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The Literature Collection contains over 11,000 references for published and grey literature on the integration of behavioral health and primary care. Learn More
Use the Search feature below to find references for your terms across the entire Literature Collection, or limit your searches by Authors, Keywords, or Titles and by Year, Type, or Topic. View your search results as displayed, or use the options to: Show more references per page; Sort references by Title or Date; and Refine your search criteria. Expand an individual reference to View Details. Full-text access to the literature may be available through a link to PubMed, a DOI, or a URL. References may also be exported for use in bibliographic software (e.g., EndNote, RefWorks, Zotero).
306 Results
61
Consultation letters for medically unexplained physical symptoms in primary care
Type: Journal Article
Year: 2010
Publication Place: England
Abstract: BACKGROUND: In primary care between 10% and 35% of all visits concern patients with medically unexplained physical symptoms (MUPS). MUPS are associated with high medical consumption, significant disabilities and psychiatric morbidity. OBJECTIVES: To assess the effectiveness of consultation letters (CLs) to assist primary care physicians or occupational health physicians in the treatment of patients with MUPS and diagnostic subgroups. SEARCH STRATEGY: We searched for randomized controlled trials (RCTs) on the Cochrane Collaboration Depression, Anxiety and Neurosis Group Controlled Trials Registers, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2009), MEDLINE (1966-2009), MEDLINE In Process (2009-08-17), EMBASE (1974-2009), PSYCINFO (1980-2009) and CINAHL (1982-2009). We screened the references lists of selected studies and consulted experts in the field to identify any additional, eligible RCTs. SELECTION CRITERIA: RCTs of CLs for patients with MUPS being treated in primary care settings. DATA COLLECTION AND ANALYSIS: Two authors independently screened the abstracts of the studies identified through the searches and independently assessed the risk of bias of the included studies. We resolved any disagreement by discussion with a third review author. We assessed heterogeneity and, where a number of studies reported the same outcomes, pooled results in a meta-analysis. MAIN RESULTS: We included six RCTs, with a total of 449 patients. In four studies (267 patients) the CL intervention resulted in reduced medical costs (in two studies the outcomes could be pooled: MD -352.55 US Dollars (95% CI -522.32 to -182.78)) and improved physical functioning (three studies, MD 5.71 (95% CI 4.11 to 7.31)). In two studies (182 patients) the intervention was a joint consultation with a psychiatrist in presence of the physician, and resulted in reduced severity of somatization symptoms, reduced medical consumption and improved social functioning. AUTHORS' CONCLUSIONS: There is limited evidence that a CL is effective in terms of medical costs and improvement of physical functioning for patients with MUPS in primary care. The results are even less pronounced in patients with clinically less severe, but more meaningful, forms of MUPS and the results vary for other patient-related outcomes. All studies, except one, were performed in the United States and therefore the results can not be generalized directly to countries with other healthcare systems. Furthermore all studies were small and of only moderate quality. There is very limited evidence that a joint consultation with the patient by a psychiatrist in the presence of the physician, together with the provision of a CL, reduces severity of somatization symptoms and medical consumption.
Topic(s):
Medically Unexplained Symptoms
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Reference Links: 
View the DOI record for Consultation letters for medically unexplained physical symptoms in primary care
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View the PubMed citation for Consultation letters for medically unexplained physical symptoms in primary care63
Coordinated care in the management of patients with unexplained physical symptoms: depression is a key issue
Type: Journal Article
Year: 2008
Publication Place: Australia
Abstract: OBJECTIVE: To evaluate the diagnosis of patients with somatisation disorders in primary care, and the effectiveness of coordinated care and evidence-based care planning on psychiatric symptoms and quality of life for these patients. DESIGN, SETTING AND PARTICIPANTS: This was a project of the SA HealthPlus Coordinated Care Trial, comprising a randomised controlled trial of 124 subjects recruited by general practitioners in southern Adelaide. Eligible patients had a GP diagnosis of somatisation, including unexplained physical symptoms as part of anxiety, chronic pain or somatoform disorders. Diagnoses were checked using the Composite International Diagnostic Interview (CIDI). The study was conducted from December 1997 to December 1999. INTERVENTION: A care plan including treatment for depression and anxiety disorders, a containment strategy for somatisation, and service coordinator-assisted self-management. Control patients received standard treatment. MAIN OUTCOME MEASURES: Psychiatric symptoms; quality of life; medication use; and depression, anxiety and hostility scores. RESULTS: Compared with CIDI diagnoses, mood disorders in patients were underdiagnosed by GPs (64 v 31), particularly major depression (46 v 1). At 12 months, the intervention group showed reductions in depression (P = 0.002), guilt (P = 0.006) and anxiety (state, P = 0.043; trait, P = 0.001). Compared with the control group, physical role functioning improved for the intervention group (P = 0.006), and their medication use decreased by 8.9%. CONCLUSIONS: Conservative management, treatment of depression, and case management by service coordinators is effective in managing somatising patients in primary care. GPs require training in the diagnosis of depression and how to say "no" to patients with unexplained physical symptoms who request further unnecessary investigations or referrals.
Topic(s):
Medically Unexplained Symptoms
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Reference Links: View the PubMed citation for Coordinated care in the management of patients with unexplained physical symptoms: depression is a key issue
65
Cost and quality impact of Intermountain's mental health integration program
Type: Journal Article
Year: 2010
Publication Place: United States
Abstract: Most patients with mental health (MH) conditions, such as depression, receive care for their conditions from a primary care physician (PCP) in their health/medical home. Providing MH care, however, presents many challenges for the PCP, including (1) the difficulty of getting needed consultation from an MH specialist; (2) the time constraints of a busy PCP practice; (3) the complicated nature of recognizing depression, which may be described with only somatic complaints; (4) the barriers to reimbursement and compensation; and (5) associated medical and social comorbidities. Practice managers, emergency departments, and health plans are stretched to provide care for complex patients with unmet MH needs. At the same time, payment reform linked to accountable care organizations and/or episodic bundle payments, MH parity rules, and increasing MH costs to large employers and payers all highlight the critical need to identify high-quality, efficient, integrated MH care delivery practices. Over the past ten years, Intermountain Healthcare has developed a team-based approach-known as mental health integration (MHI)-for caring for these patients and their families. The team includes the PCPs and their staff, and they, in turn, are integrated with MH professionals, community resources, care management, and the patient and his or her family. The integration model goes far beyond co-location in its team-based approach; it is operationalized at the clinic, thereby improving both physician and staff satisfaction. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes. The MHI program is financially sustainable in routinized clinics without subsidies. MHI is a successful approach to improving care for patients with MH conditions in primary care health homes.
Topic(s):
Education & Workforce
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, Financing & Sustainability
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, Medically Unexplained Symptoms
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, Healthcare Policy
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Reference Links: View the PubMed citation for Cost and quality impact of Intermountain's mental health integration program
67
Costs of an intervention for primary care patients with medically unexplained symptoms: a randomized controlled trial
Type: Journal Article
Year: 2007
Publication Place: United States
Abstract: OBJECTIVE: This study sought to determine whether an intervention for patients with medically unexplained symptoms in primary care reduced total costs, components of cost, and longer-term costs and whether it led to decreased service use outside the health maintenance organization (HMO). METHODS: A randomized controlled trial involving 206 patients with medically unexplained symptoms was conducted in a staff-model HMO. The protocol emphasized the provider-patient relationship and included cognitive-behavioral therapy and pharmacological management. Cost data for medical treatments were derived from the HMO's electronic database. Patients were interviewed about work days lost and out-of-pocket expenses for medical care outside the HMO. RESULTS: The difference in total costs ($1,071) for the 12-month intervention was not significant. The treatment group had significantly higher costs for antidepressants than the usual-care group ($192 higher) during the intervention, and a larger proportion received antidepressants. The intervention group used less medical care outside the HMO and missed one less work day per month on average (1.23 days), indicating a slight improvement in productivity, but the difference was not significant. The between-group difference in estimated total cost was smaller in the year after the intervention (difference of $341) but were not significant. CONCLUSIONS: The total costs for the intervention group were not significantly different, but the group had greater use of antidepressants. Coupled with findings of improved mental health outcomes for this group in a previous study, the results indicate that the intervention may be cost-effective. The longer-term impact needs to be further studied.
Topic(s):
Financing & Sustainability
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, Medically Unexplained Symptoms
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Reference Links:
View the DOI record for Costs of an intervention for primary care patients with medically unexplained symptoms: a randomized controlled trial
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View the PubMed citation for Costs of an intervention for primary care patients with medically unexplained symptoms: a randomized controlled trial68
Course and prediction of somatoform disorder and medically unexplained symptoms in primary care
Type: Journal Article
Year: 2011
Publication Place: United States
Topic(s):
Medically Unexplained Symptoms
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Reference Links:
View the DOI record for Course and prediction of somatoform disorder and medically unexplained symptoms in primary care
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View the PubMed citation for Course and prediction of somatoform disorder and medically unexplained symptoms in primary care70
Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment
Type: Journal Article
Year: 2001
Publication Place: United States
Abstract: This article reviews cultural variations in the clinical presentation of depression and anxiety. Culture-specific symptoms may lead to underrecognition or misidentification of psychological distress. Contrary to the claim that non-Westerners are prone to somatize their distress, recent research confirms that somatization is ubiquitous. Somatic symptoms serve as cultural idioms of distress in many ethnocultural groups and, if misinterpreted by the clinician, may lead to unnecessary diagnostic procedures or inappropriate treatment. Clinicians must learn to decode the meaning of somatic and dissociative symptoms, which are not simply indices of disease or disorder but part of a language of distress with interpersonal and wider social meanings. Implications of these findings for the recognition and treatment of depressive disorders among culturally diverse populations in primary care and mental health settings are discussed.
Topic(s):
Healthcare Disparities
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, Medically Unexplained Symptoms
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Reference Links: View the PubMed citation for Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment
72
Dementia care initiative in primary practice: study protocol of a cluster randomized trial on dementia management in a general practice setting
Type: Journal Article
Year: 2009
Publication Place: England
Abstract: BACKGROUND: Current guidelines for dementia care recommend the combination of drug therapy with non-pharmaceutical measures like counselling and social support. However, the scientific evidence concerning non-pharmaceutical interventions for dementia patients and their informal caregivers remains inconclusive. Targets of modern comprehensive dementia care are to enable patients to live at home as long and as independent as possible and to reduce the burden of caregivers. The objective of the study is to compare a complex intervention including caregiver support groups and counselling against usual care in terms of time to nursing home placement. In this paper the study protocol is described. METHODS/DESIGN: The IDA (Initiative Demenzversorgung in der Allgemeinmedizin) project is designed as a three armed cluster-randomized trial where dementia patients and their informal caregivers are recruited by general practitioners. Patients in the study region of Middle Franconia, Germany, are included if they have mild or moderate dementia, are at least 65 years old, and are members of the German AOK (Allgemeine Ortskrankenkasse) sickness fund. In the control group patients receive regular treatment, whereas in the two intervention groups general practitioners participate in a training course in evidence based dementia treatment, recommend support groups and offer counseling to the family caregivers either beginning at baseline or after the 1-year follow-up. The study recruitment and follow-up took place from July 2005 to January 2009. 303 general practitioners were randomized of which 129 recruited a total of 390 patients. Time to nursing home admission within the two year intervention and follow-up period is the primary endpoint. Secondary endpoints are cognitive status, activities of daily living, burden of care giving as well as healthcare costs. For an economic analysis from the societal perspective, data are collected from caregivers as well as by the use of routine data from statutory health insurance and long-term care insurance. DISCUSSION: From a public health perspective, the IDA trial is expected to lead to evidence based results on the community effectiveness of non-pharmaceutical support measures for dementia patients and their caregivers in the primary care sector. For health policy makers it is necessary to make their decisions about financing new services based on strong knowledge about the acceptance of measures in the population and their cost-effectiveness. TRIAL REGISTRATION: ISRCTN68329593.
Topic(s):
Medically Unexplained Symptoms
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73
Depression and anxiety in multisomatoform disorder: prevalence and clinical predictors in primary care
Type: Journal Article
Year: 2008
Publication Place: South Africa
Abstract: OBJECTIVE: Multisomatoform disorder (MSD) is characterised by > or = 3 medically inexplicable, troublesome physical symptoms, together with a > or = 2-year history of somatisation. The aim of this study was to evaluate the prevalence of depressive and anxiety disorders in a South African sample MSD, and to compare demographic and clinical outcomes in those patients with and without co-morbidity. METHODS: Fifty-one adult outpatients with MSD were recruited from primary care clinics in the Cape Town metropolitan area. Participants were assessed for the presence of co-morbid depressive and anxiety disorders using the Mini Neuropsychiatric Interview-Plus (MINI-Plus). Outcomes included somatic symptom severity, disability, reported sick days and health care visits, pain experience, patient satisfaction with health services, and clinician-experienced difficulty. RESULTS: A current co-morbid depressive disorder was present in 29.4% (N = 15) of patients, and a current co-morbid anxiety disorder in 52.9% (N = 27). MSD patients with a co-morbid depressive disorder (current or lifetime) had significantly higher physical symptom counts, greater functional impairment, higher unemployment rates, more clinician-reported difficulties, and more dissatisfaction with health care services than those without the disorder. A larger number of co-morbid disorders was associated with greater overall disability. CONCLUSION: High rates of co-morbid depressive and anxiety disorders were present in a South African sample of primary care patients with MSD. Not all patients had co-morbidity, which is consistent with the view that MSD should be viewed as an independent disorder. However, co-morbid depressive disorders were associated with increased symptom severity and functional impairment, consistent with previous reports from developing countries, emphasising the importance of comorbidity in MSD.
Topic(s):
Medically Unexplained Symptoms
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Reference Links: View the PubMed citation for Depression and anxiety in multisomatoform disorder: prevalence and clinical predictors in primary care
74
Depression in African Americans: Breaking barriers to detection and treatment
Type: Journal Article
Year: 2006
Publication Place: United States
Abstract: OBJECTIVE: Recent studies in primary care settings indicate that African Americans face health disparities in the treatment of major depression. We reviewed the literature to find evidence of specific patient, physician, and practice-setting factors related to such barriers. DATA SOURCES: We searched for and retrieved articles in Medline (1966-2004) and hand-checked bibliographies to find additional articles that were relevant to the evaluation and treatment of African Americans with depression. STUDY SELECTION AND DATA EXTRACTION: Two investigators (AKD, MO) independently examined the abstracts retrieved from the literature search, and excluded articles that did not match a predefined search strategy. Two other investigators (HLC, MMW) identified potential articles through bibliographic review. In the extracted set articles, we examined cited barriers to diagnosis and effective management. RESULTS: We found 24 articles that fulfilled our criteria. These studies indicate that African Americans face a number of barriers in the recognition and treatment of major depression including clinical presentation with somatization, stigma about diagnosis, competing clinical demands of comorbid general medical problems, problems with the physician-patient relationship, and lack of comprehensive primary care services. CONCLUSIONS: Research indicates that African Americans who have depression may be frequently under diagnosed and inadequately managed in primary care as a result of patient, physician, and treatment-setting factors. Our systematic review can assist family physicians in understanding how to overcome such barriers to the diagnosis and treatment of depressive disorders in African American patients.
Topic(s):
Healthcare Disparities
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, Medically Unexplained Symptoms
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Reference Links: View the PubMed citation for Depression in African Americans: Breaking barriers to detection and treatment
75
Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment
Type: Journal Article
Year: 2008
Publication Place: United States
Abstract: OBJECTIVE: To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment. METHOD: Two thousand ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment. RESULTS: In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment. CONCLUSIONS: Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.
Topic(s):
Medically Unexplained Symptoms
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Reference Links:
View the DOI record for Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment
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View the PubMed citation for Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment76
Depression, anxiety, and somatoform disorders: vague or distinct categories in primary care? Results from a large cross-sectional study
Type: Journal Article
Year: 2009
Publication Place: England
Abstract: OBJECTIVE: Depression, anxiety, and somatization are the most frequently observed mental disorders in primary health care. Our main objective was to draw on the often neglected general practitioners' (GPs) perspective to investigate what characterizes these three common mental diagnoses with regard to creating more suitable categories in the DSM-V and ICD-11. METHODS: We collected independent data from 1751 primary care patients (participation rate=77%) and their 32 treating GPs in Germany. Patients filled out validated patient self-report measures for depression (PHQ-9), somatic symptom severity (PHQ-15), and illness anxiety (Whiteley-7), and questions regarding coping and attribution of illness. GPs' clinical diagnoses and associated features were assessed. RESULTS: Patients diagnosed by their GPs with depression, anxiety, and/or somatoform disorders were significantly older, less educated, and more often female than the reference group not diagnosed with a mental disorder. They had visited the GP more often, had a longer duration of symptoms, and were more often under social or financial stress. Among the mental disorders diagnosed by the GPs, depression (OR=4.4; 95% CI=2.6 to 7.5) and comorbidity of somatoform, depressive, and anxiety disorders (OR=9.5; 95% CI=4.6 to 19.4) were associated with the largest degrees of impairment compared to the reference group. Patients diagnosed as having a somatoform/functional disorder only had mildly elevated impairment on all dimensions (OR=2.0; 95% CI=1.4 to 2.7). Similar results were found for the physicians' attribution of psychosocial factors for cause and maintenance of the disease, difficult patient-doctor relationship, and self-assessed mental disorder. CONCLUSION: In order to make the DSM-V and ICD-11 more suitable for primary care, we propose providing appropriate diagnostic categories for (1) the many mild forms of mental syndromes typically seen in primary care; and (2) the severe forms of comorbidity between somatoform, depressive, and/or anxiety disorder, e.g., with a dimensional approach.
Topic(s):
Medically Unexplained Symptoms
See topic collection
77
Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition
Type: Journal Article
Year: 2007
Publication Place: United States
Abstract: Recent studies emphasize the negative impact of comorbidity on the course of depression. If undiagnosed, depression and comorbidity contribute to high medical utilization. We aimed to assess (1) prevalences of depression alone and with comorbidity (anxiety/somatoform disorders) in primary care, (2) coexistence of anxiety/somatoform disorders in depressive patients, and (3) diagnostic validity of two screeners regarding depression with versus without comorbidity. We examined 394 primary care outpatients using the Composite International Diagnostic Interview (CIDI), the General Health Questionnaire (GHQ-12), and the Well-Being Index (WHO-5). We conducted configurational frequency analyses to identify nonrandom configurations of the disorders and receiver operating characteristic (ROC)-analyses to assess diagnostic validity of the screeners. Point prevalence of any depressive disorder was 22.8%; with at least one comorbid disorder, 15%; and with two comorbid conditions, 6.1%, which significantly exceeded expected percentage (0.9%, P< or =.0001). Depression without comorbidity occurred significantly less often than expected by chance (P< or =.0007). Comorbidity of depressive and anxiety or somatoform disorders was associated with a high odds ratio (6.25). The screeners were comparable regarding their diagnostic validity for depression with [GHQ-12: area under the curve (AUC)=0.86; WHO-5: AUC=0.88] and without comorbidity (GHQ-12: AUC=0.84; WHO-5: AUC=0.86). It can be concluded that comorbidity between depression and anxiety/somatoform disorders in primary care may occur much more frequently than expected. These results confirm assumptions that the current division between depression and anxiety might be debatable. Validity of screeners tested in our study was not affected by comorbid conditions (e.g., anxiety or somatoform disorders).
Topic(s):
Medically Unexplained Symptoms
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Reference Links:
View the DOI record for Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition
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View the PubMed citation for Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition78
Detecting somatoform disorders in primary care with the PHQ-15
Type: Journal Article
Year: 2009
Publication Place: United States
Abstract: PURPOSE: Because recognition and management of patients with somatoform disorders are difficult, we wanted to determine the specificity, sensitivity, and the test-retest reliability of the 15-symptom Patient Health Questionnaire (PHQ-15) for detection of somatoform disorders in a high-risk primary care population. METHODS: We studied the performance of the PHQ-15 in comparison with the Structured Clinical Interview for the Diagnostic and Statistical Manual-IV Axis I disorders (SCID-I) as a reference standard. From January through September 2006, we approached patients for participation. This study was conducted in primary care settings in the Netherlands. Patients aged between 18 and 70 years were eligible if they belonged to 1 or more of the following groups: (1) patients with unexplained somatic complaints, (2) frequent attenders, and (3) patients with mental health problems. For the SCID-I interview we invited all patients with a PHQ-15 score of 6 or greater and a random sample of 30% of patients with a PHQ-15 score of less than 6. The primary study outcomes were the sensitivity and specificity for the validity and the kappa coefficient for the test-retest reliability. RESULTS: Of 2,147 eligible patients, 906 (42%) participated (mean age 48 years, 62% female). At a cutoff level of 3 or more severe somatic symptoms during the past 4 weeks, sensitivity was 78% and specificity 71%. The test-retest reliability was 0.60. CONCLUSIONS: The PHQ-15 is a valid and moderately reliable questionnaire for the detection of patients in a primary care setting at risk for somatoform disorders.
Topic(s):
Medically Unexplained Symptoms
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Reference Links:
View the DOI record for Detecting somatoform disorders in primary care with the PHQ-15
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View the PubMed citation for Detecting somatoform disorders in primary care with the PHQ-1580
Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial
Type: Journal Article
Year: 2003
Publication Place: England
Abstract: BACKGROUND: Somatisation is highly prevalent in primary care (present in 25% of visiting patients) but often goes unrecognised. Non-recognition may lead to ineffective treatment, risk of iatrogenic harm, and excessive use of healthcare services. AIM: To examine the effect of training on diagnosis of somatisation in routine clinical practice by general practitioners (GPs). DESIGN OF STUDY: Cluster randomised controlled trial, with practices as the randomisation unit. SETTING: Twenty-seven general practices (with a total of 43 GPs) in Vejle County, Denmark. METHOD: Intervention consisted of a multifaceted training programme (the TERM [The Extended Reattribution and Management] model). Patients were enrolled consecutively over a period of 13 working days. Psychiatric morbidity was assessed by means of a screening questionnaire. GPs categorised their diagnoses in another questionnaire. The primary outcome was GP diagnosis of somatisation and agreement with the screening questionnaire. RESULTS: GPs diagnosed somatisation less frequently than had previously been observed, but there was substantial variation between GPs. The difference between groups in the number of diagnoses of somatisation failed to reach the 5% significance (P = 0.094). However, the rate of diagnoses of medically unexplained physical symptoms was twice as high in the intervention group as in the control group (7.7% and 3.9%, respectively, P = 0.007). Examination of the agreement between GPs' diagnoses and the screening questionnaire revealed no significant difference between groups. CONCLUSION: Brief training increased GPs' awareness of medically unexplained physical symptoms. Diagnostic accuracy according to a screening questionnaire remained unaffected but was difficult to evaluate, as there is no agreement on a gold standard for somatisation in general practice.
Topic(s):
Medically Unexplained Symptoms
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Reference Links: View the PubMed citation for Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial