THE DIFFICULT PATIENT - PREVALENCE, PSYCHOPATHOLOGY, AND FUNCTIONAL IMPAIRMENT

OBJECTIVE: To determine the proportion of primary care patients who ar e experienced by their physicians as ''difficult,'' and to assess the association of difficulty with physical and mental disorders, function al impairment, health care utilization, and satisfaction with medical care. DESIGN: Survey. SETTING:Four primary care clinics. PATIENTS: Six -hundred twenty-seven adult patients. MEASUREMENTS: Physician percepti on of difficulty (Difficult Doctor-Patient Relationship Questionnaire) , mental disorders and symptoms (Primary Care Evaluation of Mental Dis orders, PRIME-MD]), functional status (Medical Outcomes Study Short-Fo rm Health Survey [SF-20]), utilization of and satisfaction with medica l care by patient self-report. RESULTS: Physicians rated 96 (15%) of t heir 627 patients as difficult (site range 11-20%). Difficult patients were much more likely than not-difficult patients to have a mental di sorder (67% vs 25%, p < .0001). Six psychiatric disorders had particul arly strong associations with difficulty: multisomato-form disorder (o dds ratio [OR] = 12.3, 95% confidence interval [CI] = 5.9-25.8), panic disorder (OR = 6.9, 95% CI = 2.6-18.1), dysthymia (OR = 4.2, 95% CI = 2.0-8.7), generalized anxiety (OR = 3.4, 95% CI = 1.7-7.1), major dep ressive disorder (OR = 3.0, 95% CI = 1.8-5.3), and probable alcohol ab use or dependence (OR = 2.6, 95% CI = 1.01-6.7). Compared with not-dif ficult patients, difficult patients had more functional impairment, hi gher health care utilization, and lower satisfaction with care, wherea s demographic characteristics and physical illnesses were not associat ed with difficulty. The presence of mental disorders accounted for a s ubstantial proportion of the excess functional impairment and dissatis faction in difficult patients. CONCLUSIONS: Difficult patients are pre valent in primary care settings and have more psychiatric disorders, f unctional impairment, health care utilization, and dissatisfaction wit h care. Future studies are needed to determine whether improved diagno sis and management of mental disorders in difficult patients could dim inish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians' experience of difficulty .