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Anxiety in family practice
Journal of Affective Elsevier
179
Disorders, 12 (1987) 179-183
JAD 00449
Anxiety in family practice Daniel R. Wilson l3*, Remi J. Cadoret 2 Departments
*, Reuben
Widmer
2 and Kenneth
J. Judiesch
*
’ Department of Psychiatry, McLean Hospital, Belmont, MA and of Psychiatry and Family Practice, University of Iowa College of Medicine, IA, U.S.A (Received 18 August 1986) (Accepted 16 February 1987)
Summary The time course of patient initiated visits, somatic, functional, and other medical complaints was studied in a group of 58 patients from a family practice who had been diagnosed and treated for anxiety. The findings were contrasted with two other groups of patients from the same practice: 101 depressives and 101 controls. Results indicate that the anxiety patients differed markedly from the depressives in having a very short-lived episode of anxiety or somatic complaints in contrast to depressives’ much longer history of somatic and functional complaints which appeared to precede by months the diagnosis of depression. The findings suggest that the anxiety patients in this practice either had a qualitatively different condition from the depressives, or possibly suffered from a short-lived and unrecognized depression.
Key words: Anxiety; Depression;
Somatic symptoms
Introduction Primary care physicians manage the great preponderance of patients treated for depressive or anxiety disorders (Priest 1982). The incidence of anxiety disorders in family populations is an estimated 15%, with depression approaching 10% (Watts 1965). In order to optimize treatment the different clinical pictures of depressed and anxious patients ideally require sharper diagnostic dis-
Address for correspondence: Remi J. Cadoret, M.D., 500 Newton Road, University of Iowa, Iowa City, IA 52242, U.S.A. * Dr. Wilson is a fellow in the Department of Psychiatry, McLean Hospital, Belmont, MA.
0165-0327/87/$03.50
0 1987 Elsevier Science Publishers
tinctions. Indeed, anxiety and depressive symptoms have little diagnostic specificity. Many medical and mental illnesses may feature either or both; moreover, epidemiologic and natural historic differences notwithstanding, syndromes composed of depressive and anxiety symptoms are rarely cleanly demarcated and depressive syndromes can occur during the course of anxiety conditions such as phobias, obsessions and compulsions (Clancy and Noyes 1981; Priest 1982). A mixed picture is particularly true in the milieu of family practice (Eiland 1974) where depressed patients are noteworthy for their ‘ . . . extremely high levels of psychic and somatic anxiety, insomnia and sexual impairment and extremely low levels of suicidal tendencies, guilt, and retardation . . . ’
B.V. (Biomedical
Division)
180 (Cassano
et al. 1976).
It is not
surprising
that
many family physicians often simply focus upon and treat psychologic target symptoms without fully differentiating anxiety and depressive diagnoses. A more refined clinical description of psychiatric disorders in the primary care setting should facilitate
more prompt
and effective
management.
To this end we have previously described features of depression seemingly unique to family practice in that multiple somatic complaints appear early and increase markedly before depression, and decrease with
the diagnosis of treatment of the
Fig. 1. Experimental
design.
diagnosis of anxiety disorder were studied as well. The experimental scheme is shown in Fig. 1. A total of 58 patients with anxiety disorder were studied. Anxiety was diagnosed by the family
disorder (Widmer and Cadoret 1978; Widmer et al. 1979; Cadoret et al. 1980). A recent study of depressives in a solo private family practice (Wilson et al. 1983) confirmed that somatic symptoms - as well as the more ‘classic’ diagnostic criteria heralded the onset of depression. In many
practitioner (K.J.J.) when patients complained of feeling tense, anxious, worried, stressed, unable to relax, or fluttery inside. In only a very few instances did patients complain of panic attacks. In
patients anxiety was a prominent feature and anxiety disorder was the principal diagnosis of exclusion. The question naturally arose whether
Depression, on the other hand, was diagnosed when additional symptoms were present such as more sleep disturbance, decreased appetite, crying
somatic symptoms are similarly harbingers of anxiety diagnoses, for if they are not, their presence or absence could prove valuable in promptly
spells, loss of interest, suicidal ideation.
differentiating the two illnesses. We have since studied patients from the practice studied in Wilson et al. (1983) to determine if anxiety syndromes exhibit somatoform found in depression.
prodromata
similar
to those
Method This retrospective record audit reviewed a solo and private family practice located in Iowa City, IA. The practice was constituted primarily of middle-class whites but also reflected the ethnic, educational and economic diversity complimenting a midwestern university community of 40 000. Nearly 4000 patient charts were reviewed and only anxious patients diagnosed after 1964 were used since methods of recording diagnosis and treatment have been more uniform after that date. Four periods were examined to clarify symptoms associated with the diagnosis of anxiety disorders: (A) 18-12 months before diagnosis, (B) six months before to the day before, (C) the day following to six months after, and (D) 12-18 months after diagnosis. Findings on the day of
many cases the anxiety feelings context of family- or work-related
fatigue,
occurred in the problems.
and death wishes or
There were two contrast groups: (1) a group of 101 patients diagnosed as depressed from the same time period who had been described in Wilson et al. (1983), and (2) a group of 101 controls originally matched by age and sex to the 101 depressives. Examination of the 58 anxiety patients showed that their average age and male-female sex distribution was similar to the controls (and the depressives). The complaints and physician consultations of each control and depressed patient were reviewed
for each of the four time periods
used for the anxious no control equivalent existed.
probands but by definition to day of ‘anxiety’ diagnosis
The number of office visits and complaints were examined during the four periods for both patient groups. Complaints were tabulated in the following categories: (1) Definite diagnosis or procedure (minor surgery, history and physical, arthritis, etc.); (2) Znfections (URI, UTI, boils. etc.); (3) Somatic unrelated to definite diagnosis or infection: (a) functional (dizziness, fatigue, flatulence, etc.), and (b) pain (headache, backache, pelvic, etc.);
181
(4) Anxiety (worry, palpitations, agitation, etc.). Significant differences between patient groups and over the time periods were tested by chi-square analyses of contingency tables with a significance level of 5% throughout.
a
=contrc’
H =Anx,ety
q = Depressed
Results 18
Figure 2 graphs the mean number of visits during each time period for anxiety, depressive and control groups. The anxiety and control groups are both different from the depressives. Anxiety patient visits are increased over controls only for period C, O-6 months after diagnosis of anxiety. Figure 3 depicts etiologically obscure pain complaints. For each period, anxious patients evidenced more complaints than controls but reached statistical significance only during period B. On the other hand, the depressives are significantly different from the control group in periods A and B, and the depressives are significantly higher than anxiety patients in these two periods. Similar results obtained for functional somatic complaints are shown in Fig. 4 with the anxiety group indistinguishable from controls. However, the depressive group again shows significant increase in this type of complaint in periods A, B and C. Anxiety complaints in Fig. 5 showed a markedly different pattern over time between depressed and anxious patients. During no time period did the number of anxiety complaints made by the anxious patients exceed the level shown by controls. In contrast, the depressives show increased anxiety compared to controls in time periods A, B and C.
D
Fig. 3. Pain complaints.
0
= Control
m = Anxiety
q = Depressed
A
e
C
Tome period
Fig. 4. Functional
50 40
complaints.
F
0
I :
=contro,
H =A”x,ety
q = Depressed
$ 6-
20
3 10 0
30 I A
0 T!me
Fig. 5. Anxiety
D
C
period
complaints. 0
= cant ro1
m =A”x,ety 5
W = Depressed
* 1
A
B
C
D
Tome per,od
Fig. 2. Visits.
Time
Fig. 6. Definite
diagnosis.
period
182
Fig. 7. Infections.
Rates for definite diagnoses and infection are shown in Figs. 6 and 7, respectively. Here neither depressives nor anxiety patients show significant differences from the controls. Complaints on day of diagnosis do not figure in the graphs, but functional, pain and anxiety complaints were quite prevalent in the anxiety group on the day of diagnosis: 93% had one or more complaints of anxiety, 47% had one or more functional somatic complaints, and 22% had somatic pain complaints. Thirty-seven of the 58 anxiety patients received a minor tranquilizer for a varied period of time following their date of diagnosis. Discussion
This study has contrasted patients with anxiety and depressive diagnoses with a group of control patients without psychiatric diagnosis. The findings with depressives have been described elsewhere (Wilson et al. 1983) and contrast markedly with the present findings with patients diagnosed anxious. With the exception of pain complaints, the anxiety patients did not show the dramatic increase in anxiety, functional complaints and number of visits shown by the depressives in the six-month period prior to diagnosis. Thus the longitudinal findings support the division by the clinician into two diagnoses: anxiety and depression. However, it is possible that the anxiety patients could have had an extremely short-lived depression and so would not show changes on the time scale chosen here. Alternatively, the anxious patients could represent a
totally different condition unconnected with depression, one characterized by what appears to be short-lived pain, functional and anxiety complaints. The short time period of anxiety is evident from the fact that on the day of diagnosis 54 of 58 patients had an anxiety complaint whereas in both the preceding and the following 6-month time period only 3 patients had such a complaint. We have previously considered the limitations of this method in investigations regarding depression in primary care and clearly such criticism applies to this study as well (Wilson et al. 1983). General population analyses are necessary to fully define syndromes of anxiety and depression more comprehensively. Prospective studies are needed to objectively assess the major features and natural history of psychiatric illness in family practice. In this retrospective study it is difficult to determine explicit diagnostic criteria used in each case, but to diagnose ‘anxiety’ this practitioner generally required patients to have apprehension and motor tension with autonomia and dysphoria often, but not consistently, present, not unlike the criteria currently cited in DSM-III for generalized anxiety disorder, with the exception that there were no stipulations as to duration of the condition. In some of the individuals, adjustment disorder with anxious mood would be another diagnosis. Hardly any of the patients would meet criteria for panic disorder or agoraphobia. Alone these results are of limited value but in the context of four previous studies by the same investigators utilizing similar methods to study depression striking distinctions between these two common and important illnesses emerge as demonstrated in Figs. 2 through 6. Somatic symptoms have consistently been a harbinger of the depressive diagnosis in the primary care practices we have studied (including this one. Wilson et al. 1983). In contrast, over a prolonged period somatization does not herald the onset of anxiety diagnosis in this sample of patients diagnosed as anxious. Moreover, in our studies of primary care practices an insidious and persistent clinical picture of somatic complaints (especially with, but even without, anxiety or the classical criteria of depression) occurred so frequently that it could provide a basis for the presumptive diagnosis of depression.
183
The data are consistent with other possibilities. It is certainly possible the diagnostician involved in this retrospective study arrived at some diagnoses intuitively rather than explicitly. In the absence of explicit diagnostic criteria it could be that the time course may have been decisive in his diagnosis with people complaining over months diagnosed depressed while those more acutely afflicted may have more likely been diagnosed as anxious. However, examination of patients’ records over time suggests that depressed individuals diagnosed ‘anxious’ often continue somatic complaints (despite tranquilizer medication), show increased visits and eventually are called ‘depressed’ and clear up on antidepressants. Similarly, selection may have occurred if the diagnostician were in any way predisposed to consider somatization an analogue of depression which would only ensure our tautologic description. Further studies of psychiatric illness in general and family practice are required to progress beyond anecdotal descriptions of important early phases of psychopathology.
References Cadoret, R.J., Widmer, R.B. and Troughton, E.P., Somatic complaints: Harbinger of depression in primary care, J. Affect. Disord., 2 (1980) 61-70. Cassano, G.B., Cashogiovanni, P., Conti, L. and Nardini, A.C., Depression as seen by non-psychiatrist physicians, Compr. Psychiatry, 17 (1976) 315-323. Clancy. J. and Noyes Jr., R., Anxiety disorder: Management of a chronic illness, J. Clin. Psychiatry, 42 (1981) 330-332. Eiland, D.C., The chronically anxious patient, Am. J. Fam. Prac. 9 (1974) 157-164. Priest, R.G., The treatment of anxiety and depression in general practice, Practitioner, 226 (1982) 549-56. Watts, C.A.H., Depressive Disorders in the Community, John Wright, Bristol, U.K., 1965. Widmer, R.B. and Cadoret, R.J., Depression in primary care: Changes in pattern of patient visits and complaints during a developing depression, J. Fam. Pratt.. 7 (1978) 293-302. Widmer, R.B., Cadoret, R.J. and North, C.S., Depression in primary care: Changes in pattern of patient visits and complaints during subsequent developing depression, J. Fam. Pratt., 9 (1979) 1017-1021. Wilson, D.R., Widmer, R.B., Cadoret, R.J. and Judiesch, K., Somatic symptoms: A major feature of depression in a family practice, J. Affect. Disord., 5 (1983) 199-207.
179
Disorders, 12 (1987) 179-183
JAD 00449
Anxiety in family practice Daniel R. Wilson l3*, Remi J. Cadoret 2 Departments
*, Reuben
Widmer
2 and Kenneth
J. Judiesch
*
’ Department of Psychiatry, McLean Hospital, Belmont, MA and of Psychiatry and Family Practice, University of Iowa College of Medicine, IA, U.S.A (Received 18 August 1986) (Accepted 16 February 1987)
Summary The time course of patient initiated visits, somatic, functional, and other medical complaints was studied in a group of 58 patients from a family practice who had been diagnosed and treated for anxiety. The findings were contrasted with two other groups of patients from the same practice: 101 depressives and 101 controls. Results indicate that the anxiety patients differed markedly from the depressives in having a very short-lived episode of anxiety or somatic complaints in contrast to depressives’ much longer history of somatic and functional complaints which appeared to precede by months the diagnosis of depression. The findings suggest that the anxiety patients in this practice either had a qualitatively different condition from the depressives, or possibly suffered from a short-lived and unrecognized depression.
Key words: Anxiety; Depression;
Somatic symptoms
Introduction Primary care physicians manage the great preponderance of patients treated for depressive or anxiety disorders (Priest 1982). The incidence of anxiety disorders in family populations is an estimated 15%, with depression approaching 10% (Watts 1965). In order to optimize treatment the different clinical pictures of depressed and anxious patients ideally require sharper diagnostic dis-
Address for correspondence: Remi J. Cadoret, M.D., 500 Newton Road, University of Iowa, Iowa City, IA 52242, U.S.A. * Dr. Wilson is a fellow in the Department of Psychiatry, McLean Hospital, Belmont, MA.
0165-0327/87/$03.50
0 1987 Elsevier Science Publishers
tinctions. Indeed, anxiety and depressive symptoms have little diagnostic specificity. Many medical and mental illnesses may feature either or both; moreover, epidemiologic and natural historic differences notwithstanding, syndromes composed of depressive and anxiety symptoms are rarely cleanly demarcated and depressive syndromes can occur during the course of anxiety conditions such as phobias, obsessions and compulsions (Clancy and Noyes 1981; Priest 1982). A mixed picture is particularly true in the milieu of family practice (Eiland 1974) where depressed patients are noteworthy for their ‘ . . . extremely high levels of psychic and somatic anxiety, insomnia and sexual impairment and extremely low levels of suicidal tendencies, guilt, and retardation . . . ’
B.V. (Biomedical
Division)
180 (Cassano
et al. 1976).
It is not
surprising
that
many family physicians often simply focus upon and treat psychologic target symptoms without fully differentiating anxiety and depressive diagnoses. A more refined clinical description of psychiatric disorders in the primary care setting should facilitate
more prompt
and effective
management.
To this end we have previously described features of depression seemingly unique to family practice in that multiple somatic complaints appear early and increase markedly before depression, and decrease with
the diagnosis of treatment of the
Fig. 1. Experimental
design.
diagnosis of anxiety disorder were studied as well. The experimental scheme is shown in Fig. 1. A total of 58 patients with anxiety disorder were studied. Anxiety was diagnosed by the family
disorder (Widmer and Cadoret 1978; Widmer et al. 1979; Cadoret et al. 1980). A recent study of depressives in a solo private family practice (Wilson et al. 1983) confirmed that somatic symptoms - as well as the more ‘classic’ diagnostic criteria heralded the onset of depression. In many
practitioner (K.J.J.) when patients complained of feeling tense, anxious, worried, stressed, unable to relax, or fluttery inside. In only a very few instances did patients complain of panic attacks. In
patients anxiety was a prominent feature and anxiety disorder was the principal diagnosis of exclusion. The question naturally arose whether
Depression, on the other hand, was diagnosed when additional symptoms were present such as more sleep disturbance, decreased appetite, crying
somatic symptoms are similarly harbingers of anxiety diagnoses, for if they are not, their presence or absence could prove valuable in promptly
spells, loss of interest, suicidal ideation.
differentiating the two illnesses. We have since studied patients from the practice studied in Wilson et al. (1983) to determine if anxiety syndromes exhibit somatoform found in depression.
prodromata
similar
to those
Method This retrospective record audit reviewed a solo and private family practice located in Iowa City, IA. The practice was constituted primarily of middle-class whites but also reflected the ethnic, educational and economic diversity complimenting a midwestern university community of 40 000. Nearly 4000 patient charts were reviewed and only anxious patients diagnosed after 1964 were used since methods of recording diagnosis and treatment have been more uniform after that date. Four periods were examined to clarify symptoms associated with the diagnosis of anxiety disorders: (A) 18-12 months before diagnosis, (B) six months before to the day before, (C) the day following to six months after, and (D) 12-18 months after diagnosis. Findings on the day of
many cases the anxiety feelings context of family- or work-related
fatigue,
occurred in the problems.
and death wishes or
There were two contrast groups: (1) a group of 101 patients diagnosed as depressed from the same time period who had been described in Wilson et al. (1983), and (2) a group of 101 controls originally matched by age and sex to the 101 depressives. Examination of the 58 anxiety patients showed that their average age and male-female sex distribution was similar to the controls (and the depressives). The complaints and physician consultations of each control and depressed patient were reviewed
for each of the four time periods
used for the anxious no control equivalent existed.
probands but by definition to day of ‘anxiety’ diagnosis
The number of office visits and complaints were examined during the four periods for both patient groups. Complaints were tabulated in the following categories: (1) Definite diagnosis or procedure (minor surgery, history and physical, arthritis, etc.); (2) Znfections (URI, UTI, boils. etc.); (3) Somatic unrelated to definite diagnosis or infection: (a) functional (dizziness, fatigue, flatulence, etc.), and (b) pain (headache, backache, pelvic, etc.);
181
(4) Anxiety (worry, palpitations, agitation, etc.). Significant differences between patient groups and over the time periods were tested by chi-square analyses of contingency tables with a significance level of 5% throughout.
a
=contrc’
H =Anx,ety
q = Depressed
Results 18
Figure 2 graphs the mean number of visits during each time period for anxiety, depressive and control groups. The anxiety and control groups are both different from the depressives. Anxiety patient visits are increased over controls only for period C, O-6 months after diagnosis of anxiety. Figure 3 depicts etiologically obscure pain complaints. For each period, anxious patients evidenced more complaints than controls but reached statistical significance only during period B. On the other hand, the depressives are significantly different from the control group in periods A and B, and the depressives are significantly higher than anxiety patients in these two periods. Similar results obtained for functional somatic complaints are shown in Fig. 4 with the anxiety group indistinguishable from controls. However, the depressive group again shows significant increase in this type of complaint in periods A, B and C. Anxiety complaints in Fig. 5 showed a markedly different pattern over time between depressed and anxious patients. During no time period did the number of anxiety complaints made by the anxious patients exceed the level shown by controls. In contrast, the depressives show increased anxiety compared to controls in time periods A, B and C.
D
Fig. 3. Pain complaints.
0
= Control
m = Anxiety
q = Depressed
A
e
C
Tome period
Fig. 4. Functional
50 40
complaints.
F
0
I :
=contro,
H =A”x,ety
q = Depressed
$ 6-
20
3 10 0
30 I A
0 T!me
Fig. 5. Anxiety
D
C
period
complaints. 0
= cant ro1
m =A”x,ety 5
W = Depressed
* 1
A
B
C
D
Tome per,od
Fig. 2. Visits.
Time
Fig. 6. Definite
diagnosis.
period
182
Fig. 7. Infections.
Rates for definite diagnoses and infection are shown in Figs. 6 and 7, respectively. Here neither depressives nor anxiety patients show significant differences from the controls. Complaints on day of diagnosis do not figure in the graphs, but functional, pain and anxiety complaints were quite prevalent in the anxiety group on the day of diagnosis: 93% had one or more complaints of anxiety, 47% had one or more functional somatic complaints, and 22% had somatic pain complaints. Thirty-seven of the 58 anxiety patients received a minor tranquilizer for a varied period of time following their date of diagnosis. Discussion
This study has contrasted patients with anxiety and depressive diagnoses with a group of control patients without psychiatric diagnosis. The findings with depressives have been described elsewhere (Wilson et al. 1983) and contrast markedly with the present findings with patients diagnosed anxious. With the exception of pain complaints, the anxiety patients did not show the dramatic increase in anxiety, functional complaints and number of visits shown by the depressives in the six-month period prior to diagnosis. Thus the longitudinal findings support the division by the clinician into two diagnoses: anxiety and depression. However, it is possible that the anxiety patients could have had an extremely short-lived depression and so would not show changes on the time scale chosen here. Alternatively, the anxious patients could represent a
totally different condition unconnected with depression, one characterized by what appears to be short-lived pain, functional and anxiety complaints. The short time period of anxiety is evident from the fact that on the day of diagnosis 54 of 58 patients had an anxiety complaint whereas in both the preceding and the following 6-month time period only 3 patients had such a complaint. We have previously considered the limitations of this method in investigations regarding depression in primary care and clearly such criticism applies to this study as well (Wilson et al. 1983). General population analyses are necessary to fully define syndromes of anxiety and depression more comprehensively. Prospective studies are needed to objectively assess the major features and natural history of psychiatric illness in family practice. In this retrospective study it is difficult to determine explicit diagnostic criteria used in each case, but to diagnose ‘anxiety’ this practitioner generally required patients to have apprehension and motor tension with autonomia and dysphoria often, but not consistently, present, not unlike the criteria currently cited in DSM-III for generalized anxiety disorder, with the exception that there were no stipulations as to duration of the condition. In some of the individuals, adjustment disorder with anxious mood would be another diagnosis. Hardly any of the patients would meet criteria for panic disorder or agoraphobia. Alone these results are of limited value but in the context of four previous studies by the same investigators utilizing similar methods to study depression striking distinctions between these two common and important illnesses emerge as demonstrated in Figs. 2 through 6. Somatic symptoms have consistently been a harbinger of the depressive diagnosis in the primary care practices we have studied (including this one. Wilson et al. 1983). In contrast, over a prolonged period somatization does not herald the onset of anxiety diagnosis in this sample of patients diagnosed as anxious. Moreover, in our studies of primary care practices an insidious and persistent clinical picture of somatic complaints (especially with, but even without, anxiety or the classical criteria of depression) occurred so frequently that it could provide a basis for the presumptive diagnosis of depression.
183
The data are consistent with other possibilities. It is certainly possible the diagnostician involved in this retrospective study arrived at some diagnoses intuitively rather than explicitly. In the absence of explicit diagnostic criteria it could be that the time course may have been decisive in his diagnosis with people complaining over months diagnosed depressed while those more acutely afflicted may have more likely been diagnosed as anxious. However, examination of patients’ records over time suggests that depressed individuals diagnosed ‘anxious’ often continue somatic complaints (despite tranquilizer medication), show increased visits and eventually are called ‘depressed’ and clear up on antidepressants. Similarly, selection may have occurred if the diagnostician were in any way predisposed to consider somatization an analogue of depression which would only ensure our tautologic description. Further studies of psychiatric illness in general and family practice are required to progress beyond anecdotal descriptions of important early phases of psychopathology.
References Cadoret, R.J., Widmer, R.B. and Troughton, E.P., Somatic complaints: Harbinger of depression in primary care, J. Affect. Disord., 2 (1980) 61-70. Cassano, G.B., Cashogiovanni, P., Conti, L. and Nardini, A.C., Depression as seen by non-psychiatrist physicians, Compr. Psychiatry, 17 (1976) 315-323. Clancy. J. and Noyes Jr., R., Anxiety disorder: Management of a chronic illness, J. Clin. Psychiatry, 42 (1981) 330-332. Eiland, D.C., The chronically anxious patient, Am. J. Fam. Prac. 9 (1974) 157-164. Priest, R.G., The treatment of anxiety and depression in general practice, Practitioner, 226 (1982) 549-56. Watts, C.A.H., Depressive Disorders in the Community, John Wright, Bristol, U.K., 1965. Widmer, R.B. and Cadoret, R.J., Depression in primary care: Changes in pattern of patient visits and complaints during a developing depression, J. Fam. Pratt.. 7 (1978) 293-302. Widmer, R.B., Cadoret, R.J. and North, C.S., Depression in primary care: Changes in pattern of patient visits and complaints during subsequent developing depression, J. Fam. Pratt., 9 (1979) 1017-1021. Wilson, D.R., Widmer, R.B., Cadoret, R.J. and Judiesch, K., Somatic symptoms: A major feature of depression in a family practice, J. Affect. Disord., 5 (1983) 199-207.