Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care

OBJECTIVES: To examine the effect of patients' causal attributions of common somatic symptoms on recognition by general practitioners of cases of depression and anxiety and to test the hypothesis that normalising attributions make recognition less likely. DESIGN: Cross sectional survey. SETTING: One general practice of eight doctors in Bristol. SUBJECTS: 305 general practice attenders. MAIN OUTCOME MEASURE: The rate of detection by general practitioners of cases of depression and anxiety as defined by the general health questionnaire. RESULTS: Consecutive attenders completed the general health questionnaire and the symptom interpretation questionnaire, which scores style of symptom attribution along the dimensions of psychologising, somatising, and normalising. General practitioners detected depression or anxiety in 56 (36%; 95% confidence interval 28% to 44%) of the 157 patients who scored highly on the general health questionnaire. Subjects with a normalising attributional style were less likely to be detected as cases; doctors did not make any psychological diagnosis in 46 (85%; 73% to 93%) of 54 patients who had high questionnaire and high normalising scores. Those with a psychologising style were more likely to be detected; doctors did not detect 21 (38%; 25% to 52%) of 55 patients who had high questionnaire and high psychologising scores. The somatisation scale was not associated with low detection rates. This pattern of results persisted after adjustment for age, sex, general health questionnaire score, and general practitioner. CONCLUSIONS: Normalising attributions minimise symptoms and are non-pathological in character. The normalising attributional style is predominant in general practice attenders and is an important cause of low rates of detection of depression and anxiety.     

Prevalence and correlates of depressive syndromes among adults visiting an Indian Health Service primary care clinic

Depression is common among patients visiting primary care clinics. In order to describe the prevalence of depressive syndromes in an American Indian primary care clinic population and to help define the clinical correlates of depressive syndromes in this setting, a clinic-based research study of depression was undertaken by the Indian Health Service (IHS). One hundred and six patients from an IHS primary care clinic were systematically enlisted for participation in the study. Participants completed the Inventory for Diagnosing Depression (IDD). Twenty-two (20.7%) responded with answers scoring positive for a depressive syndrome. Nine of these 22 (8.9% of the 106 participants) met IDD criteria for a major depressive syndrome. A diagnosis of depression, a past history of depression, use of mental health facilities, unexplained pains, and antidepressant medication use were associated with the presence of a depressive syndrome.     

The role of psychologists in the care of Iraq and Afghanistan veterans in primary care settings.

Although military personnel serving in Iraq and Afghanistan are at high risk of developing mental health problems, many report significant barriers to care and few seek help. Integrated primary care is a comprehensive model of health care that aims to improve access to care and provides a framework to assess and meet the complex psychiatric needs of newly returning veterans by embedding mental health specialists within primary care. We describe the role of psychologists in a Department of Veterans Affairs (VA) integrated primary care clinic that serves veterans of Iraq and Afghanistan. Psychologists based in primary care can assist veterans with reintegration to civilian life by providing rapid mental health assessment, normalizing re-adjustment concerns, planning for veterans’ safety, implementing brief interventions within primary care, facilitating transition to additional mental health care, and informing veterans of other available psychosocial services. A case example demonstrating the psychologist’s role highlights the benefits of an integrated care model. Implications of employing this model include reduction of symptoms and impairment by reducing stigma and barriers to seeking mental health care, increased motivation to engage in treatment, and implementation of early interventions. This model may also be beneficial in the civilian health care sector with groups that are at high risk for mental health problems, yet experience barriers to care, particularly stigma. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' perspectives on the management of emotional distress in primary care settings

OBJECTIVE: To investigate how important treatment for emotional distress is to primary care patients in general and to primary care patients with depression, and to evaluate the types of mental health interventions they desire. DESIGN: Patient surveys. SETTING: Five private primary care practices. MEASUREMENTS AND MAIN RESULTS: Patients' desire for treatment of emotional distress and for specific types of mental health interventions were measured, as well as patients' ratings of the impact of emotional distress, the frequency of depressive symptoms, and mental health functioning. Of the 403 patients, 33% felt that it was "somewhat important" and 30% thought it was "extremely important" that their physician tries to help them with their emotional distress. Patient desire for this help was significantly related to a diagnosis of depression (p < .001), perceptions about the impact of emotional distress (p < .001), and mental health functioning (p < .001). Among patients with presumptive diagnoses of major and minor depression, 84% and 79%, respectively, felt that it was at least somewhat important that they receive this help from their physician. Sixty-one percent of all primary care patients surveyed and 69% of depressed patients desired counseling: 23% of all patients and 33% of depressed patients wanted a medication: and 11% of all patients and 5% of depressed patients desired a referral to a mental health specialist. CONCLUSIONS: A majority of these primary care patients and almost all of the depressed patients felt that it was at least somewhat important to receive help from their physician for emotional distress. The desire for this help seems to be related to the severity of the mental health problem. Most of the patients wanted counseling, but relatively few desired a referral to a mental health specialist.     

Health care and the poor: Psychological implications of restrictive policies.

Describes a field experiment with 180 women (mean age 25.9 yrs) visiting an urban welfare office to examine the possible effects of 2 aspects of restrictive Medicaid policies: (a) the loss of choice of providers and (b) adverse patient mix (i.e., when the majority of a provider's clients are Medicaid beneficiaries). Results indicate that health care presented within the context of not having a choice was derogated and that choice and patient mix combined to influence intentions to seek care. Ss who did not choose the health plan in a simulated choice, who had fewer choices than expected, and who did not accept restricted choice also had negative perceptions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chronicity of Psychological Strain in Occupational Settings and the Accuracy of the General Health Questionnaire.

This article examines the proposition that the traditional scoring method of the General Health Questionnaire (GHQ) underestimates the number of respondents classified as "cases." A revised "chronic" scoring method (the CGHQ) is used and demonstrates superior construct validity and greater sensitivity. A comparison of the CGHQ and GHQ also shows the CGHQ to be a superior criterion measure. These claims are demonstrated by survey data gathered from 3 occupational samples (Ns = 11,637, 2,253, and 2,124). Results show that the CGHQ is more appropriate as a screening instrument for psychological morbidity. Tests of construct validity also favor the CGHQ with only a slight advantage for predictive validity in terms of variance explained. The more desirable statistical properties of the CGHQ result in a reduction of significant interaction terms and are strongly recommended in future studies as a means of controlling Type I errors when tests of moderation are examined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review.

Although alcohol screening and brief intervention (SBI) reduces drinking in primary care patients with unhealthy alcohol use, incorporating SBI into clinical settings has been challenging. We systematically reviewed the literature on implementation studies of alcohol SBI using a broad conceptual model of implementation, the Consolidated Framework for Implementation Research (CFIR), to identify domains addressed by programs that achieved high rates of screening and/or brief intervention (BI). Seventeen articles from 8 implementation programs were included; studies were conducted in 9 countries and represented 533,903 patients (127,304 patients screened), 2,001 providers, and 1,805 clinics. Rates of SBI varied across articles (2–93% for screening and 0.9–73.1% for BI). Implementation programs described use of 7–25 of the 39 CFIR elements. Most programs used strategies that spanned all 5 domains of the CFIR with varying emphases on particular domains and sub-domains. Comparison of SBI rates was limited by most studies' being conducted by 2 implementation programs and by different outcome measures, scopes, and durations. However, one implementation program reported a high rate of screening relative to other programs (93%) and could be distinguished by its use of strategies that related to the Inner Setting, Outer Setting, and Process of Implementation domains of the CFIR. Future studies could assess whether focusing on Inner Setting, Outer Setting, and Process of Implementation elements of the CFIR during implementation is associated with successful implementation of alcohol screening, as well as which elements may be associated with successful, sustained implementation of BI. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The practice of critical care medicine. A national survey report. ACCP Council on Critical Care

Aggressive reimbursement reform has been an imposing directive for care providers of ICU medicine. Timely knowledge of actual care routines obtained from a large sample of actively practicing physicians should be mandatory when developing any guidelines or practice standards. A questionnaire was therefore designed by the steering committee of the ACCP Council on Critical Care and sent to its members. The 1,294 responses were analyzed for demographics of the individual practitioner, local aspects of ICU staffing and policies, reimbursement, and a specific practice issue, nutrition. The typical respondent was aged 41 to 50 (41 percent), was a pulmonary subspecialist (68 percent), was not critical care certified (55 percent), worked 25 to 50 percent of his or her total time in the ICU (40 percent), and would continue ICU practice despite poor reimbursement (82 percent). Physicians practiced within a group (53 percent), in a 100- to 500-bed hospital (69 percent), with house staff available (60 percent), and predominantly cared for Medicare patients (55 percent). The following data may allow better judgments to be made pertaining to the implementation of care policies in the current ICU environment.     

Problems and new directions in the evaluation of primary care

The updated experience of the McGill Teaching Hospitals in treating cancer of the bladder with short course, high-dose radiation and immediate cystectomy is presented. Five-year life table survival for the 135 patients so managed was 43.9 per cent. Survivorship at five years was 34.5 per cent in high-stage disease and 64.1 per cent in low-stage disease. It was concluded that preoperative radiation and surgery as outlined in selected cases remains an effective method of management.     

Psychological consultation with primary care physicians: Obstacles and opportunities in the medical setting.

This article discusses the relationship between psychologists and primary care physicians and describes the training and practice of physicians in the areas of mental and behavioral health care. Issues affecting the relationship between psychologists and primary care physicians are then reviewed. Different models of psychological consultation are discussed, and an integrated behavioral systems model of psychological consultation is presented as a potentially effective model for consultation with primary care physicians. This model provides a framework for psychologists to function as coproviders of primary health care services. Practical strategies to enhance collaboration between psychologists and primary care physicians in private practice are discussed. The need for more research on primary care and for the inclusion of psychologists in managed care and health care reform are also highlighted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A study of anxiety and learning in children.

"A general anxiety scale and a test anxiety scale were administered to 747 grade school children. Out of this group, 24 HA-LA pairs of subjects were given 2 modified paired-associate learning tasks, separated by neutral, failure, and success instructions. The results showed no differences due to instructions, but LA Ss performed better than HA Ss in the second task. Alternative explanations for the lack of differences on the first task were offered. The study was interpreted as positive evidence for the validity of the anxiety scales." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A cross-cultural study of the structure of comorbidity among common psychopathological syndromes in the general health care setting.

This study presents analyses of 7 common psychopathological syndromes in the World Health Organization (WHO) Collaborative Study of Psychological Problems in General Health Care (T. B. Ustun & N. Sartorius, 1995). Data on depression, somatization, hypochondriasis, neurasthenia, anxious worry, anxious arousal, and hazardous use of alcohol were analyzed for 14 countries (Ns for each country ranged from 196 to 800). Four models were evaluated: a 1-factor model; a 2-factor model in which all syndromes except hazardous use of alcohol represented internalizing problems; and two 3-factor models. The 2-factor model fit best. These results extend previous research on the 2-factor model to the current complaints of attendees of general health care clinics, to a new set of syndromes, and to a variety of both Western and non-Western countries. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health status and satisfaction with health care: Results from the medical outcomes study.

Relations between self-assessed health status and satisfaction with health care were examined using 2 waves of data obtained from participants in the Medical Outcomes Study. Using a multisample covariance modeling framework, separate models were examined for patients with significant symptoms of depression (n?=?417 ) and patients with chronic physical health conditions (n?=?535 ). The pattern of findings was essentially identical for both patient subgroups. General satisfaction with care was cross-sectionally associated with mental?but not physical--health status. In addition, significant cross-lagged effects were found linking baseline satisfaction with care to subsequent mental health and baseline mental health to subsequent satisfaction with care. By contrast, no crosslagged directional effects linking satisfaction with care and physical health status were identified. Finally, no evidence was found that satisfaction with specific aspects of health care contributed independently to either mental or physical health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines

The Depression Guideline Panel of the Agency for Health Care Policy and Research in 1993 published recommendations for treating major depression in primary care practice that were often based on studies of tertiary care psychiatric patients. We reviewed reports of randomized controlled trials in primary care settings published between 1992 and 1998. This evidence indicates that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are efficacious when transferred from psychiatric to primary care settings. In most cases, the choice between these treatments should depend on patient preference. Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.     

Prevalence of primary acquired melanosis and nevi of the conjunctiva and uvea in the dysplastic nevus syndrome. A case-control study

PURPOSE: To investigate whether conjunctival and uveal nevi and primary acquired melanosis are more common in individuals with the dysplastic nevus syndrome than in control subjects derived from the general population. METHODS: Power calculations were used to determine the sample size. After invitation, 162 individuals with the dysplastic nevus syndrome and 119 control subjects, matched for sex and age but otherwise randomized from the Stockholm county census file, were entered into the study. All individuals were examined in a masked fashion by the same ophthalmologist, and the presence of conjunctival and uveal melanocytic lesions and the iris color, skin type, and hair color of each individual were recorded. Contingency tables and odds ratios were used for statistical evaluation. RESULTS: The proportions of individuals with the dysplastic nevus syndrome featuring primary acquired melanosis of the conjunctiva, or nevi of the iris and choroid were not significantly different from those of control subjects. However, individuals with the dysplastic nevus syndrome appeared to have a more sun-sensitive skin type and a reddish or blond hair color more often than control subjects. CONCLUSION: In contrast to previous reports, this study suggests that ocular melanocytic lesions are no more common in individuals with the dysplastic nevus syndrome than in the general population. Therefore, this work does not provide support that periodic ophthalmic surveillance of individuals with the dysplastic nevus syndrome for the purpose of detecting conjunctival or uveal melanomas, or their precursors, is meaningful.     

Validation of the General Health Questionnaire-12: Using a sample of employees from England's health care services.

Psychiatric interviews were carried out to validate the General Health Questionnaire-12 (GHQ-12; Goldberg, 1972) for use with staff of England's National Health Service (NHS), and to determine the appropriate threshold score to identify probable cases. In a sample of 551 NHS staff, the correlation between the GHQ-12 and the Clinical Interview Schedule-Revised (CIS-R) was found to be .70. The receiver operating characteristic showed that a 3/4 threshold, higher than used in all but one previous study, gave the best conservative estimate of minor psychiatric morbidity. This threshold gave an estimated sensitivity of the GHQ-12 of .69 and specificity of .88. It reduced case rates by between 8% and 17% as compared with lower possible thresholds. Convergent and discriminant validation of the GHQ-12 was demonstrated through comparison with other measures of mental and physical health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)