Editorials 5

From an epidemiological point of view the lack of reliability in psychiatric diagnoses seriously re- stricts the usefulness of primary health care statis- tics. Work in progress to find new ways of describ- ing the problems of primary health care (5) patients may here contribute to the improvement of both reliability and validity but in the evaluation of this the area of mental problems must be especially observed.

From another aspect, the question marks regard- ing the rationality of the primary health care doc- tors’ handling of mental health problems underlines the need for further studies to try to get a clearer picture of how GPs treat their patients, why they do it in certain ways and what the effects are on the patients’ quality of life and social functioning.

Claes-Goran Westrin Uppsala

REFERENCES 1 . Hoult J, Reynolds I. Psychiatric hospital versus com-

munity treatment. Department of Health, New South Wales State Health Publications No. (HSR) 83-046, 1983.

2. Stein LI, Test MA , eds., Alternatives to mental hospi- tal treatment. New York: Plenum Press, 1978.

3. Bensing J . Watching doctors-using videotape for re- search reasons. Conference Proceedings 10th WONCA World Conference on Family Medicine, Singapore, 1983.

4. Westerling R. Diagnoses at physician visits with pre- scriptions of psycho-pharmaceutical drugs. Uppsala: Uppsala University, Center for Primary Care Re- search, 1984. (In Swedish.)

5. Lamberts H, Meads S, Woods M. Results of the inter- national field trial with the Reason for Encounter Clas- sification (RFEC). The evolution of the International Classification of Primary Care (ICPC). Conference Proceedings WG-6 International Conference on the Role of Informatics in Health Data Coding and Classifi- cation Systems, Ottawa, Canada, September 1984.

Mental Health Problems and Primary Care

In this issue of the Scandinavian Journal of Primary Health Care a study of the prevalence of mental and psycho-social problems as presented in prima- ry health care is described. The study comprised the work at Tierp Health Centre over four weeks, and is presented by Lars Kebbon, Per G. Swartling and Bj@m Smedby.

The study confirms the long known fact that such symptoms and problems are very prevalent in the daily experience of primary care physicians. There seems to be a striking consistency in the rates reported in different studies independent of time or place of study (1, 2, 3, 4).

A great inter-observer variation was found with regard to the recording of mental health problems: from 5 % to 33 % of the encounters. Fourteen gen- eral practitioners and different specialists who were working at the Tierp Health Centre took part in the study. The specialists represented paediatrics, gy- necology, ophthalmology, psychiatry and internal medicine. Qualified general practitioners had the highest recording rates, while the specialists had the lowest. The difference in recording intensity may partly be explained by the differences in age of the patients seen. For example, specialists saw chil-

dren more often (28 %) than general practitioners (10%). However, another explanation could be present. The variation might reflect the individual physicians’ awareness of problems of “the whole person”, mental and psycho-social problems in- cluded, or an orientation directed mainly towards the presented physical problems.

Another remarkable finding was that 17 % of pa- tients with such problems were assessed to be in need of specialist referral. This is a far higher fre- quency than other studies have shown.

This study presented definitions for the different “diagnoses” and its goal was to have a record of what the physicians would have recorded routinely. However, if consistency in a study like this should be the aim, not only definitions, but standardization of recording are a must. That implies training of those recording by using Video-tapes and other training methods. This study included “autonomic and psychosomatic problems”, i.e. “headache, sweating and colitis”. It would have been of inter- est to look into these complaints separately.

Are primary care physicians prepared to meet the challenges of the patients’ mental and psycho-so- cia1 health problems which are infiltrating everyday

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6 Editorials

practice? The education of physicians in “everyday PsYchiam” should be strengthened both at the undergraduate, graduate and postgraduate level. However, these “everyday problems” are often different from those met in patients under psychia- trists’ care.

This study underlines the need for further studies in this area. There are st i l l important features of

been adequately clarified. This applies both to their causal factors, their extent and course and their relationship to other health problems. We are also still searching for the best therapeutic methods. All this implies standardization of research tools, and further development of research methods.

REFERENCES 1. Bremer I. A social psychiatric investigation of a small

community in Northern Norway. Acta Psychiat Scand 1951 SUPPI- 62, 166,

2. Bentsen BG. Illness and general practice. A survey of medical care in an inland population in South-East Norway, 1952-1955. OsbBergen-Troms@: Univeni- ‘tetsforlaget, 1970.

3. Fugelli P. Helsetilstand og helsetjeneste p& V w @ y og

4. Rutle 0. Pasienten 6-am i lyset - analyse av legekon- SIFF‘s gruppe for

mental and psychosocial disorders which have not R@st* Oslo: Universitetsforlaget, 1978.

dter i phierhelsetjeneste. helsetjenesteforsk. ~appor t N 1, 1983.

Bent Guttorm Bentsen Trondheim

Control of Diabetes Mellitus in General Practice

The methods used for the evaluation of the degree of control of diabetes are becoming more and more sophisticated and at the same time easier to use for both the patient and general practice. Up until now the evaluation in diabetic control has been mostly based upon a few urine- and bloodsugar estimations when the patient comes to the doctor’s office or the out-patient clinic. As everyone with knowledge of diabetes knows, both professionals and patients, these results are not very representative of the real degree of control, as most patients will have followed their prescribed regimen much more strictly during the days before the control takes place. This fact has been disregarded by many professionals and patients because it is difficult to prove, and it has made clinical scientific work in diabetes very diffi- cult.

Recently there has been a marked increase in teaching the diabetic to control his own disease, mak- ing the assessment of control and the sharing of re- sponsibility for it much easier. In the work of Agardh and Schersten the clinical evaluation has been sup- plemented by the knowledge of previous blood-sugar levels and the patient’s degree of self-control, thus improving the evaluation.

The newest tool for assessment of diabetic control

is hemoglobin A , , or glycosylated hemoglobin, which allows a reasonably reliable measure of the average blood-sugar level during the 6-8 weeks pre- ceding the test. Any modem laboratory can easily do this test if requested (an Austrian general practitioner has been doing it himself for years in his own labora- tory in his mountain village) and problems with labile fractions of the glycosylated hemoglobin are now behg solved.

Thus the testing of glycosylated hemoglobin has given us the possibility of giving the diabetic good or bad marks, but how should it be used in the control of diabetes? We could use it for reprimanding the pa- tient for not following our advice, by keeping to his diet etc, and when the patient gets complications we can tell him that they are due to poor control. This is easy for us but it does’nt make it easier for the patient, who is being placed in the “naughty child” situation, leaving the professional in the authoritarian role and making teaching and communication very difficult. This does’nt comply with the image of the general practitioner as the patient’s adviser and friend.

We have to see the glycosylated hemoglobin as well as blood-sugars and urine-sugars as the patient’s tools and offering the possibility of obtaining a reliable feed-back from his own efforts to keep his diabetes

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