Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population

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Original Research

Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population

J Fam Pract. 2001 January;50(1):41-47

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Results

Prevalence of Psychiatric Diagnoses

Table 1 shows the study sample demographics. Table 2 presents a comparison of the prevalence of current disorders in the Marillac study with those in the PHQ 3000 study. The percentage of Marillac patients with at least 1 current psychiatric diagnosis is almost twice the prevalence of the PHQ study (51% vs 28%). Marillac patients had between 2 and 3 times as many of each of the current threshold diagnoses. The rates of each current subthreshold disorder are mildly higher than the PHQ study except for probable alcohol abuse, which is more than twice as high.

Functional Status, Disability Days, and Health Care Use

Figure 1 displays the adjusted means for the 6 scales of the SF-20 and shows that patients with one or more current threshold psychiatric disorders have significantly (P <.001) lower functional status on all SF-20 scales compared with the other 2 groups, which did not differ except for mental health. The percentage of patients in each of the 3 psychiatric symptom groups were: symptom screen negative, 31%; symptom screen positive/subthreshold diagnosis, 34%; and threshold diagnosis, 35%.

Screen-negative patients reported a mean (SD) of 4.3 (8.5) disability days; screen-positive/subthreshold patients reported 5.6 (12.2) days; and threshold diagnosis patients reported 18.9 (25.6) days. Controlling for physical comorbidity and personal income, patients with threshold psychiatric diagnoses had significantly more disability days than either of the 2 other groups, which did not differ from one another (F[2453]=30.20; P <.001). The 3 groups differed in number of physician visits in the previous 3 months. Controlling for physical comorbidity and personal income, percentages of patients within each diagnostic group with 3 or more physician visits were: screen negative, 15.7%; screen positive/subthreshold, 21.7%; and threshold, 34.5%. Patients in the threshold group were more likely to report 3 or more visits than patients in the other 2 groups (c2=16.27; df=2; P <.001). Differences between the screen-positive/subthreshold and the threshold group were also significant (c2=6.77; P <.009), but differences between screen-negative and screen-positive/subthreshold groups did not reach significance (c2=1.87; P <.17).

Patient Preferences for Medical and Mental Health Service Designs

Table 3 shows patient preferences. After choosing a first option patients were asked to make a second choice, which meant changing the location of service to maintain interprovider communication or eliminating communication to maintain service at a preferred location. Of the 284 patients who marked 2 votes, 246 (87%) chose the 2 options for providers to communicate with one another. The proportion of votes for the 2 communication options within each of the symptom groups was: threshold, 91%, subthreshold/screen positive, 86%, and screen negative, 90%.

Discussion

Using an instrument recently validated across 3000 primary care patients (the PRIME-MD PHQ) we found the proportion of the patients in this clinic with current major mental illnesses to be roughly twice the number in the general population (35% vs 15%). Overall, a larger proportion of patients in the Marillac population report some current psychiatric distress compared with the sample from Spitzer and coworkers³⁰ (51% vs 28%). Because the PHQ does not diagnose dysthymia, non-alcohol–related substance abuse, or other chronic mental illnesses such as bipolar disorder, these findings represent a conservative view of the prevalence of mental illness and addictive disorders in this sample. Also, because primary care providers did not evaluate whether physical symptoms were secondary to a medical illness, somatoform disorders were not diagnosed.

Consistent with other studies^9,33 patients with threshold disorders report significantly lower functional status compared with patients with subthreshold diagnoses or who are screen positive for psychiatric distress or without any psychiatric symptoms. However, these other studies have found a gradient of functional status inversely proportional to the degree of psychiatric impairment that was absent in the Marillac sample. The mean scores for Marillac symptom screen-negative patients are 7 to 15 points lower than the PHQ 3000 symptom screen-negative patients across all 6 SF-20 scales. These findings are consistent with findings reported by Woolf and colleagues¹⁷ who found mean scores on all the functional status indices for low-income patients to be significantly lower than their overall population means. It is unclear whether these findings are because of more severe mental disorders, a higher prevalence of physical disorders, or other characteristics of low-income populations.

Consistent with other studies,^10,30 patients at Marillac with higher levels of psychiatric symptoms report increasing numbers of disability days and physician visits. Comparing disability days in PHQ 3000 patients in the threshold diagnosis (17), subthreshold (6.6), and screen-positive (4.8) groups shows similar numbers to our sample. However, the number of disability days for the Marillac patients without any psychiatric symptoms is almost twice as high as that in the PHQ 3000 sample (2.4) and consistent with the lower levels of functional status in the Marillac screen-negative group.