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Clinical Predictors of Mental Disorders Among Medical Outpatients
Jeffrey L. Jackson, MD, MPH;
James S. Houston, BS;
Steven R. Hanling, BS;
Kenneth A. Terhaar, BS;
Joon S. Yun, BS
Arch Intern Med. 2001;161:875-879.
ABSTRACT
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Background Mental disorders are common among primary care patients and often not
detected by primary care physicians. We report on clinical cues that may allow
physicians to target patients for psychiatric screening.
Methods Two hundred fifty consecutive adults presenting to a walk-in clinic
completed previsit surveys assessing demographics, symptom characteristics,
recent stress, functional status (Medical Outcomes Study Short Form–6),
and mental disorders (Primary Care Evaluation of Mental Disorders [PRIME-MD]).
Patients with positive findings for a mental disorder on the PRIME-MD underwent
a semistructured interview. Immediately after the visit, physicians completed
the Difficult Doctor Patient Relationship Questionnaire.
Results Patients averaged 50.5 years of age (range, 18-92 years). Little more
than half were women (53%); 43%, white; 44%, African American; 8%, Hispanic;
and 6%, other. Twenty-six percent had an underlying mental disorder; 11% had
more than 1 mental disorder. Sixteen percent had a depressive disorder; 6%,
major depression; 11%, an anxiety disorder; 2%, panic disorder; and 9%, a
somatoform disorder. Independent correlates of a mental disorder included
reporting recent stress (odds ratio [OR], 6.7; 95% confidence interval [CI],
3.3-13.6), having 5 or more physical symptoms (OR, 4.0; 95% CI, 2.1-7.9),
or reporting health to be less than very good (OR, 2.2; 95% CI, 1.1-4.3).
There was a stepwise increase in the likelihood of having a mental disorder
and number of correlates present. Among patients with no predictors, only
2% had an underlying mental disorder, compared with 72% among patients with
all 3 clinical predictors.
Conclusions Patients who report recent stress, 5 or more physical symptoms, or poor
health are more likely to have an underlying mental disorder. These clinical
cues may allow clinicians to select patients in whom formal screening for
mental disorders would be particularly fruitful.
INTRODUCTION
MENTAL DISORDERS are present in up to one third of patients seen in
the outpatient setting.1-8
Despite the availability of a number of case-finding instruments,2, 9-10 however, such disorders
frequently remain undiagnosed.2-3,11
Screening for mental disorders in all outpatients has not been shown to be
cost-effective or feasible. An alternative strategy would be to target patients
at higher risk, especially given the time constraints and competing demands
of primary care clinicians.12-13
In a previous study of 500 patients presenting to an ambulatory clinic
with physical complaints, we discerned the following 4 clinical predictors
that significantly increased the likelihood of a depressive or anxiety disorder:
recent stress, severity of the presenting symptom, total number of physical
symptoms, and poor self-rated health status (S4 model).4
These 4 factors also have been found to predict the presence of a depressive
or anxiety disorder among referrals to a rheumatology clinic.14
The S4 model factors often become apparent during the normal course of an
interview, and identify a population of patients in whom psychiatric screening
may be particularly warranted.
In this study, we sought to examine how well this model behaves in another
cohort of primary care walk-in patients, and expanded mental disorders to
include somatoform disorders as well as depressive and anxiety disorders.
PATIENTS AND METHODS
Consecutive walk-in patients to the Adult Primary Care Clinic at Walter
Reed Army Medical Center, Washington, DC, during the month of August 1998
were invited to participate. Enrollment was conducted during all clinic hours
and during every clinic, until 250 patients had been enrolled. Only patients
with dementia were excluded from the study. Immediately before seeing the
physician, all patients completed a questionnaire on symptom severity (0-10
scale) and duration (number of days), previous visits for the symptom (yes
or no), worry about serious illness (yes or no), stress in the previous week
(yes or no), and presence of common symptom-related expectations.15-16 They also completed the Medical Outcomes
Study Short Form–6, a 6-item scale that measures functional status in
the following 6 domains: overall health, role function, physical function,
social function, emotional health, and physical pain.17
Patients also underwent evaluation for Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV)18
depressive and anxiety disorders using the Primary Care Evaluation of Mental
Disorders (PRIME-MD).2 Patients with positive
findings on the Patient Questionnaire portion of the PRIME-MD were interviewed
using the Clinician Evaluation Guide to make criteria-based diagnoses of DSM-IV depressive and anxiety disorders. The PRIME-MD has
been found to be 86% accurate, compared with evaluation by independent mental
health professionals, with an overall sensitivity of 83% and specificity of
88%. For threshold disorders (major depression, generalized anxiety disorder,
and panic disorders), the specificity is higher, ranging from 92% to 99%.
Our institution's human use committee approved this protocol. The demographics,
case-mix, and psychometric properties of patients seen in military settings
have previously been shown to be comparable to those in civilian practice.19-20
After each patient visit, physicians completed the 10-item Difficult
Doctor Patient Relationship Questionnaire21
to assess clinician-perceived difficulty of the encounter, and indicated whether
a subspecialty referral was provided. This questionnaire previously has been
shown to be a reliable instrument with an internal consistency of 0.88 to
0.96, with a score of greater than 30 indicating a difficult encounter.22
Statistical analyses were performed using Stata Statistical Software.23 Categorical variables were analyzed using  2 testing, and continuous variables were assessed using Student t or Kruskal-Wallis testing as appropriate. Our primary
outcome variable was the presence of a mental disorder. Variables significant
on univariate screen at P<.20 were identified
as potential predictive variables and fit into a logistic regression model
after the methods of Hosmer and Lemeshow.24
The performance of individual predictors and the overall model were compared
with the model's original performance in the derivation set of 500 general
medical patients.4
RESULTS
PATIENT CHARACTERISTICS
Two hundred sixty-three consecutive patients were approached, and 250
agreed to participate in our study. No patient was excluded because of a language
barrier. Patients averaged 50.5 years in age (range, 18-92 years); 53% were
women. Forty-three percent were white, and 44% African American. Patients
presented with a variety of symptoms, with more than 1 symptom present 11%
of the time. The leading symptom category was musculoskeletal complaints,
present in one third of subjects. Pain of some type was reported among 155
patients (62%). Fifty percent had experienced their symptom less than 2 weeks
and 69% less than a month.
Nearly all patients (99%) had at least 1 previsit expectation, including
a desire for a causal explanation (81%), anticipated time for recovery (65%),
medication prescription (66%), diagnostic test (50%), a focused physical examination
(48%), or a subspecialty referral (40%). Nearly two thirds (62%) were worried
that their symptom might represent a serious illness. Twenty patients (8%)
were considered difficult by their clinician.
PREVALENCE OF PSYCHIATRIC DISORDERS
A mental disorder was present in 65 (26%) of patients, with 25 (10%)
experiencing 2 or more disorders. A depressive disorder was present in 40
(16%); major depression, 15 (6%); anxiety disorders, 26 (10%); panic disorder,
3 (1%); and somatoform disorder, 23 (9%).
There were no differences between patients with and without psychiatric
disorders in age, race, marital status, or educational attainment (Table 1). There were also no differences
in symptom duration or symptom severity, number or type of previsit expectations,
patient worry that the symptom could potentially represent a serious illness,
or likelihood that the patient was considered difficult by their clinician.
However, patients with psychiatric disorders were more likely to be female
(relative risk [RR], 1.6; 95% confidence interval [CI], 1.02-2.5), to report
recent stress (RR, 2.3; 95% CI, 1.8-2.8), and to report a greater number of
other somatic symptoms (5.4 vs 2.8; P<.001). Patients
with mental disorders also had worse functioning in all 6 domains assessed
(Figure 1).
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Table 1. Characteristics of 250 Walk-in Patients Stratified by Psychiatric
Status
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Functional status score by presence of depressive, anxiety, or somatoform
disorder. Functional status was measured in 6 domains using the Medical Outcomes
Study Short Form–6.17 Five of the domains
use 5-point Likert questions scored from 1 to 5,
with 5 representing better
functioning. Pain is scored on a 6-point scale. The 6 domains of functioning
include overall ("In general, would you say your health is excellent, very
good, good, fair, or poor,"
with excellent scored as 5
and poor as 1); physical ("In the past week, to what extent did your health
problems limit you in your everyday physical activities? [1-5]"); pain ("How
much bodily pain have you had during the past week? [1-6]"); emotion ("During
the past week, how much have you been bothered by emotional problems [such
as feeling anxious, depressed, or irritable] [1-5]?"); role ("During the past
week, how much difficulty did you have doing your daily work, both inside
and outside the house, because of your physical health or emotional problems?
[1-5]"); and social ("During the past week, to what extent has your physical
health or emotional problems interfered with your normal social activities
with family, friends, neighbors, or groups? [1-5]"). P<.001
for all comparisons between patients with and without a mental disorder.
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REGRESSION MODELING
Variables that differed between patients with and without mental disorders
on univariate screen at P<.20 included age, sex,
symptom duration and severity, recent stress, number of somatic symptoms,
serious illness worry, and overall health status; these were included in our
initial regression model. Variables independently significant in predicting
the presence of an underlying mental disorder included recent stress (odds
ratio [OR], 6.7; 95% CI, 3.3-13.6), 6 or more somatic symptoms (OR, 4.0; 95%
CI, 2.1-7.9), and reporting oneself to have less than very good overall health
(OR, 2.2; 95% CI, 1.1-4.3) (Table 2).
There was a stepwise increase in the likelihood of a mental disorder with
increasing number of predictors; patients with 0, 1, 2, or 3 predictors had
a likelihood of a depressive or anxiety disorder of 2%, 19%, 39%, or 72%,
respectively. Using regression coefficients, 79% of patients were correctly
classified as having or not having a mental disorder. Sensitivity and specificity
were calculated for different thresholds of the 3-predictor model. A threshold
of at least 1, 2, and 3 predictors had a sensitivity for depressive or anxiety
disorders of 98%, 74%, and 30%, respectively, and a specificity of 33%, 70%,
and 95%, respectively. In other words, 74% of patients with a depressive,
anxiety, or somatoform disorder diagnosed by means of the PRIME-MD had 2 or
more clinical predictors, whereas 98% of patients without a disorder had 1
or fewer predictors.
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Table 2. Independent Predictors of Depressive or Anxiety Disorders
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COMMENT
Mental disorders were present in one fourth of patients presenting to
our walk-in clinic. Three of the variables (symptom count, stress, and health
status) in the original S4 model predicted patients with underlying depressive,
anxiety, and somatoform disorders, validating the results of our previous
study.4 In both studies, the strongest predictor
of an underlying mental disorder was the presence of recent stress, followed
by greater number of physical symptoms. The weakest predictor of an underlying
disorder in our previous studies4, 14
was patient rating of their presenting symptom severity as greater than 5
(on a visual analog scale of 0 [none] to 10 [unbearable]). In the present
study, although patients reporting their symptom severity as greater than
5 (on the same visual analog scale from 1 to 10) were more likely to have
a mental disorder (RR, 1.3; 95% CI, 1.0-1.6), this variable was not an independent
predictor when included with the other 3 predictors (OR, 1.4; 95% CI, 0.7-2.7).
As in our previous studies, there was a stepwise increase in the percentage
of patients with mental disorders with increased number of predictors present.
Among patients with no clinical predictors, only 2% had an underlying disorder;
among those with all 3 predictors, 72% had an underlying mental disorder.
The exact questions in our study were (1) "During the past week, have
you been under stress?" and (2) "In general, would you say your health is
excellent, very good, good, fair, or poor?" scored as positive for patients
answering less than very good. Physical symptom count was measured using the
PRIME-MD 15-symptom checklist, with endorsement of 6 or more symptoms considered
positive for this model. During clinic encounters, multiple somatic complaints
often become apparent early in the interview and might serve as a surrogate
for a formal symptom checklist.
A number of barriers to recognizing mental disorders in the busy outpatient
setting have been identified, including time, stigmatization, and somatization.
Most primary care visits are completed in less than 15 minutes.25
Given the limited time, coupled with an expanded agenda of tasks expected
from primary care physicians, case finding in selected patients may be more
feasible than screening for mental disorders in every clinic attendee. There
are a number of instruments available to make the diagnosis of mental disorders;
in this study, we used the PRIME-MD. There are 2 versions of this instrument
available, one that involves questions by clinicians based on patient responses
to a questionnaire,2 and another that requires
clinicians to review patient answers to a questionnaire.26
Both allow rapid diagnoses of the most common mental disorders in primary
care, the first averaging 8.4 minutes of clinician time and the second taking
less than 3 minutes in 85% of encounters. Patient time to complete either
questionnaire is less than 10 minutes.4 Both
questionnaires have been found to have a high degree of agreement with diagnoses
made by independent mental health professionals ( , 0.65-0.71; 85%-88%
accuracy). Other case-finding instruments for depression have been found to
take only 2 to 6 minutes to administer, with equally high accuracy.9 However, management of mental disorders includes more
than making the diagnosis. Once identified, further evaluation of the patients'
psychosocial environment, ie, deciding whether this is a self-limited situational
disorder or one that merits treatment, followed by a discussion about the
risks and benefits of various treatment options must occur. There have been
no studies assessing how much more time it takes clinicians to manage mental
disorders in primary care than other common primary care problems, although
several studies have shown that most treatment of mental disorders occurs
in primary care settings.27 The burden of mental
disorders to patients is enormous. Patients report greater stress, worse functioning
in all aspects of their life, and greater worry. Patients with mental disorders
consequently have higher utilization rates of health care services. Patients
with mental disorders constitute a disproportionate percentage of referrals
to gastroenterology,28 rheumatology,29 and neurology clinics.30
Patients seen in these subspecialty settings with underlying mental disorders
are significantly less likely to have an underlying gastroenterological, rheumatological,
or neurologic cause for their symptoms. Safe, effective treatment for major
depression or panic or generalized anxiety disorders is available, and treatment
has been found to improve significantly the quality of patients' lives and
to reduce their somatic complaints.
The S3 or S4 models are not suggested as substitutes for direct inquiry
about items that permit criteria-based diagnosis of depressive, anxiety, or
somatoform disorders. Preliminary evidence suggests that simply asking a few
questions about depressed mood or anhedonia is quite sensitive (>90%) in screening
for depressive disorders,31 although single-item
screens for anxiety or somatoform disorders have not been studied. Although
not replacing diagnostic questions, S3 items may nonetheless be clinically
useful for several reasons. First, if 1 or more of the items spontaneously
surface during the clinical interview of a medical patient, they may serve
as red flags for a potential underlying mental disorder. Recent stress, multiple
physical complaints, or low ratings of overall health identify patients at
higher risk for underlying mental disorders in whom specific probing about
mental disorders is particularly warranted.
Second, most patients who present with mental disorders in the medical
setting report physical rather than emotional symptoms,4, 32-34
and premature questioning about depression or anxiety can elicit negative
reactions in some patients. A gradual approach linking physical complaints
and psychological symptoms may be more effective. Indeed, the causal relationship
(and directionality) between physical and emotional symptoms is not clear-cut
in many medical patients. Therefore, the physician need not always insist
on depression, anxiety, or somatization as the cause of the patient's physical
symptoms, but rather can adopt a more neutral position by considering depressive
or anxiety symptoms as simply coexisting conditions or a potential consequence
of persistent physical distress.
Our study has several limitations. First, this sample consisted of patients
presenting to a primary care walk-in clinic with a physical complaint. It
would be helpful to test it in a sample of patients within the context of
continuity-of-care visits. Second, a substantial proportion of patients had
subthreshold diagnoses, such as minor depressive and anxiety disorders, for
which antidepressants or other treatment have been studied inadequately. Although
it is likely that the natural history of these disorders is more favorable,
it has been found that such patients have higher rates of unmet expectations,
are more likely to be reported as difficult by their provider, and have persistence
of psychological symptoms for months after the initial encounter. Therefore,
identification of such patients may be important.
Currently, the American Academy of Family Physicians, the Canadian Task
Force on the Periodic Health Examination, and the US Preventive Services Task
Force do not recommend the routine use of case-finding instruments among all
clinic patients, recommending instead that clinicians remain alert for symptoms
of mental disorders.9 Unfortunately, this strategy
results in up to half of such patients being missed. The S3 or S4 models may
be a way to alert clinicians to patients at high risk for an underlying disorder,
since the number of predictors (symptom count, stress, health status) stratify
them into groups ranging from a very low to a very high likelihood of a mental
disorder.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
The opinions or assertions contained herein are the private views of
the authors and are not to be construed as official or as reflecting those
of the Department of the Army or the Department of Defense.
Corresponding author: Jeffrey L. Jackson, MD, MPH, Department of
Medicine-EDP, Uniformed Services University of Health Sciences, 4301 Jones
Bridge Rd, Bethesda, MD 20814 (e-mail: jejackson{at}usuhs.mil).
From the Department of Medicine, Uniformed Services University of the
Health Sciences, Bethesda, Md.
REFERENCES
| |
1. Ormel J, VonKorff M, Uston TB, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures: results from
the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA. 1994;272:1741-1748.
ABSTRACT
2. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary
care: the PRIME-MD 1000 study. JAMA. 1994;272:1749-1756.
ABSTRACT
3. Sartorius N, ed, Goldberg D, ed, de Girolamo G, ed, Costa e Silva JA, ed, Lecrubier Y, ed, Wittchen HU, ed. Psychological Disorders in General Medical Settings. Lewiston, NY: Hofgrebe & Huber; 1990.
4. Kroenke K, Jackson JL, Chamberlin J. Depressive and anxiety disorders in patients presenting with physical
complaints. Am J Med. 1997;103:339-347.
FULL TEXT
|
ISI
| PUBMED
5. Lipowski ZJ. Somatization and depression. Psychosomatics. 1990;31:13-21.
FREE FULL TEXT
6. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in primary care. Arch Gen Psychiatry. 1988;45:1100-1106.
ABSTRACT
7. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic and treatment
direction. Gen Hosp Psychiatry. 1988;10:79-87.
FULL TEXT
|
ISI
| PUBMED
8. Philbrick JT, Connelly JE, Wofford AB. The prevalence of mental disorders in rural office practice. J Gen Intern Med. 1996;11:9-15
ISI
| PUBMED
9. Mulrow CD, Williams JW, Gerety MB, Ramirez G, Montiel OM, Kerber C. Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913-921.
FREE FULL TEXT
10. Broadhead WE, Leon AC, Weissman MM, et al. Development and validation of the SDSS-PC screen for multiple mental
disorders in primary care. Arch Fam Med. 1995;4:211-219.
ABSTRACT
11. Ormel J, Koeter MWJ, van den Brink W, van de Willig G. Recognition, management, and course of anxiety and depression in general
practice. Arch Gen Psychiatry. 1991;48:700-706.
ABSTRACT
12. Klinkman MS. Competing demands in psychosocial care: a model for the identification
and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997;19:98-111.
FULL TEXT
|
ISI
| PUBMED
13. Kroenke K. Discovering depression in medical patients: reasonable expectations. Ann Intern Med. 1997;126:463-465.
FREE FULL TEXT
14. Jackson JL, O'Malley PG, Kroenke K. Clinical predictors of mental disorders among medical outpatients:
validation of the "S4" model. Psychosomatics. 1998;39:431-436.
FREE FULL TEXT
15. Good MD, Good BJ, Nassi AJ. Patient requests in primary health care settings: development and validation
of a research instrument. J Behav Med. 1983;6:151-169.
FULL TEXT
|
ISI
| PUBMED
16. Marple R, Lucey C, Kroenke K, Wilder J, Lucas C. A prospective study of concerns and expectations in patients presenting
with common symptoms. Arch Intern Med. 1997;157:1482-1488.
ABSTRACT
17. Ware JE, Nelson EC, Sherbourne CD, Stewart AL. Preliminary tests of a 6-item general health survey: a patient application. In: Ware JE, Stewart EL, eds. Measuring Functioning
and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke
University Press; 1992:291-308.
18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition. Washington, DC: American Psychiatric Association; 1994.
19. Jackson JL, Strong J, Cheng E, Meyer G. Patients, diagnoses, and procedures in a military internal medicine
clinic: comparison with civilian practices. Mil Med. 1999;164:194-197.
ISI
| PUBMED
20. Jackson JL, O'Malley PG, Kroenke K. A psychometric comparison of military and civilian medical practices. Mil Med. 1999;164:112-115.
ISI
| PUBMED
21. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology and functional impairment. J Gen Intern Med. 1996;11:1-8.
ISI
| PUBMED
22. Hahn SR, Thompson KS, Stern V, Budner NS, Wills TA. The difficult doctor-patient relationship: somatization, personality
and psychopathology. J Clin Epidemiol. 1994;47:647-658
FULL TEXT
|
ISI
| PUBMED
23. Stata Corporation. Stata Statistical Software: Release 6.0. College Station, Tex: Stata Corp; 1999.
24. Hosmer DW, Lemeshow S. A goodness-of-fit test for the multiple logistic regression model. Commun Stat. 1980;10:1043-1069.
25. Schappert SM. National Ambulatory Medical Care Survey: 1989 summary: National Center
for Health Statistics. Vital Health Stat 13. 1992;(110):1-80.
26. Spitzer RL, Kroenke K, Williams JBW. Validation and utility of a self-report version of PRIME-MD: the PHQ
Primary Care Study. JAMA. 1999;282:1737-1744.
FREE FULL TEXT
27. Schurman RA, Krooner PD, Mitchell JB. The hidden mental health network: treatment of mental illness by nonpsychiatric
physicians. Arch Gen Psychiatry. 1985;42:89-94.
ABSTRACT
28. O'Malley PG, Wong PW, Kroenke K, Roy MJ, Wong RK. The value of screening for psychiatric disorders prior to upper endoscopy. J Psychosom Res. 1998;44:279-287.
FULL TEXT
|
ISI
| PUBMED
29. O'Malley PG, Jackson JL, Kroenke K, Yoon K, Hornstein E, Dennis GJ. The value of screening for psychiatric disorders in rheumatology referrals. Arch Intern Med. 1998;158:2357-2362.
FREE FULL TEXT
30. Ekstrand J, O'Malley P, Labutta R, Jackson J. Mental disorders in a neurology clinic setting [abstract]. J Gen Intern Med. 2000;15(suppl 1):113.
31. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good
as many. J Gen Intern Med. 1997;12:439-445.
FULL TEXT
|
ISI
| PUBMED
32. Katon W, Kleinman A, Rosen G. Depression and somatization: a review. Am J Med. 1982;72:127-135, 241-247.
FULL TEXT
|
ISI
| PUBMED
33. Bridges KW, Goldberg DP. Somatic presentations of DSM III psychiatric
disorders in primary care. J Psychosom Res. 1985;29:563-569.
FULL TEXT
|
ISI
| PUBMED
34. Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: prevalence, co-occurrence
and sociodemographic characteristics. J Nerv Ment Dis. 1991;179:647-655.
ISI
| PUBMED
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