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Outcome of Depression and Anxiety in Primary Care: A Three-Wave 31/2-

Year Study of Psychopathology and Disability

Article  in  Archives of General Psychiatry · November 1993

DOI: 10.1001/archpsyc.1993.01820220009001 · Source: PubMed

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Outcome of Depression and Anxiety
in Primary Care
A Three-Wave 31/2-Year Study of Psychopathology and Disability
Johan Ormel, PhD; Tineke Oldehinkel, MA; Els Brilman, MA; Wim vanden Brink, MD, PhD

Background: We evaluated the long-term outcome of
depression and anxiety and associated disability among
primary-care attenders with common psychiatric disor-
ders and symptoms (n=201) using binary and multicat-
egorical, interview-based outcome measures of psychiat-
ric illness and disability.
Methods: A two-stage design was used. In the first
stage, 1994 consecutive attenders of 25 general practi-
tioners were screened on psychiatric illness with the
General Health Questionnaire and by their physicians.
A stratified random sample (n=292) with differing
probabilities was selected for second-stage
view (Present State Examination and Groningen Dis-
ability Schedule). Patients with psychiatric symptoms
(n=201) were reassessed 1 (n=182) and 3 1/2 (n=154)
disability levels had substantially dropped. However,
partial remission, not full recovery, was the rule, and
was associated with residual disability. Depression had
better outcomes than anxiety and mixed anxiety-
depression.
Conclusions: We concluded that a multicategorical,
rather than a binary, outcome measure better reflects
patient outcomes, since it highlights partial remission,
mild symptoms, and residual disability, and as such,
stresses the need to supplement short-term treatment.
A multicategorical caseness model may be advanta-
inter- geous for research and clinical practice. We suggest a
dynamic-equilibrium model to account for residual
symptoms and disability. This study is a follow-up to
two earlier reports on the recognition, treatment, and

years later. 1-year course of common psychiatric illnesses in gen-

eral practice.
Results: At 1- and 31/2-year follow-ups, many cases no
longermet the criteria of their baseline diagnosis and (Arch Gen Psychiatry. 1993;50:759-766)

NXIETY, DEPRESSION, and Because of méthodologie problems, the

From the Departments of
Psychiatry (Drs Ormel and
vanden Brink and Messrs
Oldehinkel and Brilman) and
Health Sciences (Dr Ormel),
University of Groningen
(the Netherlands).
anxiety-depression co- available evidence on outcome of com¬
morbidity are common mon psychiatric disorders in primary
in primary-care set¬ care1·22'30 is difficult to interpret." Studies
7
tings.1 Epidemiologie in primary-care settings suggest that one
community, primary-care, and
studies in fifth to one half of the patients with de¬
outpatient settings have also docu¬ pression are depressed at follow-up, often
mented moderate, but clinically signifi¬ less than a year after the baseline (Tl) as¬
cant, cross-sectional821 and longitudi¬ sessment. The outcome of anxiety seems
nal1014 associations of psychiatric symptom worse, with data on the natural history of
severity with disability (impaired physical mixed anxiety and depression almost non¬
and role function, as well as increased num¬ existent.
ber of disability days). This combination The outcome of depression and anxi-
of psychiatric disorder and associated
disability has considerable effect on per¬
sonal well-being, social relationships, and
public health costs.8-9 The extent of this pub¬
lic health problem is highly dependent on
the long-term course and outcome of these
disorders.
 SUBJECTS AND METHODS
The study was carried out in the province of Groningen,
the Netherlands, during the late 1980s. The methods have
been fully described,340 but are summarized herein.
SUBJECTS
We used a two-stage design. At stage 1, 2237 patients of 25
GPs between ages 16 and 65 years were screened with the
30-item General Health Questionnaire (GHQ43·44) and rated
by their GP on current mental health status (43% and 28%
were positive with the GHQ and by their GPs, respectively:
87% of the men and 91% of women responded; n=1994).
The GPs represented the total population of GPs in the city
of Groningen and surrounding towns. General practitio¬
ners also noted if the patient had a mental health problem
in the year preceding the index visit. If this was the case,
the patient was denoted "old" (n=554) and, if not, "new"
(n=1450).
At stage 2, stratified random sample with differing
a
probabilities depending on GP status (GP-positive/GP-
negative), GHQ status (GHQ-positive/GHQ-negative), and
old/new status was selected for the Tl examination. The
main study objective was to determine the effects of rec¬
ognition and diagnosis by the GP on treatment and 1-year
course of new GP-detected and nondetected cases of psy¬
chiatric illness. As such, the following sampling probabili¬
ties were used: all new GP-positive/GHQ-positive (n=160)
and GP-positive/GHQ-negative (n=46) patients; a random
ety among psychiatric inpatients and outpatients has been
examined frequently and perhaps with better
more
methods.32·33 However, referral and help-seeking are in¬
fluenced by diagnosis, symptom severity, and disability,
which may produce bias in subject selection.13-34"37 This
makes it difficult to extrapolate findings to the primary-
care setting.34·38
The study reported herein differs from most out¬
come studies in primary care in a number of aspects. We
used a two-stage sampling procedure to recruit patients
from 1994 consecutive attenders of 25 general practitio¬
ners (GPs). We assessed outcome twice (1 and 3Vi years
after the Tl assessment) in terms of both psychopathol¬
ogy and disability, using interview-based measures and
standardized diagnostic procedures. Finally, we used a
binary as well as a multicategorical outcome approach and
followed up not only definite disorders and cases de¬
tected by the GP, but also subthreshold and nondetected
cases.
In binary outcome measures based on psychiatric
classifications, outcome is expressed the number of
as
baseline cases that do not meet diagnostic criteria for a
sample (n=91) from the 397 new GP-negative/GHQ-positive
patients; a random sample (n=62) from the 847 new GP-negative/
GHQ-negative patients; and a random sample (n=42) from
the 221 old GP-positive/GHQ-positive patients. (In the
earlier article addressing recognition, treatment, and 1-year
course,41 the 46 new GP-positive/GHQ-negative and the 42
old GP-positive/GHQ-positive patients were excluded.) Of
401 patients who were eligible, 105 refused to participate, so
that 296 were interviewed at Tl. Because of missing values,
baseline analyses are based on 292 patients.
Ninety-one normal or control patients had fewer than
three psychiatric symptoms at Tl. They were excluded for
follow-up 1 year (T2) and 3 Vi years (T3) after the index
visit. Of the 201 patients eligible for follow-up, 182 par¬
ticipated at T2, and 154 at T3. Based on log-linear analyses,
we found that refusal of the second-stage interview at Tl
was not associated with gender, age, and GHQ scores. Re¬
sponse at follow-up was not associated with symptom or
disability level at Tl.
MEASURES
At Tl, T2, and T3, symptoms and disability in the previous
4 weeks were measured with two standardized semistruc¬
tured interviews—the nonpsychotic section of the Present
State Examination (PSE)45 and the Groningen Social Dis¬
ability Schedule (SDS).4647 Their interviewer-observer reli¬
ability is very satisfactory.40'46'47 Data from the PSE were used
to construct a total score that takes into account the total
number and the severity of PSE symptoms.
The SDS measures role dysfunction and provides more
definite case at follow-up. The binary approach does
not provide much detail about the extent of improve¬
ment, and may blur reality. Patients may have recov¬
ered fully and become asymptomatic, or only partially,
and still suffer from borderline disorders and/or persis¬
tent symptoms without meeting the diagnostic criteria.
Four outcomes, or "caseness" levels, were distin¬
guished—definite disorder, borderline disorder, non¬
specific psychiatric symptoms, and full recovery, ie,
fewer than three psychiatric symptoms (also denoted as
normals or controls).
We included patients with "ill-defined" borderline
and mixed anxiety-depressive disorders among those who
were followed up, since they are frequently presented in
primary care.1'3·5'9·39 These disorders are not adequately
incorporated into classification systems like the DSM-ÍÍI.
General practitioners treat these patients for psychologi¬
cal distress if it is recognized, but they rarely make a for¬
mal diagnosis.40"42 We wanted to know how significant
these ill-defined disorders are, in terms of associated dis¬
ability and outcome, compared with the "well-defined"
u
or definite disorders.9
 information on the specific nature of social role impairment
than self-report disability measures. Disability is defined as
a restriction or inability to perform activities and/or mani¬
fest behaviors expected in defined social roles. In this ar¬
ticle, we focus on the following four roles of the SDS: self-
care, family, social, and occupational. Scores on each role
range from 0 through 3, with 0 indicating no disability; 1,
mild disability; 2, moderate disability; and 3, severe dis¬
ability. The scores are based on behavioral deviations from
prevailing norms and expectations, typically in the local com¬
munity. For instance, in the occupational role for people in
gainful employment, we focus on daily routine, perfor¬
mance, and contacts with others at work. Mild disability is
defined as some difficulties in adjusting to daily routine,
absence for up to 25% of the time, and performance falling
short of expectations, ie, complaints have been expressed,
superiors may have discussed the reduced performance with
the patient, but no consequences are imminent. Moderate
disability is defined as major difficulties in adjusting to daily
routine, absence for 25% to 75% of the time, and a poor
performance. Dismissal or removal from the job may be im¬
minent. Since analyses showed that the four roles consti¬
tute a one-dimensional hierarchical scale (Loevinger's co¬
efficient, H>.50), so a total SDS score was constructed.
DIAGNOSTIC CLASSIFICATION
The Bedford College study diagnosis was assigned to each
patient using PSE scores and the diagnostic algorithm de¬
veloped by Finlay-Jones et al.48 The Bedford College clas¬
sification includes the following four diagnostic categories:
RESULTS
CROSS-SECTIONAL FINDINGS
Sociodemographic Characteristics
More women were found among cases (PSE total score
higher than 2; 67.7%) than among the normals (PSE total
score lower than 3; 53.8%; P<.05 with Wald's test) and
the general population. However, the gender ratio among
the cases was similar to that among consecutive attenders
of the same ages. No clear association of age and educa¬
tional attainment with caseness was observed (among nor¬
mals, mean age was 37.7 years and proportion with only
primary education, 22.2%; among cases, mean age was
37.5 years and patients with primary education, 19.8%).
Cases did not differ markedly either from consecutive at¬
tenders or from the general population in terms of mean
age and educational attainment. Within the cases, there
were some differences across study diagnoses in the pro¬
portion of women (range, 50.0% to 71.9%), the mean
age (range, 32.5 to 38.6 years), and the level of educa-
(1) depression, (2) borderline depression (BD), (3) anxiety,
and (4) borderline anxiety (BA). In addition, a category of
"nonspecific symptoms" was created for patients who did
not meet the criteria for BD or BA, but had at least three
"nonspecific" symptoms (eg, worrying, tension pains, mus¬
cular tension, tiredness, restlessness, hypochondriasis, irri¬
tability, and poor concentration). Depression and anxiety
were not mutually exclusive, thereby allowing comorbidity
of these disorders, which is indicated herein as mixed anxiety-
depression. More generally, definite disorders, as opposed
to borderline disorders, include anxiety, depression, and mixed
anxiety-depression.
MULTICATEGORICAL OUTCOME
Four caseness levels were used to classify outcome—
definite disorder (anxiety, depression, or mixed anxiety-
depression), borderline disorder (BA, BD, or mixed BA and
BD), nonspecific PSE symptoms (at least three), and symptom-
free patients or normals (fewer than three PSE symptoms).
ANALYSIS
Since weighting not affect the diagnosis-specific find¬
did
ings on unweighted data are presented. For two
outcome,
reasons, the results of the significance tests should be in¬
terpreted cautiously: (1) we do not have a simple random
sample, and (2) the number of patients varies substantially
across diagnostic category. Both conditions limit the use¬
fulness of comparing statistical significance across diagnos¬
tic category.
tional attainment (range, 16.7% to 29.0%). However, we
did not find a clear pattern suggesting, for instance, that
severity or diagnosis was related to demographic charac¬
teristics (table available on request).
Psychopathologic Features and Disability at Tl
Table 1 presents mean PSE and SDS total scores, as well
as the percentage of patients with at least mild (score 1)
impairment in a particular role. Considerable differences
were found in mean symptom levels between the diagnos¬
tic categories (analysis of variance, F=243.4, P<.001). Simi¬
larly, the proportion of patients with disability in specific
roles varied substantially across diagnostic categories (P< .001
using nonparametric Kruskal-Wallis test; self-care was not
significant). Levels generally increased from nonspecific psy¬
chiatric symptoms through borderline disorders to defi¬
nite disorders. Patients with both anxiety and depression
had the highest symptom level. The findings for patients
with definite anxiety, however, are based on only six cases.
Most disability was found in social and occupational role
functioning, although a quarter ofthe patients with depres-
 *
Values are total scores.
^Patients with PSE total scores lower than 3 at baseline, also denoted as "controls.
"

^Nonspecific psychiatric symptoms (PSE total score at baseline of at least 3 but no BC diagnosis).
^Includes patients with comorbidity of anxiety and (borderline) depression or depression and borderline anxiety.

*T2 indicates 1-year outcome; T3, 3'A-year outcome. Values for patients with three or more nonspecific psychiatric
symptoms but no BC diagnosis at follow-up are not shown, therefore proportions do not add up to 100%.
^Present State Examination total score lower than 3.
^Includes patients with anxiety, patients with depression, and patients with both.
¡¡Includes patients with comorbidity of anxiety and (borderline) depression or depression and borderline anxiety.

sion had also at least mild impairment in self-care and fam¬ tients with a definite disorder (Bedford College diagnoses

ily role. Borderline anxiety was associated less with disabil¬
ity than BD and mixed BA and BD were (P<.05 with the
Mann-Whitney 17 test). The same holds true for definite
anxiety relative to definite depression and mixed anxiety-
depression (P<.01 with the Mann-Whitney U test).
OUTCOME
Psychopathologic Outcome
Table 2 provides detailed information about outcome
using the multicategorical outcome measure. On average,
there was substantial improvement, but also considerable
residual psychopathology. Fewer than a third of the pa-
of anxiety, depression, mixed anxiety-depression) had fully
recovered at T2. At T3, up to an additional 15% had fully
recovered. The proportion of patients with definite dis¬
orders who still met the criteria for a definite disorder at
follow-up was similar across the diagnostic categories.
The data suggest differences in outcome between the
diagnostic categories. However, owing to the small num¬
bers, these differences should be considered tentative even
if they are statistically significant. The results suggest
(1) a better outcome of BD compared with BA and mixed
BD and BA (P<.01 and P<.07, respectively, using Wald's
test, for the proportion of patients who fully recovered),
and (2) a less favorable outcome of anxiety and mixed
anxiety-depression compared with depression in terms of
 views. In general, total disability substantially decreased
over time. For all diagnostic categories, the decrease be¬
tween Tl and T3 was statistically significant, except for
anxiety (P<.05 with the Wilcoxon test). In patients with
depression who suffered from substantial disability at Tl,
the long-term improvement was impressive, with re¬
sidual disability mainly in the social role. The improve¬
ment in the family role seems to have largely occurred
after T2. In patients with anxiety, only the occupational
role improved somewhat; the disability in the social role
did not improve, suggesting persistent mild dysfunction
in this role. Aspects of both anxiety and depression were
seen in the mixed anxiety-depression cases—substantial

disability at Tl and considerable improvement as in the

cases with depression, but also mild residual dysfunction
similar to that seen in cases with anxiety.

COMMENT

OUTCOME ACCORDING TO A BINARY VS

MULTICATEGORICAL CASENESS MEASURE

The follow-up psychopathologic data revealed two ap¬

parently contradictory findings. The binary outcome mea¬
sure suggested that more than four fifths of the patients
recovered. The multicategorical outcome measure, how¬
ever, demonstrated considerable residual psychopathol¬
ogy. Substantially fewer than half the patients with a dis¬
order recovered fully. Definite disorders tended to improve
into borderline disorders or nonspecific psychiatric symp¬
toms. Borderline disorders remained the devel¬
same or

oped intononspecific psychiatric symptoms, with the ex¬

ception of BD, which showed a rather favorable long-

term outcome. In sum, a binary outcome measure based
on psychiatric classification systems may suggest too fa¬
vorable an outcome. A multicategorical outcome measure
better reflects patient outcomes, since it highlights partial
remission, mild symptoms, and residual disability.

DOES OUTCOME IN SYMPTOMS DEPEND

ON DIAGNOSIS AND SEVERITY?

*T2 indicates 1-year outcome; T3, 3'/>-year outcome. The major difference between the three diagnostic cat¬
"[Patients with Present State Examination total score at baseline of at
least 3 and no BC diagnosis. egories was the greater proportion with residual psycho¬
$The four cases of definite anxiety with complete disability data at all
waves were excluded.
pathologic disorder (borderline disorder or nonspecific
^Includes patients with comorbidity of anxiety and (borderline) symptoms) among patients with anxiety and mixed anxiety-
depression or depression and borderline anxiety. depression than among patients with depression. With
regard to baseline severity, patients with BD did better
than patients with definite depression. This confirms find¬
residual psychopathology (P<.05, using Wald's test, for ings on depression reported by others.22-23·26"30 No such
patients with at least borderline disorder). association between outcome and baseline severity was
found among patients with anxiety and mixed anxiety-
Disability Outcome depression, which may be due to the small number of
patients with definite anxiety.
Table 3 shows the outcome of disability at T2 and T3 We rediagnosed 21% of the patients with depres¬
among patients who completed all three disability inter- sion at Tl as having depression at T2. In the Epidemio-
logic Catchment Area study, 20% of the subjects who had
major depressive disorder at Tl were diagnosed again at
T2 as having major depression.37-49 This suggests that the
outcome of depression at T2 may be similar among com¬
munity and primary-care cases. The 20% "chronicity" ob¬
served among our depressed patients is less than that typi¬
cally reported in outcome studies among psychiatric
outpatients with depression.32-33·49 These studies have docu¬
mented that at T2, 20% to 35% still meet diagnostic cri¬
teria, and another 25%, on average, relapse. Thus, the
outcome of depression in community and primary-care
samples seems to be somewhat better than that in treated
outpatient samples, due, possibly, to selective referral effects.
WHAT IS THE OUTCOME OF DISABILITY?
Disability was clearly related to diagnosis and psycho¬
pathologic severity. Most dysfunction was found in the
social and occupational roles. In depressed patients with
and without anxiety, the level of disability was similar to
that found among psychiatric outpatients.41' Patients with
BA and nonspecific psychiatric symptoms were less dys¬
functional than patients with depression or mixed anxiety-
depression, with BD taking a position in between. A more
detailed analysis of the cross-sectional relationship of symp¬
toms and disability can be found elsewhere.11 These find¬
ings on disability are consistent with previous observa¬
tions in community cases1517 and GP attenders with
psychiatric symptoms.16
Functional outcome showed patterns similar to psy¬
chopathologic outcome—substantial improvement of func¬
tion but also residual dysfunction, in particular among
patients with mixed anxiety-depression. As documented
elsewhere,14 the improvements in symptoms and in dis¬
ability were largely synchronous, ie, patients with im¬
proved symptoms generally showed corresponding changes
in disability level while patients with unimproved or re¬
sidual symptoms continued to be dysfunctional. Similar
findings have been reported by others.10
Dysfunction in the social role was relatively stable,
even among patients whose symptoms improved. Par¬
ticularly in combination with BA (which rarely im¬
proved), a dysfunctional social role may reflect inad¬
equate social skills and personality traits.
ARE THE RESULTS OF OUR STUDY
GENERALIZABLE?
For some diagnostic categories, the number of patients is
small, which renders our findings tentative. Further¬
more, our study sample may not be fully representative
of the patients with psychiatric illness presenting in primary-
care settings. However, it is unlikely that the sampling
scheme has resulted in marked underestimation of chro¬
nicity. The sampling scheme was nonproportionally strati¬
fied. Patients who presented with a psychiatric disorder
in the previous year and were then recognized as such by
their GP were sampled with a very low probability to in¬
crease the recruitment of incident cases. As documented
elsewhere,31 this has not resulted in a cohort of exclu¬
sively incidental cases. On the contrary, in more than half
the patients enrolled in the follow-up study, the onset of
the disorder was more than a year before the Tl inter¬
view, although 38% of these remote-onset cases experi¬
enced a recent exacerbation.
RECOGNITION, TREATMENT, AND OUTCOME
We did not present data on the relationship of recogni¬
tion and treatment with long-term outcome. We previ¬
ously reported that although detection of psychiatric ill¬
ness by the physician was associated with the provision
of treatment and with a better 1-year course41 and out¬
come,3 treatment itself was unrelated to outcome.3 Lo¬
gistic analysis of the outcome data at T3 showed that a
weak positive effect of recognition could still be observed
after 3Vi years (data available on request). With regard to
treatment, no such association with outcome was found.
This, however, does not imply that treatment is unim¬
portant. Treatment may well influence the course of the
disorder, but since course also influences treatment (the
worse the course, the more treatment),3 an observational
study may end up finding no association. Only experi¬
mental studies can examine the effects of treatment in pri¬
mary care.
A DYNAMIC-EQUILIBRIUM MODEL MIGHT
EXPLAIN RESIDUAL SYMPTOMS AND DISABILITY
A dynamic-equilibrium model50,51 may be helpful in un¬
derstanding the long-term course of psychopathologic dis¬
order and social disability among primary-care attenders,
in particular, the phenomenon of residual symptoms and
disability. This model assumes the following: (1) people
have, in the absence of events, stable intraperson symp¬
tom levels (a characteristic level) reflecting their stable psy¬
chobiological and environmental characteristics; (2) these
characteristic levels may differ considerably between sub¬
jects; (3) for each person, internal and external events (stress)
deflect symptom levels from his or her characteristic level;
(4) adaptive mechanisms (time and treatment) tend to neu¬
tralize the effects of these events and restore a person's
characteristic symptom level; and (5) persons differ in the
amplitude and duration of the exacerbations as a result of
differences in psychobiological and environmental char¬
acteristics. High characteristic symptom levels probably
reflect persistent life stress,5253 personal vulnerabilities such
as ineffective coping strategies, personality abnormalities,
eg, high neuroticism, low self-esteem, and obsessive-
compulsive tendencies,53"57 as well as lack of adequate treat¬
ment.41-58 It is often during such an exacerbation that pa¬
tients visit their GP.
 The significance of this model is that it allows the
discussion on how to address residual psychopathology
and disability. Does it represent lack of adequate short-
term treatment or a person's characteristic level? Further,
knowledge ofthe determinants of high characteristic symp¬
tom levels50·51 may facilitate the discussion on how to modify
these determinants and whether this can be done in the
health-care setting or whether important societal changes
are needed.
ADVANTAGES OF A MULTICATEGORICAL
OUTCOME MODEL
The essential feature of a multicategorical outcome, or case¬
ness measure, is that it stresses the presence of borderline
disorders and nonspecific psychiatric distress, both ill-
defined, but common in general practice and associated
with mild disability.9 In the current DSM-IÍÍ-based re¬
search practice, these common, ill-defined disorders tend
to escape further scrutiny. A multicategorical approach
may also benefit clinical practice and community ser¬
vices. It forces the clinician to consider treatment of re¬
sidual psychopathology, which may imply addressing the
determinants of high characteristic symptom levels, ie, per¬
sistent life stress, biological vulnerability, and inadequate
coping strategies and resources. It may be cost-effective
to supplement the short-term treatment with long-term
programs. Psychosocial treatment, self-help programs, and
maintenance pharmacotherapy59 may be treatment mo¬
dalities appropriate to the health-care setting.
This research was supported by grants 900-556-002 and 900-
556-050 from the Medical Foundation of the Dutch Organi¬
zation for Scientific Research, and grant 28-1209 from the
Prevention Fund (Dr Ormel).
Reprint requests to Department of Psychiatry, Univer¬
sity of Groningen, Oostersingel 59, 9713 EZ Groningen,
the Netherlands (Dr Ormel).
REFERENCES
1. Blacker CVR, Clare AW. Depressive disorder in primary care. Br J Psychiatry.
1987;150:737-751.
2. Shepherd M, Cooper B, Brown AC, Kalton GW. Psychiatric Illness in General
Practice. London, England: Oxford University Press; 1966.
3. Ormel J, vanden Brink W, Koeter MWJ, Giel R, Meer K van der, van de Willige
G, Wilmink FW. Recognition, management and outcome of psychological dis-
orders in primary care: a naturalistic follow-up study. Psychol Med. 1990;20:
909-923.
4. Von Korff M, Shapiro S, Burke JD, Teitlebaum M, Skinner EA, German P, Turner
RW, Klein L, Burns B. Anxiety and depression in a primary care clinic: com-
parison of DIS, GHQ and practitioner assessments. Arch Gen Psychiatry. 1987;
44:152-156.
5. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric
disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100-1119.
6. Goldberg D, Bridges K. Screening for psychiatric illness in general practice: the
general practitioner versus the screening questionnaire. J R Coll Gen Pract
Occas Pap. 1987;37:15-18.
7. Hoeper EW, Nycz GR, Cleary PD, Regier DA, Goldberg ID. Estimated preva-
lence of RDC mental disorder in primary medical care. Int J Ment Health. 1979;
8:6-15.
8. Wells KB, Golding JM, Burnham MA. Psychiatric disorder in a sample of the
general population with and without chronic medical illness. Am J Psychiatry.
1988;145:976-981.
9. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and
days lost from work in a prospective epidemiologic survey. JAMA. 1990;264:
2524-2528.
10. Von Korff M, Ormel J, Katon, W, Lin EHB. Disability and depression among
high utilizers of health care: a longitudinal analysis. Arch Gen Psychiatry. 1992;
49:91-100.
11. Wohlfarth TD, vanden Brink W, Ormel J, Koeter MWJ, Oldehinkel AJ. The re-
lationship between social dysfunctioning and psychopathology among primary
care attenders. Br J Psychiatry. In press.
12. Berkman LF, Berkman CS, Kasl S, Freeman DH, Leo L, Ostfeld AM, Cornoni-
Huntley J, Brody JA. Depressive symptoms in relation to physical health and
functioning in the elderly. Am J Epidemiol. 1986;124:372-388.
13. Turner RJ, Beiser M. Major depression and depressive symptomatology among
the physically disabled: assessing the role of chronic stress. J Nerv Ment Dis.
1990;178:343-350.
14. Ormel J, Von Korff M, vanden Brink W, Katon W, Brilman E, Oldehinkel T.
Depression, anxiety and disability show synchrony of change. Am J Public
Health. 1993;83:385-390.
15. Dohrenwend BS, Dohrenwend BP, Link B, Levav I. Social functioning of psy-
chiatric patients in contrast with community cases in the general populations.
Arch Gen Psychiatry. 1983;40:1174-1182.
16. Casey PR, Tyrer PJ, Platt S. The relationship between social functioning and
psychiatric symptomatology in primary care. Soc Psychiatry. 1985;20:5-9.
17. Hecht H, Zerssen D, Wittchen HU. Anxiety and depression in a community
sample: the influence of comorbidity on social functioning. J Affect Dis. 1990;
18:137-144.
18. Rodin G, Voshart K. Depression in the medically ill: an overview. Am J Psy-
chiatry. 1986;143:696-705.
19. Craig TJ, Van Natta PA. Disability and depressive symptoms in two commu-
nities. Am J Psychiatry. 1983;140:598-601.
20. Blumenthal MD, Dielman, TE. Depressive symptomatology and role function in
a general population. Arch Gen Psychiatry. 1975;32:985-991.
21. Paykel ES, Weissmann MM. Social adjustment and depression. Arch Gen Psy-
chiatry. 1973;28:659-663.
22. Mann AH, Jenkins R, Belsey E. The twelve-month outcome of patients with
neurotic illness in general practice. Psychol Med. 1981;11:535-550.
23. Schulberg HC, McClelland M, Gooding W. Six-month outcomes for medical
patients with major depressive disorders. J Gen Intern Med. 1987;2:312-317.
24. Regier DA, Burke JD, Manderscheid RW, Burns BJ. The chronically mentally ill
in primary care. Psychol Med. 1985;15:265-273.
25. Cooper B, Fry J, Kalton GW. A longitudinal study of psychiatric morbidity in a
general practice population. Br J Prev Soc Med. 1969;23:210-217.
26. Kessler LG. Cleary PD, Burke JD. Psychiatric disorders in primary care: results
of a follow-up study. Arch Gen Psychiatry. 1985;42:583-587.
27. Hankin JR, Locke BZ. The persistence of depressive symptomatology among
prepaid group practice enrollees: an exploratory study. Am J Public Health.
1982;29:2-10.
28. Parker G, Holmes S, Manicavasagar V. Depression in general practice attend-
ers: caseness, natural history and predictors of outcome. J Affect Dis. 1986;
10:27-35.
29. Kukull WA, Koepsell T, Inui TS, Borson S, Okimoto J, Raskmol MA, Gale JL.
Depression and physical illness among general medical clinic patients. J Affect
Dis. 1986;10:153-162.
30. Johnson D, Mellor V. The severity of depression in patients treated in medical
practice. J R Coll Gen Pract Occas Pap. 1977;27:419-422.
31. Brilman El, vanden Brink W, Giel R, Ormel J. Prevalentie en beloop psychische
stoornissen in de huisartspraktijk. Tijdschr Psychiatr. 1992;34:385-399.
32. Bronisch T, Wittchen H-U, Krieg C, Rupp H-U, Von Zerssen D. Depressive neu-
rosis: a long-term prospective follow-up study of former inpatients. Acta Psy-
chiatr Scand. 1985;71:237-248.
33. Keller MB, Klerman GL, Lavori PW, Coryell W, Endicott J, Taylor J. Long-term
outcome in major depression. JAMA. 1984;252:788-792.
34. Giel R, Koeter MWJ, Ormel J. Detection and referral of primary care patients
with mental health problems: the second and third filters in the pathway to
psychiatric care. In: Goldberg D, Tantam D, eds. The Public Health Impact of
 Mental Disorder. Toronto, Ontario: Hogrefe & Huber Publishers; 1990.
35. Mechanic D. Medical Sociology. 2nd ed. New York, NY: Free Press; 1978.
36. Robins LN, Regier DA, eds. Psychiatric Disorders in America: The Epidemio-
logic Catchment Area Study. New York, NY: Free Press; 1991.
37. Sargeant JK, Bruce ML, Florio LP, Weissman MM. Factors associated with
1-year outcome of major depression in the community. Arch Gen Psychiatry.
1990;47:519-526.
38. Shapiro S, Skinner EA, Kessler LG, VonKorff M, German PS, Tischler GL, Leaf
PJ, Benham L, Cottler L, Regier DA. Utilization of health and mental health
services: three Epidemiologic Catchment Area sites. Arch Gen Psychiatry. 1984;
41:971-976.
39. Sireling LI, Paykel ES, Freeling P, Rao BM, Patel SP. Depression in general
practice: case thresholds and diagnoses. Br J Psychiatry. 1985;147:113-119.
40. Wilmink FW. Patient, Physician, Psychiatrist: Assessment of Mental Health Prob-
lems in Primary Care. Groningen, the Netherlands: University of Groningen;
1989. Thesis.
41. Ormel J, Koeter MWJ, vanden Brink W, van de Willige G. Recognition, man-
agement and course of anxiety and depression in general practice. Arch Gen
Psychiatry. 1991;48:700-706.
42. vanden Brink W, Leenstra A, Ormel J, van de Willige G. Mental health inter-
vention programs in primary care: their scientific basis. J Affect Disord. 1991;
21:273-284.
43. Goldberg DP. Detection and assessment of emotional disorders in primary care.
Int J Ment Health. 1979;8:30-48.
44. Koeter MWJ, Ormel J. Handleiding van de Nederlandse versie van de General
Health Questionnaire. Lisse, the Netherlands: Swets & Zeitlinge; 1991.
45. Wing JK, Cooper J, Sartorius N. The Measurement and Classification of
Psychiatric Symptoms. Cambridge, England: Cambridge University Press;
1974.
46. Wiersma D, DeJong A, Ormel J, Kraaykamp HJM. Groningen Social Disability
Schedule and Manual. 2nd ed. Groningen, the Netherlands: University of Gronin-
gen; 1990.
47. Wiersma D, DeJong A, Ormel J. The Groningen Social Disability Schedule: de-
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velopment, relationship with ICIDH, and psychometric properties. Int J Rehab
Res. 1988;11:213-224.
48. Finlay-Jones R, Brown GW, Duncan-Jones P, Harris T, Murphy E, Prudo R.
Depression and anxiety in the community: replicating the diagnosis of a case.
Psychol Med. 1980;10:445-454.
49. Ceroni GB, Nevi C, Pezolli A. Chronicity in major depression. J Affect Disord.
1984;7:123-132.
50. Duncan Jones P, Fergusson D, Ormel J, Horwood U. A model for stability and
change in minor psychiatric symptoms. Psychol Med Monogr Suppl. 1990;
18:1-28.
51. Ormel J, Schaufeli W. Stability and change of psychological distress and their
relationship with self-esteem and locus of control. J Pers Soc Psychol. 1991;
60:288-299.
52. Ormel J, Wohlfarth T. How neuroticism, long-term difficulties, and life situation
change influence psychological distress: a longitudinal model. J Pers Soc Psy-
chol. 1991;60:744-755.
53. Depue RA, Monroe SM. Life stress and human disorder: conceptualization and
measurement of the disordered group. In: Sarason IG, Sarason BR, eds. Social
Support: Theory, Research and Applications. Dordrecht, the Netherlands: Mar-
tinus Nijhoff Publishers; 1985:303-324.
54. Watson D, Pennebaker JW. Health complaints, stress, and distress: exploring
the central role of negative negativity. Psychol Rev. 1989;96:234-254.
55. Duggan CF, Lee AS, Murray RM. Does personality predict long-term outcome
in depression. Br J Psychiatry. 1990;157:19-24.
56. Hirschfeld RMA, Klerman GL. Personality attributes and affective disorders.
Am J Psychiatry. 1979;136:67-70.
57. Ormel J. Moeite met Leven of een Moeilijk Leven. Groningen, the Netherlands:
Konstapel; 1980.
58. Katon W, Von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of
antidepressant treatment in primary care. Med Care. 1992;30:67-76.
59. Frank E, Kupfer DJ, Perel JM, Corner C, Jarrett DB, Mallinger AG, Thase ME,
McEachran AB, Grochocinski VJ. Three-year outcome for maintenance thera-
pies in recurrent depression. Arch Gen Psychiatry. 1990;47:1093-1099.
suggestions for inclusion or any
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