Psychiatry and Primary CareDepression and frequent attendance in elderly primary care patients
Introduction
Frequent attenders (FAs) represent a substantial proportion of the workload and a major challenge for primary care physicians (PCPs). As demonstrated by several studies, frequent attendance is related to a complex interaction between a variety of factors including age, gender, socioeconomic status, psychological characteristics, physical disease and psychiatric disorders, including depression [1], [2], [3], [4], [5], [6].
It is well known that FAs are overrepresented in the elderly [7], [8]. With regard to the elderly subjects, physical illness, especially chronic and multiproblematic, is considered the most important predictor of frequent attendance [9], [10]. Depression has not been consistently associated with frequent attendance in primary care [11], [12], although the depressed elderly patients have been shown to use more general medical services than the nondepressed [13], [14], [15] with significantly higher health care costs [16], [17].
The impact of late-life depression on primary care use appears relevant because it is common [18], [19], [20] and often complicated by comorbid physical illness [20], [21], [22] and high levels of functional impairment [13], [23]. Using the cross-sectional data gathered as part of a nationwide project on depressive disorders in primary care, organized by the Institute of Psychiatry of the University of Bologna in cooperation with the Italian Society of General Practitioners [24], the present research aims to examine the relationship between depression and frequent attendance in the elderly. The second aim of the study is to compare prevalence and clinical characteristics of FAs in the elderly and the nonelderly in order to detect possible differences between these two age groups.
Section snippets
Setting and participants
The data presented in this paper are drawn from a national survey on depressive disorders in primary care conducted in 18 out of 20 Italian regions, with the collaboration of 191 PCPs. The study methodology has been described in detail elsewhere [24].
In each administrative region of Italy, 10 PCPs were recruited and trained to the use of study instruments. Because PCP participation was voluntary, no formal selection criteria were adopted, but an effort was made to balance the number of PCPs
Sample characteristics
Of the 1854 PCP attendees who entered in the study, 1239 (66.8%) were women. The mean age of the sample was 49.1 (range, 14–92; S.D.=17.5). The majority of patients were married (66.0%). Regarding occupation, 41.0% of the sample was employed, 28.1% homemaker, 26.7% retired and 4.2% unemployed. About one quarter (24.9%) of the patients had a moderate–severe physical illness. The prevalence of ICD-10 CD was 8.4%. Ten percent of the sample suffered from unexplained somatic complaints. The elderly
Discussion
This large nationwide study examines the effect of depression on the high use of primary care. Our main finding is that depression is a strong risk factor for being an FA in the elderly, independent of other clinical predictors such as physical illness and unexplained somatic complaints. Comparing age groups, depression seems to play a more important role in determining frequent attendance in the elderly compared to the nonelderly patients.
In our sample, the elderly subjects meeting ICD-10
Conclusions
Despite these limitations, our findings highlight that frequent attendance in primary care is associated with depressive disorders. In particular, the depressed elderly patients without clinically relevant physical problems seem to be at a high risk of excess utilization of health services. Depression seems to play a more important role in determining frequent attendance in the elderly patients in respect to the nonelderly. In contrast to most other predictors of high use of services, like
Acknowledgments
This project was carried out with the support of the Italian Society of General Practitioners and the commitment of the participating PCPs. We thank Paolo Carbonatto, Mauro Pigni, Mauro Bertoluzza, Marcello Zancan, Romano Paduano, Alberto Gianmarini Barsanti, Giuseppe Landini, Giancarlo Rasconi, Mario Vichi, Luigi Milani, Damiano Volpone, Pasqualino Lalli, Nicola Tarallo, Gaetano Piccinocchi, Salvatore Moretti, Cosimo Nume, Gennaro Gadaleta Cardarola, Antonio Pompeo Coviello, Bruno Cristiano,
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