Economics of medically unexplained symptoms: a systematic review of the literature

Opinions and experience of neurologists and neurology trainees in Saudi Arabia on functional neurological disorders: a survey based study

BACKGROUND

Functional Neurological Disorder (FND) is commonly encountered in clinical practice, causing functional impairment and poor quality of life. As there is limited data from Saudi Arabia, our study aims to explore the experience and opinions of Saudi neurologists and neurology trainees regarding FND.

METHODS

In our cross-sectional observational study, we included 100 neurology consultants and trainees. Data was collected using an online questionnaire from March to August 2023.

RESULTS

A total of one hundred neurologists participated in the survey. Although 41% of physicians encountered FND patients on a weekly basis or more frequently, only 41.7% of trainees reported receiving dedicated lectures on FND. Furthermore, only 46% of respondents felt comfortable providing a clear explanation of the FND diagnosis to their patients. While the majority (64%) used the term "Functional Neurological Disorder" in medical documentation, only 43% used this term when communicating the diagnosis to patients, with the terminology varying widely. Clinicians emphasized that inconsistent and variable neurological examinations were key indicators raising diagnostic suspicion, which aligns with the recommended reliance on detailed clinical history and neurological examination. Lastly, 61% of physicians stated that their approach to patients with FND lacked a structured management plan.

CONCLUSION

Our study findings emphasize that FND is commonly encountered in clinical practice and reveal a significant lack of targeted education on FND for neurology trainees. Enhancing educational programs for both trainees and practicing neurologists on this prevalent neurological condition is essential for improving patient care and outcomes.

Optimism, Resilience, and General Self-Efficacy Predict Lower Somatic Burden during the COVID-19 Pandemic

There is scarce evidence of a relationship between positive and psychosomatic characteristics. This study aimed to examine the associations of somatic burden with psychological resources such as optimism, resilience, and general self-efficacy. Russian participants (n = 1020) completed measures of psychological resources at Time 1 and somatic symptoms at Time 2. The results showed that somatic burden decreased with greater levels of optimism, resilience, and general self-efficacy. Regarding health and sociodemographic characteristics, female sex increased somatic burden in the model with optimism scores, university education decreased somatic burden in the model with resilience scores, and history of COVID-19 disease increased somatic burden in the models with optimism, resilience, and general self-efficacy scores. This study has theoretical and practical contributions. It combines positive psychology and psychosomatic medicine and highlights the value of psychological resource interventions in the treatment and prevention of somatic burden. These findings may be useful for scientists, clinicians, and practitioners.

Integrated care model for patients with functional somatic symptom disorder - a co-produced stakeholder exploration with recommendations for best practice

BACKGROUND

Functional somatic symptoms (FFS) and bodily distress disorders are highly prevalent across all medical settings. Services for these patients are dispersed across the health care system with minimal conceptual and operational integration, and patients do not currently access therapeutic offers in significant numbers due to a mismatch between their and professionals' understanding of the nature of the symptoms. New service models are urgently needed to address patients' needs and to align with advances in aetiological evidence and diagnostic classification systems to overcome the body-mind dichotomy.

METHOD

A panel of clinical experts from different clinical services involved in providing aspects of health care for patients with functional symptoms reviewed the current care provision. This review and the results from a focus group exploration of patients with lived experience of functional symptoms were explored by the multidisciplinary expert group, and the conclusions are summarised as recommendations for best practice.

RESULTS

The mapping exercise and multidisciplinary expert consultation revealed five themes for service improvement and pathway development: time/access, communication, barrier-free care, choice and governance. Service users identified four meta-themes for best practice recommendations: focus on healthcare professional communication and listening skills as well as professional attributes and knowledge base to help patients being both believed and understood in order to accept their condition; systemic and care pathway issues such as stronger emphasis on primary care as the first point of contact for patients, resources to reduce the length of the patient journey from initial assessment to diagnosis and treatment.

CONCLUSION

We propose a novel, integrated care pathway for patients with 'functional somatic disorder', which delivers care according to and working with patients' explanatory beliefs. The therapeutic model should operate based upon an understanding of the embodied nature of patient's complaints and provide flexible access points to the care pathway.

Frontal alpha asymmetry is associated with chronic stress and depression, but not with somatoform disorders

Cardinal characteristics of somatoform disorders (SFDs) are worry of illness, and impaired affective processing. We used relative frontal alpha asymmetry (FAA), a method to measure functional lateralization of affective processing, to investigate psychobiological correlates of SFDs. With alpha activity being inversely related to cortical network activity, relative FAA refers to alpha activity on the right frontal lobe minus alpha activity on the left frontal lobe. Less relative left frontal activity, reflected by negative FAA scores, is associated with lower positive and greater negative affectivity, such as observed in depression. Due to its negative affective component (illness anxiety), we expected to find less relative left frontal activity pattern in SFDs, and positive associations with self-reported chronic stress and depression symptoms. We recorded resting-state EEG activity with 64 electrodes, placed in a 10-10 system in 26 patients with a primary SFD, 23 patients with a major depressive disorder and 25 healthy control participants. The groups did not differ in FAA. Nevertheless, across all participants, less relative left frontal activity was associated with chronic stress and depression symptoms. We concluded that FAA may not serve as an indicator of SFDs. As the relationship of FAA and depressive symptoms was fully mediated by chronic stress, future studies have to clarify whether the association between FAA and chronic stress may represent a shared underlying factor for the manifestation of mental health complaints, such as depression.

Medically unexplained symptoms are common in women in tertiary neurological healthcare center: A survey cohort study of persons investigated for suspected multiple sclerosis

BACKGROUND

A significant proportion of individuals with suspicious onset of multiple sclerosis (MS) does not fulfill the diagnostic criteria. Although some receive other diagnoses, many remain undiagnosed and lack healthcare follow-up. This study aimed to characterize persons with undetermined diagnosis (PwUD) through a questionnaire.

METHODS

Incident cases with suspected MS were consecutively admitted to a tertiary neurological healthcare center in a prospective cohort study. Those who remained undiagnosed after 40 months (mean, range 31-52) were considered PwUD. They completed a modified questionnaire, previously used in a population-based case-control study of incident MS cases. Their responses were compared with two control cohorts, persons with MS (PwMS) and healthy controls, randomly selected from national registries, matched by age, gender, and area of residence.

RESULTS

Out of 271 patients with suspected MS onset, 72 (20.3%) were PwUD with a female majority (79%). The response rate was 83% and 39% reported persisting MS-like symptoms. Compared to controls (n = 548) and PwMS (n = 277), fewer PwUD were currently smoking (p = .4 and p = .03), consumed less alcohol (p = .04 and p = .01), and had children (p = .02 and p = .002). PwUD reported occurrence of other autoimmune disease in 29%, higher compared to PwMS and controls (p < .001 and p < .001).

CONCLUSIONS

UD is common among persons investigated for suspected MS, in particular among female parents. Our data suggest that PwUD can be characterized as nonsmokers with low alcohol consumption and a higher prevalence of autoimmune disease, in particular thyroid disease.

Treatment and life goals among veterans with Gulf War illness

Medically unexplained syndromes (MUS), also termed persistent physical symptoms, are both prevalent and disabling. Yet treatments for MUS are marked by high rates of patient dissatisfaction, as well as disagreement between patients and providers on the management of persistent physical symptoms. A better understanding of patient-generated goals could increase collaborative goal setting and promote person-centered care, a critical component of MUS treatment; yet research in this area is lacking. This paper aimed to develop a typology of treatment and life goals among Gulf War veterans with a medically unexplained syndrome (Gulf War Illness). We examined participants' responses to open-ended questions about treatment and life goals using Braun and Clarke's thematic analysis methodology. Results showed that treatment goals could be categorized into four overarching themes: 1) Get better/healthier, 2) Improve quality of life, 3) Improve or seek additional treatment, and 4) Don't know/Don't have any. Life goals were categorized into six overarching themes: 1) Live a fulfilling life, 2) Live a happy life, 3) Live a healthy life, 4) Be productive/financially successful, 5) Manage GWI, and 6) Don't know/Don't have any. Treatment goals were largely focused on getting better/healthier (e.g., improving symptoms), whereas life goals focused on living a fulfilling life. Implications for the treatment of Gulf War Illness and patient-provider communication are discussed. ClinicalTrials.gov Identifier: NCT02161133.

The distribution of somatic symptom disorder and bodily distress syndrome in general hospital outpatients in China: A multicenter cross-sectional study

OBJECTIVE

To investigate the distribution of somatic symptom disorder (SSD) and bodily distress syndrome (BDS) and analyze the differences in psychosocial characteristics of patients with the two diagnoses.

METHODS

A total of 694 general hospital outpatients completed the diagnostic interviews for SSD and BDS, and a set of questionnaires evaluating their psychosocial characteristics. A secondary analysis of these data is done.

RESULTS

SSD and BDS had a moderate overlap (kappa value = 0.43). Patients who fulfilled both SSD and BDS diagnosis showed significantly higher levels of symptom-related psychological distress (SSD-12), somatic symptom severity (PHQ-15), depression (PHQ-9), and general anxiety (GAD-7), as well as lower mental and physical quality of life (SF-12) compared to patients with neither diagnosis and patients with only one diagnosis. Patients with either diagnosis were associated with significantly higher psychosocial impairments as compared to those with neither diagnosis. Patients who only met SSD had higher SSD-12 scores, whereas those with only BDS had higher PHQ-15 scores (p<0.001).

CONCLUSIONS

SSD and BDS appear to represent somewhat different psychopathologies, with SSD more associated with psychological distress and BDS associated with greater experience of somatic symptoms. Patients fulfilling both diagnosis show higher symptom severity in various psychosocial aspects.

Recognition, explanation, action, learning: Teaching and delivery of a consultation model for persistent physical symptoms

OBJECTIVE

To describe the teaching and delivery of an extended consultation model designed for clinicians to use with patients with persistent physical symptoms and functional disorders. The model is underpinned by current scientific knowledge about persistent physical symptoms and the communication problems that arise in dealing with them.

METHODS

Process evaluation of training and delivery of the Recognition, Explanation, Action, Learning (REAL) model within the Multiple Symptoms Study 3: a randomised controlled trial of an extended-role GP "Symptoms Clinic". Evaluation used clinician and patient interviews and consultation transcripts.

RESULTS

7 GPs were trained in the intervention and 6 of them went on to deliver the REAL model in Symptoms Clinics either face-to-face or online. The Symptoms Clinic provided a set of 4 extended consultations to approximately 170 patients. Evaluation of training indicated that there was a considerable load in terms of new knowledge and skills. Evaluation of delivery found clinicians could adapt the model to individual patients while maintaining a high level of fidelity to its core components.

CONCLUSION

REAL is a teachable consultation model addressing specific clinical communication issues for people with persistent physical symptoms.

PRACTICE IMPLICATIONS

REAL enables clinicians to explain persistent physical symptoms in a beneficial way.

Cost of Illness Analysis of Common Mental Disorders: A Study from an Indian Academic Tertiary Care Hospital

Background

The cost of illness (COI) for common mental disorders (CMDs) that include depression, anxiety, and somatoform disorder is less studied in India. Hence, we studied the COI and disability of CMDs and their relationship in patients with depression, anxiety, and somatoform disorders.

Methods

In this cross-sectional study, we recruited 220 patients (110 with depression, 58 with anxiety disorders, and 52 with somatoform disorders) and evaluated disability using the Sheehan Disability Scale (SDS). The schedule for the cost of illness (S-COI) was used for evaluating COI for the last year.

Results

The annual COI of CMDs from the patient perspective was ₹21,620 (interquartile range [IQR], ₹47,761; ≈US$290). The median annual direct COI was ₹4,907 (IQR ₹7,502), and indirect COI was ₹12,900 (IQR ₹37744). The direct COI was 18%, whereas the indirect COI was 82%. The direct and indirect COI in the three groups were similar. In all three groups with ongoing treatment, the mean scores indicated a mild level of disability. Total and indirect COI, but not the direct COI, correlated positively with the severity of illness and disability.

Conclusion

All the CMDs with ongoing treatment are associated with a mild level of disability and are a significant financial burden, with higher indirect costs.

Characteristics and economic burden of patients with somatoform disorders in Chinese general hospitals: a multicenter cross-sectional study

BACKGROUND

In China, patients with somatoform disorders (SFD) often seek medical treatment repeatedly in outpatient clinics of general hospitals, which increases unreasonable medical expenses. It is imperative to provide early screening to these patients and specialized treatment to reduce the unnecessary cost. This study aimed to screen patients with SFD in general hospitals using a new Chinese questionnaire and explore the characteristics and economic burden of these patients.

METHODS

Patients (n = 1497) from the outpatient department of neurology, cardiology and gastroenterology of three large general hospitals were included. Participants were screened using a newly developed questionnaire, the Self-screening Questionnaire for Somatic Symptoms (SQSS), to identify the patients with SFD (total SQSS score ≥ 29 points). We compared the demographics and clinical information of patients with and without SFD. Logistic regression was used to explore potential factors related to medical expenses, visits to doctors and sick leave days taken.

RESULTS

The frequency of detection of patients with SFD was 17.03%. There were significant differences in employment, doctor visits, symptom duration, medical expenses, sick leave days, PHQ-15 scores, and PHQ-9 scores between patients with SFD and without SFD. General nonspecific somatic symptoms were frequently present in patients with SFD. Several potential factors were associated with higher medical expenses, repeated doctor visits, and sick leave days taken in the regression analysis.

CONCLUSION

The findings indicate that patients with SFD are common in general hospitals, and their direct and indirect economic burden is higher than that of non-SFD patients, which indicates that more screening effort should be made to this group to early identify their problems. Certain characteristics were identified among patients with SFD and several factors were associated with negative consequences of SFD, all of which might be prevented by developing a preventive intervention program to reduce the economic burden of the patients.

Economic Cost of Functional Neurologic Disorders: A Systematic Review

BACKGROUND AND OBJECTIVES

Functional neurologic disorder (FND) represents genuine involuntary neurologic symptoms and signs including seizures, weakness, and sensory disturbance, which have characteristic clinical features, and represent a problem of voluntary control and perception despite normal basic structure of the nervous system. The historical view of FND as a diagnosis of exclusion can lead to unnecessary health care resource utilization and high direct and indirect economic costs. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess these economic costs and to assess for any cost-effective treatments.

METHODS

We searched electronic databases (PubMed, PsycInfo, MEDLINE, EMBASE, and the National Health Service Economic Evaluations Database of the University of York) for original, primary research publications between inception of the databases and April 8, 2022. A hand search of conference abstracts was also conducted. Key search terms included "functional neurologic disorder," "conversion disorder," and "functional seizures." Reviews, case reports, case series, and qualitative studies were excluded. We performed a descriptive and qualitative thematic analysis of the resulting studies.

RESULTS

The search resulted in a total of 3,244 studies. Sixteen studies were included after screening and exclusion of duplicates. These included the following: cost-of-illness (COI) studies that were conducted alongside cohort studies without intervention and those that included a comparator group, for example, another neurologic disorder (n = 4); COI studies that were conducted alongside cohort studies without intervention and those that did not include a comparator group (n = 4); economic evaluations of interventions that were either pre-post cohort studies (n = 6) or randomized controlled trials (n = 2). Of these, 5 studies assessed active interventions, and 3 studies assessed costs before and after a definitive diagnosis of FND. Studies showed an excess annual cost associated with FND (range $4,964-$86,722 2021 US dollars), which consisted of both direct and large indirect costs. Studies showed promise that interventions, including provision of a definitive diagnosis, could reduce this cost (range 9%-90.7%). No cost-effective treatments were identified. Study comparison was limited by study design and location heterogeneity.

DISCUSSION

FND is associated with a significant use of health care resources, resulting in economic costs to both the patient and the taxpayer and intangible losses. Interventions, including accurate diagnosis, seem to offer an avenue toward reducing these costs.

Costs of adult functional neurological disorders at a tertiary hospital in central South Africa

Background

Functional neurological disorders (FND) lead to increased care requirements and costs, negatively impacting healthcare budgets. Healthcare expenditure in FND has escalated beyond other neurologic disorders during the past decade.

Objectives

To assess inpatient costs in adults admitted to the neurology ward at Universitas Academic Hospital (UAH) in central South Africa.

Methods

A retrospective observational study with a comparative component was conducted on patients admitted during 2018 and 2019. All FND cases (n = 29) and a systematic sample of other neurological disorders were included in the comparison group (n = 29). Data were obtained from the Meditech billing system and clinical records.

Results

FND patients accounted for 5.5% of 530 admissions in the neurology ward during the study period. No significant differences regarding daily median cost, age categories, gender or medical comorbidity were observed between FND and the comparison group. However, the length of stay was significantly shorter for the FND patients (median of four versus eight days), translating to approximately half the total costs of patients admitted for other neurological disorders.

Conclusion

The daily median cost was similar for FND and other neurology-related admissions. The lower overall inpatient costs for FND patients were only related to significantly shorter durations of stay, which may reflect new diagnostic approaches resulting from changes in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. The prevalence of FND was similar to those reported in previous studies conducted at neurology clinics.

Contribution

The study contributes towards better understanding the prevalence and cost of FND in local neurology inpatient care settings.

Psychosocial determinants of healthcare use costs in kidney transplant recipients

Introduction

Psychosocial factors frequently occur in kidney transplant recipients (KTRs), leading to behavioral alterations and reduced therapeutic adherence. However, the burden of psychosocial disorders on costs for KTRs is unknown. The aim of the study is to identify predictors of healthcare costs due to hospital admissions and emergency department access in KTRs.

Methods

This is a longitudinal observational study conducted on KTRs aged >18 years, excluding patients with an insufficient level of autonomy and cognitive disorder. KTRs underwent psychosocial assessment via two interviews, namely the Mini-International Neuropsychiatric Interview 6.0 (MINI 6.0) and the Diagnostic Criteria for Psychosomatic Research Interview (DCPR) and via the Edmonton Symptom Assessment System Revised (ESAS-R) scale, a self-administrated questionnaire. Sociodemographic data and healthcare costs for hospital admissions and emergency department access were collected in the 2016-2021 period. Psychosocial determinants were as follows: (1) ESAS-R psychological and physical score; (2) symptomatic clusters determined by DCPR (illness behavior cluster, somatization cluster, and personological cluster); and (3) ICD diagnosis of adjustment disorder, anxiety disorder, and mood disorder. A multivariate regression model was used to test the association between psychosocial determinants and total healthcare costs.

Results

A total of 134 KTRs were enrolled, of whom 90 (67%) were men with a mean age of 56 years. A preliminary analysis of healthcare costs highlighted that higher healthcare costs are correlated with worse outcomes and death (p < 0.001). Somatization clusters (p = 0.020) and mood disorder (p < 0.001) were positively associated with costs due to total healthcare costs.

Conclusions

This study showed somatization and mood disorders could predict costs for hospital admissions and emergency department access and be possible risk factors for poor outcomes, including death, in KTRs.

The cost-effectiveness of an indicated blended care intervention in primary care compared to usual care in patients with moderate persistent somatic symptoms

INTRODUCTION

Appropriate treatment for people with an increased risk for developing chronic Persistent Somatic Symptoms (PSS) is of great importance at an early stage to improve quality of life and prevent high costs for society.

OBJECTIVE

To evaluate the cost-effectiveness of an integrated blended care intervention compared to usual care for QALYs, subjective symptom impact and physical and mental health status in patients with moderate PSS.

METHODS

This economic evaluation was conducted alongside a 12-month prospective, multicenter cluster randomized controlled trial in Dutch primary care. 80 participants received the intervention and 80 participants received usual care. Seemingly unrelated regression analyzes were performed to estimate cost and effect differences. Missing data were imputed using multiple imputation. Bootstrapping techniques were used to estimate uncertainty.

RESULTS

We found no significant difference in total societal costs. Intervention, primary and secondary healthcare and absenteeism costs were higher for the intervention group. The ICER for QALYs demonstrated the intervention was on average less costly and less effective compared to usual care. For the subjective symptom impact and physical health, the ICER indicated that the intervention group was on average less costly and more effective. For mental health, the intervention was on average more costly and less effective.

CONCLUSION

We didn't find an integrated blended primary care intervention to be cost-effective compared to usual care. However, when looking on relevant, but specific outcome measures (subjective symptom impact and physical health) for this population, average costs are found to be lower and the effectiveness found to be higher.

Early identification of persistent somatic symptoms in primary care: data-driven and theory-driven predictive modelling based on electronic medical records of Dutch general practices

OBJECTIVE

The present study aimed to early identify patients with persistent somatic symptoms (PSS) in primary care by exploring routine care data-based approaches.

DESIGN/SETTING

A cohort study based on routine primary care data from 76 general practices in the Netherlands was executed for predictive modelling.

PARTICIPANTS

Inclusion of 94 440 adult patients was based on: at least 7-year general practice enrolment, having more than one symptom/disease registration and >10 consultations.

METHODS

Cases were selected based on the first PSS registration in 2017-2018. Candidate predictors were selected 2-5 years prior to PSS and categorised into data-driven approaches: symptoms/diseases, medications, referrals, sequential patterns and changing lab results; and theory-driven approaches: constructed factors based on literature and terminology in free text. Of these, 12 candidate predictor categories were formed and used to develop prediction models by cross-validated least absolute shrinkage and selection operator regression on 80% of the dataset. Derived models were internally validated on the remaining 20% of the dataset.

RESULTS

All models had comparable predictive values (area under the receiver operating characteristic curves=0.70 to 0.72). Predictors are related to genital complaints, specific symptoms (eg, digestive, fatigue and mood), healthcare utilisation, and number of complaints. Most fruitful predictor categories are literature-based and medications. Predictors often had overlapping constructs, such as digestive symptoms (symptom/disease codes) and drugs for anti-constipation (medication codes), indicating that registration is inconsistent between general practitioners (GPs).

CONCLUSIONS

The findings indicate low to moderate diagnostic accuracy for early identification of PSS based on routine primary care data. Nonetheless, simple clinical decision rules based on structured symptom/disease or medication codes could possibly be an efficient way to support GPs in identifying patients at risk of PSS. A full data-based prediction currently appears to be hampered by inconsistent and missing registrations. Future research on predictive modelling of PSS using routine care data should focus on data enrichment or free-text mining to overcome inconsistent registrations and improve predictive accuracy.

Exploring maladaptive cognitions and behaviors as perpetuating factors in patients with persistent somatic symptoms: a longitudinal study

OBJECTIVE

Maladaptive cognitions and behaviors may influence symptoms and impairment in patients with persistent somatic symptoms (PSS). Aims of this study were to examine: (i) whether maladaptive cognitions and behaviors are associated with symptom severity and functional health over time; (ii) if these associations are the result of changes within individuals over time or of differences between individuals; (iii) directions of changes within individuals over time.

METHODS

Longitudinal data of a heterogeneous sample of patients with PSS were analyzed (n = 322 patients enrolled in the PROSPECTS cohort study). Cognitive and behavioral responses to symptoms (CBRQ), symptom severity (PHQ-15) and physical and mental functioning (RAND-36 PCS and MCS) were assessed seven times over a five-year period (0, 6 months, 1, 2, 3, 4, 5 year). Longitudinal mixed model and hybrid model analysis with and without time-lag were applied.

RESULTS

Maladaptive cognitions and behaviors were associated with more severe symptoms and reduced physical and mental functioning over time. Both changes within individuals over time and differences between individuals were associated with higher symptom severity and reduced physical and mental functioning. The between-subject component was about twice the effect size of the within-subject component. Changes in several specific maladaptive cognitions and behaviors were associated with more severe symptoms and reduced physical and mental functioning later in time and vice versa.

CONCLUSION

This study shows that maladaptive cognitions and behaviors are associated with symptom severity and reduced physical and mental functioning over time in patients with PSS.

Higher Health Service Costs Associated With Delayed Diagnosis of Functional Neurological Disorder

OBJECTIVE

Functional neurological disorder (FND) is frequently encountered in clinical practice but commonly misdiagnosed, which might lead to higher direct costs for the health care system. The investigators analyzed the direct costs associated with the diagnosis of FND compared with costs associated with other neurological conditions and explored possible cost trends related to the clinical and demographic features of FND.

METHODS

Consecutive patients attending a general neurology clinic were recruited and underwent a structured assessment aimed to collect information pertaining to their demographic and clinical characteristics, as well as data regarding their prior diagnostic processes (e.g., the number of consulted specialists, number and type of investigations, emergency department visits, etc.). The costs were hence calculated and compared between the study groups.

RESULTS

A total of 155 consecutive patients were recruited; of these, 18.6% had FND, 55.84% had one or more other neurological disorder (OND), and 27.10% presented with comorbid FND and OND. The total prediagnostic costs (in euros [€]) were higher in the FND group compared with the OND group (median=€289, interquartile range [IQR] €385 vs. median=€98, IQR €216; Mann-Whitney U=879.5, p=0.04). There was a higher diagnostic delay in the FND group compared with the OND group (median=48 months, IQR 60 months vs. median=12 months, IQR 6 months; Mann-Whitney U=162.00, p<0.01). Diagnostic delay significantly correlated with the total costs in the entire study sample (Spearman's ρ=0.25, p=0.003) but more strongly in the FND group (Spearman's ρ=0.81, p<0.001). In the FND group, higher numbers of investigations and costs were associated with the presence of a physiological or psychological trigger and multiple symptoms.

CONCLUSIONS

Delayed diagnosis of FND significantly affects health care system costs, and raising awareness about FND to improve the diagnostic process and outcomes is necessary.

Head-to-head comparison of somatic symptom scales: The Patient Health Questionnaire (PHQ-15) and the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ-S)

OBJECTIVE

The goal of this study was to compare the 15-item Patient Health Questionnaire (PHQ-15) and the somatization subscale of the Four-Dimensional Symptoms Questionnaire (4DSQ-S) with respect to their latent structure and reliability, and to examine whether their scores are affected by age and gender, and whether the scales measure the same construct(s).

METHODS

The study population consisted of individuals with a tendency to experience persistent somatic symptoms, recruited in multiple healthcare settings, who completed the PHQ-15 and 4DSQ-S concurrently. We analyzed the scales' latent factor structure using confirmatory factor analysis (CFA), the scales' reliability, and differential item functioning (DIF) due to age and gender. We performed a head-to-head comparison by fitting structural equation models of the questionnaires' factors.

RESULTS

We included 234 participants. CFA showed that both questionnaires fitted a bifactor model with a general factor and four specific factors, three of which (labeled "musculoskeletal", "gastrointestinal", and "cardiopulmonary") were substantively similar. Both scales were essentially unidimensional. The reliability of the PHQ-15 and 4DSQ-S was equally high (omega 0.933 and 0.942, respectively). DIF-analysis showed minor DIF for age in one item of each questionnaire, with negligible impact on the scale score. Head-to-head comparison showed that the PHQ-15 and 4DSQ-S measured the same constructs. We present PHQ-15 - 4DSQ-S cross-walk tables.

CONCLUSIONS

Both questionnaires mainly measure a single somatic symptom burden dimension of which all symptoms (covered by the questionnaires) are adequate indicators. They do so equally accurately and they behave the same across gender and age categories.

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.

Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners

BACKGROUND

When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides.

OBJECTIVES

To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful.

METHODS

Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation.

RESULTS

Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function.

CONCLUSIONS

Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.

Psychometric properties of the Persian version of the somatic symptom disorder-B Criteria Scale (SSD-12) in community and clinical samples

OBJECTIVE

In the DSM-5's diagnostic criteria of somatic symptom disorders (SSD), the presence of psychological problems (i.e., excessive thoughts, feelings, or behaviors) is emphasized more than the absence of the medical causes of patients' bothersome symptoms. In this regard, the Somatic Symptom Disorder-B Criteria Scale (SSD-12) is a screening tool for assessing these psychological features in somatic symptom disorder. This study aimed to validate the Persian version of SSD-12 in the Iranian community (non-clinical) and clinical samples.

METHODS

Data was gathered from 291 individuals in a community sample (aged 18 to 54, M-age = 36.62, SD = 10.56, 79.7% females) and from clinical setting, including 118 patients diagnosed with major depressive disorder (MDD, aged 18 to 60, M-age = 36.52, SD = 11.39, 75.8% females) and 120 patients diagnosed with somatic symptom disorders (aged 18 to 60, M-age = 35.17, SD = 8.77, 73.7% females). To assess the convergent validity of SSD-12 in the clinical samples, participants were asked to complete measures assessing anxiety, depression, somatic symptoms, health anxiety, and emotional regulation.

RESULTS

Confirmatory Factor Analyses (CFAs) showed that the three-factor model of the SSD-12 reached acceptable fit in the community and clinical samples and yielded excellent internal consistency across the samples. Also, test-retest reliability analysis results were good in the community sample. Convergent validity could be shown in the clinical samples. A cut-off score greater than 14 was in the optimal state with a sensitivity of 70.83 and a specificity of 70.07.

CONCLUSION

The current study provides evidence on the factor structure, reliability, and validity of the Persian SSD-12 in the Iranian community and clinical samples. A sum score of 14 can be recommended as the cut-off point. Further studies are needed to assess SSD-12 in different clinical populations and larger samples.

Female sex and femininity independently associate with common somatic symptom trajectories

BACKGROUND

Multiple predictors have been associated with persistent somatic symptoms. However, previous studies problematically defined the persistence of symptoms, conflated participants' sex and gender, and focused on patient populations. Therefore, we studied associations between predictors, especially sex and gender, and longitudinal patterns of somatic symptoms in the general adult population. We also assessed whether predictors for persisting symptoms differ between sexes.

METHOD

To identify developmental trajectories of somatic symptoms, assessed by the SCL-90 SOM, we used latent class trajectory modeling in the Dutch Lifelines Cohort Study [N = 150 494; 58.6% female; median time to follow-up: 46.0 (min-max: 22.0-123.0) months]. To identify predictors of trajectories, we applied multiple logistic regression analyses. Predictors were measured by surveys at baseline and a composite gender index was previously developed.

RESULTS

A five-class linear LCGA model fitted the data best: 93.7% of the population had a stable symptom trajectory, whereas 1.5% and 4.8% of the population had a consistently increasing or decreasing symptom trajectory, respectively. Female sex predicted severe, stable symptom severity (OR 1.74, 95% CI 1.36-2.22), but not increasing symptom severity (OR 1.15, 95% CI 0.99-1.40). Femininity was protective hereof (OR 0.60, 95% CI 0.44-0.82 and OR 0.66, 95% CI 0.51-0.85, respectively). Merely a few predictors of symptom severity, for instance hours of paid employment and physical functioning, differed in strength between sexes. Yet, effect sizes were small.

CONCLUSION

Female sex and femininity predict symptom trajectories. No large sex differences in the strength of additional predictors were found, thus it may not be clinically useful to distinguish between predictors specific to male or female patients of persistent somatic symptoms.

Risk factors in adolescence as predictors of trajectories of somatic symptoms over 27 years

BACKGROUND

Somatic symptoms among adolescents are common, yet little is known about long-term trajectories of somatic symptoms and the factors in adolescence that shape them. We examined individual, family and school-based factors at age 16 as predictors of trajectories of somatic symptoms over 27 years.

METHODS

Participants from the Northern Swedish Cohort (n = 1001) responded to questions about individual factors (e.g. health behaviours), family factors (e.g. contact with parents, social and material adversity) and school satisfaction at age 16; as well as 10 somatic symptoms at ages 16, 18, 21, 30 and 43. Teacher assessments at age 16 included overall ability at school and peer relations. Age 16 predictors of somatic symptom trajectory group membership were analysed using multinomial logistic regression.

RESULTS

Poor contact with mother and poor school satisfaction were significant predictors of adverse symptom trajectories among both men and women. Low birth weight and low parental academic involvement were contributing factors for women, while smoking and social adversity were more relevant factors for men.

CONCLUSIONS

Our findings emphasize the importance of a holistic approach that considers the unique contributions of individual, family and school-based factors in the development of trajectories of somatic symptoms from adolescence to middle age.

Experiences of general practitioners explaining central sensitisation to patients with persistent physical symptoms: a focus group study

OBJECTIVE

Patients with persistent physical symptoms (PPS) require an explanation that is acceptable and comprehensible to them. Central sensitisation (CS) is an explanatory model for PPS and chronic pain that has been broadly applied in the context of pain medicine, but, until recently, not by general practitioners (GPs). We explored how GPs used the CS model in their consultations with patients with PPS.

DESIGN AND SETTING

A qualitative focus group study among GPs in the Netherlands.

METHODS

We instructed 33 GPs on how to explain CS to patients with PPS. After 0.5-1.5 years of using the CS model, 26 GPs participated in focus groups and interviews to report and discuss their experiences with CS as an explanatory model. Audio recordings were transcribed and two researchers independently analysed the data. The text was coded, codes were organised into themes and discussed until consensus was reached.

RESULTS

We identified eleven themes and grouped these into four categories.The GPs regarded the CS model as evidence-based, credible and giving recognition to the patient. On the other hand, they found explaining the CS model difficult and time-consuming. They tailored the CS model to their patients' needs and used multiple consultations to explain the model. The GPs reported that the use of the CS model seemed to improve the understanding and acceptance of the symptoms by the patients and seemed to reduce their need for more diagnostic tests. Furthermore, patients seemed to become more motivated to accept appropriate therapy.

CONCLUSION

GPs reported that they were able to provide explanations with the CS model to their patients with PPS. They regarded the model as evidence-based, credible and giving recognition to the patient, but explaining it difficult and time-consuming.

Using clinical patient characteristics to predict treatment outcome of cognitive behavior therapies for individuals with medically unexplained symptoms: A systematic review and meta-analysis

OBJECTIVE

For individuals with medically unexplained symptoms (MUS), cognitive behavioral therapy (CBT) is the best-evaluated treatment. This systematic review and meta-analyses identify clinical patient characteristics associated with the treatment outcome of CBT for MUS.

METHODS

A systematic literature search (PubMed, PsycInfo, Web of Science) resulted in 53 eligible studies; of these 32 studies could be included in meta-analyses. Pooled correlation coefficients between predictors and treatment outcome were calculated with a random-effects model. Moderator analyses were conducted to examine differences between subgroups of MUS and different levels of methodological study quality.

RESULTS

Meta-analyses demonstrated that individuals with higher symptom intensity (r = 0.38; p < 0.001), lower physical functioning (r = -0.29; p < 0.001), lower emotional and social functioning (r = -0.37; p < 0.001), more potential symptom-related incentives (r = -0.15; p = 0.001), or longer symptom duration (r = 0.10; p = 0.033) at the beginning of treatment reported less change of symptom severity until the end of therapy or higher end-of-treatment symptom severity. The pooled effect sizes did not differ between certain subgroups of MUS or between different levels of methodological quality.

CONCLUSION

Our findings indicated that clinical characteristics of MUS patients are associated with treatment outcome of CBT. We discuss how the results can be used to optimize and personalize future treatments for MUS.

Mental health specialist video consultations for patients with somatic symptom disorder in primary care: protocol for a randomised feasibility trial (the VISION trial)

INTRODUCTION

General practitioners (GP) report increasing difficulties in referring patients with somatic symptom disorder (SSD) in specialised psychosocial care. Barriers are structural conditions of the respective healthcare system and patients' reservations against receiving specialised psychosocial care. As patients with SSD often predominantly assume somatic influencing factors for the development and maintenance of their somatic complaints, close collaboration between the GP and mental health specialist (MHS) seems particularly important. Integrating internet-based video consultations by remotely located MHS and primary care can improve effective treatment of patients with SSD by overcoming structural barriers and provide low-threshold and timely care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing MHS video consultations in primary care practices.

METHODS AND ANALYSIS

Fifty primary care patients with SSD will be individually randomised in two groups receiving either enhanced treatment as usual as provided by their GP (control group) or two versus five video consultations conducted by an MHS additionally to enhanced treatment as usual. The video consultations focus on (a) diagnostic clarification, (b) the development of a biopsychosocial disorder model, and (c) development of a treatment plan against the background of a stepped-care algorithm based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters.

ETHICS AND DISSEMINATION

This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-620/2021). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial.

TRIAL REGISTRATION NUMBER

DRKS00026075.

Validity and responsiveness of GHC-index in patients with amalgam-attributed health complaints

OBJECTIVE

Many patients have medically unexplained physical symptoms (MUPS); some of them attribute their health complaints to dental amalgam fillings. The aim of this study was to assess the validity and responsiveness of General Health Complaints index (GHC-index) for measuring the symptom load in MUPS patients compared to the widely used symptom outcome measure, Giessen Subjective Complaints List (GBB-24).

METHODS

Three outcome measures - GHC-index, GBB-24, and Munich Amalgam Scale (MAS) - were administered at baseline and 12 months after removal of all dental amalgam restorations. The validity and responsiveness of these symptom measures were tested against external anchors: bodily distress syndrome (BDS), SF-36 vitality, and visual analogue scale (VAS). We tested both convergent and known group validities. We also examined the predictive validity and responsiveness to changes for each instrument.

RESULTS

All the main outcome measures showed evidence of convergent and known group validities. The GHC-index, GBB-24 and MAS were all able to detect the anticipated differences in BDS and Energy. But the GBB-24 was more efficient in discriminating the BDS compared with the GHC-index (relative efficiency: RE = 0.69; 95% CI: 0.41-0.96) and MAS (RE = 0.59; 95% CI: 0.32-0.86). Each main outcome variable revealed good predictive validity for vitality (standardized coefficient: b ≈ 0.71 and R² ≈ 0.50). Moderate to high sensitivity to change over time was demonstrated, with GHC-index performing better.

CONCLUSION

The GHC-index is a valid and responsive instrument for assessing symptom load in MUPS patients attributing their health complaints to amalgam fillings and undergoing amalgam removal.

Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel

Background

Frequent Attenders with Medically Unexplained Symptoms (FA/MUS) are common in primary care, though challenging to identify and treat.

Objectives

This study sought to compare FA/MUS to FA with organic illnesses (FA/OI) and the general clinic population (Non-FA) to understand their demographic characteristics and healthcare utilisation patterns.

Methods

For this retrospective, observational study, Electronic Medical Records (EMR) were obtained from Clalit Health Services, regarding the population of a sizeable primary care clinic in Be’er-Sheva, Israel. Electronic medical records were screened to identify the top 5% of FA. FA were stratified based on whether they had OI. FA without OI were then corroborated as having MUS by their physicians. Demographics, healthcare utilisation and costs were analysed for FA/OI, FA/MUS and Non-FA.

Results

Out of 594 FA, 305 (53.6%) were FA/OI and 264 (46.4%) were FA/MUS. FA/OI were older (69.1 vs. 56.4 years, p<.001) and costlier (ILS27693 vs. ILS9075, p<.001) than FA/MUS. Average costs for FA/MUS were over four times higher than Non-FA (ILS9075 vs. ILS2035, p<.001). The largest disparities between FA/OI and FA/MUS were in hospitalisations (ILS6998 vs. ILS2033) and surgical procedures (ILS8143 vs. ILS3175). Regarding laboratory tests, differences were smaller between groups of FA but significantly different between FA and Non-FA.

Conclusion

FA/MUS are more costly than Non-FA and exhibit unique healthcare utilisation and costs patterns. FA/OI had more severe illnesses necessitating hospitalisations and surgical interventions, while FA/MUS had more investigations and tests, attempting to find an explanation for their symptoms.

Patients' Perspectives on the Usability of a Blended Approach to an Integrated Intervention for Patients With Medically Unexplained Physical Symptoms: Mixed Methods Study

Background

Medically unexplained physical symptoms are physical symptoms, such as pain, fatigue, and dizziness, that persist for more than a few weeks and cannot be explained after adequate medical examination. Treatment for preventing the chronicity of symptoms is recommended. A promising approach is identifying patients who are at risk and subsequently offering a blended care intervention that focuses on promoting self-management while using eHealth as a supportive tool. When these interventions match with a patient’s expectations, their effectiveness grows.

Objective

This study aimed to obtain more insights into usability from the patient perspective to improve future interventions.

Methods

A mixed methods design (ie, the use of qualitative and quantitative data) was used. Through semistructured interviews, in-depth insights were gained into patients’ perspectives on usability. The analysis process was continuous and iterative. Data were synthesized and categorized into different themes. The System Usability Scale, which measures the usability of a system, was used to compare participants that found usability to be low, medium, or high. This study was approved by the Medical Ethical Committee Utrecht (approval number: 17-391/C).

Results

Saturation was reached after interviewing 13 participants. The following four themes emerged from the interviews: motivations and expectations prior to participating in the program, the applicability of e-coaching, the role of health care professionals, and the integrated design of the blended approach.

Conclusions

The successful implementation of integrated blended care interventions based on patients’ perspectives requires matching treatments to patients’ individual situations and motivations. Furthermore, personalizing the relative frequency of face-to-face appointments and e-coaching can improve usability.

Identifying persistent somatic symptoms in electronic health records: exploring multiple theory-driven methods of identification

OBJECTIVE

Persistent somatic symptoms (PSSs) are defined as symptoms not fully explained by well-established pathophysiological mechanisms and are prevalent in up to 10% of patients in primary care. The present study aimed to explore methods to identify patients with a recognisable risk of having PSS in routine primary care data.

DESIGN

A cross-sectional study to explore four identification methods that each cover part of the broad spectrum of PSS was performed. Cases were selected based on (1) PSS-related syndrome codes, (2) PSS-related symptom codes, (3) PSS-related terminology and (4) Four-Dimensional Symptom Questionnaire scores and all methods combined.

SETTING

Coded electronic health record data were extracted from 76 general practices in the Netherlands.

PARTICIPANTS

Patients who were registered for at least 1 year during 2014-2018, were included (n=169 138).

OUTCOME MEASURES

Identification methods were explored based on (1) PSS sample sizes and demographics, (2) presence of chronic conditions and (3) healthcare utilisation (HCU) variables. Overlap between methods and practice specific differences were examined.

RESULTS

The percentage of cases identified varied between 0.3% and 7.0% across the methods. Over 58.1% of cases had chronic physical condition(s) and over 33.8% had chronic mental condition(s). HCU was generally higher for cases selected by any method compared with the total cohort. HCU was higher for method B compared with the other methods. In 26.7% of cases, cases were selected by multiple methods. Overlap between methods was low.

CONCLUSIONS

Different methods yielded different patient samples which were general practice specific. Therefore, for the most comprehensive data-based selection of PSS cases, a combination of methods A, C and D would be recommended. Advanced (data-driven) methods are needed to create a more sensitive algorithm for identifying the full spectrum of PSS. For clinical purposes, method B could possibly support screening of patients who are currently missed in daily practice.

The general practitioners perspective regarding registration of persistent somatic symptoms in primary care: a survey

Background

Persistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is unambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations.

Method

Dutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs’ need for improvement of PSS classification, registration and care.

Results

GPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines.

Conclusions

Registration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01525-6.

Economic evaluations of educational, physical, and psychological treatments for fibromyalgia: a systematic review with meta-analysis

ABSTRACT

Nonpharmacological interventions are recommended for the treatment of fibromyalgia, but there is a lack of knowledge about the cost-effectiveness of these interventions. The aim of this study was to systematically review economic evaluations of educational, physical, and psychological interventions for the treatment of fibromyalgia. The search was performed in PUBMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, PsycINFO, EconLit, National Health Service Economic Evaluation Database, and Health Technology Assessment. Economic evaluations of educational, physical, and psychological interventions for adult patients with fibromyalgia were included. Primary outcomes were healthcare and societal costs, and quality-adjusted life-years, and secondary outcomes were any disease-specific clinical outcome. Costs and effects were pooled in a meta-analysis, when possible. Eleven studies were included, of which 7 compared a psychological intervention with another intervention or usual care/control. Over a 6-month time horizon, healthcare and societal costs of the psychological intervention were significantly lower than usual care (mean difference: $-2087, 95% confidence interval [CI]: -3061 to -1112; mean difference: $-2411, 95% CI: -3582 to -1240, respectively), and healthcare costs were significantly lower for the psychological intervention compared with a pharmacological intervention (mean difference: $-1443, 95% CI: -2165 to -721). Over a 12-month time horizon, healthcare costs for the psychological intervention were significantly lower than for usual care (mean difference: $-538, 95% CI: -917 to -158). Incremental cost-effectiveness ratios for quality-adjusted life-years and impact of fibromyalgia showed that the psychological intervention was cost-effective compared with other interventions and control conditions. There is a need of more economic evaluations conducted alongside randomized controlled trials with interventions recommended for the treatment of fibromyalgia, such as physical exercise.

Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Functionalsomatic disorders (FSD) are common and costly, thereby driving the need for the development of effective brief treatment options. Short-term psychodynamic psychotherapy (STPP) is one candidate treatment method.

OBJECTIVE

To review and meta-analyze, where possible, randomized controlled trials (RCTs) of STPP for FSD.

METHODS

Following a systematic search of the literature, we performed a meta-analysis of available RCT groups to determine the effects of STPP on a range of outcomes after treatment, and medium- and long-term follow-ups.

RESULTS

In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias.

CONCLUSIONS

STPP is a valid treatment option for diverse FSD conditions resulting in somatic symptom reductions that persist over time. STPP should be included in FSD treatment guidelines.

Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders

Importance

There is limited information about health care use and costs in patients with functional neurological disorders (FNDs).

Objective

To assess US emergency department (ED) and inpatient use and charges for FNDs.

Design, Setting, and Participants

This economic evaluation used Healthcare Cost and Utilization Project data to assess all-payer (1) adult (age, ≥18 years) hospitalizations (2008-2017), (2) pediatric (age, 5-17 years) hospitalizations (2003, 2006, 2009, 2012, and 2016), and (3) adult and pediatric ED evaluations (2008-2017). International Classification of Diseases, Ninth Revision, Clinical Modification code 300.11 (conversion disorder) or 306.0 (musculoskeletal malfunction arising from mental factors) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification codes for conversion disorder/functional neurological symptom disorder (F44.4 to F44.7) were used to conservatively define FNDs and to compare them with other neurological disorders that are associated with high levels of health care use. Analysis was performed between January 2019 and July 2020.

Main Outcomes and Measures

Admission traits (eg, demographic characteristics of patients, length of stay, and discharge disposition) and hospital charges.

Results

Compared with other neurological disorders in 2017, emergency FND evaluations of 36 359 adults (25 807 women [71.0%] and 3800 children (2733 girls [71.9%]) more frequently resulted in inpatient admissions (22 895 adult admissions [69.2% female] and 1264 pediatric admissions [73.4% ]). These FND admissions had a shorter mean (SEM) hospital length of stay (5.21 [0.15] days vs 6.03 [0.03] days, P < .001) but higher workup rates than admissions for comparable neurological diagnoses. Admissions for FNDs had low rates of inpatient physical therapy, occupational therapy, speech and language pathology, and psychiatric consultation. The total annual costs (a proxy for total costs in 2017 US dollars) were $1066 million (95% CI, $971-$1160 million) for adult FND inpatient charges in 2017 compared with $1241 million (95% CI, $1132-$1351 million) for anterior horn cell disease; $75 million (95% CI, $57-$92 million) for pediatric FND inpatient charges in 2012 compared with $86 million (95% CI, $63-$108 million) for demyelinating diseases; and $163 million (95% CI, $144-$182 million) for adult and pediatric ED visits in 2017 compared with $135 million (95% CI $111-$159 million) for refractory epilepsy. Total charges per admission for ED care of FNDs were higher than the other comparison groups in adults. Total costs and costs per admission for FNDs increased from 2008 to 2017 at a higher rate than that of other neurological disorders.

Conclusions and Relevance

This economic evaluation found that the more than $1.2 billion and increasing annual costs for ED and inpatient care of FNDs were similar to other investigation-intensive and pharmacologically demanding neurological disorders. Unnecessary investigations and iatrogenic harm inflate costs at the expense of necessary but neglected psychiatric and rehabilitative treatments.

Application and validation of the bodily distress syndrome checklist in a psychosomatic outpatient sample

OBJECTIVE

The BDS checklist is a self-report measure to assess the most common somatic symptoms in functional somatic syndromes, based on the diagnostic concept of Bodily Distress Syndrome. The aim of the study was to examine the psychometric properties and validity of the BDS checklist in a psychosomatic sample and to investigate whether it is suitable to detect DSM-5 somatic symptom disorders (SSD).

METHOD

In a cross-sectional study, n = 368 patients from a psychosomatic outpatient clinic completed the BDS checklist and a semi-structured clinical interview on SSD. Item and scale characteristics and measures of reliability and validity were determined.

RESULTS

The BDS checklist showed good item characteristics and reliability (Cronbach α = 0.89). Factor analysis confirmed four symptom clusters (CFI = 0.95, TLI = 0.95, RMSEA = 0.091, 90% CI = 0.085-0.097). The BDS total score showed significant correlations with other measures of somatic symptom burden (r = 0.79, p < .001), health anxiety (r = 0.46, p < .001), depression (r = 0.45, p < .001), and general anxiety (r = 0.41, p < .001). Higher BDS checklist scores were associated with higher physical and mental health impairment and higher health care use. Diagnostic accuracy regarding somatic symptom disorder was moderate (AUC = 0.72, 95% CI: 0.67-0.77).

CONCLUSION

Findings of our study indicate that the BDS checklist is a reliable and valid measure to assess the most common somatic symptoms in a psychosomatic setting. It is however not sufficient to detect persons at risk for somatic symptom disorder. A combination with further questionnaires could probably improve diagnostic accuracy.

Functional neurological disorders presenting as emergencies to secondary care

BACKGROUND

Functional neurological disorders (FND) represent a significant proportion of presentations to outpatient adult neurology services. There is little information relating to patients presenting to acute inpatient care.

METHODS

We identified patients presenting as acute admissions with FND to Christchurch Hospital, Christchurch, New Zealand, from 2016 to 2018. We analyzed relevant demographic and clinical data from electronic records and measured incidence of presentation to secondary care and healthcare utilization.

RESULTS

One hundred sixty-two patients presented on 173 occasions with FND, representing 9% of all admissions to the neurology service during the 3-year study period. The mean age was 40 (SD 17) years, 111 (69%) patients were female and the median length of stay was 3 (IQR 2-4) days. A total of 92 computed tomography brain scans, 77 magnetic resonance imaging brain scans and 42 electroencephalograms were carried out. On 22 (13%) occasions, patients were referred for outpatient psychological therapy. In the 3 years prior to each patient's last presentation in the study period, these 162 patients had a total of 671 presentations to the emergency department. Healthcare demand did not decrease after the index admission. The rate of acute inpatient admission for FND was 10 per 100,000 per year for the total Christchurch Hospital catchment, 6/100,000/year in rural areas, and 11/100,000/year in urban areas.

CONCLUSION

FND represented almost 1 in 10 acute neurology admissions with significant inpatient healthcare resource utilization.

A brief cognitive behavioural intervention is cost-effective for primary care patients with medically unexplained physical symptoms compared to usual care

OBJECTIVE

To assess the cost-effectiveness of a brief cognitive behavioural intervention for patients with medically unexplained physical symptoms (MUPS) provided by a mental health nurse practitioner (MHNP) in primary care in comparison with usual care.

METHODS

We performed an economic evaluation from a societal perspective alongside a cluster randomised controlled trial with 12 months follow-up. The primary outcome was quality-adjusted life-years (QALYs). Secondary outcomes were the RAND-36 physical component summary score (PCS), somatic symptom severity (Patient Health Questionnaire (PHQ-15), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale (HADS)). Missing data were imputed using multiple imputation. We used non-parametric bootstrapping to estimate statistical uncertainty. The bootstrapped cost-effect pairs were used to estimate cost-effectiveness planes and cost-effectiveness acceptability curves.

RESULTS

Mean total costs in the intervention group were significantly lower than in the usual care group (mean difference - 2300€, 95% CI -3257 to -134). The mean difference in QALYs was 0.01 (95% CI -0.01 to 0.04), in PCS 2.46 (95% CI 1.44 to 3.47), in PHQ-15 -0.26 (95% CI -0.81 to 0.28), and in HADS -0.07 (-0.81 to 0.67). At a willingness to pay of 0 € per additional unit of effect, the probability of the intervention being cost-effective was 0.93 for QALYs and 0.92 for PCS, PHQ-15 and HADS scores.

CONCLUSION

Our intervention is cost-effective compared to usual care for patients with MUPS. Implementation of the intervention has the potential to result in a significant decline in costs. However, large scale implementation would require increased deployment of MHNPs.

Demographic and health-related factors associated with reduced work functioning in people with moderate medically unexplained physical symptoms: a cross-sectional study

BACKGROUND

Medically unexplained physical symptoms (MUPS) are a leading cause of reduced work functioning. It is not known which factors are associated with reduced work functioning in people with moderate MUPS. Insight in these factors can contribute to prevention of reduced work functioning, associated work-related costs and in MUPS becoming chronic. Therefore, the aim of this study was to identify which demographic and health-related factors are associated with reduced work functioning, operationalized as impaired work performance and absenteeism, in people with moderate MUPS.

METHODS

Data of 104 participants from an ongoing study on people with moderate MUPS were used in this cross-sectional study. Ten independent variables were measured at baseline to determine their association with reduced work functioning: severity of psychosocial symptoms (four domains, measured with the Four-Dimensional Symptom Questionnaire), physical health (RAND 36-Item Health Survey), moderate or vigorous physical activity (Activ8 activity monitor), age, sex, education level and duration of complaints. Two separate multivariable linear regression analyses were performed with backward stepwise selection, for both impaired work performance and absenteeism.

RESULTS

Absenteeism rate rose with 2.5 and 0.6% for every increased point on the Four-Dimensional Symptom Questionnaire for domain 'depression' (B = 0.025, SE = 0.009, p = .006) and domain 'somatization' (B = 0.006, SE = 0.003, p = .086), respectively. An R² value of 0.118 was found. Impaired work performance rate rose with 0.2 and 0.5% for every increased point on the Four-Dimensional Symptom Questionnaire for domain 'distress' (B = 0.002, SE = 0.001, p = .084) and domain 'somatization' (B = 0.005, SE = 0.001, p < .001), respectively. An R² value of 0.252 was found.

CONCLUSIONS

Severity of distress, probability of a depressive disorder and probability of somatization are positively associated with higher rates of reduced work functioning in people with moderate MUPS. To prevent long-term absenteeism and highly impaired work performance severity of psychosocial symptoms seem to play a significant role. However, because of the low percentage of explained variance, additional research is necessary to gain insight in other factors that might explain the variance in reduced work functioning even better.

Impact of symptom focusing and somatosensory amplification on persistent physical symptoms: A three-year follow-up study

OBJECTIVE

The somatosensory amplification theory considers symptom focusing and somatosensory amplification as important perpetuating factors of persistent physical symptoms. We investigated whether symptom focusing and somatosensory amplification were associated with symptom severity and mental and physical functioning over a three-year period in patients with persistent physical symptoms (PPS).

METHODS

Baseline, 6-, 12-, 24- and 36-months follow-up data from the PROSPECTS study, a prospective cohort consisting of 325 patients with PPS, were used. We applied longitudinal mixed model analyses to investigate if symptom focusing (CBRQ Symptom Focusing Subscale) and somatosensory amplification (Somatosensory Amplification Scale) at baseline were associated with symptom severity (PHQ-15), mental and physical functioning (RAND-36 MCS and PCS) over three years, using all measurements.

RESULTS

Symptom focusing was associated with increased symptom severity and lower mental and physical functioning over time. Somatosensory amplification at baseline was associated with increased symptom severity and lower mental and physical functioning over time. Effect sizes were small. Associations with baseline symptom focusing decreased over time, associations with baseline somatosensory amplification were more stable. There was no interaction effect of both constructs, but they partly overlapped.

CONCLUSION

This is the first study to show that over an extended period, symptom focusing and somatosensory amplification are associated with symptom severity and lower mental and physical functioning in patients with PPS. These results support the impact of both symptom focusing and somatosensory amplification on the perpetuation of symptoms and lowered mental and physical functioning in individuals with PPS.

Patients' experiences with fluctuations in persistent physical symptoms: a qualitative study

OBJECTIVES

To explore patients' experiences with fluctuations in persistent physical symptoms (PPS) and to understand which factors-from their viewpoint-play a role in these fluctuations.

DESIGN

Qualitative study using semistructured interviews and thematic content analysis.

SETTING

This qualitative study is part of a multicentre prospective cohort study on the course of PPS. Patients were recruited in general practices and specialised treatment facilities for PPS throughout the Netherlands.

PARTICIPANTS

Interviews were conducted with a sample of fifteen patients with PPS to explore their experiences with fluctuations in symptom severity.

RESULTS

We identified three themes in the analysis: (1) patterns in symptom fluctuations (2) perceived causes of symptom exacerbations and (3) Patients' strategies in gaining control over symptom exacerbations. Daily and weekly fluctuations in symptoms were an important element in patients' experiences. In particular anticipating on the worsening of symptoms impacted their daily routines and posed various challenges. Symptom exacerbations were attributed to overstepping physical limits and/or the impact of negative emotions. Resigning to physical limits, adjusting ones daily planning, weighing personal needs and learning to say 'no' were described as different strategies in gaining control over symptom exacerbations.

CONCLUSIONS

Fluctuations in the severity of symptoms-and in particular daily and weekly symptom exacerbations-are an important element of the symptom experience in patients with PPS and poses various challenges. Patients attributed symptom exacerbation to overstepping physical limits and/or negative emotions. Patients described different strategies in gaining control over symptom exacerbations.

The importance of contextual aspects in the care for patients with functional somatic symptoms

Functional somatic symptoms refer to physical symptoms that cannot be (bio) medically explained. The pattern or clustering of such symptoms may lead to functional syndromes like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, among many others. Since the underlying pathophysiology remains unknown, several explanatory models have been proposed, nearly all including social and psychological parameters. These models have stimulated effectiveness studies of several psychological and psychopharmacological therapies. While the evidence for their effectiveness is steadily growing, effect-sizes are at most moderate and many patients do not benefit. We hypothesize that the context in which interventions for functional somatic symptoms are delivered substantially influences their effectiveness. Although this hypothesis is in line with explanatory models of functional somatic symptoms, to our knowledge, studies primarily focusing on the influence of contextual aspects on treatment outcome are scarce. Contextual research in the field of somatic symptoms has (irrespective whether these symptoms can be medically explained or not), however, just begun and already yielded some valuable results. These findings can be organized according to Duranti's and Goodwin's theoretical approach to context in order to substantiate our hypothesis. Based on this approach, we categorized empirical findings in three contextual aspects, i.e. 1) the setting, 2) the behavioural environment, and 3) the language environment. Collectively, some support is found for the fact that early identification of patients with functional somatic symptoms, starting treatment as soon as possible, having a neat appearance and an organized office interior, a warm and friendly nonverbal approach and a language use without defensiveness are contextual parameters which enhance the assessment by the patient of the physician's competence to help. Nonetheless, in vivo studies addressing the most aspects, i.e. nonverbal behaviour and language, are needed for better understanding of these contextual aspect. Moreover, future research should address to what extent optimizing contextual aspects improve care for functional somatic symptoms.

Cost-Utility of Attachment-Based Compassion Therapy (ABCT) for Fibromyalgia Compared to Relaxation: A Pilot Randomized Controlled Trial

A recent study has supported the efficacy of Attachment-Based Compassion Therapy (ABCT) compared to relaxation (REL) for the management of fibromyalgia (FM). The main objective of this paper is to examine the cost-utility of ABCT compared to REL in terms of effects on quality-adjusted life years (QALYs) as well as healthcare costs. Forty-two Spanish patients with FM received 8 weekly group sessions of ABCT or REL. Data collection took place at pre- and 3-month follow-up. Cost-utility of the two treatment groups (ABCT vs. REL) was compared by examining treatment outcomes in terms of QALYs (obtained with the EQ-5D-3L) and healthcare costs (data about service use obtained with the Client Service Receipt Inventory). Data analyses were computed from a completers, ITT, and per protocol approach. Data analysis from the healthcare perspective revealed that those patients receiving ABCT exhibited larger improvements in quality of life than those doing relaxation, while being less costly 3 months after their 8-week treatment program had ended (completers: incremental cost M, 95% CI = €−194.1 (−450.3 to 356.1); incremental effect M, 95% CI = 0.023 QALYs (0.010 to 0.141)). Results were similar using an ITT approach (incremental cost M, 95% CI = €−256.3 (−447.4 to −65.3); incremental effect M, 95% CI = 0.021 QALYs (0.009 to 0.033)). A similar pattern of results were obtained from the per protocol approach. This RCT has contributed to the evidence base of compassion-based interventions and provided useful information about the cost-utility of ABCT for FM patients when compared to relaxation. However, the small sample size and short follow-up period limited the generalizability of the findings.

Psychological therapists' judgments of pain and treatment decisions: The impact of 'medically unexplained symptoms'

BACKGROUND

Clinical judgments of pain are influenced by patient and observer factors, and affect their treatment decisions. This study investigated the factors of a lack of a medical explanation for pain, 'medically unexplained' comorbid conditions, and ethnicity, on CBT therapists' judgments of pain and treatment.

METHOD

An online experimental study was conducted in which participants viewed computer-generated faces expressing pain with a brief written patient history, then estimated the severity and likely exaggeration of pain, and likelihood of pain being caused by a mental or physical health problem. Participants ranked a number of treatment options for priority.

RESULTS

107 CBT therapists were recruited as participants. Estimates of pain were lower, and of likely exaggeration higher, for patients with pain presented without a medical explanation or with a comorbid 'medically unexplained' condition. They were also more likely to be recommended CBT for depression over referral to a specialist service or psychological treatment for pain. Contrary to expectations, ethnicity produced no effect on pain judgments, only on treatment decisions. Participants' training also affected their treatment decisions.

CONCLUSIONS

Lack of medical explanation for pain and other long-term conditions biases assessment and treatment decisions by CBT therapists. As CBT therapists are increasingly referred people with 'medically unexplained' symptoms in primary care, these biases need to be addressed for better treatment.

Latent structure and factor invariance of somatic symptoms in the patient health questionnaire (PHQ-15)

BACKGROUND

Somatic symptoms are highly prevalent in primary care although insufficiently understood. The Patient Health Questionnaire (PHQ-15) is a valuable screening test but it has not yet been possible to unequivocally demonstrate its latent structure and measurement invariance.

METHODS

A total of 1,255 patients from 28 primary care centres suffering symptoms of anxiety, depression or somatisation participated in a clinical trial. They completed the PHQ-15 at baseline and 374 retook it at three months. Exploratory structural equation modelling (ESEM) was used to compare three models: 1) a single global factor for somatisation, 2) four specific correlated factors, and 3) a bifactor model integrating the first two models.

RESULTS

A multi-group invariance analysis of the best-fit model was performed: the bifactor model (χ²=25.17, df=23, p = 0.34, RMSEA=0.009, CFI=1.00, TLI=0.999). Strict invariance was good for both gender (RMSEA = 0.046, CFI = 0.973, TLI = 0.963) and age (RMSEA = 0.048, CFI = 0.964, TLI = 0.962). Configural and metric invariance were confirmed for moment of assessment, but scalar invariance was not.

LIMITATIONS

The two main limitations were the sample (primary care patients with emotional disorders), which was not representative of the general population, and the utilisation of ESEM (vs. confirmatory factor analysis), which did not allow a second-order factor model to be tested.

CONCLUSIONS

PHQ-15 showed a bifactor structure, providing both a single global measure of somatisation and specific measures of pain, gastrointestinal, cardiopulmonary and fatigue factors. Its factor invariance with regard to both gender and age was confirmed.

Detecting DSM-5 somatic symptom disorder: criterion validity of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12)

BACKGROUND

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced somatic symptom and related disorders (SSD) to improve the diagnosis of somatoform disorders. It is unclear whether existing questionnaires are useful to identify patients with SSD. Our study investigates the diagnostic accuracy of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12).

METHODS

For this cross-sectional study, participants were recruited from a psychosomatic outpatient clinic. PHQ-15, SSS-8, and SSD-12 were administered and compared with SSD criteria from a diagnostic interview. Sensitivity and specificity were calculated for optimal individual and combined cutpoints. Receiver operator curves were created and area under the curve (AUC) analyses assessed.

RESULTS

Data of n = 372 patients [31.2% male, mean age: 39.3 years (s.d. = 13.6)] were analyzed. A total of 56.2% fulfilled the SSD criteria. Diagnostic accuracy was moderate for each questionnaire (PHQ-15: AUC = 0.70; 95% CI = 0.65-0.76; SSS-8: AUC = 0.71; 95% CI = 0.66-0.77; SSD-12: AUC = 0.74; 95% CI = 0.69-0.80). Combining questionnaires improved diagnostic accuracy (PHQ-15 + SSD-12: AUC = 0.77; 95% CI = 0.72-0.82; SSS-8 + SSD-12: AUC = 0.79; 95% CI = 0.74-0.84). Optimal combined cutpoints were ⩾9 for the PHQ-15 or SSS-8, and ⩾23 for the SSD-12 (sensitivity and specificity = 69% and 70%).

CONCLUSIONS

The combination of the PHQ-15 or SSS-8 with the SSD-12 provides an easy-to-use and time- and cost-efficient opportunity to identify persons at risk for SSD. If systematically applied in routine care, effective screening and subsequent treatment might help to improve quality of life and reduce health care excess costs.

Application of ICD-11 among individuals with chronic pain: A post hoc analysis of the Stanford Self-Management Program

BACKGROUND

Chronic primary pain (CPP) is one of seven diagnostic groups within the proposed classification of chronic pain in ICD-11. Our aims were to apply the proposed ICD-11 criteria in a large cohort of chronic pain patients participating in the Chronic Pain Self-Management Program (CPSMP) and further investigate whether participants with CPP differed from participants with chronic secondary pain (CSP) regarding health, health expenditure and the effect of participating in the CPSMP.

METHODS

A secondary analysis of a randomized, controlled trial on the effect of the CPSMP. Four examiners categorized participants' pain according to ICD-11 using register-based medical diagnoses and patients' self-reported symptoms. Afterwards, differences between CPP and CSP were examined.

RESULTS

Out of 394 participants, 312 were successfully classified into CPP (n = 164) or CSP (n = 148) whereas 76 had a mixed pain condition. Participants with CPP were younger, more likely to be women, and had longer pain duration compared to participants with CSP. Participants with CPP reported worse health-related quality of life on the SF-36 Mental Component Summary and subscales of vitality, social functioning and bodily pain. Participants with CSP had more physical comorbidities and higher total health expenditure. None of the groups benefitted from the CPSMP.

CONCLUSIONS

We successfully applied the new classification of chronic pain in ICD-11 on the basis of ICD-10 medical diagnoses and symptom self-report. Participants with CPP differed significantly from participants with CSP on baseline characteristics, self-reported health measures and total health expenditure. The CPSMP was not effective in any of the groups.

SIGNIFICANCE

The current study applies the proposed new classification of chronic pain in ICD-11 and shares the experiences of the diagnostic rating procedure of individuals with chronic pain. Furthermore, it evaluates the effect of the Stanford Self-Management Program.