Psychosomatics 43:394-399, October 2002
© 2002 The Academy of Psychosomatic Medicine
Treatment of Patients With Somatized Mental Disorder: Effects of Reattribution Training on Outcomes Under the Direct Control of the Family Doctor
Richard K. Morriss, and
Linda Gask
Received Nov. 6, 2001; revision received Feb. 18, 2002; accepted March 8, 2002. From the University of Liverpool, Liverpool, U.K., and the University of Manchester, Manchester, U.K. Address reprint requests to Professor Morriss, University of Liverpool Department of Psychiatry, 2nd Floor UCD Building, Royal Liverpool Hospital, Prescot Street, Liverpool L69 3GA, U.K.; r.k.morris{at}liverpool.ac.uk (e-mail).
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ABSTRACT
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Reattribution training is an 8-hour, skills-based training program delivered to family doctors so that they may better manage patients with somatized mental disorder. Separate consecutive cohorts of 103 and 112 patients with somatized mental disorder, respectively, visited eight family doctors before and after these physicians had undergone reattribution training. Reattribution training was associated with more frequent endorsement by patients after 1 month that they received the help they wanted and fewer beliefs by patients after 3 months that their symptoms had only a physical cause. Reattribution training did not change the incidence of investigations initiated by the family doctor, prescriptions for psychotropic or nonpsychotropic drugs, or referrals over 3 months.
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INTRODUCTION
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In primary care, somatized mental disorder can be defined as a mental disorder accompanied with a physical symptom or symptoms that the patient believes to be physically rather than emotionally caused but that cannot be fully explained by physical pathology.1 Somatized mental disorder accounts for 4% of all visits to family doctors,2 but many family doctors feel ill-equipped to manage these patients.3
Reattribution is used by family doctors within a single or a series of 10-minute consultations to manage somatized mental disorder.1,4 The family doctor takes a relevant history of physical and psychosocial problems, beliefs about the cause of their symptoms, and carries out a focused physical examination. Results are fed back to the patient, who receives a tentative explanation from his or her family doctor that their physical symptoms might be linked to psychosocial and lifestyle factors. If the patient seems willing to accept this explanation, then a physiological or temporal link between the psychosocial or lifestyle problem and the symptom is fully explained. For instance, a patient may have back pain because of workplace stress that resulted in tension in the muscles of his or her back and after a while these muscles tired and started to ache. Further help for the patient's symptoms or psychosocial problems may then be negotiated by the general practitioner. The aim of reattribution is to normalize the patient's interpretations of their bodily symptoms, modify their beliefs about causes of their symptoms, and treat any underlying depression.
In three independent studies, training family doctors in reattribution led to specific improvements in family doctor communication with actors playing the role of patients with somatized mental disorder.1,5,6 Using a before- and after-training design, reattribution training significantly improved function and reduced psychopathology at 3 months among patients who did not have fixed beliefs that their symptoms had a physical cause.1 Among patients who had fixed beliefs that their symptoms had a physical cause, reattribution training significantly reduced the prevalence of major depression by 50% at 1 month. Reattribution training also significantly decreased the costs of health contacts (secondary health care, external health providers coming to practices, private health care) outside the primary care health team by 23% with no change in primary care costs.7 The aim of this study was to determine whether reattribution training could change outcomes that could be directly attributed to the family doctor, namely patient satisfaction with care, patient beliefs that the symptoms are physically caused, and doctor-initiated investigations, prescriptions, and referrals.
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METHOD
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Design and Subjects
A representative sample of eight family doctors, working with other family doctors in community settings, was recruited.1 This study used a before- and after-training design with the same family doctors but with different cohorts of patients with somatized mental disorder. A research assistant attended randomly selected office visits of each family doctor in the study. Patients were consecutively recruited in the waiting room of the family doctor's office until there were 150 eligible patients for interview in each cohort. Inclusive criteria were 1) at least one bodily symptom complaint lasting at least 2 weeks, 2) belief that the complaint had a physical cause, 3) score of 3 or more on the 12-item General Health Questionnaire,8 and 4) no physical pathology that explained all symptoms and disability. One month later a research psychologist interviewed the patient at home using a standardized psychiatric interview9 to establish the presence of a DSM-IV anxiety, depressive, or somatoform disorder.10 The interrater reliability for DSM-IV diagnosis between the research psychologist and a senior psychiatrist (R.M.) for 10 jointly rated patients was satisfactory, with a Cohen's kappa of 0.78 (p<0.001). Patients were excluded if they had no diagnosable DSM-IV anxiety, somatoform, or depressive disorder or if they had a psychotic disorder, a primary substance misuse disorder, an organic mental disorder, or a mental disorder entirely secondary to a potentially catastrophic medical disorder.
Measures
At baseline (while in the waiting room) and after 3 months (through a postal survey), patients self-rated their own belief about the cause of their physical symptom or symptoms as being either entirely physically caused or not entirely physically caused. Patient satisfaction with the doctor's care was evaluated only once: 1 month after baseline during an interview at the home of the patient. The satisfaction scale11 consisted of seven items relating to key aspects of communication between the family doctor and the patient: 1) The doctor understood the nature of the patient's problem. 2) The doctor understood the worry about the symptom. 3) The doctor understood how the patient was feeling emotionally. 4) The doctor understood the problems that the patient experienced. 5) The doctor explained the physical examination. 6) The doctor explained the psychological cause. 7) The patient received the help that he or she wanted. Each item consists of four possible ratings (items 1–6: 1=poorly, 2=adequately, 3=well, 4=very well; item 7: 1=definitely not, 2=not really, 3=mostly, 4=definitely). Extremes of dissatisfaction were rarely reported, so each item was reduced to a binary outcome, either complete satisfaction with an aspect of the general practitioner's care or some dissatisfaction. Prescription of antidepressants and other psychiatric drugs—based on their classification in the British National Formulary12—investigations, and referrals to secondary health care were examined at baseline and after 3 months from physician records and at patient interview. The number and nature of the physical symptoms of the patient were established from the patient's verbatim written account in the waiting room and checked by the research psychologist at the 1-month interview. Further details of the other assessments that were made and power calculations are described elsewhere.1,7
Interventions
Reattribution training
Four 2-hour training sessions were delivered by two psychiatrists (L.G., R.M.) and a family doctor on a weekly basis. Each training session consisted of 1) viewing videotaped training materials; 2) role playing in pairs, with feedback from the trainers to practice skills; 3) video feedback supervision of two of the family doctor's cases from clinical practice in small groups; and 4) written material to promote rehearsal of skills learned in the sessions. Attitudes regarding managing patients with somatized mental disorder were explored in group discussions with the supervisors, and knowledge about somatized mental disorder was delivered through a written manual. The training constitutes a multifaceted educational intervention that has been effective in changing physician performance.13
The family doctors were invited to manage their identified cases as usual in the way that they saw fit, such as prescribing symptomatic relief for the physical symptoms; prescribing hypnotic, sedating, and antidepressant drugs; and referring to secondary care (commonly hospital medicine and surgery inpatient/outpatient care, physiotherapy, dietician, district nurse, or counselor).7
Data Analysis
The effects of reattribution training on the beliefs that patients had about their symptoms after 3 months were examined by using multiple logistic regression with the training condition, the identity of the family doctor, the baseline symptom belief, and duration of symptoms entered as independent categorical variables. Patient satisfaction with the doctor's care after 1 month was examined by using multiple logistic regression with the training condition, the identity of the doctor, and duration of symptoms entered as independent variables. The presence or absence of an intervention (investigation, prescription, or referral) initiated by the family doctor was also explored after 3 months by using multiple logistic regression with the training condition, the identity of the doctor, the baseline use of the intervention by the doctor (in the month before training), and duration of symptoms entered as independent variables. Adjusted odds ratios for the training effect and 95% confidence intervals for the odds ratios are reported for all the multiple logistic regression analyses. All the analyses were intention-to-treat analyses; data were complete for all patient satisfaction data and for all but one patient (in the after-training cohort) for physician record of service contacts. For 31 patients (19%) missing symptom belief data after 3 months, baseline values were used (i.e., no change over time in symptom beliefs was assumed).
RESULTS
The eight family doctors were a mean age of 42 years (range=34–45), and the mean time spent working as a family doctor was 13 years (range=6–18). Four family doctors were male, and four were female. Six worked full-time, and two worked part-time in the British National Health Service, with a fixed list of registered patients receiving care through the national health insurance system.
Figure 1 provides a flow chart of subject progression in each cohort. The before-training cohort was recruited from April 1994 to January 1995, with 103 (69%) meeting study criteria at 1 month. The after-training cohort of patients was recruited from January 1995 to July 1995, with 112 (72%) meeting study criteria. In total, 3,538 consecutive patients were screened in 197 doctor's offices.
In the whole study group, there were 29 different physical symptoms present at baseline, the most common being back pain (N=31), fatigue (N=23), limb pain (N=19), and abdominal pain (N=18). The most common somatized DSM-IV disorders at baseline were agoraphobia (N=95, 44%), major depression (N=90, 42%), depressive disorder not otherwise specified (N=88, 41%), dysthymia (N=84, 39%), generalized anxiety disorder (N=83, 39%), and panic disorder (N=36, 17%). Sixty-three (29%) had only one of the following diagnoses: depressive disorder not otherwise specified, anxiety disorder not otherwise specified, undifferentiated somatoform disorder, hypochondriasis, or somatoform disorder not otherwise specified.
Table 1 shows that the two cohorts of patients did not differ significantly in baseline sociodemographic or clinical factors except that the after-training cohort contained significantly more patients whose main physical symptom had lasted more than 12 months. The subjects who declined to be interviewed at 1 month did not statistically differ from those who were interviewed in terms of age and gender.
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TABLE 1. Baseline Demographic and Clinical Characteristics of Patients With Somatized Mental Disorder Seeking Treatment Before and After Their Family Doctor Received Reattribution Training
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Table 2 shows that after 1 month, there was a higher proportion of patients in the after-training cohort than in the before-training cohort who stated that they definitely received the help from the family doctor that they wanted (adjusted odds ratio=2.00, 95% CI=1.07–3.74). However, reattribution training did not change any measure of patient satisfaction with the doctor's understanding or explanation of their problems. After 3 months, a lower proportion of patients in the after-training cohort than in the before-training cohort believed that their symptoms were entirely caused by physical problems (adjusted odds ratio=0.43, 95% CI=0.19–0.97). Among the physicians, there was no change in the incidence of investigations, prescriptions, or referrals to secondary health care services after reattribution training compared with before training. Among the 90 patients with major depression, 44 (49%) received antidepressants, and 38 (42%) received adequate doses of antidepressants. The proportion of patients with major depression who received antidepressants or adequate doses of antidepressants showed a small nonsignificant improvement after reattribution training (data not shown).
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TABLE 2. Effects of Reattribution on Patient Satisfaction With Care, Symptom Beliefs, and Doctor-Initiated Investigations, Prescriptions, and Referrals
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DISCUSSION
Reattribution training was not associated with a change in any aspect of doctor-initiated health care (investigations, prescriptions, or referrals). However, reattribution training was associated with clinically important changes: improvement in patient satisfaction with the overall help that they received from their family doctor after 1 month and a decrease in patient-held beliefs that their symptoms were entirely physically caused after 3 months.
There are important limitations in the study design that may have mimicked beneficial effects of treatment. The study was not a randomized controlled trial and did not use contemporaneous control subjects. Seasonal effects were reduced by recruitment over both winter and summer months in both cohorts. None of the family doctors received any other systematic training in mental health over the period of the study. Nevertheless, the before- and after-training design is more likely than a randomized controlled trial to introduce unintended confounding factors or selection bias. In this study, the after-training cohort of patients with somatized mental disorder may have been more difficult to treat and less likely to remit spontaneously because of their longer duration of symptoms. A high proportion of subjects with a 12-item General Health Questionnaire score of 3 or more had a diagnosable DSM-IV anxiety, depressive, or somatoform disorder. The psychologist had been specifically trained to make these diagnoses and showed high interrater reliability with a senior psychiatrist in making these diagnoses. The psychologist may have had too low a threshold for diagnosing mild psychiatric disorder (false positives), but excluding the 63 patients with one minor psychiatric disorder diagnosis (depressive disorder not otherwise specified, anxiety disorder not otherwise specified, hypochondriasis, undifferentiated somatoform disorder, or somatoform disorder not otherwise specified) made little difference to our results. An alternative explanation for the high proportion of subjects with a diagnosable mental disorder is that the 12-item General Health Questionnaire score of 3 is too high in somatizing patients, who may minimize symptoms of anxiety and depression on self-report.14
Improved doctor-patient communication after reattribution training has been demonstrated in three studies of role-playing consultations between family doctors and actors playing patients with somatized mental disorder.1,6,7 In the current study, greater patient satisfaction with the care they received from their family doctor may reflect improved doctor-patient communication that meets the patients' needs. There are parallels between our studies of reattribution, with improved satisfaction with care at 1 month followed by improvements in emotional symptoms and function at 3 months, and a naturalistic study of the management of physical symptoms in primary care. In the latter study, the meeting of patient's needs through good doctor-patient communication was associated with improved satisfaction with care at 2 weeks and improved symptoms and function at 3 months.15 In reattribution training, the family doctor tries to find explanations that are compatible with the patient's experience of illness,16 and such explanations may change the patient's belief about the cause of his or her illness. In contrast to the randomized controlled trials of psychiatric consultation letters,17,18 reattribution training is not cost effective for the family doctor, which may limit health care utilization.7 Instead, the benefits of reattribution training may be seen in the reductions in health utilization that occur as a natural consequence of the patient having a greater sense of control over their symptoms and more confidence in their family doctor. As a result, the patient may have less need to make contact with secondary care.
We conclude that there is preliminary evidence that reattribution training may be clinically and cost effective for patients with somatized mental disorder through improved doctor-patient communication. However, further research is required to establish whether reattribution training is clinically and cost effective in the longer term, and whether it would be widely used by family doctors in routine practice.
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ACKNOWLEDGMENTS
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This study was funded by the Mental Health Foundation. Statistical advice was provided by Professor G. Dunn and Dr. B. Faragher. Reattribution training was performed with the help of Dr. Clare Ronalds.
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REFERENCES
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- Morriss RK, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Goldberg D: Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract 1999; 49:263-267[Medline]
- Weich S, Lewis G, Donmall R, Mann A: Somatic presentation of psychiatric morbidity in general practice. Br J Gen Pract 1995; 45:143-147[Medline]
- Kerwick S, Jones R, Mann A, Goldberg D: Mental health care training priorities in general practice. Br J Gen Pract 1997; 47:225-227[Medline]
- Goldberg D, Gask L, O'Dowd T: The treatment of somatization: teaching techniques of reattribution. J Psychosom Res 1989; 33:689-695[CrossRef][Medline]
- Gask L, Goldberg D, Porter R, Creed F: The treatment of somatization: evaluation of a training package with general practice trainees. J Psychosom Res 1989; 33:697-703[CrossRef][Medline]
- Kaaya S, Goldberg D, Gask L: Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners. Med Educ 1992; 26:138-144[Medline]
- Morriss R, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Leese B, Goldberg D: Cost effectiveness of a new treatment for somatized mental disorder taught to family doctor. Fam Pract 1999; 15:119-125[Abstract/Free Full Text]
- Goldberg DP, Williams P: The User's Guide to the General Health Questionnaire. Slough, UK, National Foundation for Educational Research-Nelson, 1988
- Kisely S, Faragher B, Gask L, Goldberg DP: Measuring psychiatric disorder in the recent past: the use of the Psychiatric Assessment Schedule retrospectively. Psychol Med 1992; 22:457-463[Medline]
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994
- Gask L: The Impact on Patient Care, Clinical Outcome and Patient Satisfaction of Improving the Psychiatric Interviewing Skills of General Practitioners (doctoral dissertation). Manchester, UK, University of Manchester, 1991
- British Medical Association and Royal Pharmaceutical Society of Great Britain: British National Formulary, 40th ed. Oxford, UK, Pharmaceutical Press, 2000
- Davies DA, Thomson MA, Oxman AD, Haynes RB: Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995; 274:700-705[Abstract/Free Full Text]
- Bridges K, Goldberg D, Evans B, Sharpe T: Determinants of somatization in primary care. Psychol Med 1991; 21:473-483[Medline]
- Jackson JL, Chamberlin J, Kroenke K: Predictors of patient satisfaction. Soc Sci Med 2001; 52:609-620
- Epstein RM, Quill TE, McWhinney IR: Somatization reconsidered: incorporating the patient's experience of illness. Arch Intern Med 1999; 159:215-222[Abstract/Free Full Text]
- Smith G, Monson RA, Ray DC: Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med 1986; 314:1407-1413[Abstract]
- Smith G, Rost K, Kashner TM: A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995; 52:238-243[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
