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Response to Violence, Mental Health, and Substance Abuse in Patients Who Are Seen in Primary Care Settings
The article by Wyshak and Modest1 suggested that an 18-item, self-administered questionnaire can provide useful information to primary care providers about violence and its relationship to health. This survey contains too many confounders to be of practical value. First, the population group is too small and not homogeneous enough to benefit any one group of people. Second, the benefits that primary care physicians should obtain from administering the 18-item survey are not clearly stated. Third, this study takes advantage of statistics to promote conclusions based on too little data.
In this study, the population group consisted of only 136 nonhomogeneous participants. Fourteen were African American, 48 were white, 61 were Hispanic or Portuguese, and 13 were of an unknown racial background. The confounders associated with this group included a mixture of socioeconomic backgrounds, and data from these groups were collected from 2 different sites. Subsequently, these data were summarized and treated as one homogeneous population, and commentary statements were made that the data demonstrated few sex differences. References to published works were not given to support this conclusion, and no comments were made in reference to the few men in this study. Without clarification of these obvious problems, no conclusions should be made about sex differences in this study.
The issue of race, and how it affected the results of this study, was inadequately planned for and addressed. The authors stated that ethnic differences were observed among women and that white women compared with nonwhite women seemed to be more affected by being the victims of violence during childhood. No comments were made about the possible causes of violence and its relationship to mental health and substance abuse among the nonwhite racial groups in the study. The nonwhite racial groups made up most of the study participants, and the results are given as though the nonwhite group is a homogeneous group of participants. Any conclusion made about the white or the nonwhite group has the potential for being misleading and potentially harmful to patients.
The use of this 18-item survey to evaluate violence, mental health, and substance abuse in patients seen in primary care settings is limited, and the risks for harm by use of this survey outweigh any benefits that could be gained. Primary care physicians are not at liberty to investigate, diagnose, or treat patients without their patients' knowledge. The introduction of this survey into the patient-physician relationship would certainly lead to an increased risk of mislabeling patients, misdiagnosing their conditions, and medically managing patients in ways that are not the standard of care. The patient-physician relationship should not be abused; for physicians to search for acts of violence in patients' lives without their knowledge is unacceptable and without proper cause, maybe illegal. The use of this survey is not of practical benefit to patients or primary care providers.
James Everett, Jr, PhD, MD
Morehouse School of Medicine
Atlanta, Ga
1. Wyshak G, Modest GA. Violence, mental health, and substance abuse in patients who are seen in primary care settings. Arch Fam Med. 1996;5:441-447.
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In reply
In response to Dr Everett's letter regarding our article,1 we want to state, as we did in the article, that this was a preliminary study. We noted that we were uncertain whether the ethnic differences would be observed in a large sample of patients or in patients seen in different settings. We also stated that a possible limitation was the sample size, which precludes more detailed analyses by ethnicity, particularly for men.
On the other hand, our results, as stated, seem to be valid and consistent with the findings of other studies on depression and anxiety and fall within the range of findings from other investigations.
We disagree with Dr Everett's view that the introduction of the instrument by primary care physicians would be harmful or illegal. Our intention is to provide physicians with a screening tool that would help them in the assessment of physical and emotional problems that might not be otherwise easily detected. Several previously published editorials and articles support our views.2-6
Grace Wyshak, PhD
Harvard Medical School and Harvard School of Public Health
Boston, Mass
Geoffrey A. Modest, MD
Boston University School of Medicine and Uphalls Corner Neighborhood Health Center
1. Wyshak G, Modest GA. Violence, mental health, and substance abuse in patients who are seen in primary care settings. Arch Fam Med. 1996;5:441-447.
2. Flitcraft AH. Violence, values and gender. JAMA. 1992;267:3194-3195.
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3. Randall T. Coping with violence epidemic. JAMA. 1990;263:2612, 2614.
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4. Randall T. Domestic violence begets other problems of which physicians must be aware to be effective. JAMA. 1993;264:940-943.
5. Council on Scientific Affairs, American Medical Association. Violence against women: relevance for medical practitioners. JAMA. 1992;267:3184-3189.
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6. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence. JAMA. 1992;267:3190-3193.
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Arch Fam Med. 1998;7:209.
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