Psychiatric diseases and their treatment in general practice in Germany. Results of a World Health Organization (WHO) study

As part of an international study initiated by the World Health Organization (WHO) about psychological disorders in primary health care, patients in the Federal Republic of Germany were compared with patients in other European centres. Patients from Germany do not differ from other European patients in respect to sociodemographic variables or psychiatric disorders. The most frequent CIDI-based diagnoses recorded in patients attending general practices are current depressive episodes (8.6%), generalized anxiety disorders (8.5%), neurasthenia (7.5%), and alcohol dependence (6.3%). In 20.9% of the patients at least one psychiatric diagnosis based on ICD-10 was recorded. In Germany significantly lower global ratings of health status are given than in other European centres although there is no difference in diagnostic prevalence rates. The recognition rate, i.e. the agreement between the CIDI-based ICD-10 diagnoses and the recognition as a case by the physician, is 56.2%-60.2%. On the other hand, the CIDI detects 90% of the patients described as psychologically ill by the physicians if subthreshold cases are also counted, or 46.4% if only defined diagnoses are taken into account. There is a significant correlation between severity of the psychiatric disorder and disability in social functioning. In Mainz and in the other European countries the disability rate of patients with a well-defined disorder is between 67.0% and 72.7%, whereas in Berlin this relation is not as clear, because especially in East Berlin there is a higher rate of unemployment in view of the political situation. Drug treatment is prescribed for 16.1% of the patients in primary care for psychiatric disorders. Half the patients recognized by physicians as cases receive medication. In the rest of Europe patients receive significantly more tranquillizers than in Germany, where the use of herbal drugs is more wide spread.     

Screening for anxiety disorders. Sensitivity and specificity of the Anxiety Screening Questionnaire (ASQ-15)

BACKGROUND: The paper describes the rationale, sensitivity and specificity of the Anxiety Screening Questionnaire (ASQ), a disorder-specific screening instrument for use in primary care. METHOD: Two hundred and fifty subjects sampled from psychiatric, primary care settings and the community, participated in a test-retest reliability as well as a procedural validity study, using the M-CIDI with DSM-IV algorithms as a diagnostic yardstick. RESULTS: The ASQ was found to be easy to administer and acceptable and efficient in terms of sensitivity and specificity for generalised anxiety syndromes. The test-retest item reliability was good to excellent with kappa values of 0.6 or above. As compared with the validity standard, the DSM-IV/CIDI diagnoses caseness sensitivity was generally high (above 82%) for all diagnostic domains covered, whereas the specificity was only high for DSM-IV threshold and subthreshold generalised anxiety disorder. CONCLUSIONS: These preliminary findings demonstrate the usefulness of this anxiety screening questionnaire, constructed closely following the guidelines of specific diagnostic criteria.     

Prevalence of comorbid anxiety disorders in primary care outpatients

OBJECTIVE: To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions. DESIGN: Observational study. SETTING: Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes. PATIENTS: Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression. MEASURES: Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed). METHODS: Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers. RESULTS: Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%). CONCLUSION: Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.     

Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care

Psychiatric disorders occur in 14% to 20% of American children and adolescents and are a leading cause of disability among them, yet fewer than one in five of these children are recognized. The most common psychiatric disorders presenting to pediatricians include ADHD, anxiety disorders, depression, substance-use disorders, and conduct disorder, Approaches to recognition include screening for psychosocial concerns using specific questions in the clinical interview, and using brief, written questionnaires. Case vignettes illustrate comprehensive treatment planning for children with psychiatric disorders in the primary care context. As psychopharmacologic treatments and the new subspecialty of pediatric psychopharmacology take on growing importance, the traditional oversight role of the pediatrician and effective communication among referring and consulting physicians remain critical to quality care.     

Untreated anxiety among adult primary care patients in a Health Maintenance Organization

BACKGROUND: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. METHOD: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. RESULTS: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. CONCLUSION: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.     

Mental disorders and disability among patients in a primary care group practice

OBJECTIVE: This article examines social and occupational disability associated with several DSM-IV mental disorders in a group of adult primary care outpatients. METHOD: The subjects were 1,001 primary care patients (aged 18-70 years) in a large health maintenance organization. Data on each patient's sociodemographic characteristics and functional disability, including scores on the Sheehan Disability Scale, were collected at the time of a medical visit. A structured diagnostic interview for current DSM-IV disorders was then completed by a mental health professional over the telephone within 4 days of the visit. RESULTS: The most prevalent disorders were phobias (7.7%), major depressive disorder (7.3%), alcohol use disorders (5.2%), generalized anxiety disorder (3.7%), and panic disorder (3.0%). A total of 8.3% of the patients met the criteria for more than one mental disorder. The proportion of patients with co-occurring mental disorders varied by index disorder from 50.0% (alcohol use disorder) to 89.2% (generalized anxiety disorder). Compared with patients who had a single mental disorder, patients with co-occurring disorders reported significantly more disability in social and occupational functioning. After adjustment for other mental disorders and demographic and general health factors, compared with patients with no mental disorder, only patients with major depressive disorder, bipolar disorder, phobias, and substance use disorders had significantly increased disability, as measured by the Sheehan Disability Scale. CONCLUSIONS: Primary care patients with more than one mental disorder are common and highly disabled. Individual mental disorders have distinct patterns of psychiatric comorbidity and disability.     

Pharmacotherapy]

The high prevalence of anxiety disorders implies the necessity of adequate treatment by GPs. Regarding psychopharmacological treatment benzodiazepines and antidepressants are the drugs of first choice, low potency neuroleptics, beta-blockers as well as the herbal medicine kava-kava may be indicated in special cases (e.g. low degree of anxiety, abuse or tolerability problems). The separation of generalized anxiety disorder from panic disorder seems to be essential due to treatment implications: antidepressants like Imipramine or SSRIs are the drugs of choice in the latter case. Hints regarding handling as well as possible side-effects of the different psychotropics are given, the combination with psychotherapy (relaxation techniques, behaviour therapy) is recommended being the best way of effective treatment.     

Current Issues in Anxiety and Depression: Comorbid, Mixed, and Subthreshold Disorders.

Recent attention has been given to the high frequency of coexisting anxiety and depressive symptoms that has served to challenge the more traditional view that these two disorders are typically discrete syndromes. Furthermore, research suggests that less severe states of anxiety and depression continue to be overlooked, despite their capacity to produce significant psychosocial impairment. Given the implications for diagnostic and treatment outcome, psychologists need to be aware of the epidemiology, clinical presentations, and treatment strategies surrounding comorbid and subthreshold anxiety and depression. We review the literature, present issues related to these syndromes, and discuss the implications for diagnostic and clinical activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Basal expression, subcellular distribution, and up-regulation of the proto-oncogene c-JUN in the rat dentate gyrus after unilateral entorhinal cortex lesion

OBJECTIVE: To compare perceived current mental health and disablement between primary care and end-stage renal disease (ESRD) patients, and to study social support and stress and severity of illness as possible determinants of mental health and disablement. METHOD: Observational cross-sectional analysis of 414 primary care patients in a rural community health center and 125 ESRD patients requiring hemodialysis in two community dialysis units. The Duke Health Profile (DUKE) anxiety-depression scale was used to assess mental health; the DUKE disability scale, to indicate disablement; the Duke Social Support and Stress Scale, to measure support and stress; and the Duke Severity of Illness Scale, to rate severity of illness. RESULTS: Perceived current mental health in terms of anxiety and depression symptoms was worse for primary care than for ESRD patients, and perceived current disablement was no different for the two groups. Patients' perception of their health status and of stress from family members were more closely associated with their level of anxiety and depression symptoms than were their diagnostic profiles or overall severity of illness. In turn, their level of anxiety and depression symptoms was the principal correlate of their disablement. CONCLUSIONS: The demonstration of strong relationships among anxiety and depression symptoms, disablement, and family stress in these two very different patient populations should stimulate further research and motivate clinicians to evaluate all three parameters as part of routine patient care.     

Prevalence of minor psychiatric disorders in an adult African rural community in South Africa

BACKGROUND: This paper reports on a two-stage community-based epidemiological study of selected minor psychiatric disorders conducted on an adult African population in South Africa. METHODS: Using a modified random cluster sampling method, 354 adults were identified as the first-stage sample, with the SRQ-20 being used as a first-stage screen. Clinical interviews based on DSM-IV checklists for generalized anxiety disorder, major depression and dysthymia were administered as the second-stage criterion to 81 subjects from the sample. RESULTS: The weighted prevalence for generalised anxiety and depressive disorders was 23.9% (95% CI 15.1%-32.7%), comprising: generalized anxiety 3.7%, major depression 4.8%, dysthymia 7.3%, and major depression and dysthymia 8.2%. Statistically significant associations were found between caseness and age, marital status, employment, income and educational level. CONCLUSIONS: The results are discussed in relation to comparative local and international data as well as in the context of the current restructuring of the mental-health care system in South Africa from tertiary curative care to integrated primary mental-health care.     

The spectrum of generalised anxiety in clinical practice: the role of short-term, intermittent treatment

BACKGROUND: DSM-IV generalised anxiety disorder (GAD) has a high lifetime prevalence, but subthreshold anxiety states are even more common, particularly in family practice. METHOD: Generalized anxiety is conceptualised as a spectrum of disorders, with transient anxiety at one end and GAD at the other. RESULTS: Based on long-term experience with family practice patients, the authors suggest that most anxious patients, wherever on this continuum they are placed, could be treated with short-term, possibly intermittent, rather than chronic anxiolytic therapy. Data are presented which show that 50% of chronic GAD patients are only in need of such short-term intermittent therapy. CONCLUSIONS: Further clinical research is needed to refine short-term, intermittent treatments for anxiety spectrum disorders, to make effective treatments available to those suffering from anxiety but falling short of diagnostic criteria for GAD, and to target more effectively the different treatment strategies.     

Stroke services in general practice--are they satisfactory?

BACKGROUND: The contribution of general practice and primary care teams to stroke care has received surprisingly little attention despite research evidence on the importance of coordinated care. AIM: To determine general practitioners' (GPs') and their patients' satisfaction with hospital and community services for stroke patients in Grampian Region, Scotland. METHOD: A questionnaire survey of 138 stroke patients and their GPs was carried out six weeks after each patient was discharged home between June 1995 and January 1996. Outcomes measured were GP and patient satisfaction with services, Barthel Index, Hospital Anxiety and Depression scores, London Handicap Score, and Homsat and Hospsat scores (satisfaction with stroke services). RESULTS: Response rates of 95% (131) for GPs and 91% (125) for patients were obtained. GPs and patients were generally satisfied with services. Stroke patients were more likely to have had contact with their GP than with any other service. Adverse comments from GPs focused on problems with hospital discharge letters. At six weeks, patients received an average of 2.5 community services and 1.5 hospital services, but there was wide variation across disability groups. CONCLUSIONS: Levels of satisfaction were high, but the wide range and variation in services used by patients emphasized the complexity of the primary care of stroke patients; the need for coordination, review and effective links with hospital; and the key role of the GP.     

Minor depression in a cohort of young adults in Israel

BACKGROUND: A diagnosis of minor depression was considered for DSM-IV. Mild depression is thought to be common in primary care settings and the community, but studies of the validity of minor depression as a separate diagnostic category are few. METHODS: Minor depression as defined by Research Diagnostic Criteria was assessed by psychiatrists using a modified Schedule for Affective Disorders and Schizophrenia-Lifetime version in a cohort of 5200 young adults in Israel. Subjects with year-prevalent minor depression were compared with subjects with major depression or generalized anxiety disorder and with controls on aspects of psychopathologic condition, psychosocial functioning, help-seeking behaviors, and demographic correlates. RESULTS: Symptomatically, minor depression appeared to be a mild version of major depression. Minor depression was associated with good teenage and general social functioning, but also with absence from work, separation or divorce, recent impairment in overall functioning, and help-seeking. CONCLUSIONS: The results lend support for including minor depression or expanding severity modifiers in future classifications to better capture the phenomenon of subthreshold depression.     

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.     

Psychopharmacologic treatment of panic, generalized anxiety disorder, and social phobia

The anxiety disorders discussed in this article are common, affecting 5% to 10% of the general population. They may cause significant distress and disability and are often complicated by substance abuse and depression. Fortunately, these disorders can be treated successfully in the majority of patients, with alleviation of the most distressing symptoms and significant improvement in occupational and social functioning. Systematic research studies during the past decade have identified both specific medication-responsive anxiety syndromes and a variety of psychopharmacologic agents effective in their management. Psychopharmacologic treatment, often in combination with cognitive-behavioral therapies, can be tailored for the individual patient based on that patient's specific anxiety syndrome, comorbid disorders, and vulnerability to side effects. Careful monitoring of target symptoms can be used to assess the efficacy of treatment. Future research will help to develop new classes of antianxiety agents for currently treatment-resistant patients, and to investigate further the necessary duration of psychopharmacologic treatment.     

Deposition of genetically engineered human antibodies into the egg yolk of hens

This is an exploratory study that investigated factors influencing the psychosocial adjustment of Central American immigrants with disabilities. The relationships between stress, and perception of disability severity and (a) depression and (b) anxiety were assessed. Furthermore, this study investigated whether social support moderated the impact of stress and severity of disability on depression and anxiety. Stress, severity of disability, and social support explained a high percentage (54%) of the variance in depression. High levels of stress, increased perceptions of severity of disability, and low social support were associated with increased depression. The interactions between support and stress and between support and disability severity did not significantly add to the original model which predicted depression. Main effects were found for stress, disability severity, and the interaction between support and disability severity. Stress and social support significantly accounted for 31% of the variance in anxiety. Increased stress and decreased social support were associated with greater levels of anxiety. The interaction between support and stress did not significantly predict anxiety. Implications of the study in terms of future research and intervention programs targeting mental health outcomes for Latino immigrants with disabilities are discussed.     

Eating habits of employees in the metal industry: determinants and patterns]

OBJECTIVE: To describe the proportion of frequent attenders among primary health care patients and their sociodemographic characteristics, morbidity and reasons for encounter. DESIGN: A cross-sectional case-control study. SETTING: A municipal health centre in Oulainen, a small rural town in northern Finland. PARTICIPANTS: Three hundred and four frequent attenders (eight or more visits to health centre physicians (GPs) during the year 1994) and 304 age- and sex-matched controls. MAIN OUTCOME MEASURES: Sociodemographic characteristics, numbers of encounters, chronic diseases classified by ICD-9 and reasons for encounter coded by the International Classification of Primary Care chapter codes (ICPC). RESULTS: 4.7% of the population aged 15 years or older and 6.8% of the annual patients were frequent attenders and they made 23.5% of all encounters with GPs. The frequent attenders had lower basic education and there were more people on disability pension among them. They had significantly more mental disorders and diseases of the musculoskeletal and digestive systems than the controls. The frequent attenders' most common reasons for encounter were musculoskeletal problems, and they had significantly more musculoskeletal, digestive system and psychiatric reasons for encounters than the controls. CONCLUSIONS: Frequent attenders express more somatic and less psychiatric reasons for encounter than can be assumed according to their morbidity. The role of somatization is discussed.     

Primary immunodeficiency disorders

The primary immunodeficiency diseases are a relatively rare group of congenital disorders that are linked by the expression of an excessive number, duration, or severity of infections. The clinical features of most of the primary immunodeficiency diseases have been well described by astute physicians over several decades and have provided important clues to our basic understanding of human immunology. In contrast, the genetic basis and potential life-saving therapies for many of these disorders have been established only over the past few years. These recent advances have resulted in the prognosis of many of these disorders being largely dependent on their rapid recognition and treatment. Increased awareness of the differentiating epidemiologic, clinical, laboratory and genetic features of these diseases hold the promise of both furthering our understanding of basic human immunology and providing improved care for this challenging group of patients.     

Natural killer and lymphokine-activated cytotoxicity following anaesthesia in patients with uveal malignant melanoma

OBJECTIVE: The aim of the study was to determine the pattern of health care utilization of people aged 55-74 years with arthritic pain in the knee or hip. DESIGN: People with current pain were identified in a population-based study. A filter model was used to describe the pattern of health care utilization of people who presented as patients at different levels (GPs or specialist) of the health care system in the Netherlands. SETTING: The study was carried out in the district of Ommoord in Rotterdam in an age- and gender-representative sample of 831 (response 83%; n = 691) people. STUDY PARTICIPANTS: A group of 186 people with current pain was identified. They completed a questionnaire and were interviewed. MAIN OUTCOME MEASURES: Background variables, illness-related variables (including radiological osteoarthritis), and self-reported diagnoses were described and compared for attenders and non-attenders of GPs and specialists. A reference group of patients of GPs was used to determine the validity and generalizability of the findings. RESULTS: Eighty-two per cent consulted a GP (passed filter 1). In 69% of the GP attenders, 'arthritis' was identified (passed filter 2), and 65% of them attended a specialist (passed filter 3). People who did not pass the various filters were different from those who did with respect to the body mass index (lower; OR 1.24), the chronicity of pain (less chronic pain; OR 4.9) and attendance of a physiotherapist (lower; OR 5.6). The chronicity of pain seems of more importance in determining the health care utilization pattern than the severity of pain, the level of disability or the presence of radiological osteoarthritis. We suggest that health promotion interventions could increase the self-management ability of patients and could lower costs.