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Gautam S, Gautam M, Jain A, Yadav K. Overview of practice of Consultation-Liaison Psychiatry. Indian J Psychiatry 2022; 64:S201-S210. [PMID: 35602371 PMCID: PMC9122154 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_1019_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/05/2022] [Accepted: 01/15/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Shiv Gautam
- Department of Psychiatry, Gautam Hospital and Institute of Behavioural Sciences, Jaipur, Rajasthan, India
| | - Manaswi Gautam
- Gautam Hospital and Research Center, Jaipur, Rajasthan, India
| | - Akhilesh Jain
- Department of Psychiatry, ESI Model Hospital, Jaipur, Rajasthan, India E-mail:
| | - Kuldeep Yadav
- Department of Psychiatry, ESI Model Hospital, Jaipur, Rajasthan, India E-mail:
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van Tilburg ML, van Westrienen PE, Pisters MF. Demographic and health-related factors associated with reduced work functioning in people with moderate medically unexplained physical symptoms: a cross-sectional study. BMC Public Health 2020; 20:1316. [PMID: 32867731 PMCID: PMC7457349 DOI: 10.1186/s12889-020-09415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medically unexplained physical symptoms (MUPS) are a leading cause of reduced work functioning. It is not known which factors are associated with reduced work functioning in people with moderate MUPS. Insight in these factors can contribute to prevention of reduced work functioning, associated work-related costs and in MUPS becoming chronic. Therefore, the aim of this study was to identify which demographic and health-related factors are associated with reduced work functioning, operationalized as impaired work performance and absenteeism, in people with moderate MUPS. METHODS Data of 104 participants from an ongoing study on people with moderate MUPS were used in this cross-sectional study. Ten independent variables were measured at baseline to determine their association with reduced work functioning: severity of psychosocial symptoms (four domains, measured with the Four-Dimensional Symptom Questionnaire), physical health (RAND 36-Item Health Survey), moderate or vigorous physical activity (Activ8 activity monitor), age, sex, education level and duration of complaints. Two separate multivariable linear regression analyses were performed with backward stepwise selection, for both impaired work performance and absenteeism. RESULTS Absenteeism rate rose with 2.5 and 0.6% for every increased point on the Four-Dimensional Symptom Questionnaire for domain 'depression' (B = 0.025, SE = 0.009, p = .006) and domain 'somatization' (B = 0.006, SE = 0.003, p = .086), respectively. An R2 value of 0.118 was found. Impaired work performance rate rose with 0.2 and 0.5% for every increased point on the Four-Dimensional Symptom Questionnaire for domain 'distress' (B = 0.002, SE = 0.001, p = .084) and domain 'somatization' (B = 0.005, SE = 0.001, p < .001), respectively. An R2 value of 0.252 was found. CONCLUSIONS Severity of distress, probability of a depressive disorder and probability of somatization are positively associated with higher rates of reduced work functioning in people with moderate MUPS. To prevent long-term absenteeism and highly impaired work performance severity of psychosocial symptoms seem to play a significant role. However, because of the low percentage of explained variance, additional research is necessary to gain insight in other factors that might explain the variance in reduced work functioning even better.
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Affiliation(s)
- Mark L van Tilburg
- Department of Rehabilitation, Physiotherapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands. .,Expertise Center Healthy Urban Living, Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Heidelberglaan 7, 3584 CS, Utrecht, the Netherlands. .,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands.
| | - Paula Elisabeth van Westrienen
- Department of Rehabilitation, Physiotherapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands.,Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands
| | - Martijn F Pisters
- Department of Rehabilitation, Physiotherapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, the Netherlands.,Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, the Netherlands
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Abstract
The development of liaison psychiatry services over the last 20 years is briefly reviewed--sophisticated liaison services have been confined to teaching hospitals. Limited manpower and other resources have prevented the development of liaison services in most district general hospitals; further developments are unlikely unless these deficiencies are corrected and psychiatrists take a more active role in developing links with physicians and surgeons. The time is right for such development as physicians are keen to extend our understanding of psychological and social factors in causing non-organic disorders, reduce unnecessary investigations and provide more comprehensive care. Increased collaboration between physicians and psychiatrists will provide a better service for many patients and this should be extended to all district general hospitals.
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Affiliation(s)
- F Creed
- University Department of Psychiatry, Manchester Royal Infirmary
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5
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Goddard N, Bernadt M, Wessely S. Sharing medical records: comparison of general psychiatric patients with somatisation disorder patients. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.21.8.489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The responses of somatisation disorder (SD) patients to reading their main clinical summary were compared with those of general psychiatric patients, to assess whether the sharing of information and psychiatic opinion might help in the management of SD. Overall the SD patients responded favourably on 8 out of 11 measures; 28 of the 30 (93%) thought it was a good idea to have read the summary and 26 (87%) thought it had provided helpful information. Significantly more of the SD patients (57% compared with 27% of the general psychiatric patients) had their concerns about undiagnosed illness increase as a result of reading their clinical summary.
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Nwokocha ARC, Chinawa JM, Onukwuli V, Ubesie A, Ndukuba A, Chinawa AT, Aniwada E, Uwaezuoke S. Somatization disorder among adolescents in southeast Nigeria: a neglected issue. Int J Ment Health Syst 2017; 11:57. [PMID: 28947913 PMCID: PMC5609071 DOI: 10.1186/s13033-017-0161-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/04/2017] [Indexed: 11/21/2022] Open
Abstract
Background Adolescents do present with somatization disorder which is often neglected by pediatricians. This could have serious consequences if not curbed early. Objectives This study is aimed at determining the pattern and types of Somatization disorder among adolescents attending secondary schools in south east Nigeria. Methods Somatization disorder was investigated among 485 adolescents from mixed schools using a stratified random sampling of adolescents from four secondary schools in southeast Nigeria. The Enugu somatization scale was used to evaluate for presence of somatization in the participants. Statistical analysis was with statistical package for social sciences (SPPS) version 19 (Chicago IL). Results A total of 485 adolescents aged 10–19 years were included in this study. The mean age of the respondents was 16.36 with standard deviation (SD) of 3.14 years. Two hundred and fifty-one (51.8%) had head features, 262 (54.0%) had body features, 303 (62.5%) had either head or body features while 210 (43.3%) had both head and body features. One hundred and thirty-four males (51.3%) compared to 117 females (52.2%) reported symptoms consistent with head symptoms (p = 0.038). One hundred and eleven males (42.5%) compared to 99 females (44.2) reported symptoms related to the head and body (p = 0.137) while 135 males (51.7%) compared to 127 females (56.7%) reported symptoms related to the body (p = 0.925). There were significant associations of age in categories with head, body, either head or body as well as both head and body features (all p value <0.001). Conclusions Psychosomatic problems do exist and may be on the rise among adolescents. Electronic supplementary material The online version of this article (doi:10.1186/s13033-017-0161-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A R C Nwokocha
- Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria
| | - J M Chinawa
- Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria.,Department of Pediatrics, UNTH, PMB 01129, Enugu, 400001 Enugu State Nigeria
| | - V Onukwuli
- Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria
| | - A Ubesie
- Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria
| | - Appolos Ndukuba
- Department of Psychological Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria
| | - A T Chinawa
- Department of Community Medicine, ESUT Teaching Hospital, Enugu, Enugu State Nigeria
| | - Elias Aniwada
- Department Community Medicine, College of Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria
| | - Samuel Uwaezuoke
- Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State Nigeria
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Ketterer MW, Chawa M, Paone G. Prospective correlates of early (30 day) readmissions on a Cardiothoracic Surgery Service. PSYCHOL HEALTH MED 2017; 22:947-954. [PMID: 28161983 DOI: 10.1080/13548506.2017.1287408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Known to vary widely among hospitals for unclear reasons, early readmissions are associated with higher mortality and are suspected to frequently be due to inadequate discharge preparation/planning. It has been previously documented that the strongest and most consistent predictor of early readmissions in CHF patients is chronic cognitive impairment, and compensatory assistance with adherence on discharge improves early readmission rates. Prospective observational study. The present investigation examined multiple putative perioperative predictors of early readmission in a hospitalized Cardiothoracic Surgery Service. A subtest of the Mini-Cog, Short Term Memory, was the strongestunivariate predictor of early readmissions (p < .001), but the overall Mini-Cog (p = .024), Age (p = .045), Number of Admissions over the Preceding Year (p = .036), an Anxiety Scale (p = .035), Years of Education (p = .055) and a Depression Scale (p = .056) also demonstrated covariation. In a Logistic Regression, only Short Term Memory survived as a predictor variable (p = .007), correctly classifying 76% of patients. Chronic cognitive impairment is a predictor of early readmissions in Cardiothoracic patients. A brief bedside exam interpreted in medical context may permit identification of patients requiring familial assistance for adherence on discharge.
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Affiliation(s)
- Mark W Ketterer
- a Department of Behavioral Health , Henry Ford Hospital/WSU , Detroit , MI , USA
| | - Mansi Chawa
- b Behavioral Health , Henry Ford Health System , Detroit , MI , USA
| | - Gaetano Paone
- c Division of Cardiothoracic Surgery , Henry Ford Hospital , Detroit , MI , USA
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Murphy M, Kontos N, Freudenreich O. Electronic Support Groups: An Open Line of Communication in Contested Illness. PSYCHOSOMATICS 2016; 57:547-555. [PMID: 27421707 PMCID: PMC5529167 DOI: 10.1016/j.psym.2016.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/22/2016] [Accepted: 04/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with functional somatic syndromes are often difficult to treat. The relationship between doctors and patients can be strained, which limits communication. Instead, patients often communicate with each other over the Internet in electronic support groups. OBJECTIVE This perspective summarizes studies of patient-to-patient communication over the Internet and uses the concept of contested illness to provide insights into the experiences of patients with functional somatic disorders. DISCUSSION Conflict between a patient and their physician is a key feature of functional somatic syndromes. Physicians and patients do not have a shared understanding or appreciation of the patient's experiences. Patients with functional somatic syndromes often value their own embodied experience over medical knowledge. At the same time, they remain deeply invested in finding a "good doctor" who believes that the patient is suffering, agrees with their conception of the cause, and assents to the treatment as directed by the patient. Electronic support groups reinforce these beliefs. CONCLUSION Patients may benefit from a compromising, collaborative approach that is realistic about the limitations of medical knowledge. However, physicians should not engage in unsafe treatment practices. Electronic support groups exist for a wide range of illnesses and the issues that rise to the surface in functional somatic syndromes likely occur to some extent with almost every patient.
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Affiliation(s)
- Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; McLean Hospital, Belmont, MA.
| | - Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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[How burdensome is the treatment of patients with somatoform disorders?]. ZEITSCHRIFT FUR PSYCHOSOMATISCHE MEDIZIN UND PSYCHOTHERAPIE 2016; 60:383-91. [PMID: 25528873 DOI: 10.13109/zptm.2014.60.4.383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study examines the influence of self-perceived emotional stress during the treatment of patients with somatoform disorders. It asks whether emotional stress can be influenced by psychosomatic education. METHODS Via online questionnaire general practitioners were asked about the prevalence of patients presenting with somatoform disorders and emotional stress during treatment. RESULTS The prevalence of somatoform disorders in general practices was estimated at around 27.7 %. Practitioners educated in psychosomatic medicine estimate the prevalence of patients with somatoform disorders higher than practitioners without such education (n = 79; r = 0.242; p = 0.032). The treatment of patients presenting with somatoform disorders causes 42.6% more emotional stress among general practitioners compared with the treatment of an average patient (n = 79; t = 16.67; p ≤ 0.001). Doctors with additional education in psychosomatic medicine rate stress 17.2% lower than doctors without such education (n = 79; t = 1.875; p = 0.033). CONCLUSIONS General practitioners experience the treatment of patients presenting with somatoform disorders as emotionally stressful. This emotional stress is mainly explained by increases in time expenditure, but it can be reduced by additional psychosomatic education.
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Open Trial of Integrated Primary Care Consultation for Medically Unexplained Symptoms. J Behav Health Serv Res 2016; 44:590-601. [PMID: 27530260 DOI: 10.1007/s11414-016-9528-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Within primary care settings, patients with medically unexplained symptoms (MUS) are common, often present with comorbid psychopathology, and have high rates of healthcare utilization. Despite increased healthcare utilization, these patients often have poor outcomes that frustrate patients and providers alike. A behavioral consultation intervention for primary care patients with MUS (n = 10) was developed and assessed. All participants completed all intervention and assessment sessions and rated the intervention favorably. Participants self-report scores revealed statistically significant improvements from baseline to 3-month follow-up on physical functioning, mental functioning, and physical symptoms. Notwithstanding the limitations of open trial designs, these findings demonstrate high feasibility for a behavioral health consultation treatment model for patients with MUS and highlight the need for further research.
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Elderkin-Thompson V, Silver RC, Waitzkin H. Narratives of Somatizing and Non somatizing Patients in a Primary Care Setting. J Health Psychol 2016; 3:407-28. [DOI: 10.1177/135910539800300309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Somatizing patients, who comprise approximately 20 percent of the primary care population, often present physicians with recurrent but confusing combinations of symptoms without organic explanations. Illness narratives presented during initial medical encounters with primary care physicians were examined qualitatively to determine if the narrative structure, chronological development of symptoms and temporal frame differed between somatizing and non-somatizing patients. Following a structured interview to identify somatization tendency and co-morbidities of depression and post-traumatic stress disorder, 116 patients' encounters with primary care physicians were video-recorded and transcribed. Somatizers demonstrated a narrative structure that was similar to that of non-somatizing patients, but they used a thematic rather than a chronological development of symptoms and they did not convey a clear time frame. Somatizing patients with a co-morbid psychological condition focused on concrete physical sensations, were unable to provide contextual history or chronological organization, and did not develop a temporal frame. The narratives of somatizing and non-somatizing patients differed sufficiently to warrant further research for use as a clinical aid in the diagnosis of somatization.
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Stewart DE. Emotional Disorders Misdiagnosed as Physical Illness: Environmental Hypersensitivity, Candidiasis Hypersensitivity, and Chronic Fatigue Syndrome. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2015. [DOI: 10.1080/00207411.1990.11449173] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Beach SR, Kroshinsky D, Kontos N. Case records of the Massachusetts General Hospital. Case 37-2014. A 35-year-old woman with suspected mite infestation. N Engl J Med 2014; 371:2115-23. [PMID: 25427115 DOI: 10.1056/nejmcpc1305989] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Primary care providers play a crucial role in the recognition and appropriate treatment of patients with multiple somatic complaints. Both the number of somatic symptoms and the persistence of symptoms are associated with co-occurring depression or anxiety disorders. It can be challenging to simultaneously address possible medical causes for physical symptoms while also considering an associated psychiatric diagnosis. In this article, strategies to improve the care and outcomes among these patients are described, including collaboration, education about the interaction between psychosocial stressors and somatic symptoms, regularly scheduled visits, focus on improving functional status, and evidence-based treatment of depression and anxiety.
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Affiliation(s)
- Carmen Croicu
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 359911, 325 Ninth Avenue, Seattle, WA 98104, USA.
| | - Lydia Chwastiak
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 359911, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Wayne Katon
- Division of Health Services and Psychiatric Epidemiology, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 356560, 1959 Northeast Pacific, Seattle, WA 98195, USA
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Lo studio internazionale multicentrico dell'Organizzazione Mondiale della Sanità sui disturbi psichici nella medicina generale: risultati relativi all'area di Verona. ACTA ACUST UNITED AC 2014. [DOI: 10.1017/s1121189x0001023x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryObjectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.
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The Medical-Psychiatric Coordinating Physician–Led Model: Team-Based Treatment for Complex Patients. PSYCHOSOMATICS 2014; 55:333-342. [DOI: 10.1016/j.psym.2013.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 12/26/2013] [Accepted: 12/27/2013] [Indexed: 11/18/2022]
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Abstract
AbstractWe report the case of a 48 year old woman who presents with a 25 year history of somatisation disorder. She has ten volumes of notes from four hospitals in one city which together weigh almost 10kg. She has been under the care of ten hospital specialities, had eleven operations, with 77 admissions and a total of 856 days in hospital over a period of twenty-five years. No physical diagnoses can satisfactorily explain her presentations which have been accurately costed to a total of over £250,000 as a conservative estimate.Somatisation disorder is a chronic illness with financial, medical and personal costs. We report in detail recurrent dangers and pitfalls which arose during her hospital contact. By undertaking a case note review, contacting all the physicians involved and writing a “Key” summary letter outlining the contribution of psychological factors to her problems, her annual health care costs were reduced from a total of over £10,000 a year to a little over £2,000 after psychiatric intervention and the appointment of one physician to take overall charge of her case. Implications for service provision are discussed.
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Martlew J, Pulman J, Marson AG. Psychological and behavioural treatments for adults with non-epileptic attack disorder. Cochrane Database Syst Rev 2014; 2014:CD006370. [PMID: 24519702 PMCID: PMC11032749 DOI: 10.1002/14651858.cd006370.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Psychogenic non-epileptic seizures, also known as non-epileptic attack disorder (NEAD), have the outward appearance of epilepsy in the absence of physiological or electroencephalographic correlates. Non-epileptic seizures can occur in isolation or in combination with epileptic seizures. The development and maintenance of non-epileptic seizures has been well documented and there is a growing literature on the treatment of non-epileptic seizures which includes non-psychological (including anti-anxiety and antidepressant pharmacological treatment) and psychological therapies (including cognitive behavioural therapy (CBT), hypnotherapy and paradoxical therapy). Various treatment methodologies have been tried with variable success. The purpose of this Cochrane review was to establish the evidence base for the treatment of non-epileptic seizures with behavioural and psychological therapies only. OBJECTIVES To assess whether behavioural or psychological treatments for non-epileptic seizures or NEAD result in a reduction in the frequency of seizures or improvement in quality of life, or both, and whether any treatment is significantly more effective than others. SEARCH METHODS We searched the Cochrane Epilepsy Group's Specialised Register (4 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1) (January 2013), MEDLINE (1946 to 4 February 2013), PsycINFO (4 February 2013) and SCOPUS (4 February 2013). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies SELECTION CRITERIA Randomised controlled trials (RCTs) and before and after controlled and non-controlled studies were eligible for inclusion. Studies were required to assess one or more types of behavioural or psychological interventions, or both, for the treatment of non-epileptic seizures. Studies of childhood non-epileptic seizures were excluded from our review. DATA COLLECTION AND ANALYSIS Two review authors (JM, JP) independently assessed the trials for inclusion and extracted data. Outcomes included reduction in seizure frequency and improvements in quality of life. MAIN RESULTS Twelve studies, with a total of 343 participants, met our inclusion criteria (four RCTs and eight before and after non-controlled studies). Of the four RCTs, one examined patients with non-epileptic seizures and three had a mixed diagnosis (pseudoseizures, conversion disorder and somatisation disorder). Most of the non-randomised studies used non-epileptic seizure patients exclusively. Overall, five studies examined the effectiveness of psychotherapy, three examined CBT, two investigated hypnosis, one assessed paradoxical intention and one had a mixed intervention design. We classified two included studies as low risk of bias, one as unclear and nine as high risk of bias. Meta-analysis could not be undertaken due to the heterogeneity of design and interventions. Most included studies reported improved outcomes for the intervention under investigation. One RCT investigating the effectiveness of CBT in this patient group found a significant reduction in seizure frequency compared to controls (P < 0.001). AUTHORS' CONCLUSIONS There is little reliable evidence to support the use of any treatment, including CBT, in the treatment of non-epileptic seizures. Further randomised controlled trials of CBT and other interventions are needed.
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Affiliation(s)
- Jayne Martlew
- The Walton CentreDepartment of NeuropsychologyJubilee House, 10th AvenueFazakerleyLiverpoolMersysideUKL9 7AL
| | - Jennifer Pulman
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Reuber M, Howlett S, Kemp S. Psychologic treatment of patients with psychogenic nonepileptic seizures. Expert Rev Neurother 2014; 5:737-52. [PMID: 16274332 DOI: 10.1586/14737175.5.6.737] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Psychogenic nonepileptic seizures are relatively common, often disabling and costly to patients and society. Most authorities consider psychologic treatment as the therapeutic intervention of choice. This review is intended primarily for psychologists and therapists who treat patients with psychogenic nonepileptic seizures, and for neurologists who make the diagnosis and wish to find out more about psychologic treatment options. The first section describes the nature and etiology of psychogenic nonepileptic seizures. General questions regarding the psychologic treatment of patients with psychogenic nonepileptic seizures are addressed, before discussing specific therapeutic approaches. The final part summarizes the authors' views on optimal treatment and the direction of future research.
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Affiliation(s)
- Markus Reuber
- Academic Neurology Unit, University of Sheffield, Department of Neurology, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
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Lai HH, North CS, Andriole GL, Cupps L, Song D, Ness TJ, Hong BA. Urological symptoms in a subset of patients with urological chronic pelvic pain syndrome and a polysymptomatic, polysyndromic pattern of presentation. J Urol 2013; 191:1802-7. [PMID: 24361369 DOI: 10.1016/j.juro.2013.12.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2013] [Indexed: 01/28/2023]
Abstract
PURPOSE We characterized urological symptoms in a subset of patients with urological chronic pelvic pain syndrome who have a high somatic symptom burden and a wide symptom distribution fitting a polysymptomatic, polysyndromic presentation pattern. MATERIALS AND METHODS A total of 81 patients with urological chronic pelvic pain syndrome enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases MAPP Research Network Study at Washington University in St. Louis and University of Alabama at Birmingham sites. They completed a symptom questionnaire to assess the somatic symptom burden and its distribution, and GUPI (Genitourinary Pain Index) to assess urological chronic pelvic pain syndrome symptoms, impact on quality of life and self-reported treatment seeking behaviors for urological chronic pelvic pain symptoms. The polysymptomatic, polysyndromic symptom pattern was defined by self-report of numerous painful and nonpainful somatic symptoms across many organ systems and by symptom categories on the polysymptomatic, polysyndromic questionnaire. RESULTS Patients with urological chronic pelvic pain syndrome and the symptom pattern reported more severe genitourinary pain on a Likert scale, more frequent pain in the last week and more widespread pain distribution in the genital and pelvic areas than patients with urological chronic pelvic pain syndrome without the pattern. Patients with the symptom pattern also had significantly higher scores on the GUPI pain subscale, quality of life subscale (worse) and total questionnaire scores than patients without the pattern. Patients with the pattern reported significantly more treatment seeking behavior than others. CONCLUSIONS The polysymptomatic, polysyndromic pattern might be an important phenotypic factor to assess in the evaluation of urological chronic pelvic pain syndrome with clinical and research implications. This may be a distinct clinical subgroup among patients with urological chronic pelvic pain syndrome.
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Affiliation(s)
- H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
| | - Carol S North
- Departments of Psychiatry and Surgery/Division of Emergency Medicine, North Texas Veterans Affairs Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gerald L Andriole
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Lori Cupps
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - David Song
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Timothy J Ness
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barry A Hong
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
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Castro Pérez SM, Rudolph Quezada CI, Aguilar Romero JE. Psychiatric consulting in primary care. Medwave 2013. [DOI: 10.5867/medwave.2013.03.5646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Konnopka A, Schaefert R, Heinrich S, Kaufmann C, Luppa M, Herzog W, König HH. Economics of medically unexplained symptoms: a systematic review of the literature. PSYCHOTHERAPY AND PSYCHOSOMATICS 2013; 81:265-75. [PMID: 22832397 DOI: 10.1159/000337349] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 02/18/2012] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To review cost-of-illness studies (COI) and economic evaluations (EE) conducted for medically unexplained symptoms and to analyze their methods and results. METHODS We searched the databases PubMed, PsycINFO and National Health Service Economic Evaluations Database of the University of York. Cost data were inflated to 2006 using country-specific gross domestic product inflators and converted to 2006 USD purchasing power parities. RESULTS We identified 5 COI and 8 EE, of which 6 were cost-minimization analyses and 2 were cost-effectiveness analyses. All studies used patient level data collected between 1980 and 2004 and were predominantly conducted in the USA (n = 10). COI found annual excess health care costs of somatizing patients between 432 and 5,353 USD in 2006 values. Indirect costs were estimated by only one EE and added up to about 18,000 USD per year. In EE, educational interventions for physicians as well as cognitive-behavioral therapy approaches for patients were evaluated. For both types of interventions, effectiveness was either shown within EE or by previous studies. Most EE found (often insignificant) cost reductions resulting from the interventions, but only two studies explicitly combined changes in costs with data on effectiveness to cost-effectiveness ratios (ratio of additional costs to additional effects). CONCLUSIONS Medically unexplained symptoms cause relevant annual excess costs in health care that are comparable to mental health problems like depression or anxiety disorders and which may be reduced by interventions targeting physicians as well as patients. More extensive research on indirect costs and cost-effectiveness is needed.
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Affiliation(s)
- Alexander Konnopka
- Department of Medical Sociology and Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. a.konnopka @ uke.de
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Lemche E, Giampietro VP, Brammer MJ, Surguladze SA, Williams SCR, Phillips ML. Somatization severity associated with postero-medial complex structures. Sci Rep 2013; 3:1032. [PMID: 23301153 PMCID: PMC3538283 DOI: 10.1038/srep01032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/13/2012] [Indexed: 01/29/2023] Open
Abstract
Somatisation is a frequent problem in various psychiatric disorders, yet the cerebral mechanisms of somatisation remain unexamined. To test if somatisation is susceptible to emotional states, we investigated relationships between somatisation severity, neural effective connectivity, and autonomic responses to emotional facial expressions. Volunteering participants (N = 20) were presented with facial expressions of happy and sad emotion at three intensity levels (0%–50%–100%) in a fast implicit ER-fMRI design with concurrent derivation of skin conductance levels (SCL). Self-reported somatisation severity as assessed with Rief's SOMS-2 index was correlated with neural response controlling for other clinical traits to ascertain brain bases of somatisation. Regression analyses estimated effective connectivity of main clusters so determined with peripheral autonomic responses. Regions in which magnitude of activity correlated with somatisation severity consisted in both happy and sad conditions of the anterior ventral precuneus (BA7), along with posterior cingulate gyrus (PCC, BA23, sad condition) and anteromedial thalamus (happy condition).
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Affiliation(s)
- Erwin Lemche
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, King's College Medical School, London SE5 8AF, United Kingdom.
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Andersen NLT, Eplov LF, Andersen JT, Hjorthøj CR, Birket-Smith M. Health care use by patients with somatoform disorders: a register-based follow-up study. PSYCHOSOMATICS 2012; 54:132-41. [PMID: 23218064 DOI: 10.1016/j.psym.2012.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 07/15/2012] [Accepted: 07/22/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Studies have shown a greater use of medical than mental health services in patients with somatoform disorders. However, not many studies are based on structured interviews and include the entire somatoform spectrum of diagnoses. We conducted a register-based case-control study to investigate medical care use prior to and three years after diagnosis in patients with somatoform disorders. METHODS We included 380 patients with somatoform diagnoses (SCID-NP for DSM-IIIR) in a case-control study and compared them with 174 patients with anxiety disorders and 5540 controls from the background population. Data from the Danish National Registers were used to assess health care use in both primary and secondary care. RESULTS Somatoform patients incurred 2.11 (2.09-2.12) times the primary care visits of controls. They had 3.12 (3.08-3.16) times as many somatic bed-days than controls and 3.94 (3.91-3.97) as many psychiatric bed-days. Primary care use remained stable 3 years after diagnosis (p = 0.14) and the award of disability pension (p = 0.82). However, the number of somatic admissions decreased from 5.64 to 2.76 (p = 0.0004) 3 years after diagnosis. Somatization had an independent effect on health care use when controlling for psychiatric comorbidity. CONCLUSIONS Patients with somatoform disorders make significantly greater use of health care services than do controls and patients with anxiety. Somatoform patients made more use of psychiatric services than expected. The use of somatic health care was independent of psychiatric comorbidity. Primary care use and disability pension award were not influenced by proper diagnosing of somatoform disorders whereas number of somatic admissions were halved.
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Morriss R, Lindson N, Coupland C, Dex G, Avery A. Estimating the prevalence of medically unexplained symptoms from primary care records. Public Health 2012; 126:846-54. [PMID: 22922044 DOI: 10.1016/j.puhe.2012.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 03/08/2012] [Accepted: 05/21/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To develop models to estimate the likely prevalence of medically unexplained symptoms (MUS) and severe MUS in a primary care practice from existing patient electronic records collected in the previous 2 years for secondary prevention and commissioning of psychological treatment. STUDY DESIGN Cross-sectional survey comparing general practitioners' (GPs) assessment of the presence or absence of MUS and severe MUS with clinical, demographic and service use variables associated with MUS or functional somatic syndromes from previous research in the patient's routine electronic record over the previous 2 years. METHODS Seventeen GPs from eight practices identified cases of MUS and severe MUS in 828 consecutive consulters in primary care. Models of variables associated with MUS and severe MUS were constructed using multivariate multilevel logistic regression. The predictive validity of the final models was tested, comparing predicted with observed data and expected prevalence rates from the literature. RESULTS Models to predict MUS and severe MUS had areas under the receiver operating characteristic curve of 0.70 [95% confidence interval (CI) 0.65-0.74] and 0.76 (95% CI 0.70-0.82), respectively. Both models showed adequate goodness of fit with observed data, and had good predictive validity compared with the expected prevalence of MUS, severe MUS, and anxiety or depression. CONCLUSION Models to predict the prevalence of MUS and severe MUS from routine practice records for commissioning purposes were successfully developed, but they require independent validation before general use. The sensitivity of these models was too low for use in clinical screening.
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Affiliation(s)
- R Morriss
- Department of Psychiatry, Institute of Mental Health, University of Nottingham, Innovation Park, Triumph Road, Nottingham NG7 2TU, UK.
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Morriss R, Kai J, Atha C, Avery A, Bayes S, Franklin M, George T, James M, Malins S, McDonald R, Patel S, Stubley M, Yang M. Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention. BMC FAMILY PRACTICE 2012; 13:39. [PMID: 22607525 PMCID: PMC3390898 DOI: 10.1186/1471-2296-13-39] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/20/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context. METHODS/DESIGN A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6-22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined. DISCUSSION The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.
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Affiliation(s)
- Richard Morriss
- Psychiatry and Community Mental Health, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
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López-García-Franco A, del-Cura-González MI, Caballero-Martinez L, Sanz-Cuesta T, Díaz-García MI, Rodriguez-Monje MT, Chahua M, Muñoz-Sanchez I, Serrano-González D, Rollán-Llanderas T, Nieto-Blanco E, Losada-Cucco L, Caballero-Martínez F, Sanz-García N, Pose-García B, Jurado-Sueiro M, Rey ML, de Blas González FG, Abanto MAM, Bayona TS, Ayllón-Camargo R, Lopez IS, Hernando MLS, Beltran-Alvarez R, Aguilar-Gutierrez AI, Mota-Rodriguez JL, Cosculluela-Pueyo R, López-Martín-Aragón T, Bonilla-Sanchez R, Aritieda-González-Granda MC, Razola-Rincón R, Sanchez-de-la-Ventana MA, Martinez-Guinea C, Huerta-Galindo L, Barrio-Ovalle AB, Miguel-Martín S, Portero-Fraile P, Pensado-Freire H, Herrera-Garcia ML, Azcoaga-Lorenzo A, Gómez-García I, Llamas-Sandino N, López-Borja I, Maldonado-Castro H, Lumbreras-Villarán P, Ascanio-Durán C. Effectiveness of a cognitive behavioral intervention in patients with medically unexplained symptoms: cluster randomized trial. BMC FAMILY PRACTICE 2012; 13:35. [PMID: 22551252 PMCID: PMC3515424 DOI: 10.1186/1471-2296-13-35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 05/02/2012] [Indexed: 11/21/2022]
Abstract
Background Medically unexplained symptoms are an important mental health problem in primary care and generate a high cost in health services. Cognitive behavioral therapy and psychodynamic therapy have proven effective in these patients. However, there are few studies on the effectiveness of psychosocial interventions by primary health care. The project aims to determine whether a cognitive-behavioral group intervention in patients with medically unexplained symptoms, is more effective than routine clinical practice to improve the quality of life measured by the SF-12 questionary at 12 month. Methods/design This study involves a community based cluster randomized trial in primary healthcare centres in Madrid (Spain). The number of patients required is 242 (121 in each arm), all between 18 and 65 of age with medically unexplained symptoms that had seeked medical attention in primary care at least 10 times during the previous year. The main outcome variable is the quality of life measured by the SF-12 questionnaire on Mental Healthcare. Secondary outcome variables include number of consultations, number of drug (prescriptions) and number of days of sick leave together with other prognosis and descriptive variables. Main effectiveness will be analyzed by comparing the percentage of patients that improve at least 4 points on the SF-12 questionnaire between intervention and control groups at 12 months. All statistical tests will be performed with intention to treat. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. Discussion This study aims to provide more insight to address medically unexplained symptoms, highly prevalent in primary care, from a quantitative methodology. It involves intervention group conducted by previously trained nursing staff to diminish the progression to the chronicity of the symptoms, improve quality of life, and reduce frequency of medical consultations. Trial registration The trial was registered with ClinicalTrials.gov, number NCT01484223 [
http://ClinicalTrials.gov].
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Abstract
There is a wide debate among the researchers and clinicians over the diagnostic categories subsumed under the rubric of somatoform disorders (SDs). Recent proposals vary from radical views that call for removing this category altogether to the conservative views that suggests cosmetic changes in the diagnostic criteria of SDs. We have the reviewed the relevant literature through PUBMED search supplemented with manual search on current concepts of SD.
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Affiliation(s)
- Amlan K. Jana
- Department of Psychiatry, KPC Medical College and Hospital, Kolkata, West Bengal, India
| | | | - Joyita Mazumdar
- Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
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Affiliation(s)
- Mary Lynn Dell
- Division of Child and Adolescent Psychiatry, University Hospitals Case Medical Center, Cleveland, OH 44106, USA.
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Puri PR, Dimsdale JE. Health care utilization and poor reassurance: potential predictors of somatoform disorders. Psychiatr Clin North Am 2011; 34:525-44. [PMID: 21889677 PMCID: PMC3170079 DOI: 10.1016/j.psc.2011.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Somatoform disorders are common conditions, but the current diagnostic criteria are considered to be unreliable, based largely on medically unexplained symptoms. DSM-5 is considering other possible characteristics of somatizers including high utilization, dissatisfaction with care, and poor response to reassurance. This paper reviews the available literature for evidence to support these criteria, and evaluates if distinctive aspects of these characteristics exist in somatizers. METHODS The Pubmed database was searched combining terms such as “somatoform disorder” with “reassurance,” “satisfaction,” and “utilization.” Articles were individually inspected. RESULTS Many studies report a deficit in long-term response to reassurance in somatizers; there was some evidence that patients respond initially to reassurance, followed by return of anxiety, leading to further reassurance seeking. There was insufficient evidence to support poor satisfaction with care as a characteristic of somatizers. While there is no standard criterion for high utilization, regardless of definition, evidence was found to support over-utilization, particularly in outpatient visits. However, no unique pattern of utilization was found that could identify somatizers within a broader group of high utilizers. CONCLUSIONS This review revealed evidence of over-utilization in many areas of healthcare, as well as poor long term response to reassurance in somatizers. Dissatisfaction with care, though, was not a consistent finding. It is difficult to study alternative diagnostic criteria for somatoform patients when the current criteria rest on so many problematic assumptions. Future research should attempt to validate criteria empirically in patient groups, with selection not based on medically unexplained symptoms.
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Affiliation(s)
- Paul R Puri
- Department of Psychiatry, University of California, San Diego, CA, USA.
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Katon W, Unützer J. Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. Gen Hosp Psychiatry 2011; 33:305-10. [PMID: 21762825 PMCID: PMC3140951 DOI: 10.1016/j.genhosppsych.2011.05.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 05/17/2011] [Accepted: 05/18/2011] [Indexed: 01/17/2023]
Affiliation(s)
- Wayne Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA.
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA
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Hoedeman R, Blankenstein AH, van der Feltz-Cornelis CM, Krol B, Stewart R, Groothoff JW. Consultation letters for medically unexplained physical symptoms in primary care. Cochrane Database Syst Rev 2010:CD006524. [PMID: 21154369 DOI: 10.1002/14651858.cd006524.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In primary care between 10% and 35% of all visits concern patients with medically unexplained physical symptoms (MUPS). MUPS are associated with high medical consumption, significant disabilities and psychiatric morbidity. OBJECTIVES To assess the effectiveness of consultation letters (CLs) to assist primary care physicians or occupational health physicians in the treatment of patients with MUPS and diagnostic subgroups. SEARCH STRATEGY We searched for randomized controlled trials (RCTs) on the Cochrane Collaboration Depression, Anxiety and Neurosis Group Controlled Trials Registers, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2009), MEDLINE (1966-2009), MEDLINE In Process (2009-08-17), EMBASE (1974-2009), PSYCINFO (1980-2009) and CINAHL (1982-2009). We screened the references lists of selected studies and consulted experts in the field to identify any additional, eligible RCTs. SELECTION CRITERIA RCTs of CLs for patients with MUPS being treated in primary care settings. DATA COLLECTION AND ANALYSIS Two authors independently screened the abstracts of the studies identified through the searches and independently assessed the risk of bias of the included studies. We resolved any disagreement by discussion with a third review author. We assessed heterogeneity and, where a number of studies reported the same outcomes, pooled results in a meta-analysis. MAIN RESULTS We included six RCTs, with a total of 449 patients. In four studies (267 patients) the CL intervention resulted in reduced medical costs (in two studies the outcomes could be pooled: MD -352.55 US Dollars (95% CI -522.32 to -182.78)) and improved physical functioning (three studies, MD 5.71 (95% CI 4.11 to 7.31)). In two studies (182 patients) the intervention was a joint consultation with a psychiatrist in presence of the physician, and resulted in reduced severity of somatization symptoms, reduced medical consumption and improved social functioning. AUTHORS' CONCLUSIONS There is limited evidence that a CL is effective in terms of medical costs and improvement of physical functioning for patients with MUPS in primary care. The results are even less pronounced in patients with clinically less severe, but more meaningful, forms of MUPS and the results vary for other patient-related outcomes. All studies, except one, were performed in the United States and therefore the results can not be generalized directly to countries with other healthcare systems. Furthermore all studies were small and of only moderate quality. There is very limited evidence that a joint consultation with the patient by a psychiatrist in the presence of the physician, together with the provision of a CL, reduces severity of somatization symptoms and medical consumption.
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Affiliation(s)
- Rob Hoedeman
- University Medical Center Groningen, Department of Health Sciences, University of Groningen, ArboNed, Postbus 85092, Utrecht, Netherlands, 3508 AB
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Kolko DJ, Campo JV, Kelleher K, Cheng Y. Improving access to care and clinical outcome for pediatric behavioral problems: a randomized trial of a nurse-administered intervention in primary care. J Dev Behav Pediatr 2010; 31:393-404. [PMID: 20495474 PMCID: PMC3057358 DOI: 10.1097/dbp.0b013e3181dff307] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care. The study includes boys and girls from six primary care offices in metropolitan Pittsburgh, PA. METHODS One hundred sixty-three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention or to enhanced usual care. Protocol for on-site, nurse-administered intervention applied treatment modules from an evidence-based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; enhanced usual care offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome measures such as standardized rating scales, including the Pediatric Symptom Checklist-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected. RESULTS Protocol for on-site, nurse-administered intervention cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time. CONCLUSIONS A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.
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Affiliation(s)
- David J. Kolko
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - John V. Campo
- Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | - Kelly Kelleher
- Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | - Yu Cheng
- Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA
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van der Feltz-Cornelis CM, Van Os TWDP, Van Marwijk HWJ, Leentjens AFG. Effect of psychiatric consultation models in primary care. A systematic review and meta-analysis of randomized clinical trials. J Psychosom Res 2010; 68:521-33. [PMID: 20488268 DOI: 10.1016/j.jpsychores.2009.10.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 10/27/2009] [Accepted: 10/27/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Psychiatric consultation in primary care is meant to enhance and improve treatment for mental disorder in that setting. An estimate of the effect for different conditions as well as identification of particularly effective elements is needed. METHODS Database search for randomized controlled trials (RCTs) on psychiatric consultation in primary care. Validity assessment and data extraction according to Cochrane criteria were performed by independent assessors in duplicate. Meta-analysis was performed. RESULTS Data were collected from 10 RCTs with a total of 3408 included patients with somatoform disorder or depressive disorder, which compared psychiatric consultation to care as usual (CAU). Meta-analysis irrespective of condition showed a weighted mean indicating a combined assessment of illness burden as outcome of psychiatric consultation, compared to CAU, of 0.313 (95% CI 0.190-0.437). The effect was especially large in somatoform disorder (0.614; 95% CI 0.206-1.022). RCTs in which after the consult, consultation advice was given by means of a consultation letter, showed a combined weighted mean effect size of 0.561 (95% CI 0.337-0.786), while studies not using such a letter showed a small effect of 0.210 (95% CI 0.102-0.319). Effects are highest on utilization of health care services with 0.507 (95% CI 0.305-0.708). CONCLUSION Psychiatric consultation in the primary care setting is effective in patients with somatoform and depressive disorder. Largest effects are seen in reduction of utilization of health care services.
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Affiliation(s)
- Christina M van der Feltz-Cornelis
- Diagnosis and Treatment of Common Mental Disorders, Trimbos-Instituut/Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.
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What is the role of consultation-liaison psychiatry in the management of depression in primary care? A systematic review and meta-analysis. Gen Hosp Psychiatry 2010; 32:246-54. [PMID: 20430227 DOI: 10.1016/j.genhosppsych.2010.02.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 02/01/2010] [Accepted: 02/03/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the effectiveness of consultation-liaison services, involving mental health professionals working to advise and support primary care professionals in the management of depression. METHODS Studies of consultation-liaison for depression in primary care were identified from a systematic search of electronic databases, augmented by identification of papers from reference lists, published reviews and from hand searching. Data on study quality, intervention characteristics and outcomes were extracted by two reviewers, and outcome data were meta-analyzed. RESULTS Five studies met the criteria. There was no significant effect of consultation-liaison on antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or depression outcomes in the short- (standardized mean difference -0.04, 95% CI -0.21 to 0.14) or long-term (standardized mean difference 0.06, 95% CI -0.13 to 0.26). CONCLUSIONS Evidence concerning consultation-liaison for depression in primary care remains limited, but the existing studies do not suggest it is more effective than usual care. Further research is required to explore the mechanisms by which consultation-liaison might be made more effective, including the potential role of consultation-liaison in combination with other models of care, and in other patient populations.
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Begré S, Traber M, Gerber M, von Känel R. Physician speciality and pain reduction in patients with depressive symptoms under treatment with venlafaxine. Eur Psychiatry 2010; 25:455-60. [PMID: 20427156 DOI: 10.1016/j.eurpsy.2009.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 10/20/2009] [Accepted: 10/20/2009] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Excessive pain perception may lead to unnecessary diagnostic testing or invasive procedures resulting in iatrogenic complications and prolonged disability. Naturalistic studies on patients with chronic pain and depressive symptoms investigating the impact of medical speciality on treatment outcome in a primary care setting are lacking. METHODS In this observational study, we examined whether the magnitude of pain reduction in 444 patients with depressive symptomatology under venlafaxine would relate differently to the medical speciality of the 122 treating physicians, namely psychiatrists (n=110 patients), general practitioners (n=236 patients), and internists (n=98 patients). RESULTS Independent of age, gender, patient's region of origin, comorbidity, severity and duration of pain, and depressive symptoms at study entry, patients seemed to benefit significantly less in terms of pain reduction (p<0.001) and of reduction in severity of depressive symptomatology by psychiatrists as compared to general practitioners (p<0.019) and internists (p<0.002). CONCLUSIONS The findings suggest that patients referred to psychiatrists are more difficult to treat than those referred to general practitioners and internists, and might not have been adequately prepared for psychiatric interventions. A supporting cooperation and networking between psychiatrists and primary care physicians may contribute to an integrated treatment concept and therefore, may lead to a better outcome in this challenging patient group.
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Affiliation(s)
- S Begré
- Department of General Internal Medicine, Division of Psychosomatic Medicine, University Hospital/Inselspital, 3010 Bern, Switzerland.
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Kathol RG, Kunkel EJS, Weiner JS, McCarron RM, Worley LLM, Yates WR, Summergrad P, Huyse FJ. Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface. PSYCHOSOMATICS 2009; 50:93-107. [PMID: 19377017 DOI: 10.1176/appi.psy.50.2.93] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.
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Affiliation(s)
- Roger G Kathol
- Dept. of Internal Medicine and Psychiatry, Univ. of Minnesota, USA.
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Melzer J, Schrader E, Brattström A, Schellenberg R, Saller R. Fixed herbal drug combination with and without butterbur (Ze 185) for the treatment of patients with somatoform disorders: randomized, placebo-controlled pharmaco-clinical trial. Phytother Res 2009; 23:1303-8. [DOI: 10.1002/ptr.2771] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Huyse FJ. Consultation/liaison psychiatry: the state of the art and future developments. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/08039489109106166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Leentjens AFG, Boenink AD, Sno HN, Strack van Schijndel RJM, van Croonenborg JJ, van Everdingen JJE, van der Feltz-Cornelis CM, van der Laan NC, van Marwijk H, van Os TWDP. The guideline "consultation psychiatry" of the Netherlands Psychiatric Association. J Psychosom Res 2009; 66:531-5. [PMID: 19446712 DOI: 10.1016/j.jpsychores.2009.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 02/24/2009] [Accepted: 03/03/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2008, the Netherlands Psychiatric Association authorized a guideline "consultation psychiatry." AIM To set a standard for psychiatric consultations in nonpsychiatric settings. The main objective of the guideline is to answer three questions: Is psychiatric consultation effective and, if so, which forms are most effective? How should a psychiatric consultations be performed? What increases adherence to recommendations given by the consulting psychiatrist? METHOD Systematic literature review. RESULTS Both in general practice and in hospital settings psychiatric consultation is effective. In primary care, the effectiveness of psychiatric consultation is almost exclusively studied in the setting of "collaborative care." Procedural guidance is given on how to perform a psychiatric consultation. In this guidance, psychiatric consultation is explicitly looked upon as a complex activity that requires a broad frame of reference and adequate medical and pharmacological expertise and experience and one that should be performed by doctors. Investing in a good relation with the general practitioner, and the use of a "consultation letter" increased efficacy in general practice. In the hospital setting, investing in liaison activities and an active psychiatric follow-up of consultations increased adherence to advice. CONCLUSION Psychiatric consultations are effective and constitute a useful contribution to the patients' treatment. With setting a standard consultations will become more transparent and checkable. It is hoped that this will increase the quality of consultation psychiatry.
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Affiliation(s)
- Albert F G Leentjens
- Department of Psychiatry, Maastricht University Medical Center, Maastricht, The Netherlands.
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olde Hartman TC, Borghuis MS, Lucassen PLBJ, van de Laar FA, Speckens AE, van Weel C. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res 2009; 66:363-77. [PMID: 19379952 DOI: 10.1016/j.jpsychores.2008.09.018] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Revised: 09/22/2008] [Accepted: 09/23/2008] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To study the course of medically unexplained symptoms (MUS), somatisation disorder, and hypochondriasis, and related prognostic factors. Knowledge of prognostic factors in patients presenting persistent MUS might improve our understanding of the naturalistic course and the identification of patients with a high risk of a chronic course. METHODS A comprehensive search of Medline, PsycInfo, CINAHL, and EMBASE was performed to select studies focusing on patients with MUS, somatisation disorder, and hypochondriasis, and assessing prognostic factors. Studies focusing on patients with single-symptom unexplained disorder or distinctive functional somatic syndromes were excluded. A best-evidence synthesis for the interpretation of results was used. RESULTS Only six studies on MUS, six studies on hypochondriasis, and one study on abridged somatisation could be included. Approximately 50% to 75% of the patients with MUS improve, whereas 10% to 30% of patients with MUS deteriorate. In patients with hypochondriasis, recovery rates vary between 30% and 50%. In studies on MUS and hypochondriasis, we found some evidence that the number of somatic symptoms at baseline influences the course of these conditions. Furthermore, the seriousness of the condition at baseline seemed to influence the prognosis. Comorbid anxiety and depression do not seem to predict the course of hypochondriasis. CONCLUSIONS Due to the limited numbers of studies and their high heterogeneity, there is a lack of rigorous empirical evidence to identify relevant prognostic factors in patients presenting persistent MUS. However, it seems that a more serious condition at baseline is associated with a worse outcome.
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Affiliation(s)
- Tim C olde Hartman
- Department of Family Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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The challenge of integrated care for mental health: leaving the 50 minute hour and other sacred things. J Clin Psychol Med Settings 2009; 16:40-6. [PMID: 19184375 DOI: 10.1007/s10880-009-9147-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/07/2009] [Indexed: 10/21/2022]
Abstract
A growing body of research has demonstrated the effectiveness of integrating mental/behavioral healthcare with primary care in improving health outcomes. Despite this rich literature, such demonstration programs have proven difficult to maintain once research funding ends. Much of the discussion regarding maintenance of integrated care has been focused on lack of reimbursement. However, provider factors may be just as important, because integrated care systems require providers to adopt a very different role and operate very differently from traditional mental health practice. There is also great variability in definition and operationalization of integrated care. Provider concerns tend to focus on several factors, including a perceived loss of autonomy, discomfort with the hierarchical nature of medical care and primary care settings, and enduring beliefs about what constitutes "good" treatment. Providers may view integrated care models as delivering substandard care and passively or actively resist them. Dissemination of available data regarding effectiveness of these models is essential (e.g. timeliness of treatment, client satisfaction). Increasing exposure and training in these models, while maintaining the necessary training in traditional mental health care is a challenge for training at all levels, yet the challenge clearly opens new opportunities for psychology and psychiatry.
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Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Syst Rev 2009; 2009:CD000532. [PMID: 19160181 PMCID: PMC7068168 DOI: 10.1002/14651858.cd000532.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs). OBJECTIVES To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs). SEARCH STRATEGY The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library). SELECTION CRITERIA Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. MAIN RESULTS Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population. AUTHORS' CONCLUSIONS This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.
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Affiliation(s)
- Elaine F Harkness
- University of ManchesterNational Primary Care Research and Development CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
| | - Peter J Bower
- University of ManchesterNational Primary Care Research and Development CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
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Improving efficiency and access to mental health care: combining integrated care and advanced access. Gen Hosp Psychiatry 2008; 30:546-51. [PMID: 19061681 DOI: 10.1016/j.genhosppsych.2008.09.004] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 08/29/2008] [Accepted: 09/03/2008] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To provide an example of implementation of a new program that enhances access to mental health care in primary care. METHOD A general and specialized mental health service was redesigned to introduce open access to comprehensive mental health care in a primary care clinic. Key variables measured before and after implementation of the clinic included numbers of completed referrals, waiting time for appointments and clinic productivity. Workload and pre/post-implementation waiting time data were gathered through a computerized electronic monitoring system. RESULTS Waiting time for new appointments was shortened from a mean of 33 days to 19 min. Clinician productivity and evaluations of new referrals more than doubled. These improvements have been sustained for 4 years. CONCLUSION Moving mental health services into primary care, initiating open access and increasing use of technological aids led to dramatic improvements in access to mental health care and efficient use of resources. Implementation and sustainability of the program were enhanced by using a quality improvement approach.
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Pols RG, Battersby MW. Coordinated care in the management of patients with unexplained physical symptoms: depression is a key issue. Med J Aust 2008; 188:S133-7. [PMID: 18558914 DOI: 10.5694/j.1326-5377.2008.tb01877.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2007] [Accepted: 04/28/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the diagnosis of patients with somatisation disorders in primary care, and the effectiveness of coordinated care and evidence-based care planning on psychiatric symptoms and quality of life for these patients. DESIGN, SETTING AND PARTICIPANTS This was a project of the SA HealthPlus Coordinated Care Trial, comprising a randomised controlled trial of 124 subjects recruited by general practitioners in southern Adelaide. Eligible patients had a GP diagnosis of somatisation, including unexplained physical symptoms as part of anxiety, chronic pain or somatoform disorders. Diagnoses were checked using the Composite International Diagnostic Interview (CIDI). The study was conducted from December 1997 to December 1999. INTERVENTION A care plan including treatment for depression and anxiety disorders, a containment strategy for somatisation, and service coordinator-assisted self-management. Control patients received standard treatment. MAIN OUTCOME MEASURES Psychiatric symptoms; quality of life; medication use; and depression, anxiety and hostility scores. RESULTS Compared with CIDI diagnoses, mood disorders in patients were underdiagnosed by GPs (64 v 31), particularly major depression (46 v 1). At 12 months, the intervention group showed reductions in depression (P = 0.002), guilt (P = 0.006) and anxiety (state, P = 0.043; trait, P = 0.001). Compared with the control group, physical role functioning improved for the intervention group (P = 0.006), and their medication use decreased by 8.9%. CONCLUSIONS Conservative management, treatment of depression, and case management by service coordinators is effective in managing somatising patients in primary care. GPs require training in the diagnosis of depression and how to say "no" to patients with unexplained physical symptoms who request further unnecessary investigations or referrals.
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Affiliation(s)
- Rene G Pols
- Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, SA, Australia.
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[Somatoform disorders. Clinical evidence, etiology, pathogenesis, and therapy]. DER NERVENARZT 2008; 79:99-115; quiz 116-7. [PMID: 18066520 DOI: 10.1007/s00115-007-2388-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patients presenting with bodily symptoms and complaints that are not explained by organic pathology or well-known pathophysiological mechanisms comprise a major challenge to any medical care system. From a perspective of psychiatric classification, such medically unexplained somatic symptoms are diagnosed as depressive and anxiety disorders on the one hand or somatoform disorders on the other. In clinical physical medicine a quite different diagnostic approach is taken to conceptualize functional somatic syndromes. Concepts of somatoform disorders are outlined, critical issues regarding existing diagnostic systems are discussed, and possible alternative approaches for upcoming versions of DSM-V and ICD-11 are mentioned. The main somatoform disorders are described in their clinical characteristics. Etiopathogenetically, somatoform disorders may best be considered within a multifactorial model. Some pragmatic guidelines for multimodal treatment of somatoform disorders are outlined.
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Recent developments in the understanding and management of functional somatic symptoms in primary care. Curr Opin Psychiatry 2008; 21:182-8. [PMID: 18332668 DOI: 10.1097/yco.0b013e3282f51254] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Medically unexplained or functional somatic symptoms are prevalent in primary care, but general practitioners commonly find them difficult to treat. We focus on the conceptual issues and treatment from a primary care perspective, although the field is difficult to review because of the inconsistency and multiplicity of terminology used by different authors and specialties. RECENT FINDINGS The training of general practitioners in management techniques has been hampered by an obsolete theoretical framework and outdated diagnostic systems. Epidemiological studies, however, indicate that valid, empirically based diagnostic criteria for functional disorders may be developed. Management studies in primary care have shown disappointing effects on patient outcome, but a lot may be gained by making the training programmes more sophisticated. Recently, stepped care approaches have been introduced but they need scientific evaluation. SUMMARY There is an immediate need for a common language and a theoretical framework of understanding of functional symptoms and disorders across medical specialties, clinically and scientifically. Any names that presuppose a mind-body dualism (such as somatization, medically unexplained) ought to be abolished. The overall ambition for treatment is to offer patients with functional somatic symptoms the same quality of professional healthcare as we offer any other patient.
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Sumathipala A. What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med 2007; 69:889-900. [PMID: 18040100 DOI: 10.1097/psy.0b013e31815b5cf6] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review published literature for the highest level of evidence on the efficacy of treatment for patients with medically unexplained symptoms. METHODS A comprehensive literature search was carried out in Cochrane library, Medline (1971-2007), PsychINFO (1974-2006), and EMBASE (1980-2007) to identify pharmacological, nonpharmacological, psychological, and other interventions, using the search terms "medically unexplained symptoms," "somatisation," "somatization," "somatoform disorders," "psychological therapies," "cognitive behavior therapy," "pharmacological therapies," "management," "therapy," "drug therapy," and "anti-depressants" with Boolean operators AND and OR on the entire text. Searches were confined to literature in English. RESULTS Studies were carried out in primary, secondary, and tertiary care settings. The therapists ranged from medical specialists, psychiatrists, and psychologists to primary care physicians. Three types of interventions (antidepressant medication, cognitive behavioral therapy (CBT), and other nonspecific interventions) were supported by evidence on the efficacy of treatment for patients with medically unexplained symptoms. There is more level I evidence for CBT compared with the amount for other approaches. There was only one study reported from the developing world. CONCLUSIONS CBT is efficacious for either symptom syndromes or for the broader category of medically unexplained symptoms, reducing physical symptoms, psychological distress, and disability. A relatively small number of studies were carried out in primary care, but the trend has been changing over the last decade. No studies have compared pharmacological and psychological treatments. Most trials assessed only short-term outcomes. Use of divergent selection procedures, interventions, outcome measures, and instruments, and other methodological differences observed in these studies hamper the ability to compare treatment effects across studies.
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Affiliation(s)
- Athula Sumathipala
- Department of Health Services Research, Kings College, University of London, London, UK.
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