Family Practice Vol. 19, No. 1, 23-28
© Oxford University Press 2002
Original Paper |
Determinants of consultation rate in patients with anxiety and depressive disorders in primary care
Ladybarn Group Practice, Fallowfield, Manchester,
a University Department of Psychiatry, Manchester Royal Infirmary and
b University Department of General Practice, Rusholme Health Centre, Manchester, UK.
Dr Nav Kapur, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
Ronalds C, Kapur N, Stone K, Webb S, Tomenson B and Creed F. Determinants of consultation rate in patients with anxiety and depressive disorders in primary care. Family Practice 2002; 19: 23–28.
Received 5 January 2001; Revised 29 June 2001; Accepted 3 September 2001.
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Abstract |
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Background. Although it is recognized that anxiety and depression are associated with frequent attendance in primary care, not all patients with these disorders attend frequently. The factors associated with general practice consultation in the important group of patients with anxiety and depressive disorders are not clear.
Objectives. Our aim was to determine prospectively the factors which predict consultation rate in a cohort of patients with anxiety and depressive disorders in primary care.
Methods. A total of 148 adult patients with a depressive, anxiety or panic disorder (DSM-III criteria) were studied prospectively for 6 months to determine the factors which predicted consultation rate during this time. Measures at baseline included: the Psychiatric Assessment Schedule, Hamilton Depression Rating Scale, Life Events and Difficulties Schedule, Clinical Anxiety Scale, details of substance misuse and demographic data. The principal outcome measure was the number of consultations recorded in the GP records over the following 6 months. The variables associated with consultation rate were assessed by multiple regression analysis, with number of consultations as the dependent variable.
Results. The median consultation rate during the 6 months of the study was five (range: 1–22). Thirty per cent of the sample consulted seven or more times during the 6 months and 10% consulted 12 or more times. The regression analysis demonstrated that the following variables contributed to the best model: prior consultation rate, past psychiatric history, ongoing social difficulties, current level of alcohol consumption, total psychiatric symptom score and total anxiety score. These variables together accounted for 41% of the variance in consultation rate.
Conclusion. The detection and rigorous treatment of psychiatric disorder, the provision of social support and interventions for alcohol dependence may help to reduce the frequency of consultation of anxious and depressed patients in primary care. Future research to identify additional variables which explain the major part of the variance in consultation rate may pave the way for novel treatment approaches to the phenomenon of frequent attendance.
Keywords. Anxiety, consultation rate, depression, primary care.
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Introduction |
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Studies carried out in a variety of primary care settings in different parts of the world have established that a minority of patients consult their GPs very frequently.1–6 Research suggests that the 3% of patients who consult most frequently account for 15% of the doctors' workload,1 10% of patients account for 30–40% of all consultations3,4 and the most frequently attending 25% of patients are responsible for 60–70% of primary care contacts.7
A recent systematic review indicated that the variables associated with frequent consultation include: female sex, single status, low socio-economic group, unemployment, presence of physical illness, psychological distress, somatization, alcohol problems, perception of poor health and a tendency to regard common bodily sensations as abnormal.8 Studies which have used multivariate statistics to model frequent attendance have suggested that physical illness, psychological symptoms, the individual's perception of their health, older age and current life stress are particularly important.2–6
The prevalence of anxiety and depressive disorder in patients who frequently attend general practice is between 40 and 60%.1,3,4 Although there is reasonable consensus about the factors associated with frequent attendance generally, it is much less clear which factors are associated with frequent consultation within the important group of patients with anxiety and depressive disorders.
Studies of frequent attenders to date have been mainly cross-sectional in design, making it difficult to draw any conclusions about the direction of any observed associations. They have also tended to use self-report measures for the assessment of complex variables such as psychiatric disorder and life stress. In addition, most research in this area has relied on arbitrary definitions of what constitutes ‘frequent attendance’.
In the current study, we aimed to investigate prospectively the association between patient-related factors and consulting behaviour in subjects with anxiety or depressive disorder in primary care. We used standardized interview schedules to measure independent variables and decided to consider consultation rate as our main outcome variable rather than rely on an arbitrary definition of frequent attendance.
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Methods |
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The methodology has been described in detail elsewhere9 and only the main points of the method will be repeated here. The study was carried out in a large inner city practice, with 13 000 patients, nine GP principals and four GP trainees. The practice has a close link with local psychiatric and psychology departments.
Subjects and assessments
Consecutive surgery attenders aged 16 or over completed the 28-item version of the General Health Questionnaire (GHQ 28).10 Those who scored 6 or more, or who indicated current or past treatment for ‘nerves’ underwent a standardized psychiatric interview [the Psychiatric Assessment Schedule (PAS)11] within a few days. We excluded patients who spoke English with difficulty or were planning to leave the area soon. Those patients who had a DSM-III diagnosis of generalized anxiety, panic or depressive disorder on the basis of the interview were entered into the study. The patients continued their usual treatment from the GP, who was not informed of the psychiatric assessment results.
Severity of psychiatric disorder was established using the Hamilton Depression Rating Scale (HDRS)13 and the Clinical Anxiety Scale.14 Duration of the disorder was recorded. The interview also documented details of past and family psychiatric history and substance misuse.
At a separate interview, the research worker collected detailed demographic data and information on social support and social problems using the Life Events and Difficulties Schedule (LEDS).15 Life events and difficulties were established for 1 year prior to the index consultation irrespective of duration of the psychiatric disorder. ‘Social stress’ scores were derived by combining the number and severity of the life events and difficulties into a single score using the method of Surtees and Ingham.16 This gives greatest weight to severe and recent events and difficulties. ‘Chronic ongoing difficulties’ were scored according to the method of Brown et al.17 In this scoring method, high scores are given to the most marked difficulties, and the scores from difficulties in different areas (e.g. marital, housing, illness) are added together.
All measures were repeated at follow-up interviews after 6 months.
Six months after the initial assessments, the general practice case notes were examined and the number of consultations was recorded for two time periods: the 12 months preceding the initial assessments and the 6 months following the initial assessment. A consultation was defined as an entry in the case notes reporting face to face contact between a patient and a GP.2
Data analysis
Univariate analysis, using Spearman's correlation coefficient and the Mann–Whitney U-test, was used to identify the variables associated with consultation rate over the subsequent 6 months. All of the variables which were significant or nearly significant (P < 0.1) were entered into a multiple regression analysis, with number of consultations for the subsequent 6 months as the dependent variable. The Mann–Whitney U-test was used to assess the effect of improving or worsening psychiatric symptoms on consultation rate.
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Results |
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Over an 18-month period, 1251 GHQs were returned completed. Of these, 571 (46%) scored >6 and/or indicated current or past treatment for psychiatric disorder. Of those eligible for a screening interview, 61% (277/457) were interviewed successfully. Subjects interviewed had slightly higher GHQ 28 scores than subjects not interviewed [mean (SD) GHQ 28 scores: 12.3 (6.1) for those interviewed versus 11.3 (5.8) for those not interviewed]. On the basis of the interview, nine patients who were psychotic and 86 with too few symptoms to fulfil DSM-III criteria were excluded. Thus 182 patients were identified with sufficient symptoms for a DSM-III diagnosis: all these patients agreed to enter the study. One hundred and forty-eight subjects (81%) were followed-up successfully 6 months later. Of the 34 lost to follow-up, 21 left the area, 11 refused a second interview and two had incomplete data. These 34 subjects were not significantly different from those completing the study, with the exception of having a higher prevalence of alcohol problems (7/34 (21%) versus 12/148 (8%)).
Two-thirds of the study group were women. The mean age was 35 years (range 16–78 years); 58 (39%) were single, 57 (39%) married or co-habiting and 33 (22%) were widowed or divorced. Seventy-seven patients were employed (including 17 students), 17 were housewives, 16 retired and 48 (32%) were unemployed through either lack of work or ill health. A total of 76 patients had no academic qualifications, and 34 had a degree or higher qualification. Fifteen of the group were born outside the UK.
A total of 74 patients had major depressive disorder and 74 patients had generalized anxiety or panic disorder. Table 1
shows scores on the psychiatric rating scales for these patients. In 66 patients (45%), the disorder had persisted for 6 months or more prior to the index consultation; in 32 (22%), the disorder had been present for more than 1 year. The median number of consultations in the 6 months following the initial assessment was five (range: 1–22), with 30% of the sample consulting seven or more times, and 10% consulting 12 or more times.
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Factors associated with consultation rate
Table 2
shows the association between categorical variables and consultation rate over 6 months. Table 3 shows the same relationship for continuous variables. Variables which showed sufficient association to be included in the multiple regression were: sex, educational level, chronic physical illness, employment status, past psychiatric history, chronic ongoing difficulties score, total PAS score, total HDRS score, total Clinical Anxiety Scale score, alcohol consumption per day and consultation rate in the previous 12 months.
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Multiple regression analysis
There were no significant differences between patients with anxiety and those with depression with respect to the predictors of consultation rate in the multivariate model, and so both groups were considered together. Table 4
shows the results for the multiple regression analysis using number of GP contacts over the study 6 months as the dependent variable. Seven variables together accounted for 28.5% of the variance in 6 month consultation rate. Entering the number of consultations over the previous 12 months into the regression analysis improved the model, with five variables explaining 41.0% of the variance (Table 5).
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Recognition of psychiatric disorder by the GP
Although the main aim in the current study was to investigate the relationship between patient factors and subsequent consultation rate, we also recorded whether the patients' GP recognized their psychiatric disorder at the index consultation. Recognition by the doctor (84/148 cases) was associated with a higher consultation rate over the following 6 months [median (range): 6 (1–20) versus 4 (1–22)] and also strongly related to the severity of psychiatric symptoms (i.e. the more severe the patients' symptoms, the more likely the doctor was to detect their psychiatric disorder). When the recognition variable was entered into the multiple regression analysis, it made no difference to the overall model. This suggests that it is the severity of psychiatric symptoms themselves (as measured by the rating scales), rather than their recognition by the GP that is more strongly associated with subsequent consultation.
The effect of symptoms of anxiety and depression
In order to explore further the effect of psychiatric symptoms on consultation rates, we compared the 6 month consultation rates for patients whose symptoms of depression (as measured by the HDRS scale) had worsened with consultation rates for patients whose symptoms had improved or stayed the same. We repeated the analysis for anxiety symptoms as measured by the Clinical Anxiety Scale.
We found that worsening depressive symptoms were associated with a higher consultation rate (median consultation rate: eight for those 23 subjects with worse HDRS scores versus five for the 125 subjects with improved or stable HDRS scores, P = 0.003, Mann–Whitney U-test). Worsening anxiety symptoms were not associated with a higher consultation rate (median consultation rate: six for those 27 subjects with worse Clinical Anxiety Scale scores versus five for the 121 subjects with improved or stable Clinical Anxiety scores, P = 0.11, Mann– Whitney U-test).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This study used a prospective design and standardized interview measures to investigate the predictors of consultation rate for anxious and depressed subjects in general practice. Nearly half our sample had a consultation rate of 10 visits or more per annum, and would be considered ‘frequent attenders’ using criteria employed in previous research.8 Our findings agree with previous cross-sectional studies of all patients in general practice which suggest that past psychiatric history, current psychiatric symptoms and alcohol consumption are associated with attending patterns in primary care.8 Chronic physical illness seemed less relevant in our sample, but unemployment and social problems were important predictors of consultation rate even after psychiatric illness was accounted for. Preliminary analysis suggested that changes in patients' depressive symptoms might be more important determinants of consultation rates than changes in anxiety symptoms.
Methodological considerations
The current study recruited patients with only anxiety or depressive disorder and our results may therefore not be generalizable to all patients in general practice. However, previous research suggests that these patients are an important clinical subgroup of all frequent attenders in primary care.18
We did not differentiate between patient- and doctor-initiated frequent attendance in this study. Like others,6 we feel it is difficult for researchers or clinicians to make reliable categorical judgements about the motivation to consult in the context of the complex doctor–patient relationship.
We wished to include all cases of psychiatric disorder and used a two-stage screening procedure. Sixty-one per cent of GP attenders eligible for second stage psychiatric interview were recruited successfully. Although this compares well with previous studies which have used similar methodology,19,20 it nevertheless introduces a potential selection bias. Overall, the severity of psychiatric disorder of patients in this study (judged by the HDRS score) was similar to that in previous studies.21,22 However, the patients lost in the sampling process during the current study had GHQ scores slightly lower than those included, so our sample may have been representative of the more severely ill patients seen in general practice.
Implications for future research and practice
Our findings show that a number of demographic, psychological, social and lifestyle factors make independent contributions to the consultation rate of depressed and anxious individuals in primary care. Frequent attendance might therefore be best understood using a multifactorial explanatory model. Prior consultation rate is also an important predictor of future consultation patterns, but even adding this to our model allows us to account for less than half the variance in consultation rate. Future research could be directed towards identifying variables which explain the major part of the variance in consultation rate. These may include doctor as well as patient factors. There is growing evidence from both qualitative and quantitative studies supporting the assertion that doctors may cause and perpetuate frequent attendance.23,24 Individual practice-related factors such as ease of getting appointments may be relevant, but these were controlled for in the current study by collecting data at a single practice. Research suggests constitutional and psychological factors such as childhood experience,25 health anxiety,26 illness perception27 and symptom attribution28 may also be important, and these require further investigation.
From a clinical perspective, our results show an association between the severity of psychiatric symptoms and consultation rate. It is difficult to infer a causal relationship but it may be that the detection and rigorous treatment of psychiatric disorder, and the provision of social support and interventions for alcohol dependence might help to reduce the frequency of consultation of anxious and depressed patients in primary care. Changes in depressive symptoms could be more important determinants of consultation frequency than changes in anxiety symptoms, although this is a preliminary finding and requires replication. Our findings are in agreement with clinical experience in primary care which suggests that detection and treatment of psychiatric disorder may result in a transient increase in consultation rate. However, the benefits of treatment in terms of improved functional status and reduced longer term health utilization are clear.29 Refining our theoretical models through further research should pave the way for novel treatment approaches to the phenomenon of frequent attendance in primary care.
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Acknowledgments |
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We would like to thank the Departments of General Practice and Psychiatry at the University of Manchester for their support, and all the patients and staff at the Robert Darbishire Practice, Rusholme for their participation in this study. This study was part-funded by a grant from North West Regional Health Authority.
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References |
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1 Neal RD, Heywood PL, Morley S et al. Frequency of patients' consulting patterns in general practice and workload generated by frequent attenders: comparisons between practices. Br J Gen Pract 1998; 48:895–898.[Web of Science][Medline]
2 Heywood PL, Blackie GC, Cameron IH, Dowell AC. An assessment of the attributes of frequent attenders to general practice. Fam Pract 1998; 25:198–204.
3 McFarland BH, Freeborn DK, Mullooly JP, Pope CR. Utilization patterns among long-term enrolees in a prepaid group practice health maintenance organization. Med Care 1985; 23:1221–1233.[Web of Science][Medline]
4 Baez K, Aiarzaguena JM, Grandes G, Pedrodo E, Aranguren J, Retolaza A. Understanding patient-initiated frequent attendance in primary care: case control study. Br J Gen Pract 1998; 48:1824–1827.[Web of Science][Medline]
5 Bellon JA, Delgado A, De Dios Luna J, Lardelli P. Psychosocial and health belief variables associated with frequent attendance in primary care. Psychol Med 1999; 29:1347–1357.[Web of Science][Medline]
6 Dowrick CF, Bellon JA, Gomez MJ. GP frequent attendance in Liverpool and Granada: the impact of depressive symptoms. Br J Gen Pract 2000; 50:361–365.[Web of Science][Medline]
7 Svab I, Zalatel-Kragelj L. Frequent attenders in general practice: a study from Slovenia. Scand J Primary Health Care 1993; 11:38–43.[Medline]
8 Gill D, Sharpe M. Frequent consulters in general practice: a systematic review of studies of prevalence, associations and outcome. J Psychsom Res 1999; 47:115–130.[Web of Science][Medline]
9
Ronalds C, Creed FH, Webb S, Stone K, Webb S, Tomenson B. The outcome and anxiety of depressive disorders in primary care. Br J Psychiatry 1997; 171:427–433.
10 Goldberg D. Manual of the General Health Questionnaire. Windsor: NFER-Nelson, 1978.
11 Dean C, Surtees PG, Sashidaran SP. Comparison of research diagnostic systems in an Edinburgh community sample. Br J Psychol 1983; 142:247–256.
12 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. Washington (DC): American Psychiatric Association, 1980.
13 Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967; 6:278–296.[Medline]
14
Snaith RP, Baugh SJ, Clayden AD, Hussain A, Sipple M. The Clinical Anxiety Scale: a modification of the Hamilton Anxiety Scale. Br J Psychiatry 1982; 141:518–523.
15 Brown G, Harris T. Social Origins of Depression. London: Tavistock Publications, 1978.
16 Surtees PG, Ingham JG. Life stress and depressive outcome: application of a dissipation model to life events. Soc Psychiatry 1980; 15:21–31.
17 Brown GW, Adler Z, Bifulco A. Life events, difficulties and recovery from chronic depression. Br J Psychol 1988; 152:487–498.
18 Karlsson H, Joukamaa M, Lahti I et al. Frequent attender profiles: different clinical subgroups among frequent attender patients in primary care. J Psychosom Res 1997; 42:157–166.[Web of Science][Medline]
19 Freeling P, Rao B, Paykel E, Sireling L, Burton R. Unrecognised depression in general practice. Br Med J 1985; 290:1880–1883.
20 Ormel J, Van den Brink W, Koeter MWJ et al. Recognition, management and outcome of psychological disorders in primary care: a naturalistic follow-up study. Psychol Med 1990; 20:909–923.[Web of Science][Medline]
21
Sireling LI, Paykel ES, Freeling P, Rao BM, Patel SP. Depression in general practice: case thresholds and diagnosis. Br J Psychiatry 1985; 147:113–119.
22 Paykel E, Hollyman J, Freeling P, Sedgwick P. Predictors of therapeutic benefit for amitriptyline in mild depression: a general practice placebo-controlled trial. J Affective Disord 1988; 14:83–95.[Web of Science][Medline]
23 Neal RD, Morley S, Heywood PL. "I always seem to be there"—qualitative study of frequent attenders. Br J Gen Pract 2000; 50:972–976.[Web of Science][Medline]
24 Neal RD, Heywood PL, Morley S. Frequent attenders' consulting patterns with general practitioners. Br J Gen Pract 2000; 50:716–723.[Web of Science][Medline]
25
Portegijs PJM, Jeuken FMH, van der Horst FG, Kraan HF, Knottnerus JA. A troubled youth: relations with somatization, depression and anxiety in adulthood. Fam Pract 1996; 13:1–11.
26 Conroy RM, Smyth O, Siriwardena R, Fernandes P. Health anxiety and characteristics of general practitioner-initiated consultations. J Psychosom Res 1999; 46:45–50.[Web of Science][Medline]
27 Weinman J, Petrie K, Ross-Morris R, Horne R. The Illness Perception Questionnaire: a new method for assessing the cognitive representation of illness. Psychol Health 1996; 11:431–445.[Web of Science]
28
Cameron L, Leventhal EA, Leventhal H. Seeking medical care in response to symptoms and life stress. Psychosom Med 1995; 57:37–47.
29
Von Korff M, Ormel J, Katon W, Lin EHB. Disability and depression among high utilisers of health care. A longitudinal analysis. Arch Gen Psychiatry 1992; 49:91–100.
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