The depression in primary care tool kit.

OBJECTIVE: A tool kit was developed to help primary care physicians overcome some of the barriers to recognition and management of depression. METHOD: Tools were collected from a variety of sources, categorized by function, and evaluated on the basis of previously established criteria, with the best tools selected for inclusion in the tool kit. New tools were developed when an adequate tool for a desired function was not available. The tool kit was reviewed and then revised based on the feedback from eleven experts on depression in primary care, five medical directors from health care systems or managed care companies, and eighteen primary care physicians. All eighteen primary care physicians completed a questionnaire after reviewing the tool kit as part of the evaluation process. RESULTS: Only five of the eighteen physicians were using any kind of tool for depression prior to reviewing the tool kit. All eighteen physicians indicated that they were likely to use one or more of the components of the tool kit. On average, physicians indicated they were likely to use 6.5 of the ten types of tools included in the kit. CONCLUSIONS: A depression tool kit containing screening, diagnostic, management planning, and outcomes assessment questionnaires as well as treatment and counseling guidelines, information tables, flow charts, and patient education materials is likely to be well received by primary care physicians. However, its effectiveness may have as much to do with how its use is organized and implemented as it does with the intrinsic value of its components.

The primary care provider's view.

To take advantage of the services of mental health professionals, primary care physicians must improve their flexibility, communication, and teamwork. All parties must be willing to surrender a measure of autonomy and control, but the result is worth the effort.

Health-related quality of life and symptom profiles of female survivors of sexual abuse.

OBJECTIVES: To determine the association between severity of sexual abuse and psychiatric or medical problems in a sample of female patients from primary care medical settings and to assess the relationship between sexual abuse severity and health-related quality of life before and after controlling for the effects of a current psychiatric or medical diagnosis. DESIGN: Structured interview and self-report questionnaire. SETTING: Three family practice outpatient clinics. SUBJECTS: A total of 252 women selected by somatization status using a screen for unexplained physical symptoms. MAIN OUTCOME MEASURES: Patient assessment after administering the Medical Outcomes Study 36-item Short-Form Health Survey and self-report medical problems questionnaire; the quality-of-life scale developed by Andrews and Withey; Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, diagnoses and symptom counts from the Diagnostic Interview Schedule; the Dissociative Experiences Scale; and the modified Dissociative Disorders Interview Schedule. RESULTS: A history of sexual abuse is associated with substantial impairment in health-related quality of life and a greater number of somatized symptoms (P < .001), medical problems (P < .01), and psychiatric symptoms and diagnoses (P < .001). In regression analyses, sexual abuse severity was a significant predictor of high scores on 6 of the 8 subscales of the Medical Outcomes Study Short-Form Health Survey (P < .05) and all of the quality-of-life subscales developed by Andrews and Withey (P < .01), with average decrements of up to 0.41 SDs for moderately abused women and 0.56 SDs for severely abused women. Furthermore, sexual abuse severity remained a significant predictor of high scores on the subscales mental health (P < .05), social functioning (P < .05), and quality of life (P < .05), even after adjusting for the presence of several common psychiatric diagnoses. CONCLUSIONS: Female primary care patients with a history of sexual abuse have more physical and psychiatric symptoms and lower health-related quality of life than those without previous abuse. In addition, a linear relationship exists between the severity of sexual abuse and impairment in health-related quality of life, both before and after controlling for the effects of a current psychiatric diagnosis.

Identifying patients with depression in the primary care setting: a more efficient method.

OBJECTIVE: To determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression. METHODS: One thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship. RESULTS: Four symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables. CONCLUSION: A strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.

Complex posttraumatic stress disorder: evidence from the primary care setting.

Sexual abuse is a common problem among female primary care medical patients. There is a wide spectrum of long-term sequelae, ranging from mild to the complex symptom profiles consistent with the theories of a posttraumatic sense of identity. Generally, the latter occurs in the context of severe, chronic abuse, beginning in childhood and often compounded by the presence of violence, criminal behavior, and substance abuse in the family of origin. In this study we search for empirical evidence for the existence of a complex posttraumatic stress syndrome in 99 women patients at 3 family practice outpatient clinics who report a history of sexual abuse. A structured interview was administered by trained female interviewers to gather data on family history and psychiatric symptoms and diagnoses. Empirical evidence from cluster analysis of the data supports the theory of a complex posttraumatic syndrome. The severity gradient based on symptoms roughly parallels the severity gradient based on childhood abuse and sociopathic behavior and violence in the family of origin, with the most severely abused subjects characterized by symptom patterns that fit the description of a complex posttraumatic stress syndrome.

A symptom checklist to screen for somatoform disorders in primary care.

Current DSM-IV somatoform diagnoses may inadequately capture many somatizing patients in primary care. By using data from two studies (1,000 and 258 patients, respectively), the authors determined 1) the optimal threshold on a checklist of 15 physical symptoms to screen for a recently proposed somatoform diagnosis, multisomatoform disorder (MSD), and 2) the concordance between MSD and somatization disorder. The optimal threshold for pursuing a diagnosis of MSD was seven or more physical symptoms. The majority (88%) of the patients who met criteria for MSD had either full or abridged somatization disorder. MSD was intermediate between abridged and full somatization disorder in terms of its association with functional impairment, psychiatric comorbidity, family dysfunction, and health care utilization and charges.

Drug-induced disorders.

Recent estimates suggest that each year more than 1 million patients are injured while in the hospital and approximately 180,000 die because of these injuries. Furthermore, drug-related morbidity and mortality are common and are estimated to cost more than $136 billion a year. The most common type of drug-induced disorder is dose-dependent and predictable. Many adverse drug events occur as a result of drug-drug, drug-disease or drug-food interactions and, therefore, are preventable. Clinicians' awareness of the agents that commonly cause drug-induced disorders and recognition of compromised organ function can significantly decrease the likelihood that an adverse event will occur. Patient assessment should include a thorough medication history, including an analysis of all prescribed and over-the-counter medications, vitamins, herbs and "health-food" products to identify drug-induced problems and potentially reversible conditions. An increased awareness among clinicians of drug-induced disorders should maximize their recognition and minimize their incidence.

Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care.

BACKGROUND: For clinical or research use in primary care, the DSM-IV diagnostic criteria for somatization disorder are too restrictive, while the criteria for undifferentiated somatoform disorder are overly inclusive. In this article, we examine the validity of multisomatoform disorder, defined as 3 or more medically unexplained, currently bothersome physical symptoms plus a long (> or = 2 years) history of somatization. METHODS: Data from the Primary Care Evaluation of Mental Disorders Study of 1000 patients from 4 primary care sites were analyzed. The outcomes assessed were 6 domains of health-related quality of life, using the 20-item Short-Form General Health Survey; self-reported disability days and health care use; satisfaction with care; and physician-rated difficulty of the encounter. RESULTS: Multisomatoform disorder was diagnosed in 82 (8.2%) of the 1000 patients who were enrolled in the Primary Care Evaluation of Mental Disorders Study. Compared with mood and anxiety disorders, multisomatoform disorder was associated with comparable impairment in health-related quality of life, more self-reported disability days and clinic visits, and greater clinician-perceived patient difficulty. CONCLUSIONS: Multisomatoform disorder may be a valid diagnosis and potentially more useful than the DSM-IV diagnosis of undifferentiated somatoform disorder. Also, because multisomatoform disorder has a large and independent effect on impairment, its diagnosis should not be precluded simply because of a coexisting mood or anxiety disorder.

Major depression in primary medical care practice. Research trends and future priorities.

This paper reviews recent developments in assessing and treating major depression in primary care practice and proposes needed research directions for the coming years. Topics warranting attention include the predictive validity of psychiatric nomenclatures specific to general medical settings; the impact of patient, clinician, and system factors on the physician's assessment of major depression; the relationship between diagnostic and treatment decisions; and the course of this disorder when treated in primary care facilities by generalists or specialists.

Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study.

BACKGROUND: Recently there has been increased interest in the special mental health needs of women. We used data from the PRIME-MD 1000 study to assess gender differences in the frequency of mental disorders in primary care settings, and to explore the potential impact of these differences on health-related quality of life (HRQL). SUBJECTS AND METHODS: One thousand primary care patients (559 women) were interviewed during the PRIME-MD study, which was conducted at four primary care clinics affiliated with university hospitals throughout the eastern United States. Patients completed a one-page questionnaire in the waiting room prior to being seen by the physician; patients and physicians then completed together a clinician evaluation guide that used DSM-III-R algorithms to diagnose mood, anxiety, somatoform, eating, and alcohol related disorders. Health-related quality of life was assessed with the Medical Outcomes Study SF-20 General Health Survey. RESULTS: Women were more likely than men to have at least one mental disorder (43% versus 33%, P < 0.05). Higher rates were particularly prominent for mood disorders (31% of women versus 19% of men, odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.4 to 2.6), anxiety disorders (22% versus 13%, OR = 1.9, CI = 1.3 to 2.8), and somatoform disorders (18% versus 9%, OR = 2.2, CI = 1.5 to 3.4). Psychiatric comorbidity was also more common in women (26% of women had two or more mental disorders versus 15% of men, P < 0.05). Unadjusted HRQL scores, ranging from 0 to 100, with 100 = best health, were all significantly lower in women than in men (eg, physical function = 67 in women versus 76 in men, P < 0.0001; mental health = 69 in women versus 76 in men, P < 0.0001). Many HRQL differences persisted after controlling for age, education, ethnicity, marital status, and number of physical disorders; however, differences in HRQL were eliminated in 5 of 6 domains after controlling for number of mental disorders. When compared with female patients of male physicians, female patients of female physicians demonstrated similar satisfaction with care, health care utilization, HRQL, and recognition rate of mental disorders. CONCLUSIONS: In the 1,000 patients of the PRIME-MD study, mood, anxiety, and somatoform disorders and psychiatric comorbidity were all significantly more common in women than men. The HRQL scores were poorer in women than men, although most of this difference was accounted for by the difference in prevalence of mental disorders. These data suggest that one of the most important aspects of a primary care physician's care of female patients is to screen for and treat common mental disorders.

The difficult patient: prevalence, psychopathology, and functional impairment.

OBJECTIVE: To determine the proportion of primary care patients who are experienced by their physicians as "difficult," and to assess the association of difficulty with physical and mental disorders, functional impairment, health care utilization, and satisfaction with medical care. DESIGN: Survey. SETTING: Four primary care clinics. PATIENTS: Six-hundred twenty-seven adult patients. MEASUREMENTS: Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MDI]), functional status (Medical Outcomes Study Short-Form Health Survey [SF-20]), utilization of and satisfaction with medical care by patient self-report. RESULTS: Physicians rated 96 (15%) of their 627 patients as difficult (site range 11-20%). Difficult patients were much more likely than not-difficult patients to have a mental disorder (67% vs 35% [corrected], p < .0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR] = 12.3. 95% confidence interval [CI] = 5.9-26.8), panic disorder (OR = 6.9, 95% CI = 2.6-18.1), dysthymia (OR = 4.2, 95% CI = 2.0-8.7), generalized anxiety (OR = 3.4, 95% CI = 1.7-7.1), major depressive disorder (OR = 3.0, 95% CI = 1.8-5.3), and probable alcohol abuse or dependence (OR = 2.6, 95% CI = 1.01-6.7). Compared with not-difficult patients, difficult patients had more functional impairment, higher health care utilization, and lower satisfaction with care, whereas demographic characteristics and physical illnesses were not associated with difficulty. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction in difficult patients. CONCLUSIONS: Difficult patients are prevalent in primary care settings and have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care. Future studies are needed to determine whether improved diagnosis and management of mental disorders in difficult patients could diminish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians experience of difficulty.

Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study.

OBJECTIVE: To determine if different mental disorders commonly seen in primary care are uniquely associated with distinctive patterns of impairment in the components of health-related quality of life (HRQL) and how this compares with the impairment seen in common medical disorders. DESIGN: Survey. SETTING: Four primary care clinics. SUBJECTS: A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians using PRIME-MD (Primary Care Evaluation of Mental Disorders) to make diagnoses of mood, anxiety, alcohol, somatoform, and eating disorders. MAIN OUTCOME MEASURES: The six scales of the Short-Form General Health Survey and self-reported disability days, adjusting for demographic variables as well as psychiatric and medical comorbidity. RESULTS: Mood, anxiety, somatoform, and eating disorders were associated with substantial impairment in HRQL. Impairment was also present in patients who only had subthreshold mental disorder diagnoses, such as minor depression and anxiety disorder not otherwise specified. Mental disorders, particularly mood disorders, accounted for considerably more of the impairment on all domains of HRQL than did common medical disorders. Finally, we found marked differences in the pattern of impairment among different groups of mental disorders just as others have reported unique patterns associated with different medical disorders. Whereas mood disorders had a pervasive effect on all domains of HRQL, anxiety, somatoform, and eating disorders affected only selected domains. CONCLUSIONS: Mental disorders commonly seen in primary care are not only associated with more impairment in HRQL than common medical disorders, but also have distinct patterns of impairment. Primary care directed at improving HRQL needs to focus on the recognition and treatment of common mental disorders. Outcomes studies of mental disorders in both primary care and psychiatric settings should include multidimensional measures of HRQL.

Gender differences in depression in primary care.

OBJECTIVES: To determine gender differences in the frequency and manifestation of depression in primary care. STUDY DESIGN: PRIME-MD, a new assessment tool, was tested in 1000 patients as an aid to diagnose depression in primary care patients. Answers to a self-assessment questionnaire completed by patients determined whether physicians administered the mood module in the Clinician Evaluation Guide to diagnose depression. Functional status was assessed with the Medical Outcomes Study Short Form (SF-20). RESULTS: More women than men were diagnosed as having a mood disorder (31% vs 19%; p < 0.01), and an antidepressant was newly prescribed only for women (p < 0.001). There were no gender differences in physician ratings of patients' health, but women rated their health significantly more poorly than did men. Similarly, functional impairment scores were significantly lower in women than in men. CONCLUSIONS: Women are much more likely than men to have depressive disorders, and when these disorders are diagnosed, to receive a prescription for antidepressant medication. Further research is needed to determine why women seem to suffer disproportionately from symptoms of depression and signs of functional impairment.

Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse and dependence in primary care patients: findings of the PRIME MD-1000 study.

The psychiatric comorbidity, health, and functioning of primary care patients with alcohol abuse and dependence (AAD) were investigated in a sample of 1,000 patients. Psychiatric symptomatology was assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic system. Health and functional status was assessed with the Medical Outcomes Study Short Form General Health Survey (SF-20). Results indicated that use of the PRIME-MD system brought about a 71% increase in physician recognition of AAD. AAD patients were diagnosed with substantial psychiatric comorbidity, and they reported poorer health and functioning than did patients without any psychiatric disorders. However, they reported less impairment and psychiatric comorbidity than did patients with other psychiatric disorders. Results also indicated that AAD patients' health and functioning were associated with the presence or absence of psychiatric comorbidity.

Stability of standardized patients' performance in a study of clinical decision making.

BACKGROUND: Standardized patients (SPs) have been used extensively in teaching, but their reliability for use in research has been infrequently addressed. This study analyzes the reliability of performance of 13 SPs during 228 doctor-patient encounters in a year-long study related to the diagnosis of depression. METHODS: Patient scenarios were based on real patient cases. Four of the five cases had major depressive disorder. Two to three SPs were coached to enact each of the five case scenarios. Medical encounters were videotaped. Interview content was extracted onto a standardized checklist. Interaction between physician and patient was measured by the Interactional System for Interview Evaluation. Tests of SP performance reliability included the: 1) consistency of symptoms volunteered, 2) stability of affect and behavior, and 3) association of SP performance to detection of depression. RESULTS: The mean number of SP performances was 20.8 (SD = 5.8), with a range of 6 to 28. Problems with reliability emerged in one of the five patient cases. Results otherwise revealed high intra-performance and inter-performance reliabilities. Detection of depression was consistent across SPs and with the rates reported in the literature. CONCLUSIONS: This study provides evidence that performances, within and among SPs, remained consistent, even when intervals between performances were as long as 3 months.