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Am J Psychiatry 1993; 150:734-741
Copyright © 1993 by American Psychiatric Association
Somatization and the recognition of depression and anxiety in primary care
LJ Kirmayer, JM Robbins, M Dworkind and MJ Yaffe
Institute of Community and Family Psychiatry, Sir Mortimer B. Davis- Jewish General Hospital, Montreal, Canada.
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.
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