Sharing medical records: comparison of general psychiatric patients with somatisation disorder patients

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Nick Goddard, Morris Bernadt and Simon Wessely
The responses of somatisation disorder (SD) patients to reading their main clinical summary were compared with those of general psychiatric patients, to assess whether the sharing of information and psychialic opinion might help in the management of SD. Overall the SD patients responded favourably on 8 out of 11 measures; 28 of the 30 (93%) thought it was a good idea to have read the summary and 26 (87%) thought it had provided helpful information. Significantly more of the SD patients (57% compared with 27% of the general psychiatric patients) had their concerns about undiagnosed illness increase as a result of reading their clinical summary.
"There are no substantial drawbacks and con siderable benefits, both practical and ethical, to be derived from giving patients their records" concluded a review (Gilhooly & McGhee, 1991) published shortly before the Access to Health Records Act 1990 took effect. Even in such a sensitive area as oncology, patients who received a physician's letter about their cancer were more satisfied than those who did not, and the reported usefulness of the letter was greater for "bad news" compared with "good news" (DamiÃ¡n & Tattershall, 1991). In a review of the literature on access to psychiatric records for people with mental illness, Laugharne & Stafford (1996) stated that the reservations of professionals about allowing access have not been substan tiated. Little work, however, has been done on the attitudes of subgroups of psychiatric pa tients.
Giving patients accurate information and their doctor's opinion about their condition might have particular benefit in somatisation disorder (SD). This diagnosis refers to patients with multiple, recurrent, medically unexplained, so matic complaints of several years duration, many of whom are referred to psychiatrists, sometimes after extensive medical investiga tions. Kashner et al (1992) has described the high level of use of medical services by this group. A frank and open approach might be much appreciated by patients who are long-term attenders, experiencing little change as a result of their contacts with doctors. The potential educative effects of their reading and re-reading the main assessment about themselves might reduce worry about bodily symptoms and lead to an improvement in their state. On the other hand, if such patients do not accept a psycho logical formulation of their complaints, there may be more bodily concern and a desire for more physical investigation.
The aim of this study was to compare the responses of SD patients given access to the main clinical summary about themselves with those of general psychiatric patients. Do SD patients respond as favourably as general psychiatric ones, and are there differences between the two groups?

The study
Patients attending a psychiatric-medical liaison clinic with a special interest in somatisation disorder met DSM-III-R (American Psychiatric Association, 1987) criteria for this diagnosis. The comparison group were consecutive attenders at the same hospital's general adult psychiatry out patient clinic who had other DSM-III-R diag noses. Demographic details that were recorded included social class (Office of Population Cen suses and Surveys, 1970).
The questionnaire was used in a previous study (Bernadt et al. 1991), although three questions were added concerning whether, as a result of reading the summary, there had been a change in symptoms, a desire for further in vestigations, or greater concern about undiag nosed physical illness. The wording of another question was changed from 'outlook after reading the summary' to 'reassurance' by it. The full list of questions is shown in Table 1. although they were asked in a different order. The questions had five response choices, ranging from a most favourable to a most unfavourable response (not shown in Table 1). These ordinal scales were constructed using published guidelines (McKenzie & Charlson, 1986). The clinical summary used was a copy of the psychiatrist's letter to the general practitioner, written after the patient's first out-patient attendance, and describing the patient's history, mental state and diagnosis. The psychiatrists did not know that patients would read the letters and no modification was made to any of them; they were about one and a half typed A4 pages in length. Patients were posted the questionnaire with the main clinical summary enclosed and requested to return the completed questionnaire.
The maximum number of SD patients available for recruitment was 32. We aimed to recruit the same number of control patients, thereby achiev ing a statistical power of 71% for a chi-squared test with one degree of freedom, a P criterion of 0.05 and the ability to detect a 'medium size effect' (94% for a 'large effect') (Cohen, 1969).
Very small numbers of patients choosing the most unfavourable options led to ordinal scales being collapsed to binary ones giving a 'favour able' (one of the two most favourable options) or 'unfavourable' measure (the remaining options).

Findings
Of a total of 68 out-patients (32 SD patients and 36 consecutively attending controls), three general psychiatric patients were thought by the treating psychiatrist to be too unwell at the time to be included. Five patients (three nonsomatisers and two somatisers) did not return their questionnaires despite reminders. This left 30 patients in each group.
Comparing the SD patients with the general psychiatric ones, the mean ages were the same (42Â± 10years v. 42Â± 11years) but there were more females in the somatisation group (24 v. 12; X2=8.4. d.f.=l. P<0.01). Social class distribu tions did not differ significantly. Table 1shows that for both groups 80% or more of patients gave favourable ratings for the first eight items in the table. Although the clinical summary was a letter to the general practitioner, all patients gave a favourable response in respect of their understanding of its content. In both groups, 27 of the 30 (90%)reported favourably on not experiencing a worsening of symptoms. Only the somatisation group recorded less than a 50% favourable response on any item. The somatisa tion disorder patients gave more unfavourable ratings for the emphasis of the summary and for their being more concerned about undiagnosed illness as a result of reading the letter (Table 1). For each of these two questionnaire items, logistic regression showed that the only statistically significant variable was a diagnosis of SD, whereas age, sex and social class had no significant effect. Although 63% of SD patients desired further investigation of their condition, this was also true of 40% of the non-SD patients (X2=2.4;d.f.=l:P=0.12).

Comment
This is the first study of the effects of SD patients reading their main clinical summary. In the opinion of 28 of the 30 (93%) it was a good idea to have read the summary: 26 of the 30 (87%) thought that it provided helpful information and the same number were reassured by reading it. Despite their diagnosis of SD. 27 (90%) of the patients did not experience a worsening of symptoms. Although a large number of SD compared with non-SD patients rated the written summary unfavourably in respect of it having a wrong emphasis, the more important betweengroup difference from a clinical point of view was that as a result of reading the summary the SD patients had greater concern about having an undiagnosed physical illness. This suggests the SD patients did not readily accept the psycholo gical formulation of their symptoms contained in the written summary. It may seem contradictory that 17 (57%) of the SD patients were worried about an undiagnosed physical illness, yet 26 (87%) were reassured by reading the summary, but it may be that the SD patients were reassured in other ways than about having an undiagnosed physical illness. A surprising finding was that 12 (40%)ofthe general psychiatric patients wished to have further investigations of their condition as a result of reading the psychiatrist's letter.
When primary care physicians in the US were educated about SD there was a resultant saving in costs (Smith et al, 1986;Kashner et al, 1992) with no reduction in patient satisfaction or measures of physical and mental health. Giving educative written material to SD patients is part of many clinicians' practice, but it has not been formally evaluated. The merit of sharing clinical correspondence is that it is simple to do, but we have not shown it to have unequivocal gain. A dedicated educational programme for these patients requires evaluation.