Donald E. Nease, Jr, MD Robert J. Volk, PhD Alvah R. Cass, MD, SM Ann Arbor, Michigan; Houston and Galveston, Texas Submitted, revised, July 27, 1999. This paper was presented at the 25th annual meeting of the North American Primary Care Research Group, Orlando, Florida, on November 14, 1997. From the Department of Family Medicine, University of Michigan, Ann Arbor, Michigan (D.E.N.); the Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas (R.J.V.); and the Department of Family Medicine, University of Texas Medical Branch, Galveston, Texas (A.R.C.). Requests for reprints should be addressed to Donald E. Nease, Jr, MD, Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109-0708. E-mail: dnease@umich.edu
References
Because our instrument did not include other symptom severity measures we were unable to compare it with others, such as the Hamilton Depression Rating Scale.31 However, questions exist about the ability of the Hamilton Scale to serve as a measure of depression severity.35 Beyond these concerns, a 15-item self report measure of severity appears to have advantages in a busy clinical setting.
Finally, given the apparent sensitivity of symptom severity for impairment and utilization differences, we postulate that our severity instrument could be useful in initially identifying patients at risk, as well as in monitoring previously identified patients. Existing instruments are not well accepted by primary care clinicians, perhaps because of high rates of false positives.36 We are currently testing whether such a use would be feasible. With intervention studies of treatment-resistant patients now being undertaken, use of a severity measure to identify patients for intervention could be very helpful. This work could proceed along the lines of stepped-care approaches for other disease entities, such as diabetes, asthma, or depression.
Conclusions
We agree with Klinkman and Okkes,37 who have called for more primary epidemiology within the area of mental health in primary care. Our work demonstrates that the relationship between symptom severity and the presence of a mood or anxiety disorder is very complex and worthy of further exploratory study. Indeed, the utilization implications here are profound because our classifications have the potential to identify patients who have high levels of health care utilization in a way other than by traditional diagnoses or medical comorbidity. Cluster analysis has provided a useful tool for examining new ways of understanding how mood and anxiety symptoms are present in the primary care setting. Further prospective work should continue to enlarge this understanding.
Acknowledgments
This project was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (AA09496) and the Bureau of Health Professions, Health Resources and Services Administration (D32-PE16033 and D32-PE10158).
