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Management of medically unexplained symptoms: outcomes of a specialist liaison clinic

  • Frank Röhricht (a1) and Thomas Elanjithara (a2)
Abstract
Aims and method

Service utilisation and clinical outcomes of a newly developed specialist primary–secondary care liaison clinic for patients with medically unexplained symptoms (MUS) were evaluated in a cross-sectional and feasibility pilot study. The impact of body-oriented psychological therapy (BOPT) was explored in a small cohort of patients with an identified somatoform disorder.

Results

Of 147 consecutive referrals, 113 patients engaged with the assessment process. Of patients with MUS, 42% (n= 45) had a primary diagnosis of somatoform disorder, 36% (n= 38) depressive disorder, and depressive symptoms (even subsyndromal) mediated the effect of somatic symptoms. A marked variation of presenting complaints and service utilisation across ethnic groups was noted. A significant reduction in somatic symptom levels and service utilisation was achieved for patients undergoing BOPT.

Clinical implications

A high proportion of patients with MUS have undiagnosed and therefore untreated mental disorders. New and locally derived collaborative care models of active engagement in primary care settings are required. Patients with somatoform disorder may benefit from BOPT; this requires further evaluation in adequately powered clinical trials.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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None.

Footnotes
References
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Management of medically unexplained symptoms: outcomes of a specialist liaison clinic

  • Frank Röhricht (a1) and Thomas Elanjithara (a2)
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eLetters

A proactive and acceptable clinic solution for medically unexplained patients

Joanna S Bromley, Consultant Liaison Psychiatrist
31 August 2014

In their service development for Medically Unexplained Symptoms (MUS) Rohricht and Elanjithara (1) bring much needed attention to the problem ofdeveloping both an effective service and one that patients choose to attend. They highlight that a significant proportion may only engage in a collaborative model at primary care level. One of the first reasons for this is the terminology in this field (2). The patients find 'somatoform' and 'medically unexplained symptoms' unsatisfactory terms which have connotations that "it is all in the mind". They wonder if the low referralrate from some GP's and the non-attendance by nearly a quarter of patientsreferred is related to this. We have developed pilot services for MUS and chose to call our service the "Symptom Management Clinic" and locate it within GP surgeries to avoid prejudicing its acceptability by alignment with mental health hospitals or psychological terminology. On auditing our attendees many said they "would not have attended a clinic located with a mental health provider" and we achieved high user satisfaction ratings for the ease of accessibility and format of the clinic.

We also incorporated the proactive identification that they call for in their paper. We decided to "case find" and asked GPs in four separate surgeries to identify any patients that had been seen at the surgery more than 10 times in two years; had at least two negative diagnostic tests andwere not currently involved in specialist mental health services. We then examined case notes and excluded patients with current diagnostic codes onthe GP database. This process was time consuming, although it has future potential to be automated, but it did have the benefit of finding patientswho had not been thought by the GP as having MUS but were actually presenting and being referred for repeated investigations without a diagnosis. Similarly, Burton et al (3) used repeated referrals to secondary care as a guide and found that "at least three times in five years" identified MUS patients with high levels of secondary care usage.

In one surgery alone we identified 17 patients who had 286 outpatientand hospital attendances between them over two years with an average cost of ~2396 pounds/year (range ~374 to ~7403 pounds). Of these referrals 13 patients attended a Symptom Management Clinic appointment with a consultant in liaison psychiatry or a consultant clinical neuropsychologist. Involvementof the GP was considered crucial with a short feedback session with both GP and patient following the clinic to develop a collaborative approach toongoing management. This also provided a concurrent training benefit for GPs which they valued.

A cost analysis of the patient's healthcare usage prior to the Symptom Management Clinic and for two years following assessment used standard hospital tariff costs and showed a reduction of 48% in secondary care usage alone. We also showed an increase in functioning, as measured by the EQ5, and some evidence of a reduction in HADS. Around half of the patients went onto access psychotherapy via the IAPT pathway and other established programmes such as pain management but many remained managed in primary care alone (4).

We look forward to commissioners placing some confidence and resources in these preliminary MUS services to encourage learning and development of methods for improved identification and adequate treatment of this large, neglected and often costly patient group (5).

References:

1. Rohricht F, Elanjithara T. Management of Medically Unexplained Symptoms: Outcomes of a Specialist Liaison Clinic. Psychiatric Bulletin 2014; 38: 102-107

2. Creed F, Kronke K, Hennningsen P, Gudi A, White P. Evidence-based Treatment. In: Creed F, Henningsen P, Fink P (eds.) Medically Unexplained Symptoms, Somatisation and Bodily Distress. Cambridge: Cambridge; 2011. p69-96.

3. Burton C, McGorm K, Richardson G, Weller D, Sharpe M. Healthcare costs incurred by patients repeatedly referred to secondary medical care with medically unexplained symptoms: a cost of illness study. J Psychosom Res. 2012 Mar;72(3):242-7

4. Poster presented at Liaison Faculty Annual Conference in Malahide, Dublin, Ireland March 2012. A Pilot Project in Primary Care to develop a Symptom Management Clinic to assess and manage Medically Unexplained Symptoms. Dr Joanna Bromley and Ann Turner, Devon Partnership Trust, Exeter, UK.

5. Andersen NL, Eplov LF, Andersen JT, Hjorth CR, Birket-Smith M. HealthCare Use by Patients with Somatoform Disorders: A Register-based Follow-upStudy. Psychosomatics 2013; 54(2): 132-141.

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Conflict of interest: None declared

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Reflections on the management of medically unexplained symptoms

Chizoba Unigwe, Specialty Doctor
04 June 2014

We read with interest the article by Rohricht and Elanjithara (1). They have succinctly presented outcomes associated with delivering a medically unexplained liaison service in a community setting. They usefully highlight the absence of current guidelines for the management of medically unexplained symptoms in primary care.

Evidence for treating medically unexplained symptoms (MUS), until now, has been dominated by talking-based therapies (2). Patients often describe a mismatch between their physical problems and offered psychological solutions. They have come to associate body-based problems with body-based solutions and this mismatch may contribute to reluctance to consider psychological therapy. Only 29% of patients referred to body-oriented psychological therapy (BOPT), participated in assessment and treatment, with an Asian cultural predominance (1). As Rohricht and Elanjithara propose, talking based therapies may be less acceptable, especially to non-Caucasian populations seeking body based solutions. While the authors have given us an introduction into BOPT, one still does not grasp how this therapy was delivered in practice.

106 out of 113 patients received a mental health diagnosis. One wonders what the remainder were thought to have. The importance of this isthat most existing models for treatment of MUS have been limited by "uniprofessional" (3) nature of treating teams includingthe one described. Distress associated with unmet social needs may indeed undergo "conversion" to physical symptoms and where expertise is limited to any one professional discipline then outcomes may be affected. This study highlights what may be flawed about the current policy focus on only psychological treatments for these patients. It shows value in clarifying or establishing diagnoses. It may also be that establishment onpsychotropics can help patients to then engage in psychological therapy.

The authors noted that about a quarter of referrals did not attend their initial appointment. Current models of treatment depend on patients turning up for appointments which they may invariably not even remember. They may have been too disabled by their symptoms at the time of appointment or may have considered non-acute services as not useful. Theseproblems are further compounded by frequent non-colocation of liaison services. Perhaps commissioning for co-location of services and adoption of assertive outreach approaches may be ways around this block.

Persons with MUS are often not perceived as having chronic, enduring mental and physical illness. There is a need for greater awareness of the suffering experienced by this group of patients and the enormous toll thatthey may have on acute and community services (4).

References:

1.Rohricht F, Elanjithara T. Management of Medically Unexplained Symptoms: Outcomes of a Specialist Liaison Clinic. Psychiatric Bulletin [internet]. 2014 [cited 12 April 2014]. EPub 2014 Feb 20. Available from the Psychiatric Bulletin: http://pb.rcpsych.org/content/early/2014/01/27/pb.bp.112.040733.full.pdf+html. 2.Creed F, Kronke K, Hennningsen P, Gudi A, White P. Evidence-based Treatment. In: Creed F, Henningsen P, Fink P (eds.) Medically Unexplained Symptoms, Somatisation and Bodily Distress. Cambridge: Cambridge; 2011. p69-96.

3.British Pain Society. British Pain Society Response to the Department of Health Improving Access to Psychological Therapies (IAPT) Documents: Long- term Conditions Positive Practice Guide, Medically Unexplained Symptoms Positive Practice Guide. http://www.britishpainsociety.org/members_IAPT_MUPS_response.pdf. (accessed 12 April 2014)

4.Andersen NL, Eplov LF, Andersen JT, Hjorth?j CR, Birket-Smith M. Health Care Use by Patients with Somatoform Disorders: A Register-based Follow-up Study. Psychosomatics 2013; 54(2): 132-141.

... More

Conflict of interest: None declared

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