Showing papers on "Referral published in 1989"

Social competence and behavioral adjustment of children who are long-term survivors of cancer.

Abstract: Relatively little is known about the special needs of long-term survivors of childhood cancer or the factors that make this growing population vulnerable to chronic psychologic disorders. We therefore surveyed 183 children who had been treated for cancer at St Jude Children's Research Hospital and were free of the disease for greater than or equal to 2 years after completing therapy. Parental responses to the Child Behavior Checklist, a standardized inventory of social competence and behavioral problems, were analyzed in relation to demographic and medical variables, as well as the children's appearance and functional status. School-related problems and somatic complaints of undetermined origin were increased fourfold relative to age- and gender-adjusted rates for peer groups in the general population. The presence of functional but not cosmetic impairments increased the risk of academic and adjustment problems. An older age at evaluation, treatment with cranial irradiation, and residence in a single-parent household were also associated with an increased risk of psychologic problems. General pediatricians must eventually assume responsibility for the extended follow-up care of children who have survived a malignancy. Their awareness of the high-risk groups described in this report should facilitate more timely identification of problems and referral of the children to appropriate services.

Teacher Assistance Teams: Five Descriptive Studies on 96 Teams

Abstract: School-based teacher support teams are being established by many educational agencies in an effort to assist teachers in more effectively serving students with learning and behavior problems within the general classroom setting. This article addresses questions most frequently asked by educators who are interested in establishing or strengthening school-based teams. Data are summarized from five studies conducted on 96 teams in seven states with respect to intervention goals of teams, team impact on student performance and the special education referral process, reactions of classroom teachers to teams, factors related to team effectiveness or ineffectiveness, and recommendations for improving team effectiveness.

Increase in hospital admissions for childhood asthma: trends in referral, severity, and readmissions from 1970 to 1985 in a health region of the United Kingdom.

Abstract: Admissions to hospital for childhood asthma have continued to increase, but the reasons are unknown. Because the incidence of acute asthmatic attacks in the community greatly exceeds the admission rate, this increase could be a result of changes in medical practice shifting the balance of care towards the hospital without there being any underlying change in morbidity. In the South West Thames Region (population 2.9 million) over the eight years 1978-85 the number of hospital admissions among those aged 0-4 and 5-14 rose by 186% and 56%. A random sample of case notes from all hospitals in the region was examined for evidence of changes in mode of referral, severity on admission (duration of episode, vital signs on admission), and readmission ratio. The findings indicate that there has been no reduction in severity on admission or increase in readmission rate since 1978. The findings for the 5-14 age group contrast with those from an earlier study (1970-8) in the same region, in which a substantial increase in self referral was observed together with an increase in readmissions and a reduction in the duration of the attack; pulse and respiration rates on admission have, however, remained unchanged over the 16 year period. Overall, these findings indicate that the increase in admissions cannot be satisfactorily explained by changes in medical practice alone and may be due to an increase in the number of asthmatic children experiencing severe attacks. This points to a change in the epidemiology of childhood asthma.

Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism.

Abstract: Although alcoholism is prevalent in both general and inpatient populations, barriers to its timely diagnosis and effective treatment exist. These are often attributed to physicians' inadequate understanding and skill development and negative attitudes toward the disease. All Johns Hopkins' medical students and house staff, during 1986 through 1987, received a self-administered survey of their attitudes, skills, perceived role responsibility, knowledge, and reported practices with regard to alcoholism. Results indicate a strong relationship between perceived role responsibility, confidence in skills, and reported screening and referral practices among students and house staff. Knowledge levels strengthened the association between skills and practices for medical students. House staff perceived less of a responsibility for screening than medical students. There was a trend toward lower confidence and more negative attitudes among house staff than medical students. The results point to areas where educational interventions can be improved to enhance quality of care and outcomes for this major chronic disease. (JAMA. 1989;261:3115-3120)

General practitioners' referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics.

Abstract: There has been much concern about the wide variations in general practitioners9 referral rates and the consequent implications for cost and quality of care. This has led to a call to evaluate the appropriateness and effectiveness of referrals. A collaborative audit of referrals to outpatient clinics was conducted by 127 general practitioners in 33 practices in the Oxford region. Records were kept of 18,754 referrals, which included data on diagnoses and reasons for referral. Overall, 6553 (35.4%) of the referrals were for particular treatments or operations and a further 6475 (34.9%) were for specific investigation or diagnosis. Advice on management was the main reason for referral in 2656 (14.3%) cases, and in 1719 (9.3%) cases the general practitioners wanted the consultants to take over managing their patients. Reassurance of either the general practitioner or the patient was recorded as the main reason in only 762 (4.1%) referrals. There seems to be scope for rationalising the referral process. A programme with three stages for evaluating referrals to outpatient clinics is recommended.

Screening for severe mental disorder in jails: The development of the Referral Decision Scale.

Abstract: Despite the demonstrated prevalence of severe mental disorder among jail detainees and the legal mandate to provide mental health services, most jails do not have the resources to incorporate traditional, time-consuming psychological assessment techniques into their routine intake process. As a result, a number of mentally ill jail detainees remain undetected and untreated. This study outlines the development of the “Referral Decision Scale” (RDS), which detects persons who have a high probability of having a severe mental disorder so that they can be given a complete diagnostic evaluation. The 14-item RDS was statistically derived using discriminant analysis from data collected via the NIMH Diagnostic Interview Schedule on 728 randomly selected male jail detainees and then validated on 1,149 prison inmates. The final validated version of the RDS had an overall sensitivity of 0.791, specificity of 0.987, and positive and negative predictive value of 0.791 and 0.013, respectively. Since these statistics far exceed current detection rates, the RDS is likely to facilitate the diversion of mentally ill detainees in situations where it is impractical to administer psychological examinations to all incoming inmates. Training requirements for the RDS and directions for future research are discussed.

Assessing the effects of clinic-based psychotherapy with children and adolescents.

Abstract: Recent meta-analyses suggest that psychotherapy is quite effective with children and adolescents. However, most research in those analyses involved controlled laboratory interventions that may not represent typical therapy in clinics. We studied more representative treatment as it routinely occurs, in 9 clinics. We compared 93 youngsters who completed a course of therapy with 60 who dropped out after intake. At intake, the groups did not differ on demographic, family, or clinical measures, including Child Behavior Checklist (CBCL) scores. Six months later (when therapy had ended for 98% of the treated children) and again 1 year later, the 2 groups were compared on CBCL scores, parent ratings of each child's major referral problem, and (for a subsample) teacher reports. No comparison showed significant main effects of therapy. The findings (a) raise questions about the generalizability of findings from research-oriented therapy and (b) suggest that the control and precision of research therapy may be needed in clinical practice. How effective is psychotherapy with children and adolescents? Two recent meta-analyses offer quite positive assessments. Casey and Herman (1985) analyzed outcome studies involving children 12 years of age or younger, and Weisz, Weiss, Alicke, and Klotz (1987) analyzed studies with children and adolescents aged 4-18 years. In both analyses, the average treated youngster functioned better after treatment than three fourths of the untreated controls. These positive findings are subject to a potentially important limitation, however: Most of the studies reviewed may have involved conditions and interventions unrepresentative of usual clinical practice. For example, in the large majority of studies in Weisz, Weiss, Alicke, & Klotz (1987), (a) youngsters were recruited for treatment rather than being clinic-referred; (b) samples were selected for homogeneity, with all youngsters displaying a similar problem (e.g., a specific phobia); (c) therapy was focused primarily or exclusively on the focal problem or problems; (d) therapists were specially selected and were trained immediately prior to therapy in the specific techniques they would use; and (e) therapy involved nearly exclusive reliance on those techniques.

Effects of information on recently diagnosed cancer patients' and spouses' satisfaction with care.

Abstract: The effects of an intervention consisting of information, referral, counseling, and follow-up care individualized to patient and spouse needs on satisfaction and coping were determined from data gathered from 30 recently diagnosed male cancer patients and their spouses. A control group of 30 recently diagnosed cancer patients and their spouses received routine information, referral, counseling, and follow-up care. All participants were assessed for their informational needs using the Informational Needs Assessment instrument, and all self-rated their satisfaction with information received using the Satisfaction (SAT) instrument. Couples in the experimental groups received formal individualized intervention as described earlier. Two weeks after the initial testing but before medical intervention, all participants again self-rated their satisfaction using the SAT instrument. The results of a repeated measures analysis of variance test indicated that the experimental groups gained more information and were more satisfied with that information when compared with their counterpart control groups.

Prescription of Psychotropics to Children in Office-Based Practice

Abstract: • Multiple authors have stressed the need for close follow-up and simultaneous psychotherapy in most children treated with psychotropic drugs. However, little is known about the actual prescription of psychotropic medications in pediatric settings. Using the 1985 National Ambulatory Medical Care Survey, we investigated the frequency of follow-up arrangements and concurrent psychotherapy among US children in visits to office-based practices. We then explored determinants of psychotropic drug prescriptions. Mental health indicators, sociodemographic characteristics, provider type, and provider familiarity with the patient were important predictors of psychotropic prescriptions. Few providers report referral or concurrent psychotherapy for their patients receiving psychotropics, and follow-up plans were no different for children with or without psychotropics after controlling for other variables. This means that many children in outpatient care who are taking psychotropic medications may not be receiving optimal management for behavioral or emotional problems. ( AJDC . 1989;143:855-859)

Over- and undercontrolled clinic referral problems of Jamaican and American children and adolescents: the culture general and the culture specific.

Abstract: Child behavior problems and corresponding clinic referral patterns may be significantly influenced by cultural factors. Prevailing values and childrearing practices within a culture may discourage development of some child problems while fostering others. We explored this possibility, focusing on clinic referral problems of two different societies: (a) Jamaica, where the Afro-British culture discourages child aggression and other Undercontrolled behavior and possibly fosters inhibition and other overcontrolled behavior, and (b) the United States, where Undercontrolled child behavior is seemingly more generally accepted. We coded clinic-referred problems listed by parents of Jamaican and American youngsters (N = 720). Cross-cultural differences were striking: Overcontrolled problems were noted more often for Jamaican than American youngsters, whereas the converse was true for Undercontrolled problems. These and other findings suggest that factors such as culture and sex may be linked to substantial differences in the problems for which youngsters of different countries are treated in clinics.

Utilization of formal services for maternal nutrition and health care.

Abstract: Service-related and user-related factors affecting utilization of maternal health care in developing countries are analyzed and recommendations are made for improving utilization and for more appropriate research. Service factors range from physical aspects such as accessibility to user costs and time costs to quality of care such as efficacy of treatment availability of supplies and competence and attitude of personnel. User factors include age parity education information income competing time demands and sociocultural and attitudinal factors. Several issues about existing research were cited e.g. the assumption that acceptable maternal care means 9-12 prenatal visits a hospital delivery and several postnatal visits. Probably a few prenatal visits and home delivery by a trained attendant are sufficient for most women. Generally research indicates that service- related factors are more important than user-related factors in underutilization of maternal health care. The most important of these were physical distance lack of transportation inconvenient hours separate clinics or even administrations for each needed service long waiting times inadequate supplies and provide limitations such as poor technical and interpersonal skills inadequate training poor living conditions all leading to corruption. The main user-relate factor is limited time. It is likely that a strong negative correlation between utilization and age and parity is a reflection of time demands. It is peculiar to maternal health care utilization that women avail themselves of preventive prenatal care to a much greater extent than obstetric services which have more in common with curative care. Barriers to use of childbirth services are the proximity of traditional birth attendants (TBAs) who are female offer emotional support privacy and perform religious rituals. Barriers that particularly need to be overcome are transportation to referral clinics (walking or bumpy ride on bicycle or breasts of burden are formidable for women in labor); female health workers (easier to train TBAs in formal medicine than to indoctrinate formally trained health providers in traditional culture); community education and use of and supply of simple delivery kits; housing and personal and needs of health workers (to improve attitudes and morale); and equipment supplies (to reduce corruption). Future research needs to go beyond correlation analysis of a limited number of factors and look for users perceptions of provider-related factors. Several new methods were suggested: focus groups cognitive ethnographic approach anthropological rapid assessment procedures and random great observation of time allocation. Several research priorities are suggested: including role of husbands and other influentials in decisions on utilization and how innocuous traditional practices can be incorporated into formal maternal care services.

Prevalence, detection and referral of psychiatric morbidity in general medical patients.

Abstract: Twenty seven per cent of medical emergency admissions were found to have diagnosable psychiatric disorders, mostly mild. Although ward staff assessed 31.1% of admissions as having emotional or psychological problems, only a minority had diagnosable psychiatric disorders. Few patients were referred for specialist psychiatric help. This partly reflected the milder nature of problems identified by ward staff, and partly indifference to psychiatry.

The economic impact and multiplier effect of a family practice clinic on an academic medical center.

Abstract: Academic medical centers are facing the need to expand their primary care referral base in an increasingly competitive medical environment. This study describes the medical care provided during a 1-year period to 6304 patients registered with a family practice clinic located in an academic medical center. The relative distribution of primary care, secondary referrals, inpatient admissions, and their associated costs are presented. The multiplier effect of the primary care clinic on the academic medical center was substantial. For every $1 billed for ambulatory primary care, there was $6.40 billed elsewhere in the system. Each full-time equivalent family physician generated a calculated sum of $784 752 in direct, billed charges for the hospital and $241 276 in professional fees for the other specialty consultants. The cost of supporting a primary care clinic is likely to be more than offset by the revenues generated from the use of hospital and referral services by patients who received care in the primary care setting. ( JAMA . 1989;262:370-375)

Detroit's avoidable mortality project: breast cancer control for inner-city women.

Abstract: Mammography remains substantially under-used in low-income minority populations despite its well-established efficacy as a means of breast cancer control. The Metropolitan Detroit Avoidable Mortality Project is a 2-year controlled clinical trial of coordinated interventions which seek to improve the use of early breast cancer detection services at five clinical sites providing primary health care services to inner-city women. Baseline assessment for two of the five participating clinic populations demonstrated that only one-quarter of women who visited these clinics were referred for mammography in 1988, and only half of those who were referred were able to complete the procedure. Patient characteristics including age, marital status, ethnicity, and insurance status were not associated with use of mammography during the baseline period. Each of the project's intervention components is a cue to action: a physician prompt for mammography referral within the medical record of procedure-due women, a reminder postcard for scheduled appointments, and a telephone call to encourage rescheduling of missed appointments. The interventions are initiated by a computerized information management system in the existing network of health care services. The patient's out-of-pocket mammography expense has been eliminated in three of the five sites. Although their efficacy as individual interventions has been well established, a controlled trial of computer prompts to physicians, reduced expense for patients, and patient appointment reminders as an integrated system in inner-city medical care settings has not been previously described. We have implemented the prompting, facilitated rescheduling procedures, and eliminated patient expense for mammography at three of five eventual clinical sites. This report provides an overview of the study's design, data management system, and methodology for evaluation.

Neurology in Gloucestershire: the clinical workload of an English neurologist.

Abstract: Attempts to determine the ideal number of consultant neurologists that will be required in the United Kingdom in the future are hampered by a lack of information on a variety of topics, one of which concerns the workload of the average neurologist at the present time. This paper attempts to correct this deficiency by examining the clinical workload of a single handed neurologist practising in the south west of England. Diagnostic information is given on the 3020 new patients seen during 1984-1986 and is compared with similar data on 836 new patients seen in 1975. The pattern of diagnoses on these patients varies little from year to year, indicating a constancy of referral habit of those who seek neurological advice. However, the referral rates for different conditions do not correspond with what would be expected from epidemiological data, for when the incidence of particular conditions in the neurology clinic is compared with the calculated incidence in the community, very wide variations are noted. The implications of these data are discussed and it is suggested that further studies should be performed before detailed predictions are made on how many neurologists will be needed in this country in the future.

Prospective evaluation of an assessment strategy for geriatric urinary incontinence.

Abstract: The objectives of this study were to design and prospectively evaluate a strategy to assess geriatric urinary incontinence in primary care settings. A management plan for urinary incontinence was determined for 264 elderly incontinent patients (205 females and 59 males) based on a clinical evaluation, simple tests of lower urinary tract function, and several criteria for referral for further evaluation derived from the literature on incontinence. Of the 264 patients, 168 (64%) also consented to undergo a urologic and formal urodynamic evaluation. Half of these 168 patients met at least one criterion for referral for further evaluation. At least one-quarter of the patients who met one or more of the criteria were found not to require surgical intervention, and probably did not benefit from the urologic and urodynamic evaluation. Among 84 patients who did not meet any of the criteria for referral, the urologic and urodynamic evaluation changed the initial treatment plan in only 10 (12%). The risks associated with the treatment plan based on the clinical assessment in these patients were, however, relatively small. While further refinement and testing in larger numbers of incontinent patients are needed, the data presented document that a substantial proportion of elderly patients with a treatable and often ignored problem can be appropriately managed based on a relatively simple and inexpensive assessment, which can easily be carried out in primary care settings.

Preventive care in diabetes mellitus. Current practice in urban health-care system.

Abstract: Early identification and treatment of complications of diabetes mellitus may reduce the severity of the complications. As part of a program to reduce these complications in the Denver Department of Health and Hospitals patient population, our study determined how frequently preventive care, e.g., fundoscopic examinations, referral to an ophthalmologist, foot examinations, and assessment of cardiovascular risk factors, was provided to diabetic patients. With the use of billing records to identify a large sample of diabetic patients, a chart review of 544 patients was conducted. During the study year, the mean +/- SE number of visits to primary-care clinics was 5.7 +/- 0.22, with 86.4% having at least one visit. Most diabetic patients were seen by primary-care physicians; only 9% received care in a specialized diabetes clinic. Despite frequent primary-care visits, most diabetic patients in this county health-care system did not have documentation of care to detect complications of diabetes mellitus, and referral services for detection and treatment of these complications were infrequently used. Moreover, among patients seen on greater than or equal to 10 occasions in a primary-care setting, preventive care was not provided to 30% of the patients. Preventive care does not appear to be a regular part of a primary-care visit for most of the diabetic patients in this study.

Referral to child psychiatry: parent and doctor motives and expectations.

Abstract: We studied general practitioner and parental attitudes towards the referral to child psychiatric clinics of 65 children aged 7–12 yrs. The doctors gave parental request and anxiety and the seriousness of the child's condition as the most common reasons for the referral. Their expectations of it were well in line with current psychiatric practice. There was a wide variety of parental motivations in attending the surgery, and the expectations of the referral were similarly diverse, Most prominent though were help for the child and a need to know underlying reasons. Although three-quarters of parents were satisfied with the general practitioner intervention, the majority said that they had not been given information about die psychiatric assessment process, nor knew what to expect from it, and three-quarters of the children were referred after only one consultation.

Do referral rates vary widely between practices and does supply of services affect demand? A study in Milton Keynes and the Oxford region.

Abstract: Two commonly held beliefs about referral rates were investigated in this study: first that demand for services is determined by supply and secondly that there is wide variation between general practices in their referral rates. All referrals to specialist outpatient clinics were recorded during two 11-week periods by general practitioners in eight practices in the new town of Milton Keynes and in 17 practices elsewhere in the Oxford region. During the first period, only a limited outpatient service was available in the new town; for many specialist services, people had to be referred to hospitals outside the district. Referral rates from Milton Keynes were very similar to those from the rest of the region. By the second period the range of specialist facilities available locally had expanded considerably with the opening of the new district general hospital and during this period there was a statistically significant but rather small increase in referral rates from Milton Keynes. Variation in referral rates between general practices within each geographical group was greater than that between the two groups. Overall, there was about a three-fold variation between general practices in outpatient referral rates which is considerably less than that commonly thought to exist.

Activity and severity of rheumatoid arthritis in Hannover/FRG and in one regional referral center.

Abstract: Between November 1984 and July 1988 a total of 8044 randomly selected German residents of the city of Hannover/FRG, aged 25 to 74, have been screened for rheumatic complaints by means of a postal questionnaire. An average 87% of the probands contacted returned completed questionnaires. Respondents with a “positive” questionnaire, i.e. suggestive of the existence of an inflammatory joint disease were invited for a rheumatological examination at the Hannover Medical School. 72% participated. 45 of a total of 1291 participants were identified as suffering from active or inactive, mostly rheumatoid arthritis.This yields a minimum prevalence of 0.56% (+/-0.19%). The true prevalence is estimated to be 0.91% (99%-confidence interval 0.64-1.18). In 1985 and 1986103 German RA sufferers aged 25 to 74, all citizens of Hannover, were referred to our outpatient rheumatology clinic for a first consultation.A comparison between the two groups revealed a higher disease activity in terms of “objective” criteria (joint swe...

Patients who seek a second opinion: are they different from the typical referral?

Abstract: Little is known about what factors determine when a patient decides to seek a second opinion from an internist. The Canadian health care system, which places no responsibility for payment on the patient, allows a unique opportunity to assess such factors when financial influences are minimized. We hypothesized that in such a milieu patients with functional diseases might be more apt to seek a second opinion. In a university-based gastrointestinal unit we investigated how many of the patients, referred for the first time, were seeking a second opinion—i.e., a second consultation within 2 years of seeing a gastroenterologist. We compared the characteristics of 20 patients with 246 patients referred for the first time to a university-based gastrointestinal unit. All patients were interviewed at clinic registration, prior to seeing the gastroenterologist. Variables assessed included demographic characteristics, health care utilization within the last year, and perceived health status. A second questionnaire was offered to second opinion patients to determine (1) reasons for seeking a second opinion, and (2) whose decision it was to seek the second opinion. Following the interview, the patient's referring physician was contacted and asked identical questions. Both referring physician and gastroenterologist assessed every patient on a functional rating (FR) scale of 1 to 5 (with 1 being definitely organic and 5 being definitely functional). Patients who sought a second opinion were more apt to (a) have symptoms for >2 years (75 versus 41%, p 6 days in hospital in the last year (35 versus 12%, p < 0.01). There were no differences in the FR for either group. Second opinion referrals were generally patient-initiated rather than physician-generated. These patients either (a) believed that the original gastroenterologist had not spent enough time with them or (b) wanted a confirmation of the original diagnosis. There were no significant differences in costs of evaluating either group of patients.

Differences in referral rates from general practice.

Abstract: There are many unexplained differences in the rates at which general practitioners make referrals to other medical specialists. This study investigated 17,586 referrals from 141 general practitioners to specialists in seven specialties in Ringkjobing county in Denmark. As an expression of the referral rate, a referral index was estimated for every general practitioner. The referral index was the number of referrals to the specialist per 1000 patients per year, including children, standardized for age and sex to the average population in Ringkjobing county. The following six variables were evaluated in relation to the referral index: specialists in the local area, doctors per practice, consultations per general practitioner per year, patients registered, consultations per 1000 patients per year standardized for age and sex, and supplementary procedures per consultation. Stepwise multiple regression analysis was used. The study showed that the referral index rose both with a better access to specialist and with an increasing number of consultations per practitioner per year. The referral index fell with increased numbers of patients registered. No correlation was found between the referral index and number of supplementary procedures per consultation, number of doctors per practice and number of consultations per 1000 patients per year.

The spectrum of psychiatric morbidity in a defined geographical area.

Abstract: The concept of 'the pathway to psychiatric care' as described by Goldberg & Huxley (1980) using a scheme of five 'levels' and four 'filters', has provided a useful framework in investigating referral processes in places where health services are organized in a way similar to the British National Health Service. Previous estimates of psychiatric morbidity at each of the levels of this model have been calculated, based upon data obtained from diverse geographical areas and over different time frames. The value of these estimates for service planning is therefore limited by the heterogeneity of the data sources. This paper provides data related to all five levels based upon the same geographical area (South-Verona, Italy) and within the same time frame (one week in 1987). The importance of studying the full spectrum of psychiatric morbidity at all levels in the same area is discussed. In particular, it is shown that the assessment of morbidity in the primary medical care setting (levels 2 and 3) and data about filters 2 and 3 can provide useful information for the evaluation of specialist services (levels 4 and 5) as well as for understanding changes in the provision of specialist care.

Referrals from general practitioners to psychiatrists and paramedical mental health professionals.

Abstract: The literature on referral of patients by GPs to psychiatrists and mental health specialists is examined. Referrals to psychiatrists account for 3% of all those made by GPs, but the individual rates vary widely. The proportion of patients referred to psychiatrists and paramedical mental health workers in general practice is unknown, but probably substantial.

Psychiatric cases: an ethnography of the referral process.

Abstract: Investigation into the referral histories of a consecutive series of new patients attending two psychiatric out-patient clinics questioned the assumption that only the more severe and problematic cases are selected by general practitioners for specialist referral. In 40% of cases, clinical indications only became decisive in relation to emergent difficulties in managing the case, while 38% of patients or their relatives requested referral. The implications of these observations are considered in relation to alternative models of psychiatric intervention in the management of psychosocial disorders in primary care.