Psychosomatics 41:321-329, August 2000
© 2000 The Academy of Psychosomatic Medicine
Psychological Distress Among Patients With Musculoskeletal Illness in General Practice
Carsten Krogh Jørgensen, M.D., Ph.D.,
Per Fink, M.D., Ph.D., Dr. Med. Sci., and
Frede Olesen, M.D., Dr. Med. Sci.
Received June 6, 1999; revised August 19, 1999; accepted November 19, 1999. From Research Unit and Department of General Practice and Research Unit for Functional Disorders, University of Aarhus, Denmark. Address reprint requests to Dr. Jørgensen, Research Unit and Department of General Practice, Vennelyst Boulevard 6, DK-8000 Aarhus C.; email: ckj{at}alm.au.dk
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ABSTRACT
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The authors investigated the importance of psychological distress and somatization among patients with musculoskeletal illness in general practice. The authors used the Hopkins Symptom Check List (SCL-8) and the Whiteley Index to rate 1,720 patients with musculoskeletal illness referred to physiotherapy from general practice. General practitioners (GPs), patients, and physiotherapists often noted stress or psychological distress to be a possible cause of the patient's musculoskeletal illness, but agreement between them was low. If the GP included the patient's own view on psychological distress, the result of the SCL-8 did not add much to the detection of distress. The results emphasize the importance of discussing psychological distress when dealing with patients with musculoskeletal illness.
Key Words: Musculoskeltal Illness
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INTRODUCTION
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Musculoskeletal illness accounts for 9.3%–17% of all patient contacts in general practice.1–3 Over the past few years the prevalence has increased in general practice as well as in the general population.1,4–6 Physiotherapy is a well-established treatment, and 6% of the Danish population are referred to physiotherapy each year (Jørgensen and Olesen, unpublished results). Along with the increase in the prevalence of musculoskeletal problems in the population, an increase in the use of physiotherapy has also been observed.4
Psychological factors have been indicated to be of importance for the course, especially low back pain and syndromes like fibromyalgia and whiplash.7–10 In a primary health care setting one-quarter to one-third of the patients suffer from some level of psychological distress,11–13 but psychological distress has been shown to be underrecognized.11–14 This is largely because patients seek medical help for physical symptoms unaccounted for by pathological findings or out of proportion to the pathological findings (somatizing patients).12,13,15–18 Somatizing patients may present symptoms from any organ system; they are often multisymptomatic, and pain is a frequent complaint.19,20 To provide the most appropriate treatment and avoid unnecessary diagnostic testing in the pursuit of diagnosing an organic disease, it is important for the health professionals to detect psychological distress and somatization.
Brief standard rating scales for measuring psychological distress and possible psychiatric disorder have proved useful in clinical research. Studies have also shown that standard rating scales can detect psychiatric distress with higher sensitivity and specificity than primary care doctors.21,22 Theoretically, rating scales could be used by general practitioners (GPs) as an aid in directing the GPs and the patients to psychiatric disorders in the cases not otherwise suspected by the GP or the patient.
In light of the increasing prevalence of musculoskeletal complaints and the rather dismal results of preventive strategies and treatment regimens so far, we hypothesized that patients with musculoskeletal illness often have mental health problems. In order to address this hypothesis, the study first describes the prevalence of psychological distress and somatization among patients with musculoskeletal illness referred to physiotherapy from general practice.
Second, to find possible sources of information to increase the GPs attention toward psychological distress, the study investigated the following: 1) patient's, GP's, and physiotherapist's notion of psychological distress as a possible contributory cause of the patient's musculoskeletal illness; 2) the extent a psychiatric rating scale (SCL-8) could provide added value to the GP's assessment alone; and 3) the extent a psychiatric rating scale (SCL-8) could provide added value if both the GP's assessment and the patient's notion of "stress or psychological distress as a possible contributory cause of the musculoskeletal illness" were included in the assessment of possible psychological distress.
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METHODS
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In the Danish health care system the GPs serve as gatekeepers for the secondary health care system. The national health insurance is tax-financed. All residents are covered, and they are able to choose one of two different kinds of coverage. Of the population, 97% belong to group one; they are listed with one GP practice and can see a specialist only after referral by their GP. The remaining 3% of the population belong to group two; they can freely choose any GP or specialist, but must pay a portion of the fee themselves. All GPs registered with the public health insurance in the County of Aarhus, Denmark, by February 1996 were invited to participate in the study. GPs were randomly assigned to 12 periods of 8 weeks, evenly distributed over a year starting August 1996. A total of 194 GPs (47%), representing 124 practices in the county (46%), agreed to participate. The project was approved by the Scientific Ethics Committee in the County of Aarhus and the Danish Data Protection Agency.
Patient Inclusion
The GPs included all patients age 18 years or older referred by the GPs to physiotherapy during surgery hours. We excluded patients who would not be able to complete the questionnaires because of either mental retardation or lack of knowledge of the Danish language. Patients could only be included in the study once.
Questionnaires
We used the following three questionnaires in this study:
1) The GP Questionnaire (GP-Q) contained questions within the following themes: patients' present musculoskeletal illness, present mental health, treatment, and referrals. The mental health issues included GP-identified psychiatric disorder based on questions used in a Nordic multicenter study by Munk-Jorgensen et al.13 Furthermore, the GPs were asked to what extent psychological distress or stress could be a possible cause of the patient's musculoskeletal complaints. The wording of the questions can be seen in Table 1.
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TABLE 1. Wording of questions used in the questionnaires given to patients, general practitioners (GPs), and physiotherapists
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2) The Patient Questionnaire-1 (PQ1) was handed to the patient by the GP upon inclusion in the study. The patient returned it directly to the research unit in a postage-paid envelope. The main themes were the patient's present musculoskeletal illness, psychological distress, general health, and sociodemographic information. Similar to the GP, the patients were asked to what extent psychological distress or stress could be a possible cause of their musculoskeletal complaints. The patients also answered the questions of two standard rating scales: 1) an 8-item shortened version of the Hopkins Symptom Check List (SCL-90)23 was used to measure the level of psychological distress, and 2) a 7-item shortened version of the Whiteley Index (Whiteley-7)24 was used to measure somatization. The shortened versions of both rating scales have previously been validated against a standardized psychiatric interview (Present State Examination) in a population of consecutive general practice patients in Denmark.13,21,25,26 As neither the SCL-8 nor the Whiteley-7 is diagnostic of psychiatric disorder or somatization, respectively, the scores were grouped as follows: "0"=No distress/somatization, "1–2"=Medium level distress/somatization and "3–8"=High level distress/somatization. The psychometric properties (sensitivity, specificity, and positive predictive value) were calculated according to this grouping. In this way the prevalence of psychiatric disorder and somatization can be calculated on a group level. The gold standard for psychiatric disorder and somatization is specified in Table 2.
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TABLE 2. Psychometric properties of the Hopkins Symptom Checklist (SCL-8) and Whiteley-7 in a general practice setting
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3) A short Physiotherapist Questionnaire (PhyQ) contained information about the encounter with the patient. The physiotherapists, along with the GPs and the patients, were asked to what extent psychological distress or stress could be a possible cause of the patient's musculoskeletal complaints. The wording of the questions can be seen in Table 1.
Statistical Analyses
To calculate the psychometric properties of the two standard questionnaires, SCL-90 and Whiteley-7, data from a previous study of 190 consecutive general practice patients from 28 GPs in the County of Aarhus were used. SCL-8 scores were available for all 190 patients and Whiteley-7 scores for 98 patients in the validation study, which compare the questionnaire data with a standardized psychiatric interview (PSE). Details have been published elsewhere.13,21
Distribution of scores on standard questionnaires are presented as unstandardized proportions with 95% confidence intervals (CI). Statistical testing of differences in score distribution among age groups was done by Chi-Square test with a test for trends on the unstandardized proportions. A significance level of 0.05 was used. Interrater agreement is presented in Wenn diagrams and with Cohen's weighted kappa statistics.27
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RESULTS
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In 1 year, 1,720 patients who fulfilled the inclusion criteria were included in the study. A total of 1,092 patients (63%) answered the patient questionnaire. We received 1,019 questionnaires (59%) from the physiotherapists. All three questionnaires were returned for 818 (48%) patients. As for the remaining 902 referred patients, the PQ1 and/or the PhyQ was missing.
There was no difference in GP rating of illness chronicity, stress, psychiatric disorder, and somatization between patients responding and patients not responding (data not shown). However, more women than men responded (66% vs. 55%), and the median age was 46 years for responders and 44 years for nonresponders.
Distress and Somatization in the Study Population
A total of 42% (95% CI: 39%–45%) scored  1 on SCL-8. According to the psychometric properties (Table 2), 51% of these (21% of the study population) would have probable or definite psychiatric disorder. A total of 17% (95% CI: 14%-19%) scored 3 on SCL-8. When screening for somatization 56% (95% CI: 50%–61%) of the patients scored 1 on the Whiteley-7. According to the psychometric properties (Table 2), 56% of these (31% of the study population) would have at least one ICD-10 somatoform disorder. A total of 18% (95% CI: 14%–22%) scored 3 on Whiteley-7.
Patient Subgroups
SCL-8 score distribution for subgroups of patients referred to physiotherapy is listed in Table 3. There was no significant difference in score distribution between 10-year age groups;  2=0,073, df=1, P>0.75 (data not shown). More women than men had high scores. High scores were more prevalent among patients on disability pension and patients being unemployed or on social welfare than any other employment status groups. Fewer patients with whiplash and more patients with nonspecific neck pain had high scores compared with other diagnostic groups. More patients for whom the GP described the musculoskeletal illness as chronic or chronic with acute exacerbation had high scores compared with patients with an acute episode of musculoskeletal illness.
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TABLE 3. Psychological distress among different groups of patients with musculoskeletal illness referred to physiotherapy in general practice measured by Hopkins Symptom Check List 8-item version (SCL-8). Age and gender standardized proportions (N=1,011).
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The GP, the Patient, and the Physiotherapist
GPs found that 23% (95% CI: 21%–25%) of all the patients currently had a minor and not a clinically relevant or a more severe psychiatric disorder (see questions in Table 1). However, in 48% (95% CI: 46%–51%) of the patients, the GP judged that stress or psychological distress was "a little" or more important as a possible cause of the patient's musculoskeletal complaints. When causes of musculoskeletal complaints were judged by the patients or by the physiotherapists, the proportions were 45% (42%–48%) and 52% (49%–55%) respectively. However, agreement among the GP, the patient, and the physiotherapist was poor (Figure 1). Weighted kappa values ranged from 0.22 to 0.30. When comparing the GP, the patient, and the physiotherapist with Whiteley-7, the agreement was low for all and did not differ much. The kappa values were 0.12 for both the GPs and the physiotherapists and 0.15 for the patients.
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FIGURE 1. Agreement between GP, physiotherapist and patient about psychological distress as a possible cause of the patient's musculoskeletal illness (N=764)
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The GP and SCL-8
Figure 2 shows the potentially added value of a standard questionnaire in helping the GP to detect psychological distress in patients. With a cutoff point between 2 and 3 on SCL-8, a positive score would direct the GP's attention to a possible psychiatric disorder in 44% (7/16) of the "highly distressed" patients otherwise not suspected by the GP to be mentally ill. Choosing a lower cut-off point, a positive score would draw the GP's attention to possible psychiatric disorder in 67% (28/42) of the patients categorized as "medium distressed" to "highly distressed" and otherwise not suspected by the GP.
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FIGURE 2. Psychological distress among patients referred to physiotherapy, judged by the GP and a standard questionnaire (N=1,007)
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Asking the Patient
Figure 3 shows the potentially added value of asking the patient about stress and psychological distress as a possible contributory cause of the musculoskeletal illness. The percentages of patients scoring positively on SCL-8 decreased to 2% and 11%, respectively, depending on the chosen cutoff on SCL-8. In other words, the sensitivity in relation to SCL-8 increases meaning. That is, if the GP asks the patient whether stress or psychological distress could be a possible contributory cause of the illness, the result of SCL-8 would only add very little to the detection of psychological distress.
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FIGURE 3. Psychological distress among patients referred to physiotherapy, judged by the GP and/or the patient compared with a standard questionnaire (N=994)
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DISCUSSION
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Psychological distress was common among patients with musculoskeletal illness who were referred to physiotherapy. The prevalence of psychiatric disorders could not be determined directly, but on the basis of the psychometric properties of the rating scales used, it is possible to estimate the prevalence when taking into account that the rating scales were not diagnostic of psychiatric disorders. Whether psychological distress caused the musculoskeletal illness or vice versa was not possible to conclude from the present study. However, depression has been found to be predictive of a poor outcome in patients with musculoskeletal illness.10,28 Therefore, it is important to consider psychological distress in patients with musculoskeletal illness in the clinical situation.
The proportion of patients having some ICD-10 somatoform disorder was high but only a little higher than reported in other studies of patients in general practice.29–31 However, the proportion of ICD-10 disorders in the present study may be overstated, as some patients with chronic musculoskeletal illness may endorse several of the items in Whiteley-7 rather because of the reality of their illness than because of a hypochondrical ideation.
The subgroup analysis of the different diagnostic groups showed little difference in the level of distress between employment groups. Hence, psychological distress seemed to be a universal problem. It was somewhat surprising to find that patients with whiplash are less distressed than others. This may indicate that whiplash patients who are seen in general practice are less severe and more acute cases (GPs categorized half of the whiplash patients in this study as acute cases). As indicated in other studies, psychological distress in patients with whiplash is secondary to the physical pain and disability.9 Also, the GPs may use the whiplash diagnosis as a description of the mechanism of injury rather than as a clinical manifestation. Therefore the group of whiplash patients in this general practice setting is not comparable to patients with chronic whiplash-associated disorders.
Patients, GPs, and physiotherapists often considered stress and psychological distress to be a contributory cause of the patient's musculoskeletal illness. Guldbrandsen et al.32 investigated GPs' awareness of psychosocial problems in patients with somatic reasons for encounter and found that GPs recognize such problems in 19%–53% of the cases, depending on the type of problem. They also found that patients with musculoskeletal illness were likely to tell the GP about their psychosocial problems.33 In the present study, GPs recognized 62% of patients reporting stress or psychiatric distress. Even though the percentage is higher than found by Guldbrandsen, the agreement was low. The lack of agreement suggests that the issue of psychological distress is not addressed explicitly in the communication among patient, GP, and physiotherapist. Answers to the question of stress or psychological distress were dichotomized (+distress/-distress) with a cutpoint between "not at all" and "a little," so it is not likely that lack of agreement between GPs, physiotherapists, and patients was based on differences in degree of importance indicated for individual patients by the GP, the patient, and the physiotherapist.
The low kappa values for agreement between Whiteley-7 and patient, GP, and physiotherapist, respectively, may to some extent be based on the difference in measurement scale and the dichotomization of the answers. The important point is that there is very little difference between the kappa values of the patient, the GP, and the physiotherapist, which suggests that none is better or worse as predictor than the other.
Disagreement between GP and SCL-8 is not necessarily a sign of GP inadequacy as SCL-8 is not a gold standard and also has false positive and false negative results. The disagreement illustrates, however, that the use of a standard questionnaire could draw the GP's attention to psychological issues otherwise not considered by the GP in the first place and thus lead to further investigation by the GP. However, just asking the patient will increase the chance of detecting psychological distress dramatically and make the short standard questionnaire less efficient as a first-line screening instrument. Combining the information from the GP and the patient increases the sensitivity but decreases the specificity. The results illustrate the paradox that is often experienced when shortening standard questionnaires. If the patient is asked the right couple of questions, the standard questionnaire does not add much more information. Standard questionnaires may then be used as a second-line test (e.g., a blood test) to increase the specificity.
The results of this study stress the importance of improving recognition of psychological distress in general practice. Brief standard scales may be of help here. However, just asking the patient one question may provide almost as much information as SCL-8. Standard questionnaires are only to a small extent used by GPs. Results from studies investigating the use of rating scales as a screening tool for psychiatric disorders in general practice have shown an effect on recognition, but the effect on treatment and patient outcome is less well documented.34,35 However, before rating scales can be used in daily clinical practice, more research is needed. This research should focus on the use of rating scales as a second-line screening tool compared with the use as a first-line screening tool.
Generalizing the results of this study to other populations should be done with caution. The results are based on a subpopulation of patients with musculoskeletal illness (those referred to a physiotherapist) for whom the response rate was 63%. The patients responding, however, did not differ markedly from the nonresponders with respect to GP ratings of illness chronicity, stress, psychiatric disorder, and somatization. Consequently, there is no reason to believe that no response has introduced bias. The fact that more women than men responded may tend toward an overestimation of the proportion of psychologically distressed in the patient population.
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CONCLUSION
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Psychological distress was more common in a population of general practice patients with musculoskeletal illness than in a population of consecutive general practice patients. The level of distress depended only to a slight degree on diagnostic groups. Stress and psychological distress as possible contributory causes of musculoskeletal illness were considered to be important by many patients, GPs, and physiotherapists, but agreement was low, suggesting that the issue of psychological distress is not discussed explicitly in the consultation process. A standard rating scale measuring psychological distress may be beneficial in drawing the GP's attention to possible psychological distress and for opening an explicit discussion of the issue with the patient. However, just asking the patients whether they think stress or psychological distress may to some extent be a possible contributory cause of their musculoskeletal illness will make SCL-8 redundant to a large extent.
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ACKNOWLEDGMENTS
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The authors thank the GPs in the County of Aarhus, participating patients, and the participating physiotherapists for their invaluable contribution to the data collection. The authors appreciate the advice given by psychiatrist Marianne Engberg, M.D., Ph.D. This project was funded by the Aarhus County Health Services Research Initiative, the Ministry of Health's National Health Fund for Research and Development (Grant 1400/9–99–1996), Danish Society of General Practitioners' Lundbeck Grant, The General Practitioners' Foundation for Education and Development, The Danish Rheumatism Association (grant no. 233–955–31.1.96 MP), and The Danish Medical Association Research Fund.
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Psychosomatics,
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ABSTRACT
INTRODUCTION
