Can Physicians

Family Genogram Use

Information to Identify Patients
at Risk of Anxiety or Depression?
John C. Rogers, MD, MPH

Advocates
of family-oriented care assert that physicians' use of family genograms can
improve clinical practice, such as in the recognition of patients' emotional problems.
The purpose of this article is to investigate whether physicians could use family geno-
gram information to identify their patients at high risk of the two most common men-
tal disorders, anxiety and depression. Physicians' use of family genograms to stratify their patients'
risk raises two questions about the information recorded on the genograms: is family information
reliable and valid, and is family information associated with anxiety and depression? A review of
the published epidemiological literature revealed that some basic family information recorded on
genograms is useful for risk stratification. (Arch Fam Med. 1994;3:1093-1098)

The genogram is a "biopsychosocial fam¬
ily tree"that "shows the clinician where
the family is in its life cycle" and "reveals
important family patterns of illness, dis¬
ease, and psychosocial problems."1 Nearly
every family medicine textbook de¬
scribes the benefits of using the family
genogram in clinical practice.17 Propo¬
nents of family-oriented care have ar¬
gued that physicians' use of the geno¬
gram can improve the process and
outcome of clinical practice,8"13 particu¬
provide complete and reliable family in¬
formation. (3) Both physician- and self-
administered genograms identify more pa¬
tients and family members with emotional
problems than do physicians' routine fam¬
ily histories.23"25 (4) A method of reading
and interpreting genograms relevant to this
task has been developed.26,27
The method of systematically read¬
ing and interpreting genograms consid¬
ers four types of family information that
are recorded on family genograms: fam¬

larly the detection of emotional prob¬ ily structure, family demographic infor¬
lems. mation, family life events, and family so¬
cial and health problems.26,27 This approach
Often the genogram yields important clues that
views the genogram as a device for effi¬
allow the physician to hone right in on the prob¬
lem, rather than spending a lot of time going ciently recording family information, in
contrast with the genogram interview, dur¬
through laundry lists of symptoms. This is par¬
ticularly true for familial problems that often ing which a clinician gathers family infor¬
present in vague ways, such as depression and mation to construct the genograrp and also
anxiety disorders.13 begins to join with and help the patient
or family. Characterizing the genogram as
The following characteristics suggest that a tool for recording family information fo¬
the family genogram may be useful for cuses attention on the utility of that in¬
stratifying patients' risk for emotional formation for medical decision making.
problems, such as anxiety or depression:
(1) Several family practice training pro¬
grams and community practices already
use genograms.14"17 (2) Physician-,18
self-,19 and computer-administered20"22
genograms are accepted by patients and
From the Department of Family Medicine, Baylor College of Medicine, Houston, Tex.
The genogram interview may have
value beyond the information that
is gathered and recorded in the geno¬
gram format,28 but this article herein
regards the genogram solely as a
graphic means of displaying family
information so clinicians can use
that information for clinical judg¬
ments.
In a clinical encounter where a
physician is considering whether a pa¬
tient may be anxious or depressed,
the family genogram may be helpful
if the physician can use the informa¬
tion recorded on the genogram to as¬
sess the patient's risk for anxiety or
depression. Such risk stratification
may make the physician's clinical in¬
terview more efficient by encourag¬
ing in-depth questions about anxiety
or depression symptoms if the patient
is at high risk of these conditions or
byredirecting the questioning to other
diagnostic hypotheses if the patient
is at low risk, particularly if a few ques¬
tions confirm the low likelihood of
either anxiety or depression. This use
of the family genogram
to stratify patients by
their risk for
depression
anxiety
raises
use of the family genogram
to stratify patients by their risk
or
questions about the re¬
liability and validity of for anxiety or depression
family information re¬
corded on the geno-
gram and the association between
family information and the presence
or development of anxiety or depres¬
sion. To address these questions, this
article reviews the literature relating
anxiety and depression to the family
information commonly recorded on
family genograms. The hope is that
there would be profiles of family in¬
formation physicians could use to
identify patients at high risk of anxi¬
ety or depression.
Searches of MEDLINE and Psy¬
chological Abstracts identified the ar¬
ticles included in this review through
the following key words: anxiety, de¬
pression, genogram, family pedi¬
gree, family tree, genetics-medical,
intergenerational, and medical his¬
tory-taking methods. The follow¬
ing sections first present literature
about the reliability and validity of
patients' reports about family infor¬
mation and then review the associa¬
tion between anxiety and depres¬
sion and each of the four types of
family information noted above.
RELIABILITY AND VALIDITY
OF FAMILY INFORMATION
The reliability and validity of pa¬
tients' reports of family information
are critical if physicians are going to
use the information in their deci¬
sion making. Haggerty29 reported the
reliability of standard family socio-
demographic information obtained
by a fill-in-the-blank-space format.
This information included birth date,
marriage date, educational level,
household composition, occupa¬
tion, ethnic origin, age of parents, pre¬
vious marriage, and religion. Test-
retest agreement, measured as a
proportion of questions answered the
same on both testings, ranged be¬
tween 75% and 100%, with a mean
of 96.1%.29 Mother-father agree¬
ment on the same standard sociode-
mographic data ranged from 86% to
100%, with a mean of 88.6%.29 Test-
retest reliability of similar data for a
self-administered genogram was
89.7%.19
Mental health researchers have
studied the validity of family re¬
ports about mental disorders.30"32 In
these studies, family members were
asked about psychiatric disorders in
their first-degree relatives and
spouses. The interviews were con¬
ducted in such a way that informa¬
tion needed for the application of Re¬
search Diagnostic Criteria32 was
obtained on each family member for
whom the informant indicated the
possibility of a psychiatric disor¬
der. All family members were inter¬
viewed and also completed the
Schedule for Affective Disorder and
Schizophrenia-Lifetime Ver¬
sion,30"32 which served the gold
as
standard for the presence of mental
disorder in the individual being in¬
terviewed. The family history re¬
ports were then compared with the
psychiatric diagnoses established by
the instrument.30"32
The sensitivity and specificity
of the family history method varied
by the relationship of the infor-
mant to the affected family mem¬
ber and by the psychiatric diagno¬
sis.30 In general, specificity was very
high (93% to 99%), indicating few
false-positive reports of mental dis¬
orders in family members. For ma¬
jor depression, sensitivity was low
(33%) when parents reported about
children, but reports by siblings,
spouses, or offspring of the af¬
fected individual were 58% to 70%
sensitive. Sensitivities for general¬
ized anxiety disorder and phobia
were extremely low (0% to 17%), but
these estimates were based on be¬
tween eight and 32 subjects and may
not be stable.30
One study observed that ill¬
ness variables affected the sensitiv¬
ity of the family history: "Family his¬
tory reports are more accurate for
detecting the severest cases of de¬
pression while milder or untreated
forms of the disorder are unre-
ported or underreported."31 A study
by Andreasen et al32 observed simi¬
lar sensitivity and specificity re¬
sults for affective disorders and that
increasing the number of infor¬
mants increased the sensitivity with¬
out decreasing the specificity. There
are no validity studies of simple di¬
rect questions about anxiety or de¬
pression without follow-up Re¬
search Diagnostic Criteria questions.
It is likely that family information
collected by physicians to con¬
struct family genograms could be
more sensitive and less specific than
the family information collected dur¬
ing research diagnostic interviews,
since strict diagnostic criteria prob¬
ably are not used by the physicians
while taking their clinical histo¬
ries.
The high reliability of pa¬
tients' reports about family demo¬
graphic information suggests that
this type of information may be used
in assessing a patient's risk for men¬
tal disorder. Considering the very
high specificity of the Research Di¬
agnostic Criteria family history
method, patients' positive reports of
anxiety or depression in their fam¬
ily members may be treated with rea¬
sonable confidence, even when phy¬
sicians' clinical interviewsare used
to gather family
the information that
is displayed on the genogram. On the
other hand, patients' negative fam¬
ily histories for anxiety disorders
should be interpreted with cau¬
tion, owing to the extremely low sen¬
sitivity of patients' reports of these
conditions in their family mem¬
bers. However, patients' negative re¬
ports about major depression in their
parents, siblings, or spouses may be
treated with reasonable confi¬
dence, even if the sensitivity of phy¬
sicians' clinical interviews is not
much better than that of the Re¬
search Diagnostic Criteria family his¬
tory method. These findings show
that the information recorded on
family genograms is probably reli¬
able and valid enough to be used for
risk stratification. The next ques¬
tion is whether the family informa¬
tion displayed on genograms is as¬
sociated with anxiety or depression
in such a way that the information
is useful for risk stratification.
GENOGRAM INFORMATION
AND RISK FOR ANXIETY
OR DEPRESSION
Family Structure
The family's structure is defined by
the marital and parental status of the
identified patient, such as a couple
without children, nuclear family, or
single parent. The rates for major de¬
pression vary according to marital
status, with the rate of depression in
unmarried people being two to four
times greater than the rate in mar¬
ried people.33 The rate for single
people is about half of that for sepa¬
rated or divorced persons. Interest¬
ingly, the rate varies more by the
quality of the marital relationship
than by marital status alone. The rate
of major depression in married per¬
sons who do not get along with their
spouses is 25 times that of married
people who do get along. The in¬
creased risk is similar for husbands
and wives.33 Information about the
relationship between marital status
and anxiety disorders is not avail¬
able, nor are data on the relation¬
ship between parental status and the
risk for anxiety disorders or major
depression. Marital status is part of
the core family information re¬
corded on family genograms, but the
quality of marital relationships may
not be recorded. Hence, marital sta¬
tus is the primary piece of family
stucture information physicians can
use for genogram-based risk strati¬
fication.
Family Demographic
Information
Investigators have used data from the
Epidemiological Catchment Area
sponsored by the National
studies
Institute of Mental Health, Rock¬
ville, Md, calculate lifetime and
to
6-month prevalence rates for anxi¬
ety disorders (agoraphobia, simple
phobias, and panic disorder) and
major depression.34,35 The results
high reliability of patients'
reports about family
demographic information
from three cities (New Haven, Conn;
Baltimore, Md; and St Louis, Mo) in¬
dicate a relationship between age and
prevalence of anxiety and depres¬
sion, with the highest rate of these
disorders in the group aged 25 to 44
years. Rates in the groups aged 18
to 24 and 45 to 64 years are compa¬
rable and in general significantly
higher than the rate for those aged
65 years and older.34 The data on
6-month prevalence rates show simi¬
lar differential rates according to age
group and indicate that these differ¬
ences persist for men and women
separately.35 Gender is a risk factor,
with the rates of these emotional dis¬
orders being two to three times
higher in women than in men. Race
and education are also risk factors
for agoraphobia and simple pho¬
bias, with higher rates noted in black
than in nonblack subjects and in
those without a college degree than
in college graduates.
These methodologically sound
data have their limitations, how¬
ever. First, the associations be¬
tween the demographic factors (age,
sex, race, and education) and the
emotional disorders (anxiety or de¬
pression) are not statistically signifi¬
cant at all three sites. Second, the de¬
mographic factors are not uniformly
associated with each of the specific
diagnoses included in the class of
anxiety disorders. Specifically, the fe¬
male predominance is inconsistent
across the Epidemiological Catch-
ment Area sites for panic disorder
but is consistent at all three sites for
agoraphobia and simple phobias. In
addition, panic disorder is not as¬
sociated with race or education,
whereas the other anxiety disor¬
ders (agoraphobia and simple pho¬
bias) are. These inconsistencies
make it difficult to lump the anxi¬
ety disorders together for risk strati¬
fication. Despite these limitations,
the Epidemiological Catchment Area
data do identify some risk profiles.
A high-risk profile for major depres¬
sion appears to be being female and
aged 18 to 44 years.
For the phobias, a
high-risk profile is
being female, aged
less than 65 years,
black, and with no
college degree. The
high-risk profile for
panic disorder is not
very specific, ie, being under 65 years
of age and perhaps female.
Family Life Events
The typical family genogram re¬
cords a number of major stressful life
events, including marriage, separa¬
tion/divorce, births, deaths, job
change, change in household com¬
position, and medical or emotional
illness. Most of the available re¬
search data on the relationship be¬
tween these life events and mental
disorders are presented as the num¬
ber of life events during a defined pe¬
riod of time; so, to apply this infor¬
mation to genogram-based risk
stratification, physicians would need
to scan the genograms for the num¬
ber of events recorded. In one study
in an ambulatory practice, de¬
pressed patients had nearly twice as
many upsetting events in the 6
months prior to a research inter¬
view as nondepressed patients.36 In
a community-based study of depres¬
sion, depressed persons recalled
three to five times as many moder¬
ately to severely stressful life events
as nondepressed persons in the 3
months prior to the research inter¬
view.37 The utility of these results for
genogram-based risk stratification
may be somewhat limited, because
the two studies included life events
that are not always recorded on typi¬
cal genograms. Nevertheless, phy-
sicians should be able to use the
number of life events recorded on
family genograms to identify pa¬
tients at high risk of depression.
This research shows that phy¬
sicians can use the number of life
events recorded on family geno¬
grams for risk stratification. But, can
physicians use specific life events for
risk stratification? An article about
mothers of children with (chronic
stress group) and without disabili¬
ties (controls) addressed the ques¬
tion of whether medical illness in
one family member confers in¬
creased risk for emotional disor¬
ders on other family members.38
Mothers of children with cystic fi-
brosis, cerebral palsy, myelodyspla-
sia, and multiple physical handi¬
caps did not have higher rates of
major depression than the con¬
trols, although the chronic stress
group had significantly more de¬
pressive episodes than the con¬
trols.38 The authors concluded that
"the data do not support an etio-
logic role for chronic stress in ma¬
jor depression. The evidence sup¬
ports the role of chronic stress in
. . .
precipitating depressive epi¬
sodes."38 Another specific stressful
life event, early parental loss, has also
been shown to be unrelated to de¬
pression in adulthood.39 At this
point, knowledge about the relation¬
ship between anxiety or depression
and specific family life events that
may be recorded on genograms is in¬
sufficient for the use of such spe¬
cific life events in risk prediction.
However, physicians could use the
number of life events to stratify pa¬
tients by their risk for anxiety or de¬
pression.
Family Social
and Health Problems
The research in this category has
demonstrated increased rates of
mental disorders in the family mem¬
bers of patients who are already af¬
flicted. The rate of major depres¬
sion in first-degree relatives of
probands with unipolar or bipolar
depression is, in general, three times
that of the general population.40,41
Furthermore, the risk for major de¬
pression in first-degree family mem¬
bers increases as the age of the pro-
band at the onset of depression
*
Indicates the number of stressful life events
cannot be determined from the data available.
decreases. For onset under 20 years
of age, the risk is five times normal;
for onset at 20 to 29 years of age,
over 3 Vi times normal; for onset at
30 to 39 years of age, 2 Vi times nor¬
mal; and for onset at over 40 years
of age, IVi times normal.40 The risk
for panic disorder is six to eight times
that of the general population in
first-degree relatives of probands
with panic disorder, but the risk for
phobias is not increased in family
members of probands with pho¬
bias.4244 Lastly, the risk for panic dis¬
order is four times that of the gen¬
eral population in second-degree
relatives of probands.43
SUMMARY AND CLINICAL
APPLICATION
Family genograms display four cat¬
egories of information about fami¬
lies and their members: family struc¬
ture, family demographics, family life
events, and family social and health
problems. This family information
is reliable and valid except for the
low sensitivity of patients' reports of
anxiety disorders in their family
members. The Epidemiological
Catchment Area data show that
marital status (family structure) and
age, gender, ethnicity, and educa¬
tion (family demographics) are po¬
tential risk factors for anxiety or de¬
pression (Table). In addition, other
recently experienced by the patient. Relative risk
research36·37,40"45 shows that the num¬
ber of stressful events (family life
events) and the presence of anxiety
or depression in first- or second-
degree relatives (family social and
health problems) are also potential
risk factors (Table).
How would a physician use
these results in patient care? The
genograms in Figure I and
Figure 2, which were obtained as
part of another project,46·47 provide
good examples. The patient in Fig¬
ure 1 presented to the clinic with
dyspnea, and the genogram ob¬
tained at this visit reveals four risk
factors for major depression: being
unmarried (family structure), young,
female, and no college education
(family demographics). The pres¬
ence of these factors makes this pa¬
tient's likelihood of depression eight
to 24 times that of the normal popu¬
lation, so the physician perhaps
should have asked specifically about
symptoms of major depressive dis¬
order. In contrast, the patient in Fig¬
ure 2 presented to the clinic with
bronchitis and asthma, and the geno¬
gram obtained that day reveals no
risk factors for depression or anxi¬
ety (unless he and his wife are not
getting along in their marriage,
which would make his risk for de¬
pression 25 times that of the nor¬
mal population). In this case, a quick
question about the patient's mar-
 Lebanese German
quite functional for primary care

7-1968
physicians who may benefit from
tools that help guide clinical in¬
quiry. This review suggests that phy¬
sicians could use the basic family in-
formation recorded on family
genograms to stratify patients' risk
for anxiety and depression. Whether
the family genogram can fulfill this
role for other psychosocial prob¬
lems, as some case series sug¬
gest,48"50 will depend on advances in
family health research.
Accepted for publication June 22,1994.
Reprints not available.
August 1985
REFERENCES
Stillborn Infant With
School Down's Syndrome
Problems 1. Rakel RE, ed. Essentials of Family Practice. Phila-
delphia, Pa: WB Saunders Co; 1993:26-27.
2. Rakel RE, ed. Textbook of Family Practice. 4th
Figure 1. Genogram of a female patient, aged 32 years (double circle). Squares indicate males; ed. Philadelphia, Pa: WB Saunders; 1990:1721\x=req-\
circles, females; numbers in circles or squares, age of the individual (in years) when the genogram 1739.
was constructed; line encircling several individuals, current household; zigzag line, conflict in a 3. Taylor RB, ed. Family Medicine Principles and
relationship; parallel lines, very close relationship; broken line, significant (unmarried) relationship; Practice. 3rd ed. New York, NY: Springer\x=req-\
and X, deceased. Verlag NY Inc; 1988:30-33.
4. Sloane PD, Slatt LM, Baker RM. Essentials of
Family Medicine. Baltimore, Md: Williams &
Wilkins; 1988:9-12.
German Farmers 5. Driscoll CE, Bope ET, Smith CW, Carter BL. The
Norwegian
Family Practice Desk Reference. 2nd ed. St Louis,
1880S-1960S
Diabetes Diabetes I
Foreman
I jHigh School
^"Homemaker
QxQ High School Mo: Mosby\p=m-\Year Book; 1991:9.
LSJ
Heart Attack
Mellitus Mellitus Education Cancer Education 6. Medalie JH. Family Medicine: Principles and Ap-
1914- 1917- plications. Baltimore, Md: Williams & Wilkins;
È®
Heart Heart Heart Heart Irish
1978:38-39.
7. McWhinney IR. A Textbook of Family Medicine.
Disease Disease Disease Disease 922-1973 1924- New York, NY: Oxford University Press; 1989:
Machinist Homemaker s\ 331.
High School High School A_/ 8. Milhorn HT. The genogram: a structured ap-
Education Heart Education'.'.rtigh
Attack /,·'/ Blood
///Pressure
proach to the family. J Miss State Med Assoc.
1981;22:250-252.
9. Sproul MS, Gallagher RD. The genogram as an
1951/ 954- 1968- aid to crisis intervention. J Fam Pract. 1982;14:
959-960.
1977-1981 High School 10. Troncale JA. The genogram as an aid to diag-
nosis of distal renal tubular acidosis. J Fam Pract.
Born June 1947 Born October 1948 1983;17:707-708.
Starledge (Sales) 11. Tomson PR. Genograms in general practice.
College Education 38 Occupational School (37 Supervisor,
Bell Laboratories J R Soc Med. 1985;78(suppl 8):34-39.
Allergies,
Asthma 12. Garrett RE, Klinkman M, Post L. If you meet Bud-
Masters Degree
Married 1973
dha on the road, take a genogram: Zen and the art
1973- 1976- 1980- 1982- of family medicine. Fam Med. 1987;19:225-226.
(g) 13. Crouch MA, Roberts L. The Family in Medical
Practice: A Family Systems Primer. New York,
NY: Springer-Verlag NY Inc; 1987:177.
14. Jaffe A, Armstrong EG, Robbins AC, Froom J. A
Figure 2. Genogram of a male patient, aged 38 years (double square). Squares indicate males;
circles, females; numbers in circles or squares, age of the individual (in years) when the genogram comprehensive clerkship in family medicine. Med
was constructed; line encircling several individuals, current household; three parallel lines, very close Educ. 1984;18:159-163.
relationship; and X, deceased. 15. Shore WB, Wilkie HA, Croughan-Minihane M. Fam-
ily of origin genograms: evaluation of a teach-
ing program for medical students. Fam Med. 1994;
riage may be helpful, with fol¬ depression. On the other hand, the 26:238-243.
low-up questions about depression purpose of risk stratification is not 16. Rogers J, Durkin M, Kelly K. The family geno-
asindicated. to diagnose specific conditions but gram: an underutilized clinical tool. N J Med.1985;
The risk profiles shown in the to identify the patients who should 82:887-892.
17. North S, Marvel MK, Hendricks B, Morphew P,
Table are rather broad and unfortu¬ undergo closer scrutiny owing to North D. Physicians' usefulness ratings of family-
nately do not provide precise esti¬ their higher risk. From this perspec¬ oriented clinical tools. J Fam Pract. 1993;37:30\x=req-\
mates of patients' risk for anxiety or tive, the profiles in the Table are 34.
18. McGoldrick M, Gerson R. Genograms in Family
Assessment. New York, NY: WW Norton & Co;
1985:9-38.
19. Rogers J, Holloway R. Completion and reliabil-
ity of self-administered genogram. Fam Pract.
1990;7:149-151.
20. Gerson R, McGoldrick M. The computerized geno-
gram. Prim Care. 1985;12:535-545.
21. Chan DH, Donnan SP, Chan NF, Chow G. A mi-
crocomputer-based computerized medical rec-
ord system for a general practice teaching clinic.
J Fam Pract. 1987;24:537-541.
22. Ebell MH, Heaton CJ. Development and evalua-
tion of a computer genogram. J Fam Pract. 1988;
27:536-538.
23. Rogers JC, Durkin M. The semi-structured geno-
gram interview, I: protocol; II: evaluation. Fam
Syst Med. 1984;2:176-188.
24. Rogers JC, Cohn P. Impact of a screening fam-
ily genogram on first encounters in primary care.
Fam Pract. 1987;4:291-301.
25. Rogers J, Cohn P. The genogram's contribution
to family-centered care. N J Med. 1988;85:300\x=req-\
306.
26. Like RC, Rogers J, McGoldrick M. Reading and
interpreting genograms: a systematic ap-
proach. J Fam Pract. 1988;26:407-412.
27. Rogers JC. The self-administered genogram. In:
Rakel RE, ed. Textbook of Family Practice. 4th
ed. Philadelphia, Pa: WB Saunders; 1990:1732\x=req-\
1739.
28. Rogers J, Rohrbaugh M. The SAGE-PAGE trial:
do genograms make a difference? J Am Board
Fam Pract. 1991;4:319-326.
29. Haggerty RJ. Family diagnosis: research meth-
ods and their reliability for studies of the medical-
social unit, the family. Am J Public Health. 1965;
10:1521-1533.
30. Thompson WD, Orvaschel H, Prusoff BA, Kidd
KK. An evaluation of the family history method
for ascertaining psychiatric disorders. Arch Gen
Psychiatry. 1982;39:53-58.
31. Orvaschel H, Thompson WD, Belanger A, Pru-
soff BA, Kidd KK. Comparison of the family his-
tory method to direct interview: factors affect-
ing the diagnosis of depression. J Affect Disord.
March 1982;4:49-59.
32. Andreasen NC, Endicott J, Spitzer RL, Winokur
G. The family history method using diagnostic
criteria: reliability and validity. Arch Gen Psy-
chiatry. 1977;34:1229-1235.
33. Weissman MM. Advances in psychiatric epide-
miology: rates and risks for major depression.
Am J Public Health. 1987;77:445-451.
34. Robins LN, Helzer JE, Weissman MM, et al. Life-
time prevalence of specific psychiatric disor-
ders in three sites. Arch Gen Psychiatry. 1984;
41:949-958.
35. Myers JK, Weissman MM, Tischler GL, et al. Six-
month prevalence of psychiatric disorders in three
communities: 1980 to 1982. Arch Gen Psychia-
try. 1984;41:959-967.
36. Block M, Schulbert HC, Coulehan JC, McClel-
land M, Gooding W. Diagnosing depression among
new patients in ambulatory training settings.
J Am Board Fam Pract. 1988;1:91-97.
37. Bebbington PE, Tennant C, Hurry J. Adversity
and the nature of psychiatric disorder in the com-
munity. J Affect Disord. 1981;3:345-366.
38. Breslau N, Davis GC. Chronic stress and major de-
pression. Arch Gen Psychiatry. 1986;43:309-314.
39. Pfohl B, Stangl D, Tsuang MT. The association be-
tween early parental loss and diagnosis in the Iowa
500. Arch Gen Psychiatry. 1983;40:965-967.
40. Weissman MM, Wickramaratne P, Merikangas R,
et al. Onset of major depression in early adult-
hood. Arch Gen Psychiatry. 1984;41:1136-1143.
41. Smeraldi E, Negri F, Melica AM. A genetic study
of affective disorders. Acta Psychiatr Scand. 1977;
56:382-398.
42. Noyes R, Clancy J, Crowe R, Hoenk P, Slymen
D. The familial prevalence of anxiety neurosis.
Arch Gen Psychiatry. 1978;35:1057-1059.
43. Crowe R, Pauls D, Slymen D, Noyes R. A family
study of anxiety neurosis. Arch Gen Psychiatry.
1980;37:77-79.
44. Hopper JL, Judd FK, Derrick PL, Burrows GD. A
family study of panic disorder. Genet Epide-
miol. 1987;4:33-41.
45. Pauls DL, Noyes R, Crowe RR. The familial preva-
lence in second-degree relatives of patients with
anxiety neurosis (panic disorder). J Affect Dis-
ord. 1979;1:279-285.
46. Rogers J, Rohrbaugh M, McGoldrick M. Can ex-
perts predict health risk from family geno-
grams? Fam Med. 1992;24:209-215.
47. Rohrbaugh M, Rogers J, McGoldrick M. How do
experts read family genograms? Fam Syst Med.
1992;10:79-89.
48. Davies SM, Rutledge CM, Davies TC. A family
physician-counselor program for medical stu-
dents. Fam Med. 1993;25:327-330.
49. Vukov MG, Eljdupovic G. The Yugoslavian drug
addict's family structure. Int J Addict. 1991;26:
415-422.
50. Sproul-Marga S, Gallagher-Rollin M. The geno-
gram as an aid to crisis intervention. J Fam Pract.
1982;14:959-960.

Practice Commentary

Central to family practice is an appreciation of the inseparability of the mind and body in various disease states.
Rogers' review of the family genogram literature about the management of anxiety and depression indicates its
limited but useful role in risk stratification, especially when knowledge of the family history is combined with
individual demographics. Incorporating questions that elicit a family history of anxiety and depression along with questions
about organic diseases and family relationships adds value to the family genogram tool.
For 14 years, my group practice of four family physicians has used a family genogram as part of the family folder in
which all household members' medical records are stored. At the initial visit of a member of a new family, a medical assistant
draws the genogram in the family folder based on the answers to standard questions about any family history of alcoholism,
hypertension, diabetes, cancer, myocardial infarction, mental illness, suicide, etc. The genogram is expanded and periodi-
cally updated by the physician to reflect births, deaths, marriages, divorces, and significant new family illnesses. My regular
perusal of the genogram during an office visit has enhanced my appreciation of family psychodynamics when family alco¬
holism or mental illness is identified, allowed anticipation of concerns about possible cancer or heart disease iu-tha "worried
well," and provided a basis for counseling about chronic disease risk factors and modifying periodic health maintenance
screening for those patients at increased risk. Organizing records by household, accompanied by a family genogram, strength¬
ens the family perspective in family medicine.
The family genogram is a tool that helps keep the family in family practice. The tool is perhaps most effective when, like
any family, its elements change in a dynamic fashion over time and are accessible in a nonredundant fashion with the rec¬
ords of all household members. Incorporating data derived mostly from patient interviews, the tool is imperfect. It should
not be accepted as fact but serve as a guide to assess patients' concerns about self-reported symptoms, counsel patients about
risk factors, anticipate patterns of behavior, and individualize preventive health screening recommendations.

Kirk D. Gulden, MD
Wilkes Family Health Center, PA
North Wilkesboro, NC