Elsevier

General Hospital Psychiatry

Volume 28, Issue 2, March–April 2006, Pages 125-132
General Hospital Psychiatry

Psychiatry and Primary Care
Patients with a psychiatric disorder in general practice: determinants of general practitioners' psychological diagnosis

https://doi.org/10.1016/j.genhosppsych.2005.11.001Get rights and content

Abstract

Background

Although psychiatric disorders are highly prevalent in the community, many patients with a psychiatric morbidity remain unidentified as such in primary care.

Objective

The aim of this study was to analyze which clinical and sociodemographic characteristics of patients with psychiatric morbidity are related to general practitioners' (GPs) diagnosis of mental illness.

Methods

A 1-year naturalistic survey of primary care contacts of patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of affective disorder, anxiety disorder or alcohol abuse was carried out.

Results

Of the patients with a DSM-IV diagnosis, 10% did not visit their GP at all during 1 year, 40% visited their GP but were only diagnosed as having somatic diagnoses and 50% were given a psychological or social diagnosis at least once during 1 year. Affective disorders are more frequently diagnosed than anxiety disorders or alcohol abuse. The chances of psychological GP diagnosis increase with the number of GP contacts.

Conclusions

GPs appear to have few indications to help them distinguish patients with a psychiatric morbidity from others, as long as the patients themselves do not express more explicit clues to their condition. Public mental health education and a better public relations policy are badly needed.

Introduction

Psychiatric disorders are highly prevalent in the community. The 1-year prevalence rates of any psychiatric disorder, measured among more than 60,000 community-dwelling adults between 2001 and 2003 in 14 countries, varied between 4.7% and 26.4% [1], with a 14.9% rate for the Netherlands [2]. Nevertheless, the rates of psychiatric disorders diagnosed in general practice are lower. Lamberts [3], using the International Classification of Primary Care (ICPC) [4], showed a 2.9% prevalence rate of psychiatric diagnoses in 1991. The Second National Survey of General Practice [5] presented a 1-year prevalence rate of 4.7% psychiatric diagnoses using the ICPC.

In this article, we will focus on the characteristics of patients and their psychiatric disorder that may boost their chances of being diagnosed as having psychological or social problems. From earlier research, it is known that female patients and patients well known to their general practitioners (GPs) have a better chance of being recognized as suffering from a mental illness [6], [7]. Characteristics of the disorder may play a role as well: depression is better recognized than anxiety disorder [8]; more severe disorders are better recognized than mild forms of psychopathology [8], [9], [10]; and physical comorbidity has been reported as both an advantage [11] and a disadvantage [12] with regard to recognition of depression. Psychiatric comorbidity increases the chances of GP recognition of depression [13].

The research question underlying this article is as follows: Which characteristics (sociodemographic, health status, psychopathology) of patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of depression, anxiety disorder or alcohol abuse/addiction increase the probability of a GP diagnosis of psychological disorder or social problems?

Section snippets

Design and patients

The data originate from the Second Dutch National Survey of General Practice. A nationwide, representative sample of 104 general practices participated with 400,000 registered patients (see Fig. 1).

During 1 year, data on all contacts between GPs and patients, including diagnoses, prescribed medications and referrals, were extracted from routine electronic medical records. A random 5% sample of patients was invited to participate in a comprehensive health interview (65% response rate) including

Results

Three hundred seventy-six patients were identified with at least one DSM-IV diagnosis of mood disorder, anxiety disorder or alcohol abuse or addiction. Three hundred forty-four had at least one contact with their GP. (See Table 1 for the distribution of DSM-IV diagnoses, as assessed during interview.)

Mood disorders and anxiety disorders were both common among the included patients. Approximately half of the patients with alcohol disorder or anxiety disorder had a coexistent mood disorder; half

Discussion

Ninety percent of patients with a DSM-IV disorder have primary care contacts during 1 year. Many of them have more than one DSM-IV disorder, indicating a highly prevalent psychiatric comorbidity. For instance, approximately half of the patients with an anxiety disorder or substance abuse are depressed as well.

Approximately half of the patients with a DSM-IV disorder were given a psychological or social diagnosis by their GP at least once during the year in which the DSM-IV diagnosis was

How should these findings be interpreted?

Apparently, quite a lot of people with enough symptoms to meet DSM-IV criteria do not put forward explicit demands for psychological help to their GP and in some cases do not even visit their GP during 1 year. The reasons for not making any such demand have been documented in the literature. As Jorm [35] reported, many lay people cannot recognize specific disorders and have incorrect beliefs about the causes and effective treatment of mental illness.

Most patients with a DSM-IV disorder do not

Clinical implications

  • GPs should be aware of the fact that patients with a psychiatric disorder are not likely to ask explicitly for help for their psychological problems.

  • The public should be better informed about the treatment possibilities of mental disorder in primary care.

Limitations of the study

  • No exact match in time framework between CIDI (diagnosis concerning 1 year before the interview) and GP registration (1-year registration around the interview date).

  • No datum available about patients' reasons for their GP visits (only GP diagnoses).

Acknowledgments

This study was supported by a grant from ZonMw (The Netherlands Organization for Health Research and Development) (Z/CZ-TT 2001).

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