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Carson et al 1 reported that one third of the patients referred by general practitioners to general neurology outpatient clinics had symptoms that were poorly explained by identifiable organic disease. Similar trends have been reported from a developing country—namely, India. Bagadiaet al,2 for example, have reported that 57% of non-acutely ill patients attending a general hospital medical outpatient department scored high on the general health questionnaire, indicating a likelihood of psychiatric morbidity. The same authors in another study3 have reported that in a general medical outpatient department, 36% of the patients had psychiatric morbidity, of which 24% had pure psychiatric illness and 12% had psychiatric disorders with associated physical illnesses. These figures have an important bearing on the health care delivery system. These patients take up considerable time of a medical specialist for reasons other than those he specialises in and they also account for higher medical expenses.
Other findings of the same study give us important clues for circumventing this problem. For instance, 66% of those patients whose symptoms were not fully explained by “organicity” had diagnosable anxiety and depressive disorders. Referring such patients directly to a psychiatrist would save time of both the consultant neurologists and the patients. One way of doing this would be to “sensitise” the general practitioners about identification of psychiatric problems. An Indian study showed that after a brief period of training in detection of psychiatric morbidity, the sensitivity of rural primary care physicians increased.4
We highlight some of the shortcomings of the report of Carsonet al.1 In a strict sense, the design does not fulfil the requirements for a “prospective cohort study”.5 The follow up assessments were based only on the review of “neurological case notes”, the details of which are not made explicit in the article.
The degree by which patients' symptoms were considered to be medically explained was rated by five neurologists using a four point Likert scale. This measure is central to the study. Development and standardisation of the scale are not mentioned in the report. For assessing the prevalence rates a reliable and valid scale is needed. The authors have attempted to validate the scale by reviewing the “neurological case notes” after 6 months in consultation with the treating consultant when necessary. Whether the authors reviewing the case notes were blind to the first rating is not clear. The lack of blindness can lead to serious biases. Further, provision of the components of the “initial consultation” (whether it was based only on history and physical examination or it included relevant investigation) would have helped in understanding the use of the Likert scale better.
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