JGAP Grant Final Written Report – Grant Code G0608
To Department of Family Practice, Michigan State University
For Project Titled “Depression, Anxiety and Health Risk Behaviors: What is the Real Scope of the
Problem in Primary Care?”
Jodi Summers Holtrop, PhD, Principal Investigator
Grant Period from January 1, 2007 through June 30, 2009
BACKGROUND
The leading causes of death in the U.S. are tobacco use, physical inactivity/poor diet and alcohol use.1
Serious efforts are needed to decrease the prevalence of these unhealthful behaviors in the population in order
to reduce the associated morbidity and mortality. A potentially large proportion of these individuals are those
with co-occurring depression and/or anxiety. Numerous studies have documented an association of
depression and/or anxiety disorders with tobacco use and heavy alcohol use2-7 as well as with co-morbid
conditions often resulting from obesity and/or poor diet and lack of physical activity.8-11
Only two studies were found that measured health behaviors and depression concurrently specifically in
primary care populations. Brown, et al., (2000) found that nicotine dependence was significantly associated
with symptoms of depression in that 26% of nicotine dependent patients reported depressive symptoms
compared with 12% of never smokers.12 The study was limited in that only two urban internal medicine
practices in a university-affiliated system were included and surveyed only 526 patients. Rowe, et al., (1995)
assessed correlates of depression in primary care, surveying 1898 patients in 88 primary care offices. A
significant relationship was found between depression and cigarette smoking, heavy alcohol heavy drinking,
binge drinking, and scores on the CAGE (an alcohol dependency screening measure). The relationship with
depression was more than 50% higher in persons who drank five or more drinks per day than for lighter
drinkers. The rate of depression in that primary care sample was approximately double the general
population.13 That study, however, is now over 10 years old and was conducted only in urban settings. Less is
known about the co-occurrence of overweight or obesity with depression or with anxiety. Recent studies of
overweight and obesity find opposing results regarding the association between depression and anxiety
disorders and overweight.14, 15
Lacking in the literature is a current, comprehensive description of how these unhealthful behaviors are related
to these mental health conditions in primary care populations. Therefore, the purpose of this study was to
determine the prevalence of depression and anxiety in patients with unhealthful behaviors in primary care
practice. The results of this research may inform future efforts to impact upon unhealthful behaviors within the
primary care setting.
METHODS
Settings and Participants
Practices were recruited for participation from within the Great Lakes Research Into Practice Network (GRIN),
Michigan’s statewide primary care practice-based research network (PBRN). First, an analysis was conducted
to determine the state’s primary care distribution both geographically and representing different community
types (urban, rural, suburban). Practices were also recruited based on the distribution of the patient population
with respect to race/ethnicity and income that represents the distribution of these characteristics in Michigan.
Practices were recruited for participation from within the GRIN database of practices. An initial letter was sent
to the practice contact describing the study, benefits, and requirements of participation and follow-up calls were
made until the practice consented to participating or declined. Because GRIN lacked enough practices in some
geographic regions of the state, other contacts were made to identify suitable practices. The practices were
found by searching telephone directories, on the internet and through inquiries to known individuals in those
areas.
Measures and Data Collection
Data for this study was collected by consecutive anonymous patient survey. Although random sampling of
patients would be ideal, practical considerations including a likely low response rate to a mailed survey and
practice staffs burden and expense, it was determined that across a large number of practices, representative
data sets could be obtained by consecutive patient sampling. An additional goal was to develop a survey that
was able to be reasonably completed by patients within 10 minutes while awaiting their medical visit.
A written survey instrument was developed to assess the presence of the variables under study (described
below). Study hired and trained research assistants distributed the survey to every adult (over age 18) patient
in consecutive order, using a waiting room intercept approach until 120 surveys were completed per practice.
This resulted in a variable number of days spent at each practice, but generally was 2-3 total days. The
research assistant used a scoring sheet to calculate refusals, completed surveys, and surveys completed with
assistance. No incentive was given for completion of the survey. The survey was written in English only,
therefore, participants needed to be able to read English and complete the survey unassisted. In a minimal
number of circumstances, a private room for the research assistant to read the survey to patients was
available. There were eight practices with a low patient volume (such as single doctor practices) in which the
research assistant instead trained the reception staff to distribute the survey and provided the survey packets
(cover letters and surveys) and thus the surveys were distributed by the reception staff. Practices were paid a
small amount for their time in doing so.
The survey assessed patient factors in the following categories: demographics and background, health
behaviors, and mood disorders.
Demographics/Background: Patients demographic data included age, race, ethnicity, gender, level of
education, number of years as a patient at the practice, and health insurance. Health status was measured
using the one global assessment question that measures Self-Reported Health (that is, "Would you say that in
general your health is excellent, very good, good, fair, or poor?") which has a substantial research track for its
usefulness in community studies,16 and the presence of chronic conditions by one question “Have you ever
been told by a doctor that you have any of the following?” with a list of common chronic conditions for the
answers.
Health Behaviors: Two behaviors (tobacco use, alcohol use) and one clinical health risk indicator (body
mass index/obesity) were assessed. These were determined to be the most prevalent and detrimental health
behaviors in general primary care. Tobacco use was assessed using the two standard questions adopted from
the Behavior Change consortium recommendations17, 18 which include: “Have you smoked 100 cigarettes in
your entire life?” and “Have you smoked a cigarette, even a puff, in the past 7 days?” Patients answering “yes”
to the first question were considered past smokers. Those answering “yes” to both questions were considered
current smokers. For those answering “yes” to smoking in the past 7 days, two questions considered the best
predictors of nicotine dependence were used from the Fagerstrom Test for Nicotine Dependence (FTND)19
including number of cigarettes per day and time to first cigarette. Additionally, one question was asked
regarding other tobacco use in the past 30 days.
Alcohol use was measured using five questions from the Behavioral Risk Factor Surveillance Survey
(BRFSS) and assessed any alcohol use, volume of alcohol use and binge drinking in the past 30 days.20
Although it would be ideal to measure patient physical activity and diet to assess these health behaviors, there
is a lack of well-validated, reliable, self-administered, written instruments that is short enough to be
administered in time-constrained primary care.21 Therefore, we chose instead to ask about height and weight
and calculate a body mass index (BMI) as a measure of overweight and obesity. We realize this is not a
substitute for measurements of diet and physical activity, but provides some insight into potential diet and
physical activity behaviors.
Mood Disorders: Current depressive symptoms were measured using the Patient Health Questionnaire
(PHQ)-8, an 8 question depression screening and severity assessment commonly used in primary care.22, 23
We used the 8 instead of 9 question assessment because the PHQ-9 includes a question regarding thoughts
of harming self. Since this was an anonymous survey, we did not wish to burden practice staff with review of
this answer for safety concerns. Therefore, we omitted this question. History of depression was assessed by
the question “Have you been diagnosed by a doctor as having depression?” and depression medication-taking
by the question “Are you currently taking any medication for depression?”
Current anxiety symptoms were measured using the Generalized Anxiety Disorder (GAD)-7, a parallel
instrument to the PHQ-8 and developed for use in primary care.24 Anxiety history was assessed by the question:
”Have you been diagnosed by a doctor as having either anxiety or panic attacks?” and anxiety medication taking
by the question “Are you currently taking any medication for anxiety?”
Analysis
The written survey data was hand entered, cross-checked and cleaned by trained research assistants using a
specially-designed FileMaker Pro database. These data were then exported to the STATA 10.0 program for
analysis. The analysis accounted for the differing variance between practice clusters and the variable sampling
fractions due to practice size. Descriptive and summary statistics were calculated for demographics, single and
multiple health behaviors and mood disorders, and their combinations. Bivariate analysis included
chi-square tests of the relationships in each of the contingency tables.
RESULTS
Thirty-eight primary care practices in Michigan
participated in the study; 31 family medicine, 3 internal
medicine and 4 family/internal. Different community
types were represented with 12 urban, 13 rural, and 13
suburban practices participating. The total number of
patient surveys completed was 4,469 with an 83.4%
completion rate. The average patient age was 49.1
(+17.2) and the average number of years a person was a
patient at the practice was 9.2 (+9.1). The survey results
are depicted in tables 1-6.
Table 1 describes the demographic characteristics of the
patients participating in the survey which represents the
demographic breakdown of the state of Michigan. The
mean age was 49.1 (SD=17.2; range 18-96) and the
means years as a patient in that practice was 9.2
(SD=9.1; range 0-70). Patients were predominantly
female, white, had at least some college education, and
privately insured.
Table 1: Patient Demographics
Number Percent
Gender
N=4,449*
Female
2,963
66.6
Male
1,486
33.4
Education
N=4,450
Less than high school
353
7.9
High school graduate
1,336
30.0
Some college
1,503
33.8
College graduate
1,258
28.3
Race **
N=4,459
White
3,652
81.9
Black or African American
653
14.6
Asian
34
0.8
American Indian
113
2.5
Other
105
2.4
Ethnicity
Hispanic/Latino/a
144
3.4
Health insurance**
N=4,456
Private insurance
3,048
68.4
Medicaid
736
16.5
Medicare
1,072
24.1
No insurance
195
4.4
Other
334
7.5
Table 2 describes the health behaviors, including the
percentage of respondents with each and combinations
*Percentages within each category are calculated out of the
of the health behaviors. The mean BMI was 29.4
patients who responded to that particular question noted as
(SD=7.3; range 14.9-82.8). The rate of current smoking
the category N. **Percentages add up to more than100%
(defined as one cigarette, even a puff, in the past 7 days)
because the respondent could check more than one box
is higher than the state reported adult smoking rate
(answer) for the survey question.
according to the Michigan Behavioral Risk Factor
Surveillance Survey (24.5% versus 20.5%).25 Smokers smoked an average of 13.5 cigarettes per day (SD=9.5;
range 0-60) and 18% and 40% smoked within 5 and 30 minutes of arising, respectively.
Table 2: Patient Health Behaviors
TOBACCO USE
Currently Smoke (defined as having a
cigarette in the past 7 days + 100 cigs life)
Of current smokers, those whose first cigarette
is
<=5 minutes of awakening
Of current smokers, those who are “somewhat”
or “very” motivated to quit
Of current smokers, the average number of
cigarettes smoked per day
Use Other Tobacco Products (defined as any
tobacco use other than cigarettes in the past
30 days)
ALCOHOL USE
Currently drink alcohol (defined as having at least
one drink of any alcoholic beverage in the past 30
days)
Of current drinkers, those who had 5 or more
drinks on one occasion in past 30 days
Of current drinkers, those who are “somewhat”
or
“very” motivated to stop or reduce alcohol use
BODY MASS INDEX (BMI)
Underweight (BMI < 18.5)
Normal weight (BMI 18.5 – 24.9)
Overweight (BMI 25.0 – 29.9)
Obese (BMI > 30)
Of overweight or obese respondents, those
who
are “somewhat” or “very” motivated to:
-Eat healthier
-Exercise
-Lose weight
MULTIPLE BEHAVIORS
Smoke + Binge Drink
Smoke + Overweight/Obese
Binge Drink +
Overweight/Obese
Smoke + Binge Drink +
Overweight/Obese
N=4,385
Number
Percent
1,075
24.5
190
18.3
883
85.3
13.5 (±9.5)
0-60
N/A
249
5.8
N=4,432
Number
Percent
2,160
48.7
167
7.7
457
21.2
N=4,302
Number
62
1,178
1,414
1,648
2,557
2,602
2,602
Responden
ts
4,341
4,228
Percent
1.4
27.4
32.9
38.3
93.9
93.0
93.0
Percent
6.4
16.5
4,252
9.6
4,469
3.7
*Calculated out of respondents answering, excluding missing values.
Table 3 describes the prevalence of
mood disorders in the population.
The data indicates that depression
and anxiety are prevalent in primary
care patients and there is a high
degree of overlap in medication
taking for the two conditions.
Table 4 describes the prevalence of
health behaviors in the context of
mood disorders. The analysis
reveals significant relationships
between smoking and both
depression and anxiety, and
depression and high BMI, but not
other behaviors.
Table 3: Patient Mood Disorders
DEPRESSION
Number
Percent
Depressive Symptoms (PHQ-8)
N=4,271
None (0 – 4)
2,491
58.3
Mild (5 – 9)
1,040
24.4
Moderate (10 – 14)
425
10.0
Moderate-severe (15 – 19)
210
4.9
Severe (> 19)
105
2.5
Taking Medication for Depression
N=4,365
Yes
899
20.6
Diagnosis of Depression
N=4,438
Yes
1,426
32.1
ANXIETY
Number
Percent
Anxiety Symptoms (GAD-7)
N=4,340
None (0 – 4)
2,839
65.4
Mild (5 – 9)
963
22.2
Moderate (10 – 14)
514
11.8
Severe (> 14)
24
0.6
Taking Medication for Anxiety
N=4,326
Yes
618
14.3
Diagnosis of Anxiety
N=4,431
Yes
1,087
24.5
Table 4: Patient Health Behaviors and Mood Disorders
Smoking
DEPRESSION
Percent of Smokers
**Current moderate-severe or severe symptoms (N=4,196)
29.3
**History of depression (N=4,359)
42.5
**Taking medication for depression (N=4,291)
26.3
ANXIETY
**Current moderate-severe symptoms (N=4,263)
21.9
**History of anxiety (N=4,352)
33.9
**Taking medication for anxiety (N=4,248)
19.4
Alcohol Use (Binge drinking in past month)
Percent of Binge
DEPRESSION
Drinkers
Current moderate-severe or severe symptoms (N=4,220)
16.6
History of depression (N=4,383)
32.9
*Taking medication for depression (N=4,313)
17.2
ANXIETY
Current moderate-severe symptoms (N=4,288)
13.8
History of anxiety (N=4,376)
26.6
Taking medication for anxiety (N=4,272)
14.2
Body Mass Index (BMI)
Percent of those w/
DEPRESSION
BMI < 25
***Current moderate-severe or severe symptoms (N=4,125)
14.5
*History of depression (N=4,274)
29.2
**Taking medication for depression (N=4,222)
16.5
ANXIETY
Current moderate-severe symptoms (N=4,189)
11.6
History of anxiety (N=4,267)
23.8
Taking medication for anxiety (N=4,171)
12.9
Significant difference in groups: *=p<0.05, **=p<0.01, ***=p<0.001
Percent of
Non-smokers
13.3
28.6
18.7
9.2
21.5
12.5
Percent of Nonbinge Drinkers
17.4
32.1
21.2
12.2
24.2
14.2
Percent of those
with BMI > 25
18.4
33.2
22.0
12.7
24.8
14.6
Tables 5 and 6 describe participant’s selfreported practice assessment of their health
behaviors and mood disorders and indicates
practice factors involved in these issues.
DISCUSSION
In summary, poor health behaviors are prevalent
and overlap significantly with mood disorders in
primary care. There is an especially strong
relationship between current smoking and mood
disorders.
Table 5: Patient Responses to Survey Question: Has
anyone in this practice ever asked if you…
Number*
Percent
Smoke or use tobacco?
3,808
88.9
Drink alcohol?
3,662
85.6
Are trying to lose weight?
2,062
49.1
Eat a healthy or nutritious
2,843
68.6
diet?
Are physically active or
3,239
77.2
exercise?
Are depressed?
1,127
26.2
Are anxious?
807
18.9
*Number of respondents who answered “yes” to the survey question.
Study limitations include the fact that patients
self-reported information and they could have been
incorrect or misrepresented their results. This is
Table 6: Patient Responses to Survey Question: Have you
ever been told by a doctor that you have:
somewhat common in surveys of health
behaviors, especially height/weight and alcohol
Number*
Percent
use. Patients may have incorrectly reported their
Hypertension/high blood
1,720
38.5
pressure?
use of depression or anxiety medication taking,
Asthma?
719
16.1
either intentionally or due to not understanding
Congestive heart failure?
192
4.3
the intended use of the medication they are
High
cholesterol?
1,556
34.8
taking. Given the limited number of surveys
Diabetes?
646
14.5
collected from each practice, this study was not
Coronary
heart
meant to represent any one practice, but to paint
292
6.5
disease/heart attack?
a picture of the prevalence of these conditions
Pulmonary disease (COPD
overall. Response rates to the survey were high
225
5.0
or emphysema)?
and averaged 83.4%. Due to the anonymous
Other condition?
641
14.4
nature of the survey distributed in practice
* Number of respondents who answered “yes” to the survey question.
waiting rooms, we were not able to administer
the survey to patients who could not read in English, therefore, some patients were not represented. Also, as
this study was conducted in Michigan, it was not meant to represent patients in other settings outside the state.
The study results represent primarily family medicine practices rather than other types of primary care practice
settings.
These results have potential implications for how preventive care is delivered in primary care. Since patients
present with overlapping health behavior and mood disorders, perhaps combination treatment is warranted.
Should depression or anxiety be a pre-treatment sequential to health behavior change, integrated together into
one approach, or handled separately, but at the same time? This study was not constructed to answer these
questions, but provides the evidence that health behaviors and mood disorders are significantly related and
perhaps provide a barrier for one another to improve either. Future research should investigate potential
mechanisms of action and investigate treatment efficacy for these patients. Clinicians should be aware of the
overlapping nature of health behaviors and mood disorders and consider the prevalence in planning quality
improvement in their practices and in care planning with individual patients.
Regarding this study, the following four presentations have been completed thus far. Further publications and
presentations are being planned.
 Holtrop J Summers, Rios-bedoya C, Pomerleau C, Nease D, Weismantel D, Fitzpatrick L. The
Overlap of Depression and Anxiety With Unhealthful Behaviors In Primary Care. NAPCRG, Montreal,
Canada, November 14-16, 2009.
 Holtrop J Summers, Rios-bedoya C, Pomerleau C, Nease D, Weismantel D, Fitzpatrick L. Multiple
Health Risks In Adult Primary Care Patients. NAPCRG, Montreal, Canada, November 14-16, 2009.
 Holtrop J Summers, Rios-Bedoya CF, Pomerleau C, Nease D, Weismantel D. The Overlap of
Tobacco Use with Depression and Anxiety in Primary Care. Society for Research on Nicotine and
Tobacco. Dublin, Ireland, April 27-30, 2009.

Holtrop J, Rios-Bedoya C, Weismantel D, Holtrop D. Depression, Anxiety and Health Behaviors: What
is the Real Scope of the Problem in Primary Care? North American Primary Care Research Group, Rio
Grande, Puerto Rico, November, 2008.
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