Introduction

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Recognition of depression and anxiety is a key issue in general practice. If these disorders are not recognised they cannot be treated. There are a number of treatments of proved efficacy ^{1 2} and some evidence to show that recognition improves outcome, ^{3 4} though this has been questioned.⁵

Most episodes of depression and anxietythe "common mental disorders"are contained and managed in primary care.⁶ Yet less than half of these episodes are identified in the consultation.⁷ Why is recognition of depression and anxiety such a problem in general practice? Doctors' skills and attitudes play a part. Certain key skills in the consultation have been identified that are both teachable and associated with increased rates of recognition.⁸ Teaching better consultation skills, however, leads to only a modest increase in detection rates.

Most consultations in primary care are initiated by the patient. The content of the typical primary care consultation and its outcome will be influenced by what the patient chooses to present and how he or she chooses to present it.⁹ Common somatic symptoms are the currency of general practice; they are also concomitants of anxiety and depression.¹⁰ Numerous studies have categorised this combination of mood disorder and somatic symptomatology as "somatisation" and have shown it reduces general practitioners' ability to identify mental disorder. ^{10 11} But this use of the term somatisation has certain disadvantages in the context of primary care. It associates a common mode of presentation with the much rarer, more serious, chronic, and treatment resistant "somatisation disorder."¹² It also implies that patients who present with psychological disorders and common bodily symptoms tend to think of themselves as physically ill. Attempts to redefine somatisation for primary care have led to a confusion of multiple and at times complex definitions. ^{10 11 13} One way to simplify the issue is to ask patients themselves for their causal attributions for common somatic symptoms.

Patients' beliefs about their symptoms are powerful influences on their decision to consult a doctor and how they present their problem when they do consult.¹⁴ In other words, do we think our fatigue is caused by emotional exhaustion? Is it due to anaemia? Or could it be because we have been overdoing it or not doing enough exercise? In the example given above three types of explanation or attribution have been offered for a common somatic symptom, fatigue. The first, the idea that it is due to emotional exhaustion, can be called a psychologising attribution. The second, that it is caused by anaemia, is a somatising attribution. In the third explanation the experience of fatigue is thought to be related to overexertion or not exercising enough. This type of attribution has been called normalising.¹⁵

Until now most studies that have looked at patients' beliefs about their symptoms have focused on the dichotomy between somatising and psychologising. These are, in effect, "illness beliefs." Normalising attributions are qualitatively different in that they are non-pathological. They are the most prevalent attribution in primary care attenders as well as in the population as a whole.¹⁵ This study asks whether such attributions have any effect on the general practitioner's ability to make a diagnosis of depression or anxiety. In particular it tests the hypothesis that normalising attributions reduce the likelihood of the detection of such disorders.

	Methods

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The study took place in an eight partner urban practice which serves 12 800 patients and has a slightly larger than average population of patients aged over 75. Surgeries were selected to ensure that both morning and evening attenders were represented and that all doctors were covered by the study. Consecutive attenders aged over 16 years were given two questionnaires before seeing their general practitioner. Twenty four questionnaires were incomplete, and 26 patients declined to participate.

The 12 item general health questionnaire has been widely used to detect psychiatric disorder in primary care¹⁶ and validated in comparison with more detailed assessments. In a recent study it was compared with a more detailed psychiatric assessment and the optimal threshold for "caseness" found to be a score of 3 or more.¹⁷ We have adopted this definition of a case of psychological disorder.

The symptom interpretation questionnaire is a self report questionnaire consisting of a list of 13 common bodily symptoms or sensations.¹⁵ Attached to each symptom are three possible explanations, each one corresponding to one of the three styles of attribution: psychologising, somatising, or normalising. The patients were asked to choose one explanation for each symptom, giving each subject a numerical score from 0-13 along the three attributional dimensions. The sum of all three scales was therefore 13. Subjects were classified as predominantly normalisers, psychologisers, or somatisers if they scored 7 or more on that scale. Validation research has shown that these scores remain reasonably consistent over time, supporting the theory that they may reflect underlying health beliefs.¹⁵

General practitioners, who were blind to the results of the questionnaires, were asked to report any diagnoses of depression or anxiety they made and to note whether this was a new diagnosis or if the patient was already under treatment. The proportion of patients diagnosed as anxious or depressed was calculated according to scores on the normalising, psychologising, and somatising scales of the symptom interpretation questionnaire. For presentation purposes the scores were divided into four categories, but the scales were also examined as continuous variables. Logistic regression was used to estimate odds ratios for the detection of psychiatric disorder and to adjust for the confounding variables of age, sex, general health questionnaire score, and general practitioner consulted (as a categorical variable). Results were unchanged when data from the subjects who were "false positives" on the general health questionnaire were excluded. Statistical analysis was done with STATA.¹⁸ Ethical approval was obtained from the local research ethics committee.

	Results

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There were 225 women and 80 men in the study, a ratio of 2.8:1. The mean (range) age was 44 (16-90) years. The men were significantly older than the women (mean age 49.2 v 42.0 years; P<0.003). On the general health questionnaire 157 (52%; 95% confidence interval 46% to 57%) of all the attenders scored 3 or more. The general practitioners made a diagnosis of depression in 57 (19%; 15% to 24%) patients and anxiety in 14 (5%; 3% to 8%). Measured against the general health questionnaire threshold of 3 or more the general practitioners showed a specificity of 80% (69% to 89%) and a sensitivity of 57% (50% to 63%). There were 14 false positive results: patients who were diagnosed as depressed or anxious by the general practitioner but scored less than 3 on the general health questionnaire. Of these, seven had already been diagnosed with depression by a general practitioner and were receiving treatment.

In the symptom interpretation questionnaire the normalising attribution was most often selected, with 146 out of 305 (48%) choosing seven or more normalising explanations out of a possible 13. Seventy one patients (23%) selected seven or more psychologising explanations, and only 16 patients (5%) chose seven or more somatising attributions (table 1). This pattern of distribution was also found in the initial validation studies.¹⁵ High scorers on the somatisation scale were older, normalisers younger (F_3,301=7.54; P<0.0001). Psychologisers were more likely to be female and normalisers and somatisers to be male (likelihood ratio ² =11.2; df=3; P<0.01).

Symptom interpretation questionnaire and general practitioner diagnosis of anxiety and depression
Table 2 shows that the higher the patient's score on the normalising dimension of the symptom interpretation questionnaire the less likely the general practitioner was to diagnose depression or anxiety (P<0.0001) and that the higher the patient's score on the psychologising dimension the more likely was the general practitioner to diagnose depression or anxiety (P<0.0001). For normalising and psychologising the relation was still present after adjustment for age, sex, general health questionnaire score, and which doctor the patient saw. There was no evidence of an association between detection by the general practitioner and the patient's somatising score (table 2). This lack of relation was confirmed by using somatisation as a continuous variable (likelihood ratio ²=0.19; df=1; P=0.7).

Recognition of anxiety and depression in general health questionnaire cases with different symptom attributional styles
General practitioners did not diagnose depression or anxiety in 21 (38%; 25% to 52%) of the 55 patients who were cases according to the general health questionnaire and had a predominantly psychologising style of symptom attribution. In contrast depression or anxiety went undetected in 46 (85%; 73% to 93%) of the 54 patients who were cases according to the general health questionnaire but had a predominantly normalising style of symptom attribution (see table 1). There was no evidence that the association between normalising style and low rates of detection was influenced by score on the general health questionnaire (test for interaction, likelihood ratio ²=0.19, df=1, P=0.66). Patients with a normalising style were less likely to be detected even when the analysis was restricted to those with a score of 7 or more.

	Discussion

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We found that different styles of symptom attribution are strongly associated with different rates of detection of depression and anxiety. Patients who make psychologising attributions are more likely to get a psychological diagnosis; the stronger their tendency to make such attributions the more likely such a diagnosis becomes. A normalising style of attribution has the opposite effect, and the stronger a patient's tendency to normalise or minimise his or her symptoms the less likely he or she is to be seen as depressed or anxious by the general practitioner. Somatising attributions, which are the least common, had no measurable effect on diagnostic rates, though this may have been because of lack of statistical power.

Normalising attributions are the most common both in studies of populations and primary care attenders.¹⁵ Even among those with a high general health questionnaire score there are large numbers of "normalisers." It is in this group, who tend to be younger and male, that general practitioners particularly did not detect depression and anxiety. Only eight out of 54 patients with a normalising attributional style and a high general health questionnaire score were diagnosed as being depressed or anxious. Forty six of the 101 (45.5%; 35.6% to 55.8%) undetected cases had a predominantly normalising style of attribution. Does this strong association between a normalising style of attribution and low rates of detection of mental disorder represent a causal relation? Our study suggests that it does. The association is robust and remains strong even after adjustment for which general practitioner the patient saw, general health questionnaire score, age, and sex. One limitation of the study is that we were not able to adjust for presenting symptom, but we might expect this to be influenced by causal attributional style. The normalising style arises out of the "discounting principle."¹⁹ This is the idea that symptoms are often "explained away" as being caused by a minor environmental irritant or as the result of "overdoing it." Such explanations propose a non-pathological cause for the symptom. In other words "normalisers" play down the significance of their symptoms. For the general practitioner to respond to the patient's own attribution of his or her symptoms is an expression of empathy and an important part of the negotiation between patient and doctor in moving towards a diagnosis. Such negotiations are the cornerstone of the doctor-patient relationship in general practice. Thus a psychological style of attribution is likely to elicit questions from the doctor about mental wellbeing and mood state and would favour a psychological formulation for the problem. In contrast, a normalising attribution, with its powerful "commonsensical" overtones, may influence the doctor to join with the patient in minimising and even dismissing the symptoms.

It is easy to understand why people who make a somatising attribution for their symptoms would seek the advice of their general practitioner. It is also clear that the general practitioner is the first port of call for many in psychological distress. But when "normalising" attributions are concerned there seems to be a paradox. Why should someone who is making a normalising attribution seek a doctor's advice? The answer may lie in a need to check the normalising style of attribution and to be reassured that it is the correct one. If this is so, then the implicit question that the normaliser asks the physician is "there's nothing really wrong with me, is there?" In the same way that we respond to somatisers and psychologisers by accepting their attribution, so we may respond to the normalisers by agreeing with them. This collusion could result in a tendency to neglect symptoms of depression and anxiety.

The rate of apparent underdiagnosis of psychological disorder in primary care remains stubbornly high. Patients with such disorders may often present with somatic symptoms but are rarely committed "somatisers." Instead they are more likely to be normalising their symptoms and giving them a non-pathological attribution. The question of whether such patients would benefit from detection could be examined by a comparison of outcomes for detected and undetected depressed patients with different attributional styles.

	Acknowledgments

With thanks to the patients, doctors, and staff at Horfield Health Centre, Bristol.

Contributors: DK had the original idea for the study, which was developed in discussions with KL and DPG. These three designed the study. DK undertook the data collection. DK, KL, and GL analysed the data. DK drafted the paper, which was edited by GL. DK is the guarantor.

Funding: DPG was funded by the NHS Executive to undertake research on depression.

Competing interests: None declared.

	References

Top Abstract Introduction Methods Results Discussion References

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2. Hollyman JA, Freeling D, Paykel ES. Double-blind placebo-controlled trial of amitriptyline among depressed patients in general practice. J R Coll Gen Pract 1988; 38: 393-397[Medline].
3. Johnstone A, Goldberg D. Psychiatric screening in general practice. Lancet 1976; i: 605-608.
4. Zung WWK, Magill M, Moore J, George DT. Recognition and treatment of depression in a family medicine practice. J Clin Psychiatry 1983; 44: 3-6[Medline].
5. Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995; 311: 1274-1276[Abstract/Free Full Text].
6. Shepherd M, Cooper B, Brown A. Psychiatric illness in general practice. Oxford: Oxford University Press , 1966.
7. Goldberg D, Huxley P. Common mental disorders. London: Routledge , 1992.
8. Gask L, Goldberg D, Porter R, Creed F. The treatment of somatisation: evaluation of a teaching package with general practice trainees. J Psychosom Res 1989; 33: 697-703[Medline].
9. Weich S, Lewis G, Donmall R, Mann A. Somatic presentation of psychiatric morbidity in general practice. Br J Gen Pract 1995; 45: 143-147[Medline].
10. Bridges K, Goldberg D, Evans B. Determinants of somatisation in primary care. Psychol Med 1991; 21: 473-483[Medline].
11. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatisation and the recognition of depression and anxiety in primary care. Am J Psych 1993; 150: 734-741[Abstract/Free Full Text].
12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington DC: American Psychiatric Association , 1994.
13. Bridges KW, Goldberg D. Somatic presentation of DSM III disorders in primary care. J Psychosom Res 1985; 29: 563-569[Medline].
14. King J. Attribution theory and the health belief model. In: Hewstone M, ed. Attribution theory: social and functional extensions. Basil Blackwell: Oxford, 1983:170-186.
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16. Goldberg D, Williams P. A user's guide to the general health questionnaire. Windsor: NEFR Nelson , 1991.
17. Bashir K, Blizard R, Jenkins R, Mann A. Validation of the 12-item general health questionnaire in British general practice. Primary Care Psychiatry 1996; 2: 4-7.
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Commentary: There must be limits to the medicalisation of human distress

Iona Heath, general practitioner. 

Caversham Group Practice, London NW5 2UP

pe31{at}dial.pipex.com

This paper sets out to elucidate further the much reported "failure" of general practitioners to diagnose depression. The 12 item general health questionnaire was administered to 305 consecutive patients attending general practice, and the threshold for the diagnosis of depression was set at a score of 3 or more, which meant that a staggering 51.5% of the patients were considered by the researchers to have measurable depression. This extraordinary finding does not seem to have disturbed them. The patients' general practitioners made a diagnosis of depression or anxiety in only 23% of the attenders, but this is still a huge proportion of unselected patients from a waiting room. None the less, the paper reports these figures as showing a significant and serious failure to diagnose.

The patients were also given a questionnaire which enabled them to be divided into three categories: those who tend to find psychological explanations for their symptoms, those who find physical explanations, and those who tend to normalise their symptoms by finding explanations in their life circumstances. The major finding of the paper is that general practitioners are much more likely to "fail" to diagnose depression in patients who tend to normalise their symptoms. Surely this conclusion provides us with a superlative example of the folly of medicalisation.¹

The general health questionnaire includes the following questions. In the past few weeks, have you been able to concentrate on whatever you're doing? been able to enjoy your normal day to day activities? been feeling reasonably happy, all things considered? By setting the threshold for caseness at 3, the researchers will have defined as depressed all those who answered "less so than usual" to all of these three questions or any other three questions out of the full range of 12.

Patients come to the general practitioner for many reasons but most commonly because they are disturbed or distressed. They may be in pain, and they may be worried that their symptoms are the first indication of serious or life threatening disease. They may have lost someone close, their job may be under threat, their partner may have hit them, or their home may be damp or frightening or overcrowded. Any such patient is likely to answer "less so than usual" to the three questions but is it helpful to consider them as depressed?

Human beings struggle to make sense of suffering and illness by finding meaning for it in the very particular context of each individual life. Patients who normalise their experience may have already begun this process of finding meaning, making sense, and learning to cope.² Do we have any evidence that the medical treatment of depression improves outcomes to an extent which would justify pressurising patients into accepting psychiatric explanations for symptoms they are willing to normalise? What evidence we do have suggests that the depression which is apparently missed by general practitioners runs a relatively benign and self limiting course.³

General practitioners should not be castigated when they try, alongside the patient, to find out what is the matter rather than to make a diagnosis.⁴

	References

1. Barsky AJ, Borus JF. Somatization and medicalization in the era of managed care. JAMA 1995; 274: 1931-1934[Abstract/Free Full Text].
2. Howie JGR, Heaney DJ, Maxwell M. Measuring quality in general practice. London: Royal College of General Practitioners , 1997(Occasional Paper 75.)
3. Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995; 311: 1274-1276.
4. Toombs SK. The meaning of illness: a phenomenological account of the different perspectives of physician and patient. Dordrecht: Kluwer Academic, 1993:12.