Teaching an experiential mind-body method to medical students to increase interpersonal skills: a pilot study.

OBJECTIVE: The authors investigate whether inner relationship focusing increases self-awareness in medical students and, in the process, to give them experience with empathic listening. METHODS: Thirteen second-year medical students were randomized into experimental and control groups and surveyed pre-course and post-course about their self-awareness and perceived comfort with clinical interpersonal skills. Subjects attended a 20-h course on inner relationship focusing, followed by 5 months of weekly sessions. Pre-course and post-course survey scores were averaged by group, and mean differences were calculated and compared using the two-sample t test. RESULTS: The experimental group showed improvement in all areas compared to the control group. Improvement in one area (comfort talking to patients about how recurring symptoms might relate to issues in their lives) reached statistical significance (P = 0.05). CONCLUSIONS: Inner relationship focusing is a potential tool to increase self-awareness and empathic listening in medical students.

Depression remission decreases outpatient utilization at 6 and 12 months after enrollment into collaborative care management.

Collaborative care management (CCM) for depression has been demonstrated to improve clinical outcomes. The impetus for this study was to determine if outpatient utilization patterns would be associated with depression outcomes. The hypothesis was that depression remission would be independently correlated with outpatient utilization at 6 and 12 months after enrollment into CCM. The study was a retrospective chart review analysis of 773 patients enrolled into CCM with 6- and 12-month follow-up data. The data set comprised baseline demographic data, patient intake self-assessment scores (Patient Health Questionnaire [PHQ-9], Generalized Anxiety Disorder-7, Mood Disorder Questionnaire, and Alcohol Use Disorders Identification Test), the number of outpatient visits, and follow-up PHQ-9 scores. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured. With a logistic regression model for outpatient visit outlier status as the dependent variable, remission at 6 months (odds ratio [OR] 0.519, CI [confidence interval] 0.349-0.770, P=0.001) and remission at 12 months (OR 0.573, CI 0.354-0.927, P=0.023) were predictive. With this inverse relationship between remission and outlier status, those patients who were not in remission had an OR of 1.928 for outpatient visit outlier status at 6 months after enrollment and an OR of 1.745 at 12 months. Patients who improved clinically to remission while in CCM had decreased odds of outlier status for outpatient utilization at 6 and 12 months when controlling for all other study variables. Improvement in health care outcomes by CCM could translate into decreased outpatient utilization for depressed patients.

Effects of concurrent low back conditions on depression outcomes.

CONTEXT: Depression and low back problems are common issues in primary care. OBJECTIVE: To compare 6-month depression outcomes (specifically, clinical results and number of outpatient visits) in patients with or without comorbid low back conditions (LBCs). The authors hypothesized that the presence of an LBC within 3 months of the diagnosis of depression would negatively affect clinical outcomes of depression treatment after 6 months. DESIGN: Retrospective record review. SETTING: Collaborative care management program in a large primary care practice. PARTICIPANTS: Patients with a diagnosis of depression enrolled in collaborative care management (N=1326), including 172 with and 1154 without evidence of an LBC within 3 months of enrollment. MAIN OUTCOME MEASURES: Clinical depression outcomes (remission and persistent depressive symptoms) and number of outpatient visits at 6 months. RESULTS: Regression modeling for clinical remission and persistent depressive symptoms at 6 months demonstrated that LBCs were not an independent factor affecting clinical remission (P=.24) but were associated with persistent depressive symptoms (odds ratio, 1.559; 95% confidence interval, 1.065-2.282; P=.02); LBCs remained an independent predictor of outlier status for outpatient visits (≥8 clinical visits after 6 months of enrollment), with an odds ratio of 1.581 (95% confidence interval, 1.086-2.30; P=.02). CONCLUSION: Increased odds of persistent depressive symptoms and increased number of outpatient visits were found in patients with depression and concomitant LBCs 6 months after enrollment into collaborative care management, compared with those in patients with depression and without LBCs. The data suggest that temporally related LBCs could lead to worse outcomes in primary care patients being treated for depression, encouraging closer observation and possible therapeutic changes in this cohort.

Association of HbA1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 diabetes mellitus.

BACKGROUND: The extant literature lacks breadth on psychological variables associated with health outcome for type 2 diabetes mellitus (T2DM). This investigation extends the scope of psychological information by reporting on previously unpublished factors. OBJECTIVE: To investigate if intolerance of uncertainty, emotion regulation, or purpose in life differentiate T2DM adults with sustained high HbA(1c) (HH) vs. sustained acceptable HbA(1c) (AH). SUBJECTS AND METHODS: Cross-sectional observational study. Adult patients with diagnosed T2DM meeting inclusionary criteria for AH, HH, or a nondiabetic reference group (NDR) were randomly selected and invited to participate. Patients who consented and participated resulted in a final sample of 312 subgrouped as follows: HH (n = 108); AH (n = 98); and NDR (n = 106). Data sources included a survey, self-report questionnaires, and electronic medical record (EMR). RESULTS: HH individuals with T2DM reported lower purpose in life satisfaction (p = 0.005) compared to the NDR group. The effect size for this finding is in the small-to-medium range using Cohen's guidelines for estimating clinical relevance. The HH-AH comparison on purpose in life was nonsignificant. The emotion regulation and intolerance of uncertainty comparisons across the three groups were not significant. CONCLUSIONS: The present study determined that lower purpose in life satisfaction is associated with higher HbA(1c). In a T2DM patient with sustained high HbA(1c), the primary care clinician is encouraged to consider screening for purpose in life satisfaction by asking a single question such as "Do the things you do in your life seem important and worthwhile?" The patient's response will assist the clinician in determining if meaning or purpose in life distress may be interferring with diabetes self-care. If this is the case, the clinician can shift the conversation to the value of behavioral and emotional health counseling.

Inter-relationship of the functional status question of the PHQ-9 and depression remission after six months of collaborative care management.

In collaborative care management (CCM) for depression, a restoration of premorbid functional status is as important as symptom reduction. The goal of this study was to investigate if the baseline functional status of the patient (as determined by the tenth question of the PHQ-9) was an independent predictor of clinical outcomes six months after enrollment into CCM and the interdependence of clinical outcomes on functional improvement at six months. One thousand eighty three adult patients who were enrolled in CCM for the diagnosis of major depression or dysthymia and had a PHQ-9 score of 10 or greater were retrospectively reviewed. Using a multiple regression model for clinical remission six months after enrollment into CCM; age, race and gender were not significant predictors of remission, however, being married was (OR 1.323 CI 1.013-1.727, P = 0.040). Patients in the Extremely Difficult category had an odds ratio of remission of 0.610 (CI 0.392-0.945, P = 0.028) at six months compared to the Somewhat Difficult group. Also, the odds of a patient achieving normal functional status at six months was highly correlated to clinical remission (PHQ-9 <5) with an odds ratio of 218.530 (P < 0.001). Depressed patients with worsening functional status at enrollment into CCM are less likely to achieve remission after six months, independent of all other variables studied. Also, improvement of a patient's functional status at six months was highly correlated with clinical remission.

Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management.

BACKGROUND: Collaborative care management (CCM) is effective for improving depression outcomes. However, a subset of patients will still have symptoms after 6 months. This study sought to determine whether routinely obtained baseline clinical, demographic, and self-assessment variables would predict which patients endorse persistent depressive symptoms (PDS) after 6 months. By estimating the relative risk associated with the patient variables, we aimed to outline the combinations of factors predictive of PDS after CCM enrollment. METHODS: We retrospectively reviewed 1,110 adult primary care patients with the diagnosis of major depressive disorder enrolled in a CCM program and evaluated those with PDS (defined as patient health questionnaire-9score ≥10) 6 months after enrollment. RESULTS: At baseline, an increased depression severity, worsening symptoms of generalized anxiety, an abnormal screening on the mood disorder questionnaire (MDQ) and the diagnosis of recurrent episode of depression were independent predictors of PDS. A patient with severe, recurrent depression, an abnormal MDQ screen, and severe anxiety at baseline had a predicted 42.1% probability of PDS at 6 months. In contrast, a patient with a moderate, first episode of depression, normal MDQ screen, and no anxiety symptoms had a low probability of PDS at 6.6%. CONCLUSIONS: This study identified several patient self-assessment scores and clinical diagnosis that markedly predicted the probability of PDS 6 months after diagnosis and enrollment into CCM. Knowledge of these high-risk attributes should alert the clinician to monitor select patients more closely and consider altering therapy appropriately.

PHQ-9 Response Curve: Rate of Improvement for Depression Treatment With Collaborative Care Management.

Major depressive disorder is common in primary care. Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), using a collaborative care model, was first implemented in March 2008 starting with 5 clinics and expanding to more than 70 clinics statewide by 2010. This was intended to improve depression management and to augment the relationship between the patient, the primary care provider, and the psychiatrist. Prior retrospective studies have demonstrated the clinical effectiveness of our program. This study was designed to examine those patients who were in clinical remission (defined as a Patient Health Questionnaire-9 [PHQ-9] score <5) at 6 months (180 days) after enrollment in collaborative care management. By determining the subsequent PHQ-9 data that were obtained, a PHQ-9 response curve was developed for those patients who did improve. The pilot study demonstrated that there appeared to be rapid response to depression treatment, evident by the first month of treatment and more pronounced in severely depressed patients. Also, it demonstrated that in the patients who did respond, there was no any difference in the remission rates over the study period when evaluated by the initial severity of the depression.

Depression remission after six months of collaborative care management: role of initial severity of depression in outcome.

Aim The impact of initial severity of depression on the rate of remission has not been well studied. The hypothesis for this study was that increased depression severity would have an inverse relationship on clinical remission at six months while in collaborative care management. Participants The study cohort was 1128 primary care patients from a south-eastern Minnesota practice and was a longitudinal retrospective chart review analysis. Results Clinical remission at six months was less likely in the severe depression group at 29.6% compared with 36.9% in the moderately severe group and 45.6% in the moderate depression group (P < 0.001). Multivariate analysis of a sub-group demonstrated that increased initial anxiety symptoms (odds ratio [OR] 0.9645, 95% confidence interval [CI] 0.9345-0.9954, P = 0.0248) and an abnormal screening for bipolar disorder (OR 0.4856, 95% CI 0.2659-0.8868, P = 0.0187) predicted not achieving remission at six months. A patient with severe depression was significantly less likely to achieve remission at six months (OR 0.6040, 95% CI 0.3803-0.9592, P = 0.0327) compared with moderate depression, but not moderately severe depression (P = 0.2324). There was no statistical difference in the adjusted means of the PHQ-9 score for those patients who were in remission at six months. However, in the unremitted patients, the six-month PHQ-9 score was significantly increased by initial depression severity when controlling for all other variables. Conclusion Multivariate analysis in our study demonstrated that patients with severe depression have a decreased OR for remission at six months compared with moderate depression. Also, there was a significant increase in the six-month PHQ-9 score for those unremitted patients in the severe vs. moderate depression groups.

Personality disorders: review and clinical application in daily practice.

Personality disorders have been documented in approximately 9 percent of the general U.S. population. Psychotherapy, pharmacotherapy, and brief interventions designed for use by family physicians can improve the health of patients with these disorders. Personality disorders are classified into clusters A, B, and C. Cluster A includes schizoid, schizotypal, and paranoid personality disorders. Cluster B includes borderline, histrionic, antisocial, and narcissistic personality disorders. Cluster C disorders are more prevalent and include avoidant, dependent, and obsessive-compulsive personality disorders. Many patients with personality disorders can be treated by family physicians. Patients with borderline personality disorder may benefit from the use of omega-3 fatty acids, second-generation antipsychotics, and mood stabilizers. Patients with antisocial personality disorder may benefit from the use of mood stabilizers, antipsychotics, and antidepressants. Other therapeutic interventions include motivational interviewing and solution-based problem solving.

Age of depressed patient does not affect clinical outcome in collaborative care management.

Clinical response and remission for the treatment of depression has been shown to be improved utilizing collaborative care management (CCM). Prior studies have indicated that the presence of mental health comorbidities noted by self-rated screening tools at the intake for CCM are associated with worsening outcomes; few have examined directly the impact of age on clinical response and remission. The hypothesis was that when controlling for other mental health and demographic variables, the age of the patient at implementation of CCM does not significantly impact clinical outcome, and that CCM shows consistent efficacy across the adult age spectrum. We performed a retrospective chart analysis of a cohort of 574 patients with a clinical diagnosis of major depression (not dysthymia) treated in CCM who had 6 months of follow-up data. Using the age group as a categorical variable in logistic regression models demonstrated that while maintaining control of all other variables, age grouping remained a nonsignificant predictor of clinical response (P ≥ 0.1842) and remission (P ≥ 0.1919) after 6 months of treatment. In both models, a lower Generalized Anxiety Disorder-7 score and a negative Mood Disorder Questionnaire score were predictive of clinical response and remission. However, the initial Patient Health Questionnaire-9 score was a statistically significant predictor only for clinical remission (P = 0.0094), not for response (P = 0.0645), at 6 months. In a subset (n = 295) of the study cohort, clinical remission at 12 months was also not associated with age grouping (P ≥ 0.3355). The variables that were predictive of remission at 12 months were the presence of clinical remission at 6 months (odds ratio [OR], 7.4820; confidence interval [CI], 3.9301-14.0389; P < 0.0001), clinical response (with persistent symptoms) (OR, 2.7722; CI, 1.1950-6.4313; P = 0.0176), and a lower initial Patient Health Questionnaire-9 score (OR, 0.9121; CI, 0.8475-0.9816; P = 0.0140). Our study suggests that using CCM for depression treatment may transcend age-related differences in depression and result in positive outcomes regardless of age.

Depression care management: impact of implementation on health system costs.

This study examined the mental health care costs associated with implementation of a collaborative care management (CCM) of treatment for depression in primary care. A retrospective review of all costs was performed over a 2-year period associated with providing care to adult patients at clinical sites with CCM versus those with usual care, comparing total and mental health per member per month (PMPM) costs for 2008 and 2009 (patient population = 103,000). The mental health-PMPM costs as a percentage of total health care costs at the clinic without CCM were 4.65% in 2008 and 4.5% in 2009 (p = .085). In the clinics with CCM, there was a significant difference between the 2 years with a decrease noted in 2009 of 4.91% compared with 4.36% in 2008 (p < .0001). This study demonstrated that, on a population basis with the implementation of CCM, the metric of mental health-PMPM (using the actual costs of delivering care) suggested that an increased short-term cost of care is not always realized. Collaborative care management treatment for depression may be a more cost-efficient method of care for the population as a whole, even in the short term.

Increased Anxiety and Length of Treatment Associated With Depressed Patients Who are Readmitted to Collaborative Care.

In 2008, the Institute for Clinical Systems Improvement (ICSI) in Minnesota implemented a model of collaborative care management (CCM) for treatment of depression in primary care. This resulted in significant improvements on both clinical response and remission over usual care, although an increase in utilization metrics has been observed. Mental health comorbidities have previously been significantly associated with an increased likelihood of not responding to initial treatment. This retrospective study hypothesized that patients with mental health comorbidities are more likely to be associated with patients who were readmitted into CCM with recurrent depression. A total of 145 patients who had completed CCM were studied; of these, 32 were diagnosed with recurrent depression and were readmitted to CCM, and 113 were in remission for at least 4 months. There were no statistically significant demographic differences between the 2 groups. The initial screening GAD-7 score for anxiety was significantly increased in the readmission group (12.81 vs 9.20, P = .001) as was the average length of treatment from initial diagnosis to remission (168.09 vs 120.99 days, P = .002). All other initial screening tests were not different between the groups. When controlling for the independent variables by multiple logistic regression, the odds ratio for GAD-7 was 1.1156 (CI = 1.0.192 to 1.2212, P = .0177) and for days of treatment in CCM was 1.0123 (CI = 1.0041 to 1.0206, P = .0033). Patients who are readmitted to CCM for recurrent depression have a statistically increased risk of associated anxiety and a longer treatment course than those who have remained in remission for at least 4 months.

Coping style in primary care adult patients with abridged somatoform disorders.

Background and objective Empirical data are scarce regarding the adaptive response to stress for patients with somatoform disorders. Our objective was to identify the preferred coping strategies of patients with abridged somatisation, a common condition in primary care. Because of the functional impairment associated with somatisation, we predicted a preference for less effective, emotion-focused coping strategies over more effective, problem-focused adaptations.Design We conducted a cross-sectional, observational study of physician referred primary care patients who presented with persistent, medically unexplained, physical symptoms. Patients were classified into two abridged somatisation groups by symptom frequency and duration, as determined by the Diagnostic Interview Schedule. The groups were compared with each other and with a non-clinical reference group; outcome variables were eight emotion- and problem-focused strategies, as measured by the Ways of Coping Questionnaire.Results Of the 72 eligible individuals, 48 participated in the study. Median age was 48 years and 75% of patients were women; 26 had somatic syndrome and 22 had a subthreshold somatising level. Patients with abridged somatisation disorders preferred emotion-focused coping strategies - typically detachment and impact minimisation, wishful thinking and problem avoidance.Conclusions Patients with abridged somatising disorder responded to stress with predominantly emotion-focused strategies, which may be associated with a lower level of positive adaptive outcome. Our findings suggest that patients with abridged somatising disorders might benefit from emphasis on problem-focused coping strategies, delivered through primary care, to improve quality of life and decrease healthcare utilisation costs.

The MMPI-2: a contemporary normative study of midwestern family medicine outpatients.

For more than 60 years it has been known that profiles from the Minnesota Multiphasic Personality Inventory (MMPI), obtained from medical patients, are elevated when scores are plotted using general population norms. These elevations have been most apparent on the neurotic triad (NTd), the first 3 clinical scales on the MMPI profile. More than 45 years have passed since a nonreferred, normative sample of MMPIs was established from 50,000 consecutive medical outpatients. We present comparable but contemporary normative data for the revised MMPI (MMPI-2) based on a nonreferred sample of 1,243 family medicine outpatients (590 women; 653 men). As true for the original MMPI, contemporary medical outpatients have profiles that are significantly different, clinically and statistically, from the general population norms for the MMPI-2. This is particularly evident in elevations on the NTd. New normative tables of uniform medical T (UMT) scores were developed following the procedures used to create the uniform T scores for the MMPI-2. Measures of internal consistency are reported; test-retest reliability was established over a mean of 3.7 weeks, and results characterizing the stability of the validity and clinical scales are presented.

Physical symptoms that predict psychiatric disorders in rural primary care adults.

RATIONALE, AIMS AND OBJECTIVES: There is a robust association between physical symptoms and mental distress, but recognition rates of psychiatric disorders by primary care doctors are low. We investigated patient-reported physical symptoms as predictors of concurrent psychiatric disorders in rural primary care adult outpatients. METHOD: A convenience sample of 1092 patients were assessed with a two-stage diagnostic system consisting of a brief screening questionnaire and a clinician-administered semi-structured interview that linked common physical symptoms with the concurrent presence of psychiatric disorders. RESULTS: Somatoform physical symptoms were highly predictive of the concurrent presence of a psychiatric disorder, with odds ratios ranging from 10.4 (fainting spells) to 54.6 (shortness of breath). Aggregate analysis of somatoform and non-somatoform symptoms relative to no physical symptom produced odds ratios of 3.0 or higher for headaches, chest pain, dizziness, sleep problem, shortness of breath, tired or low energy, and fainting spells. As the number of symptoms (especially somatoform) increased, the odds of a psychiatric disorder increased. CONCLUSION: Although individual physical symptoms are valid triggers for suspecting a psychiatric disorder, the most powerful correlates are total number of physical complaints and somatoform symptom status.

Marital status, feeling depressed and self-rated health in rural female primary care patients.

OBJECTIVE: To determine whether marital status and self-assessed mental health are independent risk factors for poor self-rated overall health among female primary care patients. DESIGN: We conducted a cross-sectional survey of family medicine patients treated in a clinic in rural Minnesota. Complete responses were obtained from 723 women. Self-ratings of mental health, demographics and symptoms were used to predict self-rated overall health. RESULTS: Women who were single, divorced or otherwise not married, or widowed had lower odds of good self-rated overall health (OR = 0.39, P = 0.004) compared with married women. Women who were 65 years of age and over (OR = 0.31, P = 0.017), women who rated themselves as depressed (OR = 0.54, P = 0.029), and women who reported more physical symptoms (OR = 0.78, P = 0.000) also were less likely to have good health, compared with younger women, women who did not feel depressed, and women with fewer physical symptoms, respectively. Education was not independently related to health in this sample. Worry was related to health in the univariate analysis but not after controlling for self-assessed depression. CONCLUSIONS: In order to improve overall health among rural women seen in primary care settings, special attention may need to be directed at women who are single, are older, report more physical symptoms, and feel depressed. Programmes should include self-help materials, support groups and counselling services addressing social isolation, employment and financial hardship.

Somatisation and alexithymia in patients with high use of medical care and medically unexplained symptoms.

Background and objective Few reports in the medical literature examine physician agreement on a standard assessment for somatisation in primary care patients. We describe somatising patients who were subjectively identified by family physicians and subsequently classified on the somatisation spectrum by a standard evaluation. We also examine the relation between somatisation and alexithymia.Method Responding to a brief verbal prompt, family physicians referred high-utilising patients 18 years old and older who had 'persistent medically unexplained symptoms for at least 6 months' (n = 72). Patients who agreed to participate in the study (n = 48) were assessed individually using a structured diagnostic interview and two measures of alexithymia.Results All participating patients met inclusion criteria for one of two abridged subtypes on the somatisation spectrum. Somatisation was not related to alexithymia.Conclusions Family physicians subjectively identified patients who had somatisation, with a high level of accuracy and without formal screening or diagnostic tests. Embedded in a disease-management system, especially an electronic version, a brief verbal prompt to physicians to identify patients on the somatisation spectrum could potentially realise considerable savings in physician time and medical system financial expenditures.

Obesity and symptom burden in family medicine patients.

BACKGROUND: Medical visits are initiated by patients in search of symptom relief. The extent to which obesity independently increases the risk of common symptoms is unknown. OBJECTIVES: To assess how obesity affects symptom burden among family medicine patients, after adjustment for severity of illness, via retrospective analysis of electronic medical records pertaining to 1738 adult family medicine patients treated in a large family medicine department in Rochester, Minnesota, USA. METHODS: A symptom index was used to measure symptom burden. Body mass index (BMI; kg/m) was measured during clinic visits. Multiple logistic regression analysis was used to test for an independent relationship between BMI category and the presence of three or more common symptoms. RESULTS: Adjusting for co-morbidity and other confounders using multiple logistic regression analysis revealed that having a BMI ≥35 kg/m was independently related to symptom burden (adjusted odds ratio [OR] = 1.80; 95% CI 1.24, 2.63). Patients with low and moderate co-morbidities (as measured by the Charlson Co-morbidity Index) also had higher odds of reporting more symptoms (OR = 1.60; 95% CI 1.17, 2.17 and OR = 1.87; 95% CI 1.36, 2.56, respectively). Symptom burden increased with age. Odds of having three or more symptoms were lower for married patients (OR 0.63; 95% CI 0.47, 0.83). CONCLUSIONS: In our sample of family medicine patients, increased symptom burden may be associated with a BMI ≥35 kg/m. Lower levels of obesity do not appear to be related to symptom burden.

Health behavior counseling in primary care: provider-reported rate and confidence.

BACKGROUND AND OBJECTIVES: This study's purpose was to identify variables associated with primary care providers' self-reported rate of health behavior change counseling and confidence in counseling abilities. Of particular interest was the association of provider personal health behavior with reported rate of counseling and confidence in counseling abilities. METHODS: Surveys were mailed to primary care providers. Self-report items assessed rate of health behavior change counseling, perceived importance of counseling, extent of counseling training, confidence in counseling abilities, and clinician personal health behavior. RESULTS: One hundred providers completed the survey, with 31% reporting difficulty counseling patients on a health behavior that they struggle with themselves. Provider type (eg, nurse or physician) and extent of training in health behavior change counseling were significantly associated with reported rate of counseling in a multiple regression model (adjusted R2=.30). Years in practice, extent of training, and importance of counseling were significantly associated with confidence in counseling in a multiple regression model (adjusted R2=.31). CONCLUSIONS: Some providers report difficulty counseling patients on behaviors that they struggle with themselves. Extent of training in health behavior counseling appears to be particularly important to both provider-reported rate of counseling and confidence to counsel.

Family history of mental illness and frequent mental distress in community clinic patients.

OBJECTIVE: The objective of this study was to investigate the importance of family history of mental illness as a risk factor for self-reported frequent mental distress among patients who use community-based clinics. DESIGN: A cross-sectional survey was distributed to a convenience sample in three community clinics serving largely low-income patients. Forms were completed by 793 clinic patients. Multiple logistic regression analysis was to control for the effects of demographic variables. RESULTS: In this sample of primary care patients, 27.1% had frequent mental distress. Having a family history of mental illness or substance abuse was found to be associated with frequent mental distress in this population [adjusted odds ratio (OR) = 2.24, P = 0.000]. Also associated with increased odds of frequent mental distress were avoiding medical care owing to cost (OR = 1.86, P = 0.003) and obesity (OR = 1.73, P = 0.006). CONCLUSIONS: Having a family history of mental illness or substance abuse is independently associated with increased odds of frequent mental distress among primary care patients seen in community clinics. Three strategies are suggested for using this information to prevent frequent mental distress: health education via mass communication to the general population of primary care patients being followed in a clinic, health education to at-risk patients, and targeted screening of clinic patients who have the risk factor.