra case-load may be offset by economies in therapeutic time gained by group therapy. The psychiatric outpatient clinic, both in its purposes and in its processes, can be redesigned and modernised to deal with a bigger demand with greater efficiency. For such a programme there must be local discussions. Meetings between psychiatrists and general practitioners are increasing, but these clubs-a word chosen to describe the small but faithful band of regular attenders-mostly spend the time discussing individual patients. It might be profitable for them to consider the respective potentialities of general practitioner and specialist treatment and the kinds of patients suitable for referral, depending on the interests and abilities of the particular doctors concerned. Practice will not wait for formal answers to the questions posed in this paper, but current practice is faulty and some theorising and discussion would References
at
be
timely.
foot of next column
Special
Articles
TABLE I-ECTROMELIA AND MICROTIA IN CHILDREN BORN IN
1962
THE INCIDENCE OF LIMB AND EAR DEFECTS SINCE THE WITHDRAWAL OF THALIDOMIDE R. W. SMITHELLS M.B. Lond., M.R.C.P., M.R.C.P.E., D.C.H. LECTURER IN CHILD HEALTH, UNIVERSITY OF LIVERPOOL; CONSULTANT PÆDIATRICIAN, ALDER HEY CHILDREN’S HOSPITAL, LIVERPOOL
IAN LECK M.B., Ph.D. Birm. LECTURER IN SOCIAL MEDICINE, UNIVERSITY OF BIRMINGHAM
SEVERAL investigators have suggested that the recent epidemic of limb and ear defects may not be attributable entirely to thalidomide. In studies based on 30, 60, and 500 cases respectively, Petersen (1962), Smithells (1962a), and the Ministry of Health (1962) were unable to establish that thalidomide had been taken by more than about half of the mothers of children with major limb defects. Similar defects have been reported in a few children born after the administration of other drugs (Carter and Wilson 1962, Corner 1962, Cullis 1962, Dunn et al. 1962, Fagg 1962, Frost 1962, Giroud and Tuchmann-Duplessis 1962, Moss 1962, Watson 1962). In Birmingham there was a small epidemic of reduction deformities of the thumbs and radii (associated in most cases with other malformations like those caused by thalidomide), which preceded the introduction of thalidomide by several months (Leck and Millar 1963). As retrospective information about drugs taken during pregnancy is often unreliable, the role of thalidomide in the recent outbreak of limb defects cannot be fully evaluated except by exploring the correlation between thalidomide consumption and the incidence of these malformations over the last few years. Birmingham data for the period in which the drug was introduced were examined in this way by Leck and Millar (1962). Our purpose in this communication is (a) to report a similar study of the incidence of ectromelia and microtia among infants born in Birmingham, Liverpool, and Bootle in 1962, when the effects of withdrawing thalidomide should have become apparent; and (b) to relate our results to those obtained in previous years. We restrict the term
* L =Liverpool and Bootle.
B== Birmingham.
microtia to cases of imperforate external auditory meatus and/or absence of the auricle, and ectromelia denotes limb defects involving absence or substantial shortening of one or more long bones. The methods by which affected individuals were ascertained were similar to those used in previous years (Leck and Millar 1962, Smithells 1962b). RESULTS
16 instances of ectromelia and four of microfia were observed among 41,399 infants (including stillbirths) born in 1962 to residents of Birmingham, Liverpool, and Bootle. Table i gives details of the affected children. Phocomelia is described as proximal if only the humerus or femur was
shortened, and lower leg.
as
distal if confined
to
the forearm
3 children with ectromelia and 2 with microtia DR. KESSEL: REFERENCES
Blacker, C. P. (1946) Neurosis and the Mental Health Services. London. Bodkin, N. J., Gaze, R. B., Gomez, G., Howlett, M. J., Leigh, D. (1953) Brit. med. J. ii, 723. Carstairs, G. M., Bruhn, J. G. (1962) Sociological Review Monograph, no. 5. University of Keele. Craddock, D. (1958) Introduction to General Practice. London. Davies, B. M. (1958) Survey of Psychiatric Illness at Three General Outpatient Clinics. M.D. thesis, University of Wales. Fry, J. (1959) Brit. med. J. ii, 1322. Guttmann, L. (c. 1945) On Cases to be Referred to the Psychiatrist by the General Practitioner. Unpublished. Hare, E. H. (1959) Bethlem Royal Hospital and the Maudsley Hospital Third Triennial Statistical Report. Shrewsbury. Hopkins, P. (1955) in Modern Trends in Psychosomatic Medicine (edited by D. O’Neill). London. Jaques, E. (1951) Changing Culture of a Factory. London. Kessel, W. I. N. (1960) Brit. J. prev. soc. Med. 14, 16. - Shepherd, M. (1962) J. ment. Sci. 108, 159. Lewis, A. J. (1953) Brit. J. Sociol. 4, 109. Mowbray, R. M., Blair, W., Jubb, L. G., Clarke, A. (1961) Scot. med. J. 6, 314. Pinsent, R. J. F. H. (1953) An Approach to General Practice. London. Priest, W. M. (1962) Lancet, ii, 1043. Rawnsley, K., Loudon, J. B. (1962a) Brit. J. prev. soc. Med. 16, 174. (1962b) Sociological Review Monograph, no. 5. University of Keele. Read, J. C. (1954) Lancet, i, 822. Richards, H. (1960) Psychiatric Referrals from General Practice. D.P.M. dissertation, University of London. Shepherd, M., Davies, B. M., Culpan, R. H. (1960) Acta psychiat., Kbh. —
or
were
TABLE II-NUMBER OF CHILDREN WITH ECTROMELIA OR MICROTIA BORN IN 1960-62
—
35, 518. Watts, C. A. H., Watts, B. M. (1952) Psychiatry in General Practice. London.
*L= Liverpool and Bootle. B= Birmingham. t Children whose affected limbs were not all malformed in the same are classified according to the most severe limb defect present.
way
Points of View WHO OUGHT TO SEE A PSYCHIATRIST ? M.B.
NEIL KESSEL Cantab., M.R.C.P., D.P.M.
ASSISTANT DIRECTOR, M.R.C. UNIT FOR RESEARCH ON THE EPIDEMIOLOGY ILLNESS, DEPARTMENT OF PSYCHOLOGICAL MEDICINE,
OF PSYCHIATRIC
UNIVERSITY OF EDINBURGH
WHO ought to receive psychiatric care in Britain today ? The processes by which people at present obtain it are devious and often arbitrary. Within the context of our semi-affluent health service it is pertinent to examine them. In some ways it is fortuitous to single out psychiatric care for similar considerations apply in other specialties. Our tripartite medical system creates a general problem. Patients often have to be transferred from family doctor to specialist, and the separate administration of the hospital service and general practice makes this more complex than it ought to be. In one respect, however, psychiatry is atypical. The limits of its competence are not agreed. Partly the psychiatrist has fixed them himself, to be followed, with tolerant reluctance, by other doctors. Partly they have been set by the importunity of a public none too critically informed. Lewis (1953) expressed this dichotomy when he wrote that the psychiatrist is " asked to investigate and treat disturbances of behaviour in children which can hardly be included within any warranted conception of illness.... It may be that there is no form of social deviation in an individual which psychiatrists will not claim to treat or prevent-the pretensions of some psychiatrists are extreme." Both psychiatrist and public contribute to the growing demand for psychiatric care. Thus some psychiatrists consider that the techniques they have developed can help people with a variety of human problems and overstep the traditional boundaries of medicine; while patients tend to ask for psychiatric attention because they have troubles and believe that psychiatry holds the answer. Usually these requests are made through the family doctor, who has little option but to arrange for a psychiatric consultation. Such is the case, for instance, where this is suggested by lawyers or by the courts. There is also a small but increasing demand for the right of self-referral. Many
patients already directly approach privately practising psychiatrists; and some groups, such as students (Read 1954) and people in industry (Jaques 1951), have direct access to a psychiatrist serving their organisation. Those who oppose these tendencies are in a weak position. Many people who are not medically qualified are capable of recognising that a condition is psychological-often better than some doctors. For this reason we number of direct referrals to increase.
can
expect the
CHOICE OF PATIENT
The largest number of referrals, however, still come from the family doctor. How does he decide when to obtain psychiatric care for patients who come to him with psychiatric conditions, overt or covert ? In a small series of patients who were recognised by their general practitioner as having conspicuous psychiatric morbidity but who had not been referred, two psychiatrists found clinical syndromes akin in type and severity to those with which they were daily familiar in psychiatric outpatient clinics (Kessel 1960). The general practitioners could not tell why these particular patients had not been referred nor, conversely, what were their criteria for
selection. Certainly selection was occurring, since only a tenth of the psychiatric patients were sent to a psychiatrist. Psychotics, for the most part, got themselves to psychiatric attention, but they were only a small proportion of the doctors’ case-load. Comparison of age-rates for neuroses in general practice and psychiatric outpatient clinics shows that young people are more likely to be referred (Kessel and Shepherd 1962). There are probably three reasons for this. The practitioner may have higher hopes for successful treatment of the less ingrained neuroses of young adults. There is more pressure on him to take action, because neuroses at this age are more eruptive and difficult for the family to contain. In older people neuroses somehow become linked to physical infirmities, and they are more likely to have bodily complaints which the doctor, feeling himself more secure, is inclined to accept at face value. If neurotic patients with somatic symptoms need specialist care, probably they will be sent to a nonpsychiatric clinic. Shepherd, Davies, and Culpan (1960) found that a large proportion of patients at general medical and surgical clinics suffer primarily from psychological disorders. Priest (1962), a general physician, described 1000 consecutive outpatients seen at his clinic. A sixth of them had neuroses and nothing else; psychosomatic conditions were excluded. Strangely enough he considered that this figure " did not imply any misuse of the hospital services". Davies (1958) has shown that the diagnosis of neurosis was often in the mind of the referring doctor who might, however, have wished to have physical disease excluded or to turn to therapeutic account the reassuring effect of careful examination and investigation in the prestige-laden atmosphere of the hospital. Whether such management has the intended therapeutic effect would be worth studying. Hopkins (1955) noted that some of these patients return to their own doctors bewildered because their symptoms persist though they had been told there was nothing wrong. Others continue to attend for investigation and treatment at the clinic, especially where the exclusion of a physical lesion is difficult. Physical-medicine departments are often reservoirs of neurotic patients. Referral-rates vary from doctor to doctor. Propinquity of the doctor’s surgery to the clinic leads to high referralrates (Hare 1959). Certainly supply of psychiatric services creates demand; whenever a new outpatient clinic is opened it is very soon fully used. Rawnsley and Loudon (1962a) considered that the wide range of referral-rates from six general practices in a South Wales mining valley could not be accounted for by social and demographic variations in the populations at risk, nor by selective recruitment of psychiatric patients to the list of certain practices. Nor was it related to variations in clinical severity or diagnosis of the patients referred. Fry (1959) cited five factors influencing referral-the doctor, the patient, the illness, the hospital, and the area. Rawnsley and Loudon (1962b) found that the doctor’s attitude to psychiatry and psychiatrists powerfully affected the number of people he referred. 3 out of the 8 doctors they interviewed also said that pressure from relatives influenced their decisions, and this is a sixth factor to be added to Fry’s five. Mowbray et al. (1961) found that most doctors did not refer patients on the basis of a diagnosis, but in their letters cited chiefly abnormalities of conduct, social
problems,
or
"
inappropriate
responses
to
medical
1093
Though abnormalities of conduct may be the other two items are not, unless matters, psychiatric positive psychological features are present. Richards (1960) discovered that, though over half a series of patients sent to a psychiatric outpatient department had been treated for their present illness by their general practitioner in only a third was failure of treatment the principal reason for referral. Indeed, some patients appeared to the doctor to have been helped by his treatment, but they were referred all the same. A third of the referrals had been instigated by the patient or his relatives. One must doubt whether this proportion would be as high in any other attention".
specialty. Clearly general practitioners are not using the correct criteria when selecting patients to send to a psychiatrist. Not diagnosis, not clinical severity, not failure of treatment are their reasons. Young adults are more likely to be referred than older people. -Pressure from the patient his relatives exerts considerable influence, and the doctor’s own attitude is important. Non-clinical considerations, in fact, are among the most weighty in the choice of patients. What is the reason for, this ? I suggest that it is because few general practitioners know what psychiatrists do. Unless they qualified recently, probably no part of their undergraduate training was pertinent to the management of neuroses. Many general practitioners have overcome this handicap in so far as their own psychiatric work is concerned, but they remain in ignorance of what psychiatrists do. or
THE PSYCHIATRIST AND HIS MYSTERIES
surrounded by an aura of mystery, of doings and this is entirely because few general magic even, attended a psychiatric outpatient have ever practitioners is the heart of the Here clinic. problem. During his will the student have training spent some time in the outof every other specialty, will learn patient department what happens there, and which cases may be profitably referred. But in psychiatry the mystique has been preserved and doctors enter practice lacking experience of whom to send to outpatients, and of the kinds of patient that psychiatrists can most appropriately handle there. It is less generally appreciated that this is also true of many psychiatrists; they too may have idiosyncratically invented their own ideas of the outpatient clinic transaction. Most psychiatrists have been trained in mental hospitals, not teaching centres, and their training has been almost exclusively in the management of the psychotic patients for whom these hospitals were designed. Outpatient clinics are a recent development in mental hospital practice. Originally most of them provided little more than aftercare of discharged inpatients. However, it has been estimated that nowadays about half the patients seen at these clinics have neuroses (Hare 1959, Kessel and Shepherd 1962). The psychiatrist’s time for clinic work is so restricted that to see all the patients sent to him he can often give them little longer than their own doctor, who may already know a good deal of their history. Moreover, any training in the management of outpatients that the psychiatrist has is likely to have been almost completely unsupervised. Only the patients and himself know what went on in those little offices. Carstairs and Bruhn (1962) mournfully relate: " Short term treatments with relatively brief interviews and much reliance on drugs is the rule.... British practice approximates rather closely to that of the busy doctor’s surgery-both in its concentration upon somatic These
are
symptoms and somatic remedies and in its tendency to neglect the time-consuming but vitally important task of taking a full social history and appraising the patient’s current personal problems." In 1946 Blacker could describe: "
practitioner is confronted with what is for him a difficult psychological ’ case ... and sends the patient up with a letter. Later, the patient returns with an unfavourable report on the clinic ... She was interviewed by a doctor who seemed td be in a hurry, asked her a lot of peculiar questions (and) did not examine her physically ... In due course the practitioner receives a short letter saying that the patient is suffering from an anxiety state with features of depression and that the possibility of schizophrenia must be borne in mind. He finds the letter quite unhelpful and the patient is no better for her visit to A
the clinic."
Is the position so very different today ? Of the 8 doctors interviewed by Rawnsley and Loudon (1962b), 4 had less confidence in psychiatric reports than in those from other specialties. 4 had little confidence in ,the physical therapies used by psychiatrists. Psychological treatments fared little better. These attitudes spring a failure to understand the purposes of from principally Yet where can doctors turn to learn a referring patient. these purposes ? THE BEST GUIDANCE WE HAVE
only British book devoted exclusively to in psychiatry general practice, Watts and Watts (1952) are cryptically oracular: " If the practitioner feels he has reached an impasse, he should refer the case to a In the
psychiatrist." Craddock (1958) suggests that a psychiatrist should be If consulted " immediately " for five types of patient: there is any real dread of killing or suicide ’as distinct from empty threats ’; if there is a phobia which does not yield easily; if the difficulties are deep-seated and evaluation has no effect; if a psychogenic cause for symptoms is suspected but cannot be found; if the condition is longstanding, particularly in older people." There is little help here for the practitioner seeking guidance. The categories are far too broad and vague. Pinsent (1953) considers that the practitioner should ask himself the following questions in deciding whether to advise a consultation. Is the patient aware of the nature of his condition ? Is he a danger to himself or to others ? Will the patient cooperate in treatment aimed at restoring "
him to normal ? Is he unable to manage his own domestic and other affairs ? Is there evidence of mental disability ? But surely these are questions to be asked if one is considering admission to mental hospital. There are other reasons for advising a consultation. What do the psychiatrists say? Guttmann (c. 1945) wrote: "
It is where no specific cause can be assigned to the patient’s illness or where the symptoms do not fit a pattern which can easily be related to the known circumstances of the case, that the need for referral on diagnostic grounds most usually arises. It is a sound rule to refer for diagnosis any patient who seeks advice for purely psychological symptoms such as fears, depression, convulsions, unless the doctor is able to spend sufficient time for a diagnostic interview himself. The same is true of patients worried or partially incapacitated by vague, somatic or psychosomatic symptoms for which the practitioner is puzzled to find a cause. Roughly the same rules apply to the chronic neurotic with an acute exacerbation of his symptoms." ...
Thus he would have the
number, possibly
a
general practitioner refer a great third, of his patients. Perhaps it was
with this in mind that Blacker warned that
a
"
descent
1094
in vast multitudes upon the psychiatric clinics of this country might be caused by nothing more than an alteration of standpoint among general practitioners ". Blacker
recognised three main groups of patients who are sent to the psychiatric clinic: those with disordered behaviour, those where the doctor wanted a diagnosis and guidance in management, and those where a course of needed which was outside the doctor’s There is, however, no guide to help the practitioner decide which patients fall into the last two treatment was resources.
groups.
Leigh and four general practitioners (Bodkin et al. 1953) recommend that psychotics, mental defectives, and the depressed patient should be referred. Of neurotics they say: " On the whole we have devoted our main energies to young, intelligent people who show good evidence of dealing with most facets of life on a realistic basis and whose neurotic symptoms are of recent origin. We have had no hesitation in rejecting for treatment cases which we have considered as falling into the category ...
of chronic neurosis."
Yet elsewhere in the
same
paper,
discussing psychoneurosis, they write: " The treatment of these patients is largely beyond the capacity of the general practitioner." So apparently the general practitioner cannot treat them and the psychiatrist will not. And what about
acute
neurotics who
are
neither young
nor
intelligent? Only Leigh and his colleagues give specific recommendations, simple to understand, and which take into account the limited psychiatric time available. But their defeatist position will not commend itself to many general practitioners. Psychiatrists themselves do not agree about who should be referred. One psychiatrist would like referrals limited to the insane or nearly so, while another believes that help should be offered to everyone seeking it, no matter what the condition. The views of rival schools cannot be The general practitioner, however, He wants cares little for such schismatic scholasticism. to know what sort of cases psychiatrists feel they can usefully treat, and he would like these to bear some relation to the patients he finds hard to manage.
readily reconciled.
general practitioner, for his part, often fails to pass the psychiatrist important pieces of relevant information. Almost invariably he does not tell the psychiatrist whether he is himself willing to manage a case if he is given advice. In general medicine the respective roles of the specialist and the family doctor are fairly clearly recognised, but in psychological medicine this is not so. Today this is being overcome by letting medical students watch psychiatrists at work and so learn their functions, but it is unnecessary to wait until the effects of educational progress make themselves widely felt. The
on to
Psychiatrists need to discuss what sorts of patients they wish to see. Should they urge general practitioners to send them more patients or fewer; patients freshly diagnosed or only those who have not responded to treatment ; easier cases that might be helped fairly simply and quickly, or more difficult cases needing protracted treatment ; only cases with psychological symptoms or patients with somatic complaints thought psychogenically determined ? Do psychiatrists want general physicians and surgeons to refer more of their neurotic patients ? Do psychiatrists want routine referral for certain behaviour such as attempted suicide or persistent truancy ? Do psychiatrists want to encourage lay bodies and individuals
psychiatric aid ? On the answers to such questions depends the proper planning of a psychiatric service.
to
seek
CONCLUSION
Partly because it has oversold itself, psychiatry has It is the mid-20th-century become oversubscribed. panacea, and some psychiatrists are far from educating the public otherwise. So long as treatment facilities remain limited, psychiatrists face a dilemma. They need to appraise and guard their therapeutic potential, so that those people most likely to benefit receive most of the available time. Yet psychiatrists are public servants and they cannot repudiate the role that the public awards them. Some resolution of this situation is possible. Psychiatrists will not be able to resist increasing public demand for their services, and indeed they should welcome it. General practitioners and specialists should be encouraged to refer patients freely when they want advice. They must be firmly dissuaded from allowing their practice to be influenced by their prejudices. For patients other than neurotics, the advice of Leigh and his co-authors may serve as a guide, bearing in mind that depression can wear a hundred disguises. In deciding whether to refer neurotic patients, his largest psychiatric group, the general practitioner should not stand upon niceties of diagnosis nor on length of history, but use two criteria for selection: first, clinical severity, judged both by the degree of distress that the illness is causing to the patient and by the amount of social disability that it engenders; and, secondly, failure to respond to treatment. At present many patients are referred before the family doctor has used his own therapeutic armoury or waited to see its effects. He must accept that his resources extend beyond the prescription pad and that it is as much his function to perform planned minor psychotherapy as planned minor surgery. At least for a transitional period, more patients are likely to be referred, though probably not as many as predicted by some’Cassandras. To meet this the psychiatric clinic will have to become more consultative than at present. Some patients will have no psychiatric disorder, and the psychiatrist must recognise them and state firmly that distress due to social difficulties is not synonymous with psychological illness. In many uncomplicated cases he should draw up plans for treatment, pharmacological or psychotherapeutic, clear enough for general practitioners to carry out. He must give a realistic prognosis and a treatment goal. The numbers of patients he need treat himself should not rise considerably, and the extra case-load may be offset by economies in therapeutic time gained by group therapy. The psychiatric outpatient clinic, both in its purposes and in its processes, can be redesigned and modernised to deal with a bigger demand with greater efficiency. For such a programme there must be local discussions. Meetings between psychiatrists and general practitioners are increasing, but these clubs-a word chosen to describe the small but faithful band of regular attenders-mostly spend the time discussing individual patients. It might be profitable for them to consider the respective potentialities of general practitioner and specialist treatment and the kinds of patients suitable for referral, depending on the interests and abilities of the particular doctors concerned. Practice will not wait for formal answers to the questions posed in this paper, but current practice is faulty and some theorising and discussion would References
at
be
timely.
foot of next column
Special
Articles
TABLE I-ECTROMELIA AND MICROTIA IN CHILDREN BORN IN
1962
THE INCIDENCE OF LIMB AND EAR DEFECTS SINCE THE WITHDRAWAL OF THALIDOMIDE R. W. SMITHELLS M.B. Lond., M.R.C.P., M.R.C.P.E., D.C.H. LECTURER IN CHILD HEALTH, UNIVERSITY OF LIVERPOOL; CONSULTANT PÆDIATRICIAN, ALDER HEY CHILDREN’S HOSPITAL, LIVERPOOL
IAN LECK M.B., Ph.D. Birm. LECTURER IN SOCIAL MEDICINE, UNIVERSITY OF BIRMINGHAM
SEVERAL investigators have suggested that the recent epidemic of limb and ear defects may not be attributable entirely to thalidomide. In studies based on 30, 60, and 500 cases respectively, Petersen (1962), Smithells (1962a), and the Ministry of Health (1962) were unable to establish that thalidomide had been taken by more than about half of the mothers of children with major limb defects. Similar defects have been reported in a few children born after the administration of other drugs (Carter and Wilson 1962, Corner 1962, Cullis 1962, Dunn et al. 1962, Fagg 1962, Frost 1962, Giroud and Tuchmann-Duplessis 1962, Moss 1962, Watson 1962). In Birmingham there was a small epidemic of reduction deformities of the thumbs and radii (associated in most cases with other malformations like those caused by thalidomide), which preceded the introduction of thalidomide by several months (Leck and Millar 1963). As retrospective information about drugs taken during pregnancy is often unreliable, the role of thalidomide in the recent outbreak of limb defects cannot be fully evaluated except by exploring the correlation between thalidomide consumption and the incidence of these malformations over the last few years. Birmingham data for the period in which the drug was introduced were examined in this way by Leck and Millar (1962). Our purpose in this communication is (a) to report a similar study of the incidence of ectromelia and microtia among infants born in Birmingham, Liverpool, and Bootle in 1962, when the effects of withdrawing thalidomide should have become apparent; and (b) to relate our results to those obtained in previous years. We restrict the term
* L =Liverpool and Bootle.
B== Birmingham.
microtia to cases of imperforate external auditory meatus and/or absence of the auricle, and ectromelia denotes limb defects involving absence or substantial shortening of one or more long bones. The methods by which affected individuals were ascertained were similar to those used in previous years (Leck and Millar 1962, Smithells 1962b). RESULTS
16 instances of ectromelia and four of microfia were observed among 41,399 infants (including stillbirths) born in 1962 to residents of Birmingham, Liverpool, and Bootle. Table i gives details of the affected children. Phocomelia is described as proximal if only the humerus or femur was
shortened, and lower leg.
as
distal if confined
to
the forearm
3 children with ectromelia and 2 with microtia DR. KESSEL: REFERENCES
Blacker, C. P. (1946) Neurosis and the Mental Health Services. London. Bodkin, N. J., Gaze, R. B., Gomez, G., Howlett, M. J., Leigh, D. (1953) Brit. med. J. ii, 723. Carstairs, G. M., Bruhn, J. G. (1962) Sociological Review Monograph, no. 5. University of Keele. Craddock, D. (1958) Introduction to General Practice. London. Davies, B. M. (1958) Survey of Psychiatric Illness at Three General Outpatient Clinics. M.D. thesis, University of Wales. Fry, J. (1959) Brit. med. J. ii, 1322. Guttmann, L. (c. 1945) On Cases to be Referred to the Psychiatrist by the General Practitioner. Unpublished. Hare, E. H. (1959) Bethlem Royal Hospital and the Maudsley Hospital Third Triennial Statistical Report. Shrewsbury. Hopkins, P. (1955) in Modern Trends in Psychosomatic Medicine (edited by D. O’Neill). London. Jaques, E. (1951) Changing Culture of a Factory. London. Kessel, W. I. N. (1960) Brit. J. prev. soc. Med. 14, 16. - Shepherd, M. (1962) J. ment. Sci. 108, 159. Lewis, A. J. (1953) Brit. J. Sociol. 4, 109. Mowbray, R. M., Blair, W., Jubb, L. G., Clarke, A. (1961) Scot. med. J. 6, 314. Pinsent, R. J. F. H. (1953) An Approach to General Practice. London. Priest, W. M. (1962) Lancet, ii, 1043. Rawnsley, K., Loudon, J. B. (1962a) Brit. J. prev. soc. Med. 16, 174. (1962b) Sociological Review Monograph, no. 5. University of Keele. Read, J. C. (1954) Lancet, i, 822. Richards, H. (1960) Psychiatric Referrals from General Practice. D.P.M. dissertation, University of London. Shepherd, M., Davies, B. M., Culpan, R. H. (1960) Acta psychiat., Kbh. —
or
were
TABLE II-NUMBER OF CHILDREN WITH ECTROMELIA OR MICROTIA BORN IN 1960-62
—
35, 518. Watts, C. A. H., Watts, B. M. (1952) Psychiatry in General Practice. London.
*L= Liverpool and Bootle. B= Birmingham. t Children whose affected limbs were not all malformed in the same are classified according to the most severe limb defect present.
way