Alexithymia, hypochondriacal beliefs, and psychological distress among frequent attenders in primary health care.

Frequent use of health services has been associated with such concepts as alexithymia, hypochondriasis, and psychological distress. The aim of this case-control study was firstly to assess whether alexithymia, hypochondriasis, and psychological distress are associated with frequent attendance and secondly to assess the gender differences of these associations in a primary health care setting. A sample of 304 frequent attenders (eight or more visits during 1 year), including all of the frequent attenders during 1994, and 304 randomly selected age- and sex-matched controls were selected. Half of the sample (every second individual selected in date-of-birth order) was invited for an interview, 113 frequent attenders and 107 controls completed a questionnaire during the interview. Alexithymia was measured with the Toronto Alexithymia Scale-20 (TAS-20), hypochondriasis was screened with the Whiteley Index (WI), and Symptom Checklist-36 (SCL-36) was used to determine psychological distress. We found a distinct gender difference in the associations of these characteristics with frequent attending. Significant associations of alexithymia, hypochondriasis, and psychological distress with frequent attending were found among men, but not among women. Alexithymia, hypochondriasis, and psychological distress should be considered when treating frequent attenders, especially males.     

Children with psychiatric disorders who are frequent attenders to primary care

Child psychiatric disorder has been found to be linked to enhanced primary care attendance. We studied the somatic and psychological associations of psychiatric disorder amongst frequent (four or more consultations a year) primary care attending school children. We compared 32 children aged 7–12 years with a psychiatric disorder with 77 non-disordered (also frequently attending) children. Psychiatric disorder was not associated with type of presenting complaint at the surgery nor with chronic physical illness. However disordered children were more likely to be described by their mothers as handicapped by existing physical problems, in poor health, with low energy levels and likely to experience physical symptoms under stress. Problems in social relationships and educational difficulties were reported in more disordered children; more of them came from broken homes and had mothers who reported other psycho-social and health stresses and showed characteristic health beliefs. The findings indicate that knowledge about the child's general physical well-being and relationships and about maternal mental health may assist in the primary care identification and management of psychiatric disorders of frequently attending school children. Accepted: 17 September 1998     

Adolescents who are frequent attenders to primary care: contribution of psychosocial factors

Background  

Frequent attendance to primary care services has shown an association with psychosocial factors in adult and child populations. Little is known about the psychosocial correlates of attendance in adolescents.     

Somatized depression in primary care attenders

OBJECTIVE: The aim of this study is to determine, within the context of primary care, the frequency of the various ways in which depression is presented with respect to somatic symptoms and to compare depressed patients who present their distress somatically with those with psychological complaints. METHOD: In the two-phase cross-sectional study, first, we screened 906 consecutive patients, and second, we interviewed in detail 306 selected patients. RESULTS: The prevalence of depression was 16.8% (CI 95%: 13.4-20.2). There were 59 cases with psychological presentation, 45 somatizers and 16 had organic disorders with depressive comorbidity. Somatizers had lower level of education, and somatized depression was less serious and caused less repercussion. Detection, antidepressive treatment and psychiatric care were lower for somatizers than for psychologizers. CONCLUSIONS: Somatization is a frequent way to present depression in primary care. For somatizers, depression is less severe and is associated with less repercussion. Somatization is associated with the under-detection of the underlying psychiatric process.     

Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8--18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3--47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5--2959.0), and more GP visits (95% CI for difference=-10.2 to -5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.     

Depressive symptoms amongst adolescent primary care attenders

Abstract. Background: Background High rates of depressive disorder have been documented amongst adolescents attending general practitioners (GPs) in urban areas. However, little is known about the associations of adolescent depression in primary care. Method: We completed a cross-sectional questionnaire survey of adolescents, their parents and general practitioners, following adolescent attendance at the surgery. Results: We found high levels of depressive symptoms to be present in adolescent attenders of a broad range of social backgrounds. Depressive symptoms were associated with the following demographic and contextual factors: older age, female gender and parental psychiatric symptoms. They were also associated with the presence of physical symptoms causing psychosocial impairment, with health risks (use of cannabis and exposure to drugs) and with use of services (both primary care and mental health services). Levels of depressive symptoms were similar in urban and suburban groups. However, associations of depressive symptoms with smoking, exposure to drugs, cannabis use and primary care attendance were demonstrated in the suburban group and not the urban group. Conclusion: Adolescent GP attenders have high levels of depressive symptomatology. GP recognition and intervention should have the potential to impact on adolescent depression and on associated risks.     

Somatization in frequent attenders of general practice

The DSM-III-(R) definition of somatization disorder is too restrictive for use in general practice. A more comprehensive definition, the somatic symptom index (SSI) has shown good validity in open populations. However, a definition has to differentiate validlywithin a population of frequent attenders to be a useful diagnostic instrument in general practice. We studied a threshold of five complaints (nearly identical to the SSI) in 80 Dutch general practice patients. Patients were selected on age (20–44 years), history of back, neck or abdominal complaints, and on frequency of consultation—at least 12 consultations in the previous 3 years, corrected for consultations with compelling somatic reason for encounter. Prevalence of somatization in this group was 45%. Women had a 2 times higher risk of somatization. A relation with age was not found. Somatization was related to depressive complaints (relative risk 2.5) and probably also to anxiety. Somatizing patients consulted their general practitioner more often and had more health problems (especially psychic problems) than non-somatizers. These results support the validity of this definition. The distinction between our definition of somatization and somatization defined as a symptom of psychiatric (e.g. depressive or anxiety) disorder is emphasized.     

Mental, physical and functional status in primary care attenders

OBJECTIVE: The purpose of the present study was to analyze the association, in primary care attenders, between psychiatric disorders, medical comorbidity, and impairment in mental and physical function status. METHODS: The study had a two-stage design. The GHQ-12 was used to screen 1647 patients, and 323 of them were then interviewed using the CIDI-PHC to obtain ICD-10 diagnoses. Severity of mental illness was assessed using the Hamilton scales for anxiety and depression. The DUSOI was used to evaluate the severity of physical illness. The MOS SF-36 was used to assess health related quality of life. RESULTS: The estimated prevalence of ICD-10 psychiatric disorders and subthreshold disorders was 12.4 percent and 18 percent respectively. The most common psychiatric disorders were generalized anxiety, major depression, and neurasthenia. The severity of physical illness did not vary across diagnostic status categories. Significant impairment, both in physical and mental functioning was seen in patients suffering from ICD-10 full-fledged and subthreshold disorders. Severity of impairment increased from sub-threshold cases to full-fledged cases, and among the latter according to the severity of depressive and anxious symptoms, assessed using Hamilton scales. The most frequent psychiatric disorders were associated with significant worsening in health related quality of life, with relevant differences between psychiatric diagnoses regarding the domains affected. Impairment associated with mental disorders was greater than that associated with physical illness. CONCLUSIONS: The results of the present study confirm that ICD-10 psychiatric disorders are common in general practice and are associated with relevant impairment in physical and mental functional status. Psychiatric morbidity is not related to severity of physical illness rated by general practitioner.     

The frequent consulter in primary medical care

A comparison is reported between a group of frequent consulters of general medical practitioners and a group of infrequent consulters. The frequent consulters reported more symptoms, particularly upper respiratory, gastro-intestinal and back troubles. They took more proprietory medicines and more vitamin pills and were less inclined to ignore symptoms. They were more inclined to negative mood. Although they had slightly fewer stressful life events they coped less well with them, perhaps because they had less satisfactory family and social support and found less distraction in social activities. By means of a model the symptoms of these subjects are contrasted with symptoms found in psychosomatic disorder.     

Post-traumatic stress associated with low self-rated well-being in primary care attenders

In this study, we assessed the prevalence of self-rated post-traumatic stress in relation to reported trauma in an unselected primary care population. A total of 1,113 out of 1,378 consecutive attenders (response rate 81%) to 10 health centres completed the self-report instruments Impact of Event Scale (IES), and Post Traumatic Symptom Scale (PTSS-10). A horizontal visual analogue scale (VAS; 0-100 mm) resembling the EuroQoL (quality of life) health barometer was used for evaluating well-being. Trauma was reported by 325 attenders (29.2%) when applying DSM-IV trauma criteria. Prevalence of possible post-traumatic stress disorder (PTSD) was 6.5% (n=72) using cut-off scores of >35 for IES and >5 for PTSS-10. The two most common traumas in the PTSD group were accidents (2.0%, n=22), followed by cancer (1.3%, n=15). When excluding diseases and unspecified death as trauma, the rate of possible PTSD was 3.5% (n=39). Mean VAS-QoL score was 39.6 mm in the PTSD group (n=72), and 64.7 mm in the non-PTSD group with a reported trauma (n=253). In a multiple logistic regression analysis low self-rated well-being showed the strongest association with possible PTSD, followed by sexual assault, female gender, immigrant status and less than 2 years since trauma.     

The prevalence of personality disorder among UK primary care attenders

OBJECTIVE: To determine the prevalence rate of personality disorder among a consecutive sample of UK primary care attenders. Associations between a diagnosis of personality disorder, sociodemographic background and common mental disorder were examined. METHOD: Three hundred and three consecutive primary care attenders were examined for the presence of ICD-10 and DSM-4 personality disorders using an informant-based interview. RESULTS: Personality disorder was diagnosed in 24% (95% CI: 19-29) of the sample. Personality-disordered subjects were more likely to have psychiatric morbidity as indicated by GHQ-12, to report previous psychological morbidity, to be single and to attend the surgery on an emergency basis. 'Cluster B' personality disorders were particularly associated with psychiatric morbidity. CONCLUSION: There is a high prevalence rate of personality disorders among primary care attenders. These disorders are associated with the presence of common mental disorder and unplanned surgery attendance. Personality disorders may represent a significant source of burden in primary care.     

Prevalence of khat chewers among primary health clinic attenders in Kenya

In a rural district hospital in Kenya, the authors screened 100 randomly selected outpatients for khat (miraa) chewing. A surprisingly high number of them admitted chewing khat leaves. The implications of this finding and the controversy about whether or not khat is a harmful drug are discussed.     

Depression and frequent attendance in elderly primary care patients

OBJECTIVE: The aim of this study is to investigate the association between depression and frequent attendance in elderly primary care patients. Moreover, we compare the prevalence and clinical characteristics of frequent attenders (FAs) in the elderly and the nonelderly patients. METHODS: This nationwide, cross-sectional, two-phase epidemiological study involved 191 primary care physicians (PCPs) and 1896 patients aged 14 and over. We consider FAs those subjects attending PCP practice more than once a month in the last 6 months. Screening for psychiatric disorders was conducted by using the General Health Questionnaire-12. Subsequently, probable cases were assessed by the PCPs with the WHO ICD-10 Checklist for Depression. RESULTS: Prevalence value of frequent attendance was 22.4% in the elderly. Depression was associated with frequent attendance in the elderly even after controlling for physical illness and unexplained somatic complaints. The risk for being an FA was more than twofold in the elderly than in the nonelderly (cOR=2.58; 95% confidence interval, 1.97-3.37). Considering subjects without medical illness, depression increased the risk of being an FA fivefold among the elderly and threefold among the nonelderly. CONCLUSION: Frequent attendance in primary care is associated with depressive disorder in the elderly. Depression seems to play a more important role in determining frequent attendance in the elderly patients in respect to the nonelderly.     

A survey of frequent attenders at a gastroenterology clinic

OBJECTIVE: To examine a group of patients satisfying criteria for "frequent attending" as part of an audit of an outpatient gastroenterology service, and to note the prevalence of those with no conspicuous organic disease to account for their symptomatology. METHODS: We used the hospital computer (Oxford Patient Administration System, OXPAS) to identify 2530 consecutive patients who were given an appointment to attend the gastroenterology clinic during an 11-month period. Patients designated "frequent attenders" had their notes flagged before the clinic attendance and were examined in more detail. A frequent attender was defined as a patient who had attended any hospital outpatient clinic in the three Oxford general hospitals on four or more occasions in the previous 12 months. The gastroenterologist then interviewed the patients satisfying these criteria and indicated whether he/she was satisfied that there was no relevant organic disease to account for the symptoms. RESULTS: Of the total 2530 patients, 762 (30%) satisfied our criteria for frequent attendance (FA). Of these, 452 (59%) had organic disease, 128 (17%) either did not attend or cancelled and 159 (21%) had no relevant organic disease. The diagnosis was uncertain in 23 patients (3%). Of patients satisfying our criteria for frequent attending, approximately 20-25% had no established gastroenterological disease. CONCLUSIONS: Frequent attenders present formidable management problems for the gastroenterologist. If they can be identified by computer before the outpatient visit then assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.     

Psychiatric morbidity, disability and service use amongst primary care attenders in France.

Attenders (n = 124, response rate 84%) of five GPs in Montpellier completed questionnaires on health (reason for visit, cause of problem, GHQ-12), disability (WHODAS II) and service use (CSRI). For each patient, the GP filled in a brief form including a rating of severity of physical and psychological illness. Overall 30.6% of patients were classified as GHQ cases indicating probable non-psychotic psychiatric morbidity and 58.9% were rated as having a physical illness by the GP. Patients with psychiatric morbidity showed as high levels of disability as those with a physical illness, with however a greater number of domains of life affected. They also had a greatly increased number of disability days and used services to a greater extent than those without psychiatric morbidity, these links being stronger than with physical illness. Use of the WHODAS II and the CSRI has not been previously reported in France. This study shows that they could be useful instruments for depicting disability and service use in general practice. The findings from this initial study indicate the need for greater research in primary care focusing on accurate detection and treatment of patients so that disability and excess service use associated with psychiatric morbidity might be reduced.     

The FEAR: a rapid screening instrument for generalized anxiety in elderly primary care attenders

OBJECTIVE: To develop a shorter version of the Anxiety Disorder Scale (ADS) for use as a rapid screening instrument in primary care. DESIGN: Two-stage screening design. Primary care attenders aged 65 and over were screened for generalized anxiety in the surgery with the 11-item generalized anxiety subscale of the ADS (ADS GA), a selected subsample then proceeding to a clinical validation interview. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Scores on the ADS GA, non-hierarchical ICD-10 caseness for generalized anxiety established by brief clinical interview by an old age psychiatrist. RESULTS: The prevalence rate of generalized anxiety was 16% using the established cutpoint and showed an age-related decline. A cutpoint of 2-3/11 appeared to give optimal performance in this small sample (sensitivity 85%, specificity 77%, positive predictive value 52%), suggesting that 36% of elderly general practice attenders might be diagnosed as having generalized anxiety. A reduced four-item version gave a predicted sensitivity of 77%, a specificity of 83% and a positive predictive value of 63% (cutpoint 1-2/4). CONCLUSIONS: A four-item version of the ADS GA, the FEAR (frequency of anxiety; enduring nature of anxiety; alcohol or sedative use; restlessness or fidgeting), has potential as a rapid screening instrument for use in primary care.     

Frequent attenders without organic disease in a gastroenterology clinic. Patient characteristics and health care use

We used a hospital computer to identify 50 patients (35 women, 15 men) satisfying research criteria for "frequent attenders" at a gastroenterology outpatient clinic (four or more visits to a general hospital clinic in the previous 12 months). Their mean duration of symptoms was 5 years, and 80% reported fatigue as a significant complaint. Thirteen (37%) of the women were also consulting a gynecologist, and in nine of these their status was normal. Seven (21%) of the 35 women who were interviewed had a history of childhood sexual abuse, and these patients reported significantly more lifetime somatic symptoms (9.7, SD = 3.8) than those without such a history (5.4, SD = 3.5, p = < 0.01). The 50 patients reported high levels of disability and psychological distress, and were more likely to rate the probability of their symptoms as being due to "bowel disease" than to "stress" or "other problems." Forty-five patients had at least one current psychiatric diagnosis and 24 at least two, with somatoform disorders being the most common. Nineteen (38%) reported infrequent panic attacks, but only three had somatization disorder. The mean number of lifetime somatic symptoms was 5.9 (SD = 3.6; range 1-14). Seventeen patients (35%) also satisfied criteria for frequent attending in primary care (> 12 visits over the previous 12 months), and the patients reported a mean number of 5.7 (SD = 2.1) specialist appointments in the previous year. There may be a case for using the hospital computer to identify frequent attenders proactively at an earlier stage of their hospital visits so that appropriate management can be instituted. If such patients can be identified in this way, their assessment and management might be more appropriately supervised in designated clinics by more experienced gastroenterology staff.