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Symptom Presentation, Interventions, and Outcome of Emotionally-Distressed Patients in Primary Care
Original Research Reports Symptom Presentation, Interventions, and Outcome of Emotionally-Distressed Patients in Primary Care Kurt Fritzsche, M.D., Hagen Sandholzer, M.D. Edda Wetzler-Burmeister, M.D., Armin Hartmann, Ph.D. Manfred Cierpka, M.D., Hans-Christian Deter, M.D. Rainer Richter, Ph.D., Bettina Schmidt, M.D. Martin Ha¨rter, M.D., Ph.D., Christoph Ho¨ger, M.D. Michael Wirsching, M.D.
Background: Patients with psychosocial problems often present somatic symptoms in primary care. Objective: The authors compare interventions and outcomes of emotionally-distressed patients by presenting physical disease, somatoform symptoms, or psychological symptoms. Method: General practitioners (N⫽191) documented data from 1,286 patients with psychosocial problems. Experts rated the presented reasons for encounter. Results: Somatoform symptoms, as well as physical disease, result in patients’ receiving physical treatments. Psychologicallyoriented treatment is more likely with psychological presentation, but not significantly related to somatoform symptoms. Conclusion: These findings underline the importance of a specific treatment approach for patients with somatoform symptoms, so as to avoid inappropriate treatment. (Psychosomatics 2010; 51:386 –394)
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atients with psychosocial problems that affect their health are common in general practice.1–4 These patients seldom raise their psychosocial problems directly in consultations with the general practitioner (GP).5 About 20% of patients who consult their GP present with phys-
Received December 13, 2008; revised April 3, 2009; accepted April 7, 2009. From the Univ. of Freiburg, Dept. of Psychosomatic Medicine and Psychotherapy; Univ. of Leipzig, Dept. of General Medicine; Univ. of Heidelberg, Dept. of Psychosomatic Research and Family Therapy; Univ. Benjamin Franklin of Berlin, Dept. of Psychosomatics and Psychotherapy; Univ. of Hamburg, Dept. of Psychosomatics and Psychotherapy; Univ. of Leipzig, Dept. of Psychosomatic Medicine and Psychotherapy; Univ. of Freiburg, Dept. of Psychiatry and Psychotherapy; Hamburg Institute and Policlinic for Medical Psychology; Univ. of Go¨ttingen, Dept. of Child and Adolescent Psychiatry. Send correspondence and reprint requests to Kurt Fritzsche, M.D., Dept. of Psychosomatic Medicine and Psychotherapy, Hauptstr. 8, D-79104 Freiburg, Germany. e-mail: [email protected] © 2010 The Academy of Psychosomatic Medicine
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ically unexplained symptoms.6 About 25% of patients with psychiatric morbidity in general practice present with only somatic symptoms.7,8 Thus, presentation of a physical complaint becomes the “entry ticket” to the doctor’s office.9 Despite the belief of the GP that disease is absent, he or she routinely offers these patients somatic treatment.10,11 To improve the recognition and treatment of patients with psychosocial problems, Psychosocial Primary Care (PPC) was introduced in Germany in 1987. Since 1994, PPC has become established as a standard postgraduate training course in Germany. The implementation of curricula and standardized qualification requirements for billing the PPC by German health insurance companies led to a clear improvement in psychosocial primary care.12,13 According to the regulations, doctors have to complete an 80-hour training course consisting of 20 hours on the Psychosomatics 51:5, September-October 2010
Fritzsche et al. recognition and treatment of psychological disorders, including the management of somatizing patients, 30 hours on communication skills, and 30 hours in a Balint group. Since its introduction, about 50% of all German GPs have completed the training. However, previous studies have shown that GPs are selective regarding psychosocial treatment, giving preference to patients who present with psychological symptoms.1,4,14,15
Hypothesis Although general practitioners may have been trained in PPC, there are significant differences concerning the psychosocial treatment offered and the outcomes of such treatment for patients presenting with physical disease, somatoform symptoms, or psychological problems and symptoms. We surmise that patients who present with somatoform symptoms are treated like patients with a physical illness, which means that they get more somatic diagnostics, fewer psychosocial interventions, and fewer referrals to psychotherapy than patients who present psychological symptoms. Furthermore, we presume that patients with somatoform symptom presentation are less satisfied and that the success of the treatment is lower than in patients with psychological symptoms or physical disease.
50% of professional time as a primary-care physician and being involved in administering psychotherapy. The program was intended as a partnership, and the clinical decision was to remain autonomous. To convince the largest possible number of doctors to fill in their documentation, a cross-sectional study design was chosen because many doctors would not have participated in the study at two subsequent times. The cross-sectional study design resulted in increased acceptance and motivation to participate in the study and enabled fast data feedback to the GPs. The decision that the doctors pick the patients independently, based on the criterion of “psychosocial distress” over a period of 3 months was made to prevent any disturbances of the practice routine. In all, 191 doctors participated in the survey, documenting 1,286 treatment episodes; 28% of the participating doctors work in joint practices. The average participant’s age was 46 years (standard deviation [SD]: 13.5); 46% of the physicians were women. The number of treated patients per physician per quarter was distributed as follows: 11%: ⬍500 patients; 42%: 500 –999 patients; 33%: 1,000 –1,500 patients; and 15%: ⬎1,500 patients. The inclusion and assessment process is shown in Table 1. All participants gave their informed consent, and the ethical and legal acceptability of the study was confirmed before its start by the responsible Ethics Committee. After the end of the consultation, the GPs filled in a TABLE 1.
METHOD The data were taken from the multicenter study “Quality Management in Psychosocial Primary Care,” which was promoted by the Ministry of Health and coordinated by the Department of General Practice, Go¨ttingen.12,15 The participants were general practitioners who had taken part in an 80-hour training course in PPC. The aim of the project was the development, testing, and evaluation of methods in quality management for GPs. The project had three phases: 1) Target-group poll of 51 GPs to quality objectives and development of documentation instruments; 2) Documentation of the treatment of patients with psychosocial distress; 3) Feedback of the results and initiation of measures for quality improvement—for example, case conferences and quality circles. GPs were recruited from a nationwide pool of physicians. Inclusion criteria were qualifications in Psychosocial Primary Care and willingness to document and help develop measures for quality improvement. Exclusion criteria were spending less than Psychosomatics 51:5, September-October 2010
Inclusion and Assessment Process ● Cover letter to all doctors with qualifications in Psychosocial Primary Care in six study centers, representing general practitioners (GPs) from urban vs. rural areas, in east, west, north, and south of Germany (N⫽2,574) ● GPs giving written consent to participate (N⫽191) ● Treatment episodes documented from GPs and patients (N⫽1,338) ● Excluded because of incomplete data (N⫽52) ● Sample size: GPs (N⫽191); patients (N⫽1,286)
GPs Filling Out Questionnaires Reason for visit Psychosocial distress Treatment Outcome
Patients Filling Out Questionnaires Hospital Anxiety and Depression Scale (HADS) Giessen Subjective Complaints List (GBB) Outcome
Rating of reason for visits by experts on a scale of 0-100, on three dimensions: 1) Physical disease 2) Somatoform symptoms 3) Psychological symptoms and problems
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Distressed Patients in Primary Care questionnaire on the treatment process and its outcome, and the patients filled in a questionnaire on sociodemographic data, emotional distress, and treatment outcome. Most of the patients (95%) had been treated by the same GP for quite some time. Questionnaire for General Practitioners (GPs) The GPs completed a questionnaire with the following items: the reason for the patient’s visit; current psychosocial distress according to nine categories: anxiety, depression, partner/family conflicts, physical illness, stressful life events, sleep disorders, pain, work problems, and alcohol and substance abuse. Each problem was rated on a scale from 0 to 3 (0: no problems or stress; 3: highest degree of problems or stress). In the review of systems for treatment, the following were recorded: whether the complaints at the time improved or worsened since the diagnosis was made (–2 to ⫹ 2) and the number of consultations over the previous 12 months. We asked whether the psychological attribution of the patient’s illness was initially present, developed during treatment, or was not present. The interventions comprised physical treatment, psychosocial treatment, and referrals. The psychosocial treatment included 1) a psycho-diagnostic interview; 2) psychosocial interventions; 3) referral to mental health services (psychotherapists) if indicated. Outcome measures Three variables were used to measure outcome: 1) Doctor–patient relationship: “Do you have the feeling that the patient understood you?” 2) treatment effect: “Success of the treatment;” and 3) treatment satisfaction: “Satisfaction of the patient with the treatment.” They were rated on a 5-point Likert scale (–2 to ⫹2). Finally, the importance of an exchange between colleagues were also rated on a 5-point Likert scale (not at all important: –2, to ⫹2: very important) and whether this exchange took place (e.g., Balint group) for documented patients (Yes/No). The questionnaire could be filled out in about 15 minutes. Questionnaires for Patients Outcome measures The questions to the patients were matched with the questions to the doctors. 1) Doctor– patient relationship: “To what extent did you feel understood by your doctor?” 2) treatment effect: “How successful, do you think, was your treatment?,” and 3) treatment 388
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satisfaction: “How satisfied are you with your treatment?” They were also rated on a 5-point Likert scale (–2 to ⫹2). Hospital Anxiety and Depression Scale (HADS)16,17 The HADS is a well-validated, routinely used screening instrument for the detection of emotional distress in physically ill patients. Giessen Subjective Complaints List (GBB) The GBB18 is a self-report instrument for health complaints. The 24 items are rated on 5-point-scales from 0 (not at all) to 5 (strong). The questionnaire yields four summary scores: exhaustion, gastric symptoms, pain, and cardiovascular complaints. The GBB was standardized in samples representative of the whole population of Germany. The factor structure and internal consistency of the subscales have remained largely constant. Reason-for-Visit Classification The reason for visit given by patients was classified with the German version of Reason-for-Visit Classification (RVC).19 The RVC20 was developed by the American Medical Record Association in the National Center for Health Statistics of the United States for use in outpatient care. Its goal is to document complaints on the level of symptoms, diagnosis, and administrative reasons. We rated the reasons for the visit according to three dimensions: 1) physical disease; 2) somatoform symptoms; and 3) psychological problems and symptoms. The probability of the cause being physical, somatoform, or psychological was rated on a scale from 0% to 100% (in five steps, by 25%). Thus, the probability of each of the three dimensions of a complaint was assessed. Anxiety, depression, and other emotional disorders were rated as being 100% psychological. Chest pain, nausea, headaches, or dizziness were rated as being 75% somatoform and 25% physical. Encephalitis disseminata and coronary heart disease were rated as being 100% physical. Complaints of a patient reporting depression, headache, and a separation conflict as the reasons for the visit were rated as being 100% psychological, 25% somatoform, and 0% physical. It may happen that a presentation is rated as being physical as well as psychological (e.g., cancer and depression) in any other combination. In case of doubt, the complaint was rated as being physical. The ratings of the reported symptoms were aggregated into the final variables, measuring the overall case presentation. The reliability of judges was tested with 20 randomly selected cases. The raters were a clinically-experienced Psychosomatics 51:5, September-October 2010
Fritzsche et al. psychiatrist and psychotherapist (EW-B) and a clinicallyexperienced internist and psychoanalytically-trained psychotherapist (KF) They independently estimated the probability that the presented complaints were attributed to physical disease, somatoform symptom, or psychological symptom. The calculation of interclass correlation (ICC) showed values around 0.88 (for physical disease), 0.94 (somatoform symptoms), and 0.98 (psychological symptoms). Because of low frequencies, the three middle categories were collapsed into one, leading, therefore, to three remaining categories: 100%, 75%–25%, and 0%. Statistical Analysis The statistical evaluation was calculated with the statistical program SPSS, Release 11ff. Simple descriptive statistics were used to describe the sample and the univariate distribution (mean, SD, frequency tables). For the interval-scaled data, we used the t-test for independent samples to test differences between the two groups. We used cross-tables and chi-square statistics for the nominal data. Simple Pearson’s correlation coefficients were calculated to quantify relationships between variables. The dependent variables (N⫽13) that describe the doctor’s activity were grouped into two factors by factor analysis (principal-component analysis [PCA] varimax rotation; see Table 2). The seven interventions and activities: physical therapies, somatic medication, other somatic therapies, alternative treatment, patient information, refer to specialist TABLE 2.
Factor Loadings on 13 Activities Activity
Physicotherapeutics Other medications Patient information Other somatic therapy Alternative treatment Referral to a specialist (excluding somatic illness) Work disability Psychotherapeutic interventions Psychodiagnostic interview Psychotropics Referral psychotherapy Family interview Relaxation therapy
Factor 1: Somatic
Factor 2: Psychological
0.653 0.576 0.560 0.509 0.498 0.390 0.326 0.756 0.640 0.492 0.445 0.425 0.290
Principal-components analysis, varimax rotation: explained variance: 28.7%. Loadings below 0.25 are suppressed.
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(excluding somatic illness), and work disability formed the factor Physical Treatment (model parameters: Hosmer Lemeshow⫽9.64; df: 8; p⬎0.25; model chi-square⫽107; df: 5; p⬍0.001; Nagelkerke pseudo R2⫽0.12). The six activities: psychodiagnostic interview, psychosocial intervention, psychotropics, family interview, relaxation therapy, and referral to psychotherapy constituted the factor Psychological Treatment (model parameters: Hosmer Lemeshow⫽17; df: 8; p⫽0.026; model chisquare⫽109; df: 6; p⬍0.001; Nagelkerke pseudo R2⫽0.12). Factors values for Physical Treatment and Psychological Treatment were then dichotomized at the level of the upper tertile (upper tertile: Intensive versus lower two tertiles: Not Intensive). Logistic-regression analysis was used in multivariate models to detect genuine predictors for “Intensive Physical” and “Intensive Psychological” treatment. Missing values were excluded from all analyses, so that the sample sizes varied for the individual tests.
RESULTS
Sociodemographic Data Sociodemographic and clinical data for the sample are shown in Table 3. There were no differences between men and women concerning physical disease, somatoform, and psychological symptoms as the reason for visit. Older age was more likely to be related to physical disease presentation (r⫽0.386; p⬍0.001), whereas younger age was correlated with psychological symptom presentation (r ⫽ – 0.281; p⬍0.001). No difference in age were found for somatoform presentation. These values for emotional distress (HADS) and physical complaints (GBB) are considerably higher than the average for the general population in this age-group. The mean value for Depression in the German general population age 40 to 59 is 4.8 (SD: 3.7) and, for Anxiety, 5.2 (SD: 3.4). In the questionnaire concerning general physical symptoms (GBB), patients reported a two- (exhaustion, overall complaints) to three-times (stomach trouble) higher distress level than the general population. The most common reasons for the visit, in declining order, were stomach trouble, headache, anxiety, sleeping disorders, hypertension, dizziness, heart complaints, depression, and back pain. http://psy.psychiatryonline.org
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TABLE 3.
Sociodemographic and Clinical Data of the Sample Variable
Age, years, mean (SD) Gender Men Women Marital status, % Married Single Education level, % Elementary school Secondary modern school College preparatory school Others Occupation, % Employed fulltime Unemployed Retired Homemaker HADS, mean (SD) Depression Anxiety GBB: Patients in Q4, % Exhaustion Stomach pain Rheumatic pain Heart problems Total distress Symptom presentation,a mean (SD) of % Physical Somatoform Psychological
378 (29.4) 903 (70.2) 51.4 24.5 43.1 31.4 20.1 6.8 61.9 7.7 16.9 13.5 7.75 (4.66) 9.99 (4.43) 47.2 76.9 42.8 39.3 48.4 37.0 (42.7) 53.0 (52.5) 48.0 (48.3)
Psychosocial Distress and Symptom Presentation Correlations of actual psychosocial distress, as rated by GPs, and symptom presentation are shown in Table 4. In the self-rated questionnaires, patients with physical disease presentation showed a positive and significant (p⬍0.01) correlation (r⬎0.20) with physical illness (r⫽0.259) and a negative correlation with anxiety (r ⫽ – 0.210). Somatoform symptom presentation was positively correlated with pain (r⫽0.273). Psychological symptom presentation was positively correlated with depression (r⫽0.229) and sleep disorder (r⫽0.224), and negatively correlated with pain (r ⫽ – 0.247). The correlations with GBB health complaints are weak (p⬍0.05) and point in the expected direction: Patients with stronger somatoform symptom presentation showed a positive correlation with stomach trouble (r⫽0.119) and rheumatic pain (r⫽0.159); patients with http://psy.psychiatryonline.org
Correlations Between Doctors’ Rating of Actual Biopsychosocial Stress and Symptom Presentation of the Patients
46.3 (15.6)
Because of missing data, N ranges from 959 to 1,286. SD: standard deviation; HADS: Hospital Anxiety and Depression Scale; Q4: upper quartile of normal population. a The correlation between variables ranged from – 0.39 to – 0.28.
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TABLE 4.
Symptom Presentation
Biopsychosocial Stress
Physical
Somatoform
Psychological
Physical illness Substance abuse Anxiety Depression Pain Sleep disorders Partnership/family Profession Life events
0.259** 0.074* –0.210** –0.172** –0.001 –0.127** –0.067* –0.012 –0.061*
–0.007 –0.077** 0.046 –0.015 0.273** –0.064* –0.018 –0.031 –0.008
–0.163** 0.117** 0.198** 0.229** –0.247** 0.224** 0.123** 0.060* 0.118**
* p ⬍0.05; ** p ⬍0.01.
physical disease presentation showed a negative correlation with exhaustion (r ⫽ – 0.111) and heart problems (r ⫽ – 0.116). Patients with psychological symptom presentation showed a positive correlation with exhaustion (r⫽0.105).
Interventions Two indices: “Intensive Physical Treatment” (Table 5 [A]) and “Intensive Psychological Treatment (Table 5 [B]),” were built out of the interventions made by general practitioners (see Method section). Multivariate logisticanalysis models (forward stepwise procedure: PIN: 0.05; POUT: 0.10) were used to build up the most parsimonious models for these two treatment types. Predictor candidates tested were: age, sex, the three presentation modes (physical, somatoform, psychological), experience with psychotherapy, improvement of the symptoms, psychological attributions to the symptoms initially present or developed during treatment, and the number of doctor visits in the last year. For the “Intensive Physical Treatment,” the final model contained five predictors: age, number of consultations, and the three presentation modes. Physical Treatment was significantly more likely for patients with older age, higher number of consultations, and presentation of a physical disease and somatoform symptoms. The relationship with psychological presentation was not significant (p⫽0.09; Table 5 [A]). For “Intensive Psychological Treatment,” the final model contained five predictors: number of consultations, psychological attribution of the symptoms, and physical, psychological, and somatoform presentation. Psychological treatment was significantly Psychosomatics 51:5, September-October 2010
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TABLE 5.
Multivariate Logistic-Regression Model on Intensive Physical Treatment and Intensive Psychological Treatment
[A]: Intensive Physical Treatment (Upper Tertile of Factor: Physical Intervention of GP) Parameter

df
Significance (Wald)
OR
95% CI
Presentation: physical: Presentation: psychological Presentation: somatoform Age, years Consultations, N Constant
0.342 –0.139 0.396 0.015 0.437 –3.361
1 1 1 1 1 1
⬍0.001 0.093 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
1.408 .870 1.486 1.015 1.549
1.178–1.684 0.740–1.023 1.255–1.759 1.006–1.023 1.338–1.793
Model development: forward stepwise (PIN 0.05, POUT 0.10); forced entry. [B]: Intensive Psychological Treatment (Upper Tertile of Factor: Psychological Intervention of GP) Parameter

df
Significance (Wald)
OR
95% CI
Presentation: physical Presentation: psychological Presentation: somatoform Psychological attribution to the symptoms initially present developed during treatment Consultations, N Constant
–0.323 0.278 –0.089
1 1 1 2
⬍0.001 ⬍0.001 0.274 ⬍0.001
0.724 1.321 0.915
0.607–0.863 1.125–1.551 0.780–1.073
1 1
⬍0.001 ⬍0.01 ⬍0.001 ⬍0.001
1.946 1.657 1.570
1.386–2.767 1.208–2.272 1.364–1.807
0.666 0.505 0.451 –2.503
Reference category for “Psychological attribution to the illness”: “Not Present.” GP: general practitioner; OR: odds ratio; CI: confidence interval.
more likely if the psychological attribution to the symptoms was initially prevalent or developed during treatment, if the number of previous consultations was higher, and with a psychological presentation. It was significantly less likely with physical disease presentation. The relationship with somatoform presentation was not significant (see Table 5 [B]).
1,254; p⫽0.032). Concerning the level of importance, there were no differences for physical disease and psychological symptom presentation. For 331 physicians (26.4%), an exchange had taken place, for example, in a Balint group or a quality circle. In contrast to the importance of an exchange between colTABLE 6.
Outcomes
Correlations Between Treatment Outcome and Symptom Presentation
[A]: From the Perspective of the General Practitioners (GPs)
There was a weak positive correlation between treatment outcomes and patients with physical disease and psychological symptom presentation. There was a weak negative correlation between treatment outcomes and patients with somatoform symptom presentation (see Table 6 [A] and 6 [B]).
Symptom Presentation GPs
Physical
Somatoform
Psychological
Mutual understanding Success Satisfaction
0.008 0.051 0.060*
–0.117** –0.101** –0.120**
0.125** 0.063* 0.055*
* p ⬍0.05; ** p ⬍0.01.
Exchange Between Colleagues
[B]: From the Perspective of the Patients Symptom Presentation
For 676 of the patients (53.8%), the physicians found an exchange between colleagues very important. GPs felt an exchange more important for patients with a more somatoform symptom presentation than for patients with a less somatoform symptom presentation (M [important]⫽0.55; M [not important]⫽0.495; t ⫽ –2.147; df: Psychosomatics 51:5, September-October 2010
Patients
Physical
Somatoform
Psychological
Mutual understanding Success Satisfaction
0.005 0.078 0.065*
–0.072* –0.113** –0.156**
0.112** 0.017 0.085*
* p ⬍0.05; ** p ⬍0.01.
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Distressed Patients in Primary Care leagues, the exchange was more likely to occur in the case of a more psychological symptom presentation (M [occur]⫽0.5275; M [not occur]⫽0.4675; t ⫽ –2.079; df: 2.21; p⫽0.038). There were no differences for physical disease and somatoform symptom presentation. DISCUSSION Patients who presented their emotional distress directly are significantly more likely to get psychological treatment, that is, psychosocial intervention or psychotropics, and they were more often referred to outpatient psychotherapy, as well. Patients with mainly somatoform symptom presentations are significantly more likely to get somatic treatment, that is, medication, physical treatments, alternative treatment, and referrals for the exclusion of physical disease. Our results partly confirm those of some earlier studies with similar queries. In a study to determine the frequency and treatment of psychosocial problems in the German Primary Health Care setting, 31% of the patients rated themselves as emotionally stressed and received psychosocial interventions; 9.5% of these patients were referred for psychotherapy. The patients with somatoform symptoms did not receive any recommendation for psychotherapy, and only 16% received psychosocial interventions.4 In a Dutch study,21 patients who presented their complaints as being psychosocial received more treatment than those reporting complaints somatically. There were 11⁄2 times as many counseling consultations for psychological symptoms as for somatic symptoms. Referrals to and consultations with mental health specialists almost always concerned psychological symptoms. The average duration of consultation was 20% longer when purely psychological symptoms were involved.21 The treatment outcome of our study differs from the study by Cape;22 in this study, patients with psychological problems presenting only somatic symptoms have clinical outcomes equivalent to patients presenting psychological problems in a direct way. This study is subject to several methodological limitations: First, a major flaw of the study might be selection bias of patients. Since all physicians have been trained in psychosocial primary care, they might be more likely to recognize psychosocial distress. The doctors themselves selected their patients. Therefore, this is a sample of convenience, rather than a consecutive or random sample. Second, in grouping the reasons for visits, the external 392
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raters could have erroneously classified patients with organic diseases as “somatizers” or vice versa. Third, the retrospective documentation of the data introduces the possibility of a recall bias, because many doctors would not have been willing to participate in the study at two subsequent times. The cross-sectional study design resulted in increased acceptance and enabled fast data feedback to the GPs. Fourth, we have a huge sample size with various types of problems presented and different interventions. Therefore, the data-reduction creating two intervention factors is a simplification. Fifth, the data on treatment results are based on three global items from the viewpoint of the doctor and the patient and are not validated, standardized outcome measures. A check of the results within a prospective design with validated, standardized psychometric questionnaires is necessary. Generalizability The patients are representative concerning their sociodemographic data for the population of a GP, as shown by comparison with the EvaS Study, a trial of outpatient medical care in Germany.23 However, results are limited to qualified GPs interested in Psychosocial Primary Care (PPC). Therefore, the results cannot be applied to GPs without qualification in PPC. Overall Evidence Why do even GPs trained in psychosocial care offer their somatizing patients somatic treatment? A positive explanation is that the GPs, recognizing the psychosocial aspects of somatization, first offer somatic treatment in order to establish a therapeutic alliance. Later on, they may lead the patient to a psychological approach to his or her symptoms. But it is also possible that the GPs react to the patient’s repeated complaints with negative countertransference and less empathic discussion, and attempt to regain authority by viewing the complaints as a medical problem in an area they are most familiar with.24 Specific psychosocial interventions for patients with somatoform symptoms in primary care are necessary and should be integrated into GP training programs.25 First, published results regarding the effectiveness of those treatments in somatizing patients, as applied by the GP26 –29 and in cooperation with a mental health specialist30 are not as effective as expected. Patients with medically unexplained physical symptoms remain a challenge for the GP and for psychosomatic research. Psychosomatics 51:5, September-October 2010
Fritzsche et al. A full report is available: Qualita¨tssicherung in der Psychosomatik. Verbundstudie innerhalb des Demonstrationsprojekts in der ambulanten Versorgung “Hrsg.: Das Bundesministerium fu¨r Gesundheit, Projektkoordinator: Hagen Sandholzer. Baden-Baden 1999: Nomos Verl.Ges., 1999 (Schriftenreihe des Bundesministeriums fu¨r Gesundheit, Bd 118) ISBN 3–7890-6119 – 0). The authors thank all actively participating GPs for their cooperation, for the manifold discussions, inspirations, and provision of data. In addition to the authors, the
following employees contributed to this study: Berlin, Germany: Dilg, Freiburg, Dept. of Psychosomatic Medicine: Hammel, Campagnolo; Freiburg, Dept. of Psychiatry: Kenk; Go¨ttingen, Dept. of Family Therapy: Bohlen; Go¨ttingen, project coordination: Liebler, Pelz; Go¨ttingen, Dept. of Child and Adolescent Psychiatry: Witte-Lakemann; Hamburg: Albota; Leipzig: Ziener; Marburg: Wahl. The study was funded by Grant no. 217-43794-3/13 from the German Federal Ministry of Health.
References 1. Verhaak PF, Tuhuis M: Psychosocial problems in primary care: some results from the Dutch National Study of Morbidity and Interventions in General Practice: Soc Sci Med 1992; 35:105– 110 2. Ormel J, Von Korff M, Ustun TB, et al: Common mental disorders and disability across cultures: results from the World Health Organization Collaborative Study on Psychological Problems in General Health Care: JAMA 1994; 272:1741–1748 3. Linden M, Maier W, Achberger M, et al: Psychische erkrankungen und ihre behandlung in allgemeinarztpraxen in Deutschland. Ergebnisse aus einer Studie der Weltgesundheitsorganisation (World Health Organization): Nervenarzt 1996; 67:2058 –2150 4. Tress W, Kruse J, Heckrath C, et al: Psychogene Erkrankungen in hausa¨rztlichen Praxen. Z Psychosom Med 1997; 43:211–232 5. Bridges KW, Goldberg DP: Somatic presentation of DSM–III disorders in primary care. J Psychosom Res 1985; 29:563–569 6. Peveler R, Kilkenny L, Kinmoth AL: Medically unexplained physical symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 1997; K42:245–252 7. Wright AF: A study of the presentation of somatic symptoms in general practice by patients with psychiatric disturbance: Br J Gen Pract 1990; 40:459 – 463 8. Weich S, Lewis G, Donmall R, et al: Somatic presentation of psychiatric morbidity in general practice: Br J Gen Pract 1995; 45:143–147 9. Guldbrandsen P, Fugelli P, Hjortdahl P: Psychosocial problems presented by patients with somatic reason for encounter: tip of the iceberg? Fam Pract 1998; 15:1– 8 10. Ring A, Dowrick CF, Humphris GM, et al: The somatizating effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med 2005; 61:1505–1515 11. Barsky AJ, Ettner SL, Horsky J, et al: Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care 2001; 39:705–715 12. Fritzsche K, Sandholzer H, Brucks U, et al: Psychosocial care by general practitioners: where are the problems? results of a demonstration project on quality management in psychosocial primary care. Int J Psychiatry Med 1999; 29:395– 409 13. Fritzsche K, Larisch A, Cierpka M, et al: Improving the biopsychosocial competence of German primary care physicians in diagnosing and treating somatoform disorders. Fam System and Health 2004; 22:352–364
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14. Goldberg D, Bridges K: Somatic presentations of psychiatric illness in primary care setting: J Psychosom Res 1988; 32:137– 144 15. Sandholzer H, Pelz J: Quality assurance in basic psychosomatic care: report of an expert survey within the scope of the Federal Public Health Administration-instigated pilot project. Z Arztl Fortbild 1996; 90:434 – 440 16. Zigmond AS, Snaith RP: The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67:361–370 17. Herrmann C, Buss U, Snaith RP: HADS–D: Hospital Anxiety and Depression Scale: Deutsche Version [German Version]. Bern, Switzerland, Huber, 1995 18. Bra¨hler E, Scheer JW: Der Giessener Beschwerdebogen. Bern, Switzerland, Huber, 1995 19. Wagner P, Schach E, Schwartz FW: RVC: A Reason-for-Visit Classification for Ambulatory Care: Ein Klassifikationsschema fu¨r Kontaktanla¨sse in der ambulanten Versorgung: Ko¨ln, Ger¨ rzte-Verlag, 1989 many, Deutscher A 20. Schneider D, Appleton L, McLemure TH: A Reason-for-Visit Classification for Ambulatory Care: Data Evaluation and Methods Research, Series 2, #87, National Center for Health Statistics: U.S. Dept. of Health and Human Services: Public Health Service, Washington, DC, U.S. Government Printing Office, 1979 21. Verhaak PF, Wennink HJ: What does a doctor do with psychosocial problems in primary care? Int J Psychiatry Med 1990; 20:151–162 22. Cape J: How general-practice patients with emotional problems presenting with somatic or psychological symptoms explain their improvement. Br J Gen Pract 2001; 51:724 –729 23. Schach E, Schwartz FW, Krek-Bodden HE: Die EVaS-Studie. Eine Erhebung u¨ber die ambulante medizinische Versorgung in der Bundesrepublik Deutschland. (The EvaS Study 1: A trial of outpatient medical care in Germany.) Ko¨ln, Germany, Deutscher ¨ rzte-Verlag, 1989 A 24. Salmon P, Humphris GM, Ring A, et al: Why do primary care physicians propose medical care to patients with medically unexplained symptoms? a new method of sequence analysis to test theories of patient pressure: Psychosom Med 2006; 68:570 –577 25. Fink P, Rosendale M, Toft T: Assessment and treatment of functional disorders in general practice: the extended reattribution and management model: an advanced educational program for nonpsychiatric doctors. Psychosomatics 2002; 43:93–131 26. Morris R, Gask L, Ronalds C, et al: Clinical and patient satis-
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Distressed Patients in Primary Care faction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract 1999; 49: 263–267 27. Larisch A, Schweickhardt A, Wirsching M, et al: Psychosocial interventions for somatizing patients by the general practitioner: a randomized, controlled trial. J Psychosom Res 2004; 57:507– 514 28. Blankenstein AH, van der Horst HE, Schilte AF, et al: Effectiveness of reattribution for somatisation in general practice: a randomised, controlled trial, in Somatising Patients in General
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Practice: Reattribution, A Promising Approach. Edited by Blankenstein AH. Amsterdam, The Netherlands, Ph.D. Thesis, Vrije Universiteit, 2001, pp 49 – 65 29. Rief W, Martin A, Rauh E, et al: Evaluation of general practitioners’ training: how to manage patients with unexplained physical symptoms. Psychosomatics 2006; 47:304 –311 30. Van der Feltz-Cornelis C, van Oppen P, Ade`r H, et al: Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice: Psychother Psychosom 2006; 75:282–289
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Background: Patients with psychosocial problems often present somatic symptoms in primary care. Objective: The authors compare interventions and outcomes of emotionally-distressed patients by presenting physical disease, somatoform symptoms, or psychological symptoms. Method: General practitioners (N⫽191) documented data from 1,286 patients with psychosocial problems. Experts rated the presented reasons for encounter. Results: Somatoform symptoms, as well as physical disease, result in patients’ receiving physical treatments. Psychologicallyoriented treatment is more likely with psychological presentation, but not significantly related to somatoform symptoms. Conclusion: These findings underline the importance of a specific treatment approach for patients with somatoform symptoms, so as to avoid inappropriate treatment. (Psychosomatics 2010; 51:386 –394)
P
atients with psychosocial problems that affect their health are common in general practice.1–4 These patients seldom raise their psychosocial problems directly in consultations with the general practitioner (GP).5 About 20% of patients who consult their GP present with phys-
Received December 13, 2008; revised April 3, 2009; accepted April 7, 2009. From the Univ. of Freiburg, Dept. of Psychosomatic Medicine and Psychotherapy; Univ. of Leipzig, Dept. of General Medicine; Univ. of Heidelberg, Dept. of Psychosomatic Research and Family Therapy; Univ. Benjamin Franklin of Berlin, Dept. of Psychosomatics and Psychotherapy; Univ. of Hamburg, Dept. of Psychosomatics and Psychotherapy; Univ. of Leipzig, Dept. of Psychosomatic Medicine and Psychotherapy; Univ. of Freiburg, Dept. of Psychiatry and Psychotherapy; Hamburg Institute and Policlinic for Medical Psychology; Univ. of Go¨ttingen, Dept. of Child and Adolescent Psychiatry. Send correspondence and reprint requests to Kurt Fritzsche, M.D., Dept. of Psychosomatic Medicine and Psychotherapy, Hauptstr. 8, D-79104 Freiburg, Germany. e-mail: [email protected] © 2010 The Academy of Psychosomatic Medicine
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ically unexplained symptoms.6 About 25% of patients with psychiatric morbidity in general practice present with only somatic symptoms.7,8 Thus, presentation of a physical complaint becomes the “entry ticket” to the doctor’s office.9 Despite the belief of the GP that disease is absent, he or she routinely offers these patients somatic treatment.10,11 To improve the recognition and treatment of patients with psychosocial problems, Psychosocial Primary Care (PPC) was introduced in Germany in 1987. Since 1994, PPC has become established as a standard postgraduate training course in Germany. The implementation of curricula and standardized qualification requirements for billing the PPC by German health insurance companies led to a clear improvement in psychosocial primary care.12,13 According to the regulations, doctors have to complete an 80-hour training course consisting of 20 hours on the Psychosomatics 51:5, September-October 2010
Fritzsche et al. recognition and treatment of psychological disorders, including the management of somatizing patients, 30 hours on communication skills, and 30 hours in a Balint group. Since its introduction, about 50% of all German GPs have completed the training. However, previous studies have shown that GPs are selective regarding psychosocial treatment, giving preference to patients who present with psychological symptoms.1,4,14,15
Hypothesis Although general practitioners may have been trained in PPC, there are significant differences concerning the psychosocial treatment offered and the outcomes of such treatment for patients presenting with physical disease, somatoform symptoms, or psychological problems and symptoms. We surmise that patients who present with somatoform symptoms are treated like patients with a physical illness, which means that they get more somatic diagnostics, fewer psychosocial interventions, and fewer referrals to psychotherapy than patients who present psychological symptoms. Furthermore, we presume that patients with somatoform symptom presentation are less satisfied and that the success of the treatment is lower than in patients with psychological symptoms or physical disease.
50% of professional time as a primary-care physician and being involved in administering psychotherapy. The program was intended as a partnership, and the clinical decision was to remain autonomous. To convince the largest possible number of doctors to fill in their documentation, a cross-sectional study design was chosen because many doctors would not have participated in the study at two subsequent times. The cross-sectional study design resulted in increased acceptance and motivation to participate in the study and enabled fast data feedback to the GPs. The decision that the doctors pick the patients independently, based on the criterion of “psychosocial distress” over a period of 3 months was made to prevent any disturbances of the practice routine. In all, 191 doctors participated in the survey, documenting 1,286 treatment episodes; 28% of the participating doctors work in joint practices. The average participant’s age was 46 years (standard deviation [SD]: 13.5); 46% of the physicians were women. The number of treated patients per physician per quarter was distributed as follows: 11%: ⬍500 patients; 42%: 500 –999 patients; 33%: 1,000 –1,500 patients; and 15%: ⬎1,500 patients. The inclusion and assessment process is shown in Table 1. All participants gave their informed consent, and the ethical and legal acceptability of the study was confirmed before its start by the responsible Ethics Committee. After the end of the consultation, the GPs filled in a TABLE 1.
METHOD The data were taken from the multicenter study “Quality Management in Psychosocial Primary Care,” which was promoted by the Ministry of Health and coordinated by the Department of General Practice, Go¨ttingen.12,15 The participants were general practitioners who had taken part in an 80-hour training course in PPC. The aim of the project was the development, testing, and evaluation of methods in quality management for GPs. The project had three phases: 1) Target-group poll of 51 GPs to quality objectives and development of documentation instruments; 2) Documentation of the treatment of patients with psychosocial distress; 3) Feedback of the results and initiation of measures for quality improvement—for example, case conferences and quality circles. GPs were recruited from a nationwide pool of physicians. Inclusion criteria were qualifications in Psychosocial Primary Care and willingness to document and help develop measures for quality improvement. Exclusion criteria were spending less than Psychosomatics 51:5, September-October 2010
Inclusion and Assessment Process ● Cover letter to all doctors with qualifications in Psychosocial Primary Care in six study centers, representing general practitioners (GPs) from urban vs. rural areas, in east, west, north, and south of Germany (N⫽2,574) ● GPs giving written consent to participate (N⫽191) ● Treatment episodes documented from GPs and patients (N⫽1,338) ● Excluded because of incomplete data (N⫽52) ● Sample size: GPs (N⫽191); patients (N⫽1,286)
GPs Filling Out Questionnaires Reason for visit Psychosocial distress Treatment Outcome
Patients Filling Out Questionnaires Hospital Anxiety and Depression Scale (HADS) Giessen Subjective Complaints List (GBB) Outcome
Rating of reason for visits by experts on a scale of 0-100, on three dimensions: 1) Physical disease 2) Somatoform symptoms 3) Psychological symptoms and problems
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Distressed Patients in Primary Care questionnaire on the treatment process and its outcome, and the patients filled in a questionnaire on sociodemographic data, emotional distress, and treatment outcome. Most of the patients (95%) had been treated by the same GP for quite some time. Questionnaire for General Practitioners (GPs) The GPs completed a questionnaire with the following items: the reason for the patient’s visit; current psychosocial distress according to nine categories: anxiety, depression, partner/family conflicts, physical illness, stressful life events, sleep disorders, pain, work problems, and alcohol and substance abuse. Each problem was rated on a scale from 0 to 3 (0: no problems or stress; 3: highest degree of problems or stress). In the review of systems for treatment, the following were recorded: whether the complaints at the time improved or worsened since the diagnosis was made (–2 to ⫹ 2) and the number of consultations over the previous 12 months. We asked whether the psychological attribution of the patient’s illness was initially present, developed during treatment, or was not present. The interventions comprised physical treatment, psychosocial treatment, and referrals. The psychosocial treatment included 1) a psycho-diagnostic interview; 2) psychosocial interventions; 3) referral to mental health services (psychotherapists) if indicated. Outcome measures Three variables were used to measure outcome: 1) Doctor–patient relationship: “Do you have the feeling that the patient understood you?” 2) treatment effect: “Success of the treatment;” and 3) treatment satisfaction: “Satisfaction of the patient with the treatment.” They were rated on a 5-point Likert scale (–2 to ⫹2). Finally, the importance of an exchange between colleagues were also rated on a 5-point Likert scale (not at all important: –2, to ⫹2: very important) and whether this exchange took place (e.g., Balint group) for documented patients (Yes/No). The questionnaire could be filled out in about 15 minutes. Questionnaires for Patients Outcome measures The questions to the patients were matched with the questions to the doctors. 1) Doctor– patient relationship: “To what extent did you feel understood by your doctor?” 2) treatment effect: “How successful, do you think, was your treatment?,” and 3) treatment 388
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satisfaction: “How satisfied are you with your treatment?” They were also rated on a 5-point Likert scale (–2 to ⫹2). Hospital Anxiety and Depression Scale (HADS)16,17 The HADS is a well-validated, routinely used screening instrument for the detection of emotional distress in physically ill patients. Giessen Subjective Complaints List (GBB) The GBB18 is a self-report instrument for health complaints. The 24 items are rated on 5-point-scales from 0 (not at all) to 5 (strong). The questionnaire yields four summary scores: exhaustion, gastric symptoms, pain, and cardiovascular complaints. The GBB was standardized in samples representative of the whole population of Germany. The factor structure and internal consistency of the subscales have remained largely constant. Reason-for-Visit Classification The reason for visit given by patients was classified with the German version of Reason-for-Visit Classification (RVC).19 The RVC20 was developed by the American Medical Record Association in the National Center for Health Statistics of the United States for use in outpatient care. Its goal is to document complaints on the level of symptoms, diagnosis, and administrative reasons. We rated the reasons for the visit according to three dimensions: 1) physical disease; 2) somatoform symptoms; and 3) psychological problems and symptoms. The probability of the cause being physical, somatoform, or psychological was rated on a scale from 0% to 100% (in five steps, by 25%). Thus, the probability of each of the three dimensions of a complaint was assessed. Anxiety, depression, and other emotional disorders were rated as being 100% psychological. Chest pain, nausea, headaches, or dizziness were rated as being 75% somatoform and 25% physical. Encephalitis disseminata and coronary heart disease were rated as being 100% physical. Complaints of a patient reporting depression, headache, and a separation conflict as the reasons for the visit were rated as being 100% psychological, 25% somatoform, and 0% physical. It may happen that a presentation is rated as being physical as well as psychological (e.g., cancer and depression) in any other combination. In case of doubt, the complaint was rated as being physical. The ratings of the reported symptoms were aggregated into the final variables, measuring the overall case presentation. The reliability of judges was tested with 20 randomly selected cases. The raters were a clinically-experienced Psychosomatics 51:5, September-October 2010
Fritzsche et al. psychiatrist and psychotherapist (EW-B) and a clinicallyexperienced internist and psychoanalytically-trained psychotherapist (KF) They independently estimated the probability that the presented complaints were attributed to physical disease, somatoform symptom, or psychological symptom. The calculation of interclass correlation (ICC) showed values around 0.88 (for physical disease), 0.94 (somatoform symptoms), and 0.98 (psychological symptoms). Because of low frequencies, the three middle categories were collapsed into one, leading, therefore, to three remaining categories: 100%, 75%–25%, and 0%. Statistical Analysis The statistical evaluation was calculated with the statistical program SPSS, Release 11ff. Simple descriptive statistics were used to describe the sample and the univariate distribution (mean, SD, frequency tables). For the interval-scaled data, we used the t-test for independent samples to test differences between the two groups. We used cross-tables and chi-square statistics for the nominal data. Simple Pearson’s correlation coefficients were calculated to quantify relationships between variables. The dependent variables (N⫽13) that describe the doctor’s activity were grouped into two factors by factor analysis (principal-component analysis [PCA] varimax rotation; see Table 2). The seven interventions and activities: physical therapies, somatic medication, other somatic therapies, alternative treatment, patient information, refer to specialist TABLE 2.
Factor Loadings on 13 Activities Activity
Physicotherapeutics Other medications Patient information Other somatic therapy Alternative treatment Referral to a specialist (excluding somatic illness) Work disability Psychotherapeutic interventions Psychodiagnostic interview Psychotropics Referral psychotherapy Family interview Relaxation therapy
Factor 1: Somatic
Factor 2: Psychological
0.653 0.576 0.560 0.509 0.498 0.390 0.326 0.756 0.640 0.492 0.445 0.425 0.290
Principal-components analysis, varimax rotation: explained variance: 28.7%. Loadings below 0.25 are suppressed.
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(excluding somatic illness), and work disability formed the factor Physical Treatment (model parameters: Hosmer Lemeshow⫽9.64; df: 8; p⬎0.25; model chi-square⫽107; df: 5; p⬍0.001; Nagelkerke pseudo R2⫽0.12). The six activities: psychodiagnostic interview, psychosocial intervention, psychotropics, family interview, relaxation therapy, and referral to psychotherapy constituted the factor Psychological Treatment (model parameters: Hosmer Lemeshow⫽17; df: 8; p⫽0.026; model chisquare⫽109; df: 6; p⬍0.001; Nagelkerke pseudo R2⫽0.12). Factors values for Physical Treatment and Psychological Treatment were then dichotomized at the level of the upper tertile (upper tertile: Intensive versus lower two tertiles: Not Intensive). Logistic-regression analysis was used in multivariate models to detect genuine predictors for “Intensive Physical” and “Intensive Psychological” treatment. Missing values were excluded from all analyses, so that the sample sizes varied for the individual tests.
RESULTS
Sociodemographic Data Sociodemographic and clinical data for the sample are shown in Table 3. There were no differences between men and women concerning physical disease, somatoform, and psychological symptoms as the reason for visit. Older age was more likely to be related to physical disease presentation (r⫽0.386; p⬍0.001), whereas younger age was correlated with psychological symptom presentation (r ⫽ – 0.281; p⬍0.001). No difference in age were found for somatoform presentation. These values for emotional distress (HADS) and physical complaints (GBB) are considerably higher than the average for the general population in this age-group. The mean value for Depression in the German general population age 40 to 59 is 4.8 (SD: 3.7) and, for Anxiety, 5.2 (SD: 3.4). In the questionnaire concerning general physical symptoms (GBB), patients reported a two- (exhaustion, overall complaints) to three-times (stomach trouble) higher distress level than the general population. The most common reasons for the visit, in declining order, were stomach trouble, headache, anxiety, sleeping disorders, hypertension, dizziness, heart complaints, depression, and back pain. http://psy.psychiatryonline.org
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TABLE 3.
Sociodemographic and Clinical Data of the Sample Variable
Age, years, mean (SD) Gender Men Women Marital status, % Married Single Education level, % Elementary school Secondary modern school College preparatory school Others Occupation, % Employed fulltime Unemployed Retired Homemaker HADS, mean (SD) Depression Anxiety GBB: Patients in Q4, % Exhaustion Stomach pain Rheumatic pain Heart problems Total distress Symptom presentation,a mean (SD) of % Physical Somatoform Psychological
378 (29.4) 903 (70.2) 51.4 24.5 43.1 31.4 20.1 6.8 61.9 7.7 16.9 13.5 7.75 (4.66) 9.99 (4.43) 47.2 76.9 42.8 39.3 48.4 37.0 (42.7) 53.0 (52.5) 48.0 (48.3)
Psychosocial Distress and Symptom Presentation Correlations of actual psychosocial distress, as rated by GPs, and symptom presentation are shown in Table 4. In the self-rated questionnaires, patients with physical disease presentation showed a positive and significant (p⬍0.01) correlation (r⬎0.20) with physical illness (r⫽0.259) and a negative correlation with anxiety (r ⫽ – 0.210). Somatoform symptom presentation was positively correlated with pain (r⫽0.273). Psychological symptom presentation was positively correlated with depression (r⫽0.229) and sleep disorder (r⫽0.224), and negatively correlated with pain (r ⫽ – 0.247). The correlations with GBB health complaints are weak (p⬍0.05) and point in the expected direction: Patients with stronger somatoform symptom presentation showed a positive correlation with stomach trouble (r⫽0.119) and rheumatic pain (r⫽0.159); patients with http://psy.psychiatryonline.org
Correlations Between Doctors’ Rating of Actual Biopsychosocial Stress and Symptom Presentation of the Patients
46.3 (15.6)
Because of missing data, N ranges from 959 to 1,286. SD: standard deviation; HADS: Hospital Anxiety and Depression Scale; Q4: upper quartile of normal population. a The correlation between variables ranged from – 0.39 to – 0.28.
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TABLE 4.
Symptom Presentation
Biopsychosocial Stress
Physical
Somatoform
Psychological
Physical illness Substance abuse Anxiety Depression Pain Sleep disorders Partnership/family Profession Life events
0.259** 0.074* –0.210** –0.172** –0.001 –0.127** –0.067* –0.012 –0.061*
–0.007 –0.077** 0.046 –0.015 0.273** –0.064* –0.018 –0.031 –0.008
–0.163** 0.117** 0.198** 0.229** –0.247** 0.224** 0.123** 0.060* 0.118**
* p ⬍0.05; ** p ⬍0.01.
physical disease presentation showed a negative correlation with exhaustion (r ⫽ – 0.111) and heart problems (r ⫽ – 0.116). Patients with psychological symptom presentation showed a positive correlation with exhaustion (r⫽0.105).
Interventions Two indices: “Intensive Physical Treatment” (Table 5 [A]) and “Intensive Psychological Treatment (Table 5 [B]),” were built out of the interventions made by general practitioners (see Method section). Multivariate logisticanalysis models (forward stepwise procedure: PIN: 0.05; POUT: 0.10) were used to build up the most parsimonious models for these two treatment types. Predictor candidates tested were: age, sex, the three presentation modes (physical, somatoform, psychological), experience with psychotherapy, improvement of the symptoms, psychological attributions to the symptoms initially present or developed during treatment, and the number of doctor visits in the last year. For the “Intensive Physical Treatment,” the final model contained five predictors: age, number of consultations, and the three presentation modes. Physical Treatment was significantly more likely for patients with older age, higher number of consultations, and presentation of a physical disease and somatoform symptoms. The relationship with psychological presentation was not significant (p⫽0.09; Table 5 [A]). For “Intensive Psychological Treatment,” the final model contained five predictors: number of consultations, psychological attribution of the symptoms, and physical, psychological, and somatoform presentation. Psychological treatment was significantly Psychosomatics 51:5, September-October 2010
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TABLE 5.
Multivariate Logistic-Regression Model on Intensive Physical Treatment and Intensive Psychological Treatment
[A]: Intensive Physical Treatment (Upper Tertile of Factor: Physical Intervention of GP) Parameter

df
Significance (Wald)
OR
95% CI
Presentation: physical: Presentation: psychological Presentation: somatoform Age, years Consultations, N Constant
0.342 –0.139 0.396 0.015 0.437 –3.361
1 1 1 1 1 1
⬍0.001 0.093 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
1.408 .870 1.486 1.015 1.549
1.178–1.684 0.740–1.023 1.255–1.759 1.006–1.023 1.338–1.793
Model development: forward stepwise (PIN 0.05, POUT 0.10); forced entry. [B]: Intensive Psychological Treatment (Upper Tertile of Factor: Psychological Intervention of GP) Parameter

df
Significance (Wald)
OR
95% CI
Presentation: physical Presentation: psychological Presentation: somatoform Psychological attribution to the symptoms initially present developed during treatment Consultations, N Constant
–0.323 0.278 –0.089
1 1 1 2
⬍0.001 ⬍0.001 0.274 ⬍0.001
0.724 1.321 0.915
0.607–0.863 1.125–1.551 0.780–1.073
1 1
⬍0.001 ⬍0.01 ⬍0.001 ⬍0.001
1.946 1.657 1.570
1.386–2.767 1.208–2.272 1.364–1.807
0.666 0.505 0.451 –2.503
Reference category for “Psychological attribution to the illness”: “Not Present.” GP: general practitioner; OR: odds ratio; CI: confidence interval.
more likely if the psychological attribution to the symptoms was initially prevalent or developed during treatment, if the number of previous consultations was higher, and with a psychological presentation. It was significantly less likely with physical disease presentation. The relationship with somatoform presentation was not significant (see Table 5 [B]).
1,254; p⫽0.032). Concerning the level of importance, there were no differences for physical disease and psychological symptom presentation. For 331 physicians (26.4%), an exchange had taken place, for example, in a Balint group or a quality circle. In contrast to the importance of an exchange between colTABLE 6.
Outcomes
Correlations Between Treatment Outcome and Symptom Presentation
[A]: From the Perspective of the General Practitioners (GPs)
There was a weak positive correlation between treatment outcomes and patients with physical disease and psychological symptom presentation. There was a weak negative correlation between treatment outcomes and patients with somatoform symptom presentation (see Table 6 [A] and 6 [B]).
Symptom Presentation GPs
Physical
Somatoform
Psychological
Mutual understanding Success Satisfaction
0.008 0.051 0.060*
–0.117** –0.101** –0.120**
0.125** 0.063* 0.055*
* p ⬍0.05; ** p ⬍0.01.
Exchange Between Colleagues
[B]: From the Perspective of the Patients Symptom Presentation
For 676 of the patients (53.8%), the physicians found an exchange between colleagues very important. GPs felt an exchange more important for patients with a more somatoform symptom presentation than for patients with a less somatoform symptom presentation (M [important]⫽0.55; M [not important]⫽0.495; t ⫽ –2.147; df: Psychosomatics 51:5, September-October 2010
Patients
Physical
Somatoform
Psychological
Mutual understanding Success Satisfaction
0.005 0.078 0.065*
–0.072* –0.113** –0.156**
0.112** 0.017 0.085*
* p ⬍0.05; ** p ⬍0.01.
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Distressed Patients in Primary Care leagues, the exchange was more likely to occur in the case of a more psychological symptom presentation (M [occur]⫽0.5275; M [not occur]⫽0.4675; t ⫽ –2.079; df: 2.21; p⫽0.038). There were no differences for physical disease and somatoform symptom presentation. DISCUSSION Patients who presented their emotional distress directly are significantly more likely to get psychological treatment, that is, psychosocial intervention or psychotropics, and they were more often referred to outpatient psychotherapy, as well. Patients with mainly somatoform symptom presentations are significantly more likely to get somatic treatment, that is, medication, physical treatments, alternative treatment, and referrals for the exclusion of physical disease. Our results partly confirm those of some earlier studies with similar queries. In a study to determine the frequency and treatment of psychosocial problems in the German Primary Health Care setting, 31% of the patients rated themselves as emotionally stressed and received psychosocial interventions; 9.5% of these patients were referred for psychotherapy. The patients with somatoform symptoms did not receive any recommendation for psychotherapy, and only 16% received psychosocial interventions.4 In a Dutch study,21 patients who presented their complaints as being psychosocial received more treatment than those reporting complaints somatically. There were 11⁄2 times as many counseling consultations for psychological symptoms as for somatic symptoms. Referrals to and consultations with mental health specialists almost always concerned psychological symptoms. The average duration of consultation was 20% longer when purely psychological symptoms were involved.21 The treatment outcome of our study differs from the study by Cape;22 in this study, patients with psychological problems presenting only somatic symptoms have clinical outcomes equivalent to patients presenting psychological problems in a direct way. This study is subject to several methodological limitations: First, a major flaw of the study might be selection bias of patients. Since all physicians have been trained in psychosocial primary care, they might be more likely to recognize psychosocial distress. The doctors themselves selected their patients. Therefore, this is a sample of convenience, rather than a consecutive or random sample. Second, in grouping the reasons for visits, the external 392
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raters could have erroneously classified patients with organic diseases as “somatizers” or vice versa. Third, the retrospective documentation of the data introduces the possibility of a recall bias, because many doctors would not have been willing to participate in the study at two subsequent times. The cross-sectional study design resulted in increased acceptance and enabled fast data feedback to the GPs. Fourth, we have a huge sample size with various types of problems presented and different interventions. Therefore, the data-reduction creating two intervention factors is a simplification. Fifth, the data on treatment results are based on three global items from the viewpoint of the doctor and the patient and are not validated, standardized outcome measures. A check of the results within a prospective design with validated, standardized psychometric questionnaires is necessary. Generalizability The patients are representative concerning their sociodemographic data for the population of a GP, as shown by comparison with the EvaS Study, a trial of outpatient medical care in Germany.23 However, results are limited to qualified GPs interested in Psychosocial Primary Care (PPC). Therefore, the results cannot be applied to GPs without qualification in PPC. Overall Evidence Why do even GPs trained in psychosocial care offer their somatizing patients somatic treatment? A positive explanation is that the GPs, recognizing the psychosocial aspects of somatization, first offer somatic treatment in order to establish a therapeutic alliance. Later on, they may lead the patient to a psychological approach to his or her symptoms. But it is also possible that the GPs react to the patient’s repeated complaints with negative countertransference and less empathic discussion, and attempt to regain authority by viewing the complaints as a medical problem in an area they are most familiar with.24 Specific psychosocial interventions for patients with somatoform symptoms in primary care are necessary and should be integrated into GP training programs.25 First, published results regarding the effectiveness of those treatments in somatizing patients, as applied by the GP26 –29 and in cooperation with a mental health specialist30 are not as effective as expected. Patients with medically unexplained physical symptoms remain a challenge for the GP and for psychosomatic research. Psychosomatics 51:5, September-October 2010
Fritzsche et al. A full report is available: Qualita¨tssicherung in der Psychosomatik. Verbundstudie innerhalb des Demonstrationsprojekts in der ambulanten Versorgung “Hrsg.: Das Bundesministerium fu¨r Gesundheit, Projektkoordinator: Hagen Sandholzer. Baden-Baden 1999: Nomos Verl.Ges., 1999 (Schriftenreihe des Bundesministeriums fu¨r Gesundheit, Bd 118) ISBN 3–7890-6119 – 0). The authors thank all actively participating GPs for their cooperation, for the manifold discussions, inspirations, and provision of data. In addition to the authors, the
following employees contributed to this study: Berlin, Germany: Dilg, Freiburg, Dept. of Psychosomatic Medicine: Hammel, Campagnolo; Freiburg, Dept. of Psychiatry: Kenk; Go¨ttingen, Dept. of Family Therapy: Bohlen; Go¨ttingen, project coordination: Liebler, Pelz; Go¨ttingen, Dept. of Child and Adolescent Psychiatry: Witte-Lakemann; Hamburg: Albota; Leipzig: Ziener; Marburg: Wahl. The study was funded by Grant no. 217-43794-3/13 from the German Federal Ministry of Health.
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