Vol. 1, núm. 3 - Noviembre 2002
Revista Internacional On-line / An International On-line Journal
The understanding and management of psychological problems and
psychiatric disorders by primary-care physicians
Danielle Goerg*, Werner Fischer*, Eric Zbinden*, José Guimón**.
University Hospital of Geneva.
Geneva, Switzerland
* Sociologists, Department of Psychiatry, University Hospital of Geneva
**Professor of Psychiatry, University Hospital of Geneva
Correspondece:
D. Goerg, Department of Psychiatry
University Hospital of Geneva
2, Chemin du Petit-Bel-Air
CH-1225 Chêne-Bourg
Geneva, Switzerland
Tel. +4122/305.57.50 / fax +4122/305.57.99
E-mail : Danielle.Goerg@hcuge.ch
Resumen
Como los médicos generales juegan un papel importante en la detección y el tratamiento de los
trastornos mentales, es importante conocer sus ideas, conocimientos y concepciones acerca de la
Psiquiatría. En una encuesta realizada entre médicos generales de Ginebra acerca de los
conocimientos y habilidades que deberían enseñarse durante la carrera a los médicos no psiquiatras,
se estudió sus cobncepciones de la Püsiquiatría a través del análisis factorial. Sde obtuvieron tres
aproximaciones : la clínico-biológica, la psicosocial y la psicodinámica. La concepción psicosocial y la
clínico-biológica son sustentadas sobrev todo por los médicos generales y los internistas quienes
reconocen que tienen entre sus enfermios un alto porcentajecon problemas existenciales o
psiquiátricos-. Los pediatras sustentan sobre todo el enfoque psicodinámico.
Un quinto de los médicos encuestados tienen un interés marcado por la Psiquiatría , lo que supone
un porcentaje superior al de los médicos de otras especialidades. Estos datos llaman la atención
sobre la necesidad de formar a lois médicos generales en distintos aspectos de la psiquiatría
Summary
Objective: As primary-care physicians play a very important role in detecting and treating mental
disorders, the different conceptions of psychiatry they might endorse and their interest in psychiatry
need to be examined. Method: The data come from a survey, carried out in Geneva, Switzerland,
among physicians on the psychiatric knowledge and skills which a non-psychiatric physician should
have. The main conceptions of psychiatry were extracted by factorial analysis. Results: The three
main conceptions of psychiatry fostered by primary-care physicians are the psychosocial, the clinicalbiological and the psychodynamic conceptions. The psychosocial conception encompasses the
complex and long-lasting problems having social implications for the patient and effects on the
physician-patient relationship. The clinical-biological understanding of psychiatry emphasizes the
importance of differential diagnosis, treatment and medication. These two conceptions are mainly
favored by general practitioners and general internists. Physicians fostering these conceptions
consider that they have among their patients a higher percentage of people suffering from
psychiatric or existential problems. The third approach, psychodynamic, is principally endorsed by
pediatricians; these physicians refer a higher number of their patients to psychiatrists. One-fifth of
primary-care physicians can be considered as having a particularly great interest in psychiatry.
Comparison with non primary-care physicians indicates that the latter are less oriented towards
psychiatry. Conclusions: These data show the importance of the training of primary-care physicians
in different areas of psychiatry. Further research would be necessary to delineate the type of
relationship that primary-care physicians have with psychiatrists (competition, delegation or
cooperation) according to their conception of psychiatry.
Key words: primary health care; physicians, family; psychiatry; knowledge, attitudes, practice.
INTRODUCTION
It has been shown that knowledge of mental illness is poor in the general population and recognition
of mental disorders infrequent. Recognition of these disorders is also under-estimated by the
physicians themselves, although to a lesser extent. A proportion of psychiatric disorders are rarely
recognized, rarely diagnosed and still less often treated by primary-care physicians (Kesser LG,
Cleary PD, Burke JD, 1985) (Boardman AP, 1987) (Howe A, 1996). Üstün and Sartorius (Ustun TB,
Sartorius N, 1995), reviewing research in highly developed countries, mention that 30 to 70% of
cases of mental disorder in general practice go undetected. This underdiagnosis can lead to
unnecessary medical treatment and increase the risks of chronic illness. In order to understand the
mechanisms underlying this underestimation, several studies have inquired into the attitudes of
physicians towards patients suffering from mental disorders, towards psychiatrists and psychiatry
(Buchanan A, Bughra D, 1992) or dealt with the possibilities of improving physicians' knowledge in
this field (Howe A, 1996).
In a more general fashion, the question of the connection between primary-care medicine and
psychiatry is dealt with. According to country and region, observations were made on the extent of
the primary-care physician's role as "gatekeeper" for mental health-care services, under various
systems of insurance, as well as on the increase in the number of psychiatrists working in the
primary-care field of medicine, in various forms of cooperation (liaison psychiatry, for example). A
proposal to extend the role of psychiatrists in the somatic treatment of chronic psychiatric patients is
even foreseen to provide improved care for this group of under-served patients and to counteract
the influence of general practitioners in this field (Shore JH, 1996). To cooperate or to compete: this
is the question which arises, with all the resulting implications for training and subspecialization, the
organization of services, relations with insurance systems and public authorities.
We have made a secondary analysis of data from a study on the knowledge and skills in psychiatric
matters that a non-psychiatric physician should possess. The first analysis had shown that, when
asked about the knowledge of and expertise in psychiatry that is necessary for all medical
practitioners, physicians mainly insisted on several items referring to the doctor-patient relationship,
to the detection of the principal psychiatric disorders and the risks that might be linked to them, and
finally to psychosocial aspects of some psychiatric or somatic disorders (Goerg D, De Saussure C,
Guimon J, 1999).
The objective sought here is to examine, more specifically, the three following questions:
Does there exist, among primary-care physicians, different conceptions of psychiatry?
What factors may be linked to these conceptions of psychiatry or contribute to explaining
them?
How great is the interest of primary-care physicians in psychiatry?
The different conceptions of psychiatry might also be considered as different needs expressed by
doctors towards psychiatry or psychiatric training. The analysis focuses on primary-care physicians.
A comparison between them and specialists who do not work in the primary-care field will allow us to
discern elements which are specific to the former.
METHODS
Sample
A brief questionnaire was sent out, in 1995, to Geneva physicians, both in private practice and the
public sector. In all, 1593 questionnaires were sent out and 697 analyzable questionnaires were
returned (reply rate 43.8%). Since the characteristics of the reference population are not accurately
known, it was not possible to determine whether our sample was representative. Primary-care
physicians represented 53.1% of the sample. Other medical specialists (surgeons, gynecologists,
neurologists, etc.) represented 26.4% of the total, psychiatrists 20.5%.
Questionnaire
The questionnaire asked for some indications on the physician's background, specialization, training
in the psychiatric field (courses, group training in interpersonal relationships), an estimate of the
percentage of their patients suffering from psychiatric or existential problems, as well as an estimate
of the number of patients that they refer to psychiatrists.
It included a list of 23 psychiatric topics generally taught during undergraduate training; they
correspond to the psychiatric knowledge and skills which a non-psychiatric physician should possess
(such as an awareness of when and how to refer a patient to a psychiatrist, an understanding of the
emotional aspects of the chronically ill or dying patient, a basic knowledge of current psychiatric
treatment modalities, etc.). To the list used by Johnson & Snibbe in the United States (Johnson W,
Snibbe J, 1975) and by Guimón et al. in Spain (Guimon J, Totorica K, Villasana A, Ozamiz A, 1980),
we added two new aspects: psychiatric aspects of molecular biology and neuroimagery and
knowledge of both the normal and pathological processes of mental aging. Each field had to be
evaluated between 0 "not at all important " and 3 " essential/ indispensable".
Statistical methods
A factor analysis was undertaken on 22 of the 23 items concerning the information about, and the
expertise on, psychiatry necessary for any physician. One item, concerning the ability to talk with
patients about their personal problems, was not included since most physicians gave it a very high
rating. The factor analysis explained, with six factors, 58.1% of the variance. The first three factors
are used in the following analysis. For each of the underlying dimensions, an additive index was
created using the values of the items with factor loadings equal to or greater than .50.
The usual statistical tests were used (x2 for dichotomic or dichotomized variables, t-test, respectively
Mann-Whitney U test, or variance analysis (anova) for continuous variables). Only the results
presenting statistically significant differences will be presented here.
RESULTS
1. Characteristics of the primary-care physicians
Among the 370 primary-care physicians, 20.0% were general practitioners, 48.4% were general
internists, 16.2% internists with further training in a subspecialty of internal medicine (cardiology,
rhumatology, gastroenterology, etc.), 11.9% pediatricians and 3.5% somatic physicians who, as
they did not specify their field, were considered to be primary-care physicians. They were mainly
male (77.9%) and the average age was 48 1/2.
Nearly three-quarters of them worked in private practice (71.7%), 22.9% in public service and only
5.4% worked in both private and public sectors.
One fifth of these physicians (20.8%) had acquired knowledge of psychiatric problems through postgraduate training in psychiatry. Furthermore, half of them (50.5%) had taken part in group training
to improve their interpersonal relationship skills, Balint groups for example. Thus nearly six out of
ten primary-care physicians (57.7%) had some training in the field of psychiatry, acquired through
one or both of these means.
Primary-care physicians considered that approximately 10% of their patients, on average, suffered
from psychiatric problems, and 35% from existential problems. They mentioned the referral of 13
patients a year, on average, to a psychiatrist (private psychiatrists or public mental health services).
2. The understanding of psychiatry by primary-care physicians
2.1. Three main conceptions of psychiatry
In order to show the different conceptions of psychiatry of primary-care physicians, we undertook a
factor analysis on 22 items related to the knowledge and skills in psychiatry needed by any
physician. The underlying dimensions of the first three factors retained were a psychosocial, a
psychodynamic and a clinical-biological dimension.
The additive index created for each of these dimensions thus corresponded to what might be
considered as three different conceptions of psychiatry. These conceptions were rather implicit ones,
resulting from the emphasis placed by primary-care physicians on certain aspects of their practice
which pertained to psychological problems and psychiatric disorders. But it is important to note that
they evoked three of the main theoretical models which are commonly referred to in psychiatry
itself.
Table 1: The conceptions of psychiatry of primary-care physicians
(items with factor loadings >= .50)
The psychosocial understanding of psychological disorders (Table 1.1) included the complex
problems ranging from those arising from chronic illness, aging, substance abuse, to the somatic
effects of stress. These problems, which have social implications for the patients, seemed to create
important difficulties in the physician-patient relationship.
Within the psychodynamic conception, normal personality development and disorders in children and
adolescents were underlined, in a highly psychological perspective. Psychodynamic, or even psychoanalytical knowledge, or an interest in psychological testing, appeared important (Table 1.2).
Finally, the clinical-biological understanding of psychiatry highlighted the importance of establishing
a differential diagnosis and of psychiatric treatment and medication (Table 1.3).
2.2 Factors linked to the different conceptions of psychiatry
As far as the psychosocial conception of psychiatry was concerned, it appeared that primary-care
physicians under the age of 50 had a greater psychosocial understanding than those who were older
(p <.05). With regard to types of medical specialization, general practitioners favored such a
conception more markedly (average of the index : 15.1) than general internists (14.3), and
particularly internists with subspecialization (13.3), or pediatricians (12.4) (p.<.001). Physicians who
had a certain training in psychiatry (p < .01), especially those who participated in group training in
interpersonal relationships (p < .01), emphasized this type of understanding more often than
physicians without such training.
When we compared primary-care physicians with a high psychosocial understanding of psychiatry
(i.e. having values above the mean on the psychosocial index) to those having a lower one (values
lower or around the mean), we observed that the former thought that they had among their patients
a higher percentage of people suffering from psychiatric (p < .05) or existential problems (p < .01).
A preference for the psychodynamic conception of psychiatry was principally displayed by
pediatricians (9.0). General practitioners (7.5) and general internists (7.1) ranked in the middle of
the index range while internists with further specialization very rarely showed this orientation (6.1)
(p <.001).
Physicians working in private practice fostered such an orientation more markedly than those
working in public or in both private and public sectors (p < .01). Primary-care physicians with an
important psychodynamic understanding of psychiatry referred a higher number of their patients to
psychiatrists (p < .05).
The clinical-biological understanding of psychiatry was endorsed, as was the psychosocial one,
mainly by general practitioners (6.3) and general internists (6.2), less often by internists with
subspecialization (5.8) and much less by pediatricians (4.5) (p < .001). Physicians with a stronger
orientation towards biological psychiatry thought that a relatively high number of their patients had
psychiatric (p < .01) or existential (p < .05) problems.
2.3. Degree of interest in psychiatry
It was possible that some physicians might foster two or even three different conceptions of
psychiatry. In order to evaluate the degree of their interest in psychiatry, a variable was created
based on a combination of the three indices previously described. The indices were first
trichotomized, with values below the mean considered as indicating a low degree of interest in
psychiatry, values around the mean medium interest, and values above the mean a high degree of
interest. Physicians with high values on at least two indices and without low values on the third were
considered to have a high degree of interest in psychiatry. Those with at least two low values and
none high were considered to have a low degree of psychiatric interest. The others displayed an
average one.
More than a fifth (21.4%) of the primary-care physicians showed a particularly high interest in
psychiatry, while more than half of them (53.6%) could be considered to have an average one, and
one-quarter (25.0%) a low degree of interest. A certain number of characteristics differentiated
those physicians with a high degree of interest in psychiatry from those with little interest. The
former, who were more often general practitioners (p < .01), had more training than the latter in
the psychiatric aspects of their practice (p < .01). They thought that a higher number of their
patients suffered from psychiatric (p < .05) or existential (p < .05) problems.
2.4. The conceptions of psychiatry endorsed by specialists other than primary-care physicians
There were important differences between primary-care and non-primary care physicians such as
surgeons, dermatologists, radiologists, gynecologists, etc. (n=184). The support of these specialists
for the different conceptions of psychiatry, be they psychosocially (p < .001), psychodynamically (p
< .05) or biologically oriented (p < .001), was weaker than that of primary-care physicians. Among
them, it was mainly surgeons who contributed to creating these differences. The degree of interest
of these specialists in psychiatric matters was lower than that of primary-care physicians: half of
them showed little interest in psychiatry, whereas only a quarter of primary-care physicians (p
< .001) did. They also considered that a lower percentage of their patients had psychiatric (p
< .001) or existential (p < .001) problems and they referred fewer patients to psychiatrists than
primary-care physicians (p < .001).
When we compared these specialists only to internists with subspecialization, we observed that some
differences remained. Specialized internists more often endorsed a clinical-biological understanding
of psychiatry and took into account the psychiatric (p < .05) or existential problems (p < .05) of
their patients.
DISCUSSION
· Three conceptions of psychiatry
The secondary analysis of the data covering the knowledge and expertise deemed necessary to the
practice of medicine allows us to delineate three different types of understanding of psychiatry in
primary-care physicians: the psychosocial, the psychodynamic and the clinical-biological
conceptions. The first type corresponds to a set of difficulties for the patients which are often hard to
bear and in general long-lasting, with consequences on their social life and important implications for
the relationship between the physician and the patient. For the second, on a clearly more
psychological level, the necessity of having psychological knowledge, or even psychoanalytical skill,
is linked to an interest in normal personality development and disorders in early life. The third
underlines the importance for physicians of knowing how to diagnose and treat, mainly through
drugs, the principal psychiatric disorders. These three conceptions, which can be considered as an
expression of attitudes towards psychiatry and as corresponding to three types of needs concerning
problems of a psychiatric nature, present an analogy with the orientations described for psychiatrists
themselves. A survey carried out among Swiss psychiatrists (Guimon J, Fischer W, Goerg D, Zbinden
E, 1997) showed the existence, though founded on very different data, of these main theoretical
orientations.
Important differences exist in the conceptions of psychiatry physicians favor according to their
specialization. Among primary-care physicians, it is general practitioners and general internists who
adhere most strongly to a psychosocial understanding on the one hand and a clinical-biological one
on the other. Internists with subspecialization (cardiology, rhumatology, etc.) and pediatricians have
a lower profile in these two types of understanding. On the contrary, pediatricians appear to endorse
most clearly a psychodynamic conception. The degree to which primary-care physicians are
interested in psychiatric matters is variable. It can be considered that slightly more than one-fifth of
these physicians show a high degree of interest in psychiatry. It is particularly the case for general
practitioners who display this tendency more frequently than do other primary-care physicians.
These different references are probably linked, among others, to the training and education they
have received, to the particularities of their patients and to the physician's specific fields of activity
(long-term treatment vs. evaluation, or general care vs. treatment of specific disorders, for
example).
Specialized physicians who do not handle primary-care differ from primary-care physicians. They
have, in general, little attraction to any type of psychiatric understanding, and surgeons even less
than most other specialists. These observations resemble those of other studies undertaken with
physicians of various specialties. Thus, Cohen-Cole & Friedman (Cohen-Cole SA, Friedman CP, 1982)
note that hospital specialists in family medicine and internists consider that their patients suffer from
illnesses with an important psychological element more often than do surgeons, pediatricians or
gynecologist-obstetricians. Among physicians working in private practice, internists consider, more
often than surgeons, that an important proportion of their clients suffer from psychiatric disorders
(Fauman MA, 1983). In a study undertaken with hospital physicians, it appeared that surgeons were
much less interested than other physicians in the emotional problems of their patients and felt less
responsible for their treatment (Mayou R, Smith EBO, 1986).
We noted that internists with subspecialization ranked in an intermediate position between general
internists, who were often closer to general practitioners, and specialized physicians who did not
work in primary care. It seems that in a region with a very high medical population those doctors
might as well work as general practitioners or as super-specialists. Their position on psychiatric
orientation, with regard to the ways in which different patients are viewed, would indicate that both
types of functioning exist, either among physicians, or for the same physician.
· Consequences on referral to psychiatry
The aim of this study was not to examine the relationship that primary-care physicians have with
psychiatry or psychiatric services as these relationships have already been the object of research in
certain specific contexts. Some results, however, can indirectly suggest the existence of differing
mind-sets, needs and expectations in physicians towards this discipline. Thus, physicians with a
strong psychodynamic tendency, i.e. those who appear to have the greatest affinities with one of the
predominant tendencies of Swiss psychiatry, refer a higher number of their patients to psychiatrists.
It would be important to know whether, in these cases, the motivation behind these referrals is a
desire to delegate authority or to cooperate.
Physicians who favor a psychosocial conception of psychiatry and who attach great importance to the
doctor-patient relationship, emphasize the difficulties that patients face coping with everyday
problems as well as the psychiatric disorders of their patients, but do not refer more patients to
psychiatrists than those physicians without a marked psychosocial orientation. The same applies to
physicians who foster a biological approach to psychiatry. In the first case, the question arises as to
whether physicians are prepared to cope with their patients' difficulties through improving their own
methods of handling interpersonal relationships, for example Balint groups, which might help them
to better assess the treatment to be given to their own patients and to decide when to refer them to
psychiatrists. In the second case, it is possible that physicians think themselves better able to treat
certain psychiatric disorders, often through the use of drugs.
· Scope and limitations
Our data do not permit a more in-depth study of these different questions. This is one of the
constraints placed upon a secondary analysis of data, which were not expressly gathered for a
certain purpose and which were limited in nature. Other studies will be necessary to ascertain the
conceptions physicians have of psychiatry and how they interpret their relations to it : as partners,
as proxies or as competitors. The current outcry to reduce health-care costs and the increasing
pressure brought to bear by insurance companies might also modify the relations physicians working
in different fields of specialization have to psychiatry.
These results have implications for the training of physicians in the field of psychiatry since it can be
considered that the vast majority of patients suffering from psychiatric disorders are to be found in
primary-care medicine. According to Shepherd et al. (Shepherd M, Cooper B, Brown AC, Kalton G,
1981), among the patients of general practitioners, one patient out of seven shows symptoms of
psychiatric disorder. The World Health Organization Collaborative Study on psychological problems in
general health care shows that 24% (on average) of all patients contacting general health services,
in a wide range of health-care settings and cultural contexts, have current mental disorders. A
certain proportion of patients (9%) suffer from a sub-threshold condition that has clinically
significant symptoms and functional impairment, while 31% have a few mental disorder symptoms
(Goldberg DP, Lecrubier Y, 1995). Thus primary-care physicians are de facto an essential resource of
the mental health-care system (Regier DA, Goldberg ID, Taube CA, 1978) and their training in
mental health should be improved.
As knowledge of diagnosis and treatment of the most frequent psychiatric disorders is already
included in the undergraduate curriculum, the interest displayed in the development of learning how
to cope with interpersonal relationships and the expansion of psychodynamic knowledge which
appear in this report indicate that these subjects should form an integral part of the undergraduate,
postgraduate and professional training of physicians.
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