Mental health training of primary care physicians: an outcome study

It is well documented that primary care physicians encounter many patients in their practices who suffer psychiatric morbidity, especially affective, anxiety and substance abuse disorders. These physicians have been unable to effectively address the needs of these patients, over half of whom receive care exclusively in the primary care sector. Five years after implementing a curriculum to train family practice physicians to assume a comprehensive psychiatric role with patients in their practices, the authors undertook an outcome evaluation. The focus was on psychiatric disorder recognition, diagnosis, documentation, and management, including referral. It was hoped that biopsychosocial and community mental health orientations emphasized during training would be incorporated into the subsequent primary care practices of physicians in the study. In the research design, physician-generated diagnoses were compared with DIS/DSM-III diagnoses; physician interviews and chart audits enabled processes of care delivery to be evaluated. Unexpectedly, physicians were not found to assume an appropriately active or comprehensive mental health role in their practices following the training intervention. Of ninety-four DIS-generated diagnoses in the study population of fifty-one patients, 79 percent were unrecognized. Patients were assumed to function well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of cases. The physicians did diagnose and treat a number of patients with mental symptoms who were not identified by the DIS. These patients had high, but sub-diagnostic, DIS symptom counts. Most received a diagnosis of adjustment disorder in response to medical illness. Though this finding underscores shortcomings of present psychiatric nosology when applied in the general medical setting, the foremost consideration was the large number of DIS-identified patients with serious psychopathology, needing active assessment and intervention, who were unrecognized, undiagnosed or untreated. Implications of these findings for the psychiatric training of primary care physicians are examined.