Psychosocial problem disclosure by primary care patients

Abstract

The vast majority of psychologically distressed primary care patients present exclusively somatic concerns at the outsets of their visits. However, it is not known how often such patients subsequently disclose psychosocial problems to their primary care physicians (PCPs) and what variables predict such disclosures. Our objectives were to measure, among psychologically distressed primary care patients, the frequency of disclosure of psychosocial problems (disclosure), the effects of prior psychosocial inquiry (prior inquiry) by PCPs and various patient variables on disclosure, and the effect of disclosure on mental health problem recognition (recognition) by PCPs. The study was based in the practices of 69 community-based PCPs and involved 308 adult patients with 28-item General Health Questionnaire scores of 5 or greater, indicating significant psychological distress.

Disclosure occurred during 51% of visits overall and 67% of visits with prior inquiry. The odds of disclosure were increased by prior inquiry (p<0.001), greater physician–patient familiarity (p<0.001) and greater severity of patient psychological distress (p<0.001). Prior inquiry and physician–patient familiarity had a negative interaction (p<0.05) of smaller size than either variable's main effect, so that their combined effect on disclosure exceeded the effect of either variable alone but was less than multiplicative. The estimated odds ratio for recognition given disclosure was 24.13 (95% confidence interval, 11.28–51.63) after adjustment for the effects of significant covariates. We conclude that if PCPs inquire, most psychologically distressed, somatically presenting patients will disclose psychosocial problems. Inquiry is particularly productive with unfamiliar patients. PCPs can engender a substantial increase in psychosocial disclosure simply by adding one or two questions about mood or interpersonal problems to their clinical interviews.

Introduction

It is estimated that 19–26% of primary care patients have mental disorders Kessler et al., 1987, Von Korff et al., 1987, Barrett et al., 1988, Leon et al., 1995, Philbrick et al., 1996, Tiemens et al., 1996 and 31–46% have significant psychological distress (Hoeper et al., 1984, Rucker et al., 1986, Shapiro et al., 1987, Von Korff et al., 1987, Rand et al., 1988, Ormel et al., 1990, Kirmayer et al., 1993, Philbrick et al., 1996 Tiemens et al., 1996). However, investigators have shown that only 24–56% of these mental disorders are recognized by primary care physicians Hoeper et al., 1984, Schulberg et al., 1987, Wells et al., 1989, Magruder-Habib et al., 1990, Ormel et al., 1990, Kirmayer et al., 1993, Coyne et al., 1995, Simon and Von Korff, 1995, Tiemens et al., 1996. It is unclear to what extent this under-recognition of mental disorders by primary care physicians (PCPs) is due to under-disclosure of psychosocial problems by their patients. If questioned prior to visiting their PCPs, only 17% of patients with mental disorders report psychosocial reasons for their visits Bridges and Goldberg, 1985, Kirmayer et al., 1993; the remainder report only somatic reasons. However, how often such somatic presenters subsequently disclose psychosocial problems during the course of their visits is unknown.

We were unable to find a reported study that measured the rate of psychosocial problem disclosure among primary care patients known by researchers to be psychologically distressed. We found 4 studies that observed office visit content after researchers determined whether patients were psychologically distressed, but none identified the occurrence of psychosocial disclosure, per se Marks et al., 1979, Brodaty et al., 1982, Goldberg et al., 1982, Tylee et al., 1995. We found 2 studies that identified the occurrence of psychosocial disclosure by observing office visit content, but neither identified the presence of psychological distress prior to the visit Bensing and Sluijs, 1985, Verhaak, 1988. Thus, none of these studies reported a rate of psychosocial disclosure among primary care patients with known psychological distress.

When queried by researchers immediately prior to office visits, 43–60% of psychologically distressed, somatically presenting primary care patients reveal psychological contributors to their somatic distress Bridges and Goldberg, 1985, Kirmayer et al., 1993. This suggests that psychosocial inquiry by PCPs ought to substantially increase the rate of psychosocial problem disclosure by their patients.

The first aim of this study was to measure the frequency of psychosocial problem disclosure (disclosure) by psychologically distressed primary care patients during visits to PCPs. The second aim was to measure the effects on disclosure of various physician and patient variables, including psychosocial inquiry by PCPs and the extent of physician–patient familiarity. The third aim was to measure the effect of disclosure on PCPs' recognition of mental health problems.