AN ESTIMATED 12% OF PRIMARY care patients report persistent physical symptoms for which no good medical explanation can be found. These patients make heavy demands on a physician’s time. Despite a physician’s assertion that nothing is wrong, they request further tests or procedures. Many physicians regard such patients as refractory. These patients are not happy with their physicians, either. Their pain, fatigue, weakness, gastrointestinal disturbances, or other physical symptoms cause emotional distress and often hinder their ability to work, care for a family, and see friends. Some fear they have a fatal illness. They regard a referral to a psychiatrist as dismissive of the validity of their concerns. They often “doctor shop.” The growing integration of psychiatry with primary care offers new strategies for helping these individuals, according to speakers at a symposium on the treatment of somatoform disorders at the annual meeting of the American Psychiatric Association (APA) in Atlanta this past summer. Better treatment might well cut health care costs, too, according to Arthur Barsky, MD, co-chair of the symposium and director of psychiatric research at the Brigham and Women’s Hospital, Boston, Mass. He and Harvard Medical School colleagues found that somatizing patients use twice as many outpatient and inpatient medical care services as nonsomatizing patients do, at twice the annual cost (Barsky et al. Arch Gen Psychiatry. 2005;62:903-910). The more physical symptoms a patient reports, the more likely he or she has a psychiatric disorder, said Javier Escobar, MD, professor and chair of psychiatry, Robert Wood Johnson Medical School, in Piscataway, NJ. “Just counting physical symptoms is a good way to screen for psychopathology,” he said. Involvement of several organ systems predicts greater disability. Members of some ethnic groups— Latinos, for example, Escobar said— are more likely than others to express mental distress through physical symptoms (Lewis-Fernandez et al. J Am Board Fam Pract. 2005;18:282-296). A physician’s sensitivity to cultural differences in patients’ experience and reporting of symptoms can improve rates of detection of psychiatric disorders, he asserted. With funding from the National Institute of Mental Health (NIMH), Escobar and colleagues assessed the efficacy of cognitive behavioral therapy (CBT) in 180 adults with multiple unexplained physical symptoms, with and without concurrent depression or anxiety symptoms, recruited at an urban clinic with a large Latino population. Half were randomly assigned to receive 10 weekly, hour-long individual CBT sessions with a psychologist. The therapy, designed for a medical population and adapted to low-income, Spanish-speaking patients, targeted physical symptoms. Using a step-bystep management program, therapists worked to engage the patient, highlight the benign nature of the physical symptoms, and change negative perceptions of the symptoms, relating them to stressful events. Therapists also taught breathing and relaxation exercises, assigning homework practice. Patients in the control group received no CBT therapy; their physicians received a letter outlining treatment “do’s and don’ts,” such as “see at regular intervals,” “reassure,” and “do not tell patient it’s all in his/her head.” Researchers followed up patients for 12 months after the CBT sessions ended. Preliminary findings in the first Error bars indicate SE. Source: Arch Gen Psychiatry. 2005;62:903-910. Effects of Somatization and Psychiatric Disorders on Medical Care Utilization
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