Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms.

OBJECTIVES: Investigators and clinicians almost always rely on Diagnostic and Statistical Manual of Mental Disorder, 4th edition's (DSM-IV) somatoform disorders (and its derivative diagnoses) to characterize and identify patients with medically unexplained symptoms (MUS). Our objective was to evaluate this use by determining the prevalence of DSM-IV somatoform and nonsomatoform disorders in patients with MUS proven by a gold standard chart review. METHODS: In a community-based staff model HMO, we identified subjects for a clinical trial using a systematic and reliable chart rating procedure among high-utilizing MUS patients. Only baseline data are reported here. The World Health Organization Composite International Diagnostic Interview provided full and abridged DSM-IV diagnoses. Patients with full or abridged DSM-IV somatoform diagnoses were labeled "DSM somatoform-positive," whereas those without them were labeled "DSM somatoform-negative." RESULTS: Two hundred six MUS patients averaged 13.6 visits in the year preceding study, 79.1% were females, and the average age was 47.7 years. We found that 124 patients (60.2%) had a nonsomatoform ("psychiatric") DSM-IV diagnosis of any type; 36 (17.5%) had 2 full nonsomatoform diagnoses, and 41 (19.9%) had >2; 92 (44.7%) had some full anxiety diagnosis and 94 (45.6%) had either full depression or minor depression diagnoses. However, only 9 of 206 (4.4%) had any full DSM-IV somatoform diagnosis, and only 39 (18.9%) had abridged somatization disorder. Thus, 48 (23.3%) were "DSM somatoform-positive" and 158 (76.7%) were "DSM somatoform-negative." The latter exhibited less anxiety, depression, mental dysfunction, and psychosomatic symptoms (all p <.001) and less physical dysfunction (p = .011). Correlates of this DSM somatoform-negative status were female gender (p = .007), less severe mental (p = .007), and physical dysfunction (p = .004), a decreased proportion of MUS (p <.10), and less psychiatric comorbidity (p <.10); c-statistic = 0.77. CONCLUSION: We concluded that depression and anxiety characterized MUS patients better than the somatoform disorders. Our data suggested radically revising the somatoform disorders for DSM-V by incorporating a new, very large group of now-overlooked DSM somatoform-negative patients who were typically women with less severe dysfunction.

Symptom clusters in elderly patients with lung cancer.

PURPOSE/OBJECTIVES: To identify the number, type, and combination (cluster) of symptoms experienced by patients with lung cancer. DESIGN: A secondary analysis of data collected as part of a larger study. SETTING: 24 sites that included community hospitals, medical clinics, oncology clinics, and radiation-oncology clinics. SAMPLE: 220 patients newly diagnosed with lung cancer, ranging in age from 65-89 years (mean = 72 years, SD = 5.02), 38% with early-stage and 62% with late-stage lung cancer. METHODS: Subject self-report. FINDINGS: Factor analysis found that the symptoms of fatigue, nausea, weakness, appetite loss, weight loss, altered taste, and vomiting form a cluster. Initial staging of cancer, the number of comorbid conditions, and being treated with chemotherapy emerged as significant predictors of the symptoms reported. Few differences were noted between men and women. Correlation was found among the numbers of symptoms reported, symptom severity, and limitations attributed to symptoms. CONCLUSIONS: Patients with lung cancer report multiple distressing symptoms related to symptom severity and limitations. IMPLICATIONS FOR NURSING: Assessment of multiple symptoms is recommended in patients with lung cancer.

Treating patients with medically unexplained symptoms in primary care.

BACKGROUND: There are no proven, comprehensive treatments in primary care for patients with medically unexplained symptoms (MUS) even though these patients have high levels of psychosocial distress, medical disability, costs, and utilization. Despite extensive care, these common patients often become worse. OBJECTIVE: We sought to identify an effective, research-based treatment that can be conducted by primary care personnel. DESIGN: We used our own experiences and files, consulted with experts, and conducted an extensive review of the literature to identify two things: 1). effective treatments from randomized controlled trials for MUS patients in primary care and in specialty settings; and 2). any type of treatment study in a related area that might inform primary care treatment, for example, depression, provider-patient relationship. MAIN RESULTS: We developed a multidimensional treatment plan by integrating several areas of the literature: collaborative/stepped care, cognitive-behavioral treatment, and the provider-patient relationship. The treatment is designed for primary care personnel (physicians, physician assistants, nurse practitioners) and deployed intensively at the outset; visit intervals are progressively increased as stability and improvement occur. CONCLUSION: Providing a comprehensive treatment plan for chronic, high-utilizing MUS patients removes one barrier to treating this common problem effectively in primary care by primary care personnel.

Using nurse practitioners to implement an intervention in primary care for high-utilizing patients with medically unexplained symptoms.

Patients with medically unexplained symptoms (MUS) often are a source of frustration for clinicians, and despite high quality biomedical attention and frequent diagnostic tests, they have poor health outcomes. Following upon progress in depression treatment approaches, we developed a multidimensional treatment protocol for deployment by primary care personnel. This multi-faceted intervention for MUS patients emphasized cognitive-behavioral principles, the provider-patient relationship, pharmacological management, and treating comorbid medical diseases. We deployed it in an HMO using nurse practitioners (NP) to deliver the intervention to 101 patients, while 102 controls continued to receive medical care from their usual primary care physician. Successful deployment of the intervention required training the NPs, continuing support for the NPs in their management of this difficult population, and establishing strong communication links with the HMO. This paper addresses the practical considerations of using primary care personnel to implement a complex intervention in primary care, and it includes a discussion of special challenges encountered as well as solutions developed to overcome them.

Colorectal cancer screening barriers in persons with low income.

PURPOSE: The purpose of this study was to provide insight into the modest success of a physician and patient education and reminder program that improved screening rates from 37% to 49% among rural Medicaid-eligible patients in western Michigan. DESCRIPTION OF STUDY: The following four focus groups were conducted: African American men, African American women, White men, and White women, matched with moderators by gender and ethnicity. The sample was selected by contacting prior eligible screening refusers, completing groups with a convenience sample who had accepted screening. Twenty-one patients participated who were ages >50 years. The screening refusal rates were 19% for men and 9% for women. Open-ended questions guided the discussion of colorectal cancer (CRC) attitudes, beliefs, and practices. RESULTS: All participants believed in the efficacy of cancer screening. White women were better informed about screening purposes and procedures. The major barriers to screening were quality of care (ie, the perceived lack of offering screening and the follow-up of test results) and the potential for pain from screening or treatment of CRC, should it be discovered. CLINICAL IMPLICATIONS: Successful efforts to improve awareness of the importance and efficacy of screening must further address deeply held skepticism and fears about CRC screening in this population. A fruitful direction for this difficult problem appears to be improved communication (both negative and positive test results). Without feedback, patients with negative results may assume lack of provider follow-through.

Minor acute illness: a preliminary research report on the "worried well".

OBJECTIVES: Our objectives were to determine how patients who make frequent use of the medical system (high users) with medically unexplained symptoms met our chart-rating criteria for somatization and minor acute illness and what the stability of such diagnoses were over time. STUDY DESIGN: A chart review was performed at baseline and 1 and 2 years; we re-rated the charts of patients initially rated as having somatization, as well as a 15% sample of those with minor acute illness. POPULATION: We obtained a random sample of high-use patients (= 6 visits/year) aged 21 to 55 years who were identified from the management information system. OUTCOMES: We measured chart review designations as organic disease, somatization, or minor acute illness. RESULTS: Among 883 high users at baseline, 35% had organic diseases; 14% had somatization; and 51% had minor acute illness as their primary problems. No patients with initial minor acute diagnoses were reclassified as having somatization 1 or 2 years later, and all but 2 patients had minor acute illness in 1 or both follow-up years. CONCLUSIONS: Minor acute illness was more common among high users than somatization and organic diseases combined. It has not previously been studied but probably has been recognized by clinicians as the "worried well." Diagnoses of somatization were unstable over 2 years follow-up, while minor acute diagnoses were stable, supporting the latter as a valid entity.