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Under-diagnosis of alcohol-related problems and depression in a family practice in Japan

Under-diagnosis of alcohol-related problems and depression in a family practice in Japan Aim: The aim of this survey was to assess the accuracy of a family physician's diagnosis of depression and alcoholism. Methods: Consecutive new adult patients attending a family practice in Japan between April 2004 and August 2006 were enrolled. Excluded were those with dementia or visual disturbance, and emergency cases. Participants completed a questionnaire regarding their complaints and socio- demographics. A research nurse conducted the Japanese version of the Mini-International Neuropsychiatric Interview (J-MINI) in the interview room. The doctor independently performed usual practice and recorded his own clinical diagnoses. A researcher listed the clinical diagnoses and complaints, including J-MINI or clinically-diagnosed alcoholism and depression, using the International Classifications for Primary Care, Second Edition (ICPC-2) and calculated kappa statistics between the J-MINI and clinical diagnoses. Results: Of the 120 adult first-visit patients attending the clinics, 112 patients consented to participate in the survey and were enrolled. Fifty-one subjects were male and 61 female, and the average age was 40.7 ± 13.2 years. Eight alcohol-related disorders and five major depressions were diagnosed using the J-MINI, whereas no cases of alcoholism and eight depressions were diagnosed by the physician. Clinically overlooked patients tended to have acute illnesses like a common cold. Concordance between the clinical and research diagnosis was achieved only for three episodes of Major depression, resulting in a kappa statistic of 0.43. Conclusion: Although almost half of the major depressions were identified, all alcoholism was missed. A mental health screening instrument might be beneficial in family practice, especially to detect alcoholism. considerable potential as a site for prevention of and Background Alcohol-related problems and depression are highly prev- interventions for alcoholism [2]. Screening and interven- alent in general practice [1]. More than half of all persons tions for alcoholism in primary care has been demon- with alcohol-related problems obtain all of their care strated to reduce drinking [3]. from their general practitioner. Hence, primary care has a Page 1 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 However, depression and alcoholism often are under- to August 2006. The survey was conducted over a total of diagnosed and untreated in family practice. For example, 25 days within the study period. family physicians in Australia failed to identify 65% of CAGE-defined alcohol abuse [CAGE: an acronym of key Subjects words found in the following screening questions for All consecutive new adult patients attending the above- alcoholism: "Have you felt that you need to cut down on noted research clinics for the first time were enrolled in your drinking?" "Have people annoyed you by criticizing the study. To be eligible, a patient had to be 18 or more your drinking?" "Have you ever felt bad or guilty about years old and had to provide informed consent. Patients your drinking?" "Have you ever had a morning eye- were excluded if they had a high fever (≥ 38.0°C), or any opener?" [4]]. Physicians in the United States (US) condition requiring emergency management, such as detected only 49% of the current alcohol problems diag- impaired consciousness, extensive drug reactions or deep nosed using the Diagnostic Interview Schedule (DIS) [5]. burns. Otherwise eligible subjects also were excluded if An international multi-centre study conducted by the they were unable to complete the questionnaire for any World Health Organization (WHO) revealed that physi- reason (e.g., patients with language barriers, dementia or cians recognize just 42% of all cases of Major Depression visual disturbance). diagnosed by means of the Composite International Diag- nostic Interview (CIDI) [6]. These studies examined the Measurements percentage of simple agreement between physicians' diag- The survey was conducted in the following order. First, nosis and diagnostic tools, or assessed characteristics that each new adult patient was asked to complete a written influence the detection of mental illnesses. However, few questionnaire in the waiting room. This questionnaire studies have evaluated patient complaints and doctors' included questions on socio-demographics, in addition to diagnoses as potential causes of diagnostic errors pertain- the following question: "What is your problem? Please ing to mental health. write the reason for your visit." Second, the Japanese ver- sion of the Mini-International Neuropsychiatric Interview Consequently, the aims of this survey were: 1) to evaluate (J-MINI) was conducted by a research nurse in the inter- the accuracy of a family physician's diagnosis of depres- view room. Third, the doctor performed his usual clinical sion and alcoholism using a validated screening instru- practice and recorded his own clinical diagnosis on the ment; and 2) to assess patient complaints and physician face sheet of each patient's registration form. Note that the diagnoses that result in alcoholism and depression being research interview conducted by the research nurse and overlooked in family practice. the clinical evaluation performed by the physician were carried out independently. Finally, the reason for visit and the clinical diagnosis were classified according to the Methods Research settings International Classifications for Primary Care, Second In Japan, almost everyone is covered by national health Edition (ICPC-2) by an investigator independent of the insurance and pay 30 percent of medical fee. Patients gen- attending physician and research nurse. The degree of erally have the freedom to choose the health care provider agreement between the results of the research interview that they feel best fits their needs without concerns regard- and the clinical evaluation were estimated, in terms of the ing costs. diagnoses of Major Depressive Episode and Alcoholism, using kappa statistics, calculated using SPSS, version The survey was conducted of a single family practice. The 11.0J. physician had 22 years of clinical experience and had been well-trained in the diagnosis and treatment of depression. Diagnostic tools The clinic was a solo practice under private management, The MINI is an abbreviated, structured, diagnostic inter- located in Matsudo City, a suburb of Tokyo, Japan. The view that requires an administration time of 10–20 min- number of patients seen daily in the clinic generally utes. It is designed to allow non-specialists who have ranged between 80 and 110 (average number 95). received formal training to screen for certain psychiatric Approximately 10 percent of the patients seen were there diagnoses. It conforms both to the International Classifica- for their first visit, and 45 percent of the patients were tion of Mental and Behavioral Disorders, Tenth Revision (ICD- adults. Research clinics were pre-arranged, so that a 10) and the Diagnostic and Statistical Manual of Mental Dis- research nurse was available to perform structured inter- orders, Fourth Edition (DSM-IV), and has been validated views. Research clinics were set for every second and relative to the Structured Clinical Interview for DSM-III-R fourth Saturday from April to September 2004, every sec- (SCID) and the Composite International Diagnostic Interview ond Saturday from November 2004 to March 2005, and (CIDI) [7]. The Japanese version of the MINI (J-MINI) every second Tuesday and Saturday from September 2005 also has been validated [8]. Prior to starting this survey, research nurses received practical training in the use of an Page 2 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 instruction videotape, dealing with the use of the MINI, a either had an acute illness, like a common cold, or had training process which was comparable to the standard attended the clinic for the sole purpose of a check-up. training packet used in the study validating the J-MINI. Concordance between the MINI and physician diagnosis The ICPC-2 is problem-oriented disease classification sys- was limited to three patients with major depression. Table tem developed by the World Organization of Family Doc- 4 is a cross table for major depression, comparing the tors (WONCA). It has compatibility with the ICD-10, and MINI and family physician's diagnoses. The estimated health care providers can classify, using a single classifica- kappa statistic for major depression was 0.43. tion, three important elements of the health care encoun- ter: the reasons for the encounter, the diagnoses or Discussion problems, and the process of care [9]. In this survey of a single family physician's practice, the kappa statistic, which measured the degree of agreement between the family physician and the J-MINI for major Results Of the 120 consecutive patients who fulfilled the inclu- depression, was 0.43. Compared to the diagnostic accu- sion criteria during the observation period, 8 patients racy by psychiatrists reported in J-MINI validation study were excluded (5 refused, and 3 due to high fever) and by Otsubo and colleague [8], the family doctor in this sur- 112 patients (93.3% of all eligible) were enrolled. Among vey had an acceptable level of diagnostic accuracy for the 112, 51 (45.5%) were male and 61 were female, and major depression. Otsubo and colleagues reported that the average age was 40.7 ± 13.2 years. Descriptive charac- the kappa statistic estimating agreement between expert teristics of the subjects are shown in Table 1. psychiatrists' diagnoses using diagnostic criteria and the J- MINI is 0.36 for major depression and 0.26 for alcohol- Eight alcohol-related disorders and five Major Depressive ism [8]. Spitzer and Fleiss used the kappa statistic to meas- Episodes were diagnosed by research nurses using the J- ure inter-observer agreement between psychiatrists before MINI, while no alcoholism and eight depressive episodes the era of research diagnostic criteria, and estimated a were diagnosed by the doctor. Table 2 is a list of the com- kappa of 0.41 for affective disorder (including neurotic or plaints and clinical diagnoses among the patients with manic-depression) and 0.71 for alcoholism [10]. Even MINI-diagnosed alcohol-related disorders. Table 3 is a list using the Structured Clinical Interview for DSM-III-R of the MINI or clinically-diagnosed major depressive epi- (SCID), kappa statistics estimated between mental health sodes, and of patient complaints. Almost all patients professionals were 0.42 for current major depression, and whose depression or alcoholism was clinically overlooked 0.76 for alcoholism, when they were used in general pop- ulation [11]. For the Primary Care Evaluation of Mental Disorders (PRIME-MD), kappa statistics were 0.61 for Table 1: Descriptive characteristics of patients (n = 112) major depression and 0.71 for alcoholism between pri- mary care physicians and mental health professionals Characteristics No (%) [12]. Age, mean years (SD) 40.7 (13.2) Sex Because it corrects for chance agreement, the kappa statis- Male 51 (45.5) tic definitely is useful for calculating inter-observer con- Female 61 (54.5) cordance. A limitation, however, is that it depends upon Marital status disease prevalence or base rate. Consequently, estimates Single 22 (19.6) tend to be low when prevalence is low (especially below Married or Common-law 79 (70.5) 10%), even if a high level agreement of agreement is Divorced 6 (5.4) Widowed 4 (3.6) observed [13-15]. Among the 112 patients screened in Unknown 1 (0.9) this survey, the rates of major depression and alcoholism Occupational status were 4.5% and 7.1%, respectively. Both major depression Unemployed 29 (25.9) and alcoholism have a reported prevalence of 3.7% Part-time job 13 (11.6) among new adult patients in Japanese family practice, Full-time job 65 (58.0) when the J-MINI is used [16]. Using the Diagnostic Inter- In school 3 (2.7) view Schedule (DIS), the prevalence among first-visit Unknown 2 (1.8) Educational level adult patients seen in general medicine outpatient clinics Junior high school graduate 8 (7.1) in Japan is reported to be 4.7% for major depression and High school graduate 28 (25.0) 9.4% for alcoholism [17]. Among outpatients in hospital- College graduate 36 (32.1) based general practice in the US, the prevalence of major University graduate or higher 39 (34.8) depression ranged from 7 to 19%, and of alcoholism from Unknown 1 (0.9) 3 to 7% [12]. The prevalence has been shown to vary Page 3 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 Table 2: Clinical diagnoses and patient complaints among MINI-diagnosed alcohol-related disorders Age and sex MINI diagnoses Clinical diagnoses (ICPC2) Patient complaints (ICPC2) 40 years, male Current alcoholism Upper respiratory infection (R74) counseling with a preventive purpose(A98) and cough(R05) 39 years, male Current alcoholism Streptococcal pharyngitis(R72) Cough(R05) 48 years, male Current alcoholism Upper respiratory infection (R74) Common cold(R74) and cough(R05) 36 years, female Current alcoholism and Obsessive- Upper respiratory infection (R74) and Common cold(R74) Compulsive disorder migraine(N89) 28 years, male Current alcoholism and Hypomanic Upper respiratory infection (R74) Cough(R05) and runny nose(R07) episode 46 years, male Current alcohol abuse Hypertension(K86) Fear of hypertension(K25) 29 years, male Current alcohol abuse Acute bronchitis(R78) Cough(R05) 41 years, male Current alcohol abuse Upper respiratory infection (R74) and Sputum(R25) depression(P76) ICPC2; International Classifications for Primary Care, Second Edition MINI: Mini-International Neuropsychiatric Interview dependent upon the diagnostic tools and the settings in clinical skills, but also the patients' expectations and the which surveys are conducted. constraints of the health care system [2]. In fact, even the MINI, which is the shortest structured psychiatric inter- The doctor in this survey, despite exhibiting an acceptable view available, may be impractical in a busy clinical prac- level of diagnostic accuracy for major depression, relative tice. Mental health screening may be required in primary to experts, nonetheless missed all cases of alcoholism. care settings. Interestingly, almost every patient for whom a MINI-diag- nosed mental health disorder was missed by the doctor Our study does have several limitations. First, our results had some acute illness, like a common cold or asthma. were obtained from a single clinical practice and the sam- Because the reason for their visit was specific to physical ple size was small. These two limitations restrict both the symptoms, mental health problems might have been generalizability of our results and the confidence we can overlooked, except for the structured screening instru- place upon them. Second, the physician who served as the ment. In typical medical practice, physicians often are not attending in this study has extensive experience detecting very successful diagnosing and treating alcohol-related depression in a primary care setting, and was a member of problems or mental illnesses, likely due not only to their the research team, which may have led to a higher detec- Table 3: MINI or clinically-diagnosed depression and patient complaints Age and sex MINI diagnoses Clinical diagnoses (ICPC2) Patient complaints (ICPC2) 62 years, female Major depressive episode Glossitis (D83) and upper respiratory Common cold (R74) infection (R74) 27 years, female Major depressive episode Upper respiratory infection (R74) Common cold (R74) 25 years, female* Major depressive episode and Depression (P76) and gastritis Epigastria (D02) Agoraphobia (D87) 35 years, female* Major depressive episode Depression (P76) dehydration Dizziness (N17), headache (N01) (T11) and dizziness (N17) and loss of appetite (T03) 31 years, male* Major depressive episode Depression (P76), anxiety Fainting (A06), thirst (T01) and neurosis (P74) and fainting (A06) loose bowel movements(D11) 63 years, male Agoraphobia Depression (P76) Fatigue (A04) 31 years, male Hypomanic episode, Obsessive- Depression (P76), dehydration (T11) Vomiting (D10), loss of appetite (T03) Compulsive disorder and Agoraphobia and vomiting (D10) and feeling depressed (P03) 47 years, male Depression (P76) and tension headache Cough (R05), nausea (D09), headache (N95) (N01) 24 years, female Depression (P76) and upper Feeling ill (A05) and common cold (R74) respiratory infection (R74) 41 years, male Current alcohol abuse Depression (P76) and upper Sputum(R25) respiratory infection (R74) * Concordance between research and clinical diagnosis ICPC2; International Classifications for Primary Care, Second Edition MINI: Mini-International Neuropsychiatric Interview Page 4 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 Table 4: Cross table of major depression between MINI and family physician (FP) diagnosis Major depressive episode (MINI) Positive (%) (N = 5) Negative (%) (N = 107) Major depression (FP) Positive (N = 8) 3 (60.0) 5 (4.7) Negative (N = 104) 2 (40.0) 102 (95.3) FP; family physician, MINI; Mini-International Neuropsychiatric Interview 3. Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH: Address- tion rate of depression than in most clinical practices. ing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and Third, convenience, rather than random, sampling was intervention in primary care (SIP) study. Ann Intern Med 2003, used for a variety of practical reasons, including the lack 138(5):372-82. 4. Rydon P, Redman S, Sanson-Fisher RW, Reid AL: Detection of alco- of research funding and our reluctance to over-burden hol-related problems in general practice. J Stud Alcohol 1992, staff. Further research is warranted using validated Japa- 53(3):197-202. nese version self-report diagnostic tools, and a larger and 5. Buchsbaum DG, Buchanan RG, Poses RM, Schnoll SH, Lawton MJ: Physician detection of drinking problems in patients attend- more representative sample. ing a general medicine practice. J Gen Intern Med 1992, 7(5):517-21. 6. Simon GE, Goldberg D, Tiemens BG, Ustun TB: Outcomes of rec- Conclusion ognized and unrecognized depression in an international pri- In this survey, even though almost half of major depres- mary care study. Gen Hosp Psychiatry 1999, 21(2):97-105. sive episodes were identified, a rate that is acceptable rel- 7. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.: The Mini-International Neuropsychiatric Interview ative to previously-reported experts, all cases of (M.I.N.I.): the development and validation of a structured alcoholism were missed. Because a detailed psychiatric diagnostic psychiatric interview for DSM-IV and ICD-10. J interview might be impractical in a busy clinical practice, Clin Psychiatry 1998, 59(Suppl 20):22-33. quiz 34–57. 8. Otsubo T, Tanaka K, Koda R, Shinoda J, Sano N, Tanaka S, et al.: Reli- a mental health screening instrument might be beneficial ability and validity of Japanese version of the Mini-Interna- in primary care settings, especially for alcohol-related tional Neuropsychiatric Interview. Psychiatry Clin Neurosci 2005, 59(5):517-26. problems 9. Classification Committee of WONCA: ICPC-2 International Classification of Primary Care. Oxford: Oxford University Competing interests Press; 1998. 10. Spitzer RL, Fleiss JL: A re-analysis of the reliability of psychiatric The authors declare that they have no competing interests. diagnosis. Br J Psychiatry 1974, 125(0):341-7. 11. Williams JB, Gibbon M, First MB, Spitzer RL, Davies M, Borus J, et al.: The Structured Clinical Interview for DSM-III-R (SCID). II. Authors' contributions Multisite test-retest reliability. Arch Gen Psychiatry 1992, KY participated in the study's design, conducted classifica- 49(8):630-6. tions using the ICPC-2 and all statistical analysis, and 12. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, et al.: Utility of a new procedure for diagnosing mental dis- drafted the manuscript. KY and TM performed data collec- orders in primary care. The PRIME-MD 1000 study. Jama tion and processing. KW participated in study design, 1994, 272(22):1749-56. especially with respect to ethical issues, and offered the 13. Feinstein AR, Cicchetti DV: High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990, research setting. TS and TM participated in study design 43(6):543-9. and coordination and helped to draft the manuscript. All 14. Cicchetti DV, Feinstein AR: High agreement but low kappa: II. authors read and approved the final manuscript. Resolving the paradoxes. J Clin Epidemiol 1990, 43(6):551-8. 15. Spitznagel EL, Helzer JE: A proposed solution to the base rate problem in the kappa statistic. Arch Gen Psychiatry 1985, Ethics approval 42(7):725-8. 16. Yamada K, Maeno T, Ono M, Sato T, Otsubo T, Isse K: Depression The Institutional Review Board of the Japanese Associa- in a family practice in Japan: doctor shopping and patient tion of Family Medicine approved this research. complaints. Primary Care and Community Psychiatry 2005, 10(1):7-11. 17. Sato T, Takeichi M: Lifetime prevalence of specific psychiatric Acknowledgements disorders in a general medicine clinic. Gen Hosp Psychiatry 1993, We would like to express our deepest gratitude to Ms. Noriko Oshiyama 15(4):224-33. (Research Nurse, Sonoda Daiichi hospital). References 1. Sullivan LE, Fiellin DA, O'Connor PG: The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med 2005, 118(4):330-41. 2. Kamerow DB, Pincus HA, Macdonald DI: Alcohol abuse, other drug abuse, and mental disorders in medical practice. Prev- alence, costs, recognition, and treatment. Jama 1986, 255(15):2054-7. Page 5 of 5 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Under-diagnosis of alcohol-related problems and depression in a family practice in Japan

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Springer Journals
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Copyright © 2008 by Yamada et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-7-3
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18973707
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Abstract

Aim: The aim of this survey was to assess the accuracy of a family physician's diagnosis of depression and alcoholism. Methods: Consecutive new adult patients attending a family practice in Japan between April 2004 and August 2006 were enrolled. Excluded were those with dementia or visual disturbance, and emergency cases. Participants completed a questionnaire regarding their complaints and socio- demographics. A research nurse conducted the Japanese version of the Mini-International Neuropsychiatric Interview (J-MINI) in the interview room. The doctor independently performed usual practice and recorded his own clinical diagnoses. A researcher listed the clinical diagnoses and complaints, including J-MINI or clinically-diagnosed alcoholism and depression, using the International Classifications for Primary Care, Second Edition (ICPC-2) and calculated kappa statistics between the J-MINI and clinical diagnoses. Results: Of the 120 adult first-visit patients attending the clinics, 112 patients consented to participate in the survey and were enrolled. Fifty-one subjects were male and 61 female, and the average age was 40.7 ± 13.2 years. Eight alcohol-related disorders and five major depressions were diagnosed using the J-MINI, whereas no cases of alcoholism and eight depressions were diagnosed by the physician. Clinically overlooked patients tended to have acute illnesses like a common cold. Concordance between the clinical and research diagnosis was achieved only for three episodes of Major depression, resulting in a kappa statistic of 0.43. Conclusion: Although almost half of the major depressions were identified, all alcoholism was missed. A mental health screening instrument might be beneficial in family practice, especially to detect alcoholism. considerable potential as a site for prevention of and Background Alcohol-related problems and depression are highly prev- interventions for alcoholism [2]. Screening and interven- alent in general practice [1]. More than half of all persons tions for alcoholism in primary care has been demon- with alcohol-related problems obtain all of their care strated to reduce drinking [3]. from their general practitioner. Hence, primary care has a Page 1 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 However, depression and alcoholism often are under- to August 2006. The survey was conducted over a total of diagnosed and untreated in family practice. For example, 25 days within the study period. family physicians in Australia failed to identify 65% of CAGE-defined alcohol abuse [CAGE: an acronym of key Subjects words found in the following screening questions for All consecutive new adult patients attending the above- alcoholism: "Have you felt that you need to cut down on noted research clinics for the first time were enrolled in your drinking?" "Have people annoyed you by criticizing the study. To be eligible, a patient had to be 18 or more your drinking?" "Have you ever felt bad or guilty about years old and had to provide informed consent. Patients your drinking?" "Have you ever had a morning eye- were excluded if they had a high fever (≥ 38.0°C), or any opener?" [4]]. Physicians in the United States (US) condition requiring emergency management, such as detected only 49% of the current alcohol problems diag- impaired consciousness, extensive drug reactions or deep nosed using the Diagnostic Interview Schedule (DIS) [5]. burns. Otherwise eligible subjects also were excluded if An international multi-centre study conducted by the they were unable to complete the questionnaire for any World Health Organization (WHO) revealed that physi- reason (e.g., patients with language barriers, dementia or cians recognize just 42% of all cases of Major Depression visual disturbance). diagnosed by means of the Composite International Diag- nostic Interview (CIDI) [6]. These studies examined the Measurements percentage of simple agreement between physicians' diag- The survey was conducted in the following order. First, nosis and diagnostic tools, or assessed characteristics that each new adult patient was asked to complete a written influence the detection of mental illnesses. However, few questionnaire in the waiting room. This questionnaire studies have evaluated patient complaints and doctors' included questions on socio-demographics, in addition to diagnoses as potential causes of diagnostic errors pertain- the following question: "What is your problem? Please ing to mental health. write the reason for your visit." Second, the Japanese ver- sion of the Mini-International Neuropsychiatric Interview Consequently, the aims of this survey were: 1) to evaluate (J-MINI) was conducted by a research nurse in the inter- the accuracy of a family physician's diagnosis of depres- view room. Third, the doctor performed his usual clinical sion and alcoholism using a validated screening instru- practice and recorded his own clinical diagnosis on the ment; and 2) to assess patient complaints and physician face sheet of each patient's registration form. Note that the diagnoses that result in alcoholism and depression being research interview conducted by the research nurse and overlooked in family practice. the clinical evaluation performed by the physician were carried out independently. Finally, the reason for visit and the clinical diagnosis were classified according to the Methods Research settings International Classifications for Primary Care, Second In Japan, almost everyone is covered by national health Edition (ICPC-2) by an investigator independent of the insurance and pay 30 percent of medical fee. Patients gen- attending physician and research nurse. The degree of erally have the freedom to choose the health care provider agreement between the results of the research interview that they feel best fits their needs without concerns regard- and the clinical evaluation were estimated, in terms of the ing costs. diagnoses of Major Depressive Episode and Alcoholism, using kappa statistics, calculated using SPSS, version The survey was conducted of a single family practice. The 11.0J. physician had 22 years of clinical experience and had been well-trained in the diagnosis and treatment of depression. Diagnostic tools The clinic was a solo practice under private management, The MINI is an abbreviated, structured, diagnostic inter- located in Matsudo City, a suburb of Tokyo, Japan. The view that requires an administration time of 10–20 min- number of patients seen daily in the clinic generally utes. It is designed to allow non-specialists who have ranged between 80 and 110 (average number 95). received formal training to screen for certain psychiatric Approximately 10 percent of the patients seen were there diagnoses. It conforms both to the International Classifica- for their first visit, and 45 percent of the patients were tion of Mental and Behavioral Disorders, Tenth Revision (ICD- adults. Research clinics were pre-arranged, so that a 10) and the Diagnostic and Statistical Manual of Mental Dis- research nurse was available to perform structured inter- orders, Fourth Edition (DSM-IV), and has been validated views. Research clinics were set for every second and relative to the Structured Clinical Interview for DSM-III-R fourth Saturday from April to September 2004, every sec- (SCID) and the Composite International Diagnostic Interview ond Saturday from November 2004 to March 2005, and (CIDI) [7]. The Japanese version of the MINI (J-MINI) every second Tuesday and Saturday from September 2005 also has been validated [8]. Prior to starting this survey, research nurses received practical training in the use of an Page 2 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 instruction videotape, dealing with the use of the MINI, a either had an acute illness, like a common cold, or had training process which was comparable to the standard attended the clinic for the sole purpose of a check-up. training packet used in the study validating the J-MINI. Concordance between the MINI and physician diagnosis The ICPC-2 is problem-oriented disease classification sys- was limited to three patients with major depression. Table tem developed by the World Organization of Family Doc- 4 is a cross table for major depression, comparing the tors (WONCA). It has compatibility with the ICD-10, and MINI and family physician's diagnoses. The estimated health care providers can classify, using a single classifica- kappa statistic for major depression was 0.43. tion, three important elements of the health care encoun- ter: the reasons for the encounter, the diagnoses or Discussion problems, and the process of care [9]. In this survey of a single family physician's practice, the kappa statistic, which measured the degree of agreement between the family physician and the J-MINI for major Results Of the 120 consecutive patients who fulfilled the inclu- depression, was 0.43. Compared to the diagnostic accu- sion criteria during the observation period, 8 patients racy by psychiatrists reported in J-MINI validation study were excluded (5 refused, and 3 due to high fever) and by Otsubo and colleague [8], the family doctor in this sur- 112 patients (93.3% of all eligible) were enrolled. Among vey had an acceptable level of diagnostic accuracy for the 112, 51 (45.5%) were male and 61 were female, and major depression. Otsubo and colleagues reported that the average age was 40.7 ± 13.2 years. Descriptive charac- the kappa statistic estimating agreement between expert teristics of the subjects are shown in Table 1. psychiatrists' diagnoses using diagnostic criteria and the J- MINI is 0.36 for major depression and 0.26 for alcohol- Eight alcohol-related disorders and five Major Depressive ism [8]. Spitzer and Fleiss used the kappa statistic to meas- Episodes were diagnosed by research nurses using the J- ure inter-observer agreement between psychiatrists before MINI, while no alcoholism and eight depressive episodes the era of research diagnostic criteria, and estimated a were diagnosed by the doctor. Table 2 is a list of the com- kappa of 0.41 for affective disorder (including neurotic or plaints and clinical diagnoses among the patients with manic-depression) and 0.71 for alcoholism [10]. Even MINI-diagnosed alcohol-related disorders. Table 3 is a list using the Structured Clinical Interview for DSM-III-R of the MINI or clinically-diagnosed major depressive epi- (SCID), kappa statistics estimated between mental health sodes, and of patient complaints. Almost all patients professionals were 0.42 for current major depression, and whose depression or alcoholism was clinically overlooked 0.76 for alcoholism, when they were used in general pop- ulation [11]. For the Primary Care Evaluation of Mental Disorders (PRIME-MD), kappa statistics were 0.61 for Table 1: Descriptive characteristics of patients (n = 112) major depression and 0.71 for alcoholism between pri- mary care physicians and mental health professionals Characteristics No (%) [12]. Age, mean years (SD) 40.7 (13.2) Sex Because it corrects for chance agreement, the kappa statis- Male 51 (45.5) tic definitely is useful for calculating inter-observer con- Female 61 (54.5) cordance. A limitation, however, is that it depends upon Marital status disease prevalence or base rate. Consequently, estimates Single 22 (19.6) tend to be low when prevalence is low (especially below Married or Common-law 79 (70.5) 10%), even if a high level agreement of agreement is Divorced 6 (5.4) Widowed 4 (3.6) observed [13-15]. Among the 112 patients screened in Unknown 1 (0.9) this survey, the rates of major depression and alcoholism Occupational status were 4.5% and 7.1%, respectively. Both major depression Unemployed 29 (25.9) and alcoholism have a reported prevalence of 3.7% Part-time job 13 (11.6) among new adult patients in Japanese family practice, Full-time job 65 (58.0) when the J-MINI is used [16]. Using the Diagnostic Inter- In school 3 (2.7) view Schedule (DIS), the prevalence among first-visit Unknown 2 (1.8) Educational level adult patients seen in general medicine outpatient clinics Junior high school graduate 8 (7.1) in Japan is reported to be 4.7% for major depression and High school graduate 28 (25.0) 9.4% for alcoholism [17]. Among outpatients in hospital- College graduate 36 (32.1) based general practice in the US, the prevalence of major University graduate or higher 39 (34.8) depression ranged from 7 to 19%, and of alcoholism from Unknown 1 (0.9) 3 to 7% [12]. The prevalence has been shown to vary Page 3 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 Table 2: Clinical diagnoses and patient complaints among MINI-diagnosed alcohol-related disorders Age and sex MINI diagnoses Clinical diagnoses (ICPC2) Patient complaints (ICPC2) 40 years, male Current alcoholism Upper respiratory infection (R74) counseling with a preventive purpose(A98) and cough(R05) 39 years, male Current alcoholism Streptococcal pharyngitis(R72) Cough(R05) 48 years, male Current alcoholism Upper respiratory infection (R74) Common cold(R74) and cough(R05) 36 years, female Current alcoholism and Obsessive- Upper respiratory infection (R74) and Common cold(R74) Compulsive disorder migraine(N89) 28 years, male Current alcoholism and Hypomanic Upper respiratory infection (R74) Cough(R05) and runny nose(R07) episode 46 years, male Current alcohol abuse Hypertension(K86) Fear of hypertension(K25) 29 years, male Current alcohol abuse Acute bronchitis(R78) Cough(R05) 41 years, male Current alcohol abuse Upper respiratory infection (R74) and Sputum(R25) depression(P76) ICPC2; International Classifications for Primary Care, Second Edition MINI: Mini-International Neuropsychiatric Interview dependent upon the diagnostic tools and the settings in clinical skills, but also the patients' expectations and the which surveys are conducted. constraints of the health care system [2]. In fact, even the MINI, which is the shortest structured psychiatric inter- The doctor in this survey, despite exhibiting an acceptable view available, may be impractical in a busy clinical prac- level of diagnostic accuracy for major depression, relative tice. Mental health screening may be required in primary to experts, nonetheless missed all cases of alcoholism. care settings. Interestingly, almost every patient for whom a MINI-diag- nosed mental health disorder was missed by the doctor Our study does have several limitations. First, our results had some acute illness, like a common cold or asthma. were obtained from a single clinical practice and the sam- Because the reason for their visit was specific to physical ple size was small. These two limitations restrict both the symptoms, mental health problems might have been generalizability of our results and the confidence we can overlooked, except for the structured screening instru- place upon them. Second, the physician who served as the ment. In typical medical practice, physicians often are not attending in this study has extensive experience detecting very successful diagnosing and treating alcohol-related depression in a primary care setting, and was a member of problems or mental illnesses, likely due not only to their the research team, which may have led to a higher detec- Table 3: MINI or clinically-diagnosed depression and patient complaints Age and sex MINI diagnoses Clinical diagnoses (ICPC2) Patient complaints (ICPC2) 62 years, female Major depressive episode Glossitis (D83) and upper respiratory Common cold (R74) infection (R74) 27 years, female Major depressive episode Upper respiratory infection (R74) Common cold (R74) 25 years, female* Major depressive episode and Depression (P76) and gastritis Epigastria (D02) Agoraphobia (D87) 35 years, female* Major depressive episode Depression (P76) dehydration Dizziness (N17), headache (N01) (T11) and dizziness (N17) and loss of appetite (T03) 31 years, male* Major depressive episode Depression (P76), anxiety Fainting (A06), thirst (T01) and neurosis (P74) and fainting (A06) loose bowel movements(D11) 63 years, male Agoraphobia Depression (P76) Fatigue (A04) 31 years, male Hypomanic episode, Obsessive- Depression (P76), dehydration (T11) Vomiting (D10), loss of appetite (T03) Compulsive disorder and Agoraphobia and vomiting (D10) and feeling depressed (P03) 47 years, male Depression (P76) and tension headache Cough (R05), nausea (D09), headache (N95) (N01) 24 years, female Depression (P76) and upper Feeling ill (A05) and common cold (R74) respiratory infection (R74) 41 years, male Current alcohol abuse Depression (P76) and upper Sputum(R25) respiratory infection (R74) * Concordance between research and clinical diagnosis ICPC2; International Classifications for Primary Care, Second Edition MINI: Mini-International Neuropsychiatric Interview Page 4 of 5 (page number not for citation purposes) Asia Pacific Family Medicine 2008, 7:3 http://www.apfmj.com/content/7/1/3 Table 4: Cross table of major depression between MINI and family physician (FP) diagnosis Major depressive episode (MINI) Positive (%) (N = 5) Negative (%) (N = 107) Major depression (FP) Positive (N = 8) 3 (60.0) 5 (4.7) Negative (N = 104) 2 (40.0) 102 (95.3) FP; family physician, MINI; Mini-International Neuropsychiatric Interview 3. Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH: Address- tion rate of depression than in most clinical practices. ing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and Third, convenience, rather than random, sampling was intervention in primary care (SIP) study. Ann Intern Med 2003, used for a variety of practical reasons, including the lack 138(5):372-82. 4. Rydon P, Redman S, Sanson-Fisher RW, Reid AL: Detection of alco- of research funding and our reluctance to over-burden hol-related problems in general practice. J Stud Alcohol 1992, staff. Further research is warranted using validated Japa- 53(3):197-202. nese version self-report diagnostic tools, and a larger and 5. Buchsbaum DG, Buchanan RG, Poses RM, Schnoll SH, Lawton MJ: Physician detection of drinking problems in patients attend- more representative sample. ing a general medicine practice. J Gen Intern Med 1992, 7(5):517-21. 6. Simon GE, Goldberg D, Tiemens BG, Ustun TB: Outcomes of rec- Conclusion ognized and unrecognized depression in an international pri- In this survey, even though almost half of major depres- mary care study. Gen Hosp Psychiatry 1999, 21(2):97-105. sive episodes were identified, a rate that is acceptable rel- 7. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.: The Mini-International Neuropsychiatric Interview ative to previously-reported experts, all cases of (M.I.N.I.): the development and validation of a structured alcoholism were missed. Because a detailed psychiatric diagnostic psychiatric interview for DSM-IV and ICD-10. J interview might be impractical in a busy clinical practice, Clin Psychiatry 1998, 59(Suppl 20):22-33. quiz 34–57. 8. Otsubo T, Tanaka K, Koda R, Shinoda J, Sano N, Tanaka S, et al.: Reli- a mental health screening instrument might be beneficial ability and validity of Japanese version of the Mini-Interna- in primary care settings, especially for alcohol-related tional Neuropsychiatric Interview. Psychiatry Clin Neurosci 2005, 59(5):517-26. problems 9. Classification Committee of WONCA: ICPC-2 International Classification of Primary Care. Oxford: Oxford University Competing interests Press; 1998. 10. Spitzer RL, Fleiss JL: A re-analysis of the reliability of psychiatric The authors declare that they have no competing interests. diagnosis. Br J Psychiatry 1974, 125(0):341-7. 11. Williams JB, Gibbon M, First MB, Spitzer RL, Davies M, Borus J, et al.: The Structured Clinical Interview for DSM-III-R (SCID). II. Authors' contributions Multisite test-retest reliability. Arch Gen Psychiatry 1992, KY participated in the study's design, conducted classifica- 49(8):630-6. tions using the ICPC-2 and all statistical analysis, and 12. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, et al.: Utility of a new procedure for diagnosing mental dis- drafted the manuscript. KY and TM performed data collec- orders in primary care. The PRIME-MD 1000 study. Jama tion and processing. KW participated in study design, 1994, 272(22):1749-56. especially with respect to ethical issues, and offered the 13. Feinstein AR, Cicchetti DV: High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990, research setting. TS and TM participated in study design 43(6):543-9. and coordination and helped to draft the manuscript. All 14. Cicchetti DV, Feinstein AR: High agreement but low kappa: II. authors read and approved the final manuscript. Resolving the paradoxes. J Clin Epidemiol 1990, 43(6):551-8. 15. Spitznagel EL, Helzer JE: A proposed solution to the base rate problem in the kappa statistic. Arch Gen Psychiatry 1985, Ethics approval 42(7):725-8. 16. Yamada K, Maeno T, Ono M, Sato T, Otsubo T, Isse K: Depression The Institutional Review Board of the Japanese Associa- in a family practice in Japan: doctor shopping and patient tion of Family Medicine approved this research. complaints. Primary Care and Community Psychiatry 2005, 10(1):7-11. 17. Sato T, Takeichi M: Lifetime prevalence of specific psychiatric Acknowledgements disorders in a general medicine clinic. Gen Hosp Psychiatry 1993, We would like to express our deepest gratitude to Ms. Noriko Oshiyama 15(4):224-33. (Research Nurse, Sonoda Daiichi hospital). References 1. Sullivan LE, Fiellin DA, O'Connor PG: The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med 2005, 118(4):330-41. 2. Kamerow DB, Pincus HA, Macdonald DI: Alcohol abuse, other drug abuse, and mental disorders in medical practice. Prev- alence, costs, recognition, and treatment. Jama 1986, 255(15):2054-7. Page 5 of 5 (page number not for citation purposes)

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Asia Pacific Family MedicineSpringer Journals

Published: Sep 29, 2008

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