Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization

Risk factors for more severe regional musculoskeletal symptoms: A two-year prospective study of a general working population

OBJECTIVE

To quantify the relative contribution of work-related physical and psychosocial factors, individual factors, and health-related factors to the development of more severe musculoskeletal pain in the neck and upper limbs and the back and lower limbs.

METHODS

In this cohort study of 5,604 workers from industrial and service companies, we collected information on work-related physical and psychosocial exposures and on individual and health-related factors. Questionnaires were completed at baseline by 4,006 participants (71.5%) and after 24 months by 3,276 (82%). At followup, participants with no or minor pain were included in Cox regression analyses to determine which factors predicted more severe regional pain.

RESULTS

Of the 4,006 baseline respondents, only 7.7% were free of regional pain. A total of 1,513 participants were free of severe pain at baseline and completed the 24-month followup. Highly repetitive work predicted arm pain, heavy lifting and prolonged standing predicted low back pain, and heavy pushing or pulling predicted lower limb pain. Low job satisfaction predicted neck/shoulder pain and lower limb pain, whereas other psychosocial work place factors were only of marginal importance. High levels of fear avoidance were associated with arm pain and lower limb pain. A high body mass index was highly associated with lower limb pain.

CONCLUSION

Very few workers are totally free of pain in musculoskeletal regions, and we question the concept of incidence of musculoskeletal pain. The transition from no or minor pain to more severe pain was influenced by physical and psychosocial work place factors together with individual and health-related factors.

Körperbeschwerden und Gesundheitsangst in der Primärmedizin

Zusammenfassung. Patienten mit erhöhter Gesundheitsangst verursachen erhebliche Kosten für das Gesundheitssystem. Die durchgeführten medizinischen Untersuchungen und Behandlungen sind häufig unangemessen, denn in etwa der Hälfte der Fälle liegt den Krankheitsbefürchtungen keine organische Erkrankung zugrunde. Im Rahmen der kontrollierten cluster-randomisierten Studie FUNKTIONAL wurden in 29 Hausarztpraxen bei 1751 Patienten systematisch Gesundheitsangst (Whiteley-7), körperliche und psychische Symptome (PHQ-D) sowie die ärztliche Einschätzung des Hausarztes erfasst. Es fand sich eine verstärkte psychische und globale Funktionsbeeinträchtigung bei Patienten mit erhöhter Gesundheitsangst, die auf Patient- und Arztseite angegeben wird. Psychosoziale Faktoren werden vom Behandler häufiger als für die Erkrankung relevant betrachtet, wenn Patienten erhöhte Gesundheitsangst zeigen. Die Erkennung und Reduktion von Gesundheitsangst in der Allgemeinarztpraxis stellt sich also als relevanter Behandlungsaspekt dar, auch wenn keine hypochondrische Erkrankung im engeren Sinne vorliegt.

Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice

BACKGROUND

Patients with persistent medically unexplained symptoms often exhibit general dysfunction and psychiatric comorbidity and frequently resist psychiatric referral. The aim of this study was to evaluate the efficacy of a collaborative care model including training for general practitioners (GPs) and a psychiatric consultation model for patients with persistent medically unexplained symptoms in general practice.

METHOD

Randomised controlled trial. Cluster randomisation at GP practices and multilevel analysis were performed. A total of 81 patients from 36 general practices completed the study. A collaborative care model of training and psychiatric consultation in general practice in the presence of the GP was compared with training plus care as usual by the GP. Outcome assessment on the patients' well-being, functioning and utilisation of health care services was performed 6 weeks and 6 months later.

RESULTS

All the patients had somatoform disorders (Whitely Index 7.46), and 86% had comorbid psychiatric disorders. In the intervention group, the severity of the main medically unexplained symptoms decreased by 58%. The patients' social functioning improved. The utilization of health care was lower than in the care as usual group.

CONCLUSIONS

A collaborative care model combining training with psychiatric consultation in the general practice setting is an effective intervention in the treatment of persistent medically unexplained symptoms. Anxiety and depressive disorders are highly comorbid in this group. The findings warrant a larger study.

Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study

BACKGROUND

Previous studies performed in selected hypertensive subjects have reported several possible determinants of isolated clinic hypertension (ICH). The purpose of this study was to assess the prevalence and determinants of ICH in a randomly selected nationwide population.

METHODS

We studied a representative sample of the general adult population (1440 45-74-year-old subjects) in Finland not treated for hypertension. The subjects were drawn from the participants of a multidisciplinary epidemiological survey, the Health 2000 Study. Subjects included in the study underwent a clinical interview, determination of serum lipids and glucose, measurement of clinic and home blood pressure (BP), and psychometric tests for psychological distress, hypochondriasis, depression, and alexithymia. The diagnosis of ICH was based on a clinic BP of 140/90 mmHg or greater and a home BP less than 135/85 mmHg.

RESULTS

The prevalence of ICH in the untreated Finnish adult population was 15.6 and 37.5% among untreated clinic hypertensive individuals. In a multivariate logistic regression analysis, ICH was associated with mildly elevated systolic and diastolic BP, lower body mass index (BMI), and non-smoking status. Subjects with ICH represent an intermediate group between the normotensive and sustained hypertensive individuals where cardiovascular risk is concerned (age, BP, diabetes prevalence, lipid profile, and BMI).

CONCLUSION

ICH is a common phenomenon in the general population. Non-smoking individuals with mildly elevated BP and low BMI have a higher risk of ICH. Physicians should disassociate the diagnosis of ICH from any psychosocial disorders, but should remember that patients with ICH have an increased risk of cardiovascular disease.

Dimensionality of the Whiteley Index: assessment of hypochondriasis in an Australian sample of primary care patients

OBJECTIVE

The Whiteley Index (WI) is a widely used instrument for measuring hypochondriacal worries and beliefs. Several studies explored the structural validity of the WI obtaining contrary results concerning the number of factors as well as the item composition. The main aim of this study is to compare factor solutions from previous studies to draw conclusions about the most valid scale model of the WI for administration in primary care.

METHODS

Weighted least squares (WLS) confirmatory factor analyses of the WI were conducted. The sample in study consisted of 1800 patients from primary care practices. Seven different models were compared, including single- and three-factor conceptualisations.

RESULTS

A seven-item, single-factor model best described the data, while three-factor models were clearly inadequate.

CONCLUSIONS

Results support a one-dimensional conceptualisation of the WI and suggest a certain subscale of the WI, the WI-7, to constitute the most psychometrically sound scale for use as a screening instrument for hypochondriasis in primary care. In addition to psychometric considerations, the brevity and simplicity of the WI-7 also make it attractive as a screening tool in the context of primary care. A cutoff score of 2/3, calculated on the basis of general practitioners' diagnoses, yielded the best balance of sensitivity and specificity in the present study.

Somatoform disorders among first-time referrals to a neurology service

Consecutive new neurology inpatients and outpatients (N=198) were assessed for somatoform disorders by using the Schedules for Clinical Assessment in Neuropsychiatry. Sixty-one percent of the patients (59% of the female patients and 63% of the male patients) had at least one medically unexplained symptom, and 34.9% fulfilled the diagnostic criteria for an ICD-10 somatoform disorder (27.7% of the male patients, 41.3% of the female patients, 20.5% of the inpatients, and 43.2% of the outpatients). The prevalence figures were about the same when DSM-IV criteria for somatoform disorders were used. Of the patients with a somatoform disorder, 60.5% also had another mental disorder. Somatization disorder, somatoform autonomic dysfunction, pain disorder, and neurasthenia were equally prevalent (6%-7%); dissociative (conversion) disorders and undifferentiated somatoform disorders were found in 2-3% of the patients. Fifty percent of the patients with somatoform disorders were identified by the neurologists.

The patients' illness perceptions and the use of primary health care

OBJECTIVE

To investigate if primary care patients' perceptions of a current health problem were associated with use of health care.

METHOD

One thousand seven hundred eighty-five patients presenting a new health problem to 1 of 38 physicians from 28 general practices in Aarhus County, Denmark. Patients completed a questionnaire on their illness perceptions and emotional distress before the consultation. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Register data on primary health care utilization 3 years before and 2 years after baseline were obtained. Odds ratios were estimated to examine associations between previous health care use and illness perceptions. Linear regression analysis was performed to examine if illness perceptions predicted later health care use.

RESULTS

Previous use: Higher use was associated with psychosocial, stress, and lifestyle attributions. Accident/chance attributions were associated with higher use for patients with a chronic disorder but with lower use for patients without a chronic disorder. A strong illness identity (number of self-reported symptoms), illness worry, a long timeline perspective, a belief that the symptoms would have serious consequences, and all emotional distress variables were associated with higher use. Use during follow-up: Infection/lowered immunity attributions were associated with higher use for patients with a chronic disorder, whereas psychosocial and lifestyle attributions were associated with higher use for all patients. Illness worry and all emotional distress variables predicted higher health care use. A strong illness identity, a long timeline perspective, a belief in serious consequences, and stress and accident/chance attributions were among the strongest predictors of health care use in a multivariate model including all variables.

CONCLUSIONS

Patients' perceptions of a current health problem are associated with health care use and may offer an obvious starting point for a biopsychosocial approach in primary care.

The uncertain consultation and patient satisfaction: the impact of patients' illness perceptions and a randomized controlled trial on the training of physicians' communication skills

OBJECTIVE

To identify predictors of patient satisfaction among a range of patient and practitioner variables. In particular, to focus on patients' illness perceptions and the impact of a randomized controlled trial on the training of physicians in general communication skills and how to treat patients presenting with poorly defined illness.

METHODS

A randomized controlled follow-up study conducted in 28 general practices in Aarhus County, Denmark. Half of the physicians were randomized into an educational program on treatment of patients presenting with medically unexplained symptoms (somatization). One thousand seven hundred eighty-five general practice attenders presenting a new health problem completed questionnaires on illness perceptions, physical functioning, and mental distress before the consultation. After the consultation, a questionnaire including relational and communicative domains of patient satisfaction with the current consultation was completed. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Predictors of patient satisfaction were determined by logistic regression.

RESULTS

A large number of patient and practitioner variables predicted satisfaction in univariate logistic regression models. Results from a multivariate logistic model showed that the illness perceptions "uncertainty" (patient not knowing what is wrong) and "emotional representations" (the complaint making the patient feel worried, depressed, helpless, afraid, hopeless) predicted dissatisfaction at OR (CI) = 1.8 (1.3-2.4), p < .001 and OR (CI) = 1.5 (1-2.3), p = .03 respectively. Trained physicians were associated with dissatisfaction at OR (CI) 0.7 (0.5-1), p = .06 in the multivariate model. Furthermore, uncertain patients consulting a trained physician were less likely to be dissatisfied OR (CI) = 0.6 (0.3-1), p = .04.

CONCLUSIONS

A randomized controlled trial on the training of general practitioners' communication skills improved patient satisfaction. Illness perceptions predict satisfaction. In particular, patients feeling uncertain and negatively emotionally involved in their health problem were more inclined to being dissatisfied with the consultation.

Screening for common mental disorders: who will benefit? Results from a randomised clinical trial

BACKGROUND

Outcomes of studies on mental health screening in primary care are conflicting. A feasible and effective case-finding approach could benefit both GPs and their patients.

OBJECTIVES

(1) to examine the effect of using a composite screening questionnaire (SQ) on GPs' recognition and provision of care, and (2) to outline useful strategies for case-finding.

METHODS

38 GPs in Aarhus County, Denmark, volunteered to participate in this trial. 1785 consecutive patients aged 18-65 years consulting with new health problems were included. Patients were screened before consultation using an SQ including scales for somatisation, anxiety, depression and alcohol abuse. Patients were randomised into one of two groups: 900 questionnaires were disclosed to and scored by GPs, 885 were blinded. Number of diagnoses, subjects of conversation, and actions taken were analysed. Additional analyses aimed to identify GP and patient factors that could predict improved outcomes.

RESULTS

Overall, disclosure of SQ results increased GPs' recognition of mental disorders by 3.8% [95% confidence interval (CI) -0.5% to 8.0%], and 6.6% (95% CI 1.2% to 12.0%) for patients screened positive. There was a marked variation in GPs' detection rates, and for GPs with moderate or low recognition rates increases were significant (P = 0.001). Conversation on psychological topics increased by 3.2% (95% CI -0.7% to 7.1%), and by 7.0% (95% CI 1.8% to 12.3%) for patients screened positive. Rates of planned follow-up consultations increased by 3.9% (95% CI 0.6% to 7.3%) and by 4.9% (95% CI 0.7% to 9.1%) for patients screened positive. GPs' self-reported benefit from screening was related to better outcomes. A range of patient and GP factors suggesting added value from using SQs were identified.

CONCLUSION

GPs' recognition and provision of mental health care can be influenced by the use of composite SQs. Perceived benefit from screening may serve as a useful predictor of better patient management. Pragmatic case-finding approaches need further evaluation.

The worried young adult as a primary care patient

BACKGROUND

Being worried about one's complaint is common among primary health care patients. Persistent and intensive worry may, however, have negative consequences.

OBJECTIVES

We explored complaint-related worry and factors associated with it among 18- to 39-year-old primary health care patients.

METHODS

Sixty-two patients evaluated the intensity of their worry and the severity of their complaint before seeing their GP. They were also interviewed about their background and filled in questionnaires about general tendency to illness-related worry and psychiatric symptoms.

RESULTS

The intensity of worry varied greatly. One fourth of the patients reported intense worry. A general tendency to worry about health and hostile reactions were associated with both the intensity of worry and the severity appraisals. The patient's education and the duration and perceived course of the complaint also played a role in worrying and in the perceptions of the severity of the complaint.

CONCLUSIONS

Some psychological characteristics may dispose patients to intensive worrying and pessimistic appraisals of their complaint. This challenges the GP to pay attention to the patients' perspectives and knowledge. Careful elucidation of the patients' experiences of their complaints is especially indicated in the case of complaints of long duration and a stable course.

A brief case-finding questionnaire for common mental disorders: the CMDQ

OBJECTIVES

The aim of the study was to validate a new case-finding instrument for common mental disorders (CMDQ).

METHODS

A cross-sectional, stratified, two-phase study was carried out in 28 general practices in Aarhus County, Denmark. 1785 consecutive patients, 18-65 years old, consulting 38 GPs with a new health problem participated. Patients were screened before consultation using a one-page screening questionnaire including subscales for somatisation (SCL-SOM and Whiteley-7), anxiety (SCL-ANX4), depression (SCL-DEP6) and alcohol abuse (CAGE). A stratified subsample of 701 patients was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external validity of the scales using the SCAN interview as gold standard. All data were analysed using appropriate weighted procedures to control for the two-phase sampling design and non-response bias.

RESULTS

Estimates of sensitivity and specificity for relevant ICD-10 diagnoses at theoretical optimal cut-off points on subscales: Depressive disorder: 78/86 (SCL-DEP6); Alcohol abuse or dependence: 78/97 (CAGE); Severe anxiety disorder: 77/85 (SCL-ANX4); Somatisation disorder: 83/56 (SCL-SOM); and 75/52 (Whiteley-7); any mental disorder: 72/72 (SCL-8). At the theoretical optimal cut-off points the CMDQ demonstrated higher diagnostic accuracy than GPs on any diagnosis evaluated.

CONCLUSION

The study results suggest that the CMDQ has excellent external validity for use as a diagnostic aid in primary care settings.

Assessment of the Hypochondriasis Domain: The Multidimensional Inventory of Hypochondriacal Traits (MIHT)

Although hypochondriasis is associated with the costly use of unnecessary medical resources, this mental health problem remains largely neglected. A lack of clear conceptual models and valid measures has impeded accurate assessment and hindered progress. The Multidimensional Inventory of Hypochondriacal Traits (MIHT) addresses these deficiencies with scales that correspond to a 4-factor model. The MIHT was built with construct validity as a guiding principle and began with an item pool that broadly assessed dimensions identified in the literature. The items were administered to large samples; factor analyses of the responses led to item pool revisions and scale refinements. Multiple studies validated the final MIHT scales and 4-factor model; these findings suggest that the MIHT will contribute to theory and research.

Mental illness and health care use: a study among new neurological patients

We investigated 198 new neurological patients to learn if mental illness had an impact on nonpsychiatric health care use. Mental illness was assessed in a two-phase design, including the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), providing ICD-10 diagnoses and two brief rating scales: the Symptom Check List (SCL-8) for anxiety and depression and the Whiteley-7 for somatization. The patients' use of health care was studied 5-10 years before and 18 months after the psychiatric assessment, using data from national patient registers. Mental illness was linked to data on health care use through weighted logistic regression. ICD-10 psychiatric disorders increased the risk of subsequent high use of nonpsychiatric hospital admissions - somatoform disorders with more than five times (OR=5.6; 95% CI=1.6-20.1) and anxiety/depression with almost four times (OR=3.7; 95% CI=1.1-12.0). There was also a trend, though less marked, linking mental illness to previous hospital use. Use of primary care was also markedly increased by mental disorders, however, only in patients entering the study as inpatients. In conclusion, neurological patients are at risk of being high users of health care if they have a mental illness, somatoform disorders being the most powerful risk factor. The results are consistent with the findings among internal medical patients.

Physical, mental and social factors associated with frequent attendance in Danish general practice. A population-based cross-sectional study

Knowledge of which factors are prompting patients to seek primary care is important to the ongoing effort to improve management in general, and management of frequent attenders (FAs) in particular. We conducted a cross-sectional population-based study with the aim at examining associations between physical, mental and social factors and frequent attendance in general practice. We collected questionnaire and registry data in the County of Aarhus (630,000 inhabitants), Denmark. Half of the county general practices (132 practices, 220 GPs) were selected randomly. FAs were defined as the top 10% attenders over the past 12 months. A questionnaire including SF-36 and questions about physical and mental health and social conditions was sent to age and gender stratified samples of FAs and non-FAs from these practices. Impairments (SF-36) associated with frequent attendance were physical in 54-71% (prevalence difference (PD): 16-33%, adjusted prevalence ratio (adj. PR): 1.1-1.7), mental in 58-70% (PD: 17-25%, adj. PR:1.1-1.4) and social in 40-59% (PD: 13-28%, adj. PR:0.9-1.5). Among FAs, 46-88% had used three or more different drugs (PD: 26-39%, adj. PR:1.5-2.3) and 27-41% had been referred one or more times to outpatient specialists (PD: 4-19%, adj. PR:1.2-2.5). Although our data cannot determine the direction of causality, they clearly demonstrate that FAs carry a large burden of physical, mental and social impairments which underpins the complexity and heterogeneity of the problems which they present. The results make clear that biopsychosocial management is a core issue in FA management in general practice.

The presentation of irritable bowel syndrome in the context of somatization disorder

BACKGROUND AND AIMS

Somatization disorder, a female predominant disorder, has been found with higher than expected prevalence in previous studies of irritable bowel syndrome (IBS) and might be responsible for some of the comorbidity and excessive health care resource use associated with IBS. The study's aim was to determine within a female IBS population the degree of segregation of psychiatric illness, functional disorders, and health care utilization with somatization disorder.

METHODS

In a prospective, 6-month follow-up study, psychiatric disorders were assessed with the Diagnostic Interview Schedule, gastrointestinal and other symptoms with self-report questionnaires, and medically unexplained complaints by thorough chart review. The setting was a university gastroenterology clinic. The participants were a convenience sample of female clinic attendees with IBS (N = 56).

RESULTS

Somatization disorder was diagnosed in 25% of patients and highly probable in another 5%. Somatization disorder was associated with significantly greater numbers of gastrointestinal and other symptoms, psychiatric disorders, physicians consulted, telephone calls to physicians, urgent care visits, medication changes, and missed work days and with benzodiazepine use. On follow-up, somatization disorder was associated with psychiatric and IBS symptoms, medication changes, and treatment dissatisfaction. Both somatization disorder and other psychiatric illnesses were associated with other functional gastrointestinal disorders; only somatization disorder remained predictive in a regression model that controlled for the presence of other psychiatric illness.

CONCLUSIONS

Among female IBS patients attending a university gastroenterology clinic, many aspects of comorbidity and health care behaviors previously associated with IBS segregated with the diagnosis of somatization disorder. Recognition and appreciation of somatization disorder in IBS have important ramifications for the conduct of research and clinical practice.

Follow-Up on Mental Illness in Medical Inpatients: Health Care Use and Self-Rated Health and Physical Fitness

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.

The prevalence of somatoform disorders among internal medical inpatients

OBJECTIVE

To find the prevalence of somatoform disorders (SDs) among internal medical inpatients and to study the comorbidity with other psychiatric disorders.

METHODS

Of 392 eligible consecutive medical inpatients, 294 (75%) accepted to participate and, using a two-phase design, were assessed for ICD and DSM-IV somatoform diagnoses and for ICD-10 psychiatric diagnoses.

RESULTS

A total of 18.1% (95% CI: 12.8-24.9%) of the patients fulfilled the diagnostic criteria for an ICD-10 disorder, and 20.2% (95% CI:14.7-27.2% ) for a DSM-IV SD. The prevalence of specified disorders revealed marked differences between the two diagnostic systems, e.g., concerning somatisation disorder (SD), which was more prevalent in the ICD-10 (5%) than in the DSM-IV (1.5%) equivalent. Quite the contrary was found in undifferentiated SD (0.7% in ICD-10 and 10% in DSM-IV). According to ICD-10 criteria, 3.5% had hypochondriasis, 2.6% a dissociative disorder, 3.2% a somatoform autonomic dysfunction, 1.5% had neurasthenia or persistent somatoform pain disorder, and 5% had an SD, unspecified. SDs were more prevalent among younger females. Thirty-six percent of the patients with SDs also had another psychiatric disorder, 11% a depression, and 25% an anxiety disorder. The physicians detected about 1/3 of the cases.

CONCLUSION

Somatoform disorders were prevalent among internal medical inpatients especially among younger women.

Detecting mental disorders in general hospitals by the SCL-8 scale

OBJECTIVE

The objective of this study is to validate the eight-item dichotomised version of the Symptoms Check List (SCL-8d) as a screening tool for psychiatric disorders.

METHODS

The study population included 198 consecutive new neurological inpatients and outpatients and 294 consecutive internal medical inpatients, aged 18 or older. All patients received the SCL-8d questionnaire, and a stratified subsample was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external SCL-8d validity using the SCAN interview as gold standard. The test was performed based on weighted data to correct for the skewness introduced by stratification.

RESULTS

The diagnostic performance of the SCL-8d was excellent in the internal medical setting but not quite as good in the neurological sample. It performed better among the older compared with the younger patients, whereas the scale was not affected by gender. In the combined sample at the cut point 0/1, the sensitivity (SE) of the SCL-8d was 0.73 (confidence interval [CI](95%): 0.60-0.82), the specificity (SP) 0.61 (CI(95%): 0.53-0.68) and the positive predictive value (PPV) 0.42 (CI(95%): 0.34-0.50), using any International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) psychiatric disorder, excluding somatoform and substance abuse disorders, as gold standard. The risk of a patient having a mental disorder (except phobia, substance abuse or somatoform disorder) was less than 6% in case of a negative screening test. In patients with a current depressive disorder, 87.1% (27/31) were screening positive, and all except 1 (93.0%) of the 14 patients with a modest to severe depression scored 1 or higher on the SCL-8d. All 17 patients with an anxiety disorder, excluding phobias, were screening positive.

CONCLUSION

The study suggests that the SCL-8d is a valid, brief screening tool for use in nonpsychiatric medical settings, especially to detect emotional psychiatric disorders (EPDs).

Use of complementary therapy among internal medical inpatients. Prevalence, costs and association with mental disorders and physical diseases

OBJECTIVES

The aims of this study were to determine the prevalence of complementary therapy/medicine (CT) use among internal medical inpatients. Furthermore, to examine the association between the use of CT and (a) mental disorders, (b) physical diseases, and (c) use of health care.

METHODS

A total of 294 consecutive medical inpatients were interviewed about their use of CT. A stratified subsample of 157 people was assessed for current mental disorders, using an extensive, standardized, semistructured interview (Schedules for Clinical Assessment in Neuropsychiatry version 2.1 [SCAN]). Health care use was assessed by use of national patient registers.

RESULTS

There were 22.5% CT utilizers. More females than males used CT (P=.033). CT utilization was not associated with age, mental disorders, life-threatening or chronic physical diseases or with use of health care services.

CONCLUSIONS

The use of CT is common among medical inpatients. More research is needed to understand why a significant proportion of patients seeks CT.

Assessment of somatoform disorders: a review of strategies and instruments

We provide an overview of methods and instruments developed for the assessment of somatoform disorders. Four diagnostic purposes have been identified: (i) classification according to a diagnostic system; (ii) screening for probable cases; (iii) dimensional measurement of syndrome severity; and (iv) assessment of associated clinical features. Existing instruments designed for each of these strategies are described, including specifications of their psychometric properties, particular features, advantages and disadvantages. A conclusion of this review is that the currently existing 'family of assessment instruments' in the field of somatoform disorders should be used to improve the comparability of scientific findings in different cultures and settings.

Predictors of somatic symptoms in depressive disorder

We explored the relative contribution of potential psychological predictors of somatic symptoms in outpatients with major depressive disorder, including; 1) severity of depression; 2) general anxiety; 3) hypochondriacal worry; 4) somatosensory amplification; and, 5) alexithymia by sampling 100 consecutive outpatients with DSM-IV diagnoses of major depressive disorder attending the psychiatry clinics of general hospitals in Turkey. The subjects were rated by clinicians on depressive symptomatology (Hamilton Depression Rating Scale), and anxiety (Hamilton Anxiety Scale), and completed self-report measures of Hypochondriacal worry (7-item version of the Whiteley Index), the Somatosensory Amplification Scale, and the Toronto Alexithymia Scale. Multivariate models tested the independent contribution of each of the scales to the level of somatic symptoms as measured by a modified version of the SCL-90 somatization scale. At the bivariate level, somatic symptoms were associated with female gender and lower educational level, as well as the Hamilton Depression and Anxiety scales, the Whitely Index, and the Somatosensory Amplification and Alexithymia scales. In multiple regression models incorporating all variables, female gender and higher scores on the anxiety, somatosensory amplification and alexithymia scales all made independent contributions to the level of somatic symptoms and accounted for 54% of the variance. Therefore, somatic symptoms in depression are related to concomitant anxiety, tendency to amplify somatic distress, and difficulty identifying and communicating emotional distress. However, these factors do not account for the tendency for women to report more somatic symptoms.

Hypochondrie in der Allgemeinbevölkerung:

Zusammenfassung. Der Whiteley-Index ist ein Instrument zur Erfassung von Hypochondrie. Für diesen Fragebogen wurde eine Normierungs- und Validierungsstudie anhand einer bevölkerungsrepräsentativen Stichprobe (n = 1996) durchgeführt. Hypochondrie zeigt eine etwa lineare Altersabhängigkeit (r = .24). Frauen haben in allen Altersstufen höhere Hypochondrie-Ausprägungen als Männer. Für verschiedene Alters- und Geschlechtsgruppen werden Normwerte bereit gestellt. Die in der Literatur beschriebene dreidimensionale Struktur des Whiteley-Index (Krankheitsängste, somatische Beschwerden und Krankheitsüberzeugung) konnte mit gewissen Einschränkungen bestätigt werden. Validierungsuntersuchungen mit anderen Instrumenten (Hospital Anxiety and Depression Scale, Multidimensional Fatigue Inventory, Gießener Beschwerdebogen, Screening für Somatoforme Störungen und Nottingham Health Profile) zeigten, dass eine auf sieben Items reduzierte Kurzskala der Gesamtskala mit 14 Items ebenbürtig ist. Für differenzierte Analysen wird jedoch die Originalskala empfohlen. Durch die angegebenen Normwerte ist es künftig besser möglich, Patientengruppen verschiedener Alters- und Geschlechtsverteilungen untereinander oder auch mit Stichproben der Normalbevölkerung zu vergleichen.

Mental disturbances and perceived complexity of nursing care in medical inpatients: results from a European study

AIMS AND OBJECTIVES

The relationship between mental disturbances - anxiety and depression, somatization and alcohol abuse - on admission to internal medicine units and perceived complexity of care as indicated by the nurse at discharge was studied. The goal was to study the utility of short screeners for mental disturbances to select patients for case-management on admission.

DESIGN

The study had a cohort design: patients were included on admission and followed through their hospital stay until discharge. The study was conducted within the framework of the European Biomed 1 Risk Factor study. RESEARCH METHODS AND INSTRUMENTS: In the first 3 days of admission the patients were interviewed by a trained health care professional, who scored the SCL-8D, a somatization questionnaire based on the Whiteley-7 and the CAGE. At discharge, nurses rated the complexity of the patient's care.

RESULTS

Patients with high scores on anxiety and depression (SCL-8D) and on somatization received higher ratings on perceived nursing complexity than those with low scores, with and without control for age, severity of illness and chronicity. The actual nursing intensity and medical care utilization, as measured daily by means of a checklist, could not explain these relations. No differences were found between patients with high or low scores on alcohol abuse.

CONCLUSIONS

The study shows a potential use of screeners for mental disturbances to detect patients for whom nurses might need additional help. However, mental disturbance is not the sole criterion: functional status and other variables that predict medical and nursing care utilization should be included in a screening strategy for case-management programmes.

Complexity of care and mental illness in medical inpatients

We investigated the complexity of medical inpatient care to learn it was associated with the presence and type of mental disorders, and with emotional distress and somatization. Six indicators of care complexity, including length of stay (LOS), were assessed for 294 consecutive medical inpatients. Patients rated their own health and physical disability, and medical consultants assessed them for chronic and life-threatening diseases. A subsample of 157 patients was assessed for ICD-10 psychiatric diagnoses by means of an extensive semi-structured interview known as Schedules for Clinical Assessment in Neuropsychiatry (SCAN). With a few exceptions, the indicators of complexity of care were not statistically significantly associated to ICD-10 mental disorders; psychological distress, measured by the SCL-8 rating scale; or somatization, measured by the Whiteley-7 rating scale. On the other hand, four of six complexity indicators were significantly associated with self-rated physical disability or health, or both, when controlling for the severity of the medical condition. In conclusion, complexity of care, including LOS, was substantially associated with the patient's own health perception but only marginally with the presence of mental illness. This is noteworthy, as previously published results concerning the same patients have shown a clear association of mental illness with utilization of admissions to nonpsychiatric departments, and with utilization of primary care resources.

Psychological distress as a predictor of frequent attendance in family practice: a cohort study

In cross-sectional studies, psychological distress has been associated with frequent health care utilization. However, there is a need for prospective studies to confirm these findings. This cohort study evaluated whether psychological distress predicted frequent attendance in family practice. In 1990, 185 consecutive adults who consulted their primary care physician (PCP) about an illness were rated on two psychometric scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7), and their annual number of face-to-face contacts with a family practice was followed until 1996. Frequent attenders (FAs) were defined as the top 10%. A logistic regression analysis showed a significantly increased risk of becoming an FA with an increase of 1 point (odds ratio [OR] 1.17 [1.03-1.33]) on SCL and 1.28 (1.06-1.53) on Whiteley). An association was found between score and number of years as an FA (OR 1.16 [0.99-1.36] for SCL and OR 1.31 [1.05-1.65] for Whiteley). Psychological distress involved an increased risk of future frequent attendance among adult patients consulting family practice in the daytime about an illness.

Mental disorders among internal medical inpatients: prevalence, detection, and treatment status

OBJECTIVE

To determine the prevalence of ICD-10 mental disorders among internal medical inpatients, the relation between mental disorder, age, and gender, and the recognition and referral of the disordered patients.

METHOD

294 consecutive medical inpatients were examined with a two-phase design using the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) for ICD-10 psychiatric diagnoses. Information from questionnaires and interviews with patients, doctors, nurses, and from medical records.

RESULTS

The prevalence of current mental disorders was 38.7%, being heavily increased in young patients. Main diagnoses were somatoform disorders (17.6%), phobias (12.9%), substance use disorders (10.9%), and depression (8.3%). Psychiatric consultations were very few. About 38-56% of the cases were recognized by medical doctors and nurses, and only about 20% were in mental health treatment.

CONCLUSION

The prevalence of mental disorders among internal medical inpatients is high and increased in young patients and women. Detection and referral are low, and few are treated.

Mental disorders in medical inpatients and the association to severity of illness, self-rated physical disability, and health perception

In a study of 294 consecutive medical inpatients, the authors assessed a subsample of 157 patients for psychiatric diagnoses using an extensive semistructured interview, Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Patients rated their health and physical functioning, and medical consultants assessed them for chronic and life-threatening diseases. A life-threatening condition increased odds for having a psychiatric diagnosis by 3.1 times (95% Confidence Interval (CI): 1.03-9.1), while a chronic medical disease had no such impact (OR=1.1; 95% CI: 0.5-2.3). In women, mental disorders were strongly associated with self-rated disability (OR=6.7; 95% CI: 1.6-27.8) and self-rated health (OR=9.4; 95% CI: 2.7-32.4). This association was absent in men (OR(disability)=0.7; 95% CI: 0.2-2.7; OR(health)=1.6; 95% CI: 0.6-4.7). Analyses included adjustment for age and gender.

Psychological distress among patients with musculoskeletal illness in general practice

The authors investigated the importance of psychological distress and somatization among patients with musculoskeletal illness in general practice. The authors used the Hopkins Symptom Check List (SCL-8) and the Whiteley Index to rate 1,720 patients with musculoskeletal illness referred to physiotherapy from general practice. General practitioners (GPs), patients, and physiotherapists often noted stress or psychological distress to be a possible cause of the patient's musculoskeletal illness, but agreement between them was low. If the GP included the patient's own view on psychological distress, the result of the SCL-8 did not add much to the detection of distress. The results emphasize the importance of discussing psychological distress when dealing with patients with musculoskeletal illness.

Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition

To study the prevalence of somatoform disorders (SDs) in primary care, a questionnaire including the modified 25-item version of the Symptom Checklist-90 was administered to 191 patients consecutively consulting their family physician. A stratified sample of the patients was interviewed with the Schedules for Clinical Assessment in Neuropsychiatry. The study showed that 22.3% (confidence interval [CI]: 95%: 16.4-28.1) of the patients fulfilled the diagnostic criteria for an International Classification of Diseases--10th Revision (ICD-10) SD, excluding SD, unspecified, and 57.5% (CI: 95%: 50.5-64.5) for DSM-IV SD. But 30.3% met the criteria (CI: 95%: 23.8-36.9) when the DSM-IV Not Otherwise Specified (NOS) diagnostic group is excluded. The most frequent ICD-10 diagnosis was autonomous dysfunction, for which 14.1% of the patients fulfilled the criteria, whereas the prevalence of the other somatoform diagnosis was between 3.0% and 8.1%. The most frequent DSM-IV diagnoses were SD NOS and undifferentiated SD, which 29.93% and 27.3% of the interviewed patients, respectively, received, whereas the prevalence of the other diagnoses was between 1.0% and 8.1%. A high comorbidity between SDs and other mental disorders was found. The general practitioners identified between 50% and 71% of the patients with an ICD-10 SD and between 36% and 48%, according to DSM-IV criteria. Patients with SDs used more nonpsychiatric health care facilities than other patients (P = 0.01).