BMJ 1999;318:436-440 ( 13 February )

General Practice

Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care

David Kessler, honorary research fellow, ^a Keith Lloyd, senior lecturer, ^b Glyn Lewis, professor of community and epidemiological psychiatry, ^c Dennis Pereira Gray, professor of general practice. ^a

^a Institute of General Practice, Postgraduate Medical School, University of Exeter, Exeter EX2 5DW, ^b Department of Mental Health, University of Exeter, Wonford House Hospital, Exeter EX2 5AF, ^c Division of Psychological Medicine, University of Wales College of Medicine, Cardiff CF4 4XN

Correspondence to: Dr Kessler Gaywood House Surgery, North Street, Bristol BS3 3AZ DavidKessler1{at}compuserve.com

Objectives: To examine the effect of patients' causal attributions of common somatic symptoms on recognition by general practitioners of cases of depression and anxiety and to test the hypothesis that normalising attributions make recognition less likely.
Design: Cross sectional survey.
Setting: One general practice of eight doctors in Bristol.
Subjects: 305 general practice attenders.
Main outcome measure: The rate of detection by general practitioners of cases of depression and anxiety as defined by the general health questionnaire.
Results: Consecutive attenders completed the general health questionnaire and the symptom interpretation questionnaire, which scores style of symptom attribution along the dimensions of psychologising, somatising, and normalising. General practitioners detected depression or anxiety in 56 (36%; 95% confidence interval 28% to 44%) of the 157 patients who scored highly on the general health questionnaire. Subjects with a normalising attributional style were less likely to be detected as cases; doctors did not make any psychological diagnosis in 46 (85%; 73% to 93%) of 54 patients who had high questionnaire and high normalising scores. Those with a psychologising style were more likely to be detected; doctors did not detect 21 (38%; 25% to 52%) of 55 patients who had high questionnaire and high psychologising scores. The somatisation scale was not associated with low detection rates. This pattern of results persisted after adjustment for age, sex, general health questionnaire score, and general practitioner.
Conclusions: Normalising attributions minimise symptoms and are non-pathological in character. The normalising attributional style is predominant in general practice attenders and is an important cause of low rates of detection of depression and anxiety.

Key messages Many patients with psychological disorders present to their general practitioner with common somatic symptoms. This combination has been referred to as "somatisation" and is associated with lower rates of diagnosis of depression and anxiety When questioned directly about the cause of their symptoms most patients choose "normalising" attributions, which tend to minimise the importance of the symptoms; somatising attributions are uncommon The more normalising attributions patients choose, the less likely are general practitioners to diagnose depression or anxiety; the association remain after adjustment for age, sex, general health questionnaire score, and which doctor the patient saw The normalising attributional style makes a considerable contribution to the non-detection of depression and anxiety. A better understanding of how depressed patients view their symptoms may be the key to understanding low diagnostic rates

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