Psychiatry and Primary CareValidity and applicability of the Mini International Neuropsychiatric Interview administered by family medicine residents in primary health care in Brazil
Introduction
Epidemiological studies on the adult population have found that prevalence for mental disorders ranges from 20% to 30% in 1 year, and 30% to 50% in a lifetime [1], [2], [3] including in Brazil [2], [4]. Most people with these disorders receive treatment at primary health care (PHC) services [1], [5], [6]. A multicenter study performed in 14 countries, coordinated by the World Health Organization (WHO), showed that, on the average, 24% of people who attended primary care presented at least one current mental disorder, while another 9% presented clinically significant subsyndromal conditions [5], [7].
Disabilities, decreased quality of life and the economic consequences associated with the presence of the most common mental disorders — such as anxiety, depression and psychoactive substance abuse — are at the least as important as those associated with common physical problems like hypertension, diabetes, arthritis, asthma or back pain [8], [9], [10].
Therefore, detecting, treating and appropriately referring people with mental disorders to specialized services are abilities necessary for PHC physicians to work effectively. Particularly regarding detection and diagnosis, studies show that general practitioners fail to detect or incorrectly diagnose about 50% of mental disorder cases presented to primary care [1], [5], [7], [11].
Two strategies have been proposed to improve this situation: (1) improving general practitioners' psychiatric knowledge and their diagnostic capacity through training in general interview abilities; and (2) training on how to use standardized, more structured interviews, reducing heterogeneity in the collection and interpretation of data from the patients' history and exam, and, thus, facilitating concordance with the established diagnosis criteria [12], [13].
Questions are raised about the first strategy due to its longer duration and training, which requires more time from specialized professionals; and the lack of guarantees, at the end of this process, that the diagnoses will be made according to the existing criteria. As to the second strategy, there is a concern with the risk of administering the structure in a way that is not sensitive to the demands of each patient care situation, thus harming the physician–patient relationship, which is essential to obtaining useful and reliable information [14], [15].
In addition, studies have shown that, when PHC professionals are trained for screening, diagnosing and treating mental disorders, and the improved diagnostic services are connected to organized systems of mental care [16], there is a better chance of reaching effective outcomes. This is true for services delivered within a structured organization, with specific characteristics, for instance: patient follow-up done by the same physician, longitudinally; enough time for physicians to provide appropriate screening, diagnosis and treatment; access to specialized consultation and liaison to clarify doubts and make decisions together regarding conducts, including referring to specialized services; the possibility of following specific PHC cases together with specialized professionals; readiness and quickness to initiate specialized service treatments when indicated [17], [18], [19], [20], [21], [22].
In Brazil, since 1994, the Health Ministry has proposed the Family Health Program (FHP, in Portuguese: “Programa de Saúde da Família”) as the key strategy to organize PHC and the public health care system as a whole. The FHP proposed the work of PHC teams composed of, at least, one family medicine physician, one nurse, two auxiliary nurses and four lay community health workers in each catchment area that includes 600–1000 families. These teams should perform health actions at the collective and individual levels, including health promotion, disease prevention and treatment (especially the most common ones), and constitute the prevailing contact interface between the community and the public Brazilian health care system [23], [24], [25].
Therefore, family medicine physicians are needed to implement this new model in Brazil. Furthermore, they should also effectively manage the demand related to mental health. There is a need for abilities related to screening and diagnosing mental disorders, so that these physicians can adequately meet this demand. One possible form of developing these professionals' abilities — during specialization — would be to integrate standardized interview training in a program for practical and theoretical psychiatry training. This program would be largely performed in PHC services with the previously described structural characteristics.
Three semistructured interviews, developed in the 1990s, have been studied regarding their everyday use by general practitioners for diagnosing mental disorders: the Symptom-Drive Diagnostic System for Primary Care, the Primary Care Evaluation of Mental Disorder (PRIME-MD) and the MINI. These interviews were developed to obtain good concordance when compared to interviews administered by professionals specialized in mental health. In addition, they are sufficiently brief, of easy understanding, and readily available, and provide clinically significant data (which would not be obtained with the same quality through nonstandardized interviews), when used daily by PHC physicians [26], [27], [28], [29], [30].
The MINI was developed by French and North American researchers, and presented good validity in a multicenter study (performed in Europe) that compared the diagnoses by general practitioners obtained using the MINI with the diagnoses obtained by psychiatrists using nonstructured interviews. In these studies, it took 15 to 30 minutes to administrate the MINI [28], [29], [30]. It was translated into Brazilian Portuguese and there are no restrictions to its clinical and research use [31]. Until today, no studies have validated the Brazilian version of the MINI.
Hence, the purpose of the present study was to evaluate the MINI administered by family medicine resident physicians at a Brazilian PHC service.
Section snippets
Context of the study
In 1999, family medicine residency (FMR) activities were established at the Clinics Hospital of the University of Sao Paulo at Ribeirao Preto Medical School (FMRPUSP). The residency's main field of clinical practice is a FHP service. Also in 1999, the FMRPUSP Psychiatry Discipline initiated collaboration with the FHP service, as well as with the FMR. One psychiatrist (one of the researchers) became the coordinator of the family medicine residency in the fields of mental health and psychiatry.
Results
Table 2 presents the frequencies of the broader current diagnostic categories and comorbidity according to the SCID, in absolute figures and percentages. The most common specific diagnoses were major depressive episode (19 cases, corresponding to 15.8% of the sample), generalized anxiety disorder (12 cases, 10% of the sample), panic disorder (5 cases, 4.2% of the sample) and dysthymia (4 cases, 3.3% of the sample). The most common comorbidity occurred in cases of depressive and anxiety
Discussion
The present study found a 36.7% frequency for mental disorders. It should be emphasized, however, that this study did not aim to describe the epidemiology of mental disorders at the service under study. Thus, cases that had been previously discussed or evaluated by the researcher were systematically excluded, which could have favored the lower frequency of these disorders, when compared to previous studies performed in Brazilian PHC services, which obtained current mental disorder frequencies
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