Underrecognition of anxiety and mood disorders in primary care: why does the problem exist and what can be done?

Despite current debate on the methodology of existing research into depression and anxiety disorders, there is still general agreement that recognition rates of these conditions in primary care could be improved. This review examines the factors that influence recognition of these disorders from both the patients' perspective and the primary care givers' perspective. Approaches and methods for improving recognition in primary care, including guidelines, mental health skills training, screening, and increasing public awareness, are considered in detail.     

Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review

Objective: Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. Method: This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. Results: Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. Conclusion: Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed.     

Depression, anxiety, and somatoform disorders: Vague or distinct categories in primary care? Results from a large cross-sectional study

Objective

Depression, anxiety, and somatization are the most frequently observed mental disorders in primary health care. Our main objective was to draw on the often neglected general practitioners' (GPs) perspective to investigate what characterizes these three common mental diagnoses with regard to creating more suitable categories in the DSM-V and ICD-11.

Methods

We collected independent data from 1751 primary care patients (participation rate=77%) and their 32 treating GPs in Germany. Patients filled out validated patient self-report measures for depression (PHQ-9), somatic symptom severity (PHQ-15), and illness anxiety (Whiteley-7), and questions regarding coping and attribution of illness. GPs' clinical diagnoses and associated features were assessed.

Results

Patients diagnosed by their GPs with depression, anxiety, and/or somatoform disorders were significantly older, less educated, and more often female than the reference group not diagnosed with a mental disorder. They had visited the GP more often, had a longer duration of symptoms, and were more often under social or financial stress. Among the mental disorders diagnosed by the GPs, depression (OR=4.4; 95% CI=2.6 to 7.5) and comorbidity of somatoform, depressive, and anxiety disorders (OR=9.5; 95% CI=4.6 to 19.4) were associated with the largest degrees of impairment compared to the reference group. Patients diagnosed as having a somatoform/functional disorder only had mildly elevated impairment on all dimensions (OR=2.0; 95% CI=1.4 to 2.7). Similar results were found for the physicians' attribution of psychosocial factors for cause and maintenance of the disease, difficult patient-doctor relationship, and self-assessed mental disorder.

Conclusion

In order to make the DSM-V and ICD-11 more suitable for primary care, we propose providing appropriate diagnostic categories for (1) the many mild forms of mental syndromes typically seen in primary care; and (2) the severe forms of comorbidity between somatoform, depressive, and/or anxiety disorder, e.g., with a dimensional approach.     

Physical activity counseling in primary care and patient well-being: Do patients benefit?

Background: Promoting physical activity is an important public health strategy for long-term reductions in incidence or severity of clinical disease. Benefits to health-related quality of life (HRQL) and subjective well-being may be as important and take less time to accrue.Purpose:We examined the HRQL benefits of a social-cognitive-theory-based intervention of the Activity Counseling Trial (ACT), both directly in terms of changes in physical fitness and indirectly from increased self-efficacy associated with the intervention.Methods: In ACT, 395 female and 479 male inactive patients ages 35 to 75 years were randomized to one of: physician advice, advice plus behavioral counseling during primary care visits, or advice plus behavioral counseling that also included telephone contact and behavioral classes. Participants were assessed at baseline, 6 months, and 24 months. HRQL was assessed as perceived quality of life, perceived stress, depression, and general health. Satisfaction with function and appearance, self-efficacy, and social support were also assessed.Results: At 24 months women who received counseling or assistance had significant reductions in daily stress and improvements in satisfaction with body function compared to those receiving advice only. Men had reductions in daily stress across all treatment arms. These results mirrored V0₂max changes observed per group. Change in barriers self-efficacy was significantly associated with reductions in daily stress at 24 months.Conclusions: Patient benefit from ACT intervention was mediated by enhanced cardiorespiratory fitness and by barriers self-efficacy.     

Can an electronic device improve mood and well-being, and decrease anxiety?

This study used a double-blind crossover design to investigate the effect of a small electronic device, the Quantum Companion, on mood, quality of life and anxiety levels. Thirty-four subjects were stratified on age, sex, and current stress levels and randomly assigned to receive either a placebo or a Quantum Companion, and then after a two week "recovery period," the other instrument. Standardized tests were administered before and after each two-week experimental period, along with an open ended questionnaire of other life-events during the past two weeks. The two weeks with the placebo were marked by (1) more immediate positive and fewer immediate negative effects, (2) greater reductions in anxiety, and (3) nonsignificant improvement in mood and quality of life, compared to the two-week Quantum Companion periods. This study brings out the power of a placebo for changing mood, and the importance of using rigorous designs to test claims.     

Do women who screen positive for mental disorders in primary care have lower mammography rates?

Disparities in mammography rates have been documented for underserved populations, yet no data are available for women with mental illness in primary care settings. We analyzed data on mammography rates for 526 women age 40-70 who were new patients and completed the Primary Care Evaluation of Mental Disorders (PRIME-MD). There were no significant differences in mammography rates among women who screened negative and positive for any mental illness (56% and 53%, respectively). Screening for mental disorders in primary care does not appear to identify women at risk for nonreceipt of mammography.     

Ethnicity,familism and willingness to care: Important influences on caregiver mood?

Objective: Few studies have to date examined the effects of ethnicity on caregiver motivations, coping responses and mood. This theoretically informed study uses the socio-cultural model of stress and coping to explore these relationships amongst a White-British and British South-Asian caregiver sample.

Method: A total of 235 primary family caregivers were recruited for a cross-sectional questionnaire survey; of which 162 were White-British and 73 were British South-Asian.

Results : British South-Asian caregivers differed from White-British caregivers on several variables within the stress-coping framework. British South-Asian caregivers were younger, had significantly higher levels of familism, used significantly more behavioural disengagement and religious coping and reported having significantly less support than White-British caregivers. White-British caregivers were more likely to make use of substances and humour as coping methods, and also in these caregivers, familism was significantly related to caregiver depression. Whilst levels of willingness to care did not differ between the two caregiver groups, opposing relationships were seen in the association between willingness to care and caregiver anxiety. Regression analyses found that self-blame explained a significant proportion of variance in South-Asian anxiety and depression, whereas depression amongst White-British caregivers was associated with high use of substances, low use of humour and low mean satisfaction with support.

Conclusion: These findings offer support to the socio-cultural model of stress and coping in that coping is associated with two outcomes (anxiety and depression), but motivational factors are also highlighted which have additional implications for the development of culturally specific interventions aimed at reducing caregiver distress.