5 and 20 per cent of adult patients at the primary care level have mental ... younger (50 per cent were less than 39 years old) than White females (70% were over ...
PUBLIC HEALTH BRIEFS
Mental Disorders among Physical Disability Determination Patients JAMES D. LEEPER, PHD, LEE W. BADGER, MSW,
AND TAMAR
MILO, PHD
were two graduate students trained Abstract: Persons claiming physical disability who were evaluated at a primary care health center in a small southern city were administered the Diagnostic Interview Schedule. Fifty-six per cent of the 43 patients were found to have one or more psychiatric disorders. The relationship between physical disability and psychiatric disorders needs to be recognized in the disability evaluation system. (Am J Public Health 1985; 75:78-79.)
Introduction A person who considers himself/herself disabled to the point of being unable to work may present his/her complaints to the state agency designated to determine eligibility for social security disability payments. If that agency thinks the complaint warrants evaluation, the person is referred for an evaluation which may be physical, psychiatric, psychological, orthopedic, or neurological in nature, depending upon the patient's presenting complaints. This paper investigates the presence of psychiatric problems among persons referred for physical evaluations. The rates of mental disorders among patients claiming physical disability are unknown. It is estimated that between 5 and 20 per cent of adult patients at the primary care level have mental disorders. 1,2 Patients with psychiatric problems typically come to the doctor with physical complaints.3'4 Nonetheless, it is known that physical complaints may be secondary to an underlying mental problem, and if the mental problem is recognized and successfully treated, the physical problems may be alleviated as well.3,4 This pilot study was designed to investigate the extent and nature of mental disorders among those patients claim-
ing physical disability.
Methods Prior to their physical examination, all physical disability determination patients (N = 43) at a primary care health center in a small southern city were interviewed with the Diagnostic Interview Schedule (DIS). The DIS was developed at the initiative of the National Institute of Mental Health as a fully structured interview designed to yield reliable and valid psychiatric diagnoses.5 Diagnoses are made on a lifetime basis as well as by defined recency via a determination of when diagnostic criteria were last met. The DIS provides a total symptom count across diagnoses as well as a count of diagnostic criteria met. In addition, a scale similar and complementary to the format of the DIS was used to measure anxiety.* The interviewers for this study *Developed by and obtained from Leslie Dunn, PhD, Western Psychiatric Institute, Pittsburgh, PA. From the Department of Community Medicine (Leeper, Milo) and the Department of Psychiatry (Badger), University of Alabama College of Community Health Sciences. Address reprint requests to Dr. James D. Leeper, P.O. Box 6291, College of Community Health Sciences, University of Alabama, University, AL 35486. This paper, submitted to the Journal February 6, 1984, was revised and accepted for publication July 30, 1984. © 1984 American Journal of Public Health 0090-0036/84 $1.50
*78
on the research team.
by the certified trainer
Chi-square analyses using Yates correction were used relationships of race, sex, age, and marital status with the presence of psychiatric disorders. to test the
Results
Forty-three consecutive disability determination patients were the subjects for this pilot study. There were 23 males, 15 of them White; the 20 females were equally divided between Black and White. Sixty per cent (N = 9) of the White males were between ages 50 and 59 whereas the Black males were represented approximately equally in the 10-year intervals between ages 30 and 69. Black females were younger (50 per cent were less than 39 years old) than White females (70% were over 50 years old). Fifty-six per cent of the patients were found to have one or more current psychiatric disorders according to the DIS. Ten patients had one disorder, seven had two disorders, two had three disorders, two had four disorders, and three had five disorders. The most common DIS diagnoses were phobia (15 patients), anxiety (11 patients), and panic (8 patients). Other diagnoses were alcoholism (5), depression (4), somatization (4), organic brain syndrome (3), schizophrenia (2), and barbiturate dependence (1). Two-thirds of Blacks and 48 per cent of Whites had one or more diagnosis. Proportionately more males (61 per cent) than females (50 per cent) had one or more diagnosis. An equal percentage (56 per cent) of those under age 50 and those age 50 or older had one or more diagnosis. Married patients had a slightly lower prevalence of disorder than those unmarried (52 per cent versus 59 per cent). None of these relationships was statistically significant. Discussion
The present pilot study was designed to investigate the presence of psychiatric problems. This study found an estimated prevalence of mental disorders of 56 per cent among persons claiming physical disability; this is a much higher rate than that estimated for the general adult population. Although it is clear from the literature that we do not know yet how often psychiatric disorder precedes major physical illness or how often it is secondary,6 there is strong evidence that, in order to evaluate self-reported disabilities, one must consider psychological factors, especially the presence of depressive symptoms.7'8 The findings suggest that there are gaps in the disability evaluation system. First, more patients might appropriately and initially seek psychiatric evaluations, rather than, or in addition to, physical disability evaluations. Only two of the 43 subjects in this study had been referred for psychiatric evaluations in addition to their physical evaluation. Second, the relationship between physical and mental problems requires further attention in the disability setting to determine if, as the literature indicates is true in general medicine,9 psychiatric intervention reduces both mental and physical problems, thus enabling the patient to return to a more productive life. As Craig and Van Natta concluded,". . . the impact of AJPH January 1985, Vol. 75, No. 1
PUBLIC HEALTH BRIEFS
REFERENCES
3. Locke BZ, Gardner EA: Psychiatric disorders among the patients of general practitioners and internists. Public Health Rep 1969; 84:167-173. 4. Goldberg D, Huxley P: Mental Illness in the Community: The Pathway to Psychiatric Care. London: Tavistock Publications, 1980. 5. Robins LN, Helzer JE, Croughan J, Ratcliff KS: National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Arch Gen Psychiatry 1981; 38:381-389. 6. Cooper B, Morgan HG: Epidemiological Psychiatry. Springfield, IL: Charles C. Thomas, 1973. 7. Lomas HD, Berman JD: Diagnosing for administrative purposes: the process and problems. Compr Psychiatry 1982; 23:545-551. 8. Bennett AE, Garrad J, Halil T: Chronic disease and disability in the community: a prevalence study. Br Med J 1970; 3:762-764. 9. Jones KR, Vischi TR: Impact of alcohol, drug abuse and mental health treatment on medical care utilization. Med Care 1979; (Suppl) 17. 10. Craig TJ, Van Natta PA: Disability and depressive symptoms in two communities. Am J Psychiatry 1983; 140:598-601.
1. Goldberg ID, Babigian HM, Locke BZ, Rosen BM: Role of nonpsychiatrist physicians in the delivery of mental health services: implications from three studies. Public Health Rep 1978; 92:240. 2. Goldberg DP, Blackwell B: Psychiatric illness in general practice: a detailed study using a new method of case identification. Br Med J 1970; 2:439-443.
This work was supported by a Biomedical Research Support Grant. An earlier version of this study was presented at the 111th annual meeting of the American Public Health Association, Dallas, Texas, 1983.
depression or demoralization, whether primary or secondary, on functional disability in the general population may be considerably greater than is currently appreciated.. . . [and] the identification and treatment of disability-associated depression should be given high priority in public health, industrial health, and vocational rehabilitation programs."'0 This pilot study needs to be replicated in larger populations utilizing examination by experienced psychiatric clinicians. The temporal relationship between physical and psychiatric problems and the effectiveness of psychiatric intervention in returning patients to productive lives require further investigation.
ACKNOWLEDGMENTS
The Teaching of Occupational Health in United States Medical Schools: Five-year Follow-up of an Initial Survey BARRY S. LEVY, MD Abstract: A survey of Ill of the 127 United States medical schools revealed that 73 (66 per cent) specifically taught occupational health during the 1982-83 academic year, compared to 50 per cent in 1977-78. Occupational health was a required part of the curriculum in 54 per cent of the schools compared to 30 per cent in 1977-78. However, the median required curriculum time for occupational health was four hours during both academic years. Increased attention needs to be given to occupational health in medical school curricula. (Am J Public Health 1985; 75:79-80.)
Introduction During the 1977-78 academic year, a survey of United States medical schools indicated that in only 46 (50 per cent) of the 92 responding schools was occupational health specifically taught, and only 28 (30 per cent) required it in their curricula, usually in the preclinical years.' Among these 28 schools, the median required time was four hours. The present survey was conducted in mid-1983 to determine the current status of occupational health teaching in US medical schools.
Address reprint requests to Dr. Barry S. Levy, Director, Occupational Health Service, and Associate Professor of Occupational and Environmental Health, Department of Family and Community Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01605. This paper, submitted to the Journal June 25, 1984, was revised and accepted for publication August 2, 1984. C 1984 American Journal of Public Health 0090-0036/84 $1.50
AJPH January 1985, Vol. 75, No. 1
Methods In April 1983, a questionnaire was sent to chairpersons of Departments of Preventive Medicine and/or Community Health at the 127 US medical schools. Each recipient of the questionnaire was instructed to have it completed by the school faculty member who had the most responsibility for occupational health teaching. The questionnaire was identical to that of the earlier survey' and covered information on faculty members involved in occupational health teaching, occupational health curriculum, and related activities.
Results After mail and telephone follow-up, 111 (87 per cent) of the 127 US medical schools responded to the survey. Seventy-three respondents (66 per cent) stated that occupational health was specifically taught at their schools during the 1982-83 academic year. These 73 schools had specifically taught occupational health for a median of four years, including 1982-83. At 60 schools (54 per cent), occupational health was a required part of the curriculum. The median amount of required curriculum time at these 60 schools was four hours, usually as lectures and/or seminars as part of a preventive medicine or community health course in the preclinical years. Fifty-four (49 per cent) of the 111 responding schools offered an elective course or clerkship or an elective segment of a required course in occupational health. Thirteen of these 54 schools did not have any required curriculum time in occupational health. Elective courses and clerkships were offered more frequently in the clinical than in the preclinical curriculum; respondents often noted that these courses and clerkships were taken by few students. These electives 79
