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1.
Bergner M.  Quality of life, health status, and clinical research. Med Care . 1989;27:S148-S156.Article
2.
Guyatt GH, Feeny DH, Patrick DL.  Measuring health-related quality of life. Ann Intern Med . 1993; 118:622-629.Article
3.
Mosteller F, Ware JE, Levine S.  Final panel: comments on the Conference on Advances in Health Status Assessment. Med Care . 1989;27:S282-S294.Article
4.
Nelson EC, Berwick DM.  The measurement of health status in clinical practice. Med Care . 1989; 27:S77-S90.Article
5.
Wilson IB, Cleary PD.  Linking clinical variables with health-related quality of life. JAMA . 1995; 273:59-65.Article
6.
Ware JE, Gandek B.  The SF-36 Health Survey: development and use in mental health research and the IQOLA Project. Int J Ment Health . 1994;23:49-73.
7.
Stewart AL, Ware JE, eds. Measuring Functioning and Well-being: The Medical Outcomes Study Approach . Durham, NC: Duke University Press; 1992.
8.
Patrick DL, Erickson P. Health Status and Health Policy: Quality of Life in Health Care Evaluation and Resource Allocation . New York, NY: Oxford University Press; 1993.
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.Article
10.
Mintz J, Mintz LI, Arruda MJ, Hwang SS.  Treatments of depression and the functional capacity to work. Arch Gen Psychiatry . 1992;49:761-768.Article
11.
Wells KB, Stewart A, Hays RD, et al.  The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA . 1989;262:914-919.Article
12.
Stewart AL, Greenfield S, Hays RD, et al.  Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA . 1989;262:907-913.Article
13.
Kessler LG, Tessler RC, Nycz GR.  Co-occurrence of psychiatric and medical morbidity in primary care. J Fam Pract . 1983;16:319-324.
14.
Ormel J, Von Korff M, Ustun TB, Pini S, Korten A, Oldehinkel T.  Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA . 1994;272:1741-1748.Article
15.
Fryback DG, Dasbach RJ, Klein R, et al.  The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors. Med Decis Making . 1993;13:89-102.Article
16.
Spitzer RL, Williams JBW, Kroenke K, et al.  Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA . 1994;272:1749-1756.Article
17.
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community. JAMA . 1992;267:1478-1483.Article
18.
Williams JW, Kerber CA, Mulrow CD, Medina A, Aguilar C.  Depressive disorders in primary care: prevalence, functional disability, and identification. J Gen Intern Med . 1995;10:7-12.Article
19.
Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB.  Somatization in the community: relationship to disability and use of services. Am J Public Health . 1987;77:837-840.Article
20.
Stewart AL, Hays RD, Ware JE.  The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care . 1988; 26:724-732.Article
21.
McHorney CA, Ware JE, Rogers W, Raczek AE, Lu JFR.  The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts. Med Care . 1992;30:MS253-MS265.Article
22.
Kazis LE, Anderson JJ, Meenan RF.  Effect sizes for interpreting changes in health status. Med Care . 1989;27:S178-S189.Article
23.
Woodwell DA.  Office visits to internists, 1989. Advance Data From Vital and Health Statistics . No.209. Hyattsville, Md: National Center for Health Statistics; April 28, 1992.
24.
Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart LG.  The content of ambulatory medical care in the United States: an interspecialty comparison. N Engl J Med . 1983;309:892-897.Article
25.
Mintz J, Mintz LI, Arruda MJ, Hwang SS.  Treatments of depression and the functional capacity to work. Arch Gen Psychiatry . 1992;49:761-768.Article
26.
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.Article
27.
Kirmayer LJ, Robbins JM, eds. Current Concepts of Somatization: Research and Clinical Perspectives . Washington, DC: American Psychiatric Press; 1991.
28.
Mulrow CD, Williams JW, Gerety MB, Ramirez G. Montiel OM, Kerber C.  Case-finding instruments for depression in primary care settings. Ann Intern Med . 1995;122:913-921.Article
29.
Ware JE. SF-36 Health Survey: Manual and Interpretation Guide . Boston, Mass: The Health Institute, New England Medical Center; 1993.
30.
Parkerson GR, Broadhead WE, Tse CK.  Health status and severity of illness as predictor of outcomes in primary care. Med Care . 1995;33:53-66.Article
31.
Connelly JE, Philbrick JT, Smith GR, Kaiser DL, Wymer A.  Health perceptions of primary care patients and the influence on health care utilization. Med Care . 1989;27:S99-S109.Article
32.
Calkins DR, Rubenstein LV, Cleary PD, et al.  Failure of physicians to recognize functional disability in ambulatory patients. Ann Intern Med . 1991;114:451-454.Article
33.
Schor EL, Lerner DJ, Malspeis S.  Physicians' assessment of functional health status and wellbeing. Arch Intern Med . 1995;155:309-314.Article
34.
Parkerson GR, Broadhead WE, Tse CK.  Quality of life and functional health of primary care patients. J Clin Epidemiol . 1992;45:1303-1313.Article
35.
Endicott J, Spitzer RL, Fleiss JL, et al.  The Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry . 1976;33:766-771.Article
36.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994.
37.
Depression Guideline Panel. Depression in Primary Care, Volume 2: Treatment of Major Depression . Clinical practice guideline No. 5. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Policy and Research; April 1993. AHCPR publication 93-0551.
38.
Wells KB, Golding JM, Burnam MA.  Psychiatric disorder and limitations in physical functioning in a sample of the Los Angeles general population. Am J Psychiatry . 1988;145:712-717.
39.
Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL.  Quality of life in panic disorder. Arch Gen Psychiatry . 1989;46:984-992.Article
40.
Massion AO, Warshaw MG, Keller MB.  Quality of life and psychiatric comorbidity in panic disorder and generalized anxiety disorder. Am J Psychiatry . 1993;150:600-607.
41.
Spitzer RL, Yanovski S, Wadden T, et al.  Binge eating disorder: its further validation in a multisite study. Int J Eat Disord . 1993;13:137-153.Article
42.
Johnson JG, Spitzer RL, Williams JBW, et al.  Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse/ dependence in primary care patients: findings of the PRIME-MD 1000 study. J Clin Consult Psychology . 1995:63:133-140.Article
43.
Ware JE, Sherbourne CD.  The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection. Med Care . 1992;30: 473-483.Article
44.
Klerman GL.  Treatments for panic disorder. J Clin Psychiatry . 1992;53( (suppl 3) ):14-19.
45.
Üstün TB, Sartorius N, eds. Mental Illness in General Health Care: An International Study . West Sussex, England: John Wiley & Sons Ltd; 1995.
Original Contributions
November 15, 1995

Health-Related Quality of Life in Primary Care Patients With Mental DisordersResults From the PRIME-MD 1000 Study

Author Affiliations

From the Biometrics Research Department, New York State Psychiatric Institute and the Department of Psychiatry, Columbia University, New York, NY (Drs Spitzer and Williams and Mr Davies); Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (Dr Kroenke); Department of Medicine, University of Wisconsin Medical School, Madison (Dr Linzer); Department of Medicine, Albert Einstein College of Medicine, Bronx, NY (Dr Hahn); Department of Family Practice in Community Medicine, University of South Alabama College of Medicine, Mobile (Dr deGruy); and Department of Medicine, Mercy Catholic Medical Center, Darby, Pa (Dr Brody).

JAMA. 1995;274(19):1511-1517. doi:10.1001/jama.1995.03530190025030
Abstract

Objective.  —To determine if different mental disorders commonly seen in primary care are uniquely associated with distinctive patterns of impairment in the components of health-related quality of life (HRQL) and how this compares with the impairment seen in common medical disorders.

Design.  —Survey.

Setting.  —Four primary care clinics.

Subjects.  —A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians using PRIME-MD (Primary Care Evaluation of Mental Disorders) to make diagnoses of mood, anxiety, alcohol, somatoform, and eating disorders.

Main Outcome Measures.  —The six scales of the Short-Form General Health Survey and self-reported disability days, adjusting for demographic variables as well as psychiatric and medical comorbidity.

Results.  —Mood, anxiety, somatoform, and eating disorders were associated with substantial impairment in HRQL. Impairment was also present in patients who only had subthreshold mental disorder diagnoses, such as minor depression and anxiety disorder not otherwise specified. Mental disorders, particularly mood disorders, accounted for considerably more of the impairment on all domains of HRQL than did common medical disorders. Finally, we found marked differences in the pattern of impairment among different groups of mental disorders just as others have reported unique patterns associated with different medical disorders. Whereas mood disorders had a pervasive effect on all domains of HRQL, anxiety, somatoform, and eating disorders affected only selected domains.

Conclusions.  —Mental disorders commonly seen in primary care are not only associated with more impairment in HRQL than common medical disorders, but also have distinct patterns of impairment. Primary care directed at improving HRQL needs to focus on the recognition and treatment of common mental disorders. Outcomes studies of mental disorders in both primary care and psychiatric settings should include multidimensional measures of HRQL.(JAMA. 1995;274:1511-1517)

References
1.
Bergner M.  Quality of life, health status, and clinical research. Med Care . 1989;27:S148-S156.Article
2.
Guyatt GH, Feeny DH, Patrick DL.  Measuring health-related quality of life. Ann Intern Med . 1993; 118:622-629.Article
3.
Mosteller F, Ware JE, Levine S.  Final panel: comments on the Conference on Advances in Health Status Assessment. Med Care . 1989;27:S282-S294.Article
4.
Nelson EC, Berwick DM.  The measurement of health status in clinical practice. Med Care . 1989; 27:S77-S90.Article
5.
Wilson IB, Cleary PD.  Linking clinical variables with health-related quality of life. JAMA . 1995; 273:59-65.Article
6.
Ware JE, Gandek B.  The SF-36 Health Survey: development and use in mental health research and the IQOLA Project. Int J Ment Health . 1994;23:49-73.
7.
Stewart AL, Ware JE, eds. Measuring Functioning and Well-being: The Medical Outcomes Study Approach . Durham, NC: Duke University Press; 1992.
8.
Patrick DL, Erickson P. Health Status and Health Policy: Quality of Life in Health Care Evaluation and Resource Allocation . New York, NY: Oxford University Press; 1993.
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.Article
10.
Mintz J, Mintz LI, Arruda MJ, Hwang SS.  Treatments of depression and the functional capacity to work. Arch Gen Psychiatry . 1992;49:761-768.Article
11.
Wells KB, Stewart A, Hays RD, et al.  The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA . 1989;262:914-919.Article
12.
Stewart AL, Greenfield S, Hays RD, et al.  Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA . 1989;262:907-913.Article
13.
Kessler LG, Tessler RC, Nycz GR.  Co-occurrence of psychiatric and medical morbidity in primary care. J Fam Pract . 1983;16:319-324.
14.
Ormel J, Von Korff M, Ustun TB, Pini S, Korten A, Oldehinkel T.  Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA . 1994;272:1741-1748.Article
15.
Fryback DG, Dasbach RJ, Klein R, et al.  The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors. Med Decis Making . 1993;13:89-102.Article
16.
Spitzer RL, Williams JBW, Kroenke K, et al.  Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA . 1994;272:1749-1756.Article
17.
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community. JAMA . 1992;267:1478-1483.Article
18.
Williams JW, Kerber CA, Mulrow CD, Medina A, Aguilar C.  Depressive disorders in primary care: prevalence, functional disability, and identification. J Gen Intern Med . 1995;10:7-12.Article
19.
Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB.  Somatization in the community: relationship to disability and use of services. Am J Public Health . 1987;77:837-840.Article
20.
Stewart AL, Hays RD, Ware JE.  The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care . 1988; 26:724-732.Article
21.
McHorney CA, Ware JE, Rogers W, Raczek AE, Lu JFR.  The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts. Med Care . 1992;30:MS253-MS265.Article
22.
Kazis LE, Anderson JJ, Meenan RF.  Effect sizes for interpreting changes in health status. Med Care . 1989;27:S178-S189.Article
23.
Woodwell DA.  Office visits to internists, 1989. Advance Data From Vital and Health Statistics . No.209. Hyattsville, Md: National Center for Health Statistics; April 28, 1992.
24.
Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart LG.  The content of ambulatory medical care in the United States: an interspecialty comparison. N Engl J Med . 1983;309:892-897.Article
25.
Mintz J, Mintz LI, Arruda MJ, Hwang SS.  Treatments of depression and the functional capacity to work. Arch Gen Psychiatry . 1992;49:761-768.Article
26.
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.Article
27.
Kirmayer LJ, Robbins JM, eds. Current Concepts of Somatization: Research and Clinical Perspectives . Washington, DC: American Psychiatric Press; 1991.
28.
Mulrow CD, Williams JW, Gerety MB, Ramirez G. Montiel OM, Kerber C.  Case-finding instruments for depression in primary care settings. Ann Intern Med . 1995;122:913-921.Article
29.
Ware JE. SF-36 Health Survey: Manual and Interpretation Guide . Boston, Mass: The Health Institute, New England Medical Center; 1993.
30.
Parkerson GR, Broadhead WE, Tse CK.  Health status and severity of illness as predictor of outcomes in primary care. Med Care . 1995;33:53-66.Article
31.
Connelly JE, Philbrick JT, Smith GR, Kaiser DL, Wymer A.  Health perceptions of primary care patients and the influence on health care utilization. Med Care . 1989;27:S99-S109.Article
32.
Calkins DR, Rubenstein LV, Cleary PD, et al.  Failure of physicians to recognize functional disability in ambulatory patients. Ann Intern Med . 1991;114:451-454.Article
33.
Schor EL, Lerner DJ, Malspeis S.  Physicians' assessment of functional health status and wellbeing. Arch Intern Med . 1995;155:309-314.Article
34.
Parkerson GR, Broadhead WE, Tse CK.  Quality of life and functional health of primary care patients. J Clin Epidemiol . 1992;45:1303-1313.Article
35.
Endicott J, Spitzer RL, Fleiss JL, et al.  The Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry . 1976;33:766-771.Article
36.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994.
37.
Depression Guideline Panel. Depression in Primary Care, Volume 2: Treatment of Major Depression . Clinical practice guideline No. 5. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Policy and Research; April 1993. AHCPR publication 93-0551.
38.
Wells KB, Golding JM, Burnam MA.  Psychiatric disorder and limitations in physical functioning in a sample of the Los Angeles general population. Am J Psychiatry . 1988;145:712-717.
39.
Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL.  Quality of life in panic disorder. Arch Gen Psychiatry . 1989;46:984-992.Article
40.
Massion AO, Warshaw MG, Keller MB.  Quality of life and psychiatric comorbidity in panic disorder and generalized anxiety disorder. Am J Psychiatry . 1993;150:600-607.
41.
Spitzer RL, Yanovski S, Wadden T, et al.  Binge eating disorder: its further validation in a multisite study. Int J Eat Disord . 1993;13:137-153.Article
42.
Johnson JG, Spitzer RL, Williams JBW, et al.  Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse/ dependence in primary care patients: findings of the PRIME-MD 1000 study. J Clin Consult Psychology . 1995:63:133-140.Article
43.
Ware JE, Sherbourne CD.  The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection. Med Care . 1992;30: 473-483.Article
44.
Klerman GL.  Treatments for panic disorder. J Clin Psychiatry . 1992;53( (suppl 3) ):14-19.
45.
Üstün TB, Sartorius N, eds. Mental Illness in General Health Care: An International Study . West Sussex, England: John Wiley & Sons Ltd; 1995.
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