Problems In Primary Care Settings Research Articles

The Reliability and Validity of a Brief Self-Report Questionnaire to Screen for Mental Health Problems: The Health Dynamics Inventory

Mental health problems are underrecognized in medical settings, leading to inadequate treatment. The present paper describes the development of the Health Dynamics Inventory (HDI), a brief, self-report questionnaire developed to evaluate mental health functioning. The HDI was written to evaluate the three aspects of mental disorders as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM): (1) the experience of emotional or behavioral symptoms; (2) emotional distress; and (3) psychosocial impairment. This study evaluated the psychometric properties and construct validity of its items, scales, and subscales. Results indicated that the items distinguish patients from nonpatients, that the instrument's scales and subscales are reliable, and that the scales and subscales discriminates between persons with mental health concerns or diagnosable problems and those without such concerns or problems. The utility of the instrument for screening mental health problems in primary care settings is discussed.

The Surgical Nosology In Primary-care Settings (SNIPS): a simple bridging classification for the interface between primary and specialist care.

BackgroundThe interface between primary care and specialist medical services is an important domain for health services research and policy. Of particular concern is optimising specialist services and the organisation of the specialist workforce to meet the needs and demands for specialist care, particularly those generated by referral from primary care. However, differences in the disease classification and reporting of the work of primary and specialist surgical sectors hamper such research. This paper describes the development of a bridging classification for use in the study of potential surgical problems in primary care settings, and for classifying referrals to surgical specialties.MethodsA three stage process was undertaken, which involved: (1) defining the categories of surgical disorders from a specialist perspective that were relevant to the specialist-primary care interface; (2) classifying the 'terms' in the International Classification of Primary Care Version 2-Plus (ICPC-2 Plus) to the surgical categories; and (3) using referral data from 303,000 patient encounters in the BEACH study of general practice activity in Australia to define a core set of surgical conditions. Inclusion of terms was based on the probability of specialist referral of patients with such problems, and specialists' perception that they constitute part of normal surgical practice.ResultsA four-level hierarchy was developed, containing 8, 27 and 79 categories in the first, second and third levels, respectively. These categories classified 2050 ICPC-2 Plus terms that constituted the fourth level, and which covered the spectrum of problems that were managed in primary care and referred to surgical specialists.ConclusionOur method of classifying terms from a primary care classification system to categories delineated by specialists should be applicable to research addressing the interface between primary and specialist care. By describing the process and putting the bridging classification system in the public domain, we invite comment and application in other settings where similar problems might be faced.

Factors associated with adolescents receiving drug treatment: findings from the National Household Survey on Drug Abuse.

This article examines factors associated with adolescents receiving treatment for drug-related problems. Data on adolescents (aged 12-17) from the 1995 and 1996 National Household Survey on Drug Abuse (NHSDA, N = 9133) were used. Information was obtained concerning adolescent drug use, smoking, drinking and related problems, as well as sociodemographics. Many adolescents with drug-related problems did not receive treatment. Among predisposing factors, gender and age were associated with drug treatment. Severity of drug problems and comorbid emotional and health problems also predicted seeking treatment. The results call for an improved service delivery system. Screening for drug problems in primary care settings, at school, and in mental health programs will help in the early identification and treatment of drug use disorders in youth.

Multidimensional adaptive testing for mental health problems in primary care.

Efficient and accurate instruments for assessing child psychopathology are increasingly important in clinical practice and research. For example, screening in primary care settings can identify children and adolescents with disorders that may otherwise go undetected. However, primary care offices are notorious for the brevity of visits and screening must not burden patients or staff with long questionnaires. One solution is to shorten assessment instruments, but dropping questions typically makes an instrument less accurate. An alternative is adaptive testing, in which a computer selects the items to be asked of a patient based on the patient's previous responses. This research used a simulation to test a child mental health screen based on this technology. Using half of a large sample of data, a computerized version was developed of the Pediatric Symptom Checklist (PSC), a parental-report psychosocial problem screen. With the unused data, a simulation was conducted to determine whether the Adaptive PSC can reproduce the results of the full PSC with greater efficiency. PSCs were completed by parents on 21,150 children seen in a national sample of primary care practices. Four latent psychosocial problem dimensions were identified through factor analysis: internalizing problems, externalizing problems, attention problems, and school problems. A simulated adaptive test measuring these traits asked an average of 11.6 questions per patient, and asked five or fewer questions for 49% of the sample. There was high agreement between the adaptive test and the full (35-item) PSC: only 1.3% of screening decisions were discordant (kappa = 0.93). This agreement was higher than that obtained using a comparable length (12-item) short-form PSC (3.2% of decisions discordant; kappa = 0.84). Multidimensional adaptive testing may be an accurate and efficient technology for screening for mental health problems in primary care settings.

A continuing dilemma: whether and how to screen for concerns about children's behavior.

1. Ellen Perrin, MD, MA* 2. Terry Stancin, PhD† 1. *Professor of Pediatrics, The Floating Hospital for Children, Tufts-New England Medical Center, Boston, MA 2. †Associate Professor of Pediatrics, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH After completing this article, readers should be able to: 1. Describe the prevalence of child behavior problems in primary care settings. 2. List possible reasons that child behavior problems are underidentified by pediatricians. 3. Describe formal and informal procedures for identifying behavioral problems in children. 4. Delineate the advantages of and concerns about formal and informal methods for screening and assessing behavioral problems in children. 5. Decide whether and how to incorporate screening methods into practice. 6. Describe options for improving mental health services for children, including development of collaborative care practices. Pediatricians are accustomed to the use of screening in the course of primary care for children and adolescents. Screening for some problems, such as lead poisoning or anemia, involves relatively simple procedures compared with the more daunting task of screening for possible behavioral or developmental concerns. To merit population screening, a condition must be important, reasonably common, identifiable by screening before becoming evident clinically, have an effective treatment that is enhanced if provided early, and have an acceptable screening test available. Screening tests must be inexpensive to administer and score, be acceptable to patients, produce reliable results, and have adequate validity. It has been established that substantial variations and delays in children’s motor and cognitive development meet these criteria. (1) However, behavioral variations and problems are harder to define and to classify, and the boundaries of pediatricians’ responsibility are less clearly delineated. Clearly, behavioral and emotional difficulties are important in terms of both personal suffering and social consequences. High rates of depression, school failure, and violence are some indicators of late consequences. These problems are common, with up to 50% of parents expressing concern about their child’s behavior and many surveys documenting an identifiable emotional difficulty in 25% of school-age children. Limited but improving evidence documents the effectiveness of treatment for various mental health …

The vaginitis monologues: women's experiences of vaginal complaints in a primary care setting

Vaginal complaints are a common presenting problem in primary care settings. A disease model has dominated current research and treatment paradigms, with little attention to the illness or experiential dimensions of vaginal complaints. In this paper, we report data from a qualitative study of the experiences of women diagnosed with vaginitis. In semi-structured interviews with 44 women in New York City, United States, we investigated women's interpretations and explanations of their illness, their accounts of its impact on their lives, their experiences with treatment, and the role of vaginal symptoms in communicating distress and anger. We found that women's explanations of vaginal complaints differed strikingly from the current medical model described in the literature on vaginitis. Vaginal symptoms often occasioned extreme anxiety; their impact on social and sexual functioning could be severe. Finally, vaginal symptoms often functioned to express distress and gender conflict. These findings have important implications for the management of the disorder.

Assessment of Attention in Children with Attention Deficit Hyperactivity Problems in Primary Care Settings

Clinical child psychologists in primary care settings are often asked to evaluate children with suspected attention and learning problems. This paper will review some of the methods and assessments available to child psychologists to enable them to perform this task. Some problems with current practice will be described and some of the newer techniques will be introduced. A research-based understanding of areas of chronic impairment of children with Attention Deficit Hyperactivity Disorder (ADHD) will be discussed, and a new approach to the assessment of both executive functions and attention will be explored. This paper will primarily explore assessment in the primary care setting.

Gaps in the treatment for alcohol-related problems in primary care settings

Traditionally, the medical approach to the management of alcohol-related problems has been limited to the treatment of ‘alcoholism’, based on intensive medical and social rehabilitation, made by psychiatrists with a specialization in ‘addiction’, often in inpatient settings and for long periods of time. Treatment was given for those with presenting symptoms of dependence and withdrawal, several medical and psychiatric problems, asking for help or brought by the family, after a long ‘career’ of heavy alcohol consumption and numerous attempts at stopping alcohol use without any success. However, at the beginning of the 1980s, the need for a public health approach to reduce the impact of alcohol use in society led to the development of earlier and low-cost interventions which could benefit a larger number of people and be delivered before dependence and chronic disability had been established. It was realized that the burden of illness imposed on society by heavy drinkers was comparable to that imposed by al...

Screening for Depression in Elderly Primary Care Patients

Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations. One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics. Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis. The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices.

Primary care patients' reactions to mental health screening.

The authors examined whether there is empirical support for the notion that medical patients are upset by being asked questions about psychiatric disorders. Six hundred and one patients attending a primary care clinic completed the SCREENER-a newly developed, brief self-administered questionnaire that surveys a broad range of psychopathology. In addition, they completed a second questionnaire that assessed their attitudes toward the SCREENER. We found a high level of acceptance by patients. The questions were judged easy to answer, and they rarely aroused significant negative affect. Fewer than 2 percent of the patients judged the questions difficult to answer, and fewer than 3 percent were "very much" embarrassed, upset, annoyed, or uncomfortable with the questions. Individuals with a history of psychiatric treatment and poorer current mental health reacted more unfavorably to the questionnaire. From the patient's perspective, it is feasible and acceptable to use self-administered questionnaires for routine screening of psychiatric problems in primary care settings.

Depression Comorbid with Anxiety: Results from the WHO Study on Psychological Disorders in Primary Health Care

The World Health Organization collaborative study on "Psychological Problems in General Health Care" investigated the form, frequency, course and outcome of common psychological problems in primary care settings at 15 international sites. The research employed a two-stage case-finding procedure. GHQ-12 was administered to 25916 adults who consulted health-care services. The second-stage assessment (n = 5438) consisted of the Composite international Diagnostic Interview (CIDI), the Social Disability Schedule, and questionnaires. Possible cases or borderline cases of mental disorder, and a sample of known cases, were followed up at three months and one year. Using standard diagnostic algorithms (ICD-10), prevalence rates were calculated for current disorder (one-month) and lifetime experience disorder. Well-defined psychological problems are frequent in all the general health-care settings examined (median 24.0%). Among the most common were depression anxiety, alcohol misuse, somatoform disorders, and neurasthenia. Nine per cent of patients suffered from a "subthreshold condition" that did not meet diagnostic criteria but had clinically significant symptoms and functional impairment. The most common co-occurrence was depression and anxiety. Comorbidity increases the likelihood of recognition of mental disorders in general health care, and the likelihood of receiving treatment.

The impact on employment of an intervention to increase recognition of previously untreated anxiety among primary care physicians

Anxiety is a common, though often unrecognized, problem in primary care settings. This study examines the effect on employment of an intervention designed to attune primary care physicians to previously unrecognized and untreated anxiety. Primary care physicians in a mixed-model health maintenance organization (HMO) were randomized by practice site to groups with (intervention) and without (usual care) intensive one-on-one education about anxiety and periodic feedback about their patients with anxiety. All persons 21–65 years of age presenting to the offices of these primary care providers were screened for anxiety with the SCL-90-R on two occasions. Those meeting the SCL-90-R cutpoints for anxiety and whose medical records provided no evidence of recognition or treatment for a mental health condition within the last 6 months were eligible for the study ( n = 637). Of these, 573 (90%) completed two follow-up assessments. The present study evaluates the impact of the intervention aimed at the primary care physicians on the labor force participation rate of the persons with anxiety after 5 months of follow-up. The study also evaluates the impact of the intervention on hours of work and the presence of days spent in bed among the persons with anxiety working at the baseline interview and after 5 months. At baseline, the patients of intervention and usual care physicians with previously unrecognized and untreated anxiety did not differ in labor force participation rates. At the conclusion of the study, the patients of the intervention group physicians had significantly lower rates of labor force participation than those of the usual care group physicians. Among those working both at the beginning and conclusion of the study, the intervention had no impact on hours of work or the presence of days spent in bed. We conclude that attuning physicians to anxiety may reduce labor force participation rates.

The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care

There has been increasing recognition and documentation of the impact of psychiatric problems on the outcome and cost of medical care. Because consultation-liaison psychiatrists have the expertise to address the psychiatric aspects of medical illness, this group should be in a strong position to facilitate integration of medical and psychiatric services in managed care delivery systems. Although consultation-liaison psychiatry (CLP) has documented its ability to shorten inpatient medical lengths of stay for some disorders, a greater challenge exists in developing comprehensive systems to identify and care for patients with mental health problems in primary care settings. This paper reviews the fiscal and programmatic implications for managed medical care systems of findings from outcome-based C-L research. The future role of CLP and combined medical-psychiatric units in an era of managed care is also discussed.

The Role of Parents in the Detection of Developmental and Behavioral Problems

The success of early identification of children with developmental and behavioral problems is influenced by the manner in which pediatricians elicit, recognize, and select clinical information and derive appropriate impressions. Parents are ready sources of clinical information, and they can be asked to provide two broad types of data: appraisals, including concerns, estimations, and predictions; and descriptions, including recall and report. The purpose of this article is to help pediatricians make optimal use of clinical information from parents to increase the accuracy of clinical judgment in detecting children with developmental and behavioral problems. Review of 78 research articles and tests relying on parent information from pediatric, psychological, and education literature. There are several formats for eliciting parental information that are superior in terms of accuracy and ease of evocation. Specifically, parents' concerns and good-quality standardized parent report measures such as the Child Development Inventories capitalize best on parents' observations and insights into their children. In combination, these two types of parental information offer an effective method for the early detection of behavioral and developmental problems in primary-care settings.

Psychiatric Morbidity in Developing Countries and American Psychiatry's Role in International Health

Economic and social change in the developing countries of Asia, Africa, Latin America, and the Pacific Islands is associated with increased rates of behavior-related illnesses, including psychiatric disorders, alcoholism, and substance abuse. Between 10 and 20 percent of the presenting problems in primary care settings in those countries are psychosocial. The authors provide an overview of the epidemiology of psychiatric and psychosocial morbidity in developing countries and summarize its effect on medical care systems in those settings. They suggest that American psychiatry increase its involvement in improving mental health care in developing countries. Consultation should be directed toward priorities determined locally in those countries, including assessment of current clinical practices, applied epidemiologic research, and training of indigenous researchers.

Training primary care medical officers in mental health care: assessment using a structured clinical examination

Mental health problems in primary care settings have received wider attention in recent years (Wilkinson, 1985). In India, the National Mental Health Programme (NMHP) was formulated with the purpose of promoting mental health care through primary health care (National Mental Health Programme, 1982). As part of the implementation of NMHP, training programmes for medical officers and health workers have been initiated in a number of centres in the country (National Mental Health Programme for India, Progress Report, 1988). At the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, a monthly training programme for doctors and health workers of primary health centres has been carried out since 1982. In order to evaluate the gain in knowledge and clinical skills, a multiple-choice questionnaire and case vignettes have been standardised (Sriram et al, in press). The doctors are also evaluated through a structured clinical examination which is carried out on the last training day. The focus of the present report is to evaluate the clinical skills of medical officers using the structured clinical examination.

An algorithmic method for management of mental health problems in developing countries.

A new problem-oriented cross-cultural method has been developed to identify the appropriate management of mental health problems in primary-care settings. It is designed to be used by multipurpose health workers in out-patient clinics in many developing countries. Presenting mental health problems in many cultural settings can be placed into one or more of eight behaviourally determined categories. After this initial categorization an algorithmic process is used to determine the sequence of observations which must be made in order to identify the appropriate management. The system allows for variations in available resources and local constraints. We outline the design principles of this algorithmic method and the rules for using it, and describe a training programme developed to teach people to adapt it and use it effectively. The evaluation studies that have been done in different developing countries confirm that the method is acceptable and efficient, and gives management decisions with a high degree of repeatability.

Collaborative research between a Department of Pediatrics and its clinical faculty.

Collaborative research involving members of the full-time and clinical faculties of a Department of Pediatrics increases our knowledge of problems encountered in primary care practice by bringing the practitioner's perspective on the nature of such problems and the population of patients he serves to the investigative arena. For the practitioner, active involvement in collaborative research is rewarding because he or she formulates the questions to be addressed and takes part in planning and implementing the research and reporting results. Through such collaboration, the academician gains immeasurably by being able to study common clinical problems in primary care settings, where they are encountered most often. To be successful, collaborative research must be a joint effort with ongoing communication and sharing of responsibilities between academicians and practitioners.