Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care   Commentary: There must be limits to the medicalisation of human distress

Abstract

Objectives To examine the effect of patients' causal attributions of common somatic symptoms on recognition by general practitioners of cases of depression and anxiety and to test the hypothesis that normalising attributions make recognition less likely. Design Cross sectional survey. Setting One general practice of eight doctors in Bristol. Subjects 305 general practice attenders. Main outcome measure The rate of detection by general practitioners of cases of depression and anxiety as defined by the general health questionnaire. Results Consecutive attenders completed the general health questionnaire and the symptom interpretation questionnaire, which scores style of symptom attribution along the dimensions of psychologising, somatising, and normalising. General practitioners detected depression or anxiety in 56 (36%; 95% confidence interval 28% to 44%) of the 157 patients who scored highly on the general health questionnaire. Subjects with a normalising attributional style were less likely to be detected as cases; doctors did not make any psychological diagnosis in 46 (85%; 73% to 93%) of 54 patients who had high questionnaire and high normalising scores. Those with a psychologising style were more likely to be detected; doctors did not detect 21 (38%; 25% to 52%) of 55 patients who had high questionnaire and high psychologising scores. The somatisation scale was not associated with low detection rates. This pattern of results persisted after adjustment for age, sex, general health questionnaire score, and general practitioner. Conclusions Normalising attributions minimise symptoms and are non-pathological in character. The normalising attributional style is predominant in general practice attenders and is an important cause of low rates of detection of depression and anxiety.

Primary attributions in women suffering fibromyalgia emphasize the perception of a disruptive onset for a long-lasting pain problem

“…The results indicated that attributions were often referring to the psychological dimension of the events mentioned by the participants (such as relational problems or death of a relative), even when the events also had a clear somatic dimension, such as violence during childhood, accident, or gynaecological/ obstetrical problems. These results corroborate estimates of patients' psychological distress observed in other studies [43,44] with approximately 60% of patients expressing psychological attributions for various symptoms. Other studies on causal attributions also emphasized the importance of psychological attributions although multiple causal attributions may coexist [16,19].…”

Improving general practitioners’ interviewing skills in managing patients with depression and anxiety: a randomized controlled clinical trial

“…As a result, there is a need to provide more training for primary care physicians to improve their skills in managing these patients (Von Korff et al 1987;Simpson et al 1991;Kessler et al 1999). Although studies conducted in the West have demonstrated the effectiveness of CME courses in improving doctors' consultation skills, few randomized controlled trials have been conducted in Asia.…”

“…These studies are important because although 60% of mental health care is provided in primary care settings, primary care practitioners fail to recognize up to two thirds of the emotional disorders manifested by their patients (Von Korff et al 1987;Kessler et al 1999). Many studies (Borus et al 1988;Young et al 2001) showed that practitioners often lack the skills to detect or deal with psychosocial problems in primary care when patients clearly…”

Common mental disorders in Petrópolis-RJ: a challenge to integrate mental health into primary care strategies

“…As a result, undetected CMD patients go regularly to primary care centers, where complementary exams are excessively requested and they are frequently referred to specialists, or receive inadequate treatment by general practitioners. 13,14 Another important aspect that has been demonstrated is that a higher prevalence of CMD is associated with socio-economic and demographic factors, such as income, gender, education and marital status. [15][16][17][18][19][20][21][22] The association between CMD and low income is so frequent that Patel and Kleinmann have suggested they should be considered a disease associated with poverty.…”