Journal of General Internal Medicine

, Volume 19, Issue 6, pp 615–623 | Cite as

Does a depression intervention result in improved outcomes for patients presenting with physical symptoms?

  • Robert D. KeeleyEmail author
  • Jeffrey L. Smith
  • Paul A. Nutting
  • L. Miriam Dickinson
  • W. Perry Dickinson
  • Kathryn M. Rost
Original Articles


OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1) depression management and outcomes under usual care conditions, and 2) the impact of an intervention to improve management and outcomes.

DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices.

PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression.

MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months.

MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physicial presenters to complete an adequate trial of anti-depressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physicial symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P=.06), receipt of any antidepressant (63.0% vs 20.1%; P=.001), and an adequate antidepressant trial (34.9% vs 5.9%; P=.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P=.01) and an adequate antidepressant trial (46.0% vs 23.8%; P=.004), and also improved depression severity and physical and emotional role functioning.

CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Key words

depressive disorder affective symptoms moderator variables somatoform disorders 


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  1. 1.
    Jackson JL, Houston JS, Hanling SR, Terhaar KA, Yun JS. Clinical predictors of mental disorders among medical outpatients. Arch Intern Med. 2001;161:875–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Kirmayer LJ, Robbins JM. Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychol Med. 1996;26:937–51.PubMedCrossRefGoogle Scholar
  3. 3.
    Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care setting. J Psychosom Res. 1988;32:137–45.PubMedCrossRefGoogle Scholar
  4. 4.
    Wilson DR, Widmer RB, Cadoret RJ, Judiesch K. Somatic symptoms. A major feature of depression in a family practice. J Affect Disorders. 1983;5:199–207.PubMedCrossRefGoogle Scholar
  5. 5.
    Watts CAH. The mild endogenous depression. BMJ. 1957;I:4–8.Google Scholar
  6. 6.
    Clarke RL. The treatment of depression in general practice. South African Med J. 1969;1:724–5.Google Scholar
  7. 7.
    Kleinman A. Culture and patient care—psychiatry among the Chinese. Drug Ther. 1981;11:134–40.Google Scholar
  8. 8.
    APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1995.Google Scholar
  9. 9.
    Escobar JI, Gomez J, Tuason VB. Depressive phenomenology in North and South American patients. Am J Psychiatry. 1983;140:47–51.PubMedGoogle Scholar
  10. 10.
    Kleinman A. Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry. 1982;6:117–90.PubMedCrossRefGoogle Scholar
  11. 11.
    Katon W, Kleinman A, Rosen G. Depression and somatization: a review. Part I. Am J Med. 1982;72:127–35.PubMedCrossRefGoogle Scholar
  12. 12.
    Zung WW, Magill M, Moore JT, George DT. Recognition and treatment of depression in a family medicine practice. J Clin Psychiatry. 1983;44:3–8.PubMedGoogle Scholar
  13. 13.
    Williamson PS, Yates WR. The initial presentation of depression in family practice and psychiatric outpatients. Gen Hosp Psychiatry. 1989;11:189–93.CrossRefGoogle Scholar
  14. 14.
    Magruder-Habib K, Zung WW, Feussner JR. Improving physicians’ recognition and treatment of depression in general medical care. Results from a randomized clinical trial. Med Care. 1990;28:239–50.PubMedCrossRefGoogle Scholar
  15. 15.
    Kroenke K, Jackson JL, Chamberlin J. Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med. 1997;103:339–47.PubMedCrossRefGoogle Scholar
  16. 16.
    Maier W. The epidemiology of comorbidity between depression, anxiety disorders and somatic diseases. Int Clin Psychopharmacol. 1999;(14 suppl 2):S1–S6.Google Scholar
  17. 17.
    Rost K, Nutting P, Smith JS, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial of the QuEST intervention. Quality enhancement by strategic teaming. J Gen Intern Med. 2001;16:143–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Rost K, Nutting PA, Smith J, Werner JJ. Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression. Gen Hosp Psychiatry. 2000;22:66–77.PubMedCrossRefGoogle Scholar
  19. 19.
    Zimmerman M, Coryell W, Wilson S, Corenthal C. Evaluation of symptoms of major depressive disorder: self-report vs. clinician ratings. J Nerv Ment Dis. 1986;174:150–3.PubMedCrossRefGoogle Scholar
  20. 20.
    Andrews G, Peters L. The psychometric properties of the Composite International Diagnostic Interview. Soc Psychiatry Psychiatr Epidemiol. 1998;33:80–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Tacchini G, Coppola MT, Musazzi A, Altamura AC, Invernizzi G. Multinational validation of the Composite International Diagnostic Interview (CIDI). Minerva Psichiatr. 1994;35:63–80.PubMedGoogle Scholar
  22. 22.
    AHCPR. Depression Guideline Panel: Depression in Primary Care. Detection and Diagnosis. Clinical Practice Guideline. No. 5. Vol. 1. Rockville, MD: U. S. Department of Health and Human Services, Public Health Agency, Agency for Health Care Policy and Research; 1993.Google Scholar
  23. 23.
    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  24. 24.
    Orlando M, Sherbourne CD, Thissen D. Summed-score linking using item response theory: application to depression measurement. Psychol Assess. 2000;12:354–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Ware JEJ, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Boston, Mass: Health Institute, New England Medical Center; 1993.Google Scholar
  26. 26.
    WHO. Composite International Diagnostic Interview for Primary Care. Version 2.0. Geneva, Switzerland: World Health Organization; 1996.Google Scholar
  27. 27.
    Byrk AS, Raudenbush SW. Hierarchical Linear Models: Applications and Data Analysis Methods. 1st ed. Newbury Park, Calif: Sage Publications; 1992.Google Scholar
  28. 28.
    Littell RC, Milliken GA, Stroup WW, Wolfinger RD. SAS System for Mixed Models. Cary, NC: SAS Instiute, Inc.; 1999.Google Scholar
  29. 29.
    Hedeker D, Gibbons RD. Application of random-effects pattern-mixture models for missing data in longitudinal studies. Psychol Methods. 1997;2:64–78.CrossRefGoogle Scholar
  30. 30.
    Bair MJ, Robinson RL, Eckert GJ, Stang PE, Croghan TW, Kroenke K. Impact of pain on depression treatment response in primary care. Psychosom Med. 2004;66:17–22.PubMedCrossRefGoogle Scholar
  31. 31.
    Ohayon MM, Schatzberg AF. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry. 2003;60:39–47.PubMedCrossRefGoogle Scholar
  32. 32.
    Bridges KW, Goldberg DP. Somatic presentations of DSM-III psychiatric disorders in primary care. J Psychosom Res. 1985;29:563–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Simon GE, Heiligenstein J, Revicki D, et al. Long-term outcomes of initial antidepressant drug choice in a ‘real world’ randomized trial. Arch Fam Med. 1999;8:319–25.PubMedCrossRefGoogle Scholar
  34. 34.
    Susman JL, Crabtree BF, Essink G. Depression in rural family practice: easy to recognize, difficult to diagnose. Arch Fam Med. 1995;4:427–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Freeling P, Rao BM, Paykel ES, Sireling LI, Burton RH. Unrecognized depression in general practice. Br Med J. 1985;290:1880–3.CrossRefGoogle Scholar
  36. 36.
    Williams JWJ, Mulrow CD, Korenke K, et al. Case-finding for depression in primary care: a randomized trial. Am J Med. 1999;106:36–43.PubMedCrossRefGoogle Scholar
  37. 37.
    Simon GE, Von Korff M, Picinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999;341:1329–35.PubMedCrossRefGoogle Scholar
  38. 38.
    Von Korff M, Goldberg D. Improving outcomes for depression. BMJ. 2001;323:948–9.CrossRefGoogle Scholar
  39. 39.
    Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997;19:98–111.PubMedCrossRefGoogle Scholar
  40. 40.
    Fortney J, Rost K, Zhang M, Pyne J. The relationship between quality and outcomes in routine depression care. Psychiatr Serv. 2001;52:56–62.PubMedCrossRefGoogle Scholar
  41. 41.
    Koike AK, Unutzer J, Wells KB. Improving the care for depression in patients with comorbid medical illness. Am J Psychiatry. 2002;159:1738–45.PubMedCrossRefGoogle Scholar
  42. 42.
    Manning JS. Difficult-to-treat depressions: a primary care perspective. J Clin Psychiatry. 2003;64(suppl 1):24–31.PubMedGoogle Scholar
  43. 43.
    Goldstein DJ, Mallinckrodt C, Lu Y, Demitrack MA. Duloxetine in the treatment of major depressive disorder: a double-blind clinical trial. J Clin Psychiatry. 2002;63:225–31.PubMedGoogle Scholar
  44. 44.
    Hamilton KE, Dobson KS. Cognitive therapy of depression: pretreatment patient predictors of outcome. Clin Psychol Rev. 2002;22:875–93.PubMedCrossRefGoogle Scholar
  45. 45.
    Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836–45.PubMedCrossRefGoogle Scholar
  46. 46.
    Dowrick C, Dunn G, Ayuso-Mateos JL, et al. Problem solving treatment and group psychoeducation for depression: multicentre randomised controlled trial. Outcomes of Depression International Network (ODIN) Group. BMJ 2000;9:1450–4.CrossRefGoogle Scholar
  47. 47.
    Barsky AJ. Clinical practice: the patient with hypochondriasis. N Engl J Med. 2001;345:1395–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Keeley R, Smith M, Miller J. Somatoform symptoms and treatment nonadherence in depressed family medicine outpatients. Arch Fam Med. 2000;9:46–54.PubMedCrossRefGoogle Scholar
  49. 49.
    Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psycho Psychosom. 2000;69:205–15.CrossRefGoogle Scholar
  50. 50.
    Bass C, May S. ABC’s of psychological medicine: chronic multiple functional somatic symptoms. BMJ 2002;325:323–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Mayou R, Farmer A. ABC’s of psychological medicine: functional somatic symptoms and syndromes. BMJ 2002;325:265–8.PubMedCrossRefGoogle Scholar
  52. 52.
    O’sMalley PG, Jackson JL, Santoro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999;48:980–90.Google Scholar
  53. 53.
    Dickinson WP, Dickinson LM, deGruy FV, et al. The somatization in primary care study: a tale of three diagnoses. Gen Hosp Psychiatry. 2003;25:1–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Dickinson WP, Dickinson LM, deGruy FV, Main DS, Candib LM, Rost KM. A randomized clinical trial of a care recommendation letter intervention for somatization in primary care. Ann Fam Med. 2003;1:228–35.PubMedCrossRefGoogle Scholar
  55. 55.
    Loldrup D, Langemarck M, Hansen H, Olesen J, Bech P. Clomipramine and mianserin in chronic idiopathic pain syndrome: a placebo controlled study. Psychopharmacology. 1989;99:1–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Couch JR, Hassanein RS. Amitriptyline in migraine prophylaxis. Arch Neurol. 1979;36:695–9.PubMedGoogle Scholar
  57. 57.
    Dwight-Johnson M, Sherbourne CD, Liao D, Wells KB. Treatment preferences among depressed primary care patients. J Gen Intern Med. 2000;15:527–34.PubMedCrossRefGoogle Scholar
  58. 58.
    Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine. 2001;26:1418–24.PubMedCrossRefGoogle Scholar
  59. 59.
    Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain. Spine. 2000;25:2825–31.PubMedCrossRefGoogle Scholar
  60. 60.
    Allen LA, Woolfolk RL, Leher PM, Gara MA, Escobar JI. Cognitive behavior therapy for somatization disorder: a preliminary investigation. J Behav Ther Exp Psychiatry. 2001;32:53–62.PubMedCrossRefGoogle Scholar
  61. 61.
    Kroenke K. The interface between physicial and psychological symptoms. Prim Care Companion J Clin Psychiatry. 2003;5(suppl 7):11–8.Google Scholar
  62. 62.
    Kraemer HC, Wilson T, Fairburn CG, Agras WS. Mediators and moderators of treatment effects in randomized clinical trials. Arch Gen Psychiatry. 2002;59:877–83.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Robert D. Keeley
    • 1
    Email author
  • Jeffrey L. Smith
    • 2
  • Paul A. Nutting
    • 2
  • L. Miriam Dickinson
    • 1
  • W. Perry Dickinson
    • 1
  • Kathryn M. Rost
    • 1
  1. 1.Department of Family MedicineUniversity of Colorado Health Sciences CenterAurora
  2. 2.Center for Research StrategiesDenver

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