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TABLE 2.-SCORES FOR CRITERIA OF PSYCHOLOGICAL DISTRESS, FOR THE EXPERIMENTAL GROUPS AND THE

CONTROL GROUP DURING THE YEAR PRIOR TO PSYCHOTHERAPY (1959)

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In order to facilitate comparison of the experimental (psychotherapy) and control (non-psychotherapy) groups, one last criterion for inclusion in the matched group was employed. Each subject in the control group had to be a Health Plan member for the first three consecutive years under investigation inasmuch as the experimental group, though demonstrating attrition in continued membership after that time, remained intact for those years.

Dependent variable.-Each psychiatric patient's utilization of health facilities was investigated first for the full year preceding the day of his initial interview, then for each of the succeeding five years beginning with the day after his initial interview.

The corresponding years were investigated for the control group which, of course, was not seen in the Department of Psychiatry. This investigation consisted of a straightforward tabulation of each contact with any outpatient facility, each laboratory report and x-ray report. In addition a tabulation of number of days of hospitalization was made without regard to the type or quantity of service provided. Each patient's utilization scores consisted of the total number of separate outpatient and inpatient tabulations.

RESULTS

The results of this study are summarized in Table 3. which shows the differences by group in utilization of outpatient medical facilities in the year before and the five years after the initial interview for the psychiatric sample, and the utilization of outpatient medical services for the corresponding six years for the non-psychotherapy sample.

TABLE 3.-UTILIZATION OF OUTPATIENT MEDICAL SERVICES (EXCLUDING PSYCHIATRY) BY PSYCHOTHERAPY

GROUPS FOR THE YEAR BEFORE (1-B) AND THE 5 YR AFTER (1-A, 2-A, 3-A, 4-A, 5-A) THE INITIAL INTERVIEW, AND THE CORRESPONDING YEARS FOR THE NON PSYCHIATRIC GROUP

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The data of Table 3 are summarized as percentage in Table 4, which indicates a decline in outpatient medical (not including psychiatric) utilization for all three psychotherapy groups for the years following the initial interview, while there is a tendency for the non-psychotherapy patients to increase medical utilization during the corresponding years. Applying t-tests of the significance of the standard error of the difference between the means of the "year before" and the means of each of the five "years after" (as compared to the year before), the following results obtain. The declines in outpatient (non-psychiatric) utilization for the “one session only" and the “long-term therapy” groups are not significant for the first year following the initial interview while the declines are significant at either the .05 or .01 levels for the remaining four years. In the “brief therapy" group, there are statistically significant declines in all five of the years following the initial interview. As further indicated in Table 4, there is a tendency for the control group to increase its utilization of medical services, but this proved significant for the "fourth year after” only.

TABLE 4-COMPARISON OF THE YEAR PRIOR TO THE INITIAL INTERVIEW WITH EACH SUCCEEDING YEAR, INDI

CATING PERCENT DECLINE OR PERCENT INCREASE (LATTER SHOWN IN PARENTHESES) IN OUTPATIENT MEDICAL (NONPSYCHIATRIC) UTILIZATION BY PSYCHOTHERAPY GROUPING, AND CORRESPONDING COMPARISONS FOR THE CONTROL GROUP, WITH LEVELS OF SIGNIFICANCE

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Group

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The question was raised as to whether the patients demonstrating declines in medical utilization have done so because they have merely substituted protracted psychotherapy visits for their previous medical visits.

As shown in Table 5, the number of patients in the one-session-only group who return in the third to fifth years for additional visits is negligible. Comparable results are seen in the brief-therapy group. In contrast, the long-term-therapy group reduces its psychiatric utilization by more than half in the "second year after," but maintains this level in the succeeding three years. By adding the outpatient medical visits to the psychiatric visits, it becomes clear that whereas the first two psychotherapy groups have not substituted psychotherapy for medical visits, this does seem to be the case in the long-term psychotherapy group. These results are shown in Table 6, and indicate that the combined outpatient utilization remains about the same from the "year before" to the "fifth year after" for the third psychotherapy group, while declines are evident for the first two psychotherapy groups. As regards the combined (medical plus psychiatric) utilization, the long-term psychotherapy group is not appreciably different from the control (non-psychiatric) group.

TABLE 5.-AVERAGE NUMBER OF PSYCHOTHERAPY SESSIONS PER YEAR FOR 5 YEARS BY EXPERIMENTAL

GROUP

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1.00 6.22 12.33

0

0.02

0.06

1 session only
Brief therapy.
Long-term therapy.

0
0
5. 08

.09
5.56

57 5. 88

12 5.05

TABLE 6.-COMBINED AVERAGES (OUTPATIENT MEDICAL PLUS PSYCHOTHERAPY VISITS) OF UTILIZATION BY YEARS BEFORE AND AFTER PSYCHOTHERAPY FOR THE EXPERIMENTAL GROUPS, AND TOTAL OUTPATIENT UTILIZATION BY CORRESPONDING YEARS FOR THE CONTROL (NONPSYCHIATRIC) GROUP

Group

1-B

1-A

2-A

3-A

4-A

5-A

1 session only -
Brief therapy.
Long-term therapy.
All experimental (psychotherapy) groups.
Control group.

11.4
19.0
11.6
13.5
11.4

11.2 17.7 22.7 15,3 11.5

7.7 8.6 14. 1

9. 2 11.3

6.5 6.4 14.3

8.3 12.4

6.1 7.7 12.4

7.9 14.5

4.5 6.2 10.8

6.2 12,9

Investigation of inpatient utilization reveals a steady decline in utilization in the three psychotherapy groups from the “year before" to the second year after," with the three remaining "years after" maintaining the level of utilization attained in the "second year after.” In contrast, the control sample demonstrated a constant level in number of hospital days throughout the six years studied. These results are shown in Table 7, which indicates that the approximately 60 per cent decline in number of days of hospitalization between the "year before" and the "second year after” for the first two psychotherapy groups is maintained to the "fifth year after"; this decline is significant at the .01 level. The inpatient utilization for the “long-term therapy" group in the "year before" was over twice that of the nonpsychiatric sample, and about three times that of the first two psychotherapy groups. The significant (.01 level) decline of 88 per cent from the "year before" to the "second year after" is maintained through the "fifth year after," rendering the inpatient utilization of the third psychotherapy group comparable to that of the first two psychotherapy groups.

TABLE 1.-NUMBER OF DAYS OF HOSPITALIZATION AND AVERAGES BY PSYCHOTHERAPY GROUP FOR THE YEAR

BEFORE AND THE 5 YR AFTER PSYCHOTHERAPY, AND THE CORRESPONDING PERIOD FOR THE NONPSYCHOTHERAPY GROUP

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In terms of decline in use of inpatient services (days of hospitalization), however, the long-term psychotherapy group and the control group are different, in that the former patients significantly reduce their inpatient utilization from the "year before" to the "fifth year after.” However, the small size of the samples limits the conclusions that can be drawn.

DISCUSSION

The original pilot study of which this project is an outgrowth was proposed by the senior author as an aid in planning for psychiatric care as part of comprehensive prepaid health-plan coverage. It had long been observed that some of this psychiatric clinic's patients, as well as many patients in the hospital for whom a psychiatric consultation was requested, had very thick medical charts. It was also repeatedly noted that when these patients were treated from a psychiatric point of reference, i.e., as a person who might have primarily emotional distress which was expressed in physical symptoms, they often abandoned their physical complaints. It seemed reasonable to expect that for many of these people, psychiatrically-oriented help was a more specific and relevant kind of treatment than the usual medical treatments.

This would be especially true if the effects of psychiatric help were relatively long-lasting, or if a change in the patient affected others in his immediate environment. In the long run, the interruption of the transmission of sick ways of living to succeeding generations would be the most fundamental and efficient kind of preventive medicine. It therefore seemed imperative to test the intuitive impressions that this kind of patient could be treated more effectively by an unstructured psychiatric interview technique than by the more traditional medical routine with its directed history.

The Balints [2, 3] have published many valuable case reports which describe the change in quantity and quality in patients' appeals to the general practioner after the latter learns to listen and understand his patients as people in distress because of current and past life experiences. It would be difficult, however, to design a statistical study of those patients and of a matched control group treated for similar complaints in a more conventional manner.

Psychiatry has been in an ambivalent position in relation to the rest of medicine: welcomed by some, resented by others, often, however, with considerable politeness which serves to cover up deep-seated fears of and prejudices against "something different." In a medical group associated with a prepaid health plan, conditions are favorable for integrating psychiatry into the medical fraternity as a welcomed and amiliar (thereore unthreatening) member specialty. The inherent ease of referral and communication within such a setting would be much further enhanced by the factor of prepayment, which eliminates the financial barrier for all those who can afford health insurance. For many reasons, then, this setting provides both the impetus and the opportunity to attempt an integration of psychiatry into general medical practice and to observe the outcome. In the past two decades, medicine has been changing in many significant ways, among which are prepaid health insurance, group practice, increasing specialization, automation, and a focus on the "whole person" rather than on the "pathology."

Forsham [7] and others have suggested that at some not-too-distant date the patient will go through a highly automated process of history, laboratory pro(edures and physical tests, with the doctor at the end of the line doing a physical examination but occupying mainly the position of a medical psychologist. He will have all the results of the previously completed examinations which he will interpret for the patient, and he will have time for listening to the patient, if he wishes to do so. The "Multiphasic Health Check," [4] which has been used for many years in the Northern California Region in the Kaiser Foundation Medical Clinics and which is constantly being expanded, is just such an automated health survey, and Medical Group doctors are in the process of becoming continually better psychologists. Eventually many more of the patients who are now seen in the psychiatric clinic will be expertly treated in the general medical clinics by more "compleat physicians."

A study such as this raises more questions than it provides answers. One question alluded to above is whether, with an ongoing training program such as Balint has conducted for general practitioners at Tavistock Clinic, internists might not be just as effective as psychiatric personnel in helping a greater percentage of their patients. A training seminar such as this has been conducted by Dr. Edna Fitch in the department of Pediatrics of Permanente Medical Group in San Francisco for many years and has been effective in helping pediatricians to treat, with more insight and comfort, emotional problems of children and their families and physical disorders which are an expression of emotional distress.

l'sing a broader perspective than the focus on the clinical pathology, one can wonder what social, economic or cultural factors are related to choice of symptoms, attitudes toward being "sick” (mentally or physically), attitudes toward and expectations of the doctor, traditions of family illness superstitions relating to bodily damage, child raising practices, etc. How often is the understanding of such factors of crucial importance for effective and efficient treatment for the patient? Of special interest in general medical practice and overlooked almost routinely by physicians (and by many in the psychological field) are the “anniversary reactions” in which symptoms appear at an age at which a relative had similar symptoms and/or died.

Health Plan statistics indicate an increase in medical utilization with increasing age in adults. This is consistent with the relatively flat curve seen in the "medical utilization" of the control sample over the six year period and is in marked contrast to that of the experimental sample. There is the implication in this that some of the increasing symptoms and disability of advancing years are psychogenic and that psychotherapeutic intervention may in some cases function as preventive medical care for the problems associated with aging as well as preventive medicine in children.

A certain percentage of the long-term psychotherapy group seems to continue without diminution of number of visits to the psychiatric clinic; these patients appear from the data to be interminable or life-long psychiatric utilizers just as they had been consistently high utilizers of non-psychiatric medical care before. They seem merely to substitute psychiatric visits for some of their medical clinic visits. A further breakdown of the long-term group into three parts, e.g., less

than 50, 50 to 150, and more than 150 visits, would probably help to sort this population's utilization into several patterns. More precise data on these groups would suggest modifications in classifications and methods of therapy or might suggest alternatives to either traditional medical or traditional psychiatric treatment in favor of some attempt to promote beneficial social changes in the environments of these chronically disturbed people. Sources of criticism

(1) one problem in providing a control group comparable to an experimental group in this kind of study is that, although undoubtedly having emotional distress, and in a similar "quantity" according to our yardstick, the control group did not get to the psychiatric clinic by either self- or physician referral. The fact that the control patients had not sought psychiatric help may reflect a more profound difference between this group and the experimental group than is superficially apparent. One cannot assume that the medical utilization of this control group would change if they were seen in the Psychiatric Clinic. (This objection will be minimized in the “prospective" part of this study, which will be reported in another paper.) Although the average inpatient utilization for the three combined psychotherapy groups is the same as that of the control group in the year before (1959), the inpatient utilization of the long-term psychotherapy group is two and a half times that of the control group. If the study were extended to several years before, rather than just one year, it would become evident whether this was just a year of crisis for the long-term group or whether this had been a longer pattern of high inpatient utilization.

(2) Patients who visit the psychiatric clinic may, for one reason or another, seek medical help from a physician not associated with the Medical Group so that his medical utilization is not recorded in the clinic record, the source of information about utilization. In the long-term-therapy group the therapist is usually aware if his patient is visiting an outside physician, and although it is an almost negligible factor in that group, there can be no information in this regard for the one-session-only and brief-therapy groups without follow-up investigation.

(3) There is no justification in assuming that decreased utilization means better medical care, necessarily. Criteria of improvement would have to be developed and applied to a significantly large sample to try to answer this important question.

(4) Patients may substitute for physical or emotional symptoms behavioral disturbances which do not bring them to a doctor but may be just as distressing to them or to other people.

(5) The "unit" of utilization cannot be used as a guide in estimating costs, standing as it does for such diverse items. In itself the units are not an exact indicator of severity of illness nor of costs. A person with a minor problem may visit the clinic many times, while a much more severely ill person may visit the clinic infrequently. Even more striking is the variation in the cost of a unit, varying from about a dollar for certain laboratory procedures to well over a hundred dollars for certain hospital days (with admissions procedures, laboratory tests, X-rays, consultations, etc.) each worth one "unit.” To arrive at an approximation of costs, the units have to be retabulated in cost-weighted form. Suggested further studies

(1) The question of treatment of patients by non-medical professional clinicians has been argued for more than a half century. It is generally recognized that there are not enough psychiatrists now and that there will not be enough in the foreseeable future to treat all those persons who have disabling emotional disorders. In the late President Kennedy's program for Mental Health this lack was recognized; the recommendation for professional staff for community Mental Health Centers included clinical psychologists, psychiatric social workers and other trained personnel. Having little distinction in our psychiatric clinic between the various disciplines as far as their functions are concerned, it would be feasible and interesting to compare therapeutic results of the disciplines as well as individuals with various types of patients and various types of psychotherapy.

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