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Published online before print March 30, 2007, 10.1097/PSY.0b013e3180314b59
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Psychosomatic Medicine 69:270-276 (2007)
© 2007 American Psychosomatic Society

ORIGINAL ARTICLES

Outcome and Impact of Mental Disorders in Primary Care at 5 years

Jeffrey L. Jackson, MD, MPH, Mark Passamonti, MD and Kurt Kroenke, MD

From the Department of Medicine (J.L.J.), Uniformed Services University of the Health Sciences, Bethesda, MD; Walter Reed Army Medical Center, Washington DC; Department of Medicine (M.P.), General Medicine Division, Fort Stewart, Georgia; Department of Medicine (K.K.), Regenstrief Institute for Health Care, Indianapolis University School of Medicine, Indianapolis, IN.

Address correspondence and reprint requests to Jeffrey L. Jackson, Department of Medicine (EDP), Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Objective: To assess 5-year mental disorder recognition rates and determine the natural history of mental disorders in primary care.

Methods: A prospective cohort of adults presenting to a primary care walk-in clinic with a physical symptom were evaluated at baseline (n = 500) and at 5 years (n = 387) for mental disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD). Additional measures included functional status (Medical Outcomes Study SF-6; MOS-SF6), Patient Health Questionnaire-15, Satisfaction (Rand-9), unmet expectations, and symptom outcome. Patients self-reported whether their disorder was diagnosed or treated at the 5-year follow-up.

Results: At baseline, 29% of patients had a mental disorder (major depression: 8.4%, minor depression 10.4%, Panic disorder 1.4%, generalized anxiety disorder 2%, anxiety not otherwise specified (NOS) 11.4%); of these patients, 26% had more than one mental disorder. Over 5 years, 33% were recognized. Threshold disorders were more likely to be recognized (major depression 56%, panic 100%, generalized anxiety disorder 88%) than subthreshold disorders (minor depression 20%, anxiety NOS 25%). Correlates of recognition included having a threshold or multiple disorders; recognition was associated with greater likelihood of persistence. Most patients with subthreshold disorders at baseline had no disorder at 5 years and few progressed to threshold disorders (minor to major depression 12%, anxiety NOS to generalized anxiety or panic 8%).

Conclusions: Mental disorders are common and their recognition and treatment remain low. Subthreshold disorders have a better prognosis. Patients with threshold or multiple disorders, worse functioning or persistence of their disorder were more likely to be diagnosed.

Key Words: depression • anxiety • mental disorders • outcomes

Abbreviations: NOS = not otherwise specified.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Mental disorders are prevalent in primary care, present in up to a third of patients (1,2), and are a source of substantial suffering (3–5). Unfortunately, mental disorders are frequently missed (6–16), with one systematic review finding an overall undiagnosed rate of 50% (17). Lack of recognition of mental disorders is a worldwide problem (6,18–22) and it is particularly unfortunate, as effective treatments for depression and anxiety exist. Two clinical practice guidelines support universal screening for mental disorders in primary care, particularly depression, when linked with a systematic method of treatment and follow-up (23,24).

Most previous studies reporting missed diagnoses focus on a single encounter, with only a handful examining how frequently mental disorders are missed over time (10,25–28). All but one of these studies followed patients for ≤1, and all studies followed only patients identified at baseline with mental disorders, comparing outcomes between patients whose mental disorders were or were not recognized. A comparison group of patients without mental disorders has not been included. Our study asks several questions: a) How frequently do mental disorders remain unrecognized over 5 years of follow-up? b) What is the natural history and impact of diagnosed and undiagnosed mental disorders on patient-centered outcomes compared with patients without disorders? c) Are there patient characteristics that increase the likelihood of detection of underlying mental disorders?


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Patients
This cohort was originally assembled to test the effects of providing previsit information on patients' concerns and expectations (29). Adults presenting to the primary care walk-in clinic at Walter Reed Army Medical Center with a chief complaint of a physical symptom were eligible to participate in the study. Exclusion criteria included non-English speaking and the presence of dementia. This clinic provides primary care to a panel of active duty and retired military beneficiaries and their dependents in the Washington, DC metropolitan area. Patient age, gender, and case mix in this clinic are similar to those seen in nonmilitary US internal medicine office practices (30,31). Participants were similar to nonparticipants in terms of age, race, sex, and type of presenting symptom. Our Institutional Review Board approved this study and all patients provided informed consent.

Previsit Assessment
Immediately before their clinic visit, subjects were evaluated for mental disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD), a structured psychiatric interview that makes Diagnostic and Statistical Manual, 4th revision (DSM-IV) diagnoses (2). The subjects also completed a questionnaire that asked about demographics, symptom type, duration, and severity (0 = none to 10 = unbearable), recent stress, symptom-specific expectations, and functional status (Medical Outcomes Study SF-6; MOS-SF6) (32). Other bothersome symptoms were assessed using the Patient Health Questionnaire that assesses for the 15 most common symptoms in primary care (33).

Postvisit Assessment
Immediately after the visit, the patient questionnaire assessed satisfaction (MOS 9 item satisfaction survey) (34), residual serious illness worry, and unmet expectations. Two weeks, 3 months, and 5 years after the visit, patients completed a follow-up questionnaire that assessed symptom outcome (completely resolved, better, same, or worse), symptom severity, recent stress, functional status (MOS SF6), overall satisfaction, and unmet expectations. Two weeks and 3 months after the index visit, patients were also asked two questions about depressive symptoms ("During the past week have you often been bothered by little interest or pleasure in doing things?" "During the past week have you often been bothered by feeling down, depressed or hopeless?") (35) and two questions about anxiety symptoms ("During the past week, have you often been bothered by nerves or feeling anxious or on edge?" "During the past week have you often been bothered by worrying about a lot of different things?"). These two questions on depression have been demonstrated to have diagnostic performance comparable to longer depression scales (36).

Additionally, at 5 years, patients completed a self-report version of the PRIME-MD as well as symptom outcome (frequency, symptom-related disability), and unmet expectations. Patients, who were screened positive for anxiety disorders at 5 years, completed the PRIME-MD anxiety module via a telephone interview. In addition, the 5-year questionnaire included the PHQ-15 and also asked the patients whether they had been diagnosed or treated for depressive or anxiety disorders over the 5 years after their index visit. Patients were sent three mailings, at 2-week intervals, followed by phone interviews to encourage participation. Patient deaths were assessed using the national death index. Three-month postvisit health utilization rates were obtained from the centralized computer registries, counting all visits with any health provider within our system.

Analysis
Functional status scores were created by summing the six questions from the MOS SF-6, giving a range from 6 to 31. All analyses were done using Stata (Version 9.2, College Station, Texas). Independent variables were compared using Students t tests or the Kuskall-Wallis signed rank test or analysis of variance for continuous variables and {chi}2 for categorical ones, using two-tailed tests of significance. The variables were analyzed in their original state, as either continuous or dichotomous; no continuous variables were dichotomized or categorized. Logistic regression was used to determine clinical characteristics associated with clinician recognition of mental disorders. Our goal was to develop the best-fitting, most parsimonious model possible. Variables were selected for inclusion in the model on the basis of a two-step filter. First, all variables that have been shown to have relationship with the dependent variables in the literature were included in the initial model (functional status, stress, gender, age, serious illness worry, symptom severity, and symptom count). The remaining variables were screened for potential inclusion based on a p < .25 on univariate screen (37), although no nonbiologically plausible variables were included in this step. From this full model, we reduced the model by excluding variables that contributed little or nothing to the fit, using the likelihood ratio test of goodness of fit, with a two-tailed test and a p < .10 as the criterion. Finally, we confirmed the final model's goodness of fit using the Hosmer-Lemeshow method (37).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 NOTES
 REFERENCES
 
Patient Characteristics
Among 537 patients approached, 93% agreed to participate in the study. Two patients presenting solely with mental health complaints were excluded. No patients were excluded on the basis of language barriers. The 500 patients enrolled at baseline averaged 55 years in age, half were women, 49% were white, and 45% were African American. A depressive or anxiety disorder was present in 146 (29%) of the patients, with 34% of these having more than one disorder. Major depression was present in 8.4%, dysthymia in 1.4%, minor depression in 13.2%, panic disorder in 1.8%, generalized anxiety disorder in 2%, and anxiety not otherwise specified (NOS) in 11.4% (Table 1).


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  		TABLE 1. Follow-up, Death, and Recognition Rates According to Baseline Mental Disorder Status

 

Over the 5-year course, there were 49 (9%) deaths. Among 451 surviving subjects, we achieved follow-up in 387 (86%). Patients lost to follow-up tended to be younger but otherwise were similar to respondents in other demographic features, symptom characteristics, and baseline prevalence of mental disorders. At 5 years, a depressive or anxiety disorder was present in 55 (14%) patients; 38% had more than one disorder (Table 2).


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  		TABLE 2. Mental Disorders at 5 Years

 

Major depression was present in 8%, minor depression in 9%, generalized anxiety disorder in 0.7%, and anxiety NOS in 6%. Patients with a mental disorder at baseline were significantly more likely to still have a mental disorder 5 years later (Relative risk (RR) 3.5, 95% confidence interval (CI) 2.1–5.8). Patients whose mental disorder was recognized over the 5 years of follow-up were more likely to have persistent mental disorders than those whose mental disorders were not recognized (RR 3.9, 95% CI 2.1–7.0).

Of patients with a mental disorder at the index visit, 33% reported being diagnosed and/or treated for this disorder over the subsequent 5 years of follow-up. However, recognition was not uniform across the cohort. Patients with threshold disorders (major depression, generalized anxiety disorder, panic disorder) were more likely to be diagnosed or treated compared with those with subthreshold (minor depression, anxiety NOS) disorders (67% versus 22%, p < .0001, Table 1). At all four time points (baseline, 2 weeks, 3 months, and 5 years), patients with recognized mental disorders had worse functional status than those with unrecognized or no mental disorder (Figure 1).


Figure 18
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  		Figure 1. Functional status among patients with no mental disorders compared with patients with recognized and unrecognized disorders.

 

Depression
More than half (56%) of patients with major depression at baseline reported being diagnosed or treated at 5-year follow-up, compared with 32% of those with subthreshold depression. Among the patients with major depression alone (no comorbid anxiety) at baseline, only 20% met the study criteria for any disorder at 5 years, all of whom still had major depression (Table 3). Among those with subthreshold depression alone (no comorbid anxiety) at the index visit, 70% had no mental disorder at 5 years, 19% still had subthreshold depression, and 12% had progressed to major depression. No patients with isolated subthreshold depression at the index visit developed an anxiety disorder over the ensuing 5 years.


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  		TABLE 3. Diagnostic Status at 5 Years by Baseline Diagnostic Status

 

Recognition of the presence of major depression was associated with a marked increased risk of still being depressed 5 years later (RR 5.9, 95% CI 3.6–9.8), compared with the reference group of patients with no mental disorders at baseline. In comparison, those with major depression at baseline who remained unrecognized over the 5 years of follow-up had an increased but lower and nonsignificant risk of still suffering from major depression (RR 3.6, 95% CI 0.81–15.9). Among patients with no mental disorder at baseline, 3% developed major depression and 7% developed subthreshold depression over the subsequent 5 years.

Anxiety
All five patients with panic disorder at initial presentation were recognized, and none still met the criteria for panic disorder or generalized anxiety 5 years later, although one patient had subthreshold anxiety (anxiety NOS). Two of the five patients with panic disorder had major depression at baseline and both still met the criteria for major depression 5 years later.

Of the eight patients with generalized anxiety disorder, 88% were recognized. Only 38% still met the criteria for anxiety 5 years later—25% with persistent generalized anxiety disorder and 13% improving to anxiety disorder NOS. None developed panic disorder, although 50% met the criteria for major depression. Among those with subthreshold anxiety (i.e., anxiety NOS) at baseline, 26% were recognized over the 5 years follow-up. At 5 years, 58% had no disorder and none had developed panic disorder, although one patient progressed to generalized anxiety disorder, and 13% still had subthreshold anxiety. Patients with recognized anxiety disorders were more likely to have persistence of their anxiety disorder (RR 4.0, 95% CI 1.8–9.1) than those without a baseline mental disorder, although those with unrecognized anxiety disorders were not at increased risk of an anxiety disorder at 5-year follow-up compared with the group with no disorder.

Comorbid Depression and Anxiety
Patients with comorbid depression and anxiety fared worse than those with isolated disorders, with 44% meeting the criteria for a disorder at 5 years compared with 23% of those with a single disorder. Recognized or not, patients with more than one mental disorder were likely to have a mental disorder 5 years later (RR 2.3, 95% CI 1.2–4.3), compared with patients with a single mental disorder.

Among the patients with baseline major depression, 35% had a coexisting anxiety disorder. At 5 years, 46% of these patients with comorbid anxiety continued to have a mental disorder; 60% still had major depression; 35% had subthreshold depression; and 5% had generalized anxiety alone. Among those with subthreshold depression, an anxiety disorder was present in 27%. At 5 years, 40% of these patients with a comorbid anxiety disorder still had a disorder; a third progressed to major depression; a third still had subthreshold depression; and a third met the criteria for generalized anxiety. Over half (57%) of patients with generalized anxiety disorders at baseline met the criteria for major depression or dysthymia, and 44% still met the criteria at the 5-year follow-up.

Impact of Mental Disorders
At all time points, the presence of any mental disorder significantly impaired the individual's functional status, with a stepwise decrease in functional status from patients with no mental disorders to those with subthreshold disorders to those with threshold disorders (Figure 2). Patients with mental disorders also reported greater severity of their presenting physical symptom, were more likely to be worried that this symptom was due to something serious, and were more likely to endorse ongoing stress (Table 4).


Figure 28
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  		Figure 2. Functional status among subjects with no disorder versus those with subthreshold and threshold mental disorders.

 

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  		TABLE 4. Impact of Mental Disorders on Physical Symptoms, Stress, and Illness Worry

 

Patients with mental disorders also reported a greater number of "currently bothersome" symptoms at both baseline and at five years on the PHQ-15, although the presence of a mental disorder did not affect the outcome of the symptom for which medical care was initially sought. There was no difference in satisfaction with care at any time point between those with and those without mental disorders. Patients with mental disorders had higher 3-month utilization rates than those without mental disorders (5.5 versus 4.5 visits, p = .02). There was no relationship between mental disorders and death during the 5 years of follow-up.

Correlates of Mental Disorder Detection
Patients were more likely to be detected as having a mental disorder if they had more than one disorder (odds ratio (OR) 13.4, 95% CI 4.1–43.9), a threshold disorder, (OR 6.6, 95% CI 1.9–23.5), persistence of mental disorders over the 5-year period (OR 4.1, 95% CI 1.1–15.2), or worse functional status (OR 1.1, 95% CI 1.03–1.2).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
NOTES
 REFERENCES
 
Mental disorders were common (29%) in our primary care sample of patients presenting to a walk-in clinic for evaluation of a physical symptom. Over 5 years, approximately a third of patients with a mental disorder reported that their disorder was recognized, although this rate of recognition was not uniform across disorders. Patients with more severe mental disorders, including those with multiple disorders, threshold disorders, persistent disorders, or worse functional status were more likely to be recognized, as previously documented (27,38–44). Paradoxically, recognition of the depressive or anxiety disorder was associated with a greater likelihood of persistence. Similar to other studies, patients with mental disorders when recognized may not do better than patients with unrecognized cases (40,43). In our patients, those whose disorders were recognized were more likely to have multiple disorders, threshold disorders, and worse functional status; it is likely these indicators of greater mental disorder severity were partially responsible for higher rates of chronicity and may help explain previous study findings. An alternate explanation may be that the depression and anxiety disorders, when recognized, were inadequately treated.

Patients with subthreshold disorders had a more favorable course. Among those with subthreshold depression, most had no mental disorder at 5 years, a fifth had persistent subthreshold depression; only 12% progressed to major depression. Among those with subthreshold anxiety, most had no disorder at 5-year follow up, 13% still had some anxiety, but only one developed a threshold anxiety disorder (generalized anxiety). This is similar to studies that have found threshold disorders to be more persistent than subthreshold ones (28,45). Depression and anxiety have also been shown to frequently co-occur (44–48), and this comorbidity is associated with more impairment and chronicity (48). In our study, comorbid mental disorders were a particularly poor prognostic finding and most patients with more than one disorder experienced persistence of their disorder at 5 years.

Why is the recognition and treatment of mental disorders so low? Many barriers, including patient, provider, and system problems have been identified. Patients reduce the likelihood of being diagnosed by presenting with somatic rather than emotional complaints (46–48), may perceive these disorders as being due to personal weakness or other stigma (49,50), may believe that antidepressant treatment can be harmful (51), or may have cultural barriers to admitting psychological stress (52,53). In addition, some patients may resist a diagnosis of depression or anxiety by attributing their symptoms to physical causes (54,55). Provider barriers include concerns about potential patient stigma (17,56), time pressures (17,57), a belief that such diagnoses are burdensome (6), inadequate knowledge about diagnostic criteria or treatment options (58–60), lack of a psychosocial orientation (61,62), practice style not conducive to psychosocial talk (15,63), and inadequate insight into different cultural presentations of mental disorders (64). System barriers include productivity pressures, limitations of third-party mental health coverage, restrictions on specialist, drug, and psychotherapeutic care (17,56), lack of a systematic method for detecting and managing such patients (65), and inadequate continuity of care (56).

Our study has several limitations. First, the results are from a single medical center, limiting generalizability. Second, we relied on patient self-report to assess the diagnosis and treatment of mental disorders. We have no data on what treatment, if any, the respondents received. It is possible that patients could have systematically either under- or over-reported the recognition rates of their disorder. This seems unlikely because our finding that patients with more severe disease were more likely to be recognized is consistent with previous research. However, if patients received treatment in the intervening period and did not report it, our conclusions regarding watchful waiting in some patient populations would be erroneous. Third, we have no information on the course of either the patients' physical symptoms or mental disorders over the intervening period between the 3-month and 5-year follow-up. Fourth, our sample of individuals with certain disorders, such as panic disorder, was low. Other studies on panic disorder in primary care and community settings have found slightly higher prevalence rates (2% to 3%), less psychiatric comorbidity (2,66), and lower detection rates. It is likely, given our 100% detection rate, that our identified patients with panic disorder represented the more severe cases. The low prevalence of panic disorder in our sample makes any definitive conclusions regarding this disorder impossible. Fifth, we ascertained the presence of a mental disorder using different versions of the PRIME-MD. For our initial screen, we used the interview form; at the 5-year follow-up, we used a self-administered version. The two versions are similar but have not been directly compared. Both were validated by comparison with mental health interviews and the two versions have similar test characteristics (67). Nonetheless, it would have been better had the two time points used the exact same instrument. Sixth, the use of a univariate screen for selecting potential variables has been criticized as potentially biased. This bias could exist either by including extraneous variables by chance or by excluding potentially important effect modifiers that failed to have a univariate association. To avoid both of these, we used a liberal p < .25 as our criterion. This cut point has been suggested as the optimal one to reduce potential chance associations while not missing important multivariate associations (37). The potential for a chance association is particularly strong when analysts do screening as part of a "fishing" expedition; including variables that are part of a database with no a priori reason to believe are associated with the dependent variable. We avoided this by specifically including in our initial model all variables that had previous literature to support a potential association. Moreover, because the final model we present has numerous other publications that found similar relationships, it seems unlikely that we have inadvertently included chance associations.

Nonetheless, several important findings emerge from this study. First, mental disorders are common in primary care and their recognition and treatment remain low. Subthreshold disorders have a better prognosis and seldom progress to more severe disorders. Comorbid disorders, whether a combination of two subthreshold or a threshold and subthreshold disorder, have a poor prognosis; most patients with comorbid disorders will still have a disorder at their 5-year follow-up. Patients with threshold or multiple disorders, worse functioning, or persistence of their disorder were more likely to be diagnosed. Patients with mental disorders reported worse functioning, a greater number of other bothersome physical symptoms, and greater stress. Because somatic symptoms are the predominant manner in which patients with mental disorders present in primary care, having a high index of suspicion in such patients as well as understanding factors predicting poorer recognition and persistence is important to improving detection and treatment.

Naturalistic, primary care-based studies may provide information that help clinicians tailor treatment and follow-up based on patient characteristics and preferences. The more favorable course of patients with certain features (e.g., subthreshold disorders, no comorbidity, less functional impairment) may mean watchful waiting is warranted for some patients, taking into account patient preferences, symptom severity, and persistence. At the same time, the chronic or recurring nature of disorders that are threshold, more severe, or comorbid suggests a substantial unmet need for improving care.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
REFERENCES
 
The views expressed in this article are those of the authors and should not be construed to represent in any way those of the Department of Defense or the Department of the Army.

Received for publication May 3, 2006; revision received October 26, 2006.

This study was supported by intramural Grant 32001 from the Uniformed Services University of the Health Sciences (J.L.J.).

DOI:10.1097/PSY.0b013e3180314b59


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 

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H. Leigh, R. Mallios, and D. Stewart
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