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Chaabouni A, Houwen J, Grewer G, Liebau M, Akkermans R, van Boven K, Walraven I, Schers H, Olde Hartman T. The burden of persistent symptom diagnoses in primary care patients: a cross-sectional study. Scand J Prim Health Care 2024; 42:112-122. [PMID: 38189313 PMCID: PMC10851811 DOI: 10.1080/02813432.2023.2293930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION The burden of symptoms is a subjective experience of distress. Little is known on the burden of feeling unwell in patients with persistent symptom diagnoses. The aim of this study was to assess the burden in primary care patients with persistent symptom diagnoses compared to other primary care patients. METHODS A cross-sectional study was performed in which an online survey was sent to random samples of 889 patients with persistent symptom diagnoses (>1 year) and 443 other primary care patients after a transactional identification in a Dutch primary care data registry. Validated questionnaires were used to assess the severity of symptoms (PHQ-15), Symptom Intensity and Symptom Interference questionnaires, depression (PHQ-9), anxiety (GAD-7), quality of life (SF-12 and EQ-5D-5L)) and social functioning (SPF-ILs). RESULTS Overall, 243 patients completed the survey: 178 (73.3%) patients in the persistent symptom diagnoses group and 65 (26.7%) patients in the control group. In the persistent group, 65 (36.5%) patients did not have persistent symptom(s) anymore according to the survey response. Patients who still had persistent symptom diagnoses (n = 113, 63.5%) reported significantly more severe somatic symptoms (mean difference = 3.6, [95% CI: 0.24, 4.41]), depression (mean difference = 3.0 [95% CI: 1.24, 3.61]) and anxiety (mean difference = 2.3 [95% CI: 0.28, 3.10]) and significantly lower physical functioning (mean difference = - 6.8 [95% CI: -8.96, -3.92]). CONCLUSION Patients with persistent symptom diagnoses suffer from high levels of symptoms burden. The burden in patient with persistent symptoms should not be underestimated as awareness of this burden may enhance person-centered care.
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Affiliation(s)
- Asma Chaabouni
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Juul Houwen
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Georg Grewer
- USUMA Markt- und Sozialforschung GmbH, Berlin, Germany
| | - Martin Liebau
- USUMA Markt- und Sozialforschung GmbH, Berlin, Germany
| | - Reinier Akkermans
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kees van Boven
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Iris Walraven
- Department for Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henk Schers
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tim Olde Hartman
- Department of Primary and Community care, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Pozuelo Moyano B, Duquenne C, Favrat B, Francois-Xavier B, Kokkinakis I, Tzartzas K. Clinical impact and misdiagnosis of functional ophthalmological symptoms: a case report. J Med Case Rep 2023; 17:340. [PMID: 37563729 PMCID: PMC10416532 DOI: 10.1186/s13256-023-04063-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/02/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND There is a high prevalence of somatoform disorders and medically unexplained symptoms. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder. The case presented demonstrates the impact on disability benefits and the subsequent psychosocial repercussions of misdiagnosing between a factitious disorder and a somatoform disorder. CASE PRESENTATION A 42-year-old Caucasian woman worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Afterward, she developed total blindness, not explained by a physiological process, accompanied by distress in a crucial emotional context. We evaluated the patient for a revision of a disability income after a diagnosis of factitious disorder with severe consequences such as disability income suspension and family conflict. Our psychiatric examination concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance. CONCLUSIONS Blindness not explained by a physiological process may accompany trauma and psychological distress. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.
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Affiliation(s)
- Beatriz Pozuelo Moyano
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - Catherine Duquenne
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - Bernard Favrat
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | | | - Ioannis Kokkinakis
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - Konstantinos Tzartzas
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
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Bokov P, Peiffer C, Gallego J, Pautrat J, Matrot B, Delclaux C. A decrease in plant gain, namely CO 2 stores, characterizes dysfunctional breathing whatever its subtype in children. Front Physiol 2023; 14:1217391. [PMID: 37469562 PMCID: PMC10352948 DOI: 10.3389/fphys.2023.1217391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Background: Whether dysfunctional breathing (DB) subtype classification is useful remains undetermined. The hyperventilation provocation test (HVPT) is used to diagnose DB. This test begins with a 3-min phase of hyperventilation during which fractional end-tidal CO2 (FETCO2) decreases that could be an assessment of plant gain, which relies on CO2 stores. Our aim was to assess 1) whether the children suffering from different subtypes of DB exhibit decreased plant gain and 2) the relationships between HVPT characteristics and plant gain. Methods: We retrospectively selected 48 children (median age 13.5 years, 36 females, 12 males) who exhibited during a cardiopulmonary exercise test either alveolar hyperventilation (transcutaneous PCO2 < 30 mmHg, n = 6) or inappropriate hyperventilation (increased VE'/V'CO2 slope) without hypocapnia (n = 18) or dyspnea without hyperventilation (n = 18) compared to children exhibiting physiological breathlessness (dyspnea for sports only, n = 6). These children underwent tidal-breathing recording (ventilation and FETCO2 allowing the calculation of plant gain) and a HVPT. Results: The plant gain was significantly higher in the physiological group as compared to the dyspnea without hyperventilation group, p = 0.024 and hyperventilation without hypocapnia group, p = 0.008 (trend for the hyperventilation with hypocapnia group, p = 0.078). The slope of linear decrease in FETCO2 during hyperventilation was significantly more negative in physiological breathlessness group as compared to hyperventilation without hypocapnia group (p = 0.005) and dyspnea without hyperventilation group (p = 0.049). Conclusion: The children with DB, regardless of their subtype, deplete their CO2 stores (decreased plant gain), which may be due to intermittent alveolar hyperventilation, suggesting the futility of our subtype classification.
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Affiliation(s)
- Plamen Bokov
- Service de Physiologie Pédiatrique -Centre du Sommeil—CRMR Hypoventilations Alvéolaires Rares, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, Université de Paris, Paris, France
| | - Claudine Peiffer
- Service de Physiologie Pédiatrique, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Robert Debré, Paris, France
| | - Jorge Gallego
- INSERM NeuroDiderot, Université de Paris, Paris, France
| | - Jade Pautrat
- Service de Physiologie Pédiatrique, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Robert Debré, Paris, France
| | - Boris Matrot
- INSERM NeuroDiderot, Université de Paris, Paris, France
| | - Christophe Delclaux
- Service de Physiologie Pédiatrique -Centre du Sommeil—CRMR Hypoventilations Alvéolaires Rares, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, Université de Paris, Paris, France
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Hüsing P, Smakowski A, Löwe B, Kleinstäuber M, Toussaint A, Shedden-Mora MC. The framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSY-PSS). Front Psychiatry 2023; 14:1142484. [PMID: 37091694 PMCID: PMC10113674 DOI: 10.3389/fpsyt.2023.1142484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/16/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Numerous psychological factors are believed to play a pivotal role in the development and maintenance of persistent somatic symptoms (PSS) in all fields of medicine. However, very few of these factors have been empirically investigated in relation to PSS. The aim of this study is firstly to propose a framework and define search terms for systematic reviews on the empirical evidence and diagnostic value of psychological risk factors for PSS and PSS-related outcomes (PSY-PSS). Secondly, the application of the framework is illustrated using the example of a systematic review on the relevance of psychological factors in somatic symptom disorders (SSD; DSM-5) and bodily distress disorders (BDD; ICD-11). Methods Following a narrative review approach, two comprehensive lists of search terms to identify studies in (1) relevant patient groups with PSS and (2) relevant psychological factors were generated by reviewing the current literature and employing an iterative process of internal revision and external expert feedback. Results We identified 83 relevant symptoms, syndromes and disorders for which we defined a total of 322 search terms (list 1). We further comprised 120 psychological factors into 42 subcategories and 7 main categories (list 2). The introduced lists can be combined to conduct systematic reviews on one or more specific psychological factors in combination with any symptom, syndrome or disorder of interest. A protocol of the application of this framework in a systematic review and meta-analysis on psychological etiological factors of SSD and BDD is presented following the PRISMA guidelines. Discussion This framework will help to gather systematic evidence on psychological factors in order to improve the understanding of the etiology of PSS, to refine future diagnostic conceptualizations of PPS, and to develop optimized mechanism-based interventions for individuals with PPS and related syndromes and disorders.
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Affiliation(s)
- Paul Hüsing
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Abigail Smakowski
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Kleinstäuber
- Department of Psychology, Utah State University, Logan, UT, United States
| | - Anne Toussaint
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Crosky S, McFarlin M, Sullivan N, Winograd D, Litke D, Masheb RM, Lu SE, Costanzo M, Anastasides N, Gonzalez C, Doshi J, Graff F, Khatib L, Thien S, McAndrew LM. Randomized controlled trial protocol of health coaching for veterans with complex chronic pain. Trials 2023; 24:239. [PMID: 36997946 PMCID: PMC10061706 DOI: 10.1186/s13063-023-07113-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/23/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Pain predominant multisymptom illness (pain-CMI) refers to symptom-based conditions where pain is a primary symptom. There is initial evidence that health coaching may be efficacious in treating pain-CMI because it can be tailored to the veteran's goals and emphasizes long-term behavior change, which may indirectly impact the maintaining factors of pain-CMI (e.g., catastrophizing, poor pain control, and limited activity). This paper describes the study protocol and rationale of a randomized controlled trial that will compare the efficacy of remote-delivered health coaching in reducing disability and pain impairment for veterans with pain-CMI to remote-delivered supportive psychotherapy. METHODS This randomized controlled trial will consist of two treatment arms: remote-delivered health coaching and remote-delivered supportive psychotherapy, the active control. Each treatment condition will consist of twelve, weekly one-on-one meetings with a study provider. In addition to the baseline assessment, participants will also complete 6-week (mid-treatment), 12-week (post-treatment), and 24-week (follow-up) assessments that consist of questionnaires that can be completed remotely. The primary aims for this study are to determine whether health coaching reduces disability and pain impairment as compared to supportive psychotherapy. We will also examine whether health coaching reduces physical symptoms, catastrophizing, limiting activity, and increasing pain control as compared to supportive psychotherapy. DISCUSSION This study will contribute to the existing literature on pain-CMI and report the effectiveness of a novel, remote-delivered behavioral intervention.
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Affiliation(s)
- Sarah Crosky
- Department of Educational and Counseling Psychology, University at Albany-State University of New York, Albany, USA
| | - Mikhaela McFarlin
- Department of Educational and Counseling Psychology, University at Albany-State University of New York, Albany, USA
| | - Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Darren Winograd
- Department of Educational and Counseling Psychology, University at Albany-State University of New York, Albany, USA
| | - David Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Robin M Masheb
- VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA
- Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06610, USA
| | - Shou-En Lu
- Epidemiology and Statistics, School of Public Health, Rutgers University, Piscataway, NJ, 08854, USA
| | - Michelle Costanzo
- War Related Illness and Injury Study Center, Washington DC VA Medical Center, 50 Irving St. NW, Washington, DC, 20422, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nicole Anastasides
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Christina Gonzalez
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Jaineel Doshi
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Fiona Graff
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Linda Khatib
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Scott Thien
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA.
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Wortman MSH, Olde Hartman TC, van der Wouden JC, Dankers S, Visser B, Assendelft WJJ, van der Horst HE. Perceived working mechanisms of psychosomatic therapy in patients with persistent somatic symptoms in primary care: a qualitative study. BMJ Open 2022; 12:e057145. [PMID: 35022178 PMCID: PMC8756260 DOI: 10.1136/bmjopen-2021-057145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To explore the perceived working mechanisms of psychosomatic therapy according to patients with persistent somatic symptoms (PSS) and their psychosomatic therapists. DESIGN Qualitative study using semistructured face-to-face interviews and focus groups. All interviews were audiorecorded, transcribed verbatim and analysed, by two researchers independently, based on the thematic analysis. SETTING Alongside a randomised controlled trial to establish the (cost-)effectiveness of psychosomatic therapy in patients with PSS in primary care, we conducted a process evaluation with a qualitative study. Patients were recruited in general practice in three regions in the Netherlands. PARTICIPANTS Interviews were conducted with twenty patients with PSS who received psychosomatic therapy and 25 psychosomatic therapists. In addition, two focus groups were conducted with six and seven psychosomatic therapists, respectively. INTERVENTION Psychosomatic therapy, delivered by specialised exercise and physical therapists, is a multimodal and tailored treatment based on the biopsychosocial model. OUTCOME MEASURES Experiences, opinions and views from patients' and therapists' perspective on psychosomatic therapy were identified. RESULTS A total of 37 interviews with patients, 25 interviews and two focus groups with therapists were analysed. Three main themes emerged from the data of the patients: (1) continuous alternation of psychosocial conversations and body-oriented exercises; (2) awareness of body-mind connection and (3) good relationship with therapist. Four main themes emerged from the data of the therapists (1) building rapport; (2) continuously searching for common ground; (3) making patients aware of the interaction between body and mind; and (4) continuous alternation between exploration and treatment. CONCLUSION According to patients as well as therapists, the continuous alternation of psychosocial conversations and body-oriented exercises to provide awareness of the interaction between body and mind are the perceived working mechanism of psychosomatic therapy. Therapeutic alliance and finding common ground between patient and therapist are prerequisites for the success of psychosomatic therapy. TRIAL REGISTRATION NUMBER NL7157 (NTR7356).
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Affiliation(s)
- Margreet S H Wortman
- Department of General Practice, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Sarah Dankers
- Department of General Practice, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Bart Visser
- Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen, Nijmegen, The Netherlands
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The randomized clinical trial results of the anxiety treatment in patients with somatoform dysfunction and neurotic disorders. Sci Rep 2021; 11:24282. [PMID: 34930979 PMCID: PMC8688518 DOI: 10.1038/s41598-021-03727-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
The existing treatments for somatoform dysfunction (SfD), reaction to severe stress (RSS), and adjustment disorders (AjD) are insufficiently effective and safe. Anxiolytic drug Tenoten proved effective in clinical trials (CT). The aim of this multicenter double-blind placebo-controlled randomized CT was to investigate the safety and efficacy of Tenoten in the treatment of anxiety in adults with SfD, RSS, AjD and other neurotic disorders (oNDs). 390 adult patients with SfD, RSS and AjD or oNDs with the Hospital Anxiety and Depression scale-anxiety (HADS-A) score ≥ 11 were randomized into 4 groups (n = 127 in Tenoten group 1 (4 tablets/day); n = 131 in Tenoten group 3 (8 tablets/day), n = 132 in combined Placebo group 2 + 4). The changes from baseline in the mean Hamilton Anxiety Rating Scale (HAM-A) score in groups 1 and 3 after 12 weeks were the primary outcome. The decrease of the HAM-A score from 18.81 ± 5.81 to 7.26 ± 4.63 (in group 1) and from 18.38 ± 4.3 to 6.40 ± 4.02 (in group 3) was observed post-treatment (pgroup 1/placebo = 0.0055, pgroup 3/placebo < 0.0001). Overall, 46 adverse events (28 in the Tenoten groups and 18 in the Placebo) were reported without any difference between the study groups. Tenoten performed significantly more effective than placebo in the anxiety treatment of adults with SfD, RSS, AjD and oNDs (clinicaltrials.gov NCT03036293).
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The effects of music listening on somatic symptoms and stress markers in the everyday life of women with somatic complaints and depression. Sci Rep 2021; 11:24062. [PMID: 34911978 PMCID: PMC8674261 DOI: 10.1038/s41598-021-03374-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/30/2021] [Indexed: 12/18/2022] Open
Abstract
Despite a growing body of literature documenting the health-beneficial effects of music, empirical research on the effects of music listening in individuals with psychosomatic disorders is scarce. Using an ambulatory assessment design, we tested whether music listening predicts changes in somatic symptoms, subjective, and biological stress levels, and examined potential mediating processes, in the everyday life of 58 women (M = 27.7 years) with somatic symptom disorder (SSD) and depressive disorders (DEP). Multilevel models revealed that music listening predicted lower subjective stress ratings (p ≤ 0.02) irrespective of mental health condition, which, in turn, predicted lower somatic symptoms (p ≤ 0.03). Moreover, specific music characteristics modulated somatic symptoms (p = 0.01) and autonomic activity (p = 0.03). These findings suggest that music listening might mitigate somatic symptoms predominantly via a reduction in subjective stress in women with SSD and DEP and further inform the development of targeted music interventions applicable in everyday life.
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Toonders SAJ, van Westrienen PE, Konings S, Nieboer ME, Veenhof C, Pisters MF. Patients' Perspectives on the Usability of a Blended Approach to an Integrated Intervention for Patients With Medically Unexplained Physical Symptoms: Mixed Methods Study. J Med Internet Res 2021; 23:e19794. [PMID: 34581674 PMCID: PMC8512187 DOI: 10.2196/19794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/17/2020] [Accepted: 10/28/2020] [Indexed: 12/16/2022] Open
Abstract
Background Medically unexplained physical symptoms are physical symptoms, such as pain, fatigue, and dizziness, that persist for more than a few weeks and cannot be explained after adequate medical examination. Treatment for preventing the chronicity of symptoms is recommended. A promising approach is identifying patients who are at risk and subsequently offering a blended care intervention that focuses on promoting self-management while using eHealth as a supportive tool. When these interventions match with a patient’s expectations, their effectiveness grows. Objective This study aimed to obtain more insights into usability from the patient perspective to improve future interventions. Methods A mixed methods design (ie, the use of qualitative and quantitative data) was used. Through semistructured interviews, in-depth insights were gained into patients’ perspectives on usability. The analysis process was continuous and iterative. Data were synthesized and categorized into different themes. The System Usability Scale, which measures the usability of a system, was used to compare participants that found usability to be low, medium, or high. This study was approved by the Medical Ethical Committee Utrecht (approval number: 17-391/C). Results Saturation was reached after interviewing 13 participants. The following four themes emerged from the interviews: motivations and expectations prior to participating in the program, the applicability of e-coaching, the role of health care professionals, and the integrated design of the blended approach. Conclusions The successful implementation of integrated blended care interventions based on patients’ perspectives requires matching treatments to patients’ individual situations and motivations. Furthermore, personalizing the relative frequency of face-to-face appointments and e-coaching can improve usability.
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Affiliation(s)
- Suze Adriana Johanna Toonders
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, Netherlands.,Physical Therapy Research Group, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Paula Elisabeth van Westrienen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, Netherlands.,Physical Therapy Research Group, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sophie Konings
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.,Physical Therapy Sciences Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marianne E Nieboer
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
| | - Cindy Veenhof
- Physical Therapy Research Group, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands.,Physical Therapy Sciences Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands.,Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Martijn F Pisters
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, Netherlands.,Physical Therapy Research Group, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands.,Physical Therapy Sciences Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands
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Kitselaar WM, Numans ME, Sutch SP, Faiq A, Evers AW, van der Vaart R. Identifying persistent somatic symptoms in electronic health records: exploring multiple theory-driven methods of identification. BMJ Open 2021; 11:e049907. [PMID: 34535479 PMCID: PMC8451292 DOI: 10.1136/bmjopen-2021-049907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Persistent somatic symptoms (PSSs) are defined as symptoms not fully explained by well-established pathophysiological mechanisms and are prevalent in up to 10% of patients in primary care. The present study aimed to explore methods to identify patients with a recognisable risk of having PSS in routine primary care data. DESIGN A cross-sectional study to explore four identification methods that each cover part of the broad spectrum of PSS was performed. Cases were selected based on (1) PSS-related syndrome codes, (2) PSS-related symptom codes, (3) PSS-related terminology and (4) Four-Dimensional Symptom Questionnaire scores and all methods combined. SETTING Coded electronic health record data were extracted from 76 general practices in the Netherlands. PARTICIPANTS Patients who were registered for at least 1 year during 2014-2018, were included (n=169 138). OUTCOME MEASURES Identification methods were explored based on (1) PSS sample sizes and demographics, (2) presence of chronic conditions and (3) healthcare utilisation (HCU) variables. Overlap between methods and practice specific differences were examined. RESULTS The percentage of cases identified varied between 0.3% and 7.0% across the methods. Over 58.1% of cases had chronic physical condition(s) and over 33.8% had chronic mental condition(s). HCU was generally higher for cases selected by any method compared with the total cohort. HCU was higher for method B compared with the other methods. In 26.7% of cases, cases were selected by multiple methods. Overlap between methods was low. CONCLUSIONS Different methods yielded different patient samples which were general practice specific. Therefore, for the most comprehensive data-based selection of PSS cases, a combination of methods A, C and D would be recommended. Advanced (data-driven) methods are needed to create a more sensitive algorithm for identifying the full spectrum of PSS. For clinical purposes, method B could possibly support screening of patients who are currently missed in daily practice.
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Affiliation(s)
- Willeke M Kitselaar
- Health, Medical and Neuropsychology, Leiden University Faculty of Social and Behavioural Sciences, Leiden, The Netherlands
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
| | - Stephen P Sutch
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ammar Faiq
- Public Health and Primary Care / LUMC-Campus The Hague, Leiden University Medical Center, Den Haag, The Netherlands
| | - Andrea Wm Evers
- Health, Medical and Neuropsychology, Leiden University Faculty of Social and Behavioural Sciences, Leiden, The Netherlands
- Medical Delta, Leiden University, Delft University of Technology & Erasmus University, Leiden / Delft/ Rotterdam, The Netherlands
| | - Rosalie van der Vaart
- Health, Medical and Neuropsychology, Leiden University Faculty of Social and Behavioural Sciences, Leiden, The Netherlands
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11
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Kitselaar WM, van der Vaart R, van Tilborg-den Boeft M, Vos HMM, Numans ME, Evers AWM. The general practitioners perspective regarding registration of persistent somatic symptoms in primary care: a survey. BMC FAMILY PRACTICE 2021; 22:182. [PMID: 34511065 PMCID: PMC8436507 DOI: 10.1186/s12875-021-01525-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 08/18/2021] [Indexed: 12/28/2022]
Abstract
Background Persistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is unambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations. Method Dutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs’ need for improvement of PSS classification, registration and care. Results GPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines. Conclusions Registration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01525-6.
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Affiliation(s)
- Willeke M Kitselaar
- Health, Medical and Neuropsychology Department, Leiden University, Faculty of Social and Behavioral Sciences, Leiden, the Netherlands. .,Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands.
| | - Rosalie van der Vaart
- Health, Medical and Neuropsychology Department, Leiden University, Faculty of Social and Behavioral Sciences, Leiden, the Netherlands
| | - Madelon van Tilborg-den Boeft
- Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands
| | - Hedwig M M Vos
- Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care Department / LUMC-Campus Den Haag, Leiden University Medical Center, The Hague, the Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Department, Leiden University, Faculty of Social and Behavioral Sciences, Leiden, the Netherlands
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12
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Somatic Symptoms and Sleep Disorders: A Literature Review of Their Relationship, Comorbidities and Treatment. Healthcare (Basel) 2021; 9:healthcare9091128. [PMID: 34574901 PMCID: PMC8465276 DOI: 10.3390/healthcare9091128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/19/2021] [Accepted: 08/27/2021] [Indexed: 12/02/2022] Open
Abstract
This study aimed to investigate the relationship between somatic symptom disorder (SSD) and sleep disorders, following three research questions: (1) How are these disorders correlated? (2) What are the comorbidities reported in these patients? and (3) What are the most effective pharmacological and non-pharmacological treatments for both conditions? PubMed, Scopus, OVID, Medline, and ProQuest databases were searched for relevant articles published between 1957–2020. Search terms included “somatic symptoms disorder”, “sleep disorders”, “insomnia”, “somatoform”, “somatization”, “therapeutic”, “psychotherapy”, and alternative, formerly used terms for SSD. Forty papers were finally included in the study. Prevalence of insomnia in SSD patients ranged between 20.4–48%, with this being strongly correlated to somatic symptoms and psychosocial disability. The most relevant comorbidities were generalized anxiety disorder, depression, fatigue, negative mood, substance use, orthorexia, alexithymia, anorexia, weight loss, poor eating habits, and acute stress disorder. Patients receiving antidepressant therapy reported significant improvements in insomnia and somatic symptoms. In terms of non-pharmacological interventions, cognitive-behavioral therapy (CBT) showed improvements in sleep outcomes, while the Specialized Treatment for Severe Bodily Distress Syndromes (STreSS) may represent an additional promising option. Future research could include other medical and psychosocial variables to complete the picture of the relationship between sleep disorders and somatic symptoms.
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13
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Healthcare professionals' perspectives on a blended care program in primary care; A qualitative study. Internet Interv 2021; 26:100440. [PMID: 34401397 PMCID: PMC8358151 DOI: 10.1016/j.invent.2021.100440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 07/23/2021] [Accepted: 08/03/2021] [Indexed: 11/21/2022] Open
Abstract
Increasingly, healthcare policies have changed focus from cure and care to behaviour and health. Prevention is becoming more important, which requires a change in the role of healthcare professionals. Healthcare professionals' role is changing from being a therapist to taking on the role of a coach. To prevent chronicity in Medically Unexplained Physical Symptoms (MUPS), an integrated blended care program was developed. To apply this new program in daily practice, it is important to gain insight into the usability. From the healthcare professionals' point of view the concept of usability consists of performance, satisfaction and acceptability. In this qualitative study participants were recruited after participating in the PARASOL program. Demographics were collected. Semi-structured interviews were conducted and analysed using thematic analysis. Ten healthcare professionals (six physical therapists and four mental health nurses) were interviewed. Four themes on usability were identified: (1) Who fits in the program, (2) preparation, (3) experience with the program and (4) interprofessional collaboration. This study gathered healthcare professionals' experiences with and attitudes towards integrating healthcare and offering blended care programs. An integrated blended care program offers the possibility to personalize treatment. Findings show attention should be given to the new responsibilities of healthcare professionals, and their role in integrated and blended care. This new approach of delivering healthcare can facilitate interprofessional collaboration. Achieving sustainable change in patients however still requires instruction and support for healthcare professionals implementing behavioural change techniques.
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14
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Marcinow M, Sandercock J, D'Silva C, Daien D, Ellis C, Dias C, Mansfield E. Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms. BMC FAMILY PRACTICE 2021; 22:142. [PMID: 34210272 PMCID: PMC8252243 DOI: 10.1186/s12875-021-01495-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/17/2021] [Indexed: 11/23/2022]
Abstract
Objectives Health services to date have inadequately addressed the physical and mental health needs of patients with medically unexplained symptoms. This qualitative study evaluates a piloted facilitated support group (FSG) developed for patients with medically unexplained symptoms to inform recommendations and resources for this patient population. Methods Using a qualitative descriptive design, we conducted and thematically analyzed semi-structured interviews with participants (n = 8) and facilitators (n = 4) to explore their experiences of the facilitated support group. Common themes that captured strengths and challenges of the facilitated support group were identified. Results The following key themes were identified through analysis of the data: Participants described 1) feeling validated through sharing similar experiences with peers; 2) learning practical symptom management and coping strategies; and 3) gaining new perspectives for navigating conversations with PCPs. Conclusions Our findings show that a facilitated support group may provide additional forms of support and resources for patients with medically unexplained symptoms, filling a gap in currently available clinical care offered by health care professionals. Potential implications: This paper highlights lessons learned that can inform the design and delivery of future supports and resources directed toward optimizing patient care for this underserved patient population. Our findings are relevant to those who are involved in direct patient care or involved in designing and implementing self-management programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01495-9.
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Affiliation(s)
- Michelle Marcinow
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
| | - Jane Sandercock
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Chelsea D'Silva
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - David Daien
- Family Medicine, Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Carly Ellis
- Strategic Projects, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Christine Dias
- Medical Psychiatry Alliance, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Elizabeth Mansfield
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.,Department of Occupational Health, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
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15
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Goldstein LH, Robinson EJ, Pilecka I, Perdue I, Mosweu I, Read J, Jordan H, Wilkinson M, Rawlings G, Feehan SJ, Callaghan H, Day E, Purnell J, Baldellou Lopez M, Brockington A, Burness C, Poole NA, Eastwood C, Moore M, Mellers JD, Stone J, Carson A, Medford N, Reuber M, McCrone P, Murray J, Richardson MP, Landau S, Chalder T. Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT. Health Technol Assess 2021; 25:1-144. [PMID: 34196269 DOI: 10.3310/hta25430] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures. DESIGN This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. SETTING This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services. PARTICIPANTS Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. INTERVENTIONS Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. MAIN OUTCOME MEASURES The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. RESULTS In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway. LIMITATIONS Unlike outcome assessors, participants and clinicians were not blinded to the interventions. CONCLUSIONS There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy. FUTURE WORK Examination of moderators and mediators of outcome. TRIAL REGISTRATION Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emily J Robinson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Izabela Pilecka
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iain Perdue
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iris Mosweu
- King's Health Economics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Julie Read
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Harriet Jordan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Matthew Wilkinson
- Canterbury Christ Church University, Salamons Institute for Applied Psychology, Tunbridge Wells, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Gregg Rawlings
- School of Clinical Psychology, University of Sheffield, Sheffield, UK
| | - Sarah J Feehan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hannah Callaghan
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Elana Day
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Purnell
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maria Baldellou Lopez
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alice Brockington
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Norman A Poole
- Department of Neuropsychiatry, St George's Hospital, South West London and St George's NHS Mental Health NHS Trust, London, UK
| | - Carole Eastwood
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michele Moore
- Centre for Social Justice and Global Responsibility, School of Law and Social Sciences, London South Bank University, London, UK
| | | | - Jon Stone
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Nick Medford
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Paul McCrone
- King's Health Economics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Joanna Murray
- Department of Health Services & Population Research, Institute of Psychiatry,Psychology and Neuroscience, King's College London, London, UK
| | - Mark P Richardson
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Abstract
Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles.
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Affiliation(s)
- Mujtaba Husain
- South London and Maudsley NHS Foundation Trust (SLaM), London, UK
| | - Trudie Chalder
- King's College London, London, UK and South London and Maudsley NHS Foundation Trust (SLaM), London, UK
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17
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Cathébras P. Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress. Front Med (Lausanne) 2021; 8:585495. [PMID: 33987188 PMCID: PMC8110699 DOI: 10.3389/fmed.2021.585495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/10/2021] [Indexed: 12/02/2022] Open
Abstract
This paper argues that “functional,” “medically unexplained,” or “somatoform” symptoms and disorders necessarily require a patient-centered approach from the clinicians. In the first part, I address the multiple causes of the patients' suffering and I analyze the unease of the doctors faced with these disorders. I emphasize the iatrogenic role of medical investigations and the frequent failure in attempting to reassure the patients. I stress the difficulties in finding the right terms and concepts, despite overabundant nosological categories, to give a full account of psychosomatic complexity. Finally, I discuss the moral dimension attached to assigning a symptom, at times arbitrarily, to a psychogenic origin. The following part presents a brief reminder of the patient-centered approach (PCA) in medicine. In the last part, I aim to explain why and how patient-centered medicine should be applied in the context of functional disorders. First, because PCA focuses on the patients' experience of illness rather than the disease from the medical point of view, which is, indeed, absent. Second, because PCA is the only way to avoid sterile attribution conflicts. Last, because PCA allows doctors and patients to collaboratively create plausible and non-stigmatizing explanations for the symptoms, which paves the way toward effective management.
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Affiliation(s)
- Pascal Cathébras
- Department of Internal Medicine, Jean-Monnet University, Saint-Etienne, France
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18
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Hüsing P, Löwe B, Olde Hartman TC, Frostholm L, Weigel A. Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial. BMJ Open 2021; 11:e044244. [PMID: 33762239 PMCID: PMC7993177 DOI: 10.1136/bmjopen-2020-044244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial. METHODS AND ANALYSIS In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures. ETHICS AND DISSEMINATION Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER DRKS00018803.
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Affiliation(s)
- Paul Hüsing
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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19
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Fordham B, Sugavanam T, Edwards K, Hemming K, Howick J, Copsey B, Lee H, Kaidesoja M, Kirtley S, Hopewell S, das Nair R, Howard R, Stallard P, Hamer-Hunt J, Cooper Z, Lamb SE. Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis. Health Technol Assess 2021; 25:1-378. [PMID: 33629950 PMCID: PMC7957459 DOI: 10.3310/hta25090] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. OBJECTIVES This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. DATA SOURCES The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. REVIEW METHODS Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. RESULTS A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. LIMITATIONS Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. CONCLUSION Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. FUTURE WORK Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. STUDY REGISTRATION This study is registered as PROSPERO CRD42017078690. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thavapriya Sugavanam
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Katherine Edwards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Bethan Copsey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Milla Kaidesoja
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Shona Kirtley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roshan das Nair
- Department of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | | | | | - Zafra Cooper
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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20
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Holtman GA, Burger H, Verheij RA, Wouters H, Berger MY, Rosmalen JG, Verhaak PF. Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study. BMJ Open 2021; 11:e040730. [PMID: 33419906 PMCID: PMC7799137 DOI: 10.1136/bmjopen-2020-040730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Patients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS. DESIGN AND SETTING Records from the longitudinal population-based ('Lifelines') cohort study were linked to electronic health records from general practitioners (GPs). PARTICIPANTS We included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort. OUTCOME MEASURES The outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed. RESULTS 18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29-0.47). CONCLUSIONS Several theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huibert Burger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Verheij
- NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Hans Wouters
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith Gm Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Fm Verhaak
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands
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21
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Maroti D, Johansson R. Is Cognitive Change Necessary to Alleviate Symptoms in Patients With Functional Somatic Syndrome? Front Psychiatry 2021; 12:781083. [PMID: 34795604 PMCID: PMC8593391 DOI: 10.3389/fpsyt.2021.781083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel Maroti
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Robert Johansson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Psychology, Stockholm University, Stockholm, Sweden
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22
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Maroti D, Ek J, Widlund RM, Schubiner H, Lumley MA, Lilliengren P, Bileviciute-Ljungar I, Ljótsson B, Johansson R. Internet-Administered Emotional Awareness and Expression Therapy for Somatic Symptom Disorder With Centralized Symptoms: A Preliminary Efficacy Trial. Front Psychiatry 2021; 12:620359. [PMID: 33679478 PMCID: PMC7928393 DOI: 10.3389/fpsyt.2021.620359] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/20/2021] [Indexed: 01/04/2023] Open
Abstract
Background: There is growing evidence that trauma, psychosocial conflict, and difficulties with emotional processing contribute to centralized somatic symptoms. Emotional Awareness and Expression Therapy (EAET) was developed to address these factors and reduce symptoms, and EAET has shown efficacy in face-to-face formats. No trial of an internet-delivered EAET (I-EAET) exists, however, so we developed such an intervention and conducted an uncontrolled feasibility and potential efficacy trial of I-EAET for patients with Somatic Symptom Disorder (SSD) with centralized symptoms (SSD-CS). Method: After screening potential participants, a sample of 52 patients (50 women, two men; age M = 49.6, SD = 11.9) diagnosed with SSD-CS initiated treatment. I-EAET consisted of nine weekly modules focused on psychoeducation, emotional awareness and exposure, and anxiety regulation with self-compassion. Therapists communicated with each patient by email for about 20 min per week during treatment, answering questions and giving feedback on homework assignments. Patients completed measures of somatic symptoms, depression, anxiety, trauma-related symptoms, and functional disability before treatment and again at post-treatment and 4-month follow-up. Results: A large reduction in somatic symptoms (PHQ-15) occurred pre-to post-treatment (d = 1.13; 95% CI: 0.84-1.47) which was fully maintained at 4-month follow-up (d = 1.19; 95% CI: 0.88-1.56). Twenty-three percent of the patients at post-treatment and 27% at follow-up achieved a 50% or greater reduction in somatic symptoms, and about 70% achieved a minimally important clinical difference. In addition, at post-treatment, there were small to medium reductions (d's from 0.33 to 0.72) in anxiety (GAD-7), depression (PHQ-9), trauma-related symptoms (PCL-5), and functional disability (Sheehan Disability Scale). For all of these secondary outcomes, improvements were slightly to substantially larger at follow-up than at post-treatment (d's from 0.46 to 0.80). Conclusion: I-EAET appears to be a feasible treatment for adults with SSD and centralized symptoms, resulting in substantial and durable improvement not only in somatic symptoms but in other psychiatric symptoms and functioning. Controlled trials are needed determine the effects of I-EAET specifically and how this approach compares to face-to-face EAET and to other internet-delivered treatments, such as cognitive-behavioral interventions. Research should also identify treatment responders and mechanisms of change in EAET. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04122846.
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Affiliation(s)
- Daniel Maroti
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Josefine Ek
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | | | - Howard Schubiner
- Department of Internal Medicine, Ascension Providence-Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI, United States
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, MI, United States
| | - Peter Lilliengren
- Department of Health Care Sciences, St. Lukas Educational Institute, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Indre Bileviciute-Ljungar
- Department of Clinical Sciences, Karolinska Institutet and Multidisciplinary Pain Unit, St Göran Hospital, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Robert Johansson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Psychology, Stockholm University, Stockholm, Sweden
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Vendrell-Serres J, Soto-Angona Ó, Rodríguez-Urrutia A, Arteaga-Henríquez G, Ramos-Quiroga JA. Improvement of functional neurological disorder after administration of esketamine nasal spray: a case report. Ther Adv Psychopharmacol 2021; 11:20451253211022187. [PMID: 34188796 PMCID: PMC8212365 DOI: 10.1177/20451253211022187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/14/2021] [Indexed: 01/01/2023] Open
Abstract
Functional neurological disorder (FND) is a complex neuropsychiatric condition characterized by the presence of neurological symptoms and signs (either motor or sensory) that cannot be explained by any known medical or mental disease. It is frequently presented with psychiatric comorbidities, such as major depression. Its prognosis is poor, with low improvement or recovery rates at 1 year after their onset, and no particular treatment has demonstrated significant efficacy in this regard. Here, we describe the management of a patient affected by treatment-resistant depression (TRD) and FND characterized by mixed paralysis (sensory and motor) in the left arm, and who was successfully treated with esketamine nasal spray, achieving remission in both disorders. The US Food and Drug Administration and the European Medicines Agency recently approved esketamine, the S-enantiomer of ketamine, for treatment of TRD. It is a fast-acting drug that provides a rapid-onset improvement of depressive symptoms. We have presented the first case, to our knowledge, of functional neurological symptoms being successfully treated with esketamine in a patient with comorbid TRD. While the novelty of this data implies a clear need for further research, it is suggested that esketamine might be a useful tool for the treatment of FND, acting through different theorized mechanisms that are in tune with recent advances in knowledge of the etiopathology of FND.
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Affiliation(s)
- Júlia Vendrell-Serres
- Department of Psychiatry, Vall d'Hebron University Hospital, Barcelona, Catalonia, Spain
| | - Óscar Soto-Angona
- Department of Psychiatry, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129 Barcelona 08035, Spain
| | | | - Gara Arteaga-Henríquez
- Department of Psychiatry, Vall d'Hebron University Hospital, Barcelona, Catalonia, Spain
| | - Josep A Ramos-Quiroga
- Department of Psychiatry, Vall d'Hebron University Hospital, Barcelona, Catalonia, Spain
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24
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Patel M, James K, Moss-Morris R, Ashworth M, Husain M, Hotopf M, David AS, McCrone P, Landau S, Chalder T. BMC family practice integrated GP care for patients with persistent physical symptoms: feasibility cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:207. [PMID: 33028243 PMCID: PMC7542765 DOI: 10.1186/s12875-020-01269-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/13/2020] [Indexed: 05/30/2023]
Abstract
BACKGROUND Patients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS). General practitioners (GPs) play a key role in the management of PPS and require further training. Patients are often frustrated with the care they receive. This study aims to assess the acceptability of an 'integrated GP care' approach which consists of offering self-help materials to patients with PPS and offering their GPs training on how to utilise cognitive behavioural skills within their consultations, as well as assessing the feasibility of conducting a future trial in primary care to evaluate its benefit. METHODS A feasibility cluster randomised controlled trial was conducted in primary care, South London, UK. GP practices (clusters) were randomly allocated to 'integrated GP care plus treatment as usual' or 'treatment as usual'. Patients with PPS were recruited from participating GP practices before randomisation. Feasibility parameters, process variables and potential outcome measures were collected at pre-randomisation and at 12- and 24-weeks post-randomisation at cluster and individual participant level. RESULTS Two thousand nine hundred seventy-eight patients were identified from 18 GP practices. Out of the 424 patients who responded with interest in the study, 164 fully met the eligibility criteria. One hundred sixty-one patients provided baseline data before cluster randomisation and therefore were able to participate in the study. Most feasibility parameters indicated that the intervention was acceptable and a future trial feasible. 50 GPs from 8 GP practices (randomised to intervention) attended the offer of training and provided positive feedback. Scores in GP knowledge and confidence increased post-training. Follow-up rate of patients at 24 weeks was 87%. However estimated effect sizes on potential clinical outcomes were small. CONCLUSIONS It was feasible to identify and recruit patients with PPS. Retention rates of participants up to 24 weeks were high. A wide range of health services were used. The intervention was relatively low cost and low risk. This complex intervention should be further developed to improve patients'/GPs' utilisation of audio/visual and training resources before proceeding to a full trial evaluation. TRIAL REGISTRATION NCT02444520 (ClinicalTrials.gov).
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Affiliation(s)
- Meenal Patel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Kirsty James
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neurosciences, Psychology and Neuroscience King's College, London, UK
| | - Rona Moss-Morris
- Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine King's College London, London, UK
| | - Mujtaba Husain
- UK South London and Maudsley NHS Foundation Trust, London, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.,UK South London and Maudsley NHS Foundation Trust, London, UK
| | - Anthony S David
- Division of Psychiatry, Maple House, UCL Institute of Mental Health, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Paul McCrone
- Institute for Lifecourse Development, University of Greenwich, Old Royal Naval College, Park Row, Greenwich, London, SE10 9LS, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neurosciences, Psychology and Neuroscience King's College, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
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25
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Roenneberg C, Sattel H, Schaefert R, Henningsen P, Hausteiner-Wiehle C. Functional Somatic Symptoms. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:553-560. [PMID: 31554544 DOI: 10.3238/arztebl.2019.0553] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/12/2019] [Accepted: 06/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive. METHODS The guideline group (32 medical and psychological professional societies, two patients' associations) carried out a systematic survey of the literature and ana- lyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly. RESULTS Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the pres- ence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ- focused treatments. CONCLUSION The cornerstones of diagnosis and treatment are biopsychosocial ex- planatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.
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Affiliation(s)
- Casper Roenneberg
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich (TUM); Department of Psychosomatics, University and University Hospital, Basel, Switzerland; Department of General Internal Medicine and Psychosomatic Medicine, University Hospital Heidelberg; Psychosomatic Medicine/Neurocenter, Berufsgenossenschaftliche Unfallklinik Murnau
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27
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Colizzi M, Lasalvia A, Ruggeri M. Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? Int J Ment Health Syst 2020; 14:23. [PMID: 32226481 PMCID: PMC7092613 DOI: 10.1186/s13033-020-00356-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/16/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Similar to other health care sectors, mental health has moved towards the secondary prevention, with the effort to detect and treat mental disorders as early as possible. However, converging evidence sheds new light on the potential of primary preventive and promotion strategies for mental health of young people. We aimed to reappraise such evidence. METHODS We reviewed the current state of knowledge on delivering promotion and preventive interventions addressing youth mental health. RESULTS Half of all mental disorders start by 14 years and are usually preceded by non-specific psychosocial disturbances potentially evolving in any major mental disorder and accounting for 45% of the global burden of disease across the 0-25 age span. While some action has been taken to promote the implementation of services dedicated to young people, mental health needs during this critical period are still largely unmet. This urges redesigning preventive strategies in a youth-focused multidisciplinary and trans-diagnostic framework which might early modify possible psychopathological trajectories. CONCLUSIONS Evidence suggests that it would be unrealistic to consider promotion and prevention in mental health responsibility of mental health professionals alone. Integrated and multidisciplinary services are needed to increase the range of possible interventions and limit the risk of poor long-term outcome, with also potential benefits in terms of healthcare system costs. However, mental health professionals have the scientific, ethical, and moral responsibility to indicate the direction to all social, political, and other health care bodies involved in the process of meeting mental health needs during youth years.
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Affiliation(s)
- Marco Colizzi
- 1Section of Psychiatry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
- 2Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF UK
| | - Antonio Lasalvia
- 1Section of Psychiatry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
| | - Mirella Ruggeri
- 1Section of Psychiatry, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
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Sullivan N, Phillips LA, Pigeon WR, Quigley KS, Graff F, Litke DR, Helmer DA, Rath JF, McAndrew LM. Coping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors. Int J Behav Med 2020; 26:665-672. [PMID: 31701389 DOI: 10.1007/s12529-019-09817-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship. METHODS The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis. RESULTS Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior. CONCLUSIONS These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02161133.
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Affiliation(s)
- Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.
| | | | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Karen S Quigley
- Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, 01730, USA.,Department of Psychology, Northeastern University, Boston, MA, 02115, USA
| | - Fiona Graff
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - David R Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.,Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Drew A Helmer
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.,Department of Medicine, Rutgers University- New Jersey Medical School, Newark, NJ, USA
| | - Joseph F Rath
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA.,Rusk Institute of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.,Department of Educational and Counseling Psychology, University at Albany, 1400 Washington Ave Ext, Albany, NY, 12222, USA
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Agarwal V, Nischal A, Praharaj SK, Menon V, Kar SK. Clinical Practice Guideline: Psychotherapies for Somatoform Disorders. Indian J Psychiatry 2020; 62:S263-S271. [PMID: 32055068 PMCID: PMC7001354 DOI: 10.4103/psychiatry.indianjpsychiatry_775_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Vivek Agarwal
- Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
| | - Anil Nischal
- Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
| | - Samir Kumar Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vikas Menon
- Department of Psychiatry, JIPMER, Puducherry, India
| | - Sujita Kumar Kar
- Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
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Friedlander ML, Kangos K, Maestro K, Muetzelfeld H, Wright ST, Silva ND, Kimber J, Helmer DA, McAndrew LM. Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships. COUNSELING PSYCHOLOGIST 2019; 47:796-819. [PMID: 32372766 DOI: 10.1177/0011000019891434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System, University at Albany
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31
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Wortman MSH, van der Wouden JC, Grutters JPC, Visser B, Assendelft WJJ, van der Horst HE, Olde Hartman TC. Psychosomatic therapy for patients frequently attending primary care with medically unexplained symptoms, the CORPUS trial: study protocol for a randomised controlled trial. Trials 2019; 20:697. [PMID: 31818310 PMCID: PMC6902505 DOI: 10.1186/s13063-019-3913-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/15/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Medically unexplained symptoms (MUS) are highly prevalent and pose a burden both on patients and on health care. In a pilot study psychosomatic therapy delivered by specialised therapists for patients with MUS showed promising results with regard to patient's acceptability, feasibility and effects on symptoms. The aim of this study is to establish whether psychosomatic therapy by specialised psychosomatic exercise therapists is cost- effective in decreasing symptoms and improving functioning in patients who frequently consult their general practitioner (GP) with MUS. METHODS A randomised effectiveness trial with an economic evaluation in primary care with 158 patients aged 18 years and older who are frequently consulting their GP with MUS. Patients will be assigned to psychosomatic therapy in addition to usual care or usual care only. Psychosomatic therapy is a multi-component and tailored intervention, aiming to empower patients by applying psycho-education, relaxation techniques, mindfulness, cognitive approaches and/or graded activity. Patients assigned to the psychosomatic therapy receive 6 to 12 sessions of psychosomatic therapy, of 30-45 min each, delivered by a specialised exercise or physical therapist. Primary outcome measure is patient-specific functioning and disability, measured with the Patient-Specific Functional Scale (PSFS). Secondary outcome measures are symptom severity, consultation frequency and referrals to secondary care, patient satisfaction, quality of life and costs. Assessments will be carried out at baseline, and after 4 and 12 months. An economic evaluation alongside the trial will be conducted from a societal perspective, with quality-adjusted life years (QALYs) as outcome measure. Furthermore, a mixed-methods process evaluation will be conducted. DISCUSSION We expect that psychosomatic therapy in primary care for patients who frequently attend the GP for MUS will improve symptoms and daily functioning and disability, while reducing consultation frequency and referrals to secondary care. We expect that the psychosomatic therapy provides value for money for patients with MUS. TRIAL REGISTRATION Netherlands Trial Register, ID: NL7157 (NTR7356). Registered 13 July 2018.
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Affiliation(s)
- Margreet S H Wortman
- ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Visser
- ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Development of Grip self-help: An online patient-tailored self-help intervention for functional somatic symptoms in primary care. Internet Interv 2019; 19:100297. [PMID: 31879599 PMCID: PMC6920205 DOI: 10.1016/j.invent.2019.100297] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/21/2022] Open
Abstract
Functional Somatic Symptoms (FSS) are somatic symptoms for which no somatic cause can be identified despite adequate diagnostic testing. FSS are common, costly, and disabling, and treatment options are limited. Psychotherapy is one of few evidence-based treatments for FSS. Yet, this form of therapy is not widely used, since it is usually reserved for severe symptoms, requires a highly trained therapist, and is not well accepted by patients. The current paper describes the development of the online intervention 'Grip self-help' and provides a description of the intervention itself. Grip self-help is an early intervention for mild to moderate FSS in primary care, which aims to reduce somatic symptoms and improve quality of life. In the Grip self-help intervention, patients fill out a set of online questionnaires exploring unhelpful cognitions, emotions, behaviors, and social factors associated with the symptoms. Using this information, a personal profile is generated, identifying factors that might maintain FSS in that individual. As a next step, patients are offered online self-help exercises that are tailored to these factors. Guidance is offered by a primary care professional. The intervention will ultimately result in a personalized self-help guide, composed of texts that are extracted from the exercises patients found useful during the intervention. Grip self-help is the first intervention for FSS combining the concepts of e-health, self-help, and personalized medicine. Guided by a primary care professional, patients are offered an easily accessible, yet highly personalized treatment. Grip self-help thus has the potential to meet the needs of the large group of patients with mild to moderate FSS.
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Abstract
Somatic symptom disorder (SSD) is a diagnosis that was introduced with publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. It eliminated the diagnoses of somatisation disorder, undifferentiated somatoform disorder, hypochondriasis and pain disorder; most of the patients who previously received these diagnoses are now diagnosed in DSM-5 with SSD. The main feature of this disorder is a patient's concern with physical symptoms for which no biological cause is found. It requires psychiatric assessment to exclude comorbid psychiatric disease. Failure to recognise this disorder may lead the unwary physician or surgeon to embark on investigations or diagnostic procedures which may result in iatrogenic complications. It also poses a significant financial burden on the healthcare service. Patients with non-specific abdominal pain have a poor symptomatic prognosis with continuing use of medical services. Proven treatments include cognitive behavioural therapy, mindfulness therapy and pharmacological treatment using selective serotonin reuptake inhibitors or tricyclic antidepressants. The authors describe the case of a 31-year-old woman with an emotionally unstable personality disorder and comorbid disease presenting to the emergency department with a 3-week history of left-sided abdominal and leg pain. Despite a plethora of investigations, no organic cause for her pain was found. She was reviewed by the multidisciplinary team including surgeons, physicians, neurologists and psychiatrists. A diagnosis of somatoform symptom disorder was subsequently rendered. As patients with SSD will present to general practice and the emergency department rather than psychiatric settings, this case provides a cautionary reminder of furthering the need for appropriate recognition of this condition.
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Affiliation(s)
- Louise Dunphy
- Department of General Surgery, Wexham Park Hospital, Slough, UK
| | - Marta Penna
- Department of General Surgery, Wexham Park Hospital, Slough, UK
| | - Jihene El-Kafsi
- Department of General Surgery, Wexham Park Hospital, Slough, UK
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34
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van Westrienen PE, Pisters MF, Toonders SAJ, Gerrits M, de Wit NJ, Veenhof C. Quality of life in primary care patients with moderate medically unexplained physical symptoms. Qual Life Res 2019; 29:693-703. [PMID: 31732910 DOI: 10.1007/s11136-019-02358-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Medically Unexplained Physical Symptoms (MUPS) have a large impact on patient's quality of life. Most studies have been limited to chronic MUPS and thus, little is known about moderate MUPS. Improved knowledge concerning determinants influencing quality of life in moderate MUPS patients can be helpful in managing MUPS. This study is aimed at describing the common characteristics seen in moderate MUPS patients and compare them with characteristics seen in chronic MUPS patients and general population. We also identified determinants of the physical and mental components of quality of life in moderate MUPS patients. METHODS In a cross-sectional study, moderate MUPS patients (n = 160) were compared with chronic MUPS patients (n = 162) and general population (n = 1742) based on demographic characteristics and patient's quality of life. Multivariable linear regression analyses were performed to identify determinants associated with a patient's quality of life, assessed with the RAND-36. RESULTS Moderate MUPS patients experienced a better quality of life than chronic MUPS patients, but a worse quality of life as compared to the general population. Determinants associated with the physical and mental components of quality of life explain 49.1% and 62.9% of the variance, respectively. CONCLUSION Quality of life of patients with MUPS varies with MUPS disease stage. Based on their quality of life scores, moderate MUPS patients would be adequately distinguished from chronic MUPS patients. Half of the variance in the physical component and almost two thirds of the mental component would be explained by a number of MUPS-related symptoms and perceptions.
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Affiliation(s)
- P E van Westrienen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Th Fliednerstraat 2, 5600 AH, Eindhoven, The Netherlands.
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands.
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - M F Pisters
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Th Fliednerstraat 2, 5600 AH, Eindhoven, The Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S A J Toonders
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Th Fliednerstraat 2, 5600 AH, Eindhoven, The Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Gerrits
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, The Netherlands
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Chalder T, Patel M, James K, Hotopf M, Frank P, Watts K, McCrone P, David A, Ashworth M, Husain M, Garrood T, Moss-Morris R, Landau S. Persistent physical symptoms reduction intervention: a system change and evaluation in secondary care (PRINCE secondary) - a CBT-based transdiagnostic approach: study protocol for a randomised controlled trial. BMC Psychiatry 2019; 19:307. [PMID: 31640632 PMCID: PMC6805658 DOI: 10.1186/s12888-019-2297-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 09/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Persistent physical symptoms (PPS), also known as medically unexplained symptoms (MUS), affect approximately 50% of patients in secondary care and are often associated with disability, psychological distress and increased health care costs. Cognitive behavioural therapy (CBT) has demonstrated both short- and long-term efficacy with small to medium effect sizes for PPS, with larger treatment effects for specific PPS syndromes, including non-cardiac chest pain, irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS). Research indicates that PPS conditions share similar cognitive and behavioural responses to symptoms, such as avoidance and unhelpful beliefs. This suggests that a transdiagnostic approach may be beneficial for patients with PPS. METHODS A randomised controlled trial (RCT) will be conducted to evaluate the efficacy and cost-effectiveness of a transdiagnostic CBT-based intervention for PPS. 322 participants with PPS will be recruited from secondary care clinics. Participants stratified by clinic and disability level will be randomised to CBT plus standard medical care (SMC) versus SMC alone. The intervention consists of 8 CBT sessions delivered by a qualified therapist over a period of 20 weeks. Outcomes will be assessed at 9, 20, 40- and 52-weeks post randomisation. Efficacy will be assessed by examining the difference between arms in the primary outcome Work and Social Adjustment Scale (WSAS) at 52 weeks after randomisation. Secondary outcomes will include mood, symptom severity and clinical global impression at 9, 20, 40 and 52 weeks. Cost-effectiveness will be evaluated by combining measures of health service use, informal care, loss of working hours and financial benefits at 52 weeks. DISCUSSION This trial will provide a powered evaluation of the efficacy and cost-effectiveness of a transdiagnostic CBT approach versus SMC for patients with PPS. It will also provide valuable information about potential healthcare pathways for patients with PPS within the National Health Service (NHS). TRIAL REGISTRATION ClinicalTrials.gov NCT02426788. Registered 27 April 2015. Overall trial status: Ongoing; Recruitment status: No longer recruiting.
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Affiliation(s)
- Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
| | - Meenal Patel
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Kirsty James
- 0000 0001 2322 6764grid.13097.3cDepartment of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Matthew Hotopf
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Philipp Frank
- 0000000121901201grid.83440.3bDepartment of Behavioural Science and Health, University College London, London, UK
| | - Katie Watts
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Paul McCrone
- 0000 0001 2322 6764grid.13097.3cHealth Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony David
- 0000000121901201grid.83440.3bDivision of Psychiatry, University College London, London, UK
| | - Mark Ashworth
- 0000 0001 2322 6764grid.13097.3cPopulation Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Mujtaba Husain
- 0000 0000 9439 0839grid.37640.36South London and Maudsley NHS Foundation Trust, London, UK
| | - Toby Garrood
- grid.420545.2Department of Rheumatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Rona Moss-Morris
- 0000 0001 2322 6764grid.13097.3cSchool of Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- 0000 0001 2322 6764grid.13097.3cDepartment of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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van Gils A, Hanssen D, van Asselt A, Burger H, Rosmalen J. Personalized, Web-Based, Guided Self-Help for Patients With Medically Unexplained Symptoms in Primary Care: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e13738. [PMID: 31596246 PMCID: PMC6913687 DOI: 10.2196/13738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/09/2019] [Accepted: 06/15/2019] [Indexed: 12/22/2022] Open
Abstract
Background Medically unexplained symptoms (MUS) constitute a major health problem because of their high prevalence, the suffering and disability they cause, and the associated medical costs. Web-based interventions may provide an accessible and convenient tool for managing MUS. We developed a personalized, Web-based, guided self-help intervention for MUS in primary care (Grip self-help) and would compare its effectiveness with that of usual care. Objective This paper aims to describe the rationale, objectives, and design of a pragmatic randomized controlled trial (RCT) assessing the effectiveness of Grip self-help. Methods For a pragmatic multicenter RCT, 165 adult patients with mild to moderate MUS will be recruited through general practices in the Netherlands. Randomization will be performed at general practice level. Over the course of several months, patients in the intervention group will receive a personalized set of Web-based self-help exercises, targeting the unhelpful cognitions, emotions, behaviors, and social factors that are relevant to them. The intervention is guided by a general practice mental health worker. The control group will receive care-as-usual. Primary outcome is physical health-related quality of life (RAND-36 or 36-item general health survey, physical component score). Secondary outcomes include severity of physical and psychological symptoms, mental health–related quality of life, cost-effectiveness, and acceptability. Assessments will take place at baseline, end of treatment, and at 16-, 26-, and 52-week follow-ups. Results Recruitment started in December 2018, and enrolment is ongoing. The first results are expected to be submitted for publication in December 2021. Conclusions To our knowledge, this is the first study to combine the concepts of electronic health, self-help, and personalized medicine in the treatment of MUS. By improving the quality of life and reducing symptoms of patients with MUS, Grip self-help has the potential to reduce costs and conserve scarce health care resources. Trial Registration Dutch Trial Register NTR7390; https://www.trialregister.nl/trial/7390. International Registered Report Identifier (IRRID) PRR1-10.2196/13738
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Affiliation(s)
- Anne van Gils
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Denise Hanssen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Antoinette van Asselt
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Huibert Burger
- Department of General Practice, University Medical Center Groningen, University of Groningen,, Groningen, Netherlands
| | - Judith Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Franco JVA, Turk T, Jung JH, Xiao Y, Iakhno S, Tirapegui FI, Garrote V, Vietto V. Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev 2019; 10:CD012552. [PMID: 31587256 PMCID: PMC6778620 DOI: 10.1002/14651858.cd012552.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disorder in which the two main clinical features are pelvic pain and lower urinary tract symptoms. There are currently many approaches for its management, using both pharmacological and non-pharmacological interventions. The National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) score is a validated measure commonly used to measure CP/CPPS symptoms. We considered a 25% decrease of NIH-CPSI baseline score or a six-point reduction as MCID. OBJECTIVES To assess the effects of pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome. SEARCH METHODS We performed a comprehensive search using CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, trial registries, grey literature and conference proceedings, with no restrictions on the language of publication or publication status. The date of the latest search of all databases was July 2019. SELECTION CRITERIA We included randomised controlled trials. Inclusion criteria were men with a diagnosis of CP/CPPS. We included all available pharmacological interventions compared to placebo or in head-to-head comparisons. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed the risks of bias of included studies. We assessed the quality of the evidence (QoE) using the GRADE approach. MAIN RESULTS We included 99 unique studies in 9119 men with CP/CPPS, with assessments of 16 types of pharmacological interventions. Unless stated otherwise, our comparisons were based on short-term follow-up (less than 12 months). Most studies did not specify their funding sources; 21 studies reported funding from pharmaceutical companies.1. Alpha blockers: (24 studies, 2061 participants). We are uncertain about the effects of these drugs on prostatitis symptoms when compared to placebo at short-term follow-up (mean difference (MD) in total NIH-CPSI score -5.01, 95% confidence interval (CI) -7.41 to -2.61; 18 studies, 1524 participants, very low QoE) and at long-term follow-up (MD -5.60, 95% CI -10.89 to -0.32; 4 studies, 235 participants, very low QoE). Alpha blockers may be associated with an increased incidence of adverse events, such as dizziness and postural hypotension (risk ratio (RR) 1.60, 95% CI 1.09 to 2.34; 19 studies, 1588 participants; low QoE). Alpha blockers probably result in little to no difference in sexual dysfunction, quality of life and anxiety and depression (moderate to low QoE).2. 5-alpha reductase inhibitors (5-ARI): (2 studies, 177 participants). Finasteride probably reduces prostatitis symptoms compared to placebo (NIH-CPSI score MD -4.60, 95% CI -5.43 to -3.77; 1 study, 64 participants; moderate QoE) and may not be associated with an increased incidence of adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.3. Antibiotics: (6 studies, 693 participants). Antibiotics (quinolones) may reduce prostatitis symptoms compared to placebo (NIH-CPSI score MD -2.43, 95% CI -4.72 to -0.15; 5 studies, 372 participants; low QoE) and are probably not associated with an increased incidence in adverse events (moderate QoE). Antibiotics probably result in little to no difference in sexual dysfunction and quality of life (moderate QoE). There was no information on anxiety or depression.4. Anti-inflammatories: (7 studies, 585 participants). Anti-inflammatories may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -2.50, 95% CI -3.74 to -1.26; 7 studies, 585 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.5. Phytotherapy: (7 studies, 551 participants). Phytotherapy may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -5.02, 95% CI -6.81 to -3.23; 5 studies, 320 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). Phytotherapy may not improve sexual dysfunction (low QoE). There was no information on quality of life or anxiety and depression.6. Botulinum toxin A (BTA): Intraprostatic BTA injection (1 study, 60 participants) may cause a large reduction in prostatitis symptom (NIH-CPSI scores MD -25.80, 95% CI -30.15 to -21.45), whereas pelvic floor muscle BTA injection (1 study, 29 participants) may not reduce prostatitis symptoms (low QoE). Both comparisons used a placebo injection. These interventions may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.7. Allopurinol: (2 studies, 110 participants). Allopurinol may result in little to no difference in prostatitis symptoms and adverse events when compared to placebo (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.8. Traditional Chinese medicine (TCM): (7 studies, 835 participants); TCM may reduce prostatitis symptoms (NIH-CPSI score, MD -3.13, 95% CI -4.99 to -1.28; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). TCM probably does not improve sexual dysfunction (moderate QoE) and may not improve symptoms of anxiety and depression (low QoE). There was no information on quality of life.The most frequent reasons for downgrading the QoE were study limitations, inconsistency and imprecision. We found few trials with active comparators. AUTHORS' CONCLUSIONS We found low- to very low-quality evidence that alpha blockers, antibiotics, 5-ARI, anti-inflammatories, phytotherapy, intraprostatic BTA injection, and traditional Chinese medicine may cause a reduction in prostatitis symptoms without an increased incidence of adverse events in the short term, except for alpha blockers which may be associated with an increase in mild adverse events. We found few trials with active comparators and little evidence of the effects of these drugs on sexual dysfunction, quality of life or anxiety and depression. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient-important outcomes, including potential treatment-related adverse events, and appropriate sample sizes.
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Affiliation(s)
- Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresBuenos AiresArgentinaC1199ACL
| | - Tarek Turk
- Damascus UniversityFaculty of MedicineMazzeh StreetDamascusSyrian Arab Republic
| | - Jae Hung Jung
- Yonsei University Wonju College of MedicineDepartment of Urology20 Ilsan‐roWonjuGangwonKorea, South26426
| | - Yu‐Tian Xiao
- Changhai Hospital, Second Military Medical UniversityDepartment of Urology168 Changhai RoadShanghaiChina
| | | | - Federico Ignacio Tirapegui
- Hospital Italiano de Buenos AiresUrology DivisionJuan D. Peron 4190Ciudad Autónoma de Buenos AiresBuenos AiresArgentinaC1181ACH
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Valeria Vietto
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
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Řiháček T, Čevelíček M. Common therapeutic strategies in psychological treatments for medically unexplained somatic symptoms. Psychother Res 2019; 30:532-545. [PMID: 31345126 DOI: 10.1080/10503307.2019.1645370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: Medically unexplained somatic symptoms (MUSS) represent a frequent complaint in health care services. While psychological treatments have demonstrated some effect in patients with MUSS, further progress may be achieved by a synthesis of clinical strategies used in diverse treatment models. The aim of this study was to identify clinical strategies shared across multiple psychological treatments intended for the treatment of adult patients with MUSS. Method: Descriptions of psychological treatments for patients with MUSS were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. N = 135 resources met inclusion criteria and were subjected to qualitative analysis. Results: Similarities across treatments were captured in 8 broad categories and 18 subcategories that covered aspects of the therapeutic relationship, specific skills (bodily, emotional, and relational) for patients to develop, search for the meaning of symptoms, and the orientation on life beyond symptoms. Conclusions: Despite the differences in technique, it was possible to identify common therapeutic strategies in psychological treatments for patients with MUSS. These overarching treatment strategies, many of which have already obtained empirical support, may inspire further research and the development of comprehensive treatments with enhanced efficacy. Limitations of the present study include the lack of focus on specific syndromes.
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Affiliation(s)
- Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| | - Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
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Patel M, James K, Moss-Morris R, Husain M, Ashworth M, Frank P, Ferreira N, Mosweu I, McCrone P, Hotopf M, David A, Landau S, Chalder T. Persistent physical symptoms reduction intervention: a system change and evaluation (PRINCE)-integrated GP care for persistent physical symptoms: protocol for a feasibility and cluster randomised waiting list, controlled trial. BMJ Open 2019; 9:e025513. [PMID: 31340956 PMCID: PMC6661663 DOI: 10.1136/bmjopen-2018-025513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Persistent physical symptoms (PPS), also known as medically unexplained symptoms are associated with profound physical disability, psychological distress and high healthcare costs. England's annual National Health Service costs of attempting to diagnose and treat PPS amounts to approximately £3 billion. Current treatment relies on a positive diagnosis, life-style advice and drug therapy. However, many patients continue to suffer from ongoing symptoms and general practitioners (GPs) are challenged to find effective treatments. Training GPs in basic cognitive behavioural skills and providing self-help materials to patients could be useful, but availability in primary care settings is limited. METHODS AND ANALYSIS A cluster randomised waiting list, controlled trial will be conducted to assess the feasibility of an integrated approach to care in general practice. Approximately 240 patients with PPS will be recruited from 8 to 12 GP practices in London. GP practices will be randomised to 'integrated GP care plus treatment as usual' or waiting list control. Integrated GP care plus treatment as usual will include GP training in cognitive behavioural skills, GP supervision and written and audio visual materials for both GPs and participants. The primary objectives will be assessment of trial and intervention feasibility. Secondary objectives will include estimating the intracluster correlation coefficient for potential outcome measures for cluster effects in a sample size calculation. Feasibility parameters and identification of suitable primary and secondary outcomes for future trial evaluations will be assessed prerandomisation and at 12 and 24 weeks' postrandomisation, using a mixed-methods approach. ETHICS AND DISSEMINATION Ethical approval was granted by the Camberwell St Giles Ethics Committee. Results will be disseminated via peer-reviewed publications and conference presentations. This trial will inform researchers, clinicians, patients and healthcare providers about the feasibility and potential cost-effectiveness of an integrated approach to managing PPS in primary care. TRIAL REGISTRATION NUMBER NCT02444520; Pre-results.
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Affiliation(s)
- Meenal Patel
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Kirsty James
- Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Mujtaba Husain
- Persistent Physical Symptoms Research and Treatment Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Philipp Frank
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicola Ferreira
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Iris Mosweu
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Matthew Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony David
- Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Trudie Chalder
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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McAndrew LM, Friedlander ML, Litke D, Phillips LA, Kimber J, Helmer DA. Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them. COUNSELING PSYCHOLOGIST 2019; 47:741-769. [PMID: 32015568 PMCID: PMC6996203 DOI: 10.1177/0011000019888874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.
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Affiliation(s)
- Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System University at Albany
| | | | - David Litke
- Veterans Affairs New Jersey Health Care System
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The prevalence and impact of psychiatric symptoms in an undiagnosed diseases clinical program. PLoS One 2019; 14:e0216937. [PMID: 31170170 PMCID: PMC6553712 DOI: 10.1371/journal.pone.0216937] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 05/01/2019] [Indexed: 12/12/2022] Open
Abstract
In 2008, the NIH launched an undiagnosed diseases program to investigate difficult to diagnose, and typically, multi-system diseases. The objective of this study was to evaluate the presence of psychiatric symptoms or psychiatric diagnoses in a cohort of patients seeking care at the Emory Special Diagnostic Service clinic. We hypothesized that psychiatric symptoms would be prevalent and associated with trauma exposure, and a decreased quality of life and functioning. This is a cross-sectional, retrospective analysis of 247 patients seen between February 7, 2014 and May 31, 2017. The sources for data included the Emory Health History Questionnaire (HHQ) that had the work and social adjustment and quality of life enjoyment and satisfaction questionnaire–short form (QLSQ) embedded in it; medical records, and the comprehensive standardized special diagnostic clinic forms. Primary outcomes were presence of any psychiatric symptom, based on report of the symptom on the HHQ or medical record, or presence of a confirmed preexisting psychiatric disorder. Seventy-two percent of patients had at least one psychiatric symptom while 24.3% of patients had a pre-existing psychiatric diagnosis. Patients with any psychiatric symptom had significantly diminished Q-LES-Q scores (45.27 ± 18.63) versus patients with no psychiatric symptoms (62.01 ± 21.57, t = 5.60, df = 225, p<0.0001) and they had significantly greater functional disability. Patients with a psychiatric disorder also had significantly diminished Q-LES-Q scores (45.16 ± 17.28) versus those without a psychiatric diagnosis (51.85 ± 21.54, t = 2.11, df = 225, p = 0.036) but did not have significantly increased functional impairment. Both patients with psychiatric symptoms and ones with psychiatric disorders had an increased prevalence of trauma. Psychiatric symptoms are prevalent in patients evaluated for undiagnosed disorders. The presence of any psychiatric symptom, with or without a formal psychiatric diagnosis, significantly decreases quality of life and functioning. This suggests that assessment for psychiatric symptoms should be part of the evaluation of individuals with undiagnosed disorders and may have important diagnostic and treatment implications.
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Khadartsev AA, Tokarev AR, Tokareva SV, Hromushin VA. [The role of transcranial electrostimulation in the treatment of psychosomatic disorders in industrial workers]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2019; 96:39-44. [PMID: 31095128 DOI: 10.17116/kurort20199602139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The prevalence of psychosomatic disorders (PD) is steadily increasing from year to year. Suffice it to mention that the appealability for the primary health care during the recent period increased from 20% to 40-49%. Various psychological, pharmacological and physical methods for the treatment of somatoform disorders have been developed. However, the physiotherapeutic methods for the management of psychosomatic disorders remain virtually unexplored. At the same time, the stress-limiting effects of transcranial electrical stimulation (TES) have been convincingly demonstrated. AIM The objective of the present study was to determine the effectiveness of the treatment of psychosomatic disorders based on the application of transcranial electrostimulation. MATERIAL AND METHODS We evaluated during 4 months the general functional state (GFS) as well as the psychosomatic and vegetative status (VS) of the employees of the Scientific development and production enterprise 'Splav' including 14 women and 14 men who complained of deterioration of health. All the participants of the study were divided into groups depending on their functional disorders. The patients in one of the groups underwent transcranial electrostimulation. The age of the patients ranged from 36 to 66 years. The mean age of the men and women was 56±1.4 and 48±2.2 years respectively. The study was designed to estimate GFS and VS based on the integral characteristics obtained with the use of the 'Simona 111' hardware-software complex. The complaints of stressful conditions, deteriorated GFS, and psycho-somatic disorders were revealed in the relevant questionnaire studies. The participants of the study were divided into two groups: the main study group and the control group matched for the age and sex of their members. Those of the former group underwent relaxation procedures in the combination with transcranial electrostimulation whereas the control subjects were managed with the use of the relaxation procedures alone. RESULTS The workers comprising the group with the impaired functional indices and psychosomatic disorders were initially characterized by the moderate or high stress level with the poor general functional state. These parameters as well as the indicators of the vegetative status were significantly improved after the course of transcranial electrical stimulation. Specifically, the activity of the parasympathetic nervous system increased in comparison with the baseline level, the activity of the sympathetic nervous system decreased, and the manifestations of psychosomatic disorders became less pronounced. The authors maintain that these effects were due to the selective activation of the stress-limiting mechanisms operating in the brain that caused normalization of the activity of the vegetative nervous system and the psycho-emotional state of the patients together with the improvement of their general functional condition. CONCLUSION This study has demonstrated that psychosomatic disorders are especially common among the industrial workers with the poor general functional state of the organism. The clinical data give evidence of the effectiveness of transcranial electrical stimulation for the correction of the functional state and psychosomatic disorders.
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Affiliation(s)
- A A Khadartsev
- FSBEI HPE 'Tula State University', Medical Institute, Tula, Russia
| | - A R Tokarev
- The Tula City D.Ya. Vanykin Clinical Emergency Hospital, Tula, Russia; FSBEI HPE 'Tula State University', Medical Institute, Tula, Russia
| | - S V Tokareva
- FSBEI HPE 'Tula State University', Medical Institute, Tula, Russia
| | - V A Hromushin
- FSBEI HPE 'Tula State University', Medical Institute, Tula, Russia
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Vink M, Vink-Niese A. Cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective. Re-analysis of a Cochrane review. Health Psychol Open 2019; 6:2055102919840614. [PMID: 31080632 PMCID: PMC6498783 DOI: 10.1177/2055102919840614] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Analysis of the 2008 Cochrane review of cognitive behavioural therapy for chronic fatigue syndrome shows that seven patients with mild chronic fatigue syndrome need to be treated for one to report a small, short-lived subjective improvement of fatigue. This is not matched by an objective improvement of physical fitness or employment and illness benefit status. Most studies in the Cochrane review failed to report on safety or adverse reactions. Patient evidence suggests adverse outcomes in 20 per cent of cases. If a trial of a drug or surgical procedure uncovered a similar high rate, it would be unlikely to be accepted as safe. It is time to downgrade cognitive behavioural therapy to an adjunct support-level therapy, rather than a treatment for chronic fatigue syndrome.
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Affiliation(s)
- Mark Vink
- Family and Insurance Physician, Amsterdam, The Netherlands
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Röhricht F, Sattel H, Kuhn C, Lahmann C. Group body psychotherapy for the treatment of somatoform disorder - a partly randomised-controlled feasibility pilot study. BMC Psychiatry 2019; 19:120. [PMID: 31014294 PMCID: PMC6480707 DOI: 10.1186/s12888-019-2095-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 03/29/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Clinical outcomes for patients with heterogeneous somatoform disorder (bodily distress disorder, including medically unexplained symptoms) are suboptimal, new treatments are required to improve acceptance. Body-oriented psychological therapy approaches have been identified as potentially beneficial additions to the portfolio of treatments. This study was aiming to assess the acceptability, the potential benefits, and associated change processes of manualised group body psychotherapy (BPT) for outpatients with Somatoform Disorder. METHODS A randomized controlled feasibility trial was carried out with follow-up at 6 months after baseline assessments using the Primary Health Questionnaire (PHQ), Somatic Symptom Screening Scale (SOMS-7), quality of life ratings (Short-Form Health Survey-36; SF-36) and body image measures (Dresden Body Image Questionnaire). Acceptance was assessed with the Helping Alliance Scale (HAS). RESULTS A total of 24 patients were recruited to participate. Sixteen patients were randomly assigned to receive either manualised BPT or TAU, eight patients were directly assigned to BPT. Drop-out rates were acceptable, patients reported to be highly satisfied with the group intervention. Somatic symptom levels reduced significantly in the BPT group. Additionally, a significant effect on self-acceptance and the mental component of quality of life was observed. CONCLUSION Group body psychotherapy is a feasible and acceptable treatment for patients with somatoform disorder and a larger trial studying the effectiveness of BPT in these patients should be conducted. TRIAL REGISTRATION Retrospectively registered SRCTN12277345 ; Trial Registraton Date: 27/03/2019.
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Affiliation(s)
- Frank Röhricht
- Wolfson Institute of Preventive Medicine, Centre for Psychiatry, Queen Mary University of London, London, UK.
- East London NHS Foundation Trust, Trust Headquarter, Robert Dolan House, 9 Allie Street, E1 8DE, London, UK.
| | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christian Kuhn
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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van Westrienen PE, Pisters MF, Gerrits M, Veenhof C, de Wit NJ. Identifying Treatment Modalities for a Multidisciplinary and Blended Care Intervention for Patients With Moderate Medically Unexplained Physical Symptoms: Qualitative Study Among Professionals. JMIR Ment Health 2019; 6:e12203. [PMID: 30977737 PMCID: PMC6484260 DOI: 10.2196/12203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/30/2019] [Accepted: 02/14/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Medically unexplained physical symptoms (MUPS) are a substantial health problem in primary care with a high burden for patients, general practitioners, and the health care system. Most studies focus on chronic MUPS patients. Little research is conducted in patients with moderate MUPS, and an effective primary care intervention for prevention of chronic MUPS is lacking. OBJECTIVE The objective of our study was to identify treatment modalities based on expert opinions for the development of a multidisciplinary and blended intervention for patients with moderate MUPS to prevent chronicity. METHODS Two focus groups with 8 and 6 experts (general practitioners, physical therapists, psychologists, and mental health nurses) were carried out. The focus groups were structured using the nominal group technique. RESULTS A total of 70 ideas were generated from two nominal group meetings, and 37 of these got votes, were included in the rank order, and were sorted into 8 separate themes. According to the participants, the most important treatment modalities for a multidisciplinary and blended intervention in patients with moderate MUPS were (1) coaching to a healthier lifestyle, (2) education regarding psychosocial factors, (3) therapeutic neuroscience education, (4) multidisciplinary intake, (5) multidisciplinary cooperation and coordination, (6) relaxation or body awareness exercises, (7) clear communication by professionals to the patient, and (8) graded activity. Five independent researchers checked the ideas and linked them to themes to confirm the content analysis and check the validity of the themes. CONCLUSIONS From professional expert perspectives, 8 themes should be included in a multidisciplinary and blended intervention to prevent chronicity. These themes provide a first step in developing an intervention for patients with moderate MUPS. Future research should focus on further development steps in which patients with moderate MUPS should be involved to determine if the intervention matches their needs.
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Affiliation(s)
- Paula Elisabeth van Westrienen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martijn F Pisters
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marloes Gerrits
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cindy Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands.,Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands.,Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Niek J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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Symptom management for medically unexplained symptoms in primary care: a qualitative study. Br J Gen Pract 2019; 69:e254-e261. [PMID: 30858336 DOI: 10.3399/bjgp19x701849] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/12/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND GPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS. AIM This study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice. DESIGN AND SETTING Qualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed. METHOD A thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed. RESULTS The study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication. CONCLUSION Symptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.
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Internet-Delivered Cognitive Behavior Therapy for Young Taiwanese Female Nursing Students with Irritable Bowel Syndrome-A Cluster Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050708. [PMID: 30818837 PMCID: PMC6427663 DOI: 10.3390/ijerph16050708] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
Irritable Bowel Syndrome (IBS) is prevalent within the general population. Studies have shown that stress and anxiety co-exist with IBS. Young Taiwanese women commonly exhibit physical and psychological health problems caused by academic stress. The purpose of our current study was to evaluate the efficacy of short-term Internet-delivered cognitive-behavioral therapy (ICBT) on female nursing students in practicum. We performed a cluster randomized controlled trial comprised of 160 participants who met the inclusion criteria, which were divided into three groups: (1) ICBT, (2) expressive writing (EW), and (3) wait-list control. Treatment interventions lasted for 6 weeks. Levels of anxiety, depression, and IBS symptoms were assessed at four time points, baseline assessment at T0, 2 weeks after T0 (T1), at the end of practicum (T2), and at 3-month follow-up (T3). The results showed that ICBT and EW groups exhibited a significant, yet small, reduction in anxiety and depression at T2 and T3 compared to the wait-list control group. The EW group exhibited significantly greater reduction in anxiety and depression compared to the ICBT group at T2. However, the ICBT group demonstrated greater improvements in alleviating anxiety and depression at T3 compared to the EW group. These data indicate that ICBT and EW groups exhibited small effects on anxiety and depression reduction at T2 and T3 compared to the wait-list control group, with no effects on IBS symptoms in young Taiwanese female nursing students.
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CBT to reduce healthcare use for medically unexplained symptoms: systematic review and meta-analysis. Br J Gen Pract 2019; 69:e262-e269. [PMID: 30692089 DOI: 10.3399/bjgp19x701273] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/02/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Studies have reported that medically unexplained symptoms (MUS) tend to be associated with increased healthcare use, which is demanding of resources and potentially harmful to patients. This association is often used to justify the funding and study of psychological interventions for MUS, yet no systematic review has specifically examined the efficacy of psychological interventions in reducing healthcare use. AIM To conduct a systematic review and meta-analysis to evaluate the effectiveness of cognitive behavioural therapies (CBT) for MUS in reducing healthcare use. DESIGN AND SETTING Systematic review and meta-analysis. METHOD The search from a previous systematic review was updated and expanded. Twenty-two randomised controlled trials reported healthcare use, of which 18 provided data for meta-analysis. Outcomes were healthcare contacts, healthcare costs, medication, and medical investigations. RESULTS Small reductions in healthcare contacts and medication use were found for CBT compared with active controls, treatment as usual, and waiting list controls, but not for medical investigations or healthcare costs. CONCLUSION Cognitive behavioural interventions show weak benefits in reducing healthcare use in people with MUS. The imprecise use of MUS as a diagnostic label may impact on the effectiveness of interventions, and it is likely that the diversity and complexity of these difficulties may necessitate a more targeted approach.
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Ezra Y, Hammerman O, Shahar G. The Four-Cluster Spectrum of Mind-Body Interrelationships: An Integrative Model. Front Psychiatry 2019; 10:39. [PMID: 30881314 PMCID: PMC6405696 DOI: 10.3389/fpsyt.2019.00039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/21/2019] [Indexed: 01/01/2023] Open
Abstract
Despite the shift toward a biopsychosocial paradigm of medicine, many physicians and mental health professionals (MHPs) find it difficult to treat patients with psycho-somatic disorders. This situation is particularly troublesome due to the high prevalence of these conditions. Although progress has been made over the last few decades in understanding mechanisms underlying the mind-body relationship, disparities remain between research and its clinical implementation. One possible reason for this is the lack of a comprehensive, agreed-upon model that incorporates a biopsychosocial framework and is rooted in an understanding of the various psychobiological pathways. Such a model would enable better communication between physicians and MHPs, allowing them to provide coordinated, stratified treatment. In this paper, four archetypal case studies, together with standard care options are presented to illustrate the current state of affairs. A four-tiered conceptual model of mind-body interrelationships based on pathophysiological and psychopathological mechanisms is suggested to help optimize the treatment of somatic complaints. This Four-Cluster model consists of: (1) Organic Conditions: Structural, or degenerative processes that can affect mood and psychological responses but are not clearly exacerbated by stress. (2) Stress Exacerbated Diseases: Biological disorders with a distinct pathophysiology, such as inflammatory or autoimmune diseases, whose progression is clearly exacerbated by stress. (3) Functional Somatic Syndromes: Conditions wherein heightened sensitivity to stimuli together with hyper-reactivity of the autonomic system form a "vicious cycle" of mutually enhancing learning processes. These processes involve biological mechanisms, such as central sensitization and psychological mechanisms such as catastrophization and selective attention. (4) Conversion Disorder: Physical manifestations of psychological distress, expressed somatically. Symptoms are solely an expression of problems in patients' psychic functioning and are not caused by biological pathology. Finally, suggested management of the aforementioned case studies is presented through the lens of the Four-Cluster model and a proposed integration of our model with existing theories is discussed. As it is rooted in an understanding of psychobiological pathways of illness, the proposed model enables a new way to discern which form of mind-body interaction is manifesting in different diseases and proposes a way to coordinate treatment plans accordingly, to enhance the accuracy and efficacy of care.
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Affiliation(s)
- Yacov Ezra
- Faculty of Medical Sciences, Ben Gurion University of the Negev, Beersheba, Israel.,Department of Neurology, Soroka University Medical Center, Beersheba, Israel
| | - Oded Hammerman
- Faculty of Medical Sciences, Ben Gurion University of the Negev, Beersheba, Israel.,Department of Neurology, Soroka University Medical Center, Beersheba, Israel
| | - Golan Shahar
- Psychology Department, Ben Gurion University of the Negev, Beersheba, Israel
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Hilton LG, Marshall NJ, Motala A, Taylor SL, Miake-Lye IM, Baxi S, Shanman RM, Solloway MR, Beroesand JM, Hempel S. Mindfulness meditation for workplace wellness: An evidence map. Work 2019; 63:205-218. [PMID: 31156202 PMCID: PMC6598008 DOI: 10.3233/wor-192922] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/14/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Mindfulness interventions aim to foster greater attention and awareness of present moment experiences. Uptake of mindfulness programs in the workplace has grown as organizations look to support employee health, wellbeing, and performance. OBJECTIVE In support of evidence-based decision making in workplace contexts, we created an evidence map summarizing physical and mental health, cognitive, affective, and interpersonal outcomes from systematic reviews of randomized controlled trials (RCTs) of mindfulness interventions. METHODS We searched nine electronic databases to July 2017, dually-screened all reviews, and consulted topic experts to identify systematic reviews on mindfulness interventions. The distribution of evidence is presented as an evidence map in a bubble plot. RESULTS In total, 175 systematic reviews met inclusion criteria. Reviews included a variety of mindfulness-based interventions. The largest review included 109 randomized controlled trials. The majority of these addressed general health, psychological conditions, chronic illness, pain, and substance use. Twenty-six systematic reviews assessed studies conducted in workplace settings and with healthcare professionals, educators, and caregivers. The evidence map shows the prevalence of research by the primary area of focus. An outline of promising applications of mindfulness interventions is included. CONCLUSIONS The evidence map provides an overview of existing mindfulness research. It shows the body of available evidence to inform policy and organizational decision-making supporting employee wellbeing in work contexts.
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Affiliation(s)
- Lara G. Hilton
- Evidence-Based Practice Center (EPC), RAND Corporation, Santa Monica, CA, USA
- Deloitte Consulting LLP, Los Angeles, CA, USA
| | - Nell J. Marshall
- Evidence-Based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center, Los Angeles, CA, USA
- VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Aneesa Motala
- Evidence-Based Practice Center (EPC), RAND Corporation, Santa Monica, CA, USA
| | - Stephanie L. Taylor
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy, UCLA, Los Angeles, CA, USA
| | - Isomi M. Miake-Lye
- Evidence-Based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center, Los Angeles, CA, USA
| | - Sangita Baxi
- Evidence-Based Practice Center (EPC), RAND Corporation, Santa Monica, CA, USA
| | - Roberta M. Shanman
- Evidence-Based Practice Center (EPC), RAND Corporation, Santa Monica, CA, USA
| | - Michele R. Solloway
- Child and Adolescent Health Measurement Initiative, Department of Population, Family and Reproductive Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Jessica M. Beroesand
- Evidence-Based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center, Los Angeles, CA, USA
| | - Susanne Hempel
- Evidence-Based Practice Center (EPC), RAND Corporation, Santa Monica, CA, USA
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