Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients.

BACKGROUND: Current Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications describe spectrums of symptoms that define mood and anxiety disorders. These DSM classifications have been applied to primary care populations to establish the frequency of these disorders in primary care. DSM classifications, however, might not adequately describe the underlying or natural groupings of mood and anxiety symptoms in primary care. This study explores common clusters of mood and anxiety symptoms and their severity while exploring the degree of cluster congruency with current DSM classification schemes. We also evaluate how well the groupings derived from these different classifying methods explain differences in patients' health-related quality of life. METHODS: Study design was cross-sectional, using a sample of 1333 adult primary care patients attending a university-based family medicine clinic. We applied cluster analysis to responses on a 15-item instrument measuring symptoms of mood and anxiety and their severity. We used the PRIME-MD to determine the presence of DSM-III-R disorders. The SF-36 Health Survey was used to assess health-related quality of life. RESULTS: Cluster analysis produced four groups of patients different from groupings based on the DSM. These four groups differed from each other on sociodemographic indicators, health-related quality of life, and frequency of DSM disorders. Cluster membership was associated in three of four clusters with a clinically significant and progressive decrease in mental and physical health functioning as measured by the SF-36 Health Survey. This decline was independent of the presence of a DSM diagnosis. CONCLUSIONS: A primary care classification scheme for mood and anxiety symptoms that includes severity appears to provide more useful information than traditional DSM classifications of disorders.

Does the severity of mood and anxiety symptoms predict health care utilization?

BACKGROUND: Traditional diagnostic criteria for depression and anxiety fail to account for symptom severity. We previously evaluated a severity-based classification system of mood and anxiety symptoms. This study examines whether those severity groups are predictive of differences in health care utilization. METHODS: We used a cohort design to compare the health care utilization of 1232 subjects classified into 4 groups according to symptom severity. Health care billing data were evaluated for each subject for a 15-month period around the index visit. Multiple linear regression models were used to examine relative contributions of individual variables to differences in health care utilization. Analysis of variance procedures were used to compare charges among the severity groups after adjusting for demographic and medical comorbidity variables. RESULTS: After adjustment, significant differences in health care utilization between groups were seen in all but 3 of the 15 months studied. Also, after adjustment, the presence of a mood or anxiety disorder influenced utilization for only a 6-month period. At 9 to 12 months, subjects in the high-severity group showed a more than twofold difference in adjusted charges compared with the low-severity group ($225.36 vs $94.37). CONCLUSIONS: Our severity-based classification predicts statistically and clinically significant differences in health care utilization over most of a 15-month period. Differences in utilization persist even after adjustment for medical comorbidity and significant demographic covariates. Our work lends additional evidence that beyond screening for the presence of mood and anxiety disorders, it is important to assess symptom severity in primary care patients. Further study directed toward developing effective methods of identifying patients with high levels of mood and anxiety symptom severity could result in significant cost savings.

Health-related quality of life in primary care patients with recognized and unrecognized mood and anxiety disorders.

OBJECTIVE: Primary care providers have been criticized for underrecognizing and undertreating mental health disorders. This criticism assumes patients with recognized disorders and those with unrecognized disorders suffer the same burden of illness. This study describes differences in health-related quality of life (HRQOL) in patients with recognized and unrecognized mood and anxiety disorders in a primary care setting. METHODS: A probability sample of 500 adult ambulatory patients from a university-based, family practice clinic, completed the PRIME-MD mood and anxiety disorder modules and the SF-36 Health Survey. Computerized patient records were reviewed retrospectively to determine recognition of mood and anxiety disorders. The Mental Health (MCS) and Physical Health (PCS) Component Summary scales of the SF-36 served as the primary outcome measures. RESULTS: Sub-threshold mood and anxiety disorders were less likely to be recognized by physicians than disorders meeting DSM-III-R criteria. Recognized mood disorders were associated with a significant decrement in MCS scores (poorer HRQOL) compared with unrecognized disorders. In contrast, recognized mood disorders demonstrated slightly higher PCS scores. Recognized and unrecognized mood disorders differed significant ly in physical functioning, vitality, social functioning, role functioning related to emotional state, and mental health. Recognition of anxiety disorders was not related to HRQOL. CONCLUSIONS: Patients with mental health disorders that have been recognized by their health providers appear to suffer from poorer HRQOL than patients whose disorders have not been recognized. This relationship, though, is only apparent for mood disorders. Poorer physical functioning may mask less severe emotional symptoms in mood disorders; profound emotional symptoms make recognition easier.

Patient attitudes regarding physician inquiry into spiritual and religious issues.

BACKGROUND: Most physicians do not address spiritual and religious issues with patients, although there are data documenting the relationship between religious variables and disease, health, and well-being. The purpose of this study was twofold: to examine patient attitudes regarding physician-directed inquiry about issues related to spiritual matters and faith; and to identify screening variables that would identify patients who would be receptive to such a discussion. METHODS: A Spiritual and Religious Inquiry (SRI) questionnaire was administered to patients presenting for care in a family practice center. RESULTS: Patients' frequency of religious service attendance (at least monthly) predicted their acceptance of physician inquiry into their religion and personal faith (P < .01) and acceptance of physician referral to pastoral professionals for spiritual problems (P < .01). CONCLUSIONS: This study supports the use of frequency of religious service attendance as a screening variable for patients receptive to physician-directed inquiry into religious and spiritual issues. It also confirms that patients are accepting of physicians' referring patients to pastoral professionals (ie, clergy) for spiritual problems.

Supportive family members of diabetic adults.

OBJECTIVE: Family members usually become involved during the course of care for a chronic illness. This study identified the diabetic adult's perceived supportive family member(s) and analyzed whether family participation was associated with the diabetic adults' level of metabolic control. METHODS: A telephone survey of 131 diabetic adults was conducted from a family practice residency office asking patients to identify family members participating in their diabetes care and to enumerate specific support activities. Demographic and metabolic control data were abstracted from patient records. RESULTS: Two broad categories of family participation exist. The first is the family health monitor (FHM), or internal "health expert" for the family. The other is the often distinct primary supportive family member; or "helper," defined as a family member who performs at least one supportive task in the care of the illness. Three-fourths of diabetic adults identified an FHM within their families. Eighty-seven percent of FHM's were women, usually adult daughters of diabetic women or wives of diabetic men. Forty-nine percent of diabetic women and 70% of diabetic men also identified a "helper." The most frequent helping tasks involved: dietary issues (48%), medication (23%), general support (15%) and blood sugar monitoring (9%). No relationship emerged between the presence or absence of an FHM or a helper and the level of metabolic control as measured by HbA1C level, which was categorized as "poor" in 55% of the sample. CONCLUSIONS: An FHM or some other helping family member is available to most diabetic adults in our patient population. The mere presence of an available FHM or other potential resource person is not necessarily related to a positive influence on metabolic control.

Perceptions and treatment of sexual problems.

In this research, perceptions and beliefs which affect the family physician's treatment of sexual problems were studied. A 66-item questionnaire, the Survey of Sexual Problem Care (SSPC), was completed by 68 individuals. Respondents reported that they would be more likely to consult a family physician for the treatment of sexual problems than any other individual; however, few (11%) of those surveyed had actually sought treatment for sexual problems. Confidentiality was reported to be the most important characteristic in persons consulted for sexual problems, and treatment was more likely to be sought from family physicians when problems were believed to have a physical (vs. psychological) etiology. The implications of these results are discussed.