COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care

The study of the use of the COOP/WONCA charts in Brazilian primary care is exciting for a number of reasons. To appreciate this it is important, though, to look beyond the context of the actual study of screening for health problems, instruments and their value. The COOP/WONCA charts were designed for a user-friendly, comprehensive assessment of patients functioning. The concept behind ‘functional status’ and its measuring was that this would encapsulate essential characteristics of people [1, 2]: the ability to perform activities of everyday living. This would require physical, mental and social involvement. The ability to achieve this would add substantial information to the health status assessment in the traditional medical context, where the ‘diagnosis’ traditionally always took central stage. Yet, often, ‘self limiting’ acute illness will have limited impact on daily functioning. The same is true for the early phase of chronic diseases. Both self limiting acute, and low symptomatic chronic diseases comprise a substantial part of the morbidity pattern in the primary care population, and this may explain why the interest in generically measuring functional status has come from primary care.

A first important observation from the study of Mazzoncini de Azevado- Marques and Waldo-Zuardi [3] is that the charts – and with it, the concepts of functional status – make sense in the Brazilian (primary) care setting. This is in line with earlier findings of the COOP/WONCA charts being robust in trans-cultural settings [2, 4], although there is evidence that social constraints in certain societies limited its application [5]. The study stresses the value of ‘functional status’ for the international community of primary care. A second important observation is that the authors found a clear relation between ‘depression’ and functional impairment. This is particularly relevant against the concerns of the rather loose and simplistic symptom- based depression diagnostic criteria [6]. It stresses that signs and symptoms, once they have an impact on patients’ daily functioning, pose a relevant case for primary care. Although this does not solve the question whether consequently screening for this condition is appropriate, it points into the direction of how diagnosis, case-finding and screening may be pursued, when appropriate: relating assessment of function to the assessment of symptoms. A third point is the conceptual frame that the charts offer. Mazzoncini de Azevado-Marques and Waldo-Zuardi [3] focus on abnormality: the correlation between impaired functioning and presence of signs and symptoms. The empirical data of COOP/WONCA assessment has been that often functional status is unimpaired in people with a state-of-the-art diagnosis. This, the ‘salutogenic’, as opposed to pathogenic approach to population health, presents in fact a paradigm change in health care. Recently, an international expert meeting proposed to re-define the concept of ‘health’ [7]. In the concept presented by that group, functional status plays an important role to distinguish between illness and disease, and health. It would be interesting to know how and where people with a DSM-compatible diagnosis of depression but unimpaired functioning, differed from those with substantial problems in their daily functioning. This reflects a true paradigm of primary care, that understanding health is as important for patient care as knowing all of diseases.

References

1. Nelson EC, Wassson J, Kirk J, et al. Assessment of function in routine clinical practice: description of the coop charts method and preliminary findings. J Chron Dis 1987; 40 (Suppl 1):55S-64S.

2. Weel, C. van, König Zahn, C., Touw Otten, F.W.M.M., Duijn, N.P. van, & Meyboom de Jong, B. (1995). COOP/WONCA Charts. Groningen: Noordelijke Centrum voor Gezondheidsvraagstukken, 1995. Also: http://www.globalfamilydoctor.com/research/research.asp#R4 (accessed 05 August 2011)

3. Mazzoncini de Azevado-Marques J, Waldo-Zuardi A. COOP/WONCA Charts and Screen for Mental Disorders in Primary Care. Ann Fam Med 2011; 9: 359-365

4. Lam, C.L.K., Weel, C. van, & Lauder, I.J. (1994). Can the Dartmouth COOP/WONCA Charts be Used to Assess the Functional Status of Chinese Patients?. Fam Pract, 11, 85 94.

5. Scholten, J.H.G., van Weel, C. Functional Status Assessment in Family Practice. Lelystad: Medi¬Tekst, 1992. ISBN 90 5070 019 5.

6. Practice guideline for major depressive disorder in adults. American Psychiatric Association. Am J Psychiatry 1993;150:1-26.

7. Huber M Knottnerus AJ, Green L, van der Horst H, Jadad AR, Kromhout D, Leonard B, Lorig K, Loureiro MI, van der Meer JWM, Schnabel P, Smith R, van Weel C, Smid H. How should we define health? BMJ 2011;343:d4163

Competing interests:   None declared