Family Practice Vol. 18, No. 1, 71-77
© Oxford University Press 2001
Psychological Problems |
Agreement in symptoms of anxiety and depression between patients and GPs: the influence of ethnicity
a Centre for Health Equity, Training, Research, and Evaluation, Old Clinical School Building, Liverpool Hospital, PO Box 103, Liverpool NSW 2170,
b School of Community Medicine and
c Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Sydney NSW 2052, Australia.
Correspondence to Dr Elizabeth Comino, Department of General Practice, Fairfield Hospital, PO Box 5, Fairfield, NSW, Australia 1860.
Comino EJ, Silove D, Manicavasagar V, Harris E and Harris MF. Agreement in symptoms of anxiety and depression between patients and GPs: the influence of ethnicity. Family Practice 2001; 18: 71–77.
Received 10 December 1999; Revised 22 May 2000; Accepted 5 September 2000.
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Abstract |
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Background. Few studies have focused specifically on the role of ethnicity in the identification and treatment of anxiety and depressive symptoms among patients consulting GPs.
Methods. A survey was conducted of 4753 patients aged 18–90 years attending general practices in Sydney, Australia. Three methods of case detection were used: a GHQ-12 score (
3), self-report symptoms (using a checklist) and GP detection of symptoms. Four regional groupings based on country of birth [other English speaking countries (ESB), European, Asian (predominantly south east Asian) and other non-English speaking (other NESB)] were compared with Australian (AB) patients.
Results. Compared with AB patients, Asian patients had a lower mean GHQ-12 score (2.04 versus 2.54) and a lower rate of GP detection (10.4% versus 20.5%) but they recorded a similar rate of self-report symptoms (16.7% versus 20.1%). For Asian patients, 24.6% of all cases identified by self-report or by GP detection were identified by both methods, compared with 44% for AB patients. Similar patterns of treatment and referral were observed for detected cases. Compared with AB patients, Asian and other NESB patients were more likely to desire more time to discuss their problems with their GP (18.5% versus 42.0%, 37.3%) and receive an explanation of medications prescribed (18.9% versus 46%, 40.0%).
Conclusion. These results suggest that there are substantial variations in the rates of detection of anxiety and depressive symptoms in GP patients depending on the screening methods used and the broad ethnic background of patients. Such symptoms may be under-diagnosed in Asian patients in particular.
Keywords. Anxiety, depression, epidemiology, ethnic groups, family practice.
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Introduction |
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As in other countries, GPs in Australia are the initial point of contact for most patients suffering from psychological ill-health, particularly symptoms of anxiety and depression.1,2 Reported rates of such symptoms among patients presenting to GPs in Australia vary from 6.6 to 36% depending on the criteria for caseness used,3,4 with the impression being that variation in detection rates by GPs may be partly responsible for the differences in prevalence rates reported across studies.5–8 One factor may be that the ethnic background of the patient influences GP detection, an issue that is important to urban areas such as Sydney, Australia, where ~23% of the population are from immigrant backgrounds.9,10
There is evidence that people from immigrant backgrounds do not access in-patient or community-based mental health services at the same rate as do Australian patients.11 Potential explanations for these observed differences include cross-ethnic variation in the actual prevalence of illness, transcultural differences in the manifestations, self-recognition and reporting of mental distress, and practical issues relating to the accessibility of services.9 Weissman and co-workers12 observed similarities in the patterns of bipolar disorder across 10 countries but striking differences in patterns of major depression and anxiety. They suggested that cultural variation in expressing distress and in risk factor profiles may explain these transcultural differences. There is evidence that a combination of factors such as social disruption due to migration, low socio-economic status and under-employment influence the prevalence of psychological ill-health in particular ethnic minorities.13–15
An important issue, however, is whether ethnic differences influence rates of detection by GPs. While ethnic communities attend GPs at similar rates as Australian communities, there are a number of factors that may mask the expression of psychological distress among immigrant patients attending GPs. Cultural norms that determine the expression of health and illness may result in a reluctance to recognize or disclose psychological distress or encourage its expression as physical.16,17 Nevertheless, whether certain cultures are more likely to ‘somatize' their symptoms remains controversial.18,19 Recent evidence suggests that the tendency to somatize may be universal.17 Communicating psychological health, however, may be complicated further by problems associated with language, stigma and level of knowledge among immigrant groups about the health care system in Australia and other western countries.9 GPs themselves may find it difficult to detect mental disorder in people from other cultures, either because of language difficulties or because of their implicit assumptions about the low prevalence of emotional disorders in some immigrant groups.6 A further barrier may be the tendency to rely exclusively on western-based concepts and diagnostic traditions when assessing persons from other cultures.16
Thus, under-recognition of mental health problems amongst immigrants treated in general practice may be a factor accounting for the low referral rates of ethnic minorities to specialist mental health services.9 For example, immigrants from Asia and Southern Europe are less likely to utilize Australian public hospital services for mental health problems.11 Low rates of referral by GPs may be one reason for this pattern. If such under-recognition in general practice is occurring, then it may have important implications, since it is likely to lead to suboptimal management of mental health problems in ethnic minorities, and the associated risk of chronicity and ongoing impairment in social and occupational functioning in these groups.20,21
Nevertheless, there have been few published studies in Australia or in other western countries investigating GP detection of mental health problems in immigrant groups. The aims of the present study were to investigate the prevalence of common symptoms of anxiety and depression among GP patients from ethnically diverse backgrounds and levels of agreement between GPs and such patients on the presence or absence of common symptoms of anxiety and depression. Furthermore, we sought to determine whether detection influenced the treatment received by broad ethnic groups of patients, and whether there were differential levels of satisfaction with GP services according to ethnicity.
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Methods |
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The details of the methods used to select the sample have been published elsewhere.4 The study comprised a cross-sectional survey of patients aged 18–90 years, without a diagnosis of a ‘major' psychiatric disorder such as psychosis or dementia, attending 117 general practices in south-west and south-east Sydney. The GP or the receptionist gave questionnaires and information sheets to 50 consecutive patients and invited them to participate in the study.
The three page self-administered questionnaire (available from the authors on request) included demographic characteristics (age, gender, country of birth, language spoken at home and employment status); whether the patient was seeing his/her usual GP; the General Health Questionnaire (GHQ-12); self-reported symptoms of anxiety and depression (rated on a brief checklist) during the last 4 weeks that were severe enough to seek a medical opinion; medical treatment received; whether they had been referred by the GP to a range of health professionals dealing with psychological problems; and satisfaction with care and support from the GP. Patient satisfaction with care was assessed by three questions: whether patients desired more time to discuss their problems with their GP; whether they wished for more explanation of their care; and, finally, overall satisfaction with care, measured on a five-point Likert scale devised for the study. As well as the English version, the whole questionnaire was available in Vietnamese, Chinese, Spanish and Arabic translations, since these were the main language groups treated by the GPs.
Patients returned their questionnaires to the GP who completed the final page during the consultation. The GP section of the questionnaire inquired whether the GP had treated the patient for anxiety or depression during the previous 12 months including the present consultation; what treatment, if any, was prescribed for such symptoms; and what referrals to or communication with other health professionals had occurred as a consequence.
Patients were classified according to five broad groups according to their country/region of birth: Australian born (AB); born in another English-speaking country, e.g. the UK or USA (ESB); European born excluding the UK or Ireland (European); Asian born, predominantly south-east Asia and China (Asian); or born in another non-English speaking country (other NESB; including the Middle East, Africa and South America).
The questionnaire included three methods for assessing symptoms of anxiety and depression: the GHQ-1222,23 (a screening aid for GPs); a self-reported checklist which included the items: worry, nerves, stress, anxiety, depression and sleep problems; and the GP's report of a diagnosis of and/or treatment for anxiety or depression over the previous 12 months. Individual items scored on the GHQ-12 as three or four were regarded as positive in accordance with past research and given a score of one. Ratings were summated across the 12 items to give an individual GHQ-12 score ranging between 0 and 12. Following previous norms, an overall score of three or more was regarded as indicative of a ‘case' of anxiety and/or depression.24,25 Patients who endorsed one or more items on the self-reported checklist were identified as self-reported cases.
Statistical analysis
All analyses were conducted using the Statistical Package for the Social Sciences (SPSS, Version 6.2; SPSS Inc., Chicago IL, USA). The mean (±standard deviation) GHQ-12 scores and the percentage of patients with a score of three or more [together with 95% confidence intervals (95% CI)] are reported. Comparisons between groups for GHQ-12 scores were examined using one-way analysis of variance and the F-ratio. Categorical data were summarized as proportions (95% CI), and the relationships across groups were examined using contingency tables and the chi-square statistic.
Multivariate logistic regression analyses were used to examine the relationship of region of birth and occurrence of anxiety and depression when age, gender and employment status were controlled. The estimates of the logistic regression coefficients (presented as odds ratios and their 95% CI) were derived from an iterative maximum likelihood method using SPSS.
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Results |
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Study sample
A total of 4753 of the 4867 eligible patients (overall response 85%) representing 42 patients from each participating practice were included in the present analysis. Australian (AB) patients comprised 64.0% of the sample and those born in ESB countries comprised 10.2%. Patients born in a non-English speaking country comprised 25.9%: European, 13.5%; Asian, 6.3%; other NESB, 6.1%. Twenty-seven per cent of patients spoke a language other than English at home, and only 4.8% of completed surveys were returned using the translated forms.
Patient characteristics are summarized in Table 1
. There was a preponderance of females (60.2%; 95% CI 58.7–61.5%); the proportion of males consulting GPs was slightly higher for patients who were born overseas (P = 0.04). The mean age of patients was 46.1 ± 18.1 years. A language other than English was spoken at home by <10% of AB and ESB patients and by 82.5% of all other patient groups. Unemployment was reported by 8.9% (95% CI 8.1–9.7%) of patients and varied significantly across groups (chi-squared4: 81.1, P < 0.001, Table 1). The majority of all patients were consulting their usual GP.
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Symptoms of anxiety and depression
The mean GHQ-12 score for all patients was 2.54 (±3.2). Mean GHQ-12 scores varied significantly across the regional groups (F4,4748: 3.22; P = 0.01). Asian patients (2.04 ± 2.75) had a lower score than AB patients (2.51 ± 3.2; t3337: 2.42, P = 0.02), while other NESB patients (2.86 ± 3.15) returned a slightly higher mean score than AB patients (2.51 ± 3.2; t3327: 2.42, P = 0.07). An above threshold score was recorded by 36% of patients, with significant variation between groups (Fig. 1
). After adjustment for age, gender and employment status, Asian patients remained less likely to return threshold GHQ scores (OR: 0.67, 95% CI 0.51–0.89), while the other NESB group was significantly more likely to do so (OR: 1.46, 95% CI 1.12–1.91) (Table 2).
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GPs indicated that they had diagnosed and treated 970 (20.4%; 95% CI 19.3–21.6%) patients for symptoms of anxiety and/or depression during the previous 12 months. Among ESB, European and other NESB patients, case identification by GPs was similar to that of AB patients (Fig. 1
). However, for Asian patients, GP case detection was half that of AB patients (10.4%; 95% CI 7.3–14.5% compared with 20.5% 95% CI 19.1–22%; chi-squared1: 17.7, P < 0.001). Adjustment for age, gender and employment status did not alter the results (Table 2), with Asian patients being less likely to be identified (OR: 0.44; 95% CI 0.30–0.65).
According to the patient self-report checklist, a total of 983 (20.7%; 95% CI 19.5–21.9%) patients reported at least one symptom of anxiety and/or depression during the previous 4 weeks which was severe enough for them to seek medical attention (Fig. 1). European patients (23.8%; 95% CI 20.5–27.3%) were more likely to report symptoms of anxiety and/or depression than AB patients (20.1%; 95% CI 18.7–21.5%; chi-squared1: 4.4, P = 0.04), while Asian patients (16.7%; 95% CI 12.8– 21.6%) were only slightly less likely than AB patients to report such symptoms. Importantly, while caseness based on the GHQ-12 and GP assessment was significantly lower among Asian patients, the difference in self-reported symptoms according to the checklist was not statistically significant. Adjusted odds ratios did not differ significantly across the groups (Table 2).
The degree of agreement between GP's identification and patient self-report of symptoms of anxiety and/or depression was assessed next (Table 3). Of the 1375 patients who reported symptoms on the checklist or who were identified by their GP, 42% (95% CI 39.4–44.7%) were identified by both methods. For AB, ESB and European, the percentages of cases identified by both GP and self-report were 40% or more and exceeded the percentages identified by either method alone (Table 3). A similar trend emerged for other NESB patients although the proportion who were identified by patient self-report alone was greater than that of GP alone detection. A significantly different pattern of case identification emerged for Asian patients compared with AB patients (chi-squared2: 19.1, P < 0.001). More than half of cases were identified by self-report and only 24.6% were identified by mutual detection.
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Treatment and referral
Half of all patients (52.8%; 95% CI 49.6–56.0%) who identified themselves using the checklist of symptoms during the previous 4 weeks (n = 983) reported being treated with psychotropic medication, and 25% (95% CI 22.4–27.9%) reported that they had been referred for treatment to a psychiatrist, psychologist or counsellor. These patient-reported rates of medication use or specialist referral did not vary across regional groupings.
Of the patients (n = 970) whom the GP identified as a case during the previous year, 45.8% (95% CI 42.6– 49.0%) had been prescribed medication (antianxiety, antidepressants or nocturnal sedation) and 23.9% (95% CI 21.3–26.8%) had been referred for specialist care. There were no significant differences in referral patterns across the five regional groups (chi-squared4: 1.6, P = 0.8) or by language of consultation (chi-squared2: 2.1, P = 0.3). Individual contrasts did suggest, however, that Asian cases (16.1%; 95% CI 6.1–34.5%) were referred by GPs significantly less often than AB cases (24.2%; 95% CI 21.0–27.8%; chi-squared1: 5.4, P = 0.02).
Satisfaction with care
Cases identified by self-report checklist were asked a number of questions about their satisfaction with aspects of their care by their GP. Overall, 23.4% (95% CI 20.8– 26.2%) of these cases reported that they would have liked more opportunity to discuss their emotional problems with their GP. There was a significant variation across the regional groupings (chi-squared4: 47.6, P < 0.001), with Asian (42.0%, 95% CI 28.5–56.7%) and other NESB (37.3%, 95% CI 26.7–49.3%) desiring more opportunities to discuss their emotional problems with their GP compared with AB cases (18.5%, 95% CI 15.6–21.9%). Similarly, trends were observed for self-report cases (overall result: 24.5%, 95% CI 21.9–27.4%) in their desire for more explanation about prescribed medication. Asian (46.0%, 95% CI 35.7–64.3%) and other NESB (40.6%, 95% CI 29.1–52.0%) patients again desired greater explanation than AB cases (18.9%, 95% CI 15.9–22.2%; chi-squared4: 60.3, P < 0.001).
While most self-reported cases (68.6%, 95% CI 65.5– 71.4%) agreed that the treatment and advice that they received from the GP had been helpful, Asian (50.0%; 95% CI 35.7–64.3%) and other NESB cases (53.3%; 95% CI 41.5–64.8%) were significantly less likely to agree that the advice was helpful compared with AB cases (74.1%; 95% CI 70.4–77.5%; chi-squared4: 28.2, P < 0.001).
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Discussion |
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The present data may assist in identifying obstacles to detection of common symptoms of anxiety and depression amongst members of ethnic minorities attending general practice in Australia. The data need to be interpreted with the reservation that the population rates of such symptoms across the five regional groups in Australia are not known, there is little information concerning possible differential patterns of GP utilization according to ethnicity and simple measures that were readily applicable in the general practice setting were used.
These results suggest that there are important differences across these broad ethnic groups using each of the three methods of case detection. Importantly, the data support previous work that suggests that a single case threshold for the GHQ-12 for case detection across cultures may be inappropriate.26 It was not possible to corroborate the GHQ-12 cut-off for each regional group since no other standard diagnostic method, such as the Composite International Diagnostic Instrument, was used.23,25 For all groups, the rate of detection by the GHQ-12 was higher than for the other two methods. The results suggest that there is a significant cultural difference in the detection of cases by patients themselves and by their GPs. The importance of this is unclear given that for those who were detected by either method, treatment did not vary across regional groups.
The close concordance in self-reported and GP-diagnosed caseness in the AB, other ESB and European groups suggests that the rates yielded by these two methods might be closer to the practical clinical threshold for identifying caseness. That these two methods varied most significantly amongst Asian and other NESB groups suggests differences for these groups in recognition or interpretation of these problems. The analyses presented in Table 3 provide further support for this inference. These results suggest that there may be a substantial under-detection by GPs of symptoms of anxiety and depression amongst Asian patients, even though the patients are able to identify common symptoms of anxiety and depression themselves. Several reasons for the lack of concordance amongst GPs and Asian patients may be responsible—culturally based variations in conceptualizing symptoms of anxiety and depression,16 language barriers or difficulties that western or western-trained GPs experience in eliciting such symptoms in Asian patients. Our additional analysis (unpublished) investigating groups defined according to the similarities or differences in the language spoken at home by patients and by GPs during consultation suggested that language may not be the primary issue. Further research is warranted to identify which of these factors may be most salient.
Once a case was detected by the GP, however, ethnicity exerted few influences on the rates of treatments prescribed or of referral to other health professionals. This finding adds to the importance of the apparent under-detection of cases amongst Asian patients.
Asian patients differed significantly from other regional grouping in reporting a greater desire for further discussion with their GP about their emotional problems, and a wish for fuller explanations about the medications prescribed. Asian and other NESB cases were also significantly less likely to report that the advice they received from their GPs was helpful. These findings concur with other studies in the mental health field which suggest that Asian groups are relatively dissatisfied with the level of mental health information offered to them by generic health services.27 While the questions had face validity only and were not measured using a psychometrically validated instrument, nevertheless this finding suggests, albeit indirectly, that patients from other cultures, especially Asia, may not be as reluctant to explore their symptoms of anxiety and depression as was previously thought.28 Indeed, the findings suggest that greater efforts need to be made to overcome the stereotype that patients from Asian cultures are inhibited about discussing their emotional problems with their GPs.
In interpreting the data, the limitations of the study need to be acknowledged. First, broad geographical groupings represented heterogeneous nationalities and ethnic subgroups. Thus, to assume that persons from the diversity of Asian backgrounds interact with GPs in the same way may be misleading. Issues such as urban–rural background, level of acculturation, period of time in Australia and individual health belief systems might all influence the way any patient interacts with the GP. The methodology did not allow GPs to be blinded as to patients' responses to the questionnaire although it was believed that GPs completed their section independently. If the patient section was read by the GP, this would have the effect of increasing, not decreasing, the agreement between patient self-report and GP detection. Similarly, a range of GP characteristics may influence the efficiency of case detection across cultures. Limited information (language spoken at home for patients and language used during consultations for the GP) was available on the concordance in ethnicity of GPs and their patients. It is well recognized, however, that patients prefer to consult GPs who are fluent in their preferred language. In this study, GPs from a range of ethnic backgrounds participated in the study. The number of ethnic groups, the sample size and the logistic constraints of the study prevented a more detailed examination of those important variables. Furthermore, as was indicated, there was no ‘gold standard’ to confirm a diagnosis of anxiety or depression in participating patients. Thus, no conclusion can be drawn about the actual prevalence of such disorders in various ethnic groups. Also, the GHQ and self-report items were based on western conceptualizations of common anxiety and depressive symptoms. This, in itself, may have influenced the prevalence patterns obtained, and different findings might have emerged if culture-specific forms of assessment were used.16
In conclusion, the overall pattern suggests that difficulties do exist within the general practice setting for Asian and, to a lesser extent, people of other non-English speaking backgrounds (other than European origin). In particular, there is a lack of agreement between methods commonly used in general practice for case detection in communicating common symptoms of anxiety and depression to GPs, and in feeling satisfied with the treatments administered for such problems. Nevertheless, the data indicate that once such problems are identified, GPs treat patients from different cultural backgrounds similarly. The cause of lower rate of referral of Asian-born patients for specialist mental health services needs further investigation to determine if this was related to a culturally determined reluctance to attend mental health specialists amongst Asian patients, or a referral bias in the GPs. Importantly though, Asian patients clearly desire greater GP discussion and explanation of their mental health problems. Again, cultural and language barriers may contribute to the unsatisfactory nature of the GP–patient interaction.
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Acknowledgments |
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We would like to thank the South-western and South-east Divisions of General Practice in Sydney and the GPs and patients who participated in the study. This study was funded by a grant from the General Practice Evaluation Program of the Commonwealth Department of Human Services and Health.
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