Psychiatrya0~ PsychiatricEpidemiology
Soc Psychiatry Psychiatr Epidemiol (1992) 27:234-241
Social
9 Springer-Verlag 1992
DSM-III mental disorders in general medical sector: a follow-up and incidence study over a two-year period G. Berti Ceroni 1, E Berti Ceroni 2, R. Bivi 3, M. A. Corsino 4, P. D e Marco 4, E. Gallo 5, G. Giovannini 5, S. Gherardi 5, A. Pezzoli 4, E Rucci 6, and C. Neri 4 Servizio di Salute Mentale, USL 29, East Bologna, Italy 2Servizio di Salute Mentale, USL 26, S. Giovanni in Persiceto (Bologna), Italy 3Servizio di Salute Mentale, USL 31, Ferrara, Italy 4Servizio di Salute Mentale, USL 27, West Bologna, Italy Servizio di Salute Mentale, USL 23, Imola (Bologna), Italy 6Consultant in Statistics, USL 29, East Bologna, Italy Accepted: June 29, 1992
Summary. In three general medical settings (general practice, hospital medical wards and emergency rooms) about 20 % of the adult attenders had a DSM-III mental disorder, mainly in the area of affective and anxious disorders. Some of these disorders were quite severe. Of those cases reassessed i year and 2 years after the first interview, less than a quarter reached a "no-diagnosis status". The chronicity of most cases dependent on the interplay not only of either relapse or duration of the main disorder but also of comorbidity and incidence of new disorders. A high incidence of more transient disorders in subjects who were well at first assessment was also found.
In the 1970s, Regier et al. [1] found that in the United States only one fifth of the people affected by mental disorders were served by the specialized mental health care sector, with slightly over one half seeking treatment in the general medical care sector. Even in the 1980s, in four locations in the United States E C A programme, 45-59 % of people with mental disorders had contacted general medical practices while only between 8 and 12 % had contacted mental health services [2]. In Verona-South (Italy), Tansella and Williams [3], on the basis of different studies using the General Health Questionnaire and Clinical Interview Schedule, estimated a 1-week prevalence of 22.7 % in the community and of 3.4 % in general practice, while in the psychiatric services the 1-week prevalence by case register - was only 0.37%. Despite the huge amount of data obtained over the last 30 years on the clinical features of mental disorders in the general medical sector, we are still very much in the dark in such crucial areas as incidence, prevalence, severity and course. This is partly a result of the diversity in diagnostic methods. Categorical diagnostic systems, which have been greatly improved in American psychiatry during the last 20 years, have come in for criticism because they often fail to pick up all the nuances of mental disorders when used in the general medical sector. On the other hand, dimensional methods, such as questionnaires or scales, provide data that cannot be collated or related to mental disorders as diagnosed in
psychiatric settings by categorical systems. Wittchen [4] has recently reviewed the problems of the assessment of mental disorders in primary care. In hospitals, where mental disorders are more likely to be associated with physical disease, the diagnostic problem is even greater because diagnostic systems are inadequately validated for people with physical illness [5]. Studies with a sound methodology are rare [6]. The emergency room, which is most likely to be attended by people with psychic disturbances, is rarely studied [7]. We, therefore, decided to study DSM-III [8] mental disorders in three general medical settings, i. e. general practice, hospital emergency rooms and medical wards.
Methods The aim of this study was to investigate mental disorders in adults attending the general medical sector, using a categorical diagnostic system, the DSM-III, to diagnose cases [8]. Apart from the findings of the cross-sectional survey, our main aim was to obtain a prospective view of the course of these disorders over a 2-year period and see how many disorders would appear in those who were, at first, "non-cases". We believe that a better knowledge of such clinical features would be of importance in providing proper programmes to improve the detection and treatment of these disorders. We extended the field of the study to the global general medical sector rather than limiting it to general practice, mainly because the three parts of the general medical sector (general practice, medical wards and emergency rooms) cannot be kept distinct in the Italian health organization. Indeed, the "emergency" service is frequently overused in Italy, with people considering it a simple extension of their doctor's surgery, so much so that the government is now trying to modify this misuse. At present, the Italian Health Service allows everyone a fee-free general practitioner of their own choice whom they can see at will or whom they have to see for a variety of administrative practices. During the night and at weekends,
235 Table 1. Progressive steps towards identification of cases in three general medical settings
Contacted Refused SQ Could not be located Refused interview Excluded because in treatment Excluded for other reasons Assessed Cases
General practice n Women 4d3 57 % 49 65 % 10 70 % 70 74 % ]0 60 % 5 60 % 299 51% 66 76 %
MedicaI ward n Women 312 25 0 8 14 29 236 40
46% 60% 0% 50% 79 % 3t % 44% 70%
Emergency rooms
Total
n 186 48 6 5 7 2 118 25
n 941 122 16 83 31 36 653 131
Women 51% 69% 50 % 60% 71% 50 % 42% 72%
Women 57% 66% 63 % 71% 71% 36 % 53% 73%
SQ, Kellner Symptom Questionnaire
when the GP is not available, or in those cases needing urgent examination involving instruments (even something as simple as an E C G ) , patients are allowed free use of hospital emergency departments. On the request of a hospital doctor, patients can be admitted to hospital, usually to a medical ward if there is no precise diagnosis. It is, in fact, from medical wards that the largest number of requests for psychiatric consultation come [9, 10]. This study was carried out in four sites of the Regione Emilia Romagna, and administrative area ("Regione") in northern Italy with 4,150,000 inhabitants, which enjoys a high socio-economic and cultural standard of living and with health and psychiatric services among the best in Italy. The four sites are: a 65,000 inhabitant district of Bologna, Emilia Romagna's main town with more than 450,000 inhabitants; Casalecchio, a 50,000 inhabitant suburb of Bologna; Imola, a small town with fewer than 100,000 inhabitants; and Lugo, a small thriving country town of about 50,000 inhabitants. These four sites were sufficiently representative of the whole Regione with similar health and psychiatric services. The study involved adults contacted while they were attending their GP's practice or local hospital emergency room or who had been admitted to a hospital medical ward. Eleven GPs were chosen by their Association (Federazione Italiana Medici di Medicina Generale) on the basis of more than 10 years' serLiority and regular attendance at in-service training courses. The emergency rooms and medical ward belong to the three different hospitals (Imola, Lugo, Bologna's Ospedale Maggiore) serving the four sites where the research was carried out. Subjects were contacted in the first and in the last 4 months of 1987. The summer months were excluded because it would have been difficult to contact people at this time and a 3-month follow-up had already been planned. Each doctor's surgery and hospital medical ward was visited on five different weekdays over a 5-week period. Each of the emergency rooms was visited at different times of day over a 1-week period, in order to cover two full 24-h cycles. In the emergency rooms and medical wards patients were contacted only if they lived in the four sites studied. All stages of the examination were carried out by postgraduate medical students specializing in psychiatry. The first stage was to present the self-evaluative Kellner Symptom Questionnaire (SQ) [11] to all subjects between the ages of 18 and 59 years inclusive. The SQ was chosen because it had already been translated and validated for use in Italy [12] at the time of the present study.
The first 253 people were interviewed independently of their SQ scoring in order to obtain a control group and to confirm the cut-off points of the four SQ subscales; we obtained a good sensitivity, though at some cost to specificity (detailed data will be published elsewhere). Only subjects who scored greater than 6 on one of the anxiety, depression and hostility subscales and greater than 8 on the somatization subscale were subsequently interviewed. The interview took place whenever and wherever the subjects requested it: at the GP's surgery, at hospital or at home. The interview was unstructured, although anchored to the different scales which make up the minicompendium of rating scales that Bech et al. [13] have put forward as an aid to making a diagnosis with DSM-III. These are: Hamilton Anxiety Scale (HAS) [14], Hamilton Depression Scale (HDS) [15], Melancholia Scale (MES) [16], Mania Scale (MAS) [17] and Brief Psychiatric Rating Scale (BPRS) [18]. In the "cases" and in some of the "noncases" (202 subjects) the interviewers also gathered other clinical and social data: marital, professional and educational status; lifestyle (living alone, number of children, number of children under 14, social support in and outside the home); life events and prolonged major difficulties of more than 2 years duration; clinical history of subject and subject's family, including age and type of onset and duration of present disorder if any. Finally, the Global Assessment Scale [19] score was rated. The normality of the scales (SQ, HAS, HDS and BPRS) was assessed by means of the Kolmogorov-Smirnov test. A moderate skewness was present in BPRS (noncases), but this does not invalidate the analysis of variance results. All the data relating to each patient were reviewed during weekly sessions by the more experienced clinicians (G.B.C and A.R). It was sometimes necessary to obtain more detailed information by means of a supplementary interview. We decided to exclude subjects for the following reasons: 1. To spare them the distress of an unnecessary medical examination; patients affected by organic mental disorders, mental retardation, schizophrenia, severe or incurable diseases and pregnant women were excluded. 2. Since it would have been difficult to locate them for follow-up, persons of no fixed abode, drug addicts and alcoholics were excluded. 3. In order not to interfere in the relationship with their therapist, patients already undergoing specialist mental
236 Table 2. Distribution of diagnoses (%) following hierarchy in three general medical settings. The overall diagnoses are given for the total sample in the last column. Hierarchy is shown moving down in the left column General practice
Medical wards
Emergency rooms Total hierarchy
Total overall
Major depressive disorders
13.6
22.5
8.0
15.3
15.3
Panic disorders + agoraphobia either with and without panic attacks Adjustment disorders
7.60 10.6
25.0 15.0
28.0 -
16.8 9.90
19.8 11.4
Dysthymic disorders
36.4
22.5
20.0
29.0
35.9
Generalized anxiety disorders Personality disorders
10.6 12.1
12,5
20.0
13.0
19.8
Other disorders (miscellaneous) Total
-
9.10 50.4
4.00 2.50
30.5
health t r e a t m e n t were excluded, A n additional reason for this was that, while general practitioners and hospital doctors were involved in the research p r o g r a m m e , no such inv o l v e m e n t was possible with scattered therapists all working independently. 4. Since we disagreed with D S M - I I I about simple phobia, which we consider a very f r e q u e n t psychological characteristic, rather than a disorder deserving medical treatment, we included p e o p l e having simple p h o b i a either a m o n g cases, if they had a n o t h e r D S M - I I I disorder, or a m o n g non-cases, if they had not. In all, 120 subjects out of the 131 w h o were given at least one diagnosis by means of D S M - I I I and 134 out of the 202 with no diagnosis were r e c o n t a c t e d for further interviews at intervals of 3, 12 and 24 months.
In the general medical sector, 941 subjects were contacted. Table 1 shows that almost o n e - q u a r t e r of these could not be interviewed. A b o u t 10 % were excluded; the principal reason for exclusion was that the subject was already undergoing mental health specialist treatment, which is not to say that all these persons h a d a D S M - I I I disorder. T h e r e was no significant age difference b e t w e e n the various categories considered in Table 1. Females prevailed in subjects w h o could not be examined, in those w h o were excluded because they were already receiving t r e a t m e n t and in subjects with at least one D S M - I I I disorder. T h e diagnostic picture for cases followed a hierarchical criterion; the overall diagnosis is given for the total sample (Table 2). T h e hierarchical criterion takes into account only the m a i n diagnosis on axis I following the indications in D S M - I I I . T h e f r e q u e n c y of diagnoses was similar in the three settings except for panic disorder/agoraphobia, which was m o r e frequent in the e m e r g e n c y r o o m setting. M a j o r depressive disorder (20 subjects) consisted mostly of single episodes (15 subjects), while recurrent episodes were rarer (5 subjects). Bipolar disorder was also rare (2 subjects) and was, therefore, included in the other disorders group. A g o r a p h o b i a without panic attacks was also infrequent (4 subjects) and was included in
24.4
9.20
19.1
12.2
100
138.8
panic disorder (16 subjects) and a g o r a p h o b i a with panic attacks (14 subjects) rather than in other disorders. Table 3 shows that, at first assessment, demographic, clinical and social differences b e t w e e n cases and noncases were highly significant. T h e r e was a higher prevalence of w o m e n a m o n g the cases, although o n e - w a y analysis of variance of the scales with two factors (sex and group) showed that the differences were mainly due to "caseness". Differences c o n c e r n e d both observer scales and the self-report questionnaire on clinical symptoms. O f the social variables, only the lack of social support (both inside and outside the h o m e ) and the presence of m a j o r Table 3. Comparison between cases and non-cases at the first interview Cases (131) Non-cases (202) Mean age (+ SD)
Results
6.90
20.0
Sex:M F Mean age F
40.5_+12.3 t - - 1.05 NS 35 (26.7%) 105 (52%) Z2= 19.79'** 96 (73.3%) 97 (48%) 37.3 _+11.4 40.2_+12.2 t = - 1.66 NS
Duration of disorder > 1 year %
60.30
Hamilton Depression Scale(mean _ + S D ) Hamilton Anxiety Scale (mean _+SD) Brief Psychiatric Rating Scale (mean + SD)
39.1+11.5
11.9+5.2
3.8_+2.9
t = 15.74"**
15.2 + 6.1
5.1 _+3.7
t = 16.35"**
1.93 -+1.63
t = 15.48'**
6.5 -+2.9
Symptom Questionnaire (total of the four subscales: 32.8-+ 10.9 20.8_+10.1 mean _+SD) Axis IV of DSM-IIf (mean • 2.66_+1.7 2.26 + 1.5
t = 2.61"*
Major difficulties % of which multiple %
t = 10.1'**
53.4 10.7
16.4 3.5
z = 7.013"** z = 2,405*
No social support in and outside the home % 15.3
2.9
z = 3.301"**
49.2
71.1
z = 3.556***
80.8
16.4
Z2= 114.09"**
Social support in and outside the home % Global Assessment Scale (% subjects < 70)
* P < 0.05; ** P < 0.01; *** P < 0.001; NS, non-significant
237 100% 90%
~ - -
MDD
--*--
AD
~ - -
GAD
~ - -
OD
80%
PA/Ag
70% 60%
DD
50% 40% 30%
PeD
20% 10% 9 0~ tO
total
I
I
I
3 months
1 year
2 years
Fig.1. Diagnostic pattern of continuing illness in the 62 cases assessed at all three follow-ups. MDD Major Depressive Disorder; PaD/Ag Panic Disorder +Agoraphobia either with and without panic attacks; A D Adjustment Disorder; GAD Generalized Anxiety Disorder; DD DysthymicDisorder; PeD PersonalityDisorder; OD Other Disorders (miscellaneous)
34
35 %
3~fthr.._o,hF 20
.....................
~
................
25
...........................
20
.......................
MDD PzO/Ag
AD
GAD
DO
0eD
OD
MOO PaOeAg AD
GAD
OD
PeD
OO
Moo P~O/Ag
AO
GAD
DO
Pea
OD
MDD PaD/Ag
GAD
DO
PeO
O0
AD
Fig.2. Foursubsequentdiagnosticreassessmentsfor eachsingledisorder in the 62 cases assessed in all three follow-ups.MDD Major Depressive Disorder; PaD/Ag Panic Disorder + Agoraphobia either with and without panic attacks; A D Adjustment Disorder; GAD Generalized Anxiety Disorder; DD Dysthymic Disorder; PeD PersonalityDisorder; OD Other Disorders (miscellaneous)
difficulties differed significantly between cases and noncases. Ratings on the Global Assessment Scale differed significantly between the two groups. Of the 20 cases of major depressive disorder, 5 were rated higher than 20 on the Hamilton Depression Scale. Of the 120 cases who were invited for 1-year reassessment 85, accepted (70.8%). No significant differences existed at the first assessment between the 85 who sub-
sequently accepted 1-year reassessment and the 35 who declined. At the 1-year reassessm~nt, only 17 (20 %) had recovered and this had, for the most part, already occurred by the 3-month reassessment and remained stable at the 2-year reassessment (22.1%). Of the cases who attended 1-year reassessment, 80% also attended 3month and 2-year reassessments. Figure 1 shows the pattern of continuing illness in those 62 cases seen at all three follow-ups: while personality and dysthymic disorders persisted, other disorders (adjustment, major depressive and panic/agoraphobia) decreased greatly. There were, in addition, 4 recurrences: 1 major depressive disorder reappeared at the 2-year follow-up after 1 year of well-being; 1 panic/agoraphobia disorder had remitted by the 3month follow-up, but was newly present at the 1-year follow-up and then had remitted by the 2-year follow-up; a new adjustment disorder appeared in two patients at the 1-year and the 2-year follow-ups, respectively. Eight subjects had ten "new" disorders at the 1-year reassessment which were not present at the initial interview and four of these "new" disorders were already present at the 3month assessment. Of the 62 subjects reassessed after 2 years, a further 3 had four "new" disorders. The new disorders affected people suffering major depressive disorder (three dysthymic disorders) adjustment disorder (one major depressive disorder, one panic disorder/agoraphobia and one other disorder) and above all dysthymic disorders (four major depressive disorders, two generalized anxiety disorders, and one other disorder). However, the most striking feature was that the diagnostic picture of cases changed at each follow-up. Figure 2 shows clearly how varied the course of each individual illness was. Each column in the left top panel represents a diagnostic group. In the subsequent panels it can be seen that each groups is dramatically modified: the disappearance of one disorder not only brings out situations of no diagnosis but also hierarchically inferior disorders underlying the main diagnosis; hierarchically superior disorders may sometimes appear. Table 4 shows a rapid change in the rates of many scales and questionnaires and in the frequency of signs of social distress. By the second assessment, 3 months after the first, rates and percentages were as they would be at either the 1- or 2-year reassessment. In non-cases, the scores on some scales showed a sharp decrease as early as 3 months after initial assessment (from 5.1 + 11.1 to 3.2 _+3.2 in the Hamilton Depression Scale, from 6.5 + 11.2 to 4.5 + 3.6 in the Hamilton Anxiety Scale, from 20.1 + 9.3 to 12.8 _+10.5 in the Symptom Questionnaire total score) and then remained stable at subsequent reassessments. Non-cases, in contrast, did not show any change in the scores on the Global Assessment Scale or in the rate of other social variables over time, apart from the subjective evaluation of the lack of social support inside and outside the home. The analysis of variance (ANOVA) showed that the 1-year change in scores on the different scales was significantly larger in cases than in non-cases (P < 0.001 for Hamilton Depression and Anxiety scales, Symptom Questionnaire depression and Global Assessment Scale and P < 0.01 for Symptom Questionnaire total score). It may be of interest that in cases the scores in the scales built on symptoms de-
238 Table 4. Clinical and social features in cases at four assessments First 3-Month 1-Year 2-Year Mean age 39.8.+ 11.6 % females 77.6 Hamilton Depression Scale (mean _+SD) 13.1 .+ 11 7.7 _+5.6 8.1 .+6.1 7.1 _+5 Hamilton Anxiety Scale (mean _+SD) 16.2_+10.9 10_+6.5 11.3_+7.4 9.6_+6.2 Brief Psychiatric Rating Scale (mean 6.35 .+2.86 4.4 _+2.9 4.76+ 3.42 4.42_+3.09 .+SD) Symptom Questionnaire (total of the 4 subscales:mean .+SD) 32.7_+11 23.3_+15.623.7+15.3 21.8_+14.6 Axis IV of DSM III 2.67 • 1.7 2.07+ 1.5 2.51+ 1.7 2.63+ 1.6 (mean _+SD) Major difficulties% 56.4 39.7 40.0 32.8 11.8 14.7 9.4 6.0 of which multiple % No socialsupport in and 16.2 12.9 9.0 outside the home % 8.6 Social support in and 41.2 47.1 53.1 outside the home 55.6 Global Assessment Scale (% subjects< 70) 78.8 64.7 58.8 61.2
creased more rapidly than the Global Assessment Scale score increased, while the subjective evaluation of social support become even worse at the first two reassessments. In non-cases, as in cases, new disorders appeared at the reassessments: three new disorders in three subjects at the 3-month follow-up, seven in seven subjects at the 1-year follow-up and seven in six subjects at the 2-year follow-up. These new disorders in previous non-cases mainly concerned adjustment disorder (7 subjects) and panic disorder plus agoraphobia (3 subjects), but one case of major depression also occurred. Only 5 subjects had a history of mental disorder prior to the first assessment, while for 11 it would seem that we were dealing with a first incidence. A new disorder, however, occurred more frequently in the subjects who had a history of previous mental disorders (p < 0.05). Apart from this there were no significant differences between those with a new disorder and those who remained non-cases.
Discussion Prevalence
The prevalence of DSM-III mental disorders in the three general medical settings taken together was 20 %. This figure was certainly less than the real prevalence because of the inclusion criteria we adopted. (1) If all the 31 persons not included because they were already receiving treatment had a DSM-III mental disorder, the prevalence would rise to 23.7 % (131 + 31/653 + 31). Although possible, this would not be very likely because in the present study we found a group of 42 persons who had a distress, usually manifested by a high score in the Symptom Questionnaire, that did not meet the criteria of any DSM-III mental disor-
der. The impression these persons made at the clinical interview was that they merited treatment and they would have been accepted had they gone to a psychotherapist [20]. (2) Disorders that in the community [21] account for one-third of a 1-month prevalence (15.4 % ) (schizophrenia, drugs/alcohol abuse and antisocial personality) were excluded. The most frequent disorder in the study by Regier et al., phobia, includes simple phobia cases which we excluded. (3) If overall diagnoses were considered without taking account of the diagnostic hierarchy, a practice adopted in other studies, prevalence in our study would increase by more than a third. Taking all these correcting factors into account our data were close to those of the other few studies regarding primary care: H o e p e r et al. [22], using SADS-L in a site in Wisconsin, found an overall non-hierarchical prevalence of 26.7%. A similar prevalence (26.5 %) was found by Barrett et al. [23], again in small towns (in New Hampshire) and using SADS-L, but adopting diagnostic hierarchy in cases seen in a general medicine group over a 15-month period which was chosen to pick up low users. In an urban sample in Baltimore of low or moderately low income mainly non-white, female and middleaged, Von Korff et al. [24] established a hierarchical prevalence of 25 % using DIS/DSM-III. The prevalence in general medical settings is higher than that in the community, which is around 15 % when DIS/DSM-III is used [21, 25]. This must be borne in mind later in our discussion, when we are forced to use community data, given the scarcity of data on single disorders in general medical settings. In the present study affective and anxiety disorders accounted for more than 70 % of total disorders. However, chronic disorders such as dysthymic disorder and generalized anxiety (in additon to personality disorders) were most frequent. Rates for depressive disorders were at the lowest end of the wide range shown by the recent Zung [26] survey. This is particularly true for major depression, which in the present study was much less frequent than dysthymic disorder, while rates for the two conditions are equal in some R D C studies [27] and major depression is the more frequent in the Von Korff et al. DIS/DSM-III study [24]. The low rate of major depression and the higher rate of dysthymia might depend on the exclusion of the subjects already treated if there are several cases of major depression among them. In the community 1-month prevalence study [21], however, dysthymic disorder is about 30 % more frequent than major depression. Anxiety disorders in the present study were also low down in the 20 % range observed by H o p p e et al. [28] in their review. In the community 1-month prevalence study [21], anxiety disorders, even excluding generalized anxiety, are more frequent than depressive disorders. Having grouped together agoraphobia without panic attacks with either panic or agoraphobia with panic attacks, we have a rate neither for panic disorder, which otherwise varies over a wide range in other studies [29], nor for agoraphobia. The hierarchical prevalence of generalized anxiety disorder (3.2 %) was also lower than that obtained in other studies (3.6%, Sashidaran et al. [30]; 6%, Von Korff et al. [24]; 5.4% and 11.1%) for women and men, respectively, in H o p p e et al. [28]. Apart from the data of H o p p e et al. [28], which differ from ours both in their high overall rate and in
239 their difference between the sexes, we believe our stringent exclusion criteria were important in de~:ermining these differences. Especially surprising was the low rate of comorbidity between generalized anxiety and other disorders (looking at the total figure for all diagnoses, generalized anxiety increased by only 50%) given that, in a clinical sample, generalized anxiety has been diagnosed in cases of major depression, panic, and agoraphobia with panic, with a probability varying between 66.7 % and 83 % [30]. Overall, the rate of comorbidity was rather low. Many studies carried out in different settings insist particularly on anxious or depressive disorders being present at the same time, once the DSM-III diagnostic hierarchy has been suspended [31]. Hecht et al. [32] however, have shown how widely this comorbidity can vary due to a multiplicity of variables, and consequently our data in general medical settings may not be anomalous. Finally, our rate of personality disorders (1.4 %, excluding antisocial personality disorder) did not correlate with the findings in other studies in general medical settings and was higher, at 0.5 %, than that in the community [21].
Severity and the seeking of specialist treatment Observer rating scales and self-report questionnaires clearly discriminate between cases and non-cases for both symptoms and social conditions. They do not, however, discriminate between cases and outpatients attending psychiatric services in the same places for the first time (detailed data will be published elsewhere). The doubt expressed by Blacker and Clare [27] about the long-held view that only mild depressive disorders are found in general medical settings was confirmed by our data, which showed that one-quarter of case s of maj or depression had a score of greater than 20 on the Hamilton Depression Scale. In spite of these two indices of severity (scores not unlike those for new outpatients and quite high scores on the Hamilton Depression Scale in a group of cases with major depression), specialist mental health treatment is rarely sought. Even if the 31 subjects previously excluded because they were receiving treatment had a DSM-III disorder they would account for only 19.1% of the total cases (3!/131 + 31). Hough et al. [2] found an even lower proportion (1/6) of subjects seeking treatment in the specialized mental health care sector. Surprising data emerged from Florence, a town only 65 miles away from Bologna, where 80 % of the cases with a mood disorder consulted the family doctor and 60% of them were referred, sooner or later (the exact time is not given in the study), to specialist mental health treatment [33].
Coupe Two principal interrelated data emerged: the persistence of being a case and the changing of the diagnostic pattern, due to the disappearance of hierarchically superior disorders and the consequent emergence of hierarchically inferior ones and, to a lesser extent, to the appearance of new disorders, sometimes hierarchically superior to the previous ones.
Adjustment disorder had the highest recovery rate as a single disorder, followed by major depression and panic/agoraphobia. A recovery rate, although lower, also existed for generalized anxiety, dysthymic and even personality disorders. Comparison data are unavailable in the general medical care sector, and we must address ourselves to community and sometimes only to outpatient studies. In the community, the major depression rate halves in 1 year as a result of the interplay between chronicity and relapse [34, 35]. Panic/agoraphobia falls by onehalf in i year [36] and falls further over more prolonged periods [37]. A low recovery rate is established in the outpatient sector for generalized anxiety [31, 38] and a lower rate for dysthymic disorder [39]. The picture becomes more complex if we add the variables of comorbidity and incidence to the interplay of recovery, relapse and chronicity. It is widely established in clinical settings that comorbidity worsens the prognosis of each single disorder, and Schulberg et al. [40] have shown that this can hold even in the general medical care sector. But comorbidity at the inital assessment is an important factor in follow-up studies to explain why hierarchically inferior diagnoses will appear once superior ones have disappeared. Finally, the incidence of new disorders in those already recorded as cases must be considered. All these variables made it difficult for us to reach a no-diagnosis status, which only rose from 17.6% to 22.1% in the interval between the 3-month and the 2-year reassessment. The older studies, which often used idiosyncratic diagnostic procedures, reviewed by Kessler et al. [41] for primary care and Mayou et al. [42] for medical inpatients, agreed on the prolonged course of several cases. Kessler et al. [41] had the merit of highlighting the existence of continuing cases at two different assessments. In their study, however, the continuing cases at the 6-month follow-up of Hoeper et al.'s [22] SADS-L cases were fewer in number than the remitted ones. In the present study, in contrast, the continuing cases prevailed. This may have been due to the wider coverage or the larger mesh of the DSM-III net compared with SADS-L, which being the lifetime version gathers a larger number of cases than the instruments measuring current prevalence. The importance of the method in determining the heterogeneity of results in studies on depression and anxiety has recently been shown by Angst [43]. Other reasons, such as a different health organization, may also be hypothesized. Even at the first reassessment the scales scores changed dramatically but remained stable at the subsequent reassessments. A similar change was also observed in noncases. This pattern was noted by Kessler et al. [41] for the General Health Questionnaire and the Global Assessment Scale both in remitted and in continuing cases. In our data the scales built on the symptoms scores decreased more than the Global Assessment Scale score increased. The subjective evaluation of the social support received at home and outside the home worsened at the first and the second reassessments. Rather than expressing a decrease in severity, it is possible that this change in scales based on symptoms may denote a retest effect, that makes recall and dating of psychiatric symptoms less reliable [44, 45].
240 Incidence In 2 years, m a n y of those who were already cases at the initial assessment presented with a new disorder. We obtained a rate of 9.4% at the 1-year and of 4.4% at the 2-year follow-up. This was one of the factors in the overall course of cases discussed above. E v e n m o r e interesting were the data concerning incidence in those subjects who were not cases at the initial assessments: the rates of subjects who became cases at the 1-year and the 2-year reassessments were 13 % and 8.5 %, respectively. This was a notable total incidence pattern, higher than that found by Kessler et al. [41] in their 6-month follow-up study (8.2 %) and those found by the older studies reviewed by Kessler et al. [41]. There were m a n y other differences between our data and those of Kessler et al. [41]: the percentage of first incidence was as high as 68.7 % in the present study, while it was only 14 % in that of Kessler et al. [41]. Almost twothirds (58.8 %) of the new disorders in the present study belonged to the more acute and transient disorders (adjustment and panic with or without agoraphobia), while major depression and labile personality were the most frequent diagnoses in the new cases in the Kessler et al. [41] study. A p a r t from a different diagnostic system, it is not easy to account for such differences and not much help can be obtained from community studies [34, 37, 46], since these are both scarce and limited to particular epidemiological and methodological aims.
Conclusions The main cross-sectional and longitudinal findings were: 1. At least one in five people attending for care the general medical sector had a D S M - I I I disorder. Rates were higher for female patients. 2. Some of these disorders were severe. One-quarter of cases of major depression scored 20 or m o r e on the Hamilton Depression Scale. 3. These disorders were often chronic. More than 60 % of cases had a disorder lasting i year or m o r e at first assessment. The high rates either of dysthymic or personality disorders accounted for this long duration. 4. Chronicity was confirmed by the follow-up study. The recovery rate was low (less than one-quarter of cases in 2 years), although much higher rates were found if single disorders (such as adjustment, major depressive and panic/agoraphobia) were considered. 5. Chronicity in the follow-up study depended on the interplay, not only of either relapse or duration of the main disorder, but also of comorbidity and incidence of new disorders. 6. The incidence rate was quite high (13 % and 8.5 % in the 2 years following first assessment) even for non-cases at first assessment. It was a true first incidence for most cases, who mainly had transient disorders, such as adjustment and panic. The picture which emerged was thus quite complex. Although mild and chronic disorders prevailed, the opportunity of meeting either severe or transient disorders must
be kept in mind by those working in the general medical sector.
Acknowledgements. This work was supported by research grant no. 630 from Regione Emilia Romagna. We are grateful to M. Weissman, PhD, for her helpful suggestions.
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241 prevalence of mental disorders in the United States. Arch Gen Psychiatu 45:977-986 22. Hoeper EW, Nycz GR, Cleary PD, Regier DA, Goldberg ID (1979) Estimated prevalence of RD C mental disorder in primary care. Int J Ment Health 8:6-15 23. Barrett JE, Barrett JA, Oxman TE, Gerber PD (1988) The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 45:1100-1106 24. Von Korff M, Shapiro S, Burke JD, Teitelbaum M, Skinner EA, German R Turner RW, Klein D, Burns B (1987) Anxiety and depression in a primary care clinic: comparison of Diagnostic Interview Schedule, General Health Questionnaire and practitioner assessments. Arch Gen Psychiatry 44:152-156 25. Babigian HM, Reed SK (1989) Epidemiology of psychiatric disorders. Curr Op in Psychiatry 2:261-266 26. Zung WWK (1990) The role of rating scales in the identification and management of the depressed patient., in the primary care setting. J Clin Psychiatry [Suppl] 51:72-80 27. Blacker CVR~ Clare AW (1987) Depressive disorder in primary care. Br J Psychiatry 150:737-751 28. Hoppe SK, Leon RL, Realini JP (1989) Depression and anxiety among Mexican Americans in a family health center. Soc Psychiatry Psychiatr Epidemio124:63~58 29. Katon W (1986) Panic disorder: epidemiology, diagnosis and treatment in primary care. J Clin Psychiatry 47:21-27 30. Sashidharan SR Surtees PG, Kreitman NB, Ingham JG, Miller PMcC (1988) Hospital-treated and general-population morbidity from affective disorders. Comparison of prevalence and inception rates. Br J Psychiatry 152:499-505 31. Barlow DH, Blanchard EB, Vermilyea JA, Vermilyea BB, Di Nardo PA (1986) Generalized anxiety and generalized anxiety disorder: description and reconceptualization. Am J Psychiatry 143:40-44 32. Hecht H, Von Zerssen D, Wittchen H-U (1990) Anxiety and depression in a community sample: the influence of comorbidity on social functioning. J Affective Disord 18:137-144 33. Faravelli C, Guerrini Degl'Innocenti B, Aiazzi L, Incerpi G, Pailanti S (1990) Epidemiology of mood disorders: a community survey in Florence. J Affective Disord 20:135-141 34. Surtees PG, Sashidharan SR Dean C (1986) Affective disorder amongst women in the general population: longitudinal study. Br J Psychiatry 148:176-186 35. Sargeant JK, Bruce ML, Florio LR Weissman MM (1990) Factors associated with 1-year outcome of depression in the community. Arch Gen Psychiatry 47:519-526
36. Maier W, Buller R (1988) One-year follow-up of panic disorder. Eur Arch Psychiatry Neurol Sci 238:105-109 37. Vollrath M, Angst J (1989) Outcome of panic and depression in a seven-year follow-up: results of the Zurich study. Acta Psychiatr Scand 80:591-596 38. Nisita C, Petracca A, Akiskal HS, Galli L, Gepponi I, Cassano GB (1990) Delimination of generalized anxiety disorder: clinical comparison with panic and major depressive disorders. Compr Psychiatry 31:409-415 39. Keller MB, Sessa FM (1990) Dysthymia: development and clinical course. In: Burton SW, Akiskal HS (ed) Dysthymic disorder. Gaskell, London, pp 113-123 40. Stuhlberg HC, McClelland M, Gooding W (1987) Six month outcome for medical patients with major depressive disorders. J Gen Intern Med 2:312-317 41. Kessler LG, Cleary PD, Burke JD (1985) Psychiatric disorders in primary care. Results of a follow-up study. Arch Gen Psychiatry 42:583-587 42. Mayou R, Hawton K, Feldman E (1988) What happens to medical patients with psychiatric disorder? J Psychosom Res 32: 541549 43. Angst J (1990) Depression and anxiety: a review of studies in the community and in primary health care. In: Sartorius N, Gotdberg ID, De Girolamo G, Corte Esilva JA, Lecrubier Y, Wittchen H-U (eds) Psychological disorders in general medical settings. Hogrefe & Huber, Toronto, pp 60-68 44. Wittchen H-U, Burke JD, Semler G, Pfister H, Von Cranach M, Zaudach M (1989) Recall and dating of psychiatric symptoms. Arch Gen Psychiatry 46:437-443 45. Ormel J, Koeter MWJ, Van den Brink W (1989) Measuring change with the General Health Questionnaire (GHQ). Soc Psychiatry Psychiatr Epidemio124:227-232 46. Eaton WW, Kramer M, Anthony JC, Dryman A, Shapiro S, Locke BZ (1989) The incidence of specific DIS/DSMIII mental disorders: data from the NIMH Epidemiologic Catchment Area Program. Acta Psychiatr Scand 79:163-178
Dr. G. Berti Ceroni USL 29 Via Toscana 17/19 1-40068 Bologna Italy
Soc Psychiatry Psychiatr Epidemiol (1992) 27:234-241
Social
9 Springer-Verlag 1992
DSM-III mental disorders in general medical sector: a follow-up and incidence study over a two-year period G. Berti Ceroni 1, E Berti Ceroni 2, R. Bivi 3, M. A. Corsino 4, P. D e Marco 4, E. Gallo 5, G. Giovannini 5, S. Gherardi 5, A. Pezzoli 4, E Rucci 6, and C. Neri 4 Servizio di Salute Mentale, USL 29, East Bologna, Italy 2Servizio di Salute Mentale, USL 26, S. Giovanni in Persiceto (Bologna), Italy 3Servizio di Salute Mentale, USL 31, Ferrara, Italy 4Servizio di Salute Mentale, USL 27, West Bologna, Italy Servizio di Salute Mentale, USL 23, Imola (Bologna), Italy 6Consultant in Statistics, USL 29, East Bologna, Italy Accepted: June 29, 1992
Summary. In three general medical settings (general practice, hospital medical wards and emergency rooms) about 20 % of the adult attenders had a DSM-III mental disorder, mainly in the area of affective and anxious disorders. Some of these disorders were quite severe. Of those cases reassessed i year and 2 years after the first interview, less than a quarter reached a "no-diagnosis status". The chronicity of most cases dependent on the interplay not only of either relapse or duration of the main disorder but also of comorbidity and incidence of new disorders. A high incidence of more transient disorders in subjects who were well at first assessment was also found.
In the 1970s, Regier et al. [1] found that in the United States only one fifth of the people affected by mental disorders were served by the specialized mental health care sector, with slightly over one half seeking treatment in the general medical care sector. Even in the 1980s, in four locations in the United States E C A programme, 45-59 % of people with mental disorders had contacted general medical practices while only between 8 and 12 % had contacted mental health services [2]. In Verona-South (Italy), Tansella and Williams [3], on the basis of different studies using the General Health Questionnaire and Clinical Interview Schedule, estimated a 1-week prevalence of 22.7 % in the community and of 3.4 % in general practice, while in the psychiatric services the 1-week prevalence by case register - was only 0.37%. Despite the huge amount of data obtained over the last 30 years on the clinical features of mental disorders in the general medical sector, we are still very much in the dark in such crucial areas as incidence, prevalence, severity and course. This is partly a result of the diversity in diagnostic methods. Categorical diagnostic systems, which have been greatly improved in American psychiatry during the last 20 years, have come in for criticism because they often fail to pick up all the nuances of mental disorders when used in the general medical sector. On the other hand, dimensional methods, such as questionnaires or scales, provide data that cannot be collated or related to mental disorders as diagnosed in
psychiatric settings by categorical systems. Wittchen [4] has recently reviewed the problems of the assessment of mental disorders in primary care. In hospitals, where mental disorders are more likely to be associated with physical disease, the diagnostic problem is even greater because diagnostic systems are inadequately validated for people with physical illness [5]. Studies with a sound methodology are rare [6]. The emergency room, which is most likely to be attended by people with psychic disturbances, is rarely studied [7]. We, therefore, decided to study DSM-III [8] mental disorders in three general medical settings, i. e. general practice, hospital emergency rooms and medical wards.
Methods The aim of this study was to investigate mental disorders in adults attending the general medical sector, using a categorical diagnostic system, the DSM-III, to diagnose cases [8]. Apart from the findings of the cross-sectional survey, our main aim was to obtain a prospective view of the course of these disorders over a 2-year period and see how many disorders would appear in those who were, at first, "non-cases". We believe that a better knowledge of such clinical features would be of importance in providing proper programmes to improve the detection and treatment of these disorders. We extended the field of the study to the global general medical sector rather than limiting it to general practice, mainly because the three parts of the general medical sector (general practice, medical wards and emergency rooms) cannot be kept distinct in the Italian health organization. Indeed, the "emergency" service is frequently overused in Italy, with people considering it a simple extension of their doctor's surgery, so much so that the government is now trying to modify this misuse. At present, the Italian Health Service allows everyone a fee-free general practitioner of their own choice whom they can see at will or whom they have to see for a variety of administrative practices. During the night and at weekends,
235 Table 1. Progressive steps towards identification of cases in three general medical settings
Contacted Refused SQ Could not be located Refused interview Excluded because in treatment Excluded for other reasons Assessed Cases
General practice n Women 4d3 57 % 49 65 % 10 70 % 70 74 % ]0 60 % 5 60 % 299 51% 66 76 %
MedicaI ward n Women 312 25 0 8 14 29 236 40
46% 60% 0% 50% 79 % 3t % 44% 70%
Emergency rooms
Total
n 186 48 6 5 7 2 118 25
n 941 122 16 83 31 36 653 131
Women 51% 69% 50 % 60% 71% 50 % 42% 72%
Women 57% 66% 63 % 71% 71% 36 % 53% 73%
SQ, Kellner Symptom Questionnaire
when the GP is not available, or in those cases needing urgent examination involving instruments (even something as simple as an E C G ) , patients are allowed free use of hospital emergency departments. On the request of a hospital doctor, patients can be admitted to hospital, usually to a medical ward if there is no precise diagnosis. It is, in fact, from medical wards that the largest number of requests for psychiatric consultation come [9, 10]. This study was carried out in four sites of the Regione Emilia Romagna, and administrative area ("Regione") in northern Italy with 4,150,000 inhabitants, which enjoys a high socio-economic and cultural standard of living and with health and psychiatric services among the best in Italy. The four sites are: a 65,000 inhabitant district of Bologna, Emilia Romagna's main town with more than 450,000 inhabitants; Casalecchio, a 50,000 inhabitant suburb of Bologna; Imola, a small town with fewer than 100,000 inhabitants; and Lugo, a small thriving country town of about 50,000 inhabitants. These four sites were sufficiently representative of the whole Regione with similar health and psychiatric services. The study involved adults contacted while they were attending their GP's practice or local hospital emergency room or who had been admitted to a hospital medical ward. Eleven GPs were chosen by their Association (Federazione Italiana Medici di Medicina Generale) on the basis of more than 10 years' serLiority and regular attendance at in-service training courses. The emergency rooms and medical ward belong to the three different hospitals (Imola, Lugo, Bologna's Ospedale Maggiore) serving the four sites where the research was carried out. Subjects were contacted in the first and in the last 4 months of 1987. The summer months were excluded because it would have been difficult to contact people at this time and a 3-month follow-up had already been planned. Each doctor's surgery and hospital medical ward was visited on five different weekdays over a 5-week period. Each of the emergency rooms was visited at different times of day over a 1-week period, in order to cover two full 24-h cycles. In the emergency rooms and medical wards patients were contacted only if they lived in the four sites studied. All stages of the examination were carried out by postgraduate medical students specializing in psychiatry. The first stage was to present the self-evaluative Kellner Symptom Questionnaire (SQ) [11] to all subjects between the ages of 18 and 59 years inclusive. The SQ was chosen because it had already been translated and validated for use in Italy [12] at the time of the present study.
The first 253 people were interviewed independently of their SQ scoring in order to obtain a control group and to confirm the cut-off points of the four SQ subscales; we obtained a good sensitivity, though at some cost to specificity (detailed data will be published elsewhere). Only subjects who scored greater than 6 on one of the anxiety, depression and hostility subscales and greater than 8 on the somatization subscale were subsequently interviewed. The interview took place whenever and wherever the subjects requested it: at the GP's surgery, at hospital or at home. The interview was unstructured, although anchored to the different scales which make up the minicompendium of rating scales that Bech et al. [13] have put forward as an aid to making a diagnosis with DSM-III. These are: Hamilton Anxiety Scale (HAS) [14], Hamilton Depression Scale (HDS) [15], Melancholia Scale (MES) [16], Mania Scale (MAS) [17] and Brief Psychiatric Rating Scale (BPRS) [18]. In the "cases" and in some of the "noncases" (202 subjects) the interviewers also gathered other clinical and social data: marital, professional and educational status; lifestyle (living alone, number of children, number of children under 14, social support in and outside the home); life events and prolonged major difficulties of more than 2 years duration; clinical history of subject and subject's family, including age and type of onset and duration of present disorder if any. Finally, the Global Assessment Scale [19] score was rated. The normality of the scales (SQ, HAS, HDS and BPRS) was assessed by means of the Kolmogorov-Smirnov test. A moderate skewness was present in BPRS (noncases), but this does not invalidate the analysis of variance results. All the data relating to each patient were reviewed during weekly sessions by the more experienced clinicians (G.B.C and A.R). It was sometimes necessary to obtain more detailed information by means of a supplementary interview. We decided to exclude subjects for the following reasons: 1. To spare them the distress of an unnecessary medical examination; patients affected by organic mental disorders, mental retardation, schizophrenia, severe or incurable diseases and pregnant women were excluded. 2. Since it would have been difficult to locate them for follow-up, persons of no fixed abode, drug addicts and alcoholics were excluded. 3. In order not to interfere in the relationship with their therapist, patients already undergoing specialist mental
236 Table 2. Distribution of diagnoses (%) following hierarchy in three general medical settings. The overall diagnoses are given for the total sample in the last column. Hierarchy is shown moving down in the left column General practice
Medical wards
Emergency rooms Total hierarchy
Total overall
Major depressive disorders
13.6
22.5
8.0
15.3
15.3
Panic disorders + agoraphobia either with and without panic attacks Adjustment disorders
7.60 10.6
25.0 15.0
28.0 -
16.8 9.90
19.8 11.4
Dysthymic disorders
36.4
22.5
20.0
29.0
35.9
Generalized anxiety disorders Personality disorders
10.6 12.1
12,5
20.0
13.0
19.8
Other disorders (miscellaneous) Total
-
9.10 50.4
4.00 2.50
30.5
health t r e a t m e n t were excluded, A n additional reason for this was that, while general practitioners and hospital doctors were involved in the research p r o g r a m m e , no such inv o l v e m e n t was possible with scattered therapists all working independently. 4. Since we disagreed with D S M - I I I about simple phobia, which we consider a very f r e q u e n t psychological characteristic, rather than a disorder deserving medical treatment, we included p e o p l e having simple p h o b i a either a m o n g cases, if they had a n o t h e r D S M - I I I disorder, or a m o n g non-cases, if they had not. In all, 120 subjects out of the 131 w h o were given at least one diagnosis by means of D S M - I I I and 134 out of the 202 with no diagnosis were r e c o n t a c t e d for further interviews at intervals of 3, 12 and 24 months.
In the general medical sector, 941 subjects were contacted. Table 1 shows that almost o n e - q u a r t e r of these could not be interviewed. A b o u t 10 % were excluded; the principal reason for exclusion was that the subject was already undergoing mental health specialist treatment, which is not to say that all these persons h a d a D S M - I I I disorder. T h e r e was no significant age difference b e t w e e n the various categories considered in Table 1. Females prevailed in subjects w h o could not be examined, in those w h o were excluded because they were already receiving t r e a t m e n t and in subjects with at least one D S M - I I I disorder. T h e diagnostic picture for cases followed a hierarchical criterion; the overall diagnosis is given for the total sample (Table 2). T h e hierarchical criterion takes into account only the m a i n diagnosis on axis I following the indications in D S M - I I I . T h e f r e q u e n c y of diagnoses was similar in the three settings except for panic disorder/agoraphobia, which was m o r e frequent in the e m e r g e n c y r o o m setting. M a j o r depressive disorder (20 subjects) consisted mostly of single episodes (15 subjects), while recurrent episodes were rarer (5 subjects). Bipolar disorder was also rare (2 subjects) and was, therefore, included in the other disorders group. A g o r a p h o b i a without panic attacks was also infrequent (4 subjects) and was included in
24.4
9.20
19.1
12.2
100
138.8
panic disorder (16 subjects) and a g o r a p h o b i a with panic attacks (14 subjects) rather than in other disorders. Table 3 shows that, at first assessment, demographic, clinical and social differences b e t w e e n cases and noncases were highly significant. T h e r e was a higher prevalence of w o m e n a m o n g the cases, although o n e - w a y analysis of variance of the scales with two factors (sex and group) showed that the differences were mainly due to "caseness". Differences c o n c e r n e d both observer scales and the self-report questionnaire on clinical symptoms. O f the social variables, only the lack of social support (both inside and outside the h o m e ) and the presence of m a j o r Table 3. Comparison between cases and non-cases at the first interview Cases (131) Non-cases (202) Mean age (+ SD)
Results
6.90
20.0
Sex:M F Mean age F
40.5_+12.3 t - - 1.05 NS 35 (26.7%) 105 (52%) Z2= 19.79'** 96 (73.3%) 97 (48%) 37.3 _+11.4 40.2_+12.2 t = - 1.66 NS
Duration of disorder > 1 year %
60.30
Hamilton Depression Scale(mean _ + S D ) Hamilton Anxiety Scale (mean _+SD) Brief Psychiatric Rating Scale (mean + SD)
39.1+11.5
11.9+5.2
3.8_+2.9
t = 15.74"**
15.2 + 6.1
5.1 _+3.7
t = 16.35"**
1.93 -+1.63
t = 15.48'**
6.5 -+2.9
Symptom Questionnaire (total of the four subscales: 32.8-+ 10.9 20.8_+10.1 mean _+SD) Axis IV of DSM-IIf (mean • 2.66_+1.7 2.26 + 1.5
t = 2.61"*
Major difficulties % of which multiple %
t = 10.1'**
53.4 10.7
16.4 3.5
z = 7.013"** z = 2,405*
No social support in and outside the home % 15.3
2.9
z = 3.301"**
49.2
71.1
z = 3.556***
80.8
16.4
Z2= 114.09"**
Social support in and outside the home % Global Assessment Scale (% subjects < 70)
* P < 0.05; ** P < 0.01; *** P < 0.001; NS, non-significant
237 100% 90%
~ - -
MDD
--*--
AD
~ - -
GAD
~ - -
OD
80%
PA/Ag
70% 60%
DD
50% 40% 30%
PeD
20% 10% 9 0~ tO
total
I
I
I
3 months
1 year
2 years
Fig.1. Diagnostic pattern of continuing illness in the 62 cases assessed at all three follow-ups. MDD Major Depressive Disorder; PaD/Ag Panic Disorder +Agoraphobia either with and without panic attacks; A D Adjustment Disorder; GAD Generalized Anxiety Disorder; DD DysthymicDisorder; PeD PersonalityDisorder; OD Other Disorders (miscellaneous)
34
35 %
3~fthr.._o,hF 20
.....................
~
................
25
...........................
20
.......................
MDD PzO/Ag
AD
GAD
DO
0eD
OD
MOO PaOeAg AD
GAD
OD
PeD
OO
Moo P~O/Ag
AO
GAD
DO
Pea
OD
MDD PaD/Ag
GAD
DO
PeO
O0
AD
Fig.2. Foursubsequentdiagnosticreassessmentsfor eachsingledisorder in the 62 cases assessed in all three follow-ups.MDD Major Depressive Disorder; PaD/Ag Panic Disorder + Agoraphobia either with and without panic attacks; A D Adjustment Disorder; GAD Generalized Anxiety Disorder; DD Dysthymic Disorder; PeD PersonalityDisorder; OD Other Disorders (miscellaneous)
difficulties differed significantly between cases and noncases. Ratings on the Global Assessment Scale differed significantly between the two groups. Of the 20 cases of major depressive disorder, 5 were rated higher than 20 on the Hamilton Depression Scale. Of the 120 cases who were invited for 1-year reassessment 85, accepted (70.8%). No significant differences existed at the first assessment between the 85 who sub-
sequently accepted 1-year reassessment and the 35 who declined. At the 1-year reassessm~nt, only 17 (20 %) had recovered and this had, for the most part, already occurred by the 3-month reassessment and remained stable at the 2-year reassessment (22.1%). Of the cases who attended 1-year reassessment, 80% also attended 3month and 2-year reassessments. Figure 1 shows the pattern of continuing illness in those 62 cases seen at all three follow-ups: while personality and dysthymic disorders persisted, other disorders (adjustment, major depressive and panic/agoraphobia) decreased greatly. There were, in addition, 4 recurrences: 1 major depressive disorder reappeared at the 2-year follow-up after 1 year of well-being; 1 panic/agoraphobia disorder had remitted by the 3month follow-up, but was newly present at the 1-year follow-up and then had remitted by the 2-year follow-up; a new adjustment disorder appeared in two patients at the 1-year and the 2-year follow-ups, respectively. Eight subjects had ten "new" disorders at the 1-year reassessment which were not present at the initial interview and four of these "new" disorders were already present at the 3month assessment. Of the 62 subjects reassessed after 2 years, a further 3 had four "new" disorders. The new disorders affected people suffering major depressive disorder (three dysthymic disorders) adjustment disorder (one major depressive disorder, one panic disorder/agoraphobia and one other disorder) and above all dysthymic disorders (four major depressive disorders, two generalized anxiety disorders, and one other disorder). However, the most striking feature was that the diagnostic picture of cases changed at each follow-up. Figure 2 shows clearly how varied the course of each individual illness was. Each column in the left top panel represents a diagnostic group. In the subsequent panels it can be seen that each groups is dramatically modified: the disappearance of one disorder not only brings out situations of no diagnosis but also hierarchically inferior disorders underlying the main diagnosis; hierarchically superior disorders may sometimes appear. Table 4 shows a rapid change in the rates of many scales and questionnaires and in the frequency of signs of social distress. By the second assessment, 3 months after the first, rates and percentages were as they would be at either the 1- or 2-year reassessment. In non-cases, the scores on some scales showed a sharp decrease as early as 3 months after initial assessment (from 5.1 + 11.1 to 3.2 _+3.2 in the Hamilton Depression Scale, from 6.5 + 11.2 to 4.5 + 3.6 in the Hamilton Anxiety Scale, from 20.1 + 9.3 to 12.8 _+10.5 in the Symptom Questionnaire total score) and then remained stable at subsequent reassessments. Non-cases, in contrast, did not show any change in the scores on the Global Assessment Scale or in the rate of other social variables over time, apart from the subjective evaluation of the lack of social support inside and outside the home. The analysis of variance (ANOVA) showed that the 1-year change in scores on the different scales was significantly larger in cases than in non-cases (P < 0.001 for Hamilton Depression and Anxiety scales, Symptom Questionnaire depression and Global Assessment Scale and P < 0.01 for Symptom Questionnaire total score). It may be of interest that in cases the scores in the scales built on symptoms de-
238 Table 4. Clinical and social features in cases at four assessments First 3-Month 1-Year 2-Year Mean age 39.8.+ 11.6 % females 77.6 Hamilton Depression Scale (mean _+SD) 13.1 .+ 11 7.7 _+5.6 8.1 .+6.1 7.1 _+5 Hamilton Anxiety Scale (mean _+SD) 16.2_+10.9 10_+6.5 11.3_+7.4 9.6_+6.2 Brief Psychiatric Rating Scale (mean 6.35 .+2.86 4.4 _+2.9 4.76+ 3.42 4.42_+3.09 .+SD) Symptom Questionnaire (total of the 4 subscales:mean .+SD) 32.7_+11 23.3_+15.623.7+15.3 21.8_+14.6 Axis IV of DSM III 2.67 • 1.7 2.07+ 1.5 2.51+ 1.7 2.63+ 1.6 (mean _+SD) Major difficulties% 56.4 39.7 40.0 32.8 11.8 14.7 9.4 6.0 of which multiple % No socialsupport in and 16.2 12.9 9.0 outside the home % 8.6 Social support in and 41.2 47.1 53.1 outside the home 55.6 Global Assessment Scale (% subjects< 70) 78.8 64.7 58.8 61.2
creased more rapidly than the Global Assessment Scale score increased, while the subjective evaluation of social support become even worse at the first two reassessments. In non-cases, as in cases, new disorders appeared at the reassessments: three new disorders in three subjects at the 3-month follow-up, seven in seven subjects at the 1-year follow-up and seven in six subjects at the 2-year follow-up. These new disorders in previous non-cases mainly concerned adjustment disorder (7 subjects) and panic disorder plus agoraphobia (3 subjects), but one case of major depression also occurred. Only 5 subjects had a history of mental disorder prior to the first assessment, while for 11 it would seem that we were dealing with a first incidence. A new disorder, however, occurred more frequently in the subjects who had a history of previous mental disorders (p < 0.05). Apart from this there were no significant differences between those with a new disorder and those who remained non-cases.
Discussion Prevalence
The prevalence of DSM-III mental disorders in the three general medical settings taken together was 20 %. This figure was certainly less than the real prevalence because of the inclusion criteria we adopted. (1) If all the 31 persons not included because they were already receiving treatment had a DSM-III mental disorder, the prevalence would rise to 23.7 % (131 + 31/653 + 31). Although possible, this would not be very likely because in the present study we found a group of 42 persons who had a distress, usually manifested by a high score in the Symptom Questionnaire, that did not meet the criteria of any DSM-III mental disor-
der. The impression these persons made at the clinical interview was that they merited treatment and they would have been accepted had they gone to a psychotherapist [20]. (2) Disorders that in the community [21] account for one-third of a 1-month prevalence (15.4 % ) (schizophrenia, drugs/alcohol abuse and antisocial personality) were excluded. The most frequent disorder in the study by Regier et al., phobia, includes simple phobia cases which we excluded. (3) If overall diagnoses were considered without taking account of the diagnostic hierarchy, a practice adopted in other studies, prevalence in our study would increase by more than a third. Taking all these correcting factors into account our data were close to those of the other few studies regarding primary care: H o e p e r et al. [22], using SADS-L in a site in Wisconsin, found an overall non-hierarchical prevalence of 26.7%. A similar prevalence (26.5 %) was found by Barrett et al. [23], again in small towns (in New Hampshire) and using SADS-L, but adopting diagnostic hierarchy in cases seen in a general medicine group over a 15-month period which was chosen to pick up low users. In an urban sample in Baltimore of low or moderately low income mainly non-white, female and middleaged, Von Korff et al. [24] established a hierarchical prevalence of 25 % using DIS/DSM-III. The prevalence in general medical settings is higher than that in the community, which is around 15 % when DIS/DSM-III is used [21, 25]. This must be borne in mind later in our discussion, when we are forced to use community data, given the scarcity of data on single disorders in general medical settings. In the present study affective and anxiety disorders accounted for more than 70 % of total disorders. However, chronic disorders such as dysthymic disorder and generalized anxiety (in additon to personality disorders) were most frequent. Rates for depressive disorders were at the lowest end of the wide range shown by the recent Zung [26] survey. This is particularly true for major depression, which in the present study was much less frequent than dysthymic disorder, while rates for the two conditions are equal in some R D C studies [27] and major depression is the more frequent in the Von Korff et al. DIS/DSM-III study [24]. The low rate of major depression and the higher rate of dysthymia might depend on the exclusion of the subjects already treated if there are several cases of major depression among them. In the community 1-month prevalence study [21], however, dysthymic disorder is about 30 % more frequent than major depression. Anxiety disorders in the present study were also low down in the 20 % range observed by H o p p e et al. [28] in their review. In the community 1-month prevalence study [21], anxiety disorders, even excluding generalized anxiety, are more frequent than depressive disorders. Having grouped together agoraphobia without panic attacks with either panic or agoraphobia with panic attacks, we have a rate neither for panic disorder, which otherwise varies over a wide range in other studies [29], nor for agoraphobia. The hierarchical prevalence of generalized anxiety disorder (3.2 %) was also lower than that obtained in other studies (3.6%, Sashidaran et al. [30]; 6%, Von Korff et al. [24]; 5.4% and 11.1%) for women and men, respectively, in H o p p e et al. [28]. Apart from the data of H o p p e et al. [28], which differ from ours both in their high overall rate and in
239 their difference between the sexes, we believe our stringent exclusion criteria were important in de~:ermining these differences. Especially surprising was the low rate of comorbidity between generalized anxiety and other disorders (looking at the total figure for all diagnoses, generalized anxiety increased by only 50%) given that, in a clinical sample, generalized anxiety has been diagnosed in cases of major depression, panic, and agoraphobia with panic, with a probability varying between 66.7 % and 83 % [30]. Overall, the rate of comorbidity was rather low. Many studies carried out in different settings insist particularly on anxious or depressive disorders being present at the same time, once the DSM-III diagnostic hierarchy has been suspended [31]. Hecht et al. [32] however, have shown how widely this comorbidity can vary due to a multiplicity of variables, and consequently our data in general medical settings may not be anomalous. Finally, our rate of personality disorders (1.4 %, excluding antisocial personality disorder) did not correlate with the findings in other studies in general medical settings and was higher, at 0.5 %, than that in the community [21].
Severity and the seeking of specialist treatment Observer rating scales and self-report questionnaires clearly discriminate between cases and non-cases for both symptoms and social conditions. They do not, however, discriminate between cases and outpatients attending psychiatric services in the same places for the first time (detailed data will be published elsewhere). The doubt expressed by Blacker and Clare [27] about the long-held view that only mild depressive disorders are found in general medical settings was confirmed by our data, which showed that one-quarter of case s of maj or depression had a score of greater than 20 on the Hamilton Depression Scale. In spite of these two indices of severity (scores not unlike those for new outpatients and quite high scores on the Hamilton Depression Scale in a group of cases with major depression), specialist mental health treatment is rarely sought. Even if the 31 subjects previously excluded because they were receiving treatment had a DSM-III disorder they would account for only 19.1% of the total cases (3!/131 + 31). Hough et al. [2] found an even lower proportion (1/6) of subjects seeking treatment in the specialized mental health care sector. Surprising data emerged from Florence, a town only 65 miles away from Bologna, where 80 % of the cases with a mood disorder consulted the family doctor and 60% of them were referred, sooner or later (the exact time is not given in the study), to specialist mental health treatment [33].
Coupe Two principal interrelated data emerged: the persistence of being a case and the changing of the diagnostic pattern, due to the disappearance of hierarchically superior disorders and the consequent emergence of hierarchically inferior ones and, to a lesser extent, to the appearance of new disorders, sometimes hierarchically superior to the previous ones.
Adjustment disorder had the highest recovery rate as a single disorder, followed by major depression and panic/agoraphobia. A recovery rate, although lower, also existed for generalized anxiety, dysthymic and even personality disorders. Comparison data are unavailable in the general medical care sector, and we must address ourselves to community and sometimes only to outpatient studies. In the community, the major depression rate halves in 1 year as a result of the interplay between chronicity and relapse [34, 35]. Panic/agoraphobia falls by onehalf in i year [36] and falls further over more prolonged periods [37]. A low recovery rate is established in the outpatient sector for generalized anxiety [31, 38] and a lower rate for dysthymic disorder [39]. The picture becomes more complex if we add the variables of comorbidity and incidence to the interplay of recovery, relapse and chronicity. It is widely established in clinical settings that comorbidity worsens the prognosis of each single disorder, and Schulberg et al. [40] have shown that this can hold even in the general medical care sector. But comorbidity at the inital assessment is an important factor in follow-up studies to explain why hierarchically inferior diagnoses will appear once superior ones have disappeared. Finally, the incidence of new disorders in those already recorded as cases must be considered. All these variables made it difficult for us to reach a no-diagnosis status, which only rose from 17.6% to 22.1% in the interval between the 3-month and the 2-year reassessment. The older studies, which often used idiosyncratic diagnostic procedures, reviewed by Kessler et al. [41] for primary care and Mayou et al. [42] for medical inpatients, agreed on the prolonged course of several cases. Kessler et al. [41] had the merit of highlighting the existence of continuing cases at two different assessments. In their study, however, the continuing cases at the 6-month follow-up of Hoeper et al.'s [22] SADS-L cases were fewer in number than the remitted ones. In the present study, in contrast, the continuing cases prevailed. This may have been due to the wider coverage or the larger mesh of the DSM-III net compared with SADS-L, which being the lifetime version gathers a larger number of cases than the instruments measuring current prevalence. The importance of the method in determining the heterogeneity of results in studies on depression and anxiety has recently been shown by Angst [43]. Other reasons, such as a different health organization, may also be hypothesized. Even at the first reassessment the scales scores changed dramatically but remained stable at the subsequent reassessments. A similar change was also observed in noncases. This pattern was noted by Kessler et al. [41] for the General Health Questionnaire and the Global Assessment Scale both in remitted and in continuing cases. In our data the scales built on the symptoms scores decreased more than the Global Assessment Scale score increased. The subjective evaluation of the social support received at home and outside the home worsened at the first and the second reassessments. Rather than expressing a decrease in severity, it is possible that this change in scales based on symptoms may denote a retest effect, that makes recall and dating of psychiatric symptoms less reliable [44, 45].
240 Incidence In 2 years, m a n y of those who were already cases at the initial assessment presented with a new disorder. We obtained a rate of 9.4% at the 1-year and of 4.4% at the 2-year follow-up. This was one of the factors in the overall course of cases discussed above. E v e n m o r e interesting were the data concerning incidence in those subjects who were not cases at the initial assessments: the rates of subjects who became cases at the 1-year and the 2-year reassessments were 13 % and 8.5 %, respectively. This was a notable total incidence pattern, higher than that found by Kessler et al. [41] in their 6-month follow-up study (8.2 %) and those found by the older studies reviewed by Kessler et al. [41]. There were m a n y other differences between our data and those of Kessler et al. [41]: the percentage of first incidence was as high as 68.7 % in the present study, while it was only 14 % in that of Kessler et al. [41]. Almost twothirds (58.8 %) of the new disorders in the present study belonged to the more acute and transient disorders (adjustment and panic with or without agoraphobia), while major depression and labile personality were the most frequent diagnoses in the new cases in the Kessler et al. [41] study. A p a r t from a different diagnostic system, it is not easy to account for such differences and not much help can be obtained from community studies [34, 37, 46], since these are both scarce and limited to particular epidemiological and methodological aims.
Conclusions The main cross-sectional and longitudinal findings were: 1. At least one in five people attending for care the general medical sector had a D S M - I I I disorder. Rates were higher for female patients. 2. Some of these disorders were severe. One-quarter of cases of major depression scored 20 or m o r e on the Hamilton Depression Scale. 3. These disorders were often chronic. More than 60 % of cases had a disorder lasting i year or m o r e at first assessment. The high rates either of dysthymic or personality disorders accounted for this long duration. 4. Chronicity was confirmed by the follow-up study. The recovery rate was low (less than one-quarter of cases in 2 years), although much higher rates were found if single disorders (such as adjustment, major depressive and panic/agoraphobia) were considered. 5. Chronicity in the follow-up study depended on the interplay, not only of either relapse or duration of the main disorder, but also of comorbidity and incidence of new disorders. 6. The incidence rate was quite high (13 % and 8.5 % in the 2 years following first assessment) even for non-cases at first assessment. It was a true first incidence for most cases, who mainly had transient disorders, such as adjustment and panic. The picture which emerged was thus quite complex. Although mild and chronic disorders prevailed, the opportunity of meeting either severe or transient disorders must
be kept in mind by those working in the general medical sector.
Acknowledgements. This work was supported by research grant no. 630 from Regione Emilia Romagna. We are grateful to M. Weissman, PhD, for her helpful suggestions.
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