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  • Letters to the Editor
  • Erin Imler, Ralph V. Katz, B. Lee Green, Bianca A. Dearing, and Darcell P. Scharff

Re: Marks SL, Wegelin JA, Bourgeois, JA, Perkins J. Anxiety disorders in rural primary care: use of the MINI to estimate prevalence in clinic patients. J Health Care Poor Underserved. 2010 May;21(2):680–90.

The article by Marks et al. reminds us that integrated mental health-primary care model is invaluable in improving care for the underserved and that anxiety screening is important.1

The authors site the MINI as a possible limitation to the accurate assessment of prevalence of anxiety disorders as it is a self-report instrument and may overestimate rates. While it is true that other screening tools may have yielded slightly lower rates, the fact that the screening was even accomplished is a step in the right direction. The authors posit that the estimate of patients in medical clinics who meet criteria for psychiatric diagnosis (35%2) may be an overestimation; however, I would argue that the converse may actually be true. As stated, psychiatric illness is largely under-recognized and under-treated in busy primary care offices. Identification through screening, regardless of overestimation, helps to direct the physician toward further evaluation and treatment.

Working in an underserved setting can be extraordinarily challenging, particularly when patients with numerous complicated medical problems have coexistent mental health disorders in the context of difficult social situations. Attempts to find access to quality mental health care can be completely overwhelming and frustrating, leaving the primary care physician feeling powerless. The integrated program is an immeasurable resource. After identifying a problem, the physician is able to immediately refer the patient for help in real time, right in the office. This eliminates one barrier to effective, compassionate care for the underserved.

Placing mental health professionals in primary care clinics along with training aimed at improving recognition, diagnosis, and treatment of mental health disorders improves physician satisfaction when working with this very challenging patient population. The authors recommend that the integrated model be tested further to evaluate its role in improving care. I would suggest physician satisfaction as one area of exploration.

—Erin Imler, MD
University of Pittsburgh Medical Center
St. Margaret Family Medicine

Re: Scharff DP, Matthews KJ, Jackson P, Hoffsuemmer J, Martin E, Edwards D. More than Tuskegee: understanding mistrust about research participation. J Health Care Poor Underserved. 2010 Aug;21(3):879–97.

Having read "More than Tuskegee: Understanding Mistrust about Research Participation" by Scharff et al., in the JHCPU August 2010 issue (21(3):879–97) with keen interest, we would like to compliment the authors on their research inquiry into this important national issue of research participation among African Americans. They have clearly advanced the discussion on this topic by their suggestion that additional, deeper level research is needed into understanding the mistrust issues among African Americans regarding participation barriers related to the "… more involved clinical studies or trials" (vs. other, less invasive, community level studies).

While we have drawn the same conclusions (i.e., that the issue of mistrust of research among African Americans is indeed an ongoing phenomenon) from our most recent direct analyses of mistrust in our Tuskegee Legacy Project, we also (having included Whites in our surveys) found that mistrust in research also appears to be high among Whites, i.e., across two surveys in 7 U.S. cities a majority of both African Americans and Whites expressed either "no trust," "a little trust" or only "some trust" in either medical researchers or medical research findings.3,4 This parallel finding in Whites, on an issue primarily thought to have been a concern focused within the African American community, echoes one of our prior "unexpected" findings when we not only observed in our data the widely held belief among African Americans that the subjects in the USPHS Syphilis Study at Tuskegee had been injected with syphilis (~81% of African Americans in our study), but also detected how ubiquitous this same mistaken belief was even among Whites (~68%).5

Given Scharff et al.'s presentation in their article of past findings which support their concerns about this ongoing mistrust of research participation in African...

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