Primary Care Evaluation Of Mental Disorders Research Articles

Prevalence and comorbidity of common mental disorders in primary care

ObjectiveTo estimate the prevalence and comorbidity of the most common mental disorders in primary care practice in Spain, using the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. DesignA systematic sample of 7936 adult primary care patients was recruited by 1925 general practitioners in a large cross-sectional national epidemiological study. The PRIME-MD was used to diagnose psychiatric disorders. Setting1356 primary care units proportionally distributed throughout the country. Results53.6% of the sample presented one or more psychiatric disorder. The most prevalent were affective (35.8%), anxiety (25.6%), and somatoform (28.8%) disorders. 30.3% of the patients had more than one current mental disorder. 11.5% presented comorbidity between affective, anxiety, and somatoform disorders. ConclusionsThe study provides further evidence of the high prevalence and high comorbidity of mental disorders in primary care. Given the large overlap between affective, anxiety and somatoform disorders, future diagnostic classifications should reconsider the current separation between these entities.

Assessment of Anxiety in Older Home Care Recipients

This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services. Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD). Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified). These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.

Depression Screening of Perinatal Women: An Evaluation of the Healthy Start Depression Initiative

Depression Screening of Perinatal Women: An Evaluation of the Healthy Start Depression Initiative

Relationships Among Depression, Chronic Pain, Chronic Disabling Pain, and Medical Costs

Although evidence suggests that patients with depression use more medical services than those without depression, few studies have examined whether specific subgroups of patients with depression have higher utilization than others. The study compared costs for general medical care with and without psychiatric care for patients with major depression and disabling chronic pain (reference group) with costs for five other groups: those with depression and nondisabling chronic pain, those with major depressive disorder alone, those with no depression who had disabling chronic pain, those with depression who had chronic pain that was not disabling, and those who had neither pain nor depression. Costs for the group with major depressive disorder alone were compared to costs for the three groups without depression. A questionnaire assessing major depressive disorder, chronic pain, and pain-related disability was mailed to a random sample of Kaiser Permanente patients who visited a primary care clinic. A total of 5,808 patients responded (54% participation rate). Costs for a two-year period were obtained from Kaiser Permanente's Cost Management Information System. Analyses were adjusted for presence of any of four major chronic medical illnesses. Total costs for patients in the reference group were significantly higher than costs for the other five subgroups. Regression analyses indicated that continuous measures of severity of pain and severity of depression were associated with increased costs, but no statistically significant interaction of depression and pain on total cost was observed. Patients with major depressive disorder and comorbid disabling chronic pain had higher medical service costs than other groups of patients with and without depression. However, findings suggest that the increases in cost from having both pain and depression are additive and not multiplicative.

Relationships Among Depression, Chronic Pain, Chronic Disabling Pain, and Medical Costs

Relationships Among Depression, Chronic Pain, Chronic Disabling Pain, and Medical Costs

A Rural Perspective on Perinatal Depression: Prevalence, Correlates, and Implications for Help‐Seeking Among Low‐Income Women

CONTEXT/PURPOSE: To examine a low-income sample of women in the rural Midwest (N = 1,086) who were screened for perinatal depression through the outreach and education activities within a Healthy Start Initiative project. Specifically, we describe the frequency and severity of depressive symptoms, explore social and demographic correlates of depression, and examine help-seeking through patterns of self-referral to a Healthy Start perinatal depression project in a rural, medically underserved community. Depression screening data using the Primary Care Evaluation of Mental Disorders (PRIME-MD) as well as intake records from the project were analyzed in a retrospective analysis to identify important demographic and psychosocial characteristics associated with elevated levels of depressive symptoms and help-seeking patterns. Thirty-six percent of screened women met criteria for major, minor, or subthreshold depression, with 13% meeting diagnostic criteria for major depression alone. Less than 8% were currently receiving any type of mental health services or treatment at screening. The most significant correlate of self-referral to the Healthy Start project was meeting symptom criteria for major depression, although minor depression, subthreshold depression, and status as low-income/Temporary Aid to Needy Families (TANF)-eligible were all significantly associated with self-referral. The findings from this study highlight the potential significance of identifying and addressing the unmet mental health needs of low-income rural women during and around pregnancy. In addition, the study illustrates that low income, in addition to depressive symptoms, impacts mental health service delivery in this rural community with a fragmented mental health service infrastructure.

Family history of suicide: A clinical marker for major depression in primary care practice?

Background The aim of this study was to investigate the family history of suicide among primary care patients with or without current major depressive episode (MDE). Methods This study was performed in 2 GP practices in Budapest on 255 consecutively investigated primary care attendees. The diagnosis of current MDE (symptomatic MDE or MDE in partial remission) was made by the Hungarian version of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Family history of suicide was rated as positive where the patients reported at least one first or second degree relative with completed suicide. Results Out of the 255 consecutively investigated patients 45 (17.6%) have had current MDE and 24 (9.4%) have had positive family history of suicide. The family history of suicide was significantly more common among patients with current MDE than among those without it (26.6% vs 5.7%, p = 0.0001). Fifty percent of patients with, and 14.3% of patients without family history of suicide have had current MDE ( p = 0.0001). Limitation Small sample size, and lacking data on fully remitted major depressives as well as on comorbid psychiatric and medical disorders. Conclusion History of completed suicide among first or second degree relatives could be a good and simple clinical marker for current and lifetime MDE in primary care patients.

Depressive Symptoms in Medical Students and Residents: A Multischool Study

This multisite, anonymous study assessed depressive symptoms and suicidal ideation in medical trainees (medical students and residents). In 2003-2004, the authors surveyed medical trainees at six sites. Surveys included content from the Center for Epidemiologic Studies-Depression scale (CES-D) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) (measures for depression), as well as demographic content. Rates of reported major and minor depression and of suicidal ideation were calculated. Responses were compared by level of training, gender, and ethnicity. More than 2,000 medical students and residents responded, for an overall response rate of 89%. Based on categorical levels from the CES-D, 12% had probable major depression and 9.2% had probable mild/moderate depression. There were significant differences in depression by trainee level, with a higher rate among medical students; and gender, with higher rates among women (chi2 = 10.42, df = 2, and P = .005 and chi2 = 22.1, df = 2, and P < .001, respectively). Nearly 6% reported suicidal ideation, with differences by trainee level, with a higher rate among medical students; and ethnicity, with the highest rate among black/African American respondents and the lowest among Caucasian respondents (chi2 = 5.19, df = 1, and P = .023 and chi2 = 10.42, df = 3, and P = .015, respectively). Depression remains a significant issue for medical trainees. This study highlights the importance of ongoing mental health assessment, treatment, and education for medical trainees.

Test-retest reliability of the PRIME-MD: limitations in diagnosing mental disorders in primary care

The primary care evaluation of mental disorders (PRIME-MD) can be seen as characteristic for successive refinements of criteria and structured interview techniques for diagnosing psychiatric disorders in primary care. It is one of the most widely used instruments, but there is no evidence to support its test-retest reliability. With 1-week intervals between interviews, a test-retest study of the PRIME-MD was conducted in a general practice population of 100 distressed patients (20- to 60-years old) who were on sick leave. Almost everyone (89%) received one or more diagnoses at both measurements, and there was fair total agreement (kappa = 0.27). The best agreement was found for more severe threshold disorders [major depressive disorder (kappa = 0.58), dysthymia (kappa = 0.57), and generalized anxiety disorder (kappa = 0.59)], while we found indefinite results for the sub-threshold disorders [anxiety disorder not otherwise specified (NOS) (kappa =.30), minor depressive disorder (kappa = -0.03), and somatoform disorder NOS (kappa = 0.11)]. The PRIME-MD is one of the few instruments in primary care that actually diagnoses specific mental disorders according to the DSM criteria. However, there was a failure to adequately classify sub-threshold disorders. Mental disorders, as seen in primary care, encompass important specific symptoms and clinical syndromes that vary in duration and severity over time, but they also encompass an admixture of somatic and psychological symptoms that do not match current diagnostic systems. This most likely resulted in methodological uncertainty about the level of agreement. Diagnostic criteria in psychiatry need to be operationalized for use in primary care and require further evaluation.

Relationships Between Body Mass Index, Mental Health, and Suicidal Ideation: Population Perspective Using Two Methods

The aim of the present study was to examine the relationship between body mass index (BMI), mental health, and suicidal ideation in a general population. Two random and representative samples were drawn from the South Australian population. The interview techniques differed, as did the measures of depression and suicidality. One involved 3034 people in face-to-face interviews, and the other involved 30 214 persons providing information via a computer-assisted telephone interviewing (CATI) system. BMI was classified according to World Health Organization criteria. In face-to-face interviews, major depression was defined by the Primary Care Evaluation of Mental Disorders (PRIME-MD) and suicidal ideation by direct enquiry. In the CATI data, psychological distress was assessed on the Kessler 10 instrument and suicidal ideation by four items on the General Health Questionnaire (GHQ). Data analysis controlled for demographic and physical health variables. In the face-to-face interviews, the combined obese and morbidly obese men were significantly less likely to have major depression or suicidal ideation than those of a healthy weight. For the telephone interview-derived data, the only significant finding was for overweight women to report less psychological distress than those of a healthy weight. It is no longer tenable to assume that increased BMI is necessarily associated with major depression, psychological distress, or suicidal ideation. Indeed, it appears protective for some people.

Risk factors for psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment

To identify risk factors associated with depression and anxiety in infertile women and men undergoing in vitro fertilization (IVF). Prospective study. A university hospital in Sweden during a 2-year period. 825 participants (413 women and 412 men). Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), as the diagnostic tool for evaluating mood and anxiety disorders, and fertility history and outcome of IVF treatment collected from the patients' medical records. Risk factors associated with depression and anxiety disorders. A negative pregnancy test and obesity were the independent risk factors for any mood disorders in women. Among men, the only independent risk factor for depression was unexplained infertility. No IVF-related risk factors could be identified for any anxiety disorder. A negative pregnancy test is associated with an increased risk for depression in women undergoing IVF, but no risk of developing anxiety disorders is associated with the pregnancy test result after IVF. Pregnancy test results were not a risk factor for depression or anxiety among men.

Subjective memory impairment in a rural population with low education in the Amazon rainforest: an exploratory study

The high prevalence of subjective memory impairment (SMI) in the elderly living in developed countries may be partly dependent on greater demand placed on them by new technologies. As part of a comprehensive study on cognitive impairment in a population living in the Amazon rainforest, we evaluated the prevalence of SMI and investigated the features associated with it. We evaluated 163 subjects (82 females) with a mean age of 62.3 years (50-94 years), 110 of whom were illiterate, using the answer to a single question "Do you have memory problems?" to classify them into groups with or without SMI. The assessment involved application of the Mini-mental State Examination (MMSE), delayed recall from the Brief Cognitive Battery designed for the evaluation of low educated and illiterate individuals, the Patient Questionnaire (PQ) of the Primary Care Evaluation of Mental Disorders (PRIME-MD), and the Happiness Analogical Scale. A very high prevalence of SMI (70%) was observed, exceeding rates reported by similar studies conducted in developed countries. SMI was more frequent in women, whereas age and education did not impact on prevalence. Subjects with SMI had significantly more somatic and psychiatric symptoms on the PQ, as well as lower means on the MMSE, but not on the delayed recall test. Multiple logistic regressions showed that the most important factor associated with the presence of SMI was a high score on the PQ (OR: 3.84, p = 0.011). Psychological and somatic symptoms may be the principal cause of SMI in this population.

Primary care management of major depression in patients aged ≥55 years:

Late-life depression is associated with chronic illness, disability, and a poor prognosis. Primary care management may be in need of improvement. To compare the effects of an intervention programme that aims to improve the identification, diagnosis, and treatment of depression in patients aged > or =55 years with the effects of usual care. Cluster randomised controlled trial. General practices in the Netherlands. Trained GPs performed the intervention and their practice assistants conducted the screenings. Patients were screened with the 15-item Geriatric Depression Scale (GDS-15) and given a consultation with the GP who diagnosed depression with the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Antidepressant treatment was proposed. Primary outcomes were measured with the Montgomery Asberg Depression Rating Scale (MADRS). Trained independent research assistants performed independent evaluations in both arms. Eighteen practices (23 GPs) were allocated to the intervention and 16 practices (20 GPs) to usual care. From June 2000 to September 2002, 3937 patients were screened; 579 patients had a positive score on the GDS-15, 178 had major depression, of whom 145 participated in the trial. MADRS scores for the intervention group dropped from 21.66 at baseline to 9.23 at 6 months, and the usual care group from 20.94 at baseline to 11.45 at 6 months. MADRS scores decreased during the year in both arms. For the intervention group, these scores increased between 6 and 12 months. The programme resulted in lower MADRS scores in the intervention group than in the usual care group, but only at the end of the intervention, at 6 months after baseline.

Telephone-Delivered, Interpersonal Psychotherapy for HIV-Infected Rural Persons With Depression: A Pilot Trial

Telephone-Delivered, Interpersonal Psychotherapy for HIV-Infected Rural Persons With Depression: A Pilot Trial

Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment

BACKGROUNDThis study was undertaken to determine the prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization (IVF) treatment.METHODSParticipants were 1090 consecutive women and men, 545 couples, attending a fertility clinic in Sweden during a two-year period. The Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV), was used as the diagnostic tool for evaluating mood and anxiety disorders.RESULTSOverall, 862 (79.1%) subjects filled in the PRIME-MD patient questionnaire. Any psychiatric diagnosis was present in 30.8% of females and in 10.2% of males in the study sample. Any mood disorder was present in 26.2% of females and 9.2% of males. Major depression was the most common mood disorder, prevalent in 10.9% of females and 5.1% of males. Any anxiety disorder was encountered in 14.8% of females and 4.9% males. Only 21% of the subjects with a psychiatric disorder according to DSM-IV received some form of treatment.CONCLUSIONSMood disorders are common in both women and men undergoing IVF treatment. The majority of subjects with a psychiatric disorder were undiagnosed and untreated.

Is alexithymia a personality trait increasing the risk of depression? A prospective study evaluating alexithymia before, during and after a depressive episode

Whether alexithymia is a personality trait that increases the risk of major depression (MD) is still debated. In this prospective study, alexithymic levels were evaluated before, during and after a depressive episode. The alexithymic levels, the presence of MD and the severity of anxious-depressive symptoms were evaluated at intervals of about 1 month in pregnant women attending the Centers for Prenatal Care, using the Toronto Alexithymia Scale (TAS), the Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Hospital Anxiety and Depression Scale (HADS). Sixteen women affected by MD, 21 affected by subthreshold depression and 112 non-depressed women were included in the study. Women who developed depression, compared to non-depressed women, showed similar TAS and HADS scores during the pre-morbid phase, a significant increase in the scores during depression and a significant decrease after remission, whereas no change was observed in non-depressed women. Our data suggest that in pregnant women alexithymia does not represent a personality trait that increases the risk of developing a depressive episode, and they support the hypothesis that alexithymia is a state-dependent phenomenon in depressed pregnant women.

The diagnostic challenges presented by patients with medically unexplained symptoms in general practice

Objective. To describe the complexity of somatizing patients’ symptomatology and the difficulties involved in the diagnostic process. Design. Cross-sectional study of patients with medically unexplained symptoms. Setting. Basque Health Service primary care centres in Bizkaia, Spain. Subjects. The study comprised 156 patients selected at random from a list of 468 patients who had presented, over the course of their lives, six or more medically unexplained somatic symptoms for females and four or more for males, identified retrospectively by their practitioners. Main outcome measures. Physicians interviewed these patients using the somatoform symptoms section of the Composite International Diagnostic Interview (CIDI), and the Primary Care Evaluation of Mental Disorders (PRIME-MD). The Medical Outcomes Survey Short Form 36 (SF-36) was filled in at home. Organic diseases whose diagnosis was established during the previous year were included in the study by consulting patients’ medical records. Results. Patients were found to have a median of three medically explained and 12 medically unexplained symptoms. Mental disorders were found in 83% of cases, associated with other morbidity categories in 78%. The predictive value of symptoms was lower than 26% for diagnosing broad disease categories. Conclusions. These results depict an extremely difficult scenario for dichotomous diagnostic strategies aimed at classifying patients’ symptoms as either organic or functional. Rather than struggling to choose one of these hypotheses, it is suggested that both of them should always be addressed concurrently.

Screening for mental disorders in cardiology outpatients

The objective of the study was to compare the frequency of mental disorders in cardiology outpatients to the number of patients with psychological problems identified by cardiologists. In a cardiology outpatient service, 103 consecutive patients were asked to participate in the study. Of these 86 were included and screened for mental disorder with the Primary Care Evaluation of Mental Disorders (PRIME-MD), Structured Clinical Interview for DSM-IV (SCID) psychosis screening, the Clock Drawing Test, and the WHO-5 Well-being Index. The cardiologists were asked to rate the severity of somatic and mental problems in each patient on visual analogue scales (VAS-som and VAS-men). The current treatments, including psychiatric and psychological treatments, were noted, and the survival was followed for 3 years. Of the 86 patients included, 34 (40%) had a diagnosis of mental disorder. Eleven (12.8%) had major depression, six (7.0%) minor depression, six (7.0%) anxiety disorder, two unspecified somatoform disorder, seven (8.1%) dementia, one alcohol abuse and one psychosis. Three of the patients were in long-term psychopharmacological treatment. Although the cardiologists predicted mental disorder significantly better than chance, none of the patients was in relevant treatment for their mental disorder. At 3-year follow-up, 20 (24%) of the patients had died. Age and severity of heart disease predicted mortality, while the presence of a mental disorder did not. Mental disorders, especially depression, were frequent in cardiology outpatients. Even in cases where the cardiologists identified psychological problems, the diagnosis had no consequence, as none of the patients was offered relevant treatment.

Results of Screening With the Brief Headache Screen Compared With a Modified IDMigraineTM

Patients with chronic migraine and chronic daily headache syndromes have greater morbidity than patients with episodic migraine, and are less frequently diagnosed. A screening tool which identifies daily headache syndromes as well as migraine would promote more patients receiving appropriate treatment, including prophylaxis. A post-hoc analysis of data obtained to evaluate the prevalence of somatic symptoms in primary care patients was conducted on a convenience sample of primary care patients who completed the Patient Health Questionnaire portion of the PRIME-MD (Primary Care Evaluation of Mental Disorders). Patients who endorsed the symptom of headache were asked to complete the Brief Headache Screen (BHS), a 4-item screening tool, supplemented by 3 clinical questions (nausea, light sensitivity, and noise sensitivity). The data obtained allowed a post-hoc comparison of the BHS with a modified version of the screening tool, IDMigraine(TM) (IDM(TM)). Diagnostic interviews were performed on patients whose diagnoses differed by the 2 screening methods, and on patients who screened positive for daily headache on BHS. Of the 1000 patients who completed the PRIME-MD, 302 (30.2%) indicated headache as a concern, and there were sufficient data for both the BHS and IDM(TM) for 259. There was substantial concordance between the 2 instruments with 82.6% agreement in identified migraine (95% confidence interval: 77.8%-87.4%). The BHS screened positive for migraine in an additional 15.1% of patients who were not identified by IDM(TM), whereas the IDM(TM) identified an additional 2.3% of patients. Of the 173 which both tools recognized as migraine, the BHS identified 42.8% as having a daily headache syndrome (chronic migraine: 23.1%; episodic migraine + chronic tension-type headache [CTTH]: 19.7%). BHS also identified 7 non-migraine patients as having CTTH alone. Diagnostic interviews confirmed that 6/18 (33%) of BHS+ but IDM-, and one of 2 (50%) patients BHS-/IDM+ met full criteria for migraine. Additionally, interviews confirmed the diagnoses of 85.4% of those patients who the BHS identified with daily headache and 67% of those who were identified as medication overuse headache. The BHS and a modified IDM(TM) are concordant in screening for migraine in 82.6% of a primary care population who endorsed the symptom of headache. However, the BHS screens effectively not only for migraine but also for chronic daily headache and medication overuse. A screening paradigm based on headache frequency and the frequency of medication use can rapidly and sensitively identify migraine, daily headache syndromes, and medication overuse. This paradigm may improve clinical care by identifying patients who merit preventive as well as acute therapy for migraine.

Does Stigma Keep Poor Young Immigrant and U.S.-Born Black and Latina Women From Seeking Mental Health Care?

Does Stigma Keep Poor Young Immigrant and U.S.-Born Black and Latina Women From Seeking Mental Health Care?