Psychosomatics 45:302-310, August 2004
© 2004 The Academy of Psychosomatic Medicine
Follow-Up on Mental Illness in Medical Inpatients: Health Care Use and Self-Rated Health and Physical Fitness
Morten Steen Hansen, M.D., Ph.D.,
Per Fink, M.D., Ph.D., Dr.Med.Sc., and
Morten Frydenberg, M.Sc., Ph.D.
Received Feb. 11, 2003; revision received Sept. 20, 2003; accepted Oct. 17, 2003. From the Department of Psychiatric Demography, Psychiatric Hospital, Aarhus, Denmark; the Research Unit for Functional Disorders, Psychosomatics, and Consultation-Liaison Psychiatry and the Department of Biostatistics, Aarhus University Hospital. Address reprint requests to Dr. Hansen, Research Unit for Functional Disorders, Psychosomatics, and Consultation-Liaison Psychiatry, Aarhus University Hospital, DK-8200 Aarhus N, Denmark; brixhansen{at}mail1.stofanet.dk (e-mail).
|
ABSTRACT
|
Consecutively admitted internal medical inpatients (N=294) who were psychiatrically assessed with the Schedules for Clinical Assessment in Neuropsychiatry in a two-phase design were followed up in a review of public files on their use of medical care over 18 months. Self-rated outcome was assessed from health and fitness ratings at admission and after 1 year. ICD-10 mental disorders had a statistically significant impact on the risk (odds ratio) of high use (above the 80th percentile) of primary care, as did ICD-10 anxiety/depression, and worry about illness (as assessed by the Whiteley-7 Scale). The authors found a less-than-significant tendency for mental illness to influence the use of inpatient admissions and self-rated outcome.
Key Words: hospital treatment • anxiety • depression • somatoform • disorders • interviews
|
INTRODUCTION
|
Mental illness is common in medical settings,1–6 and studies on its consequences are important, both economically and clinically. Epidemiological and clinical studies have shown that patients with mental illness are high users of nonpsychiatric health care services.7–19 Because of retrospective or cross-sectional design, most of these studies are not suitable for the study of consequences, and several of them do not take comorbid medical conditions into account.
A number of follow-up studies exist on mortality after mental illness among nonpsychiatric hospital patients,13,20–26 but only few have focused on the "softer" aspects of outcome, e.g., recovery from the physical disease,27 physical functioning,25 and self-rated health,25,28,29 showing a negative influence of mental illness. The only two recent studies that we located are based on patient samples with specific physical diseases.28,29 The earliest studies did not control for confounders.
The present study examines the impact of nonorganic mental illness in medical inpatients compared with patients without mental illness on 1) the use of health care services and 2) outcome as to self-rated health and physical fitness, with control for the medical condition's impact.
|
METHOD
|
Study Group
The study group consisted of consecutive inpatients ages 18 and older who were admitted to the Department of Internal Medicine at Silkeborg Central Hospital, Silkeborg, Denmark, during a 3-month period in 1997. The department provides all medical services for the catchment area. Each patient was included only once. In all, 547 patients were admitted during the study period (Figure 1).
View larger version (40K):
[in this window]
[in a new window]
|
FIGURE 1. Flowchart Depicting Attempted Assessment of Inpatients With the Schedules for Clinical Assessment in Neuropsychiatry (SCAN)
|
A total of 97 patients died before inclusion or were excluded according to predefined criteria.30 In addition, 58 patients were discharged, and six patients died before they could be interviewed. Ninety-eight patients declined the invitation to participate in the investigation. Hence, a total of 294 patients were included.
Psychiatric Assessment
All patients were administered an admission interview that included an eight-item version of the Symptom Check List (SCL-8D),31 which assessed anxiety and depression. Furthermore, it included a slightly modified version of the Whiteley-7 Scale,32 which measures worry and conviction about illness and detects somatization. The two scales provide a dimensional evaluation of psychiatric symptoms of anxiety, depression, and somatization. The responses to the items were dichotomized to classify patients into high and low scorers.
For diagnostic psychiatric interviews, a stratified subgroup was selected that consisted of all high scorers and approximately one-third of the low scorers. These interviews were administered to 157 patients (13 patients died or refused to participate) with the Schedules for Clinical Assessment in Neuropsychiatry).33 The two interviewers who administered the Schedules for Clinical Assessment in Neuropsychiatry were certified by the World Health Organization's center in Aarhus and were blinded to the admission interviews.
Computerized ICD-10 psychiatric diagnoses were generated from the Schedules for Clinical Assessment in Neuropsychiatry interviews and were subsequently grouped into three main categories: somatoform disorders, substance use disorders, and anxiety or depression. Details on the selection procedure and the prevalence of specific disorders have been published previously.1
Health Care Service Use
Information on the patients' use of nonpsychiatric health care from the date of discharge and during the following 18 months was extracted from the Danish National Patient Register (number of hospital admissions) and from the files of Danish Public Health Insurance (reimbursed payments for primary care, excluding drugs). Almost all medical services in Denmark are free of charge. For hospital services, we did not record information on patient-level expenses.
High use was defined as being among the 20% using the most resources. Analyses were performed on the basis of annual average values. Patients were excluded from this part of the study if they had died or emigrated within the first 3 months after discharge.
Self-Rated Health and Physical Fitness
The patients rated their health and physical fitness during the admission interview and by questionnaire after 12 months. They answered one question on self-rated health ("How would you say your health has been during the last week?") (five answers, from "excellent" to "very poor") and one on physical fitness ("During the past 2 weeks, what was the hardest physical activity you could do for at least 2 minutes?") (five answers, from "fast running" to "no physical activity at all"). The latter question is from the COOP/WONCA charts questionnaire.34
Patients were regarded as nonresponders if they failed to respond after the questionnaire had been mailed to them three times. We evaluated which of the 5x5 combinations of baseline and follow-up ratings could be regarded as a satisfactory outcome (Table 1).
Severity of Medical Disease at Admission
The severity of the patients' medical diseases (chronic and/or life threatening) was rated during index admission by the responsible medical consultant.
Analysis of Patient Exclusion
Patients who died before inclusion or who were excluded (N=97), patients who declined the invitation to participate (N=98), and patients who were discharged before a research worker had contacted them (N=58) were compared to the included patients as to age, gender, and information on psychiatric and nonpsychiatric health service use, which was obtained from the Danish National Patient Register. Only in terms of age did the three excluded groups of patients differ significantly from the included patients. (For details, see our previous study7).
Dropout by Follow-Up
Information on health service use was accessible for 281 patients (95.6%; see Figure 1). Of these, 150 were from the subgroup interviewed with the Schedules for Clinical Assessment in Neuropsychiatry. The patients whose information was accessible were compared to those whose information was not accessible regarding the sociodemographic and health care use variables applied in the analysis of included and excluded patients and in regard to mental disorders (overall morbidity). These analyses (chi-square tests, Mann-Whitney U tests) did not reveal any statistically significant differences.
A total of 198 patients (67.3%) responded to the 1-year follow-up questionnaire, 107 of whom had been interviewed with the Schedules for Clinical Assessment in Neuropsychiatry. The nonresponders had a higher annual primary care reimbursement than the responders (1,011 kroner versus 603 kroner; Mann-Whitney U=7846.5, p=0.02) during the 5-year period preceding the index admission and a higher annual number of admissions to nonpsychiatric departments (0.7 versus 0.4; Mann-Whitney U=7985.5, p=0.03). More of the nonresponders than responders tended to have a chronic medical disease (odds ratio=1.46; p=0.14, chi-square test) or a life-threatening medical disease (odds ratio=1.45; p=0.15, chi-square test). The nonresponders did not differ from the responders as to age, gender, contact with the mental health care system, or mental disorders.
Data Analysis
Since the Schedules for Clinical Assessment in Neuropsychiatry was performed on a stratified subgroup, associations between the outcome variables and psychiatric morbidity were examined by weighted logistic regression analyses,35,36 with the dichotomized follow-up variables as the dependent variables and the psychiatric diagnostic categories as independent variables, taken one at a time. The weighting procedure eliminates bias introduced by stratified sampling, thus ensuring accurate estimates of prevalence rates, odds ratios, and confidence intervals representative of the total study group.
Associations between brief psychiatric rating scale scores and the follow-up variables were analyzed correspondingly on the basis of all 294 patients without weighting.
Gender, age (three groups: 18–49 years, 50–69, 70 and over), the presence of chronic medical disease, and the presence of life-threatening medical disease were included in the models for statistical control and to test for effect modification. SPSS for Windows version 6.1.3 was used for the statistical analysis (SPSS, Chicago).
|
RESULTS
|
Table 2 shows the frequency of variables sampled during the index admission and examined for prediction.
Severity of Medical Disease
A moderate or severe life-threatening medical disease at baseline was associated with a 2.5 times increased risk (odds ratio, Table 3) of subsequent high use of primary care health services. Furthermore, the risk of an unsatisfactory outcome as to physical fitness at follow-up was increased 2.6 times by the presence of a chronic medical disease at baseline (Table 4). There were no other statistically significant associations between severe physical diseases at baseline and the follow-up variables (Table 3 and Table 4).
View this table:
[in this window]
[in a new window]
|
TABLE 4. Relation of Inpatient Self-Rated Health and Physical Fitness to Mental Disorders Assessed at Index Admissiona
|
Mental Illness and Use of Health Services
Patients with mental disorders had 5.4 times increased odds of high primary care reimbursement compared to patients with no mental disorders, with adjustment for age, gender, and severity of the medical disease (i.e., chronic and life-threatening disease, Table 3). Odds ratios for patients with anxiety and/or depression were about the same. A tendency toward high use was present for somatoform disorders, whereas patients with substance use tended toward slightly reduced use. Significantly increased odds for high use of primary care were found for patients with a medium or a high score on the Whiteley-7 Scale and for patients with a medium score on the SCL-8D (Table 3).
High use of inpatient admissions to nonpsychiatric hospital departments was about twice as frequent among patients with mental disorders (any of the disorders studied, Table 3) and among patients with anxiety/depression or somatoform disorders as in patients who did not suffer from the disorders. However, the associations were not statistically significant. Use was somewhat decreased among substance users. The high scorers on the SCL-8D had a lower odds ratio than the medium scorers. For the Whiteley-7 Scale, there tended to be higher use of admissions among the medium scorers, and for the high scorers, the finding was almost statistically significant.
Mental Illness and Self-Rated Outcome After 12 Months
Table 1 shows the weighted number of patients reporting each combination of baseline and follow-up ratings and which combinations were considered satisfactory from a clinical viewpoint (i.e., by the authors).
The impact of somatoform disorders on self-rated health outcome reached statistical significance only among patients with no comorbid chronic medical disease (Table 4). Somatoform disorders increased the odds for unsatisfactory outcome by more than eight times. These patients showed a corresponding statistically significant association with unsatisfactory outcome for physical fitness (odds ratio=5.0). Neither of the associations was found among patients with chronic medical diseases. The same phenomenon ("effect modification" by chronic medical disease) was seen regarding "any mental disorder," apparently because the somatizers constituted a major part of the disordered patients.
The two other groups of mental disorders studied did not show any statistically significant impact on self-rated follow-up outcome, and the presence of chronic medical disease did not seem to be important. However, there was a tendency for unsatisfactory outcome to be present for anxiety/depression as well as for substance use disorders and regarding both types of self-rated outcome (Table 4).
With one exception (the impact of a high score on the SCL-8D for fitness outcome), medium or high scores on both psychometric rating scales were associated with increased risks of unsatisfactory outcome on both self-rated measures (Table 4). Statistical significance was reached for the impact of a high SCL-8D score and a medium Whiteley-7 Scale score on self-rated health outcome.
|
DISCUSSION
|
General Methods Aspects
The problems concerning the patients not included in the study are discussed elsewhere.1 The 96 nonresponders to the follow-up questionnaire seemed to be more physically ill than the responders. We found that mental illness had a bad impact on outcome, mainly for patients with less comorbid physical (i.e., chronic) illness. This finding suggests that some of the associations between mental illness and bad outcome presented later in the article may be slightly overestimated. However, we made an effort to overcome the problems, as we included an analysis of effect modification by variables for physical illness.
The severity of the medical disease is clearly expected to affect outcome in many ways, and statistical control is therefore essential. The task of the present study was to assess the impact of psychological factors on outcome and avoid confounding from biomedical factors. What we wanted to control for was only the biomedical aspects of disease severity. However, because the assessment of biomedical factors is difficult in a mixed medical population, overall ratings made by physicians are usually applied, as often as are prognosis ratings, e.g., the Karnofsky Performance Status Scale.37 In the present study, we decided not to rely on prognosis ratings, as it would be too difficult for a physician to rate solely relying on biomedical arguments and not include his whole impression of the patient, including psychological factors. Thus, control for only chronic and life-threatening disease in the present study was chosen to avoid excessive control. However, there is a risk that some aspects of biomedical disease may still have biased our results. Thus, we call for better ways to control for severity of illness in this type of study.
Mental Illness and Health Care Use
The present study shows that mental disorders, apart from substance use, have future impact by leading to a higher use of primary care after discharge. This increase is statistically significant and independent of whether the patient has a chronic or life-threatening disease, and the impact (i.e., the odds ratio) of a mental disorder is about twice as high as the impact of the indicators of physical disease severity. It also seems that mental illness is linked to the use of hospital admission by a weaker, but completely parallel tendency, although these results were not statistically significant.
Moreover, the study also suggests that the prediction of subsequent use of primary care is not limited to diagnosed ICD-10 mental disorders but is also possible by means of brief rating scales that are much easier to apply in clinics. Although high use seems more frequent among medium scorers on the SCL-8D than among high scorers, odds are increased for all patients with an SCL-8D score of more than 1. A possible explanation for the high scorers' relatively lower odds may be that these more severely ill patients may have been treated for their mental illness after discharge. During the index admission, more of the high scorers on the SCL-8D were undergoing treatment for mental health problems (26%) than the medium scorers (11%) and the low scorers (4%).
A clearer tendency is present for the Whiteley-7 Scale, reflecting that the level of worrying and conviction about illness or of somatization can be predictive of future use of primary care.
These findings are consistent with the results of a previous study of the same cohort7 in which mental illness was markedly linked to health services use during 5 or 10 years before the index admission. The results of the retrospective study were quite similar, consistently showing that health care use was strongly associated with exactly the same ICD-10 mental disorders as given in the present study (i.e., all except substance use) and closely related to scores on the screening instrument, particularly the Whiteley-7 Scale.
Hence, the overall finding of the present study (Table 3) is that mental illness has an impact on health service use in hospitals and in family practice, even after we controlled for central aspects of medical disease severity. This was also in accordance with the few existing prospective studies.13,15,16,25
Mental Illness and Self-Rated Follow-Up Outcome
Although few of the associations tested and presented in Table 4 were statistically significant, the overall tendency was that mental illness, as defined by ICD-10 or dimensional measures, has a negative future impact on the patient's health and physical ability. A main contribution of this article is that outcome assessment was based on the patients' ratings of health and physical fitness, using the same questions at baseline and follow-up. Studies not including baseline ratings25,28,29,38 have shown that mental illness negatively influences the self-rated outcome of an admission or a surgical procedure, but such studies are less easy to interpret in a clinically meaningful way. The present study, designed so that self-rated outcome can be interpreted as to the presence or absence of success, suggests that any type of mental illness during an admission may worsen the patients' chance of success regarding their health and physical ability. Since mental illness in the medical setting is often unrecognized and even more rarely treated,1 this is probably a considerable problem for patients.
The subgroup of mentally ill patients with the worst prognosis regarding outcome as to self-rated health and physical fitness seems to be the somatizing patients without a comorbid chronic medical disease. The reason may be that somatization makes patients feel they have poor health and fitness 1 year after discharge. However, if a somatizing patient has a biomedically well-defined chronic disease, the impact of the mental (somatization) part is less significant. This reasoning would apply for other mental disorders as well, although unsupported by our results, showing a tendency toward worse outcome for patients with anxiety/depression or substance use, irrespective of the presence or absence of a chronic medical disease (Table 4).
|
CONCLUSIONS
|
In this prospective study, efforts were made to eliminate confounding. The results serve as an argument that mental illness results in patients feeling worse and seeking more care. Focusing on the patients' mental health may be a way to improve the well-being of the patients and reduce health care costs for patients with or without comorbid medical disorders. However, it is yet to be demonstrated that the treatment of mental illness in these patients would improve the patients' well-being and decrease subsequent use of resources.39,40 For this reason, however, trials are necessary, using large study groups and long follow-up periods.
|
ACKNOWLEDGMENTS
|
Supported by the Danish Medical Research Council (grant 9601898), the Danish Health Insurance Fund, the Hede Nielsen Foundation, and the Puljen til Styrkelse af Psykiatrisk Forskning and by Biomed1 grant BMH1-CT93-1180.41
The authors thank Lene Søndergaard and Marie-Louise Oxhøj for contributing to the study design and data collection; Dr. Aksel Bertelsen and Mette Eriksen for help with the Schedules for Clinical Assessment in Neuropsychiatry; Søren Skadhede for computer programming; and F.J. Huyse, Thomas Herzog, Antonio Lobo, J.P.J. Slaets, Peter de Jonge, Graca Cardoso, and Marco Rigatelli for contributing to the study design.
|
REFERENCES
|
- Hansen MS, Fink P, Frydenberg M, Oxhoj M, Sondergaard L, Munk-Jorgensen P: Mental disorders among internal medical inpatients: prevalence, detection, and treatment status. J Psychosom Res 2001; 50:199–204[CrossRef][Medline]
- Mayou R, Hawton K: Psychiatric disorder in the general hospital. Br J Psychiatry 1986; 149:172–190[Abstract/Free Full Text]
- Seltzer A: Prevalence, detection and referral of psychiatric morbidity in general medical patients. J R Soc Med 1989; 82:410–412[Abstract]
- Silverstone PH: Prevalence of psychiatric disorders in medical inpatients. J Nerv Ment Dis 1996; 184:43–51[CrossRef][Medline]
- Arolt V, Driessen M, Dilling H: The Lübeck General Hospital Study, I: prevalence of psychiatric disorders in medical and surgical inpatients. J Psychiatr Clin Pract 1997; 1:207–216
- Martucci M, Balestrieri M, Bisoffi G, Bonizzato P, Covre MG, Cunico L, De Francesco M, Marinoni MG, Mosciaro C, Piccinelli M, Vaccari L, Tansella M: Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey. Psychol Med 1999; 29:823–832[CrossRef][Medline]
- Hansen MS, Fink P, Frydenberg M, Oxhoj ML: Use of health services, mental illness, and self-rated disability and health in medical inpatients. Psychosom Med 2002; 64:668–675[Abstract/Free Full Text]
- Fink P: Physical disorders associated with mental illness: a register investigation. Psychol Med 1990; 20:829–834[Medline]
- Fink P, Jensen J, Poulsen CS: A study of hospital admissions over time, using longitudinal latent structure analysis. Scand J Soc Med 1993; 21:211–219[Medline]
- Fink P: The use of hospitalizations by persistent somatizing patients. Psychol Med 1992; 22:173–180[Medline]
- Wallen J, Pincus HA, Goldman HH, Marcus SE: Psychiatric consultations in short-term general hospitals. Arch Gen Psychiatry 1987; 44:163–168[Abstract]
- Katon W, Berg AO, Robins AJ, Risse S: Depression-medical utilization and somatization. West J Med 1986; 144:564–568[Medline]
- Koenig HG, Shelp F, Goli V, Cohen HJ, Blazer DG: Survival and health care utilization in elderly medical inpatients with major depression. J Am Geriatr Soc 1989; 37:599–606[Medline]
- Koenig HG, Kuchibhatla M: Use of health services by hospitalized medically ill depressed elderly patients. Am J Psychiatry 1998; 155:871–877[Abstract/Free Full Text]
- Saravay SM, Pollack S, Steinberg MD, Weinschel B, Habert M: Four-year follow-up of the influence of psychological comorbidity on medical rehospitalization. Am J Psychiatry 1996; 153:397–403[Abstract/Free Full Text]
- Simon G, Ormel J, VonKorff M, Barlow W: Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995; 152:352–357[Abstract/Free Full Text]
- Barsky AJ, Wyshak G, Klerman GL: Medical and psychiatric determinants of outpatient medical utilization. Med Care 1986; 24:548–560[CrossRef][Medline]
- Fink P, Sørensen L, Engberg M, Holm M, Munk-Jorgensen P: Somatization in primary care: prevalence, health care utilization, and general practitioner recognition. Psychosomatics 1999; 40:330–338[Abstract/Free Full Text]
- Smith GRJ, Monson RA, Ray DC: Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med 1986; 146:69–72[Abstract]
- Arfken CL, Lichtenberg PA, Tancer ME: Cognitive impairment and depression predict mortality in medically ill older adults. J Gerontol A Biol Sci Med Sci 1999; 54:M152-M156
- Cole MG, Bellavance F: Depression in elderly medical inpatients: a meta-analysis of outcomes. CMAJ 1997; 157:1055–1060[Abstract]
- Covinsky KE, Kahana E, Chin MH, Palmer RM, Fortinsky RH, Landefeld CS: Depressive symptoms and 3-year mortality in older hospitalized medical patients. Ann Intern Med 1999; 130:563–569[Abstract/Free Full Text]
- Hawton K: The long-term outcome of psychiatric morbidity detected in general medical patients. J Psychosom Res 1981; 25:237–243[CrossRef][Medline]
- Herrmann C, Brand-Driehorst S, Kaminsky B, Leibing E, Staats H, Ruger U: Diagnostic groups and depressed mood as predictors of 22-month mortality in medical inpatients. Psychosom Med 1998; 60:570–577[Abstract/Free Full Text]
- Mayou R, Hawton K, Feldman E: What happens to medical patients with psychiatric disorder? J Psychosom Res 1988; 32:541–549[CrossRef][Medline]
- van Weel-Baumgarten E, van den Bosch W, van den Hoogen H, Zitman FG: Ten year follow-up of depression after diagnosis in general practice [see comments]. Br J Gen Pract 1998; 48:1643–1646[Medline]
- Querido A: Forecast and follow-up: an investigation into the clinical, social, and mental factors determining the results of hospital treatment. Br J Prev Soc Med 1959; 13:33–49[Medline]
- de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA: Pretreatment factors predicting quality of life after treatment for head and neck cancer. Head Neck 2000; 22:398–407[CrossRef][Medline]
- Mayou RA, Gill D, Thompson DR, Day A, Hicks N, Volmink J, Neil A: Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med 2000; 62:212–219[Abstract/Free Full Text]
- Hansen MS, Fink P, Frydenberg M, Oxhøj ML, Søndergaard L, Eriksen M: Mental disorders in medical inpatients and the association to severity of illness, self-rated physical disability, and health perception. Psychosomatics 2001; 42:41–47[Abstract/Free Full Text]
- Fink P, Jensen J, Borgquist L, Brevik JI, Dalgard OS, Sandager I, Engberg M, Hansson L, Holm M, Joukamaa M: Psychiatric morbidity in primary public health care: a Nordic multicentre investigation, part I: method and prevalence of psychiatric morbidity. Acta Psychiatr Scand 1995; 92:409–418[Medline]
- Fink P, Ewald H, Jensen J, Sørensen L, Engberg M, Holm M, Munk-Jorgensen P: Screening for somatization and hypochondriasis in primary care and neurological in-patients: a 7-item scale for hypochondriasis and somatization. J Psychosom Res 1999; 46:261–273[CrossRef][Medline]
- Wing JK, Sartorius N, Üstün TB: Diagnosis and Clinical Measurement in Psychiatry, 1st Ed. Cambridge, Mass, Cambridge University Press, 1998
- Van Weel C: Functional status in primary care: COOP/WONCA charts. Disabil Rehabil 1993; 15:96–101[Medline]
- Pickles A, Dunn G, Vazquez-Barquero JL: Screening for stratification in two-phase ("two-stage") epidemiological surveys. Stat Methods Med Res 1995; 4:73–89[Abstract/Free Full Text]
- Dunn G, Pickles A, Tansella M, Vazquez-Barquero JL: Two-phase epidemiological surveys in psychiatric research [editorial]. Br J Psychiatry 1999; 174:95–100[Free Full Text]
- Karnofsky DA, Abelmann WH, Craver LF, Burchenal JH: The role of nitrogen mustards in the palliative treatment of carcinoma with particular reference to bronchogenic carcinoma. Cancer 1948; 11:634–656[CrossRef]
- Mossey JM, Mutran E, Knott K, Craik R: Determinants of recovery 12 months after hip fracture: the importance of psychosocial factors. Am J Public Health 1989; 79:279–286[Abstract/Free Full Text]
- Simon GE, Katzelnick DJ: Depression, use of medical services and cost-offset effects. J Psychosom Res 1997; 42:333–344[CrossRef][Medline]
- Gater RA, Goldberg DP, Evanson JM, Lowson K, McGrath G, Tantam D, Million L: Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis. J Psychosom Res 1998; 45:437–448[CrossRef][Medline]
- Huyse FJ, Cardoso CMP, Friedman T, Herzog T, Lobo A, Malt AF, Rigatelli M: A screening instrument for the detection of psychosocial risk factors in patients admitted to general hospital wards, in European Union Biomedical and Health Research: The Biomed1 Programme, 1st Ed. Edited by Baert A, Baig SS, Bardoux C, Fracchia GN, Hallen M, Le Dour O, et al. Oxford, UK, IOS Press, 1995, p 496–497
Get information about faster international access.
Privacy Policy
Copyright © 2004
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
