Do psychiatry residents document outpatients' alcohol problems?

Abstracts

INTRODUCTION: Consumption of alcohol by psychiatric patients can lead to many negative consequences. The objectives of this study were to identify the problematic use of alcohol in a group of psychiatric outpatients and to verify if this consumption was documented in their medical records by psychiatry medical residents. METHODS: Descriptive and cross-sectional study, carried out at the psychiatric outpatient clinic of a university hospital located in Ribeirão Preto, stat of São Paulo, Brazil. A convenience sample comprising 127 psychiatric outpatients was used. Data were collected using an interview (sociodemographic data and alcohol disorder screening instrument - CAGE) and by means of a review of all the notes written by psychiatry residents on medical charts (questionnaire for collecting data from the records). For data analysis, the CAGE cutoff points > 1 and > 2 were used. RESULTS: At CAGE > 1, 33.9% were CAGE positive (n = 43). Among the individuals with a positive CAGE score, 60.5% (n = 26) had no record of alcohol use on their medical charts (chi-square = 20.12; p < 0.001). At CAGE > 2, 16.5% were CAGE positive (n = 21). In 38.1% (n = 8) of these cases, alcohol use was not documented on their medical charts (chi-square = 29.10; p < 0.001). CONCLUSION: Undernotification of alcohol use was high. Topics related to early identification of and intervention for alcohol use-related problems should be included in the training of psychiatry residents.

Diagnosis; outpatients; psychiatry; alcoholism

INTRODUÇÃO: O consumo de álcool por pacientes que fazem tratamento psiquiátrico pode trazer inúmeras consequências negativas. Os objetivos deste estudo foram identificar o uso problemático de álcool entre pacientes psiquiátricos ambulatoriais e verificar se esse consumo foi documentado nos prontuários por residentes de psiquiatria. MÉTODO: Estudo descritivo, transversal, realizado em serviço ambulatorial de clínica psiquiátrica de hospital universitário localizado em Ribeirão Preto (SP). Foi utilizada uma amostra de conveniência formada por pacientes psiquiátricos ambulatoriais (n = 127). A coleta de dados foi realizada por meio de entrevista (dados sociodemográficos e instrumento de rastreamento de abuso de álcool - CAGE) e pela leitura de todas as anotações feitas por residentes de psiquiatria nos prontuários dos pacientes entrevistados (ficha para coleta de dados do prontuário). Para a análise dos dados, foram utilizados os pontos de corte > 1 e > 2 para o CAGE. RESULTADOS: Com CAGE > 1, 33,9% pontuaram positivo (n = 43) e, entre estes, 60,5% (n = 26) não tinham registros em seus prontuários sobre o uso de álcool (qui-quadrado = 20,12; p < 0,001). Com CAGE > 2, 16,5% pontuaram positivo (n = 21) e, entre estes, 38,1% (n = 8) não tinham registros em seus prontuários referentes ao consumo de bebidas alcoólicas (qui-quadrado = 29,10; p < 0,001). CONCLUSÃO: O número de subnotificações encontrado foi alto. Sugere-se que, no treinamento dos residentes de psiquiatria, sejam incluídos conteúdos relacionados a identificação precoce e intervenções para a prevenção de problemas relacionados ao uso de álcool.

Diagnóstico; pacientes ambulatoriais; psiquiatria; alcoolismo

BRIEF COMMUNICATION

Do psychiatry residents document outpatients' alcohol problems?

Clarissa Mendonça Corradi-Webster^I; Milton Roberto Laprega^II; Erikson Felipe Furtado^III

^IMestre, Psicóloga, Departamento de Enfermagem Psiquiátrica e Ciências Humanas, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP

^IIDoutor, Professor Doutor, Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto (FMRP), USP

^IIIDoutor, Professor Doutor, Departamento de Neurociências e Ciências do Comportamento, FMRP, USP

Correspondence

ABSTRACT

INTRODUCTION: Consumption of alcohol by psychiatric patients can lead to many negative consequences. The objectives of this study were to identify the problematic use of alcohol among a group of psychiatric outpatients and to verify if this consumption was documented in their medical records by psychiatry medical residents.

METHODS: Descriptive and cross-sectional study, carried out at the psychiatric outpatient clinic of a university hospital located in Ribeirão Preto, stat of São Paulo, Brazil. A convenience sample comprising 127 psychiatric outpatients was used. Data were collected using an interview (sociodemographic data and alcohol disorder screening instrument - CAGE) and by means of a review of all the notes written by psychiatry residents on medical charts (questionnaire for collecting data from the records). For data analysis, the CAGE cutoff points > 1 and > 2 were used.

RESULTS: At CAGE > 1, 33.9% were CAGE positive (n = 43). Among the individuals with a positive CAGE score, 60.5% (n = 26) had no record of alcohol use on their medical charts (chi-square = 20.12; p < 0.001). At CAGE > 2, 16.5% were CAGE positive (n = 21). In 38.1% (n = 8) of these cases, alcohol use was not documented on their medical charts (chi-square = 29.10; p < 0.001).

CONCLUSION: Undernotification of alcohol use was high. The number of cases in which alcohol use was not recorded was high. Topics related to early identification of and intervention for alcohol use-related problems should be included in the training of psychiatry residents.

Keywords: Diagnosis, outpatients, psychiatry, alcoholism.

INTRODUCTION

In order to act preventively, early identification of the various patterns of alcohol consumption that can represent risk to individuals is important.¹ In general, health services frequently fail to diagnose a large number of problematic alcohol users, mainly because these persons manifest symptoms or problems that do not seem to be directly related to their drinking habits.

In a Brazilian study, information about alcohol consumption, abuse or dependence from subjects' medical charts from 1982 and 2002 were analyzed to see if any changes concerning the reporting of patients' alcohol consumption took place between these two periods. The authors found underreporting of alcohol use in about 50% of the medical charts, which was consistent in both samples. The findings show that the clinical staff in a large teaching hospital setting was not properly addressing alcoholism. The authors presented two reasons that may be responsible for this finding: 1) proper diagnosis was being made, but not reported on medical charts; 2) no diagnosis was being made.² In another Brazilian study, carried out in 1997, investigating the prevalence of psychiatric problems among first-time patients at a university hospital, alcoholism was diagnosed in 23.2% of the cases, of which only 7.4% had been referred for treatment.³

A further complication is that patients are often seen by health professionals who have difficulty in asking questions about alcohol use and, therefore, in diagnosing alcohol problems. Even with the well studied screening tools available to assist professionals in diagnosing, in a sample of US psychiatrists (the medical specialty that is historically responsible for dealing with alcohol disorders), it was observed that less than 20% reported the use of formal alcohol screening tools.⁴

The importance of early diagnosis and intervention is increased in the case of psychiatric patients due to the facts that alcohol can impair treatment adherence, interact with medication and worsen disease prognosis. Furthermore, according to the World Health Organization (WHO), the probability of dependence on alcohol during the lifetime for an individual with a psychiatric disorder is significantly higher than for the general population, 22 and 14%, respectively.⁵

A study carried out with patients affected by mood disorders using different questionnaires to assess alcohol use disorders found a prevalence ranging from 20 to 30%, depending on the instrument used. The authors concluded that alcohol use disorders and at-risk drinking are frequent in patients affected by mood disorders; however, no diagnosis of alcohol use disorders had previously been registered on their medical records.⁶

Many health professionals mention that they do not examine alcohol use because they do not know how to handle the problem, they lack awareness on the use of rapid screening instruments or they have not reflected upon the influence of problematic alcohol use on patient's health.^1,7 This indicates that the low level of alcohol problem diagnosis may be due to deficiencies in training and professional education. Because of the high incidence of substance use disorders among patients presenting to general psychiatry treatment settings, it is important that all psychiatry residents receive training in the screening, diagnosis, and treatment of outpatients with these problems.⁸

Objective

This brief communication aims to describe the problematic alcohol use among patients at a psychiatric outpatient clinic and to verify the occurrence of alcohol diagnosis notification on their records.

METHODS

This is a cross-sectional study, carried out at the psychiatric outpatient clinic (SACP) of Hospital das Clinicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, Brazil. A convenience sample of an outpatient population was used, selected according to adherence criteria, without a fixed inclusion order regimen and independent of any interference by the assisting professionals. The inclusion criteria were as follows: older than 18 years, attending the SACP after being screened and assessed for International Classification of Disease-10 (ICD-10) diagnoses and after a therapeutic plan was established, able to provide reliable information, and agreement to participate in the study. Patients were excluded if they needed urgent intervention.

The data were collected between January 2000 and April 2004 by research collaborators including medical students and psychologists. All collaborators received training in interview techniques, use of screening instruments and assessment to identify alcohol use disorders using the ICD-10 diagnosis criteria. Supervision of data collection was carried out regularly by the third author. The interviewers attended the SACP during opening times and, at the end of the medical visit, the resident physician explained the objectives of the research to the patients and asked them if they wished to participate. If they agreed, the psychiatry resident would leave the room and invite the collaborators to start data collection. The interviewers read, with the patient, the free and informed consent form, verified that the patient really wished to participate and then started the interview for sociodemographic data collection. After that, the CAGE was administered.

After the interview, the collaborators took the patients' chart and, due to the fact that the medical notes do not follow a standard format, read all the notes taken by the psychiatry residents since the entrance of the patient in the psychiatric clinic, including anamneses, follow-up visit notes, and notes about the case discussions carried out with the residents' supervisors. This study did not aim to evaluate the quality of the notes, but to verify the presence of any notes about alcohol consumption. Thus, if there was any mention of alcohol use, the collaborators would mark "yes" on their research protocol. Collaborators also recorded the diagnosis of the last medical visit included on the patients' charts.

Concerning the analysis of the CAGE data, the use of CAGE to identify problematic use of alcohol in this sample was frequent. The best CAGE values for sensitivity and specificity were found with the cutoff point > 1 (sensitivity = 100%; specificity = 73.7%).⁹ However, the literature suggests the use of CAGE cutoff points > 1 and > 2 for data analysis. In a study carried out with psychiatric patients, the cutoff point of 1 provided better recognition of subjects affected by a current mood disorder with a possible alcohol use disorder. The authors considered that this cutoff value could increase the risk of false-positive cases, so data were also evaluated according to a cutoff point of 2.⁶ Due to these differences, we decided to use both cutoff points, > 1 and > 2. The software Epi-Info for Windows was used for data management and statistical analysis (descriptive and chi-square tests). An alpha of 0.5 and a confidence interval of 95% were assumed.

This project was approved by the Ethics Committee of Faculdade de Medicina de Ribeirão Preto. Interviews were held after the patients had signed the free and informed consent form for volunteer subjects, respecting the ethics criteria of resolution no. 196 from October 10, 1996. After the interview, all participants received guidelines about low-risk drinking and about situations in which they should avoid the consumption of alcoholic beverages.

RESULTS

Sample characteristics

The sample consisted of 127 patients, 69.3% (n = 88) of whom were women. Mean age was 42.9 years (standard deviation, SD = 13.2; min. = 18 and max. = 77 years). Most participants declared themselves white (74.8%; n = 95), and 66 (52.0%) lived without a partner. The majority had up to 8 years of education (57.5%; n = 73). Family income for more than half (57.5%; n = 73) of the interviewees ranged between one and five minimum wages, and the majority of them (61.4%; n = 78) were religiously active. Diagnoses included schizophrenia (26.8%; n = 34), bipolar affective disorder (23.6%; n = 30), depressive episode (25.9%; n = 33), phobic anxiety disorders (2.4%; n = 3), and other anxiety disorders (21.3%; n = 27).

Identification of problematic alcohol use

Adopting a cutoff point of CAGE > 1, we found positive scores for 33.9% (n = 43) of the subjects and negative for 66.1% (n = 84). Regarding identification and notification of problematic alcohol consumption by medical residents, for positive cases, 60.5% (n = 26) had no record of alcohol use on their medical charts and, in the remaining charts, 39.5% (n = 17), alcohol use was mentioned (chi-square = 20.12; p < 0.001).

Adopting a cutoff point of CAGE > 2, we found positive scores for 16.5% (n = 21) of the subjects and negative for 83.5% (n = 106). The records of positive patients did not mention alcohol consumption in 38.1% (n = 8) of the cases, and alcohol use was mentioned in 61.9% (n = 13) (chi-square = 29.10; p < 0.001).

The total sample (n = 127) contained 104 patients for whom there was not any mention of alcohol consumption on their medical records. Twenty-six (25%) of these individuals had positive CAGE scores (considering the results found for the cutoff point > 1).

DISCUSSION

In recent years, the literature has focused on the importance of alcohol use assessment as an opportunity for educational and preventive interventions, to clarify risky drinking and to provide information on how to cut down, preventing possible alcohol use problems.₁

For these reasons, various instruments (e.g., CAGE, AUDIT - Alcohol Use Disorders Identification Test) have been developed to assist identification, characterized by easy and rapid applicability and minimal professional training requirements.¹ Based on the literature, it is possible to verify that quantity-frequency questions, clinical impressions and laboratory data do not perform as well as structured instruments, and, when choosing the screening instrument, its accuracy across the spectrum of alcohol problems needs to be considered.¹⁰

CAGE questions seem better suited to identify patients with alcohol abuse and dependence, while AUDIT is more sensitive for hazardous and harmful drinkers.¹⁰ The literature indicates that, in practice, professionals use CAGE more widely than AUDIT.¹¹ This could be due to the amount of questions each instrument contains (CAGE - four questions; AUDIT - 10 questions), considering professionals often mention lack of time as an explanation for underreporting of problematic alcohol use.¹

Despite the availability of these instruments, in our study, we found that between 38.1% (> 2) and 60.5% (> 1) of positive cases had no data about alcohol use on their records. Identification rates were higher when using a cutoff > 2. This is possibly due to the fact that these patients present more symptoms than others that can be identified by means of the > 1 cutoff point. In an Italian study carried out with patients affected by mood disorders, none of the patients had a diagnosis of alcohol use disorder on their medical records, even those with a current disorder.⁶ These data highlight an important issue: psychiatrists are not recognizing and treating alcohol use disorders.

Apart from lack of time, this deficiency can arise from the fact that health professionals are not sufficiently competent in alcohol issues to counsel their patients. Therefore, there is need of focusing attention on educational issues. The present study used information derived from medical records filled out by psychiatry residents in their first and second years of psychiatry training. Psychiatry residents receive standard theoretical training, as well as comprehensive practical supervision from a senior psychiatrist for each single medical visit, which follows the widely accepted approach for psychiatric assessment.

A Brazilian study suggested that there are insufficient hours in the medical curriculum dedicated to teaching and training for the identification and treatment of alcohol use disorders.² In the UK, it was found that few mental health workers had had enough training and/or clinical experience to prepare them to intervene with dual diagnosis patients.¹² Concerning the benefits of training, a 16-hour training course for primary health care professionals in screening tools and brief interventions for alcohol problems had a significant positive effect on the level of awareness for alcohol problems and on the confidence of the professionals in dealing with these issues.¹³ Similarly, a brief training course carried out in the UK in dual diagnosis interventions showed improvements in knowledge and self-efficacy, detectable 18 months post-training.¹²

In order to better prepare students and physicians to identify, prevent and treat problems related to alcohol use, medical school curriculum and continuing medical education should seriously approach these issues.¹⁴ The Massachusetts General Hospital/McLean Hospital sets an example of a psychiatry residency training program where residents are provided with training in addiction psychiatry at multiple treatment settings as part of their 4-year residency program.⁸

Four possible limitations of this study were identified. The first regards the acceptance to participate in the study. We did not recorded the number of patients that did not agree to participate and we could hypothesize that some people, being aware of the objective of the study, refused to take part in order to avoid undesired questions on their alcohol use. If that was the case, we may have an underestimation of the real number of problematic alcohol users.

The second limitation was that the subjects were patients who had already received a diagnosis and a treatment plan, being followed at the outpatient clinic. If we had selected first-time users of the service, we may have found a higher number of problematic alcohol users, considering that individuals with alcohol problems could have more difficulties in adhering to treatment.

The use of medical record data to obtain information about alcohol use identification could be another limitation, with the possibility that identification and intervention did occur but were not documented. Although this may account for some cases of undernotification, we believe that problematic alcohol use remains undiagnosed in many cases, which is supported by the literature.

The final limitation refers to the use of the CAGE, which identifies alcohol problems over the entire life span. In this study, some patients might have had score positive due to past alcohol use, prior to treatment, and this may account for the absence of notification by the physician. However, even if this was the case, screening and documenting past problematic alcohol use is important, as patients with this history face higher risks of relapse and would still benefit from preventive interventions.

CONCLUSION

This study highlights the issue of underdiagnosing alcohol problems by psychiatry residents. Undernotification may reflect these professionals' tendency to record clinical information considered relevant only for the specific medical visit. We suggest that more emphasis should be given to early identification and intervention of alcohol-related problems in the training of medical psychiatry residents, addressing stigma, attitudes and skill deficiencies. It is also important to emphasize the fact that both psychological and pharmacological treatments can be effective in reducing alcohol consumption.

ACKNOWLEDGEMENT

The authors acknowledge Martin Webster for the English version of this manuscript.

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Publication Dates

• Publication in this collection
  24 May 2010
• Date of issue
  Dec 2009

History

• Received
  13 Apr 2009
• Accepted
  18 June 2009