The Identification of Psychiatric Illness by Primary Care Physicians: The Effect of Patient Gender PAUL D. CLEARY, PhD, BARBARA J. BURNS, PhD, GREGORY R. NYCZ Objective: This study tested several h y p o t h e s e s a b o u t w h y w o m e n a r e m o r e likely t h a n m e n to h a v e p s y c h i a t r i c dis-

o r d e r s n o t e d by their p r i m a r y care p h y s i c i a n s .

Design: P a t i e n t s were screened f o r m e n t a l d i s o r d e r s u s i n g t h e General Health Questionnaire. A stratified sample w a s a s s e s s e d u s i n g the Schedule f o r Affective D i s o r d e r s a n d

Schizophrenia. I n f o r m a t i o n o n u t i l i z a t i o n a n d identification o f m e n t a l health p r o b l e m s w a s abstracted f r o m t h e medical records. Setting: The s t u d y w a s c o n d u c t e d a t a multispeciaity g r o u p p r a c t i c e i n a s e m i r u r a l a r e a o f Wisconsin. Patients: Study p a r t i c i p a n t s consisted o f a stratified p r o b ability sample o f 2 4 7 p a t i e n t s seeking p r i m a r y care. Results: P a t i e n t s with a p s y c h i a t r i c illness w h o w e r e relatively f r e q u e n t users o f the clinic w e r e m o s t likely to be identified by a p h y s i c i a n as h a v i n g a m e n t a l health p r o b lem. When p s y c h i a t r i c illness a n d u t i l i z a t i o n rates were statistically controlled, m e n a n d w o m e n h a d c o m p a r a b l e identification rates. Key words: p s y c h i a t r i c illness; gender, diagnosis; m e n t a l illness. J GEN INTERN MED 1990; 5:355-360.

IN RECENTYEARS, attention increasingly has focused on the role of p r i m a r y care physicians in the recognition and treatment of mental health p r o b l e m s . 1-3 There are several reasons for this attention to the interface bet w e e n p r i m a r y care and mental health services. Many studies, c o n d u c t e d in different settings and using different methodologies, have d e m o n s t r a t e d that a disproportionate n u m b e r of patients receiving general medical care have relatively serious mental health p r o b l e m s , and that patients w i t h mental health p r o b l e m s tend to use medical services frequently. 4-~1 In fact, p r i m a r y health care physicians have b e e n described as comprising a de facto mental health services system. 6 Despite the i m p o r t a n c e of mental health p r o b l e m s in p r i m a r y care settings, the available data indicate that m a n y patients with psychiatric diagnoses are not r e c o g n i z e d as having a mental health p r o b l e m ) , s, 12-14 It is not clear at this p o i n t w h e t h e r t r e a t m e n t or referral b y a p r i m a r y care p r o v i d e r is the most efficient

Received from the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (PDC), Duke University, Durham, North Carolina, (BJB), and Marshfield Medical Foundation, Marshfield, Wisconsin (GRN). Supported in part by a contract (DBE-77-0071) and grant from the National Institute of Mental Health (MH-33940) and a grant from the Robert Wood Johnson Foundation. Address correspondence and reprint requests to Dr. Cleary: Department of Health Care Policy, Harvard Medical School, 25 Shattuck Street, Parcel B, 1st Floor, Boston, MA 02115.

or efficacious w a y of treating patients w i t h mental health p r o b l e m s . Most agree, however, that in order to provide a p p r o p r i a t e care, p r i m a r y care physicians should be aware of w h e t h e r or not a patient is suffering from a mental disorder. Understanding the factors underlying the recognition o f mental health p r o b l e m s is an i m p o r t a n t step in i m p r o v i n g the t r e a t m e n t of patients w i t h such p r o b l e m s . A p r e d i c t o r of physician identification of psychiatric p r o b l e m s is gender; w o m e n are m u c h m o r e likely to be identified as having such p r o b l e m s . 4, 12, ts, 16 There are f e w data on w h e t h e r the higher identification rates for w o m e n reflect m o r e accurate diagnosis or s i m p l y m o r e frequent labeling o f w o m e n ' s p r o b l e m s as psychiatric. We have analyzed physician identification of mental health p r o b l e m s and e x a m i n e d the extents to w h i c h f r e q u e n c y of physician visits, n u m b e r o f selfr e p o r t e d symptoms, and patient gender are related to the accuracy of physician assessments of psychiatric illness.

BACKGROUND C o m p a r e d w i t h men, w o m e n m o r e f r e q u e n t l y report psychiatric symptoms, are m o r e likely to see themselves as having e m o t i o n a l p r o b l e m s , are m o r e likely to seek h e l p from general physicians and psychiatrists, are m o r e likely to receive psychiatric t r e a t m e n t in outpatient clinics, general hospitals, and mental hospitals, and are m o r e likely to receive medications p r e s c r i b e d for the treatment of mental illness. 17, is Some have int e r p r e t e d these various findings as indicating that w o m e n have higher rates of mental disorders than men. An alternative explanation is that, for any particular level of distress or psychiatric illness, w o m e n are m o r e likely to seek professional h e l p for e m o t i o n a l p r o b l e m s and to be r e c o g n i z e d as having p r o b l e m s b y their doctors because they are m o r e likely to make their feelings or p r o b l e m s known. 19 It also m a y b e that physicians have m o r e o p p o r t u n i t y to interact w i t h w o m e n patients and discuss their personal and e m o t i o n a l p r o b l e m s because w o m e n have higher utilization rates than men. 2° Both m e n and w o m e n frequently seek m e d i c a l care for vague and diffuse symptoms. Such c o m p l a i n t s are often not easily described by a specific diagnosis, and they m a y b e labeled p s y c h o g e n i c if the patient visits the doctor frequently. Since w o m e n have higher utilization rates, they m a y be m o r e likely to have such c o m p l a i n t s

355

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PATIENT GENDER AND IDENTIFICATIONOF PSYCHIATRIC ILLNESS

labeled mental health p r o b l e m s . It m a y also be that, for a given level of distress, w o m e n are m o r e likely to be p e r c e i v e d as having mental illness because they are v i e w e d as weaker, m o r e emotional, and less able to deal with stress than men. 2t, 22 In this study w e e x a m i n e d the h y p o t h e s e s that female patients are m o r e likely to b e identified b y primary care providers as having psychiatric disorders because: 1) w o m e n have m o r e psychiatric illness than men, 2) w o m e n are m o r e l i k e l y t o m a k e their p r o b l e m s evident to a physician, 3) w o m e n are m o r e likely to be labeled as having mental health p r o b l e m s because they are high users of medical services, 4) w o m e n have m o r e o p p o r t u n i t y for discussing psychosocial p r o b l e m s w i t h their physicians b e c a u s e they have higher utilization rates than men, and 5) physicians have a stereotype of w o m e n that biases their assessment.

METHODS AND PROCEDURES Setting The study was c o n d u c t e d at a 175-physician multispecialty g r o u p practice located in a semirural area in central Wisconsin. At the time of the study, the t o w n had a p o p u l a t i o n of a p p r o x i m a t e l y 17,000, w i t h a b o u t 5 0 , 0 0 0 persons in the surrounding area. A central clinic p r o v i d e d p r i m a r y health care services for all residents in this i m m e d i a t e area t h r o u g h b o t h a p r e p a i d g r o u p practice plan and a fee-for-service arrangement. The clinic had primary, specialty medical, and mental health care services physically and administratively integrated.

Patients and Methods A total of l, 327 consecutive p r i m a r y care patients, aged 18 years and older, w h o resided in the study area and w h o used the central clinic for p r i m a r y care (family practice, general internal medicine, pediatrics, or immediate care), w e r e contacted and asked to take part in the study. A total of 1,072 patients (81%) agreed to participate and w e r e s c r e e n e d for the p r e s e n c e of a mental disorder using the self-administered, 30-item General Health Questionnaire (GHQ23). The G H Q has b e e n used in several studies of p r i m a r y care populations and has b e e n s h o w n to be predictive of psychiatric disorder. 24 Based on these screening results, a disproportionate stratified r a n d o m s u b s a m p l e of 350 patients was selected. Patients w i t h high G H Q scores w e r e oversamp i e d to increase the n u m b e r of patients w i t h psychiatric disorders in the sample for o t h e r analyses. Seventyone p e r c e n t of these patients, 192 w i t h G H Q scores of 4 or above and 55 w i t h l o w e r scores, c o m p l e t e d a comp r e h e n s i v e psychiatric interview, the Schedule for Affective Disorders and S c h i z o p h r e n i a - L i f e t i m e version

(SADS-L). The SADS-L is a clinical psychiatric interview that systematically evaluates the possibility of specific diagnoses.25, 26 These interviews w e r e c o n d u c t e d b y a psychiatrist and two psychiatric social workers, and the results w e r e not revealed to the p r i m a r y care providers. In psychiatric studies of c o m m u n i t y residents or of a m b u l a t o r y medical patients, it is i m p o r t a n t to identify s y m p t o m s that are related to underlying medical illness. A previous study of the relationship b e t w e e n SADS-L diagnosis and m e d i c a l diagnosis in this population revealed a significant association b e t w e e n psychiatric disorders and genitourinary disorders (for female patients) and gastrointestinal disorders (for male patients).27 The psychiatric e x a m i n e r r e v i e w e d the medical records of all patients for w h o m a mental disorder diagnosis might have b e e n falsely given as a result of an associated physical disorder, but no case of a spurious physical cause of a psychiatric diagnosis was found. Comparisons of participants and non-participants indicated that those w h o refused to c o m p l e t e the G H Q w e r e slightly older, m o r e likely to have had a diagnosis of mental disorder in the p r e c e d i n g year, likely to have had fewer physician visits in the past year, and less likely to be m e m b e r s o f a p r e p a i d plan. Among those c o m p l e t i n g the GHQ, patients w h o did not c o m p l e t e the SADS-L w e r e slightly younger, w e r e less likely to have had a diagnosis of mental disorder in the past year, and had slightly l o w e r G H Q scores than did those w h o did c o m p l e t e the SADS-L. Patients participating in the SADS-L interview w e r e w e i g h t e d by the inverse o f their original probabilities of selection and by n o n r e s p o n s e factors so that the analysis sample had characteristics similar to those o f the 1,072 patients enrolled in the study. Weights also w e r e used to adjust for the fact that because patients w e r e selected during a brief period, the original s a m p l e had a greater p r o p o r t i o n of high users than if the sampling had taken place over an entire year. The data analyzed for this p a p e r consist of a w e i g h t e d s a m p l e of 233 patients" w h o c o m p l e t e d b o t h the G H Q and the SADS-L interview. The w e i g h t e d s a m p l e did not differ f r o m the g r o u p of all eligible patients w i t h respect to age, gender, m e t h o d of payment, p r e v a l e n c e of diagnosed mental disorders, or health care utilization. Utilization rates for the six-month p e r i o d following administration of the G H Q and SADS-L w e r e used as a measure of e x p o s u r e to a physician, because that pe"For ease of comparison, all statistical tests were calculated on tables produced from the weighted data without taking into account the effect of weighting on the distribution of the test statistics. Readers should be aware of this limitation when interpreting significance levels. All analyseswere also done using unweighted data, and none of the substantive conclusions differed. All the physicians in the study saw more than one patient. Patients were sampled consecutively and not by physician, however, so the sample is not a cluster sample. Inferences are made about the experiences of patients, not physician behaviors.

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riod c o r r e s p o n d s to the p e r i o d for w h i c h the m e d i c a l charts w e r e r e v i e w e d for indications o f identification. On the basis of a systematic r e v i e w of all subjects' medical records, a d i c h o t o m o u s variable was c o n s t r u c t e d indicating w h e t h e r there was any indication in the patient's chart of diagnosed psychiatric illness, psychiatric s y m p t o m s (as evaluated b y a board-certified psychiatrist), p s y c h o t r o p i c drug medication, referral to a mental health specialist, or p s y c h o t h e r a p y at any t i m e during this period.

Analyses The identification of psychiatric illness is described by calculating the p r o p o r t i o n s of different subsets of patients for w h o m there was any indication in their medical records of diagnosed psychiatric illness, symptoms, treatment, or referral during the six m o n t h s prior to the index visit. To evaluate the relationship b e t w e e n the factors h y p o t h e s i z e d to influence identification, w e d e v e l o p e d a multivariate logistic model. 28 The i n d e p e n d e n t variables analyzed w e r e patients' SADS-L results (no diagnosis, s o m e diagnosis), G H Q results (score of less than 4, score of 4 or more),~n u m b e r of visits to the clinic in the six m o n t h s following study entry (1, 2, 3 - 4 , 5 + ) , and g e n d e r (male, female).

RESULTS The data on physician identification w e r e consistent w i t h other findings in the literature; w o m e n w e r e m o r e likely than m e n to be r e c o r d e d as having a mental health p r o b l e m . Review of the medical charts indicated that for 22.3% ( 2 8 ) of the w o m e n and 11.9% ( 1 3 ) o f the men, a physician had indicated the existence of s o m e type of mental health p r o b l e m (Table 1). Consistent w i t h o u r first hypothesis, m o r e w o m e n (32.5%) than m e n (21.5%) w e r e judged to be currently psychiatrically ill on the basis of the SADS-L interview. The most prevalent diagnoses (using Research Diagnostic Criteria and the SADS-L evaluation) w e r e major depression (14 patients), p h o b i c disorder (13 patients), intermittent depression (12 patients), labile personality (9 patients), m i n o r depression (12 patients), cyclothymic personality (5 patients), and g e n e r a l i z e d a n x i e t y (4 patients). As e x p e c t e d , the p r e s e n c e of a psychiatric diagnosis was related to its b e i n g identified b y the physician. The relationship b e t w e e n the diagnosis and the identification was weak, however, suggesting that o t h e r factors are i m p o r t a n t in the identification pro~fAlthough responses to the GHQ can be scored to yield a continuous score, it is usually used as a dichotomy. Thus, persons reporting four or more symptoms are classified as having a "positive" score and those reporting fewer than four symptoms are classified as having a "negative" score. We follow that convention in the analyses presented.

357 TABLE 1

Percentagesof Patients Identified by Their Physiciansas Having Mental Health Problemsby Patient Characteristics Identified as Having Mental Health Problem Patient Characteristic

(%)

Results of psychiatric interview No current illness Current illness

14.6 25.5

GHQ score Negative(O- 3) Positive (4+)

15.3 22,1

Number of visits 1 2 3-4 5+

11.0 17.2 12.1 35.3

Gender Male Female

11.9 22.3

cess. Among patients w i t h no psychiatric diagnosis, the p r o p o r t i o n identified as having s u c h a diagnosis was 14.6%, whereas of those w i t h a psychiatric diagnosis, 25.5% w e r e identified as having a p r o b l e m . Also consistent w i t h o u r hypotheses, patients w i t h high G H Q scores w e r e m o r e likely to be identified as having a mental health p r o b l e m . There was a strong relationship b e t w e e n the numb e r of visits in the p r e c e d i n g six m o n t h s and identification of a mental health p r o b l e m , w i t h the rates of identification varying f r o m 11% a m o n g those w i t h only one visit to 35% a m o n g those w i t h five or m o r e visits. To investigate further the relationship b e t w e e n visit rates, diagnosed psychiatric illness, and physician identification of psychiatric illness, w e calculated the probabilities of b e i n g so identified for patients w i t h and w i t h o u t psychiatric illness within each category of visit rate (Table 2). The data in Table 2 indicate that identification rates w e r e positively related to utilization o n l y a m o n g those patients w h o w e r e psychiatrically ill. In general,

TABLE 2

Percentagesof Patients Identified by Their Physiciansas Having Mental Health Problems Number of Visits 1

2

3 or 4

S or More

No psychiatric illness

14% (60)*

18% (55)

9% (31 )

18% (23)

Some psychiatric illness

0% (15)

16% (19)

20% (11)

57% (18)

*Number of patients in parentheses.

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PATIENT GENDER AND IDENTIFICATIONOF PSYCHIATRICILLNESS

TABLE 3 Logit Coefficients for Model of Physician Identification of Mental Health Problems

Significance Independent Variable Constant

Coefficient 1.88

Results of psychiatric interview No current illness Current illness

--0.02 +0.02

GHQ Score Negative ( 0 - 3) Positive (4+)

-0.04 +0.04

Number of visits 1 2 3-4

5+

(p)

0.36

related to identification rates (p = 0.06). The unadjusted identification rates for m e n and w o m e n w e r e 11.9% and 22.3%, respectively (Table 1). W h e n the m o d e l presented in Table 3 was re-estimated w i t h o u t the t e r m relating gender to identification, the predicted rates for m e n and w o m e n w e r e similar (17.0% and 18.3%). That small difference in identification rates may have b e e n d u e to a n u m b e r o f u n m e a s u r e d factors in addition to bias.

0.92

DISCUSSION 0.03

--1.25 0.21 --0.10 1.14

Illness- visit interaction III X 1 visit 111X 2 visits II1X 3 - 4 visits III X 5 + visits

--1.20 --0.21 0.14 0.99

0.01

Gender Male Female

--0,43 0.43

0.06

these data s u p p o r t the differential-exposure hypothesis and not the labeling hypothesis. If the labeling hypothesis had b e e n correct, there w o u l d have b e e n a relationship b e t w e e n utilization and identification even a m o n g patients w h o w e r e not psychiatrically ill, w h i c h was not the case. The multivariate m o d e l that was d e v e l o p e d to test m o r e rigorously the study hypotheses i n c l u d e d gender, the p r e s e n c e or absence of SADS-L-defined psychiatric illness, w h e t h e r the patient had a high or a l o w G H Q score, utilization in the previous six months, and the interaction b e t w e e n psychiatric illness and utilization as i n d e p e n d e n t variables. That m o d e l fit the data w e l l (likelihood-ratio chi-square ----24.27; degrees of f r e e d o m = 22; p = 0 . 3 3 3 ) . The coefficients for the relationships b e t w e e n the i n d e p e n d e n t variables and identification are p r e s e n t e d in Table 3. In the multivariate model, the strongest p r e d i c t o r of identification of mental health p r o b l e m s was the interaction b e t w e e n visit rate and psychiatric illness, providing s u p p o r t for the hypothesis that identification rates are related to the p r e s e n c e of psychiatric illness, especially a m o n g patients w i t h m o r e visits. Controlling for that relationship, G H Q scores have almost no relationship to identification w h e n o t h e r predictors are controlled. Thus, the hypothesis that w o m e n are m o r e likely to express their p r o b l e m s and that this t e n d e n c y helps a c c o u n t for the gender difference in physicianidentified mental illness was not supported. Controlling for psychiatric illness, utilization rates, and G H Q scores, gender was not significantly

The results of this study indicate that patients w i t h psychiatric illnesses w h o have high utilization rates are most likely to be identified b y their p r i m a r y care physicians as having psychiatric illnesses. Controlling for other predictors, self-reported p r o b l e m s , as m e a s u r e d by the GHQ, are not statistically significant predictors of such physician identification. A possible explanation for the absence of a relationship b e t w e e n G H Q scales and identification w h e n other variables w e r e c o n t r o l l e d is that the effects of G H Q scores are m e d i a t e d by utilization patterns; patients with negative G H Q scores had an average of 3.93 visits, w h i l e those w i t h positive scores had an average of 4.54 visits. Another explanation for the lack of a relationship is that the G H Q score m a y b e a p o o r p r o x y for p r o p e n s i t y to express p r o b l e m s and is strongly related to psychiatric illness. However, the zero-order association b e t w e e n G H Q scores and identification w a s not statistically significant (p----0.28). Further w o r k w i t h better measures of p r o p e n s i t y to express p r o b l e m s is n e e d e d to test m o r e rigorously the relationship bet w e e n t h e t e n d e n c y to express e m o t i o n a l p r o b l e m s and physician identification of such p r o b l e m s . It frequently has b e e n argued that physicians are " b i a s e d " b y a patient's gender, but these data do not s u p p o r t that hypothesis. W o m e n m a y have a t e n d e n c y to be expressive in the physician's p r e s e n c e that is not reflected b y G H Q scores. However, the failure of various investigations to explain gender differences on the basis of response tendencies leads us to d o u b t this explanation. 17 It is also possible that the p r e p o n d e r a n c e of w o m e n a m o n g clinic users and the t e n d e n c y for distressed p e r s o n s to use clinic facilities m o r e frequently might lead physicians to misjudge the probability, in general, of w o m e n ' s having mental health p r o b l e m s . Stereotypes affect p e r c e p t i o n , m e m o r y , and behavior.22, 29 It is not clear h o w stereotypes affect the perceptions and responses of physicians to patients, but this is an i m p o r t a n t area for further investigation. The fact that w o m e n use medical facilities m o r e frequently than do m e n appears to result in s o m e w h a t m o r e accurate recognition of psychiatric p r o b l e m s . For example, if SADS-L results are used as the criteria, the accuracy ( p r o p o r t i o n of correct positives and correct

JOURNALOFGENERALINTERNALMEDICINE.Volume 5 (July~August), 1990

n e g a t i v e s ) f o r w o m e n is 3 5.7%, w h e r e a s f o r m e n it is 26.2%. H o w e v e r , r e c o g n i t i o n rates f o r b o t h m e n a n d women are low, and women have higher false-positive rates ( 1 9 . 0 % ) t h a n d o m e n ( 1 0 . 7 % ) . The overall low rate of recognition of psychiatric d i s o r d e r s is n o t e w o r t h y . O t h e r s t u d i e s h a v e f o u n d t h a t primary care providers correctly recognized between a b o u t a t h i r d a n d a h a l f o f d e p r e s s e d p a t i e n t s , t3, t4, 30, 3t w i t h o n e s t u d y f i n d i n g a r e c o g n i t i o n r a t e as h i g h as 73%. 32 T h e l o w e r i d e n t i f i c a t i o n rates in o u r s t u d y m a y b e d u e to a n u m b e r o f factors, b u t o n e p r o b a b l e e x p l a n a t i o n is t h a t m e d i c a l r e c o r d s d o n o t f u l l y r e f l e c t p r i mary care providers' knowledge about the psychiatric status of patients. Physicians may not record psychiatric diagnoses because they are not thought to be relevant for t h e m e d i c a l m a n a g e m e n t o f t h e p a t i e n t o r b e c a u s e of the sensitive nature of psychiatric diagnoses. This m a y b e e s p e c i a l l y t r u e s i n c e m a n y o f t h e d i s o r d e r s in p r i m a r y c a r e s e t t i n g s a r e s o m a t o f o r m d i s o r d e r s t h a t freq u e n t l y a r e n o t e a s i l y d e s c r i b e d . W e a t t e m p t e d t o add r e s s t h i s p r o b l e m b y d e f i n i n g i d e n t i f i c a t i o n as a n y mention of psychiatric symptoms, psychotropic drug prescriptions, psychotherapy, referral to a mental h e a l t h p r o f e s s i o n a l , o r a p s y c h i a t r i c d i a g n o s i s . Nevert h e l e s s , it m a y b e t h a t t h e s e m a r k e r s d o n o t f u l l y c a p ture physicians' recognition and response to psychiatr i c illness. The results presented here are important because t h e y r e p r e s e n t o n e o f t h e f e w s i t u a t i o n s in w h i c h it h a s b e e n p o s s i b l e t o c o n t r o l c a r e f u l l y f o r p s y c h i a t r i c illness a n d t o e x a m i n e t h e i n d e p e n d e n t effects o f p s y c h i a t r i c illness, s e l f - r e p o r t e d p r o b l e m s , u t i l i z a t i o n patterns, a n d p a t i e n t g e n d e r o n p h y s i c i a n r e c o g n i t i o n o f p s y c h i a t r i c illness. T h e m e a s u r e o f i d e n t i f i c a t i o n u s e d may underrepresent physician "recognition," but t h e s e d a t a p r o v i d e u s e f u l i n s i g h t s i n t o t h e f a c t o r s related to the identification process. It is c l e a r t h a t p h y s i c i a n s a r e r e s p o n d i n g t o s o m e thing other than strictly defined "psychiatric illness." T h e r e l a t i v e l y l o w r e c o g n i t i o n r a t e s f o r t h o s e w i t h psychiatric illness and the relatively high identification rates for those without psychiatric illness indicate that physicians probably respond to a variety of factors, s u c h as d e c r e a s e d s o c i a l f~anctioning a n d p a t i e n t dysp h o r i a , t h a t a r e n o t n e c e s s a r i l y d i r e c t l y r e l a t e d t o psyc h i a t r i c illness. Physician responses to patients depend on a complicated and involved series of perceptions and judgments based on clinical experience and the characteristics of a particular patient. Awareness of these influences and how they operate would be useful in s e n s i t i z i n g p h y s i c i a n s a n d p a t i e n t s to t h e i r i m p o r t a n c e and perhaps improving the quality of the physicianpatient interaction and subsequent outcome. Possible clinical consequences of the physician identification p a t t e r n s in t h e s e d a t a a r e t h a t s o m e w o m e n w i t h o u t

359

psychiatric problems may be receiving inappropriate a t t e n t i o n , w h i l e m e n w i t h p s y c h i a t r i c p r o b l e m s a r e less likely to receive needed psychological attention from their primary care physicians. Perhaps the most import a n t f i n d i n g is t h e s t r e n g t h o f t h e r e l a t i o n s h i p b e t w e e n t h e r e c o g n i t i o n o f p s y c h i a t r i c p r o b l e m s a n d v i s i t frequency. Unfortunately, the data are not detailed e n o u g h to d e t e r m i n e t h e c a u s a l o r d e r i n g o f r e c o g n i t i o n a n d u t i l i z a t i o n . T h e y s u g g e s t , h o w e v e r , t h a t efforts t o i m p r o v e p h y s i c i a n r e c o g n i t i o n s h o u l d f o c u s o n t h e inf r e q u e n t u s e r s o f c a r e as w e l l as o n t h e " o v e r - u s e r s . " Darrell A. Regier, Irving D. Goldberg, Edwin W. Hoeper, and Larry G. Kessler played central roles in the design and conduct of the study described. The authors thank AHan Horwitz and Ron Kessler for helpful comments on an earlier draft.

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