Psychiatric disorders and risk of transition to chronicity in men with first onset low back pain.

OBJECTIVE: To assess whether pre-existing psychiatric diagnoses increase the likelihood of transitioning from sub-acute to chronic back pain. DESIGN: Prospective cohort study. METHODS: Men (N = 140) experiencing a first onset of low back pain (LBP) were examined for lifetime psychiatric disorders approximately 8 weeks post pain-onset using the Diagnostic Interview Schedule (DIS-III-R), then re-evaluated at 6 months after pain onset to determine who did or did not progress to pain chronicity. OUTCOME MEASURE: Transition to chronic pain and disability was based on 6-month self-report measures of pain intensity and perceived disability. RESULTS: Men with a pre-pain lifetime diagnosis of major depressive disorder had 5 times greater risk of transitioning to chronic LBP (odds ratio [OR] = 4.99; 95% confidence interval [CI] 1.49-16.76). Increased risk was also associated with a pre-pain lifetime diagnosis of generalized anxiety (OR = 2.45; 95% CI 1.06-5.68), post-traumatic stress (OR = 3.23; 95% CI 1.11-9.44), and with current nicotine dependence (OR = 2.49; 95% CI 1.15-5.40). There were no statistically significant effects for abuse or dependence of alcohol or other psychoactive substances. DISCUSSION: Lifetime history of major depression or a major anxiety disorder may represent potential psychosocial "yellow flags" for the transition to chronicity in men with first-onset LBP. Screening for lifetime depressive or anxiety disorders may identify individuals at higher risk, who may benefit from referral for more intensive rehabilitation.

Relationships among pain, anxiety, and depression in primary care.

Pain, anxiety, and depression are commonly seen in primary care patients and there is considerable evidence that these experiences are related. This study examined associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients. Results indicate that primary care patients who endorse symptoms of muscle pain, headache, or stomach pain are approximately 2.5-10 times more likely to screen positively for panic disorder, generalized anxiety disorder, or major depressive disorder. Endorsement of pain symptoms was also significantly associated with confirmed diagnoses of several of the anxiety disorders and/or major depression, with odds ratios ranging from approximately 3 to 9 for the diagnoses. Patients with an anxiety or depressive disorder also reported greater interference from pain. Similarly, patients endorsing pain symptoms reported lower mental health functioning and higher scores on severity measures of depression, social anxiety, and posttraumatic stress disorder. Mediation analyses indicated that depression mediated some, but not all of the relationships between anxiety and pain. Overall, these results reveal an association between reports of pain symptoms and not only depression, but also anxiety. An awareness of these relationships may be particularly important in primary care settings where a patient who presents with reports of pain may have an undiagnosed anxiety or depressive disorder.

Associations between psychological trauma and physical illness in primary care.

Psychological trauma is associated with poor physical health. We examined whether specific trauma types (assaultive, sexual, any) are associated with specific medical illnesses and whether posttraumatic stress disorder (PTSD) mediated these relationships in 680 primary care patients. For men, trauma history was associated with arthritis and diabetes; PTSD mediated the association between trauma and arthritis but not diabetes. Among women, trauma was associated with digestive diseases and cancer; PTSD did not mediate these relationships. Awareness of the presence of the physical illnesses examined here may help with the identification and treatment of primary care patients with trauma histories.

Development and validation of an Overall Anxiety Severity And Impairment Scale (OASIS).

Establishing severity and impairment associated with anxiety is important in many settings. We developed a brief (five-item) continuous measure, the Overall Anxiety Severity and Impairment Scale (OASIS), which can be used across anxiety disorders, with multiple anxiety disorders, and with subthreshold anxiety symptoms. Seven hundred eleven college students completed the OASIS and additional self-report assessments of anxiety-related concerns and symptoms. A subset of students completed several measures again 1 month later. Results of a split-sample analysis suggested a single-factor structure, with all five items having salient loadings. The OASIS demonstrated excellent 1-month test-retest reliability, and convergent and divergent validity. The OASIS merits consideration as a brief measure of anxiety-related severity and impairment that can be used across anxiety disorders.

In search of mixed anxiety-depressive disorder: a primary care study.

The diagnosis of mixed anxiety-depressive disorder, as proposed in DSM-IV, is intended to be useful in settings such as primary care, where low-level anxiety and depressive symptoms may cause clinically significant impairment but are undiagnosable using current criteria. Evidence of the prevalence of this diagnosis is, however, lacking, particularly since the publication of the proposed diagnostic criteria in DSM-IV. Our study examined symptoms of anxiety and depression in 65 primary care patients screened for anxiety and depression while visiting their doctor. Results indicated that of the 37 patients without a diagnosable anxiety or depressive disorder, none had symptoms of depression and anxiety accompanied by interference that the patient deemed significant and attributable to his or her symptoms. These data dispute the need for a mixed anxiety-depression category (beyond mood and anxiety syndromes currently in DSM-IV) in future editions of the DSM.

Using five questions to screen for five common mental disorders in primary care: diagnostic accuracy of the Anxiety and Depression Detector.

OBJECTIVE: Primary care providers are increasingly taking on the role of ad hoc mental health provider. However, before patients in primary care can be treated, they must be identified. This study set out to validate a very brief screening instrument for identifying primary care patients with anxiety and depression. METHOD: Eight hundred one primary care patients completed a questionnaire screening for (1) panic disorder, posttraumatic stress disorder (PTSD) and social phobia, or (2) panic disorder, generalized anxiety disorder (GAD) and major depression. Screening was followed by a diagnostic interview. The properties of the questionnaires were examined to identify a small set of items that effectively and efficiently screened for panic disorder, PTSD, social phobia, GAD and depression. RESULTS: Five items were selected across the two versions of the questionnaire, comprising the Anxiety and Depression Detector (the ADD). The sensitivities for the items ranged from 0.62 to 1.00, and the specificity values ranged from 0.56 to 0.83. When a "yes" answer to any of the screening questions was used to predict the presence of any diagnosis, sensitivity values were 0.92 to 0.96 and specificity values were 0.57 to 0.82. Sensitivity and specificity values varied little by gender, age or ethnicity. CONCLUSIONS: The five items of the ADD appear to comprise a useful screening device for anxiety and depressive disorders in primary care settings.

An efficient method of identifying major depression and panic disorder in primary care.

The research literature is replete with evidence of and concerns about the prevalence and undertreatment of mental disorders in primary care. Although screening, on its own, may not directly affect clinical outcomes, it is still the most efficient and effective way to identify psychologically distressed patients for either research purposes or to provide patients with or refer patients to appropriate care. The current study sought to establish the utility of the MHI-5 for the detection of patients suffering from major depression or panic disorder, two of the most common psychiatric conditions seen in primary care settings. This study was conducted in a family medicine clinic and 246 adult outpatients participated. Patients completed the Mental Health Index-5 (MHI-5) as the screening measure and the PRIME-MD Patient Health Questionnaire (PHQ) as the diagnostic instrument. ROC analyses indicated that a cut-off score of 23 on the MHI-5 yielded a sensitivity of 91% and a specificity of 58% for predicting provisional diagnoses of major depression or panic disorder from the PHQ. Using a single item to screen for a PHQ diagnosis of major depression yielded a sensitivity of 88% and a specificity of 62% and a second question had a sensitivity of 100% and specificity of 63% for PHQ diagnosis of panic disorder. These results indicate that it is possible to use a small number of items to efficiently and effectively screen for mental disorders affecting a significant portion of primary care patients.

Assessing nontraditional couples: validity of the marital satisfaction inventory--revised with gay, lesbian, and cohabiting heterosexual couples.

Thirty-one gay male couples and 28 lesbian couples were compared with 36 cohabiting heterosexual couples using the Marital Satisfaction Inventory-Revised (MSI-R), a multidimensional measure of relationship functioning intended for use with both traditional and nontraditional couples. Analyses of scales' internal consistency and factor structure supported the construct validity of this measure with nontraditional couples. Analyses of mean profiles on the MSI-R indicated that cohabiting opposite-gender and same-gender couples were more alike than different, and were more similar to nondistressed samples of married heterosexual couples from the general community than to couples in therapy. Implications of current findings for clinical assessment and intervention are considered, and directions for future research are proposed.