OBJECTIVE: The authors examined the effect of patients' style of
clinical presentation on primary care physicians' recognition of depression
and anxiety. METHOD: The subjects were 685 patients attending family
medicine clinics on self-initiated visits. They completed structured
interviews assessing presenting complaints, self- report measures of
symptoms and hypochondriacal worry, the Diagnostic Interview Schedule
(DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D).
Physician recognition was determined by notation of any psychiatric
condition in the medical chart over the ensuing 12 months. RESULTS: The
authors identified three progressively more persistent forms of somatic
presentations, labeled "initial," "facultative," and "true" somatization.
Of 215 patients with CES-D scores of 16 or higher, 80% made somatized
presentations; of 75 patients with DIS-diagnosed major depression or
anxiety disorder, 76% made somatic presentations. Among patients with DIS
major depression or anxiety disorder, somatization reduced physician
recognition from 77%, for psychosocial presenters, to 22%, for true
somatizers. The same pattern was found for patients with high CES-D scores.
In logistic regression models education, seriousness of concurrent medical
illness, hypochondriacal worry, and number of lifetime medically
unexplained symptoms each increased the likelihood of recognition, while
somatized presentations decreased the rate of recognition. CONCLUSIONS:
While physician recognition of psychiatric distress in primary care varied
widely with different criteria for recognition, the same pattern of
reduction of recognition with increasing level of somatization was found
for all criteria. In contrast, hypochondriacal worry and medically
unexplained somatic symptoms increased the rate of recognition.