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Rask MT, Frostholm L, Hansen SH, Petersen MW, Ørnbøl E, Rosendal M. Self-help interventions for persistent physical symptoms: a systematic review of behaviour change components and their potential effects. Health Psychol Rev 2024; 18:75-116. [PMID: 36651573 DOI: 10.1080/17437199.2022.2163917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
Persistent physical symptoms (PPS) remain a challenge in the healthcare system due to time-constrained consultations, uncertainty and limited specialised care capacity. Self-help interventions may be a cost-effective way to widen the access to treatment. As a foundation for future interventions, we aimed to describe intervention components and their potential effects in self-help interventions for PPS. A systematic literature search was made in PubMed, EMBASE, PsycINFO and CENTRAL. Fifty-one randomised controlled trials were included. Interventions were coded for effect on outcomes (standardised mean difference ≥0.2) related to symptom burden, anxiety, depression, quality of life, healthcare utilisation and sickness absence. The Behaviour Change Technique (BCT) Taxonomy v1 was used to code intervention components. An index of potential was calculated for each BCT within an outcome category. Each BCT was assessed as 'potentially effective' or 'not effective' based on a two-sided test for binomial random variables. Sixteen BCTs showed potential effect as treatment components. These BCTs represented the themes: goals and planning, feedback and monitoring, shaping knowledge, natural consequences, comparison of behaviour, associations, repetition and substitution, regulation, antecedents and identity. The results suggest that specific BCTs should be included in new PPS self-help interventions aiming to improve the patients' physical and mental health.
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Affiliation(s)
- Mette Trøllund Rask
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
| | - Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sofie Høeg Hansen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie Weinreich Petersen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
| | - Eva Ørnbøl
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
| | - Marianne Rosendal
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
- Research Unit for General Practice, Aarhus C, Denmark
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Straub RH, Boschiero D. Medically Unexplained Symptoms Are Linked to Chronic Inflammatory Diseases: Is There a Role for Frontal Cerebral Blood Oxygen Content? Neuroimmunomodulation 2024; 31:40-50. [PMID: 38219729 DOI: 10.1159/000536204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/08/2024] [Indexed: 01/16/2024] Open
Abstract
INTRODUCTION Patients often go to the physician with medically unexplained symptoms (MUS). MUS can be autonomic nervous system-related "unspecific" symptoms, such as palpitations, heart rhythm alterations, temperature dysregulation (hand, feet), anxiety, or depressive manifestations, fatigue, somnolence, nausea, hyperalgesia with varying pains and aches, dizziness, etc. Methods: In this real-world study, we investigated MUS in a cohort of unselected outpatients from general practitioners in Italy. It was our aim to increase the understanding of MUS by using principal component analyses to identify any subcategories of MUS and to check a role of chronic inflammatory diseases. Additionally, we studied cerebral blood oxygen (rCBO2) and associations with MUS and chronic inflammatory disease. RESULTS Participants included 1,597 subjects (50.6 ± 0.4 years, 65%/35% women/men). According to ICD-10 codes, 137 subjects had chronic inflammatory diseases. MUS were checked by a questionnaire with a numeric rating scale and cerebral blood flow with optical techniques. The analyses of men and women were stratified. Psychological symptom severity was higher in the inflamed compared to the non-inflamed group (fatigue, insomnia in women and men; recent mood changes, daytime sleepiness, anxiety, apathy, cold hands only in women; abnormal appetite and heart rhythm problems only in men). Principal component analysis with MUS provided new subcategories: brain symptoms, gut symptoms, and unspecific symptoms. Brain and gut symptoms were higher in inflamed women and men. Chronic inflammatory diseases and pain were tightly interrelated in men and women (p < 0.0001). In women, not in men, average frontal rCBO2 content was higher in inflamed compared to non-inflamed subjects. In men, not in women, individuals with pain demonstrated a lower average frontal rCBO2 content compared to pain-free men. MUS did not relate to rCBO2 parameters. CONCLUSION This study shows close relationships between MUS and chronic inflammatory diseases but not between MUS and rCBO2 parameters.
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Affiliation(s)
- Rainer H Straub
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Department of Internal Medicine, University Hospital Regensburg, Regensburg, Germany
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Kushniruk A, Hedegaard L, Rask MT, Clemensen J, Frostholm L, Rosendal M. Designing and Developing an eHealth Program for Patients With Persistent Physical Symptoms: Usability Study. JMIR Hum Factors 2023; 10:e42572. [PMID: 36753312 PMCID: PMC9947758 DOI: 10.2196/42572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/22/2022] [Accepted: 01/24/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Patients with persistent physical symptoms presenting in primary care are often affected by multiple symptoms and reduced functioning. The medical and societal costs of these patients are high, and there is a need for new interventions tailored to both the patients and health care system. OBJECTIVE This study aimed to examine the usability of an unguided, self-help treatment program, "My Symptoms," developed to assist patients and general practitioners in symptom management. METHODS In all, 11 users (4 patients with persistent physical symptoms and 7 laypeople) participated in web-based thinking-aloud interviews involving the performance of predefined tasks in the program. Thematic analysis was used to categorize the severity of usability issues. General usability heuristics were cross-referenced with the usability issues. RESULTS The analysis identified important usability issues related to functionality, navigation, and content. The study shows how therapeutic knowledge in some cases was lost in the translation of face-to-face therapy to a digital format. The user testing helped uncover how the functionality of the digital elements and general navigation of the program played a huge part in locating and accessing the needed treatment. Examples of redesign to mediate the therapeutic value in the digital format involving health care professionals, web developers, and users are provided. The study also highlights the differences of involving patients and laypeople in the interviews. CONCLUSIONS Taking the experience of common symptoms as a point of departure, patients and laypeople contributed to finding usability issues on program functionality, navigation, and content to improve the program and make the treatment more accessible to users.
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Affiliation(s)
| | - Leonora Hedegaard
- Department of Culture and Learning, Aalborg University, Aalborg, Denmark
| | - Mette Trøllund Rask
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark
| | - Jane Clemensen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marianne Rosendal
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus N, Denmark.,Research Unit for General Practice, Aarhus University, Aarhus, Denmark
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Nazzal Z, Maraqa B, Abu Zant M, Qaddoumi L, Abdallah R. Somatic symptom disorders and utilization of health services among Palestinian primary health care attendees: a cross-sectional study. BMC Health Serv Res 2021; 21:615. [PMID: 34182995 PMCID: PMC8240383 DOI: 10.1186/s12913-021-06671-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/22/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many primary health care (PHC) clients come in with medically unexplained complaints, leading to frequent consultations and high usage of services and healthcare costs. This study aimed to determine the prevalence of somatic symptom disorder (SSD) among PHC attendees and explore its relation to other mental conditions and risk factors. METHODS A cross-sectional design was used to interview 400 attendees. Men and women aged over 18 years old without a psychiatric diagnosis were invited to participate. The Somatization scale of the Four-Dimensional Symptom Questionnaire was used to assess somatic symptom disorders. It is a valid tool to be used in a PHC setting. We used the Chi-square test and multivariable logistic regression to explore determinant variables. RESULTS Prevalence of SSD was 32.5% (95%CI = 27.9-37.1%). The most common symptoms were painful muscles (61.5%) followed by back pain (52.3%). Female gender [adjusted OR = 2.1 (95% CI = 1.2-3.7)], chronic diseases [adjusted OR = 2.4 (95%CI = 1.3-4.5)], depression [adjusted OR = 3.3 (95%CI = 2.0-5.5)], and anxiety [adjusted OR = 2.1 (95%CI = 1.2-3.6)] were all associated with SSD. In addition, frequent primary health care attendance was found to be associated with SSD [adjusted OR = 2.4 (95%CI = 1.4-4.1)]. CONCLUSIONS SSD significantly higher among females, patients with chronic diseases, clients with anxiety and depressive disorders, and patients with frequent doctors' visits. Painful muscles and back pain are the most common symptom presented by patients, and this could be used initially by PHC physicians as a signal to consider for screening.
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Affiliation(s)
- Zaher Nazzal
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Beesan Maraqa
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
- Primary Healthcare Directorate, Palestinian Ministry of Health, Ramallah, Palestine
| | - Marah Abu Zant
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Layali Qaddoumi
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Rana Abdallah
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Pohontsch NJ, Zimmermann T, Lehmann M, Rustige L, Kurz K, Löwe B, Scherer M. ICD-10-Coding of Medically Unexplained Physical Symptoms and Somatoform Disorders-A Survey With German GPs. Front Med (Lausanne) 2021; 8:598810. [PMID: 33859988 PMCID: PMC8042316 DOI: 10.3389/fmed.2021.598810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/08/2021] [Indexed: 12/03/2022] Open
Abstract
Background: General practitioners (GPs) are reluctant to use codes that correspond to somatization syndromes. Aim: To quantify GPs' views on coding of medically unexplained physical symptoms (MUPS), somatoform disorders, and associated factors. Design and Setting: Survey with German GPs. Methods: We developed six survey items [response options “does not apply at all (1)”—“does fully apply (6)”], invited a random sample of 12.004 GPs to participate in the self-administered cross-sectional survey and analysed data using descriptive statistics and logistic regression analyses. Results: Response rate was 15.2% with N = 1,731 valid responses (54.3% female). Participants considered themselves familiar with ICD-10 criteria for somatoform disorders (M = 4.52; SD =.036) and considered adequate coding as essential prerequisite for treatment (M = 5.02; SD = 1.21). All other item means were close to the scale mean: preference for symptom or functional codes (M = 3.40; SD = 1.21), consideration of the possibility of stigmatisation (M = 3.30; SD = 1.35) and other disadvantages (M = 3.28; SD = 1.30) and coding only if psychotherapy is intended (M = 3.39; SD = 1.46). Exposure, guideline knowledge, and experience were most strongly associated with GPs' self-reported coding behaviour. Conclusions: Subjective exposure, guideline knowledge, and experience as a GP, but no sociodemographic variable being associated with GPs' subjective coding behaviour could indicate that GPs offer a relatively homogeneous approach to coding and handling of MUPS and somatoform disorders. Strengthening guideline knowledge and implementation, and practise with simulated patients could increase the subjective competence to cope with the challenge that patients with MUPS and somatoform disorders present.
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Affiliation(s)
- Nadine J Pohontsch
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Zimmermann
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marco Lehmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lisa Rustige
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katinka Kurz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Houwen J, Lucassen PLBJ, Stappers HW, van Spaendonck K, van Duijnhoven A, Hartman TCO, van Dulmen S. How to learn skilled communication in primary care MUS consultations: a focus group study. Scand J Prim Health Care 2021; 39:101-110. [PMID: 33569982 PMCID: PMC7971340 DOI: 10.1080/02813432.2021.1882088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations. OBJECTIVE To define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees. METHODS Five focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis. RESULTS MUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs' individual needs and (3) training and supervision in daily practice. CONCLUSION Teachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.KEY POINTSMany GPs experience difficulties in communication with patients with MUS.There is a need to equip GPs with communication skills to manage MUS consultations more adequately.Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs' awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- CONTACT Juul Houwen Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Geert Grooteplein, 21, Nijmegen6525 EZ, The Netherlands
| | - Peter L. B. J. Lucassen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hugo W. Stappers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel van Spaendonck
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aniek van Duijnhoven
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim C. olde Hartman
- Department of Primary and Community Care, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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7
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Patel M, James K, Moss-Morris R, Ashworth M, Husain M, Hotopf M, David AS, McCrone P, Landau S, Chalder T. BMC family practice integrated GP care for patients with persistent physical symptoms: feasibility cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:207. [PMID: 33028243 PMCID: PMC7542765 DOI: 10.1186/s12875-020-01269-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/13/2020] [Indexed: 05/30/2023]
Abstract
BACKGROUND Patients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS). General practitioners (GPs) play a key role in the management of PPS and require further training. Patients are often frustrated with the care they receive. This study aims to assess the acceptability of an 'integrated GP care' approach which consists of offering self-help materials to patients with PPS and offering their GPs training on how to utilise cognitive behavioural skills within their consultations, as well as assessing the feasibility of conducting a future trial in primary care to evaluate its benefit. METHODS A feasibility cluster randomised controlled trial was conducted in primary care, South London, UK. GP practices (clusters) were randomly allocated to 'integrated GP care plus treatment as usual' or 'treatment as usual'. Patients with PPS were recruited from participating GP practices before randomisation. Feasibility parameters, process variables and potential outcome measures were collected at pre-randomisation and at 12- and 24-weeks post-randomisation at cluster and individual participant level. RESULTS Two thousand nine hundred seventy-eight patients were identified from 18 GP practices. Out of the 424 patients who responded with interest in the study, 164 fully met the eligibility criteria. One hundred sixty-one patients provided baseline data before cluster randomisation and therefore were able to participate in the study. Most feasibility parameters indicated that the intervention was acceptable and a future trial feasible. 50 GPs from 8 GP practices (randomised to intervention) attended the offer of training and provided positive feedback. Scores in GP knowledge and confidence increased post-training. Follow-up rate of patients at 24 weeks was 87%. However estimated effect sizes on potential clinical outcomes were small. CONCLUSIONS It was feasible to identify and recruit patients with PPS. Retention rates of participants up to 24 weeks were high. A wide range of health services were used. The intervention was relatively low cost and low risk. This complex intervention should be further developed to improve patients'/GPs' utilisation of audio/visual and training resources before proceeding to a full trial evaluation. TRIAL REGISTRATION NCT02444520 (ClinicalTrials.gov).
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Affiliation(s)
- Meenal Patel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Kirsty James
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neurosciences, Psychology and Neuroscience King's College, London, UK
| | - Rona Moss-Morris
- Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine King's College London, London, UK
| | - Mujtaba Husain
- UK South London and Maudsley NHS Foundation Trust, London, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.,UK South London and Maudsley NHS Foundation Trust, London, UK
| | - Anthony S David
- Division of Psychiatry, Maple House, UCL Institute of Mental Health, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Paul McCrone
- Institute for Lifecourse Development, University of Greenwich, Old Royal Naval College, Park Row, Greenwich, London, SE10 9LS, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neurosciences, Psychology and Neuroscience King's College, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK.
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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, van der Wouden JC, Grutters JPC, Visser B, Assendelft WJJ, van der Horst HE, Olde Hartman TC. Psychosomatic therapy for patients frequently attending primary care with medically unexplained symptoms, the CORPUS trial: study protocol for a randomised controlled trial. Trials 2019; 20:697. [PMID: 31818310 PMCID: PMC6902505 DOI: 10.1186/s13063-019-3913-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/15/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Medically unexplained symptoms (MUS) are highly prevalent and pose a burden both on patients and on health care. In a pilot study psychosomatic therapy delivered by specialised therapists for patients with MUS showed promising results with regard to patient's acceptability, feasibility and effects on symptoms. The aim of this study is to establish whether psychosomatic therapy by specialised psychosomatic exercise therapists is cost- effective in decreasing symptoms and improving functioning in patients who frequently consult their general practitioner (GP) with MUS. METHODS A randomised effectiveness trial with an economic evaluation in primary care with 158 patients aged 18 years and older who are frequently consulting their GP with MUS. Patients will be assigned to psychosomatic therapy in addition to usual care or usual care only. Psychosomatic therapy is a multi-component and tailored intervention, aiming to empower patients by applying psycho-education, relaxation techniques, mindfulness, cognitive approaches and/or graded activity. Patients assigned to the psychosomatic therapy receive 6 to 12 sessions of psychosomatic therapy, of 30-45 min each, delivered by a specialised exercise or physical therapist. Primary outcome measure is patient-specific functioning and disability, measured with the Patient-Specific Functional Scale (PSFS). Secondary outcome measures are symptom severity, consultation frequency and referrals to secondary care, patient satisfaction, quality of life and costs. Assessments will be carried out at baseline, and after 4 and 12 months. An economic evaluation alongside the trial will be conducted from a societal perspective, with quality-adjusted life years (QALYs) as outcome measure. Furthermore, a mixed-methods process evaluation will be conducted. DISCUSSION We expect that psychosomatic therapy in primary care for patients who frequently attend the GP for MUS will improve symptoms and daily functioning and disability, while reducing consultation frequency and referrals to secondary care. We expect that the psychosomatic therapy provides value for money for patients with MUS. TRIAL REGISTRATION Netherlands Trial Register, ID: NL7157 (NTR7356). Registered 13 July 2018.
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Affiliation(s)
- Margreet S H Wortman
- ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Visser
- ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Liu Y, Zhao J, Fan X, Guo W. Dysfunction in Serotonergic and Noradrenergic Systems and Somatic Symptoms in Psychiatric Disorders. Front Psychiatry 2019; 10:286. [PMID: 31178761 PMCID: PMC6537908 DOI: 10.3389/fpsyt.2019.00286] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/12/2019] [Indexed: 12/20/2022] Open
Abstract
Somatic symptoms include a range of physical experiences, such as pain, muscle tension, body shaking, difficulty in breathing, heart palpitation, blushing, fatigue, and sweating. Somatic symptoms are common in major depressive disorder (MDD), anxiety disorders, and some other psychiatric disorders. However, the etiology of somatic symptoms remains unclear. Somatic symptoms could be a response to emotional distress in patients with those psychiatric conditions. Increasing evidence supports the role of aberrant serotoninergic and noradrenergic neurotransmission in somatic symptoms. The physiological alterations underlying diminished serotonin (5-HT) and norepinephrine (NE) signaling may contribute to impaired signal transduction, reduced 5-HT, or NE release from terminals of presynaptic neurons, and result in alternations in function and/or number of receptors and changes in intracellular signal processing. Multiple resources of data support each of these mechanisms. Animal models have shown physiological responses, similar to somatic symptoms seen in psychiatric patients, after manipulations of 5-HT and NE neurotransmission. Human genetic studies have identified many single-nucleotide polymorphisms risk loci associated with somatic symptoms. Several neuroimaging findings support that somatic symptoms are possibly associated with a state of reduced receptor binding. This narrative literature review aimed to discuss the involvement of serotonergic and noradrenergic systems in the pathophysiology of somatic symptoms. Future research combining neuroimaging techniques and genetic analysis to further elucidate the biological mechanisms of somatic symptoms and to develop novel treatment strategies is needed.
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Affiliation(s)
- Yi Liu
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center on Mental Disorders, Changsha, China
| | - Jingping Zhao
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center on Mental Disorders, Changsha, China
| | - Xiaoduo Fan
- University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA, United States
| | - Wenbin Guo
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center on Mental Disorders, Changsha, China
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Henningsen P, Zipfel S, Sattel H, Creed F. Management of Functional Somatic Syndromes and Bodily Distress. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:12-31. [PMID: 29306954 DOI: 10.1159/000484413] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/17/2017] [Indexed: 12/18/2022]
Abstract
Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.
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Affiliation(s)
- Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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12
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Lian OS, Robson C. "It´s incredible how much I´ve had to fight." Negotiating medical uncertainty in clinical encounters. Int J Qual Stud Health Well-being 2018; 12:1392219. [PMID: 29063801 PMCID: PMC5654014 DOI: 10.1080/17482631.2017.1392219] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: Clinical encounters related to medically unexplained physical symptoms (MUPS) are associated with high levels of conflict between patients and doctors. Collaborative difficulties are fused by the medical uncertainty that dominates these consultations. The main aim of this study is to explore the interactional dynamics of clinical encounters riddled by medical uncertainty, as experienced by people living with long-term medically unexplained fatigue in Norway. Method: A qualitative thematic analysis of written texts from 256 study participants. Results: We found that patients experience being met with disbelief, inappropriate psychological explanations, marginalisation of experiences, disrespectful treatment, lack of physical examination and damaging health advice. The main source of their discontent is not the lack of biomedical knowledge, but doctors who fail to communicate acknowledgement of patients’ experiences, knowledge and autonomy. War metaphors are emblematic of how participants describe their medical encounters. The overarching storyline depicts experiences of being caught in a power struggle with doctors and health systems, fused by a lack of common conceptual ground. Conclusion: When physical symptoms cannot be detected, explained and managed by biomedical knowledge and technology, good doctor-patient partnerships are crucial. Without clearly acknowledging patients’ perspectives and capabilities in clinical practice, such partnerships cannot be achieved.
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Affiliation(s)
- Olaug S Lian
- a Department of Community Medicine, Faculty of health sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
| | - Catherine Robson
- a Department of Community Medicine, Faculty of health sciences , University of Tromsø - The Arctic University of Norway , Tromsø , Norway
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The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: A systematic review and meta-analysis. PLoS One 2018; 13:e0196467. [PMID: 29768436 PMCID: PMC5955495 DOI: 10.1371/journal.pone.0196467] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 04/15/2018] [Indexed: 12/28/2022] Open
Abstract
Computer-based interventions target improvement of physical and emotional functioning in patients with chronic pain and functional somatic syndromes. However, it is unclear to what extent which interventions work and for whom. This systematic review and meta-analysis (registered at PROSPERO, 2016: CRD42016050839) assesses efficacy relative to passive and active control conditions, and explores patient and intervention factors. Controlled studies were identified from MEDLINE, EMBASE, PsychInfo, Web of Science, and Cochrane Library. Pooled standardized mean differences by comparison type, and somatic symptom, health-related quality of life, functional interference, catastrophizing, and depression outcomes were calculated at post-treatment and at 6 or more months follow-up. Risk of bias was assessed. Sub-group analyses were performed by patient and intervention characteristics when heterogeneous outcomes were observed. Maximally, 30 out of 46 eligible studies and 3,387 participants were included per meta-analysis. Mostly, internet-based cognitive behavioral therapies were identified. Significantly higher patient reported outcomes were found in comparisons with passive control groups (standardized mean differences ranged between -.41 and -.18), but not in comparisons with active control groups (SMD = -.26 - -.14). For some outcomes, significant heterogeneity related to patient and intervention characteristics. To conclude, there is a minority of good quality evidence for small positive average effects of computer-based (cognitive) behavior change interventions, similar to traditional modes. These effects may be sustainable. Indications were found as of which interventions work better or more consistently across outcomes for which patients. Future process analyses are recommended in the aim of better understanding individual chances of clinically relevant outcomes.
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van Westrienen PE, Pisters MF, Toonders SA, Gerrits M, Veenhof C, de Wit NJ. Effectiveness of a Blended Multidisciplinary Intervention for Patients with Moderate Medically Unexplained Physical Symptoms (PARASOL): Protocol for a Cluster Randomized Clinical Trial. JMIR Res Protoc 2018; 7:e120. [PMID: 29739735 PMCID: PMC5964304 DOI: 10.2196/resprot.9404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/05/2018] [Accepted: 03/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Medically unexplained physical symptoms are an important health problem in primary care, with a spectrum from mild to chronic. The burden of chronic medically unexplained physical symptoms is substantial for patients, health care professionals, and society. Therefore, early identification of patients with moderate medically unexplained physical symptoms is needed in order to prevent chronicity. The preventive screening of medically unexplained physical symptoms (PRESUME) screening method was developed using data from the electronic medical record of the patients' general practitioner and demonstrated its prognostic accuracy to identify patients with moderate medically unexplained physical symptoms. In the next step, we developed a proactive blended and integrated mental health and physical therapy intervention program (PARASOL) to reduce complaints of moderate medically unexplained physical symptoms, stimulate self-management, and prevent chronicity. OBJECTIVE The primary objective of this study is to investigate the effectiveness of the blended PARASOL intervention on the impact of symptoms and quality of life in patients with moderate medically unexplained physical symptoms compared with usual care. Secondary objectives are to study the effect on severity of physical and psychosocial symptoms, general health, physical behavior, illness perception, and self-efficacy in patients with moderate medically unexplained physical symptoms as well as to determine the cost-effectiveness of the program. METHODS This paper presents the study protocol of a multicenter cluster randomized clinical trial. Adult patients with moderate medically unexplained physical symptoms will be identified from electronic medical record data using the PRESUME screening method and proactively recruited for participation in the study. Cluster randomization will be performed at the level of the participating health care centers. In total 248 patients with moderate medically unexplained physical symptoms (124 patients per arm) are needed. The PARASOL intervention is a 12-week blended primary care program consisting of 4 face-to-face consultations with the mental health nurse and 5 physical therapy sessions, supplemented with a Web-based program. The Web-based program contains (1) information modules and videos on self-management and educative themes, (2) videos and instructions on prescribed home exercises, and (3) assignments to gradually increase the physical activity. The program is directed at patients' perception of symptoms as well as modifiable prognostic risk factors for chronicity using therapeutic neuroscience education. It encourages self-management, as well as an active lifestyle using a cognitive behavioral approach and graded activity. Primary outcomes are impact of symptoms and quality of life. Secondary outcomes are severity of physical and psychosocial symptoms, general health, physical behavior, illness perceptions, self-efficacy, and cost-effectiveness. All measurements will be performed at baseline, 3 and 12 months after baseline. Retrospective cost questionnaires will also be sent at 6 and 9 months after baseline and these will be used for the cost-effectiveness analysis. RESULTS The intervention has been developed, and the physical therapists and mental health nurses in the participating experimental health care centers have received two days of training on the content of the blended PARASOL intervention. The recruitment of health care centers started in June 2016 and inclusion of patients began in March 2017. Follow-up assessments of patients are expected to be completed in March 2019. CONCLUSIONS This study is the first randomized clinical trial to determine the effectiveness (including cost-effectiveness) of a proactive, blended, and integrated mental health and physical therapy care program for patients with moderate medically unexplained physical symptoms. The findings will help to improve the treatment for patients with moderate medically unexplained physical symptoms and prevent chronicity. TRIAL REGISTRATION Netherlands Trial Register NTR6755; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6755 (Archived by WebCite at http://www.webcitation.org/6ywporY7u).
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Affiliation(s)
- Paula Elisabeth van Westrienen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martijn F Pisters
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Suze Aj Toonders
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marloes Gerrits
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cindy Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
- Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Niek J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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15
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Novel primary care treatment package for patients with medically unexplained symptoms: a cohort intervention study. BJGP Open 2017; 1:bjgpopen17X101121. [PMID: 30564684 PMCID: PMC6181103 DOI: 10.3399/bjgpopen17x101121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/28/2017] [Indexed: 12/13/2022] Open
Abstract
Background Existing care models for patients with persistent medically unexplained symptoms (MUS) do not adequately address the needs of these patients. New and innovative intervention strategies are necessary to achieve better health and corresponding economic outcomes. Aim To explore the feasibility of implementing a pragmatic care package that provides primary care treatment for patients with persistent MUS and to evaluate recruitment, retention, and acceptability as well as the potential impact on clinical outcomes and service utilisation. Design & setting Prospective cohort intervention study involving a cluster of seven GP surgeries in Newham, East London, providing a 'One-Stop-Shop' primary care treatment service. Method The care package included: identification, assessment, engagement, psychoeducation, and a choice of group interventions (mindfulness-based stress reduction [MBSR] and body-oriented psychological therapy [BOPT]). Baseline and follow-up data on somatic symptom levels (PHQ-15), health-related quality of life (SF-36, EQ-5D) and service utilisation was analysed. Results In total, 145 patients were referred and assessed for eligibility, and 93 were included in the study. Participants engaged well with different components of the care package and gained significant improvements in somatic symptom levels with corresponding increases of quality-of-life ratings and a reduction in healthcare utilisation (GP contacts and referrals to specialist services) as well as associated healthcare costs. Conclusion The primary care treatment package can be successfully implemented in primary care at a relatively low cost and easily adopted into routine care. The body-oriented approach is well accepted by clinicians and patients. Controlled trials should be conducted to test the efficacy of the treatment package.
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What do guidelines and systematic reviews tell us about the management of medically unexplained symptoms in primary care? BJGP Open 2017; 1:bjgpopen17X101061. [PMID: 30564678 PMCID: PMC6169926 DOI: 10.3399/bjgpopen17x101061] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Functional somatic syndrome (FSS) occurs in as many as 30% of patients in general medical practice, but it is infrequently a topic of formal instruction. Many physicians feel uncomfortable with medically unexplained symptoms and are unfamiliar with how to assess or manage them. Traditional medical approaches can be ineffective and can contribute to iatrogenic or adverse physiologic effects in patients. Physicians treating patients with FSS should not only consider standard medical tests, but they should also try to gain a deeper behavioral understanding of the mind-body connections that underlie the presenting symptoms. Osteopathic physicians, with their emphasis on holistic patient care, are in a key position to treat patients with FSS. This review provides a brief recapitulation of the literature and illustrates key factors in the assessment and management of FSS.
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18
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Helpful strategies for GPs seeing patients with medically unexplained physical symptoms: a focus group study. Br J Gen Pract 2017; 67:e572-e579. [PMID: 28673960 DOI: 10.3399/bjgp17x691697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/23/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Patients with long-lasting and disabling medically unexplained physical symptoms (MUPS) are common in general practice. GPs have previously described the challenges regarding management and treatment of patients with MUPS. AIM To explore GPs' experiences of the strategies perceived as helpful when seeing patients with MUPS. DESIGN AND SETTING Three focus group interviews with a purposive sample of 24 experienced GPs were held in southern Norway. METHOD Discussions were audiotaped and transcribed. Systematic text condensation was used for analysis. RESULTS Several strategies were considered helpful during consultations with patients with MUPS. A comprehensive outline of the patient's medical past and present could serve as the foundation of the dialogue. Reviewing the patient's records and sharing relevant information with them or conducting a thorough clinical examination could offer 'golden moments' of trust and common understanding. A very concrete exchange of symptoms and diagnosis interpretation sometimes created a space for explanations and action, and confrontations could even strengthen the alliance between the GP and the patient. Bypassing conventional answers and transcending tensions by negotiating innovative explanations could help patients resolve symptoms and establish innovative understanding. CONCLUSION GPs use tangible, down-to-earth strategies in consultations with patients with MUPS. Important strategies were: thorough investigation of the patient's symptoms and story; sharing of interpretations; and negotiation of different explanations. Sharing helpful strategies with colleagues in a field in which frustration and dissatisfaction are not uncommon can encourage GPs to develop sustainable responsibility and innovative solutions.
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Chowdhury S, Burton C. Associations of treatment effects between follow-up times and between outcome domains in interventions for somatoform disorders: Review of three Cochrane reviews. J Psychosom Res 2017; 98:10-18. [PMID: 28554364 DOI: 10.1016/j.jpsychores.2017.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 04/19/2017] [Accepted: 04/21/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Interventions for somatoform disorders typically address a range of outcomes. We aimed to examine treatment effects across outcome domains and specifically assess the association, at study level, between short and long term treatment effects and between treatment effects in different outcome domains. METHODS We used data from recent systematic reviews of interventions for somatoform disorders to address three questions: We described outcome domains and measures by compiling forest plots of standardised mean difference. We examined the association of changes in outcome between short and long-term and between different outcome domains by non-parametric correlation. RESULTS We analysed data from 47 studies across four outcome domains: physical symptoms, health-related quality of life, depression and anxiety. Short-term and long-term treatment effects within each outcome domain were broadly similar and were correlated Reported reduction in physical symptoms was correlated with reductions in depression (rho=0.73, p=0.002) and anxiety (0.70, p<0.001) and increase in quality of life (0.54, p=0.03). CONCLUSION Short term changes in outcome measures are correlated with longer term changes; outcome changes are correlated across domains independently of the type of treatment.
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Affiliation(s)
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, UK; Institute of Applied Health Sciences, University of Aberdeen, UK.
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Gustafsson PE, Bozorgmehr K, Hammarström A, Sebastian MS. What role does adolescent neighborhood play for adult health? A cross-classified multilevel analysis of life course models in Northern Sweden. Health Place 2017; 46:137-144. [PMID: 28527329 DOI: 10.1016/j.healthplace.2017.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 03/29/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
Abstract
This study examined whether, and by which life course models, adolescent neighborhood environment relate to health in mid-adulthood. Data came from the Northern Swedish Cohort (n=1001), surveyed at age 16, 21, 30 and 42 years including functional somatic symptoms at age 42, and individual disadvantage neighborhood disadvantage at all four ages. Results from cross-classified multilevel models showed that 12.7% of age 42 health variance was explained by an interaction of age 16 and age 42 neighborhood of residence. Our study thus suggests that health variation by neighborhood in mid-adulthood may partly depend on neighborhood of residence in adolescence.
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Affiliation(s)
- Per E Gustafsson
- Dept of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå SE-901 87, Sweden.
| | - Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg D-69120, Germany.
| | - Anne Hammarström
- Dept of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå SE-901 87, Sweden.
| | - Miguel San Sebastian
- Dept of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå SE-901 87, Sweden.
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Yon K, Habermann S, Rosenthal J, Walters KR, Nettleton S, Warner A, Lamahewa K, Buszewicz M. Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop. BMJ Open 2017; 7:e014720. [PMID: 28450466 PMCID: PMC5719648 DOI: 10.1136/bmjopen-2016-014720] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. DESIGN Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. SETTING Nineteen foundation schools in England, Wales and Northern Ireland PARTICIPANTS: Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. RESULTS The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2-3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor-patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients' symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. CONCLUSIONS There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Joe Rosenthal
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kate R Walters
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Alex Warner
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
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Morton L, Elliott A, Thomas R, Cleland J, Deary V, Burton C. Developmental study of treatment fidelity, safety and acceptability of a Symptoms Clinic intervention delivered by General Practitioners to patients with multiple medically unexplained symptoms. J Psychosom Res 2016; 84:37-43. [PMID: 27095157 DOI: 10.1016/j.jpsychores.2016.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/11/2016] [Accepted: 03/12/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND There is a need for primary care interventions for patients with multiple medically unexplained symptoms (MUS). We examined whether GPs could be taught to deliver one such intervention, the Symptoms Clinic Intervention (SCI), to patients. The intervention includes recognition and validation of patients' symptoms, explanation of symptoms and actions to manage symptoms. METHODS We conducted an uncontrolled observational study in Northeast Scotland. GPs were recruited and received two days of structured training. Patients were identified via a two stage process (database searching followed by postal questionnaire) and received the SCI intervention from a GP in their practice. Treatment fidelity was assessed by applying a coding framework to consultation transcripts. Safety was assessed by examining changes in patient symptoms (PHQ-15) and checking for unexpected events. Acceptability was primarily assessed by patient interview. RESULTS Four GPs delivered the SCI to 23 patients. GPs delivered all core components of the SCI, and used the components flexibly across the consultations and between patients. They spent more time on recognition than either explanation or actions components. 10 out of 17 patients interviewed described feeling validated, receiving useful explanation and learning actions. 9 out of 20 patients (45%) reported an improvement in PHQ-15 of between 3 and 8 points. Patients who reported the most improvement also described receiving all three components of the intervention. CONCLUSIONS GPs can be taught to deliver the SCI with reasonable fidelity, safety and acceptability, although some items were inconsistently delivered: further training would be needed before use.
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Affiliation(s)
- LaKrista Morton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Alison Elliott
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Ruth Thomas
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jennifer Cleland
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Vincent Deary
- Department of Psychology, Northumbria University, Newcastle-upon-Tyne NE1 8ST, UK
| | - Christopher Burton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
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Richardson M, Garner P, Donegan S. Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice. PLoS One 2016; 11:e0151818. [PMID: 26982697 PMCID: PMC4794236 DOI: 10.1371/journal.pone.0151818] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objective Systematic reviews can include cluster-randomised controlled trials (C-RCTs), which require different analysis compared with standard individual-randomised controlled trials. However, it is not known whether review authors follow the methodological and reporting guidance when including these trials. The aim of this study was to assess the methodological and reporting practice of Cochrane reviews that included C-RCTs against criteria developed from existing guidance. Methods Criteria were developed, based on methodological literature and personal experience supervising review production and quality. Criteria were grouped into four themes: identifying, reporting, assessing risk of bias, and analysing C-RCTs. The Cochrane Database of Systematic Reviews was searched (2nd December 2013), and the 50 most recent reviews that included C-RCTs were retrieved. Each review was then assessed using the criteria. Results The 50 reviews we identified were published by 26 Cochrane Review Groups between June 2013 and November 2013. For identifying C-RCTs, only 56% identified that C-RCTs were eligible for inclusion in the review in the eligibility criteria. For reporting C-RCTs, only eight (24%) of the 33 reviews reported the method of cluster adjustment for their included C-RCTs. For assessing risk of bias, only one review assessed all five C-RCT-specific risk-of-bias criteria. For analysing C-RCTs, of the 27 reviews that presented unadjusted data, only nine (33%) provided a warning that confidence intervals may be artificially narrow. Of the 34 reviews that reported data from unadjusted C-RCTs, only 13 (38%) excluded the unadjusted results from the meta-analyses. Conclusions The methodological and reporting practices in Cochrane reviews incorporating C-RCTs could be greatly improved, particularly with regard to analyses. Criteria developed as part of the current study could be used by review authors or editors to identify errors and improve the quality of published systematic reviews incorporating C-RCTs.
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Affiliation(s)
- Marty Richardson
- Centre for Evidence Synthesis in Global Health, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sarah Donegan
- Department of Biostatistics, Block F Waterhouse Building, University of Liverpool, Liverpool, United Kingdom
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Gustafsson PE, Hammarström A, San Sebastian M. Cumulative contextual and individual disadvantages over the life course and adult functional somatic symptoms in Sweden. Eur J Public Health 2014; 25:592-7. [PMID: 25527526 DOI: 10.1093/eurpub/cku213] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Disadvantage, originating in one's residential context or in one's past life course, has been shown to impact on health in adulthood. There is however little research on the accumulated health impact of both neighbourhood and individual conditions over the life course. This study aims to examine whether the accumulation of contextual and individual disadvantages from adolescence to middle-age predicts functional somatic symptoms (FSS) in middle-age, taking baseline health into account. METHODS The sample is the age 16, 21, 30 and 42 surveys of the prospective Northern Swedish Cohort, with analytical sample size n = 910 (85% of the original cohort). FSS at age 16 and 42, and cumulative socioeconomic disadvantage, social adversity and material adversity between 16 and 42 years were operationalized from questionnaires, and cumulative neighbourhood disadvantage between 16 and 42 years from register data. RESULTS Results showed accumulation of disadvantages jointly explained 9-12% of FSS variance. In the total sample, cumulative neighbourhood and socioeconomic disadvantage significantly predicted FSS at age 42 in the total sample. In women, neighbourhood disadvantage but not socioeconomic disadvantage contributed significantly, whereas in men, socioeconomic but not neighbourhood disadvantage contributed significantly. In all analyses, associations were largely explained by the parallel accumulation of social and material adversities, but not by symptoms at baseline. CONCLUSION In conclusion, the accumulation of diverse forms of disadvantages together plays an important role for somatic complaints in adulthood, independently of baseline health.
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Affiliation(s)
- Per E Gustafsson
- 1 Division of Social Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anne Hammarström
- 1 Division of Social Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Miguel San Sebastian
- 2 Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Burton C, Lucassen P, Aamland A, Olde Hartman T. Explaining symptoms after negative tests: towards a rational explanation. J R Soc Med 2014; 108:84-8. [PMID: 25389231 DOI: 10.1177/0141076814559082] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Christopher Burton
- Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Peter Lucassen
- Department of Primary & Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Aase Aamland
- Research Unit for General Practice, Unit Health, Bergen, Norway
| | - Tim Olde Hartman
- Department of Primary & Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
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Van Dessel N, Den Boeft M, van der Wouden JC, Kleinstäuber M, Leone SS, Terluin B, Numans ME, van der Horst HE, van Marwijk H. Non-pharmacological interventions for somatoform disorders and medically-unexplained physical symptoms (MUPS) in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011142] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Aamland A, Malterud K, Werner EL. Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice. BMC FAMILY PRACTICE 2014; 15:107. [PMID: 24885524 PMCID: PMC4041895 DOI: 10.1186/1471-2296-15-107] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/19/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Further research on effective interventions for patients with peristent Medically Unexplained Physical Symptoms (MUPS) in general practice is needed. Prevalence estimates of such patients are conflicting, and other descriptive knowledge is needed for development and evaluation of effective future interventions. In this study, we aimed to estimate the consultation prevalence of patients with persistent MUPS in general practice, including patients' characteristics and symptom pattern, employment status and use of social benefits, and the general practitioners' (GPs) management strategy. METHOD During a four-week period the participating Norwegian GPs (n=84) registered all consultations with patients who met a strict definition of MUPS (>3 months duration and function loss), using a questionnaire with simple tick-off questions. Analyses were performed with descriptive statistics for all variables and split analysis on gender and age. RESULTS The GPs registered 526 patients among their total of 17 688 consultations, giving a consultation prevalence of persistent MUPS of 3%. The mean age of patients was 46 years, and 399 (76%) were women. The most frequent group of symptoms was musculoskeletal problems, followed by asthenia/fatigue. There was no significant gender difference in symptom pattern. Almost half of the patients were currently working (45%), significantly more men. The major GP management strategy was supportive counseling. CONCLUSION A consultation prevalence rate of 3% implies that patients with persistent MUPS are common in general practice. Our study disclosed heterogeneity among the patients such as differences in employment status, which emphasizes the importance of personalized focus rather than unsubstantiated stereotyping of "MUPS patients" as a group.
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Affiliation(s)
- Aase Aamland
- Research Unit for General Practice, Uni Research Health Bergen, Kalfarveien 31, N-5018 Bergen, Norway.
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