G. Richard Smith

Persistently poor outcomes of undetected major depression in primary care

Despite its relevance for quality care initiatives, the field of psychiatry has little scientific knowledge regarding the course of current major depression when primary care patients with the disorder remain undetected. Using statewide telephone screening, we identified and followed 98 adults with current major depression who made one or more visits to a primary care physician during the 6 months following baseline. Thirty-two percent of primary care patients with current major depression remained undetected for up to 1 year. Almost half of undetected patients developed suicidal ideation. Less than one-third of undetected patients made a visit during the month they reported their worst symptoms. Fifty-three percent of undetected patients reported five or more current symptoms at 1 year follow-up. Primary care patients with undetected major depression report persistently poor outcomes. Comparison of outcomes with detected patients suggests that quality improvement efforts directed at improving detection without improving management of detected patients may not improve outcomes.

The epidemiology and treatment of depression when it coexists with somatoform disorders, somatization, or pain

This article reviews the relationship between depressive disorders and somatoform disorders, somatization, and pain. These disorders and symptoms are clinically interrelated, yet the nature of the interrelation is not well understood. This review of the literature from 1975 through mid-year 1990 addresses the epidemiology and treatment of these conditions and/or symptoms when they occur together. When robust criteria are used to determine which publications are included, only 14 are available that address depressive disorders, somatoform disorders, and somatization. Similarly, there are only 13 that address depressive disorders and pain. Taken together, these studies indicate that 1) in somatization disorder patients, there is a high prevalence of depression; 2) in patients with major depression, there are substantial levels of hypochondriacal and somatizing symptoms; 3) that depression in the face of coexisting somatization disorder can be successfully treated; 4) in chronic pain patients, there is a high prevalence of depressive disorders; 5) in patients with major depression, pain is a frequent complaint; 6) and finally, that pain improves with the treatment of depression. What is most striking from this review, however, is the very limited number of studies that address these important problems. This lack of research-based data calls for new aggressive research efforts in this area.

Rural-Urban Differences in Depression Treatment and Suicidality

OBJECTIVES Because there are fewer per capita providers trained to deliver mental health services in rural areas, the authors hypothesized that depressed rural individuals would receive less outpatient treatment and report higher rates of hospital admittance and suicide attempts than their urban counterparts. METHODS The authors recruited 74% of eligible participants (n = 470) from a 1992 telephone survey and followed up 95% of subjects for 1 year. The authors collected data from subjects on psychiatric problems and service use and from insurers/providers on treatment and expenditures. RESULTS Although there were no rural-urban differences in the rate, type, or quality of outpatient depression treatment, rural subjects made significantly fewer specialty care visits for depression. Depressed rural individuals had 3.05 times the odds of being admitted to the hospital for physical problems (P = 0.02) and 3.06 times the odds of being admitted for mental health problems (P = 0.08) during the year. Elevated rates of hospital admittance disappear in models controlling for number of specialty care depression visits in the previous month. Rural subjects reported significantly more suicide attempts during the period of 1 year (P = 0.05). CONCLUSIONS Additional work is warranted to determine how to alter barriers to outpatient specialty care if the rural health care delivery system is to provide cost-effective depression care.

Enhancing the health of somatization disorder patients : effectiveness of short-term group therapy

To identify an effective method of treating patients with somatization disorder (SD), the authors conducted a randomized controlled clinical trial of group therapy with 70 SD patients. Primary care physicians treating all patients in the study received a consultation letter offering treatment recommendations for SD. The experimental patients were invited to attend eight group therapy sessions in addition to the consultation provided to their physicians; 45% attended one or more sessions. The experimental patients reported significantly better physical (P < 0.05) and mental (P < 0.01) health in a 1-year period during and after group therapy. The more group sessions SD patients attended, the greater the improvement in general and mental health. The 52% net savings in health care charges associated with group therapy plus the consultation indicate that it is economically feasible to improve outcomes without escalating the cost of care in this group of high users of medical resources.

Effectiveness of psychiatric intervention with somatization disorder patients: Improved outcomes at reduced costs

In order to determine the health effects of an intervention that reduces the cost of care for somatization disorder (SD) patients, 59 primary care physicians were randomized to receive a psychiatric consultation letter providing treatment recommendations for 73 patients either at baseline or the end of the year-long study. Seventy of these patients (96%) were followed every 4 months for 1 year by a research assistant blind to randomization. A year following the intervention, patients of experimental physicians reported greater physical capacity than patients of control physicians (mean difference = 17.9, 95% CI 1.0-34.9) with a

The Course of Somatization and Its Effects on Utilization of Health Care Resources

466 reduction (95% CI

The comorbidity of DSM-III-R personality disorders in somatization disorder

132-

Somatization Disorder in Primary Care

699) in health care charges. In addition to a net 21% reduction in health care charges for the typical SD patient, the consultation letter improved physical functioning in a group of highly impaired subjects.

Diagnosing depression in the medically ill: validity of a lay-administered structured diagnostic interview

Patients with somatization disorder (SD), subthreshold somatization, and somatization that is comorbid with another mental or physical disorder use a remarkably high level of general medical services. Because these patients view themselves as more seriously ill than do patients in the general medical population, their use of health care services may be as high as nine times greater than that of the general population. It is important to understand the course and prevalence of SD because 1) these patients tend to overuse health care resources and services, and 2) the associated costs are enormous. It is vital that expert clinical care and research be directed at this important patient group so that appropriate treatment regimens can be developed to help these patients and control the overutilization of limited health care resources.

Healthy patients who perceive poor health and their use of primary care services

In order to understand psychiatric factors that complicate the medical management of somatizing patients, 94 subjects with known somatization disorder (SD) were evaluated for 13 personality disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. Referred from multiple primary care settings, the patient sample was predominantly female (85%), married (67%), high school graduates (64%), and had a mean age of 43. Structured interviews documented that 23.4% of SD patients had one personality disorder, and 37.2% had two or more disorders. The four most frequently identified personality disorders were avoidance 26.7%, paranoia 21.3%, self-defeating 19.1%, and obsessive-compulsive 17.1%. Interestingly histrionic personality disorder was identified in only 12.8% of the sample and antisocial personality disorder in 7.4%. In making the diagnosis of SD, health care providers need to avoid the common clinical impression that histrionic behavior often accompanies the disorder. Further research with SD patients is needed to examine the relationship of co-occurring personality disorders to symptom recurrence, health care utilization, and readiness for psychiatric referral.