Healthy patients who perceive poor health: why are they worried sick?

OBJECTIVE: To explore characteristics of patients who are physically healthy but who perceive poor health by investigating the hypothesis that mental health problems, financial strain, and deficiencies in social support underlie why these patients are "worried sick." METHODS: Three hundred forty-eight continuity patients in 2 rural primary care practices were administered the PRIME-MD, the MOS SF-36, a health-related worry (1-item, 5-point) scale, the MOS social support survey, and perceived economic strain instruments. The patient's physician rated physical health on a 10-point scale. Health care utilization was defined as the number of office visits and total office and laboratory charges for 6 months before and after the interview date. RESULTS: Two hundred thirty-seven patients (group A) scored in the upper and middle terciles on the MOS health perceptions scale. One hundred eleven patients scored in the lower tercile on health perceptions: 59 (group B) were rated as having good physical health (physical health rating > 6) and 52 (group C) as having poor health (rating < or = 6). The "worried sick" patients (group B) resembled Group A with regard to physical health, but resembled the sick (group C) with regard to all MOS functional scales, prevalence of mental health diagnoses, and worry. Social support was similar across groups. Only 1 of 3 measures of economic strain was less in group A than B and C. CONCLUSIONS: Our measures of mental health problems, financial strain, and deficiencies in social support accounted only in part for the differences among the three groups. Other explanations of why some are "worried sick" require study, such as other life stressors and personality traits.

The prevalence of mental disorders in rural office practice.

OBJECTIVE: To determine the prevalence of mental disorders in rural primary care office practice. DESIGN: Patient interview; chart review. SETTING: Two rural primary care office practices. PATIENTS: Three hundred-fifty scheduled or walk-in patients age 18 years or older. MEASUREMENTS: Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36), the Primary Care Evaluation of Mental Disorders (PRIME-MD), physical health using Greenfield's index of coexistent disease (ICED), and health care utilization using the number of office visits and total office and laboratory charges six months before until six months after the interview. RESULTS: Of these patients 34% met criteria for one or more of the 18 mental disorders evaluated by the PRIME-MD; 19% met criteria for specific disorders according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R). Mood disorders were most common (21.7%), followed by anxiety disorders (12.3%), somatoform disorders (11.1%), probable alcohol abuse or dependence (6.0%), and eating disorders (2.0%). By logistic regression, there was an association of age, sex, race (black), and education with lower prevalence of various mental disorder categories. Even after adjustment for demographic variables and physical health (ICED score), those with PRIME-MD diagnoses had significantly lower function as measured by the eight MOS SF-36 scales and higher utilization of office services (p < .001). CONCLUSIONS: The prevalence of mental disorders in rural primary care office practice is as high as in urban office practice.

Cognitive screening of nursing home residents: factor structures of the Mini-Mental State Examination.

OBJECTIVE: To examine factor structures of the Mini-Mental State Examination, attempting first to replicate any of previously proposed 2-factor solutions; and to explore, secondly, the presence of clinically more differentiated and statistically stable factor structures representing common neurocognitive dimensions. DESIGN: Factor analytic investigation of descriptive dataset collected on nursing home residents. Two factor analyses were performed, one in which the number of factors was fixed at 2 in an effort to replicate previous studies, and one in which the number of factors to retain was determined by the scree test. Both factor analyses used established methods for judging the adequacy of the correlation matrix and the significance of factor loadings, and both applied principal components analysis for initial factor extraction and the equamax criterion for orthogonal rotation. SETTING: Seven nursing homes with a total of 894 beds. PARTICIPANTS: 922 assessments on nursing home residents were performed, of which 892 were complete and entered into the factor analyses. The observation-to-variable ratio exceeded 81:1, assuring the statistical stability of factor solutions derived. MEASUREMENT: The Mini-Mental State Examination, with standardization of words to be recalled and the inverted spelling of "world" as the mental reversal task. MAIN RESULTS: Two factor structures were derived. A 2-factor solution, explaining 36.5% of the variance and statistically and conceptually different from those obtained in previous studies, distinguished between Perceptual-Organizational and Psychomotor skills. A 4-factor solution, which explained 56.1% of the variance, included a factor named Executing Psychomotor Commands, while also further differentiating the perceptual-organizational processes into the factors of Memory, Concentration, and Language. CONCLUSION: The 2-factor solution shows that, notwithstanding previous claims to the contrary, the MMSE can make stable and independent distinctions between psychomotor and perceptual-organizational processes. However, this solution is statistically and conceptually limited and, therefore, of limited clinical and scientific relevance. The 4-factor solution of the MMSE maps well onto commonly recognized dimensions of neurocognitive ability. It offers a stable, intuitively sound, and statistically supported framework for clinical differentiation of cognitive screening data into independent clinical dimensions of neurocognitive functioning. Thus, it offers clinicians and researchers a 4-dimensional framework for interpreting data obtained by means of the MMSE. Studies with other populations of cognitively impaired and intact elderly are recommended to validate and extend the present findings.