Global versus specific symptom attributions: predicting the recognition and treatment of psychological distress in primary care

OBJECTIVE: Researchers have shown that primary care patients utilize global attribution styles to interpret ambiguous physical symptoms, diminishing the ability of practitioners to recognize psychological disorders. The present study examined the extent to which patients' specific beliefs about their presenting symptoms versus their global symptom attribution styles predict physician recognition of psychological distress and mental health treatment recommendations. METHODS: Participants included primary care patients attending a five-physician medical practice. Patients completed surveys regarding their level of psychological distress, symptom attribution style, and perceptions of their presenting problems and medical consultations. Physicians completed brief assessments of each patient encounter. RESULTS: Patient gender, age, severity of psychological distress, and beliefs about their presenting symptoms were reliable predictors of physician recognition and treatment recommendations. Global symptom attribution styles did not relate to these outcomes above and beyond the specific beliefs of patients. CONCLUSION: Patients' specific beliefs about their presenting symptoms play an important role in predicting physician recognition and treatment of psychological distress.     

Severity of child maltreatment, pain complaints and medical utilization among women

High medical utilization in adults has been linked to both reported history of childhood abuse and mental health problems. However, few studies have explored relationships between abuse severity and psychological distress to identify subgroups with unique utilization patterns and medical complaints. This study compared two groups of psychologically distressed, high utilizers. One group (DS) was comprised of those with psychological distress, who reported a history of child sexual abuse (CSA); the other group (DSP) consisted of those with psychological distress, who reported CSA plus a history of childhood physical abuse. The groups were compared on severity of sexual and nonsexual child maltreatment, medical complaints and medical utilization. From a convenience sample of 206 females age 20–63, recruited while waiting for a physician appointment in a primary care clinic, we compared 25 DSPs to 33 DSs. Compared with DSs, DSPs reported significantly more severe: (1) sexual abuse including completed intercourse; (2) emotional abuse; (3) emotional neglect; and (4) psychological distress. DSPs also showed a nonsignificant trend towards more severe physical neglect. In addition to being significantly higher on emergency room visits, DSPs were marginally higher than DSs on nonpsychiatric outpatient visits. DSPs had significantly more frequent chronic and acute pain complaints at emergency room (ER) visits. Headaches were the most frequently coded diagnosis at ER visits in this sample. DSPs accounted for 89% of these ER visits attributable to headaches. The interaction of psychological distress and reported severity of child maltreatment reveals subgroups with unique utilization patterns and medical complaints. Physicians should screen patients for child maltreatment severity and psychological distress and should be involved in mental health referral where necessary.     

Depressive symptoms and psychiatric distress in low income Asian and Latino primary care patients: prevalence and recognition

The aims of the study were to: (a) assess the degree to which primary care physicians recognize psychiatric distress among an ethnically diverse primary care sample composed primarily of Asians and Hispanics; and (b) to investigate the relationship between patient and physician sociodemographic factors and overall diagnostic recognition of psychiatric distress. The study sample is comprised of 252 consecutively-selected patients and eleven primary care general internists from general medicine clinics in a large public ambulatory medical center. The measures used were the Center for Epidemiologic Studies-Depression (CES-D) scale, a demographic questionnaire, and an acculturation scale; these measures were completed during interviews conducted by trained bilingual research assistants. Physicians completed a mental health treatment summary immediately after the patient's visit. Hierarchical logistic regression analyses were performed in order to examine: (1) the degree to which providers identified psychiatric distress and (2) overall diagnostic recognition among this sample in relation to demographic characteristics and degree of acculturation. As measured by the CES-D, almost one half (47.3%) of the Latino and 41.6% of the Asian patients had depressive symptoms indicative of psychiatric distress. In contrast, physicians identified 43.8% of Latino patients and only 23.6% of Asian patients as being psychiatrically distressed (p < .01). Physicians were more likely to classify Latinos and those with higher acculturation status as distressed (p < .01 and p < .05, respectively). Higher patient acculturation status was the only factor significantly associated with overall diagnostic recognition (p < .05), as measured by physician agreement with the CES-D. Being Asian and/or having low acculturation levels may put the patient at risk for non-detection of psychiatric distress. The high prevalence of distress lends support to initiating improved methods for screening and detection of depression among low income and racially diverse primary care patients.     

Primary care physicians' detection of psychological distress among elderly patients.

OBJECTIVES: Elderly persons suffer from high rates of psychological distress that are sometimes unrecognized by healthcare providers. Authors compared rates of psychological distress and physician detection among elderly and non-elderly primary-care patients and examined, among elderly patients, variables associated with distress and physician detection. METHODS: This was a national survey of a sample of 2,325 Israeli primary healthcare recipients and 67 physicians. Patients completed the General Health Questionnaire (GHQ) and background questionnaires. Physicians completed forms indicating their diagnosis and treatment and their attitudes toward elderly patients. RESULTS: Of those age 60 and over, 58.7% had a GHQ score reflecting distress, as did 49% of those age 40-59 and 30.4% of those age 18-39. There was no age-group difference in physician concordance on GHQ. In elderly patients, variables associated with GHQ psychological distress were being female, having more self-reported chronic diseases, poorer self-reported health, and more frequent primary-care clinic visits. Physician agreement with GHQ distress for elderly patients was best for female patients and patients who visited a physician more often. Physicians treated 71% of the instances of distress they noted in older patients and 42% of the GHQ-detected cases. CONCLUSIONS: Physicians appear to detect distress no less accurately among older than younger patients. A majority of elderly primary-care patients are distressed, and many of them are neither diagnosed nor treated for distress. Increased attention by primary-care physicians to possible psychological distress among elderly patients who perceive their health status as poor and those patients who visit more frequently could improve detection of distress among these elderly patients.     

Disaster severity and emotional disturbance: implications for primary mental health care in developing countries

Two months following the 1987 earthquakes in Ecuador, 150 patients in the primary health care clinics of the area were screened for emotional problems; 40% of them were emotionally distressed. Risk factors included not being married, reporting poor physical or emotional health, and having ill-defined physical complaints. The findings from this research are discussed in relation to a disaster of much greater intensity, whose victims were studied by the authors, utilizing the same instrument and research design. The comparison between these 2 groups of disaster victims revealed that: 1) the prevalence of emotional distress was smaller among the Ecuador victims, but the frequency of symptoms among the distressed was similar for both groups; 2) the symptom profiles were remarkably similar; and 3) the most frequent symptoms and the strongest predictors of emotional distress were very similar. These findings support a focused training of health care workers on selected emotional problems that are regularly present among victims of different disasters.     

Perceived health status and perceived diabetes control: psychological indicators and accuracy

OBJECTIVE: The aim of this study is to assess the association of psychological, as well as physical and sociodemographic, indicators with patients' ratings of personal health status and diabetes control and to investigate the association of mental health and depression with errors in the perception of diabetes control. METHOD: A sociodemographically diverse sample of 623 diabetes patients was recruited from the general medicine clinics of a county health care system and a Veterans Affairs health care system. We examined three types of determinants of patients' health perceptions: physical health indicators (symptoms, comorbid diagnoses, and glycosylated hemoglobin or HbA1c levels), psychological health indicators (general mental health and diabetes-related worry), and sociodemographic factors (age, race, gender, income, and education). RESULTS: After controlling for patient' sociodemographic characteristics, perceived general health was associated with patients' symptom burden and emotional distress (but not with patients' HbA1c levels). Perceived diabetes control additionally was associated with HbA1c and diabetes-related worries. Further analyses showed that both mental health and diagnosed depression were associated with errors in personal appraisals of diabetes control, with depressed patients more often inaccurately assessing their glycemic control as poor (false-positive error) and nondepressed patients more often missing poor HbA1c levels (false-negative error). CONCLUSIONS: Findings indicate that patients use a comprehensive model for assessing their general health and that depression may lead to more accurate assessments of poor glucose control.     

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.     

Family Support, Self-Rated Health, and Psychological Distress

BACKGROUND: Comprehensive health care is becoming an important issue; however, little is known about the complex relationships between perceived family support, self-rated health, and psychological distress in mixed middle-aged/older primary care patient samples. METHOD: In this cross-sectional and predominantly male sample of 137 patients attending their appointments at a primary care clinic in a Department of Veterans Affairs Medical Center, participants completed several questionnaires including the Family Adaptation, Partnership, Growth, Affection, and Resolve; the General Health Questionnaire-12; the Symptom Checklist-10; and the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questionnaire and interview. Data were collected in 1998. Eighteen percent of the participants were diagnosed with a mood disorder, and 15% were diagnosed with an anxiety disorder (PRIME-MD diagnoses). RESULTS: Perceived family support and self-rated health were negatively associated with psychological symptoms and certain psychological disorders, while perceived family support and self-rated health were positively rated. In addition, the interaction between perceived family support and self-rated health was significant (p <.01) in relating to psychological symptoms such that psychological symptoms were most elevated in participants reporting dissatisfying family support combined with poor self-rated health. However, the cross-sectional nature of the study prevents causal conclusions from being made. CONCLUSIONS: Physicians and other health care professionals are encouraged to assess both the perceived family support and self-rated health in an effort to conceptualize their patients' problems in a more comprehensive manner.     

Posttraumatic stress disorder in primary care: a hidden diagnosis

Posttraumatic stress disorder (PTSD) is common worldwide, with prevalence rates ranging from 1% to nearly 40%, depending on the population studied. The disability and natural course of PTSD in psychiatric patients have been well characterized. However, even though the primary care setting has been described as the "de facto mental health care system," surprisingly little is known about PTSD in primary care. Available data from primary care clinics in the United States and Israel suggest that PTSD may be as prevalent in this setting as has been reported in large epidemiologic studies. Patients may be unlikely to endorse traumatic experiences or may not consider them related to their current psychological problems. The prevalence of PTSD in primary care may indeed be higher than expected because of underreporting of domestic violence and other histories of trauma. Recognition of PTSD in primary care could be greatly improved if simple trauma histories were integrated into routine medical examinations. Primary care clinicians who maintain a high index of suspicion for PTSD in their patients with positive histories of trauma plus symptoms of depression or anxiety or other signs of psychological distress, suicidal thoughts or actions, alcohol or substance abuse, or excessive health care service utilization may increase the recognition rate of this disorder in their practices.     

Mental health outcome of unilateral lower limb amputee soldiers in two districts of Sri Lanka

BACKGROUND: Thousands of armed forces personnel in Sri Lanka have undergone lower limb amputations due to war injuries. AIMS: The aims were to describe the mental health outcome of unilateral lower limb amputee male soldiers of the Sri Lanka Army in comparison with nonamputee males and to identify factors affecting the mental health outcome. METHODOLOGY: Selected amputee soldiers (n = 461) and controls (n = 461) were evaluated for psychological distress using self-administered versions of GHQ-30 and BSI. Alcohol and drug consumption patterns were compared. Probable addiction to alcohol and drugs were assessed using the CAGE questionnaire. RESULTS: A majority were below-knee amputees (413, 89.6%). Among amputee soldiers 36% were found to be psychologically distressed according to GHQ-30 while 13.4% were found to be psychologically distressed using BSI. Psychological distress was greater among amputee soldiers compared to controls (p < 0.001). Alcohol consumption and substance abuse were more common among amputees (p < 0.05), as was probable addiction to alcohol (p < 0.001). Being less than 30 years of age (OR =1.6, 95% CI (1.12-2.26)) was a factor influencing presence of psychological distress, characterized by psychological symptoms. Employment in the army adversely influenced psychological distress, characterized by psychological symptoms (OR = 2.35, 95% CI (2.0-3.64)) and by somatic symptoms (OR = 1.8, 95% CI (1.23-3.14)). CONCLUSIONS: The study concluded that amputees have a comparatively poor mental health outcome, which could be improved by modifying some associated factors.     

Use of mental health and primary care services by caregivers of patients with bipolar disorder: a preliminary study

OBJECTIVES: Caring for a relative with schizophrenia or dementia has been associated with reports of caregiver burden, symptoms of anxiety, depression, poor self-rated health, and elevated health service use; however, comparable data for caregivers of relatives with bipolar disorder are lacking. This study reports preliminary data on the health, psychological distress and health service use of caregivers of patients with bipolar disorder. It additionally evaluates the relationship of the level of burden caregivers report experiencing to their use of health services, controlling for level of psychological distress and health status. METHODS: Subjects were primary caregivers of 264 patients with Research Diagnostic Criteria-diagnosed bipolar disorder and their bipolar relatives. Caregiver mental health and primary care service use were assessed retrospectively for the 7-month period prior to inpatient or outpatient admission of the bipolar patient. Caregiver depression, anxiety, medical conditions and patient symptomatology were assessed as well. RESULTS: Hierarchical logistic regression analysis demonstrated that caregiver burden significantly increased the likelihood of mental health service use (OR = 13.53, p < 0.001) even after controlling for caregiver psychological distress and medical conditions, while anxiety and depression level, but not burden, significantly increased the likelihood of primary care service use, controlling for other variables (OR = 1.72, p = 0.02). CONCLUSIONS: Burdens experienced by family caregivers appear to increase use of health services, and presumably cost, and may be reduced by psychosocial intervention.     

Use of health care services for psychological distress by immigrants in an urban multicultural milieu.

OBJECTIVE: Research in the United States tends to attribute low rates of use of mental health services by immigrants to economic barriers. The purpose of our study was to examine this issue in the context of Canada's universal health care system. METHODS: A survey of the catchment area of a comprehensive clinic in Montreal interviewed random samples of 924 Canadian-born individuals and 776 immigrants born in the Caribbean (n = 264), Vietnam (n = 234), or the Philippines (n = 278) to assess their health care use for somatic symptoms, psychological distress, and recent life events. RESULTS: Overall rates of use of medical services in the past year were similar in immigrant (78.5%) and nonimmigrant (76.5%) groups. Rates of use of health care services for psychological distress were significantly lower among immigrants (5.5% compared with 14.7%, P < 0.001). This difference was attributable both to a lower rate of use of specialty mental health services by immigrants (2.5% compared with 11.7%, P < 0.001) and to differential use of medical services for psychological distress (3.5% compared with 5.8%, P = 0.02). When level of psychological distress was controlled, Vietnamese and Filipino immigrants were one-third as likely as Canadian-born residents to make use of mental health services. The lower rate of use by immigrants could not be explained by differences in sociodemographics, somatic or psychological symptoms, length of stay in Canada, or use of alternative sources of help. CONCLUSION: Immigrant status is associated with lower rates of use of mental health services, even with universal health insurance. This lower rate of use likely reflects cultural and linguistic barriers to care.     

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care

OBJECTIVE: This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. METHOD: Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. RESULTS: Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. CONCLUSIONS: Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.     

Mental health experiences and needs among primary care providers treating OEF/OIF veterans: preliminary findings from the Geisinger Veterans Initiative

This study describes the results of the Reaching Rural Veterans Initiative (RRVI) funded by the Commonwealth of Pennsylvania and the Federal Government. The purpose of this project was to address the needs of veterans and their family members in rural communities who were seen by non-VA primary care providers. As part of this project, an assessment of healthcare providers' knowledge and awareness of mental health-related issues and experiences with veterans' healthcare services was conducted. Following this assessment, an education program was developed and implemented at primary care sites within the Geisinger Health System and also made available to other area providers. The survey indicated that Geisinger's primary care providers are currently involved with providing mental health care to area service members and their families. It was estimated that these providers saw about 1,200 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) patients and 3,600 of their family members in clinics over a 6 month period. A significant number of these persons had mental health problems. About two-thirds (65.4%) of providers reported having a mental health professional onsite and nearly 23% reported that over one-third of their patients have mental health problems. Significant mental health gaps discovered indicated that providers lacked knowledge of PTSD and other combat-related stress disorders, as well as knowledge of VA resources. In addition only 20% of the providers rated their mental health treatment skills as high and only about 8% reported that they had adequate knowledge of current mental health treatment strategies. Based on this needs assessment and the results of the provider intervention, further service improvements are planned.     

Self‐reported use of mental health services versus administrative records: care to recall?

Estimates of the level of unmet need for mental health treatment often rely on self-reported use of mental health services. However, depressed persons may over-report their use in relation to administrative records if they are highly distressed. This study seeks to replicate and explicate the finding that persons at a high level of distress report more mental health service use than recorded in their healthcare records. The study sample, N = 36,892, 12 years and older, was drawn from the 1996/97 Ontario portion of the Canadian National Population Health Survey. Respondents were individually linked to their administrative mental healthcare records 12 months backward in time. Of these, 96.5% agreed to the link and 23,063 (62.5%) were linked. Almost two-thirds of those who were depressed in the past year were currently at a high level of distress. Differential reporting of use for highly distressed persons in excess of 100% remained in the use of different types of physician providers after adjustments for other potential determinants of use. Telescoping was also not an explanation. The patterns of differential reporting between groups expected to diverge and converge in their recall ability were consistent with a recall bias. As this study was not able to rule out a recall bias, it further accentuates concerns about the impact of bias in the measurement of mental health-service use and inferences made concerning the determinants of use.     

Psychological problems in Christian and Moslem primary care patients in Greece

OBJECTIVE: Psychiatric problems are often expressed through, or coexist with, somatic symptoms. Cultural factors may influence this association. This study aims to 1) estimate the prevalence of mental health problems in a sample of primary care attendees in a rural area of Greece, and 2) investigate the differences in psychiatric symptomatology among patients from different religious/cultural backgrounds. METHOD: Over a three-month period, 300 consecutive adult patients (Christians and Moslems) at the rural Primary Care Health Centre of Iasmos in Thrace, Greece, were assessed with the 28-item General Health Questionnaire. RESULTS: The probable prevalence of mental health problems was estimated at 32 percent. Only for a small minority of the patients (3.3 percent) psychological problems were the presenting complaint. Moslems scored significantly higher than Christians in the somatic complaints subscale (p < 0.001). CONCLUSION: Mental health problems are common in primary care although they rarely constitute a reason for consultation. Sociocultural background may affect the presentation of psychological distress. Primary health care staff have a significant role in identifying hidden psychiatric morbidity.     

Mental health in older adult recipients of primary care services: is depression the key issue? Identification,treatment and the general practitioner

OBJECTIVES: Mental health services for older people in primary care are relatively underdeveloped. This study has sought to determine the nature and extent of mental health problems in older people presenting to primary care and to compare this with the detection and management of mental health problems by the primary health care team (PHCT). METHOD: Participants were patients aged 65 years and above attending a representative inner city general practice. Screening tools included the General Health Questionnaire (GHQ-28), Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE). The PHCT used a brief checklist to rate participants for the presence of mental health problems. Follow-up interviews using the Geriatric Mental State (GMSA), Cambridge Examination for Mental Disorders in the Elderly (CAMDEX)-cognitive subscale (CAMCOG), National Adult Reading Test (NART), were carried out. RESULTS: A high level of psychological morbidity was identified at screening (48.1%). There was a considerable degree of agreement between the HADS and GMSA, and the MMSE and GMSA at follow-up. Agreement rates between the PHCT and initial screening tools were low suggesting under-recognition of mental health problems at primary care level by the PHCT. Contributory factors included: short consultation times with a concentration on physical symptoms; few patients presenting explicitly with mental health problems; few decisions to treat or refer patients; and the general practitioners tended to monitor, or defer decisions. CONCLUSIONS: This study found lower levels of severe mental health problems, especially depression, than reported elsewhere, but higher prevalence of psychological distress. High levels of physical and mental health co-morbidity were found. These findings suggest that planning for primary care services needs to adopt a flexible assessment model. The development of effective, time-limited protocols and screening tools to assist the PHCT in improving their identification rates is recommended. This needs to be supported by the availability of appropriate treatments for the psychological distress.     

How primary care physicians treat psychiatric disorders: a national survey of family practitioners

A survey of 350 family practice physicians nationwide showed that 22.6% of their patients had significant psychiatric disorders. Physicians reported treating most psychiatric problems themselves, usually through a combination of psychotropic drugs, advice, and reassurance. The results suggest that anxiolytics are more conservatively used and referrals for mental health care more often made than past studies indicate. Physicians cited patient resistance and time limitations as the most important barriers to primary care mental health treatment, followed by limited third-party payment for mental health services, poor coordination between the primary care and mental health care sectors, and insufficient training to treat psychiatric disorders.