Diagnosing Anxiety and Depression Among Patients in Referral GI Practices: Help or Hindrance?

Abstract

It is commonly reported that symptoms of anxiety and depression are underrecognized and poorly addressed in primary care.1 Several studies have found that psychologic diagnoses frequently coexist with and may exacerbate physical symptom presentation,2 yet physicians continue to have difficulty in addressing their association and influence on the clinical presentation.3 Furthermore, as demonstrated within gastroenterology, merely making a diagnosis of a functional gastrointestinal (GI) disorder compared with an organic GI disorder can influence physician attitudes, behaviors, and clinical judgment. In this study, Keefer et al4 are to be commended for bringing these important clinical issues to light and to encourage psychosocial assessments to improve patient care. Using the Hospital Anxiety and Depression Scale (HADS) among patients seen in 2 gastroenterology referral clinics, the authors found that anxiety, more than depression, were common, though were not different between the functional and organic disorders. However, the treating gastroenterologists often missed these diagnoses, and when they did diagnose anxiety or depression, the results correlated poorly with, and had a low-positive predictive value to the standardized psychologic test. Furthermore, it seems that physicians were more likely to diagnose a functional GI disorder (FGID) when anxiety is perceived or vice versa. In effect, the authors found that the physician's ability to diagnosis anxiety and depression is poor when compared with standard measures and that their diagnostic accuracy may be biased by the perceived association of anxiety with a FGID. So, is the recommendation for medical physicians to use psychologic tests to make psychologic diagnoses going to be helpful? To fully understand and apply the recommendations into clinical practice, it is important to know (a) whether physicians are able to identify psychologic comorbidities, or whether they interpret and respond to them differently, (b) whether psychosocial screening instruments are clinically relevant and appropriate to use in medical settings, and finally (c) whether gastroenterologists need to provide a different type of care for their patients with psychosocial comorbidities. Are Physicians able to identify psychologic comorbidities or do they see them differently? The identification of psychologic diagnoses and distress can be difficult even for psychiatrists and psychologists. The risk of missing important factors in patient presentation, whether medical or psychologic, likely represents a larger trend within medical practice; the pressure to reduce the time spent with the patient because of increased financial pressures—to “increase throughput” to counter decreasing revenues.5 Thus, medical physicians may not believe it to be valuable to put in additional time to assess psychologic diagnoses. To complicate this further, patients referred to gastroenterologists maybe reluctant to acknowledge symptoms of anxiety or depression because of the risk of social stigma6 or the belief that they do not have a bona fide disorder unless it is organic.7 So rather than further address the patient's beliefs, or their own biases, the physician and patient may save time by not further engaging in a psychologic assessment. In addition, symptoms of psychosocial distress (depression or anxiety), may influence the manifestations of a structural and/or functional disorder and be interpreted by physicians within the context of that disorder, rather than as a specific psychologic diagnosis. Stress and anxiety lower visceral sensation thresholds, enhance motility,8 and can cause a rapid heart rate, sweating, dizziness, nausea, and vomiting all of which may be interpreted by clinicians as the autonomic dysfunction, commonly associated with an FGID.7 In addition, depression maybe associated with constipation, and phobic symptoms, such as agoraphobia, are easily interpreted as the patient's stated fear of leaving home without being near a bathroom. Clinicians may prescribe antianxiety and antidepressant agents specifically to treat the functional disorders and the above noted psychosocial and psychophysiologic effects. Thus, clinicians maybe “seeing” and “treating” the clinical manifestations of anxiety or depression, as part of the GI disorder, but not from data obtained by standard psychologic tests, the “gold standard” used in this study. Admittedly, and as implied by the authors, a diagnosis of an FGID may influence the physician to assume that a psychiatric disorder exists but without using proper diagnostic methods. This is an important concern. In this study, the physicians' reports of high rates of anxiety with the FGIDs compared with organic diagnosis coupled with the observed poor correlation between physician based diagnosis and the psychologic tests, supports the notion that when a diagnosis of anxiety is made, it is not performed via standard psychologic criteria and may relate to physician bias. Are psychosocial screening instruments clinically relevant and appropriate in medical settings? Keefer et al4 used the HADS9 to assess patient levels of anxiety and depression before the participants meeting with a clinician. Although the HADS has been shown to have adequate sensitivity and specificity within a predominantly medical patient population, the administration of this instrument immediately before their physician office visit may have confounded patient ratings of state anxiety. Additionally, the level of anxiety used as an indicator is a score equal to or greater than 8 in this study. In the original HADS publication, this level was indicated as representing “Low Level” of clinically significant anxiety. Others have indicated that scores at this level represent “Doubtful” cases.10 That clinicians fail to diagnose or pick up doubtful or low level cases is hardly a surprising finding and the authors may have been better served by valuing measure specificity over sensitivity in this aspect of their study. Indeed it is possible that merely having a medical diagnosis and the impairments that result may put most individuals into a low level of caseness where psychologic intervention is unwarranted. Psychologic instruments that are used with medical patients may contain items that inflate scores when administered to patients with GI symptoms. The Patient Health Questionnaire-15 (PHQ-15), for example, contains 3 GI-focused items used to diagnose somatization (“Stomach pain,” “Constipation, loose bowels, or diarrhea,” “Nausea, gas, or indigestion”) Relevant to this study, the HADS was a reasonable instrument to use, as it has been appropriately developed, normed, and standardized to a predominantly medical patient population. Clinicians involved in administering psychologic assessments are advised to choose questionnaires that have norms developed using a medical or GI population. A critical question, however, is whether the use of psychologic questionnaires within medical populations provides useful information that improves the care of the patient and the clinical outcome. Would identifying a comorbid psychologic diagnosis of anxiety disorder or depression improve the patient's understanding of their condition or enhance their sense of stigma? Would a psychologic diagnosis positively affect the physician's attitudes and treating behaviors, or be perceived as an added burden to the intended treatment plan? Would the diagnosis of a psychologic disorder lead to the referral to the psychologist or to the prescribing of a psychotropic agent? And would this increase the patient's motivation or adherence to these treatments? Indeed, would the patient's and physician's new understanding have a positive or negative affect on the physician-patient relationship and the development of common treatment goals and outcomes? It all depends on the way in which this information is understood, communicated, and used in the plan of care. Do gastroenterologists need to provide a different type of care for their patients with regard to theintegration of GI and psychosocial data? We do not intend to dismiss the importance of addressing psychologic factors in medical illness as much as to challenge the context within which factors are conceptualized. The strong impact of biomedical reductionism and dualism on medical disorders including the FGIDs may adversely affect how we understand and treat these disorders.11 The predominant dogma is that psychologic diagnoses are considered to be additional or alternative causes of the physical disorder (ie, “comorbidities”) rather than as being intrinsically associated. Much like the story of the wise blind men and the elephant, the psychologist or psychiatrist may see the psychologic symptoms in a patient with a FGID as being primary, and even part of a commonality among other medical diagnoses like fibromyalgia, chronic fatigue syndrome, or posttraumatic stress disorder. This has been considered a manifestation of an affective spectrum disorder, or a “functional somatic syndrome” where the psychologic symptoms preempt the physical manifestations. But we know that most patients as seen in primary care or in the community do not manifest these disorders12,13 Conversely, the medical physician may see the FGID either as not “real,” that is, a psychiatric condition made by inference rather than in a systematic fashion and may often be wrong, or as a GI disorder with “psychologic overlay” in which the relevancy of addressing the psychologic symptoms is unimportant. Perhaps what is important is to understand the role of psychologic factors on these disorders within a biopsychosocial construct.11 Instead of identifying cutoff points for pathologic anxiety, and treating if the cutoff is exceeded, the physician must look at these factors in an integrated fashion that incorporates the effects of psychologic factors on symptoms severity and coping in a way that is specific to the individual. Furthermore, the patient needs to understand this information within the context of the illness and personal illness schema. And all of this needs to be carried out in a fashion that is satisfying to the patient and physician to preserve the physician-patient relationship. The ability to see the whole picture requires the application of skills that establish a positive working relationship with the patient. When this occurs, the patient can more easily report and understand how the relevant psychosocial factors are associated with their medical condition. Furthermore, their roles are more easily recognized by the physician, assuming he or she is open to this association. A positive working relationship not only improves communication and diagnostic ability, but it leads to greater satisfaction in the process of care by patient and physician alike. Within this context, a discussion of the role of psychologic factors on the illness is well accepted and properly applied in their care. Other implications raised by this study include the need to make a confident diagnosis of a FGID. By using established Rome criteria, the disorder is “legitimized” for patient and physician, and treatment of the disorder follows accordingly based on the predominant symptoms. Once this is established, the role of psychosocial factors in influencing symptom presentation can be understood on a continuum. Thus 1 patient may have manifest anxiety and depression that needs to be treated or another patient may have psychologic symptoms at one point in time and not another. Additionally, the degree to which the psychologic factors are present and affecting the severity of the condition14 may then lead to effective psychologic treatments or prescribing psychotropic agents to treat the pain, bowel symptoms, and associated psychologic symptoms. Thus, a multidisciplinary treatment approach within a biopsychosocial construct can involve mental health professionals along with the medical physician in a way that integrates mind and body so it is understood, accepted, and applied by patient and physicians alike. Unfortunately, training clinicians on how to work with patients having FGIDs is inadequately addressed in most medical school curricula and postgraduate training programs. We agree that greater attention toward understanding the psychosocial manifestations of GI illness is undervalued, misunderstood, and critical to patient care. Whether the clinical assessment of patient anxiety and depression should be carried out by paper and pencil measure or within the context of the interview is perhaps less important than the context within which it is understood and communicated.