Primary care clinicians treat patients with medically unexplained symptoms
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OBJECTIVE: There is no proven primary care treatment for patients with medically unexplained symptoms (MUS). We hypothesized that a long-term, multidimensional intervention by primary care providers would improve MUS patients’ mental health.
DESIGN: Clinical trial.
SETTING: HMO in Lansing, MI.
PARTICIPANTS: Patients from 18 to 65 years old with 2 consecutive years of high utilization were identified as having MUS by a reliable chart rating procedure; 206 subjects were randomized and 200 completed the study.
INTERVENTION: From May 2000 to January 2003, 4 primary care clinicians deployed a 12-month intervention consisting of cognitive-behavioral, pharmacological, and other treatment modalities. A behaviorally defined patient-centered method was used by clinicians to facilitate this treatment and the provider-patient relationship.
MAIN OUTCOME MEASURE: The primary endpoint was an improvement from baseline to 12 months of 4 or more points on the Mental Component Summary of the SF-36.
RESULTS: Two hundred patients averaged 13.6 visits for the year preceding study. The average age was 47.7 years and 79.1% were females. Using intent to treat, 48 treatment and 34 control patients improved (odds ratio [OR]=1.92, 95% confidence interval [CI]: 1.08 to 3.40; P=.02). The relative benefit (relative “risk” for improving) was 1.47 (CI: 1.05 to 2.07), and the number needed to treat was 6.4 (95% CI: 0.89 to 11.89). The following baseline measures predicted improvement: severe mental dysfunction (P<.001), severe body pain (P=.039), nonsevere physical dysfunction (P=.003), and at least 16 years of education (P=.022); c-statistic=0.75.
CONCLUSION: The first multidimensional intervention by primary care clinicians led to clinically significant improvement in MUS patients.
- deGruy F, Columbia L, Dickinson P. Somatization disorder in a family practice. J Fam Pract. 1987;25:45–51.
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
- Smith RC, Gardiner JC, Lyles JS, et al. Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms. Psychosom Med. 2005;67:123–9. CrossRef
- Escobar JI, Waitzkin H, Silver RC, Gara M, Holman A. Abridged somatization: a study in primary care. Psychosom Med. 1998;60:466–72.
- Bridges KW, Goldberg DP. Somatic presentation of DSM III psychiatric disorders in primary care. J Psychosom Res. 1985;29:563–9. CrossRef
- Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med. 2003;18:478–89. CrossRef
- Lyles JS, Hodges A, Collins C, et al. Using nurse practitioners to implement an intervention in primary care for high utilizing patients with medically unexplained symptoms. Gen Hosp Psychiatry. 2003;25:63–73. CrossRef
- Smith RC, Korban E, Kanj M, et al. A method for rating charts to identify and classify patients with medically unexplained symptoms. Psychother Psychosom. 2004;73:36–42. CrossRef
- Ware JE Jr., Kosinski M, Keller SD. SF-36 Physical and Mental Health Summary Scales: A User’s Manual. Boston: The Health Institute, New England Medical Center; 1994.
- Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. Br Med J. 2002;324:819–23. CrossRef
- Smith RC. Patient-Centered Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002.
- Sharpe M. Cognitive behavioural therapies in the treatment of functional somatic symptoms. In: Mayou R, Bass C, Sharpe M, eds. Treatment of Functional Somatic Symptoms. Oxford: Oxford University Press; 1995:122–43.
- Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care—the PRIME-MD Study. JAMA. 1994;272:1749–56. CrossRef
- Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med. 1998;128:118–26.
- Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression—a randomized trial. Arch Gen Psychiatry. 1999;46:1109–15. CrossRef
- Sartorius N. Composite International Diagnostic Interview (CIDI)—Core Version 1.1. Copyright World Health Organization.
- Ware JJE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey—Manual and Interpretation Guide. Boston: The Health Institute, New England Medical Center; 1993.
- Von Korff M, Ustun TB, Ormel J, Kaplan I, Simon GE. Self-report disability in an international primary care study of psychological illness. J Clin Epidemiol. 1996;49:297–303. CrossRef
- Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401. CrossRef
- Chibnall J, Tait R. The Psychosomatic Symptom Checklist revisited: reliability and validity in a chronic pain population. J Behav Med. 1989;12:297–307. CrossRef
- Spielberger CD, Gorsuch RL, Lushene PR, Jacobs GA. State-Trait Anxiety Inventory (Form Y) (“Self-Evaluation Questionnaire”). Palo Alto, CA: Consulting Psychologists Press Inc; 1983.
- Smith RC, Lyles JS, Mettler JA, et al. A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study. Acad Med. 1995;70:729–32. CrossRef
- Escobar JI, Swartz M, Rubio-Stipec M, Manu P. Medically unexplained symptoms: distribution, risk factors, and comorbidity. In: Kirmayer LJ, Robbins JM, eds. Current Concepts of Somatization: Research and Clinical Perspectives. Washington, DC: American Psychiatric Press Inc; 1991:63–78.
- Hall JA, Roter DL, Milburn MA. Illness and satisfaction with medical care. Curr Dir Psychol Sci. 1999;8:96–9. CrossRef
- Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173–82. CrossRef
- Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis—a randomized controlled trial. JAMA. 2004;291:1464–70. CrossRef
- Torrance GW, Siegel JE, Luce BR. Framing and designing the cost-effectiveness analysis. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press; 1996:54–81.
- Lin E, Katon W, Simon G, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care. 1997;35:831–42. CrossRef
- Kroenke K. The interface between physical and psychological symptoms. Primary Care Companion. J Clin Psychiatry. 2003;5(Suppl 7):11–8.
- Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med. 2003;65:528–33. CrossRef
- Escobar JI, Gara M, Silver RC, Waitzkin G, Holman A, Compton W. Somatisation disorder in primary care. Br J Psychiatry. 1998;173:262–6. CrossRef
- Primary care clinicians treat patients with medically unexplained symptoms
Journal of General Internal Medicine
Volume 21, Issue 7 , pp 671-677
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- medically unexplained symptoms
- mental health in primary care
- provider-patient relationship
- Industry Sectors
- Author Affiliations
- 1. Department of Medicine, Michigan State University, East Lansing, MI, USA
- 3. Department of Epidemiology, Michigan State University, East Lansing, MI, USA
- 4. College of Nursing, Michigan State University, East Lansing, MI, USA
- 5. Department of Family Practice, Michigan State University, East Lansing, MI, USA
- 6. Department of Economics, Michigan State University, East Lansing, MI, USA