Psychological Medicine, 1992, 22, 717-723 Printed in Great Britain
Labelling and illness in primary care: comparing factors influencing general practitioners' and psychiatrists' decisions regarding patient referral to mental illness services ANNE E. FARMER1 AND HUW GRIFFITHS From the Department of Psychological Medicine, University of Wales College of Medicine; and East Glamorgan General Hospital, Mid Glamorgan, Wales
GPs and psychiatrists from South Wales were asked to make decisions based on the information included in each of 16 vignettes describing depressed and anxious subjects. This information contained randomly assigned sex, psychiatric label, good and bad psychosocial context and age as well as eight different severity ratings of depression and anxiety symptoms. Our results showed that both GPs and psychiatrists were influenced in their decision making by the severity of the illness, but that GPs alone were also strongly influenced by the presence of male sex and by the presence of a psychiatric label. Good or bad psychosocial context had no influence on the GPs' referral decision, and previous experience in psychiatry or other vocational training had no detectable effect., but this may be because of the sample size.
SYNOPSIS
INTRODUCTION Between 24 % and 29 % of adults who consult their GP annually have psychiatric symptoms, which are mostly those of minor affective disorder (Goldberg & Huxley, 1980). GP detection rates for such illnesses differ, but are of the order of 50%. However, only 5-10% of these identified psychiatrically ill subjects receive specialist care, so GPs manage most psychiatric illness themselves (Shepherd et al. 1966; Wilkinson, 1989). It might be expected that GPs' referral decisions are related to the complex interplay between the patients themselves, the services available and the GPs' experiences and interests in the treatment of psychiatric problems. In addition, the main reasons cited by GPs for referring include treatment failure, diagnostic difficulties, patient's or relative's request for referral or the doctor's view that a specialist is required to share or take over the patient's
'Address for correspondence: Dr Anne Farmer, Department of Psychological Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF4 4XN, South Wales.
management (Wilkinson, 1989). While these can be considered to be the declared reasons for GPs' decisions, other less obvious factors may also influence the decision-making process. For example, previous studies have shown that the patient's sex influences GPs in their referral decision making, with men being more readily referred compared to women despite comparable severity of symptoms (Boardman et al. 1988). Rawnsley & Loudon (1962) and Ingham et al. (1972) suggested that the referral decision was mainly influenced by social and other factors and that these overrode clinical variables such as presentation or severity of illness in a series of studies carried out in the Rhondda valleys and Vale of Glamorgan in South Wales. These authors also concluded that GPs working in the more deprived Rhondda valleys had widely divergent attitudes to psychiatric illness and in referring to psychiatric services. Another potential influence on GPs' referral practices is that of psychiatric 'label'. This was described by Scheff (1966), who proposed that mental illness is a stabilized and stigmatized social role. Scheff (1966) defines the application
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of labelling theory to mental illness as ' a theory of mental disorder in which utilized symptoms are considered to be labelled violations of social norms and stable "mental illness" to be a social role'. Thus certain deviant behaviours, e.g. taking an overdose, are labelled by doctors as mental illness. Subsequent deviant behaviour in someone who has acquired the label merely confirms the presence of psychiatric disorder according to Scheffs theory, and acquiring the status of a psychiatric patient is largely independent of the > patient's symptoms or behaviour but is a function of the doctor's uncertainty. Experiments designed to test the validity of labelling theory in mental hospitals have provoked considerable controversy (e.g. Rosenhan, 1973) but have been of doubtful scientific merit (Clare, 1976). It is worth speculating whether GPs may be influenced in their decision making by a label acquired by the patient because of past psychiatric contact. Since the earlier research in older industrial areas such as South Wales (Rawnsley & Loudon, 1962; Ingham et al. 1972), a number of factors may have altered local GPs' referral practices. First, there have been massive socio-economic changes in such areas, and in South Wales these have been mainly generated by the decline of coal mining. Secondly, by comparison with the 1960s, more psychiatry has been taught to trainee GPs at both undergraduate and postgraduate level, which may also have had an effect on their referral rates to psychiatrists. However, despite these, the development of community-based psychiatric services in this part of South Wales has lagged behind most districts in England, and psychiatric services remain largely 'traditional' and centrally organized from the local district hospital, with back-up intensive care facilities at a more distantly located psychiatric hospital scheduled for closure in 1992. In order to evaluate any changes in referral practice as well as other possible factors influencing decision making, GPs from the Rhondda valleys and the adjacent health district of Taff Ely were asked their opinions about case vignettes constructed to include eight different severity measures of depression and anxiety ranging from mild to severe, the presence or absence of a psychiatric label, and good or bad psychosocial context. Based on previous studies
carried out in the same area, it was expected that GPs would be influenced by social context as well as by label and severity of illness, although the amount or nature of postgraduate experience received may also be influential. By contrast, we predicted that a comparison group of locally based psychiatrists would be less influenced by label and psychosocial context in their decisions about whether or not a subject was a 'case' of psychiatric disorder. The following hypotheses were therefore tested. 1. GPs' decisions to refer depressed and anxious patients to hospital-based services are influenced by' label',' context' and sex of subject as well as illness severity. 2. GPs' referral decisions are related to the amount and nature of postgraduate training received. 3. Because of their specialist training psychiatrists' decisions will only be influenced by the severity of psychopathology and not 'label', 'context' or sex of subject. METHOD Sixteen case vignettes (see Appendix for example) were constructed, describing subjects with psychological problems ranging from mild disturbance to severe mental illness. Symptom profiles were taken from the Present State Examination (PSE) interviews of real patients that generated eight different severity ratings for depression and anxiety according to the Index of Definition (ID) ' caseness' measure of the PSE scoring program ID-CATEGO (Wing et al. 1974; Wing & Sturt, 1978). Two vignettes were constructed for each ID level. In addition, a psychiatric 'label' was randomly included in eight of the vignettes, the remainder having no label. Labels consisted of a history of previous contact with a psychiatrist (three cases), an episode of self-poisoning (two cases) or other form of self-harm (one case, previous drug abuse) or GP-instigated psychotropic medication (two cases). Good and poor psychosocial context, sex and age were also randomly assigned in the same way. Seventeen GPs, selected as being broadly representative of those practising in the Taff Ely and Rhondda Health Districts in Mid Glamorgan, were interviewed regarding each vignette and their decisions were recorded on a
Labelling and illness in primary care
standard coding form. The order of presentation of the vignettes was random, and the same for all GPs and psychiatrists. Ten Senior Registrar or Consultant Psychiatrists from Mid and South Glamorgan Health Districts were also interviewed, and their responses recorded on a slightly modified version of the same coding form. Both groups were asked their year of qualification, number of years in general practice or psychiatry, and medical school. GPs were asked about their postgraduate experience. Both groups were asked for their decisions regarding appropriateness of referral of the subject described in the vignette. Here the questions posed to the two groups differed as follows. GPs were asked whether the subject should be referred to a psychiatrist, another doctor - for example, a consultant physician or surgeon - another service - for example, a social worker or a psychologist - or whether they would wish to undertaken treatment themselves. The type of treatment personally undertaken by GPs for each vignette was also recorded. Psychiatrists were asked whether they thought the subject was a 'case' warranting psychiatric referral. Thus each of the 17 GPs and 10 psychiatrists was asked to make a decision regarding referral for each of the 16 vignettes, all of the doctors being 'blind' to ID level, label and context status contained in the vignettes. In order to establish that each decision was independent of the order of presentation of the vignette, a test of association was carried out between case number and referral decision. No significant association was found, and therefore the data were subsequently analysed using the SPSS PC package, assuming that for the GPs there are 17x16 and for the psychiatrists 10x16 independent decisions. Contingency tables were analysed using x2 tests. We also examined decisions regarding referral using logistic regression models as described below. RESULTS Seventeen (18-5%) of the 92 GPs practising in the Taff Ely and Rhondda Health Districts were randomly selected to participate in the study. None of those selected declined. As a group the GPs had been in practice for a shorter time than the psychiatrists (mean years in general practice for GPs = 11-24 range 1-35 years; years
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as psychiatrists mean =14-5 years, range 4-40 years). All of the psychiatrists and all but three of the GPs had received undergraduate training in the UK. Five GPs had completed vocational training and four had had some postgraduate experience in psychiatry. Only three GPs had no postgraduate experience other than House Officer posts. Table 1 shows the order of presentation of the vignettes, their ID level, sex, label, context and age. In addition, the table shows the percentage of GPs who referred the case to a psychiatrist and the percentage of psychiatrists regarding the subject described as a case. Conventionally, ID levels 1-4 are considered as 'non-cases', ID 5 to be on the threshold and ID level 6-8 to be definite psychiatric 'cases'. GPs' and psychiatrists' referral decisions for both cases and non-cases are shown in Table 2. The table shows that the majority of both cases and non-cases would not be referred to another service by the GPs. Psychiatrists considered that 95 % of cases and 36 % of non-cases required psychiatric intervention, while the GPs decided to refer 42 % of cases and 28 % of non-cases to another service. Table 2 also shows the main referral agencies that would be used by the GPs. For cases, psychiatrists would have received most referrals (31 % ) , although 8 % would have been referred to physicians or surgeons. Little use was made of case referral to psychologists, social workers and other agencies. However, these non-medical professionals would have received more non-case referrals (15%). Psychiatrists would also have received referral of 12 % of these less severely ill subjects. For all subjects with ID level 4 and above, the GP's decision was to offer further treatment unless the subjects were being referred elsewhere. GPs suggested that they would use a variety of drugs including antidepressant and benzodiazepines, although prescribing of the latter was quite limited (5 %). In addition 'counselling' and 'psychotherapy' was mentioned as a treatment the GPs would instigate themselves. However, exclusion of physical illness was the main concern for the GPs in 17% of non-cases and 31 % of cases. GPs were also asked to comment on their reasons for referral to a psychiatrist. The most commonly stated reasons were for suicidal risk (23%) and depression (19%) followed by
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Table 1. Case vignettes Case nos. and order of presentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
ID
Sex
Label
Context
Age
2
M
7
F M F M M
M F F
No No Yes No No No Yes No Yes Yes Yes Yes No
43 55 19 26 35 63 59 44 59 38 26 28 19
F
Yes
M M
No
Bad Bad Bad Bad Good Bad Bad Good Good Good Bad Bad Good Good Good Good
8
1 8
5 6 6
2 3 4
5 4 1 3 7
F
F M F
Yes
31 61 49
% referred to psychiatrist by GPs
% psychiatrists regarding subject as 'a case'
0 12 82 6 65
20 100 100 0 100 60 100 80 40 60 70 70 30 0 10
0 18
0 18 35 35 29 0 0 3 7
90
to the psychiatrist was the presence of a Table 2. GPs' and psychiatrists' referral decisions psychiatric label (x2 = 13-49, df = 1, P = 0-000; for cases (ID 6-8) and non-cases (ID 1-5) proportion of cases with psychiatric label referred by GPs to psychiatrists = 29%, CI = 21Non-cases Cases 37 %), and male sex ft2 = 7-59, df = 1, P = 0-006; proportion of male cases referred by GPs to a Psychiatrists considered psychiatric 95 36 psychiatrist = 26%, CI = 19-33%). However, intervention was required 42 28 GPs would refer to another service there was no significant association with psycho12 GPs would refer to psychiatrists 31 social context, years in general practice or any 1 GPs would refer to physicians or 8 type of postgraduate experience. surgeons 1 7 GPs would refer to psychologists By contrast, psychiatrists were not influenced GPs would refer to other agencies 2 8 in their decisions as to whether subjects were including social workers true cases, or by any factors other than severity of psychopathology. Thus psychiatric label, sex obsessional symptoms (8%), schizophrenia and context had no significant effect. To examine further the effects of factors (6%) and social problems (4%). In other instances, GPs stated that specific psychiatric influencing the GPs' decision to refer to a treatments were required such as psychotherapy psychiatrist and the psychiatrist's judgment of caseness, we carried out logistic regression or relaxation classes. We carried out a series of 2 x 2 and 2 x N x2 analysis (Feinberg, 1981). Here the proportion tests for variables we thought influenced GPs' (P) of patients referred (or of subjects deemed to and psychiatrists' decisions about caseness. GPs' be cases) was taken to be outcome variable and decisions to refer to a psychiatrist were sig- expressed as the logit transform (i.e. log (P.lnificantly associated with severity of symptoms P)). The explanatory variables were sex, ID and as reflected in the ID level ( / = 7609, df = 7, label. Thus, the saturated model can be reP = 0000; proportion of cases (ID, 6-8) referred presented as: logit (p) = grand mean + effect of by GPs to psychiatrists = 31 %, 95 %, CI = 22- ID + effect of label + effect of sex + interaction 40%). Similarly, the psychiatrists' decisions effects (ID x label) (ID x sex) (sex x label) (ID x about caseness were highly significant associated sex x label). The significance of the explanatory variables with ID level (x2 = 73-52, df = 7, P = 0-000; proportion of psychiatrists identifying and their interactions was tested by eliminating 'cases'= 95%, CI = 89-100%). Also, sig- each in turn from the model and examining the 2 nificantly associated with GPs' decisions to refer resultant x - The results are summarized in
Labelling and illness in primary care
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Table 3. Model fitting by logistic regression analysis: GPs and psychiatrists GPs' data
Psychiatrists' data
*•
df
P
X"
df
P
Saturated model referral to psychiatrist by sex, ID and label
L P
0-0 00
0 0
100 100
00 00
0 0
100 100
Remov ng label by ID* interaction from model
L P
14-79 1508
6 6
002 002
6-53 6-21
6 6
0-37 0-40
Removing 'sex' from model
L P
16-71 17-04
7 7
0-02 002
6-62 6-54
7 7
0-47 0-48
Removing ' label' from model
L P
38-72 29-40
8 8
000 000
14-85 1314
8 8
006 011
Removing ' I D ' from model
L P
86-57 100-57
14 14
000 000
107-51 83-99
15 15
0-00 000
* Removal of cither second-order interactions 'sex by label' +'sex by I D ' showed no difference from the saturated model. L, Likelihood ratio; P, Pearson x'-
Table 3 and show that for the psychiatrist's data only the removal of ID from the model is significantly different from the saturated model. Thus, ID is the main influence on the psychiatrist's decision about caseness. However for the GP data, neither label, sex, ID nor the second-order interaction between label and ID can be eliminated from the model, since all the reduced models offer a significantly poorer fit than the saturated model. DISCUSSION Despite the limited sample size, the most significant finding of this study was the strong influence of psychiatric label upon GPs' decision making. As well as having a significant effect on its own, label interacted with the severity measure, ID level, in influencing GPs' decisions to refer. However, there was no analogous influence of label on the psychiatrists, whose decisions regarding caseness were solely related to severity of psychopathology. Previously, Scheff criticized psychiatrists for diagnosing mental illness on the basis of deviant behaviour or previously acquired psychiatric labels and by implication cast doubt on the accuracy of judgement regarding clinical severity. In our study psychiatrists have been shown not to be influenced in this way, but their GP colleagues still take previously acquired labels into account in deciding to refer. Therefore, the findings seem to confirm the potency of a patient's ' label' in influencing the plan of action of the general practitioner, and as
such could be seen as providing partial support for the views of labelling theorists. In primary care, however, the use of psychiatric label in this way might assist decision making in a practical way which, it could be argued, is adaptive and appropriate. Recent studies have shown that GPs employ different means of decision making compared to their hospital-based colleagues. Jenkins et al. (1988) found that information from psychological, social and personality domains is employed in GP decision making, and there is greater agreement between GPs when rating presence and type of symptom than when ascribing cases to diagnostic categories. As well as these differences between experienced practitioners, Wilkinson (1988) examined diagnostic agreement between psychiatric and GP trainees. Using a videotape-assisted simulation consultation model of depressed women, he found that both within and between the two groups, of trainees, agreement regarding diagnosis and management was low. Crombie (1986) also showed that a problem-solving nomenclature was often employed in general practice which differs from that used by hospitalbased specialities, and which does not fit the traditional diagnostic framework taught in medical schools. Our results lend support to these findings. Ingham et al. (1972), working in the same geographical location as our study, found the overall prevalence of psychiatric disorder to be the same in both sexes, but that compared to women, men were twice as likely to be referred. Our study has also demonstrated an increased
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A. E. Farmer and H. Griffiths
tendency for males to be referred, though the ratio of male to female 'cases' was equal. Marks et al. (1979) also showed that GPs tend to underestimate severity of illness in females rather than overestimate it in males. This has been explained (Fahy, 1974; Boardman et al. 1988) as due to differing social roles traditionally adopted by men and women, men in work being preferentially referred compared to women undertaking domestic duties. Interestingly, psychiatrists seem to be uninfluenced by the sex of the subjects in deciding whether or not they are a 'case', and this is again in keeping with previous work (Fahy, 1974). However, contrary to previous studies is the failure of good or poor psychosocial context to influence the GPs' referral decisions. In this respect our results differ from those of Rawnsley and colleagues (Rawnsley & Loudon, 1962; Ingham et al. 1972), who concluded that social factors overrode diagnosis and severity of illness in Rhondda GPs' decision making. Referral to social workers also had a low frequency among GPs (4 % non-cases, 1 % cases), and psychologists were only asked their advice regarding non-cases. Both findings may reflect the limited availability of trained social workers and psychology services in the Health Districts served by the GPs in our study. It is therefore possible to speculate that GPs fail to take account of the patients' context as there is little that can be done about it. In addition, the Rhondda and Taff Ely Health Districts are ones of such high psychosocial morbidity, and poor psychosocial context is so ubiquitous, that its influence may be negated. Referral practice differed little between our selected sample of GPs. One of our original hypotheses was that increased training at undergraduate level of psychiatry would have an effect on referral practices. This has not been shown, as there is no association between number of years in general practice, vocational training, psychiatric or any other postgraduate experience, and the decision to refer. However, this is a small sample of GPs, and either the sample is too limited or specific postgraduate experience amongst younger GPs is being balanced out by a 'seniority' effect amongst older practitioners. Our findings that there were no consistent individual differences between GPs ran counter to those of Rawnsley et al. in 1962 studying 6
general practices in the Rhondda Valley, who found that there was evidence of widely divergent attitudes to psychiatric illness and in referral rates to psychiatric services. The pathway to psychiatric care has been described by Goldberg & Huxley (1980), who proposed a model of successive levels and filters representing progress from unrecognized psychiatric illness in the community to psychiatric in-patient. The identification of the patient as a 'case' represents the transition from level 2 (total primary care morbidity) via filter 2 (recognition by the GP) to level 3 (conspicuous primary care morbidity). Shepherd et al. (1966) in their London-based survey found that only one in 20 of identified psychiatric patients were referred to mental health services of any kind, while between 2 % and 10% were initially referred to a non-psychiatrist. Kessel (1960) also suggested that as many as 90% of patients identified as psychiatrically ill by GPs were not referred to psychiatric services. While the majority of both cases and non-cases in our study are not referred to psychiatric services, referral rates to any secondary service remain much higher than these earlier studies (28 % for ' noncases ' and 48 % for' cases', with 43 % of referred ' non-cases' and 64 % of referred ' cases' being referred to psychiatrists). It is likely, however, that because the GPs were aware of the purpose of the study, this could have resulted in an increased likelihood of referral compared to Shepherd's and Kessel's earlier findings. Reassuringly, all GPs state that they would instigate further management of all cases, with 'counselling' and some other form of psychotherapy being the most commonly mentioned intervention. However, this is a non-specific, vague term which may have been offered by GPs at interview, once again due to their awareness of the study's purpose. Exclusion of physical illness was also considered a priority, and this decision may explain the limited prescription of antidepressants and benzodiazepines, medication being deferred until the results of tests were known. We have attempted to tease apart some of the complex factors that influence GPs' decision making about patients with psychological symptoms. Although our study is confined to comparing a small sample of GPs working in and near two Welsh valleys with their locally
Labelling and illness in primary care
based psychiatric colleagues, we have nonetheless been able to detect certain statistically highly significant effects. Aspects of our vignette method are new (i.e. vignettes constructed from PSE ratings of real subjects with other variables randomly assigned), but the use of vignettes as a means of assessing GP diagnostic agreement has been shown to be fruitful elsewhere. For example, Jenkins et al. (1988) showed that diagnostic agreement between GPs, although low, was better with vignettes than with videotaped consultations. Kessel (1960) has also pointed out the potential for sampling error if real patients are assessed. Thus, despite its limitations we consider that our method has utility and is acceptable to both GPs and psychiatrists. In addition we consider the method to be applicable to other health districts and different service provision, and further studies are planned to include the vignettes in a teaching package for GPs' continuing medical education.
APPENDIX SAMPLE CASE VIGNETTE CASE 1 (ID = 2; N o ' l a b e l ' , ' c o n t e x t ' = bad) Forty-three-year-old man recently divorced from his wife of 15 years. She has custody of their two children. He finds it difficult to see the children on access visits as his wife has moved 30 miles away and he cannot afford the train fare. He has always been somewhat anxious about travelling on trains ever since he was a child, but since his divorce this anxiety has become slightly worse and he prefers to find other means of travelling to see his children. This is rather difficult however, as he no longer can afford to run a car and the buses are irregular and inconvenient. Made redundant from steel works where he worked as a fitter 5 years ago. Has now stopped actively looking for work but says he would be willing to work if the right job came along. Spends his days watching TV at his mother's and in the evenings goes to the pub with former workmates. Says he misses the children and his ex-wife a lot, although you know that when he was married, he and his wife used to row constantly. Complains of recurring vague upper abdominal pains, worse after meals and weekends when he admits he drinks rather more heavily than in the
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week. However, he has never had any problems due to his drinking. He has had the pains on and off for several years and he last saw your partner 3 months ago for the same problem and was prescribed 'Tagamet'. On previous occasions this has cured pains but this time has not worked. He complains of feeling offcolour and in need of 'a tonic'.
REFERENCES Boardman, A. P., Bouras, N. & Craig, T. K. G. (1988). General practitioner referrals to an ambulatory psychiatric service. The effects of establishing an ease of access service. International Journal of Social Psychiatry 34, 172-183. Clare, A. (1976). Psychiatry in dissent, pp. 104-108. Social Science Paperbacks, Tavistock Publications: London. Crombie, D. L. (1986). Classification of mental illness in primary care settings. In Mental Illness in Primary Care Settings (ed. M. Shepherd, G. Wilkinson and P. Williams), pp. 27-45. Tavistock: London. Fahy, T. J. (1974). Pathways of specialist referral of depressed patients from general practice. British Journal of Psychiatry 124, 231-239. Feinberg, S. E. (1981). The Analysis of Cross-Classified Categorical Data (2nd edn). MIT Press: Cambridge, Massachusetts. Goldberg, D. & Huxley, P. (1980). Mental Illness in the Community. Tavistock Publications: London. Ingham, J. G., Rawnsley, K. & Hughes, D. (1972). Psychiatric disorder and its declaration in contrasting areas of South Wales. Psychological Medicine 2, 281-292. Jenkins, R., Smeeton, N. & Shepherd, M. (1988). Classification of Mental Disorder in Primary Care. Psychological Medicine. Monograph Supplement 12. Kessel, W. I. N. (1960). Psychiatric morbidity in a London general practice. British Journal of Preventative and Social Medicine 14, 16-22. Marks, J. N., Goldberg, D. P. & Hillier, V. F. (1979). Determinants of the ability of general practitioners to detect psychiatric illness. Psychological Medicine 9, 337-353. Rawnsley, K. & Loudon, J. B. (1962). The attitude of general practitioners to psychiatry. In Sociological Review Monograph 5: Sociology and Medicine Studies Within the Framework of the British National Health Service. University of Keele: Keele. Rosenhan, D. L. (1973). On being sane in insane places. Science 179, 250-258. Scheff, T. J. (1966). Being Mentally III: A Sociological Theory. Aldine: Chicago. Shepherd, M., Cooper, B., Brown, A. C. & Kallon, G. W. (1966). Psychiatric Illness in General Practice. Oxford University Press: London. Wilkinson, G. (1988). A comparison of psychiatric decision-making by trainee general practitioners and psychiatrists using a simulated consultation model. Psychological Medicine 18, 167-177. Wilkinson, G. (1989). Referrals from general practitioners to psychiatrists and paramedical mental health professionals. British Journal of Psychiatry 154, 72-77. Wing, J. K. & Sturt, E. (1978). The PSE-1D-CATEGO System Supplementary Manual. Mimeograph. MRC Social Psychiatry Unit, Institute of Psychiatry: London. Wing, J. K., Cooper, J. E. & Sartorius, N. (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: Cambridge.
Labelling and illness in primary care: comparing factors influencing general practitioners' and psychiatrists' decisions regarding patient referral to mental illness services ANNE E. FARMER1 AND HUW GRIFFITHS From the Department of Psychological Medicine, University of Wales College of Medicine; and East Glamorgan General Hospital, Mid Glamorgan, Wales
GPs and psychiatrists from South Wales were asked to make decisions based on the information included in each of 16 vignettes describing depressed and anxious subjects. This information contained randomly assigned sex, psychiatric label, good and bad psychosocial context and age as well as eight different severity ratings of depression and anxiety symptoms. Our results showed that both GPs and psychiatrists were influenced in their decision making by the severity of the illness, but that GPs alone were also strongly influenced by the presence of male sex and by the presence of a psychiatric label. Good or bad psychosocial context had no influence on the GPs' referral decision, and previous experience in psychiatry or other vocational training had no detectable effect., but this may be because of the sample size.
SYNOPSIS
INTRODUCTION Between 24 % and 29 % of adults who consult their GP annually have psychiatric symptoms, which are mostly those of minor affective disorder (Goldberg & Huxley, 1980). GP detection rates for such illnesses differ, but are of the order of 50%. However, only 5-10% of these identified psychiatrically ill subjects receive specialist care, so GPs manage most psychiatric illness themselves (Shepherd et al. 1966; Wilkinson, 1989). It might be expected that GPs' referral decisions are related to the complex interplay between the patients themselves, the services available and the GPs' experiences and interests in the treatment of psychiatric problems. In addition, the main reasons cited by GPs for referring include treatment failure, diagnostic difficulties, patient's or relative's request for referral or the doctor's view that a specialist is required to share or take over the patient's
'Address for correspondence: Dr Anne Farmer, Department of Psychological Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF4 4XN, South Wales.
management (Wilkinson, 1989). While these can be considered to be the declared reasons for GPs' decisions, other less obvious factors may also influence the decision-making process. For example, previous studies have shown that the patient's sex influences GPs in their referral decision making, with men being more readily referred compared to women despite comparable severity of symptoms (Boardman et al. 1988). Rawnsley & Loudon (1962) and Ingham et al. (1972) suggested that the referral decision was mainly influenced by social and other factors and that these overrode clinical variables such as presentation or severity of illness in a series of studies carried out in the Rhondda valleys and Vale of Glamorgan in South Wales. These authors also concluded that GPs working in the more deprived Rhondda valleys had widely divergent attitudes to psychiatric illness and in referring to psychiatric services. Another potential influence on GPs' referral practices is that of psychiatric 'label'. This was described by Scheff (1966), who proposed that mental illness is a stabilized and stigmatized social role. Scheff (1966) defines the application
717
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A. E. Farmer and H. Griffiths
of labelling theory to mental illness as ' a theory of mental disorder in which utilized symptoms are considered to be labelled violations of social norms and stable "mental illness" to be a social role'. Thus certain deviant behaviours, e.g. taking an overdose, are labelled by doctors as mental illness. Subsequent deviant behaviour in someone who has acquired the label merely confirms the presence of psychiatric disorder according to Scheffs theory, and acquiring the status of a psychiatric patient is largely independent of the > patient's symptoms or behaviour but is a function of the doctor's uncertainty. Experiments designed to test the validity of labelling theory in mental hospitals have provoked considerable controversy (e.g. Rosenhan, 1973) but have been of doubtful scientific merit (Clare, 1976). It is worth speculating whether GPs may be influenced in their decision making by a label acquired by the patient because of past psychiatric contact. Since the earlier research in older industrial areas such as South Wales (Rawnsley & Loudon, 1962; Ingham et al. 1972), a number of factors may have altered local GPs' referral practices. First, there have been massive socio-economic changes in such areas, and in South Wales these have been mainly generated by the decline of coal mining. Secondly, by comparison with the 1960s, more psychiatry has been taught to trainee GPs at both undergraduate and postgraduate level, which may also have had an effect on their referral rates to psychiatrists. However, despite these, the development of community-based psychiatric services in this part of South Wales has lagged behind most districts in England, and psychiatric services remain largely 'traditional' and centrally organized from the local district hospital, with back-up intensive care facilities at a more distantly located psychiatric hospital scheduled for closure in 1992. In order to evaluate any changes in referral practice as well as other possible factors influencing decision making, GPs from the Rhondda valleys and the adjacent health district of Taff Ely were asked their opinions about case vignettes constructed to include eight different severity measures of depression and anxiety ranging from mild to severe, the presence or absence of a psychiatric label, and good or bad psychosocial context. Based on previous studies
carried out in the same area, it was expected that GPs would be influenced by social context as well as by label and severity of illness, although the amount or nature of postgraduate experience received may also be influential. By contrast, we predicted that a comparison group of locally based psychiatrists would be less influenced by label and psychosocial context in their decisions about whether or not a subject was a 'case' of psychiatric disorder. The following hypotheses were therefore tested. 1. GPs' decisions to refer depressed and anxious patients to hospital-based services are influenced by' label',' context' and sex of subject as well as illness severity. 2. GPs' referral decisions are related to the amount and nature of postgraduate training received. 3. Because of their specialist training psychiatrists' decisions will only be influenced by the severity of psychopathology and not 'label', 'context' or sex of subject. METHOD Sixteen case vignettes (see Appendix for example) were constructed, describing subjects with psychological problems ranging from mild disturbance to severe mental illness. Symptom profiles were taken from the Present State Examination (PSE) interviews of real patients that generated eight different severity ratings for depression and anxiety according to the Index of Definition (ID) ' caseness' measure of the PSE scoring program ID-CATEGO (Wing et al. 1974; Wing & Sturt, 1978). Two vignettes were constructed for each ID level. In addition, a psychiatric 'label' was randomly included in eight of the vignettes, the remainder having no label. Labels consisted of a history of previous contact with a psychiatrist (three cases), an episode of self-poisoning (two cases) or other form of self-harm (one case, previous drug abuse) or GP-instigated psychotropic medication (two cases). Good and poor psychosocial context, sex and age were also randomly assigned in the same way. Seventeen GPs, selected as being broadly representative of those practising in the Taff Ely and Rhondda Health Districts in Mid Glamorgan, were interviewed regarding each vignette and their decisions were recorded on a
Labelling and illness in primary care
standard coding form. The order of presentation of the vignettes was random, and the same for all GPs and psychiatrists. Ten Senior Registrar or Consultant Psychiatrists from Mid and South Glamorgan Health Districts were also interviewed, and their responses recorded on a slightly modified version of the same coding form. Both groups were asked their year of qualification, number of years in general practice or psychiatry, and medical school. GPs were asked about their postgraduate experience. Both groups were asked for their decisions regarding appropriateness of referral of the subject described in the vignette. Here the questions posed to the two groups differed as follows. GPs were asked whether the subject should be referred to a psychiatrist, another doctor - for example, a consultant physician or surgeon - another service - for example, a social worker or a psychologist - or whether they would wish to undertaken treatment themselves. The type of treatment personally undertaken by GPs for each vignette was also recorded. Psychiatrists were asked whether they thought the subject was a 'case' warranting psychiatric referral. Thus each of the 17 GPs and 10 psychiatrists was asked to make a decision regarding referral for each of the 16 vignettes, all of the doctors being 'blind' to ID level, label and context status contained in the vignettes. In order to establish that each decision was independent of the order of presentation of the vignette, a test of association was carried out between case number and referral decision. No significant association was found, and therefore the data were subsequently analysed using the SPSS PC package, assuming that for the GPs there are 17x16 and for the psychiatrists 10x16 independent decisions. Contingency tables were analysed using x2 tests. We also examined decisions regarding referral using logistic regression models as described below. RESULTS Seventeen (18-5%) of the 92 GPs practising in the Taff Ely and Rhondda Health Districts were randomly selected to participate in the study. None of those selected declined. As a group the GPs had been in practice for a shorter time than the psychiatrists (mean years in general practice for GPs = 11-24 range 1-35 years; years
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as psychiatrists mean =14-5 years, range 4-40 years). All of the psychiatrists and all but three of the GPs had received undergraduate training in the UK. Five GPs had completed vocational training and four had had some postgraduate experience in psychiatry. Only three GPs had no postgraduate experience other than House Officer posts. Table 1 shows the order of presentation of the vignettes, their ID level, sex, label, context and age. In addition, the table shows the percentage of GPs who referred the case to a psychiatrist and the percentage of psychiatrists regarding the subject described as a case. Conventionally, ID levels 1-4 are considered as 'non-cases', ID 5 to be on the threshold and ID level 6-8 to be definite psychiatric 'cases'. GPs' and psychiatrists' referral decisions for both cases and non-cases are shown in Table 2. The table shows that the majority of both cases and non-cases would not be referred to another service by the GPs. Psychiatrists considered that 95 % of cases and 36 % of non-cases required psychiatric intervention, while the GPs decided to refer 42 % of cases and 28 % of non-cases to another service. Table 2 also shows the main referral agencies that would be used by the GPs. For cases, psychiatrists would have received most referrals (31 % ) , although 8 % would have been referred to physicians or surgeons. Little use was made of case referral to psychologists, social workers and other agencies. However, these non-medical professionals would have received more non-case referrals (15%). Psychiatrists would also have received referral of 12 % of these less severely ill subjects. For all subjects with ID level 4 and above, the GP's decision was to offer further treatment unless the subjects were being referred elsewhere. GPs suggested that they would use a variety of drugs including antidepressant and benzodiazepines, although prescribing of the latter was quite limited (5 %). In addition 'counselling' and 'psychotherapy' was mentioned as a treatment the GPs would instigate themselves. However, exclusion of physical illness was the main concern for the GPs in 17% of non-cases and 31 % of cases. GPs were also asked to comment on their reasons for referral to a psychiatrist. The most commonly stated reasons were for suicidal risk (23%) and depression (19%) followed by
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Table 1. Case vignettes Case nos. and order of presentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
ID
Sex
Label
Context
Age
2
M
7
F M F M M
M F F
No No Yes No No No Yes No Yes Yes Yes Yes No
43 55 19 26 35 63 59 44 59 38 26 28 19
F
Yes
M M
No
Bad Bad Bad Bad Good Bad Bad Good Good Good Bad Bad Good Good Good Good
8
1 8
5 6 6
2 3 4
5 4 1 3 7
F
F M F
Yes
31 61 49
% referred to psychiatrist by GPs
% psychiatrists regarding subject as 'a case'
0 12 82 6 65
20 100 100 0 100 60 100 80 40 60 70 70 30 0 10
0 18
0 18 35 35 29 0 0 3 7
90
to the psychiatrist was the presence of a Table 2. GPs' and psychiatrists' referral decisions psychiatric label (x2 = 13-49, df = 1, P = 0-000; for cases (ID 6-8) and non-cases (ID 1-5) proportion of cases with psychiatric label referred by GPs to psychiatrists = 29%, CI = 21Non-cases Cases 37 %), and male sex ft2 = 7-59, df = 1, P = 0-006; proportion of male cases referred by GPs to a Psychiatrists considered psychiatric 95 36 psychiatrist = 26%, CI = 19-33%). However, intervention was required 42 28 GPs would refer to another service there was no significant association with psycho12 GPs would refer to psychiatrists 31 social context, years in general practice or any 1 GPs would refer to physicians or 8 type of postgraduate experience. surgeons 1 7 GPs would refer to psychologists By contrast, psychiatrists were not influenced GPs would refer to other agencies 2 8 in their decisions as to whether subjects were including social workers true cases, or by any factors other than severity of psychopathology. Thus psychiatric label, sex obsessional symptoms (8%), schizophrenia and context had no significant effect. To examine further the effects of factors (6%) and social problems (4%). In other instances, GPs stated that specific psychiatric influencing the GPs' decision to refer to a treatments were required such as psychotherapy psychiatrist and the psychiatrist's judgment of caseness, we carried out logistic regression or relaxation classes. We carried out a series of 2 x 2 and 2 x N x2 analysis (Feinberg, 1981). Here the proportion tests for variables we thought influenced GPs' (P) of patients referred (or of subjects deemed to and psychiatrists' decisions about caseness. GPs' be cases) was taken to be outcome variable and decisions to refer to a psychiatrist were sig- expressed as the logit transform (i.e. log (P.lnificantly associated with severity of symptoms P)). The explanatory variables were sex, ID and as reflected in the ID level ( / = 7609, df = 7, label. Thus, the saturated model can be reP = 0000; proportion of cases (ID, 6-8) referred presented as: logit (p) = grand mean + effect of by GPs to psychiatrists = 31 %, 95 %, CI = 22- ID + effect of label + effect of sex + interaction 40%). Similarly, the psychiatrists' decisions effects (ID x label) (ID x sex) (sex x label) (ID x about caseness were highly significant associated sex x label). The significance of the explanatory variables with ID level (x2 = 73-52, df = 7, P = 0-000; proportion of psychiatrists identifying and their interactions was tested by eliminating 'cases'= 95%, CI = 89-100%). Also, sig- each in turn from the model and examining the 2 nificantly associated with GPs' decisions to refer resultant x - The results are summarized in
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Table 3. Model fitting by logistic regression analysis: GPs and psychiatrists GPs' data
Psychiatrists' data
*•
df
P
X"
df
P
Saturated model referral to psychiatrist by sex, ID and label
L P
0-0 00
0 0
100 100
00 00
0 0
100 100
Remov ng label by ID* interaction from model
L P
14-79 1508
6 6
002 002
6-53 6-21
6 6
0-37 0-40
Removing 'sex' from model
L P
16-71 17-04
7 7
0-02 002
6-62 6-54
7 7
0-47 0-48
Removing ' label' from model
L P
38-72 29-40
8 8
000 000
14-85 1314
8 8
006 011
Removing ' I D ' from model
L P
86-57 100-57
14 14
000 000
107-51 83-99
15 15
0-00 000
* Removal of cither second-order interactions 'sex by label' +'sex by I D ' showed no difference from the saturated model. L, Likelihood ratio; P, Pearson x'-
Table 3 and show that for the psychiatrist's data only the removal of ID from the model is significantly different from the saturated model. Thus, ID is the main influence on the psychiatrist's decision about caseness. However for the GP data, neither label, sex, ID nor the second-order interaction between label and ID can be eliminated from the model, since all the reduced models offer a significantly poorer fit than the saturated model. DISCUSSION Despite the limited sample size, the most significant finding of this study was the strong influence of psychiatric label upon GPs' decision making. As well as having a significant effect on its own, label interacted with the severity measure, ID level, in influencing GPs' decisions to refer. However, there was no analogous influence of label on the psychiatrists, whose decisions regarding caseness were solely related to severity of psychopathology. Previously, Scheff criticized psychiatrists for diagnosing mental illness on the basis of deviant behaviour or previously acquired psychiatric labels and by implication cast doubt on the accuracy of judgement regarding clinical severity. In our study psychiatrists have been shown not to be influenced in this way, but their GP colleagues still take previously acquired labels into account in deciding to refer. Therefore, the findings seem to confirm the potency of a patient's ' label' in influencing the plan of action of the general practitioner, and as
such could be seen as providing partial support for the views of labelling theorists. In primary care, however, the use of psychiatric label in this way might assist decision making in a practical way which, it could be argued, is adaptive and appropriate. Recent studies have shown that GPs employ different means of decision making compared to their hospital-based colleagues. Jenkins et al. (1988) found that information from psychological, social and personality domains is employed in GP decision making, and there is greater agreement between GPs when rating presence and type of symptom than when ascribing cases to diagnostic categories. As well as these differences between experienced practitioners, Wilkinson (1988) examined diagnostic agreement between psychiatric and GP trainees. Using a videotape-assisted simulation consultation model of depressed women, he found that both within and between the two groups, of trainees, agreement regarding diagnosis and management was low. Crombie (1986) also showed that a problem-solving nomenclature was often employed in general practice which differs from that used by hospitalbased specialities, and which does not fit the traditional diagnostic framework taught in medical schools. Our results lend support to these findings. Ingham et al. (1972), working in the same geographical location as our study, found the overall prevalence of psychiatric disorder to be the same in both sexes, but that compared to women, men were twice as likely to be referred. Our study has also demonstrated an increased
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A. E. Farmer and H. Griffiths
tendency for males to be referred, though the ratio of male to female 'cases' was equal. Marks et al. (1979) also showed that GPs tend to underestimate severity of illness in females rather than overestimate it in males. This has been explained (Fahy, 1974; Boardman et al. 1988) as due to differing social roles traditionally adopted by men and women, men in work being preferentially referred compared to women undertaking domestic duties. Interestingly, psychiatrists seem to be uninfluenced by the sex of the subjects in deciding whether or not they are a 'case', and this is again in keeping with previous work (Fahy, 1974). However, contrary to previous studies is the failure of good or poor psychosocial context to influence the GPs' referral decisions. In this respect our results differ from those of Rawnsley and colleagues (Rawnsley & Loudon, 1962; Ingham et al. 1972), who concluded that social factors overrode diagnosis and severity of illness in Rhondda GPs' decision making. Referral to social workers also had a low frequency among GPs (4 % non-cases, 1 % cases), and psychologists were only asked their advice regarding non-cases. Both findings may reflect the limited availability of trained social workers and psychology services in the Health Districts served by the GPs in our study. It is therefore possible to speculate that GPs fail to take account of the patients' context as there is little that can be done about it. In addition, the Rhondda and Taff Ely Health Districts are ones of such high psychosocial morbidity, and poor psychosocial context is so ubiquitous, that its influence may be negated. Referral practice differed little between our selected sample of GPs. One of our original hypotheses was that increased training at undergraduate level of psychiatry would have an effect on referral practices. This has not been shown, as there is no association between number of years in general practice, vocational training, psychiatric or any other postgraduate experience, and the decision to refer. However, this is a small sample of GPs, and either the sample is too limited or specific postgraduate experience amongst younger GPs is being balanced out by a 'seniority' effect amongst older practitioners. Our findings that there were no consistent individual differences between GPs ran counter to those of Rawnsley et al. in 1962 studying 6
general practices in the Rhondda Valley, who found that there was evidence of widely divergent attitudes to psychiatric illness and in referral rates to psychiatric services. The pathway to psychiatric care has been described by Goldberg & Huxley (1980), who proposed a model of successive levels and filters representing progress from unrecognized psychiatric illness in the community to psychiatric in-patient. The identification of the patient as a 'case' represents the transition from level 2 (total primary care morbidity) via filter 2 (recognition by the GP) to level 3 (conspicuous primary care morbidity). Shepherd et al. (1966) in their London-based survey found that only one in 20 of identified psychiatric patients were referred to mental health services of any kind, while between 2 % and 10% were initially referred to a non-psychiatrist. Kessel (1960) also suggested that as many as 90% of patients identified as psychiatrically ill by GPs were not referred to psychiatric services. While the majority of both cases and non-cases in our study are not referred to psychiatric services, referral rates to any secondary service remain much higher than these earlier studies (28 % for ' noncases ' and 48 % for' cases', with 43 % of referred ' non-cases' and 64 % of referred ' cases' being referred to psychiatrists). It is likely, however, that because the GPs were aware of the purpose of the study, this could have resulted in an increased likelihood of referral compared to Shepherd's and Kessel's earlier findings. Reassuringly, all GPs state that they would instigate further management of all cases, with 'counselling' and some other form of psychotherapy being the most commonly mentioned intervention. However, this is a non-specific, vague term which may have been offered by GPs at interview, once again due to their awareness of the study's purpose. Exclusion of physical illness was also considered a priority, and this decision may explain the limited prescription of antidepressants and benzodiazepines, medication being deferred until the results of tests were known. We have attempted to tease apart some of the complex factors that influence GPs' decision making about patients with psychological symptoms. Although our study is confined to comparing a small sample of GPs working in and near two Welsh valleys with their locally
Labelling and illness in primary care
based psychiatric colleagues, we have nonetheless been able to detect certain statistically highly significant effects. Aspects of our vignette method are new (i.e. vignettes constructed from PSE ratings of real subjects with other variables randomly assigned), but the use of vignettes as a means of assessing GP diagnostic agreement has been shown to be fruitful elsewhere. For example, Jenkins et al. (1988) showed that diagnostic agreement between GPs, although low, was better with vignettes than with videotaped consultations. Kessel (1960) has also pointed out the potential for sampling error if real patients are assessed. Thus, despite its limitations we consider that our method has utility and is acceptable to both GPs and psychiatrists. In addition we consider the method to be applicable to other health districts and different service provision, and further studies are planned to include the vignettes in a teaching package for GPs' continuing medical education.
APPENDIX SAMPLE CASE VIGNETTE CASE 1 (ID = 2; N o ' l a b e l ' , ' c o n t e x t ' = bad) Forty-three-year-old man recently divorced from his wife of 15 years. She has custody of their two children. He finds it difficult to see the children on access visits as his wife has moved 30 miles away and he cannot afford the train fare. He has always been somewhat anxious about travelling on trains ever since he was a child, but since his divorce this anxiety has become slightly worse and he prefers to find other means of travelling to see his children. This is rather difficult however, as he no longer can afford to run a car and the buses are irregular and inconvenient. Made redundant from steel works where he worked as a fitter 5 years ago. Has now stopped actively looking for work but says he would be willing to work if the right job came along. Spends his days watching TV at his mother's and in the evenings goes to the pub with former workmates. Says he misses the children and his ex-wife a lot, although you know that when he was married, he and his wife used to row constantly. Complains of recurring vague upper abdominal pains, worse after meals and weekends when he admits he drinks rather more heavily than in the
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week. However, he has never had any problems due to his drinking. He has had the pains on and off for several years and he last saw your partner 3 months ago for the same problem and was prescribed 'Tagamet'. On previous occasions this has cured pains but this time has not worked. He complains of feeling offcolour and in need of 'a tonic'.
REFERENCES Boardman, A. P., Bouras, N. & Craig, T. K. G. (1988). General practitioner referrals to an ambulatory psychiatric service. The effects of establishing an ease of access service. International Journal of Social Psychiatry 34, 172-183. Clare, A. (1976). Psychiatry in dissent, pp. 104-108. Social Science Paperbacks, Tavistock Publications: London. Crombie, D. L. (1986). Classification of mental illness in primary care settings. In Mental Illness in Primary Care Settings (ed. M. Shepherd, G. Wilkinson and P. Williams), pp. 27-45. Tavistock: London. Fahy, T. J. (1974). Pathways of specialist referral of depressed patients from general practice. British Journal of Psychiatry 124, 231-239. Feinberg, S. E. (1981). The Analysis of Cross-Classified Categorical Data (2nd edn). MIT Press: Cambridge, Massachusetts. Goldberg, D. & Huxley, P. (1980). Mental Illness in the Community. Tavistock Publications: London. Ingham, J. G., Rawnsley, K. & Hughes, D. (1972). Psychiatric disorder and its declaration in contrasting areas of South Wales. Psychological Medicine 2, 281-292. Jenkins, R., Smeeton, N. & Shepherd, M. (1988). Classification of Mental Disorder in Primary Care. Psychological Medicine. Monograph Supplement 12. Kessel, W. I. N. (1960). Psychiatric morbidity in a London general practice. British Journal of Preventative and Social Medicine 14, 16-22. Marks, J. N., Goldberg, D. P. & Hillier, V. F. (1979). Determinants of the ability of general practitioners to detect psychiatric illness. Psychological Medicine 9, 337-353. Rawnsley, K. & Loudon, J. B. (1962). The attitude of general practitioners to psychiatry. In Sociological Review Monograph 5: Sociology and Medicine Studies Within the Framework of the British National Health Service. University of Keele: Keele. Rosenhan, D. L. (1973). On being sane in insane places. Science 179, 250-258. Scheff, T. J. (1966). Being Mentally III: A Sociological Theory. Aldine: Chicago. Shepherd, M., Cooper, B., Brown, A. C. & Kallon, G. W. (1966). Psychiatric Illness in General Practice. Oxford University Press: London. Wilkinson, G. (1988). A comparison of psychiatric decision-making by trainee general practitioners and psychiatrists using a simulated consultation model. Psychological Medicine 18, 167-177. Wilkinson, G. (1989). Referrals from general practitioners to psychiatrists and paramedical mental health professionals. British Journal of Psychiatry 154, 72-77. Wing, J. K. & Sturt, E. (1978). The PSE-1D-CATEGO System Supplementary Manual. Mimeograph. MRC Social Psychiatry Unit, Institute of Psychiatry: London. Wing, J. K., Cooper, J. E. & Sartorius, N. (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: Cambridge.
