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Subthreshold Psychiatric Symptoms in a Primary Care Group Practice

Subthreshold Psychiatric Symptoms in a Primary Care Group Practice Abstract Background: The authors define 6 groups of subthreshold psychiatric symptoms that do not meet the full criteria for a DSM-IV Axis I disorder and examine the clinical significance of these symptoms in an outpatient primary care sample. Methods: The subjects were 1001 adult primary care patients in a large health maintenance organization. Data on sociodemographic characteristics and functional impairment, including scores on the Sheehan Disability Scale, were collected at the time of the medical visit, and a structured diagnostic interview for DSM-IV disorders was completed by telephone within 4 days of the visit. Subthreshold symptoms were defined for depressive, anxiety, panic, obsessive-compulsive, drug, and alcohol symptoms. Results: Subthreshold symptoms were as or more common than their respective Axis I disorders: panic (10.5% vs 4.8%), depression (9.1% vs 7.3%), anxiety (6.6% vs 3.7%), obsessive-compulsive (5.8% vs 1.4%), and alcohol (5.3% vs 5.2%) and other drug (3.7% vs 2.4%) cases. Patients with each of the subthreshold symptoms had significantly higher Sheehan Disability Scale scores (greater impairment) than did patients with no psychiatric symptoms. Many patients (22.6%-53.4%) with subthreshold symptoms also met the full criteria for other Axis I disorders. After adjusting for the confounding effects of other Axis I disorders, other subthreshold symptoms, age, sex, race, marital status, and perceived physical health status, only depressive symptoms, major depressive disorder, and, to a lesser extent, panic symptoms were significantly correlated with the impairment measures. Conclusions: In these primary care patients, the morbidity of subthreshold symptoms was often explained by confounding mental, physical, or demographic factors. However, depressive symptoms and, to a lesser extent, panic symptoms were disabling even after controlling for these factors. Primary care clinicians who detect subthreshold psychiatric symptoms should consider a broad psychiatric assessment. References 1. Wilson M. DSM-III and the transformation of American psychiatry: a history . Am J Psychiatry . 1993:150:399-410. 2. Cooper JE. The classification of mental disorders for use in general settings . In: Sartorius N, Goldberg D, de Girolamo G, eds. Psychological Disorders in General Medical Settings . Toronto, Ontario: Hogrefe & Huber Publishers; 1990: 49-59. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version (DSM-IV-PC) . Washington, DC: American Psychiatric Association Press; 1995. 4. Barrett JE, Barrett HA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice . Arch Gen Psychiatry . 1988;45:1100-1106.Crossref 5. Jaffe A, Froom J, Galambos N. Minor depression and functional impairment . Arch Fam Med . 1994;3:1081-1086.Crossref 6. Snaith RP. The concepts of mild depression . Br J Psychiatry . 1987;150:387-393.Crossref 7. Coulehan JL, Schulberg HC, Block MR, Janosky JE, Arena VC. Depressive symptomatology and medical co-morbidity in a primary care clinic . Int J Psychiatry Med . 1990;20:335-347.Crossref 8. Sherbourne CD, Wells KB, Hays RD, Rogers W, Burnam MA, Judd LL. Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients . Am J Psychiatry . 1994;151:1777-1784. 9. Judd LL, Rapaport MH, Paulus MP, Brown JL. Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatry . 1994;55:18S-28S. 10. Philipp M. The risk of minor depression in families of probands with major depression: sex differences and familiality . Eur Arch Psychiatry Clin Neurosci . 1992;242:89-92.Crossref 11. Katon W, Lin E, von Korff M, Bush T, Walker E, Simon G, Robinson P. The predictors of persistence of depression in primary care . J Affect Disord . 1994:31:81-90.Crossref 12. Skodol AE, Schwartz S, Dohrenwend BP, Levav I, Shrout PE. Minor depression in a cohort of young adults in Israel . Arch Gen Psychiatry . 1994;51:542-551.Crossref 13. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA . 1990;264:2524-2528.Crossref 14. Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community . JAMA . 1992;267:1478-1483.Crossref 15. Berkman LF, Berkman CS, Kasl S, Freeman DH Jr, Leo L, Ostfeld AM, Cornoni Huntley J, Brody JA. Depressive symptoms in relation to physical health and functioning in the elderly . Am J Epidemiol . 1986;124:372-388. 16. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, Berry S, Greenfield S, Ware J. The functioning and well-being of depressed patients: results from the Medical Outcomes Study . JAMA . 1989;262:914-919.Crossref 17. Klerman GL, Weissman MM, Ouellette R, Johnson J, Greenwald S. Panic attacks in the community: social morbidity and health care utilization . JAMA . 1991;265:742-746.Crossref 18. Leon AC, Portera L, Weissman MM. The social costs of anxiety disorders . Br J Psychiatry . 1995;166:19-22.Crossref 19. Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB. Somatization in the community: relationship to disability and use of services . Am J Public Health . 1987;77:837-840.Crossref 20. Webb GR, Redman S, Hennrikus DJ, Kelman GR, Gibberd RW, Sanson-Fisher RW. The relationships between high-risk and problem drinking and the occurrence of work injuries and related absences . J Stud Alcohol . 1994;55:434-446. 21. Jenkins R, Harvey S, Butler T, Thomas RL. A six-year longitudinal study of the occupational consequences of drinking over 'safe limits' of alcohol . Br J Ind Med . 1992;49:369-374. 22. Calzavara LM, Coates RA, Raboud JM, Farewell WT, Read SE, Shephered FA, Fanning MM, MacFadden D. Ongoing high-risk sexual behaviors in relation to recreational drug use in sexual encounters: analysis of 5 years of data from the Toronto Sexual Contact Study . Ann Epidemiol . 1992;3:272-280.Crossref 23. Van Trigt L, Kreuger H, Westerman RF, Hull FM. Morbidity at an Amsterdam inner-city clinic in relation to drug use . Fam Pract . 1989;6:299-302.Crossref 24. Von Korff M, Shapiro S, Burke JD, Teitlebaum M, Skinner EA, German P, Turner RW, Klein L, Burns B. Anxiety and depression in a primary care clinic . Arch Gen Psychiatry . 1987;44:152-156.Crossref 25. Clayton PJ. The comorbidity factor: establishing the primary diagnosis in patients with mixed symptoms of anxiety and depression . J Clin Psychiatry . 1990;56:15S-22S. 26. Kessler RL, McGonagle KA, Zhao S, Nelson CR, Hughes M, Eshelman S, Wittchen HU, Kendler K. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey . Arch Gen Psychiatry . 1994;51:8-19.Crossref 27. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study . JAMA . 1990;264:2511-2518.Crossref 28. Liebowitz MR. Mixed anxiety and depression: should it be included in DSM-IV? J Clin Psychiatry . 1993;54:4S-7S. 29. Leon AC, Shear MK, Portera L, Klerman GL. Assessing impairment in patients with panic disorders: the Sheehan Disability Scale . Soc Psychiatry Psychiatr Epidemiol . 1992;27:78-82.Crossref 30. Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL. Quality of life in panic disorder . Arch Gen Psychiatry . 1989;46:984-992.Crossref 31. Spitzer RL, Williams JBW, Gibbon M, First M. The structured clinical interview for DSM-III-R (SCID), I: history, rationale, and description . Arch Gen Psychiatry . 1992;49:624-629.Crossref 32. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994. 33. Fleiss JL. The Design and Analysis of Clinical Experiments. New York, NY: John Wiley & Sons Inc; 1986. 33. Sheehan D, Janavs J, Knapp E, Sheehan M, Baker R. Mini-International Neuropsychiatric Interview Clinician Rated, Version 4.0. Tampa, Fla: University of South Florida College of Medicine; 1992. 34. Sheehan DV, Lecrubiier Y, Janavs J, Weiller, Bonara LI, Keskiner A, Schinka J, Knapp E, Sheehan MF, Dunbar GC. Reliability and validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P. Presented at the New Clinical Drug Evaluation Unit 35th Annual Meeting; May 31, 1995; Orlando, Fla. 35. Horwath E, Johnson J, Klerman GL, Weissman MM. Depressive symptoms as relative and attributable risk factors for first-onset major depression . Arch Gen Psychiatry . 1992;49:817-823.Crossref 36. Wells KB, Burnam MA, Rogers W, Hays R, Camp P. The course of depression in adult outpatients . Arch Gen Psychiatry . 1992;49:788-794.Crossref 37. Angst J. The history and concept of recurrent brief depression . Eur Arch Psychiatry Clin Neurosci . 1994;244:171-173.Crossref 38. Elkin I, Shea T, Watkins JT, Imber SD, Stotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP, Fiester SJ, Parloff MB. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments . Arch Gen Psychiatry . 1989;46:971-982.Crossref 39. Paykel ES, Hollyman JA, Freeling P, Sedgwick P. Predictors of therapeutic benefit from amitriptyline in mild depression: a general practice placebo-controlled trial . J Affect Disord . 1988;14:83-95.Crossref 40. Depression Guideline Panel. Depression in Primary Care: Treatment of Major Depression: Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; April 1993;2. AHCPR publication 93-0551. 41. Boyer W. Serotonin uptake inhibitors are superior to imipramine and alprazolam in alleviating panic attacks: a meta-analysis . Int Clin Psychopharmacol , 1995;10:45-49.Crossref 42. Stewart JW, Quitkin FM, Klein DF. The pharmacotherapy of minor depression . Am J Psychother . 1992;46:23-36. 43. Wells KB, Burnam MA, Leake B, Robins LN. Agreement between face-to-face and telephone-administered versions of the depressive section of the NIMH Diagnostic Interview Schedule . J Psychiatr Res . 1988;22:207-220.Crossref 44. Paulson SA, Crowe RR, Noyes R, Pfohl B. Reliability of the telephone interview in diagnosing anxiety disorders . Arch Gen Psychiatry . 1988;45:62-63.Crossref 45. Watson CG, Anderson PE, Thomas D, Nyberg K. Comparison of telephone and face-to-face diagnostic interview schedules . J Nerv Ment Dis . 1992;180:534-535.Crossref 46. Simon GE, Revicki D, Von Korff ML. Telephone assessment of depression severity . J Psychiatr Res . 1993;27:247-252.Crossref 47. Gfroerer JC, Hughes AL. The feasibility of collecting drug abuse data by telephone . Public Health Rep . 1991;106:384-393. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of General Psychiatry American Medical Association

Subthreshold Psychiatric Symptoms in a Primary Care Group Practice

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References (47)

Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0003-990X
eISSN
1598-3636
DOI
10.1001/archpsyc.1996.01830100026004
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Abstract

Abstract Background: The authors define 6 groups of subthreshold psychiatric symptoms that do not meet the full criteria for a DSM-IV Axis I disorder and examine the clinical significance of these symptoms in an outpatient primary care sample. Methods: The subjects were 1001 adult primary care patients in a large health maintenance organization. Data on sociodemographic characteristics and functional impairment, including scores on the Sheehan Disability Scale, were collected at the time of the medical visit, and a structured diagnostic interview for DSM-IV disorders was completed by telephone within 4 days of the visit. Subthreshold symptoms were defined for depressive, anxiety, panic, obsessive-compulsive, drug, and alcohol symptoms. Results: Subthreshold symptoms were as or more common than their respective Axis I disorders: panic (10.5% vs 4.8%), depression (9.1% vs 7.3%), anxiety (6.6% vs 3.7%), obsessive-compulsive (5.8% vs 1.4%), and alcohol (5.3% vs 5.2%) and other drug (3.7% vs 2.4%) cases. Patients with each of the subthreshold symptoms had significantly higher Sheehan Disability Scale scores (greater impairment) than did patients with no psychiatric symptoms. Many patients (22.6%-53.4%) with subthreshold symptoms also met the full criteria for other Axis I disorders. After adjusting for the confounding effects of other Axis I disorders, other subthreshold symptoms, age, sex, race, marital status, and perceived physical health status, only depressive symptoms, major depressive disorder, and, to a lesser extent, panic symptoms were significantly correlated with the impairment measures. Conclusions: In these primary care patients, the morbidity of subthreshold symptoms was often explained by confounding mental, physical, or demographic factors. However, depressive symptoms and, to a lesser extent, panic symptoms were disabling even after controlling for these factors. Primary care clinicians who detect subthreshold psychiatric symptoms should consider a broad psychiatric assessment. References 1. Wilson M. DSM-III and the transformation of American psychiatry: a history . Am J Psychiatry . 1993:150:399-410. 2. Cooper JE. The classification of mental disorders for use in general settings . In: Sartorius N, Goldberg D, de Girolamo G, eds. Psychological Disorders in General Medical Settings . Toronto, Ontario: Hogrefe & Huber Publishers; 1990: 49-59. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version (DSM-IV-PC) . Washington, DC: American Psychiatric Association Press; 1995. 4. Barrett JE, Barrett HA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice . Arch Gen Psychiatry . 1988;45:1100-1106.Crossref 5. Jaffe A, Froom J, Galambos N. Minor depression and functional impairment . Arch Fam Med . 1994;3:1081-1086.Crossref 6. Snaith RP. The concepts of mild depression . Br J Psychiatry . 1987;150:387-393.Crossref 7. Coulehan JL, Schulberg HC, Block MR, Janosky JE, Arena VC. Depressive symptomatology and medical co-morbidity in a primary care clinic . Int J Psychiatry Med . 1990;20:335-347.Crossref 8. Sherbourne CD, Wells KB, Hays RD, Rogers W, Burnam MA, Judd LL. Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients . Am J Psychiatry . 1994;151:1777-1784. 9. Judd LL, Rapaport MH, Paulus MP, Brown JL. Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatry . 1994;55:18S-28S. 10. Philipp M. The risk of minor depression in families of probands with major depression: sex differences and familiality . Eur Arch Psychiatry Clin Neurosci . 1992;242:89-92.Crossref 11. Katon W, Lin E, von Korff M, Bush T, Walker E, Simon G, Robinson P. The predictors of persistence of depression in primary care . J Affect Disord . 1994:31:81-90.Crossref 12. Skodol AE, Schwartz S, Dohrenwend BP, Levav I, Shrout PE. Minor depression in a cohort of young adults in Israel . Arch Gen Psychiatry . 1994;51:542-551.Crossref 13. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA . 1990;264:2524-2528.Crossref 14. Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community . JAMA . 1992;267:1478-1483.Crossref 15. Berkman LF, Berkman CS, Kasl S, Freeman DH Jr, Leo L, Ostfeld AM, Cornoni Huntley J, Brody JA. Depressive symptoms in relation to physical health and functioning in the elderly . Am J Epidemiol . 1986;124:372-388. 16. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, Berry S, Greenfield S, Ware J. The functioning and well-being of depressed patients: results from the Medical Outcomes Study . JAMA . 1989;262:914-919.Crossref 17. Klerman GL, Weissman MM, Ouellette R, Johnson J, Greenwald S. Panic attacks in the community: social morbidity and health care utilization . JAMA . 1991;265:742-746.Crossref 18. Leon AC, Portera L, Weissman MM. The social costs of anxiety disorders . Br J Psychiatry . 1995;166:19-22.Crossref 19. Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB. Somatization in the community: relationship to disability and use of services . Am J Public Health . 1987;77:837-840.Crossref 20. Webb GR, Redman S, Hennrikus DJ, Kelman GR, Gibberd RW, Sanson-Fisher RW. The relationships between high-risk and problem drinking and the occurrence of work injuries and related absences . J Stud Alcohol . 1994;55:434-446. 21. Jenkins R, Harvey S, Butler T, Thomas RL. A six-year longitudinal study of the occupational consequences of drinking over 'safe limits' of alcohol . Br J Ind Med . 1992;49:369-374. 22. Calzavara LM, Coates RA, Raboud JM, Farewell WT, Read SE, Shephered FA, Fanning MM, MacFadden D. Ongoing high-risk sexual behaviors in relation to recreational drug use in sexual encounters: analysis of 5 years of data from the Toronto Sexual Contact Study . Ann Epidemiol . 1992;3:272-280.Crossref 23. Van Trigt L, Kreuger H, Westerman RF, Hull FM. Morbidity at an Amsterdam inner-city clinic in relation to drug use . Fam Pract . 1989;6:299-302.Crossref 24. Von Korff M, Shapiro S, Burke JD, Teitlebaum M, Skinner EA, German P, Turner RW, Klein L, Burns B. Anxiety and depression in a primary care clinic . Arch Gen Psychiatry . 1987;44:152-156.Crossref 25. Clayton PJ. The comorbidity factor: establishing the primary diagnosis in patients with mixed symptoms of anxiety and depression . J Clin Psychiatry . 1990;56:15S-22S. 26. Kessler RL, McGonagle KA, Zhao S, Nelson CR, Hughes M, Eshelman S, Wittchen HU, Kendler K. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey . Arch Gen Psychiatry . 1994;51:8-19.Crossref 27. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study . JAMA . 1990;264:2511-2518.Crossref 28. Liebowitz MR. Mixed anxiety and depression: should it be included in DSM-IV? J Clin Psychiatry . 1993;54:4S-7S. 29. Leon AC, Shear MK, Portera L, Klerman GL. Assessing impairment in patients with panic disorders: the Sheehan Disability Scale . Soc Psychiatry Psychiatr Epidemiol . 1992;27:78-82.Crossref 30. Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL. Quality of life in panic disorder . Arch Gen Psychiatry . 1989;46:984-992.Crossref 31. Spitzer RL, Williams JBW, Gibbon M, First M. The structured clinical interview for DSM-III-R (SCID), I: history, rationale, and description . Arch Gen Psychiatry . 1992;49:624-629.Crossref 32. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994. 33. Fleiss JL. The Design and Analysis of Clinical Experiments. New York, NY: John Wiley & Sons Inc; 1986. 33. Sheehan D, Janavs J, Knapp E, Sheehan M, Baker R. Mini-International Neuropsychiatric Interview Clinician Rated, Version 4.0. Tampa, Fla: University of South Florida College of Medicine; 1992. 34. Sheehan DV, Lecrubiier Y, Janavs J, Weiller, Bonara LI, Keskiner A, Schinka J, Knapp E, Sheehan MF, Dunbar GC. Reliability and validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P. Presented at the New Clinical Drug Evaluation Unit 35th Annual Meeting; May 31, 1995; Orlando, Fla. 35. Horwath E, Johnson J, Klerman GL, Weissman MM. Depressive symptoms as relative and attributable risk factors for first-onset major depression . Arch Gen Psychiatry . 1992;49:817-823.Crossref 36. Wells KB, Burnam MA, Rogers W, Hays R, Camp P. The course of depression in adult outpatients . Arch Gen Psychiatry . 1992;49:788-794.Crossref 37. Angst J. The history and concept of recurrent brief depression . Eur Arch Psychiatry Clin Neurosci . 1994;244:171-173.Crossref 38. Elkin I, Shea T, Watkins JT, Imber SD, Stotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP, Fiester SJ, Parloff MB. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments . Arch Gen Psychiatry . 1989;46:971-982.Crossref 39. Paykel ES, Hollyman JA, Freeling P, Sedgwick P. Predictors of therapeutic benefit from amitriptyline in mild depression: a general practice placebo-controlled trial . J Affect Disord . 1988;14:83-95.Crossref 40. Depression Guideline Panel. Depression in Primary Care: Treatment of Major Depression: Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; April 1993;2. AHCPR publication 93-0551. 41. Boyer W. Serotonin uptake inhibitors are superior to imipramine and alprazolam in alleviating panic attacks: a meta-analysis . Int Clin Psychopharmacol , 1995;10:45-49.Crossref 42. Stewart JW, Quitkin FM, Klein DF. The pharmacotherapy of minor depression . Am J Psychother . 1992;46:23-36. 43. Wells KB, Burnam MA, Leake B, Robins LN. Agreement between face-to-face and telephone-administered versions of the depressive section of the NIMH Diagnostic Interview Schedule . J Psychiatr Res . 1988;22:207-220.Crossref 44. Paulson SA, Crowe RR, Noyes R, Pfohl B. Reliability of the telephone interview in diagnosing anxiety disorders . Arch Gen Psychiatry . 1988;45:62-63.Crossref 45. Watson CG, Anderson PE, Thomas D, Nyberg K. Comparison of telephone and face-to-face diagnostic interview schedules . J Nerv Ment Dis . 1992;180:534-535.Crossref 46. Simon GE, Revicki D, Von Korff ML. Telephone assessment of depression severity . J Psychiatr Res . 1993;27:247-252.Crossref 47. Gfroerer JC, Hughes AL. The feasibility of collecting drug abuse data by telephone . Public Health Rep . 1991;106:384-393.

Journal

Archives of General Psychiatry – American Medical Association

Published: Oct 1, 1996

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