Creating a substance abuse network in family medicine: lessons learned.

Family practice was one of several primary care specialties awarded federal contracts in 1985 to survey substance abuse training needs. Family medicine has since excelled in creating a viable substance abuse network. Key events were the sponsorship of a fellowship program, the formation of the Society of Teachers of Family Medicine (STFM) Substance Abuse Working Group, and the working group's pursuit of externally funded projects. Tangible measures of the network's success include collective funding exceeding $7.3 million, an increase in the number of substance abuse activities at annual STFM conferences, and a nearly four-fold growth in the group's membership and collaborative publications. Key factors underlying the vitality of the network that may be generalizable include: 1) initial emphasis on training family physician faculty; 2) making optimal use of the existing administrative channels within STFM; 3) acquisition of external funding; 4) some continuity of core persons working together; 5) active networking within and outside family medicine; and 6) promotion of individual success.

The effect of a telephone family assessment intervention on the functional health of patients with elevated family stress.

A randomized trial of a telephone family assessment intervention was conducted during a 2.5 month period on 224 ambulatory primary care patients, aged 18-49 years, who were selected according to self-report of elevated family stress levels. Family physicians conducted telephone interviews to collect information from patients on their supportive and stressful family members. The working hypothesis was that this process would lead to reduction in the patient's family stress and to improvement in family support and personal health status. Patients reported that the intervention caused them to think about their family support and helped them to feel better. Comparison of family factor and functional health scores before and after intervention also indicated a limited beneficial effect, but only for a small subset of black patients. These results suggest that the telephone family assessment alone is inadequate as an intervention and should be strengthened to include professional assistance to patients for the family problems that are identified by the assessment.

Effects of medical illness and somatic symptoms on treatment of depression in a family medicine residency practice.

The specific aims of this pilot study were to describe the treatment received by depressed patients in a family practice residency setting and to compare treatment modalities and intensity of treatment between patients with and without medical illnesses. A 12-month chart audit of a cohort of 340 patients randomly sampled from a family practice waiting room for a previous study revealed a 1-year period prevalence for diagnosed depression of 10.3% (35 patients). No patient met DSM-III-R criteria for major depressive disorder and yet 57% received tricyclic antidepressant therapy and 60% were eventually referred for specialist mental health care. Tricyclic therapy and follow-up visits for depression were less likely to take place for patients with more severe medical illnesses or high levels of somatic symptoms. These findings suggest that patients in primary care settings may have depressive symptoms severe enough to provoke tricyclic therapy or referral but do not meet current diagnostic criteria. Furthermore, medical illness and somatic symptoms may deleteriously affect treatment in primary care patients. Additional prospective research is needed to determine appropriate criteria for treatment of depressive symptoms in primary care patients and to evaluate the effects of medical illness and somatic symptoms on treatment by primary care physicians.

Associations among family support, family stress, and personal functional health status.

The self-reported family support and stress of 249 ambulatory adult patients, aged 18-49 years, were studied relative to their self-reported functional health. Support from family members was found to be related positively with emotional function. Stress from family members was associated negatively with symptom status, physical function, and emotional function. Patients' severity of illness was related negatively to their symptom status, physical function, and social function, but not to their emotional function. During the study a new self-report instrument, the Duke Social Support and Stress Scale (DUSOCS), was developed to measure family and non-family support and stress. Also, a new chart audit methodology, the Duke Severity of Illness Scale (DUSOI), was designed to assess severity in the ambulatory setting. Reliability and validity of the DUSOCS and the DUSOI were supported. The importance of the patient's perception of health and its family determinants is emphasized.