افسردگی، اضطراب و اختلالات شبه جسمی: دسته بندی های مبهم یا مشخص در مراقبت های اولیه؟ نتایج یک مطالعه بزرگ مقطعی

Objective Depression, anxiety, and somatization are the most frequently observed mental disorders in primary health care. Our main objective was to draw on the often neglected general practitioners' (GPs) perspective to investigate what characterizes these three common mental diagnoses with regard to creating more suitable categories in the DSM-V and ICD-11. Methods We collected independent data from 1751 primary care patients (participation rate=77%) and their 32 treating GPs in Germany. Patients filled out validated patient self-report measures for depression (PHQ-9), somatic symptom severity (PHQ-15), and illness anxiety (Whiteley-7), and questions regarding coping and attribution of illness. GPs' clinical diagnoses and associated features were assessed. Results Patients diagnosed by their GPs with depression, anxiety, and/or somatoform disorders were significantly older, less educated, and more often female than the reference group not diagnosed with a mental disorder. They had visited the GP more often, had a longer duration of symptoms, and were more often under social or financial stress. Among the mental disorders diagnosed by the GPs, depression (OR=4.4; 95% CI=2.6 to 7.5) and comorbidity of somatoform, depressive, and anxiety disorders (OR=9.5; 95% CI=4.6 to 19.4) were associated with the largest degrees of impairment compared to the reference group. Patients diagnosed as having a somatoform/functional disorder only had mildly elevated impairment on all dimensions (OR=2.0; 95% CI=1.4 to 2.7). Similar results were found for the physicians' attribution of psychosocial factors for cause and maintenance of the disease, difficult patient–doctor relationship, and self-assessed mental disorder. Conclusion In order to make the DSM-V and ICD-11 more suitable for primary care, we propose providing appropriate diagnostic categories for (1) the many mild forms of mental syndromes typically seen in primary care; and (2) the severe forms of comorbidity between somatoform, depressive, and/or anxiety disorder, e.g., with a dimensional approach.

Depression, anxiety, and somatization are the most common mental disorders in primary care [1]. General practitioners (GPs) are usually the first contact person for patients suffering from psychological and physical problems and therefore play a central role in the detection, prevention, and management of mental disorders. Adequate detection and management of these disorders pose a challenge to the health care system [2], [3], [4] and [5]. Not only do these disorders have a high prevalence [6] and [7], but patients suffering from them make up a disproportionately large portion of GPs' workloads and are often considered difficult and draining to treat [8]. Different groups often come to think about mental disorders from different viewpoints: patients based on life problems, GPs based on irregularities in management, and specialists based on preset nosological classifications [9]. This difference in perspective results in low rates of agreement between GPs' diagnoses and those derived from standard psychiatric classification systems [10] and [11]. The use of standardized psychiatric instruments in primary care is uncommon because GPs usually consider the patients' history and social and family background information for diagnosis and treatment [12]. The categories of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [13] and the International Classification of Disease (ICD-10) [14] have also been deemed inadequate for general practice usage [15] and [16]. These facts lead to the question of what information and which associated features determine the diagnosis of a specific mental disorder in general practice. Given the impending revisions of DSM-IV and ICD-10, it would be beneficial to consider how to make the new presentation more accessible and user friendly for GPs and other nonspecialists [17] and [18]. The DSM-V and ICD-11 would be more broadly relied upon if they addressed themselves also to GPs and other health care workers who do not have the same understanding of mental disorders as specialists do. Hence, the main aim of this study was to analyze clinically relevant features when GPs diagnose the three most common psychiatric syndromes in primary care: depression, anxiety, and somatization. Therefore, we used data from a large primary care study. In order to obtain more knowledge about how GPs think about mental disorders, we first compared the demographic and clinical characteristics of patient groups with different mental disorders as diagnosed by the GPs. Second, the agreement between GPs' diagnoses and patient self-report measures of depression, anxiety, and somatization was assessed. Third, we investigated which clinical characteristics, explanatory models, and patient self-report measures were associated with GPs' diagnoses.