We greatly appreciate the comments of Dr Sutton. In previous work, we had found that patients who are experienced by clinicians as difficult do tend to be those with somatization disorders, the so-called heartsink patient.1 Unfortunately, treatment of somatoform disorders is largely one of reassurance and minimization, reassuring the patient that his or her symptoms are not due to a serious underlying disease and minimizing the number of tests and referrals. No treatment of somatoform disorder has yet proved to be effective. In contrast, there are very safe and effective treatments for patients who have depressive or anxiety disorders. Recognizing that a patient has a somatoform disorder may take a visit or two, but usually becomes quickly apparent. Unfortunately, many patients with depression or anxiety remain undetected, with as few as 11% recognized at any given clinical visit. Our real hope is that clinicians will use our clinical cues to improve recognition of depressive and anxiety disorders. There are numerous competing demands in the average clinician's office, and routinely screening all patients for mental disorders has not been demonstrated to be cost-effective. Our clinical cues—reporting more than 5 symptoms, reporting stress in patients' lives, reporting poor functioning in patients' daily lives, and reporting greater symptom severity—can identify a subset of patients in whom mental disorders, including depression and anxiety, are very likely to be found. While our clinical cues do identify patients with somatoform disorders, our hope is that clinicians will use our cues to help identify this latter group of underrecognized, undertreated patients, who would particularly benefit from treatment.
Jackson JL. Osler on the "Positive Review of Systems" Patient—Reply. Arch Intern Med. 2001;161(21):2631. doi: