Psychosomatics 44:402-406, October 2003
© 2003 The Academy of Psychosomatic Medicine
The Role of Symptoms in the Recognition of Mental Health Disorders in Primary Care
János Füredi,
Sándor Rózsa,
János Zámbori, and
Erika Szádóczky
Received June 25, 2000; revision received Dec. 19, 2002; accepted Jan. 22, 2003. From the National Institute of Psychiatry and Neurology, Budapest; and the ELTE Psychological Institute, Department of Personality and Health Psychology, Budapest. Address reprint requests to Dr. Füredi, Nyéki út 10–12, 1021 Budapest; furediprof{at}axelero.hu (e-mail).
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ABSTRACT
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This study investigates the role of patients' complaints and symptoms in the diagnostic process of mood and anxiety disorders in general practice. In 12 primary care practices, 1,211 patients were diagnosed with the aid of the National Institute of Mental Health Diagnostic Interview Schedule, then the diagnoses were compared with those established by the general practitioners. A low rate of concordance was found between these diagnoses. The absence of somatic illnesses and the presence of psychological complaints were the most important factors in the recognition of a mental illness by the general practitioners. The concordance between the general practitioners and the DIS diagnoses was higher if the patients had neither an acute nor a chronic somatic illness.
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INTRODUCTION
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Owing to a high prevalence and severe health consequences, psychiatric disorders are rightly considered a primary health care problem. According to the World Health Organization,1 five mental disorders are listed among the 10 most frequent reasons for work days lost to disability, and depression is at the top of the list.
All over the world, the majority of patients with mental disorders seek help from primary care physicians. In order to improve the prognosis of the illness and to prevent a chronic or even fatal (e.g., suicide) outcome, the role of general practitioners—to recognize and treat illness and to refer patients to an expert in due course—is important. It is well known that nearly one-half of patients with depression do not seek medical help, one-half of those who turn to their doctors are not diagnosed, and only one-half of those who are correctly diagnosed receive appropriate medical treatment.2–6 The reason for nonrecognition is probably complex, and it is not thoroughly clear. In this study, the role of patient complaints to their primary care physicians was examined.
Our aims were 1) to survey the occurrence and type of complaints and symptoms as they were reported to the physicians, 2) to reveal whether or not there were such symptoms, which are specifically associated with the diagnosis of anxiety and/or mood disorders, and 3) to describe what kind of symptoms contribute to the general practitioners' diagnostic process and which of those hinder and which promote the psychiatric diagnosis.
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METHOD
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Between 1998 and 1999, with the participation of 12 general practitioners from Budapest, we examined the rate of prevalence of mood and anxiety disorders among primary care patients. A total of 1,815 patients (1,164 women and 651 men) who visited their general practitioners gave written informed consent to participate in the survey. The patients were randomly selected, and only 10% of them refused to take part in the study. Their mean age was 40.5 years (SD=13.2), the youngest patient was 18, and the oldest was 65; the female-male ratio was 2:1. We used the Hungarian version of the mood and anxiety section of the National Institute of Mental Health Diagnostic Interview Schedule (DIS),7,8 the shortened Beck Depression Inventory,9,10 and the Quality of Life in Depression Questionnaire.11 The structured interviews were conducted by lay interviewers after 1 week of intensive training. Information about the illnesses and the symptoms was collected from the general practitioners' treatment charts. DSM-III-R diagnoses were generated by computer on the basis of the DIS interviews.8
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RESULTS
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Symptoms and Diagnoses
A total of 1,211 patients (66.7%) appeared in the general practitioners' practices with current complaints; 604 subjects (33.3%) consulted their general practitioners because of other reasons (e.g., follow-up, prescription, or check-up). Only the patients who visited their physicians with current symptoms were included in the present study. The reasons for consulting their general practitioners are listed in Table 1. General symptoms, such as fever, fatigue, and headache, were the most frequent complaints (33.2%); however, ear, nose, and throat complaints (24.5%) and symptoms of chest discomfort (20.8%) were also frequent. On the basis of nearly 100 symptoms, more than 200 diagnoses were given by the general practitioners. On screening days, the general practitioners diagnosed 158 patients (13.0%) with psychiatric disorders; neurosis, anxiety, neurasthenia, personality disorder, alcohol dependency or abuse, and exhaustion were the most common diagnoses. Although the primary care physicians did not apply the traditional psychiatric categories, among the psychiatric diagnoses, 90 (7.4%) were reconcilable with DSM-III-R mood and/or anxiety disorder categories. At the same time, 168 primary care patients (13.9%) received some kind of DIS-generated diagnosis of DSM-III-R mood and/or anxiety disorder and uncomplicated bereavement. The questionnaire did not involve questions concerning personality and substance misuse disorders; consequently, these categories were not considered. Agreement between the psychiatric diagnoses given by the general practitioners and the DIS was poor; only 23 patients received an anxiety and/ or mood disorder diagnosis from their general practitioners and the DIS; thus, 13.7% of the patients with diagnoses of DIS anxiety and/or mood disorder were also recognized by the general practitioners, and 25.5% of the patients who received diagnoses of anxiety and/or mood disorders by the general practitioners were also diagnosed by the DIS. Table 2 shows the rate of agreement of these diagnoses. The agreement (kappa) concerning both mood and anxiety disorders did not reach the 0.1 level.
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TABLE 2. Agreement Between Psychiatric Diagnoses Given by General Practitioners and Those Generated by the National Institute of Mental Health Diagnostic Interview Schedule (DIS) of Patients From 12 Primary Care Practices
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Complaints of Patients With Anxiety and Depression
Next, we examined whether patients with diagnoses of DIS/DSM-III-R anxiety and/or mood disorder had any kind of specific complaints and, if so, what these complaints were. The patients who suffered from anxiety and/ or mood disorders, according to DIS and/or DSM-III-R criteria, had 4.3 times more psychological complaints and 1.6 times more symptoms of chest discomfort than those who had no DIS diagnosis (Table 3). Ophthalmological, urogenital, and dermatological complaints did not occur among the patients with a DIS diagnosis.
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TABLE 3. Symptoms of Patients From 12 Primary Care Practices Diagnosed by the National Institute of Mental Health Diagnostic Interview Schedule (DIS) as Having DSM-III-R Anxiety and/or Mood Disorders
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Complaints of Patients With Anxiety and/or Mood Disorders
Significant differences were found when we compared the complaints of the patients with DIS-generated diagnoses only and those who were diagnosed by the general practitioners only. If fever and sore throat were present, the patients received psychiatric diagnoses from the DIS more often than from the general practitioners. On the other hand, if symptoms such as anxiety and tension were present, the general practitioners made psychiatric diagnoses more often than the DIS (Table 4). Thus, if a patient had a fever, the chance that the coexisting psychiatric disorder was recognized by the general practitioner was 20% less than the chance that he or she received a diagnosis from the DIS. The presence of symptoms, such as headache, dizziness, chest pressure, sweating, or numbness, caused no difference in the frequency of psychiatric diagnoses made by the DIS and the general practitioners.
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TABLE 4. Complaints of Patients From 12 Primary Care Practices Diagnosed by the National Institute of Mental Health Diagnostic Interview Schedule (DIS) or by General Practitioners as Having Anxiety and/or Mood Disorders
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DISCUSSION
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The results of our study support earlier findings that diagnoses of anxiety and/or mood disorder established by general practitioners in primary care settings have only a slight concordance with those based on structured interviews.12,13
The DIS revealed psychiatric disorders more often if the patient had some difficulty describing his or her symptoms. (It is well known that chest and abdominal discomfort and other somatic symptoms are common manifestations of certain psychiatric illnesses.14,15 If tension, heart palpitations, or anxiety are present, general practitioners give diagnoses of anxiety and/or mood disorders more often, while the presence of acute somatic symptoms (fever or sore throat) hinder general practitioners in diagnosing an accompanying psychiatric illness. If a patient sees his or her general practitioner while experiencing an acute somatic illness, there is little chance that the accompanying anxiety and/or mood disorder will be simultaneously diagnosed. One of 46 patients with an acute physical illness and 11 of 38 patients with a chronic physical illness were recognized by our general practitioners as also having an anxiety and/or mood disorder, although all of these patients were diagnosed by the DIS. Diagnoses made by general practitioners and the DIS corresponded best if neither an acute nor a chronic illness was present. In such instances, general practitioners gave psychiatric diagnoses more frequently, sometimes even in instances in which the DIS did not.
If a patient complains of tension or anxiety, it does not definitely mean that a psychiatric disorder exists. An acute episode of anxiety might exist in connection with everyday life events without there being any psychiatric disorder.
The literature is not homogenous concerning factors that might promote or hinder the establishment of a psychiatric diagnosis. Studies show that illnesses that seem to be more serious are easier to recognize.16 In some instances, although a mental disorder is correctly identified, the correct diagnosis is not documented in order to avoid eventual stigmatization.17 Because the biomedical view is currently popular in medical education, somatic illnesses are emphasized, and psychological and social factors are often neglected. Since stigmatization appears at the same time as a diagnosis of a mental disorder, both doctors and patients avoid discussing such problems. Unfortunately, this leads to a transformation of psychiatric problems to certain somatic symptoms that are easily accepted by doctors, since these symptoms seem to be the best solution for physicians and their patients. There is no doubt that lack of time also contributes to general practitioners' failing to recognize psychiatric disorders, since three or four times more time is required to explore such problems. In these instances, somatization is still one of the most acceptable solutions for the community.
We are convinced that with close cooperation between general practitioners and psychiatrists, the shortcomings concerning diagnostic and treatment skills can be overcome. It is in the patients', general practitioners', and psychiatrists' common interest to improve the rate of recognition of mental disorders so patients receive even more appropriate and more efficient treatment.
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ACKNOWLEDGMENTS
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Supported by Servier Educational Foundation.
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REFERENCES
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[Abstract]
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ABSTRACT
INTRODUCTION
