Clinical governance and the vascular surgeon

Background

Monitoring of surgeons and their results is currently in question. The validity and the practicality of audit to determine substandard results is undetermined. To test the instrument of audit, statistical modelling was applied to two indicator vascular procedures, elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy (CEA), with accepted adverse event rates.

Methods

Binomial statistical models for varying adverse event rates were constructed. A power calculation was used in an attempt to predict the case numbers required to determine substandard results for individual surgeons and vascular units. Statistical conventions of power (80 per cent) and upper criterion of rarity (0·05) were used. Previous activity rates for CEA and elective AAA repair were used to predict the time taken to gather these data.

Results

Base rates of 3 and 6 per cent were considered, along with a range of alternate practice. Number of adverse events, number of operations to be studied and the time that this would take are shown in the Table.

Conclusion

Statistical modelling demands assumptions about accepted adverse event rates, confidence criteria and what constitutes substandard results. Large numbers of patient data are required even for common operations with accepted adverse event rates. These data raise serious questions as to the feasibility of performing clinical governance on the basis of crude morbidity and mortality event rates alone.

Are survey measures of medical care utilisation misleading? A comparison of self-reported medical care consumption with actual medical care utilisation

A substantial over-estimate of medical care consumption cost was found when estimates from self-report data from an epidemiological study were compared to actual cost data extracted from administrative records. Even though the few subjects who were actually provided with two or more services in the two-week self-report period substantially under-reported their medical care consumption, a large net over-estimate of medical care consumption was produced by the self-report data. This finding has important implications for use of self-report data from surveys such as the Australian Bureau of Statistics (ABS) National Health Survey for estimating health service consumption. By combining epidemiological survey data from the Australian Vietnam Veterans Health Study (AVVHS), with data on actual medical care for which the Health Insurance Commission (HIC) or the Department of Veterans' Affairs (DVA) paid benefits, we were able to directly compare self-reported medical care consumption with actual medical care utilisation. The comparison revealed that veterans' self-reports were a valid measure of relative medical care consumption because those who reported care over the past two weeks were much more likely to have been recent consumers than those who did not. This relationship became even stronger if the comparison of self-report was extended to data on benefits paid beyond the two-week self-report period. However, the HIC and DVA data confirmed only 51% of veterans self-reporting medical care consumption during the past two weeks actually received a service.

Cervical lymphadenitis due to non-tuberculous mycobacteria: surgical treatment and review

A retrospective study was carried out on 57 children, presenting with non-tuberculous mycobacterial (NTM) lymphadenitis of the head and neck, over a 12 year period. Cultures recovered 56 Mycobacterium avium-intracellulare (MAI), and one Mycobacterium kansasaii. Anti-mycobacterial agents were used in seven patients only. On the basis of the initial operation there were two groups. Group 1 (11 patients) had an excision, and Group 2 (46 patients) had incision and drainage (30 patients), incision and curettage (13 patients), or aspiration (three patients). There was no significant difference in the makeup of these two groups. However, Group 1 had significantly lower number of re-operations than Group 2, P<0.01, and achieved a significantly greater healing rate than Group 2, P<0.001. In Group 2 those who had an excision following failure of the first operation were significantly more likely to heal than those who did not, P<0. 005. Operative excision gives a lower rate of re-operation, and a higher rate of healing than other procedures. The treatment, natural history, clinical presentation, pathogenesis, and diagnosis of NTM cervical lymphadenitis are discussed.

Lung cancer in New South Wales: current trends and the influence of age and sex

OBJECTIVE

To examine the effects of time, sex and age at diagnosis on lung cancer incidence rates and the distribution of the histological types of lung cancer in New South Wales.

DESIGN AND SETTING

Retrospective analysis of data from the NSW Cancer Registry and Australian Bureau of Statistics population data for NSW for 1985-1995.

MAIN OUTCOME MEASURES

Trends in lung cancer incidence rates between 1985 and 1995 for men and women aged over 30 years; changes in incidence rates within age groups; and incidence rates of histological subtypes relative to sex and age.

RESULTS

The incidence of lung cancer in men aged 40-80 years fell, while that in women aged over 65 rose. Rates were stable in younger women and older men. Incidence rates in men aged 40-60 years fell by 40%-60%. Were it not for the reduction in incidence rates in men between 1985 and 1995, the number of male lung cancer cases in 1995 would have been greater by 389 (95% CI, 362-415). In women, increasing incidence rates were responsible for an extra 242 cases (95% CI, 232-253) in 1995. Adenocarcinoma comprised a greater percentage of lung cancer cases in younger people, while squamous-cell carcinoma increases steadily with age in both men and women. Women with lung cancer are less likely to have squamous-cell carcinoma (25% for women v. 40% for men) and therefore more likely than men to have adenocarcinoma (35% of new female cases v. 26% for men) or small-cell lung cancer (24% v. 19%).

CONCLUSIONS

Increased smoking cessation has seen a halving of lung cancer rates in middle-aged men. Whether this represents delayed or prevented cases is uncertain. The distribution of histological subtypes of lung cancer in women is different from that in men, and it is not clear whether this difference is hormone-dependent or related to historical patterns of smoking.

Clinical governance and the vascular surgeon

BACKGROUND

Audit of adverse outcome might allow identification of substandard surgical results. To test this hypothesis statistical modelling was applied to two indicator vascular procedures (elective abdominal aortic aneurysm repair and carotid endarterectomy) with accepted adverse event rates.

METHODS

Binomial statistical models for varying adverse event rates were constructed. A power calculation was used in an attempt to predict the case numbers required to determine substandard results for individual surgeons and vascular units. Two scenarios were considered: first a base adverse event rate of 6 per cent and surgical practice with 9, 12 and 24 per cent morbidity rates, and second a base adverse event rate of 3 per cent and surgical practice with 6, 9 and 12 per cent morbidity rates.

RESULTS

A mean of 57 elective abdominal aortic aneurysm repairs and 70 carotid endarterectomies were performed per annum. The adverse event rate for both operations was 4 per cent. Power calculations revealed that 130 patients would need to be studied to detect a surgeon with an adverse event rate twice 6 per cent and over 280 patients would be required with an adverse event rate twice 3 per cent. To gather this number of patients 2 years of unit data and between 3 and 22 years of individual data would need to be studied for a base adverse event rate of 6 per cent. A base rate of 3 per cent requires 7-47 years for an individual and 4-65 years for the unit. With a base adverse event rate of 6 per cent, detection of widely variant surgical practice (four times the morbidity rate as base) requires only 21 procedures.

CONCLUSION

Statistical modelling demands assumptions about accepted adverse event rates, confidence criteria and what constitutes substandard results. Data from large numbers of patients are required even for common operations with accepted adverse event rates. These data raise serious questions as to the feasibility of performing clinical governance on the basis of morbidity and mortality event rates alone.

Long-term benzodiazepine use by elderly people living in the community

OBJECTIVE

To investigate the prevalence of long-term benzodiazepine use in an elderly community sample, and factors associated with such use.

METHOD

Data came from the Sydney Older Persons Study, a longitudinal study of people aged 75 or over. There were 337 subjects who were interviewed in 1991-93, and subsequently followed up after three and 4.5 years. At the first interview, subjects were assessed for socio-demographic characteristics, physical and mental health, and use of health services. At the first and subsequent interviews, subjects were asked about use of medications, including benzodiazepines.

RESULTS

There were 16.6% who were using benzodiazepines at the time of all three interviews, while a further 19.6% were using them at one or two interviews. In a multivariate ordered logit regression model, long-term benzodiazepine use was associated with treatment for nervous conditions, restless sleep, being female, being divorced and greater contact with medical services.

CONCLUSIONS

The prevalence of benzodiazepine use in the elderly is high and much of this use is long term. The high prevalence of benzodiazepine use stands in contrast to the findings from national surveys that the elderly living in the community tend to have better mental health than younger age groups.

IMPLICATIONS

Efforts are needed to reduce the number of elderly people becoming long-term users. The use of benzodiazepines in this age group is of particular concern, because they may be a risk factor for falls and for cognitive impairment in the elderly.

Carer distress in the general population: results from the Sydney Older Persons Study

OBJECTIVE

To assess distress in a sample of carers who were selected from a community survey rather than recruited via community-service agencies.

METHODS

A community survey was carried out on 630 people aged 75 or over living in Sydney, Australia. Informants nominated by these elderly people were divided into full carer (n = 21), partial carer (n = 187) and non-carer groups (n = 344). Informants completed the General Health Questionnaire (a continuous measure of psychiatric symptoms), the life satisfaction index (a measure of well-being) and the interpersonal bonding measure (a measure of quality of the relationship with the elderly person). Elderly participants had a medical examination, were assessed for disability and were questioned about use of services.

RESULTS

Elderly people who had a full carer were more disabled and had more medical diagnoses. Full, but not partial, carers reported more psychiatric symptoms and lower life satisfaction. In multivariate analysis, the main determinant of carer distress was a relationship in which the carer felt controlled by the elderly person.

CONCLUSION

When carers are selected from a population-based sample, only those who are full carers are more distressed. However, relationship factors are the most important determinant of distress.

Effect of diabetes education on glucose control

After diabetes education, 39 adult diabetic patients were randomized to either an education group or control group. The two groups received identical medical care and follow-up, except that the education group met with their diabetes educator on at least a quarterly basis. Neither group showed any statistically significant change in their glycosylated hemoglobin values, although the education group did have a 4% drop after initial education compared to a 6% rise in the control group. The education group had a lower attrition rate and a better improvement in self-rated dietary compliance. Education remains the cornerstone of diabetes management. Our team identified some trends between the two groups as well as some ideas to improve motivating and developing a stronger and more effective relationship with our patients.

Informant-based staging of dementia using the clinical dementia rating

The staging of dementia is ideally based on both an examination of the patient and a history taken from an informant. However, in some circumstances, only an informant history is possible. The aim of this study was to assess the validity of the Clinical Dementia Rating (CDR) when the rating is based solely on informant data. The CDR was used in a study of 360 persons aged 78 or older who were participants in a community survey, the Sydney Older Persons Study. The CDR was completed in two ways: (1) a social scientist made the ratings based on an informant interview; and (2) a physician made the ratings after an examination of the subject. All CDRs were scored in the conventional way, as well as by the revised method proposed by Gelb and St. Laurent (Alzheimer Dis Assoc Disord 1993;4:202-11). The informant CDR showed moderate agreement with the clinician CDR, showing that it would be a valid substitute in situations in which the subject could not be examined. The revised scoring method was slightly easier to implement than the conventional method.

Impact of chronic systemic and neurological disorders on disability, depression and life satisfaction

OBJECTIVE

To assess the effects of a range of chronic systemic and neurological disorders on three life quality indicators: disability, depressive symptoms and life satisfaction.

METHODS

As part of the Sydney Older Persons Study, a community survey was carried out with 434 non-demented people aged 75 or over living in Sydney, Australia. Subjects were given a medical examination covering the following disorders: heart disease, chronic lung disease, bone and joint disease, stroke, visual loss, peripheral vascular disease, obesity, other systemic diseases, gait ataxia, gait slowing (including Parkinsonism) and cognitive impairement short of dementia. They were also assessed on a clinician-rated disability scale and given self-report depression and life satisfaction scales.

RESULTS

Gait slowing affected all three indicators of life quality. Heart disease and chronic lung disease affected disability and depressive symptoms, but not life satisfaction. These associations were present when the effects of age, sex, education and all other disorders were controlled in multiple regression analyses. However, when disability was also controlled, none of the physical disorders predicted life satisfaction and only heart disease continued to predict depressive symptoms.

CONCLUSION

Of the physical disorders considered in the study, gait slowing, heart disease and chronic lung disease had the greatest impact on life quality. These disorders affect depressive symptoms and life satisfaction largely because they increase disability.

Current combat-related disorders in the absence of PTSD among Australian Vietnam veterans

The research literature on the psychiatric consequences of the Vietnam War focuses primarily on the construct of Posttraumatic Stress Disorder (PTSD), after an initial focus in the 1970s on depression and alcohol and substance abuse. The present paper examines the hypothesis that among men without current PTSD, those with higher combat in Vietnam will be more likely to have current DSM-III-R illnesses. The Australian Vietnam Veterans' Health Study (AVVHS) collected a broad range of interview data on 641 Vietnam veterans throughout 1990-1993. Measures of combat exposure, age at embarkation to Vietnam, enlistment IQ and pre-Army personality problems were drawn from Army records of the era. Retrospective measures of combat were obtained at interview. The interview also involved the administration by trained lay interviewers of the DSM-III-R based Diagnostic Interview Schedule (DIS). This epidemiological instrument provides current psychiatric diagnoses as well as temporal (retrospective) symptom and diagnosis onset data. The results of this study show that current disorders (without PTSD comorbidity) with onsets within 5 years of embarkation to Vietnam are more likely among men who saw higher combat, as indexed by combat-exposure measures drawn from Army records of the era as well as retrospective self-report. This combat relatedness remains when age at embarkation. IQ at enlistment and pre-Army personality measures are used as covariates. No more than 11.4% of sampled Vietnam veterans currently meet DSM-III-R diagnostic criteria for PTSD, while a further 7.8% do not have current PTSD but do have some other current DIS diagnosis with onset in the 5-year period following (first) emabarkation to Vietnam. Our data support the hypothesis that the current illnesses of many of these men without PTSD are combat-related DSM-III-R illnesses.

Is More Ever Too Much? The Number of Indicators per Factor in Confirmatory Factor Analysis

We evaluated whether "more is ever too much" for the number of indicators (p) per factor (p/f) in confirmatory factor analysis by varying sample size (N = 50-1000) and p/f (2-12 items per factor) in 35,000 Monte Carlo solutions. For all N's, solution behavior steadily improved (more proper solutions, more accurate parameter estimates, greater reliability) with increasing p/f. There was a compensatory relation between N and p/f: large p/f compensated for small N and large N compensated for small p/f, but large-N and large-p/f was best. A bias in the behavior of the χ(2) was also demonstrated where apparent goodness of fit declined with increasing p/f ratios even though approximating models were "true". Fit was similar for proper and improper solutions, as were parameter estimates form improper solutions not involving offending estimates. We also used the 12-p/f data to construct 2, 3, 4, or 6 parcels of items (e.g., two parcels of 6 items per factor, three parcels of 4 items per factor, etc.), but the 12-indicator (nonparceled) solutions were somewhat better behaved. At least for conditions in our simulation study, traditional "rules" implying fewer indicators should be used for smaller N may be inappropriate and researchers should consider using more indicators per factor that is evident in current practice.

Cocaine administration in pregnant rabbits alters cortical structure and function in their progeny in the absence of maternal seizures

Previous studies have reported that cocaine exposure in utero results in structural and functional alterations in the development of the anterior cingulate cortex (ACC). In the present study, the effects of maternal cocaine dosage and of cocaine-elicited maternal seizures on the progeny were studied. The incidence of maternal generalized tonic clonic seizures (GTCSs) elicited by cocaine was recorded. No GTCSs were elicited in pregnant rabbits by doses of 2 or 3 mg/kg of cocaine, but GTCSs were sometimes elicited by the highest dose (4 mg/kg per injection). We analyzed the offspring of cocaine-exposed and control animals using three assays of ACC development: (i) the structure of apical dendrites of pyramidal neurons, (ii) the distribution of a calcium binding protein (parvalbumin) in the dendrites of GABAergic neurons, and (iii) coupling of D1-like receptors and their G proteins. In all progeny of rabbits exposed to 3 or 4 mg/kg of cocaine during pregnancy, there was a significant change in the structure of apical dendrites, a significant increase in the number of dendrites of GABAergic neurons which were parvalbumin immunoreactive, and a significant reduction in D1/G protein coupling. In assays of apical dendrites, the effects on offspring of rabbits given 2 mg/kg cocaine were as pronounced as in offspring of rabbits given 3 or 4 mg/kg, but the effects on parvalbumin immunoreactivity and D1/G protein coupling were reduced at this low dose. Thus, previous findings of ACC developmental abnormalities in offspring of rabbits given a dose of 4 mg/kg were replicated, the effects were shown to be dose-related and to be independent of maternal seizures. A mechanism by which dysfunction of the D1 receptor system could mediate cocaine-associated changes in all three parameters of ACC structure and function is discussed.

Age at onset and pattern of neuropsychological impairment in mild early-stage Alzheimer disease. A study of a community-based population

OBJECTIVES

To examine the effects of age at onset on neuropsychological functioning in a group of patients with probable Alzheimer disease (AD) and, within this group, to scrutinize further those patients with mild early-onset disease as it was hypothesized that within this group specific patterns of cognitive impairment could be identified that correlated with neuropathological staging of the disease.

DESIGN

Each patient underwent an extensive neuropsychological test battery to examine a wide range of cognitive processes to provide information to identify subtypes of dementia.

SETTING

The Memory Clinic in the Department of Geriatric Medicine, Concord Hospital, Concord, New South Wales, Australia.

PATIENTS

One hundred forty-five community-residing case patients with probable AD were studied; within this group, 51 case patients with mild AD and a Mini-Mental State Examination score greater than 19 were further examined; 36 similarly aged control patients who were part of a larger case-control study of AD in an urban population were also examined. A diagnosis of probable and possible AD was made if the case patient had evidence of memory impairment and met criteria according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association.

OUTCOME MEASURES

Individual neuropsychological test scores were compared. The tests were then grouped into 7 cognitive domains. Patterns of early cognitive impairment were derived from these comparisons.

RESULTS

With an earlier age at onset, significantly more impairment on tests of digit span and praxis was seen, while the duration of disease had no independent effect once the age at onset was fixed. Patients with mild early-onset dementia and a Mini-Mental State Examination score greater than 19 showed significant impairment in tests of attention, memory, frontal/executive functions, visuospatial ability, praxis, and visual agnosia compared with that shown by control patients. In this group, further analyses revealed that impairment in memory and frontal/ executive functions were the earliest signs of cognitive impairment.

CONCLUSIONS

These data showed that when the duration of disease was adjusted for, case patients with an earlier age at onset of AD demonstrated significantly more impairment on tests of attention span and working memory (digit span), graphomotor function (copy loops), and apraxia than those with an older age at onset. Our findings support the view that the hippocampus and its connections are affected in the early stages of AD. The deficits in the frontal/executive functions also suggest that a disruption of cortical pathways to the frontal lobes and the pathological changes in this region occur early in the disease.

Neurological signs, aging, and the neurodegenerative syndromes

OBJECTIVES

To identify the prevalence of neurological signs said to be associated with "normal" aging in subjects 75 years and older. To examine the association of these signs with age, stroke, the neurodegenerative diagnoses (dementia, cognitive impairment, gait ataxia, gait slowing, and parkinsonism), and systemic diseases.

DESIGN

Subjects participated in a standardized clinical history, examination, neurological evaluation, and neuropsychological assessment battery. A linear regression model that allowed the simultaneous consideration of multiple parameters was used to assess the independent contribution of age and disease to the presence of the signs. Correlations between the signs and age in the subgroup free of neurological diagnoses were performed.

SETTING

Community-based study in Sydney, Australia.

PARTICIPANTS

A random sample of 647 community-dwelling subjects older than 75 years.

MAIN OUTCOME MEASURES

Standardized neurological examination in 537 subjects.

RESULTS

With the exception of impaired vibration sense (beta = .009, P < .01), loss of upward gaze (beta = .005, P < .01), and bradykinesia (beta = .005, P < .01), all signs were associated with the neurodegenerative syndromes and stroke. Analysis of the subgroup free of neurological diagnoses confirmed these findings. Apart from impaired vibration sense of the thumbs (r = 0.22, P < .01) and gait instability (r = 0.20, P < .05), no significant associations with age were identified.

CONCLUSION

It is not aging to which many neurological signs should be attributed, but rather to the neurodegenerative syndromes that accompany aging.

Expression patterns of gamma-aminobutyric acid type A receptor subunit mRNAs in primary cultures of granule neurons and astrocytes from neonatal rat cerebella

Using a competitive polymerase chain reaction assay, we have quantitated the absolute amounts of mRNA encoding 14 distinct subunits of the gamma-aminobutyric acid type A (GABAA) receptor in primary cultures of rat cerebellar granule neurons and cerebellar astrocytes. We found that the total amount of GABAA receptor subunit mRNA in astrocytes was 2 orders of magnitude lower than in neuronal cells. Furthermore, granule cell cultures expressed all 14 different GABAA subunit mRNAs, while the astroglial cultures contained detectable amounts of all the subunits expressed by granule cells except the alpha 6 and the gamma 2L subunits. Of the alpha subunit family members, the alpha 1, alpha 5, and alpha 6 mRNAs were prominent in granule cells, while the alpha 1 and alpha 2 mRNAs were abundant in astrocytes. Of the beta receptor subunit mRNAs, the beta 1 and beta 3 mRNAs were abundantly expressed in both cultures. The gamma 2S and gamma 2L mRNAs constituted the great majority of gamma subunit mRNAs in neurons, while the gamma 1 subunit mRNA was the most abundant gamma subunit mRNA in astrocytes. When various allosteric modulators of GABAA receptors were tested electrophysiologically, methyl 6,7-dimethoxy-4-ethyl-beta-carboline- 3-carboxylate (DMCM) was the only one to modulate chloride currents elicited by GABA in a significantly different manner in granule cells (negative modulation) compared with astrocytes (positive modulation). The latter effect was previously observed in transiently expressed recombinant GABAA receptors containing a gamma 1 instead of a gamma 2 subunit. Our quantitative mRNA results suggest that an important molecular determinant responsible for the DMCM-positive modulatory effect on astroglial native GABAA receptors is the presence of the gamma 1 subunit in the receptor assembly.

The influence of social factors on common mental disorders. Destabilisation and restitution

This study distinguishes between processes that cause individuals to experience symptoms--destabilisation--and those that are associated with loss of symptoms over time--restitution. It is shown that different clinical, social, and personality variables are associated with each of these processes. Where destabilisation is concerned, it is shown that different variables were associated with the development of symptoms of anxiety and those of depression. Different variables were associated with restitution, and they did not show the same relationship with the symptom dimensions of anxiety and depression as those which were associated with destabilisation.

Physicians' attitudes toward generic drug substitution by pharmacists

Physicians in Southeast Texas were surveyed to obtain information on attitudes and practices concerning generic drug substitution. Questionnaires were sent to all practicing primary care physicians in the area, and responses were received from about 36% of them. The investigation revealed that a large percentage of physicians did not readily permit substitution. Two major reasons given for not permitting substitution were concerns about therapeutic inequivalency and doubts about pharmacists' ability to substitute safely.

The validity of diagnostic systems for common mental disorders: a comparison between the ID-CATEGO and the DSM-III systems

It is argued that latent trait analysis provides a way of examining the construct validity of diagnostic concepts which are used to categorize common mental illnesses. The present study adds two additional aspects of validity using multiple discriminant analysis applied to two widely used taxonomic systems. Scales of anxiety and depression derived from previous latent trait analyses are applied to individuals reaching criteria for 'caseness' on the ID-CATEGO system and the DSM-III system, both at initial diagnosis and six months later. The first multiple discriminant analysis is carried out on the initial scale scores, and the results are interpreted in terms of concurrent validity. The second analysis uses improvement scores on the two scales and relates to predictive validity. It is argued that the ID-CATEGO system provides a better classification for common mental illnesses than the DSM-III system, since it allows a better discrimination to be made between anxiety and depressive disorders.

Problems and competencies reported by parents of Australian and American children

We compared problems and competencies reported for 2600 randomly selected nonreferred children in Sydney and the U.S.A. Sydney children scored significantly higher on 82 problem items, with a mean total problem score of 31.6 versus 20.1 for the U.S.A. Nevertheless, item scores correlated 0.92 between countries, most differences between competence scores were small, and patterns were similar for sex, age, socioeconomic status, and internalizing versus externalizing problems. Although higher clinical cutoffs may be needed in Sydney, the similarity of patterns in scores permits calibration of the Child Behavior Checklist between Sydney and the U.S.A. Sex differences found in seven cultures were summarized.

Detecting anxiety and depression in general medical settings

To aid general practitioners and other non-psychiatrists in the better recognition of mental illness short scales measuring anxiety and depression were derived by latent trait analysis from a standardised psychiatric research interview. Designed to be used by non-psychiatrists, they provide dimensional measures of the severity of each disorder. The full set of nine questions need to be administered only if there are positive answers to the first four. When assessed against the full set of 60 questions contained in the psychiatric assessment schedule they had a specificity of 91% and a sensitivity of 86%. The scales would be used by non-psychiatrists in clinical investigations and possibly also by medical students to familiarise them with the common forms of psychiatric illness, which are often unrecognised in general medical settings.

Dimensions of neuroses seen in primary-care settings

This study uses methods of latent trait analysis to examine the relationship between psychiatric symptoms that constitute the common psychiatric disorders encountered in primary-care setting. Two highly correlated symptom dimensions of anxiety and depression are shown to underlie these disorders. Neurovegetative symptoms of depression are shown to be on the same dimension as psychic symptoms of depression, but to represent a more severe manifestation of depression.