Two-year effects of quality improvement programs on medication management for depression.

BACKGROUND: Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression. METHODS: A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists. RESULTS: Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group. CONCLUSIONS: Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.

Depression and diabetes: impact of depressive symptoms on adherence, function, and costs.

BACKGROUND: Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. METHODS: We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA(1c)) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA(1c) levels, functional impairment, and health care costs. RESULTS: Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). CONCLUSIONS: Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed. Arch Intern Med. 2000;160:3278-3285.

Psychiatric and otologic diagnoses in patients complaining of dizziness.

BACKGROUND: Dizziness is a common and disabling symptom in primary care practice, especially among the elderly. Though there are many organic causes of dizziness, the results of medical workups are negative in the majority of patients. METHODS: A total of 75 patients with dizziness who were referred to a community otolaryngology practice received a structured psychiatric diagnostic interview (National Institute of Mental Health Diagnostic Interview Schedule) and questionnaires that assessed psychological distress as well as a complete otologic evaluation, including electronystagmogram. Patients with evidence of a peripheral vestibular disorder were compared with those without such evidence. RESULTS: While psychiatric diagnoses were present in both those with and without evidence of a peripheral vestibular disorder, those without such evidence had a greater mean number of lifetime psychiatric diagnoses as defined by the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, and specifically, a greater lifetime prevalence of major depression and panic disorder. This group also more frequently met criteria for somatization disorder, had more current and lifetime unexplained medical symptoms, and had more severe current depressive, anxiety, and somatic symptoms. CONCLUSIONS: Psychiatric diagnoses are common among patients with dizziness referred for otologic evaluation who do not show evidence of a peripheral vestibular disorder. Specific psychiatric disorders should be part of the differential diagnosis of patients who present with dizziness.

Allergic to life: psychological factors in environmental illness.

Environmental illness is an increasingly frequent and medically unexplained syndrome of "allergy" to common environmental agents. A recent outbreak of chemical-induced illness allowed study of psychological factors in environmental illness. Thirty-seven symptomatic plastics workers completed structured diagnostic interviews and self-report measures of somatization and psychopathology. The 13 subjects who developed environmental illness scored higher on all measures than those who did not. The greatest differences were in prior history of anxiety or depressive disorder (54% versus 4%) and number of medically unexplained physical symptoms before exposure (6.2 versus 2.9). These findings suggest that psychological vulnerability strongly influences chemical sensitivity following chemical exposure.

Irritable bowel syndrome and psychiatric illness.

Psychiatric illnesses such as mood, anxiety, and somatization disorders share many common features with irritable bowel syndrome. The authors review recent developments in the definition of irritable bowel syndrome and its relationship to psychiatric illness, discuss the diagnostic validity of irritable bowel syndrome from several perspectives, and offer a pathophysiological model of irritable bowel syndrome that integrates many of the biological and psychosocial findings of earlier studies. Psychiatric evaluation appears to be an important factor in the diagnosis and treatment of patients with irritable bowel syndrome.

Psychiatric illness and irritable bowel syndrome: a comparison with inflammatory bowel disease.

Structured psychiatric interviews and psychological self-report measures were administered to 28 patients with irritable bowel syndrome and 19 patients with inflammatory bowel disease. Significantly more of the patients with irritable bowel syndrome had lifetime diagnoses of major depression, somatization disorder, generalized anxiety disorder, panic disorder, and phobic disorder. They had significantly more medically unexplained somatic symptoms, and most had suffered from psychiatric disorders, particularly anxiety disorders, before the onset of their irritable bowel symptoms.

Psychiatric disorders and functional disability in outpatients with traumatic brain injuries.

OBJECTIVE: This study examined psychiatric sequelae of traumatic brain injuries in outpatients and their relation to functional disability. METHOD: Fifty consecutive outpatients with traumatic brain injuries who came to a brain injury rehabilitation clinic for initial evaluation were examined for DSM-III-R diagnoses with the use of the National Institute of Mental Health Diagnostic Interview Schedule. The patients completed the Medical Outcomes Study Health Survey to assess functional disability and a questionnaire to assess postconcussion symptoms and self-perceptions of the severity of their brain injuries and cognitive functioning. RESULTS: Thirteen (26%) of the patients had current major depression, and an additional 14 (28%) reported a first-onset major depressive episode after the injury that had resolved. Twelve (24%) had current generalized anxiety disorder, and four (8%) reported current substance abuse. The group with depression and/or anxiety was significantly more impaired than the nondepressed/nonanxious patients according to the Medical Outcomes Study Health Survey measures of emotional role functioning, mental health, and general health perceptions. The depressed/anxious group also rated their injuries as significantly more severe and their cognitive functioning as significantly worse, despite the lack of significant differences in objective measures of severity of injury and Mini-Mental State examination scores. The depressed patients reported significantly more postconcussion symptoms that were increasing in severity over time. CONCLUSIONS: Depression and anxiety are common in outpatients with traumatic brain injuries. Patients with depression or anxiety are more functionally disabled and perceive their injury and cognitive impairment as more severe. Depressed patients report more increasingly severe postconcussion symptoms.

The patient-provider relationship: attachment theory and adherence to treatment in diabetes.

OBJECTIVE: Lack of adherence to diabetic self-management regimens is associated with a high risk of diabetes complications. Previous research has shown that the quality of the patient-provider relationship is associated with adherence to diabetes treatment. This study attempts to improve understanding of both patient and provider factors involved in lack of adherence to treatment in diabetic patients by using the conceptual model of attachment theory. METHOD: Instruments that assessed attachment, treatment adherence, depression, diabetes severity, patient-provider communication, and demographic data were administered to 367 patients with type 1 and 2 diabetes in a health maintenance organization primary care setting. Glucose control, medical comorbidity, and adherence to medications and clinic appointments were determined from automated data. Analyses of covariance were used to determine if attachment style and quality of patient-provider communication were associated with adherence to treatment. RESULTS: Patients who exhibited dismissing attachment had significantly worse glucose control than patients with preoccupied or secure attachment. An interaction between attachment and communication quality was significantly associated with glycosylated hemoglobin (Hb A(1c)) levels. Among the patients with a dismissing attachment style, there was a significant difference in glycosylated hemoglobin levels between those who rated their patient-provider communication as poor (mean=8.50%, SD=1.55%) and those who rated this communication as good (mean=7.49%, SD=1. 33%). Among all patients who were taking oral hypoglycemics, adherence to medications and glucose monitoring was significantly worse in patients who exhibited dismissing attachment and rated their patient-provider communication as poor. CONCLUSIONS: Dismissing attachment in the setting of poor patient-provider communication is associated with poorer treatment adherence in patients with diabetes.

Dissociation in women with chronic pelvic pain.

OBJECTIVE: The authors' goal was to determine if women with chronic pelvic pain are significantly more likely to use dissociation as a coping mechanism than women without pain. METHOD: The subjects were recruited from women who attended a university women's clinic during a 1-month period. Twenty-two women who reported that they had at any time in their lives experienced pelvic pain nearly every day for a period of at least 6 months were included in the study, along with 21 randomly selected women without a history of chronic pelvic pain. The 43 women were given structured sexual assault interviews and completed psychological self-report measures. RESULTS: The women with chronic pain were significantly more likely to use dissociation as a coping mechanism, to show current psychological distress, to see themselves as medically disabled, to experience vocational and social decrements in function, and to amplify physical symptoms. They were also significantly more likely to have experienced severe childhood sexual abuse. In the total study group, women with a childhood history of sexual abuse had significantly higher scores on measures of psychological distress, somatization, and dissociation and viewed their physical health and functioning as more impaired. CONCLUSIONS: The authors discuss a model for the development of somatization, dissociation, and pain symptoms in victims of early sexual abuse.

Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease.

OBJECTIVE: Two reports have suggested a possible association between a history of sexual trauma and irritable bowel syndrome, but several factors in their study designs limited their generalizability. The authors used a more rigorous methodology to confirm this association. METHOD: They administered structured psychiatric and sexual trauma interviews to 28 patients with irritable bowel syndrome and 19 patients with inflammatory bowel disease and compared prevalence rates of sexual victimization in the two groups. RESULTS: Compared with patients diagnosed as having inflammatory bowel disease, patients with irritable bowel syndrome had a significantly higher rate of severe lifetime sexual trauma (32% versus 0%), severe childhood sexual abuse (11% versus 0%), and any lifetime sexual victimization (54% versus 5%). The nine patients who had experienced severe lifetime victimization had significantly higher odds ratios for lifetime depression, panic disorder, phobia, somatization disorder, alcohol abuse, functional dyspareunia, and inhibited sexual desire than the 38 patients who had experienced less severe sexual trauma or no trauma. A logistic regression analysis showed that gender, the number of medically unexplained physical symptoms, and self-reported anxiety and hostility accounted for all of the variance in the victimized group. CONCLUSIONS: These preliminary results suggest that sexual victimization may be an important factor in the development of irritable bowel syndrome in some patients. Future studies attempting to categorize subgroups of patients with irritable bowel syndrome should inquire into past histories of sexual victimization.

PIP: This study confirms the previously studied findings by using a more rigorous methodology concerning the association of sexual victimization history and irritable bowel syndrome or inflammatory bowel disease. Structured psychiatric and sexual trauma interviews were given to 28 patients with irritable bowel syndrome and 19 inflammatory bowel disease, and the prevalence rates of sexual victimization in the 2 groups were compared. A logistic regression analysis was performed to summarize the differences between patients who had severe trauma and those who had none, and to account for intercorrelations among the study variables. Results showed that patients with irritable bowel syndrome were more likely to have a history of previous sexual victimization. The odd ratios for current and lifetime psychiatric disorders in the 9 patients who had experienced severe forms of victimization showed that they were at significantly greater risk for affective, anxiety, and somatoform disorders as well as substance abuse and sexual dysfunction. It was also demonstrated that the best predictors of having experienced severe forms of victimization were gender, the number of medically unexplained physical symptoms, and self-reported anxiety and hostility. This study suggests that irritable bowel syndrome may be part of a chronic adjustment to previous sexual victimization in some patients.

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression.

OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data. RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day. CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care.

OBJECTIVE: The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted. METHOD: They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy. RESULTS: At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy. CONCLUSIONS: Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.

Back pain in primary care: predictors of high health-care costs.

The objective of this study was to describe the health care utilization and prospective predictors of high-cost primary-care back pain patients. In the primary-care clinics of a large, staff model health maintenance organization in western Washington State, 1059 subjects were selected from consecutive patients presenting for back pain. The design was a 1-year prospective cohort study. Patients' were interviewed 1 month after an index primary-care back pain visit. Costs (back pain and total) and utilization (back pain primary-care follow-up visits, back pain specialty visits, back pain hospitalizations, back pain radiologic procedures, and pain medicine fills) were tracked over the next 11 months. Predictors assessed at 1 month were back pain diagnosis (disc disorder/sciatica, arthritis, vs. other), chronic pain grade (measure of pain intensity and related dysfunction), pain persistence (days with pain in prior 6 months), depressive symptomatology, and back pain-related disability compensation (ever/never). For the sample, 21% of patients with back pain costs > or = $600 (high back pain costs) accounted for 66% of back pain costs, 42% of total costs, 55% of primary-care follow-up visits for back pain, 91% of back pain specialty visits, 100% of back pain hospitalizations, 51% of back pain radiologic procedures, and 52% of pain medicine fills. The 21% with total costs > or = $2700 (high total costs) accounted for 67.7% of total costs, 52% of back pain costs, 29% of primary-care follow-up visits for back pain, 66% of back pain specialty visits, 100% of back pain hospitalizations, 39% of back pain radiologic procedures, and 42% of pain medicine fills. Multivariable logistic regression analyses indicated that increasing chronic pain grade, more persistent pain, and disc disorder/sciatica were strong independent predictors of high total and high back pain costs. Increasing depressive symptoms significantly predicted high total but not high back pain costs. Back pain disability compensation predicted high back pain but not high total costs. A minority of primary-care back pain patients accounted for a majority of health-care costs. Patients with high back pain costs accounted for more back pain-related health-care utilization than did patients with high total costs. Factors predicting subsequent high costs suggest behavioral interventions targeting dysfunction, pain persistence, and depression may reduce health-care utilization and prevent accumulation of high health-care costs among primary-care back pain patients.

Panic disorder: relationship to high medical utilization.

The purpose of this review is to describe the relationship between panic disorder, somatization, functional disability, and high medical utilization. Data from community, primary-care, and specialty studies were reviewed to determine the prevalence of anxiety and panic disorder in these populations. Data from the Epidemiologic Catchment Area Study were reviewed to emphasize the effect of panic disorder on health-care utilization and health perception in a community population. Data on the prevalence of panic disorder in primary care and mode of presentation of primary-care patients with panic disorder were also reviewed. Finally, the epidemiologic psychiatric findings from our recent study of distressed high utilizers of primary care were presented. Panic disorder was found to occur in 1-3% of people in the study community and 1.4-8% of primary-care patients. Of people with or without psychiatric disorder, people with panic disorder in the community had the highest risk of having multiple medically unexplained symptoms and of being high utilizers of medical ambulatory services. People with panic disorder in the community compared to both community psychiatric and nonpsychiatric controls tend to perceive themselves as having poor physical health and to be high users of emergency and hospital inpatient services, as well as ambulatory services. Most patients with panic disorder present to their primary-care physician with somatic complaints, especially cardiac (tachycardia, chest pain), gastrointestinal (epigastric pain or irritable bowel syndrome), or neurologic complaints (headaches, dizziness, or presyncope). Patients who were distressed high utilizers of primary care had an extremely high prevalence of current panic disorder (12%) and lifetime panic disorder (30%), which supported the association between panic disorder and high medical utilization found in the Epidemiologic Catchment Area (ECA) Study.

Comorbidity of gastrointestinal complaints, depression, and anxiety in the Epidemiologic Catchment Area (ECA) Study.

The purpose of this investigation is to determine if the high prevalence rates of major depression, panic disorder, and agoraphobia found in tertiary-care studies of irritable bowel syndrome and medically unexplained gastrointestinal symptoms are also found in the general population. Structured psychiatric interviews on 18,571 subjects from the NIMH Epidemiologic Catchment Area (ECA) Study were reviewed for prevalence of gastrointestinal distress symptoms and selected psychiatric disorders. Medically unexplained gastrointestinal symptoms had a high prevalence in the general population (6-25%). When compared with those reporting no gastrointestinal symptoms, subjects who report at least one of these symptoms were significantly more likely to have also experienced lifetime episodes of major depression (7.5% vs 2.9%), panic disorder (2.5% vs 0.7%), or agoraphobia (10.0% vs 3.6%). Subjects with two gastrointestinal symptoms had even higher lifetime rates of depression (13.4%), panic (5.2%), or agoraphobia (17.8%). Lifetime rates of affective and anxiety disorders in the general population are higher in subjects with gastrointestinal symptoms compared with subjects without gastrointestinal symptoms. An even higher prevalence of affective and anxiety disorders is found in patients with medically unexplained gastrointestinal symptoms in tertiary-care clinics. Future studies are needed in primary-care populations where prevalence rates of psychiatric illness are probably intermediate between those of the general population and tertiary care.

Acute infectious mononucleosis: characteristics of patients who report failure to recover.

PURPOSE: We sought to determine how often acute mononucleosis precipitates chronic illness, and to describe the demographic, clinical, and psychosocial features that characterize patients who report failure to recover. SUBJECTS AND METHODS: We enrolled 150 patients with infectious mononucleosis during the acute illness and asked them to assess their recovery at 2 and 6 months. At baseline, we performed physical and laboratory examinations; obtained measures of psychological and somatic functioning, social support, and life events; and administered a structured psychiatric interview. RESULTS: Self-assessed failure to recover was reported by 38% of patients (55 of 144) at 2 months and by 12% (17 of 142) at 6 months. Those who had not recovered reported a persistent illness characterized by fatigue and poor functional status. No objective measures of disease, including physical examination findings or serologic or laboratory markers, distinguished patients who failed to recover from those who reported recovery. Baseline predictors for failure to recover at 2 months were older age (odds ratio [OR] = 1.4, 95% confidence interval [CI]: 1.1 to 1.8, per 5-year increase), higher temperature (OR = 1.5, 95% CI: 1.1 to 2.2, per 0.5 degrees C increase), and greater role limitation due to physical functioning (OR = 1.5, 95% CI: 1.2 to 1.9, per 20-point decrease in Short Form-36 score). At 6 months, baseline predictors for failure to recover included female sex (OR = 3.3, 95% CI: 1.0 to 12), a greater number of life events more than 6 months before the disease began (OR = 1.7, 95% CI: 1.1 to 2.5, per each additional life event), and greater family support (OR = 1.9, 95% CI: 1.1 to 4.2, per 7-point increase in social support score). CONCLUSIONS: We were not able to identify objective measures that characterized self-reported failure to recover from acute infectious mononucleosis. The baseline factors associated with self-reported failure to recover at 2 months differed from those associated with failure to recover at 6 months. Future studies should assess the generalizability of these findings and determine whether interventions can hasten recovery.

Functional status in coronary artery disease: a one-year prospective study of the role of anxiety and depression.

PURPOSE: Although coronary disease is the second most common cause of work and functional disability, little is known about the relative contributions of biomedical and psychosocial factors to this disability. This study was conducted to determine the associations of depression and anxiety with self-reported physical function and activity interference in patients with coronary artery disease. METHODS: This was a 1-year prospective cohort study of 198 HMO members who had elective cardiac catheterization for coronary artery disease in 1992. Measures included: severity of coronary artery stenosis from cardiac catheterization reports; anxiety and depression severity using interviewer-administered Hamilton Anxiety and Depression Rating Scales; and self-reported physical function and activity interference. RESULTS: At the time of catheterization, patients' self-reported physical function differed significantly by number of main coronary vessels stenosed >70% (P <0.03), by anxiety quartiles (P = 0.001), and by depression quartiles (P = 0.001). At 1 year, physical function was no longer associated with the number of main coronary vessels stenosed at baseline, but still was significantly associated with baseline anxiety (P <0.001) and depression quartiles (P = 0.01). Moreover, change in physical function scores from baseline to 12 months was associated with baseline anxiety (P <0.001) or depression (P <0.001) quartiles, but not with baseline number of occluded coronaries. Results for activity interference were similar to those for physical function. These associations were largely unchanged when corrected for age, sex, education, social class, medical versus surgical management of CAD, and degree of medical comorbidity. CONCLUSION: Anxiety and depression have a significant and persistent effect on physical function in patients with coronary artery disease. Although current treatment methods appear to neutralize the influence of coronary stenosis on physical function during the year following catheterization, this is not true for anxiety and depression.

Adult health status of women with histories of childhood abuse and neglect.

PURPOSE: Several recent studies have found associations between childhood maltreatment and adverse adult health outcomes. However, methodologic problems with accurate case determination, appropriate sample selection, and predominant focus on sexual abuse have limited the generalizability of these findings. SUBJECTS AND METHODS: We administered a survey to 1,225 women who were randomly selected from the membership of a large, staff model health maintenance organization in Seattle, Washington. We compared women with and without histories of childhood maltreatment experiences with respect to differences in physical health status, functional disability, numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. RESULTS: A history of childhood maltreatment was significantly associated with several adverse physical health outcomes. Maltreatment status was associated with perceived poorer overall health (ES = 0.31), greater physical (ES = 0.23) and emotional (ES = 0.37) functional disability, increased numbers of distressing physical symptoms (ES = 0.52), and a greater number of health risk behaviors (ES = 0.34). Women with multiple types of maltreatment showed the greatest health decrements for both self-reported symptoms (r = 0.31) and physician coded diagnoses (r = 0.12). CONCLUSIONS: Women with childhood maltreatment have a wide range of adverse physical health outcomes.

Chest pain, cardiac disease, and panic disorder.

Chest pain is one of the most frequent symptoms prompting presentation to a medical clinic. In primary care, more than 80% of patients are found to have no organic etiology for chest pain. Even among selected patients referred for coronary arteriography, 10% to 30% have little or no evidence of coronary artery disease. Recent studies suggest that panic disorder is a common cause of chest pain in patients with negative cardiac test results. Panic disorder can also occur along with a chronic medical illness, such as coronary artery disease, and may lead to physiologic worsening of that illness with more frequent episodes of chest pain.

Medically unexplained symptoms in primary care.

Fourteen common physical symptoms are responsible for almost half of all primary care visits. Only about 10% to 15% of these symptoms are found to be caused by an organic illness over a 1-year period. Patients with medically unexplained symptoms are frequently frustrating to primary care physicians and utilize medical visits and costs disproportionately. This paper will review the relationship between psychological distress and the decision to seek medical care for common physical symptoms such as fatigue and headache. Evidence will be presented demonstrating that an increasing number of medically unexplained symptoms over a patient's lifetime correlate linearly with the number of anxiety and depressive disorders experienced, the score on the personality dimension of neuroticism, and the degree of functional impairment. Several scales measuring somatization and hypochondriasis are recommended for primary care and medical specialty patients.