Diagnostic barriers for somatic symptom disorders in primary care: study protocol for a mixed methods study in Germany

Estimated frequency of somatic symptom disorder in general practice: cross-sectional survey with general practitioners

BACKGROUND

Somatic symptom disorder (SSD) is the successor diagnosis of somatoform disorder in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Relevance and frequency of SSD and its clinical symptoms in general practice are still unknown. We estimate frequencies of patients fulfilling the diagnostic criteria of SSD in general practice.

METHODS

Mailed and online survey with general practitioners (GP) in Germany using a cross-sectional representative sample from registries of statutory health insurance physicians. GPs estimated percentages of their patients who show the clinical symptoms of SSD according to DSM-5; that is, one or more burdensome somatic symptoms (A criterion), excessive symptom- or illness-related concern, anxiety, or behaviour (B criterion), and persistence of the symptoms over at least 6 months (C criterion). Statistical analysis used means and confidence intervals of estimated patient proportions showing SSD symptoms. Frequency of full-blown SSD was based on the products of these proportions calculated for each GP.

RESULTS

Responses from 1728 GPs were obtained. GPs saw the clinical symptoms of SSD fulfilled (A and B criteria) in 21.5% (95% CI: 20.6 to 22.3) of their patients. They further estimated that in 24.3% (95% CI: 23.3 to 25.2) of patients, symptoms would persist, yielding a total of 7.7% (95% CI: 7.1 to 8.4) of patients to have a full-blown SSD.

CONCLUSIONS

We estimate a frequency of 7.7% of patients in general practice to fulfil the diagnostic criteria of SSD. This number may figure as a reference for the yet to be uncovered prevalence of SSD and it indicates a high clinical relevance of the clinical symptoms of SSD in general practice.

REGISTRATION

German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS).

DRKS-ID

DRKS00012942. The date the study was registered: October 2nd 2017. The date the first participant was enrolled: February 9th 2018.

Epidemiology and Prevalence of Somatic Symptom Disorder at the Primary Care Level in Muscat, Oman: A Cross-Sectional Study

OBJECTIVES

Somatic symptom disorder (SSD) is a diagnostic classification to describe the occurrence of physical symptoms without organic cause. This study aimed to identify prevalence rates and associated characteristics of SSD among adults in primary care settings.

METHODS

This cross-sectional study took place between July 2020 and March 2021 and included a random selection of 3383 Omani adults attending 12 primary healthcare centres in Muscat Governorate. Screening was conducted using an Arabic version of the Somatic Symptom Scale-8 (SSS-8).

RESULTS

A total of 2000 adults participated in the study (response rate: 67.3%), of which most were female (71.7%) and under 50 years old (86.2%). Based on their SSS-8 scores, 602 participants (17.8%) had SSD, resulting in an overall prevalence estimate of 30.1% (95% confidence interval: 28.13-32.15). Significant associations were observed between SSD and age (p = 0.002), gender (p < 0.001), marital status (p = 0.030) and chronic comorbidities (p = 0.001). In addition, adjusted odds ratio estimates revealed SSD to be significantly associated with gender (p < 0.001), education level (p < 0.001) and chronic comorbidities (p = 0.001).

CONCLUSION

The estimated prevalence of SSD in primary care settings is high compared to reports from elsewhere in the Gulf region. There is an urgent need to enhance the diagnosis of SSD at the primary care level in order to reduce healthcare service overutilisation and patient dissatisfaction. Moreover, healthcare practitioners should be aware of the effect of age, gender, educational status and chronic comorbidities on somatic symptoms.

Diagnostic and treatment barriers to persistent somatic symptoms in primary care - representative survey with physicians

Background

Many patients consult their primary care physician with persistent somatic symptoms such as pain or sickness. Quite often these consultations and further diagnostic measures yield no medical explanation for the symptoms – patients and physicians are left in uncertainty. In fact, diagnostic and treatment barriers in primary care hinder timely health-care provision for patients suffering from persistent somatic symptoms (PSS). The significance of individual barriers is still unknown. We compare and quantify these barriers from the perspective of primary care physicians and identify subpopulations of primary care physicians who experience particular barriers as most severe.

Methods

We mailed a questionnaire to primary care physicians (PCP) in Germany and asked them which barriers they consider most important. We invited a random sample of 12,004 primary care physicians in eight federal states in Germany. Physicians provided anonymous mailed or online responses. We also mailed a postcard to announce the survey and a mail reminder. Main measures were Likert rating scales of items relating to barriers in the diagnosis and treatment of PSS in primary care. Information on demography and medical practice were also collected.

Results

We analyzed 1719 data sets from 1829 respondents. PCPs showed strongest agreement with statements regarding (1.) their lack of knowledge about treatment guidelines, (2.) their perceptions that patients with PSS would expect symptom relief, (3.) their concern to overlook physical disease in these patients, and (4.) their usage of psychotropic drugs with these patients. More experienced PCPs were better able to cope with the possibility of overlooking physical disease than those less experienced.

Conclusions

The PCPs in our survey answered that the obligation to rule out severe physical disease and the demand to relieve patients from symptoms belong to the most severe barriers for adequate treatment and diagnosis. Moreover, many physicians admitted to not knowing the appropriate treatment guidelines for these patients. Based on our results, raising awareness of guidelines and improving knowledge about the management of persistent somatic symptoms appear to be promising approaches for overcoming the barriers to diagnosis and treatment of persistent somatic symptoms in primary care.

Trial registration

German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS)

https://www.drks.de/drks_web/setLocale_EN.do

The date the study was registered: October 2^nd 2017

The date the first participant was enrolled: February 9^th 2018

DRKS-ID: DRKS00012942

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01397-w.

ICD-10-Coding of Medically Unexplained Physical Symptoms and Somatoform Disorders-A Survey With German GPs

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.

Stepped, Collaborative, Coordinated Care for Somatic Symptom and Related Disorders (Sofu-Net)

Abstract. To improve early detection and adequate treatment for patients with somatic symptom and related disorders (SSRD), we implemented Sofu-Net, a stepped, collaborative, and coordinated health care network. This mixed-methods study aimed to evaluate Sofu-Net from the health care professionals’ perspective. Network partners (primary care physicians (PCPs), psychotherapists, inpatient mental health clinics) completed an evaluation survey. Following, qualitative analysis of focus groups explored facilitating factors and barriers of Sofu-Net. Of 66 network partners who completed the survey (response 83.5%), the majority was satisfied with Sofu-Net, and perceived improvements regarding management, early detection, and referral to mental health care. Both survey and focus groups identified interdisciplinary collaboration and diagnostic screening as most relevant facilitating factors. Important barriers to implementation included challenges in patient referral and structural factors. Necessary prerequisites for future stepped collaborative care for SSRD include structures facilitating diagnosis, inter-professional collaboration and referral, availability of mental health care, inclusion of comorbidities, and adequate reimbursement.

General practitioners' views on the diagnostic innovations in DSM-5 somatic symptom disorder - A focus group study

BACKGROUND

The innovations concerning the new diagnosis somatic symptom disorder (SSD) in the DSM-5 include the introduction of psychological diagnostic criteria and the elimination of the need to exclude all potential somatic causes of the symptoms. Thus far, it is unknown how general practitioners (GPs) evaluate the innovations conceptually and regarding their applicability in primary care.

METHOD

We performed six focus groups with GPs. A semi-structured interview-guideline included a presentation of the innovations of SSD and questions about the innovations and their potential (dis-)advantages from the GPs' points of view. The material was analyzed using structuring qualitative content analysis.

RESULTS

A total of 41 GPs participated (mean (sd) age = 51 (8.5) years, female = 17, male = 24). The GPs assessed that the diagnostic innovations could help them to focus on symptom-related concerns and anxiety as core aspects of the patients' complaints. However, the meaning of the term excessive in the psychological diagnostic criteria (i.e., excessive worries, anxiety, time and energy) was ambiguous for the GPs. The GPs appreciated that a mental disorder can be assigned in addition to a severe physical disease. The GPs found it unlikely that diagnostic workup of somatic symptoms would be cut short if the diagnostic criteria of SSD were fulfilled in a given patient.

CONCLUSION

Altogether, for the GPs, the advantages of the new diagnostic criteria for SSD outweighed the disadvantages. In particular, the newly included psychological criteria were seen as an important advancement in comparison to the previous need of merely excluding a physical disease.

Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study

BACKGROUND

Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.

METHODS

We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.

RESULTS

Three main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.

CONCLUSIONS

There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

Duration of untreated illness in patients with somatoform disorders

OBJECTIVE

A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders.

METHODS

In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI.

RESULTS

A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI.

CONCLUSIONS

The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.

Public Beliefs About Somatic Symptom Disorders

Objectives: Despite satisfactory effectiveness of treatment for somatic symptom disorders (SSD), treatment rates are low and treatment is usually initiated many years after first symptoms. In order to understand whether a lack of public mental health literacy might contribute to these poor treatment rates, we aimed to focus on two research questions: (1) What does the German public know and think about SSD? (2) Are knowledge and beliefs associated with socio-demographic factors and experiences with the disorder? Methods: Two vignettes with symptoms of a SSD were used in a national telephone survey in Germany (N = 1,004). Vignettes differed regarding main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Respondents were asked concerning knowledge and beliefs about causes, symptoms, and treatment using a standardized questionnaire. Results: 66% of the respondents agreed that a possible cause of the symptoms is a misinterpretation of body signals. About 1/3 recognized a mental health problem when confronted with the vignettes of cases with SSD. This rate was lower in case of a SSD with pain as the main symptom without a comorbid somatic disease (24.8%, 95%-CI: 21.1-28.6) compared to a case with fatigue as the main symptom and an earlier severe somatic disease (44.0%, 95%-CI: 39.6-48.3). Female respondents tended to have a more positive view on treatability and effectiveness of psychotherapy, while associations of knowledge and beliefs with education and age were inconsistent. Respondents who had contact with a person with SSD were more likely to think that psychotherapy is effective and that they know a lot about SSD compared to those who never had contact. Conclusions: While most of the German public seems to be well informed about causes of SSD as well as treatability and the effectiveness of psychotherapy, the majority has problems with interpreting symptoms and does not think they know a lot about symptoms like that. Increasing knowledge about SSD by education interventions may help to promote adequate help seeking.