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145 EXECUTIVE SUMMARY: COORDINATED MENTAL HEALTH CARE IN NEIGHBORHOOD HEALTH CENTERS* Jonathan F. Borus, M.D., Barbara J. Burns, Ph.D., Alan M. Jacobson, M.D., Lee B. Macht, M.D., Richard G. Morrill, M.D., and Elaine M. Wilson, B.A. This report is drawn from the authors' cumulative clinical, adminis- trative, and research experience in both Community Mental Health Centers (CMHCs) and Neighborhood Health Centers (NHCs) over the last decade as well as a review of the relevant literature. From our experience we feel that the neighborhood-based conjoint health-mental health setting of the NHC is an excellent context for the provision of primary mental health services, i.e., problem and diagnostic evaluation, crisis inter- vention, individual, group and family psychotherapies, aftercare services (including psychoactive medication) for the chronically ill in the com- munity, and prevention/educational outreach programs about mental health and mental illness. We have been impressed by the opportunities that such a setting provides for mental health professionals to collaborate with primary physicians in the latter's roles as case-finders and treaters of patients with defined mental disorder, patients with com- bined psychiatric and medical problems, and patients reacting to either external or illness-related stresses. The report's first section traces the history of public mental health and health services in the U.S., discusses levels of care, and presents an overview of the current Suctioning of NHC mental health programs. The second section outlines five hypothesized advantages of providing primary mental health services as part of primary health care in the NHC's organized neighborhood setting and the third section reviews theoretical, clinical, and research data relevant to these hypotheses. A summary of these latter two sections, in which the hypothesized advantages and related findings are reviewed, follows. 1. Advantage: The provision of mental health services within a neighborhood-based, primary health setting can improve their accessibility and - acceptability to and utilization by neighbor- hood citizens. . *An earlier version of this paper was developed at the invitation of the Institute of Medicine and was submitted to the President Is Commission on Mental Health, 1977. It was used as a background paper for this conference. The full text comprises Volume II of the conference proceedings.

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146 This hypothesis is corroborated by quantitative data from a six month study at Boston's Bunker Hill Health Center in which mental health utilization rates were five times higher than NIMH data on average national utilization. This higher utilization occurred across sexes, and for all age groups and marital statuses. The services disproportionately reached usually underserved populations including patients from the lower socio-economic classes, children and married adults. It is felt that this increased utilization reflects the easy access to these centers, whose neighborhood loca- taion decreases geographic and travel barriers to care, as well as an increased acceptability of the NHC as a mental health service setting to citizens. Acceptability is encouraged by the frequent use of indigenous care-givers who understand local culture and values and the fact that the mental health services are provided within a trusted health institution with which many people are familiar and comfortable from prior use of its health, dental or heaLth-related social services. Mental health services offered in a multi-service setting are also less stigmatized as the patient does not have to automatically label himself as mentally disordered simply by walking through the door. As below, patients frequently present with somatic complaints to the primary physician and then "slide over" into specialist mental health care. 2. Advantage: The conjoint health-mental health delivery system can improve case-finding, successful referral, coordination of care, long-term follow-up, and preventive/educational efforts to meet general and specific population needs. Primary physicians are major case-finders and treaters of patients with mental disorder. It is estimated that 60% of all patients with mental disorders seen in primary care is not referred to mental health specialists. Working side by side in the NHC, the primary physician can form a collaborative relationship with the psychiatrist and build up the necessary trust to seek consultation about patients with mental disorder whom the primary physician decides to treat alone. In the conjoint setting, the primary physician can also easily refer patients for mental health specialist care whom he cannot best handle. The latter is supported by a study of 19 Boston NHCs in which almost half of all referrals for mental health care came from the medical staff of the health center. The physical proximity and the ability to form professional relationships between primary physician and mental health specialist also facilitates collaboration, mutual training, and communication about treatment planning to foster coordinated rather than fragmented care for patients with combined or multiple health and mental health problems. The setting is also an excellent one for long-term follow- up care. Patients with chronic or episodic mental disorders often resist continuing in mental health care during a period of remission of symptoms but will continue their contacts with the NHC for their

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147 costs, including the total costs for the multiple outpatient mental health services needed by chronically ill patients living in the community. 4. Advantage: The provision of mental health services within the NHC can increase the priority of and concern for mental health problems among com- munity citizens. - Health has a much higher priority and is a less stigmatized issue for citizens groups to come together around than mental health. The 10,000-50,000 person NHC service area is smaller than the CMHC's 75,000-200,000 catchment and the smaller area's citizens are more likely to have some sense of cohesion and shared destiny which allows them to relate to the NHC as "theirs." It has been our experience that mental health professionals can work closely with citizens groups in NHCs to plan and promote mental health programs, including aftercare programs for the chronically ill, which fit well and are accepted by the neighborhood. 5. Advantage: The conjoint health-mental health setting of the NHC can offer unique opportunities for necessary training in primary health and mental health care. The NHC offers primary practice and mental health trainees opport- unities for both front-line, acute ambulatory care and long-term care of chronic illness in the community Training in their patients' neighborhood can help both sets of providers consider the impact on clinical care of socio-environmental, ethnic and cultural, and public health aspects of care often ignored in institution-bound training. Importantly, the proximity to other trainees and availability of collabor- ating role models can help both primary practice and mental health pro- fessional trainees overcome prior negative inter-professional stereotypes to learn to use each otherts expertise to their patients' benefit. The fourth section of the report develops ten issues relevant to the NHC delivery system and suggests alternatives to current national mental health policy concerning these issues, as briefly outlined below. 1. NHCs are proposed as a~preferred setting for the delivery of primary mental health care in the public sphere. The conjoint health-mental health setting and location in the community allow it to address itself to the medical' psychological, socio-environ- mental, and public health aspects of patient care. 2. Closer linkages are proposed between NHCs and CMHCs. Although the NHC setting is excellent for providing primary mental health services, CMHCs are vital sources of secondary and tertiary level care for many intensive and expensive services such as in- patient care, rehabilitation, etc. Both CMHC and Bureau of Com- munity Health Services legislation could provide incentives and requirements for closer linkages between NHCs and CMHCs.

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148 3. New sources of support are proposed to meet critical needs for consultation, collaboration, inservice training, and other indirect services which foster coordinated rather than fragmented care. Other indirect services, such as education, prevention, and screening out- reach programs to increase access to care, training of health and mental health professionals, and evaluation research efforts to under- stand these delivery systems also need to be supported. Although essential to a coordinated care system, few of these critical indirect services are paid for by current reimbursement schemes. 4. Methods are proposed to interlink NHC and CMHC citizen groups and to provide citizen and professional input into Health Services Agencies concerning mental health needs and issues. 5. Additional resources are proposed to stimulate the develop- ment of facilities in NHCs to provide long-tenm aftercare and day treatment for the chronically ill in the community. 6. Linkages are proposed between NHCs and Health Maintenance Organizations, multi-specialty private group practices, and solo private physicians to collaborate in providing coordinated care. 7. Support is proposed for greater in-service and professional training of both primary physicians and mental health professionals in NHCs and other coordinated primary health and mental health care settings. Part of residency training for both primary physicians and psychiatrists could occur in the NHC setting as well as subs specialty training for selected professionals who wish to develop the clinician-executive skills necessary to effectively lead such conjoint health delivery systems. 8. Evaluation research outcome studies are proposed of the NHC system of care to complement existent preliminary studies of service provision and utilization. 9.-10. Alternative funding mechanisms to pay for the direct and indirect services provided in NdCs prior to (9) and as part of (10) National Health Insurance plans are proposed. The report concludes with three recommendations. These are that national policy, as embodied in federal health services program legislation, government and private health financing programs, and National Health Insurance plans, should encourage and fiscally support: 1. further development of Neighborhood Health Centers and other relevant population-based settings which provide mental health services as a coordinated part of primary health care. those indirect services which facilitate coordination rather than fragmentation of primary health and mental health care and outreach into the community to increase citizen accessibility to and acceptance of necessary mental health services. 3. needed professional training in and critical evaluation research about Neighborhood Health Centers and other con- joint health-mental health primary care settings. 2.

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149 TRAINING FAMILY PHYSICIANS IN MENTAL HEALTH SKILLS IMPLICATIONS OF RECENT RESEARCH FINDINGS David Goldberg, M.D. University of Manchester England Many of the well-known surveys of mental disorders among patients attending primary care physicians have shown very wide variations between individual practitioners in their estimates of the frequency of such conditions. Shepherd 1/, for example, showed a nine-fold variation between family physicians in London, and surveys in the United States have shown even wider variations. The results of five recent surveys are summarized in Table 1, which shows the percentage of consecutive attenders thought "psychiatric" by the primary care The mean is the figure which is most usually quoted when and it is often conveniently . ~ . . ~ physician. reference Is mace co these surveys, forgotten that this mean is arrived at by averaging the pronouncements of very heterogeneous observers. Table 1. INTER-PRACTICE VARIATION IN THE DETECTION OF PSYCHIATRIC MORBIDITY: THE FIGURES REFER TO PERCENTAGES OF CONSECUTIVE ATTENDERS Number of Physicians Mean Range Marks, Goldberg & Hillier 2/ Manchester, U.K. 91 14.2% 15-64% Locke et al 3/ Prince George's County, Md. 79 9.0% 0~44% Locke & Gardner 4/ Monroe County, N.Y. 58 16.9% 0-37% Leopold, Goldberg & Schein 5/ W. Philadelphia, Pa. 32 16.3% 0-92% Goldberg & Steele 6/ Charleston, S.C. 45 39.0% 0-85%

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150 When psychiatric screening tests are used simultaneously during such surveys, they typically show much less variation between the various practice populations than that suggested by the doctors' own assessments. Figure l shows 14 practices in Michael Shepherd's well- known study , arranged in rank order, so that the prac Lice with the highest rate of ascertainment of psychiatric illness is on the extreme left while that with the lowest is on the extreme right. Figure l cot I 60 ~ 50 - - Z 40 `, 30 At us 20 a u, He 1 0 u' on-o SCORE OF 10 OR MORE ON THE M- R SECTION ~ : GENERAL PRACTITIONERS' CLI N I CAL ASSESSM ENT \ iR~ \ on Q \ a\ I o ( ! I I I I I ~ Ox I o,.__O PRACTICES ORDERED BY THEIR PATIENT CONSULTING RATES FOR PSYCHIA. RIC ILLNESS

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151 The continuous line shows these assessments -- varying from 63% on the left to 18% on the right. The dotted line shows the probable cases predicted by the Cornell Medical Inventory. It can be seen that so far from there being any association between the two variables the best regression line between the points an the dotted line has a positive slope. Nor can it be concluded that the doctor where the two lines cross is a very clever fellow, and that his colleagues perched at either end of the line are various degrees of fool. The doctor where the lines cross could be identifying completely different individuals from-those picked out by the questionnaires: it may just happen that they pick out the same proportion of the population. What we can say is that the doctor on the extreme left has some sort of bias towards perceiving patients as psychologically sick, and that the reverse may be true of the doctor on the right. Figure 2 has a familiar look about it. But we are now using the General Health Questionnaire instead of the Cornell Medical Inventory; we are studying 29 second and third year family practice residents rather than established physicians; the time is 1979, and the place is Charleston, South Carolina. But nothing else has changed. Figure 2 . . . .. Percent , 80 70- 60- 50- 40 - 30- 20- 10- Conspicuous Morbidity '7 ~ `q ,~ Probable Prevalence 1 111 8, h~ too '--- r I ~ I - I I Al 1 st 5th 1 Oth 1 5th 20th 25th 30th Ronk Order (CO'lspiClJOUS Morbidity)

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152 Table 2 shows that there is in fact no correlation between the level of disorder reported by the doctors and the level of disorder in their population predicted by a screening questionnaire. The results now include a large survey that we carried out in Manchester with similar results. Table 2. RELATIONSHIP BETWEEN THE LEVEL OF THE DISORDER REPORTED BY THE DOCTOR AND THE LEVEL ASSESSED BY THE PSYCHIATRIC SCREENING TEST Shepherd et al. 1/ 14 General Practitioners, London, England -0.31 (NS) Marks, Goldberg & Hillier 2/ 22 General Practitioners, Manchester, England Goldberg & Steele 6/ 29 Family Practice Residents, Charleston, S.C. -0.17 (NS) +0.08 (NS) Let me be very clear about the conclusion to be drawn from these data. One cannot conclude that there is no association between an individual physician's assessments and the symptom levels of his patients. The reverse is in fact true, and we shall be returning to that. But it is reasonable to assume that a doctor who tells you that 90% of his patients are mentally sick is no more likely to have a greater number of sick patients attending his office than a doctor who tells you that only 10% are sick. The difference between them resides not in their patients, but in their concepts of psychiatric disorders and the threshold that they adopt for case identification. Figure 3 shows the ratings made by an imaginary physician "A" for 60 patients, each of whom has completed a screening questionnaire. The scores on the screening questionnaire are shown on the vertical axis, and the doctor's rating of the degree of psychiatric illness is shown on the horizontal axis. It can be seen that the correlation between the two measures is quite good, at +0.6. This doctor identi- fies 62% of his patients as sick. His colleague, physician "B", makes exactly the same ratings and so has the same correlation coefficient; but he has a more restrictive view of illness. We can see in figure 4 that his threshold has been moved to the right, so that only 17% are cases. Physician "B" can be said to have a negative bias towards identifying psychiatric illness; he will report a low rate and will tend to fail to identify cases among his patients with high scores (i.e. he will have a low "identification index": see reference 2~. He will have the compensatory advantage that he will rarely accuse asymptomatic patients of being psychologi- cally sick (i.e. he will have a high "stability index": reference 6~.

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153 Figure 3 SCORE ON PSYCHIATRIC SCREENING QUESTIONNAIRE High Low . ~ - -. 1~. ~ ~. ~ I .- ~. - 1.~. .. .. I .~e l -. Be- e ~. ~. ~- _ O 0 1 j 2 . Normal Subclinical 1. Mild _~ 1 "Non-Cases" 3 4 Moderate Severe "Cases" CLINICAL ASSESSMENT BY DOCTOR (% Cases= Conspicuous Psychiatric Morbidity, CPM). Physician "A" Correlation Between Doctor and Screening Test +.60

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154 Figure 4 SCORE ON PSYCHIATRIC SCREENING QUEST ONNAIRE High Low 1 . - ~ -. ~. 1 ~ o o - ~ . . 1 ~. 1 .. - 2 3 1 4 LOW BIAS -These doctors miss many probable cases. (Identification Index- Low Stability Index - High) j CLINICAL ASSESSMENT BY DOCTOR

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155 Inevitably, physician "C" has a high bias towards diagnosing illness, with a conspicuous morbidity of 83%. Such doctors rarely fail to identify symptomatic patients as " sick"; yet this advantage will be purchased at the price of frequently identifying asymptomatic patients as "sick" probably because as raters, they tend to guess " s ick" when in doubt . Figure 5 SCORE ON PSYCHIATRIC SCREENING QUESTIONNAIRE , ! High Low ~ 1 .~. ~. O O 1 .. r ~. ~ .~. HIGH BIAS -These doctors falsely identify asymptomatic patients as "sick" (Identification Index - High Stability Index - Low) . CLINICAL ASSESSMENT BY DOCTOR

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236 Brown, B.S., Regier, D.A., and Baiter, M.B. Key interactions among psychiatric disorders, primary care, and the use of psychoactive drugs. In Brown, B.S. (ed). Clinical Anxiety/Tension in Primary Medicine. Princeton: Excerpta Medica, 1979. The authors estimate that 60 percent of persons with mental disorder are treated by primary care providers. Of all persons with mental disorder, an estimated 32 million people in a given year, 15 percent see only mental health specialists, 54 percent see only primary care providers, 3 percent use general hospitals or nursing homes, 6 percent use both primary care and mental health providers, and 22 percent go untreated or use resources outside the health care system. About 5 percent of all patient visits to physicians in office-based practice result in a diagnosis of mental disorder. About half of these visits where a mental disorder diagnosis is received involve psychoneuroses. "Nonpsychiatric physicians account for more than 50 percent of all visits in which a diagnosis of psychiatric disorder is assigned." Nonpsychiatric physicians employ psychotherapy in 22 percent of visits with a diagnosis of mental disorder, and drug therapy is used at 67 percent of these visits. The authors call for research to determine which psychiatric disorders are best treated by psychotropic drugs, which disorders require psychotherapy, and when a mixed mode of treatment is needed. Additional research is needed to determine how to divide the responsibility between the primary care physician and the psychiatrist; what is the relative effectiveness of treatment by each type of provider, and the cost effectiveness of the treatment. Carey, K., and Kogan, W.~. Exploration of factors influencing physi- cian decisions to refer patients for mental health service. Medical Care, 9:55-66, 1971. The authors asked physicians in the specialties of general practice, medicine, and surgery to describe two patients who were referred to mental health services and two patients with emotional problems who were not referred. Seventy-eight of 92 physicians of the Group Health Cooperative of Puget Sound participated. Data were obtained on 140 patients who had been referred and 125 who were not referred. Patients with acute conditions and those who requested referral were more likely to be referred. The feeling of inability or lack of experience on the part of the physician resulted in a referral. The

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237 "treatment" of mental disorder varied with the specialty: the medical group used diagnostic procedures; the surgical group, placebos; and the general practice group, psychoactive drugs. Coleman, J.V., and Patrick, D.L., Psychiatry and general health care. American Journal of Public Health, 68:451-457, 1978. The authors describe a five year experience with the Community Health Center Plan of Greater New Haven, Connecticut. This prepaid group practice integrates mental health services into primary care teams in internal medicine and pediatrics. The mental health clinician is a psychiatric social worker, a psychiatric nurse specialist, or a clinical psychologist. While the primary care providers have the major responsibility for total health care, the mental health clinician acts as a primary care extender. Psychiatrists are available for back- up support. During a two year period 15.7 percent of the patients seen were diagnosed as suffering from emotional problems (N=2,806~. Primary care clinicians alone handled 72 percent of these patients, and mental health clinicians (in addition to primary care providers) treated 28 percent. Mental health clinicians treated 55 percent of patients with chronic emotional problems. The proportion of the following diagnoses were treated by primary care clinicians alone: nonorganic psychoses (54%), anxiety (88%), depression (67%), personality disorders (47%), sexual problems (75%), alcohol pro- blems (80%), durg abuse problems (65%), situational disturbances (70%), social adjustment problems (58%), suicide ideation/attempt (75%~. The primary care physicians usually handled medication maintenance, although at times referral to mental health clini- cians was necessary to assist the primary care physician to establish the medication regimen. The authors conclude that this team approach has the major advantage of making the mental health clinician readily available to the primary care provider which can relieve him or her "of the undue, sometimes inordinate pressure of certain persistently demanding patients, usually patients with chronic characterological depressions and borderline states." Dressier, D.M. The management of emotional crisis by medical practi- tioners. Journal of the American Medical Women s Association, 28:654- 659, 1973. The person who is unable to handle stress utilizing customary modes of coping frequently consults the physician. The physician can reduce the distress and prevent further deterioration for

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238 patients experiencing emotional crises such as loss of job, financial loss, serious illness, death of a family member. The physician should first help the patient feel that he "is not 'going crazy' or 'out of control'.'' The physician should adopt an "accepting, non-judgmental attitude" and be "calm but concerned, flexible but firm, and receptive but involved." The interview should focus on the current problem, rather than delving into the past, and conflicting feelings should be recognized. The physician should help the patient broaden his/her repertoire of coping skills. Family members should be involved in treatment. Medication may be use- ful in reducing symptomatic distress. The patient should be seen once or twice a week. When the patient has recovered, the physician should assess the need for follow-up specialized psychiatric care, especially if there is evidence of psychotic or neurotic symptoms, if the patient has a history of recurrent crises, and/or if the patient is interested in a deeper subjective examination. Fink, R., Goldensohn, S., Shapiro, S., and Dailey, E. Treatment of patients designated by family doctors as having emotional problems. American Journal of Public Health, 57: 1550-1564, 1967. The authors interviewed physicians at the Jamaica Medical Group of the Health Insurance Plan of Greater New York about 422 patients over 15 years old who were diagnosed as having a mental, psychoneurotic, or personality disorder. Twenty-six patients were referred for a psychiatric consultation. Patients were more likely to be referred if they had a chronic condition, a condition that greatly interfered with life activities, and/or a condition which was thought to improve with psychiatric treat- ment. Of all patients with mental disorder, 78 percent received a psychotropic drug and 92 percent had at least one lengthy doctor-patient discussion of the problem. Patients who did not improve with these treatments were more likely to receive a psychiatric referral. A total of 380 of the 420 patients were interviewed. Among patients with psychoactive drug prescriptions, 46 percent said they were very helpful, 34 percent somewhat helpful, and 20 percent little or no help. Nearly two-thirds of the patients reported that the doctor-patient discussions about their emo- tional problems were very helpful (34%) or somewhat helpful (30%~. Twenty-three percent reported that the discussions were of very little or no help, and 13 percent said they had not had any discussion.

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239 Fisher, J.Ve ~ Mason, R.L., and Fisher, J.C. Emotional illness and the family physician. Part II: Management and Treatment. Psychosomatics, 16:107-111,1975. The authors surveyed 860 family physicians who were members of the Michigan Chapter of the American Academy of General Practice regarding detection and management of emotional illness. Physicians graduating from medical school after 1950 had a ten- dency to use psychoactive drugs with a lower percentage of their emotionally ill patients than physicians graduating prior to 1950. Physicians graduating before 1950 were more inclined to use tranquilizers and antidepressants with 50 percent or more of their emotionally ill patients than later medical school graduates. About 80 percent of all physicians used advice and reassurance for their mentally ill patients. Physicians graduating after 1950 were more likely than earlier graduates to use psychotherapy with their patients. Glasser, M. Psychiatry in family practice. Canadian Psychiatric Association Journal, 21:483-488, November, 1976. The author is a family practitioner who reviewed the charts of all patients he saw between September 1, 1964 and August 1, 1968 (N=4,801~. Of these patients, 394 were classified as psychiatrically ill. Beginning in September, 1967, he question- ed each returning psychiatric patient about the original com- plaint. A total of 287 patients identified as psychiatrically ill were evaluated. The remaining 107 psychiatric patients were seen only once and did not return for additional visits. The 287 patients involved in the follow-up study were evaluated in relation to change in symptoms' degree of functional impair- ment, mental status, level of severity of disease, and any new symptoms. The majority of patients were also rated by a psycho- logist. Nearly three quarters of the patients were diagnosed as neurotic; 11 percent had adjustment reactions; and the re- mainder were psychotics, drug and alcohol addicts, or suffered from character disorders. The author used therapy that was "eclectic, at times being supportive and fostering catharsis, while on other occasions being directive and offering interpretations of behaviour." Twenty-six patients were referred to mental health specialists. Most patients were seen by the family practitioner only five times, and none more than twenty-two. There were no signifi- cant differences in improvement rates for the patients treated by the mental health specialists versus those treated by the family practitioner. At the time of follow-up, 74 percent of the patients were judged to be better, 20 percent neutral, and 6 percent worse.

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240 Greco, R.S. Psychiatry in everyday medical practice. Psychiatry in Medicine, 3:303-309, 1972. The author participated in Balint-type training sessions at the University of Pittsburg Medical School. He became convinced that "every doctor-patient transaction has a workable psycho- therapeutic aspect." He provides several examples in the dis- cussion. When the patient presents him/herself to the physician without specific complaints (e.g., for routine physical exams), the physician should take this opportunity to practice pre- ventive psychiatry. When the patients present an unorganized illness, symptoms are presented, and the physician can work to organize the illness and restore the patient's balance. In an organized illness, the patient and doctor agree on a diagnosis, and the physician can treat the problem directly. Hesbacher, P., Rickels, K., Rial, W.Y., Segal, A., and Zamostein, B.B. Psychotropic drug prescription in family practice. Comprehensive Psychiatry, 17:607-615, 1976. The authors surveyed 1,190 patients seen in seven family practices from March to September, 1970. Of these patients, 48.2 percent were experiencing emotional problems currently or had suffered from emotional problems during the past two years. Among patients with emotional disorder, 50.4 percent had received a psychotropic drug prescription within the past two years. Twenty-nine percent of the emotionally ill patients were taking psychotropic drugs at the time of the survey. All patients completed the Hopkins Symptom Checklist (HSCL) at the time of their visit. The authors found a general trend that the scores were highest for patients with emotional problems currently on drugs, lower for patients with emotional problems who were previously on drugs, followed by patients with emotional problems who were never on drugs, and the lowest for patients without emotional problems. The patients who had been prescribed drugs in the past two years were most likely to receive anti-anxiety drugs (55 percent of all patients prescribed psychoactive drugs) followed by anti-psychotic drugs (19%), antidepressants (16%), sedatives (9%), and stimulants (1%~.

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241 Ketai, R. Family practitioners' knowledge about treatment of depressive illness. Journal of the American Medical Association, 235:2600-2603, - 1976. Ketai chose 227 family practitioners attending a seminar at the University of Michigan Medical Center as his subjects. Before the physicians heard a lecture on psychotropic drugs, they completed a multiple choice examination on the prescribing of psychotropic drugs. The answers of the physicians were compared with those of seventeen psychiatrists. The greatest discrepancy between the family practitioners and psychiatrists occurred for depressive illness. Nearly 27 percent of the family practitioners were unaware of how best to treat a depressed patient with severe anxiety and agitation. One-fourth of the family practitioners would begin treatment with tricyclics at too low a dose, while 9% at much too high a dose. Thirty-nine percent of the family practitioners would not raise the tricyclic dose to acceptable and proper levels. The author concludes that family practitioners should be taught how to use tricyclic antidepressants. He recommends a starting dose of imipramine hydrochloride or amitriptyline hydrochloride of 75 mg/day which should be raised to at least 150 mg/day within a few days. Some patients require dosage levels of 200-250 mg/day. A trial of two to three weeks at therapeutic levels is needed before determining that the drug is ineffective. Kiely, W.F. Psychotherapy for the family physician. American Family _ractice, 3:87-91, 1971 The author suggests that family practitioners practice suppressive and supportive psychotherapy, aiming toward intra- psychic equilibrium, rather than reorganizing the personality. Kiely suggests that while the initial visits may last from 30- 60 minutes, follow-up visits of 15-20 minutes are adequate. The family physician can begin the interview with simple questions like, "How have things been going generally?" or "I have the feeling that you've been working under a good deal of tension." However, the physician should avoid asking too many questions and using technical terms. Kiely argues that the physician should focus on current feelings and symptoms, rather than delving into the past. The family physician should avoid: provoking anxiety in the patient, showing judg- mental attitudes, creating a hostile reaction to the physician, and confronting the patient.

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242 Locke, B.Z., Finucane, D.L., and Hassler, F. Emotionally disturbed patients under care of private nonpsychiatric physicians. American Psychiatric Association: Psychiatric Research Report, 22:235-248, 1967. Seventy-nine general practitioners out of 107 in Prince Georges County, Maryland, kept records on patients seen in one week during February-July, 1964. A total of 7,814 patients were included. Physicians identified 7 percent of the sample as emotionally ill (9 percent of those white and 15 years of age or older). Physicians provided the following types of care to patients with mental disorder: suggested psychiatric care or counseling (25% of patients), gave supportive therapy (59%), suggested environmental or social change (19%), prescribed drugs for the psychiatric problem (60%), suggested referral to other agencies or persons (6%), suggested other recommendations or other therapy (5%), none of the above (8%~.* Locke, B.Z., Krantz, G., and Kramer, M. Psychiatric need and demand in a prepaid group practice program. American Journal of Public Health. 56:895-904, 1966. All patients aged 15 and over seen at the Group Health Association (Washington, D.C.) in the Departments of Internal Medicine, Pediatrics, Allergy, and Dermatology during a 3 1/2 month period were included, N=6,104. Nearly 15 percent of the patients seen had a mental or emotional problem. Seventy-five percent of these patients were treated with psychoactive drugs, 63 percent received counseling, and 17 percent were referred for outside psychiatric help. For another 18 percent of patients who were not referred, the physician wanted to recommend addi- tional treatment, but was reluctant to do so because s/he felt that the patient would find it unacceptable or too costly. Ornstein, P.H., and Goldberg, A. Psychoanalysis and medicine. II. Contributions to the psychology of medical practice. Diseases of the Nervous System, 34:277-283, 1973. The authors describe two techniques of psychotherapy that can be used by the primary care physician. The long interview (or focal psychotherapy) focuses on the patient's life situation and personality. The physician spends most of the time listening in order to uncover: the problem that caused the illness, the effects of the patient's behavior on others, unconscious conflict- ing motives, and the conflict which is at the root of the problem. *Percentages add to more than 100% because patients could receive more than one type of care.

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243 However, the long interview is time consuming, so an alter- native technique, the ten minute psychotherapy or "flash" may be used. The flash is empathetic understanding and "requires as a fine tuning-in, a briefly sustained intense identification with the patient that leads to a knowledge about him which doctor and patient silently share for the benefit of the patient." Raft, D. How to refer a reluctant patient to a psychiatrist. American Family Physician, 7:109-114, 1973. Psychiatric referral is more difficult when the family physi- cian has a negative attitude to psychiatry and transmits these feelings to the patient. Sometimes the referral is made because the physician is disappointed or angry with the patient who presents a physical symptom for which no organic base can be found. Even when the family physician does make a psychiatric refer- ral, the patient may be reluctant to cooperate. Many patients fear emotional illness or want to avoid exploring deep feelings. The family physician should exploit the doctor-patient relation- ship when s/he recommends psychiatric consultation. Some patients feel abandoned by the family physician when a psychiatric referral is made. The physician needs to reassure the patient that s/he will not be neglected. "The physician may simply have to refuse further investigation unless the patient will follow his advice to see a psychiatrist." Rosen, B.M., Locke, B.Z., Goldberg, I.D., and Babigian, H.M. Identi- fication of emotional disturbance in patients seen in general medical clinics. Hospital and Community Psychiatry, 23:364-370, 1972. - The authors studied patients seen in one month at four out- patient general medical clinics. Another clinic with a small case load reported on patients seen during two months. The clinics represented 5 of 6 outpatient general medical clinics in Monroe County, New York. A total of 1,413 patients aged 15 and older were studied. Twenty-two percent of the patients were diagnosed by their physicians as suffering from mental disorder. The types of treatment provided included: supportive therapy (31% of patients); drug prescriptions (14%~; environmental changes suggested (1%~; supportive therapy and drugs (35%~; supportive therapy and environmental changes (8%~; therapy, drugs, and environmental change (10%~.

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244 Shortell, S.M., and Daniel, R.S. Referral relationships between internists and psychiatrists in fee-for-service practice: An empirical examination. Medical Care, 12:229-240, 1974. The authors interviewed 127 internists practicing in the northern suburbs of Chicago. During a one month period 0.9 percent of all patients seen were referred to psychiatrists. Internists over 50 years old, those in practice 20 years or more, solo practitioners, board certified, and those without a subspecialty had higher rates of psychiatric referral. Depression, followed by anxiety and neurosis were the most frequent reasons for psychiatric referral. Alcoholics were least likely to be referred to psychiatrists. The internists were generally satisfied with their patterns. Scaramella, T.J. Management of depression and anxiety in primary care practice. Primary Care, 4:67-77, 1977. The author argues that patients with anxiety syndromes "are more manageable and respond better to therapy when they are treated by their family doctor." These patients are reluctant to see a psychiatrist. The family doctor should work to alleviate the patient's fears by reassurance and under- standing. Specific case examples are presented which illustrate management techniques. Patients with anxiety states should be referred to psychiatrists when: l) neither patient nor physician can identify the source of stress or conflict, 2) patient fails to follow or benfit from primary care physician's treatment after three months, 3) patient expresses strong interest in psychotherapy, or 4) patient's personality makes it difficult for him/her to cooperate with primary care physician. The author presents techniques to overcome a patient's resistance to psychia- tric referral. The primary care physician can provide treatment for de- pressed patients in a majority of cases. Depressive disorder is usually characterized by low spirits, sleep disturbance, somatic complaints, and inability to function effectively. The primary care physician should: l) identify for the patient what is wrong; 2) explore the factors in the patient's life which may be contributing to the depression; 3) explain to the patient that somatic complaints, feelings of hopelessness and pessimism are part of the depression; 4) while acknowledging the symptoms, do not promote the use of symptoms to avoid life events; 5) measure the extent of depression by having the patient complete a depression inventory; 6) ask about self-destructive thoughts; and 7) Outline a specific treatment plan. Patients should receive a psychiatric consultation and/or referral if patient shows signs of psychosis, strong suicidal intentions,

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245 previous episodes of mania, poor response to treatment after three months, patient has a depressive life style, or patient requests to see a psychiatrist. Smith, J.A. Office psychotherapy in family medicine. American Family Physician, 2:80-84, 1970. The author describes the symptoms, course, and treatment of anxiety by the family practitioner. Anxious patients may have acute episodes with autonomic symptoms such as cardiac palpita- tions, vertigo, dry mouth, and diffuse perspiration. The onset may be sudden and accompanied by intense fear and an urge to escape. After the acute episode, the patient may continue to complain about nausea, urinary frequency, vertigo, blurred vision, insomnia, palpitations, cardiac awareness, tinnitus, or cold hands and feet. The typical treatment of anxiety is to assure that patient that s/he does not have a dread disease. The physician should be careful about the content of both verbal and nonverbal communication. The physician should ask questions about the true cause of the patient's complaint, and should de-emphasize the importance of physical complaints. Patients with severe anxiety should receive an anti-anxiety agent. Zabarenko, R.N., Merenstein, J.; and Zabarenko, L. Teaching psychologi- cal medicine in the family practice office. Journal of the American Medical Association, 218:392-396, 1971. The authors describe an educational experiment where a psychiatrist served as a preceptor for a family physician. The physician learned not to make a rigid distinction between organic and psychiatric disease and realized the importance of seeing the total patient. It is important not to impede the flow of patient information by asking too many questions. Every be- havior of the patient should be observed (gestures, body language, banter). The physician learned to recognize major but hidden syndromes, especially depression. He learned that is was not wise to force the patient to accept the fact that no organic disease is present.

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