Hostname: page-component-586b7cd67f-t7czq Total loading time: 0 Render date: 2024-11-25T14:48:45.684Z Has data issue: false hasContentIssue false
  • English
  • Français

Depression and anxiety in patients repeatedly referred to secondary care with medically unexplained symptoms: a case-control study

Published online by Cambridge University Press:  19 May 2010

C. Burton ,
K. McGorm ,
D. Weller  and
M. Sharpe
C. Burton
Affiliation:
Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
K. McGorm
Affiliation:
Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
D. Weller
Affiliation:
Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
M. Sharpe*
Affiliation:
Psychological Medicine Research, School of Molecular and Clinical Medicine, University of Edinburgh, Edinburgh, UK
*
*Address for correspondence: Professor M. Sharpe, Psychological Medicine Research, University of Edinburgh, Kennedy Tower, Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

One third of referrals from primary to secondary care are for medically unexplained symptoms (MUS). We aimed to determine the association of depression and anxiety disorders with high use of specialist services by patients with MUS. We did this by comparing their prevalence in patients who had been repeatedly referred with symptoms for which they had received repeated specialist diagnoses of MUS with that in two control groups. We also determined the adequacy of treatment received.

Method

A case-control study in five general practices in Edinburgh, UK. Data collection was by case note review and questionnaire. Cases were 193 adults with three or more referrals over 5 years, at least two of which resulted in a diagnosis of MUS. Controls were: (a) patients referred only once over 5 years (n=152); (b) patients with three or more referrals for symptoms always diagnosed as medically explained (n=162).

Results

In total, 93 (48%) of the cases met our criteria for current depression, anxiety or panic disorders. This compared with 38 (25%) and 52 (35.2%) of the control groups; odds ratios (95% confidence intervals) of 2.6 (1.6–4.1) and 1.6 (1.01–2.4), respectively. Almost half (44%) of the cases with current depression or anxiety had not received recent minimum effective therapy.

Conclusions

Depression, anxiety and panic disorders are common in patients repeatedly referred to hospital with MUS. Improving the recognition and treatment of these disorders in these patients has the potential to provide better, more appropriate and more cost-effective medical care.

Keywords

Anxietydepressionmedically unexplained symptomsprimary carereferral
Type
Original Articles
Information
Psychological Medicine , Volume 41 , Issue 3 , March 2011 , pp. 555 - 563
Copyright
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Barsky, AJ, Orav, EJ, Bates, DW (2005). Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives of General Psychiatry 62, 903–910.CrossRefGoogle ScholarPubMed
Barsky, AJ, Orav, EJ, Bates, DW (2006). Distinctive patterns of medical care utilization in patients who somatize. Medical Care 44, 803–811.CrossRefGoogle ScholarPubMed
Burton, C (2003). Beyond somatisation: a review of the understanding and management of medically unexplained physical symptoms (MUPS). British Journal of General Practice 53, 233–241.Google Scholar
Carson, AJ, Ringbauer, B, Stone, J, McKenzie, L, Warlow, C, Sharpe, M (2000). Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. Journal of Neurology Neurosurgery and Psychiatry 68, 207–210.CrossRefGoogle Scholar
Carstairs, V, Morris, R (1990). Deprivation and health in Scotland. Health Bulletin (Edinburgh) 48, 162–175.Google ScholarPubMed
de Waal, MW, Arnold, IA, Eekhof, JA, van Hemert, AM (2004). Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. British Journal of Psychiatry 184, 470–476.CrossRefGoogle ScholarPubMed
Henningsen, P, Zimmermann, T, Sattel, H (2003). Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosomatic Medicine 65, 528–533.CrossRefGoogle ScholarPubMed
Hole, DJ, Clarke, JA, Hawthorne, VM, Murdoch, RM (1981). Cohort follow-up using computer linkage with routinely collected data. Journal of Chronic Diseases 34, 291–297.CrossRefGoogle ScholarPubMed
Hunot, VM, Horne, R, Leese, MN, Churchill, RC (2007). A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences. Primary Care Companion Journal of Clinical Psychiatry 9, 91–99.CrossRefGoogle ScholarPubMed
Joint Formulary Committee (2006). British National Formulary, 51st edn. British Medical Association and Royal Pharmaceutical Society of Great Britain: London.Google Scholar
Katon, W, von Korff, M, Lin, E, Lipscomb, P, Russo, J, Wagner, E, Polk, E (1990). Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. General Hospital Psychiatry 12, 355–362.CrossRefGoogle ScholarPubMed
Kendrick, T, Chatwin, J, Dowrick, C, Tylee, A, Morriss, R, Peveler, R, Leese, M, McCrone, P, Harris, T, Moore, M, Byng, R, Brown, G, Barthel, S, Mander, H, Ring, A, Kelly, V, Wallace, V, Gabbay, M, Craig, T, Mann, A (2009). Randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of selective serotonin reuptake inhibitors plus supportive care, versus supportive care alone, for mild to moderate depression with somatic symptoms in primary care: the THREAD (THREshold for AntiDepressant response) study. Health Technology Assessment 13, 1.CrossRefGoogle ScholarPubMed
Kroenke, K, Arrington, ME, Mangelsdorff, AD (1990). The prevalence of symptoms in medical outpatients and the adequacy of therapy. Archives of Internal Medicine 150, 1685–1689.CrossRefGoogle ScholarPubMed
Lowe, B, Decker, O, Muller, S, Brahler, E, Schellberg, D, Herzog, W, Herzberg, PY (2008 a). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care 46, 266–274.CrossRefGoogle ScholarPubMed
Lowe, B, Spitzer, RL, Williams, JB, Mussell, M, Schellberg, D, Kroenke, K (2008 b). Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. General Hospital Psychiatry 30, 191–199.CrossRefGoogle ScholarPubMed
R Development Core Team (2009). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing: Vienna.Google Scholar
Reid, S, Crayford, T, Patel, A, Wessely, S, Hotopf, M (2003). Frequent attenders in secondary care: a 3-year follow-up study of patients with medically unexplained symptoms. Psychological Medicine 33, 519–524.CrossRefGoogle ScholarPubMed
Reid, S, Wessely, S, Crayford, T, Hotopf, M (2001). Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. British Medical Journal 322, 767–770.CrossRefGoogle ScholarPubMed
Sharpe, M (2002). Medically unexplained symptoms and syndromes. Clinical Medicine 2, 501–504.Google ScholarPubMed
Smith, BJ, McGorm, KJ, Weller, D, Burton, C, Sharpe, M (2009). The identification in primary care of patients who have been repeatedly referred to hospital for medically unexplained symptoms: a pilot study. Journal of Psychosomatic Research 67, 207–211.CrossRefGoogle ScholarPubMed
Smith, RC, Korban, E, Kanj, M, Haddad, R, Lyles, JS, Lein, C, Gardiner, JC, Hodges, A, Dwamena, FC, Coffey, J, Collins, C (2004). A method for rating charts to identify and classify patients with medically unexplained symptoms. Psychotherapy and Psychosomatics 73, 36–42.CrossRefGoogle ScholarPubMed
Spitzer, RL, Kroenke, K, Williams, JB (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. Journal of the American Medical Association 282, 1737–1744.CrossRefGoogle ScholarPubMed
Stein, MB, Roy-Byrne, PP, McQuaid, JR, Laffaye, C, Russo, J, McCahill, ME, Katon, W, Craske, M, Bystritsky, A, Sherbourne, CD (1999). Development of a brief diagnostic screen for panic disorder in primary care. Psychosomatic Medicine 61, 359–364.CrossRefGoogle ScholarPubMed
Wittkampf, KA, Naeije, L, Schene, AH, Huyser, J, van Weert, HC (2007). Diagnostic accuracy of the mood module of the Patient Health Questionnaire: a systematic review. General Hospital Psychiatry 29, 388–395.CrossRefGoogle ScholarPubMed