|
Items in cart [1] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 41
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.
OCR for page 42
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
OCR for page 43
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
OCR for page 44
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
OCR for page 45
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
OCR for page 46
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
OCR for page 47
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
OCR for page 48
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.
-
OCR for page 49
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.
OCR for page 50
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.
OCR for page 51
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.
OCR for page 110
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.
OCR for page 111
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.
OCR for page 112
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.
OCR for page 113
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.
OCR for page 114
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.
OCR for page 115
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.
OCR for page 116
116
Parkes, C.M. The first year of bereavement: A longitudinal study of the
reaction of London widows to the death of their husbands. Psychiatry,
33~4~:444-467 (November) 1970.
Patterson, D. and Bise, B. Report pursuant to NIMH contract number 282-
77-0219-MS. January, 1978.
Pomerleau, O., Bass, F. and Crown, V. Role of behavior modification in
preventive medicine. New England Journal of Medicine, 292~24~:
1277-1282 (June 12) 1975.
Rappaport, M. Medically oriented psychiatry: An approach to improving
the quality of mental health care. Hospital and Community Psychiatry,
26~12~:811-815 (December) 1975.
Regier, D.A., et al. Epidemiological and health services research
findings in four organized health/mental health service settings.
Paper presented at the ADAMHA Health Maintenance Organization
Conference (November 30) 1977.
Reidenberg, M.M. Registry of adverse drug reactions. Journal of the
American Medical Association, 203~1~:85-88 (January) 1968.
Roghmann, K.J. and Haggerty, R.J. Family stress and the use of health
services. International Journal of Epidemiology, 1~3~:279-286,
1972.
Rosen, J.C. and Wiens, A.N. Changes in medical problems and utiliza-
tion of medical services following psychological intervention.
In press, American Psychologist, 1979 (prepublication ms).
Rosenberg, C.M. and Raynes, A.E. Keeping Patients in Psychiatric
Treatment. Cambridge, Massachusetts: Ballinger Publishing Co.,
1976.
Sackett, D.L. and Haynes, R.B. Compliance with Therapeutic Regimens.
Baltimore: Johns Hopkins University Press, 1976.
Schlesinger, H.J., Mumford, E. and Glass, G.V. The effects of
psychologically-informed intervention on recovery from medical
crisis. In Aldrete, J.A. and Guerra, F. Emotional Responses to
Anesthesia and Surgery. Grune and Stratton, in press.
OCR for page 117
117
Sedgewick, P. Medical individualism.
(September) 1974.
Hastings Center Studies, 2~3~:69-80
Singer, E., Garfinkel, R., Cohen, S.M. and Srole, L. Mortality and
mental health: evidence from the Midtown Manhattan restudy. Social
Science and Medicine, 10~11 & 12~:517-525 (November/ December) 1976
Stimson, G. and Webb, G. Going to See the Doctor.
Routledge and Kegan Paul, 1975.
London/Boston:
Uris, J.S. Effects of medical utilization and diagnosis on general
medical care utilization in a prepaid clinic setting. Report by
Western Interstate Commission on Higher Education (WICHE) Intern,
Boulder, Colorado, 1974.
Vayda, E. A comparison of surgical rates in Canada and in England
and Wales. The New England Journal of Medicine, 289~23~:
1224-1229 (December) 1973.
Webb, S.B., Jr., Thompson, J.D. and Whitt, I.B.
in emergency department utilization. Inquiry
(December) 1977.
. ~
Statewide trends
, 14:402-408
OCR for page 118
OCR for page 119
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.)
OCR for page 120
Representative terms from entire chapter:
medical utilization
