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You can't treat what you don't diagnose: an analysis of the recognition of somatic presentations of depression and anxiety in primary care.

Background: Research suggests that 13-25% of primary care patients who present with physical complaints have underlying depression or anxiety. Objective: The goal of this paper is to quantify and compare the frequency of the diagnosis of depression and anxiety in patients with a somatic reason for visit among primary care physicians across disciplines. Method: Data obtained from the National Ambulatory Medical Care Survey (NAMCS) from 2002 to 2010 was used to quantify primary care patients with somatic presentations who were given a diagnosis of depression or anxiety. The Patient Health Questionnaire (PHQ)-15, Somatic Symptom Scale, and the Child Behavior Checklist for Ages 6-18 were used to define what constituted a somatic reason for visit in this study. Results: Of the patients presenting with a somatic reason for visit in this nationally representative survey, less than 4% of patents in family or internal medicine were diagnosed with depression or anxiety. Less than 1% of patients were diagnosed with depression or anxiety in pediatrics or obstetrics and gynecology. Less than 2% of patients with somatic reasons for visit in any primary care specialty had documented screening for depression. Conclusion: The rates of diagnosis of depression and anxiety in patents presenting with somatic reasons for visit were significantly less than the prevalence reported in the literature across primary care disciplines.

Keywords: mental health in primary care, somatic reason for visit, depression and anxiety

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Health care fragmentation has created a system that is increasingly efficient treating the part, but not the whole (Stange & Ferrer, 2009; The Institute of Medicine, 2001). Central to this issue is the continued separation of mental health from physical health. It is well established that treating mental health conditions independent of medical problems leads to poorer outcomes and increased cost (Melek & Norris, 2008; Petterson et al., 2008).

Primary care is the largest platform of health care delivery, and also the setting where most patients with mental illness initially present; yet, patients with depression and anxiety who attribute the symptoms they experience to a physical problem often go undiagnosed (Schulberg & Burns, 1988; Kessler et al., 2005; Petterson, Miller, Payne-Murphy, & Phillips Jr., 2014). This is problematic because somatic (of the body; bodily; physical) complaints in those with mental health conditions are common. In fact, patients suffering with depression and anxiety often present with chief somatic complaints rather than emotional concerns (Goldberg, 1979; Tylee & Gandhi, 2005). This finding has been established in the literature in all primary care populations, as summarized in Table A1 of the Appendix. Furthermore, a somatic concern is listed as the reason for visit for more than half (57%) of all outpatient visits (Schappert, 1992). Thus, recognizing anxiety and depression in patients with physical complaints is a critical issue for primary care physicians.

Background

The reported prevalence of depression and anxiety among adult primary care patients with any somatic reason for visit has been consistent in the literature. One study surveyed 500 patients presenting with a somatic reason who were screened for depression and anxiety prior to their visit with the physician (Kroenke, Jackson, & Chamberlin, 1997). In this random sample of adult patients, 23% met criteria for a depressive order and 14.8% met criteria for an anxiety disorder. It was also noted that patients rarely volunteered emotional chief complaints or proposed a psychological reason for their somatic symptoms. A more recent study evaluated 917 patients ages 18 and older presenting with an acute physical complaint (Haftgoli et al., 2010). These patients were randomly selected from 21 private practices and one academic primary care center. In patients with at least one physical complaint, the prevalence of depression was 20.0% and the prevalence of anxiety was 15.5%.

Studies have also evaluated the prevalence of depression and anxiety among those with somatic complaints that lack clear medical explanations. Kroenke, whose body of research has significantly added to this area of inquiry, noted that at least one third of all patients that present with physical complaints have no physiologic pathology to explain their symptoms. Of patients who lack physiologic explanations for their symptoms, approximately 50 to 75% have a depressive disorder, and 40 to 50% have an anxiety disorder (Kroenke, 2003). Thus when looking at the prevalence of depression and anxiety among all those presenting with any somatic complaint (medically explained or un explained) in this study, 16.5 to 24.75% had a depressive disorder and 13.2 to 16.5% had an anxiety disorder as the underlying etiology for their symptoms. While a causational relationships between depression and anxiety and somatic complaints (even when they are unexplained) has not been established in the literature, the fact that they are correlational is unquestioned (Agiiera, Failde, Cervilla, DtazFernandez, & Mico, 2010; Gerrits et al., 2012).

The literature on the prevalence of depression and anxiety in children who present with somatic complaints is less consistent, often varying depending on the specific somatic symptom evaluated and the ages of the children assessed. Flowever, it has been shown that functional somatic symptoms in children are consistently associated with depressive and anxiety disorders in both controlled longitudinal and crosssectional pediatric studies (Campo, 2012; Kozlowska, 2013). One pediatric study found that the somatic symptoms of abdominal pain and perspiration without exertion better predicted depression than all DSM-IV depressive symptoms. Moreover, the symptom of abdominal pain in children persisted as a strong independent predictor of depression and anxiety, even after controlling for other important confounders (Bohman et al., 2012). Thus, evaluating mood disorders in those presenting with somatic concerns is also significant for those caring for a pediatric population.

While there are few studies looking at the prevalence of depression and anxiety in patients presenting to obstetrics and gynecology with somatic complaints, there are studies indicating the particular importance of this topic for women. One study evaluating gender difference in reporting somatic symptoms noted that depressive and anxiety disorders were the strongest correlate of symptom reporting, and that physical symptoms were reported at least 50% more often by women than by men (Kroenke & Spitzer, 1998). Even among pregnant women where somatic symptoms are common, it has been noted that women with underlying mood disorders experience a greater number of somatic symptoms as compared to pregnant women who did not meet criteria for a mood disorder (Yonkers, Smith, Gotman, & Belanger, 2009).

Goals of This Study

While the relationship between physical symptoms and emotional disorders has been well established, the purpose of this study was to take the conversation one step further by quantifying the rates at which primary care physicians diagnose depression and anxiety in patients presenting with somatic complaints. To our knowledge, this is the first study to evaluate this issue using National Ambulatory Medical Care Survey (NAMCS) data across primary care disciplines. Using this data, we are able to focus attention on the recognition of somatic presentations of depression and anxiety, which is one of the most important skills required by primary care physicians to adequately identify these mood disorders in their patient population.

Method

Data Source

Our study pools data from the National Ambulatory Medical Care Survey (NAMCS) from 2002 to 2010. NAMCS is a nationally representative survey that provides information about the use of office-based medical care services in the United States. Each participating physician is randomly assigned to a 1-week reporting period in which data for a random sample of visits are recorded on a standardized encounter form. Data is recorded by participating physicians that includes: patient demographics, reason for visit, medication prescribed, diagnosis, services ordered or provided (including whether or not a patient was screened for depression), and visit characteristics.

NAMCS uses a modular structure for classification for a patient's reason for visits that falls into one of seven categories: symptom, disease, diagnostic/screening and preventive, treatment, injuries and adverse effects, test results, administrative. The symptom model groups symptoms by body system with the exception of those that are more generalized, such as "fatigue" (Schneider, 1979). NAMCS also allows for the documentation of up to three ICD-9 diagnosis codes for a visit. Because our study was focused on an exploration of the diagnosis of depression and anxiety in those who presented with somatic complaints across primary care disciplines, NAMCS was well suited for our purposes.

Measures

Knowing that there is supported evidence that the comorbidity of somatoform (characterized by symptoms suggesting a physical disorder but for which there are no demonstrable organic findings or known physiological mechanisms) disorders with depressive and anxiety disorders is 3.3 times more likely than expected by chance, (De Waal, Arnold, Eekhof, & Van Hemert, 2004), we limited our evaluation to the physical complaints most likely to be connected with an underlying mood disorder as indicated on the Patient Health Questionnaire (PHQ)-15 Somatic Symptom Scale, the Depression and Somatic Symptom Scale (DSSS), and the somatic portion of the Child Behavior Checklist for Ages 6-18; detailed in Table A2 of the Appendix. Somatic reasons for visits not mentioned in these scales were excluded. The Depression and Somatic Symptom Scale was used to clarify which musculoskeletal complaints were considered somatoform, as this was unclear from the other two scales. While NAMCS allows for up to three reasons for visits, we restricted our analysis to those who had a somatoform complaint as a primary reason for visit.

The sample in our study were patients who presented with somatic reasons for visit from 2002-2010, meeting the aforementioned criteria, to primary care physicians. The specialties examined included: family medicine, internal medicine, and pediatrics. We also examined patients who presented to obstetrics and gynecology, since they are sometimes classified as primary care physicians.

Our main outcome was a diagnosis of depression or anxiety, regardless of whether it was the main diagnosis or not. The following ICD-9 codes were used to evaluate for the diagnosis of depression or anxiety: 311 (including all 311 codes for depressive disorders), 648.4 (postpartum depression), 313.1 (misery and unhappiness in childhood), 309.0 (adjustment disorder with depressed mood), 309.1 (prolonged depressive reaction), 300 (including all 300 codes for anxiety disorders), 313.0 (overanxious disorder in childhood), 309.21 (separation anxiety), and 309.24 (adjustment with disorder with anxiety). We also examined whether a screening for depression occurred during the visit.

Data Analysis

After restricting the analysis to visits to primary care physicians and then keeping only observations with a somatoform reason for visit, as defined above, we subdivided these visits into specific symptom categories. Thereafter, the distribution of presenting symptom categories by specialty was examined. Finally, we identified visits leading to a diagnosis of depression or anxiety and calculated the specialty-specific percentage of visits with a somatoform reason for visit that led to one of these diagnoses. Significance tests across proportions for physician specialties, using family physicians as the reference group, were calculated using Wald's chi-square tests adjusted for sample weights. This analysis was conducted with Stata 14.0.

Results

The pooled 2002-2010 NAMCS data includes a total of 259,398 office visits of which 110,125 were to family physicians, general internists, pediatricians or ob-gyn physicians. For these visits, about 15,934 or 14.5% (= 15,943/ 110,125) had a somatoform reason for visit.

The diagnosis of depression and anxiety in those with somatoform reasons for visit was notably low (Table 1). In comparison to the 13-25% expected based on previous studies, fewer than 4% of patients seen with a somatoform reason for visit by family physicians or general internists were diagnosed with depression or anxiety, and fewer than 1% of those seen by pediatricians or ob-gyn physicians. Rates of screening for depression varied across primary care specialties, with general internists more likely to screen. Yet, across all primary care specialties, less than 2% of patients were screened for depression.

Table 2 shows the predominance of the type of somatic reason for visit among primary care specialties. As to be expected, obstetrics and gynecology had the most limited variation to the types of somatic complaints among their patients, whereas the types of complaints addressed were most similar between internal and family medicine.

Limitations

The primary limitation of our study is that the evaluation of primary care physician's recognition of depression and anxiety can only be accounted for by their use of ICD-9 diagnostic codes when using NAMCS data. This limitation is significant as previous studies have demonstrated that primary care providers are disinclined to record mental health diagnoses, even when those diagnoses have been identified (Schumann, Schneider, Kantert, Lowe, & Linde, 2012). Furthermore, because NAMCS data only provides a snapshot view of what occurs in U.S. ambulatory care settings, there is no way to evaluate patients longitudinally. Thus, no comment can be made regarding the number of patients with somatic presentation without a diagnosis of depression or anxiety at the time of evaluation in our study who were eventually diagnosed with these conditions by their primary care provider. The use of NAMCS data also does not allow one to determine if a diagnosis of depression or anxiety had been made previously and simply not documented as one of the three ICD-9 diagnoses codes in that particular visit.

By limiting this study to patients with a somatic reason for visit, those patients presenting for wellness exams were not included. This may have more significantly impacted the data for pediatrics and obstetrics and gynecology where somatic symptoms may have been only discussed in the context of a routine physical or gynecologic exam.

Discussion

While the nature of this study does not allow for definitive conclusions as to why the rates of diagnosis of depression and anxiety in patients with a somatic reason for visit were lower than expected, the extraordinarily low rates of screening suggests that active evaluation for mental health conditions in this population is not routine, even rare. This finding is substantial, as NAMCS collects data on depression screening by self-reporting done by the physician at the conclusion of the visit. Moreover, our study is particularly concerning in light of the fact that its investigation was limited to the somatic symptoms most commonly associated with mental health conditions. These findings seem to be consistent with previous studies that have found that mental health diagnoses are often diagnoses of exclusion for patients complaining of physical symptoms (Henningsen, Zimmermann, & Sattel, 2003; Nimnuan, Hotopf, & Wessely, 1999).

While no primary specialty came close to the reported prevalence, the rate of diagnosis of depression and anxiety was particularly low for obstetrics and gynecology and pediatrics. Noting the real and perceived pharmacologic challenges of treating depression and anxiety in children and pregnant women, the question is raised whether the paucity of diagnoses found in this study correlates with discomfort felt by primary care physicians in prescribing antidepressant or anxiolytic medications for these populations.

The systematic separation of mental health from physical health may be traced back to how physicians are trained. In fact, in a recent survey taken of 1,365 residency directors from internal medicine, family medicine, pediatrics, and obstetrics and gynecology, more than half of these training directors were dissatisfied with the psychiatric training their program offered, with most rating their psychiatric training as suboptimal or minimal (Leigh, Mallios, & Stewart, 2006). Regardless of specialty, dissatisfied program directors noted a desire for increase in training in both didactic and clinical settings. Dissatisfied residency directors also noted a lack of diversity of the training faculty, training venues, and training formats as key barriers in providing what they would consider to be optimal psychiatric training for their primary care residents. Moreover, the common practice of teaching mental health as an isolated clinical rotation places a significant limitation on the number of hours dedicated to psychiatric training in primary care residencies. Recent studies have found this limited psychiatric training to be woefully inadequate at preparing most primary care residents to meet current societal demands; causing some to advocate for greater integration of psychiatric education with longitudinal mental health training throughout all years of primary care residents' training (Smith et al., 2014).

In this nationally representative data source, fewer than 4% of patients with a somatic reason for visit received a diagnosis of depression or anxiety in primary care settings where the estimated prevalence is 13-25%. This study highlights that the problem of under diagnosis of depression and anxiety is universal across primary care disciplines and settings. While there is clearly a need to improve mental health training for primary care residents and to increase awareness of practicing clinicians, this change in alone would not address the current deficiencies in the primary care workforce in diagnosing and treating depression and anxiety. This is of particular importance noting that current data seems to indicate that there is a rising prevalence of mood disorders and an increased lifetime risk of developing a mood disorder for younger cohorts (Hidaka, 2012).

Improved treatment of depression and anxiety will require improved diagnosis. This study highlights a need for primary care to offer an improved holistic approach to the evaluation of patients who present with somatic complaints. At a time when our country is facing an opioid overuse epidemic, we simply cannot afford to neglect the psychological underpinnings of physical pain. There is a growing body of literature demonstrating models of primary care that integrate mental health providers into primary care settings has led to increased mental health diagnoses and enhanced recognition of mental health needs among primary care patients (Zivin et al., 2010). This study supports the need for enhanced training of health care providers and continued examination of integrated models of behavioral and mental health in primary care.

http://dx.doi.org/10.1037/fsh0000229

References

Aguera, L., Failde, I., Cervilla, J. A., Dfaz-Fernandez, P., & Mico, J. A. (2010). Medically unexplained pain complaints are associated with underlying unrecognized mood disorders in primary care. BMC Family Practice, 11, 17. http://dx .doi.org/10.1186/1471-2296-11-17

Apter, G., Devouche, E., Garez, V., Valente, M., Genet, M. C., Gratier, M., & Belaisch-Allart, J. (2013). Pregnancy, somatic complaints and depression: A French population-based study. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 171, 35-39. http://dx.doi.org/ 10.1016/j.ejogrb.2013.08.013

Bohman, H., Jonsson, U., Paaren. A., von Knorring, L., Olsson, G., & von Knorring, A.-L. (2012). Prognostic significance of functional somatic symptoms in adolescence: A 15-year community-based follow-up study of adolescents with depression compared with healthy peers. BMC Psychiatry, 12, 90. http://dx.doi.org/10.1186/1471-244X-12-90

Cadoret. R. J., Widmer, R. B., & Troughton, E. P. (1980). Somatic complaints: Harbinger of depression in primary care. Journal of Affective Disorders, 2, 61-70. http://dx.doi.org/10.1016/01650327(80)90022-1

Campo, J. V. (2012). Annual research review: Functional somatic symptoms and associated anxiety and depression--Developmental psychopathology in pediatric practice. Journal of Child Psychology and Psychiatry, 53, 575-592. http://dx.doi.org/10 .1111/jd 469-7610.2012.02535.x

Campo, J. V., Bridge, J., Ehmann, M., Altman, S., Lucas, A., Birmaher, B., ... Brent, D. A. (2004). Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics, 113, 817-824. http:// dx.doi.org/10.1542/peds. 113.4.817 de Waal, M. W., Arnold, I. A., Eekhof, J. A., & Van Hemert, A. M. (2004). Somatoform disorders in general practice: Prevalence, functional impairment and comorbidity with anxiety and depressive disorders. The British Journal of Psychiatry, 184, 470-476. http://dx.doi.org/10 .1192/bjp. 184.6.470

Gerrits, M. M., Vogelzangs, N., van Oppen, P., van Marwijk, H. W., van der Horst, H., & Penninx, B. W. (2012). Impact of pain on the course of depressive and anxiety disorders. Pain, 153, 429-436. http://dx.doi.org/10.1016/j.pain.2011 .11.001

Goldberg, D. (1979). Detection and assessment of emotional disorders in a primary care setting. International Journal of Mental Health, 8, 3048. http://dx.doi.org/10.1080/00207411.1979 .11448831

Goldberg, I. D., Roghmann, K. J., McInemy, T. K., & Burke, J. D., Jr. (1984). Mental health problems among children seen in pediatric practice: Prevalence and management. Pediatrics, 73, 278-293.

Haftgoli, N., Favrat, B., Verdon, F., Vaucher, P., Bischoff, T., Burnand. B., & Herzig, L. (2010). Patients presenting with somatic complaints in general practice: Depression, anxiety and somatoform disorders are frequent and associated with psychosocial stressors. BMC Family Practice, 11, 67. http://dx.doi.org/10.1186/1471-2296-11-67

Henningsen, P., Zimmermann, T., & Sattel, H. (2003). Medically unexplained physical symptoms, anxiety, and depression: A meta-analytic review. Psychosomatic Medicine, 65, 528-533. http://dx.doi.org/10.1097/01.PSY.0000075977 .90337.E7

Hidaka, B. H. (2012). Depression as a disease of modernity: Explanations for increasing prevalence. Journal of Affective Disorders, 140, 205214. http://dx.doi.org/10.1016/j.jad.2011.12.036

Kelly, R. H., Russo, J., & Katon, W. (2001). Somatic complaints among pregnant women cared for in obstetrics: Normal pregnancy or depressive and anxiety symptom amplification revisited? General Hospital Psychiatry, 23, 107-113. http://dx.doi .org/10.1016/SO 163-8343(01)00129-3

Kessler, R. C., Berglund, P., Dernier, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. http://dx.doi.org/10.1001/ archpsyc.62.6.593

Kozlowska, K. (2013). Functional somatic symptoms in childhood and adolescence. Current Opinion in Psychiatry, 26. 485-492. http://dx.doi.org/ 10.1097/YCO.ObO 13e3283642ca0

Kroenke, K. (2003). Patients presenting with somatic complaints: Epidemiology, psychiatric comorbidity and management. International Journal of Methods in Psychiatric Research, 12, 34-43. http://dx.doi.org/10.1002/mpr. 140

Kroenke, K., Jackson, J. L., & Chamberlin, J. (1997). Depressive and anxiety disorders in patients presenting with physical complaints: Clinical predictors and outcome. The American Journal of Medicine, 103, 339-347. http://dx.doi.org/10.1016/ S0002-9343(97)00241-6

Kroenke, K., & Spitzer, R. L. (1998). Gender differences in the reporting of physical and somatoform symptoms. Psychosomatic Medicine, 60, 150-155. http://dx.doi.org/10.1097/00006842-19980300000006

Kroenke, K., Spitzer, R. L., Williams, J. B., Linzer, M., Hahn, S. R., deGruy, F. V., Ill, & Brody, D. (1994). Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Archives of Family Medicine, 3, 774779. http://dx.doi.org/10.1001/archfami.3.9.774

Leigh. H.. Mallios, R., & Stewart, D. (2006). Current status of psychosomatic training in primary care residencies in the United States. International Congress Series, 1287, 265-268. http://dx.doi.org/ 10.1016/j.ics.2005.09.1

Melek, S., & Norris, D. (2008). Chronic conditions and comorbid psychological disorders. Seattle, WA: Milliman.

Nimnuan, C., Hotopf, M., & Wessely, S. (2000). Medically unexplained symptoms: How often and why are they missed? The Quarterly Journal of Medicine, 93, 21-28. http://dx.doi.org/10.1093/ qjmed/93.1.21

Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips, R. L., Jr. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families, Systems, & Health, 32, 157-166. http:// dx.doi.org/10.1037/fsh0000036

Petterson, S. M., Phillips, R. L., Jr., Bazemore, A. W., Dodoo. M. S., Zhang, X., & Green, L. A. (2008). Why there must be room for mental health in the medical home. American Family Physician, 77, 757.

Romera, I., Femandez-Perez, S., Montejo, A. L., Caballero, F., Caballero, L., Arbesu, J. A. ... Gilaberte. I. (2010). Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status. Journal of Affective Disorders, 127, 160-168. http://dx.doi .org/10.1016/j.jad.2010.05.009

Schappert, S. M. (1992). National Ambulatory Medical Care Survey: 1989 summary. Vital and Health Statistics, Series 13: Data From National Health Survey, 110, 1-80.

Schneider, D. (1979). A reason for visit classification for ambulatory care (DHEW Publication No. [PHS] 79-1352). Hyattsville, MD: U.S. Department of Health, Education, and Welfare.

Schulberg, H. C., & Burns. B. J. (1988). Mental disorders in primary care: Epidemiologic, diagnostic, and treatment research directions. General Hospital Psychiatry, 10, 79-87. http://dx.doi.org/ 10.1016/0163-8343(88)90092-8

Schumann, I., Schneider, A., Kantert, C., Lowe, B., & Linde, K. (2012). Physicians' attitudes, diagnostic process and barriers regarding depression diagnosis in primary care: A systematic review of qualitative studies. Family Practice, 29, 255-263. http://dx.doi.org/10.1093/fampra/cmr092

Simon, G. E., VonKorff, M., Piccinelli, M., Fullerton, C., & Ormel, J. (1999). An international study of the relation between somatic symptoms and depression. The New England Journal of Medicine, 341, 1329-1335. http://dx.doi.org/10.1056/ NEJM199910283411801

Smith, R. C., Laird-Fick, H., D'Mello, D., Dwamena, F. C., Romain, A., Olson, J., ... Frankel, R. (2014). Addressing mental health issues in primary care: An initial curriculum for medical residents. Patient Education and Counseling, 94, 33-42. http://dx.doi.org/10.1016/j. pec. 2013.09.010 Stange, K. C., & Ferrer, R. L. (2009). The paradox of primary care. Annals of Family Medicine, 7, 293-299. http://dx.doi.org/10.1370/afm. 1023

The Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington. DC: The National Academy of Sciences.

Tylee, A., & Gandhi, P. (2005). The importance of somatic symptoms in depression in primary care. Primary Care Companion to the Journal of Clinical Psychiatry, 7, 167-176. http://dx.doi.org/10 ,4088/PCC.v07n0405

Yonkers, K. A., Smith, M. V., Gotman, N., & Belanger, K. (2009). Typical somatic symptoms of pregnancy and their impact on a diagnosis of major depressive disorder. General Hospital Psychiatry, 31, 327-333. http://dx.doi.org/10.1016/j.genhosppsych.2009.03.005

Zivin, K., Pfeiffer, P. N., Szymanski, B. R., Valenstein. M., Post, E. P., Miller, E. M.. & McCarthy, J. F. (2010). Initiation of Primary Care--Mental health integration programs in the VA Health System: Associations with psychiatric diagnoses in primary care. Medical Care, 48. 843-851. http://dx.doi.org/10.1097/MLR.0b 013e3181e5792b

Appendix
Table A1 Studies in Somatic Presentation of Depression and
Anxiety in Primary Care

Author                     Sample                 Study design

  (Kroenke et al.,    1.000 adult         A cross sectional study that
  1994)                 patients age 18     evaluated 1000 adult
                        to 91 years old     primary care participants
                                            with PRIME-MD and the
                                            Medical Outcomes Study
                                            Short-form Survey (SF-
                                            20) to evaluate the
                                            relation of physical
                                            symptoms and mood
                                            disorders

(Simon. VonKoff,      25,916 adult        A World Health
  Piccineli,            patients age 18     Organization cross
  Fullerton, &          to 64 years old     sectional study involving
  Ormel, 1999)                              25,916 patients at 15
                                            primary care centers in
                                            14 countries (including
                                            the US) on five
                                            continents; 5,447 of the
                                            patients underwent a
                                            structured assessment of
                                            depressive and
                                            somatoform disorders;
                                            1,146 patients (weighted
                                            prevalence, 10.1 percent)
                                            met the criteria for major
                                            depression.

(Romera, et al.,      1,317 adult         A cross sectional study
  2010)                 patients 18 and     that evaluated 422 primary
                        older               care patients with
                                            generalized anxiety
                                            disorder (GAD). 559
                                            patients with GAD and
                                            co-morbid major
                                            depressive disorder
                                            (MDD), and 336 control
                                            patients at 87
                                            participating sites in
                                            Spain between April and
                                            June of 2007 for the
                                            presence of painful
                                            physical symptoms.

(Cadoret,             117 adult and       Retrospective evaluation of
  Widmer, &             pediatric           complaints and visits of
  Troughton,            patients age 9      117 patients newly
  1980)                 to 86 years old     diagnosed with
                                            depression in a family
                                            medicine practice
                                            compared to age and
                                            sex-matched controls
                                            over 6 distinct time
                                            periods over a 2 year
                                            period starting 6 months
                                            prior to depression
                                            diagnosis.

(Goldberg,            18,351 pediatric    A cross sectional study
  Roghmann,             patients age        involving 40% of all
  Mclnemy, &            less than 1 to      pediatricians in Monroe
  Burke Jr.,            greater than 18     County, NY. Of the
  1984)                 years old           18,351 children
                                            evaluated, there were
                                            935 children detected at
                                            their first visit as having
                                            a problem behavioral
                                            health issue

(Campo, et al.,       80 pediatric        An case control study
  2004)                 patients Age 8      evaluating 42 children
                        to 15 years old     with 3 or more episodes
                                            of abdominal pain
                                            sufficient to interfere
                                            with activities or
                                            function in the previous
                                            3 months, without
                                            underlying physiologic
                                            condition or chronic
                                            illness were compared to
                                            38 control patients who
                                            were free of recurrent
                                            abdominal pain.
                                            headache, chest pain, and
                                            limb pain in the previous
                                            3 months.

(Bohman, et al.,      710 adolescent      A longitudinal population
  2012)                 patients 16 and     based study in which
                        17 years old        16-17-year-olds in
                                            Uppsala, Sweden, were
                                            screened for depression
                                            in 1991-1993. Of the
                                            2,300 adolescents
                                            evaluated, the 355 who
                                            screened positive for
                                            depression and an equal
                                            number of healthy
                                            controls took part in a
                                            semi-structured
                                            diagnostic interview
                                            including an assessment of
                                            21 different self-rated
                                            somatic symptoms. 64% of
                                            those adolescents
                                            participated in a followup
                                            structured interview 15
                                            years later.

(Kelly, Russo, &      186 obstetric       A cross sectional study
  Katon, 2001)          patients 18 and     evaluating 186 pregnant
                        older               women at a university
                                            based OB clinic patients
                                            were evaluated with the
                                            Primary Care Evaluation
                                            of Mental Disorders
                                            Patient Health
                                            Questionnaire, PRIME-
                                            MD PHQ to assess
                                            current depressive and
                                            anxiety disorders and
                                            self-reported somatic
                                            symptoms

(Apter, et al.,       706 obstetric       A cross sectional study was
  2013)                 patients 18 and     conducted on 706
                        older               consecutive pregnant
                                            women approached
                                            during OB/GYN visits at
                                            a general maternity
                                            hospital in France. They
                                            were asked to fill out a
                                            questionnaire, which
                                            contained the Edinburgh
                                            Postnatal Depression Scale
                                            (EPDS) and a checklist of
                                            18 somatic complaints.

Author                Clinical objective        Research findings

  (Kroenke et al.,    Examine how the      The likelihood of a mood or
  1994)                 type and             anxiety disorder increases
                        number of            with the presence of
                        physical             somatic symptoms. Mood
                        symptoms             disorders were present in
                        reported by          32% to 62% of patients
                        patients are         endorsing specific
                        related to           symptoms (vs 26% in the
                        psychiatric          overall sample). Anxiety
                        disorders and        disorders were present in
                        functional           24-50% of patients
                        impairment           endorsing specific
                                             symptoms (vs 18% overall)

(Simon. VonKoff,      To examine the       The range of patients with
  Piccineli,            relation             depression who reported
  Fullerton, &          between              only somatic symptoms
  Ormel, 1999)          somatic              was 45 to 95 percent
                        symptoms and         (overall prevalence, 69
                        depression.          percent; p = .002 for the
                                             comparison among
                                             centers).
                                             The symptomatic experience
                                             of depression showed
                                             little variation from one
                                             country to another

(Romera, et al.,      To assess the        28% of patients in the
  2010)                 prevalence of        control group, with
                        painful              neither generalized
                        physical             anxiety disorder or
                        symptoms in          morbid major depressive
                        patients GAD         disorder, had painful
                        vs patients          physical symptoms.
                        with GAD and         59% of patients with
                        co-morbid            generalized anxiety
                        MDD as               disorder had painful
                        compared to a        physical symptoms.
                        control group        78% of patients with
                        (patients            generalized anxiety
                        neither with         disorder and co-morbid
                        GAD nor              morbid major depressive
                        MDD).                disorder had painful
                                             physical symptoms.

(Cadoret,             Evaluate pattern     There was a notable
  Widmer, &             of patient           increase in somatic visits
  Troughton,            visits and type      in the group diagnosed
  1980)                 of complaints        with depression as
                        relating to          compared to the control
                        depressive           group. 44% of those who
                        illness in a         were newly diagnosed
                        university           with depression presented
                        family practice      for exclusively somatic
                        clinic               concerns prior to their
                                             diagnosis.

(Goldberg,            To obtain an         Of the 935 children
  Roghmann,             estimate of the      diagnosed with a mental
  Mclnemy, &            prevalence of        health condition 443
  Burke Jr.,            mental health        patients (47.38%)
  1984)                 problems             presented for an acute
                        among                physical symptom as the
                        children seen        reason for visit. Only 80
                        by                   (8.65%) of the patients
                        pediatricians.       diagnosed with a mental
                                             health condition who
                                             presented with an
                                             emotional complaint or to
                                             discuss counseling

(Campo, et al.,       To determine         Children with recurrent
  2004)                 whether              abdominal pain were
                        recurrent            significantly more likely
                        abdominal pain       to have an anxiety
                        is associated        disorder (79%) or
                        with                 depressive disorder
                        psychiatric          (43%), than control
                        symptoms and         subjects.
                        disorders.
                        anxious
                        temperament.
                        or functional
                        impairment in
                        pediatric
                        primary care.

(Bohman, et al.,      To determine if      84% of adolescents with
  2012)                 somatic              depression had at least
                        symptoms in          one somatic complaint as
                        adolescence          compared with 53% of
                        can predict          those without depression.
                        severe adult         Moreover, in depressed
                        mental health        adolescents a higher
                        disorders            number of somatic
                                             complaints had a linear
                                             correlation to higher risk
                                             of development of serious
                                             mental health conditions
                                             as an adult.

(Kelly, Russo, &      To examine           Pregnant women with
  Katon, 2001)          somatic              depression and/or anxiety
                        symptoms as a        were significantly more
                        predictor of         likely to report more
                        depressive and       somatic symptoms during
                        anxiety              pregnancy compared to
                        disorders            women without
                        among                depression or anxiety.
                        pregnant
                        women cared
                        for in an
                        obstetrics
                        clinic

(Apter, et al.,       To determine if      Logistic regression
  2013)                 the presence of      revealed that when the
                        numerous             somatic complaints total
                        somatic              score moved from 3 to 7,
                        complaints           the odds of moving from
                        contributes an       not-at-risk to at-risk for
                        increased risk       antenatal depression were
                        of depression        multiplied by 2.91
                        during
                        pregnancy

Table A2 Somatoform Reasons for Visits From PHQ-15 and
Child Behavior Checklist

                   Child Behavior     Corresponding NAMCS reason for
PHQ-15               Checklist                     visit

Stomach pain      Stomach aches      15450 Stomach and abdominal pain,
                                       cramps
                                     15451 Abdominal pain, cramps,
                                       spasms
                                     15452 Lower abdominal pain,
                                       cramps, spasms
                                     15453 Upper abdominal pain,
                                       cramps, spasms
Back pain                            19050 Back symptoms
                                     19051 Back pain, ache, soreness,
                                       discomfort
                                     19052 Back cramps, contractures,
                                       spasms
                                     19053 Limitation of movement,
                                       stiffness of back
                                     19054 Weakness of back
                                     19100 Low back symptoms
                                     19101 Low back pain, ache,
                                       soreness, discomfort
                                     19102 Low back cramps,
                                       contractures, spasms
                                     19103 Limitation of movement,
                                       stiffness of back
                                     19104 Weakness of lower back
Trouble           Nightmares         11350 Disturbances of sleep
  sleeping                           11351 Insomnia
                                     11352 Sleepiness (hypersomnia)
                                     11353 Nightmares
                                     11354 Sleepwalking
Headaches         Headaches          12100 Headache, pain in head
                                     23650 Migraine headache
Chest pain                           10500 Chest pain and related
                                       symptoms
                                     10503 Burning sensation in the
                                       chest
                                     10502 Chest discomfort, pressure,
                                       tightness
                                     10501 Chest pain
Dizziness         Feels dizzy        12250 Vertigo-dizziness
Fainting spells   Lightheaded        10300 Fainting (syncope)
Feeling your                         12600 Abnormal pulsations and
  heart pound                          palpitations
  or race                            12601 Increased heartbeat
                                     12602 Decreased heartbeat
                                     12603 Irregular heartbeat
                                     12650 Heart pain
Shortness of                         14150 Shortness of breath
  breath                             14200 Labored or difficult
                                       breathing (dyspnea)
                                     14300 Breathing problems
                                     14302 Rapid breathing
                                       (hyperventilation)
Nausea, gas, or   Nausea, feels      10250 General ill feeling
  indigestion       sick
                  Vomiting,          15250 Nausea
                    throwing up      15300 Vomiting
                                     15350 Heartburn and indigestion
                                       (dyspepsia)
                                     15850 Flatulence
Constipation,     Constipated,       15900 Constipation
  loose bowels,     doesn't          15950 Diarrhea
  or diarrhea       move bowels      16000 Other symptoms or changes
                                       in bowel function

Feeling tired     Overtired          10150 Tiredness, exhaustion
  or having         without good     10200 General weakness
  low energy        reason
Pain in your      Aches or pains     10550 Pain, specified site not
  arms, legs,       (not stomach       referable
  or joints,        or headaches)    10600 Pain and related symptoms,
  etc.                                 generalize
                                     10601 Pain, unspecified
                                     10602 Cramps, spasms, site
                                       unspecified
                                     10603 Stiffness, site unspecified
                                     19000 Neck symptoms
                                     19001 Neck pain, ache, soreness,
                                       discomfort
                                     19002 Neck cramps, contractures,
                                       spasms
                                     19003 Limitation of movement,
                                       stiffness of neck
                                     19004 Weakness of neck
                                     19400 Shoulder symptoms
                                     19401 Shoulder pain, ache,
                                       soreness, discomfort
                                     19402 Shoulder cramps,
                                       contractures, spasms
                                     19403 Limitation of movement,
                                       stiffness of shoulder
                                     19404 Weakness of shoulder
                                     19650 Symptoms of unspecified
                                       muscles
                                     19651 Unspecified muscle pain,
                                       ache, soreness
                                     19652 Unspecified muscle cramps,
                                       contracture
                                     19653 Limitation of movement,
                                       stiffness of muscles
                                     19654 Weakness of unspecified
                                       muscles
                  Overeating         All weight issues were evaluated
                                     10400 Weight gain
                                     10451 Recent weight loss
                                     10452 Underweight
                                     10450 Weight loss
                                     15700 Appetite, abnormal
                                     15701 Excessive appetite
                                     15702 Decreased appetite
                                     15750 Difficulty eating
Pain or           (Sexual issues     11601 Frigidity, loss of
  problems          mentioned in       sex drive
  during sexual     the Child
  intercourse       Behavior
                    Checklist,
                    but not in
                    the somatic
                    portion)
Menstrual                            17450 Menstrual symptoms, other
  cramps or                          17451 Premenstrual symptoms
  other                              17452 Painful menstruation
  problems with                        (dysmenorrhea)
  your periods

Received April 4, 2016
Revision received July 27, 2016
Accepted August 3, 2016


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Kristin Gates, MD

Middlesex Hospital, Middletown, Connecticut

Stephen Petterson, PhD and Peter Wingrove, BS

Robert Graham Center, Washington, DC

Benjamin Miller, PsyD

Eugene S. Farley, Jr. Health Policy Center,

University of Colorado School of Medicine

Kathleen Klink, MD

Veterans Health Administration, Office of

Academic Affairs, Washington, DC

This article was published Online First September 5, 2016.

Kristin Gates, MD, Middlesex Hospital, Middletown, Connecticut; Stephen Petterson, PhD, and Peter Wingrove, BS, Robert Graham Center, Washington. DC; Benjamin Miller, PsyD, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine; Kathleen Klink, MD, Veterans Health Administration, Office of Academic Affairs, Washington, DC.

This Research was supported by the resources and funding of the Robert Graham Center in Washington. DC.

Correspondence concerning this article should be addressed to Stephen Petterson, PhD, 1133 Connecticut Avenue, NW Suite 1100, Washington, DC 20036. E-mail: spetterson@aafp.org
Table 1
Diagnosis of Depression or Anxiety and Depression Screening
in Patients Presenting With a Somatic Reason for Visit

                                Rates of diagnosis (%) (ci)

Specialty             N        Depression            Anxiety

Family medicine     8,975   3.3 (2.9-3.7) ref   3.6 (3.2-4.1) ref
Internal medicine   3,646    2.4 (1.9-3.1) *    3.0 (2.4-3.7) (ns)
Pediatrics          2,208     .4 (.2-9) **        .7 (.4-1.4) **
Obstetrics/          460     .3 (.0-2.1) **       .7 (.2-3.5) **
  Gynecology

                       Depression
Specialty             screening (%)

Family medicine      .9 (.7-1.1) ref
Internal medicine    1.9 (1.4-2.5) *
Pediatrics            .4 (.2-,8) **
Obstetrics/         1.3 (.5-3.3) (ns)
  Gynecology

Note. Source: 2002-2010 NAMCS. Data restricted to visits to
primary care physicians with a somatoform reason for visit,
ref = reference category.

(ns) not significant. * p < .05. ** p < .01 based on Wald
tests examining for each outcome differences in the
percentage of family physicians and each of the three types
of physicians.

Table 2 Distribution of Somatic Reasons for Visit by Specialty

                                     Distribution (%)

                                       Family       Internal
                                      medicine      medicine
Symptom                 N      AH    (n = 8,975)   (n = 3,646)

Back pain             2,799   17.4      21.3          17.7
General pain          2,114   13.3      15.6          13.6
Stomach pain          1,900   12.3      10.8          10.6
Nausea                1,563   10.7       8.4           8.2
Headache              1,594   10.1      11.2           8.3
Chest pain             812    6.2        5.7           8.4
Digestive problems     907    5.7        4.2           4.4
Fatigue                790    5.5        5.5           7.1
Other                 2,810   18.7      17.3          21.7
p-value                               reference       <.01

                        Distribution (%)

                                    Obstetrics/
                      Pediatrics    Gynecology
Symptom               (n = 2.208)    (n = 460)

Back pain                 4.0           9.7
General pain              5.3           9.0
Stomach pain             18.1          35.3
Nausea                   26.7           5.6
Headache                 12.1           5.0
Chest pain                3.2           .8
Digestive problems       15.7           1.0
Fatigue                   1.6           3.0
Other                    13.4          30.6
p-value                  <.01          <.01

Note. Source: 2002-2010 NAMCS. Data restricted to visits to
primary care physicians with a somatoform reason for visit.

P-values are based on Wald test examining differences
between distribution of reasons for visits for family
medicine compared to each of the three other specialties.
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Author:Gates, Kristin; Petterson, Stephen; Miller, Benjamin; Klink, Kathleen
Publication:Families, Systems & Health
Article Type:Report
Date:Dec 1, 2016
Words:6436
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