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41 THE NATURE AND SCOPE OF MENTAL HEALTH PROBLEMS IN PRIMARY CARE: VARIABILITY AND METHODOLOGY Darrel A. Regier, M.D., M.P.H.* Director, Division of Biometry and Epidemiology, National Institute of Mental Health The current and future role of primary care providers and settings is an issue of considerable health policy interest. Realistic policy and program development concerning this role must be based, in part, on accurate understanding of the scope and nature of mental disorder with- in the primary care sector e This fact has not been lost on the research community. As demonstrated by the recent literature review by Hankin and Oktay' a striking array of prevalence data is available. 1/ But what is a planner or policy maker or educator to make of mental dis- order prevalence rates ranging from below 1 percent to over 50 percent of the population in primary care settings? Adding to the potential confusion are health services research data in primary care settings which are often focused on visits or volume of: services rather than on the number of persons using cervices e Useful though they may be, visit-based utilization data and person-haled epidemiologic data are difficult to interrelate meaningfully. At present, we can give only a general rather than a definitive estimate of the rate of mental disorder in U.S. primary care settings. But we know that much of the variance in reported rates is directly related to differences in research methodology We will examine some of the effects of methodology on prevalence rates, citing study results from the literature in which single prevalence measures are usually used, as well as results from some recent NIMH-sponsored studies in which multiple measures were used within and across sites e Results from the latter studies, which permit person-based and visit-based rates to be compared, will also be reviewed. We hope that this exercise will serve both as a guide to understanding the current state of knowledge and a goal to more systematic study. *Prepared in collaboration with Anne H. Rosenfeld, Social Science Analyst, Division of Biometry and Epidemiology, National Institute of Mental Health; Barbara Je Burns, Ph.D., Research Psychologist, Primary Care Research Section, Applied Biometrics Research Branch, Division of Biometry and Epidemiology, National Institute of Mental Health; Irving D. Goldberg, M.P.H., Chief, Applied Biometrics Research Branch, National Institute of Mental Health; and Edwin W. Hopper, MeDo ~ Psychiatrist, Marshfield Clinic, and Chief of Staff, St. Joseph's Hospital, Marshfield, Wisconsin.

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42 As background to this discussion, let us first sketch in the overall prevalence of mental disorders in the population at large and the distribution of persons with mental disorders among major sectors of the health care system. In the recent reviews prepared by the NIMH Division of Biometry and Epidemiology for the President's Commission on Mental Health, we estimated that about 15 percent of the general population could be diagnosed as having an ICD Section V- defined mental disorder in a given year. 2/ While this estimate is relatively crude, it does provide a general framework for understanding the scope of the problem. Regarding the division of responsibility in the current service system for the care of those with mental disorders, as shown in Figure 1, we have identified some 21 percent in the specialty mental health sector, another 54 percent as being seen only in the outpatient primary care sector (pith 6 percent specialty overlap), 3 percent in the general hospital-nursing home sector, and 22 percent for whom we cannot account. Thus, in discussing the mental health care role of primary practice, we are addressing the health care sector used ex- clusively by better than half of those with mental disorders in a given year. Figure 1 Not in Treatment/Other Human Services Sector* , / 21.5% General Hospital Inpatient/ Nursing Home Sector* 7 Specialty Mental ~ Health Sector 15.0% 2\ Both Specialty Mental Health / ~ Sector & Primary Care/Outpatient '/6.0% ~ Medical Sector (Overlan) _ /I Primary Care/Outpatient / Medical Sector Excludes overlap of an unknown percent of persons also seen in other sectors. NOTE: Data relating to sectors other than the specialty mental health sector reflect the number of patients with mental disorder seen in those sectors without regard to the amount or adequacy of treatment protruded. 1

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43 Shifting perspective now to the primary care sector, we might expect the prevalence rate for mental disorder to match the overall population rate of approximately 15 percent. Indeed, reported rates are predominantly in the 10-20 percent range. 1/ But, as we have noted, the variation in reported rates is considerable. Let us look more closely at its methodologic sources. Major differences in reported rates can stem from the choice of Population base (total registered, total users, or consecutive users) from the time period (one point in time, several months, one year, or lifetime), and from the principal unit of analysis (number of persons, number of visits, or allocation of resources and costs for-the treat- ment of persons with mental disorders). Further, differences can stem from the choice of case identification method. Let us take, as an example, the effect of five methods of case identification on reported rates. year had a diagnosis clinical records. 3/ studies of four ___ between 1.3 and ~ Figure 2 shows some of the prevalence rate ranges in primary care settings, grouped by case identification method. Starting with the person-based, more epidemiologically oriented studies, the first method of case identification is routine reporting of mental disorder diagnoses on clinical records of general practitioners. Using this method of case identification, Fink, et al, found that about 5 percent of the Health Insurance Plan of New York (HIP) population in a given of mental disorder routinely recorded on their _ (We have recently repeated this approach on different health programs, demonstrating a range 6.3 percent across programs. 4/ These rates increase to a range of 1.5 to 8.2 percent when the population base is utilizing patients rather than the total population potentially using services; when only patients are used as the population base, the denominator is smaller and prevalence rates correspondingly increase.) a The second case identification method is the routine recording of diagnoses, symptoms, treatments, and referrals O Hoeper, et al, have recently completed a study, using a chart review of adult patients in a prepaid group practice at Marshfield, Wisconsin, which revealed a three- month prevalence rate of some 5 percent. 5/ This rate was somewhat higher than the 2.6 percent rate for the same setting found by routinely re- corded Section V diagnosis of mental disorder. 4/ The third method of case identification, which has received the most attention within epidemiological circles, is the use of survey report form for recording mental disorder diagnoses by general medical physicians. In the classic study of this type, Dr. Michael Shepherd reported that some 14 percent of the patients in 46 general medical practices in London were identified by GP's as having mental dis- orders. 6/ In this country, Locke, Goldberg, Rosen and others of the

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44 Figure 2 CASE IDENTIFICATION METHODS IN PRIMARY CARE SETTINGS Person-Based Studies Routine recording of mental disorder diagnoses on clinical records --Fink R. et al: 4.8: --Regier DA, et al: 1.3~6.3: (1.5-8.21) Routine recording of diagnoses, symptoms, treatments, and referrals --Hoeper EW, et al: 5.0: Survey report form used for recording mental disorder diagnoses --Shepherd M, et al: 14.0: - Locke BZ, et al: 16. 9: Routine recording of mental disorder diagnoses on clinical records --NAMCS( 1975 ): 2 .1: --Regier DA, et at: 0. 4-4 .0: Visit-Based Studies Standardized psychiatric interview with general practice patients Rawnsley K: 22X --Hoeper EW, et al: 26. 7: Patient sel f-report on psychiatric symptom questionnaire Shepherd, M, et al: 20-36X Pedder JR and Goldberg DP: 30% Hoeper hW, et al: 30% Routine recording of mental health treatments --Bar ter MB, et al: 12: of vi sit s receive psychotropic drugs 18/ Division of Biometry and Epidemiology of NIMH have identified rather comparable rates. 7,8,9/ (However, since a patient population base and not a general population base was used, the rates are somewhat higher.) The fourth case identification method is a standardized psychia- tric interview with general practice patients. There have been several interviews of this type. The interview developed in the University of London, Institute of Psychiatry general practice unit by Drs. David Goldberg, Michael Shepherd, and others, 10/ has been used by Rawnsley to identify some 22 percent as having a mental disorder diagnosis in a primary care practice. 11/ Similarly, in their recently completed study in Marshfield, Wisconsin, Hoeper, et al, using the SADS-L standardized psychiatric interview, reported some 26.7 percent of patients identified with an RDC diagnosis of mental disorder. 5/ The final method of case identification is patient self-report on psychiatric symptom questionnaires. The Cornell Medical Index (CMI) was used in the original Shepherd study in which a range of 20-36 percent

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45 scored positive on the MR section of the CMI. 6/ Other studies, using the General Health Questionnaire (GHQ) developed by David Goldberg, 12/ have found rates in the range of 30 percent. 13/ Hoeper and his colleagues found the same range when they used this instrument in the Marshfield area. 5/ In reviewing Figure 2, then, it is important to recognize that the rates tend to be higher with each successive case identification method. Elevated rates are also found when consecutive patients are used, and when only the patient population is counted in the denomina- tor. Shifting now to health services research data on the volume (and cost) of services, these tend to use visits as the unit of analysis. The most common utilization data available are from routine reporting systems on medical records. However, visit-based physician practice surveys are also used. The National Ambulatory Medical Care Survey (NAMCS) of U.S. office- based physicians identified a primary diagnosis of mental disorder in only 2.1 percent of visits to all nonpsychiatrist physicians. General practitioners had a slightly higher rate of 3 percent, internists 3.6 percent, and pediatricians a lower rate of 1 percent. 13/ A similar type of diagnostic reporting was also examined in four organized health care programs, in three settings under contract with NIMH. These settings included the Bunker Hill Health Center in Boston, the Columbia Health Plan in Columbia, Maryland, and the Marshfield Clinic, which has both a fee-for-service and prepaid practice program. The rates across settings ranged from .4 to 4 percent of visits. 14,15,16/ Because multiple measures were used in these settings, it is possible to compare the relationship between visit-based and person- based rates. In all cases, the percent of patients identified with mental disorder in one year is higher than the percent of visits for such diagnoses -- indeed, on the average, about two times greater (see Table 1~. This finding seems somewhat counterintuitive, considering that patients with diagnoses of mental disorder have much higher total visits to their physicians than those without such disorders. (In fact, in the four plans that we studied, patients with mental disorder averaged from 1.4 to 2 times as many visits per patient per year as patients without mental disorder diagnoses.) (See Table 2) However, although patients with mental disorder diagnoses visit more frequently, most of their visits are for diagnoses of other medical illnesses, a fact con- sistent with the finding that patients with mental disorders have higher morbidity rates for all other categories of medical illness. 17/ The interaction among different case identification methods and their relationship with utilization indices may be illustrated by a case example involving the Marshfield Clinic, in Marshfield, Wisconsin. In this large clinic, where multiple measures of primary care practice activities were used, it was found that 2.7 percent of the visits had

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46 Table 1. Percent of Visits and Patients, in Non-Mental Health Departments with Diagnoses of Mental Disorder, By Setting, 1975 Percent Visits Associated With Ra tio of Setting Mental Disorder Diagnosis Patients/Visits Percent Patients Columbia Medical Plan 0.4 1.5 3.8 Marshfield Clinic Prepaid 2. 7 3. 7 1.4 Fee for Service 2.3 4.0 1.7 Bunker Bill Health Center 4.0 8.2 2.1 Table 2. Mean Visits to Non-Mental Health Departments Per Patient With and Without Diagnosed Mental Disorder, By Setting, 1975 Setting Mental Disorder Diagnosis Ratio of Means: Present/Absent Present Absent . Columbia Medical Plan 7.1 5.0 1.4 Marshf ield Clinic Prepaid 7.7 4. 2 1.8 Fee For Service 6.5 3.6 1.8 Bunker Hill Health Center 6.4 3.2 2.0

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47 a principal diagnosis of mental disorder. This represented 3.7 percent of patients aged O to 65. Patients with mental disorder diagnoses averaged almost twice as many visits per year as patients without such disorders, accounting for 7 percent of the total visits. However, only slightly more than one-third of their visits were for a diagnosis of mental disorder. In a recent three-month survey of adult members of this same popu- lation, it was found that 5 percent of consecutive patients could be diagnosed as having a mental health problem if prescriptions for psychotropic drugs and recorded emotional symptoms are included. Although no survey per se of the Marshfield GP's was performed, such as has been done by Shepherd, Locke, and others,-the GHQ was administered as a patient self-report form, and a standardized psychiatric interview (SADS-L) was conducted with a sample of patients. Preliminary findings indicate that 30 percent of the patients scored positive on the GHQ and approximately 27 percent received diagnoses of specific mental disorder on a standardized psychiatric interview with mental health specialists. Thus, results from the Marshfield study, in which multiple case identification techniques were used in one site, confirm the method- dependent effects noted earlier across many studies and sites: relatively low rates when GP reporting is used, and relatively high rates when self-reports of standardized psychiatric interviews are used. Elucidating precisely the prevalence of mental disorders in primary care practice is but one of the important research tasks required to guide future policy and program development. It is also important to determine the diagnostic and treatment needs of persons identified by different methodological approaches. Likewise, it is necessary to determine both the effectiveness and cost-effectiveness of services provided to such patients in either the primary care or the specialty mental health referred settings. If we are to integrate health and mental health services further, or simply to pay more attention to the role of primary care practi- tioners in treating persons with mental disorder, we will need, first, to have more data on the specific types of disorders they tend to identify, misidentify, treat, decide not to treat, or decide to refer. Second, we need to link the data on specific disorders with service utilization, cost, specific treatments, and outcome. Third, the effect of training methods on improving accurate identification and effective treatment also needs further study. If the primary care sector is to be a full partner in the treat- ment of patients with mental disorder, primary care physicians will need all of the tools of the specialty sector, in somewhat modified form, to function effectively. These include: a classification system for psychosocial problems and mental disorders oriented to the level of specificity expected of a primary care provider; a method of case

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48 identification which includes elements of symptom questionnaires in routine history taking; and more detailed structured interviews which can be used when there is doubt about diagnosis or treatment. In short, a combination of descriptive, analytic, and methodolo gically oriented studies is needed to improve understanding of the mental health service role of primary care providers, to aid them in carrying out that role, and to guide the informed development of services policy related to that role. We have a good initial effort; it must be sustained. -

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49 References Hankin, J., Oktay, J.S.: Mental Disorder and Primary Medical Care: An Analytical Review of the Literature. Rockville. DHEW Publication No. (ADM) 78-661, 1979. 2. Regier, D.A., Goldberg, I.D., Taube, C.A.: The de facto U.S. mental health services system. Arch. Gen. Psychiatry 35:685-693' 1978. 3. Fink, R., Goldensohn, S., Shapiro, S., and Daily, E.: Changes in family doctors' services for emotional disorders after addition of psychiatric treatment to a prepaid group practice program. Medical Care 7:209-224, 1969. 4. Regier, D.A., Goldberg, I.D., Burns, B.J., Hankin, J., Hoeper, E.W., and Nycz, G.R.: Mental health services in four integrated health/ mental health settings. Presented at Annual Meeting of the American Psychiatric Association, Atlanta, May, 1978. 5. Hoeper, E.W., Nycz, G.Ro ~ Cleary, P.D.: The Quality of Mental Health Services in an Organized Primary Care Setting: Final Report, Marshfield Medical Foundation, Marshfield, Wisconsin (unpublished), 1979. 6. Shepherd, M., Cooper, B., Brown, A.C., Kalton, G.W.: Psychiatric Illness in General Practice. London, Oxford University Press, 1966. Locke, B.Z., Gardner, E.P.: Psychiatric disorders among the patients of general practitioners and internists. Public Health Reports, 84:2:167-173, 1969. 8. Rosen, B.M., Locke, B.Z., Goldberg, I.D., Babigian, H.M.: Identifi- cation of emotional disturbance in patients seen in general medical clinics. Hosp. and Community Psychiatry, 23:364-370, 1972. 9. Locke, B.Z., Krantz, G., Kramer, M.: Psychiatric need and demand in a prepaid group practice program. Am. J. Pub. Hlth. 56:895- 904, 1966. 1O. Goldberg, D.P., Cooper' B., Eastwood, M.R.., Kedward, H.B., Shepherd, M.A.: Standardized psychiatric interview for use in community surveys. Brit. J. Prevent. and Soc. Med. 24:18-23, 1970. 11. Rawnsley, K.: Congruence of independent measures of psychiatric morbidity. J. Psychosomatic Rsch. 10:84-93, 1966.

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50 12. Goldberg, D.P.: The Detection of Psychiatric Illness Institute of Psychiatry, Maudsley Monographs No. 21. London, Oxford University Press, 1972. Questionnaire. - 13. Pedder, J.R., Goldberg, D.P.: A survey by questionnaire of psychiatric disturbance in patients attending a venereal disease clinic. Brit. J. of Venereal Disease, 46:58-61, 1970. Jacobson, A.M., Leet, R., Goldner, N.: 14. Burns, B.J., Orso, C., Utilization of Health and Mental Health Outpatient Services in Organized Medical Settings: Final Report, Bunker Hill Health Center of Massachusetts General Hospital, 1978. (Unpublished). 15. - Shapiro, S., Hankin, J., Steinwachs, D.M.: Utilization of Health and Mental Health Outpatient Services in Organized Medical Care Settings: Final Report, Columbia Medical Plan, Health Services Research and Development Center, The Johns Hopkins University, Baltimore, Md., 1977. (Unpublished). 16. Hoeper, E.W., Nycz, G.: Utilization of Health and Mental Health Outpatient Services in Organized Medical Care Settings: Final Report, Marshfield Clinic, Marshfield, Wisconsin, 1977 (Unpublished). 17. Eastwood, M.R.: Toronto: University of Toronto Press, 1975. The Relation Between Physical and Mental Illness. 18. Baiter, M.B.: Coping with Illness: Choices, alternatives and consequences, in Drug Development and Marketing. Helms,R.B. (ed.), American Enterprise Institute for Public Policy Research, Washington, D.C., 1974, pp. 27-46.

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51 A NEIGHBORHOOD HEALTH CENTER MODEL OF INTEGRATED AND LINKED HEALTH AND MENTAL HEALTH SERVICES Barbara J. Burns, Ph.D.* Research Psychologist, Primary Care Research Section, Applied Biometrics Research Branch, Division of Biometry and Epidemiology, National Institute of Mental Health Rockville, Maryland Efforts to provide more closely integrated health and mental health services particularly within primary care settings have taken a number of forms in community and neighborhood health centers and health maintenance organizations. A current Federal emphasis encourages closer ties between existing neighborhood or community health centers (CHCs) and community mental health centers (CMHCs). A description is provided of one organized primary care setting, a neighborhood health center (NHC), with integrated mental health services from its inception which are linked to a community mental health center. Despite its unique features, this particular example can serve as one model for the delivery of mental health services in a general health care context while maintaining a close working relationship with the specialty mental health sector. A brief description of the organization will be followed by reported patient benefits and provider issues experienced in this setting. THE MODEL The focal point of this report is the Bunker Hill Health Center (BHHC) of the Massachusetts General Hospital, a NHC serving a primarily low-income Irish-American community of about 17,000 persons who live in Charlestown, Massachusetts, a relatively isolated section of the city of Boston. Following assessment of the community's health and mental health needs, BHHC was opened in 1968 under the strong leader- ship of an Irish pediatrician. The Center is a satellite of the Massachusetts General Hospital (MGH), a teaching hospital in Boston. Its stated goals were to provide comprehensive, coordinated, continuous, personalized, non-fragmented, family-centered health care at a reason- able cost. As a physical extension of the MGH, the Center offered . *In collaboration with Darrel A. Regier, M.D'., M.P.H., Director, Division of Biometry and Epidemiology, National Institute of Mental Health, Rockville, Maryland.

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110 between the number of hours of therapy and the differential "success" rate was positive and reasonably large: +.49. Review of Controlled Experimental Studies on the Effects of Psycho- logically Informed Intervention on Patients in Medical Crisis We have been able to locate 23 experimental studies that test the effect of providing emotional support and/or understanding as an ad- junct to medically required care for patients undergoing surgery and recovering from heart attack. The course of recovery was compared with that of a control group of patients not provided the special attention. The circumstances and findings of each study and the problems in analyzing them as a group have been summarized elsewhere (Schlesinger, Mumford and Glass, 1979~. In order to compare and pool results from different studies, an "effect size" was computed. The effect size is a standardized measure of average difference between the treatment and control group on an outcome variable. The effect sizes for all 117 outcome indicators in the 23 studies average +.43 implying that the intervention groups do better than the control groups by nearly one-half standard deviation. These findings are consistent across studies; fewer than 18% of the 117 out- come comparisons were negative. Among the 117 outcome measures 66 are highly relevant to the physical recovery process ("anesthesia time," "units of blood," "degree of hypothermia," and "days in hospital") while 51 have more to do with patient comfort ("self-report of sadness". When effect sizes are calculated separately for these two types of outcome, the compari- son slightly favors larger effects for the more medically relevant indices, at +.45 versus +.40. A subset of the outcome indicators is particularly important for its cost offset implications. Ten studies reported the amount of time spent in the hospital by the treatment and the control groups. The average difference in days hospitalized for these ten studies weighted equally or weighted according to the number of patients studied is slightly more than two days in favor of the intervention group. Is this difference statistically reliable? The estimate is based on data from approximately 2,000 intervention and control patients across the ten studies. Seven of the ten studies gave infor- mation on the standard deviation of duration of hospitalization. The average standard deviation is about 4.75 days and t = 8.53, significant at any reasonable level. If we analyze the findings using the study as the unit of analysis, a significant t of at least 3.07 results.

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111 These effects occur even though the interventions are mostly modest and not tailored to the needs of the individual patient, i.e., all patients in the experimental groups received the intervention under study. Two studies that attempted to match the intervention to the patient show that when the coping style of patient is compatible with the type of support provided, the intervention appeared to be more effective (DeLong, 1971; Kennedy, 1966~. SUGARY A review of the problems in determining whether a cost offset can be expected from introducing a mental health component in primary care shows that the problems are conceptual and methodological as well as practical and statistical. The problems are difficult to solve but not insurmountable. Most of the archival studies of the effects of psychotherapy on medical utilization are flawed by problems of experimental design. A critical, quantitative review of 15 such studies that takes account of these flaws indicates a likely reduction of between O and 19% in medical utilization and costs. Further work is needed to narrow the band of uncertainty. A critical, quantitative review of 15 controlled, experimental studies assessing the effects of various kinds of psychotherapy on alcoholism and 13 such studies on asthma show positive effects on outcome indicators with clear implications for a significant and sizeable cost offset. A similar review of studies of the effects of "psychologically informed" intervention on patients recovering from heart attack or surgery shows a clear cost-offset resulting from a more than two-day shorter hospital stay for the intervention group. Quite aside from the intrinsic value of offering specific care for patient's emotional problems and humane and considerate care for their medical and surgical problems, the evidence is that providing psychotherapy and psychologically informed care can be cost effective and that a cost offset may result from the inclusion of a mental health component in primary care systems.

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112 References Aday, L. (study director) and Andersen, R. America's health care health care system: A comprehensive portrait. Robert Wood Johnson Foundation Special Report, No. 1, 1978, pp. 4-15. Barofsky, I., (Ed.) Medication Compliance. Thorofare, New Jersey: Charles B. Slack, Inc., 1977. Becker, M.N. and Maiman, L.A. Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care, 13~1~:109- 24 (January) 1975. Bercel, N.A. Concluding remarks. Diseases of the Nervous System, 29 Supplement (3~:77-78 (March) 1968. Borus, J.F., Burns, B.J., Jacobson, A.M., Macht, L.B., Morrill, R.G. and Wilson, E.M. Neighborhood health centers as providers of coordinated mental health care. Background paper for Invitational Conference on the Provision of Mental Health Services in Primary Care Settings, April 2 - 3, 1979. Brenner, H. Mental Illness and the Economy. Cambridge, Massachusetts: Harvard University Press, 1973. Budman, S.H., Wertlieb, D., Budman, S. and Demby, A. Maximizing the offset of medical utilization via psychological services: A strategy for intervention. Paper presented at the National Institute of Mental Health, April 5, 1979. Bunker, J.P. Surgical manpower, a comparison of operations and surgeons in the United States and in England and Wales. New England Journal of Medicine, 282~3~:135-144 (January 15) 1970. Cambell, D.T. and Stanley, J.C. Experimental and Quasi-experimental Designs for Research. Chicago, Illinois: Rand McNalley, 1966. Clancy, K. and Gove, W. Sex differences in mental illness: An analysis of response bias in self reports. American Journal <'f Sociology, 80(1):205-216 (July) 1974. Cummings, N.A. and Follette, W.T. Psychiatric services and medical utilization in a prepaid health plan setting, (Part II). Medical Care, 6~1~:31-41 (January/February) 1968.

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113 DeLong, R.D. Individual differences in patterns of anxiety arousal, stress-relevant information and recovery from surgery. Dissertation Abstracts International, 32: 554B-555B, 1971. Dohrenwend, B.P. and Dohrenwend, B.S. Social Status and Psychological Disorder. New York: John Wiley & Co., 1969. Duehrssen, A. and Jorswiek, E. An empirical and statistical inquiry into the therapeutic potential of psychoanalytic treatment. Der Nervenarzt, 36(4):166-169, 1965. Eisenberg, L. Disease and illness. Culture Medicine and Psychiatry, 1(1):9-23 (April) 1977. Engel, G. The need for a new medical model: A challenge for bio- medicine. Science, 196(4286):129-136 (April 8) 1977. Engel, G. Emotional stress and sudden death. Psychology Today, 11(6): 114-118; 153-154 (November) 1977. Fabrega, H. The position of psychiatry in the understanding of human disease. Archives of General Psychiatry, 32~12~:1500-1512 (December) 1975. Fink, R., et al. Psychiatric treatment and patterns of medical care. Unpublished report to NIMH, (7169), pp. 33-51. Follette, W. and C~'mrnings, N. Psychiatric services and medical utilization in a prepaid health plan setting. Medical Care 5~1~:25-35 (January-February) 1967. Fontana, A.F., Dowds, B.N., Marcus, J.D., and Rakusin, J.M. Coping with interpersonal conflicts through life events and hospitalization. The Journal of Nervous and Mental Disease, 162~2~:88-98 (February) . . 1976. Fuchs, V.R. Who Shall Live? New York: Basic Books, Inc., 1974. _ Gersten, J.C., Langer, T.S., Eisenberg, J.G. and Simcha-Fagan, 0. An evaluation of the etiologic role of stressful life-change events in psychological disorder. Journal of Health and Social Behavior, 18~3~:228-244 (September) 1977. Glass, D.C. Behavior Patterns, Stress and Coronary Disease. Hillsdale, New Jersey: Lawrence Erlbaum Associates, 1977. Glass, G.V., Willson, V.L. and Gottman, J.M. Design and Analysis of Time-Series Experiments. Boulder. Colorado Cr~1 or~-~1n Acc~r;=t-H University Press, 1975.

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114 Goldberg, E.L., Comstock, G.W. and Hornstra, R.K. Depressed mood and subsequent physical illness. American Journal of Psychiatry, 136(4B):530-534 (April) 1979. Goldberg, I.D., Krantz, G. and Locke, B.Z. Effects of a short-term outpatient psychiatric therapy benefit on the utilization of medical services in a prepaid group practice medical program. Medical Care, 8~5~:419-428 (September/October) 1970. Goldensohn, S.S. and Fink, R. Mental health services for medicaid enrollees in a prepaid group practice, (EMO). Presented at the 131st annual meeting of the American Paychiatric Association, Atlanta, Georgia, May 11, 1978. Goshen, C.E. The high cost of nonpsychiatric care. General Practi- tioner, 27(4):227-235 (April) 1963. Graves, R. and Hastrup, J. Effects of psychological treatment on medical utilization in a multidisciplinary health clinic for low income minority children. Paper presented Southwestern Psycho- logical Association Meeting, New Orleans, Louisiana, April, 1978. Jameson, J., Shuman, L.J. and Young, W.W. The effects of outpatient psychiatric utilization on the costs of providing third-party coverage. Research Series 18, Blue Cross of Western Pennsylvania, December, 1976, pp. 1-38. Kaminsky, M.J. and Slavney, P.R. Methodology and personality in Briquet's Syndrome: A reappraisal. American Journal of Psychiatry, 133(1):85-88 (January) 1976. Kaplan, H.B. Understanding the social and social-psychological antecedents and consequences of psychopathology: A review of reports of invitational conferences. Journal of Health and Social Behavior, 16~2~:135-151 (June) 1975. Kennecott Copper Corporation. INSIGHT, a program for troubled people. P.O. Box 11299, Salt Lake City, Utah, (undated draft). Kennedy, J.A. and Bakst, H. The influence of emotions on the outcome of cardiac surgery: A predictive study. Bulletin of the New York Academy of Medicine, 42~10~: 811-849 (October) 1966. Kessler, L. Episodes of psychiatric care and medical utilization in a prepaid group practice. Doctor of Science Dissertation, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland, May, 1978. Kogan, W.S., Thompson, D.J., Brown, J.R. and Newman, H.F. Impact of integration of mental health service and comprehensive medical care. Medical Care, 13~11~:934-943 (November) 1975.

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115 Lawson, D.H. and Jick, H. Drug prescribing in hospitals: An inter- national comparison. American Journal of Public Health, 66~7~: 644-648 (July) 1976. Lesse, S. Masked Depression. New York: Jason Aronson, 1974. Lipowski, Z.J. Psychiatry of somatic diseases: Epidemiology, patho- genesis, classification. Comprehensive Psychiatry, 16~2~:105-124 (March/April) 1975. Lipowski, Z.J. Psychosomatic medicine in the seventies: An overview. The American Journal of Psychiatry, 134~3~: 233-244 (March) 1977. McCarthy, E.G. and Widmer, G.W. Effects of screening by consultants on recommended elective surgical procedures. New England Journal of Medicine, 291~25~:1331-1335 (December 19) 1974. McHugh, J.P., Kahn, M.W. and Heiman, E. Relationships between mental health treatment and medical utilization among low-income Mexican- American patients: Some preliminary findings. Medical Care, 15(5):439-444 (May) 1977. Mechanic, D. Social psychologic factors affecting the presentation of bodily complaints. New England Journal of Medicine, 286~20~: 1132-1139 (May 18) 1972. Mechanic, D. Sociocultural and socio-psychological factors affecting personal responses to psychological disorder. Journal of Health and Social Behavior, 16~4~:393-404 (December) 1975. . Mechanic, D. The Growth of Bureaucratic Medicine. New York: John Wiley & Sons, 1976. Mumford, E. Culture: Life perspectives and the social meanings of illness. In: Simons, R. and Pardes, H., (Eds.), Understanding Human Behavior in Health and Illness. Baltimore: Williams and Wilkins, 1977, p. 173-183. Mumford, E., Schlesinger, H.J. and Glass, G.V. A critical review and indexed bibliography of the literature up to 1978 on the effects of psychotherapy on medical utilization. 1978 (unpublished report to NIMH contract No. 278-77-0049 (MH)~. Olbrisch, M.E. Evaluation of a stress management program for high utilizers of a prepaid university health service. Dissertation . submitted to Department of Psychology, The Florida State University, August, 1978. Ogilvie, R.I. and Ruedy, J. Adverse drug reactions during hospitali- zation. Canadian Medical Association Journal, 97~24~:1450-1457 (December 9) 1967.

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119 PLENARY PRESENTATION APRIL 3, 1979 MENTAL HEALTH AS AN INTEGRANT OF PRIMARY CARE Michael Shepherd, M.D. Professor of Epidemiological Psychiatry Institute of Psychiatry University of London Epidemiological investigations have demonstrated the high pre- valence of psychiatric morbidity presented at the level of primary health care. Further investigation shows that many of these conditions are closely associated with physical ill-health and/or social pathology. The implications of these findings for practice and research at the health/mental health interface are discussed. (The full text of Dr. Shepherd's paper appears in Section VII.)

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