Somatizing frequent attenders in primary health care

Prevalence of medically unexplained symptoms in adults who are high users of healthcare services and magnitude of associated costs: a systematic review

INTRODUCTION

Medically unexplained symptoms (MUS) is a common clinical syndrome in primary and secondary healthcare service. Outcomes for patients with persistent MUS include increased disability, poorer quality of life and higher healthcare costs. The aim of this systematic review was to determine the prevalence of MUS in patients who are high users of healthcare or high-cost patients in comparison with routine users and the magnitude of associated costs.

DESIGN

A systematic review of the available literature.

DATA SOURCES AND ELIGIBILITY CRITERIA

The following electronic databases were systematically searched without language restriction from inception to June 2018 and updated on 22 October 2021: MEDLINE, PsycINFO, EMBASE, CINAHL and PROSPERO. Inclusion criteria included studies investigating adults aged ≥18 years, who were high healthcare users or accrued high healthcare costs, in which the prevalence and/or associated costs of MUS was quantified. Two reviewers independently extracted information on study characteristics, exposure and outcomes.

RESULTS

From 5622 identified publications, 25 studies from 9 countries involving 31 650 patients were selected for inclusion. Due to high risk of bias in many studies and heterogeneity between studies, results are described narratively. There were wide variations in prevalence estimates for MUS in high users of healthcare (2.9%-76%), but MUS was more prevalent in high use groups compared with low use groups in all but one of the 12 studies that included a comparator group. Only three studies investigated healthcare costs associated with MUS, and all three reported greater healthcare costs associated with MUS.

CONCLUSION

MUS has been found to be more prevalent in high use healthcare populations than comparator groups, but the magnitude of difference is difficult to estimate due to considerable heterogeneity between studies and potential for bias. Future studies should prioritise a standardised approach to this research area, with agreed definitions of MUS and high healthcare use.

PROSPERO REGISTRATION NUMBER

CRD42018100388.

Psychosocial characteristics and affective symptomatology associated with patient self-initiated consultations in Spanish general practice

We aimed to determine the sociodemographic and psychosocial profile, and the associated subclinical affective symptomatology of users above the 95th percentile in the distribution of patient self-initiated, face-to-face consultations. Additionally, we sought to determine the contribution of subclinical symptomatology in differentiating between the groups above or below this cut-off point. A total of 16,803 users who self-initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over 1 year, were eligible. After discarding those fulfilling exclusion criteria, 129 cases and 109 controls, matched by gender and age, answered the Family APGAR, the Duke-UNC and the Goldberg Anxiety-Depression scale. Both groups did not differ significantly on any of the sociodemographic and psychosocial variables recorded showing a similar percentage distribution. However, users with high self-initiated consultation rates obtained lower scores on the affective social support subscale from the Duke-UNC. Regarding Goldberg scale, the two groups differed significantly on the likelihood of displaying depression and/or anxiety symptoms. Users with a high probability of suffering from depression and/or anxiety were more prevalent among users on the top 5% in the distribution. Altogether, results indicate that these users report a lack of affective social support and have a higher probability of suffering from subclinical depression and/or anxiety. Early detection and treatment of affective symptomatology would temperate this excess in consultation. General practitioners, social workers and psychologists could act as gatekeepers, preventing this overuse of medical services and in turn lowering economical costs, professional burnout and patients' suffering and discontent.

Relationships Between Somatic Symptoms and Panic-Agoraphobic Spectrum Among Frequent Attenders of the General Practice in Italy

Frequent attenders (FAs) of general practitioners (GPs) often complain of nonspecific physical symptoms that are difficult to define according to typical medical syndromes criteria but could be acknowledged as atypical manifestations of mental disorders. We investigated the possible correlation between somatic symptoms and panic-agoraphobic spectrum symptoms in a sample of 75 FAs of GPs in Italy, with particular attention to the impact on functional impairment. Assessments included the Patient Health Questionnaire, Panic-Agoraphobic Spectrum-Self-Report (PAS-SR) lifetime version, Global Assessment of Functioning, and Clinical Global Impression. The PAS-SR total and domains scores were significantly higher among low-functioning FAs, especially anxious somatizations, hypochondriasis, anxious expectation, and reassurance orientation domains, suggesting this undetected symptom may determine the selective attention to the physical symptoms, illness-phobic/hypochondriac elaboration, and GP frequent attendance, often aimed at searching for reassurance, leading to severe impact on overall functioning and often inefficacious treatments.

Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study

BACKGROUND

Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes.

METHODS

A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief.

RESULTS

The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death.

CONCLUSION

In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.

A register-based observational cohort study on persistent frequent users of emergency services in a Finnish emergency clinic

Background

The focus of emergency room (ER) treatment is on acute medical crises, but frequent users of ER services often present with various needs. The objectives of this study were to obtain information on persistent frequent ER service users and to determine reasons for their ER service use. We also sought to determine whether psychiatric diagnoses or ongoing use of psychiatric or substance use disorder treatment services were associated with persistent frequent ER visits.

Methods

A cohort (n = 138) of persistent frequent ER service users with a total of 2585 ER visits during a two-year-period was identified. A content analysis was performed for 10% of these visits. Register data including International Classification of Primary Care 2 (ICPC-2) –codes and diagnoses were analyzed and multivariable models were created in order to determine whether psychiatric diagnoses and psychosocial reasons for ER service use were associated with the number of ER visits after adjusting for covariates.

Results

Patients who were younger, had a psychiatric diagnosis and engaged in ongoing psychiatric and other health services, had more ER visits than those who were not. Having a psychiatric diagnosis was associated with the frequency of ER visits in the multivariable models after adjusting for age, gender and ongoing use of psychiatric or substance use disorder treatment services. Reasons for ER-service use according to ICPC-2 –codes were inadequately documented.

Conclusions

Patients with psychiatric diagnoses are overrepresented in this cohort of persistent frequent ER service users. More efficient treatments paths are needed for patients to have their medical needs met through regular appointments.

The mediating effect of health anxiety in the relationship between functional somatic symptoms and illness behavior in Chinese inpatients with depression

BACKGROUND

Functional somatic symptoms in depression disorder may cause inappropriate illness behavior hindering the treatment process. Health anxiety may play a role in this relationship, but few studies have examined it. The current study aimed to investigate the role of health anxiety in the relationship between functional somatic symptoms and illness behavior in patients with depression.

METHODS

The present study recruited 323 hospitalized patients with depression to complete the Patient Health Questionnaire-15, Whiteley-Index-7, and Scale for the Assessment of Illness Behavior, then constructed a structural equation model to examine whether health anxiety mediated the relationship between functional somatic symptoms and illness behavior.

RESULTS

The results showed significant correlations between any two of the three variables of interest. More importantly, health anxiety played a partially mediating role (42.86%) in the relationship between functional somatic symptoms and illness behavior. Further analysis suggested that elderly patients reached higher health anxiety than younger patients when their functional somatic symptoms were mild.

CONCLUSIONS

These results highlight that health anxiety may mediate the influence of functional somatic symptoms on illness behavior. The implications of assessing and intervening in health anxiety in patients with depression were discussed.

Psychological distress in frequent users of primary health care and emergency departments: a scoping review

INTRODUCTION

Frequent users of healthcare services are a small proportion of patients with disproportionately high healthcare usage. A wide array of factors, including psychological distress, leads to frequent use of healthcare services. There is no existing synthesis of research on frequent use and psychological distress in the general population. This scoping review aimed to compare psychological distress between frequent and non-frequent users and to examine the association between psychological distress and frequent use of healthcare services in primary care and emergency department (ED) services.

METHODS

A scoping review was performed following the five steps defined by Arksey and O'Malley. A search strategy was developed with an information specialist in five databases (Medline, PsycINFO, CINAHL, SCOPUS, and PubMed) for articles in English published between 1963 and October 2018. To be included, studies had to be quantitative, have taken place in a primary care or ED setting, have documented frequent use, and have measured psychological distress in patients. Two team members independently gathered the data for each of the included studies. Results were collated, summarized, and reported using narrative synthesis.

RESULTS

Seven studies met the inclusion criteria. Psychological distress in primary care is generally higher in frequent users, and increased psychological distress scores are associated with frequent use. Both studies set in EDs reported noteworthy findings, stating that frequent users reported higher levels of psychological distress and that psychological distress was associated with frequent use.

CONCLUSION

Psychological distress is prevalent in frequent users and has a significant association with frequent use. As such, psychological distress should be evaluated by physicians to prevent or reduce frequent use and to identify candidates for interventions.

One-session cognitive behavior treatment for long-term frequent attenders in primary care: randomized controlled trial

AIM

The aim of the study was to find out, if a single cognitive behavior treatment (CBT) session for long-term frequent attenders in primary care affects the attendance frequency and mental well-being of the patients.

METHODS

Out of 193 long-term frequent attenders, 56 participated and were randomized to receive either a one-session CBT intervention or usual care. The groups were compared to each other regarding change in general practitioner visits and change in depressive symptoms, sense of coherence, somatoform symptoms and hypochondriacal anxiety at six months' follow-up.

RESULTS

The attendance frequency decreased in both groups, but there was no difference between the groups. Changes in mental functioning did not differ between the groups. When patients with no mental health disorder were analyzed separately, the decrease in GP visits was significantly higher in the intervention group than in the control group (p = .004).

CONCLUSION

A single session of CBT is not useful in reducing GP visits or improving mental well-being of long-term frequent attenders. Frequent attenders without a psychiatric disorder may benefit from this kind of intervention.

The association of psychological factors and healthcare use with the discrepancy between subjective and objective respiratory-health complaints in the general population

BACKGROUND

We examined the prevalence of self-perceived respiratory symptoms (SRS) in the absence of any objective findings of respiratory pathology, and the association of such prevalence with psychological factors and healthcare use in the general population.

METHODS

The study was conducted among a nationally representative sample of Finnish adults (BRIF8901). Respiratory functioning was measured by a spirometry test. Structured questionnaires were used to measure SRS, physician visits and psychological factors of alexithymia, sense of coherence, illness worry and common mental disorders. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder, determined in a diagnostic interview, were excluded, giving a sample comprising 4544 participants.

RESULTS

Twenty-six per cent of the general population and 36% of those with no diagnosed severe psychiatric disorder or respiratory disease experienced SRS despite a normal spirometry result. Psychological factors were associated with SRS (0.0001 < p < 0.032), and on the number of physician visit explaining 42.7% of the difference in visits between individuals with and without SRS, respectively. Illness worry was associated most strongly with SRS [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.19-1.41, p < 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32-1.38, p < 0.00001), even after several adjustments.

CONCLUSIONS

Respiratory symptoms without objective findings are common in the general population. The study results underline the role of psychological factors in the reporting of respiratory symptoms and the associated medical burden, thereby indicating the functional nature of the symptomatology.

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms

PURPOSE

To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors.

METHOD

A sample of N = 224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms).

RESULTS

Two distinct clusters were identified by cluster analysis: a low (n = 106) and a high (n = 118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior.

CONCLUSION

Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.

Health care utilization in outpatients with somatoform disorders: Descriptives, interdiagnostic differences, and potential mediating factors

OBJECTIVE

Somatoform disorders are characterized by increased health care utilization producing high health costs. The aim of this study was to assess facets of and interdiagnostic differences in health care use in somatoform disorders and to examine health anxiety, symptom-related disability, depression, and phobic anxiety as potential mediating factors of the relationship between somatization and health care use.

METHOD

An outpatient sample of N=254 patients with somatoform disorders was investigated by analyzing different facets of their health care use over the last 12months. Multiple mediation analyses were applied.

RESULTS

Participants reported a mean of 28.02 doctor visits over the last year. Patients fulfilling criteria of DSM-IV somatization disorder had a significantly higher number of doctor visits than patients with undifferentiated somatoform, and somatoform pain disorder, all p≤.006. In most health care use variables, patients with comorbid mental disorders did not differ from patients without comorbidities. The mediation model on the effect of all mediator variables on the relationship between somatization and health care use reached significance (b=0.32, 95% CI: 0.0576, 0.6435). Surprisingly, specific mediator effects were found for health anxiety (b=0.06, 95% CI: 0.0004, 0.1505) and disability (b=0.18, 95% CI: 0.0389, 0.3530), but not for depression and phobic anxiety.

CONCLUSIONS

Health anxiety and symptom-related disability should be further considered when investigating potential etiological factors of increased health care use.

Consultations for injuries by frequent attenders are found to be medically appropriate from general practitioners' perspective

Aims: A study was carried out to determine whether frequent attenders' (FAs') consultations for injuries are medically appropriate or not. Methods: A retrospective review was undertaken of medical records in a primary healthcare centre. All injury consultations by frequent attenders and controls during a period of one year were evaluated by two general practitioners (GPs). Outcome variables were: number of injuries, chronic diseases, type of injuries, and their treatments. The GPs made a comprehensive picture of each case and evaluated whether it was medically appropriate to consult a doctor or not. Results: Injuries were 7.2 times more common among frequent attenders compared with the controls. Frequent attenders had significantly more chronic diseases. Mean number of injury consultations was the same for frequent attenders with or without chronic disease. There was no difference concerning medically appropriate consultations between frequent attenders and controls. Conclusions: Consultations for injuries with frequent attenders were considered medically appropriate. Chronic diseases did not explain the higher injury incidence among frequent attenders. These findings are interesting and contradict the opinion that increased healthcare consumption by FAs is a waste of resources. Our findings may suggest that FAs are more vulnerable individuals.

Family physician-patient relationship and frequent attendance of primary and specialist health care: Results from a German population-based cohort study

OBJECTIVE

To investigate the association between the quality of the family physician-patient relationship and frequent attendance of primary and specialist health care.

METHODS

Cross-sectional survey of a representative German population sample (N=2.266). Family physician-patient relationship was assessed with the Patient Doctor Relationship Questionnaire (PDRQ-9). Determinants of frequent attendance were analyzed using logistic regression.

RESULTS

Frequent attendance of family physicians was associated with lower income (OR 1.43, 95% CI 1.02-2.00), not being in paid work (OR 1.58, CI 1.08-2.30), psychological distress (OR 1.14, CI 1.07-1.22), somatic symptoms (OR 1.07, CI 1.04-1.11), and physical comorbidity (OR 1.54, CI 1.36-1.74) in the multivariate analysis. Frequent attendance of specialists was related to psychological distress (OR 1.12, CI 1.04-1.20), somatic symptoms (OR 1.08, CI 1.04-1.11), and physical comorbidity (OR 1.69, CI 1.48-1.93) in the multivariate analysis. Quality of the relationship was associated with frequent attendance only in the univariate analyses. A stronger relationship with the family physician was not associated with reduced contact with specialists.

CONCLUSIONS

The quality of the family physician-patient relationship is not independently associated with frequent attendance.

PRACTICE IMPLICATIONS

Family physicians should be aware that need factors, i.e. symptom burden and physical comorbidities, are main drivers of frequent attendance.

Adherence to health regimens among frequent attenders of Finnish healthcare

Objectives

The aim of the study was to describe adherence to health regimens and the factors associated with it among adult frequent attenders (FAs).

Design

This was a cross-sectional study. The study sample consisted of 462 healthcare FAs in 7 municipal health centres in northern Finland. An FA is a person who has had 8 or more outpatient visits to a GP (in a health centre) or 4 or more outpatient visits to a university hospital during 1 year. The main outcome was self-reported adherence to health regimens.

Results

Of the FAs, 82% adhered well to their health regimens. Carrying out self-care, medical care and feeling responsible for self-care were the most significant predictors to good adherence in all models. No significant differences in adherence were found in male and female subjects, age groups or educational levels. Support from healthcare providers and support from relatives were not significant predictors of good adherence.

Conclusion

FAs in Finland adhere well to health regimens and exceptionally well to medication. Variables that predict the best adherence of FAs to health regimens are carrying out self-care, receiving medical care and feeling responsible for self-care.

Analysing predictors for future high-cost patients using German SHI data to identify starting points for prevention

BACKGROUND

Demographic change influences not only the terms of health care, but also its financing. Hence, prevention is becoming a more important key to facing upcoming challenges. Aim of this study was to identify predictors for future high-cost patients and derive implications for potential starting points for prevention.

METHODS

Claims data from a German statutory health insurance agency were used. High-cost patients were defined as the 10% most expensive persons to insure in 2011. The predictors stemmed from the previous year. Logistic regression with stepwise forward selection for 10 sex- and age-specific subgroups was performed. Model fit was assessed by Nagelkerke's R-squared value.

RESULTS

Model fit values indicated well-suited models that yielded better results among younger age-groups. Identified predictors can be summarized as different sets of variables that mostly pertain to diseases. Some are rather broad and include different disorders, like the set of mental/behavioural disorders including depression and schizophrenia; other sets of variables are more homogenous, such as metabolic diseases, with diabetes mellitus (DM) being the dominant member of every subgroup.

CONCLUSION

Because diabetes was a significant predictor for future high-cost patients in all analysed subgroups, it should be considered as a potential starting point for prevention. The disease is specific enough to allow for the implementation of effective prevention strategies, and it is possible to intervene, even in patients already affected by DM. Furthermore, the monetary savings potential is probably high because the long-term complications of DM are expensive to treat and affect a large part of the population.

The ethnic gap in mental health: A population-based study of Russian, Somali and Kurdish origin migrants in Finland

Aims: Research demonstrates that migrants are more vulnerable to poor mental health than general populations, but population-based studies with distinct migrant groups are scarce. We aim to (1) assess the prevalence of mental health symptoms in Russian, Somali and Kurdish origin migrants in Finland; (2) compare the prevalence of mental health symptoms in these migrant groups to the Finnish population; (3) determine which socio-demographic factors are associated with mental health symptoms. Methods: We used data from the Finnish Migrant Health and Wellbeing Study and Health 2011 Survey. Depressive and anxiety symptoms were measured using the Hopkins Symptom Checklist-25 (HSCL-25), and 1.75 was used as cut-off for clinically significant symptoms. Somatization was measured using the Symptom Checklist-90 (SCL-90) somatization scale. The age-adjusted prevalence of mental health symptoms in the studied groups was calculated by gender using predicted margins. Logistic regression analysis was used to determine which socio-demographic factors are associated with mental health symptoms in the studied population groups. Results: The prevalence of depressive and anxiety symptoms was higher in Russian women (24%) and Kurdish men (23%) and women (49%) than in the Finnish population (9–10%). These differences were statistically significant ( p <.001). Socioeconomic disadvantage (e.g. unemployment and poor economic situation) and migration-related factors (e.g. poor language proficiency and short time since migration) significantly increased the odds for depressive and anxiety symptoms. Conclusions: Mental health symptoms are highly prevalent particularly in Kurdish migrants in Finland. Holistic interventions and co-operation between integration and mental health services are acutely needed.

Changing circumstances drive changing attendance: A longitudinal cohort study of time varying predictors of frequent attendance in primary health care

OBJECTIVE

To investigate risk factors for frequent attendance in primary care over time, contrasting models based on baseline and time-varying characteristics.

METHODS

Analysis of data from the Personality and Total Health (PATH) Through Life Project: a representative community cohort study from the Canberra region of Australia. A balanced sample of 1734 respondents, initially aged in their early 40s, were assessed on three occasions over 8 years. The survey assessed respondents' experience of chronic physical conditions, self-reported health, depression symptoms, personality, life events, socio-demographic characteristics and self-reported medication use. Survey data were linked to respondent's own administrative health service use data, and used to generate an objective measure of general practitioner (GP) consultations over a 12-month period. For each gender, respondents in the (approximate) highest decile of GP consultations at each time point were defined as frequent attenders (FAs).

RESULTS

Analysis showed chronic health conditions, self- reported health, mental health and medication use measured at baseline was associated with FA status, with some gender differences evident. However taking into account of changing circumstances improved the model fit and the prediction over FA status over time.

CONCLUSIONS

The study showed that there is considerable variability in frequent attender status over the study period. While baseline characteristics can predict current and future frequent attender status, it is clear that frequent attender in primary care does reflect changing circumstances over time.

Longitudinal cohort study describing persistent frequent attenders in Australian primary healthcare

OBJECTIVES

To describe patterns of frequent attendance in Australian primary care, and identify the prospective risk factors for persistent frequent attendance.

DESIGN, SETTING AND PARTICIPANTS

This study draws on data from the Personality and Total Health (PATH) Through Life Project, a representative community cohort study of residents from the Canberra region of Australia. Participants were assessed on 3 occasions over 8 years. The survey assessed respondents' experience of chronic physical conditions, self-reported health, symptoms of common mental disorders, personality, life events, sociodemographic characteristics and self-reported medication use. A balanced sample was used in analysis, comprising 1734 respondents with 3 waves of data. The survey data for each respondent were individually linked to their administrative health service use data which were used to generate an objective measure of general practitioner (GP) consultations in the 12 months surrounding their interview date.

MAIN OUTCOME MEASURES

Respondents in the (approximate) highest decile of attenders on number of GP consultations over a 12-month period at each time point were defined as frequent attenders (FAs).

RESULTS

Baseline FAs (8.4%) were responsible for 33.4% of baseline consultations, while persistent FAs (3.6%) for 15.5% of all consultations over the 3 occasions. While there was considerable movement between FA status over time, consistency was greater than expected by chance alone. While there were many factors that differentiated non-FAs from FAs in general, persistent frequent attendance was specifically associated with gender, baseline reports of depression, self-reported physical conditions and disability, and medication use.

CONCLUSIONS

The degree of persistence in GP consultations was limited. The findings of this study contribute to our understanding of the risk factors that predict subsequent persistent frequent attendance in primary care. However, further detailed investigation of longitudinal patterns of frequent attendance and consideration of time-varying determinants of frequent attendance is required.

The association between mental health symptoms and mobility limitation among Russian, Somali and Kurdish migrants: a population based study

Background

Research has demonstrated a bidirectional relationship between physical function and depression, but studies on their association in migrant populations are scarce. We examined the association between mental health symptoms and mobility limitation in Russian, Somali and Kurdish migrants in Finland.

Methods

We used data from the Finnish Migrant Health and Wellbeing Study (Maamu). The participants comprised 1357 persons of Russian, Somali or Kurdish origin aged 18–64 years. Mobility limitation included self-reported difficulties in walking 500 m or stair climbing. Depressive and anxiety symptoms were measured using the Hopkins Symptom Checklist-25 (HSCL-25) and symptoms of somatization using the somatization subscale of the Symptom Checklist-90 Revised (SCL-90-R). A comparison group of the general Finnish population was selected from the Health 2011 study.

Results

Anxiety symptoms were positively associated with mobility limitation in women (Russians odds ratio [OR] 2.98; 95% confidence interval [CI] 1.28–6.94, Somalis OR 6.41; 95% CI 2.02–20.29 and Kurds OR 2.67; 95% CI 1.41–5.04), after adjustment for socio-demographic factors, obesity and chronic diseases. Also somatization increased the odds for mobility limitation in women (Russians OR 4.29; 95% CI 1.76–10.44, Somalis OR 18.83; 95% CI 6.15–57.61 and Kurds OR 3.53; 95% CI 1.91–6.52). Depressive symptoms were associated with mobility limitation in Russian and Kurdish women (Russians OR 3.03; 95% CI 1.27–7.19 and Kurds OR 2.64; 95% CI 1.39–4.99). Anxiety symptoms and somatization were associated with mobility limitation in Kurdish men when adjusted for socio-demographic factors, but not after adjusting for obesity and chronic diseases. Finnish women had similar associations as the migrant women, but Finnish men and Kurdish men showed varying associations.

Conclusions

Mental health symptoms are significantly associated with mobility limitation both in the studied migrant populations and in the general Finnish population. The joint nature of mental health symptoms and mobility limitation should be recognized by health professionals, also when working with migrants. This association should be addressed when developing health services and health promotion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1629-1) contains supplementary material, which is available to authorized users.

Disagreement in doctor's and patient's rating about medically unexplained symptoms and health care use

BACKGROUND

Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care. It remains unclear to what extent patients and their general practitioners (GPs) agree upon the etiology of physical symptoms as well as on the number of visits to the GP.

PURPOSE

The purpose of this study is to determine patient-physician agreement on reported symptoms.

METHOD

A sample of 103 persons provided information on MUS and health care utilization (HCU) during the previous 12 months. The persons' GPs (n = 103) were asked for the same information. By determining patient-physician agreement on reported symptoms, the sample was subdivided into a concordance group (high agreement: Pt = GP) and two discordance groups (substantial disagreement: Pt > GP, Pt < GP).

RESULTS

Patients and their GPs showed substantial disagreement concerning physical symptom reports for the prior 12 months. On means, patients named 3.26 (SD = 3.23; range 0-21) physical complaints of which 71.6% were considered to be medically unexplained (MUS), whereas GPs only determined 1.77 (SD = 1.94; range 0-11) symptoms of which 57.5% were MUS. Substantial patient-physician agreement regarding the number of reported MUS was detected in 29.1% of the cases (Pt = GP). Patients of all groups underestimated their HCU.

CONCLUSION

Since patients' and GPs' reports differ substantially concerning the etiology of symptoms and concerning HCU, both sources of data gathering should be treated carefully in primary care research.

[Would the Screening of Common Mental Disorders in Primary-Care Health Services Hyper-Frequent Patients Be Useful?]

Hyper-frequentation in health services is a problem for patients, their families and the institutions. This study is aimed at determining the frequency and characteristics of common mental disorders in hyper-frequent patients showing vague symptoms and signs at a primary healthcare service during the year 2007 in the city of Cali (Colombia).

METHODOLOGY

Cross sectional. The most frequent mental disorders in hyper-frequent patients were detected through a telephone interview which included several modules of the PRIME MD instrument.

RESULTS

In general, healthcare service hyper-frequenters are working women, 38,7-year old in average. Basically, the consultation is due to cephalalgia but they also exhibit a high prevalence of common mental disorders (somatization, depression and anxiety) not easily diagnosed by physicians in primary care. Expenses for additional health activities generated by these patients are attributed basically to medical consultation and required procedures.

CONCLUSION

Considering hyper-frequenters in health care services as a risk group in terms of common mental disorders involves screening as an efficient strategy to prevent abuse in service use and to improve satisfaction with the attention received.

Predictability of persistent frequent attendance in primary care: a temporal and geographical validation study

BACKGROUND

Frequent attenders are patients who visit their general practitioner exceptionally frequently. Frequent attendance is usually transitory, but some frequent attenders become persistent. Clinically, prediction of persistent frequent attendance is useful to target treatment at underlying diseases or problems. Scientifically it is useful for the selection of high-risk populations for trials. We previously developed a model to predict which frequent attenders become persistent.

AIM

To validate an existing prediction model for persistent frequent attendance that uses information solely from General Practitioners' electronic medical records.

METHODS

We applied the existing model (N = 3,045, 2003-2005) to a later time frame (2009-2011) in the original derivation network (N = 4,032, temporal validation) and to patients of another network (SMILE; 2007-2009, N = 5,462, temporal and geographical validation). Model improvement was studied by adding three new predictors (presence of medically unexplained problems, prescriptions of psychoactive drugs and antibiotics). Finally, we derived a model on the three data sets combined (N = 12,539). We expressed discrimination using histograms of the predicted values and the concordance-statistic (c-statistic) and calibration using the calibration slope (1 = ideal) and Hosmer-Lemeshow tests.

RESULTS

The existing model (c-statistic 0.67) discriminated moderately with predicted values between 7.5 and 50 percent and c-statistics of 0.62 and 0.63, for validation in the original network and SMILE network, respectively. Calibration (0.99 originally) was better in SMILE than in the original network (slopes 0.84 and 0.65, respectively). Adding information on the three new predictors did not importantly improve the model (c-statistics 0.64 and 0.63, respectively). Performance of the model based on the combined data was similar (c-statistic 0.65).

CONCLUSION

This external validation study showed that persistent frequent attenders can be prospectively identified moderately well using data solely from patients' electronic medical records.

Somatisation disorder and its associated factors in multiethnic primary care clinic attenders

BACKGROUND

Somatisation disorder (SD) has been reported as common in all ethnic groups, but the estimates of its prevalence have varied and the evidence for its associated factors has been inconsistent.

PURPOSE

This study seeks to determine the prevalence of SD and its associated factors in multiethnic primary care clinic attenders.

METHODS

This cross-sectional study was on clinic attenders aged 18 years and above at three urban primary care clinics in Malaysia. The operational definition of SD was based on ICD-10 criteria for SD for research, frequent attendance, and excluded moderate to severe anxiety and depression. The instruments used were the ICD-10 symptom list, the Hospital Anxiety and Depression Scale, a semi-structured questionnaire, and SF-36.

RESULTS

We recruited 1,763 patients (response rate 63.8%). The mean age of respondents was 44.7 ± 15.8 years, 807 (45.8%) were male; there were 35.3% Malay, 30.1% Chinese and 34.6% Indian. SD prevalence was 3.7%; the prevalence in Malay was 5.8%, Indian 3.0% and Chinese 2.1%. Significant associations were found between SD prevalence and ethnicity, family history of alcoholism, blue-collar workers and the physical component summary (PCS) score of SF-36. Multivariate analysis showed that SD predictors were Malay ethnicity (OR 2.7, 95% CI 1.6, 4.6), blue-collar worker (OR 2.0, 95% CI 1.2, 3.5) and impaired PCS score of SF-36 (OR 0.92, 95% CI 0.90, 0.95).

CONCLUSION

The prevalence of SD was relatively uncommon with the stringent operational criteria used. SD preponderance in blue-collar workers may be attributable to secondary gain from getting sickness certificates and being paid for time off work.

Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

BACKGROUND

The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context.

METHODS/DESIGN

A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6-22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.

DISCUSSION

The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.

Somatization and health anxiety as predictors of health care use

OBJECTIVE

To assess whether the number of somatic symptoms and health anxiety are independent predictors of future health care use after adjusting for confounders.

METHODS

In a random sample of the adult UK population, questionnaires assessed the number of somatic symptoms (Somatic Symptom Inventory), health anxiety (Whiteley Index), anxiety/depression (Hospital Anxiety and Depression Scale), the number of physical illnesses and demographic variables. The number of consultations in primary care was obtained from medical records for 1 year before and after questionnaire assessment, and negative binomial regression analyses identified predictors of consultation rate.

RESULTS

The sample included 961 participants (58.0% response) with complete medical record data for 609 participants. After adjustment for consultation rate in the prior year, the predictors of subsequent consultation rate in primary care were the number of physical illnesses, off work through illness, Whiteley Index (incidence rate ratio [IRR] = 1.22, 95% confidence interval [CI] = 1.09-1.35), and the Whiteley Index-by-Somatic Symptom Inventory interaction term. Reported physical abuse predicted an increased consultation rate in women (IRR = 2.30, 95% CI = 1.08-4.90) but a reduced rate in men (IRR = 0.43, 95% CI = 0.22-0.84), interaction p = 0.003.

CONCLUSIONS

These data raise the possibility that both increased health anxiety and number of bothersome somatic symptoms predict frequent medical consultations. A more complex model of predicting future health care use is needed than has been studied previously, which is potentially relevant to the current discussions of the proposed DSM-V and International Classification of Diseases, 11th Revision, diagnostic guidelines regarding complex somatic symptom disorders.

Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices

BACKGROUND

In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor-patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment.

METHOD

We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate.

RESULTS

Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79-5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23-33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05-3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67-33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented.

CONCLUSIONS

Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

A general population study of the Chinese Whiteley-7 index in Hong Kong

OBJECTIVE

To examine the psychometric properties of the Chinese seven-item Whiteley Index (WI-7) in the general population of Hong Kong.

METHODS

A random community-based telephone survey of 3014 respondents aged 15-65 was conducted using a fully structured questionnaire that included the WI-7, 15-item Patient Health Questionnaire (PHQ-15), Sheehan Disability Scale (SDS), and items about the frequency of health service use, perceived helpfulness of doctors, level of satisfaction with doctors, and sociodemographic variables. A sub-sample of 199 respondents was re-interviewed to assess test-retest reliability.

RESULTS

The WI-7 exhibited satisfactory internal consistency (Cronbach's α=0.73) and stable one-month test-retest reliability. The most commonly endorsed item was "worrying a lot about one's health" (55.7%), followed by "worrying about getting the disease oneself if it is brought to his/her attention" (48.7%) and "bothered by many different pains and aches" (33.9%). Age, gender, and monthly family income significantly predicted WI-7 score. Confirmatory factor analysis revealed that a 2-factor structure was superior to a 1-factor structure in fitting the data. WI-7 total score was positively associated with PHQ-15 somatic distress, SDS impairment, number of healthcare visits, lower levels of perceived helpfulness of doctors and of satisfaction with doctors.

CONCLUSION

The Chinese WI-7 exhibits satisfactory reliability and internal validity in a general population. It is a promising tool for the empirical examination of health anxiety which is a common experience with a mostly typical epidemiological profile among Chinese people in Hong Kong.

Treatment of eating disorders in primary care: a systematic review

This review evaluated psychological treatments for Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder conducted in primary care. Five studies met inclusion criteria. Guided self-help cognitive-behavioral therapy via a self-help book may be a beneficial, first-line treatment for reducing binging and purging symptoms. Outcomes combining self-help with antidepressants remain unclear, although antidepressants alone may provide reduction of symptoms. High attrition and non-compliance rates among studies reviewed indicate the importance of a strong therapeutic alliance between provider and patient. Further research in primary care is needed to develop a standard of care for patients with eating disorders.

Medically unexplained presentations and quality of life: a study of a predominantly South Asian primary care population in England

Primary care subjects from a predominantly South Asian inner-city setting in Manchester, UK, were studied. We aimed to determine whether medically unexplained symptoms (MUS) are associated with worse health-related quality of life than medically explained symptoms (MES), after controlling for differences in sociodemographic variables, number of somatic symptoms, and levels of anxiety and depression. One hundred nineteen subjects attending general practice completed questionnaires to assess somatic symptoms, anxiety, depression, and quality of life. Doctors' records were later studied to ascertain whether the presentation was medically explained. Thirty-nine subjects (33%) had medically unexplained presentations. Compared to patients with MES, those with MUS had significantly more somatic symptoms (6.9 vs. 4.3, P<.001), higher levels of anxiety (Hospital anxiety and depression scale -- anxiety score) (9.8 vs. 6.7, P=.004), depression (Hospital anxiety and depression scale -- depression) (6.8 vs. 4.5, P=.005), and poorer health-related quality of life (EuroQol standardized score 54.6 vs. 73.3, P=.001). On multiple regression analysis, anxiety, depression, and somatic symptom scores independently (P<.01) predicted quality of life, after controlling for demographic factors. Whether the presentation was medically unexplained or not did not contribute to the regression model (P=.85). Our findings suggest that it is the number of somatic symptoms and the associated anxiety/depression that account for greater impairment in people's health-related quality of life, and not whether they have a medical explanation for their symptoms.

Alexithymia and somatization in general population

OBJECTIVE

Even though the association between alexithymia and somatization seems plausible according to several studies with selected populations, it has not been verified in carefully controlled and nationally representative population studies. We conducted such a study to find out whether alexithymia is associated with somatization at population level.

METHODS

This study was a part of the Finnish Health 2000 Study. The nationally representative sample comprised 5129 subjects aged 30 to 97 years. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and somatic symptom reporting with the 12-item somatization scale derived from the Hopkins Symptom Checklist. Sociodemographic and health-related variables, including depressive and anxiety disorders, and physician verified somatic diagnoses, were treated as confounders in multivariate analyses.

RESULTS

Alexithymia was associated with somatization independently of somatic diseases, depression and anxiety and confounding sociodemographic variables. The TAS-20 factor scale "Difficulties Identifying Feelings" was the strongest common denominator between alexithymia and somatization.

CONCLUSIONS

This was the first time the independent association between alexithymia and somatization was established in a large, nationally representative nonclinical sample of both young and old adults with and without mental disorders and somatic diseases.

Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population

OBJECTIVE

Somatization is related to elevated health care utilization (HCU) and high health care costs. However, it is unclear whether HCU in somatizers and nonsomatizers in the general population is determined by existing symptoms or by lower thresholds for doctor visits.

METHOD

A representative sample of the German general population (N=2510) was screened for psychopathology and HCU in the prior 12 months. The sample was subdivided into somatizers (n=712) and controls (n=1796), using the Patient Health Questionnaire (PHQ-15). A general tendency to visit doctors even for minor reasons was assessed. Demographic and psychopathological variables were additionally entered into regression analyses to predict HCU for the whole investigated sample and the two subsamples.

RESULTS

Higher somatization, unemployment or retirement, a lower decision threshold for doctor visits and higher posttraumatic symptomatology were consistent and unique positive predictors of HCU in the prior 12 months.

CONCLUSION

Not only symptoms per se but also a lower decision threshold for doctor visits contribute to increased HCU. Psychopathological and demographic variables can further predict HCU in somatizing persons and controls. Although somatization and reduced thresholds for doctor visits are associated, they have to be distinguished from each other and contribute independently to increased costs.

Follow-up study on health care use of patients with somatoform, anxiety and depressive disorders in primary care

Background

Better management of affective and somatoform disorders may reduce consultation rates in primary care. Somatoform disorders are highly prevalent in primary care and co-morbidity with affective disorders is substantial, but it is as yet unclear which portion of the health care use may be ascribed to each disorder. Our objective was to investigate the use of primary care for undifferentiated somatoform disorders, other somatoform disorders, anxiety and depressive disorders prospectively.

Methods

In eight family practices 1046 consulting patients (25–79 yrs) were screened and a stratified sample of 473 was interviewed. Somatoform disorders, anxiety and depressive disorders were diagnosed (DSM IV) using SCAN 2.1. The electronic records of 400 participants regarding somatic diseases, medication and healthcare use were available through their family physicians (FP).

Results

In the follow-up year patients with psychiatric disorders had more face-to-face contacts with the FP than patients who had no psychiatric disorder: average 7–10 versus 5. The impact on the use of primary care by patients with somatoform disorders was comparable to patients with depressive or anxiety disorders. Undifferentiated somatoform disorders had an independent impact on the use of primary care after adjustment for anxiety and depressive disorders, resulting in 30% more consultations (IRR 1.3 (95% CI: 1.1–1.7)). Anxiety disorders had no independent effect.

Conclusion

Health care planning should focus on the recognition and treatment of somatoform as well as affective disorders.

Preschool children as frequent attenders in primary health care in Croatia: retrospective study

AIM

To define predictive factors for frequent attenders among preschool children in primary health care and investigate the association between socioeconomic factors and medical factors, as well as the reasons for child's appointment in the physician's office.

METHODS

This retrospective study was conducted in 7 primary health care offices (6 family physician practices and 1 pediatric practice) in Zagreb, Croatia. The study included 964 preschool children from 1-6 years who visited these practices during 2005. Children in the highest quartile of consultation frequency (n=255) were defined as frequent attenders, while the children in the lowest quartile of consultation frequency (n=302) represented the control group (non-frequent attenders). We collected data on consultation rate, socioeconomic factors, health care providers, prescriptions and referrals, symptoms, and diagnoses. Association of the parameters and the frequency of consultations was investigated by logistic regression analysis.

RESULTS

Frequent attenders sought for consultations 10 times per year (median, range 4-26), and they had the following characteristics: had 2-3 years, attended day care center, were treated by a pediatrician, and received more prescriptions and referrals. Their major complaints were: cough, nasal discharge, rash, fever, difficult breathing, earache, digestive problems, throat soreness, and injuries. Logistic regression analysis showed significant association between frequent attendance and age of 2-3, the symptom of nasal discharge, and diagnoses of infectious and parasitic diseases, middle ear diseases, respiratory system diseases, and skin and subcutaneous tissue diseases.

CONCLUSION

Socioeconomic characteristics, symptoms, and diagnoses were important predictors for defining preschool frequent attenders in primary health care.

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.

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.

Theoretical and methodological issues in conducting research related to health care utilization among individuals with HIV infection

Although empirical information on resource use during HIV infection is vital to improving quality of care, the issues involved in conducting research on resource use have received little attention in the medical literature. The purpose of this paper is to review the theoretical and methodological issues of conducting research on health care utilization patterns among persons with HIV/AIDS. Conceptual definitions of utilization are compared and contrasted. Three theoretical frameworks, the Andersen Behavioral Model, the Health Belief Model, and the Biopsychosocial Model are described to illustrate their applicability in future research studies. Research designs, measurement considerations, sampling approaches, and existing data sources on utilization are reviewed. Recommendations for health care utilization research are summarized and highlight the importance of designing studies and generating data for investigation of the factors facilitating patients' use of an optimal array of services including prevention, long-term, and rehabilitation care.

Somatization, somatosensory amplification, attribution styles and illness behaviour: a review

Somatic symptoms have been conceptualized in many different ways in literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. This review focuses on existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization. Evidence suggests that somatosensory amplification is neither sensitive nor specific to somatizing states, and that other factors like anxiety, depression, neuroticism, alexithymia may also have an influence. Attribution research supports the existence of multiple causal attributions, which are related to the numbers of somatic symptoms. While somatizing patients have more organic attributions, depressed patients have more psychological attributions. A global somatic attribution style is associated with the number of obscure somatic symptoms, while a psychological attribution style is associated with both--psychological and somatic-- symptoms of depression and anxiety. There are conflicting findings with respect to the role of normalizing attributions in reducing physician recognition of anxiety and depression. Specific symptom attributions appear to explain physician recognition of psychological distress, but global attribution styles do not appear to explain any further variance in physician recognition beyond that explained by specific causal attributions. Illness behaviour has been studied in two distinct ways in literature. Research focusing on attendance rates as a form of illness behaviour suggests that somatization is associated with high levels of health care utilization. There is also some evidence that health care utilization, amplification and attributions styles may be interrelated among somatizing patients. More structured ways to assess illness behaviour have found high levels of abnormal illness behaviour in this population. Overall, research appears to suggest a complex (and as yet unclear) relationship between somatic symptoms and underlying cognitions/illness behaviours. While it is clear that somatization is closely related to a number of perceptual and cognitive-behavioural factors, the precise nature of these relationships are yet to be elucidated.

Clinical comorbidity was specific to disease pathology, psychologic distress, and somatic symptom amplification

OBJECTIVE

To test the hypothesis that disease pathology, psychologic distress, and somatic symptom amplification separately influence health care use by investigating the patterns of comorbidity in patients with diabetes, anxiety, and upper respiratory tract infection (URTI), respectively.

METHODS

Adult diabetes (n=4,365), anxiety (13,421), and URTI (9,854) cases, and 15,000 randomly selected controls were identified from a 1-year national survey of general practice consultations. Comorbidity was based on a standard clinical morbidity classification used by general practitioners in actual consultations.

RESULTS

In case-control analyses of 122 morbidities, the number of significant comorbid associations (P<.01) for diabetes was 30, anxiety was 72, and URTI was 49. These associations showed significant heterogeneity in the odds ratios estimated using Cochran's Q and I2 statistic, both between case groups and within each case group. Diabetes associations were stronger with peripheral vascular disease (odds ratio 2.7), candidiasis (2.5), cataract (2.4), obesity (2.2), and hypertension (1.7); anxiety with depressive disorder (4.1), affective psychosis (4.0), adjustment reaction (3.2), functional gastrointestinal disorders (2.5) and general symptoms (2.5); and URTI with nonspecific blood findings (5.5), bronchitis (5.2), and injury (3.5).

CONCLUSION

Our study shows patterns of clinical comorbidity specific to the case conditions that supports the hypothesis that different mechanisms (disease pathology, psychologic distress, and somatic symptom amplification) operate to influence consultation behavior and comorbidity.

The influence of complaint symptoms on health care utilisation, medicine use, and sickness absence. A comparison between retrospective and prospective utilisation

OBJECTIVE

The main aim was to examine the impact of reported individual symptoms on health care utilisation (HCU) in a primary health care practice population and to evaluate the impact of these symptoms on utilisation over time.

METHOD

The study was performed in 1055 out of 1442 consecutive adult patients visiting a Swedish health care centre. Logistic regression analyses were applied to assess the relationships between symptoms and HCU outcomes.

RESULTS

Each of the 30 symptoms was related to consultations with GPs and a provider of alternative medicine, use of medications and herbals, and sickness absence. Depression and tension groups were the strongest predictors of utilisation. Multisymptomatics had higher OR for most of the outcome variables than those with no symptoms.

CONCLUSION

The results of this study show a linear correlation between the numbers of symptoms and increasing GP consultations, medicine use and sickness absences days, and this persisted during the years 2001 and 2002.

Specific effects of depression, panic, and somatic symptoms on illness behavior

OBJECTIVE

In terms of restricted financial resources, the contribution of mental disorders to health care use and illness behavior is highly relevant. However, the specific contributions of panic disorder, depression, and somatic complaints to illness behavior in unselected samples is unclear.

METHODS

A representative sample of 2507 inhabitants of Germany was selected and grouped into people with panic disorder (30), somatic syndrome (102), major depression (24), depressive syndrome (77), and controls (2269). Assessment instruments were the complete version of the Patient Health Questionnaire (PHQ), the Scale for the Assessment of Illness Behavior (SAIB) as well as measures of health care use.

RESULTS

Although all clinical groups showed increased illness behavior, their impact was independent and specific. Subjects fulfilling the criteria of panic disorder showed the highest scores for illness behavior and health care use. People with mental disorders showed a greater increase in visits to general practitioners and medical specialists than to psychiatrists or psychologists. Regression analysis revealed that somatic complaints and depression have independent associations with illness behavior and health care use.

CONCLUSIONS

Different mental and psychosomatic disorders contribute independently to health care use and other aspects of illness behavior.

The Assessment of Adult Health Care Orientations: Development and Preliminary Validation of the Multidimensional Health Profile-Health Functioning Index (MHP-H) in a National Sample

This paper describes the development and preliminary validation of the Multidimensional Health Profile-Health Functioning Index (MHP-H), a 69-item self-report instrument designed to assess a variety of behaviors, perceptions, attitudes, and beliefs presumed to influence health status and the pursuit of lay and professional health care. The MHP-H briefly measures adult health history, health habits, health care utilization, health beliefs and attitudes, and response to illness (help-seeking behaviors). A national sample of adults (N = 673) was assessed, comprising 3 age groupings (18-32, 33-50, and 51-89) crossed with gender and then further subdivided into several subsamples for purposes of reliability and validity assessment. In addition, a group of spouse "key informants" was also recruited. Preliminary validation of single-item indicators as well as confirmatory factor analyses of multi-item scales was achieved. The present findings support the psychometric and practical utility of the MHP-H and warrant its use by health psychologists in a variety of research and applied settings.

Frequent attenders in general practice care: A literature review with special reference to methodological considerations

OBJECTIVE

To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs).

DESIGN

The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the 'related articles' function in the ISI Citation database and Medline.

SETTING

General practice.

SUBJECTS

Sixty-one articles (54 studies).

MEASURES

The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results.

RESULTS

There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30-50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender.

CONCLUSION

The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies.

The contribution of demographic and morbidity factors to self-reported visit frequency of patients: a cross-sectional study of general practice patients in Australia

Background

Understanding the factors that affect patients' utilisation of health services is important for health service provision and effective patient management. This study aimed to investigate the specific morbidity and demographic factors related to the frequency with which general practice patients visit a general practitioner/family physician (GP) in Australia.

Methods

A sub-study was undertaken as part of an ongoing national study of general practice activity in Australia. A cluster sample of 10,755 general practice patients were surveyed through a random sample of 379 general practitioners. The patient reported the number of times he/she had visited a general practitioner in the previous twelve months. The GP recorded all the patient's major health problems, including those managed at the current consultation.

Results

Patients reported an average of 8.8 visits to a general practitioner per year. After adjusting for other patient demographics and number of health problems, concession health care card holders made on average 2.6 more visits per year to a general practitioner than did non-card holders (p < .001). After adjustment, patients from remote/very remote locations made 2.3 fewer visits per year than patients from locations where services were highly accessible (p < .001). After adjustment for patient demographics, patients with diagnosed anxiety made on average 2.7 more visits per year (p = 0.003), those with diagnosed depression 2.2 more visits than average (p < .0001), and those with back problems 2.4 more visits (p = 0.009) than patients without the respective disorders.

Conclusions

Anxiety, back pain and depression are associated with greater patient demand for general practice services than other health problems. The effect of sociodemographic factors on patient utilisation of general practice services is complex. Equity of access to general practice services remains an issue for patients from remote areas, while concession health care card holders are attending general practice more frequently than other patients relative to their number of health problems.

Prospective association of anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency medical care

The empirical evidence concerning the relationship of psychiatric disorders to health care utilization and costs is mixed and primarily retrospective. Therefore, a case-control study was conducted to prospectively examine the association of psychiatric disorders with health care utilization in an adult primary care internal medicine patient population, controlling for the effects of medical morbidity, adverse events, age, race, gender, employment status, and health insurance coverage. Samples of primary care high utilizer (HU; 125 men, 125 women with primary care visits in 1998 above the 95th percentile) vs. mid-range utilizer (MU; 125 men, 125 women; two primary care visits in 1998) patients were compared using archival automated medical record data from the index year (1998), and from the following year (1999) for prospective analyses. HU (compared to MU) participants were younger, had higher medical and psychiatric morbidity, and had higher levels of outpatient specialty medical care utilization. In multivariate analyses, (a) anxiety disorder diagnoses uniquely contributed to identifying HU patients, and (b) after controlling for initial primary care utilization status, anxiety, depressive and addictive disorders were prospectively associated with medical illness complexity and primary, specialty, and emergency medical care utilization. Although behavioral health disorders (including addictive as well as depressive and anxiety diagnoses) and high utilization of primary health care services are related, these prospective findings suggest that behavioral health disorders make an independent contribution to non-psychiatric health care utilization.

Physical health vulnerability in adult children from divorced and intact families

OBJECTIVES

The current study evaluated family process variables associated with markers of physical health vulnerability.

METHODS

Retrospective reports of parental caring, conflict, and divorce-specific factors were examined in reference to hostility, somatic symptoms, and illness reports in young adults from divorced (n=253) and intact (n=552) families.

RESULTS

Contrary to expectations, participants from divorced and intact families were equivalent on all health-related measures. Within the intact group, parental conflict and low parental caring were associated with hostility, somatic symptoms, and illness reports. Within the divorce group, negative feelings about the divorce were associated with higher hostility, somatic complaints, and illness reports.

CONCLUSIONS

Results suggest that parental divorce in itself does not increase long-term vulnerability to physical illness; rather it is the negativity of the experience that is associated with vulnerability. Although overall health markers did not differ, the family process variables associated with physical health risk differed for individuals from divorced versus intact families.