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Original Investigation
November 23, 1998

The Value of Screening for Psychiatric Disorders in Rheumatology Referrals

Author Affiliations

From the Departments of General Internal Medicine (Drs O'Malley and Jackson) and Rheumatology (Dr Dennis), Walter Reed Army Medical Center, Washington, DC, and the Uniformed Services University of the Health Sciences, Bethesda, Md (Drs O'Malley, Jackson, and Dennis); the Regenstrief Institute for Health Care and the Department of Medicine, Indiana University School of Medicine, Indianapolis (Dr Kroenke); the 121st Hospital, Seoul, Korea (Dr Yoon); and the Department of Rheumatology, Madigan Army Medical Center, Tacoma, Wash (Dr Hornstein). The opinions or assertions herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.

Arch Intern Med. 1998;158(21):2357-2362. doi:10.1001/archinte.158.21.2357

Background  Musculoskeletal complaints are common and often unexplained and often lead to rheumatology referrals. The prevalence of psychiatric disease in patients with musculoskeletal complaints is unknown.

Objectives  To determine the prevalence of common psychiatric disorders among patients referred to a rheumatology clinic and the likelihood of establishing a rheumatic diagnosis if a psychiatric disorder is present.

Design  Prospective diagnostic survey.

Setting  Two hospital-based rheumatology clinics and a general medicine clinic.

Participants  A consecutive sample of newly referred patients (n=185) and their rheumatologists (n = 9).

Intervention  Before their visit, all patients filled out a self-administered version of PRIME-MD (Primary Care Evaluation of Mental Disorders), a questionnaire that makes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, diagnoses of depressive, anxiety, and somatoform disorders. After the visit, the study rheumatologists, who were unaware of the PRIME-MD results, completed a questionnaire regarding their diagnostic assessment. These patients were compared with 210 patients with musculoskeletal complaints who were cared for in a general medicine clinic.

Main Outcome Measures  Psychiatric and rheumatic disorders.

Results  Compared with patiens with musculoskeletal complaints in a general medicine clinic, patients referred to a rheumatology clinic had a higher prevalence of psychiatric disease (40% vs 29%; P=.008), had an almost 2-fold higher prevalence of anxiety disorders, and were more likely to have multiple psychiatric disorders (odds ratio=2.70, 95% confidence interval = 1.50-5.00). The likelihood of a psychiatric disorder differed among patients with connective tissue disease, nonsystemic articular or periarticular disorders, and nonarticular disorders (27%, 38%, 55%, respectively; P=.006). In a best-fitting logistic regression model, psychiatric disorders markedly decreased the likelihood of a connective tissue disease (odds ratio = 0.24, 95% confidence interval = 0.09-0.62).

Conclusions  Forty percent of patients referred to a rheumatology clinic in this study had a psychiatric disorder, and its presence predicted a lower likelihood of a connective tissue disease. Prospective studies are needed to determine if screening for psychiatric disease before referring patients with unexplained musculoskeletal complaints would reduce costs or improve recognition of potentially treatable psychiatric disorders.