Changes in Physical Activity Barriers among American Indian Elders: A Pilot Study​.

The objective of the present study was to assess whether selfreported physical activity barriers could be reduced among American Indian elders who participated in a 6-week randomized physical activity trial that compared the use of a pedometer only to that of pedometers with step-count goal setting. Elders (N = 32) were compared on the Barriers to Being Physically Active Quiz after participating in a pilot physical activity trial. Elders were classified into high- and low-barrier groups at baseline and compared on self-reported physical activity, health-related quality of life, pedometer step counts, and 6-minute walk performance. At the conclusion of the 6-week trial, only the lack of willpower subscale significantly decreased. The low-barrier group reported significantly higher physical activity engagement and improved mental health quality of life than the high-barrier group. The groups did not differ on daily step counts or 6-minute walk performance. Additional research is needed with a larger sample to understand relevant activity barriers in this population and assess whether they can be modified through participation in structured physical activity and exercise programs.

Barriers and Facilitators to Coordinating Care With High-Risk, High-Cost Disabled Medicaid Beneficiaries: Perspectives of Frontline Staff and Participating Clients.

This evaluation was designed to examine the perspectives of 15 frontline staff who implemented a managed care program and 154 high-risk, high-cost disabled Medicaid clients who were participants in the program. Results indicated that positive relationships between staff and clients played a key role in facilitating program implementation. Challenges included finding ways to provide a wide breadth of services including food, shelter, and transportation; handling difficulties following from staff turnover; and creating transitions of care for clients to community health clinics. Staff identified training in motivational interviewing and having both nurse care managers and social workers collaboratively deliver the intervention as among the most powerful components of the program. Staff and clients expressed high levels of satisfaction with the program, and clients believed they were experiencing positive impacts of the program. Lessons learned from this study may inform the design of services as the Affordable Care Act continues to unfold.

Clinical Needs of Patients with Problem Drug Use.

INTRODUCTION: Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of this study was to examine the baseline characteristics of people presenting in primary care with a range of problem drug use severity to identify their clinical needs. METHODS: We examined sociodemographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems. These patients were recruited from primary care clinics in a medical safety net setting. Based on Drug Abuse Screening Test results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity. RESULTS: Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drugs); high levels of homelessness (50%), psychiatric comorbidity (69%), and arrests for serious crimes (24%); and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana, with little reported use of other drugs, less psychiatric comorbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in between the substantial/severe and low drug use severity subgroups on most variables. CONCLUSIONS: Patients with the highest drug use severity are likely to require specialized psychiatric and substance abuse care, in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use, including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with the highest and lowest drug use severity. Primary care safety net clinics are in a key position to serve patients with problem drug use by developing a range of responses that are locally effective and that may also inform national efforts to establish patient-centered medical homes and to implement the Affordable Care Act.

A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs.

OBJECTIVE: To evaluate outcomes of a registered nurse-led care management intervention for disabled Medicaid beneficiaries with high health care costs. DATA SOURCES/STUDY SETTING: Washington State Department of Social and Health Services Client Outcomes Database, 2008-2011. STUDY DESIGN: In a randomized controlled trial with intent-to-treat analysis, outcomes were compared for the intervention (n = 557) and control groups (n = 563). A quasi-experimental subanalysis compared outcomes for program participants (n = 251) and propensity score-matched controls (n = 251). DATA COLLECTION/EXTRACTION METHODS: Administrative data were linked to describe costs and use of health services, criminal activity, homelessness, and death. PRINCIPAL FINDINGS: In the intent-to-treat analysis, the intervention group had higher odds of outpatient mental health service use and higher prescription drug costs than controls in the postperiod. In the subanalysis, participants had fewer unplanned hospital admissions and lower associated costs; higher prescription drug costs; higher odds of long-term care service use; higher drug/alcohol treatment costs; and lower odds of homelessness. CONCLUSIONS: We found no health care cost savings for disabled Medicaid beneficiaries randomized to intensive care management. Among participants, care management may have the potential to increase access to needed care, slow growth in the number and therefore cost of unplanned hospitalizations, and prevent homelessness. These findings apply to start-up care management programs targeted at high-cost, high-risk Medicaid populations.

Perceived social support mediates anxiety and depressive symptom changes following primary care intervention.

BACKGROUND: The current study tested whether perceived social support serves as a mediator of anxiety and depressive symptom change following evidence-based anxiety treatment in the primary care setting. Gender, age, and race were tested as moderators. METHODS: Data were obtained from 1004 adult patients (age M = 43, SD = 13; 71% female; 56% White, 20% Hispanic, 12% Black) who participated in a randomized effectiveness trial (coordinated anxiety learning and management [CALM] study) comparing evidence-based intervention (cognitive-behavioral therapy and/or psychopharmacology) to usual care in the primary care setting. Patients were assessed with a battery of questionnaires at baseline, as well as at 6, 12, and 18 months following baseline. Measures utilized in the mediation analyses included the Abbreviated Medical Outcomes (MOS) Social Support Survey, the Brief Symptom Index (BSI)-Somatic and Anxiety subscales, and the Patient Health Questionnaire (PHQ-9). RESULTS: There was a mediating effect over time of perceived social support on symptom change following treatment, with stronger effects for 18-month depression than anxiety. None of the mediating pathways were moderated by gender, age, or race. CONCLUSIONS: Perceived social support may be central to anxiety and depressive symptom changes over time with evidence-based intervention in the primary care setting. These findings possibly have important implications for development of anxiety interventions.

Does a quality improvement intervention for anxiety result in differential outcomes for lower-income patients?

OBJECTIVE: The authors examined the effects of a collaborative care intervention for anxiety disorders in primary care on lower-income participants relative to those with higher incomes. They hypothesized that lower-income individuals would show less improvement or improve at a lower rate, given that they would experience greater economic stress over the treatment course. An alternative hypothesis was that lower-income participants would improve at a higher rate because the intervention facilitates access to evidence-based treatment, which typically is less available to persons with lower incomes. METHOD: Baseline demographic and clinical characteristics of patients with lower (N=287) and higher (N=717) income were compared using t tests and chi-square tests for continuous and categorical variables, respectively. For the longitudinal analysis of intervention effects by income group, the outcome measures were jointly modeled at baseline and at 6, 12, and 18 months by study site, income, time, intervention, time and intervention, income and time, income and intervention, and time, intervention, and income. RESULTS: Although lower-income participants were more ill and had greater disability at baseline than those with higher incomes, the two income groups were similar in clinical response. The lower-income participants experienced a comparable degree of clinical improvement, despite receiving fewer treatment sessions, less relapse prevention, and less continuous care. CONCLUSIONS: These findings contribute to the ongoing discussion as to whether or not, and to what extent, quality improvement interventions work equally well across income groups or require tailoring for specific vulnerable populations.

Anxiety treatment improves physical functioning with oblique scoring of the SF-12 short form health survey.

OBJECTIVE: No studies have found a positive effect of anxiety treatment on physical functioning, but recent investigations of the 12-item Short Form Health Questionnaire (SF-12), which is frequently used to assess physical functioning, have suggested that orthogonal scoring of the summary measure may distort representations of physical health. The current study reanalyzes whether anxiety treatment improves physical functioning using oblique scoring in the Coordinated Anxiety Learning and Management (CALM) randomized clinical trial for the treatment of anxiety disorders. Replication was tested in reanalysis of data from the earlier Collaborative Care for Anxiety and Panic (CCAP) randomized clinical trial for the treatment of panic disorder. METHOD: The CALM study included 1004 primary care patients with panic, social anxiety, generalized anxiety or posttraumatic stress disorders. Patients received usual care (UC) or an evidence-based intervention (cognitive behavioral therapy, psychotropic medication or both; ITV). Physical functioning (SF-12v2) was assessed at baseline and at 6, 12 and 18 months. Oblique and orthogonal scoring methods for the physical functioning aggregate measure from SF-12 scale items were compared. RESULTS: In CALM, physical functioning improved to a greater degree in ITV than UC for oblique but not orthogonal scoring. Findings were replicated in the CCAP data. CONCLUSIONS: Evidence-based treatment for anxiety disorders in primary care improves physical functioning when measured using oblique scoring of the SF-12. Due to this scoring issue, effects of mental health treatment on physical functioning may have been understated.

Testing the effects of brief intervention in primary care for problem drug use in a randomized controlled trial: rationale, design, and methods.

BACKGROUND: A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy. METHODS/DESIGN: The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases. DISCUSSION: This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT00877331.

Implementation of the CALM intervention for anxiety disorders: a qualitative study.

BACKGROUND: Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) []) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed? METHODS: Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes. RESULTS: Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS. CONCLUSIONS: The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.

Racial and ethnic disparities in police-reported intimate partner violence perpetration: a mixed methods approach.

The objectives of this study were to examine racial and ethnic disparities in perpetrator and incident characteristics and discrepancies between police charges and reported perpetrator behaviors in police-reported intimate partner violence (IPV). This cross-sectional study used standardized police data and victim narratives of IPV incidents reported to the police in Dallas, Texas in 2004. The sample included non-Hispanic White, non-Hispanic Black, and Hispanic male perpetrators who were residents of Dallas (N = 4470). Offense charges were prioritized in descending order: sexual assault, aggravated assault, simple assault, kidnapping, robbery, and intimidation. Textual data from the victim narratives were coded, based on the revised Conflict Tactics Scales (CTS), and categorized in descending order of priority: sexual (severe, minor), physical (severe, minor), and psychological (severe, minor) assault. Perpetrators were more likely to be Black and Hispanic. Perpetrator and incident characteristics varied significantly by race/ethnicity, particularly age, age difference between partners, marital status, injury, and interracial relationships. Qualitative data revealed that greater proportions of Black and Hispanic men perpetrated severe physical, but not sexual violence, compared with White men. The greatest disparity between CTS categories and police charges occurred among those cases identified by the CTS as severe physical IPV; 84% were charged with simple assault. Significant differences by race/ethnicity were found only for simple assault charges, which were coded as severe physical as opposed to minor physical IPV more often among Black (69% and 31%) compared with White (62% and 38%) men. The disparities revealed in this study highlight the need to enhance primary and secondary prevention efforts within Black and Hispanic communities and to increase linkages between police, community, and public health organizations.

Does pedometer goal setting improve physical activity among Native elders? Results from a randomized pilot study.

We examined if step-count goal setting resulted in increases in physical activity and walking compared to only monitoring step counts with pedometers among American Indian/Alaska Native elders. Outcomes included step counts, self-reported physical activity and well-being, and performance on the 6-minute walk test. Although no significant between-group differences were found, within-group analyses indicated that elders significantly improved on the majority of step count, physical activity, health-related quality of life, and 6-minute walk outcomes.

Barriers and facilitators to walking and physical activity among American Indian elders.

INTRODUCTION: Physical inactivity is common among older American Indians. Several barriers impede the establishment and maintenance of routine exercise. We examined personal and built-environment barriers and facilitators to walking and physical activity and their relationship with health-related quality of life in American Indian elders. METHODS: We used descriptive statistics to report barriers and facilitators to walking and physical activity among a sample of 75 American Indians aged 50 to 74 years. Pearson correlation coefficients were used to examine the relationship between health-related quality of life and barriers to walking and physical activity after adjusting for caloric expenditure and total frequency of all exercise activities. RESULTS: Lack of willpower was the most commonly reported barrier. Elders were more likely to report personal as opposed to built-environment reasons for physical inactivity. Better health and being closer to interesting places were common walking facilitators. Health-related quality of life was inversely related to physical activity barriers, and poor mental health quality of life was more strongly associated with total barriers than poor physical health. CONCLUSION: We identified a variety of barriers and facilitators that may influence walking and physical activity among American Indian elders. More research is needed to determine if interventions to reduce barriers and promote facilitators can lead to objective, functional health outcomes.

Triple jeopardy: impact of partner violence perpetration, mental health and substance use on perceived unmet need for mental health care among men.

OBJECTIVES: To examine the relationship between intimate partner violence (IPV) perpetration, serious mental illness, and substance use and perceived unmet need for mental health treatment in the past year among men in the general population using the behavioral model for health-care use (Aday and Anderson in Health Serv Res 9:208-220, 1974; Andersen in A behavioral model of families' use of health services, 1968; Andersen in Med Care 46:647-653, 2008). METHODS: Non-Hispanic black, Hispanic, and non-Hispanic white males aged 18-49 years and cohabiting with a spouse/partner were included in this analysis of the 2002 National Survey on Drug Use and Health. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated using logistic regression. RESULTS: The proportion of men reporting unmet treatment need was greater among IPV perpetrators than nonperpetrators (12.1 vs. 3.4%, respectively). Hazardous drinking, illicit drug use, alcohol and drug abuse/dependence, and SMI were also more common among perpetrators. Perpetrators were twice as likely to report unmet need for treatment after taking predisposing, enabling, and need factors into account (AOR 2.00, CI 1.13-3.55). Alcohol abuse/dependence (AOR 2.96, CI 1.79-4.90), drug abuse/dependence (AOR, 1.79, CI 1.01-3.17), substance abuse treatment (AOR 3.09, CI 1.18-8.09), and SMI (AOR 8.46, CI 5.53-12.94) were independently associated with perceived unmet need for treatment. CONCLUSIONS: These findings suggest that men who perpetrate IPV are at increased risk of perceived unmet need for mental health care. This study also emphasizes the need to identify substance use disorders and mental health problems among IPV perpetrators identified in health, social service, or criminal justice settings. Further research should address barriers to care specific to men who perpetrate IPV beyond economic factors.

Low socioeconomic status and mental health care use among respondents with anxiety and depression in the NCS-R.

OBJECTIVE: This study sought to determine whether previously reported poor outcomes among patients of low socioeconomic status who have depression and anxiety could result from not receiving mental health treatment or from receiving minimally adequate treatment. METHODS: The study sample consisted of 1,772 participants in the National Comorbidity Survey Replication (NCS-R) who met criteria for a mood or anxiety disorder. Bivariate and multivariate logistic regression analyses were used to examine associations between education, income, and assets and receipt of treatment and quality of treatment (minimally adequate treatment) for mood and anxiety disorders in sectors with the capacity to deliver evidence-based treatments (the general medical and mental health specialty sectors). Multivariate analyses controlled for age, gender, race-ethnicity, marital status, health insurance, and urbanicity. RESULTS: Age, gender, marital status, and race-ethnicity were strong and fairly consistent predictors of mental health services use, with some modest variations by sector. In contrast, in bivariate and multivariate analyses, education, income, and assets were minimally related to use of mental health care and to receipt of minimally adequate care in both general medical and mental health specialty sectors. CONCLUSIONS: Socioeconomic status does not appear to play a major role in determining aspects of treatment for depression and anxiety disorders. Poor outcomes of depressed and anxious patients with low socioeconomic status may be due to differences in quality of care beyond the minimally adequate level assessed in this study or to factors unrelated to quality of care that could counteract effective treatments, such as the presence of ongoing chronic stress.

Impact of Access to Recovery services on alcohol/drug treatment outcomes.

The purpose of this study was to assess the impact of providing recovery support services to clients receiving publicly funded chemical dependency (CD) treatment through the Access to Recovery (ATR) Program in Washington State. Services included case management, transportation, housing, and medical. A comparison group composed of clients who received CD treatment only was constructed using a multistep procedure based on propensity scores and exact matching on specific variables. Outcomes were obtained from administrative data sources. Results indicated that ATR services were associated with a number of positive outcomes including increased length of stay in treatment, increased likelihood of completing treatment, and increased likelihood of becoming employed. The beneficial effects of ATR services on treatment retention were most pronounced when they were provided between 31 and 180 days after treatment began. The results reported here offer evidence for the value of ATR services.

Unmet need for mental health and addictions care in urban community health clinics: frontline provider accounts.

OBJECTIVE: To facilitate planning to improve care delivery in community health clinics, this study provides an in-depth description of the social, cultural, and organizational factors that create the context for mental health and addictions treatment delivery in this setting. METHODS: Seventeen community health clinic providers and personnel were interviewed for 45-90 minutes with open-ended questions to elicit the context of their frontline provider experiences. Major themes and subthemes of responses were identified with content analysis. RESULTS: Issues that create significant barriers to care included complex patient comorbidity and demographic characteristics; clinic organization, resources, and funding shortfalls; communication barriers with specialty mental health and addictions agencies; and stigmatizing aspects of mental health, addictions, and disadvantaged status. CONCLUSIONS: The unique barriers to care in the community health care setting, as well as the unique characteristics of patients served, are likely to require context-specific solutions. These solutions will determine the viability of existing chronic disease management models, such as collaborative care, when applied to this setting.

Racial and ethnic disparities in police-reported intimate partner violence and risk of hospitalization among women.

OBJECTIVES: We sought to examine racial and ethnic disparities in police-reported intimate partner violence (IPV) and hospitalization rates and rate ratios among women with police-reported IPV relative to those without such reports. METHODS: This retrospective cohort study linked adult male-to-female IPV police records of non-Hispanic Black, Hispanic, and non-Hispanic White women residing in a south central US city with regional hospital discharge data. Rates and incidence rate ratios (IRR) were calculated and age-adjusted where the data allowed. RESULTS: Police-reported IPV rates were 2-3 times higher among Black and Hispanic women compared with White women. Overall, hospitalization rates were higher among Black and White victims and lower among Hispanic victims than their counterparts in the comparison group (age-adjusted IRR [aIRR], 1.23; 95% confidence interval [CI], 1.08-1.41; aIRR, 1.46; 95% CI, 1.19-1.79; and aIRR, 0.68; 95% CI, 0.54-0.86, respectively). Rate ratios were significant for victims among 1) White women for any mental disorder (aIRR, 2.02; 95% CI, 1.30-3.13) and for episodic mood/depressive disorders in particular (aIRR, 2.18; 95% CI, 1.33-3.59); 2) Black and White women for any injury-related diagnosis (aIRR, 2.46; 95% CI, 1.48-4.10 and aIRR, 3.20; 95% CI, 1.65-6.19, respectively); and 3) all women for intentional injury (IRR, 10.45; 95% CI, 3.56-30.69) and self-inflicted injury (IRR, 4.91; 95% CI, 2.12-11.37). CONCLUSIONS: Exposure to IPV as reported to police increases the rate of hospital utilization among Black and White women, but lowers the rate for Hispanic women. Screening for IPV in hospitals may identify a substantial number of IPV-exposed women. Primary and secondary prevention efforts related to IPV should be culturally informed and specific.

Education is associated with physical activity among American Indian elders.

Although educational attainment and physical activity levels tend to be positively associated in majority populations, this relationship has not been investigated in American Indian and Alaska Native (AI/AN) elders. This study examined the association between education and physical activity among AI/AN elders (N = 107) using self-report and behavioral outcomes. Regression models showed that higher education was significantly associated with total caloric expenditure for moderate intensity physical activities and distance traveled during a 6-minute walk test of fitness. Additional research is needed to understand modifiable personal, social, and environmental physical activity barriers in these populations.

A randomized trial to increase physical activity among native elders.

OBJECTIVE: Physical inactivity is common among older populations and American Indians. Our objective was to compare two methods for increasing physical activity and walking among American Indian elders. METHODS: We conducted a two arm randomized trial to increase physical activity in 125 American Indians aged 50-74 years at the Seattle Indian Health Board in 2005. Participants were randomized into either an activity monitoring (N=63) or activity monitoring with a pedometer (N=62) arm over a six-week period. Outcomes included self-reported physical activity and well-being, and the 6-min walk test. RESULTS: There were no group differences in self-reported physical activities and well-being. The 6-min walk test yielded no between-group differences. All participants increased the frequency of leisure walking (p<0.01), frequency of all exercise-related activities (p<0.01), frequency of moderate-intensity exercise activities (p<0.01), and improved weekly caloric expenditure for all exercise activities (p<0.05) by the end of the trial. CONCLUSIONS: Pedometers did not confer enhanced performance on the physical activity outcomes beyond those achieved through self-monitoring. Physical activity can be promoted among at-risk groups in a brief, inexpensive manner in primary care. Exercise prescription and culturally relevant enhancement strategies may optimize physical activity outcomes for elder American Indians.

Relationships among pain, anxiety, and depression in primary care.

Pain, anxiety, and depression are commonly seen in primary care patients and there is considerable evidence that these experiences are related. This study examined associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients. Results indicate that primary care patients who endorse symptoms of muscle pain, headache, or stomach pain are approximately 2.5-10 times more likely to screen positively for panic disorder, generalized anxiety disorder, or major depressive disorder. Endorsement of pain symptoms was also significantly associated with confirmed diagnoses of several of the anxiety disorders and/or major depression, with odds ratios ranging from approximately 3 to 9 for the diagnoses. Patients with an anxiety or depressive disorder also reported greater interference from pain. Similarly, patients endorsing pain symptoms reported lower mental health functioning and higher scores on severity measures of depression, social anxiety, and posttraumatic stress disorder. Mediation analyses indicated that depression mediated some, but not all of the relationships between anxiety and pain. Overall, these results reveal an association between reports of pain symptoms and not only depression, but also anxiety. An awareness of these relationships may be particularly important in primary care settings where a patient who presents with reports of pain may have an undiagnosed anxiety or depressive disorder.