Psychological Medicine, 1992, 22, 709-715 Printed in Great Britain
A longitudinal study of general practitioner consultations for psychiatric disorders in adolescence NIGEL SMEETON,1 GREG WILKINSON, DAVID SKUSE AND JOHN FRY From the Department of Public Health Medicine, Guy's Hospital; Department of Psychiatry, London Hospital Medical College; Department of Child Psychiatry, Institute of Child Health, London; and Beckenham, Kent
Patterns of psychiatric diagnoses given during adolescence to a group of individuals continuously registered with a single general practitioner in South London over 20 years were analysed first during 'early adolescence' and secondly during 'early adulthood'. Psychiatric diagnoses were found to be relatively common. Of the young adolescents who received a psychiatric diagnosis (almost one in ten of the group), 38 % received a psychiatric diagnosis as young adults compared with only 16 % of the remainder. Comorbidity was found to be very common - over 50 % of young adults with a diagnosis of depression also had a diagnosis of anxiety and phobic neuroses. Young people with problems of a psychological nature therefore deserve more attention, particularly from the primary care team. SYNOPSIS
INTRODUCTION It is now well-established from the findings of the Second and Third National Morbidity Surveys (HMSO, 1974, 1979, 1986) that psychiatric disorders are rarely recorded by general practitioners in young children but the likelihood of being given such a diagnosis increases rapidly through adolescence and into adulthood (Smeeton, 1987). It is, therefore, of interest to quantify the extent to which the recording of a psychiatric diagnosis in 'early adolescence' by a general practitioner increases the likelihood of such a diagnosis being made in early adulthood and to investigate changes in the pattern of diagnoses made in the two periods. For this purpose longitudinal data which chart the progress of children from about ten years of age for at least ten years are required. The presence of psychiatric diagnoses should be recorded during 'early adolescence' and again during early adulthood. The general practitioner is perhaps best placed to care for patients with these problems as he or she is often involved with these patients since childhood and knows ' Address for correspondence: Mr Nigel Smeeton, Department of Public Health Medicine, UMDS (Guy's Campus), London SE1 9RT.
their background well. We have consultation data for a continuous 20-year period from a single general practice in South London from which over 200 children who satisfied the above requirement were identified. METHOD In 1957 a general practitioner (Dr Fry) compiled a case register of all 6346 patients then registered with him in his South London practice; 4243 of them remained on his list for the next seven years (Cooper et al. 1969) and 1530 of them were still registered in 1976 (Dunn & Skuse, 1981). There were no major changes in his practice during the period. The general practitioner's detailed NHS records provided both a prospective design and a satisfactory level of reliability. The ability of the general practitioner to recognize psychiatric disorder among patients attending his surgery is evidenced by a study conducted by Skuse & Williams (1984) which found his overall identification index, bias and accuracy to be 0-57, 0-71 and 0-39 respectively. These figures are very close to those found in comparable surveys of other practitioners and suggest that his ability to detect cases of psychiatric disorder is similar to that of other
709 24-2
710
TV. Smeeton and others Year 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 47 B 48 49 50
A A A A A
A A
A A A A A
A A
A A A A A
A A
A A A A A
51 Year 52 53 54 55 56 57
A A
A A A A A
A A A A
A A A A A A A A A A
A A
A A A A A A A A A A A A A A A
A A A AA
A A A A A A
AA
FIG. I. Years of birth and periods of early adolescence and early adulthood for individuals included in the study. (B = year of birth; A = year of assessment.)
psychiatric diagnosis made by the general practitioner in 'early adolescence'. The second period ('early adulthood') ran from the commencement of the year in which the individual became 18 to the end of the following year (a period of two years). This shorter comparison period was chosen because complete information was available for these years on all subjects eligible for inclusion in the first period. From Fig. 1 it can be seen that were the second period to be extended, information on the youngest would be incomplete. From the general practitioner records, for each of these individuals it was noted whether any psychiatric disorder had been diagnosed by the general practitioner during the first and second periods. These disorders were recorded in the terms of diagnostic categories which were chosen by the researchers (in 1978) in consultation with Dr Fry and were intended to be compatible with Dr Fry's diagnostic habits. The possible diagnostic categories were depressive neurosis, anxiety and phobic neuroses, personality disorder, functional psychosis, drugAge periods studied induced psychoses and drug reactions, misThe patient records were coded on a year by cellaneous neurotic disorders and alcohol abuse year basis, so it was decided to define the first and drug dependence. These had been chosen period (' early adolescence') from the commence- with a view to making diagnoses in the adult ment of the year containing the tenth birthday population attending, and consequently diagto the end of the year in which each individual noses more appropriate to childhood and adobecame 14 (a period of five years). Therefore, lescence, such as 'attention deficit disorder' and only patients aged 9 or less at the beginning of 'disorder of conduct' were not specifically noted 1957 could be included in the study (see Fig. 1). in the records. A period of this length was required in order to A logit model was fitted to the data (a linear obtain a reasonable number of subjects with a model was fitted to the log of the odds of an family doctors (Marks et al. 1979). The patients
who were studied were limited to those who had remained registered with the general practitioner. None of the sample was seen by a psychiatrist. Since the attrition was so great, it is worth considering whether the patients who remained registered with Dr Fry were representative of the original group of patients. The proportion of males in the patients remaining was very stable over the 20 years; this was 480% in 1957, 47-7 % in 1963 and 47-5 % in 1976. However, the age distribution changed considerably. Cooper et al. (1969) reported that the rates of loss for different age groups differed widely. In their study, a conspicuously high rate of loss from causes other than death for the age group 21-30 was due, probably, to the high mobility of young adults. By 1976, 75-5 % of the males and 83-4% of the females were over the age of 41 years. Hence, a disproportionate number of younger people (especially females) left the practice over the 20-year period.
GP consultations for psychiatric disorders in adolescence
individual having a psychiatric diagnosis in early adulthood) using the GLIM statistical package (Baker & Nelder, 1978). The independent variables were presence or absence of psychiatric diagnosis in 'early adolescence' (PSYCH), gender (SEX) and whether the individual was in a. younger cohort (0-4 in 1957) or an older cohort (5-10 in 1957) (COHORT). The three possible first-order interactions and the single possible second-order interaction between variables were also studied. RESULTS There were 134 males (of mean age 4-62 years in 1957) and 100 females (of mean age 3-64 years in 1957). This meant that on average the periods of interest for males preceded the periods of interest for females by one year. This shift is unlikely to Table 1. Psychiatric diagnoses given by the general practitioner to children in early adolescence and early adulthood* Early adolescence Diagnostic categories Anxiety and phobic
Early adulthood
Males
Females
g
4
10
10
6 0 2 0
2 0 1
12 1 4 0
21 2 1 0
12
2
10
1
Males
Females
neuroses Depressive neurosis Personality disorder Functional psychosis Drug-induced psychoses and drug reactions Miscellaneous neurotic disorders At least one psychiatric diagnosis No psychiatric diagnosis Total
(%) 15(11) 119(89) 134
0
(%) 6(6) 94 (94) 100
(%) 18(13) 116(87) 134
(%) 24 (24) 76 (76) 100
Patients could be given more than one diagnosis.
Table 2. The logit model parameters Parameter CONSTANT
PSYCH SEX COHORT
Mean
S.E.
P
-3-569 1-392 0-7363 -0-4255
1063 0-5104 0-3666 0-3730
< 00001 < 001
A longitudinal study of general practitioner consultations for psychiatric disorders in adolescence NIGEL SMEETON,1 GREG WILKINSON, DAVID SKUSE AND JOHN FRY From the Department of Public Health Medicine, Guy's Hospital; Department of Psychiatry, London Hospital Medical College; Department of Child Psychiatry, Institute of Child Health, London; and Beckenham, Kent
Patterns of psychiatric diagnoses given during adolescence to a group of individuals continuously registered with a single general practitioner in South London over 20 years were analysed first during 'early adolescence' and secondly during 'early adulthood'. Psychiatric diagnoses were found to be relatively common. Of the young adolescents who received a psychiatric diagnosis (almost one in ten of the group), 38 % received a psychiatric diagnosis as young adults compared with only 16 % of the remainder. Comorbidity was found to be very common - over 50 % of young adults with a diagnosis of depression also had a diagnosis of anxiety and phobic neuroses. Young people with problems of a psychological nature therefore deserve more attention, particularly from the primary care team. SYNOPSIS
INTRODUCTION It is now well-established from the findings of the Second and Third National Morbidity Surveys (HMSO, 1974, 1979, 1986) that psychiatric disorders are rarely recorded by general practitioners in young children but the likelihood of being given such a diagnosis increases rapidly through adolescence and into adulthood (Smeeton, 1987). It is, therefore, of interest to quantify the extent to which the recording of a psychiatric diagnosis in 'early adolescence' by a general practitioner increases the likelihood of such a diagnosis being made in early adulthood and to investigate changes in the pattern of diagnoses made in the two periods. For this purpose longitudinal data which chart the progress of children from about ten years of age for at least ten years are required. The presence of psychiatric diagnoses should be recorded during 'early adolescence' and again during early adulthood. The general practitioner is perhaps best placed to care for patients with these problems as he or she is often involved with these patients since childhood and knows ' Address for correspondence: Mr Nigel Smeeton, Department of Public Health Medicine, UMDS (Guy's Campus), London SE1 9RT.
their background well. We have consultation data for a continuous 20-year period from a single general practice in South London from which over 200 children who satisfied the above requirement were identified. METHOD In 1957 a general practitioner (Dr Fry) compiled a case register of all 6346 patients then registered with him in his South London practice; 4243 of them remained on his list for the next seven years (Cooper et al. 1969) and 1530 of them were still registered in 1976 (Dunn & Skuse, 1981). There were no major changes in his practice during the period. The general practitioner's detailed NHS records provided both a prospective design and a satisfactory level of reliability. The ability of the general practitioner to recognize psychiatric disorder among patients attending his surgery is evidenced by a study conducted by Skuse & Williams (1984) which found his overall identification index, bias and accuracy to be 0-57, 0-71 and 0-39 respectively. These figures are very close to those found in comparable surveys of other practitioners and suggest that his ability to detect cases of psychiatric disorder is similar to that of other
709 24-2
710
TV. Smeeton and others Year 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 47 B 48 49 50
A A A A A
A A
A A A A A
A A
A A A A A
A A
A A A A A
51 Year 52 53 54 55 56 57
A A
A A A A A
A A A A
A A A A A A A A A A
A A
A A A A A A A A A A A A A A A
A A A AA
A A A A A A
AA
FIG. I. Years of birth and periods of early adolescence and early adulthood for individuals included in the study. (B = year of birth; A = year of assessment.)
psychiatric diagnosis made by the general practitioner in 'early adolescence'. The second period ('early adulthood') ran from the commencement of the year in which the individual became 18 to the end of the following year (a period of two years). This shorter comparison period was chosen because complete information was available for these years on all subjects eligible for inclusion in the first period. From Fig. 1 it can be seen that were the second period to be extended, information on the youngest would be incomplete. From the general practitioner records, for each of these individuals it was noted whether any psychiatric disorder had been diagnosed by the general practitioner during the first and second periods. These disorders were recorded in the terms of diagnostic categories which were chosen by the researchers (in 1978) in consultation with Dr Fry and were intended to be compatible with Dr Fry's diagnostic habits. The possible diagnostic categories were depressive neurosis, anxiety and phobic neuroses, personality disorder, functional psychosis, drugAge periods studied induced psychoses and drug reactions, misThe patient records were coded on a year by cellaneous neurotic disorders and alcohol abuse year basis, so it was decided to define the first and drug dependence. These had been chosen period (' early adolescence') from the commence- with a view to making diagnoses in the adult ment of the year containing the tenth birthday population attending, and consequently diagto the end of the year in which each individual noses more appropriate to childhood and adobecame 14 (a period of five years). Therefore, lescence, such as 'attention deficit disorder' and only patients aged 9 or less at the beginning of 'disorder of conduct' were not specifically noted 1957 could be included in the study (see Fig. 1). in the records. A period of this length was required in order to A logit model was fitted to the data (a linear obtain a reasonable number of subjects with a model was fitted to the log of the odds of an family doctors (Marks et al. 1979). The patients
who were studied were limited to those who had remained registered with the general practitioner. None of the sample was seen by a psychiatrist. Since the attrition was so great, it is worth considering whether the patients who remained registered with Dr Fry were representative of the original group of patients. The proportion of males in the patients remaining was very stable over the 20 years; this was 480% in 1957, 47-7 % in 1963 and 47-5 % in 1976. However, the age distribution changed considerably. Cooper et al. (1969) reported that the rates of loss for different age groups differed widely. In their study, a conspicuously high rate of loss from causes other than death for the age group 21-30 was due, probably, to the high mobility of young adults. By 1976, 75-5 % of the males and 83-4% of the females were over the age of 41 years. Hence, a disproportionate number of younger people (especially females) left the practice over the 20-year period.
GP consultations for psychiatric disorders in adolescence
individual having a psychiatric diagnosis in early adulthood) using the GLIM statistical package (Baker & Nelder, 1978). The independent variables were presence or absence of psychiatric diagnosis in 'early adolescence' (PSYCH), gender (SEX) and whether the individual was in a. younger cohort (0-4 in 1957) or an older cohort (5-10 in 1957) (COHORT). The three possible first-order interactions and the single possible second-order interaction between variables were also studied. RESULTS There were 134 males (of mean age 4-62 years in 1957) and 100 females (of mean age 3-64 years in 1957). This meant that on average the periods of interest for males preceded the periods of interest for females by one year. This shift is unlikely to Table 1. Psychiatric diagnoses given by the general practitioner to children in early adolescence and early adulthood* Early adolescence Diagnostic categories Anxiety and phobic
Early adulthood
Males
Females
g
4
10
10
6 0 2 0
2 0 1
12 1 4 0
21 2 1 0
12
2
10
1
Males
Females
neuroses Depressive neurosis Personality disorder Functional psychosis Drug-induced psychoses and drug reactions Miscellaneous neurotic disorders At least one psychiatric diagnosis No psychiatric diagnosis Total
(%) 15(11) 119(89) 134
0
(%) 6(6) 94 (94) 100
(%) 18(13) 116(87) 134
(%) 24 (24) 76 (76) 100
Patients could be given more than one diagnosis.
Table 2. The logit model parameters Parameter CONSTANT
PSYCH SEX COHORT
Mean
S.E.
P
-3-569 1-392 0-7363 -0-4255
1063 0-5104 0-3666 0-3730
< 00001 < 001
