A new approach to the assessment of the treatment effects of somatoform disorders

The role of comorbidity in the detection of psychiatric disorders with checklists for mental and physical symptoms in primary care

OBJECTIVE

To examine the contribution of a mental and physical symptom count to the detection of single or comorbid anxiety, depressive and somatoform disorders.

METHOD

In primary care 1,046 consulting patients completed the Hospital Anxiety and Depression Scale (HADS) and the Physical Symptom Checklist (PSC-51). In a stratified sample of 473 patients DSM-IV psychiatric disorders were assessed using the WHO-SCAN interview. The diagnostic value of the HADS total score and the PSC-51 symptom count was examined with ROC-analyses.

RESULTS

The discriminative power of PSC-51 and HADS was highest for patients with both a somatoform disorder and an anxiety or depressive disorder, with an AUC of 0.86 (95% CI: 0.81-0.91) and 0.91 (95% CI: 0.87-0.94) respectively. Using both symptom counts together did not increase the diagnostic value for the detection of the psychiatric disorders.

CONCLUSION

Both symptom counts preferentially detected patients with comorbid disorders. When interpreting diagnostic values of screening questionnaires one should keep in mind that the validity of these values can be dependent of the presence of comorbid disorders.

Depression and somatisation influence the outcome of total hip replacement

Depression, somatisation and pain beliefs influence outcome of several painful musculoskeletal disorders. Their influence on the postoperative outcome of total hip replacement was investigated. A total of 79 patients who underwent primary total hip replacement completed questionnaires preoperatively and six weeks postoperatively addressing depression (Hospital Anxiety and Depression Scale-German version), pain beliefs (Pain Beliefs Questionnaire) and somatisation (Screening of Somatoform Disorders-2) as well as outcome [Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), Medical Outcomes Study 36-Item Short Form (SF-36)]. Depressive patients showed a median preoperative WOMAC sum score of 30 compared to 45 in other patients and a postoperative score of 72 compared to 85, and patients with somatoform disorder of 32 compared to 46 preoperatively and 73 versus 86 postoperatively. Patients with high somatisation and depression scores feel worse in their hips and in general well-being before and after surgery, but they experienced the same benefit from total hip replacement as those with low scores.

Cognitive-behaviour therapy for patients with Abridged Somatization Disorder (SSI 4,6) in primary care: a randomized, controlled study

BACKGROUND

Somatoform disorders are characterized by the presence of multiple somatic symptoms without an organic cause that completely explains their symptoms. These patients generate a high cost in health services. We aim to evaluate the effectiveness and feasibility of a cognitive-behaviour therapy (CBT) programme, administered in group and individual formats in primary care for patients who are diagnosed with abridged somatization disorder.

METHOD/DESIGN

DESIGN

Multicentre, randomized, controlled trial involving 3 groups, one of which is the control group consisting of standardized recommended treatment for somatization disorder in primary care (Smith's norms) and the 2 others, the intervention groups, consisting of cognitive-behavioural therapy (10 sessions) administered in individual format (intervention group 1) or in group format (intervention group 2).

SETTING

29 primary care health centres in the province of Zaragoza and 3 primary care health centres in the province of Mallorca, Spain.

SAMPLE

N = 204 patients, (68 in each of the three groups), aged 18-65 years, able to understand and read Spanish, who fulfil Escobar's criteria of Abridgged Somatization Disorder (SSI 4,6), stable with pharmacotherapy over the previous month, and who will remain stable for the next 3 months in the doctor's opinion, having signed informed consent.

INTERVENTION

CONTROL GROUP

Standardized recommended treatment for somatization disorder in primary care (Smith's norms). INTERVENTION group: 10 weekly sessions of CBT, following a protocol designed by Prof. Escobar's group at UMDNJ, USA. There are 2 different treatment conditions: individual and group format.

MEASUREMENTS

Survey on the use of health services, number and severity of somatic symptoms, anxiety, depression, quality of life and clinical global impression. The interviewers will not know which group the patient belongs to (blind). The assessments will be carried out at baseline, post-treatment, 6 months and 12 post-treatment.

MAIN VARIABLES

Utilization of health services, number and severity of somatic symptoms.

ANALYSIS

The analysis will be per intent to treat. We will use the general linear models of the SPSS v.15 statistical package, to analyse the effect of treatment on the result variable (utilization of health services, number and severity of somatic symptoms).

DISCUSSION

It is necessary to develop more effective psychological treatments for somatoform disorders. This randomised clinical trial will determine whether cognitive behaviour therapy, both in group or in individual format, is effective for the treatment of these patients.

TRIAL REGISTRATION

Current controlled trials ISRCTN69944771.

Warten, Entspannung oder Verhaltenstherapie

Zusammenfassung. Theoretischer Hintergrund: Auf Grund hoher Prävalenzen und deutlicher einhergehender sozio-ökonomischer Folgen stellen multiple somatoforme Beschwerden ein ernst zu nehmendes Problem dar. Fragestellung: Wie effektiv ist eine ambulante kognitiv-behaviorale Gruppenbehandlung im Vergleich zu einem Entspannungsverfahren und einer Wartegruppe in Bezug auf körperliche Beschwerden, Angst, Depressivität und subjektive Gesundheit. Methode: Es wurde eine randomisierte Kontrollgruppenstudie (N = 77) durchgeführt. Die manualisierten Interventionen umfassten acht 90-minütige Termine, die wöchentlich stattfanden. Die manualisierte kognitiv-behaviorale Intervention baut auf dem Behandlungsansatz von Rief und Hiller (1998) auf. Ergebnisse: Sowohl die kognitiv-behaviorale Behandlung als auch die Entspannungsgruppe führten zu einer Verbesserung der somatoformen Beschwerden (SOMS-7). Die kognitiv-behaviorale Behandlung hatte darüber hinaus einen positiven Einfluss auf die Angst (HADS-D) und die subjektive psychische Gesundheit (SF-12). Schlussfolgerungen: Diese kurze, kognitiv-behaviorale Gruppenbehandlung hat positive Effekte auf ambulante Patientinnen und Patienten mit somatoformen Symptomen, die über die Effekte einer Entspannungsgruppe hinausgehen.

Memory bias for health-related information in somatoform disorders

OBJECTIVE

Cognitive processes are considered to be relevant to the etiology and maintenance of somatoform disorders (SFDs). The aim of this study was to assess explicit and implicit information-processing bias for disorder-congruent information in SFDs.

METHODS

A clinical sample of 33 patients suffering from multiple somatoform symptoms (SSI-3/5) and 25 healthy controls performed an encoding task with computer-presented word lists (illness related, negative, positive, neutral content), subsequently followed by explicit memory tests (free recall and recognition) and an implicit test (word-stem completion).

RESULTS

The somatoform group showed a memory bias for illness-related stimuli in the word-stem completion task, whereas the two groups did not differ in explicit memory tests. This effect could not be explained by comorbid depression.

CONCLUSION

These results provide some support for current theories on SFDs.

[Bombed out--psychic and psychosomatic long term consequences of World War II for the cohort born until 1945 in the year 2004]

OBJECTIVES

In a population-based study the hypothesis was pursued as to what extent psychiatric consequences of specific war experiences of the cohort born up to 1945, exemplified through the fate of those bombed out during World War II, can be proven.

METHODS

A representative sample of 2552 participants (1206 men and 1346 women) with an age range from 14 to 92 years were questioned using the random-route-technique by an opinion research institute. The subsample of the cohort born until 1945 was comprised of 776 participants (30.4 % of the complete sample), of whom 375 were men (48.3 %) and 401 women.

RESULTS

161 participants (20.7 % of the cohort born until 1945) had been bombed out (66 men and 95 women). Comparing those who had been bombed out to those who had not been did not show any significant differences concerning their age, their place of residence (Eastern vs. Western Germany), marital status, education level or income level. From a gender perspective women had been bombed out more frequently (p < .05). Four predictors rendered in a multiple regression analysis significant contributions for the prediction of negative body functioning: age, having been bombed out, low income level and low education level (9 % of the variance could be explained).

CONCLUSIONS

The results show the necessity for a new approach to the long-term consequences of severe strain and traumata concerning psychopathology of older people. For this purpose the concept of ambivalence must be further developed.

The relationship between chronic fatigue and somatization syndrome: a general population survey

OBJECTIVE

The objective of this study was to assess the prevalence of chronic fatigue (CF) and its association with somatization syndrome [Somatization Syndrome Index (SSI) 4/6: >/=4 somatoform symptoms in men, 6 in women] in the general population.

METHODS

A representative sample of the German population (N=2412) completed a fatigue questionnaire and a screening instrument for current somatoform symptoms (Screening for Somatoform Symptoms 7).

RESULTS

The prevalence rate of CF was 6.1% (n=147). Females were affected significantly more often as compared with males (7% vs. 5.1%). The mean number of somatoform symptoms was higher in CF cases than in control subjects without CF (11 vs. 2; P<.001). Seventy-two percent of the subjects with CF fulfilled the SSI4/6 criterion for somatization syndrome. Quality of life (EUROHIS-QOL and 8-item Short-Form Health Survey) and well-being (5-item WHO Well-Being Index) were markedly decreased in CF and SSI4/6. The results of regression analyses suggest that fatigue and somatization severity had a similar impact on quality of life.

CONCLUSIONS

The results suggest that CF is relevant in the general population. Its substantial overlap with somatization syndrome supports the hypothesis that the two syndromes are only partially different manifestations of the same underlying processes.

A One-Session Treatment for Patients Suffering From Medically Unexplained Symptoms in Primary Care: A Randomized Clinical Trial

The aim of the study was to evaluate a one-session cognitive-behavior treatment (CBT) versus standard medical care for 140 primary-care patients with multiple somatoform symptoms. DSM-IV diagnoses were assessed with structured interviews. Primary outcome variables were healthcare utilization, number, and severity of somatoform symptoms, and secondary outcome measures were psychopathology dimensions. Assessments were done at study enrollment, at 4-weeks, and at 6-month follow-up. General acceptance of CBT was high (positive session evaluations, low dropout rate: 15%). Using an intent-to-treat analytic strategy, both groups improved. Yet results showed a stronger reduction in doctor visits and somatization severity in CBT versus standard care.

High somatic symptom burdens and functional gastrointestinal disorders

BACKGROUND & AIMS

Unexplained, multi-system somatic symptoms and syndromes, the hallmark features of somatization, are prevalent in patients with functional gastrointestinal disorders (FGIDs). We studied outpatients attending a gastroenterology clinic to see whether current somatic symptom burdens (a somatization state measure) or number of prior functional diagnoses (a somatization trait measure) could predict the presence of an FGID over structural gastrointestinal disease, and whether the predictive value was dependent on comorbid depression or anxiety disorders.

METHODS

Clinical data from 327 consecutive new referrals to an outpatient gastroenterology practice were reviewed, 187 with an FGID and 140 with a structural illness. Somatization state and trait were measured by using self-reported current symptoms and functional diagnoses recorded in the medical history, respectively. Psychiatric comorbidity (depression or anxiety disorders) was extracted from chart review.

RESULTS

FGID subjects endorsed more somatization state symptoms, had more somatization trait diagnoses, and had greater likelihood of psychiatric comorbidity (P < .001 for each). Logistic regression analysis adjusting for age and sex differences showed that each of these features independently predicted the likelihood of an FGID over structural disease (P < .05 for each). When high ratings on the somatization measures were present together with psychiatric comorbidity, the positive predictive value exceeded 0.95.

CONCLUSIONS

Higher burdens of either current somatic symptoms or functional diagnoses in the medical history are strong predictors of an FGID in outpatients presenting with gastrointestinal complaints. The mechanism is not solely dependent on a relationship with affective disorders, which independently predicts FGID, at least in part, through another path.

The quantification inventory for somatoform syndromes (QUISS): a novel instrument for the assessment of severity

BACKGROUND

To date, specific scales for the assessment of severity of somatoform disorders are still rare. Characteristic cognitive and behavioural domains, representing severity are not incorporated in the existing scales. Results with the novel quantification inventory for somatoform syndromes (QUISS) are presented in this paper.

METHODS

The QUISS has been developed as a qualified severity scale for patients fulfilling diagnostic criteria according to DSM-IV or/and ICD-10. It was designed to be particularly suitable for application in clinical trials and for monitoring the efficacy of psychotherapy and pharmacotherapy. Not only number, severity and frequency of somatoform symptoms, but also common cognitive and behavioural domains of somatoform disorders have been included into this instrument. Both an 18-item patient- and observer-rated version are available taking about 20 min to complete. The questionnaire was applied to patients with somatoform disorder (N = 96), major depression (N = 24), and panic disorder (N = 16).

RESULTS

The psychometric properties of the scale are satisfactory. The QUISS showed high objectivity (Cronbach's alpha = 0.90 for both versions; inter-scale correlations r = 0.64-0.88; p < 0.05), good test-retest- (r = 0.87; p < 0.05) and inter-rater-reliability (r = 0.89; p < 0.05). External validity (moderately high correlations of QUISS-T to SOMS 7T (r = 0.54), significant discrimination to major depression p < 0.05) was satisfactory. Factor structure revealed five relevant factors.

CONCLUSIONS

The QUISS could be a useful instrument in somatoform disorders for the assessment of syndrome severity and treatment outcome in scientific and clinical settings.

Cost-effectiveness of collaborative care including PST and an antidepressant treatment algorithm for the treatment of major depressive disorder in primary care; a randomised clinical trial

BACKGROUND

Depressive disorder is currently one of the most burdensome disorders worldwide. Evidence-based treatments for depressive disorder are already available, but these are used insufficiently, and with less positive results than possible. Earlier research in the USA has shown good results in the treatment of depressive disorder based on a collaborative care approach with Problem Solving Treatment and an antidepressant treatment algorithm, and research in the UK has also shown good results with Problem Solving Treatment. These treatment strategies may also work very well in the Netherlands too, even though health care systems differ between countries.

METHODS/DESIGN

This study is a two-armed randomised clinical trial, with randomization on patient-level. The aim of the trial is to evaluate the treatment of depressive disorder in primary care in the Netherlands by means of an adapted collaborative care framework, including contracting and adherence-improving strategies, combined with Problem Solving Treatment and antidepressant medication according to a treatment algorithm. Forty general practices will be randomised to either the intervention group or the control group. Included will be patients who are diagnosed with moderate to severe depression, based on DSM-IV criteria, and stratified according to comorbid chronic physical illness. Patients in the intervention group will receive treatment based on the collaborative care approach, and patients in the control group will receive care as usual. Baseline measurements and follow up measures (3, 6, 9 and 12 months) are assessed using questionnaires and an interview. The primary outcome measure is severity of depressive symptoms, according to the PHQ9. Secondary outcome measures are remission as measured with the PHQ9 and the IDS-SR, and cost-effectiveness measured with the TiC-P, the EQ-5D and the SF-36.

DISCUSSION

In this study, an American model to enhance care for patients with a depressive disorder, the collaborative care model, will be evaluated for effectiveness in the primary care setting. If effective across the Atlantic and across different health care systems, it is also likely to be an effective strategy to implement in the treatment of major depressive disorder in the Netherlands.

Cost-effectiveness of collaborative care for chronically ill patients with comorbid depressive disorder in the general hospital setting, a randomised controlled trial

BACKGROUND

Depressive disorder is one of the most common disorders, and is highly prevalent in chronically ill patients. The presence of comorbid depression has a negative influence on quality of life, health care costs, self-care, morbidity, and mortality. Early diagnosis and well-organized treatment of depression has a positive influence on these aspects. Earlier research in the USA has reported good results with regard to the treatment of depression with a collaborative care approach and an antidepressant algorithm. In the UK 'Problem Solving Treatment' has proved to be feasible. However, in the general hospital setting this approach has not yet been evaluated.

METHODS/DESIGN

CC: DIM (Collaborative Care: Depression Initiative in the Medical setting) is a two-armed randomised controlled trial with randomisation at patient level. The aim of the trial is to evaluate the treatment of depressive disorder in general hospitals in the Netherlands based on a collaborative care framework, including contracting, 'Problem Solving Treatment', antidepressant algorithm, and manual-guided self-help. 126 outpatients with diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular diseases will be randomised to either the intervention group or the control group. Patients will be included if they have been diagnosed with moderate to severe depression, based on the DSM-IV criteria in a two-step screening method. The intervention group will receive treatment based on the collaborative care approach; the control group will receive 'care as usual'. Baseline and follow-up measurements (after 3, 6, 9, and 12 months) will be performed by means of questionnaires. The primary outcome measure is severity of depressive symptoms, as measured with the PHQ-9. The secondary outcome measure is the cost-effectiveness of these treatments according to the TiC-P, the EuroQol and the SF-36.

DISCUSSION

Earlier research has indicated that depressive disorder is a chronic, mostly recurrent illness, which tends to cluster with physical comorbidity. Even though the treatment of depressive disorder based on the guidelines for depression is proven effective, these guidelines are often insufficiently adhered to. Collaborative care and 'Problem Solving Treatment' will be specifically tailored to patients with depressive disorders and evaluated in a general hospital setting in the Netherlands.

Somatization in the population: from mild bodily misperceptions to disabling symptoms

OBJECTIVE

This study investigates the prevalence of current somatization in the population by taking different levels of symptom severity into account. Somatization is described along a continuum from mild and negligible bodily misperceptions to severe and disabling somatoform symptoms.

METHODS

A representative sample of 2.552 persons in Germany was examined with a screening instrument for medically unexplained physical complaints that had occurred during the past 7 days. All 53 symptoms from the ICD-10/DSM-IV sections of somatoform disorders were included.

RESULTS

81.6% reported at least one symptom causing at least mild impairment and 22.1% at least one symptom causing severe impairment. The entire sample had an average of 6.6 symptoms associated with at least mild distress. Somatization of any degree was associated with female gender, age above 45, lower educational level, lower household income and rural area. The most common symptoms with prevalence rates > 20% were various types of pain (back, head, joints, extremities), food intolerance, sexual indifference, painful menstruations and erectile/ejaculatory dysfunction.

CONCLUSION

This population survey demonstrates that medically unclear complaints are an everyday phenomenon. About three out of four cases are below clinical relevance with only low level of impairment. Epidemiological correlates are similar between clinical and non-clinical forms of somatization.

Causal illness attributions in somatoform disorders: associations with comorbidity and illness behavior

OBJECTIVE

To compare causal illness beliefs between patients with unexplained physical symptoms and different comorbid disorders and to assess the association of causal illness beliefs with illness behavior.

METHODS

We examined a sample of 233 patients attending treatment in primary care. Inclusion criteria were "unexplained physical symptoms." All patients were investigated using structured interviews and self-rating scales [Screening for Somatoform Symptoms (SOMS), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and a 12-item instrument to assess causal attributions]. By means of factor analysis, the following illness attributions were considered: vulnerability to infection and environmental factors, psychological factors, organic causes including genetic and aging factors, and distress (including exhaustion and time pressure).

RESULTS

Most patients reported multiple illness attributions. The more somatoform symptoms patients had, the more explanations in general they considered. Especially for vulnerability and organic illness beliefs, patients with somatoform symptoms had increased scores. Comorbidity with depression and with anxiety disorders was associated with more psychological attributions. Even when the influence of somatization, depression, and anxiety is controlled for, illness beliefs still showed associations with illness behavior. Organic causal beliefs and vulnerability attributions were associated with a need for medical diagnostic examinations, increased expression of symptoms, increased illness consequences, and bodily scanning.

CONCLUSIONS

Multiple causal attributions can coexist demonstrating different associations with comorbid depression and illness behavior.

Treatment of somatoform disorders with St. John's wort: a randomized, double-blind and placebo-controlled trial

OBJECTIVE

To investigate efficacy and safety of St. John's wort (SJW) LI 160 in somatoform disorders.

METHODS

In a prospective, randomized, placebo-controlled, and double-blind parallel group study, 184 outpatients with somatization disorder (ICD-10 F45.0), undifferentiated somatoform disorder (F45.1), and somatoform autonomic dysfunction (F45.3), but not major depression, received either 300 mg of SJW extract LI 160 twice daily or matching placebo for 6 weeks. Six outcome measures were evaluated as a combined measure by means of the Wei Lachin test: Somatoform Disorders Screening Instrument--7 days (SOMS-7), somatic subscore of the HAMA, somatic subscore of the SCL-90-R, subscores "improvement" and "efficacy" of the CGI, and the global judgment of efficacy by the patient.

RESULTS

In the intention to treat population (N=173), for each of the six primary efficacy measures as well as for the combined test, statistically significant medium to large-sized superiority of SJW treatment over placebo was demonstrated (p <.0001). Of the SJW patients, 45.4% were classified as responders compared with 20.9% with placebo (p =.0006). Tolerability of SJW treatment was equivalent to placebo.

CONCLUSIONS

Administration of 600 mg of SJW extract LI 160 daily is effective and safe in the treatment of somatoform disorders, thereby confirming results from a previous study.