BRIEF REPORT
The Relationship of Life Stressors, Mood Disorder, and Health Care Utilization in Primary Care Patients Referred for Integrated Behavioral Health Services Elizabeth Sadock, MS,* Stephen M. Auerbach, PhD,* Bruce Rybarczyk, PhD,* Arpita Aggarwal, MD,† and Autumn Lanoye, MS*
Abstract: Exposure to stressful life events, mood disorder, and health care utilization were evaluated in 102 low-income, primarily minority patients receiving behavioral health and medical services at a safety-net primary care clinic. Exposure to major stressors was far higher in this sample than in the general population, with older patients having lower stress scores. Proportions of patients who met the criteria for clinical depression and anxiety were higher than in normative samples of primary care patients. Stress exposure was higher in the patients who met the criterion for clinical anxiety but was unrelated to clinical depression. Contrary to expectation, anxiety, depression, or stress exposure was not related to service utilization. Latter findings are discussed in terms of the influence of the provision of behavioral health services, the highly skewed distribution of major stressor scores, and the likely greater influence of individual differences in minor stressor exposure on utilization in this population. Key Words: Primary care psychology, health care utilization, stressful life events, anxiety, depression. (J Nerv Ment Dis 2014;202: 763–766)
O
ur health care system is heavily burdened by patients with chronic and comorbid mental and physical health problems. The primary care setting is the entry point and provider of long-term care for the vast majority of these patients (Kessler and Cubic, 2009). Prevalence rates for both depression (Tamburrino et al., 2009) and anxiety (Kroenke et al., 2007) are particularly high. Negative affect (McGrady et al., 2003) and especially generalized anxiety disorder (GAD; Fogarty et al., 2008; Jones et al., 2001) have been linked to increased health care utilization in primary care patients. Extensive findings of an association between exposure to stressful life events and anxiety and depression (e.g., Brantley et al., 1999; Kendler et al., 1999) suggest that stress may play a role in emotional dysfunction and increased service utilization in patients. However, the relationship between stress exposure and utilization seems to be a complex one. When evaluating the impact of major life stressors in primary care patients, Miranda et al. (1991) and Gortmaker et al. (1982) found that stress was associated with increased utilization, as did Lynch et al. (2005) particularly for men and Pilisuk et al. (1987) especially for men and older women. However, Barsky et al. (1996) found no relationship, and in a sample of low-income African-American primary care patients, Brantley et al. (2005) also found no relationship, although minor stressors accounted for significant variance after controlling for major stressors. The present study evaluated data obtained from a sample of lowincome, primarily minority patients attending a safety-net primary care
*Virginia Commonwealth University; and †Virginia Commonwealth University Health System (VCUHS), Richmond, VA. Send reprint requests to Elizabeth Sadock, MS, Virginia Commonwealth University, 806 West Franklin St, P.O. Box 842018, Richmond, VA 23284-2018. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20210–0763 DOI: 10.1097/NMD.0000000000000195
clinic serving uninsured or underinsured patients. Because no studies have directly assessed this objectively, we evaluated the extent to which these patients were confronting major life stressors in comparison with a normative population. We also evaluated the extent to which prior findings relating stress exposure, emotional dysfunction, and health care service utilization generalized to this population of patients. All of our patients were referred by their physician to a behavioral health service integrated into the primary care clinic (see Rybarczyk et al., 2013; Sadock et al., 2014, for a description of this service). Exposure to stressful events was assessed at the first psychological treatment session. Anxiety and depression were also assessed at this time. Medical service utilization during the year subsequent to initial contact with the clinic was tabulated. On the basis of prior findings, we expected a) high rates of clinically significant levels of anxiety and depression along with high levels of exposure to stressful life events in our sample and b) positive relationships between stress exposure, measures of emotional distress, and service utilization by patients.
METHODS Participants Data were obtained from 102 primary care patients receiving medical services from the Ambulatory Care Clinic at the Virginia Commonwealth University Health System Medical Center in Richmond, Virginia. Patient age ranged from 20 to 78 years (mean, 52.39; SD, 13.19), with 17.6% of the sample 65 years or older. Thirty-five percent were Caucasian, and 64.7% were African-American. The medical center primarily serves indigent urban and rural populations. Most of the patients referred for behavioral health services were unemployed (74.6 %). Approximately 48% had Medicare, 35% were uninsured, 15% had Medicaid, and 2% had private insurance.
Measures The Generalized Anxiety Disorder Scale The Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006) is a seven-item questionnaire that assesses symptoms of anxiety using a 4-point Likert scale. It was normed on 2739 patients in 15 primary care clinics in the United States. To determine clinically significant cutoff scores for the GAD-7, mental health professionals first used the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as the criterion for assessing patients. These scores were compared with the patients’ GAD-7 scores, and a summary score of 10 or greater was determined as the cutoff point to yield optimal sensitivity of 89% and a specificity of 82% for GAD (Spitzer et al., 2006).
The Patient Health Questionnaire–9 The Patient Health Questionnaire–9 (PHQ-9; Spitzer et al., 1999) has been used extensively for assessing depression in primary care settings (Tamburrino et al., 2009). It consists of nine items and is
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TABLE 1. Primary and Secondary Focus for Patient Visits Focus Depression Smoking Pain Anxiety Insomnia Other Weight loss Substance Intro to behavioral services Dementia screening Referral Suicide assessment Adherence
Primary Focus: No. Visits (%)
Secondary Focus: No. Visits (%)
Total No. Visits (%)
41 (40.2) 13 (12.7) 11 (10.8) 11 (10.8) 8 (7.8) 5 (4.9) 4 (3.9) 3 (2.9) 3 (2.9)
9 (8.8) 6 (5.9) 9 (8.8) 11 (10.8) 4 (3.9) 4 (3.9) 1 (1.0) 2 (2.0) 1 (1.0)
50 (31.1) 19 (11.8) 20 (12.4) 22 (13.7) 12 (7.5) 9 (5.6) 5 (3.1) 5 (3.1) 4 (2.5)
2 (2.0)
4 (0.91)
6 (3.7)
1 (1.0) 0
3 (2.9) 4 (3.9)
4 (2.5) 4 (2.5)
0
1 (1.0)
1 (0.6)
aware of the range of services available, which included addressing issues such as depression, anxiety, medication adherence, smoking cessation, diet and exercise change, as well as insomnia. Student clinicians administered measures of stressful life events, depression, and anxiety at the patients’ first visit. After the initial assessment, the student clinician administered a brief intervention focusing on the patients’ identified problem areas (Table 1 lists primary and secondary problem areas addressed during the patients’ visits). The patients were encouraged to return only if they believed that they required additional services. Therefore, the number of follow-up appointments was variable, and they occurred at variable intervals subsequent to the initial assessment.
RESULTS Patient Exposure to Stressful Life Events
designed to measure depressive symptoms experienced during the previous 2 weeks. A score of 10 was established as the cutoff for at least a moderate level of depression based on administering the PHQ-9 to the patients together with the Structured Clinical Interview for DSM-III-R and the primary care evaluation of mental disorders (the longer version from which the PHQ-9 was derived; Kroenke et al., 2001).
The Social Readjustment Rating Scale–Revised The original Social Readjustment Rating Scale (SRRS; Holmes and Rahe, 1967) consists of 43 life events. However, it has been criticized for containing outdated events that may no longer have the same impact as when the scale was originally developed (Scully et al., 2000), items that represent stress symptoms rather than life events (Hobson et al., 1998), and deficiencies in the original validation sample (Hobson et al., 1998). A revised scale (SRRS-R; Hobson et al., 1998) consisting of 51 major life events was used in the present study. Respondents were asked to indicate if they had experienced any of the events in the past year. New weights for each item and norms were established on the basis of administration of the scale to two separate national samples (Hobson and Delunas, 2001; Hobson et al., 1998). Weightings of each item in terms of stressfulness are multiplied by frequency of endorsement and summed to provide a total score.
Patient Utilization of Medical Services Patient utilization data for all medical services (i.e., emergency department use, primary care use, total utilization) were collected from patient academic health system utilization records for the year after their first behavioral health appointment. Because of referral patterns from this primary care office and self-referral constraints for safety-net patients, these patients obtain nearly 100% of their medical care within the academic health system.
SRRS-R scores (weighted by life change units) were far higher in our patient sample than in respondents from the general population (Hobson and Delunas, 2001). The mean SRRS-R score for the patients was 436.91 (SD, 379.17) vs. 278 (SD, 422) for the normative population. Even after deleting three outliers whose SRRS-R scores exceeded a standard score of 3.29, patient scores were substantially higher than those of the normative population, t(3,499) = 3.76, p < 0.0002. The median patient score was 324 (70th–75th percentile in the normative sample); the score corresponding to the 99th percentile for the patients was 4864 vs. 1936 for the respondents in the normative sample. The stressful life events most commonly cited by the patients are listed in Table 2. No significant sex or racial differences in SRRS-R scores were found in our sample, both t(100) scores of less than 1. To evaluate the relationship between age and SRRS-R scores, we divided the sample into two groups according to patient age, with younger adults consisting of ages in the lower 40% of the sample (n = 44; mean, 40.57; SD, 8.96) and older adults consisting of the upper 40% (n = 43; mean, 64.19; SD, 6.78). The older patients had significantly lower scores on the SRRS-R (t[83] = −2.21, p = 0.03). When the entire age distribution was considered, age and SRRS-R had a marginally significant relationship (r [102] = −0.15, p = 0.06).
TABLE 2. Most Frequently Endorsed SRRS-R Items by Primary Care Psychology Patients in the Past Year Top 10 Most Frequently Cited Stressful Life Events 1 2 3 4 5 6 7 8
Procedure All patients were referred by their primary care physician to an on-site psychological clinic for behavioral health services where the service providers were doctoral students in clinical and counseling psychology. All physicians were internal medicine residents whose work was being supervised by attending physicians. Physicians were made 764
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9 10
Experiencing financial problems/difficulties (bankruptcy, credit card debt, college costs, tax problems) Death of a close family member Attempting to modify addictive behavior of self (i.e., smoking, alcohol, drugs) Major injury/illness of self (i.e., cancer, AIDS) Change in residence Death of a close friend Major injury/illness of a close family member (i.e., cancer, AIDS) Discovering/attempting to modify addictive behavior of a close family member (i.e., smoking, alcohol, drugs) Being fired/laid off/unemployed Assuming responsibility for a sick or elderly loved one
% of Patients 46.51 41.86 40.70 31.40 29.07 27.91 26.74 23.26 23.26 18.60
AIDS indicates acquired immunodeficiency syndrome.
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The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
Exposure to Stressful Events and Anxiety and Depression Clinical levels of depression and anxiety (as measured by the PHQ-9 and the GAD-7, respectively) were defined as scores of 10 or greater on each measure, based on criteria described in the Methods section. A total of 67.4% of the patients (mean, 17.02) met the criterion for clinical depression, a significantly higher proportion than observed in the PHQ-9 normative sample of primary care patients (Kroenke et al., 2001; z = 10.4, p < 0.001). However, a regression analysis found no relationship between cumulative stress exposure and clinical depression. A total of 66.3% of the patients (mean, 15.59; SD, 3.42) met the criterion for clinical anxiety, a significantly higher proportion than that observed in the GAD-7 normative sample of primary care patients (Spitzer et al., 2006; z = 9.1, p < 0.001). A regression analysis indicated that the participants who met the criterion for clinical GAD had higher SRRS-R scores than those not meeting the criterion (F[1,93] = 4.17, p = 0.044; R2 = 0.043). However, after controlling for the influence of age, sex, and ethnicity in the first block of the analysis, the relationship between SRRS-R and clinical anxiety fell short of significance (change in F[1,90] = 3.19, p = 0.077; R2 change = 0.033). Analyses by sex showed that the stressful events–anxiety relationship was accounted for primarily by the men (r[34] = 0.48, p = 0.004), whereas the association for the women was minimal (r[61] = 0.04). The relationship was especially pronounced in the older men (r[10] = 0.93, p < 0.001) compared with the younger men (r[16] = 0.39, p = 0.14).
Determinants of Patient Utilization of Services Patient utilization data were obtained for the year subsequent to the patients’ first medical visit. To assess the relation between stressful events and utilization, a hierarchical regression was conducted in which SRRS-R scores were regressed on the total utilization score after including age, sex, and race in the first block of the analyses. Age ( p = 0.039) (older patients used more services) and sex ( p = 0.035) (women used more services) had a significant influence on utilization. However, SRRS-R scores were not significantly related either to total utilization or in separate analyses to subcategories of utilization, including number of emergency department visits that resulted in an inpatient admission, number of emergency department visits that resulted in outpatient care only, number of non-emergency inpatient visits, number of primary care visits, or number of non–primary care outpatient visits. Finally, we explored our hypothesis that patients with clinical levels of anxiety and depression would have more health care utilization. No effects were obtained.
DISCUSSION AND CONCLUSIONS This study evaluated relationships between stress exposure, clinical anxiety and depression, as well as medical service utilization in a sample of low-income, primarily minority patients who were referred for behavioral health services by their primary care physician. Cumulative exposure to major stressful events was far higher in this sample than in the normative national population, with close to half of the respondents having had major financial problems and more than 40% having experienced death of a close family member in the prior year. Although there are few empirical findings relating major life event exposure to age, our finding that older patients had lower stress scores is consistent with prior research indicating that older adults report experiencing considerably fewer minor stressors than do young adults (Almeida and Horn, 2004; Stawski et al., 2008). Findings for both major and minor stressors may be due to increased motivation to avoid situations that induce negative emotions (Carstensen et al., 2003) or due to health limitations that constrain activity level and reduce opportunity to experience stressors in older adults (Stawski et al., 2008). Clinical levels of anxiety and depression, as reported in our larger sample (see Sadock et al., 2014), were far more prevalent in this © 2014 Lippincott Williams & Wilkins
Relationship of Life Stressors
sample than in the primary care population as a whole, but only clinical levels of anxiety were associated with higher levels of stress exposure, especially for men. This finding may be explained by unemployment and other socioeconomic stressors faced by men, having a greater impact on anxiety in men because of role expectations and a more limited support system. Further, the expected relationships of both anxiety/ depression and stress exposure to service utilization were not obtained. This may be due to the fact that the patients in this sample were receiving behavioral health services and were therefore less likely to misinterpret their anxiety and depressive symptoms as having a somatic cause and requiring medical treatment. Fogarty et al. (2008) and Jones et al. (2001), studies with nearly identical urban underinsured/uninsured populations, found that all anxiety and depressive disorders were a strong predictor of nonuse of psychiatric service. However, mental health service utilization was not reported in the study of Jones et al., and Fogarty et al. found that patients with mental health conditions actually had fewer specialty mental health care visits than those without those conditions. In the latter study, it can be inferred that patients were likely treated with medications by their primary care physicians and did not receive any behavioral services that may be particularly effective in reducing somatization of psychological distress. The overall lack of relationship of SRRS scores to utilization should be considered in the context of generally weak associations that have been found between major life events measures such as the SRRS and illness onset (Auerbach and Gramling, 1998), the mixed findings relating major stress and utilization in unselected primary care populations, and particularly the finding by Brantley et al. (2005) in a similar population of low-income African-American patients that accumulations of minor stressors accounted for significantly more variance in service utilization and symptoms than did major life events. Exposure to minor stressors (daily hassles) was not measured in the present study. The distribution of scores on the SRRS-R was highly skewed toward the upper end, providing relatively little variance on this measure and possibly a ceiling effect limiting relationships with other variables. More research is needed investigating the nuances of the stressutilization relationship, including the impact of behavioral health services, in this chronically and highly stressed population.
DISCLOSURES The clinical service described in this article was supported by a grant from the Virginia Health Care Foundation and Health Resources and Services Administration Graduate Psychology Education program grant #D40HP19638. The authors declare no conflict of interest.
REFERENCES Almeida DM, Horn MC (2004) Is daily life more stressful during middle adulthood? In Brim OG, Ryff CD, Kessler RC (Eds), How healthy are we? A national study of well-being at midlife (pp 425–451). Chicago: University of Chicago Press. Auerbach SM, Gramling SE (1998) Stress management: Psychological foundations. Englewood Cliffs, NJ: Prentice Hall. Barsky AJ, Ahern DK, Bailey ED, Delamater BA (1996) Predictors of persistent palpitations and continued medical utilization. J Fam Pract. 42:465–472. Brantley PJ, Dutton GR, Grothe KB, Bodenlos JS, Howe J, Jones GN (2005) Minor life events as predictors of medical utilization in low income African American family practice patients. J Behav Med. 28:395–401. Brantley PJ, Mehan DJ Jr, Ames SC, Jones GN (1999) Minor stressors and generalized anxiety disorder among low-income patients attending primary care clinics. J Nerv Ment Dis. 187:435–440. Carstensen LL, Fung H, Charles S (2003) Socioemotional selectivity theory and the regulation of emotion in the second half of life. Motiv Emot. 27:103–123.
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Fogarty CT, Sharma S, Chetty VK, Culpepper L (2008) Mental health conditions are associated with increased health care utilization among urban family medicine patients. J Am Board Fam Med. 21:398–407.
McGrady A, Lynch D, Nagel R, Wahl E (2003) Application of the high risk model of threat perception to medical illness and service utilization in a family practice. J Nerv Ment Dis. 191:255–259.
Gortmaker SL, Eckenrode J, Gore S (1982) Stress and the utilization of health services: A time series and cross-sectional analysis. J Health Soc Behav. 23:25–38.
Miranda J, Pérez-Stable EJ, Muñoz RF, Hargreaves W, Henke CJ (1991) Somatization, psychiatric disorder, and stress in utilization of ambulatory medical services. Health Psychol. 10:46–51.
Hobson CJ, Delunas L (2001) National norms and life-event frequencies for the Revised Social Readjustment Rating Scale. Int J Stress Manag. 8:299–314. Hobson CJ, Kamen J, Szostek J, Nethercut CM, Tiedmann JW, Wojnarowicz S (1998) Stressful life events: A revision and update of the Social Readjustment Rating Scale. Int J Stress Manag. 5:1–23. Holmes TH, Rahe RH (1967) The Social Readjustment Rating Scale. J Psychosom Res. 11:213–218. Jones GN, Ames SC, Jeffries SK, Scarinci IC, Brantley PJ (2001) Utilization of medical services and quality of life among low-income patients with generalized anxiety disorder attending primary care clinics. Int J Psychiatry Med. 2001;31: 183–198. Kendler KS, Karkowski LM, Prescott CA (1999) Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry. 156:837–841. Kessler R, Cubic B (2009) The train is leaving the station: Is psychology aboard? J Clin Psychol Med Settings. 16:1–3. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 16:606–613. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B (2007) Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 146:317–325. Lynch DJ, McGrady A, Alvarez E, Forman J (2005) Recent life changes and medical utilization in an academic family practice. J Nerv Ment Dis. 193:633–635.
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Pilisuk M, Boylan R, Acredolo C (1987) Social support, life stress, and subsequent medical care utilization. Health Psychol. 6:273–288. Rybarczyk B, Garroway AM, Auerbach SM, Lord B, Rodriguez V, Sadock E (2013) Primary care psychology: An opportunity for closing the gap in mental health services for older adults. Clin Gerontol. 36:195–215. Sadock E, Auerbach SM, Rybarczyk B, Aggarwal A (2014) Evaluation of integrated psychological services in a university-based primary care clinic. J Clin Psychol Med Settings. 21:19–32. Scully JA, Tosi H, Banning K (2000) Life events checklists: Revisiting the Social Readjustment Rating Scale after 30 years. Educ Psychol Meas. 60:864–876. Spitzer RL, Kroenke K, Williams JB (1999) Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. JAMA. 282:1737–1744. Spitzer RL, Kroenke K, Williams JB (2006) A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 166:1092–1097. Stawski RS, Sliwinski MJ, Almeida DM, Smyth JM (2008) Reported exposure and emotional reactivity to daily stressors: The roles of adult age and global perceived stress. Psychol Aging. 23:52–61. Tamburrino MB, Lynch DJ, Nagel RW, Smit MK (2009) Primary Care Evaluation of Mental Disorders (PRIME-MD) screening for minor depressive disorder in primary care. Prim Care Companion J Clin Psychiatry. 11:339–343.
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The Relationship of Life Stressors, Mood Disorder, and Health Care Utilization in Primary Care Patients Referred for Integrated Behavioral Health Services Elizabeth Sadock, MS,* Stephen M. Auerbach, PhD,* Bruce Rybarczyk, PhD,* Arpita Aggarwal, MD,† and Autumn Lanoye, MS*
Abstract: Exposure to stressful life events, mood disorder, and health care utilization were evaluated in 102 low-income, primarily minority patients receiving behavioral health and medical services at a safety-net primary care clinic. Exposure to major stressors was far higher in this sample than in the general population, with older patients having lower stress scores. Proportions of patients who met the criteria for clinical depression and anxiety were higher than in normative samples of primary care patients. Stress exposure was higher in the patients who met the criterion for clinical anxiety but was unrelated to clinical depression. Contrary to expectation, anxiety, depression, or stress exposure was not related to service utilization. Latter findings are discussed in terms of the influence of the provision of behavioral health services, the highly skewed distribution of major stressor scores, and the likely greater influence of individual differences in minor stressor exposure on utilization in this population. Key Words: Primary care psychology, health care utilization, stressful life events, anxiety, depression. (J Nerv Ment Dis 2014;202: 763–766)
O
ur health care system is heavily burdened by patients with chronic and comorbid mental and physical health problems. The primary care setting is the entry point and provider of long-term care for the vast majority of these patients (Kessler and Cubic, 2009). Prevalence rates for both depression (Tamburrino et al., 2009) and anxiety (Kroenke et al., 2007) are particularly high. Negative affect (McGrady et al., 2003) and especially generalized anxiety disorder (GAD; Fogarty et al., 2008; Jones et al., 2001) have been linked to increased health care utilization in primary care patients. Extensive findings of an association between exposure to stressful life events and anxiety and depression (e.g., Brantley et al., 1999; Kendler et al., 1999) suggest that stress may play a role in emotional dysfunction and increased service utilization in patients. However, the relationship between stress exposure and utilization seems to be a complex one. When evaluating the impact of major life stressors in primary care patients, Miranda et al. (1991) and Gortmaker et al. (1982) found that stress was associated with increased utilization, as did Lynch et al. (2005) particularly for men and Pilisuk et al. (1987) especially for men and older women. However, Barsky et al. (1996) found no relationship, and in a sample of low-income African-American primary care patients, Brantley et al. (2005) also found no relationship, although minor stressors accounted for significant variance after controlling for major stressors. The present study evaluated data obtained from a sample of lowincome, primarily minority patients attending a safety-net primary care
*Virginia Commonwealth University; and †Virginia Commonwealth University Health System (VCUHS), Richmond, VA. Send reprint requests to Elizabeth Sadock, MS, Virginia Commonwealth University, 806 West Franklin St, P.O. Box 842018, Richmond, VA 23284-2018. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20210–0763 DOI: 10.1097/NMD.0000000000000195
clinic serving uninsured or underinsured patients. Because no studies have directly assessed this objectively, we evaluated the extent to which these patients were confronting major life stressors in comparison with a normative population. We also evaluated the extent to which prior findings relating stress exposure, emotional dysfunction, and health care service utilization generalized to this population of patients. All of our patients were referred by their physician to a behavioral health service integrated into the primary care clinic (see Rybarczyk et al., 2013; Sadock et al., 2014, for a description of this service). Exposure to stressful events was assessed at the first psychological treatment session. Anxiety and depression were also assessed at this time. Medical service utilization during the year subsequent to initial contact with the clinic was tabulated. On the basis of prior findings, we expected a) high rates of clinically significant levels of anxiety and depression along with high levels of exposure to stressful life events in our sample and b) positive relationships between stress exposure, measures of emotional distress, and service utilization by patients.
METHODS Participants Data were obtained from 102 primary care patients receiving medical services from the Ambulatory Care Clinic at the Virginia Commonwealth University Health System Medical Center in Richmond, Virginia. Patient age ranged from 20 to 78 years (mean, 52.39; SD, 13.19), with 17.6% of the sample 65 years or older. Thirty-five percent were Caucasian, and 64.7% were African-American. The medical center primarily serves indigent urban and rural populations. Most of the patients referred for behavioral health services were unemployed (74.6 %). Approximately 48% had Medicare, 35% were uninsured, 15% had Medicaid, and 2% had private insurance.
Measures The Generalized Anxiety Disorder Scale The Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006) is a seven-item questionnaire that assesses symptoms of anxiety using a 4-point Likert scale. It was normed on 2739 patients in 15 primary care clinics in the United States. To determine clinically significant cutoff scores for the GAD-7, mental health professionals first used the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as the criterion for assessing patients. These scores were compared with the patients’ GAD-7 scores, and a summary score of 10 or greater was determined as the cutoff point to yield optimal sensitivity of 89% and a specificity of 82% for GAD (Spitzer et al., 2006).
The Patient Health Questionnaire–9 The Patient Health Questionnaire–9 (PHQ-9; Spitzer et al., 1999) has been used extensively for assessing depression in primary care settings (Tamburrino et al., 2009). It consists of nine items and is
The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
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763
The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
Sadock et al.
TABLE 1. Primary and Secondary Focus for Patient Visits Focus Depression Smoking Pain Anxiety Insomnia Other Weight loss Substance Intro to behavioral services Dementia screening Referral Suicide assessment Adherence
Primary Focus: No. Visits (%)
Secondary Focus: No. Visits (%)
Total No. Visits (%)
41 (40.2) 13 (12.7) 11 (10.8) 11 (10.8) 8 (7.8) 5 (4.9) 4 (3.9) 3 (2.9) 3 (2.9)
9 (8.8) 6 (5.9) 9 (8.8) 11 (10.8) 4 (3.9) 4 (3.9) 1 (1.0) 2 (2.0) 1 (1.0)
50 (31.1) 19 (11.8) 20 (12.4) 22 (13.7) 12 (7.5) 9 (5.6) 5 (3.1) 5 (3.1) 4 (2.5)
2 (2.0)
4 (0.91)
6 (3.7)
1 (1.0) 0
3 (2.9) 4 (3.9)
4 (2.5) 4 (2.5)
0
1 (1.0)
1 (0.6)
aware of the range of services available, which included addressing issues such as depression, anxiety, medication adherence, smoking cessation, diet and exercise change, as well as insomnia. Student clinicians administered measures of stressful life events, depression, and anxiety at the patients’ first visit. After the initial assessment, the student clinician administered a brief intervention focusing on the patients’ identified problem areas (Table 1 lists primary and secondary problem areas addressed during the patients’ visits). The patients were encouraged to return only if they believed that they required additional services. Therefore, the number of follow-up appointments was variable, and they occurred at variable intervals subsequent to the initial assessment.
RESULTS Patient Exposure to Stressful Life Events
designed to measure depressive symptoms experienced during the previous 2 weeks. A score of 10 was established as the cutoff for at least a moderate level of depression based on administering the PHQ-9 to the patients together with the Structured Clinical Interview for DSM-III-R and the primary care evaluation of mental disorders (the longer version from which the PHQ-9 was derived; Kroenke et al., 2001).
The Social Readjustment Rating Scale–Revised The original Social Readjustment Rating Scale (SRRS; Holmes and Rahe, 1967) consists of 43 life events. However, it has been criticized for containing outdated events that may no longer have the same impact as when the scale was originally developed (Scully et al., 2000), items that represent stress symptoms rather than life events (Hobson et al., 1998), and deficiencies in the original validation sample (Hobson et al., 1998). A revised scale (SRRS-R; Hobson et al., 1998) consisting of 51 major life events was used in the present study. Respondents were asked to indicate if they had experienced any of the events in the past year. New weights for each item and norms were established on the basis of administration of the scale to two separate national samples (Hobson and Delunas, 2001; Hobson et al., 1998). Weightings of each item in terms of stressfulness are multiplied by frequency of endorsement and summed to provide a total score.
Patient Utilization of Medical Services Patient utilization data for all medical services (i.e., emergency department use, primary care use, total utilization) were collected from patient academic health system utilization records for the year after their first behavioral health appointment. Because of referral patterns from this primary care office and self-referral constraints for safety-net patients, these patients obtain nearly 100% of their medical care within the academic health system.
SRRS-R scores (weighted by life change units) were far higher in our patient sample than in respondents from the general population (Hobson and Delunas, 2001). The mean SRRS-R score for the patients was 436.91 (SD, 379.17) vs. 278 (SD, 422) for the normative population. Even after deleting three outliers whose SRRS-R scores exceeded a standard score of 3.29, patient scores were substantially higher than those of the normative population, t(3,499) = 3.76, p < 0.0002. The median patient score was 324 (70th–75th percentile in the normative sample); the score corresponding to the 99th percentile for the patients was 4864 vs. 1936 for the respondents in the normative sample. The stressful life events most commonly cited by the patients are listed in Table 2. No significant sex or racial differences in SRRS-R scores were found in our sample, both t(100) scores of less than 1. To evaluate the relationship between age and SRRS-R scores, we divided the sample into two groups according to patient age, with younger adults consisting of ages in the lower 40% of the sample (n = 44; mean, 40.57; SD, 8.96) and older adults consisting of the upper 40% (n = 43; mean, 64.19; SD, 6.78). The older patients had significantly lower scores on the SRRS-R (t[83] = −2.21, p = 0.03). When the entire age distribution was considered, age and SRRS-R had a marginally significant relationship (r [102] = −0.15, p = 0.06).
TABLE 2. Most Frequently Endorsed SRRS-R Items by Primary Care Psychology Patients in the Past Year Top 10 Most Frequently Cited Stressful Life Events 1 2 3 4 5 6 7 8
Procedure All patients were referred by their primary care physician to an on-site psychological clinic for behavioral health services where the service providers were doctoral students in clinical and counseling psychology. All physicians were internal medicine residents whose work was being supervised by attending physicians. Physicians were made 764
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Experiencing financial problems/difficulties (bankruptcy, credit card debt, college costs, tax problems) Death of a close family member Attempting to modify addictive behavior of self (i.e., smoking, alcohol, drugs) Major injury/illness of self (i.e., cancer, AIDS) Change in residence Death of a close friend Major injury/illness of a close family member (i.e., cancer, AIDS) Discovering/attempting to modify addictive behavior of a close family member (i.e., smoking, alcohol, drugs) Being fired/laid off/unemployed Assuming responsibility for a sick or elderly loved one
% of Patients 46.51 41.86 40.70 31.40 29.07 27.91 26.74 23.26 23.26 18.60
AIDS indicates acquired immunodeficiency syndrome.
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The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
Exposure to Stressful Events and Anxiety and Depression Clinical levels of depression and anxiety (as measured by the PHQ-9 and the GAD-7, respectively) were defined as scores of 10 or greater on each measure, based on criteria described in the Methods section. A total of 67.4% of the patients (mean, 17.02) met the criterion for clinical depression, a significantly higher proportion than observed in the PHQ-9 normative sample of primary care patients (Kroenke et al., 2001; z = 10.4, p < 0.001). However, a regression analysis found no relationship between cumulative stress exposure and clinical depression. A total of 66.3% of the patients (mean, 15.59; SD, 3.42) met the criterion for clinical anxiety, a significantly higher proportion than that observed in the GAD-7 normative sample of primary care patients (Spitzer et al., 2006; z = 9.1, p < 0.001). A regression analysis indicated that the participants who met the criterion for clinical GAD had higher SRRS-R scores than those not meeting the criterion (F[1,93] = 4.17, p = 0.044; R2 = 0.043). However, after controlling for the influence of age, sex, and ethnicity in the first block of the analysis, the relationship between SRRS-R and clinical anxiety fell short of significance (change in F[1,90] = 3.19, p = 0.077; R2 change = 0.033). Analyses by sex showed that the stressful events–anxiety relationship was accounted for primarily by the men (r[34] = 0.48, p = 0.004), whereas the association for the women was minimal (r[61] = 0.04). The relationship was especially pronounced in the older men (r[10] = 0.93, p < 0.001) compared with the younger men (r[16] = 0.39, p = 0.14).
Determinants of Patient Utilization of Services Patient utilization data were obtained for the year subsequent to the patients’ first medical visit. To assess the relation between stressful events and utilization, a hierarchical regression was conducted in which SRRS-R scores were regressed on the total utilization score after including age, sex, and race in the first block of the analyses. Age ( p = 0.039) (older patients used more services) and sex ( p = 0.035) (women used more services) had a significant influence on utilization. However, SRRS-R scores were not significantly related either to total utilization or in separate analyses to subcategories of utilization, including number of emergency department visits that resulted in an inpatient admission, number of emergency department visits that resulted in outpatient care only, number of non-emergency inpatient visits, number of primary care visits, or number of non–primary care outpatient visits. Finally, we explored our hypothesis that patients with clinical levels of anxiety and depression would have more health care utilization. No effects were obtained.
DISCUSSION AND CONCLUSIONS This study evaluated relationships between stress exposure, clinical anxiety and depression, as well as medical service utilization in a sample of low-income, primarily minority patients who were referred for behavioral health services by their primary care physician. Cumulative exposure to major stressful events was far higher in this sample than in the normative national population, with close to half of the respondents having had major financial problems and more than 40% having experienced death of a close family member in the prior year. Although there are few empirical findings relating major life event exposure to age, our finding that older patients had lower stress scores is consistent with prior research indicating that older adults report experiencing considerably fewer minor stressors than do young adults (Almeida and Horn, 2004; Stawski et al., 2008). Findings for both major and minor stressors may be due to increased motivation to avoid situations that induce negative emotions (Carstensen et al., 2003) or due to health limitations that constrain activity level and reduce opportunity to experience stressors in older adults (Stawski et al., 2008). Clinical levels of anxiety and depression, as reported in our larger sample (see Sadock et al., 2014), were far more prevalent in this © 2014 Lippincott Williams & Wilkins
Relationship of Life Stressors
sample than in the primary care population as a whole, but only clinical levels of anxiety were associated with higher levels of stress exposure, especially for men. This finding may be explained by unemployment and other socioeconomic stressors faced by men, having a greater impact on anxiety in men because of role expectations and a more limited support system. Further, the expected relationships of both anxiety/ depression and stress exposure to service utilization were not obtained. This may be due to the fact that the patients in this sample were receiving behavioral health services and were therefore less likely to misinterpret their anxiety and depressive symptoms as having a somatic cause and requiring medical treatment. Fogarty et al. (2008) and Jones et al. (2001), studies with nearly identical urban underinsured/uninsured populations, found that all anxiety and depressive disorders were a strong predictor of nonuse of psychiatric service. However, mental health service utilization was not reported in the study of Jones et al., and Fogarty et al. found that patients with mental health conditions actually had fewer specialty mental health care visits than those without those conditions. In the latter study, it can be inferred that patients were likely treated with medications by their primary care physicians and did not receive any behavioral services that may be particularly effective in reducing somatization of psychological distress. The overall lack of relationship of SRRS scores to utilization should be considered in the context of generally weak associations that have been found between major life events measures such as the SRRS and illness onset (Auerbach and Gramling, 1998), the mixed findings relating major stress and utilization in unselected primary care populations, and particularly the finding by Brantley et al. (2005) in a similar population of low-income African-American patients that accumulations of minor stressors accounted for significantly more variance in service utilization and symptoms than did major life events. Exposure to minor stressors (daily hassles) was not measured in the present study. The distribution of scores on the SRRS-R was highly skewed toward the upper end, providing relatively little variance on this measure and possibly a ceiling effect limiting relationships with other variables. More research is needed investigating the nuances of the stressutilization relationship, including the impact of behavioral health services, in this chronically and highly stressed population.
DISCLOSURES The clinical service described in this article was supported by a grant from the Virginia Health Care Foundation and Health Resources and Services Administration Graduate Psychology Education program grant #D40HP19638. The authors declare no conflict of interest.
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