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Prevalence and 12-month outcome of threshold and subthreshold mental disorders in primary care
Journal of Affective Disorders 56 (1999) 37–48 www.elsevier.com / locate / jad
Research report
Prevalence and 12-month outcome of threshold and subthreshold mental disorders in primary care a,
b
a
Stefano Pini M.D., Ph.D. *, Axel Perkonnig Ph.D. , Michele Tansella M.D. , Hans-UIrich Wittchen Ph.D., Dipl. Psich.b a
Institute of Psychiatry, University of Verona, Verona, Italy b Max Planck Institute of Psychiatry, Munich, Germany
Abstract Background: The authors investigated the occurrence and 12-month outcome of mental disorders in primary care setting. Method: Out of 1555 primary care patients screened in an index period in 16 primary care clinics, 457 subjects were selected for the second phase interview with the CIDI and 250 subjects completed the assessment. Of these, 116 patients (49 ICD-10 cases and 67 subthreshold cases) completed the 12-month follow-up evaluation. Results: Overall, 12.4% of consecutive primary care attenders had a current ICD-10 disorder and 14.2% had a subthreshold mental disorder. Psychiatric comorbidity was found in 45% of the initial sample. Physicians recognized the presence of a mental disorder at baseline in 84.6% of cases with depression comorbid with anxiety and in 44.8% of subthreshold cases. Subthreshold cases outnumbered by three times threshold cases in terms of remission after one year. However, 18% of subthreshold conditions showed no improvement after 12 months. Recognition of mental disorder by the physician at baseline was not associated with an improvement of psychopathology after 12 months, but was associated with an improvement in occupational disability and self-reported disability among threshold cases. Conclusions: Mental disorders are frequent in primary care but their outcome is relatively independent from recognition by the physician. Threshold cases have a worse 12-month outcome than subthreshold cases. However, a substantial outcome variability seems to characterize different diagnostic subgroups both in threshold and subthreshold cases. 1999 Elsevier Science B.V. All rights reserved. Keywords: Primary care physician; Recognition; 12-Month outcome; Threshold mental disorders; Subthreshold mental disorders; Comorbidity
1. Introduction Several studies on the course of psychiatric illness *Corresponding author. Department of Psychiatry, Neurobiology, Pharmacology, Biotechnology, University of Pisa, via Roma 67, 56100 Pisa, Italy. Fax: 1 39-050-21581. E-mail address: [email protected] (S. Pini)
in primary care settings conducted before 1990 described that mental disorders are relatively frequent in primary care and tend to be persistent in about 20–50% of cases at various follow-up periods (Shepherd et al., 1966; Dunn and Skuse, 1981; Mann et al., 1981; Kessler et al., 1985; Katon and Schulberg, 1992). These studies, almost exclusively conducted in the UK or the US with varying case-
0165-0327 / 99 / $ – see front matter 1999 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 99 )00141-X
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S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
finding methods based on older classification systems, were supplemented by more recent studies using a more elaborate methodology. Ormel et al. (1993) have assessed outcome of depression and anxiety using either binary (presence / absence) or multi-categorical outcome measures. In the first case, they found that over four-fifths of patients had no more diagnosable depression or anxiety after one year, while in the second case, fewer than a third of patients fully recovered after 12 months. Patients with anxiety recognized by the physician were found to have shorter duration of the symptomatology than those unrecognized, while such a difference was not found for depression (Ormel et al., 1991). Katon et al. (1994) found that 50% of primary care patients with major depression still had depressive symptoms after four months, although they were recognized by the physician as having a mental disorder, as compared to about 20% of those with minor depression. A high rate of continuing cases (59%) was reported by Hansson et al. (1994), who also found a high utilization of ambulatory care during the follow-up in these patients. Sherbourne et al. (1996) found that about 60% out of 875 patients who received general medical care had concomitant depressive or anxiety disorders. In this study, they found that patients with depression and anxiety were more likely to experience a major depressive episode in the year after baseline than were patients with depression alone, suggesting a tendency of these conditions to be persistent and to have an impact on patent’s quality of life. The outcome of depression and anxiety disorders when they occur comorbidly have also been investigated. Zung et al. (1990), for example, argued that in patients with depressive and anxiety disorders, the course of anxiety symptomatology is proportional to that of depression, that is, when depression improves co-occurring anxiety improves, and when depression worsens anxiety symptomatology parallels it. Brown et al. (1996) found that primary care patients with depression and comorbid anxiety disorders have more severe psychopathology at baseline than those with each disorder occurring singly and respond less to treatment interventions than those without comorbidity. However, such difference was accounted for by panic disorder but not by generalized anxiety. Probably the largest effort to gain more insight into the phenomenology and course of mental dis-
orders in primary care using a refined methodology was the multicentre WHO study denominated ‘Psychological Problems in General Health Care’ (Sartorius et al., 1993; Ustun and Sartorius, 1995). Baseline data have reported elsewhere (Ormel et al., 1994; Ustun and Sartorius, 1995). First longitudinal data from this study were reported by Simon and Von Korff (1995) for the American site (Seattle, USA). They found that the majority of patients with both major or minor depressive disorders showed considerable improvement in depression and disability after 12 months. However, 30% of patients with major depression continued to fulfill criteria for major depression after 12 months. Moreover, similar rates of recovery were found among patients recognized by the physician as psychiatric cases (30.3%) as compared to those unrecognized (30.4%), suggesting a lack of association between identification by physician and better outcome (Simon and Von Korff, 1995). Tiemens et al. (1996) reported follow-up data from the Holland site of the WHO study. They found that about 70% of patients with an ICD-10 psychiatric diagnosis at baseline had a major improvement and 47% of patients no longer met criteria for any psychiatric disorder after 12 months. However, only about 30% had a complete symptom remission after 12 months. The scarce association between recognition as a case by the physician and outcome was also confirmed in this study, with both recognized and unrecognized patients improving in a similar frequency and degree. This study presents 12-month follow-up results from the Verona site (Italy) of the above-mentioned WHO study, aiming: 1. To describe the outcome of identified baseline threshold and subthreshold ICD-10 mental disorders after 12 months, in terms of level of psychopathology, occupational functioning and patient’s self-reported disability. 2. To investigate, separately, in patients with both current threshold and subthreshold ICD-10 mental disorders, the relationship between recognition of the presence of a mental disorder at baseline by the physician and outcome of psychopathology, occupational functioning and patient’s self-reported disability. 3. To evaluate the impact of various psycho-
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
pathological and health-related factors (namely, initial diagnostic status, psychiatric comorbidity, reason for medical consultation, patient’s overall health self-perception, ‘concordance’ between physician’s and patient’s overall health status evaluation, patient’s physical health status and frequency of medical consultations) on identification of mental distress by the physician and improvement of mental disorders.
2. Method
2.1. Study setting The study was carried out in 16 Italian primary care clinics, located in the urban area and surroundings of the city of Verona. Data were collected within the framework of the WHO Collaborative Study on denominated ‘Psychological Problems in General Health Care’, whose design and method are extensively described elsewhere (Sartorius et al., 1993; Ormel et al., 1994; Ustun and Sartorius, 1995).
2.2. Screening Consecutive primary care attenders aged between 18 and 65 were initially investigated at baseline in a two-phase process. In the first phase, subjects were screened by the 12-item General Health Questionnaire (GHQ-12) (Goldberg and Williams, 1988) over a 10-month period of time. The aim of sampling this population was to conduct diagnostic interviews with a sample that included a large number of patients with threshold or subthreshold mental disorders, maintaining the ability to make reasonably precise estimates of the prevalence and correlates of these conditions in the population of consecutive attenders. A stratified random sample (weighted toward higher CHQ scores) was selected for the baseline interview (second phase). Center-specific cut-points were adopted in order to have similar proportion of second phase interviews across the participating centers. Using pilot test data, three GHQ-12 strata were identified based on GHQ-12 score distribution, the highest 20% were categorized as high scorers, the next highest 20% as medium
39
scorers and the lowest 60% as low scorers. The lower boundaries of the medium and high scorers in the Verona center were respectively 4 and 6. For each strata, 100% of high scorers, 35% of medium scorers and 10% of low scorers were included in the second phase assessment. Patients were excluded if they were too ill to participate in screening, had been screened on a previous visit, were not attending the clinic for a medical consultation, or had no fixed address. Of the 1555 patients who completed the screening procedure, 457 were eligible for the second phase assessment and 250 (54.7%) completed the interview. The attrition rate was high and mainly due to direct refusals, lack of time or of interest in the project, missed scheduled appointments. Three subjects interrupted the interview. Data from the screening phase showed no significant differences between responders and non-responders in age, gender and GHQ score.
2.3. Second phase assessment The second phase assessment was based on the WHO Primary Health Care Version of the Composite International Diagnostic Interview (CIDI) (Sartorius et al., 1993; Wittchen, 1994), a structured interview which allows to formulate ICD-10 psychiatric diagnoses. The CIDI was carried out by psychiatrists or clinical psychologists after having received the mandatory specific training in the use of the CIDI and the other instruments. For selected patients, physical and psychological status were additionally assessed by primary care physicians during the visit at the screening phase on standardized forms including a 5-point scale for severity of physical illness (0 5 completely healthy, 1 5 some symptoms but subclinical, 2 5 mildly ill, 3 5 moderately ill, 4 5 severely ill), and a 5-point scale for psychiatric caseness (0 5 completely normal – not mentally ill, 1 5 subclinical disturbance – some symptoms but not reaching level of psychopathology, 2 5 mild case – clinically significant psychiatric distress, 3 5 moderate case, and 4 5 severe case – severe psychological disorder). The scores of the latter mentioned scale, dichotomized collapsing respectively the first two (no psychiatric distress) and the last three categories (psychiatric
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S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
distress), was used to assess the rate of recognition by the physician. Functional disability was measured with the Brief Disability Questionnaire, an eight-item self-report scale adapted from items in the Medical Outcomes Study Short-Form General Health Survey (MOS SF36 (Stewart et al., 1988), and by the Social Disability Schedule, a structured interview which assesses disability in different areas of occupational and social functioning (Wiersma et al., 1990). In this study, analyses were restricted to the occupational role area, which concerns daily activities at work (employment or housekeeping, study, job searching). For retired subjects, the capacity to structure daily activity was assessed. The disability in occupational role was rated on a 4-point scale (0 5 none, 1 5 some, 2 5 moderate, 3 severe). Patient’s overall health self-perception was assessed using a 5-point scale (4 5 excellent, 3 very good, 2 5 good, 1 5 fair, 0 5 poor) administered by researcher during the second phase interview. The same scale was also rated by the physician during the screening phase for each patient selected for the second phase interview. As this scale was filled both by the patient and the physician, the ‘concordance’ between physician’s and patient’s overall health status evaluation was assessed on the basis of joint ratings in this scale (concordance 5 1, discordance 5 0). Patient’s main reason for medical consultation at the index visit was assessed with the CIDI on the basis of an 18-item scale and, subsequently, dichotomized into: psychological 5 1 and not psychological 5 0.
2.4. Twelve-month follow-up assessment All patients who exceeded a pre-defined number of current symptoms in one or more of seven CIDI psychopathological sections (namely, chronic pain disorder, somatoform disorder, hypochondriasis, neurasthenia, anxiety, panic disorder and depressive disorder) were selected for the 3-month and 12month follow-up evaluations (a random sample of 10% of cases who did not exceed the thresholds were also selected for follow-up but were not taken into account in this study). Among these, those subjects who fulfilled the criteria for an ICD-10 disorder were defined as threshold cases. Those subjects who,
although exceeding the predefined CIDI threshold, did not fulfill any ICD-10 research diagnostic criteria for a definite current mental disorder were categorized as subthreshold cases.
2.5. Outcome measures For assessing level of psychopathology, two different outcome measures were adopted: The first measure consisted in the overall number of symptoms of depression, anxiety, somatization and neurasthenia present after 12 months. Therefore, improvement was categorized in percentages, using a four-point scale, on the basis of the difference between baseline and 12-month level of symptoms (no improvement 5 number of symptoms increased by more than 10% or decreased by less than 10%; minor improvement 5 number of symptoms decreased by more than 11–24%; major improvement 5 number of symptoms decreased by more than 25%; remission 5 less than two symptoms). The second measure allowed us to assess the change of the diagnostic status from the baseline to the follow-up according to the following categorization: ICD-10 case, subthreshold ICD-10 case 1 (multiple psychiatric symptoms in the same diagnostic area but not sufficient to formulate any formal ICD-10 diagnosis), symptomatic (two or more psychiatric symptoms, but in different diagnostic areas), well (fewer than two psychiatric symptoms). Two other outcome measures were adopted: improvement in occupational disability and improvement in patient’ s self-reported disability, both defined as a lower score at 12-month follow-up than at baseline.
1
ST depression: any of the three symptoms of criterion B plus three or more symptoms of criterion C. ST agoraphobia: marked fear in, or avoidance of, specific situations (crowds, public spaces, traveling alone or away from home). Two symptoms of anxiety in the feared situation must occur together, on at least one occasion. ST hypochondriasis: at least 6 months of persistent belief of the presence of a serious physical disease, despite the reassurance by the doctor that there is no physical cause of the symptoms. ST panic: up to three spells in the month before. ST somatization: total of four or more symptoms occurring in at least two separate groups (gento-urinary, cardio-vascular, skin and pain, gastrointestinal). ST anxiety: at least three symptoms of anxiety of one month duration.
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
3. Statistical analyses
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136 (54.4%) patients were eligible for the follow-up phase as having exceeded a pre-defined number of symptoms in the CIDI. Of these, 116 (85.3%) completed the 12-month follow-up. There were no significant differences between those patients who dropped out and those who completed the follow-up in terms of several sociodemographic or psychopathological characteristics examined. The prevalences of current mental disorders in the baseline sample and the proportion of those completing the follow-up (last column) are shown in Table 1. Among the 60 threshold mental disorders (ICD-10 diagnoses), 28 subjects had at least two currently comorbid ICD-10 diagnoses (11.1% of patients interviewed; 4.5% of screened consecutive attenders). Of these, 22 completed the 12-month followup. Seventy-six patients were found to have a subthreshold mental disorder. Of these, 18 were found to have brief recurrent depression (BRD) monthly in the last year, of which 12 completed the
A t-test was used to compare mean values of continuous variables, and chi-square was used to compare the distribution of categorical variables between the two groups. Univariate analyses were performed on individual predictive factors, providing the odds ratios for recognition by the physician and corresponding 95% confidence interval for each of them. Crude Odds Ratios (OR) have been used in each sub-group of patients examined to obtain estimates of the strength of association between recognition by the physician and outcome. All analyses were performed using the SPSS statistical package (Version 7.0) for Windows 95.
4. Results
4.1. Baseline Of the 250 patients interviewed at the baseline,
Table 1 Prevalence of subthreshold and current ICD-10 psychiatric diagnoses at baseline and proportion of those completing the 12-month follow-up Diagnostic status (ICD-10 diagnosis)
N5
% among interviewed subjects (N 5 250)
Weighted prevalence a
N completing 12-month follow-up (%)
I. ICD-10 disorders (total)
60
24.0
12.4
49 (81.6)
A. Depressive disorders Current depression (F32 / 33) Dysthymia (F34)
34 5
13.6 2.0
4.7 2.0
29 (85.3) 4 (80.0)
B. Anxiety disorders Generalized anxiety disorder (F41.1) Panic disorder (F41.0) Agoraphobia (F40.0)
21 4 5
8.4 1.6 2.0
3.7 1.5 0.6
20 (95.3) 2 (50.0) 3 (60.0)
C. Somatoform disorders Somatization disorder (F45.0) Neurasthenia (F48.0) Hypochondriasis (F45.2)
1 16 1
0.4 6.4 0.4
0.1 2.1 0.3
1 (100.0) 15 (93.7) 1 (100.0)
D. Alcohol-related disorders Alcohol dependence (F10.2) Harmful use of alcohol (F10.1)
3 5
1.2 2.0
0.5 2.6
2 (66.6) 2 (40.0)
E. Two or more ICD-10 disorders b
28
11.2
4.5
22 (78.6)
76
30.4
14.2
67 (88.2)
II. Subthreshold disorders c a
Among consecutive primary care attenders (N 5 1555), using the GHQ-12 and a cutting score of . 3. c Subjects who exceeded a defined threshold in the CIDI diagnostic sections but not fulfilled ICD-10 criteria. (Twelve subjects fulfilled the criteria for brief recurrent depression and four for mixed anxiety / depression disorder.) b No cases of double depression were found (depression plus dysthymia).
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
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follow-up evaluation. Six subjects with subthreshold disorder were found to have a mixed anxiety depression disorder and all completed the 12-month followup. Whereas the follow-up completion rates are satisfactorily high for most conditions, almost half of the baseline patients with panic / agoraphobia, as well as alcohol abuse disorders, dropped out. Therefore, we will not specifically discuss the 12-month followup findings for these groups of disorders in more detail throughout the paper.
4.2. Sociodemographic, health and utilization characteristics of subjects completing 12 -month follow-up As shown in Table 2, no significant differences were found between patients with subthreshold syndromes and those with threshold diagnoses. Females in both groups outnumbered males by almost three times. Psychological reason for medical consultation showed a tendency to be reported more
Table 2 Sociodemographic and health-related characteristics of patients with current subthreshold and ICD-10 mental disorders completing the 12-month follow-up (%) Subthreshold cases (N 5 67)
ICD-10 cases (N 5 49)
Total (N 5 116)
x 2 , t test P value
Sex Male Female
12 (17.9) 55 (82.1)
8 (16.3) 41 (83.7)
20 (17.2) 96 (82.8)
ns
Age
40.94613.88
43.39611.80
41.97613.04
ns
Years of school
13618
8.763.5
10.1611.1
0.07
Marital status Married Not married
45 (67.2) 22 (32.8)
22 (44.9) 27 (55.1)
72 (62.1) 44 (37.9)
ns
Employment status Unemployed Employed Housewife
9 (13.4) 38 (56.7) 20 (29.9)
8 (16.3%) 24 (56.7) 17 (29.9)
17 (14.7) 62 (53.4) 37 (31.9)
ns
Main reason for medical consultation Psychological problems Others
7 (10.4) 60 (89.5)
12 (24.5) 37 (75.5)
19 (16.3) 97 (83.7)
0.07
Frequency of medical consultation in the last year Less than five More than five
36 (53.7) 31 (46.2)
22 (44.9) 27 (55.1)
58 (50) 58 (50)
ns
Overall health self-perception Good Poor
25 (37.3) 41(61.2)
10 (20.5) 39 (79.6)
35 (30.2) 80 (69.0)
ns
Concordance PCP/patient Concordant Discordant
38 (56.7) 29 (43.3)
28 (57.1) 21 (42.9)
66 (56.9) 50 (43.1)
ns
Physical status (rated by PCP) a Completely healthy Physical symptoms / problems
36 (54.5) 30 (45.5)
18 (36.7) 31 (63.3)
54 (47.0) 61 (53.0)
ns
Characteristics
a
One subject is missing.
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
frequently by threshold cases than subthreshold cases (P , 0.07). In accordance with the tendency in most clinical variables, the 12-GHQ score, administered at the first-phase screening, was significantly higher in the ICD cases than in the subthreshold cases (6.962.5 vs. 5762.6, t 5 2 2.598, df 5 111, P , 0.01), suggesting less severe levels of suffering in subthreshold cases.
43
ever, the odds for comorbidity in general did not reach statistical significance. Psychological problems as a main reason for medical consultation was also found to be associated with a greater likelihood to be recognized as compared to those who presented to the doctor with physical problems (OR 5 3.82, 95% CI 1.18–12.36). However, if the doctor rated that physical status of the patient was poor, the likelihood for the patient of being recognized as having a mental disorder also increased (OR 5 2.21, 95% CI 1.04–4.68).
4.3. Recognition as psychiatric case by primary care physicians at baseline Overall, 63 (54.3%) of threshold and subthreshold patients included in the follow-up were recognized as psychiatic cases by primary care physicians at the baseline. As shown in Table 3, subthreshold cases were significantly less likely to be recognized (OR 5 0.39, 95% CI 0.18–0.84) than those with defined psychiatric disorders (OR 5 2.54, 95% CI 1.18– 5.47). Patients with depressive disorders had a greater likelihood to be identified by the doctor (OR 5 3.70, 95% CI 1.49–9.15), as compared to subjects with other mental disorders. Comorbidity specifically between depressive and anxiety disorders was found to greatly increase the probability of recognition (OR 5 5.39, 95% CI 1.13–25.55). How-
4.4. Twelve-month outcome Table 4 describes the 12-month outcome of the 49 baseline threshold patients fulfilling the ICD-10 research criteria for one or more of the following diagnoses: current depression (mild, moderate, severe), dysthymia, generalized anxiety disorder neurasthenia, somatoform disorder, panic disorder, agoraphobia, and hypochondriasis, as well as those 67 subjects classified as having subthreshold conditions, defined as exceeding a pre-defined CIDI threshold but falling below the ICD-10 diagnostic criteria. Among subthreshold cases, 26.9% of subthreshold
Table 3 Proportion of patients recognized by physician as psychiatric cases among those included in the 12-month follow-up (total 5 116) Diagnostic status
b
ICD-10 cases Depressive disorders c Anxiety disorder d Depressive and anxiety disorders e Somatoform disorders f Alcohol-related disorders g Two or more of the above Subthreshold cases a a
N5
49 33 25 13 17 4 22 67
ICD-10 cases. Subthreshold cases. c No depressive disorders. e No depressive and anxiety disorders comorbidity. f No somatoform disorders. g No alcohol related disorders. d No anxiety disorder. b
% of recognized by PCP (%) 67.3 75.8 68.0 84.6 70.6 50.0 72.7 44.8
Recognition by physician OR
95% C.I.
2.544* 3.701* 2.079 5.394* 2.259 0.836 2.667 0.393*
1.181–5.478 1.496–9.154 0.816–5.297 1.139–25.551 0.741–6.890 0.114–6.147 0.960–7.408 0.183–0.847
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
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Table 4 Twelve-month outcome of current ICD-10 diagnoses (N 5 49) and subthreshold disorders (N 5 67) Baseline diagnosis
N5
Degree of improvement in psychopathology at follow-up (Number of psychiatric symptoms a) Absent ( $ 10% to 2 9%)c 9 5 5 2 2 3 3
(18.4) (17.2) (25.0) (13.3) (25.0) (14.3) (25.0) 0
Minor (210% to 2 24%)
Major (225% to 2 99%)
7 (14.3) 3 (10.3) 3 (15) 3 (20.0) 1 (12.5) 2 (9.5) 2 (16.7) 2 (40.0)
30 19 11 8 5 4 6 3
(61.2) (65.5) (55.0) (53.3) (62.5) (66.7) (50.0) (60.0)
Remission (2than 2 symptoms)
Threshold cases (ICD-10 diagnoses) Major depression GAD Neurasthenia Major depression plus GAD Major depression with no GAD GAD with no major depression Panic disorder/agoraphobia
49 (29) (20) (15) (8) (21) (12) (5)
3 2 1 2 0 2 1 0
(6.1) (6.9) (5.0) (13.3)
Subthreshold cases Brief recurrent depression
67 (12)
19 (28.3) 6 (50.0)
2 (3.0) 0
28 (41.8) 4 (33.3)
18 (26.9) 2 (9.1)
Cases with multiple ICD-10 diagnoses Total
(22) 116
3 (13.6) 28 (24.1)
5 (22.7) 9 (7.8)
12 (54.5) 58 (50.0)
3 (12.0) 21 (18.1)
Subthreshold
Symptomic
Well
(9.5) (8.3)
(Change of diagnostic status b ) N5
ICD-10 cases
Threshold cases (ICD-10 diagnoses) Major depression GAD Neurasthenia Major depression plus GAD Major depression with no GAD GAD with no major depression Panic disorder/agoraphobia
49 (29) (20) (15) (8) (21) (12) (5)
16 12 7 5 4 8 3 2
Subthreshold cases Brief recurrent depression
67 (12)
9 (13.4) 3 (25.0)
11 (16.4) 4 (33.3)
19 (28.5) 2 (16.6)
28 (41.8) 3 (33.3)
Cases with multiple diagnoses Total
(22) 116
9 (40.9) 25 (21.6)
4 (18.20) 20 (17.2)
4 (18.2) 35 (30.2)
5 (22.7) 36 (31.0)
(32.7) (41.4) (35.0) (33.3) (5.0) (38.1) (25.0) (40.0)
9 4 5 2 1 3 4 1
(18.4) (13.8) (25.0) (13.3) (12.5) (14.3) (33.3) (20.0)
16 7 6 4 2 5 4 1
(32.7) (24.1) (30.0) (26.7) (25.0) (23.8) (33.3) (20.0)
8 6 2 4 1 5 1 1
(16.3) (20.7) (10.0) (26.7) (12.5) (23.8) (8.3) (20.0)
a
Number of current symptoms of depression, anxiety, somatization and neuasthenia. See algorithm in the method section. c Percentages in parentheses. b
cases had a full remission after 12 months from intake, compared to 6.1% of threshold cases (P , 0.004). Generalized anxiety disorder with comorbid major depression showed the most unfavorable outcome, with no case of full remission and the highest rate of negative outcome (25%). Similarly, brief recurrent depression showed a high rate of negative outcome after 12 months (50%).
4.5. Change of ‘ diagnostic status’ ( lower part of Table 4) In the lower part of Table 4, these findings, based on a more dimensional approach (number of symptoms in the upper part), were largely confirmed. However, due to the more categorical approach. we see a higher number of ‘well’ subjects as well as a higher number of full threshold cases. Among sub-
Table 5 Odds ratios with 95% CI for the association between physician recognition and improvement in psychopathology, functioning disability and self-reported disability among ICD-10 cases (N 5 49) and subthreshold cases (N 5 67) Improvement in psychopathology
Improvement in functional disability
Improvement in self-reported disability
%
OR (95% CI)
N5
%
OR (95% CI)
N5
%
OR (95% CI)
11 22
68.7 66.7
0.90 (0.25–3.27)
3 17
18.8 51.5
4.60*(1.10–19.22)
6 15
37.5 45.5
1.38 (0.40–4.71)
Subthreshold cases Not recognized (n 5 37) Recognized (n 5 30)
30 16
81.1 53.3
0.26* (0.09–0.79)7
11 23.3
29.7 0.71 (0.23–2.16)
6
10 9.0
27.0 0.67 (0.21–2.13)
Table 6 Factors a which modify the association between recognition and improvement of psychopathology, occupational disability and separated disability in the overall sample (N 5 116) Variables
Number of patients
Odds for improvement given recognition by PCP Improvement in psychopathology
ICD-10 diagnosis Major depression ICD-10 comorbidity More than five visits a
49 29 22 58
Improvement in occupational disability
Improvement in self-reported disability
N5
%
OR (95% CI)
N5
%
OR (95% CI)
N5
%
OR (95% CI)
(...) (...) (...) 14
(...) (...) (...) 24.1
(...) (...) (...) 0.27 (0.09–0.79)
17 14 8 (...)
34.7 48.3 36.3 (...)
3.49 (1.17–10.35) 6.40 (2.02–20.25) 1.93 (0.71–6.12) (...)
15 13 10 (...)
30.6 44.8 45.5 (...)
3.33 (1.08–10.28) 6.90 (2.14–22.25) 5.45 (1.61–18.41) (...)
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
N5 ICD-10 cases Not recognized (n 5 16) Recognized (n 5 33)
Other health-related variables examined; main reason for contact, concordance between PCP and patient, overall health self-perception, physical health status.
45
46
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
threshold disorders, 41.8% had a full remission as compared to 16.3% of threshold disorders ( x 2 5 8.574, P , 0.003), and 13.4% developed an ICD-10 disorder (3.0% being an alcohol abuse disorder), compared to 32.7% of threshold cases ( x 2 5 6.l 84; P , 0.01).
disability. Psychiatric comorbidity exerted an effect on improvement in self-reported disability, while frequent contacts (more than five) with the physician during the last 12 months were predictive of a negative outcome of recognized subjects.
4.6. Recognition as psychiatric case by primary care physician and outcome
5. Discussion
Among subthreshold cases a complete remission, in terms of psychopathological symptoms after 12 months was found to be significantly more frequent in unrecognized patients (59.5%) than in recognized subjects (20.0%) (Fisher’s exact test, P , 0.001). Analogously, the total number of psychiatric symptoms was lower in unrecognized than in recognized subjects (respectively, 4.664.5 vs. 8.367.5, t 5 2 2.34, df 5 65, P , 0.01). Conversely, among ICD-10 disorders, no significant difference was found in rate of remission between not recognized and recognized (respectively 31.3% vs. 9.1%), although figures show a trend in the same direction as that found for subthreshold cases. Table 5 shows the odds for the association between recognition by the primary care physician and each of the three outcome measures examined. As to threshold cases, recognition has been found to be significantly associated with a greater improvement in occupational disability (OR 5 4.60, 95% CI 1.10–19.22). As to subthreshold cases, recognition was found to be significantly negatively associated with improvement in psychopathology (OR 5 0.26, 95% CI 0.09–0.79).
4.7. Factors associated with recognition by the physician and improvement A series of clinical and health-related variables was investigated in the overall sample, to evaluate whether there was an association between recognition by the physician and improvement in specific subgroups of patients. As shown in Table 6, the presence of a threshold mental disorder and, in particular, of major depression increased significantly the probability that the recognition of mental disorder was associated with an improvement either in occupational functioning and in self-reported
In our study, both threshold and subthreshold mental disorders are frequent in primary care settings, weighted prevalences among consecutive primary care attenders being, respectively, 12.4 and 14.2%. Depression (4.7%) and generalized anxiety disorder (3.7%) were the most frequent mental disorders, followed by neurasthenia (2.1%), dysthymia (2.0%) and panic disorder (1.5%). Psychiatric comorbidity is also a considerable phenomenon being present in 4.5% of the consecutive primary care patients screened, in 11.2% of subjects interviewed at the second phase, and in 46.6% of ICD-10 threshold cases. These prevalence estimates should be interpreted cautiously because of the high attrition rate. In fact, about 46% of subjects eligible for the second phase interview dropped out. Although level of emotional distress, as assessed by GHQ, did not differ significantly between responders and not responders, psychopathological characteristics of these latter could not be assessed. Baseline results indicate that the physician recognises more frequently the presence of a psychological problem when the patient has a threshold mental disorder than when he / she has a subthreshold condition. Moreover, the odds ratios showed that physician’s recognition may significantly vary according to specific diagnostic subgroups of mental disorders. Patients with depression, either alone or when it is concomitant with anxiety disorders, are more likely to be recognized than those without these conditions, while anxiety disorders are less likely to be detected. These data are consistent with most recent studies, showing the clear tendency by the physician to detect patients with more severe psychiatric illness, while minor psychiatric conditions tend to remain unrecognized and unmanaged (Wells et al., 1989; Ormel et al., 1991; Coyne et al., 1995; Simon and Von Korff, 1995; Pini et al., 1997). Specific comorbidity between depression and anxiety was found to be
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
significantly associated with recognition more than was psychiatric comorbidity in general. These data indicate that the phenomenology of mental illness rather than severity seems to be somehow related to recognition. Although anxiety syndromes are common in primary care and cause considerable impairment (Ormel et al., 1994), the physician is probably more prompted by depressive phenomenology or by certain depressive symptoms, while anxiety symptoms are likely to be trivialized or, when presented as physical complaints, attributed to medical conditions (Pini et al., 1997). We also found that recognition by the physician is more likely to occur when the patient openly manifests psychological problems during the visit, as well as he / she is judged by the doctor to have relevant physical problems. These findings are only apparently contradictory. It is plausible that certain physical illnesses are considered potentially predictive of the presence of mental disorders because of their severity and chronicity or because they are known to be frequently associated with psychological problems. Follow-up results showed that the rate of full remission after 12 months was about three times higher in subthreshold mental disorders than in ICD10 disorders. Parallel, only about 10% of subjects with subthreshold disorders received a formal psychiatric diagnosis after 12 months, compared to about 32% of threshold cases. Depression comorbid with generalized anxiety disorder showed the most unfavorable outcome, in terms of level of psychopathology after one year. As to subthreshold cases, it is noteworthy that about 20% of patients cases did not show any improvement, with several cases evolving in to a threshold condition after one year. This considerable proportion of negative outcome among subthreshold cases, was in part likely to be accounted for by brief recurrent depression which showed a lower rate of remission and a clear tendency to transit into a threshold mental disorder after 12 months compared to subthreshold cases in general. These findings are in general consistent with several previous studies, showing the relatively more favorable outcome of minor mental disorders as compared to threshold disorders (Simon and Von Korff, 1995; Tiemens et al., 1996). However, examining in more detail the 12-month outcome of
47
specific subgroups of patients within both threshold and subthreshold conditions, we found that outcome may vary considerably according to patients’ specific diagnostic subgroups. The ability of the physician to recognize the presence of mental problems in their patients seems to be scarcely related with outcome of mental disorders. In fact, overall, unrecognized subjects did not differ from the counterparts in terms of outcome of psychopathology. This finding is difficult to interpret. However, patients who were recognized by the doctor as having a mental problem, were more likely to have an improvement, both in their occupational functioning and self-reported disability, with this association being more evident for threshold cases and for those with comorbidity. Conversely, a negative association between recognition and outcome of psychopathology after one year was found for patients who had frequent contacts with the doctor during the follow-up period. These findings suggest that the physician is more likely to focus on variations of patient’s performance in different areas of functioning rather than to specifically explore the course of psychopathology. Therefore, lack of such associations in subthreshold cases may be explained by the fact these patients are likely to have lower degrees of disability. On the other hand, the considerable proportion of unremitted cases among subthreshold cases after one year, suggest the need of more accurate psychopathological assessment in these patients. Our findings should be interpreted in the light of recent debate and a re-appraisal of the importance of mental illness in primary care (Schulberg et al., 1987; Goldberg, 1992; Coyne et al., 1995; Ormel and Tiemens, 1995). It has been argued that minor mental disorders seen in primary care have a high likelihood of spontaneous recovery (Goldberg, 1992; Katon et al., 1994; Simon and Von Korff, 1995; Katon, 1995). Our findings suggest that outcomes of mental disorders in primary care are not simply related to their initial severity and that recognition is not always associated with a better outcome. Future efforts by researchers in the field should not be only addressed to improve physicians’ ability to detect and treat formal mental disorders. A better understanding of what comprises the definition of a mental disorder in primary care and what psycho-
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S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
pathological conditions are considered by physicians deserve attention and treatment should also be taken into account.
References Brown, C., Schulberg, H.C., Madonia, M.J., Shear, M.K., Houck, P.R., 1996. Treatment outcomes for primary care patients with major depression and lifetime anxiety disorders. Am. J. Psychiatry 153, 1293–1300. Coyne, J.C., Schwenk, T.L., Fechner-Bates, S., 1995. Nondetection of depression by primary care physicians reconsidered. Gen. Hosp. Psychiatry 17, 3–12. Dunn, G., Skuse, D., 1981. The natural history of depression in general practice: stochastic models. Psychol. Med. 11, 755– 764. Goldberg, D., 1992. The treatment of mental disorders in general medical settings. Gen. Hosp. Psychiatry 14, 83–85. Goldber, D.P., Williams, P., 1988. A users Guide to the General Health Questionnaire: GHQ. NEER-NELSON, Windsor. Hansson, L., Borgquis, L., Nettelbladt, P., Nordstrom, G., 1994. The course of psychiatric illness in primary care patients. Soc. Psych. Psychiatr. Epidemiol. 29, 1–7. Katon, W., Lin, E., Von Korff, M., Bush, T., Walker, E., Simon, G., Robinson, P., 1994. The predictors of persistence of depression in primary care. J. Affect. Disord. 31, 81–90. Katon, W., 1995. Will improving detection of depression in primary care lead to improved depressive outcomes? Gen. Hosp. Psychiatry 17, 1–2. Katon, W., Schulberg, H., 1992. Epidemiology of depression in primary care. Gen. Hosp. Psychiatry 14, 237–247. Kessler, L.G., Cleary, P.D., Burke, J.D., 1985. Psychiatric disorders in primary care: results of a follow-up study. Arch. Gen. Psychiatry 42, 583–587. Mann, A.H., Jenkins, R., Belsey, E., 1981. The twelve-month outcome of patients with neurotic illness in general practice. Psychol. Med. 11, 535–550. Ormel, J., Koeter, M.W.J., van den Brink, W., van de Willige, G., 1991. Recognition, management, and course of anxiety and depression in general practice. Arch. Gen. Psychiatry 48, 700– 706. Ormel, J., Oldehinkel, T., Brilman, E., van den Brink, W., 1993. Outcome of depression and anxiety in primary care. Arch. Gen. Psychiatry 50, 759–766. Ormel, J., Von Korff, M., Ustun, T.B., Pini, S., Korten, A., Oldehinkel, T., 1994. Common mental disorders and disability across cultures. Results from the WHO collaborative study on
psychological problems in general health care. J. Am. Med. Assoc. 272, 1741–1748. Ormel, J., Tiemens, B., 1995. Recognition and treatment of mental illness in primary care. Towards a better understanding of a multifaceted problem. Gen. Hosp. Psychiatry 17, 160–164. Pini, S., Berardi, D., Rucci, P., Piccinelli, M., Neri, C., Tansella, M., Ferrari, G., 1997. Identification of psychiatric distress by primary care physician. Gen. Hosp. Psychiatry 19, 411–418. Sartorius, N., Ustun, T.B., Costa e Silva, J.A., Goldberg, D., Lecrubier, Y., Ormel, J., Von Korff, M., Wittchen, H.-U., 1993. An international study of psychological problems in primary care. Arch. Gen. Psychiatry 50, 819–824. Schulberg, H.C., McClelland, M., Goodwin, W., 1987. Six-months outcomes for medical patients with major depressive disorders. J. Gen. Int. Med. 2, 312–317. Shepherd, M., Cooper, B., Brown, A.C., Kalton, G., 1966. Psychiatric Illness in General Practice, Oxford University Press, London. Sherbourne, C.D., Wells, K.B., Meredith, L.S., Jacksin, C.A., Camp, P., 1996. Comorbid anxiety disorder and the functioning and well-being of chronically ill patients of general medical providers. Arch. Gen. Psychiatry 53, 889–895. Simon, G.E., Von Korff, M., 1995. Recognition, management, and outcome of depression in primary care. Arch. Fam. Med. 4, 99–105. Stewart, A.L., Hays, R.D., Ware, J.E.J., 1988. The MOS shortform general health survey: reliability and validity in a patient population. Med. Care 26, 724–735. Tiemens, B.G., Ormel, J., Simon, G.E., 1996. Occurrence, recognition and outcome of psychological disorders in primary care. Am. J. Psychiatry 153, 636–644. Ustun, T.B., Sartorius, N. (Eds.), 1995. Mental Illness in General Health Care: An International Study, John Wiley and Sons, New York. Wells, K., Hays, R.D., Burnam, M.A., Rogers, W., Greenfield, S., Ware, J.E., 1989. Detection of depressive disorder for patients receiving prepaid fee-for-service care: results form the Medical Outcomes Study. J. Am. Med. Assoc. 262, 3298–3302. Wiersma, D., Jong, A., Kraaijkamp, H., Ormel, J., 1990. The Gronongen Social Disability Schedule: development, relationship with I.C.I.D.H. and psychometric properties. Int. Rehab. Res. 11, 213–224. Wittchen, H.-U., 1994. Reliability and validity studies of the WHO–Composite International Diagnostic Interview (CIDI): a critical review. J. Psychiatr. Res. 28, 57–84. Zung, W.W.K., Magruder-Habib, K., Velez, R., Alling, W., 1990. The comorbidity of anxiety and depression in general medical patients: a longitudinal study. J. Clin. Psychiatry 51 (Suppl. 6), 77–80.
Research report
Prevalence and 12-month outcome of threshold and subthreshold mental disorders in primary care a,
b
a
Stefano Pini M.D., Ph.D. *, Axel Perkonnig Ph.D. , Michele Tansella M.D. , Hans-UIrich Wittchen Ph.D., Dipl. Psich.b a
Institute of Psychiatry, University of Verona, Verona, Italy b Max Planck Institute of Psychiatry, Munich, Germany
Abstract Background: The authors investigated the occurrence and 12-month outcome of mental disorders in primary care setting. Method: Out of 1555 primary care patients screened in an index period in 16 primary care clinics, 457 subjects were selected for the second phase interview with the CIDI and 250 subjects completed the assessment. Of these, 116 patients (49 ICD-10 cases and 67 subthreshold cases) completed the 12-month follow-up evaluation. Results: Overall, 12.4% of consecutive primary care attenders had a current ICD-10 disorder and 14.2% had a subthreshold mental disorder. Psychiatric comorbidity was found in 45% of the initial sample. Physicians recognized the presence of a mental disorder at baseline in 84.6% of cases with depression comorbid with anxiety and in 44.8% of subthreshold cases. Subthreshold cases outnumbered by three times threshold cases in terms of remission after one year. However, 18% of subthreshold conditions showed no improvement after 12 months. Recognition of mental disorder by the physician at baseline was not associated with an improvement of psychopathology after 12 months, but was associated with an improvement in occupational disability and self-reported disability among threshold cases. Conclusions: Mental disorders are frequent in primary care but their outcome is relatively independent from recognition by the physician. Threshold cases have a worse 12-month outcome than subthreshold cases. However, a substantial outcome variability seems to characterize different diagnostic subgroups both in threshold and subthreshold cases. 1999 Elsevier Science B.V. All rights reserved. Keywords: Primary care physician; Recognition; 12-Month outcome; Threshold mental disorders; Subthreshold mental disorders; Comorbidity
1. Introduction Several studies on the course of psychiatric illness *Corresponding author. Department of Psychiatry, Neurobiology, Pharmacology, Biotechnology, University of Pisa, via Roma 67, 56100 Pisa, Italy. Fax: 1 39-050-21581. E-mail address: [email protected] (S. Pini)
in primary care settings conducted before 1990 described that mental disorders are relatively frequent in primary care and tend to be persistent in about 20–50% of cases at various follow-up periods (Shepherd et al., 1966; Dunn and Skuse, 1981; Mann et al., 1981; Kessler et al., 1985; Katon and Schulberg, 1992). These studies, almost exclusively conducted in the UK or the US with varying case-
0165-0327 / 99 / $ – see front matter 1999 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 99 )00141-X
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S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
finding methods based on older classification systems, were supplemented by more recent studies using a more elaborate methodology. Ormel et al. (1993) have assessed outcome of depression and anxiety using either binary (presence / absence) or multi-categorical outcome measures. In the first case, they found that over four-fifths of patients had no more diagnosable depression or anxiety after one year, while in the second case, fewer than a third of patients fully recovered after 12 months. Patients with anxiety recognized by the physician were found to have shorter duration of the symptomatology than those unrecognized, while such a difference was not found for depression (Ormel et al., 1991). Katon et al. (1994) found that 50% of primary care patients with major depression still had depressive symptoms after four months, although they were recognized by the physician as having a mental disorder, as compared to about 20% of those with minor depression. A high rate of continuing cases (59%) was reported by Hansson et al. (1994), who also found a high utilization of ambulatory care during the follow-up in these patients. Sherbourne et al. (1996) found that about 60% out of 875 patients who received general medical care had concomitant depressive or anxiety disorders. In this study, they found that patients with depression and anxiety were more likely to experience a major depressive episode in the year after baseline than were patients with depression alone, suggesting a tendency of these conditions to be persistent and to have an impact on patent’s quality of life. The outcome of depression and anxiety disorders when they occur comorbidly have also been investigated. Zung et al. (1990), for example, argued that in patients with depressive and anxiety disorders, the course of anxiety symptomatology is proportional to that of depression, that is, when depression improves co-occurring anxiety improves, and when depression worsens anxiety symptomatology parallels it. Brown et al. (1996) found that primary care patients with depression and comorbid anxiety disorders have more severe psychopathology at baseline than those with each disorder occurring singly and respond less to treatment interventions than those without comorbidity. However, such difference was accounted for by panic disorder but not by generalized anxiety. Probably the largest effort to gain more insight into the phenomenology and course of mental dis-
orders in primary care using a refined methodology was the multicentre WHO study denominated ‘Psychological Problems in General Health Care’ (Sartorius et al., 1993; Ustun and Sartorius, 1995). Baseline data have reported elsewhere (Ormel et al., 1994; Ustun and Sartorius, 1995). First longitudinal data from this study were reported by Simon and Von Korff (1995) for the American site (Seattle, USA). They found that the majority of patients with both major or minor depressive disorders showed considerable improvement in depression and disability after 12 months. However, 30% of patients with major depression continued to fulfill criteria for major depression after 12 months. Moreover, similar rates of recovery were found among patients recognized by the physician as psychiatric cases (30.3%) as compared to those unrecognized (30.4%), suggesting a lack of association between identification by physician and better outcome (Simon and Von Korff, 1995). Tiemens et al. (1996) reported follow-up data from the Holland site of the WHO study. They found that about 70% of patients with an ICD-10 psychiatric diagnosis at baseline had a major improvement and 47% of patients no longer met criteria for any psychiatric disorder after 12 months. However, only about 30% had a complete symptom remission after 12 months. The scarce association between recognition as a case by the physician and outcome was also confirmed in this study, with both recognized and unrecognized patients improving in a similar frequency and degree. This study presents 12-month follow-up results from the Verona site (Italy) of the above-mentioned WHO study, aiming: 1. To describe the outcome of identified baseline threshold and subthreshold ICD-10 mental disorders after 12 months, in terms of level of psychopathology, occupational functioning and patient’s self-reported disability. 2. To investigate, separately, in patients with both current threshold and subthreshold ICD-10 mental disorders, the relationship between recognition of the presence of a mental disorder at baseline by the physician and outcome of psychopathology, occupational functioning and patient’s self-reported disability. 3. To evaluate the impact of various psycho-
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
pathological and health-related factors (namely, initial diagnostic status, psychiatric comorbidity, reason for medical consultation, patient’s overall health self-perception, ‘concordance’ between physician’s and patient’s overall health status evaluation, patient’s physical health status and frequency of medical consultations) on identification of mental distress by the physician and improvement of mental disorders.
2. Method
2.1. Study setting The study was carried out in 16 Italian primary care clinics, located in the urban area and surroundings of the city of Verona. Data were collected within the framework of the WHO Collaborative Study on denominated ‘Psychological Problems in General Health Care’, whose design and method are extensively described elsewhere (Sartorius et al., 1993; Ormel et al., 1994; Ustun and Sartorius, 1995).
2.2. Screening Consecutive primary care attenders aged between 18 and 65 were initially investigated at baseline in a two-phase process. In the first phase, subjects were screened by the 12-item General Health Questionnaire (GHQ-12) (Goldberg and Williams, 1988) over a 10-month period of time. The aim of sampling this population was to conduct diagnostic interviews with a sample that included a large number of patients with threshold or subthreshold mental disorders, maintaining the ability to make reasonably precise estimates of the prevalence and correlates of these conditions in the population of consecutive attenders. A stratified random sample (weighted toward higher CHQ scores) was selected for the baseline interview (second phase). Center-specific cut-points were adopted in order to have similar proportion of second phase interviews across the participating centers. Using pilot test data, three GHQ-12 strata were identified based on GHQ-12 score distribution, the highest 20% were categorized as high scorers, the next highest 20% as medium
39
scorers and the lowest 60% as low scorers. The lower boundaries of the medium and high scorers in the Verona center were respectively 4 and 6. For each strata, 100% of high scorers, 35% of medium scorers and 10% of low scorers were included in the second phase assessment. Patients were excluded if they were too ill to participate in screening, had been screened on a previous visit, were not attending the clinic for a medical consultation, or had no fixed address. Of the 1555 patients who completed the screening procedure, 457 were eligible for the second phase assessment and 250 (54.7%) completed the interview. The attrition rate was high and mainly due to direct refusals, lack of time or of interest in the project, missed scheduled appointments. Three subjects interrupted the interview. Data from the screening phase showed no significant differences between responders and non-responders in age, gender and GHQ score.
2.3. Second phase assessment The second phase assessment was based on the WHO Primary Health Care Version of the Composite International Diagnostic Interview (CIDI) (Sartorius et al., 1993; Wittchen, 1994), a structured interview which allows to formulate ICD-10 psychiatric diagnoses. The CIDI was carried out by psychiatrists or clinical psychologists after having received the mandatory specific training in the use of the CIDI and the other instruments. For selected patients, physical and psychological status were additionally assessed by primary care physicians during the visit at the screening phase on standardized forms including a 5-point scale for severity of physical illness (0 5 completely healthy, 1 5 some symptoms but subclinical, 2 5 mildly ill, 3 5 moderately ill, 4 5 severely ill), and a 5-point scale for psychiatric caseness (0 5 completely normal – not mentally ill, 1 5 subclinical disturbance – some symptoms but not reaching level of psychopathology, 2 5 mild case – clinically significant psychiatric distress, 3 5 moderate case, and 4 5 severe case – severe psychological disorder). The scores of the latter mentioned scale, dichotomized collapsing respectively the first two (no psychiatric distress) and the last three categories (psychiatric
40
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
distress), was used to assess the rate of recognition by the physician. Functional disability was measured with the Brief Disability Questionnaire, an eight-item self-report scale adapted from items in the Medical Outcomes Study Short-Form General Health Survey (MOS SF36 (Stewart et al., 1988), and by the Social Disability Schedule, a structured interview which assesses disability in different areas of occupational and social functioning (Wiersma et al., 1990). In this study, analyses were restricted to the occupational role area, which concerns daily activities at work (employment or housekeeping, study, job searching). For retired subjects, the capacity to structure daily activity was assessed. The disability in occupational role was rated on a 4-point scale (0 5 none, 1 5 some, 2 5 moderate, 3 severe). Patient’s overall health self-perception was assessed using a 5-point scale (4 5 excellent, 3 very good, 2 5 good, 1 5 fair, 0 5 poor) administered by researcher during the second phase interview. The same scale was also rated by the physician during the screening phase for each patient selected for the second phase interview. As this scale was filled both by the patient and the physician, the ‘concordance’ between physician’s and patient’s overall health status evaluation was assessed on the basis of joint ratings in this scale (concordance 5 1, discordance 5 0). Patient’s main reason for medical consultation at the index visit was assessed with the CIDI on the basis of an 18-item scale and, subsequently, dichotomized into: psychological 5 1 and not psychological 5 0.
2.4. Twelve-month follow-up assessment All patients who exceeded a pre-defined number of current symptoms in one or more of seven CIDI psychopathological sections (namely, chronic pain disorder, somatoform disorder, hypochondriasis, neurasthenia, anxiety, panic disorder and depressive disorder) were selected for the 3-month and 12month follow-up evaluations (a random sample of 10% of cases who did not exceed the thresholds were also selected for follow-up but were not taken into account in this study). Among these, those subjects who fulfilled the criteria for an ICD-10 disorder were defined as threshold cases. Those subjects who,
although exceeding the predefined CIDI threshold, did not fulfill any ICD-10 research diagnostic criteria for a definite current mental disorder were categorized as subthreshold cases.
2.5. Outcome measures For assessing level of psychopathology, two different outcome measures were adopted: The first measure consisted in the overall number of symptoms of depression, anxiety, somatization and neurasthenia present after 12 months. Therefore, improvement was categorized in percentages, using a four-point scale, on the basis of the difference between baseline and 12-month level of symptoms (no improvement 5 number of symptoms increased by more than 10% or decreased by less than 10%; minor improvement 5 number of symptoms decreased by more than 11–24%; major improvement 5 number of symptoms decreased by more than 25%; remission 5 less than two symptoms). The second measure allowed us to assess the change of the diagnostic status from the baseline to the follow-up according to the following categorization: ICD-10 case, subthreshold ICD-10 case 1 (multiple psychiatric symptoms in the same diagnostic area but not sufficient to formulate any formal ICD-10 diagnosis), symptomatic (two or more psychiatric symptoms, but in different diagnostic areas), well (fewer than two psychiatric symptoms). Two other outcome measures were adopted: improvement in occupational disability and improvement in patient’ s self-reported disability, both defined as a lower score at 12-month follow-up than at baseline.
1
ST depression: any of the three symptoms of criterion B plus three or more symptoms of criterion C. ST agoraphobia: marked fear in, or avoidance of, specific situations (crowds, public spaces, traveling alone or away from home). Two symptoms of anxiety in the feared situation must occur together, on at least one occasion. ST hypochondriasis: at least 6 months of persistent belief of the presence of a serious physical disease, despite the reassurance by the doctor that there is no physical cause of the symptoms. ST panic: up to three spells in the month before. ST somatization: total of four or more symptoms occurring in at least two separate groups (gento-urinary, cardio-vascular, skin and pain, gastrointestinal). ST anxiety: at least three symptoms of anxiety of one month duration.
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
3. Statistical analyses
41
136 (54.4%) patients were eligible for the follow-up phase as having exceeded a pre-defined number of symptoms in the CIDI. Of these, 116 (85.3%) completed the 12-month follow-up. There were no significant differences between those patients who dropped out and those who completed the follow-up in terms of several sociodemographic or psychopathological characteristics examined. The prevalences of current mental disorders in the baseline sample and the proportion of those completing the follow-up (last column) are shown in Table 1. Among the 60 threshold mental disorders (ICD-10 diagnoses), 28 subjects had at least two currently comorbid ICD-10 diagnoses (11.1% of patients interviewed; 4.5% of screened consecutive attenders). Of these, 22 completed the 12-month followup. Seventy-six patients were found to have a subthreshold mental disorder. Of these, 18 were found to have brief recurrent depression (BRD) monthly in the last year, of which 12 completed the
A t-test was used to compare mean values of continuous variables, and chi-square was used to compare the distribution of categorical variables between the two groups. Univariate analyses were performed on individual predictive factors, providing the odds ratios for recognition by the physician and corresponding 95% confidence interval for each of them. Crude Odds Ratios (OR) have been used in each sub-group of patients examined to obtain estimates of the strength of association between recognition by the physician and outcome. All analyses were performed using the SPSS statistical package (Version 7.0) for Windows 95.
4. Results
4.1. Baseline Of the 250 patients interviewed at the baseline,
Table 1 Prevalence of subthreshold and current ICD-10 psychiatric diagnoses at baseline and proportion of those completing the 12-month follow-up Diagnostic status (ICD-10 diagnosis)
N5
% among interviewed subjects (N 5 250)
Weighted prevalence a
N completing 12-month follow-up (%)
I. ICD-10 disorders (total)
60
24.0
12.4
49 (81.6)
A. Depressive disorders Current depression (F32 / 33) Dysthymia (F34)
34 5
13.6 2.0
4.7 2.0
29 (85.3) 4 (80.0)
B. Anxiety disorders Generalized anxiety disorder (F41.1) Panic disorder (F41.0) Agoraphobia (F40.0)
21 4 5
8.4 1.6 2.0
3.7 1.5 0.6
20 (95.3) 2 (50.0) 3 (60.0)
C. Somatoform disorders Somatization disorder (F45.0) Neurasthenia (F48.0) Hypochondriasis (F45.2)
1 16 1
0.4 6.4 0.4
0.1 2.1 0.3
1 (100.0) 15 (93.7) 1 (100.0)
D. Alcohol-related disorders Alcohol dependence (F10.2) Harmful use of alcohol (F10.1)
3 5
1.2 2.0
0.5 2.6
2 (66.6) 2 (40.0)
E. Two or more ICD-10 disorders b
28
11.2
4.5
22 (78.6)
76
30.4
14.2
67 (88.2)
II. Subthreshold disorders c a
Among consecutive primary care attenders (N 5 1555), using the GHQ-12 and a cutting score of . 3. c Subjects who exceeded a defined threshold in the CIDI diagnostic sections but not fulfilled ICD-10 criteria. (Twelve subjects fulfilled the criteria for brief recurrent depression and four for mixed anxiety / depression disorder.) b No cases of double depression were found (depression plus dysthymia).
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
42
follow-up evaluation. Six subjects with subthreshold disorder were found to have a mixed anxiety depression disorder and all completed the 12-month followup. Whereas the follow-up completion rates are satisfactorily high for most conditions, almost half of the baseline patients with panic / agoraphobia, as well as alcohol abuse disorders, dropped out. Therefore, we will not specifically discuss the 12-month followup findings for these groups of disorders in more detail throughout the paper.
4.2. Sociodemographic, health and utilization characteristics of subjects completing 12 -month follow-up As shown in Table 2, no significant differences were found between patients with subthreshold syndromes and those with threshold diagnoses. Females in both groups outnumbered males by almost three times. Psychological reason for medical consultation showed a tendency to be reported more
Table 2 Sociodemographic and health-related characteristics of patients with current subthreshold and ICD-10 mental disorders completing the 12-month follow-up (%) Subthreshold cases (N 5 67)
ICD-10 cases (N 5 49)
Total (N 5 116)
x 2 , t test P value
Sex Male Female
12 (17.9) 55 (82.1)
8 (16.3) 41 (83.7)
20 (17.2) 96 (82.8)
ns
Age
40.94613.88
43.39611.80
41.97613.04
ns
Years of school
13618
8.763.5
10.1611.1
0.07
Marital status Married Not married
45 (67.2) 22 (32.8)
22 (44.9) 27 (55.1)
72 (62.1) 44 (37.9)
ns
Employment status Unemployed Employed Housewife
9 (13.4) 38 (56.7) 20 (29.9)
8 (16.3%) 24 (56.7) 17 (29.9)
17 (14.7) 62 (53.4) 37 (31.9)
ns
Main reason for medical consultation Psychological problems Others
7 (10.4) 60 (89.5)
12 (24.5) 37 (75.5)
19 (16.3) 97 (83.7)
0.07
Frequency of medical consultation in the last year Less than five More than five
36 (53.7) 31 (46.2)
22 (44.9) 27 (55.1)
58 (50) 58 (50)
ns
Overall health self-perception Good Poor
25 (37.3) 41(61.2)
10 (20.5) 39 (79.6)
35 (30.2) 80 (69.0)
ns
Concordance PCP/patient Concordant Discordant
38 (56.7) 29 (43.3)
28 (57.1) 21 (42.9)
66 (56.9) 50 (43.1)
ns
Physical status (rated by PCP) a Completely healthy Physical symptoms / problems
36 (54.5) 30 (45.5)
18 (36.7) 31 (63.3)
54 (47.0) 61 (53.0)
ns
Characteristics
a
One subject is missing.
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
frequently by threshold cases than subthreshold cases (P , 0.07). In accordance with the tendency in most clinical variables, the 12-GHQ score, administered at the first-phase screening, was significantly higher in the ICD cases than in the subthreshold cases (6.962.5 vs. 5762.6, t 5 2 2.598, df 5 111, P , 0.01), suggesting less severe levels of suffering in subthreshold cases.
43
ever, the odds for comorbidity in general did not reach statistical significance. Psychological problems as a main reason for medical consultation was also found to be associated with a greater likelihood to be recognized as compared to those who presented to the doctor with physical problems (OR 5 3.82, 95% CI 1.18–12.36). However, if the doctor rated that physical status of the patient was poor, the likelihood for the patient of being recognized as having a mental disorder also increased (OR 5 2.21, 95% CI 1.04–4.68).
4.3. Recognition as psychiatric case by primary care physicians at baseline Overall, 63 (54.3%) of threshold and subthreshold patients included in the follow-up were recognized as psychiatic cases by primary care physicians at the baseline. As shown in Table 3, subthreshold cases were significantly less likely to be recognized (OR 5 0.39, 95% CI 0.18–0.84) than those with defined psychiatric disorders (OR 5 2.54, 95% CI 1.18– 5.47). Patients with depressive disorders had a greater likelihood to be identified by the doctor (OR 5 3.70, 95% CI 1.49–9.15), as compared to subjects with other mental disorders. Comorbidity specifically between depressive and anxiety disorders was found to greatly increase the probability of recognition (OR 5 5.39, 95% CI 1.13–25.55). How-
4.4. Twelve-month outcome Table 4 describes the 12-month outcome of the 49 baseline threshold patients fulfilling the ICD-10 research criteria for one or more of the following diagnoses: current depression (mild, moderate, severe), dysthymia, generalized anxiety disorder neurasthenia, somatoform disorder, panic disorder, agoraphobia, and hypochondriasis, as well as those 67 subjects classified as having subthreshold conditions, defined as exceeding a pre-defined CIDI threshold but falling below the ICD-10 diagnostic criteria. Among subthreshold cases, 26.9% of subthreshold
Table 3 Proportion of patients recognized by physician as psychiatric cases among those included in the 12-month follow-up (total 5 116) Diagnostic status
b
ICD-10 cases Depressive disorders c Anxiety disorder d Depressive and anxiety disorders e Somatoform disorders f Alcohol-related disorders g Two or more of the above Subthreshold cases a a
N5
49 33 25 13 17 4 22 67
ICD-10 cases. Subthreshold cases. c No depressive disorders. e No depressive and anxiety disorders comorbidity. f No somatoform disorders. g No alcohol related disorders. d No anxiety disorder. b
% of recognized by PCP (%) 67.3 75.8 68.0 84.6 70.6 50.0 72.7 44.8
Recognition by physician OR
95% C.I.
2.544* 3.701* 2.079 5.394* 2.259 0.836 2.667 0.393*
1.181–5.478 1.496–9.154 0.816–5.297 1.139–25.551 0.741–6.890 0.114–6.147 0.960–7.408 0.183–0.847
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
44
Table 4 Twelve-month outcome of current ICD-10 diagnoses (N 5 49) and subthreshold disorders (N 5 67) Baseline diagnosis
N5
Degree of improvement in psychopathology at follow-up (Number of psychiatric symptoms a) Absent ( $ 10% to 2 9%)c 9 5 5 2 2 3 3
(18.4) (17.2) (25.0) (13.3) (25.0) (14.3) (25.0) 0
Minor (210% to 2 24%)
Major (225% to 2 99%)
7 (14.3) 3 (10.3) 3 (15) 3 (20.0) 1 (12.5) 2 (9.5) 2 (16.7) 2 (40.0)
30 19 11 8 5 4 6 3
(61.2) (65.5) (55.0) (53.3) (62.5) (66.7) (50.0) (60.0)
Remission (2than 2 symptoms)
Threshold cases (ICD-10 diagnoses) Major depression GAD Neurasthenia Major depression plus GAD Major depression with no GAD GAD with no major depression Panic disorder/agoraphobia
49 (29) (20) (15) (8) (21) (12) (5)
3 2 1 2 0 2 1 0
(6.1) (6.9) (5.0) (13.3)
Subthreshold cases Brief recurrent depression
67 (12)
19 (28.3) 6 (50.0)
2 (3.0) 0
28 (41.8) 4 (33.3)
18 (26.9) 2 (9.1)
Cases with multiple ICD-10 diagnoses Total
(22) 116
3 (13.6) 28 (24.1)
5 (22.7) 9 (7.8)
12 (54.5) 58 (50.0)
3 (12.0) 21 (18.1)
Subthreshold
Symptomic
Well
(9.5) (8.3)
(Change of diagnostic status b ) N5
ICD-10 cases
Threshold cases (ICD-10 diagnoses) Major depression GAD Neurasthenia Major depression plus GAD Major depression with no GAD GAD with no major depression Panic disorder/agoraphobia
49 (29) (20) (15) (8) (21) (12) (5)
16 12 7 5 4 8 3 2
Subthreshold cases Brief recurrent depression
67 (12)
9 (13.4) 3 (25.0)
11 (16.4) 4 (33.3)
19 (28.5) 2 (16.6)
28 (41.8) 3 (33.3)
Cases with multiple diagnoses Total
(22) 116
9 (40.9) 25 (21.6)
4 (18.20) 20 (17.2)
4 (18.2) 35 (30.2)
5 (22.7) 36 (31.0)
(32.7) (41.4) (35.0) (33.3) (5.0) (38.1) (25.0) (40.0)
9 4 5 2 1 3 4 1
(18.4) (13.8) (25.0) (13.3) (12.5) (14.3) (33.3) (20.0)
16 7 6 4 2 5 4 1
(32.7) (24.1) (30.0) (26.7) (25.0) (23.8) (33.3) (20.0)
8 6 2 4 1 5 1 1
(16.3) (20.7) (10.0) (26.7) (12.5) (23.8) (8.3) (20.0)
a
Number of current symptoms of depression, anxiety, somatization and neuasthenia. See algorithm in the method section. c Percentages in parentheses. b
cases had a full remission after 12 months from intake, compared to 6.1% of threshold cases (P , 0.004). Generalized anxiety disorder with comorbid major depression showed the most unfavorable outcome, with no case of full remission and the highest rate of negative outcome (25%). Similarly, brief recurrent depression showed a high rate of negative outcome after 12 months (50%).
4.5. Change of ‘ diagnostic status’ ( lower part of Table 4) In the lower part of Table 4, these findings, based on a more dimensional approach (number of symptoms in the upper part), were largely confirmed. However, due to the more categorical approach. we see a higher number of ‘well’ subjects as well as a higher number of full threshold cases. Among sub-
Table 5 Odds ratios with 95% CI for the association between physician recognition and improvement in psychopathology, functioning disability and self-reported disability among ICD-10 cases (N 5 49) and subthreshold cases (N 5 67) Improvement in psychopathology
Improvement in functional disability
Improvement in self-reported disability
%
OR (95% CI)
N5
%
OR (95% CI)
N5
%
OR (95% CI)
11 22
68.7 66.7
0.90 (0.25–3.27)
3 17
18.8 51.5
4.60*(1.10–19.22)
6 15
37.5 45.5
1.38 (0.40–4.71)
Subthreshold cases Not recognized (n 5 37) Recognized (n 5 30)
30 16
81.1 53.3
0.26* (0.09–0.79)7
11 23.3
29.7 0.71 (0.23–2.16)
6
10 9.0
27.0 0.67 (0.21–2.13)
Table 6 Factors a which modify the association between recognition and improvement of psychopathology, occupational disability and separated disability in the overall sample (N 5 116) Variables
Number of patients
Odds for improvement given recognition by PCP Improvement in psychopathology
ICD-10 diagnosis Major depression ICD-10 comorbidity More than five visits a
49 29 22 58
Improvement in occupational disability
Improvement in self-reported disability
N5
%
OR (95% CI)
N5
%
OR (95% CI)
N5
%
OR (95% CI)
(...) (...) (...) 14
(...) (...) (...) 24.1
(...) (...) (...) 0.27 (0.09–0.79)
17 14 8 (...)
34.7 48.3 36.3 (...)
3.49 (1.17–10.35) 6.40 (2.02–20.25) 1.93 (0.71–6.12) (...)
15 13 10 (...)
30.6 44.8 45.5 (...)
3.33 (1.08–10.28) 6.90 (2.14–22.25) 5.45 (1.61–18.41) (...)
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
N5 ICD-10 cases Not recognized (n 5 16) Recognized (n 5 33)
Other health-related variables examined; main reason for contact, concordance between PCP and patient, overall health self-perception, physical health status.
45
46
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
threshold disorders, 41.8% had a full remission as compared to 16.3% of threshold disorders ( x 2 5 8.574, P , 0.003), and 13.4% developed an ICD-10 disorder (3.0% being an alcohol abuse disorder), compared to 32.7% of threshold cases ( x 2 5 6.l 84; P , 0.01).
disability. Psychiatric comorbidity exerted an effect on improvement in self-reported disability, while frequent contacts (more than five) with the physician during the last 12 months were predictive of a negative outcome of recognized subjects.
4.6. Recognition as psychiatric case by primary care physician and outcome
5. Discussion
Among subthreshold cases a complete remission, in terms of psychopathological symptoms after 12 months was found to be significantly more frequent in unrecognized patients (59.5%) than in recognized subjects (20.0%) (Fisher’s exact test, P , 0.001). Analogously, the total number of psychiatric symptoms was lower in unrecognized than in recognized subjects (respectively, 4.664.5 vs. 8.367.5, t 5 2 2.34, df 5 65, P , 0.01). Conversely, among ICD-10 disorders, no significant difference was found in rate of remission between not recognized and recognized (respectively 31.3% vs. 9.1%), although figures show a trend in the same direction as that found for subthreshold cases. Table 5 shows the odds for the association between recognition by the primary care physician and each of the three outcome measures examined. As to threshold cases, recognition has been found to be significantly associated with a greater improvement in occupational disability (OR 5 4.60, 95% CI 1.10–19.22). As to subthreshold cases, recognition was found to be significantly negatively associated with improvement in psychopathology (OR 5 0.26, 95% CI 0.09–0.79).
4.7. Factors associated with recognition by the physician and improvement A series of clinical and health-related variables was investigated in the overall sample, to evaluate whether there was an association between recognition by the physician and improvement in specific subgroups of patients. As shown in Table 6, the presence of a threshold mental disorder and, in particular, of major depression increased significantly the probability that the recognition of mental disorder was associated with an improvement either in occupational functioning and in self-reported
In our study, both threshold and subthreshold mental disorders are frequent in primary care settings, weighted prevalences among consecutive primary care attenders being, respectively, 12.4 and 14.2%. Depression (4.7%) and generalized anxiety disorder (3.7%) were the most frequent mental disorders, followed by neurasthenia (2.1%), dysthymia (2.0%) and panic disorder (1.5%). Psychiatric comorbidity is also a considerable phenomenon being present in 4.5% of the consecutive primary care patients screened, in 11.2% of subjects interviewed at the second phase, and in 46.6% of ICD-10 threshold cases. These prevalence estimates should be interpreted cautiously because of the high attrition rate. In fact, about 46% of subjects eligible for the second phase interview dropped out. Although level of emotional distress, as assessed by GHQ, did not differ significantly between responders and not responders, psychopathological characteristics of these latter could not be assessed. Baseline results indicate that the physician recognises more frequently the presence of a psychological problem when the patient has a threshold mental disorder than when he / she has a subthreshold condition. Moreover, the odds ratios showed that physician’s recognition may significantly vary according to specific diagnostic subgroups of mental disorders. Patients with depression, either alone or when it is concomitant with anxiety disorders, are more likely to be recognized than those without these conditions, while anxiety disorders are less likely to be detected. These data are consistent with most recent studies, showing the clear tendency by the physician to detect patients with more severe psychiatric illness, while minor psychiatric conditions tend to remain unrecognized and unmanaged (Wells et al., 1989; Ormel et al., 1991; Coyne et al., 1995; Simon and Von Korff, 1995; Pini et al., 1997). Specific comorbidity between depression and anxiety was found to be
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
significantly associated with recognition more than was psychiatric comorbidity in general. These data indicate that the phenomenology of mental illness rather than severity seems to be somehow related to recognition. Although anxiety syndromes are common in primary care and cause considerable impairment (Ormel et al., 1994), the physician is probably more prompted by depressive phenomenology or by certain depressive symptoms, while anxiety symptoms are likely to be trivialized or, when presented as physical complaints, attributed to medical conditions (Pini et al., 1997). We also found that recognition by the physician is more likely to occur when the patient openly manifests psychological problems during the visit, as well as he / she is judged by the doctor to have relevant physical problems. These findings are only apparently contradictory. It is plausible that certain physical illnesses are considered potentially predictive of the presence of mental disorders because of their severity and chronicity or because they are known to be frequently associated with psychological problems. Follow-up results showed that the rate of full remission after 12 months was about three times higher in subthreshold mental disorders than in ICD10 disorders. Parallel, only about 10% of subjects with subthreshold disorders received a formal psychiatric diagnosis after 12 months, compared to about 32% of threshold cases. Depression comorbid with generalized anxiety disorder showed the most unfavorable outcome, in terms of level of psychopathology after one year. As to subthreshold cases, it is noteworthy that about 20% of patients cases did not show any improvement, with several cases evolving in to a threshold condition after one year. This considerable proportion of negative outcome among subthreshold cases, was in part likely to be accounted for by brief recurrent depression which showed a lower rate of remission and a clear tendency to transit into a threshold mental disorder after 12 months compared to subthreshold cases in general. These findings are in general consistent with several previous studies, showing the relatively more favorable outcome of minor mental disorders as compared to threshold disorders (Simon and Von Korff, 1995; Tiemens et al., 1996). However, examining in more detail the 12-month outcome of
47
specific subgroups of patients within both threshold and subthreshold conditions, we found that outcome may vary considerably according to patients’ specific diagnostic subgroups. The ability of the physician to recognize the presence of mental problems in their patients seems to be scarcely related with outcome of mental disorders. In fact, overall, unrecognized subjects did not differ from the counterparts in terms of outcome of psychopathology. This finding is difficult to interpret. However, patients who were recognized by the doctor as having a mental problem, were more likely to have an improvement, both in their occupational functioning and self-reported disability, with this association being more evident for threshold cases and for those with comorbidity. Conversely, a negative association between recognition and outcome of psychopathology after one year was found for patients who had frequent contacts with the doctor during the follow-up period. These findings suggest that the physician is more likely to focus on variations of patient’s performance in different areas of functioning rather than to specifically explore the course of psychopathology. Therefore, lack of such associations in subthreshold cases may be explained by the fact these patients are likely to have lower degrees of disability. On the other hand, the considerable proportion of unremitted cases among subthreshold cases after one year, suggest the need of more accurate psychopathological assessment in these patients. Our findings should be interpreted in the light of recent debate and a re-appraisal of the importance of mental illness in primary care (Schulberg et al., 1987; Goldberg, 1992; Coyne et al., 1995; Ormel and Tiemens, 1995). It has been argued that minor mental disorders seen in primary care have a high likelihood of spontaneous recovery (Goldberg, 1992; Katon et al., 1994; Simon and Von Korff, 1995; Katon, 1995). Our findings suggest that outcomes of mental disorders in primary care are not simply related to their initial severity and that recognition is not always associated with a better outcome. Future efforts by researchers in the field should not be only addressed to improve physicians’ ability to detect and treat formal mental disorders. A better understanding of what comprises the definition of a mental disorder in primary care and what psycho-
48
S. Pini et al. / Journal of Affective Disorders 56 (1999) 37 – 48
pathological conditions are considered by physicians deserve attention and treatment should also be taken into account.
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