You can't treat what you don't diagnose: an analysis of the recognition of somatic presentations of depression and anxiety in primary care.
Keywords: mental health in primary care, somatic reason for visit, depression and anxiety
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.
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.
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.
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.
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.
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.
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.
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.
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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: firstname.lastname@example.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|
|Date:||Dec 1, 2016|
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