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Mosler F, Packer K, Jerome L, Bird V. Structured communication methods for mental health consultations in primary care: a scoping review. BMC PRIMARY CARE 2023; 24:175. [PMID: 37661251 PMCID: PMC10476363 DOI: 10.1186/s12875-023-02129-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Majority of people with mental health problems attend primary care for support. Interventions that structure consultations have been found effective for physical health conditions and secondary mental health care. The aim of the review is to identify what tools or interventions exist to structure communication in primary care for appointments related to mental health problems and examine existing evidence for effectiveness for mental health and quality of life outcomes. METHODS Quantitative and qualitative studies were eligible for inclusion if staff was based in a primary care setting and the intervention involved bi-directional communication with adult patients. Six databases were searched (MEDLINE, Web of Knowledge, EMBASE, PsycINFO, The Cochrane Library, CINAHL) with no time restriction. Search terms combined four concepts with key words such as "structured" and "interaction" and "mental illness" and "primary care". Reference lists of eligible studies were searched. RESULTS After removing duplicates, 3578 records were found and underwent further screening. A total of 16 records were included, representing eight different interventions from five countries. The majority were delivered by primary care doctors and focused on patients experiencing psychological distress. Similarities across interventions' service delivery were that most were created for a broad patient population, used self-report assessments at the start and actions or plans as the end point, and employed group settings and didactic methods for training staff in the intervention. Booster and follow-up trainings were not offered in any of the interventions, and supervision was only part of the process for one. The evidence for effectiveness for mental health and quality of life outcomes was mixed with three out of five RCTs finding a positive effect. CONCLUSIONS Although the idea of structuring communication for mental health consultations has been around since the 1980s, relatively few interventions have attempted to structure the conversations within the consultation, rather than modifying pre-visit events. As the evidence-base showed feasibility and acceptability for a number of interventions, there is scope for those interventions to be developed further and tested more rigorously.
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Cook DA, Wilkinson JM, Foo J. Costs of Physician Continuous Professional Development: A Systematic Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1554-1563. [PMID: 35830262 DOI: 10.1097/acm.0000000000004805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE An essential yet oft-neglected step in cost evaluations is the selection of resources (ingredients) to include in cost estimates. The ingredients that most influence the cost of physician continuous professional development (CPD) are unknown, as are the relative costs of instructional modalities. This study's purpose was to estimate the costs of cost ingredients and instructional modalities in physician CPD. METHOD The authors conducted a systematic review in April 2020, searching MEDLINE, Embase, PsycInfo, and the Cochrane Library for comparative cost evaluations of CPD for practicing physicians. Two reviewers, working independently, screened articles for inclusion and extracted information on costs (converted to 2021 U.S. dollars) for each intervention overall, each ingredient, and each modality. RESULTS Of 3,338 eligible studies, 62 were included, enumerating costs for 86 discrete training interventions or instructional modalities. The most frequently reported ingredients were faculty time (25 of 86 interventions), materials (24), administrator/staff time (23), and travel (20). Ingredient costs varied widely, ranging from a per-physician median of $4 for postage (10 interventions) to $525 for learner time (13); equipment (9) and faculty time were also relatively expensive (median > $170). Among instructional modalities (≤ 11 interventions per modality), audit and feedback performed by physician learners, computer-based modules, computer-based virtual patients, in-person lectures, and experiences with real patients were relatively expensive (median > $1,000 per physician). Mailed paper materials, video clips, and audit and feedback performed by others were relatively inexpensive (median ≤ $62 per physician). Details regarding ingredient selection (10 of 62 studies), quantitation (10), and pricing (26) were reported infrequently. CONCLUSIONS Some ingredients, including time, are more important (i.e., contribute more to total costs) than others and should be prioritized in cost evaluations. Data on the relative costs of instructional modalities are insightful but limited. The methods and reporting of cost valuations merit improvement.
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Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director, Section of Research and Data Analytics, School of Continuous Professional Development, director of education science, Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - John M Wilkinson
- J.M. Wilkinson is professor of family medicine, Mayo Clinic College of Medicine and Science, and consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1156-8577
| | - Jonathan Foo
- J. Foo is a lecturer, Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-4533-8307
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Wortman MSH, Lokkerbol J, van der Wouden JC, Visser B, van der Horst HE, olde Hartman TC. Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review. PLoS One 2018; 13:e0205278. [PMID: 30321193 PMCID: PMC6188754 DOI: 10.1371/journal.pone.0205278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies. METHODS We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality. RESULTS A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes. CONCLUSION This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions. REGISTRATION Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.
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Affiliation(s)
- Margreet S. H. Wortman
- ACHIEVE – Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- * E-mail:
| | - Joran Lokkerbol
- Centre of Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Johannes C. van der Wouden
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Bart Visser
- ACHIEVE – Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Henriëtte E. van der Horst
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tim C. olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
Following ground-breaking work by Shepherd et al (1966) and, more recently, Goldberg & Huxley (1992), primary care is now recognised as the arena in which most contact occurs between the National Health Service (NHS) and people with mental health problems. General practitioners (GPs) remain the first, and in many cases the only, health professionals involved in the management of a whole range of conditions, from common anxiety and depressive disorders to severe and enduring mental illnesses.
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Howman M, Walters K, Rosenthal J, Ajjawi R, Buszewicz M. "You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms. BMC MEDICAL EDUCATION 2016; 16:27. [PMID: 26810389 PMCID: PMC4727318 DOI: 10.1186/s12909-015-0523-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 12/22/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Much of a General Practitioner's (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees' clinical and educational experiences of managing people presenting with MUS. METHOD A mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach. RESULTS Eighty questionnaires out of 120 (67%) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient. CONCLUSION Managing MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.
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Affiliation(s)
- Mary Howman
- Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
| | - Kate Walters
- Research Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
| | - Joe Rosenthal
- Research Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
| | - Rola Ajjawi
- Centre for Medical Education, Dundee Medical School, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
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7
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Visser MS, Zonneveld LNL, Van't Spijker A, Hunink MG, Busschbach JJV. The Cost-Effectiveness of Cognitive-Behavioral Group Training for Patients with Unexplained Physical Symptoms. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:570-577. [PMID: 26297084 DOI: 10.1016/j.jval.2015.03.1791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 12/03/2014] [Accepted: 03/12/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate the cost-effectiveness of a cognitive-behavioral group training compared with a wait-list control for patients with unexplained physical symptoms (UPS). METHODS A probabilistic decision-analytic Markov model was developed with three health states (poor health, average health, and death) based on a cutoff score of the Physical Component Summary of the short-form 36 health survey. To assess the cost-effectiveness in terms of cost per quality-adjusted life-year (QALY), a societal perspective was adopted. The model consisted of cycles of 3 months and a time horizon of 4 years. Data for the model were derived from a randomized controlled trial, in which 162 patients with UPS were randomized either to cognitive-behavioral group training or to the wait-list control. Data were assessed at baseline and after the training of 3 months or after a wait-list period of 3 months. In addition, the training group was followed in an uncontrolled phase and assessed at 3 months and 1 year after the training. RESULTS After 4 years, the group training was in terms of cost-effectiveness "dominant" compared with the wait-list control; there was a positive effect of 0.06 QALYs and a €828 reduction in costs. The cost-effectiveness improved with a longer time horizon. A threshold of €30,000/QALY was passed after 18 months. The group training was cost saving after 33 months. CONCLUSIONS Cognitive-behavioral group training is a cost-effective treatment compared with the wait-list control for patients with UPS.
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Affiliation(s)
- Martijn S Visser
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Lyonne N L Zonneveld
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands; Departments of Anesthesiology and Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
| | - Adriaan Van't Spijker
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Myriam G Hunink
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan J V Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
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Managing the consultation with patients with medically unexplained symptoms: a grounded theory study of supervisors and registrars in general practice. BMC FAMILY PRACTICE 2014; 15:192. [PMID: 25477194 PMCID: PMC4266896 DOI: 10.1186/s12875-014-0192-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
Background Patients with medically unexplained symptoms (MUS) commonly present in general practice. They often experience significant disability and have difficulty accessing appropriate care. Many feel frustrated and helpless. Doctors also describe feeling frustrated and helpless when managing these patients. These shared negative feelings can have a detrimental effect on the therapeutic relationship and on clinical outcomes. The aim of this study was to explore how novice and experienced GPs manage patients with MUS and how these skills are taught and learned in GP training. Methods A constructivist grounded theory study with 24 general practice registrars and supervisors in GP training practices across Australia. Results Registrars lacked a framework for managing patients with MUS. Some described negative feelings towards patients that were uncomfortable and confronting. Registrars also were uncertain about their clinical role: where their professional responsibilities began and ended. Supervisors utilised a range of strategies to address the practical, interpersonal and therapeutic challenges associated with the care of these patients. Conclusions Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from managing these patients effectively. Some of these negative feelings, such as frustration, shame and helplessness, are shared between doctors and patients. Registrars need assistance to identify and manage these difficult feelings so that consultations are more effective. The care of these patients also raises issues of professional identity, roles and responsibilities. Supervisors can assist their registrars by proactively sharing models of the consultation, strategies for managing their own feelings and frustrations, and ways of understanding and managing the therapeutic relationship in this difficult area of practice.
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Frostholm L, Petrie KJ, Ornbøl E, Fink P. Are illness perceptions related to future healthcare expenditure in patients with somatoform disorders? Psychol Med 2014; 44:2903-2911. [PMID: 25066790 DOI: 10.1017/s003329171400035x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Somatoform disorders are costly for society in terms of increased healthcare expenditure. Patients' illness perceptions have been found to play a role in somatoform disorders. However, it is unclear whether illness perceptions predict higher health costs in these patients. METHOD A total of 1785 primary care patients presenting a new health complaint completed a questionnaire on their illness perceptions and emotional distress before the consultation. The physicians completed a questionnaire for each patient on diagnostics after the consultation. In a stratified subsample, physician interviewers established diagnoses of DSM-IV somatization and undifferentiated somatoform disorders (n = 144) using the Schedules for Clinical Assessment in Neuropsychiatry. Healthcare expenditure was obtained from Danish health registers for a 2-year follow-up period. RESULTS Patients had more negative perceptions of their well-defined physical health problems when they had a co-morbid somatoform disorder. A strong illness identity [β = 0.120, 95% confidence interval (CI) 0.029-0.212, p = 0.012], perceived negative consequences (β = 0.010, 95% CI 0.001-0.019, p = 0.024), a long timeline perspective (β = 0.013, 95% CI 0.005-0.021, p = 0.001), low personal control (β = - 0.009, 95% CI -0.015 to -0.002, p = 0.011) and negative emotional representations (β = 0.009, 95% CI 0.002-0.017, p = 0.020) predicted healthcare expenditure in somatoform disorders. CONCLUSIONS The results suggest that illness perceptions play a role in the perpetuation of symptoms in somatoform disorders and predict higher future healthcare expenditure among a subgroup of these patients.
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Affiliation(s)
- L Frostholm
- Research Clinic for Functional Disorders,Aarhus University Hospital,Aarhus,Denmark
| | - K J Petrie
- Department of Psychological Medicine,Auckland University,Auckland,New Zealand
| | - E Ornbøl
- Research Clinic for Functional Disorders,Aarhus University Hospital,Aarhus,Denmark
| | - P Fink
- Research Clinic for Functional Disorders,Aarhus University Hospital,Aarhus,Denmark
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10
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Rosendal M, Blankenstein AH, Morriss R, Fink P, Sharpe M, Burton C. Enhanced care by generalists for functional somatic symptoms and disorders in primary care. Cochrane Database Syst Rev 2013:CD008142. [PMID: 24142886 DOI: 10.1002/14651858.cd008142.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with medically unexplained or functional somatic symptoms are common in primary care. Previous reviews have reported benefit from specialised interventions such as cognitive behavioural therapy and consultation letters, but there is a need for treatment models which can be applied within the primary care setting. Primary care studies of enhanced care, which includes techniques of reattribution or cognitive behavioural therapy, or both, have shown changes in healthcare professionals' attitudes and behaviour. However, studies of patient outcome have shown variable results and the value of enhanced care on patient outcome remains unclear. OBJECTIVES We aimed to assess the clinical effectiveness of enhanced care interventions for adults with functional somatic symptoms in primary care. The intervention should be delivered by professionals providing first contact care and be compared to treatment as usual. The review focused on patient outcomes only. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR-Studies and CCDANCTR-References) (all years to August 2012), together with Ovid searches (to September 2012) on MEDLINE (1950 - ), EMBASE (1980 - ) and PsycINFO (1806 - ). Earlier searches of the Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL, PSYNDEX, SIGLE, and LILACS were conducted in April 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2009. No language restrictions were applied. Electronic searches were supplemented by handsearches of relevant conference proceedings (2004 to 2012), reference lists (2011) and contact with authors of included studies and experts in the field (2011). SELECTION CRITERIA We limited our literature search to randomised controlled trials (RCTs), primary care, and adults with functional somatic symptoms. Subsequently we selected studies including all of the following: 1) a trial arm with treatment as usual; 2) an intervention using a structured treatment model which draws on explanations for symptoms in broad bio-psycho-social terms or encourages patients to develop additional strategies for dealing with their physical symptoms, or both; 3) delivery of the intervention by primary care professionals providing first contact care; and 4) assessment of patient outcome. DATA COLLECTION AND ANALYSIS Two authors independently screened identified study abstracts. Disagreements about trial selections were resolved by a third review author. Data from selected publications were independently extracted and risk of bias assessed by two of three authors, avoiding investigators reviewing their own studies. We contacted authors from included studies to obtain missing information. We used continuous outcomes converted to standardised mean differences (SMDs) and based analyses on changes from baseline to follow-up, adjusted for clustering. MAIN RESULTS We included seven studies from the literature search, but only six provided sufficient data for analyses. Included studies were European, cluster RCTs with adult participants seeing their usual doctor (in total 233 general practitioners and 1787 participants). Methodological quality was only moderate as studies had no blinding of healthcare professionals and several studies had a risk of recruitment and attrition bias. Studies were heterogeneous with regard to selection of patient populations and intensity of interventions. Outcomes relating to physical or general health (physical symptoms, quality of life) showed substantial heterogeneity between studies (I(2) > 70%) and post hoc analysis suggested that benefit was confined to more intensive interventions; thus we did not calculate a pooled effect. Outcomes relating to mental health showed less heterogeneity and we conducted meta-analyses, which found non-significant overall effect sizes with SMDs for changes at 6 to 24 months follow-up: mental health (3 studies) SMD -0.04 (95% CI -0.18 to 0.10), illness worry (3 studies) SMD 0.09 (95% CI -0.04 to 0.22), depression (4 studies) SMD 0.07 (95% CI -0.05 to 0.20) and anxiety (2 studies) SMD -0.07 (95% CI -0.38 to 0.25). Effects on sick leave could not be estimated. Three studies of patient satisfaction with care all showed positive but non-significant effects, and measures were too heterogeneous to allow meta-analysis. Results on healthcare utilisation were inconclusive. We analysed study discontinuation and found that both short term and long term discontinuation occurred more often in patients allocated to the intervention group, RR of 1.25 (95% CI 1.08 to 1.46) at 12 to 24 months. AUTHORS' CONCLUSIONS Current evidence does not answer the question whether enhanced care delivered by front line primary care professionals has an effect or not on the outcome of patients with functional somatic symptoms. Enhanced care may have an effect when delivered per protocol to well-defined groups of patients with functional disorders, but this needs further investigation. Attention should be paid to difficulties including limited consultation time, lack of skills, the need for a degree of diagnostic openness, and patient resistance towards psychosomatic attributions. There is some indication from this and other reviews that more intensive interventions are more successful in changing patient outcomes.
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Affiliation(s)
- Marianne Rosendal
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Alle 2, Århus, Denmark, DK-8000
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Sharma MP, Manjula M. Behavioural and psychological management of somatic symptom disorders: an overview. Int Rev Psychiatry 2013; 25:116-24. [PMID: 23383673 DOI: 10.3109/09540261.2012.746649] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The number of patients who seek help at primary and secondary care for somatic symptoms which cannot be explained by any known medical condition is enormous. It has been proposed to rename 'somatoform disorders' in DSM-IV as 'somatic symptom disorders' in DSM-5. This is supposed to include disorders such as somatization disorder, hypochondriasis, undifferentiated somatoform disorder, pain disorder and factitious disorder. The reason for the renaming and grouping is that all these disorders involve presentation of physical symptoms and/or concern about medical illness. In the literature, there is considerable variation adopted with respect to diagnosis and in the approaches adopted for intervention. However, the common feature of these disorders is the chronicity, social dysfunction, occupational difficulties and the increased healthcare use and high level of dissatisfaction for both the clinician and the patient. A number of behavioural and psychological interventions for somatic symptoms have been carried out at primary, secondary and tertiary care settings and recently there have been more attempts to involve the primary care physicians in the psychological interventions. This review aims at giving an overview of the components of the behavioural and other psychological interventions available for addressing medically unexplained somatic symptoms and to present their efficacy.
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Affiliation(s)
- Mahendra P Sharma
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, India.
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12
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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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Taylor RE, Marshall T, Mann A, Goldberg DP. Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices. Psychol Med 2012; 42:855-864. [PMID: 21880165 DOI: 10.1017/s0033291711001589] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor-patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment. METHOD We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate. RESULTS Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79-5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23-33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05-3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67-33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented. CONCLUSIONS Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.
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Affiliation(s)
- R E Taylor
- Barts and the London School of Medicine and Dentistry, Queen Mary, Charterhouse Square, London, UK.
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Reattribution reconsidered: narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings. J Psychosom Res 2011; 71:325-34. [PMID: 21999976 DOI: 10.1016/j.jpsychores.2011.05.008] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 04/19/2011] [Accepted: 05/05/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Medically unexplained symptoms (MUS) refer to bodily symptoms without a physical health explanation. In the context of MUS, reattribution is a process of attributing physical symptoms to a psychological cause. We review the use of a consultation model which employs reattribution, and which has been extensively utilised in teaching and research in primary care. METHODS Literature search for studies utilising the reattribution model. Narrative review of the results. RESULTS Data was extracted from 25 publications from 13 studies. The model has been modified over time and comparison between studies is limited by differences in methodology. The skills of the model can be acquired by training, which also improves practitioners' attitudes to MUS. However impact on clinical outcomes has been mixed and this can be explained in part from the findings of nested qualitative studies. CONCLUSIONS The reattribution model is too simplistic in its current form to address the needs of many people presenting with MUS in primary care. Reattribution of physical symptoms to psychological causes is often unnecessary. Further research is required into the effectiveness of stepped and collaborative care models in which education of primary care practitioners forms one part of a complex intervention. The consultation process is best seen as both a conversation and ongoing negotiation between doctor and patient in which there are no certainties about the presence or absence of organic pathology.
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Acupuncture for 'frequent attenders' with medically unexplained symptoms: a randomised controlled trial (CACTUS study). Br J Gen Pract 2011; 61:e295-305. [PMID: 21801508 DOI: 10.3399/bjgp11x572689] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Medically unexplained physical symptoms (MUPS) are common and difficult to treat. AIM To investigate the effectiveness of adding five-element acupuncture to usual care in 'frequent attenders' with MUPS. DESIGN AND SETTING Randomised controlled trial in four London general practices. METHOD Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes. RESULTS Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65% >1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control -0.6 [95% CI = -1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = -0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to -0.4 (95% CI = -0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks. CONCLUSION The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.
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Rugg S, Paterson C, Britten N, Bridges J, Griffiths P. Traditional acupuncture for people with medically unexplained symptoms: a longitudinal qualitative study of patients' experiences. Br J Gen Pract 2011; 61:e306-15. [PMID: 21801509 PMCID: PMC3103693 DOI: 10.3399/bjgp11x577972] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 09/15/2010] [Accepted: 09/23/2010] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND People with medically unexplained physical symptoms (MUPS) are helped by interventions that combine physical and psychological explanations and treatment. Traditional acupuncture may offer such a perspective, but its use for these patients has not been investigated. AIM To ascertain how patients with MUPS perceive and experience five-element acupuncture treatment. DESIGN AND SETTING A longitudinal qualitative interview study, nested in a randomised controlled trial was carried out in four general practices in socioeconomically diverse areas of London. METHOD A purposive sample of 20 trial participants was interviewed twice, at the start and the end of 6 months of acupuncture treatment. Semi-structured interviews were transcribed, coded, and analysed thematically, summarising both across-case as themes and within-case individual vignettes. RESULTS Acupuncture, initially accepted as 'just another referral' - one like many others that had been tried and proved unsuccessful - was valued for the amount of time allotted with a caring practitioner who listened and responded, as well as for the interactive and holistic nature of the sessions. These attributes encouraged many patients to take an active role in their treatment, including making cognitive or behavioural lifestyle changes. Interviewees cited a wide range of changes in their health that spanned physical, psychological, and social dimensions. These were largely positive and included an increase in physical and/or mental energy, as well as feelings of greater personal control, calmness, and relaxation. Three interviewees reported worsening health but did not ascribe this to acupuncture. CONCLUSION Many patients who were treated with five-element acupuncture perceived a range of positive effects and appeared to take on a more active role in consultations and self-care.
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Affiliation(s)
- Sue Rugg
- Institute of Health Service Research, University of Exeter, UK
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Morriss R, Gask L, Dowrick C, Dunn G, Peters S, Ring A, Davies J, Salmon P. Randomized trial of reattribution on psychosocial talk between doctors and patients with medically unexplained symptoms. Psychol Med 2010; 40:325-333. [PMID: 19573262 DOI: 10.1017/s0033291709990353] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In reattribution, general practitioners (GPs) request psychosocial information directly and explain medically unexplained symptoms (MUS) using psychosocial information in the consultation. We explored whether reattribution training (RT) increased the communication of psychosocial information and decreased communication about somatic intervention between GPs and their MUS patients. METHOD A cluster randomized controlled trial (RCT) of RT versus usual treatment in GPs from 16 practices and 141 patients with MUS on audio-recorded and transcribed doctor-patient communication in an index consultation. In a secondary data analysis, the Liverpool Clinical Interaction Analysis Scheme (LCIAS) was applied by an experienced rater to each turn of speech in the transcript from the index consultation blind to treatment allocation. RESULTS After RT, patients were more likely to disclose and discuss psychosocial problems, and propose psychosocial explanations for symptoms; around 25% of patients discussed psychosocial information extensively. In the RT group, GPs did not seek new psychosocial disclosure but they reduced advocacy for somatic intervention. After RT, GPs suggested, on average, two utterances of psychosocial explanation and six utterances of somatic intervention. CONCLUSIONS After RT, some patients discussed psychosocial issues extensively but GPs did not probe underlying psychosocial issues. They gave mixed psychosocial and somatic messages about MUS, which may have increased patients' concerns about their health. GPs should actively seek the disclosure of underlying psychosocial problems and give clear, unambiguous messages to MUS patients when they are willing to discuss psychosocial issues.
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Affiliation(s)
- R Morriss
- Division of Psychiatry, School of Community Health Sciences, University of Nottingham, Queen's Medical School, Nottingham, UK.
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Gadomski A, Wissow LS, Slade E, Jenkins P. Training clinicians in mental health communication skills: impact on primary care utilization. Acad Pediatr 2010; 10:346-52. [PMID: 20685190 PMCID: PMC2933967 DOI: 10.1016/j.acap.2010.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 06/10/2010] [Accepted: 06/22/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Although it is known that children with mental health problems utilize primary care services more than most other children, it is unknown how addressing mental health problems in primary care affects children's subsequent services utilization. This study measures primary care utilization in the context of a randomized trial of a communication skills training program for primary care clinicians that had a positive impact on child mental health outcomes. METHODS From 2002 to 2005, 48 pediatric primary care clinicians at 13 sites in rural upstate New York, urban Maryland, and Washington, DC, were randomized to in-office training or to a control group. Consecutive primary care patients between the ages of 5 and 16 years were screened for mental health problems, as indicated by a possible or probable score on the Strengths and Difficulties Questionnaire (SDQ). For 397 screened children, primary care visits during the next 6 months were identified using chart review and administrative databases. Using generalized estimating equation regression to account for clustering at the clinician level, primary care utilization was compared by study group and SDQ status. RESULTS The number of primary care visits to the trained clinicians did not differ significantly from those made to control clinicians (2.5 for both groups; P = .63). Children with possible or probable SDQ scores made, on average, 0.38 or 0.65 more visits on a per child basis, respectively, during the 6-month follow-up period than SDQ unlikely children (P = .0002). CONCLUSIONS Seeing a trained clinician did not increase subsequent primary care utilization. However, primary care utilization was greater among children with mental health problems as measured by the SDQ. Addressing children's mental health in primary care does not increase the primary care visit burden. Research on overall health services utilization is needed.
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Affiliation(s)
- Anne Gadomski
- Research Institute, Bassett Healthcare, Cooperstown, NY 13326, USA.
| | | | - Eric Slade
- U.S. Department of Veterans Affairs, VISN5 Mental Illness Research and Education Clinical Center Baltimore, MD
| | - Paul Jenkins
- Computing Center, Research Institute, Bassett Healthcare, Cooperstown, NY
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Rosendal M, Burton C, Blankenstein AH, Fink P, Kroenke K, Sharpe M, Frydenberg M, Morriss R. Enhanced care by generalists for functional somatic symptoms and disorders in primary care. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd008142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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20
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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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21
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Dwamena FC, Lyles JS, Frankel RM, Smith RC. In their own words: qualitative study of high-utilising primary care patients with medically unexplained symptoms. BMC FAMILY PRACTICE 2009; 10:67. [PMID: 19772582 PMCID: PMC2759903 DOI: 10.1186/1471-2296-10-67] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Accepted: 09/21/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND High utilising primary care patients with medically unexplained symptoms (MUS) often frustrate their primary care providers. Studies that elucidate the attitudes of these patients may help to increase understanding and improve confidence of clinicians who care for them. The objective of this study was to describe and analyze perceptions and lived experiences of high utilising primary care patients with MUS. METHODS A purposive sample of 19 high utilising primary care patients for whom at least 50% (69.6% in this sample) of visits for two years could not be explained medically, were encouraged to talk spontaneously about themselves and answer semi-structured questions. Verbatim transcripts of interviews were analyzed using an iterative consensus building process. RESULTS Patients with MUS almost universally described current and/or past family dysfunction and were subjected to excessive testing and ineffective empirical treatments. Three distinct groups emerged from the data. 1) Some patients, who had achieved a significant degree of psychological insight and had success in life, primarily sought explanations for their symptoms. 2) Patients who had less psychological insight were more disabled by their symptoms and felt strongly entitled to be excused from normal social obligations. Typically, these patients primarily sought symptom relief, legitimization, and support. 3) Patients who expressed worry about missed diagnoses demanded excessive care and complained when their demands were resisted. CONCLUSION High utilising primary care patients are a heterogeneous group with similar experiences and different perceptions, behaviours and needs. Recognizing these differences may be critical to effective treatment and reduction in utilisation.
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Affiliation(s)
| | - Judith S Lyles
- Michigan Department of Community Health, Lansing, MI, USA
| | - Richard M Frankel
- Health Services Research and Development Center of Excellence, Roudebush VAMC, Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Robert C Smith
- Department of Medicine, Michigan State University, East Lansing, MI, USA
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Peters S, Rogers A, Salmon P, Gask L, Dowrick C, Towey M, Clifford R, Morriss R. What do patients choose to tell their doctors? Qualitative analysis of potential barriers to reattributing medically unexplained symptoms. J Gen Intern Med 2009; 24:443-9. [PMID: 19089505 PMCID: PMC2659146 DOI: 10.1007/s11606-008-0872-x] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 11/12/2008] [Accepted: 11/20/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor-patient communication, though not necessarily patient health. OBJECTIVE To examine patient experiences of GPs' attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome. DESIGN Qualitative study. PARTICIPANTS Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general. APPROACH Thematic analysis of in-depth interviews. RESULTS Potential barriers include the complexity of patients' problems and patients' judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution. CONCLUSIONS Improving GP explanation of unexplained symptoms is insufficient to reduce patients' concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor-patient relationship in which patients can perceive psychosocial enquiry as appropriate.
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Affiliation(s)
- Sarah Peters
- School of Psychological Sciences, University of Manchester, Manchester, UK.
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LaFrance WC, Miller IW, Ryan CE, Blum AS, Solomon DA, Kelley JE, Keitner GI. Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy Behav 2009; 14:591-6. [PMID: 19233313 DOI: 10.1016/j.yebeh.2009.02.016] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 02/14/2009] [Indexed: 11/17/2022]
Abstract
Treatment trials for psychogenic nonepileptic seizures (PNES) are few, despite the high prevalence and disabling nature of the disorder. We evaluated the effect of cognitive behavioral therapy (CBT) on reduction of PNES. Secondary measures included psychiatric symptom scales and psychosocial variables. We conducted a prospective clinical trial assessing the frequency of PNES in outpatients treated using a CBT for PNES manual. Subjects diagnosed with video/EEG-confirmed PNES were treated with CBT for PNES conducted in 12 weekly sessions. Seizure calendars were charted prospectively. Twenty-one subjects enrolled, and 17 (81%) completed the CBT intervention. Eleven of the 17 completers reported no seizures by their final CBT session. Mean scores on scales of depression, anxiety, somatic symptoms, quality of life, and psychosocial functioning showed improvement from baseline to final session. CBT for PNES reduced the number of PNES and improved psychiatric symptoms, psychosocial functioning, and quality of life.
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Affiliation(s)
- W Curt LaFrance
- Department of Psychiatry and Human Behavior, Rhode Island Hospital, Brown Medical School, Providence, RI 02903, USA.
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Dowrick C, Gask L, Hughes JG, Charles-Jones H, Hogg JA, Peters S, Salmon P, Rogers AR, Morriss RK. General practitioners' views on reattribution for patients with medically unexplained symptoms: a questionnaire and qualitative study. BMC FAMILY PRACTICE 2008; 9:46. [PMID: 18713473 PMCID: PMC2533666 DOI: 10.1186/1471-2296-9-46] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 08/19/2008] [Indexed: 01/28/2023]
Abstract
Background The successful introduction of new methods for managing medically unexplained symptoms in primary care is dependent to a large degree on the attitudes, experiences and expectations of practitioners. As part of an exploratory randomised controlled trial of reattribution training, we sought the views of participating practitioners on patients with medically unexplained symptoms, and on the value of and barriers to the implementation of reattribution in practice. Methods A nested attitudinal survey and qualitative study in sixteen primary care teams in north-west England. All practitioners participating in the trial (n = 74) were invited to complete a structured survey. Semi-structured interviews were undertaken with a purposive sub-sample of survey respondents, using a structured topic guide. Interview transcripts were used to identify key issues, concepts and themes, which were grouped to construct a conceptual framework: this framework was applied systematically to the data. Results Seventy (95%) of study participants responded to the survey. Survey respondents often found it stressful to work with patients with medically unexplained symptoms, though those who had received reattribution training were more optimistic about their ability to help them. Interview participants trained in reattribution (n = 12) reported that reattribution increased their confidence to practice in a difficult area, with heightened awareness, altered perceptions of these patients, improved opportunities for team-building and transferable skills. However general practitioners also reported potential barriers to the implementation of reattribution in routine clinical practice, at the level of the patient, the doctor, the consultation, diagnosis and the healthcare context. Conclusion Reattribution training increases practitioners' sense of competence in managing patients with medically unexplained symptoms. However, barriers to its implementation are considerable, and frequently lie outside the control of a group of practitioners generally sympathetic to patients with medically unexplained symptoms and the purpose of reattribution. These findings add further to the evidence of the difficulty of implementing reattribution in routine general practice.
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Affiliation(s)
- Christopher Dowrick
- Division of Primary Care, School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool L69 3GB, UK.
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Friedberg F, Sohl SJ, Halperin PJ. Teaching medical students about medically unexplained illnesses: a preliminary study. MEDICAL TEACHER 2008; 30:618-621. [PMID: 18608944 DOI: 10.1080/01421590801946970] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND This study examined how an interactive seminar focusing on two medically unexplained illnesses, chronic fatigue syndrome (CFS) and fibromyalgia, influenced medical student attitudes toward CFS, a more strongly stigmatized illness. METHODS Forty-five fourth year medical students attended a 90 minute interactive seminar on the management of medically unexplained illnesses that was exemplified with CFS and fibromyalgia. A modified version of the CFS attitudes test was administered immediately before and after the seminar. RESULTS Pre-seminar assessment revealed neutral to slightly favorable toward CFS. At the end of the seminar, significantly more favorable attitudes were found toward CFS in general (t (42) = 2.77; P < 0.01) and for specific items that focused on (1) supporting more CFS research funding (t (42) = 4.32; P < 0.001; (2) employers providing flexible hours for people with CFS (t (42) = 3.52, P < 0.01); and (3) viewing CFS as not primarily a psychological disorder (t (42) = 2.87, P < 0.01). Thus, a relatively brief exposure to factual information on specific medically unexplained illnesses was associated with more favorable attitudes toward CFS in fourth year medical students. CONCLUSION This type of instruction may lead to potentially more receptive professional attitudes toward providing care to these underserved patients.
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Affiliation(s)
- Fred Friedberg
- Department of Psychiatry and Behavioral Science, Stony Brook University, New York 11794-8790, USA.
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Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, Lewis B, Charles-Jones H, Hogg J, Clifford R, Rigby C, Gask L. Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. Br J Psychiatry 2007; 191:536-42. [PMID: 18055958 DOI: 10.1192/bjp.bp.107.040683] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reattribution is frequently taught to general practitioners (GPs) as a structured consultation that provides a psychological explanation for medically unexplained symptoms. AIMS To determine if practice-based training of GPs in reattribution changes doctor-patient communication, thereby improving outcomes in patients with medically unexplained symptoms of 3 months' duration. METHOD Cluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual. RESULTS With training, the proportion of consultations mostly consistent with reattribution increased (31 v. 2%, P=0.002). Training was associated with decreased quality of life (health thermometer difference -0.9, 95% CI -1.6 to -0.1; P=0.027) with no other effects on patient outcome or health contacts. CONCLUSIONS Practice-based training in reattribution changed doctor-patient communication without improving outcome of patients with medically unexplained symptoms.
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Affiliation(s)
- Richard Morriss
- Division of Psychiatry, School of Community Health Sciences, University of Nottingham, South Block, A Floor, Queen's Medical School, Nottingham, NG7 2UH, UK.
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Salmon P. Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation. PATIENT EDUCATION AND COUNSELING 2007; 67:246-54. [PMID: 17428634 DOI: 10.1016/j.pec.2007.03.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 03/05/2007] [Accepted: 03/06/2007] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education. METHOD Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms. RESULTS Consultations about MUS often involve contest between patients' authority, resting on their knowledge of their symptoms, and practitioners' authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need. CONCLUSION Contest is a product of patients and practitioners occupying separate conceptual 'ground'. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material. PRACTICE IMPLICATIONS Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.
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Affiliation(s)
- Peter Salmon
- Division of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB, UK.
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Huibers MJH, Beurskens AJHM, Bleijenberg G, van Schayck CP. Psychosocial interventions by general practitioners. Cochrane Database Syst Rev 2007; 2007:CD003494. [PMID: 17636726 PMCID: PMC7003673 DOI: 10.1002/14651858.cd003494.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective than usual care. However, these interventions were mostly performed by health professionals other than the GP. OBJECTIVES To examine the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies. SEARCH STRATEGY The search was conducted using the CCDANCTR-Studies and CCDANCTR-References on 20/10/2005, The Cochrane Library, reference lists of relevant studies for citation tracking and personal communication with experts. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before November 2005 were eligible for entry. DATA COLLECTION AND ANALYSIS Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of selected trials were independently extracted by two review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed. MAIN RESULTS Ten studies were included in the review. Selected studies addressed different psychosocial interventions for five distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, cognitive behavioural therapy for unexplained fatigue, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting. AUTHORS' CONCLUSIONS In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression may offer promise, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.
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Affiliation(s)
- M J H Huibers
- Maastricht University, Department of Clinical Psychological Science, P.O. Box 616, Maastricht, Netherlands, 6200 MD.
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Salmon P, Peters S, Clifford R, Iredale W, Gask L, Rogers A, Dowrick C, Hughes J, Morriss R. Why do general practitioners decline training to improve management of medically unexplained symptoms? J Gen Intern Med 2007; 22:565-71. [PMID: 17443362 PMCID: PMC1855690 DOI: 10.1007/s11606-006-0094-z] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND General practitioners' (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients' problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it. OBJECTIVE To identify how GPs' attitudes to patients with MUS might inhibit their participation with training to improve management. DESIGN Qualitative study. PARTICIPANTS GPs (N = 33) who had declined or accepted training in reattribution techniques in the context of a research trial. APPROACH GPs were interviewed and their accounts analysed qualitatively. RESULTS Although attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills. CONCLUSIONS GPs' attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.
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Affiliation(s)
- Peter Salmon
- Division of Clinical Psychology, University of Liverpool, Brownlow Hill, Liverpool, UK.
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Curran J, Brooker C. Systematic review of interventions delivered by UK mental health nurses. Int J Nurs Stud 2007; 44:479-509. [PMID: 17241635 DOI: 10.1016/j.ijnurstu.2006.11.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 11/05/2006] [Accepted: 11/26/2006] [Indexed: 11/22/2022]
Abstract
The effectiveness of mental health nurse interventions has not been generally established in the literature. In this systematic review, randomised controlled trials (RCTs) were identified, undertaken in the United Kingdom, where mental health interventions delivered by mental health nurses had been evaluated. The main online literature databases were searched, key journals were hand searched and contact was made with key authors, resulting in a total of 52 studies, involving at least 7172 service users. Data were extracted and then all identified trials were assessed for inclusion by two reviewers. The results showed that in the UK, mental health nurses are involved in the delivery of a wide range of interventions in a variety of clinical health settings, with broadly positive results.
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Affiliation(s)
- Joseph Curran
- Department of Cognitive and Behavioural Psychotherapies, Michael Carlisle Centre, Sheffield, UK.
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Rasmussen NH, Furst JW, Swenson-Dravis DM, Agerter DC, Smith AJ, Baird MA, Cha SS. Innovative Reflecting Interview: Effect on High-Utilizing Patients with Medically Unexplained Symptoms. ACTA ACUST UNITED AC 2006; 9:349-59. [PMID: 17115882 DOI: 10.1089/dis.2006.9.349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.
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Affiliation(s)
- Norman H Rasmussen
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Morriss R, Dowrick C, Salmon P, Peters S, Rogers A, Dunn G, Lewis B, Charles-Jones H, Hogg J, Clifforda R, Iredale W, Towey M, Gask L. Turning theory into practice: rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (the MUST). Gen Hosp Psychiatry 2006; 28:343-51. [PMID: 16814635 DOI: 10.1016/j.genhosppsych.2006.03.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 03/28/2006] [Accepted: 03/29/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND The evidence for the effectiveness of reattribution training are limited, and optimal service delivery is not yet established. OBJECTIVES The objectives of this study were to establish the feasibility and to optimize the service delivery and design of a definitive randomized controlled trial (RCT) of reattribution training for patients with medically unexplained symptoms (MUSs) in routine primary care. METHODOLOGY The study was of a cluster RCT design with the practice as the unit of randomization. Health facilitator (HF)-delivered reattribution training was compared with no reattribution training. The primary outcome measure used is doctor-patient communication in the consultation. Quantitative and qualitative methods identify barriers to effectiveness. The acceptability and feasibility of the intervention were established by attendance rates and postal survey after completion of training. RESULTS Sixteen practices and 70 family practitioners (FPs) were recruited with representative practice and FP characteristics. Six hours of HF reattribution training to FPs in the workplace proved feasible and acceptable with all 35 FPs completing the training. Feedback from 27 (77%) FPs who received training indicated that 25 (93%) FPs believed that specific and relevant learning achievements were made, 22 (82%) felt more confident and 21 (77%) thought the training was useful. CONCLUSION HF-delivered reattribution training to whole practices is feasible and acceptable, and its effectiveness is measurable in routine primary care.
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Affiliation(s)
- Richard Morriss
- Division of Psychiatry, School of Behavioural, Community and Population Science, University of Liverpool, Royal Liverpool University Hospital, L69 3GA Liverpool, UK.
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Abstract
The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.
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Affiliation(s)
- Roger Kathol
- Cartesian Solutions, Inc., 3004 Foxpoint Road, Burnsville, MN 55337, USA.
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Ryall C, Coggon D, Peveler R, Reading I, Palmer KT. A case–control study of risk factors for arm pain presenting to primary care services. Occup Med (Lond) 2006; 56:137-43. [PMID: 16452130 DOI: 10.1093/occmed/kqj024] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate the association of occupational activities, mental health and comorbidity with care seeking for arm pain, and to test the hypothesis that specific disorders arise from physical risk factors and non-specific pain from psychological ones. METHODS Patients with a new episode of arm pain and matched controls were recruited from eight general practices. A questionnaire about risk factors was completed and cases were classified using a validated examination schedule. Questions were asked about occupational activities and psychosocial stressors. Mental health was assessed using the Hospital Anxiety Depression Scale, elements of the Brief Symptom Inventory (somatizing tendency) and the Whiteley Index (health anxiety); comorbidity from chronic fatigue syndrome (CFS) and chronic widespread pain (CWP) was ascertained using standard definitions. Associations were explored using logistic regression and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS Altogether, 132 cases and 127 controls were studied. Consulting with arm pain was strongly associated with all of the mental health variables and with CFS and CWP, irrespective of the site of arm pain or diagnosis. The OR in those with >3 versus <3 distressing somatic symptoms was 3.9 (95% CI 1.7-9.0). There were several significant associations with physical activity, but none with occupational psychosocial stressors. Repeated wrist/finger movements and carrying weights were more strongly associated with specific diagnoses than with non-specific pain. CONCLUSIONS Somatizing tendency, health anxiety, low mood, CFS and CWP are more common in arm pain consulters. Certain mechanical activities are also overrepresented, particularly in those with specific pathology.
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Affiliation(s)
- Claire Ryall
- MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
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Schweickhardt A, Larisch A, Fritzsche K. Differentiation of somatizing patients in primary care: why the effects of treatment are always moderate. J Nerv Ment Dis 2005; 193:813-9. [PMID: 16319704 DOI: 10.1097/01.nmd.0000188975.22144.3d] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The heterogeneity of somatizing patients influences outcomes, especially in unselected samples in primary care. A cluster analysis was performed as secondary analysis on an existing data set of 127 somatizing patients included in a randomized controlled clinical trial. Anxiety and depression (HADS), number and intensity of physical symptoms (SOMS), physical and emotional functioning (short form of the SF-36 Health Survey), health beliefs (KKU-G), and psychological distress (General Health Questionnaire) were used for clustering. Outcome, treatment satisfaction, and diagnosis were calculated and compared for the clusters. We differentiated three groups from this analysis: one with elevated emotional and physical stress, one in which emotional stress dominated, and one with low emotional and physical stress. The three groups did not differ in diagnoses of somatoform disorders. The high-stress groups improved over time, whereas the depression and emotional-functioning scores in the low-stress group deteriorated. All patients were satisfied with the treatment provided. Deterioration in the scores of the low-stress group may be a result of a clinically valuable change process, in that patients who were initially in denial were able to open up and admit their problems. The increased satisfaction with treatment supports this interpretation. This so-called response shift must be taken into account in the planning of studies.
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Affiliation(s)
- Axel Schweickhardt
- Department of Psychosomatics and Psychotherapy, University Hospital of Freiburg, Hauptstrasse 8, 79104 Freiburg, Germany
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Spurgeon P, Hicks C, Barwell F, Walton I, Spurgeon T. Counselling in primary care: A study of the psychological impact and cost benefits for four chronic conditions. EUROPEAN JOURNAL OF PSYCHOTHERAPY & COUNSELLING 2005. [DOI: 10.1080/13642530500367753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Frostholm L, Fink P, Oernboel E, Christensen KS, Toft T, Olesen F, Weinman J. The uncertain consultation and patient satisfaction: the impact of patients' illness perceptions and a randomized controlled trial on the training of physicians' communication skills. Psychosom Med 2005; 67:897-905. [PMID: 16314594 DOI: 10.1097/01.psy.0000188403.94327.5b] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify predictors of patient satisfaction among a range of patient and practitioner variables. In particular, to focus on patients' illness perceptions and the impact of a randomized controlled trial on the training of physicians in general communication skills and how to treat patients presenting with poorly defined illness. METHODS A randomized controlled follow-up study conducted in 28 general practices in Aarhus County, Denmark. Half of the physicians were randomized into an educational program on treatment of patients presenting with medically unexplained symptoms (somatization). One thousand seven hundred eighty-five general practice attenders presenting a new health problem completed questionnaires on illness perceptions, physical functioning, and mental distress before the consultation. After the consultation, a questionnaire including relational and communicative domains of patient satisfaction with the current consultation was completed. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Predictors of patient satisfaction were determined by logistic regression. RESULTS A large number of patient and practitioner variables predicted satisfaction in univariate logistic regression models. Results from a multivariate logistic model showed that the illness perceptions "uncertainty" (patient not knowing what is wrong) and "emotional representations" (the complaint making the patient feel worried, depressed, helpless, afraid, hopeless) predicted dissatisfaction at OR (CI) = 1.8 (1.3-2.4), p < .001 and OR (CI) = 1.5 (1-2.3), p = .03 respectively. Trained physicians were associated with dissatisfaction at OR (CI) 0.7 (0.5-1), p = .06 in the multivariate model. Furthermore, uncertain patients consulting a trained physician were less likely to be dissatisfied OR (CI) = 0.6 (0.3-1), p = .04. CONCLUSIONS A randomized controlled trial on the training of general practitioners' communication skills improved patient satisfaction. Illness perceptions predict satisfaction. In particular, patients feeling uncertain and negatively emotionally involved in their health problem were more inclined to being dissatisfied with the consultation.
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Affiliation(s)
- Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
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Larisch A, Fisch V, Fritzsche K. Kosten-Nutzen-Aspekte psychosozialer Interventionen bei somatisierenden Patienten in der Hausarztpraxis. ZEITSCHRIFT FUR KLINISCHE PSYCHOLOGIE UND PSYCHOTHERAPIE 2005. [DOI: 10.1026/1616-3443.34.4.282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Zusammenfassung. Theoretischer Hintergrund: Somatisierende Patienten führen durch das hohe Inanspruchnahmeverhalten medizinischer Leistungen zu inadäquaten Kosten im Gesundheitssystem. Fragestellung: Führen psychosoziale Interventionen des Hausarztes bei somatisierenden Patienten zu einer Reduktion der Gesundheitskosten? Methode: 42 Hausärzte und 127 Patienten nahmen an einer randomisierten kontrollierten Studie zur Verbesserung der Behandlung von somatisierenden Patienten teil. In dieser Kosten-Nutzen-Analyse wurden Arztbesuche, Arbeitsunfähigkeitstage, stationäre Aufenthalte, Medikamente sowie das Training berücksichtigt. Ergebnisse: In der Interventionsgruppe (IG) wurde gegenüber der Kontrollgruppe (KG) eine zusätzliche Ersparnis der direkten Kosten von 38,2% (262 eeee) pro Patient und Quartal erzielt. Die stärkste Kostenreduktion fand sich im stationären Bereich: IG 63,2% vs. KG 15,2%. Unter Berücksichtigung der indirekten Kosten reduzierte sich die zusätzliche Ersparnis der IG auf 11,9% (49,5 eeee). Schlussfolgerungen: Gezieltes Training zur Verbesserung der psychosozialen Kompetenz von Hausärzten bei der Behandlung von somatisierenden Patienten führte zu einer größeren Reduktion von Gesundheitskosten als die alleinige Routinebehandlung durch die Psychosomatische Grundversorgung.
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Affiliation(s)
- Astrid Larisch
- Abteilung für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Freiburg
| | - Verena Fisch
- Abteilung für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Freiburg
| | - Kurt Fritzsche
- Abteilung für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Freiburg
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Larisch A, Schweickhardt A, Wirsching M, Fritzsche K. Psychosocial interventions for somatizing patients by the general practitioner: a randomized controlled trial. J Psychosom Res 2004; 57:507-14; discussion 515-6. [PMID: 15596155 DOI: 10.1016/j.jpsychores.2004.04.372] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2003] [Accepted: 04/27/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare the effects of psychosocial interventions based on the modified reattribution model for somatizing patients in general practice (GP) with those of nonspecific psychosocial primary care (PPC) alone. METHODS Forty-two GPs were randomized, 23 into the intervention group (IG), who were trained in reattribution techniques, and 19 into the control group (CG). One hundred twenty-seven patients were included. Primary outcome measures were somatoform symptoms and quality of life. RESULTS Multilevel modeling revealed a reduction of physical symptoms (P = .007), an improvement in physical functioning (P = .0172), and a reduction of depression (P = .0211) and anxiety (P = .0388) in the IG compared with the CG at the 3-month follow-up. However, results no longer remained significant after controlling for baseline and covariate variables besides a reduction of physical symptoms at 6-month follow-up (P = .029). CONCLUSION Compared with nonspecific PPC, the effects of reattribution techniques were small and limited to physical symptoms.
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Affiliation(s)
- Astrid Larisch
- Department of Psychosomatics and Psychotherapy, University Hospital of Freiburg, Hauptstr. 8, Freiburg D-79104, Germany
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Morriss R. Specific psychosocial interventions for somatizing patients by the general practitioner: a randomised controlled trial. J Psychosom Res 2004; 57:515-6. [PMID: 15596156 DOI: 10.1016/j.jpsychores.2004.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Accepted: 08/18/2004] [Indexed: 11/21/2022]
Affiliation(s)
- Richard Morriss
- Department of Psychiatry, Royal Liverpool Hospital, University of Liverpool, Prescot Street, Liverpool L69 3GA, UK.
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Kapur N, Hunt I, Macfarlane G, McBeth J, Creed F. Childhood experience and health care use in adulthood: nested case--control study. Br J Psychiatry 2004; 185:134-9. [PMID: 15286064 DOI: 10.1192/bjp.185.2.134] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few studies have considered the role of childhood experiences in adult health care use. AIMS To examine the hypotheses that individuals frequently attending primary care report childhood adversities and illness exposures more commonly than the remainder of patients and that any association is independent of adult psychiatric disorder. METHOD A nested case-control study was carried out in a single general practice in Manchester, UK. Fifty frequent attenders (randomly selected from adult patients in the top decile of consultation frequency) and fifty normal attenders (randomly selected from the remainder of adult patients) underwent a structured psychiatric interview and a detailed, semi-structured interview of childhood experience. RESULTS There was a strong association between frequent attendance and childhood experiences. Multivariate analysis suggested that reported childhood illness exposures and reports of childhood adversity were each associated independently with adult consultation behaviour, even after adjustment for adult psychiatric disorder. CONCLUSIONS Interventions for high users of health care may need to address childhood experiences of illness and childhood adversities, as well as adult psychiatric disorder.
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Affiliation(s)
- Navneet Kapur
- Department of Psychiatry, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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43
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Guthrie E. Effectiveness of Psychodynamic Interpersonal Therapy Training for Primary Care Counselors. Psychother Res 2004. [DOI: 10.1093/ptr/kph015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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44
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Hiller W, Fichter MM. High utilizers of medical care: a crucial subgroup among somatizing patients. J Psychosom Res 2004; 56:437-43. [PMID: 15094029 DOI: 10.1016/s0022-3999(03)00628-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2002] [Accepted: 11/18/2002] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Patients with somatoform disorders (SFD) are likely to overutilize healthcare services. This study investigates (a) whether extraordinarily high medical costs can be predicted from patient characteristics or psychopathology, and (b) whether high-utilizing patients respond differently to cognitive-behavioral treatment. METHODS We compared 42 SFD high utilizers with 53 SFD average utilizers and 29 patients suffering from other than SFD mental disorders. High utilization was defined by healthcare expenditures of > or = 2500 euros during the past 2 years. Costs were computed from medical and billing records of health insurance companies. Somatization distress, hypochondriasis, depression, dysfunctional cognitions related to bodily symptoms, general psychopathology, personality profiles, and psychosocial disabilities were assessed before treatment. RESULTS High utilizers had higher levels of self- and observer-rated illness behavior, self-perceived bodily weakness, and psychosocial disabilities. Although they did not report more somatization symptoms, their subjective symptom distress was higher. There were no differences between high and average utilizers concerning general psychopathology, DSM-IV comorbidity, and personality profiles. Treatment improvements were similar. CONCLUSION High- and average-utilizing somatizers represent distinguishable subgroups. The results emphasize the importance of mechanisms specifically related to SFD and may enhance the early detection of patients who are likely to develop overutilization.
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Affiliation(s)
- Wolfgang Hiller
- Department of Clinical Psychology, University of Mainz, Germany.
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Hiller W, Fichter MM, Rief W. A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness. J Psychosom Res 2003; 54:369-80. [PMID: 12670616 DOI: 10.1016/s0022-3999(02)00397-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this prospective study was to evaluate the effects of cognitive-behavioral treatment (CBT) on mental health status and healthcare utilization in patients with somatoform disorders (SFD) of a specialized tertiary care center. METHODS According to DSM-IV interviews, 54 patients had somatization disorder (SD), 51 abridged somatization syndrome (SSI-8) and 67 other defined SFD. A clinical non-SFD comparison group consisted of 123 patients. Treatment effects were controlled against the waiting list. Cost calculations for the 2-year periods before and after treatment were based on medical and billing records from health insurance companies. RESULTS The SFD patients improved significantly with respect to physical symptom distress, health anxieties, dysfunctional beliefs towards body and health, depression and psychosocial functioning. Their outpatient plus inpatient charges during the 2 years prior to treatment were about 2.2-fold higher than for average patients of the health system. At the 2-year follow-up, we found treatment-related cost offset of 382 (-24.5%) for outpatient and 1098 (-36.7%) for inpatient care. Indirect socioeconomic costs due to days lost from work decreased by 6702 (-35.3%). Per patient savings of 32,174 (-63.9%) were found in a subgroup of somatizing high-utilizers. CONCLUSION The results encourage including treatment strategies to reduce somatoform illness behavior into clinical practice.
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Affiliation(s)
- Wolfgang Hiller
- Department of Clinical Psychology, University of Mainz, Staudingerweg 9, Germany.
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Huibers MJH, Beurskens AJHM, Bleijenberg G, van Schayck CP. The effectiveness of psychosocial interventions delivered by general practitioners. Cochrane Database Syst Rev 2003:CD003494. [PMID: 12804471 DOI: 10.1002/14651858.cd003494] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective that usual care. However, these interventions were mostly performed by health professionals other than the GP. OBJECTIVES To present a systematic review of the literature addressing the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies. SEARCH STRATEGY The literature search was conducted using the CCDAN Trials Register, the Cochrane Library and reference lists of relevant studies for citation tracking. Also, personal communication with experts took place. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before January 2002 were eligible for entry. DATA COLLECTION AND ANALYSIS Methodological quality was independently be assessed by two reviewers using the Maastricht-Amsterdam Criteria List and the CCDAN Quality Rating Scale. The qualitative and quantitative characteristics of selected trials were independently extracted by two reviewers using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed. MAIN RESULTS Eight studies were included in the review. Selected studies addressed different psychosocial interventions for four distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting. REVIEWER'S CONCLUSIONS In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression seems the most promising tool for GPs, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.
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Affiliation(s)
- M J H Huibers
- Departments of Epidemiology and General Practice, Maastricht University, P.O. Box 616, Maastricht, Netherlands.
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Croudace T, Evans J, Harrison G, Sharp DJ, Wilkinson E, McCann G, Spence M, Crilly C, Brindle L. Impact of the ICD-10 Primary Health Care (PHC) diagnostic and management guidelines for mental disorders on detection and outcome in primary care. Cluster randomised controlled trial. Br J Psychiatry 2003; 182:20-30. [PMID: 12509314 DOI: 10.1192/bjp.182.1.20] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The World Health Organization (WHO) ICD-10 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (1996) have not been evaluated in a pragmatic randomised controlled trial (RCT). AIMS To evaluate the effect of local adaptation and dissemination of the guidelines. METHOD Pragmatic, pair-matched, cluster RCT involving 30 practices. RESULTS Guideline practices were less sensitive but more specific in identifying morbidity, but these differences were not significant. Guideline patients did not differ from usual-care patients on 12-item General Health Questionnaire scores at 3-month follow-up or in the proportion who were still cases. There were no significant differences in secondary outcomes. CONCLUSIONS Attempts to influence clinician behaviour through a process of adaptation and extension of guidelines are unlikely to change detection rates or outcomes.
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Affiliation(s)
- Tim Croudace
- Department of Psychiatry University of Cambridge, UK
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Morriss RK, Gask L. Treatment of patients with somatized mental disorder: effects of reattribution training on outcomes under the direct control of the family doctor. PSYCHOSOMATICS 2002; 43:394-9. [PMID: 12297608 DOI: 10.1176/appi.psy.43.5.394] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Reattribution training is an 8-hour, skills-based training program delivered to family doctors so that they may better manage patients with somatized mental disorder. Separate consecutive cohorts of 103 and 112 patients with somatized mental disorder, respectively, visited eight family doctors before and after these physicians had undergone reattribution training. Reattribution training was associated with more frequent endorsement by patients after 1 month that they received the help they wanted and fewer beliefs by patients after 3 months that their symptoms had only a physical cause. Reattribution training did not change the incidence of investigations initiated by the family doctor, prescriptions for psychotropic or nonpsychotropic drugs, or referrals over 3 months.
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Blankenstein AH, van der Horst HE, Schilte AF, de Vries D, Zaat JOM, André Knottnerus J, van Eijk JTM, de Haan M. Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners. PATIENT EDUCATION AND COUNSELING 2002; 47:229-235. [PMID: 12088601 DOI: 10.1016/s0738-3991(01)00199-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Reattribution has been developed as a cognitive-behavioural treatment model for somatisation in general practice. Our objective is to make reattribution suitable for application on patients with long-standing somatisation, including hypochondria, and to evaluate feasibility. Three modifications were developed: (1) dealing with persistent illness worry, (2) adjustment of the doctor's speed to that of the patient, and (3) the use of symptom diaries. Performance of ten experienced general practitioners (GPs), after a 20h training programme (six sessions of variable length), was measured by self-registrations and audio-taped consultations. GPs were interviewed on factors interfering with performance. Nine GPs completed the course. Reattribution was applied to 51 out of 75 indicated somatising patients, which required on average three consultations of 10-30min duration. We conclude that the modified reattribution model offers a feasible approach to the broad spectrum of somatisation seen in general practice; only the modification 'dealing with illness worry' showed limited feasibility.
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Affiliation(s)
- Annette H Blankenstein
- Department of General Practice, Faculty of Medicine, EMGO Institute, Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
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Brown CA, Belfield CR, Field SJ. Cost effectiveness of continuing professional development in health care: a critical review of the evidence. BMJ 2002; 324:652-5. [PMID: 11895825 PMCID: PMC84405 DOI: 10.1136/bmj.324.7338.652] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- C A Brown
- Centre for Research in Medical and Dental Education, School of Education, University of Birmingham, Birmingham B15 2TT.
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