The primary health care version of ICD-11: the detection of common mental disorders in general medical settings

BackgroundThe primary health care version of the ICD-11 is currently being revised.AimTo test two brief sets of symptoms for depression and anxiety in primary care settings, and validate them against diagnoses of major depression and current generalised anxiety made by the CIDI.MethodThe study took place in general medical or primary care clinics in 14 different countries, using the Composite International Diagnostic Interview adapted for primary care (CIDI-PC) in 5,438 patients. The latent structure of common symptoms was explored, and two symptom scales were derived from item response theory (IRT), these were then investigated against research diagnoses.ResultsCorrelations between dimensions of anxious, depressive and somatic symptoms were found to be high. For major depression the 5 item depression scale has marked superiority over the usual 2 item scales used by both the ICD and DSM systems, and for anxiety there is some superiority. If the questions are used with patients that the clinician suspects may have a psychological disorder, the positive predictive value of the scale is between 78 and 90%.ConclusionThe two scales allow clinicians to make diagnostic assessments of depression and anxiety with a high positive predictive value, provided they use them only when they suspect that a psychological disorder is present.     

Seasonality in depressive and anxiety symptoms among primary care patients and in patients with depressive and anxiety disorders; results from the Netherlands Study of Depression and Anxiety

Background

Little is known about seasonality of specific depressive symptoms and anxiety symptoms in different patient populations. This study aims to assess seasonal variation of depressive and anxiety symptoms in a primary care population and across participants who were classified in diagnostic groups 1) healthy controls 2) patients with a major depressive disorder, 3) patients with any anxiety disorder and 4) patients with a major depression and any anxiety disorder.

Methods

Data were used from the Netherlands Study of Depression and Anxiety (NESDA). First, in 5549 patients from the NESDA primary care recruitment population the Kessler-10 screening questionnaire was used and data were analyzed across season in a multilevel linear model. Second, in 1090 subjects classified into four groups according to psychiatric status according to the Composite International Diagnostic Interview, overall depressive symptoms and atypical versus melancholic features were assessed with the Inventory of Depressive Symptoms. Anxiety and fear were assessed with the Beck Anxiety Inventory and the Fear questionnaire. Symptom levels across season were analyzed in a linear regression model.

Results

In the primary care population the severity of depressive and anxiety symptoms did not show a seasonal pattern. In the diagnostic groups healthy controls and patients with any anxiety disorder, but not patients with a major depressive disorder, showed a small rise in depressive symptoms in winter. Atypical and melancholic symptoms were both elevated in winter. No seasonal pattern for anxiety symptoms was found. There was a small gender related seasonal effect for fear symptoms.

Conclusions

Seasonal differences in severity or type of depressive and anxiety symptoms, as measured with a general screening instrument and symptom questionnaires, were absent or small in effect size in a primary care population and in patient populations with a major depressive disorder and anxiety disorders.     

Psychiatric status of patients with primary fibromyalgia, patients with rheumatoid arthritis, and subjects without pain: a blind comparison of DSM-III diagnoses

OBJECTIVE: The major purpose of this study was to compare the frequency of the occurrence of DSM-III diagnoses in patients with primary fibromyalgia syndrome, patients with rheumatoid arthritis, and subjects without pain. METHOD: Thirty-five patients with primary fibromyalgia, 33 patients with rheumatoid arthritis, and 31 nonpatients without pain were blindly assessed for psychiatric diagnoses with the Psychiatric Diagnostic Interview. RESULTS: Data from this interview revealed no group differences in terms of lifetime history of any psychiatric disorders, including major depression, somatization disorder, or anxiety-based disorders. Analysis of the auxiliary symptoms of depression on the Psychiatric Diagnostic Interview revealed that the patients with fibromyalgia did not report a higher frequency of vegetative signs of depression. However, analysis of the somatization scale revealed an interaction between medical and psychiatric diagnoses: patients with primary fibromyalgia syndrome and a psychiatric history endorsed significantly more somatic symptoms than did patients with rheumatoid arthritis or subjects without pain, and fibromyalgia patients without a psychiatric history were no more likely to endorse somatic symptoms than were arthritis patients or subjects without pain. CONCLUSIONS: The Psychiatric Diagnostic Interview data failed to discriminate in any major way between primary fibromyalgia syndrome (a disorder with no known organic etiology) and rheumatoid arthritis (a disorder with a known organic etiology). Therefore, these data do not support a psychopathology model as a primary explanation of the symptoms of primary fibromyalgia syndrome.     

Generalized anxiety disorder: prevalence,burden, and cost to society

Generalized anxiety disorder (GAD) is a prevalent and disabling disorder characterized by persistent worrying, anxiety symptoms, and tension. It is the most frequent anxiety disorder in primary care, being present in 22% of primary care patients who complain of anxiety problems. The high prevalence rate of GAD in primary care (8%) compared to that reported in the general population (12-month prevalence 1.9-5.1%) suggests that GAD patients are high users of primary care resources. GAD affects women more frequently than men and prevalence rates are high in midlife (prevalence in females over age 35: 10%) and older subjects but relatively low in adolescents. The natural course of GAD can be characterized as chronic with few complete remissions, a waxing and waning course of GAD symptoms, and the occurrence of substantial comorbidity particularly with depression. Patients with GAD demonstrate a considerable degree of impairment and disability, even in its pure form, uncomplicated by depression or other mental disorders. The degree of impairment is similar to that of cases with major depression. GAD comorbid with depression usually reveals considerably higher numbers of disability days in the past month than either condition in its pure form. As a result, GAD is associated with a significant economic burden owing to decreased work productivity and increased use of health care services, particularly primary health care. The appropriate use of psychological treatments and antidepressants may improve both anxiety and depression symptoms and may also play a role in preventing comorbid major depression in GAD thus reducing the burden on both the individual and society.     

Attention deficit disorder in children at risk for anxiety and depression

The comorbidity between attention deficit disorder (ADD) and anxiety and/or depressive disorders was examined in the children of parents with panic disorder, major depressive disorder, or with no diagnosis. A child received a diagnosis by a self-report, parent report, and by consensus, using a best estimate procedure. The prevalence rates of ADD were significantly greater in offspring of parents with depressive and panic disorder by the parents' report and in children of depressed parents by consensus. A significant relationship between ADD and anxiety and/or depression was found for parent, child, and consensus diagnoses. Higher rates of ADD were reported by children (1% versus 13%), parents (8% versus 31%), and in the consensus diagnoses (13% versus 29%) when anxiety and/or depression was present. These results suggest that in children referred for evaluation of ADD, the possibility of a primary anxiety or depressive disorder should be considered.     

The prevalence of atypical features across mood,anxiety, and personality disorders

This study examines and compares the prevalence rates of the atypical features subtype across each of the major mood, anxiety, and personality disorders (PDs). It also evaluates the impact that comorbid anxiety and PDs have on the likelihood that depressed patients will present with atypical symptoms. Eleven hundred thirty psychiatric outpatients were evaluated for the presence of atypical symptoms. All axis I diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID). PDs were assessed in a subset of 530 patients using the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). From a sample of 579 patients diagnosed with a current major depressive disorder, 22.5% met criteria for the atypical subtype. Prevalence rates were similar in bipolar and unipolar patients, although the pattern of symptoms was distinct. Prevalence rates were lower in patients with dysthymic disorder (12.5%), adjustment disorder with depressed mood (9.4%), and depression not otherwise specified (NOS) (7.9%). When major depression existed in the presence of a comorbid anxiety disorder, the likelihood of presenting with atypical features doubled. Nine percent of the patients diagnosed with an anxiety disorder (without a comorbid depressive disorder) met criteria for atypical features. Two of the four atypical symptoms, leaden paralysis and rejection sensitivity, were found to be especially prominent in nondepressed anxiety disorder patients. Of the 10 PDs listed in DSM-IV, only avoidant PD was associated with the atypical features subtype. In large part, this was accounted for by the high rate of rejection sensitivity in these patients. In conclusion, as many as one quarter of depressed patients who present for outpatient psychiatric treatment meet criteria for the atypical features subtype. There appears to be a strong association between anxiety and atypical depression, but the exact nature of this relationship needs to be further elucidated. It is unclear whether personality pathology is independently associated with the atypical features subtype.     

Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics

OBJECTIVE: This study assessed rates of detection and treatment of minor and major depressive disorder, panic disorder, and posttraumatic stress disorder among pregnant women receiving prenatal care at public-sector obstetric clinics. METHODS: Interviewers systematically screened 387 women attending prenatal visits. The screening process was initiated before each woman's examination. After the visit, patients were asked whether their clinician recognized a mood or anxiety disorder. Medical records were reviewed for documentation of psychiatric illness and treatment. RESULTS: Only 26 percent of patients who screened positive for a psychiatric illness were recognized as having a mood or anxiety disorder by their health care provider. Moreover, clinicians detected disorders among only 12 percent of patients who showed evidence of suicidal ideation. Women with panic disorder or a lifetime history of domestic violence were more likely to be identified as having a psychiatric illness by a health care provider at some point before or during pregnancy. All women who screened positive for panic disorder had received or were currently receiving mental health treatment outside the prenatal visit, whereas 26 percent of women who screened positive for major or minor depression had received or were currently receiving treatment outside the prenatal visit. CONCLUSIONS: Detection rates for depressive disorders in obstetric settings are lower than those for panic disorder and lower than those reported in other primary care settings. Consequently, a large proportion of pregnant women continue to suffer silently with depression throughout their pregnancy. Given that depressive disorders among perinatal women are highly prevalent and may have profound impact on infants and children, more work is needed to enhance detection and referral.     

Anxiety, depression, and quality of life in primary care patients

Background: Anxiety and depressive disorders have a significant and negative impact on quality of life. However, less is known about the effects of anxiety and depressive symptoms on quality of life. The purpose of this study was to examine the impact of anxiety and depressive symptoms on emotional and physical functioning, the effects of anxiety symptoms on functioning independent of depressive symptoms, and the effects of depressive symptoms on functioning independent of anxiety symptoms.Method: Participants included 919 patients, recruited from 2 university-affiliated primary care clinics between May 2004 and September 2006, who completed self-report measures of anxiety symptoms, depressive symptoms, and quality of life.Results: Almost 40% of the sample reported anxiety symptoms and 30% reported depressive symptoms. In both unadjusted and adjusted models, anxiety and depressive symptoms were significantly associated with all domains of quality of life. When anxiety and depressive symptoms were added simultaneously, both remained significant. As the severity of anxiety or depressive symptoms increased, quality of life decreased. Furthermore, patients with moderate to severe anxiety or depressive symptoms had greater impairments in most quality of life domains than patients with acute myocardial infarction, congestive heart failure, or diabetes.Conclusion: Detection and treatment of anxiety and depressive symptoms in the primary care setting should be emphasized.     

Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression?

We assessed whether a coexisting anxiety disorder predicts risk for persistent depression in primary care patients with major depression at baseline. Patients with major depression were identified in a 12-month prospective cohort study at a University-based family practice clinic. Presence of an anxiety disorder and other potential prognostic factors were measured at baseline. Persistent depressive illness (major depression, minor depression, or dysthymia) was determined at 12 months. Of 85 patients with major depression at baseline, 43 had coexisting anxiety disorder (38 with social phobia). The risk for persistent depression at 12 months was 44% greater [Risk Ratio (RR) = 1.44, 95% confidence interval (CI) 1.02-2.04] in those with coexisting anxiety. This risk persisted in stratified analysis controlling for other prognostic factors. Patients with coexisting anxiety had greater mean depressive severity [repeated measures analysis of variance (ANOVA), p < 0.04] and total disability days (54.9 vs 19.8, p < 0.02) over the 12-month study. Patients with social phobia had similar increased risk for persistent depression (RR = 1.40, 95% CI 0.98-2.00). A coexisting anxiety disorder indicates risk for persistent depression in primary care patients with major depression. Social phobia may be important to recognize in these patients. Identifying anxiety disorders can help primary care clinicians target patients needing more aggressive treatment for depression.     

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.     

Anxiety and depression in a primary care clinic. Comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments

Over one half of all persons seen in a primary care clinic were identified as having anxiety or depressive disorder by the primary care provider, the General Health Questionnaire (GHQ), or the Diagnostic Interview Schedule (DIS). In only about 5% of all patients were findings positive on all three assessments concurrently. Both the GHQ and the practitioners identified over 30% of all patients as having a disorder, while about 8% had one or more of five DIS anxiety or depressive disorders (major depression, dysthymia, panic disorder, generalized anxiety disorder, or obsessive-compulsive disorder). Of the patients with DIS disorders 83% had positive GHQ scores, and 73% were identified by the practitioner as having a mental disorder.     

Distress and functioning in mixed anxiety and depressive disorder

The aim of the present study was to evaluate the validity of mixed anxiety and depressive disorder (MADD) with reference to functional characteristics and symptomatic characteristics in comparison with anxiety disorders, depressive disorders, and groups showing subthreshold symptoms (exclusively depressive or anxiety related). The present study was carried out in the following three medical settings: two psychiatric and one primary care. Patients seeking care in psychiatric institutions due to anxiety and depressive symptoms and attending primary medical settings for any reason were taken into account. A total of 104 patients (65 women and 39 men, mean age 41.1 years) were given a General Health Questionnaire (GHQ-30), Global Assessment of Functioning (GAF) and Present State Examination questionnaire, a part of Schedules for Clinical Assessment in Neuropsychiatry, Version 2.0. There were no statistically relevant differences between MADD and anxiety disorders in median GHQ score (19 vs 16) and median GAF score (median 68.5 vs 65). When considering depressive disorders the median GHQ score (28) was higher, and median GAF score (59) was lower than that in MADD. In groups with separated subthreshold anxiety or depressive symptoms, median GHQ scores (12) were lower and median GAF scores (75) were higher than that in MADD. The most frequent symptoms of MADD are symptoms of generalized anxiety disorder (GAD) and depression. Mixed anxiety and depressive disorder differs significantly from GAD only in higher rates of depressed mood and lower rates of somatic anxiety symptoms. Distinction from depression was clearer; six of 10 depressive symptoms are more minor in severity in MADD than in the case of depression. Distress and interference with personal functions in MADD are similar to that of other anxiety disorders. A pattern of MADD symptoms locates this disorder between depression and GAD.     

Comorbid Depressive Disorders in Anxiety-disordered Youth: Demographic,Clinical, and Family Characteristics

Research indicates that depression and anxiety are highly comorbid in youth. Little is known, however, about the clinical and family characteristics of youth with principal anxiety disorders and comorbid depressive diagnoses. The present study examined the demographic, clinical, and family characteristics of 200 anxiety-disordered children and adolescents (aged 7–17) with and without comorbid depressive disorders (major depressive disorder or dysthymic disorder), seeking treatment at a university-based anxiety clinic. All participants met DSM-IV diagnostic criteria for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Of these, twelve percent (n = 24) also met criteria for a comorbid depressive disorder. Results suggest that anxiety-disordered youth with comorbid depressive disorders (AD-DD) were older at intake, had more severe anxious and depressive symptomotology, and were more impaired than anxiety-disordered youth without comorbid depressive disorders (AD-NDD). AD-DD youth also reported significantly more family dysfunction than AD-NDD youth. Future research should examine how this diagnostic and family profile may impact treatment for AD-DD youth.     

Synergistic effects of pain intensity and anxiety sensitivity in relation to anxiety and depressive symptoms and disorders among economically disadvantaged latinos in a community-based primary care setting

The present investigation examined the interactive effects of anxiety sensitivity and pain intensity in relation to anxious arousal, social anxiety, and depressive symptoms and disorders among 203 Latino adults with an annual income of less than $30,000 (84.4% female; M_age = 38.9, SD = 11.3 and 98.6% used Spanish as their first language) who attended a community-based primary healthcare clinic. As expected, the interaction between anxiety sensitivity and pain intensity was significantly related to increased anxious arousal, social anxiety, and depressive symptoms as well as number of depressive/anxiety disorder diagnoses. The form of the significant interactions indicated that participants reporting co-occurring higher levels of anxiety sensitivity and pain intensity evinced the greatest levels of anxious arousal, social anxiety, and depressive symptoms as well as higher levels of depressive and anxiety disorders. These data provide novel empirical evidence suggesting that there is clinically-relevant interplay between anxiety sensitivity and pain intensity in regard to a relatively wide array of anxiety and depressive variables among Latinos in a primary care medical setting.     

A Pilot Study Examining the Relationship Between Patients' Complaints and Scores on the Hirschfeld Mood Disorder Questionnaire

INTRODUCTION: The incidence of bipolar disorder in the general population has been estimated at approximately 5%. The purpose of this study was to establish a relationship between patients' complaints on arrival to a primary care clinic and their subsequent scores on the Hirschfeld Mood Disorder Questionnaire (MDQ). METHOD: After reviewing data obtained from 178 consecutive patients, 171 were found adequate for study inclusion. The inclusion criteria for this study were presentation to a family practice office for care regardless of complaint and age of 18 years or older. Study participants were asked to complete a historical/demographic questionnaire, which gathered data on primary and secondary complaints and medication history, and the MDQ. RESULTS: Thirty patients (17.5%) tested positive on the MDQ for bipolar symptoms; all were aged 65 years or under. Of those who tested positive, 20% (N = 6) presented with a primary complaint of anxiety or depression. Somatic primary complaints of pain and headache carried a high likelihood of secondary complaints of anxiety or depression. CONCLUSION: Patients with complicated or multiple somatic complaints in primary care may also have concomitant undiagnosed bipolar disorder. Clinicians should use a high index of suspicion for the diagnosis of bipolar disorder when treating patients with these assessment characteristics. Further research is necessary to determine if these trends are applicable in a larger population.     

In search of mixed anxiety-depressive disorder: a primary care study

The diagnosis of mixed anxiety-depressive disorder, as proposed in DSM-IV, is intended to be useful in settings such as primary care, where low-level anxiety and depressive symptoms may cause clinically significant impairment but are undiagnosable using current criteria. Evidence of the prevalence of this diagnosis is, however, lacking, particularly since the publication of the proposed diagnostic criteria in DSM-IV. Our study examined symptoms of anxiety and depression in 65 primary care patients screened for anxiety and depression while visiting their doctor. Results indicated that of the 37 patients without a diagnosable anxiety or depressive disorder, none had symptoms of depression and anxiety accompanied by interference that the patient deemed significant and attributable to his or her symptoms. These data dispute the need for a mixed anxiety-depression category (beyond mood and anxiety syndromes currently in DSM-IV) in future editions of the DSM.     

Asthma and mental disorders in primary care

This study examines relationships between asthma and likelihood of current mental disorders and suicidal ideation in an urban primary care population. A systematic waiting room sample of 998 adult patients was screened for mental disorders using the PRIME-MD PHQ. Asthma diagnoses were provided by primary care physicians. Multivariate logistic regression analyses were used to determine the odds of current major depression, panic attacks, generalized anxiety disorder, alcohol and drug use disorder, and suicidal ideation among patients with a diagnosis of asthma, as compared to those without asthma. After controlling for differences in sociodemographic characteristics and comorbid mental disorders, asthma was associated with increased likelihood of panic attack (OR=1.7 (1.1, 2.6)) and suicidal ideation (OR=1.9 (1.03, 3.4)). There was no statistically significant association between asthma and major depression, generalized anxiety disorder, alcohol, or drug use disorders after adjustment. Results suggest that physician-diagnosed asthma is associated with self-reported panic attacks and suicidal ideation in a systematic sample of primary care patients. Physicians who treat patients with asthma should remain vigilant for the presence of comorbid psychiatric problems and carefully evaluate whether there is a clinical need to treat each condition.     

Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses.

OBJECTIVE: To determine the prevalence of anxiety and depression in a residents' clinic and if these diagnoses are associated with patients being perceived as difficult, as well as how often these diagnoses are documented in the patients' charts. METHODS: This was a cross-sectional study conducted in a general internal medicine residents' clinic. A total of 135 patients were given the Primary Care Evaluation of Mental Disorders questionnaire (DSM-IIIR version) and their physicians filled out the Difficult Doctor-Patient Relationship Questionnaire after the visit. Charts were reviewed for documentation of a diagnosis of anxiety or depression. RESULTS: Major depression was present in 26 percent, dysthymia 16 percent, major depression in partial remission 9 percent, generalized anxiety disorder 13 percent, and panic disorder 7 percent. Overall, 38 percent had at least one and 21 percent had more than one diagnosis. Of patients with one psychiatric diagnosis, 9 percent were classified as difficult versus 100 percent of patients with four diagnoses. Documentation of depression was noted for 43 percent of patients with major depression but only 9 percent with an anxiety disorder. CONCLUSIONS: Anxiety and depression were very common among the patients in this clinic, and increasing numbers of diagnoses were associated with patients being classified as difficult. Residents diagnosed depressive disorders as often as practicing physicians in other studies, but anxiety less well. The high prevalence of mental disorders has implications for resident education in that they need to be prepared to care for these patients, but residents also may benefit from exposure to sites with more typical prevalences of these illnesses.     

Severity of depression and hypothalamic-pituitary-adrenal axis dysregulation: identification of contributing factors

Severity of depression, as reflected by total scores on depression rating scales, has been established as one of several major sources of variance associated with hypothalamic-pituitary-adrenal axis dysregulation in patients with major depressive disorder. To determine which of the symptoms comprising clinically defined severity of illness contribute most to this relationship, we studied the associations between postdexamethasone plasma cortisol levels and components of the Hamilton Rating Scale for Depression (HRSD) in 114 patients with major depressive disorder. At pretreatment baseline, severity of depression was modestly but significantly correlated with postdexamethasone plasma cortisol; a large part of this relationship was associated with the anxiety components of the HRSD. When relationships between postdexamethasone plasma cortisol and severity measures were studied longitudinally during treatment, this contribution of the anxiety items persisted. The anxiety associated with depression appears to be a major clinical factor associated with the hypothalamic-pituitary-adrenal axis dysregulation in major depressive disorder.