1. Amsterdam April 2011 Do unexplained symptoms predict anxiety or depression in primary care. Kees van Boven Peter Lucassen, Tim OldeHartman Hiske van Ravesteijn Sibo Oskam Hans Bor Evelyn van Weel-Baumgarten Chris van Weel.

2. Quizz Research questions Transition project Physical symptoms Mental health problems Conclusion and Discussion Presentation Contents

3. Symptoms are sometimes the manifestation of a disease; frequently symptoms are not explained by disease. In the latter case, the general practitioner makes a ‘symptom diagnosis’. What percentage of all diagnoses of a general practitioner per year is a ‘symptom diagnosis’? O0–10% O10-20% O20-30% O30-50%

4. Part of the patients in primary care very frequently present unexplained symptoms i.e. symptoms not explained by disease. What percentage of all patients in primary care do very frequently present unexplained symptoms? O0-2% O2-4% O4-6% O 6-8%

5. In how many patients with unexplained symptoms is depression or anxiety the causes of the symptoms? O 0-5% O 5-10% O 10-15% O 15-20%

6. Research questions Are mental health problems associated with unexplained symptoms presented to the GP? Do unexplained symptoms, presented to the GP, predict a mental health problem?

7. Transition Project 16 000 patients ICPC classification Data Patients followed for 1-11 years (1997 – 2008) 419056 encounters with patients >=15 year ICPC codes Reason for encounter Diagnosis Intervention Structured in an Episode of care

8. Somatoform symptoms Somatic symptoms Number of episodes between 1997 and 2008 Year prevalence (%) Number of episodes between 1997 and 2008 Year prevalence tiredness51793,8lymph gland enlargement 5710,4 fainting9390,7localized abdominal pain 28882,1 abdominal pain5820,4diarrhea8650.6 nausea6810,5red eye3500,3 constipation27412,0swollen ankles15241,1 palpitations12880,9shoulder symptoms23971,7 low back complaints 66254,8hand/finger symptoms 14801,1

9. Somatoform symptoms episodes Somatic symptoms episodes Number of episodes between 1997 and 2008 Year prevalence (%) Number of episodes between 1997 and 2008 Year prevalence chest symptoms 33672,5hip symptoms11640,9 muscle pain13581,0tingling fingers/toes/feet 3350,2 headache23531,7cough39982,9 dizziness20351,5throat symptoms22941,7 disturbances of sleep 36612,7pruritus13781,0 shortness of breath 10080,7urinary frequency8560,6 total3181723,1 total 2010014,6

10. Odds Ratios Somatoform symptoms Anxiety disorder OR Anxiety disorder 95% CI Depressive disorder OR Depressive disorder 95% CI tiredness1,851,53-2,232,852,61-3,12 fainting2,441,69-3,522,161,75-2,68 abdominal pain4,493,20-6,301,991,52-2,61 nausea3,082,23-4,264,243,60-5,00 constipation1,971,63-2,383,793,49-4,12 palpitations4,73,74-5,892,492,11-2,94 low back complaint1,721,47-2,021,71,56-1,86 chest symptoms2,792,29-3,391,831,61-2,08 muscle pain5,094,11-6,312,882,47-3,35 headache2,952,41-3,612,492,21-2,81 dizziness2,622,07-3,312,251,96-2,59 disturbances of sleep2,552,23-2,924,083,82-4,36 shortness of breath2,131,48-3,073,152,64-3,75 Cross-sectional analysis of data with a time frame of one year. Association of somatoform and somatic symptoms with anxiety and depressive disorder (ORs, 95%Ci)

11. Odds Ratios Somatic symptomsAnxiety disorder OR Anxiety disorder 95% CI Depressive disorder OR Depressive disorder 95% CI lymph gland enlargement 2,591,62-4,150,690,43–1,11 localized abdominal pain 1,681,30-2,172,031,79-2,32 diarrhea2,661,98-3,593,022,58-3,55 red eye1,250,59-2,641,471,01-2,14 swollen ankles1,651,23-2,223,052,68-3,47 shoulder symptoms1,591,20-2,111,61,37-1,86 hand/finger symptoms1,941,39-2,711,841,53-2,22 hip symptoms0,920,55-1,542,061,70-2,51 tingling fingers/toes/feet 2,651,49-4,722,011,40-2,88 cough1,471,21-1,801,841,66-2,04 throat symptoms1,561,17-2,091,561,34-1,83 pruritus2,351,80-3,092,432,09-2,82 urinary frequency2,421,66-3,512,472,01-3,03 Cross-sectional analysis of data with a time frame of one year. Association of somatic symptoms with anxiety and depressive disorder (ORs, 95%Ci)

12. number of symptoms number of patients no depression or anxiety (%) depression or anxiety (%) Somatoform symptoms episodes 0844798,831,17 1135796,613,39 2 or more33594,035,92 Somatic symptom episodes 0878298,541,46 1115697,662,34 2 or more20195,024,98 Cross-sectional analysis in a time frame of one year (2007). Percentages of patients with/without anxiety or depression in patients presenting with different numbers of symptom episodes.

13. This seems usefull, but…

14. Anxiety disorder Somatoform symptom episodes pretestposttestPositive predictive value Negative predictive value tiredness0,0040,003 0,996 fainting0,004 0,997 abdominal pain0,004 0,997 nausea0,0040,007 0,997 constipation0,0040,003 0,996 palpitations0,0040,0130,0120,997 low back complaint0,0040,001 0,996 chest symptoms0,004 0,997 muscle pain0,0040,002 0,996 headache0,004 0,997 dizziness0,004 0,997 disturbances of sleep0,0040,008 0,997 Shortness of breath0,0040,006 0,997

15. Anxiety disorder Somatic symtom episodes pretestposttestPositive predictive value Negative predictive value lymph gland enlargement0,0040,002 0,996 localized abdominal pain0,0040,002 0,996 diarrhea0,004 0,997 red eye0,0040,000 0,996 swollen ankles0,0040,001 0,996 shoulder symptoms0,0040,002 0,996 hand/finger symptoms0,0040,001 0,996 Hip symptoms hand/finger symptoms0,0040,002 0,996 tingling fingers/toes/feet0,0040,003 0,997 cough0,0040,002 0,996 throat symptoms0,004 0,997 pruritus0,0040,002 0,996 urinary frequency0,0040,003 0,997

16. Depressive disorder Somatoform symptomspretestposttest Positive predictive value Negative predictive value tiredness0,014 0,986 fainting0,014 0,986 abdominal pain0,0140,010 0,986 nausea0,0140,021 0,986 constipation0,014 0,986 palpitations0,0140,012 0,986 low back complaint0,0140,007 0,986 chest symptoms0,0140,005 0,986 muscle pain0,0140,008 0,986 headache0,0140,011 0,986 dizziness0,0140,009 0,986 disturbances of sleep0,0140,0260,0250,986 shortness of breath0,0140,0150,0140,986

17. Somatic symptoms pretestposttestPositive predictive value Negative predictive value lymph gland enlargement0,0140,005 0,986 localized abdominal pain0,0140,008 0,986 diarrhea0,0140,013 0,986 red eye0,0140,005 0,986 swollen ankles0,0140,0130,0120,986 shoulder symptoms0,0140,009 0,986 hand/finger symptoms0,0140,006 0,986 Hip symptoms hand/finger symptoms0,0140,005 0,986 tingling fingers/toes/feet0,0140,000 0,986 cough0,0140,008 0,986 throat symptoms0,0140,007 0,986 pruritus0,0140,007 0,986 urinary frequency0,0140,013 0,986

18. Odds Ratios Somatic symptomsAnxiety disorder OR Anxiety disorder 95% CI Depressive disorder OR Depressive disorder 95% CI lymph gland enlargement 2,591,62-4,150,690,43–1,11 localized abdominal pain 1,681,30-2,172,031,79-2,32 diarrhea2,661,98-3,593,022,58-3,55 red eye1,250,59-2,641,471,01-2,14 swollen ankles1,651,23-2,223,052,68-3,47 shoulder symptoms1,591,20-2,111,61,37-1,86 hand/finger symptoms 1,941,39-2,711,841,53-2,22 hip symptoms0,920,55-1,542,061,70-2,51 tingling fingers/toes/feet 2,651,49-4,722,011,40-2,88 cough1,471,21-1,801,841,66-2,04 throat symptoms1,561,17-2,091,561,34-1,83 pruritus2,351,80-3,092,432,09-2,82 urinary frequency2,421,66-3,512,472,01-3,03 Cross-sectional analysis of data with a time frame of one year. Association of somatic symptoms with anxiety and depressive disorder (ORs, 95% CIs)

19. Odds Ratios Somatic symptomsAnxiety disorder OR Anxiety disorder 95% CI Depressive disorder OR Depressive disorder 95% CI lymph gland enlargement 2,591,62-4,150,690,43–1,11 localized abdominal pain 1,681,30-2,172,031,79-2,32 diarrhea2,661,98-3,593,022,58-3,55 red eye1,250,59-2,641,471,01-2,14 swollen ankles1,651,23-2,223,052,68-3,47 shoulder symptoms1,591,20-2,111,61,37-1,86 hand/finger symptoms 1,941,39-2,711,841,53-2,22 hip symptoms0,920,55-1,542,061,70-2,51 tingling fingers/toes/feet 2,651,49-4,722,011,40-2,88 cough1,471,21-1,801,841,66-2,04 throat symptoms1,561,17-2,091,561,34-1,83 pruritus2,351,80-3,092,432,09-2,82 urinary frequency2,421,66-3,512,472,01-3,03 Cross-sectional analysis of data with a time frame of one year. Association of somatic symptoms with anxiety and depressive disorder (ORs, 95% CIs)