Journal of General Internal Medicine

, Volume 9, Issue 11, pp 606–615 | Cite as

Necessary but not sufficient

The effect of screening and feedback on outcomes of primary care patients with untreated anxiety
  • Susan D. Mathias
  • Sheila K. Fifer
  • Peter D. Mazonson
  • Deborah P. Lubeck
  • Don P. Buesching
  • Donald L Patrick
Original Articles

Abstract

Objective: To consider the impact on primary care patient outcomes of using both a screener to determine elevated anxiety levels among patients with previously undetected anxiety and a physician intervention to inform physicians of their patients’ conditions.

Design: Participating physicians were randomized to either the demonstration or the control arm, and patients were assigned to a study arm based on the randomization of their physicians. The patients were followed for change in outcome measures during the five-month study period.

Setting: A mixed-model health maintenance organization serving approximately 110,000 enrollees in central Colorado.

Patients/participants: 573 patients who had unrecognized and untreated anxiety identified from the approximately 8,000 patients who completed the waiting room screening questionnaire.

Interventions: A physician intervention served the dual function of 1) providing an educational demonstration of anxiety in the primary care setting and 2) providing a reporting system for summarizing the anxiety symptom levels and functioning status of the patients enrolled in the study.

Measurements and main results: Patient outcomes were measured as changes in global anxiety scores, functioning and well-being, and patients’ reports of global improvements.

Conclusions: The findings indicate that this method of reporting symptoms and functioning status to primary care physicians did not significantly change patient outcomes. Improvement in outcomes appeared to be more closely associated with the patient’s severity of psychological distress.

Key words

outcomes screeners physician intervention anxiety 

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References

  1. 1.
    Ormel J, Koeter MWJ, van den Brink W, van de Willige G. Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry. 1991;48:700–6.PubMedGoogle Scholar
  2. 2.
    Kessler LG, Cleary PD, Burke JD Jr. Psychiatric disorders in primary care: results of a follow-up study. Arch Gen Psychiatry. 1985;42:583–7.PubMedGoogle Scholar
  3. 3.
    Klerman GL, Budman S, Berwick, D, et al. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care. 1987;25:1078–88.PubMedCrossRefGoogle Scholar
  4. 4.
    Zung WWK, Magill M, Moore JT, George DT. Recognition and treatment of depression in a family medicine practice. J Clin Psychiatry. 1983;44:3–6.PubMedGoogle Scholar
  5. 5.
    DelVecchio Good M-J, Good BJ, Cleary PD. Do patient attitudes influence physician recognition of psychosocial problems in primary care? J Fam Pract. 1987;25:53–9.Google Scholar
  6. 6.
    Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system. Arch Gen Psychiatry. 1978;35:685–93.PubMedGoogle Scholar
  7. 7.
    Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Arch Gen Psychiatry. 1993;50:85–94.PubMedGoogle Scholar
  8. 8.
    Kamerow D. Alcohol abuse, other drug abuse, and mental disorders in medical practice: prevalence, costs, recognition, and treatment. JAMA. 1986;255:2054–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Shapiro S, Skinner EA, VonKorff M, et al. Utilization of health and mental health services: three catchment area sites. Arch Gen Psychiatry. 1984;41:971–8.PubMedGoogle Scholar
  10. 10.
    Goldberg D. A classification of psychological distress for use in primary care settings. Soc Sci Med. 1992;35:189–93.PubMedCrossRefGoogle Scholar
  11. 11.
    Katon W, VonKorff M, Lin E, et al. Distressed high utilizers of medical care. Gen Hosp Psychiatry. 1990;12:355–62.PubMedCrossRefGoogle Scholar
  12. 12.
    Hankin JR, Steinwachs DM, Regier DA, Burns BJ, Goldberg ID, Hoeper EW. Use of general medical care services by persons with mental disorders. Arch Gen Psychiatry. 1982;39:225–31.PubMedGoogle Scholar
  13. 13.
    Eisenberg L. Treating depression and anxiety in primary care. N Engl J Med. 1992;326:1080–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Andersen SM, Harthorn BH. The recognition, diagnosis and treatment of mental disorders by primary care physicians. Med Care. 1989;27:869–86.PubMedCrossRefGoogle Scholar
  15. 15.
    VonKorff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic. Arch Gen Psychiatry. 1987;44:152–6.Google Scholar
  16. 16.
    Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100–6.PubMedGoogle Scholar
  17. 17.
    Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW. Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry. 1988;10:317–21.PubMedCrossRefGoogle Scholar
  18. 18.
    Johnstone A, Goldberg D. Psychiatric screening in general practice. Lancet. 1976;1:605–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Myers JK, Weissman MM, Tischler GL, et al. Six-month prevalence of psychiatric disorders in three communities: 1980 to 1982. Arch Gen Psychiatry. 1984;41:959–67.PubMedGoogle Scholar
  20. 20.
    Hoeper EW, Nycz GR, Kessler LG, Burke JD Jr., Pierce WD. The usefulness of screening for mental illness. Lancet. 1984;1:33–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Magruder-Habib K, Zung WWK, Feussner JR. Improving physicians’ recognition and treatment of depression in general medical care. Med Care. 1990;23:239–50.CrossRefGoogle Scholar
  22. 22.
    Magruder-Habib K, Zung WWK, Feussner JR, Ailing WC, Saunders WB, Stevens HA. Management of general medical patients with symptoms of depression. Gen Hosp Psychiatry. 1989;11:201–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Kessler LG, Amick BC, Thompson J. Factors influencing the diagnosis of mental disorder among primary care patients. Med Care. 1985;23:50–62.PubMedCrossRefGoogle Scholar
  24. 24.
    Rost K, Burnam MA, Smith GR. Development of screeners for depressive disorders and substance disorder history. Med Care. 1993;31:189–200.PubMedCrossRefGoogle Scholar
  25. 25.
    VonKorff M. Case definitions in primary care. Gen Hosp Psychiatry. 1992;l4:293–5.CrossRefGoogle Scholar
  26. 26.
    Andersen SM, Harthorn BH. Changing the psychiatric knowledge of primary care physicians. Gen Hosp Psychiatry. 1990;12:177–90.PubMedCrossRefGoogle Scholar
  27. 27.
    Fifer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP, Buesching DP. Untreated anxiety among adult primary care patients in a health maintenance organization. Arch Gen Psychiatry. 1994;51:740–50.PubMedGoogle Scholar
  28. 28.
    Mazonson P, Mathias S, Fifer SK, Patrick DL, Buesching DP, Malek P. The impact of outcomes information relating to anxiety on primary care physicians’ practice patterns: report of an ongoing randomized trial [abstract]. Presented at the Sixth Annual National Institute of Mental Health International Research Conference on Primary Care Mental Health Research: Concepts, Methods, and Obstacles. October 18–20, 1992, Tysons Corner, Virginia.Google Scholar
  29. 29.
    Derogatis LR. SCI.-90-R Administration, Scoring and Procedures Manual-II. Towson, MD: Clinical Psychometric Research, 1983.Google Scholar
  30. 30.
    Preskorn SH, Fast GA. Beyond signs and symptoms. The case against a mixed anxiety and depression category. J Clin Psychiatry. 1993;54(suppl 1):24–32.PubMedGoogle Scholar
  31. 31.
    Howard KI, Kopta SM, Krause MS, Orlinsky DE. The dose—effect relationship in psychotherapy. Am Psychol. 1986;41:159–64.PubMedCrossRefGoogle Scholar
  32. 32.
    Katon W, Roy-Byrne PP. Mixed anxiety and depression. J Abnorm Psychol. 1991;100:337–45.PubMedCrossRefGoogle Scholar
  33. 33.
    Campbell TL. An opposing view. J Fam Pract. 1987;25:184–7.PubMedGoogle Scholar
  34. 34.
    Zung WWK, Magruder-Habib K, Velez R, Ailing W. The comorbidity of anxiety and depression in general medical patients: a longitudinal study. J Clin Psychiatry. 1990;51(suppl 6):77–80.PubMedGoogle Scholar
  35. 35.
    Catalan J, Gath DH, Bond A, Martin P. Effects of non-prescribing of anxiolytics in general practice. II. Factors associated with outcome. Br J Psychiatry. 1984;144:603–10.PubMedCrossRefGoogle Scholar
  36. 36.
    Wells KB, Burnam MA, Rogers W, Hays R, Camp P. The course of depression in adult outpatients, results from the Medical Outcomes Study. Arch Gen Psychiatry. 1992;49:788–94.PubMedGoogle Scholar
  37. 37.
    Ormel J, VonKorff M, van den Brink W, Katon W, Brilman E, Oldehinkel T. Depression, anxiety and social disability show synchrony of change in primary care patients. Am J Public Health. 1993;83:385–90.PubMedCrossRefGoogle Scholar
  38. 38.
    Gerber PD, Barrett J, Barrett J, Manheimer E, Whiting R, Smith R. Recognition of depression by internists in primary care: a comparison of internist and “gold standard” psychiatric assessments. J Gen Intern Med. 1989;4:7–13.PubMedCrossRefGoogle Scholar
  39. 39.
    Blacklow R, Broadhead WE, Weissman M, et al. Symptom Driven Diagnostic System—Primary Care (SDDS-PC): a report of work in progress [abstract]. Presented at the Sixth Annual National Institute of Mental Health International Research Conference on Primary Care, Mental Health Research: Concepts, Methods and Obstacles. October 18–20, 1992, Tysons Corner, Virginia.Google Scholar
  40. 40.
    Williams JBW, Spitzer RL. Prime-MD: a new system for the evaluation of mental disorders in primary care [abstract]. Presented at the Sixth Annual National Institute of Mental Health International Research Conference on Primary Care, Mental Health Research: Concepts, Methods and Obstacles. October 18–20, 1992, Tysons Corner, Virginia.Google Scholar
  41. 41.
    Rost K, Burnam MA, Smith GR. Development of screeners for depressive disorders and substance disorder history. Med Care. 1993;31:189–200.PubMedCrossRefGoogle Scholar
  42. 42.
    Catalan J, Gath DH, Anastasiades P, Bond SAK, Day A, Hall L. Evaluation of a brief psychological treatment for emotional disorders in primary care. Psychol Med. 1991;21:1013–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Katon W, VonKorff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67–76.PubMedCrossRefGoogle Scholar
  44. 44.
    Coleman JV, Patrick DL. Integrating mental health services into primary medical care. Med Care. 1976;14:654–61.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 1994

Authors and Affiliations

  • Susan D. Mathias
    • 1
  • Sheila K. Fifer
    • 1
  • Peter D. Mazonson
    • 1
  • Deborah P. Lubeck
    • 1
    • 2
  • Don P. Buesching
    • 3
  • Donald L Patrick
    • 4
  1. 1.Technology Assessment GroupSan Francisco
  2. 2.the Department of MedicineStanford UniversityPalo Alto
  3. 3.the Upjohn CompanyKalamazoo
  4. 4.the School of Public HealthUniversity of WashingtonSeattle

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