Necessary but Not Sufficient: The Effect of Screening and Feedback on Outcomes of Primary Care Patients with Untreated Anxiety SUSAN D. MA THIAS, MPH, SHEILA K. FIFER, PhD, PETER D. MAZONSON, MD, MBA, DEBORAH P. LUBECK, PhD, DON P. BUESCHING, PhD, DONALD L. PA TRICK, PhD, MSPH Objective: To consider the impact on primary care patient outcomes of using both a screener to determine elevated anxiety levels among patients with previously undetected anxiety and a physician intervention to inform physicians of their patients' conditions. Design: Participating physicians were randomized to either the demonstration or the control arm, and patients were assigned to a study arm based on the randomization of their physicians. The patients were followed for change in outcome measures during the five-month study period. Setting: A mixed-modal health maintenance organization serving approximately 110,000 enrollees in central Colorado. Patients~participants: 573 patients who had unrecognized and untreated anxiety identified from the approximately 8,000 patients who completed the waiting room screening questionnaire. Interventions: A physician intervention served the dual function of 1 ) providing an educational demonstration of arLxiety in the primary care setting and 2 ) providing a reporting system for summarizing the anxiety symptom levels and functioning status of the patients enrolled in the stud}'. Measurements a n d m a i n results: Patient outcomes were measured as changes in global anxiety scores, functioning and well-being, and patients' rcports of global improvements. Conclusions: The findings indicate that this method of reporting symptoms and functioning status to primary care physicians did not significantly change patient outcomes. Improvement in outcomes appeared to be more closely associated with the patient's severity of psychnk)gical distress. Kel, words: outcomes; screeners; physician intervention; anxiety. O GEN INTERN MED 1994;9:606

615.

IN TIlE UNITED STATES, t h e p r i m a r y c a r e s e c t o r p l a y s a pivotal role in treating patients with psychological con-

Received from the Technolugy Assessment Group, San Francisco, California (SDM, SKI:, PDM, DPL), the Departmcnt of Medicine, Stanford University, Palo Alto, California (DPL), the Upjohn Company, Kalamazoo, Michigan (DPB), and the School of Public Health, University of Washington, Seattle, Washington (DLP). (Dr. Buesching is currently with Eli Lilly and Company, Indianapolis, Indiana). Preliminary data from this stud}' were presented at the Seventh Annual National Institute of Mental Health International Research Conference on Mental Health Problems in the General Health Care Sector, September 20-22, 1993, McLean, Virginia, and at the first Annual Symposium of Contributed Papers on Quality of l.fie at the Drug Informatkm Association Workshop, April 20-27, 1993, Charleston, South Carolina. St,ppurted by a grant from the Upjohn Company, Kalamazoo, Michigan, and TakeCare, Colorado. (Note: Dr. Buesching is a former empk)yee of the Upjohn Company but owns no stock or option to purchase further stock in the company. Ms. Mathias, Dr. Filer, Dr. Mazonson, Dr. 1,ubeck, and Dr. Patrick own no stock or option in the Upjohn Company. ) Address correspondence and reprint requests to Ms. Mathias: Technoh)gy Assessment Group, 490 Second Street, St,ire 201, San Francisco, CA 94107.

606

ditions. The high incidcncc of psychological distress among primary care patients, reported to range from 27% to 47%? -s may be due to the fact that patients with psychological distress present more frequently to primary care physicians than to mental health professionals a n d o f t e n s o m a t i z e t h e i r distress. ~'- 13 I n d e e d , R e i g e r e t al. h a s r e f e r r e d t o p r i m a r y c a r e as t h e " d e f a c t o " mental health system, estimating that 54% of those treated for m e n t a l d i s o r d c r s a r e s e r v e d b y p r i m a r y c a r c p h y s i cians exclusively, compared with only 15% who are s e r v e d b y t h e m e n t a l h e a l t h s e c t o r . 6' 7 T h e r e is c o n s i d e r a b l e c o n t r o v e r s y o v e r t h e a c c u racy and adequacy with which psychological conditions a r e r e c o g n i z e d in t h e p r i m a r y c a r e s e t t i n g . 1~-~6 Reported estimates of recognition rates range between 8% and 39%, depending upon the mental health condition involved, the type of assessment done, and the cutoff p o i n t s u s e d . ' - " 14-1s A l t h o u g h a n x i e t y s y m p t o m s a n d d i s o r d e r s "affect b e t w e e n 6 . 6 % a n d 1 4 . 9 % o f t h e g e n e r a l population, many patients with elevated anxiety levels are neither recognized nor treated by their primary care p h y s i c i a n s . " ' s, ,,~, 211 One approach to improving the accuracy and rate of recognition of anxiety has been the use of symptom s c r e e n i n g i n s t r u m e n t s as t o o l s t o a s s i s t t h e p r i m a r y c a r e physician. Results have varied depending upon the screener and the nature of the psychological distress. 1,-'°-as P r o v i d i n g f e e d b a c k t o p h y s i c i a n s e n s u r e s neither that mental health care will be provided nor that t h i s c a r e w i l l r e s u l t i n i m p r o v e d o u t c o m e s . 13 Yet, f e w studies have examined the longitudinal effects of using mental health screeners to improve primary care patient o u t c o m e s . M a g r u d c r - H a b i b c t al. f o u n d t h a t t h e u s e o f a s c r e e n e r for p r e v i o u s l y u n r e c o g n i z e d d e p r e s s i o n i m p r o v e d b o t h r e c o g n i t i o n a n d t r e a t m e n t r a t e s , "~'ea although there was no demonstrable effect on patient outc o m e s . U s i n g a s c r e e n e r , O r m c l e t al. d e t e r m i n e d t h e r a t e at w h i c h g e n e r a l p r a c t i t i o n e r s

recognized

anxiety

d i s o r d e r s , w h i c h a r e less a c c u r a t e l y d e t e c t e d b y p h y s i c i a n s t h a n a r e o t h e r m e n t a l d i s o r d e r s , ' ~-la a n d f o u n d that recognition was associated with a shorter episode duration. Use of a physician education

program

or demon-

stration has been another approach taken to enhance r e c o g n i t i o n r a t e s , a l t h o u g h it h a s l e d to, a t b e s t , m i x e d results. The most positive results were reported

by An-

JOURNALOF GENERALINTERNALMEDICINE,Volume 9

dersen and Harthorn, w h o found that an educational intervention conveying information about psychological disorders to primary care physicians 2(' improved recognition rates, but treatment rates and outcomes were not reported. We chose to combine the two approaches: an anxiety screener and a physician intervention. In a previously reported study, we examined a population of primary care patients w h o had elevated levels of anxiety detected by the SCL-90-R screener. -'7 In the present study, we considered the longitudinal impact of using a screener and a physician intervention on outcomes of primary care patients who had previously undetected elevated anxiety levels. The objectives of the present study were twofold: 1 ) to assess whether changes in anxiety symptoms, functional status, and overall health perception were greater for patients whose physicians were made aware of their conditions, and 2) to characterize the changes in anxiety levels and functional status among anxious patients during a five-month period.

METHODS Study Design The study was conducted at TakeCare, a mixedmodel health maintenance organization (HMO) serving approximately 110,000 enrollees in central Colorado. All enrollees are eligible to receive psychiatric coverage for both inpatient and outpatient services, without deductibles, under a capitated contract with American Biodyne, a managed mental health provider. Benefit coverage includes both counseling and pharmacotherapy, with complete coverage for all visits and no allocated ceiling. The Biodyne staff comprises psychologists, psychiatrists, and social workers, to w h o m patients can be referred either by their physicians, by serf-referral, or by their employers. Patient Evaluations. The study group consisted of 573 patients who had unrecognized and untreated anxiety and who met all study requirements. They were identified from the approximately 8,000 eligible patients who completed the waiting room screening survey questionnaire when they presented to a participating physician during the four-month period. A three-step screening process determined eligibility for enrollment in the study: the initial w a i t i n g r o o m screen for elevated levels of anxiety; a m e d i c a l record r e v i e w to confirm unrecognized/untreated patient status, and a b a s e l i n e screen to confirm elevated anxiety levels. 27 Qualified patients were assigned to control and demonstration arms based on the practice group of their primary care physicians. All study patients in the two arms completed identical self-reported surveys and interviews at 12 weeks and five months following baseline. Another medical record review after the second follow-up survey determined

(November). 1994

607

whether recognition/treatment/referral of a mental heMth condition was noted. The brief self-administered waiting room screening survey contained three sections: a series of questions to assess the patient's anxiety symptoms (52 items from the SCL-90-R); a global measure of the patient's functional status and well-being (SF- 36); and additional items to determine administrative eligibility (e.g., patient's age).-'; The baseline and follow-up surveys each consisted of a self-administered questionnaire and a face-to-face interview conducted at or near the physician's office. The self-administered portions of the baseline and follow-up surveys were nearly identical, consisting of the SF-36, the entire SCL-90-R, and questions about work productivity, z" (A complete summary of survey instrumentation can be found in Appendix A.) Since the purposes of the surveys differed slightly, there were supplemental modifications in content. 1. B a s e l i n e survey: patients were asked additional questions about comorbidities. The face-to-face interview included a computerized version of the DIS (Q-DISIll-R) and a health state preferences exercise. 27 2. First f o l l o w - u p survey: patients were asked the type of anxiety treatment, if any, received since the baseline survey and whether they were satisfied with it. . Second f o l l o w - u p survey: patients were asked about perceived changes in the relationships with their physicians and in their anxiety symptoms and functional status since the first follow-up survey. The face-toface interview extended the first follow-up interview with additional questions about treatment, and readministration of the health state preferences exercise. Of the 618 patients completing baseline, only 7.3% were lost to follow-up. Incomplete follow-up occurred for only 45 patients, due to disenrollment from the HMO. P h y s i c i a n I n t e r v e n t i o n . The 75 primary care physicians contracted to TakeCare w h o participated in the study represented 23 practices, ranging in size from a solo practitioner to a group practice of 12. The physicians were randomized by call group to either the demonstrations arm ( 11 call groups) or the control arm ( 12 call groups). We chose the call group, rather than the practice group, as the unit of randomization to minimize communication between physicians in different practices who belonged to the same call group. The demonstration arm had more patients ( n = 357) than had the control arm ( n = 216). The physician intervention was composed of two parts: 1 ) an educational demonstration provided to the primary care physician by a study team physician and 2) a reporting system for summarizing the anxiety syrup-

608

Mathias et aL, ANXIETYPATIENTOUTCOMES

TABLE 1 Demographics Characteristics of the Two Patient Groups Demonstration Patients (n = 357)

Control Patients (n = 216)

p-value*

Gender Male Female

38.9% (139) 61.1% (218)

45.4% (98) 54,6% (118)

0.13

Age--mean (SO)

41.5 years (10.4 years)

43.6 years (11.5 years)

0.02

Race White Nonwhite

81.0% (289) 19.0% (68)

79.6% (172) 20.4% (44)

0.70

Education High school diploma or less Some college College degree

30,9% (110) 37,4% (133) 31.7% (113)

35.2% (76) 37.5% (81) 27.3% (59)

0,44

19,2% (68) 56.9% (202) 23.9% (85)

25.1% (54) 55.4% (119) 19.5% (42)

0.18

Marital status Married or with partner Single

79.8% (285) 20.2% (72)

78.1% (168) 21.9% (47)

0.63

Physician specialty Family practice Internal medicine

37,2% (133) 62.8% (224)

55.6% (120) 44.4% (96)

<0,01

1.3°/6 (1.3)

1.2% (1.2)

0.54

35.6% (127) 64.4% (230)

20.8% (45) 79.2% (171)

<0.01

3.3% (4.0)

2,7% (3.3)

Income $49,999

Comorbid physical condition--mean (SD) Recognition/treatment (6-month review)--mean (SD) Yes No Office visits-- mean (SD)

0.05

*t-test for interval/ratio variables (means) and chi-square for dichotomous or ordinal variables.

tom levels and functional status of the patients enrolled in the study. 28 A study team internist met with each demonstration arm physician to describe the psychometric instruments and their interpretations, explain the patient profile, review results for a minimum of three of their patients, provide educational materials on the management of anxiety, and provide a toll-free telephone number of a study team physician w h o could answer further questions. Patient profiles, designed to resemble laboratory slips, summarized all self-reported information in a simple format. 28 The demonstration arm physicians received updated patient profiles throughout the course of the study, showing the changes in each patient's scores. No recommendation about the treatment of specific patients was made. Instead, decisions regarding whether to provide counseling or medication, refer the patient, or do nothing were left entirely to the physician. The control arm physicians received the patient profiles at the conclusion of the study, one year after the baseline surveys were administered. They did not receive the one-hour demonstration.

O u t c o m e Measures. The patients were evaluated for changes in anxiety symptoms, psychological distress, functioning and well-being, and self-reports of global improvement for those w h o received treatment. To assess outcome for each study patient, we determined the change score on each of the o u t c o m e instruments by calculating the difference between the scores measured at the second follow-up survey and at baseline. Three measures of anxiety and psychological distress were calculated for each patient subgroup, the Global Anxiety Score (GAS), the Global Severity Index (GSI), and the Highest Anxiety Subscale Score (HASS). Scores on the GAS and the GSI range from 40 to 81, and scores on the HASS range from 30 to 81, with 81 representing maximal dysfunction. The GAS is derived from the four anxiety subscales of the SCL-90-R and provides a single numeric indicator of the respondent's overall anxiety distress. The GSI is based on all nine dimensions of the SCL-90-R and provides a single numeric indicator of the respondent's overall psychological distress. The SF-36 measures nine concepts of functioning and well-being. Each concept is scored from 0 to 100, with 100 rep-

JOURNALOF GENERALINTERNALMEDICINE,Volume 9

resenting optimal health status. Patients' self-reports of global improvement were derived from perceived changes in anxiety level and functioning and well-being and perceived changes in communication with their physicians since the baseline survey. We conducted a multivariate analysis of the baseline and change scores after the second follow-up survey using the General Linear Models (GIA4) procedures from SAS (Version 6.04; SAS Institute, Inc., Cary, NC) to determine the level of impact of the following key variables on global scores: gender, age, comorbid physical conditions, education, and physician specialty. These comparisons were made controlling for the study arm (demonstration vs control) or controlling for the presence of anxiety symptoms and disorders. The same analysis was conducted to determine the impact of scores on the SF-36. Results are reported by group as global anxiety or SF-36 scores adjusting for the covariates.

RESULTS The study group consisted of 573 primary care patients who had unrecognized and untreated anxiety, who completed the four patient surveys. Baseline characteristics of the 45 patients lost to follow-up were compared with those of the 573 patients w h o completed the study. The only detectable difference between the two groups was their physical functioning scores on the SF-36. The 45 patients lost to follow-up had a higher mean score (82.7) than had the study group (77.6). The physician intervention did not result in improved outcomes for the demonstration arm patients.

(November), 1994

609

All patients, control or demonstration, showed improved anxiety symptoms and functional status during the fivemonth study period. Instead, patient outcomes were associated with four subgroups when the patients were categorized by comorbid symptoms and disorders. Demonstration vs Control Arms

The demographic profiles of the patients in the two study arms were similar, based on a chi-square analysis (Table 1 ). This resemblance was particularly evident for gender, race, level of education, income, marital status, and mean number of comorbid physical conditions. The two study arms differed only with respect to four variables; patients in the control arm were slightly younger, were more equally distributed among physician specialties, were less likely to have been treated for mental health conditions, and had fewer office visits during the study period. The patients in the two study arms were also similar with respect to their baseline scores on the o u t c o m e measures. As shown in Table 2, the baseline scores on seven of the nine concepts of functioning and well-being (SF-36) were comparable. For two of the concepts, pain and mental health, the demonstration arm had slightly higher (increased functioning) baseline scores. Global anxiety (GAS, GSI, and HASS), functioning and well-being (SF-36), and patient self-reports of global improvements were compared for the two arms. Table 2 also compares the changes in global anxiety scores at baseline and five months for all patients. After five months, the two arms showed equivalent levels of improvement

TABLE 2 Baseline and Change in Functional Status and Global Anxiety Scores for the Two Patient Groups Baseline* Demonstration Patients (n = 357) Mean (SE) Short-Form 36 Physical functioning* Social functioning* Role--physical* Role--emotional* Mental* Energy* Paint General health perceptions~ Comparative health*

77.9 70.6 60.7 63.3 64.4 46.1 63.8 61.8 48.6

Global Severity Index§

(1.1) (1.2) (2.0) (2.1) (0.9) (1.0) (1.2) (1.0) (1.1)

Control Patients (n = 216) Mean (SE) 78.1 69.4 62.6 59.2 61.8 45.5 60.6 59.6 49.6

Changef

p-value (t-test)

(1.4) (1.5) (2.6) (2.6) (1.2) ( 1.3) (1.4) (1.2) (1.4)

0.94 0.54 0.56 0.22 0.08 0.72 0.08 0.16 0.57

63.8 (0.4)

64.6 (0.5)

0.19

Global Anxiety Score§

60.1 (0.3)

60.8 (0.4)

Highest Anxiety Subscale Score¶

68.2 (0.3)

68.6 (0.4)

Demonstration Patients (n = 357) Mean (SE)

Control Patients (n = 216) Mean (SE)

- 0.01 4.26 3.39 5.10 1.65 5.20 4.20 1.18 4.92

2.01 4.57 5.20 4.71 3.05 4.43 5.15 2.14 4.95

(0.88) (1.12) (1.87) (2.04) (0.87) (0.99) (1.05) (0.78) (1.13)

p value (t-test)

(1.15) (1.47) (2.42) (2.65) (1.14) (1.30) (t.38) (1_02) (1.47)

0.15 0.86 0.54 0.90 0.31 0.62 0.57 0.44 0.99

3.81 (0.45)

3.71 (0.59)

0.89

0.23

2.74 (0.34)

3.08 (0.44)

0.52

0.37

3.48 (0.37)

3.29 (0.48)

0.74

*Adjusted for gender, age, education, number of comorbid conditions, and physician practice. tAdjusted for gender, age, education, number of comorbid conditions, physician practice, treatment, number of office visits, and baseline score. tRange O-100, with 100 representing optimal score. §Range 40-81, with 81 representing maximum dysfunction. ¶Range 30-81, with 81 representing maximum dysfunction.

610

Mathias et aL, ANXIETYPATIENTOUTCOMES

across all t h r e e global scores, i n d i c a t i n g that a n x i e t y levels d e c r e a s e d regardless of w h e t h e r the p r i m a r y care physician was informed of the patient's condition. Changes in the n i n e c o n c e p t s of the SF-36 w e r e also similar for the two arms. Both study g r o u p s s h o w e d i m p r o v e m e n t o n all b u t o n e of the f u n c t i o n i n g and w e l l - b e i n g d i m e n sions. While b o t h stud)' arms s h o w e d i m p r o v e m e n t , their m e a n global a n x i e t y scores w e r e still elevated c o m p a r e d with n o r m a l levels. N o r m a t i v e data for the GSI i n d i c a t e m e a n scores of 52 for w o m e n a n d 55 for men. 29 At the c o m p l e t i o n of the study, the m e a n GSI for the d e m o n stration arm p a t i e n t s was 59.90 a n d that for the c o n t r o l arm patients was 60.89. N o r m a t i v e data for the GAS a n d HASS w e r e d e r i v e d from the w a i t i n g r o o m s c r e e n of o u r n o t - a n x i o u s p a t i e n t p o p u l a t i o n . At five m o n t h s , the demo n s t r a t i o n arm p a t i e n t s had a m e a n GAS of 57.36 and the c o n t r o l arm p a t i e n t s had a m e a n GAS of 57.72, compared with a m e a n GAS of 47.9 for the n o t - a n x i o u s pa-

tients. The HASS was also still elevated in b o t h study arms at the e n d of the study. T h e d e m o n s t r a t i o n arm patients had a m e a n HASS of 64.72 and the c o n t r o l arm patients scored 68.23, c o m p a r e d w i t h a m e a n HASS of 54.2 for the n o t - a n x i o u s patients. To test w h e t h e r o u r inability to d e t e c t differences in o u t c o m e s b e t w e e n the t w o arms was d u e to m e a n anxiety levels that lay b e l o w s o m e critical threshold, w e r e p e a t e d our analysis u s i n g a baseline cutoff score of 70, whicfi r e p r e s e n t s an a n x i e t y level in the u p p e r 2% of a n o n - p a t i e n t population. A l t h o u g h raising the c u t o f f p o i n t d i m i n i s h e d the size of the study g r o u p by 67%, the abbreviated study g r o u p still c o n t a i n e d 191 patients. Nevertheless, an identical analysis w i t h the h i g h e r cutoff p o i n t yielded results similar to those d e s c r i b e d above, with n o difference in p a t i e n t o u t c o m e s b e t w e e n the two arms. A n o t h e r o u t c o m e m e a s u r e was the p a t i e n t ' s serfreport of global i m p r o v e m e n t in a n x i e t y level a n d func-

TABLE 3 Demographics Characteristics of the Four Patient Subgroups Subgroup I

Subgroup II

Anxiety Symptoms Only (n = 136)

Anxiety Disorders Only (n 50)

Subgroup III Mixed Anxiety and DepressionSymptoms Only (n = 140)

Subgroup IV Mixed Anxiety and DepressionDisorders (n = 247)

p-value

Gender Male Female

41.2% (56) 58.8% (80)

38.0% (19) 62.0% (31)

55.0% (77) 45.0% (63)

34.4% (85) 65.6% (162)

<0.01

Age

44.2 years (11.2 years)

40.8 years (11.0 years)

44.9 years (11.5 years)

40.1 years (9.8 years)

<0.01

Race White Nonwhite

77.2% (I 05) 22.8% (31)

88.0% (44) 12.0% (6)

85.0% (I 19) 15.0% (21)

78. 1% (I 93) 21.9% (54)

0.14

Education High school diploma or less Some college Collegedegree

28.7% (39) 37.5% (51) 33.8% (46)

46.0% (23) 28.0%(14) 26.0% (13)

27.9% (39) 36.4% (51) 35.7%0 (50)

34.6% (85) 39.8% (98) 25.6% (63)

0.11

Income <$20,000 $20,000- $49,999 >$49,999

22.1% (30) 51.5% (70) 26.5% (36)

22.0% (11) 56.0% (28) 22.0% (11)

19.3% (27) 59.3% (83) 21.4% (30)

22.1% (54) 57.4% (140) 20.5% (50)

0.85

Marital status Married or with partner Single

77.9% (106) 22.1% (30)

84.0% (42) 16.0% (8)

82.0% (114) 18.0% (25)

77.3% (191) 22.7% (56)

0.57

Physician specialty Family practice Internal medicine

42.6% (58) 57.4% (78)

54.0% (27) 46.0% (23)

43.6% (61) 56.4% (79)

43.3% (107) 56.7% (140)

0.54

Comorbid physical conditionImean (SD)

1.2% (1,0)

1.1% (1.3)

1.4% (1.4)

1.2 (1.2)

0.27

Recognitiontreatment (6-month review) Yes No

26.5% (36) 73.5% (100)

28.0% (14) 72.0% (36)

27.1%0 (38) 72.9% (102)

34.0%o (84) 66.0% (163)

0.34

3.2% (3,6)

3.4% (4.8)

3.2% (4.7)

mean (SD)

Office visits-- mean (SD)

2.9 (3,0)

0.67

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611

TABLE 4 Baseline and Change in Anxiety Scores for the Four Patient Subgroups Baseline* Subgroup

I

Subgroup II

Anxiety Symptoms Only (n = 136) Mean (SE) Global Severity Index*§¶

Changer

Anxiety Disorders (n = 50) Mean (SE)

Subgroup I11 Mixed Anxiety and Depression Symptoms (n = 140) Mean (SE)

Subgroup IV Mixed Anxiety and Depression Disorders (n = 247) Mean (SE)

Subgroup I

Subgroup II

Anxiety Symptoms Only (n = 136) Mean (SE)

Anxiety Disorders (n = 50) Mean (SE)

Subgroup III Mixed Anxiety and Depression Symptoms (n 140) Mean (SE)

57.7 (0.4)

59.6 (0.7)

65.3 (0,4)

Globa] Anxiety Score§¶

56.2 (0.4)

57.2 (0.7)

Highest Anxiety Subscale Score§¶ll

65.2 (0.4)

65.8 (0.7)

Subgroup IV Mixed Anxiety and Depression Disorders (n = 247) Mean (SE)

68,0 (0.3)

4.8 (0.8)

2.3 (l .2)

5,3 (0.7)

2.6 (0.6)

60.7 (0.4)

63.3 (0.3)

3.2 (0.6)

t.6 (0.8)

4.2 (0.5)

2.1 (0.4)

68.0 (0,4)

71.0 (0.3)

4.5 (0.6)

2.3 (0.9)

4.6 (0.6)

2.3 (0.5)

*Adjusted for gender, age, education, number of comorbid conditions, and physician practice. 1Adjusted for gender, age, education, number of comorbid conditions, physician practice, treatment, number of office visits, and baseline score. it-test, p < 0.05: subgroup I vs subgroup II (baseline). §t-test, p < 0,05: subgroup III vs subgroup IV (baseline). ¶t-test, p < 0.05: subgroup III vs subgroup IV (change). lit-test, p < 0.05: subgroup I vs subgroup II (change).

tional status. Despite similar patient outcomes for the two study arms, the demonstration arm patients selfreported greater improvements in anxiety symptoms (46.3% vs 37.0%, p = 0.02) and functional status (45.8% vs 37.2%, p = 0.05). Nearly three times as many patients in the demonstration arm reported that their physicians spent more time after the intervention talking with them about their feelings (13.3% vs 4.8%, p = 0.02) (data not shown). Although the total number of patients w h o actually received treatment was low, a higher percentage of the demonstration arm patients reported receiving treatmcnt (6.7% vs 2.7% ). Chances were greater in the control arm that treatment had been initiated by the patient rather than the physician. This pattern reversed in the demonstration arm, where physicians were more likely to have suggested treatment for the patient (66.7% physician initiated, 29.2% patient initiated, 4.1% uncertain). Based on c h a r t n o t a t i o n s , c o m b i n e d r e c o g n i tion/treatment rates were significantly higher in the demonstration arm (35.6% vs 20.8%, p < 0.01). Although the physicians in the two arms prescribed psychotropics with equal frequencies (12.6% vs 12.5% ), a higher percentage of patients in the demonstration arm were referred to the mental health sector (9.5% vs 3.2%, p < 0.001 )._,8 To determine whether there was a relationship between treatment and improvement, we examined whether patients who had an improvement in global anxiety were more likely to have received treatment. Among the patients w h o improved by at least 20% on the GSI or the GAS, no association between improvement and treatment could be shown.

Four Subgroups Show Differing Rates of Improvement While the changes in patient outcomes were similar for the demonstration and the control arms, another pattern emerged from the data. The majority of the patients ( 7 0 % ) also had accompanying depression symptoms or disorders (using the SCL-90-R to identify symptoms and the DIS to determine disorders). These patients reported worse levels of functioning and well-being than did the patients w h o had anxiety alone. '7 Changes in patient outcomes reflected a natural subdivision of the entire study group into four subgroups on the basis of comorbid symptoms and disorders: Subgroup I patients had symptoms of anxiety only ( n = 136); subgroup II patients had anxiety symptoms and disorders ( n = 50); subgroup III patients had anxicty and depression symptoms ( n = 140), and subgroup IV patients had anxiety and depression symptoms and disorders ( n = 247). Overall, the demographic distributions of the four subgroups were similar, with a few interesting differences (Table 3). Both subgroups with symptoms and disorders (subgroups II and IV) contained more women, had a lower mean age, and had a higher percentage of patients with only a high school education than did either of the symptoms-only subgroups (I and III). The anxiety scores of the four subgroups at baseline reflected the progressively increasing psychological severity of the subgroups, as shown in Table 4. For the GAS, the mean scores progressively increased from 56.2 in subgroup I to 63.3 in subgroup IV. The changes in GAS, GSI, and HASS scorcs at the second follow-up sur-

612

Mathias eta/., ANXIETYPATIENTOUTCOMES

TABLE 5 Baseline and Change in Functional Status Scores for the Four Patient Subgroups Baseline* Subgroup

Short-Form 36 Subscale

Anxiety Symptoms Only (n = 136) Mean (SE)

Subgroup III Mixed Anxiety and Anxiety Depression D i s o r d e r s Symptoms (n = 50) (n = 140) Mean(SE) Mean(SE)

Subgroup IV Mixed Anxiety and Depression Disorders (n = 247) Mean (SE)

Subgroup 1

Subgroup II

Anxiety Symptoms Only (n = 136) Mean (SE)

Anxiety Disorders (n = 50) Mean (SE)

Physical functioning

80.9 (1.7)

79.7 (2.8)

79.0 (1.7)

75.4 (1.3)

0.2 (1.4)

1.0 (2.2)

1.0 (1.4)

0.7 (1.0)

Social functioning§¶

80.6 (1.7)

83.0 (2.8)

69.9 (1.7)

61.6 (1.3)

10.2 (1.8)

2.0 (2.8)

4.8 (1.7)

1.4 (1.4)

Role--physical¶

66.8 (3.2)

71.4 (5.3)

63.0 (3.2)

55.4 (2.4)

12.0 (2.9)

0.4 (4.7)

2.7 (2.8)

1.4 (2.2)

Role emotional§ll

83.5 (3.0)

79.0 (5.0)

59.3 (3.0)

47.2 (2.3)

15.7 (3.3)

4.6 (5.1)

7.9 (3.1)

-2.4 (2.5)

Mentalt§ll

76.8 (1.2)

71.6 (2.0)

61.8 (1.2)

55.0 (1.0)

5.8 (1.5)

3.7 (2.2)

4.0 (1.3)

- 1.2 (1.1)

Energy§

53.3 (1.6)

52.4 (2.6)

44.9 (1.5)

40.8 (1.2)

7.2 (1.6)

5.6 (2.5)

5.7 (1.5)

3.1 (1.2)

Paint

62.4 (1.8)

70.7 (3.0)

63.5 (1.8)

60.2 (1.4)

5.7 (1.7)

3.7 (2.7)

5.4 (1.6)

3.6 (1.2)

General health perceptions

65.7 (1.5)

66.3 (2.5)

60.7 (1.5)

57.3 (1.2)

2.0 (1.2)

- 1.8 (2.0)

2.2 (1.2)

1.5 (0.9)

Comparative health

52.7 (1.7)

51.7 (2.8)

46.9 (1.7)

47.7 (1.3)

4.0 (1.8)

4.6 (2.8)

5.8 (1.7)

4.9 (1.3)

1

Subgroup I1

Changer Subgroup III Mixed Anxiety and Depression Symptoms (n = 140) Mean (SE)

Subgroup IV Mixed Anxiety and Depression Disorders (n = 247) Mean (SE)

*Adjusted for gender, age. education, number of comorbid conditions, and physician practice. tAdjusted for gender, age, education, number of comorbid conditions, physician practice, treatment, number of office visits, and baseline score. tt-test, p < 0.05: subgroup I vs subgroup II (baseline). §t-test. p < 0.05: subgroup III vs subgroup IV baseline). ¶t-test, p < 0.05: subgroup I vs subgroup II (change). lit-test, p < 0.05: subgroup III vs subgroup IV (change).

vey compared with baseline scores still coincided with the increasing levels of psychological distress across the four subgroups. Only in one case was the final score equivalent to normal levels: the GSI subgroup I was 52.9 (compared with normative scores of 52 and 55 for women and men). While improvements of global sources was evident across all four subgroups, the subgroups fell into two distinct classes. The greatest change was seen in the two symptoms-only subgroups, I and III, which showed decreases of 4.8 and 5.3 points, respectively, on the GSI; 3.2 and 4.2 points, respectively, on the GAS; and 4.5 and 4.6 points, respectively, on the HASS. The two symptoms and disorders subgroups, II and IV, showed less dramatic improvements in all three global scores. Baseline scores on the SF-36 concepts reflected a progressive decline in functioning and well-being across the four subgroups (Table 5). Most of the subgroups showed improved outcomes (change scores), with subgroup I showing the greatest improvement. Again, the subgroups fell into two classes, with the two symptomsonly subgroups (I and Ill) showing the most substantial improvement. The patients' self-reports of global improvement in their anxiety symptoms were fairly consistent across the

four subgroups (data not shown), but subgroup II reported somewhat less improvement in anxiety symptoms and functional status than did the other subgroups. Substantially more patients in subgroups II and IV reported that their physicians spent more time than they had before talking with them. DISCUSSION

The primary aim of this study was to determine the combined impact of a screener and a physician intervention on outcomes of primary care patients with unrecognized and untreated anxiety. Contrary to our expectations, the patients in both study arms showed reduced levels of anxiety and increased functional status at the e n d of five m o n t h s . A l t h o u g h the r e c o g n i tion/treatment rates noted in the medical records were higher for the demonstration arm (35.6% vs 20.8%, p < 0.01 ), recognition was not sufficient to differentially affect outcomes. Instead, the extent of improvement coincided with the initial level of psychological distress, based on the presence of c o m o r b i d symptoms and disorders. Several factors may have contributed to the unexpected improvcment in both study arms. Our study de-

JOURNALOF GENERALINTERNALMEDICINE, Volume 9 (November), 1994

sign, like that of Magruder-Habib et al., had stringent eligibility criteria and frequent patient follow-up surveys.21, z2 T h e Magruder-Habib depression study -alsofound that by the end of the one-year study all subgroups showed improvement, including the untreated control group. In our study, stringent selection criteria may have resulted in a study population that had milder levels of anxiety. since patients with higher anxiety levels were more likely to have been previously recognized.-'-" Yet, even when our screening cutoff point was increased to 70, an e x t r e m e l y high level, both study arms still improved comparably. Furthermore, the frequency and thoroughness of our patient surveys could have constituted a patient intervention, making the patients aware of their conditions regardless of their physicians' roles. Finally, our high study compliance rate, owing to the rapport established by our interviewers, may have inadvertently had a therapeutic effect on the patients. Improvement in the control arm may also have been the result of spontaneous remission, a p h e n o m e n o n that has b e e n d e s c r i b e d by n u m e r o u s r e s e a r c h ers.2, l(). t l. ~8,30-33 The majority of our study participants were probably identified at an early stage of psychological distress, when symptoms wcre mild and more likely to spontaneously remit. Indeed, when we divided the entire study group into four subgroups on the basis of comorbid symptoms and disorders, improvement coincided with the level of psychological severity. The most dramatic progress was seen in the two symptomsonly subgroups (I and III), which appear to have had milder psychological distress. The propensity for spontaneous remission in patients with milder distress is illustrated by Johnstone and Goldberg. TM Using both the General Health Questionnaire and a nonstandardized clinician interview to identify primary care patients with minor psychiatric disorders, they randomly assigned patients to treatment or control (untreated) arms and subdivided each arm into patients with mild and severe disorders. The patients who had milder conditions in both the treated and untreated groups had improved similarly by the end of one year such that the improvements were indistinguishable due to "natural processes of recovery." However, in the initially more severe group there were still demonstrable differences between the treated and untreated patients. Other studies also confirm that a better o u t c o m e is associated with lower initial levels of distress. ~8,.~o.~4-~7 The results of our study have several implications for managing anxiety in the primary care setting. The only o u t c o m e measure that distinguished the two study arms was the patients' reports of global improvement. The demonstration arm patients not only reported a greater improvement in anxiety symptoms and functional status, they were also more satisfied with their health care and found that their physicians were willing to spend more time talking with them. Treatment of the demonstration arm patients was also more likely to be

613

initiated by the physicians. Yet, the impact on patients of their physicians' enhanced recognition was not detected using the psychometric instruments. It is tempting to suggest that there may be a discrete subpopulation of anxious primary care patients, those with comorbid symptoms and disorders (subgroups II and IV), w h o might benefit from increased recognition and treatment. This is supported by the fact that anxiety levels of the patients in subgroups II and IV were still quite elevated at the second follow-up, despite some improvement. Nevertheless, w h e n subgroups II and IV were subdivided into demonstration and control patients, the results were consistent with our overall findings: the demonstration and control patients within each subgroup improved similarly. We conclude that even in an identified subpopulation of anxious primary care patients, enhanced recognition does not necessarily affect outcomes. The question remains, what can be done to benefit primary care patients w h o have anxiety? While many psychological conditions found among primary care patients are episodic, anxiety disorders may be more cyclical, with episodic symptoms over a more prolonged period. 3° This may render anxiety conditions particularly intransigent to recognition. Still other research suggests that the psychiatric nosology may be inappropriate for the primary care setting.~- ~' 2o, 23.3o. 38 This is particularly problematic because the primary care physician continues to serve as "gatekeeper" for patients in psychological distress, treating the majority of patients themselves and selecting others for referral to the mental health sector. 6-'~,z¢' Although our results indicate that increased recognition of anxiety was not sufficient to affect outcomes, it must be kept in mind that our overall recognition rates were relatively low, maximal recognition being only 35.6%. We therefore stress the ultimate value to patients of increasing both recognition and treatment. The double screener that wc used, which relies on psychiatric nosology, may not be appropriate or practical for the primary care setting. What is needed is a brief screen or profile that can alert physicians to patients at risk for anxiety and, ideally, identify subpopulations w h o s e symptoms are most likely to spontaneously remit, or who would benefit from use of psychotropic agents or referral. Among the pragmatic screeners being tested in the clinical setting, the recent validation of a three-item screen for depression suggests the feasibility of similar brief surveys for anxiety and mixed anxiety and depression.39-4 l We have identified a subpopulation with comorbid symptoms and disorders, w h o could presumably benefit from more treatment. Yet, even with optimal recognition rates, quality treatment is not ensured. ~2 In our study there were three components to recognition: chart notations, referral for counseling, and use of psychotropics. Most increased recognition in the demonstra-

614

Mathias et aL, ANXIETYPATIENTOUTCOMES

tion arm was due to increased chart notations. While overall treatment rates (referral and use of psychotropics) for b o t h arms w e r e low, the h i g h e r t r e a t m e n t rate in t h e d e m o n s t r a t i o n a r m w a s d u e t o t h e e n h a n c e d n u m b e r of referrals. F u r t h e r m o r e ,

o u r r e s u l t s d o n o t un-

equivocally indicate the coincidence of treatment and improved outcomes. On the contrary, even among the p a t i e n t s w h o s e o u t c o m e s i m p r o v e d b y at l e a s t 2 0 % , w e could not demonstrate an association between improvem e n t a n d t r e a t m e n t . It a p p e a r s t h a t s o m e c r u c i a l i n g r e dients are missing that i m p e d e p r o g r e s s f r o m recognition to t r e a t m e n t and i m p r o v e m e n t . O n e of t h e s e m i g h t be the patient's own resistance to obtaining treatment after a r e f e r r a l h a s b e e n m a d e . A n o t h e r m a y b e t h e n e e d for g r e a t e r a w a r e n e s s o n t h e p a r t o f p r i m a r y c a r e p h y sicians of the i m p o r t a n c e

of recognizing and treating

anxiety patients. Although the primary care physicians in o u r s t u d y t r e a t e d m o r e p a t i e n t s i n t h e d e m o n s t r a t i o n arm, t h e q u a l i t y o f t h i s t r e a t m e n t m a y n o t h a v e b e e n s u f f i c i e n t t o a f f e c t c h a n g e . It r e m a i n s t o b e s e e n w h e t h e r i m p r o v e m e n t a m o n g t h e d e m o n s t r a t i o n a r m p a t i e n t s will u l t i m a t e l y last l o n g e r , o w i n g t o t h e p h y s i c i a n s ' k n o w l edge of the patients' c o n d i t i o n s and abilities to stabilize f u t u r e c y c l e s o f a n x i e t y t h a t m a y arise. This study u n d e r s c o r e s

t h e n e e d f o r f u r t h e r re-

s e a r c h i n t o n o v e l a p p r o a c h e s f o r m a n a g i n g a n x i e t y in primary care based on identification of the factors that generate improved outcomes. While physician educational i n t e r v e n t i o n s h a v e n o t b e e n s h o w n t o e f f e c t i v e l y improve patient outcomes, continuing medical education may be a useful vehicle for increasing physicians' •

•

awareness about managing anxlcty.

2(>

4~

•

' - Integratmg mental

health care into t h e p r i m a r y care setting has also b e e n p r o p o s e d as a p a r a d i g m t h a t w o u l d b e n e f i t b o t h t h c p h y s i c i a n a n d t h e p a t i e n t . 3. 1.~,4, A l t h o u g h o u r s t u d y w a s n o t d e s i g n e d t o e x a m i n e w h e t h e r s p e c i f i c t r e a t m e n t app r o a c h e s w o u l d p r o d u c e b e t t e r o u t c o m e s , it h a s s e t t h e s t a g e f o r f u t u r e s t u d i e s t o i n v e s t i g a t e t h i s q u e s t i o n further.

The authors acknowledge the valuable suggestions and contributions of Fern Alexander, Anita Stewart, and Ruth Calucin in preparing the manuscript; and Suzanne l,essard for secretarial support.

REFERENCES 1. Ormel J, Koeter MWJ, van den Brink W, van de Willige G. Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry. 1991;48:700-6. 2. Kessler 1.G, Cleary PD, Burke JD Jr. Psychiatric disorders in primaD, care: results of a follow-up study. Arch Gen Psychiatry. 1985;42:583-7. 3. Klerman GL, Budman S, Berwick, D, et al. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care. 1987;25:1078-88. 4. Zung WWK, Magill M, Moore JT, George DT. Recognition and treatment of depression in a family medicine practice. J Clin Psychiatry. 1983;44:3-6. 5. DelVecchio Good M-J, Good BJ, Clcary PD. Do patient attitudes influence physician recognition of psychosocial problems in primary care? J Faro Pract. 1987;25:53-9.

6. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system. Arch Gen Psychiatry. 1978;35:685-93. 7. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Arch Gen Psychiatry. 1993;50:85-94. 8. Kamerow D. Alcohol abuse, other drug abuse, and mental disorders in medical practice: prevalence, costs, recognition, and treatment. JAMA. 1986;255:2054-7. 9. Shapiro S, Skinner EA, VonKorff M, et al. Utilization of health and mental health services: three catchment area sites. Arch Gen Psychiatry. 1984;41:971-8. 10. Goldberg D. A classification of psychological distress for use in primary care settings. Soc Sci Med. 1992;35:189-93. 11. Katon W, VonKorff M, l.in E, et al. Distressed high utilizers of medical care. (;en Hosp Psycbiatry. 1990;12:355-62. 12. Hankin JR, Steinwachs DM, Regier DA, Bnrns BJ, Goldberg 1D, Hoeper EW. Use of general medical care services by persons with mental disorders. Arch Gen Psychiatry. 1982;39:225-31. 13. Eisenberg L. Treating depression and anxiety in primary care. N Engl J Med. 1992;326:1080-4. 14. Andersen SM, Harthorn BH. The recognition, diagnosis and treatment of mental disorders by primary care physicians. Med Care. 1989;27:869-86. 15. VonKorff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic. Arch Gen Psychiatry. 1987;44:152-6. 16. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:111)0-6. 17. Borus JF, Howes MJ, Dcvins NP, Rosenberg R, Livingston WW. Primary health care providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatr3". 1988;10:31721. 18. Johnstone A, Goldberg D. Psychiatric screening in general practice. Lancet. 1976;1:605-8. 19. MyersJK, Weissman MM, Tischler GI,, et al. Six-month prevalence of psychiatric disorders in three communities: 1980 to 1982. Arch Gen Psychiatry. 1984;41:959-67. 20. Hoeper EW, Nycz (;R, Kessler LG, Burke JD Jr., Pierce WD. The usefulness of screening for mental illness. Lancet. 1984;1:33-5. 21. Magruder-Habib K, Zung ~XrWK, Feussner JR. Improving physicians' recognition and treatment of depression in general medical care. Med Care. 1990;23:239-50. 22. Magruder-Habib K, Zung WAVK,Feussner JR, Ailing WC, Saunders WB, Stevens HA. Management of general medical patients with symptoms of depression. Gen Hosp Psychiatry. 1989;11:201-6. 23. Kessler I.G, Amick BC, Thompson J. Factors influencing the diagnosis of mental disorder among primal3' care patients. Med Care. 1985;23:50-62. 24. Rost K, Burnam MA, Smith GR. Development of screeners for depressive disorders and substance disorder history. Med Care. 1993;31 : 189- 200. 25. VonKorff M Case definitions in primary care. Gen Hosp Psychiatry. 1992;14:293-S. 26. Andersen SM, Hartborn BH. Changing the psychiatric knowledge of primary care physicians. Gen Hosp Psychiatry. 1990; 12:17790. 27. Fffer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP, Buesching DP. Untreated anxiety among adult primary care patients in a health maintenance organization. Arch Gen Psychiatry. 1994;S 1: 740- SO. 28. Mazonson P, Mathias S, Fifer SK, Patrick DI,, Buescbing DP, Malck P. The impact of outcomes information relating to anxiety on primary care physicians' practice patterns: report of an ongoing randomized trial [abstract ]. Presented at the Sixth Annual National Institute of Mental Health International Research Conference on Primary" Care Mental Health Research: Concepts, Methods, and Obstacles. October 18-20, 1992, Tysons Corner. Virginia. 29. Derogatis LR. SCI:90-R Administration, Scoring and Procedurcs Manual-ll. Towson, MD: Clinical Psychometric Research, 1983. 30. Preskorn SH, Fast GA. Beyond signs and symptoms. The case against a mixed anxiety and depression category. J Clin Psychiatry. 1993;54(suppl 1 ):24-32. 31. Howard Kl, Kopta SM, Krause MS, Orlinsky DE. The dose-effect relationship in psychotherapy. Am Psychol. 1986;41 : 159-64. 32. Katon W, Roy-Byrnc PP. Mixed anxiety and depression. J Abnorm Psychol. 1991 ; 100:337- 45.

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33. Campbell TL. An opposing view. J Fam Pract. 1987;25:184-7. 34. Zung WWK, Magruder-Habib K, Velez R, Ailing W. The comorbidity of anxiety and depression in general medical patients: a longitudinal study. J Clin Psychiatry. 1990;51(suppl 6):77-80. 35. Catalan J, Gath DH, Bond A, Martin P. Effects of non-prescribing of anxiolytics in general practice. II. Factors associated with outcome. Br J Psychiatry. 1984; 144:603-- 10. 36. Wells KB, Burnam MA, Rogers W, Hays R, Camp P. The course of depression in adult outpatients, results from the Medical Outcomes Study. Arch Gen Psychiatry. 1992;49:788-94. 37. Ormel J, VonKorff M, van den Brink W, Katon W, Brilman E, Oldehinkel T. Depression, anxiety and social disability show synchrony of change in primary care patients. Am J Public Health. 1993;83:385-90. 38. Gerber PD, Barrett J, Barrett J, Manheimer E, Whiting R, Smith R. Recognition of depression by internists in primary care: a comparison of internist and "gold standard" psychiatric assessments. J Gen Intern Med. 1989;4:7-13. 39. Blacklow R, Broadhead WE, Weissman M, et al. Symptom Driven Diagnostic System-Primary Care (SDDS-PC): a report of work in progress [abstract]. Presented at the Sixth Annual National Institute of Mental Health International Research Conference on Primary Care, Mental Health Research: Concepts, Methods and Obstacles. October 18-20, 1992, Tysons Corner, Virginia. 41). Williams JBW, Spitzer RL Prime-MD: a new system for the evaluation of mental disorders in primary care [abstract]. Presented at the Sixth Annual National Institute tff Mental Health International Research Conference on Primary Care, Mental Health Research: Concepts, Methods and Obstacles. October 18-20, 1992, Tysons Corner, Virginia. 41. Rost K, Burnam MA, Smith GR. Development of screeners for depressive disorders and substance disorder history. Med Care. 1993;31 : 189- 200. 42. Catalan J, Gath DH, Anastasiades P, Bond SAK, Day A, Hall L Evaluation of a brief psychological treatment for emotional disorders in primary care. Psychol Med. 1991 ;21 :1013- 8. 43. Katon W, VonKorff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67-76. 44. Coleman JV, Patrick DL. Integrating mental health services into primary medical care. Med Care. 1976;14:654-61.

APPENDIX A

Summary

of Survey Instrumentation

QIJAI.IF~NGM "I'EASIJRE SCL-90-R. Measures nine dimensions: four anxiety subscales ( 1 ) anxiety; 2 ) p h o b i c anxiety; 3) somatization; and 4) obs e s s i v e - c o m p u l s i v e ) ; depression; i n t e r p e r s o n a l sensitivity; hostility; paranoid ideation; and psychoticism; and it includes seven additional items.

615

OI/TCOMEMEA$'I/RE3" 1. MOS S h o r t - F o r m 36 (SF-36, also called RAND 3 6 - I t e m H e a l t h S u r v e y ) . C o m p o s e d o f nine domains m e a s u r i n g functioning and well-being: 1 ) physical functioning; 2) social functioning; 3 ) r o l e - p h y s i c a l ; 4 ) r o l e - e m o t i o n a l ; 5) mental health; 6 ) energy; 7 ) pain; 8 ) general health perceptions; and 9 ) c o m p a r a t i v e health. 2. G l o b a l A n x i e t y S c o r e (GAS). An indicator of overall anxiety s y m p t o m level. D e v e l o p e d for this study as a summary s c o r e measuring the m e a n s of the four anxiety dimensions on the SCL-90-R. 3. G l o b a l S e v e r i t y I n d e x (GSI). An indicator o f the number of s y m p t o m s and intensity of p e r c e i v e d distress. Developed by SCL-90-R authors based o n r e s p o n s e s to all items of the SCL-90-R. H i g h e s t A n x i e t y S u b s c a l e S c o r e (HASS). The highest subscale s c o r e for the four anxiety d i m e n s i o n s of the SCL-90-R m e a s u r e d at baseline. C o - m o r b i d i t y C h e c k l i s t . Checklist o f 11 c o m o r b i d physical c o n d i t i o n s for patient self-report, including: arthritis; h y p e r t e n s i o n ; heart disease; stroke; diabetes; lung disease; cancer; kidney disease; b l o o d disease; s t o m a c h disease; and urinary/gynecologic disease. Developed from the conditions m o s t frequently r e p o r t e d by r e s p o n d e n t s in the pretest p h a s e o f this study. 6. Q-DIS-III-R, C o m p u t e r i z e d evaluation given for the following anxiety disorders: p o s t t r a u m a t i c stress; simple phobia; social phobia; agoraphobia; generalized anxiety; panic; obsession; and compulsion. Also for major depression and for alcohol/substance use. Like the DIS, the Q-DIS-III-R was d e v e l o p e d to make psychiatric diagnoses in a c c o r d a n c e with DSM-III-R criteria. Its diagnostic outc o m e s are identical w i t h results o b t a i n e d for the full DISIII-R, but it can b e a d m i n i s t e r e d m o r e quickly. Recognizing its limitations and its lack of c o n s e n s u s as a standard diagnostic assessment, the Q-DIS-III-R was s e l e c t e d as the most appropriate s t r u c t u r e d diagnostic i n s t r u m e n t available. Administered by trained interviewers. 7. P a t i e n t R e p o r t o f G l o b a l I m p r o v e m e n t . Eighteen items that assess global c h a n g e s in patients' anxiety symptoms, w h e t h e r they r e c e i v e d t r e a t m e n t for anxiety and w h a t the nature of that t r e a t m e n t was, and r e p o r t qualitative changes in c o m m u n i c a t i n g w i t h the physician.