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Not all patients will recognize they have depression, anxiety

SAN DIEGO – Many patients will come to see primary care physicians reporting a range of symptoms, but the real reason for the patient’s visit in many cases is anxiety or depression, according to a presentation at the ACP Internal Meeting.

“Many patients present to primary care with somatic complaints of some sort. So primary care physicians start looking for physical etiologies that explain why they are having the particular complaints that they are making,” Heidi Combs, MD, medical director for Harborview Medical Center Inpatient Psychiatry and associate professor of psychiatry and behavioral science, University of Washington, said. “These patients often have a lot of physical experiences going on in their body, but they do not know that this is a physical manifestation of their psychological distress. People don’t realize how intensely your body can experience what’s going on in your brain.”

To illustrate her point, she cited a study of patients diagnosed with generalized anxiety disorder, of whom just 13% reported anxiety as their primary presenting complaint, while 47% reported somatic complaints.

Medical conditions associated with anxiety can affect the endocrine, cardiovascular, pulmonary, metabolic, or neurologic systems, Combs said.

According to Combs, there are several questionnaires that primary care physicians can use to help lead to better diagnosis anxiety: GAD-7, GAD-2, and the panic module of the Patient Health Questionnaire, which also asks a series of questions. For depression diagnoses, Combs suggested the Patient Health Questionnaire-2, the Patient Health Questionnaire-9, the Geriatric Depression Scale, which and the Beck Depression Inventory.

She acknowledged primary care physicians don’t always have a lot of time with their patientsand suggested several questions that can help identify the most common major disorders quickly.

Have you ever had a panic attack? (if the suspected problem is panic disorder)

Do you consider yourself a worrywart? (if the suspected problem is general anxiety disorder)

Have you ever had anything happen to you that haunts you in some way? (if the suspected problem is post-traumatic stress disorder)

Do you get thoughts stuck in your head that come in over and over that you don’t like? Or are there things that you do over and over? (if the suspected problem is obsessive compulsive disorder)

If you’re in a position where people can scrutinize you, do you feel extremely nervous or do you avoid it? Or if you have to do it, do you have a panic attack or get very uncomfortable? (if the suspected problem is social anxiety disorder

Combs emphasized that even in a busy clinic, asking these types of questions doesn’t have to be time consuming.

“How long did it take me to go through that list?” she asked the audience. “Less than a minute. It doesn’t take long to ask these screening questions.”

She said if a patient answers no to all of these questions, then the person does not have an anxiety order. If a person answers yes, then follow-up questions such as the frequency of the episodes should be asked. – by Janel Miller

Reference:

American Academy of Family Physicians Diagnosis of Anxiety Disorders in Primary Care (accessed 03-30-17)

American Psychological Association - Beck Depression Inventory (accessed 03-30-17)

Combs, H. Session MTP 083."Evaluation and Treatment of Anxiety and Depression in the Primary Care Setting". Presented at: ACP Internal Medicine Meeting; March 29-April 1, 2017; San Diego.

Center for Quality Assessment and Improvement in Mental Health (accessed 03-30-17)

PHQ Screeners (accessed 03-30-17)

Psych Congress Network GAD-7 Description (accessed 03-30-17)

The Hartford Institute for Geriatric Nursing (accessed 03-30-17)

Disclosure: Combs reports no relevant disclosures.