Current DSM-IV somatoform diagnoses may inadequately capture many somatizing patients in primary care. By using data from two studies (1,000 and 258 patients, respectively), the authors determined 1) the optimal threshold on a checklist of 15 physical symptoms to screen for a recently proposed somatoform diagnosis, multisomatoform disorder (MSD), and 2) the concordance between MSD and somatization disorder. The optimal threshold for pursuing a diagnosis of MSD was seven or more physical symptoms. The majority (88%) of the patients who met criteria for MSD had either full or abridged somatization disorder. MSD was intermediate between abridged and full somatization disorder in terms of its association with functional impairment, psychiatric comorbidity, family dysfunction, and health care utilization and charges.

OBJECTIVETo determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression.METHODSOne thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship.RESULTSFour symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables.CONCLUSIONA strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.

BACKGROUND For clinical or research use in primary care, the DSM-IV diagnostic criteria for somatization disorder are too restrictive, while the criteria for undifferentiated somatoform disorder are overly inclusive. In this article, we examine the validity of multisomatoform disorder, defined as 3 or more medically unexplained, currently bothersome physical symptoms plus a long (> or = 2 years) history of somatization. METHODS Data from the Primary Care Evaluation of Mental Disorders Study of 1000 patients from 4 primary care sites were analyzed. The outcomes assessed were 6 domains of health-related quality of life, using the 20-item Short-Form General Health Survey; self-reported disability days and health care use; satisfaction with care; and physician-rated difficulty of the encounter. RESULTS Multisomatoform disorder was diagnosed in 82 (8.2%) of the 1000 patients who were enrolled in the Primary Care Evaluation of Mental Disorders Study. Compared with mood and anxiety disorders, multisomatoform disorder was associated with comparable impairment in health-related quality of life, more self-reported disability days and clinic visits, and greater clinician-perceived patient difficulty. CONCLUSIONS Multisomatoform disorder may be a valid diagnosis and potentially more useful than the DSM-IV diagnosis of undifferentiated somatoform disorder. Also, because multisomatoform disorder has a large and independent effect on impairment, its diagnosis should not be precluded simply because of a coexisting mood or anxiety disorder.

September 1995 marked the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version (DSMIV-pC).l This manual, the result of a 5-year collaboration among leaders in mental health and primary care fields, is published by the American Psychiatric Association as an official task force report. The following organizations formally participated in the development process by recommending participants and providing resources: American Academy of Family Physicians, American Board of Family Practice, Society of Teachers of Family Medicine, Association of Departments of Family Practice, American College of Physicians, Society of General Internal Medicine, American College of Obstetrics and Gynecology, American Academy of Pediatrics, and American Psychiatric Association. The American Medical Association, acknowledging that this cooperative effort was unprecedented, also participated. We will describe the reasons for such a manual, the process whereby it was developed, its form and content, its limitations, and its intended uses. Diagnoses are fundamental to clinical conversation-they make it possible to measure the content of practice and to generalize across practices. They are an essential prerequisite to the measurement of treatment effectiveness and are indispensable to the clinician who wishes to know whether a treatment shown effective in a clinical trial is likely to help an individual patient. Mental diagnoses in the primary care setting, however, have always been problematic. Family

To the Editor. —Dr Goodwin 1 raises numerous important points concerning the intricacies of managing depression in an era of increased managed care. However, Goodwin's suggestions for pharmacotherapy were somewhat surprising. Mr N apparently showed a partial response to imipramine, but did not do well on fluoxetine; we are unclear as to his response to bupropion. It also appears that Mr N's medications will have to be managed to a certain extent by his primary care physician. Given this, the rationale is not clear for retrying bupropion and then engaging in augmentation therapy, which is usually not a part of routine primary care practice. A different approach would be to try venlafaxine as a first choice, rather than as a second- or third-line agent, since it is a mixed reuptake inhibitor 2 like imipramine, but as Goodwin mentioned, has a favorable adverse effect profile. This approach also would simplify treatment

OBJECTIVES: To determine gender differences in the frequency and manifestation of depression in primary care.STUDY DESIGN: PRIME-MD(R), a new assessment tool, was tested in 1000 patients as an aid to diagnose depression in primary care patients. Answers to a self-assessment questionnaire completed by patients determined whether physicians administered the mood module in the Clinician Evaluation Guide to diagnose depression. Functional status was assessed with the Medical Outcomes Study Short Form (SF-20).RESULTS: More women than men were diagnosed as having a mood disorder (31% vs 19%; p < 0.01), and an antidepressant was newly prescribed only for women (p < 0.001). There were no gender differences in physician ratings of patients' health, but women rated their health significantly more poorly than did men. Similarly, functional impairment scores were significantly lower in women than in men.CONCLUSIONS: Women are much more likely than men to have depressive disorders, and when these disorders are diagnosed, to receive a prescription for antidepressant medication. Further research is needed to determine why women seem to suffer disproportionately from symptoms of depression and signs of functional impairment.

Objective.-To determine if different mental disorders commonly seen in primary care are uniquely associated with distinctive patterns of impairment in the components of health-related quality of life (HRQL) and how this compares with the impairment seen in common medical disorders.Design.-Survey.Setting.-Four primary care clinics.Subjects.-A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians using PRIME-MD (Primary Care Evaluation of Mental Disorders) to make diagnoses of mood, anxiety, alcohol, somatoform, and eating disorders.Main Outcome Measures.-The six scales of the Short-Form General Health Survey and self-reported disability days, adjusting for demographic variables as well as psychiatric and medical comorbidity.Results.-Mood, anxiety, somatoform, and eating disorders were associated with substantial impairment in HRQL, Impairment was also present in patients who only had subthreshold mental disorder diagnoses, such as minor depression and anxiety disorder not otherwise specified. Mental disorders, particularly mood disorders, accounted for considerably more of the impairment on all domains of HRQL than did common medical disorders. Finally, we found marked differences in the pattern of impairment among different groups of mental disorders just as others have reported unique patterns associated with different medical disorders. Whereas mood disorders had a pervasive effect on all domains of HRQL, anxiety, somatoform, and eating disorders affected only selected domains.Conclusions.-Mental disorders commonly seen in primary care are not only associated with more impairment in HRQL than common medical disorders, but also have distinct patterns of impairment. Primary care directed at improving HRQL needs to focus on the recognition and treatment of common mental disorders. Outcomes studies of mental disorders in both primary care and psychiatric settings should include multidimensional measures of HRQL.

This study was undertaken in order to better understand the detection of depression by primary care physicians. Specifically, we investigated the relationship between information gathered during the course of the medical interview and the subsequent diagnosis of depression. Forty-seven community-based primary care physicians, unaware of the mental health focus of this research, were videotaped in the office setting, as they interviewed two “typical” standardized patients who met DSM-III-R criteria for major depression. One patient presented with headaches and the other presented with palpitations and chest pain. After each interview, physicians were provided with physical findings and results of any diagnostic procedures they ordered, then asked to construct and explicate their differential diagnoses. The two patients were correctly diagnosed as depressed by 53 and 45% of the physicians. Although detection was related to greater amounts of information gathered, inquiry about the DSM-III-R criteria symptoms was generally low, and in no case was sufficient information acquired to make a formal DSM-III-R diagnosis of depression. However, a subset of the DSM-III-R symptoms (those related to disturbances of appetite, sleep, and other neurovegetative functions) were among the reasons cited for inclusion of depression in the differential, as were psychosocial stressors and the patient's appearance. These findings suggest that detection of depression is low by primary care physicians.

OBJECTIVES:To measure primary care physicians' attitudes toward psychosocial issues, determine their relationship to the style of the medical interview, and assess whether attitudes and interview behaviors lead to correct diagnosis in patients with depression.DESIGN:Physicians were videotaped while interviewing four patients standardized with criteria symptoms of major depression. Physicians were unaware of the mental health focus of the study.SETTING:Patient examining rooms.PARTICIPANTS:Physicians were eligible for recruitment if they were board certified or eligible in family practice or internal medicine, practiced primary care medicine, and were listed in regional directories. Standardized patients were recruited from the community.MAIN OUTCOME MEASURES:Attitudes toward psychosocial issues (measured by the Physician Belief Scale), interview content (measured by review of the videotaped encounters), interview behaviors (measured by the Interaction Analysis System for Interview Evaluation), and a listing of depression in the differential diagnosis (determined by physician debriefing interviews).RESULTS:Forty-seven community-based practitioners participated. Forty-eight percent of interviews resulted in a diagnosis of depression. Physician Belief Scale scores were not significantly correlated with patient-centered interviewing, psychosocial questions, inquiry about depression symptoms, or a depression diagnosis. Longer interviews were more likely to result in a depression diagnosis.CONCLUSIONS:High interest in psychosocial issues was not associated with patient-centered interviewing behaviors, questions about psychosocial or depression symptoms, or depression diagnoses. However, certain patient-centered interviewing behaviors, particularly those defined as "affective," did lead to the recognition of depression.

Objective.-To assess the validity and utility of PRIME-MD (Primary Care Evaluation of Mental Disorders), a new rapid procedure for diagnosing mental disorders by primary care physicians. Design.-Survey; criterion standard. Setting.-Four primary care clinics. Subjects.-A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians.Main Outcome Measures.-PRIME-MD diagnoses, independent diagnoses made by mental health professionals, functional status measures (Short-Form General Health Survey), disability days, health care utilization, and treatment/ referral decisions.Results.-Twenty-six percent of the patients had a PRIME-MD diagnosis that met full criteria for a specific disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. The average time required of the primary care physician to complete the PRIME-MD evaluation was 8.4 minutes. There was good agreement between PRIME-MD diagnoses and those of independent mental health professionals (for the diagnosis of any PRIME-MD disorder, kappa=0.71; overall accuracy rate=88%). Patients with PRIME-MD diagnoses had lower functioning, more disability days, and higher rates of health care utilization than did patients without PRIME-MD diagnoses (for all measures, P<.005). Nearly half (48%) of 287 patients with a PRIME-MD diagnosis who were somewhat or fairly well-known to their physicians had not been recognized to have that diagnosis before the PRIME-MD evaluation. A new treatment or referral was initiated for 62% of the 125 patients with a PRIME-MD diagnosis who were not already being treated.Conclusion.-PRIME-MD appears to be a useful tool for identifying mental disorders in primary care practice and research.

OBJECTIVE:To examine how the type and number of physical symptoms reported by primary care patients are related to psychiatric disorders and functional impairment. DESIGN:Outpatient mental health survey. SETTING:Four primary care clinics. PATIENTS:One thousand adult clinic patients, of whom 631 were selected randomly or consecutively and 369 by convenience. MAIN OUTCOME MEASURES:Psychiatric disorders as determined by the Primary Care Evaluation of Mental Disorders procedure; the presence or absence of 15 common physical symptoms and whether symptoms were somatoform (ie, lacked an adequate physical explanation); and functional status as determined by the Medical Outcomes Study Short-form General Health Survey. RESULTS:Each of the 15 common symptoms was frequently somatoform (range, 16% to 33%). The presence of any physical symptom increased the likelihood of a diagnosis of a mood or anxiety disorder by at least twofold to three-fold, and somatoform symptoms had a particularly strong association with psychiatric disorders. The likelihood of a psychiatric disorder increased dramatically with increasing numbers of physical symptoms. The prevalence of a mood disorder in patients with 0 to 1, 2 to 3, 4 to 5, 6 to 8, and 9 or more symptoms was 2%, 12%, 23%, 44%, and 60%, respectively, and the prevalence of an anxiety disorder was 1%, 7%, 13%, 30%, and 48%, respectively. Finally, each physical symptom was associated with significant functional impairment; indeed, the number of physical symptoms was a powerful correlate of functional status. CONCLUSIONS:The number of physical symptoms is highly predictive for psychiatric disorders and functional impairment. Multiple or unexplained symptoms may signify a potentially treatable mood or anxiety disorder.

Management of pharyngitis remains an important and controversial subject. A retrospective chart review at the University of South Alabama Family Practice Center was undertaken to assess changes in physician prescribing and testing patterns since the advent of rapid testing of streptococcal pharyngitis (rapid strep tests [RST]). Charts for study were identified by encounter form coding of a diagnosis of streptococcal pharyngitis or pharyngitis not otherwise specified. Control and test groups were formed based on the availability of the RST, and a stratified sample was drawn from each group. In the group of patients studied after the RST became available, data analysis showed a significantly increased likelihood that patients received antibiotics with a positive RST (odds ratio [OR] = 6.42), whereas those patients with a negative or no RST were significantly less likely to receive antibiotics (OR = 2.50 and 2.48, respectively). Group assignment was a significant predictor of test-ordering behavior (P less than 0.05). A higher than expected rate of streptococcal pharyngitis was noted in the group of patients who had the RST available to them. The RST plays an important though not fully defined role in the current management of pharyngitis.