Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management

Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co‐morbidity include recent stress, lower self‐rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive‐behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms

Capsule Commentary on Meredith et al., Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: A Randomized Controlled Trial

Comment on Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial. [J Gen Intern Med. 2016

Somatic Symptoms Deserve Our Attention

This commentary focuses on two articles in this issue which provide important insights regarding the diagnosis and management of medically unexplained symptoms (MUS). Up to half of all outpatient visits are prompted by a physical/somatic complaint of which at least a third are MUS. Analyzing data from the National Ambulatory Care Medical Survey, Gates, Petterson, Wingrove, Miller, and Klink (2016) confirmed the common finding that depression and anxiety in patients presenting with somatic symptoms are underrecognized. Only 1–4% of such patients received a diagnosis of depression or anxiety, a rate that should have been at least four- to sixfold greater. optimize the care of chronic somatic symptoms. In the second article, Clarke draws upon clinical experience spanning several decades and thousands of patients to delineates a pragmatic approach to managing MUS. His six-step strategy augmented by illustrative cases makes more tangible the process of caring for patients with chronic symptoms

Telemedicine Screening for Eye Disease

Importance Telemedicine is a useful clinical method to extend health care to patients with limited access. Minimal information exists on the subsequent effect of telemedicine activities on eye care resources. Objective To evaluate the effect of a community-based diabetic teleretinal screening program on eye care use and resources. Design, Setting, and Participants The current study was a retrospective medical record review of patients who underwent diabetic teleretinal screening in the community-based clinics of the Atlanta Veterans Affairs Medical Center from October 1, 2008, through March 31, 2009, and who were referred for an ophthalmic examination in the eye clinic. Exposures Clinical medical records were reviewed for a 2-year period after patients were referred from teleretinal screening. The following information was collected for analysis: patient demographics, referral and confirmatory diagnoses, ophthalmology clinic visits, diagnostic procedures, surgical procedures, medications, and spectacle prescriptions. Main Outcomes and Measures The accuracy between referring and final diagnoses and the eye care resources that were used in the care of referred patients. Results The most common referral diagnoses were nonmacular diabetic retinopathy (43.2%), nerve-related disease (30.8%), lens or media opacity (19.1%), age-related macular degeneration (12.9%), and diabetic macular edema (5.6%). The percentage of agreement among these 5 visually significant diagnoses was 90.4%, with a total sensitivity of 73.6%. Diabetic macular edema required the greatest number of ophthalmology clinic visits, diagnostic tests, and surgical procedures. Using Medicare cost data estimates, the mean cost incurred during a 2-year period per patient seen in the eye clinic was approximately $1000. Conclusions and Relevance Although a teleretinal screening program can be accurate and sensitive for multiple visually significant diagnoses, measurable resource burdens should be anticipated to adequately prepare for the associated increase in clinical care

Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

Mental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurement-based care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care

Pragmatic characteristics of patient-reported outcome measures are important for use in clinical practice

OBJECTIVES: Measures for assessing patient-reported outcomes (PROs) that may have initially been developed for research are increasingly being recommended for use in clinical practice as well. Although psychometric rigor is essential, this article focuses on pragmatic characteristics of PROs that may enhance uptake into clinical practice. STUDY DESIGN AND SETTING: Three sources were drawn on in identifying pragmatic criteria for PROs: (1) selected literature review including recommendations by other expert groups; (2) key features of several model public domain PROs; and (3) the authors' experience in developing practical PROs. RESULTS: Eight characteristics of a practical PRO include: (1) actionability (i.e., scores guide diagnostic or therapeutic actions/decision making); (2) appropriateness for the relevant clinical setting; (3) universality (i.e., for screening, severity assessment, and monitoring across multiple conditions); (4) self-administration; (5) item features (number of items and bundling issues); (6) response options (option number and dimensions, uniform vs. varying options, time frame, intervals between options); (7) scoring (simplicity and interpretability); and (8) accessibility (nonproprietary, downloadable, available in different languages and for vulnerable groups, and incorporated into electronic health records). CONCLUSION: Balancing psychometric and pragmatic factors in the development of PROs is important for accelerating the incorporation of PROs into clinical practice

Comparing the Patient Health Questionnaire – 15 and the Somatic Symptom Scale – 8 as measures of somatic symptom burden

Purpose The Patient Health Questionnaire – 15 (PHQ-15) and the Somatic Symptom Scale – 8 (SSS-8) are self-report measures which assess somatic symptom burden. The present study investigates whether the two measures are comparable in terms of their psychometric properties and estimates of symptom burden. Method Item characteristics, reliability, symptom severity and construct validity with regard to other relevant psychological, health-related quality of life and disability measures were compared for the PHQ-15m and the SSS-8 in 294 primary care patients who participated in a randomized comparative effectiveness trial targeting pain and mood symptoms. Results The reliabilities of the PHQ-15m and the SSS-8 were α = 0.66 and α = 0.72, respectively. Both measures were highly correlated (r = 0.79). All item characteristics were comparable and both instruments showed the same pattern of correlations with instruments measuring depression, anxiety, pain, quality of life and impairment (r = 0.25 to 0.53). A 1-point score increase (worsening of somatic symptoms) on either instrument resulted in a 3.7% to 3.9% increase in the number of disability days reported for the last four weeks. Using the same severity thresholds (5: low, 10: medium, 15: high), both measures identified nearly identical subgroups of patients with regard to health-related quality of life and disability. Conclusion The PHQ-15m and the SSS-8 are comparable measures in terms of reliability and validity and severity classifications. These findings are in line with previous results and support the use of the SSS-8 as a valuable and short alternative to the original PHQ-15 in settings with limited assessment time