Papers

“Patient knows best”—detection of common mental disorders in Santiago, Chile: cross sectional studyCommentary: Clinical practice is as important as diagnosis

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7278.79 (Published 13 January 2001) Cite this as: BMJ 2001;322:79

“Patient knows best”—detection of common mental disorders in Santiago, Chile: cross sectional study

  1. Ricardo Araya, senior lecturera (arayari{at}cf.ac.uk),
  2. Glyn H Lewis, professor of epidemiology and community psychiatrya,
  3. Graciela Rojas, unit directorb,
  4. Anthony H Mann, professor of psychiatric epidemiologyc
  1. a Division of Psychological Medicine, University of Wales College of Medicine, Cardiff CF14 4XN
  2. b Unidad de Psiquiatria and Epidemiologia Psiquiatrica, Universidad de Chile, Facultad de Medicina, Santiago, Chile
  3. c Section of Epidemiology and General Practice, Institute of Psychiatry, London SE5 8AF
  4. Department of Psychiatry and Behavioural Sciences, Royal Free Campus, Royal Free and University College Medical School, London NW3 2PF
  1. Correspondence to: R Araya
  • Accepted 24 July 2000

Depression and anxiety are common in primary care but about half of patients with these disorders are not identified by primary care physicians. 1 2 Mental disorder is more likely to be diagnosed in patients who present with or attribute physical symptoms to psychological causes.24 We investigated how patients' ways of understanding their health problems influenced the detection of common mental disorder by primary care physicians in Santiago, Chile.

Methods and results

We studied 815 consecutive patients seen by 11 primary care physicians from five randomly selected clinics in northern Santiago, Chile. Patients with a chronic illness or patients aged over 50 were excluded because these patients are better known by doctors. Most doctors in Chile and in this study have less than four years' experience in primary care.

Before the patient saw the doctor, a lay interviewer asked the patient's reason for consultation and whether it was because of a physical or psychological problem. The interviewer inquired about other potential confounders: physical illness, disability, common somatic symptoms, and whether patients tended to interpret common somatic symptoms by using psychological, physical, or normalising explanations.

A psychiatrist administered the clinical interview schedule—revised, and patients scoring 12 or more were classified as having a common mental disorder.5 After the patient had seen the primary care physician, the doctor rated blindly whether the patient had a mental disorder using a five-point scale. Patients with a rating of “mild or greater” severity were considered to have a mental disorder.

The prevalence of mental disorders was 49% (396 of 802; 95% confidence interval 46% to 53%) according to the clinical interview schedule—revised and 35% (276 of 796; 31% to 38%) according to the doctors' ratings. Agreement of doctors' ratings was 48% (186 of 385; 43% to 53%) with the psychiatric assessment (κ=0.27), so 52% (199 of 385; 47% to 57%) of the cases identified by the clinical interview schedule went undetected. As a whole, 34% (269 of 795; 30% to 37%) of the patients chose a psychological explanation for their reason for consultation but only 69% (185 of 269; 63% to 74%) of them were psychiatric cases according to the psychiatric interviewer.

The association between patients' causal attribution (physical or psychological) of the reason for consultation and the detection of common mental disorders by primary care doctors. Only cases diagnosed according to psychiatric interview are included

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When analysis was restricted to psychiatric cases, almost half (48%) (186 of 389; 43% to 53%) of these patients attributed their reason for consultation to psychological causes. Among psychiatric cases, doctors identified correctly 34% (70 of 204; 28% to 41%) of those who attributed their reason for consultation to physical causes and 63% (116 of 185; 55% to 70%) of those who attributed their presenting problems to a psychological cause. After adjustment for confounders three variables showed significant independent associations with detection (table): a spontaneous psychological reason for consultation, a psychological causal attribution for the presenting problems, and an increased severity of the mental disorder.

Comment

Patients in primary care with mental disorders usually consult with doctors for physical problems and this can make it difficult for primary care physicians to identify mental disorder. However, our study has found that a substantial proportion of patients presenting with physical problems readily acknowledge that there is a psychological component to their physical problems. Doctors were more likely to identify patients with mental disorder who attributed their symptoms to a psychological cause than to a physical cause. Asking the patient directly about possible causes of their symptoms might be a simple way of improving the identification of mental disorder in primary care.

Learning how best to clarify patients' presenting complaints should be an important objective of communication skills programmes for clinicians. This could help improve detection rates of mental disorders, compliance, and patients' satisfaction with management. Patients' views are even more important when evidence based knowledge is difficult to come by and clinical uncertainty more common.

Acknowledgments

We thank Dr Glyn Elwyn, senior lecturer in general practice, University of Wales College of Medicine, for his valuable comments on this paper.

Contributors: RA planned and designed the study, participated in the fieldwork, analysed the data, and wrote the paper. GR commented on the design, coordinated fieldwork, and commented on the manuscript. GHL helped with data analysis and writing. AHM commented on the design and writing of the final paper. RA is guarantor for the paper.

Footnotes

  • Funding Fondo de Ciencia y Tecnologia (FONDECYT), Chile.

  • Competing interests None declared.

References

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Commentary: Clinical practice is as important as diagnosis

  1. Sunny C D Collings, visiting fellow (sunnyc{at}wnmeds.ac.nz)
  1. a Division of Psychological Medicine, University of Wales College of Medicine, Cardiff CF14 4XN
  2. b Unidad de Psiquiatria and Epidemiologia Psiquiatrica, Universidad de Chile, Facultad de Medicina, Santiago, Chile
  3. c Section of Epidemiology and General Practice, Institute of Psychiatry, London SE5 8AF
  4. Department of Psychiatry and Behavioural Sciences, Royal Free Campus, Royal Free and University College Medical School, London NW3 2PF

    For decades the relative roles of primary care and secondary care in mental illness have been debated, as has the capacity of primary care practitioners to detect and effectively treat mental illness.1 Araya et al have shown again that patients' attributions influence the detection of mental health problems in primary care. Doctors were twice as likely to detect a psychiatric problem if the patient attributed his or her reason for consultation to psychological rather than physical causes, although the doctors still missed a third of true cases, having a sensitivity of 67%. An important part of psychiatric practice is the “formulation,” where, in addition to making a diagnosis, the psychiatrist pulls together relevant information to answer the question, “Why this person with this illness at this time?” This process includes asking the patient what he or she considers to be the basis of the problem. Thus, the proposal that general practitioners should ask their patients a similar question fits with what is regarded as good practice in the mental health field and perhaps goes some way to providing that elusive quick screening test for mental disorder in primary care. It must be remembered, however, that underrecognition of psychiatric disorder may be due to patient, doctor, and factors in the system of health care, 2 3 and the exact nature and relative importance of these are likely to differ between cultures and countries.

    This work also points to another aspect of the debate about mental health in primary care. What about those patients who had no mental health problem according to the clinical interview schedule, but considered that there was a psychological basis to their presenting problem? These were a considerable proportion (a third) of those who chose a psychological explanation for their consultation. Such patients would probably expect some attention to be paid to their psychological problem, and even if they did not have a specific psychiatric illness they might well have a degree of psychological unease or distress, and attention to this might improve their mental and physical wellbeing.

    This brings us to the heart of the matter. The need is not simply to improve general practitioners' detection of true psychiatric cases (the increase in sensitivity that most studies focus on), although this is important. Primary care doctors need to be able to deal with the psychological components of what is presented to them, even if it is a “physical” illness. Of the psychological problems present in patients who attend primary care doctors, diagnosable mental illness is only an important subset. Furthermore, general practitioners may recognise and respond to psychological distress in ways other than the “standard” psychiatric treatments, but in ways that are therapeutic none the less. We need to be asking not only how we can improve general practitioners' detection of psychiatric illness but also what organising principles general practitioners use to classify possible psychological problems and how these influence their clinical practice. Exploration of questions such as these has begun recently and has shown that general practitioners probably do use conceptual models other than classification systems such as the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases(MaGPIe research group, unpublished results, 1999).4 Until we all have a better appreciation of the variety of factors influencing general practitioners' decision making, general practitioners and psychiatrists will continue to talk past each other and our patients will suffer.

    Acknowledgments

    SCDC is a member of the MaGPIe (Mental Health and General Practice Investigation) research group, a collaboration between the departments of general practice, psychological medicine, and public health at the Wellington School of Medicine, University of Otago, New Zealand.

    References

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