Somatoform Disorders In Primary Care Research Articles

Diagnosis of somatoform disorders in primary care: diagnostic agreement, predictors, and comaprisons with depression and anxiety

BackgroundTo investigate (a) the diagnostic agreement between diagnoses of somatoform disorders, depressive and anxiety disorders obtained from a structured clinical interview and diagnoses reported from primary care physicians (PCPs) and (b) to identify patient and PCP-related predictors for the diagnostic agreement regarding the presence of a somatoform disorder.MethodsData from a cross-sectional study comprising 112 primary care patients at high risk for somatoform disorders were analyzed. Diagnoses according to International Classification of Diseases, 10th revision (ICD-10) for somatoform, depressive and anxiety disorders were obtained from the Composite International Diagnostic Interview (CIDI) and compared with the diagnoses of the patients’ PCPs documented in their medical records. Using multiple regression analyses, predictors for the PCPs’ diagnosis of a somatoform disorder were analyzed.ResultsThe agreement between PCP diagnoses and CIDI diagnoses was 32.3% for somatoform disorders, 48.0% for depressive disorders and 25.0% for anxiety disorders. Multiple regression analyses revealed the likelihood of being diagnosed with a somatoform disorder by PCP increased with somatic symptom severity (OR = 1.22, 95% CI 1.03–1.44). Regarding PCP-related characteristics, a specialization in internal medicine (OR = 5.95, 95% CI 1.70–20.80) and working in a solo practice (OR = 2.92, 95% CI 1.02–8.38) increased the likelihood that patients were diagnosed with a somatoform disorder.ConclusionsThe present results indicate that the process of diagnosing somatoform disorders in primary care needs to be improved. Findings further underline the necessity to implement appropriate strategies to improve early detection of patients.Trial registrationISRCTN ISRCTN55870770. Registered 22 October 2014. Retrospectively registered.

Personal and pathopsychological features of patients with somatoform disorders in primary care

IntroductionSomatoform disorders are a therapeutic challenge for primary care physicians. Various studies show low efficacy of psychotherapy for these patients, and the need for differentiated approach to their treatment.ObjectiveExplore the differences between pathopsychological, personal characteristics of patients with somatoform disorders.MethodsIt was carried out psychometric evaluation of 108 patients with different clinical variants of somatoform disorders, using SCL-90-r, Leonhard questionnaire.ResultsPatient with somatization disorder (SD) had maximum values on the “somatization”, “depression”, “hostile”, “paranoid” scales; a high level of anxiety. Singularity personality structure of these patients defining feature of exaltation, excitability, emotivity. Patients with undifferentiated somatoform disorder (USD) also showed high levels of somatization, anxiety and obsessive-compulsive, interpersonal sensitivity, phobic anxiety. Patients with stable somatoform pain disorder (SPD), had high levels of depression, obsessive-compulsive. SPD formed in individuals with features of anxiety, seizing, high emotivity. The maximum values for the scales of anxiety (ANX, PHOB) recorded in patients with somatoform dysfunction of the autonomic nervous system (SDANS). Evaluation of coping strategies showed a preferential use of the “avoidance” strategy by patients with SD, USD, a rare use of social support strategies, responsibility. Patients with somatoform pain disorder often resorted to seek social support.ConclusionThe use of the questionnaire SCL-90-r has identified a number of clinical features of patients with different variants of the SFD. Typologically in all samples of patients revealed moderate accentuation on emotivity trait.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Collaborative stepped care for somatoform disorders: A pre–post-intervention study in primary care

ObjectiveThe successful management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy, and unstructured overuse of health care. This study aimed to investigate the feasibility of establishing a collaborative stepped health care network for somatoform disorders, and its impact on the diagnostic process and treatment recommendations in primary care. MethodThe Network for Somatoform and Functional Disorders (Sofu-Net) was established to connect 41 primary care physicians (PCP), 35 psychotherapists, and 8 mental health clinics. To evaluate Sofu-Net, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire, and were assessed in detail at the patient and PCP level. Discussion of psychosocial distress in the consultations, diagnostic detection rates and treatment recommendations were compared before and 12months after establishing the network. ResultsOut of the pre- (n=1645) and 12-months-post Sofu-Net patient samples (n=1756), 267 (16.2%) and 269 (15.3%) high-risk patients were identified. From these, 156 and 123 patients were interviewed and information was assessed from their PCP. Twelve months after Sofu-Net establishment, high-risk patients more frequently discussed psychosocial distress with their PCP (63.3% vs. 79.2%, p<.001). PCPs prescribed more antidepressants (3.8% vs. 25.2%, p<.001) and less benzodiazepines (21.8% vs. 6.5%, p<.001). Sofu-Net did not affect PCP's diagnostic detection rates or recommendation to initiate psychotherapy. ConclusionThe study results indicate feasibility of an interdisciplinary network for somatoform disorders. Collaborative care networks for somatoform disorders have the potential to improve doctor–patient-communication and prescription behavior.

Improving Health Care for Patients with Somatoform and Functional Disorders: A Collaborative Stepped Care Network (Sofu-Net)

The management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy and overuse of health care. To address these difficulties, this study aimed to establish a collaborative stepped health care network (Sofu-Net). Sofu-Net was established among 41 primary care physicians, 35 psychotherapists and 8 mental health clinics. Baseline assessment in primary care showed elevated psychopathology and deficits in health care among patients with somatoform symptoms. Network partners provided positive evaluations of Sofu-Net.

A systematic review of the current barriers to diagnosing somatoform disorders in primary care

A systematic review of the current barriers to diagnosing somatoform disorders in primary care

Effectiveness of a primary care based complex intervention to promote self-management in patients presenting psychiatric symptoms: study protocol of a cluster-randomized controlled trial

BackgroundAnxiety, Depression and Somatoform (ADSom) disorders are highly prevalent in primary care. Managing these disorders is time-consuming and requires strong commitment on behalf of the General Practitioners (GPs). Furthermore, the management of these patients is restricted by the high patient turnover rates in primary care practices, especially in the German health care system.In order to address this problem, we implement a complex, low-threshold intervention by an Advanced Practice Nurse (APN) using a mixture of case management and counseling techniques to promote self-management in these patients. Here we present the protocol of the “Self-Management Support for Anxiety, Depression and Somatoform Disorders in Primary Care” (SMADS)-Study.Methods/DesignThe study is designed as a cluster-randomized controlled trial, comparing an intervention and a control group of 10 primary care practices in each case. We will compare the effectiveness of the intervention applied by an APN with usual GP-care. A total of 340 participants will be enrolled in the study, 170 in either arm. We use the Patient Health Questionnaire-German version (PHQ-D) as a screening tool for psychiatric symptoms, including patients with a score above 5 on any of the three symptom scales. The primary outcome is self-efficacy, measured by the General Self-Efficacy Scale (GSE), here used as a proxy for self-management. As secondary outcomes we include the PHQ-D symptom load and questionnaires regarding coping with illness and health related quality of life. Outcome assessments will be applied 8 weeks and 12 months after the baseline assessment.DiscussionThe SMADS-study evaluates a complex, low threshold intervention for ambulatory patients presenting ADSom-symptoms, empowering them to better manage their condition, as well as improving their motivation to engage in self-help and health-seeking behaviour. The benefit of the intervention will be substantiated, when patients can enhance their expected self-efficacy, reduce their symptom load and engage in more self-help activities to deal with their everyday lives. After successfully evaluating this psychosocial intervention, a new health care model for the management of symptoms of anxiety, depression and somatoform disorders for ambulatory patients could emerge, supplementing the work of the GP.Trial registrationClinicaltrials.gov Identifier: NCT01726387

Barriers to the diagnosis of somatoform disorders in primary care: protocol for a systematic review of the current status

BackgroundSomatoform-type disorders and functional medically unexplained symptoms are extremely common in primary care settings. These disorders, however, are consistently underdiagnosed and under-recognised which precludes effective treatment. Given that somatoform symptoms are associated with high impairment, healthcare costs and both physician and patient frustration, it is critical to improve early detection. The first step in improving patient care is to identify the current barriers which obstruct successful diagnosis to enable the design of targeted interventions. We aim to conduct a systematic review to identify the possible physician-, patient- and society-related factors and other practical constraints which may impede successful diagnosis. In the process, we will also be able to recognise the differences in methodological techniques, recommend potential avenues for future research and comment on the literature in this field as a whole.Methods/DesignWe aim to conduct a systematic review of the relevant peer-reviewed literature published in English or German in the past 10 years in MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews. Additional studies may be identified from the reference lists of included studies. Title and abstract screening and data extraction from full text manuscripts will be conducted by two independent reviewers. Because we are including a combination of qualitative and quantitative studies, the review will provide a broad understanding of the current situation. Wherever possible, the method and reporting of the review will adhere to the guidelines outlined in the PRISMA statement and bias will be assessed using the Cochrane collaboration’s recommendations. We envisage that data will be synthesised using a multilevel (qualitative and quantitative) approach which combines textual narrative and thematic analysis. Barriers will be categorised as modifiable or non-modifiable according to a conceptual framework. The review has been registered in an international registry of systematic reviews PROSPERO (CRD42013002540).DiscussionWe hope that this study will provide an insight into the barriers to diagnosis of somatoform-type disorders and the results can be used to target appropriate interventions to improve care for these patients.

Diagnostic overlap of depressive, anxiety, stress and somatoform disorders in primary care

The aim of the present study was to determine the prevalence of somatization, anxiety, depression and stress in a primary care population, explore their association to psychosocial stressors and determine the diagnostic overlap of these four mental disorders. This is a prospective cross-sectional study. A representative sample of 2,150 patients was approached, of whom 1,762 patients agreed to participate and responded to the questionnaire (81.9%). Anxiety was assessed with the Generalized Anxiety Disorder Scale (GAD-7). Depression was assessed with the depression module Patients Health Questionnaire-8. Somatization was measured with the somatic symptom module PHQ-15. The Perceived Stress Scale (PSS) instrument was used to identify the stress cases. Of the study sample, 23.8% of the total cases were identified as probable cases. The prevalence of somatization, depression, anxiety and stress was 11.7%, 11.3%, 8.3% and 18.6%, respectively. The specific gender prevalence of these four psychological disorders was very similar in men and women: depression (11.3% versus 11.3%), anxiety (7.7% versus 8.9%), somatization (12.5% versus 10.7%) and stress disorders (19.3% versus 17.8%). A significant difference was observed in nationality and marital status for depression and anxiety (P < 0.05). The age-specific prevalence rate showed a higher prevalence in the age group 45-54 years: depression (13.3%), anxiety (9.5%), somatization (12.8%) and stress (20.4%). Unable to control worries (69.2%) was the worst symptom for anxiety disorders, while the majority of the depressed patients wanted to hurt themselves (71.9%). Stomach pain (46.1%) was the most common symptom in somatic patients. Most of the patients experiencing stress could not cope with their daily duties (65.9%). There was a high comorbidity rate of depression, anxiety, somatization and stress observed in the studied population (9.3%). The prevalence of somatization and depression was similar, but the prevalence of stress was higher in inpatient patients. Somatization, depression, anxiety and stress disorders co-occurred at higher rate in the study sample.

Screening tools of somatization in general and somatoform disorders in primary care

In this article a critical review concerning screening tools to assess medically unexplained symptoms, in primary care settings is made. Once the relevance of that screening is justified, the authors analyse: 1) the somatization dimensions presented by multi-dimensional tools; 2) the measures that primarily assess the severity of symptoms; 3) the available inventories of medically unexplained symptoms. The psychometric characteristics of each screening tool are analysed, the samples and the gold standard measures used in each validation study are referred to, as well as the cut-offs, if previously calculated. At present six screening tools for physical symptoms have a Portuguese translation, four of them do not discriminate explained and unexplained symptoms, another one was not validated in the Portuguese context and finally the SOMS-2 which discriminates unexplained symptoms and has been validated for use in primary care.

Classification characteristics of the Patient Health Questionnaire-15 for screening somatoform disorders in a primary care setting

BackgroundThis study examines how effectively the Patient Health Questionnaire-15 (PHQ-15), a self-administered screening instrument, recognizes somatoform symptoms and somatoform disorders in a German primary care setting. MethodsA selected sample of 308 patients (mean age 47.2 years, 71.4% women) from two regular primary care practices was screened with the PHQ-15 and additionally examined with structured interviews. Their primary care physicians rated symptoms reported in the interview as either “medically explained” or “medically unexplained.” ResultsSeventy-six percent of the symptoms were judged as medically unexplained. The PHQ-15 correlated significantly with the total number of symptoms as well as the number of somatoform symptoms (both r=0.63; P≤.001). A comparison between the most frequently reported symptoms in the interview and the 15 items of the PHQ-15 revealed that even though the PHQ-15 does not differentiate between medically explained and medically unexplained symptoms, it does catch many somatoform symptoms. When used to predict the diagnosis of a somatoform disorder, a cutoff of 10 points in the PHQ-15 was identified as optimal, resulting in a sensitivity of 80.2% and specificity of 58.5%. However, the cutoff has to be adjusted according to specific research or clinical purposes. ConclusionSeveral previous results could be confirmed, and under consideration of some limitations, the PHQ-15 seems to be a valuable tool for identifying somatoform symptoms and disorders in primary care.

Somatoform disorders - a revision of the epidemiology in primary health care

The prevalence of somatization is dependent on the classification methods and measures used to define it and the context from which the collected data are gathered. The aim of this study was to compare the prevalence of somatization and Somatoform Disorders (SFD) in Primary Health Care. A systematic review of the studies of the prevalence of somatization and SFD in PC (Primary Care) was made, from July 1998 to June 2009. The key words of this investigation, in Pub Med, were; somatoform disorders; somatization; somatisation; medically unexplained symptoms; MUS; functional somatic symptoms, the link with each of these key words having been made to Primary Care. A grid was drawn up for the selection of each article. The criteria for the inclusion of the studies took into account aspects related to the methodology and the instruments used (use of interview) and the clear definition of medically unexplained symptoms, amongst others. Twelve studies with prevalence values in a PC setting and 1 study of metaanalysis were selected. The values found for the total prevalence of SFD were extremely disperse, taking into consideration the various studies, being between 12% and 57.9%. The same results were found in relation to somatization disorder (between 0.5% and 16.1%) with 10.1%, referred to one study, following the very restrictive criteria of ICD-10. Results were more homogeneous for somatization defined by more abridged criteria, the Somatic Symptom Index 4.6 (SSI4,6) presenting values around 20% in almost the majority of selected studies that estimate the prevalence following this criteria. In the great majority of the studies, SFD increased the relative risk of other mental disorders (depressive and anxiety disorders). Some studies concluded that there was a relative independence of somatization in relation to those disorders, certified by the existence of a specific and cumulative effect of somatization (in relation to depressive and anxiety disorders) on the level of disability and of functional limitations as well as the level of use of resources in PC. This last decade has enabled a group of new studies that allow us to understand the extent of somatization in PC, especially in Europe and North America, and to have a more clearly based idea of the needs at service level and investigation level, within the referred area.

Detecting Somatoform Disorders in Primary Care With the PHQ-15

Because recognition and management of patients with somatoform disorders are difficult, we wanted to determine the specificity, sensitivity, and the test-retest reliability of the 15-symptom Patient Health Questionnaire (PHQ-15) for detection of somatoform disorders in a high-risk primary care population. We studied the performance of the PHQ-15 in comparison with the Structured Clinical Interview for the Diagnostic and Statistical Manual-IV Axis I disorders (SCID-I) as a reference standard. From January through September 2006, we approached patients for participation. This study was conducted in primary care settings in the Netherlands. Patients aged between 18 and 70 years were eligible if they belonged to 1 or more of the following groups: (1) patients with unexplained somatic complaints, (2) frequent attenders, and (3) patients with mental health problems. For the SCID-I interview we invited all patients with a PHQ-15 score of 6 or greater and a random sample of 30% of patients with a PHQ-15 score of less than 6. The primary study outcomes were the sensitivity and specificity for the validity and the kappa coefficient for the test-retest reliability. Of 2,147 eligible patients, 906 (42%) participated (mean age 48 years, 62% female). At a cutoff level of 3 or more severe somatic symptoms during the past 4 weeks, sensitivity was 78% and specificity 71%. The test-retest reliability was 0.60. The PHQ-15 is a valid and moderately reliable questionnaire for the detection of patients in a primary care setting at risk for somatoform disorders.

Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition

Recent studies emphasize the negative impact of comorbidity on the course of depression. If undiagnosed, depression and comorbidity contribute to high medical utilization. We aimed to assess (1) prevalences of depression alone and with comorbidity (anxiety/somatoform disorders) in primary care, (2) coexistence of anxiety/somatoform disorders in depressive patients, and (3) diagnostic validity of two screeners regarding depression with versus without comorbidity. We examined 394 primary care outpatients using the Composite International Diagnostic Interview (CIDI), the General Health Questionnaire (GHQ-12), and the Well-Being Index (WHO-5). We conducted configurational frequency analyses to identify nonrandom configurations of the disorders and receiver operating characteristic (ROC)-analyses to assess diagnostic validity of the screeners. Point prevalence of any depressive disorder was 22.8%; with at least one comorbid disorder, 15%; and with two comorbid conditions, 6.1%, which significantly exceeded expected percentage (0.9%, P< or =.0001). Depression without comorbidity occurred significantly less often than expected by chance (P< or =.0007). Comorbidity of depressive and anxiety or somatoform disorders was associated with a high odds ratio (6.25). The screeners were comparable regarding their diagnostic validity for depression with [GHQ-12: area under the curve (AUC)=0.86; WHO-5: AUC=0.88] and without comorbidity (GHQ-12: AUC=0.84; WHO-5: AUC=0.86). It can be concluded that comorbidity between depression and anxiety/somatoform disorders in primary care may occur much more frequently than expected. These results confirm assumptions that the current division between depression and anxiety might be debatable. Validity of screeners tested in our study was not affected by comorbid conditions (e.g., anxiety or somatoform disorders).

Somatoform disorders in primary care and inpatient settings.

Somatoform disorders in primary care and inpatient settings.

Treatment of somatoform disorders in primary care: a randomized, controlled trail studying the effect on disability, satisfaction with care and health care utilization

Digital health interventions have enormous potential as scalable tools to improve health and healthcare delivery by improving effectiveness, efficiency, accessibility, safety, and personalization. Achieving these improvements requires a cumulative knowledge base to inform development and deployment of digital health interventions. However, evaluations of digital health interventions present special challenges. This paper aims to examine these challenges and outline an evaluation strategy in terms of the research questions needed to appraise such interventions. As they are at the intersection of biomedical, behavioral, computing, and engineering research, methods drawn from all of these disciplines are required. Relevant research questions include defining the problem and the likely benefit of the digital health intervention, which in turn requires establishing the likely reach and uptake of the intervention, the causal model describing how the intervention will achieve its intended benefit, key components, and how they interact with one another, and estimating overall benefit in terms of effectiveness, cost effectiveness, and harms. Although RCTs are important for evaluation of effectiveness and cost effectiveness, they are best undertaken only when: (1) the intervention and its delivery package are stable; (2) these can be implemented with high fidelity; and (3) there is a reasonable likelihood that the overall benefits will be clinically meaningful (improved outcomes or equivalent outcomes at lower cost). Broadening the portfolio of research questions and evaluation methods will help with developing the necessary knowledge base to inform decisions on policy, practice, and research.

A symptom checklist to screen for somatoform disorders in primary care.

Current DSM-IV somatoform diagnoses may inadequately capture many somatizing patients in primary care. By using data from two studies (1,000 and 258 patients, respectively), the authors determined 1) the optimal threshold on a checklist of 15 physical symptoms to screen for a recently proposed somatoform diagnosis, multisomatoform disorder (MSD), and 2) the concordance between MSD and somatization disorder. The optimal threshold for pursuing a diagnosis of MSD was seven or more physical symptoms. The majority (88%) of the patients who met criteria for MSD had either full or abridged somatization disorder. MSD was intermediate between abridged and full somatization disorder in terms of its association with functional impairment, psychiatric comorbidity, family dysfunction, and health care utilization and charges.