Behavior and Mental Status
Empathic listening, careful observation, and skilled history taking help patients to reveal their deepest concerns and experiences. Clinicians often miss clues to trauma, mental illness, and harmful dysfunctional behaviors. The prevalence of mental health disorders in the U.S. population is 30%, yet only approximately 20% of affected patients receive treatment. Even for patients who obtain care, evidence suggests that adherence to treatment guidelines in primary care offices is <50%.
Often, patients have health symptoms that mirror medical illnesses. Thirty percent of symptoms last more than 6 weeks and are “medically unexplained,” masking anxiety, depression, or even somatoform disorders. See Table 5-1, Somatoform Disorders: Types and Approach, pp. 76–78. Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. “Difficult patients” are frequently those with multiple unexplained symptoms and underlying psychiatric conditions that are amenable to therapy. Without better “dual diagnosis,” patient health, function, and quality of life are at risk.
Mental Health Disorders and Unexplained Symptoms in Primary Care Settings
Mental Health Disorders in Primary Care
Approximately 20% of primary care outpatients have mental disorders, but up to 50% to 75% of these disorders are undetected and untreated.
Prevalence of mental disorders in primary care settings is roughly:
Anxiety—20%
Mood disorders including dysthymia, depressive, and bipolar disorders—25%
Depression—10%
Somatoform disorder—10% to 15%
Alcohol and substance abuse—15% to 20%
Explained and Unexplained Symptoms
Physical symptoms account for approximately 50% of office visits.
Roughly one-third of physical symptoms are unexplained; in 20% to 25% of patients, physical symptoms become chronic or recurring.
In patients with unexplained symptoms, the prevalence of depression and anxiety exceeds 50% and increases with the total number of reported physical symptoms, making detection and “dual diagnosis” important clinical goals.
Common Functional Syndromes
Co-occurrence rates for common functional syndromes such as irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity reach 30% to 90%, depending on the disorders compared.
The prevalence of symptom overlap is high in the common functional syndromes: namely, complaints of fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems.
The common functional syndromes also overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy.
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