Depressive and Anxiety Disorders in Patients Presenting With Physical Complaints: Clinical Predictors and Outcome

doi:10.1016/S0002-9343(97)00241-6

The American Journal of Medicine

Volume 103, Issue 5, November 1997, Pages 339-347

https://doi.org/10.1016/S0002-9343(97)00241-6 Get rights and content

Abstract

PURPOSE: To identify the predictors of depressive and anxiety disorders in general medical patients presenting with physical complaints and to determine the effect of these mental disorders on patient outcome.

PATIENTS AND METHODS: In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed with PRIME-MD to diagnose DSM-IV depressive and anxiety disorders. Clinical predictors were identified by logistic regression analysis. Outcomes were assessed immediately postvisit and at 2 weeks and 3 months. These included symptomatic improvement, functional status, unmet expectations, satisfaction with care, clinician-perceived patient difficulty, and health care utilization and costs.

RESULTS: A depressive or anxiety disorder was present in 146 (29%) of the patients. Independent predictors of a mental disorder included recent stress, multiple physical symptoms (ie, 6 or more), higher patient ratings of symptom severity, lower patient ratings of their overall health, physician perception of the encounter as difficult, and patient age less than 50. Patients with depressive or anxiety disorders were more likely to have unmet expectations postvisit (20% versus 8%, P < 0.001), be considered difficult (26% versus 11%, P < 0.0001), and report persistent psychiatric symptoms and ongoing stress even 3 months following the initial visit. Psychiatric status was not associated with symptomatic improvement, health care utilization, or costs.

CONCLUSION: Simple clinical clues in patients with physical complaints identify a subgroup who may warrant further evaluation for a depressive or anxiety disorder. Such disorders are associated with unmet patient expectations and increased provider frustration.

Section snippets

Patients

Eligible subjects were patients presenting to the Walter Reed Army Medical Center general medicine walk-in clinic with a chief complaint of a physical symptom. Patients were excluded if they had upper respiratory infection complaints (eg, cough, coryza, sore throat), dementia, or inability to understand English, although no subjects were excluded for language reasons. Of 528 patients approached, 500 provided informed consent; participants were similar to nonparticipants in terms of age, race,

Patient Characteristics

Patients had a mean age of 54.7 years, half were women, and 49% were white, 45% African-American, and 6% other. Patients presented with a variety of symptoms (15% with more than one complaint) which we collapsed into 14 major categories (Table 1). Pain of some type was present 65% of the time, and the leading symptom category was musculoskeletal complaints. More than half of the patients had experienced their symptom for less than 2 weeks, and 68% less than a month.

Psychiatric Disorders

A depressive or anxiety

Discussion

Depressive and anxiety disorders were present in 29% of patients presenting with physical complaints. Such disorders were associated with unmet patient expectations and increased provider frustration. Moreover, psychiatric symptoms persisted in many patients even months after their initial clinic visit. Clinical clues emerged from our analysis that should raise the suspicion of co-existing mental disorders in symptomatic patients.

Of six predictors identified, we favor a fourpredictor model for

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^☆: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

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Clinical StudiesDepressive and Anxiety Disorders in Patients Presenting With Physical Complaints: Clinical Predictors and Outcome☆

Abstract

Section snippets

Patients

Patient Characteristics

Psychiatric Disorders

Discussion

J Clin Epidemiol.

J Psychsom Res.

Psychosomatics.

Am J Med.

Soc Sci Med.

Am J Med.

J Psychosom Res.

Gastroenterology.

Am J Med.

Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care

JAMA.

Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study

JAMA.

Recognition, management, and course of anxiety and depression in general practice

Arch Gen Psychiatry.

Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses

Arch Gen Psychiatry.

Health-related quality of life in primary care patients with mental disorders: results from the PRIME-MD 1000 study

JAMA.

Service utilization and social morbidity associated with depressive symptoms in the community

JAMA.

The difficult patient: prevalence, psychopathology, and functional impairment

J Gen Intern Med.

Office visits to psychiatrists: United States, 1989–90

Advance Data From Vital and Health Statistics, No. 237

National Ambulatory Medical Care Survey: 1989 summary. National Center for Health Statistics

Vital Health Stat.

Case-finding instruments for depression in primary care settings

Ann Intern Med.

Development and validation of the SDDS-PC screen for multiple mental disorders in primary care

Arch Fam Med.

Functional somatic symptoms and hypochondriasis: a survey of empirical studies

Arch Gen Psychiatry.

Symptoms in the community: prevalence, classification, and psychiatric comorbidity

Arch Intern Med.

Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment

Arch Fam Med.

Physical symptoms of depression

Br J Psychiatry.

Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study

Am J Psychiatry.

Clinical Studies
Depressive and Anxiety Disorders in Patients Presenting With Physical Complaints: Clinical Predictors and Outcome☆