DEVELOPING A SERVICE FOR MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS. OR WHOSE HEADACHE IS IT ANYWAY?

1
DEVELOPING A SERVICE FOR MEDICALLY UNEXPLAINED
PHYSICAL SYMPTOMS.ORWHOSE HEADACHE IS IT
ANYWAY?

• Dr. Joanna Bromley
• Consultant Liaison Psychiatrist
• BM.BS. MRCPsych. M.A.
• Wonford House Hospital, Exeter.
• Devonshire Partnership Trust

2
Persistent Medically Unexplained Physical Symptoms

• Frequent, 1 in 5, new consultations in primary
  care
• 1 or more physical symptoms/gt 6 months/ Not
  explained
• Greater source of frustration and lower
  satisfaction than psychological problems.
• Chronic reduced functioning
• If MUS persist for gt6 months, then 75 still
  distressed/reduced functioning 12 months later
• Frequent co-morbidity with anxiety depression

3
Unexplained Symptoms in Outpatient Hospital
Clinics
Unexplained
Reid et al (2001)
Nimnuan et al ( 2001)

• Gastroenterology 54 58
• Neurology 50 62
• Cardiology 34 53
• Rheumatology 33 45
• Orthopaedics 30
• Ear,nose,throat 27
• Gyn Gen Surg 17 66
• Pulmonary 15 41
• Dental 37

4
Consequences of somatisation

• Cost of unnecessary use of healthcare
• Over 3 years Frequent attendees at medical
  outpatients cost DOUBLE that of other frequent
  O/P attendees e.g with COPD, IHD, Diabetes
• Investigations
• Admissions for treatment/operations
• Prescribed drug use and dependency
• Most requested investigations
• CT Brain scan 31
• Exercise electrocardiogram 20
• Endoscopy (OGD) 21
• Abdominal Ultrasound 34

5
Consequences of somatisation

• Chest pain with negative test results (normal
  coronary arteries) followed up over 6 years
  (Papanicolau et al 1986)
• Continuing chest discomfort 70
• Limitation of physical activity 51
• Anti-angina medication 27
• Impaired work 19
• Cardiac related admission in last yr 13

6
Exeter Neurology Cohort

• Sample of 300 patients from neurology department
  database between 2005 and 2009,
• MUS ( All tests NAD)
• Functional symptoms, low mood, significant
  stressors, Non-epileptic seizures
• 175 females and 76 males (49 patients (16)
  excluded as later found to have organic
  conditions)
• Mean age at first appointment 44 (range 17
  84)
• Mean number of neurology outpatient appointments
  3 (range 1 20)
• Information on costs for consultations and
  investigations provided by RDE coding department

7
PATHWAY OF CARE

• 20 of MUS referred to psychology services
• 16 presented to the ED
• most common complaints non-epileptic seizures,
  blackouts and pain.
• 2 visits mean (range 1 12)
• 54 of visits ended in admission
• 38 seen at other medical departments
• Mean of 3 departments physiotherapy, pain and
  orthopaedic services most commonly utilised

8
Medical Directorates involved in the pathway of
care for Neurology MUS cohort
9
Costs Devon Physical Health
Summary of costs of 13 cases with Medically
Unexplained Symptoms
10
The Patients (Long) Journey
G.P. consultation
Dietary lifestyle advice. Prescription meds.
Repeat 12x consultation/yr. Change
meds. Increased Pain
Alternative Medicine
Emergency Dept.
Gastroenterology referral, 12 wks, Ba enema
negative
Neurology referral, 16 wks, CT head negative
Practice Counsellor 5 sessions
Liaison Psychiatry Health Psychology
CMHT referral, 8 wks, no SMI
11
What Works??(pretty much anything else!)

• Review of 34 RCTs of Biopsychosocial Treatments
  (1986 to 2007, total no pats 3922)
• Range of therapies, including cognitive,
  behavioral, PIT, medication etc.
• Physical symptoms improved in 67
• (23/34 studies)
• CBT (11/13)
• Antidepressants (4/5)
• Other (8/16)
• Effect durable in 7 of 9 studies (6 mo.)

12
Primary Care InterventionA Consultation Clinic

• Matalon et al 2002 (Israel)
• 40 patients biopsychosocial assessment and
  narrative approach with GP present.
• Yearly costs reduced from 4035 to 1161 av per
  year (115,000 total over year)
• Clinic Cost 14,000 per yr (350 per patient)
• Van der Feltz-Cornelius 2006 (Netherlands)
• 81 patients, psychiatric assessment with GP and
  GP training in collaborative care. RCT with
  cluster design.
• 86 found to have comorbid psych disorders
• Severity on MUS reduced by 58 in intervention
  group

13
The Patients (Shorter) Journey
G.P. consultation persistent somatic symptoms.
Discussion with patient about referral

• Further Assessment
• Screening
• Biopsychosocial Interview
• Reframing shift on Mx
• Referral for therapy?

Pain Clinic? Biopsychosocial therapies? Groupwork?

Service user agreement with G.P. for ongoing
investigations
Discussion w/ psychotherapy or CMHT colleagues
14
Current Pilot Project

• Involve the GPs from outset, present to
  interested surgeries, discuss referral criteria,
  agree clinic times.
• Patient invited to attend, 2 hour interview,
  lunchbreak plus measures, feedback with GP.
• Aims of intervention
• Improve access from primary care to a more
  effective, more appropriate care pathway.
• Better use of scarce resources
• Reduce iatrogenic harm
• Improve the outcome for service users.
• Increase GP satisfaction and education.

15
Thank You Any Questions?

• Acknowledgements
• Ann Turner, Neuro-Psychologist, Department of
  Psychological Medicine, Exeter
• Dr. Sue Mizen, Consultant Psychiatrist in
  Psychotherapy, Wonford House, Exeter

16
(No Transcript)
17
Progress?

• For the greatest failure in the treatment of
  disease is that there are physicians for the body
  and physicians for the mind when the body and
  mind cannot be separated. But the Greek doctors
  overlook that fact and that is why so many
  diseases elude them.
• Plato 429-347 B.C.
• The tragedy for doctorsis that they spend
  their time at medical school learning about the
  organic causes of disease and then the rest of
  their lives dealing mostly with patients with
  non-organic problems
• Wessely, S. 2002 Br Med J 325

18
Fear of missing something?

• (All studies in National Neurological
  Hospitals)
• Author Year cases organic?
• Slater 1965 52 22 42
• Marsden 1986 35 15 44
• Couprie 1995 56 2 4
• Crimslisk 1998 73 3 4
• Binzer 1998 30 0 0

19
COMMON FUNCTIONAL SYNDROMES

• Fibromyalgia 13 of adults of working age in
  community studies (5 if more restrictive
  criteria used) MF ratio 19 in clinics
• Hunt et al. 1999 Mc Beth et al. 2001).
• IBS 12 prevalence, MF 1.21
• (Rome II criteria, Thompson et al. 2002)
• Chronic Fatigue Syndrome 20-30 chronic
  fatigue clinical definition 2.6 prevalence
• (Wessley et al 1997)

20
Other Non-CBT Nonpharmacological Therapies for
Somatic Symptoms

• Reattribution (Gask et al)
• Pain self-efficacy (Lorig et al)
• Exercise
• Behavior therapy
• Interpersonal therapy

21
Response to SSRI Antidepressants
Depression
Positive Well-Being
Somatic Nonpain
Pain
Greco, J Gen Intern Med 2002
22
Pre-Treatment Prevalence of Somatic Symptoms
in546 Primary Care Depressed Patients