Somatization and health anxiety as predictors of health care use.

OBJECTIVE: To assess whether the number of somatic symptoms and health anxiety are independent predictors of future health care use after adjusting for confounders. METHODS: In a random sample of the adult UK population, questionnaires assessed the number of somatic symptoms (Somatic Symptom Inventory), health anxiety (Whiteley Index), anxiety/depression (Hospital Anxiety and Depression Scale), the number of physical illnesses and demographic variables. The number of consultations in primary care was obtained from medical records for 1 year before and after questionnaire assessment, and negative binomial regression analyses identified predictors of consultation rate. RESULTS: The sample included 961 participants (58.0% response) with complete medical record data for 609 participants. After adjustment for consultation rate in the prior year, the predictors of subsequent consultation rate in primary care were the number of physical illnesses, off work through illness, Whiteley Index (incidence rate ratio [IRR] = 1.22, 95% confidence interval [CI] = 1.09-1.35), and the Whiteley Index-by-Somatic Symptom Inventory interaction term. Reported physical abuse predicted an increased consultation rate in women (IRR = 2.30, 95% CI = 1.08-4.90) but a reduced rate in men (IRR = 0.43, 95% CI = 0.22-0.84), interaction p = 0.003. CONCLUSIONS: These data raise the possibility that both increased health anxiety and number of bothersome somatic symptoms predict frequent medical consultations. A more complex model of predicting future health care use is needed than has been studied previously, which is potentially relevant to the current discussions of the proposed DSM-V and International Classification of Diseases, 11th Revision, diagnostic guidelines regarding complex somatic symptom disorders.

Depressive disorder and social stress in Pakistan compared to people of Pakistani origin in the UK.

PURPOSE: Depressive disorder is more common in low to middle than high-income countries, but the reasons for this have not been explicitly defined. METHOD: We compared the results of two population-based studies of people of Pakistani origin: one living in rural Pakistan and one in UK. Both samples were screened with the self-reporting questionnaire followed by research interview to determine depressive disorders and social stress. RESULTS: Logistic regression was used to compare the prevalence of depressive disorder in the two countries after adjustment for socio-demographic characteristics and social stress. The estimated prevalence of depression for men was 35.8% (95% CI 16.1-55.5) in Pakistan and 9% (5.0-13.0) in Manchester (p<0.001). Corresponding figures for women were 50.2% (40.8-59.6) and 31.1% (24.1-38.0) in Mandra and Manchester, respectively (p=0.006). The differences remained significant after adjustment for socio-demographic characteristics until we adjusted for either years of education (women only) or severe social stress (both sexes). 35% of women in Pakistan and 71% of those in UK had received 8 years or more of education. Extremely poor housing and marked poverty were experienced by 36.1% of women in Pakistan and 0.6% of those in Manchester. In Pakistan, housing and poverty predominated as correlates of depression, whereas in Manchester it was marked difficulties in physical health and close relationships. CONCLUSION: The results suggest that the higher rate of depressive disorder amongst women in Pakistan compared to UK can be attributed to less education and frequent severe social difficulties. These differences have implications for treatment.

Number of bodily symptoms predicts outcome more accurately than health anxiety in patients attending neurology, cardiology, and gastroenterology clinics.

BACKGROUND: In consecutive new outpatients, we aimed to assess whether somatization and health anxiety predicted health care use and quality of life 6 months later in all patients or in those without demonstrable abnormalities. METHOD: On the first clinic visit, participants completed the Illness Perception Questionnaire (IPQ), the Health Anxiety Questionnaire (HAQ), and the Hospital Anxiety and Depression Scale (HADS). Outcome was assessed as: (a) the number of medical consultations over the subsequent 6 months, extracted from medical records, and (b) Short-Form Health Survey 36 (SF36) physical component score 6 months after index clinic visit. RESULTS: A total of 295 patients were recruited (77% response rate), and medical consultation data were available for 275. The number of bodily symptoms was associated with both outcomes in linear fashion (P<.001), and this was independent of anxiety and depression. Similar associations were found in people with or without symptoms due to demonstrable structural abnormalities. Health anxiety was associated only with health-related quality of life in patients with symptoms explained by demonstrable abnormalities. CONCLUSION: The number of bodily symptoms and degree of health anxiety have different patterns of association with outcome, and these need to be considered in revising the diagnoses of somatization and hypochondriasis.

Childhood adversity and frequent medical consultations.

We assessed possible psychological mediators of the relationship between childhood adversity and frequent medical consultations among new outpatients at neurology, cardiology, and gastroenterology clinics. We assessed whether these differed in patients with and without organic disease that explained their symptoms. At first clinic visit we recorded Hospital Anxiety and Depression scale (HADS--anxiety and depression subscale scores), Illness Perception Questionnaire (IPQ--four subscales: consequences, cure, identity, timeline), Health Anxiety Questionnaire (total score), and Symptom Amplification Scale (total score). Subjects were divided into two groups according to whether they had experienced any type of childhood adversity using the Childhood Experience of Care and Abuse Schedule. Outcome was the (log) number of medical consultations for 12 months before and 6 months after the index clinic visits. Multiple regression analysis was used to determine mediators; this was performed separately for patients with symptoms explained and not explained by organic disease. One-hundred and twenty-nine patients (61% response) were interviewed. Fifty-two (40.3%) had experienced childhood adversity; they made a median of 16 doctor visits compared with 10 for those without adversity (adjusted P=.026). IPQ identity score (number of symptoms attributed to the illness) and HAD depression scores were significantly associated with both childhood adversity and number of medical consultations and these variables acted as mediators between childhood adversity and frequency of consultation in the multiple regression analyses. This association was limited to patients with medically unexplained symptoms and was mediated by IPQ Identity Score (number of symptoms attributed to the patient's illness) and HAD depression score. Sexual abuse and overt neglect were the adversities most closely associated with frequent consultations. In patients with medically unexplained symptoms the association between childhood adversity and frequent medical consultations is mediated by the number of bodily symptoms attributed to the illness. Psychological treatments should be targeted at these patients with a view to reducing their frequent doctor visits.

Differences between out-patients with physical disease and those with medically unexplained symptoms with respect to patient satisfaction, emotional distress and illness perception.

OBJECTIVES: This study aimed to assess whether patients with medically unexplained symptoms (MUS) attending cardiology and neurology out-patient clinics were less satisfied with their consultation than patients whose presenting symptoms were explained by an organic diagnosis. The multidimensional nature of satisfaction and its relationships with emotional distress and illness perception were also assessed within the two groups. DESIGN AND SETTING: A prospective cohort study was carried out at a large inner city teaching hospital. PARTICIPANTS: New attenders at cardiology and neurology out-patient clinics participated in the study. MEASURES: The Satisfaction Questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Health Anxiety Questionnaire (HAQ) and the Illness Perception Questionnaire (IPQ) were used in the study. RESULTS: There were no overall significant differences in satisfaction between organic and MUS patients. Factor analysis yielded four factors: satisfaction with information, satisfaction with style of doctor-patient interaction, satisfaction with clinic environment, and satisfaction with patient's health. Levels of internal consistency were good, with Cronbach's alphas between .74 and .95 for the four subscales. CONCLUSION: When considering patients with MUS, these findings emphasize the need to examine healthcare satisfaction from a detailed and multidimensional perspective. Relationships between satisfaction dimensions, clinic specialties and measures of psychological well-being and of illness perception show interesting patterns. These findings raise both theoretical and service delivery questions concerning communication strategies.

Dream characteristics of stock brokers after a major market downturn.

Dream characteristics of 28 stock brokers during the second worst weekly performance of the Dow Jones Industrial Average in the last 11 yr. were measured using the KJP Dream Inventory. Additional measures of powerlessness and stress were administered as well. Significant correlations appeared between the amount of stress brokers reported during this week and the appearance of recurring nightmares (.59), feelings of being chased (.42), and dreams' pleasantness (-.64). The brokers' clients' investment performance was correlated significantly with changes in the brokers' experience of traumatic dreams (-.57) and dreams of falling (-.43). Further, as the brokers' own personal investments deteriorated overall, dreaming increased (.48), suggesting compensatory mechanisms. Results were discussed in terms of the relationship between onset of acute traumatic states and dreaming.

Does depression predict the use of urgent and unscheduled care by people with long term conditions? A systematic review with meta-analysis.

BACKGROUND: Factors that drive the use of urgent healthcare among people with chronic physical illness (i.e. long term conditions-LTCs) are poorly understood. We conducted a systematic review with meta analysis to examine the strength of association between depression and subsequent use of urgent healthcare among people with LTCs. METHODS: Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane Library 2011 were conducted, supplemented by hand-searching bibliographies, citation tracing eligible studies and asking experts about relevant studies. Studies were eligible for inclusion if they: i)used prospective cohort design, ii)included patients with diabetes, asthma, chronic obstructive pulmonary disease or coronary heart disease, iii)used a standardised measure of depression, and iv)assessed urgent healthcare utilisation prospectively. Data on the subjects recruited, methods used and the association between depression and subsequent urgent healthcare utilisation were extracted from eligible studies. Odds ratios (ORs) were calculated for each study and pooled using random effects models. RESULTS: 16 independent studies were identified. Pooled effects indicated that depression was associated with a 49% increase in the odds of urgent healthcare utilisation (OR=1.49, p<.0005). This effect was not significantly affected by publication bias or inclusion of studies of low quality. Effects were much smaller and non-significant among the 3 studies that controlled for other covariates, including severity of illness (OR=1.13, p=.31). CONCLUSIONS: Depression was associated with increased urgent healthcare use, but not in the minority of studies that controlled for other covariates. This possibly suggests confounding, but the severity measures may themselves have been influenced by depression.

The epidemiology of multiple somatic symptoms.

BACKGROUND: The risk factors for a high total somatic symptom count are unclear; and it is not known whether total somatic symptoms count is a predictor of impaired health status. METHOD: A prospective population-based cohort study in North West England. Randomly sampled residents (1443 participants; 58% response) completed questionnaires to determine number of somatic symptoms (SSI), health status and a wide range of risk factors; 741 completed questionnaires 1 year later. We used logistic regression to identify risk factors for high SSI at follow-up and for persistently high SSI. We used ANCOVAR and multiple regression to assess whether baseline SSI predicted health status at follow-up. RESULTS: Twenty-one percent of participants scored over 25 on the Somatic Symptom Inventory (SSI) at baseline and 14% at both baseline and follow-up. Risk factors for a persistent high SSI were: fewer than 12 years of education, separated, widowed or divorced status, reported psychological abuse during childhood, co-existing medical illnesses, anxiety and depression. In multivariate analysis baseline SSI predicted health status (SF12 physical component score and health-related quality of life (EuroQol)) 12 months later. Persistent high SSI was a clinically meaningful predictor of these outcomes. CONCLUSIONS: Our data support a biopsychosocial approach to somatic symptoms rather than the dualistic approach of identifying "medically unexplained" symptoms. The risk factors for total somatic symptom count were those associated with psychiatric disorders including physical illness. A persistent high somatic symptom count provides a readily measured dimension of importance in epidemiology as a predictor of health status.

Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn's disease.

OBJECTIVE: The determinants of health-related quality of life in inflammatory bowel disease are not completely understood. The present study aimed to assess two factors in patients with inflammatory bowel disease: a) whether health-related quality of life is independently associated with both bowel disease severity and psychological disorder, and b) whether Crohn's disease is associated with more marked psychological disorder than ulcerative colitis. METHODS: 116/170 (68%) consecutive patients with inflammatory bowel disease attending a GI clinic (37 patients with ulcerative colitis, 75 patients with Crohn's disease, and four unspecified) completed the following self-report questionnaires: demographic details, a modified disease activity index, a total severity measure, the Hospital Anxiety and Depression Scale, and the Short Form-36. RESULTS: Thirty patients (25.9%) scored 11 or more on either the depression or anxiety subscales of the Hospital Anxiety and Depression Scale indicating probable psychological disorder; 55% (47.4%) scored over 8 indicating possible psychological disorder. Stepwise multiple regression analyses showed that both psychological symptoms and disease severity or activity contributed independently to impaired health-related quality of life. After severity of disease was taken into account, there were no significant differences between Crohn's disease and ulcerative colitis in terms of depression scores and health-related quality of life. CONCLUSIONS: The presence of psychological disorder in inflammatory bowel disease contributes to poor health-related quality of life, regardless of the severity of the condition. Detection and treatment of psychological disorder in inflammatory bowel disease carries the potential to improve health-related quality of life for these patients.

Association of depression and rheumatoid arthritis.

This study assessed the relative strength of the association of physical characteristics and social stresses with a diagnosis of depression in patients with rheumatoid arthritis. Depression and social difficulties were assessed in 74 patients with rheumatoid arthritis by using standardized research interviews. Rheumatoid arthritis activity, damage related to rheumatoid arthritis, and subjective functional disability were assessed with well-validated methods. Twenty-nine patients (39.2%) were depressed. Compared to nondepressed patients, depressed patients had more marked social difficulties related to rheumatoid arthritis (72.4% versus 46.7%, respectively) and more marked social difficulties independent of rheumatoid arthritis (55.2% versus 31.1%, respectively). With logistic regression, social difficulties, independent of rheumatoid arthritis, was the only variable significantly associated with depression. Demographic characteristics and rheumatoid arthritis were not associated with a diagnosis of depression. Recognition by clinicians of the importance of social stresses, independent of disease state, should lead to more appropriate and specific psychological and social treatment of depression in rheumatoid arthritis.