| | Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disordersAbstract Consultation-liaison (C-L) psychiatry has an important role in the management of somatoform disorders (SD). Characteristics of SD patients in C-L psychiatry are largely unknown and are presented in this paper. We analyzed 13,314 Dutch psychiatric consultations from 1984 to 1991 and compared patients diagnosed with SD to patients with other mental disorders and to those without a mental disorder. The comparison included socio-demographic variables, consult characteristics, medical history, current somatic morbidity, information about additional diagnostic tests, hospital admission time and aftercare management. Of the 544 SD patients 39.5% (n = 215) were diagnosed with a conversion disorder that illustrates the highly selected nature of SD patients in C-L psychiatry. Employment among SD patients decreased significantly from 58% in the group aged 20–29 years to 6% in the group aged 50–59 years. This decrease was significantly larger as compared to other mental disorders and no mental disorders and was virtually unaffected by correction for potential confounding by gender. Contrary to our expectation no difference between the three groups was observed in claims for disability benefits. Of the SD patients 74.5% were referred for aftercare management, significantly more than the other two groups which is considered a promising development in C-L psychiatry.
1. Introduction  Somatoform disorders (SD) represent a serious problem in psychiatry. Impairing symptoms, misapplied medical treatment [1] and economic burden [2], [3], [4], [5] make proper (clinical) management important. Various studies stress the role of consultation-liaison psychiatry (C-L psychiatry) in the management of SD [6], [7], [8]. Of all inpatients seen in C-L psychiatry, a minority of 6 to 9% is diagnosed with an SD [9], [10], [11], [12]. Characteristics of these patients are largely unknown. We had the opportunity to analyze 13,314 consultations in C-L psychiatry, using an existing database in the Netherlands. The primary aim of this study was to establish the characteristics of SD patients as compared to patients with other mental disorders or with no mental disorders in C-L psychiatry. This study was part of a research program on the characteristics and prognostic issues concerning SD in general practice, outpatient neurology and inpatient C-L psychiatry. 2. Materials and methods Multi-center data on psychiatric consultations were collected by members of the Netherlands Consortium for C-L Psychiatry (NCCP) in 4 university hospitals and 16 general hospitals in the Netherlands from 1984 to 1991 [11]. During this period psychiatric consultants registered their final consultations on standardized forms based on guidelines according to Hengeveld et al. [11]. The main items on the forms were devised after extensive study of epidemiological C-L psychiatric literature. Throughout the years, minor adaptations were made based on ongoing discussion of the registration items and categories with NCCP-members. These consensus meetings enhanced the face and content validity of the registration form on which the consultations were reported. Primary psychiatric diagnoses were coded on the basis of the two successive versions of the Diagnostic and Statistical Manual of mental disorders, third and third revised edition (DSM-III and DSM-III-R) [13], [14]. Our study included inpatients aged 15 to 85 years. Excluded were intensive care and emergency ward patients, patients on a pediatric ward and outpatients. Patients were also excluded when the diagnostic DSM-code was missing. Since recording of some items on the consult forms was optional, some hospitals did not complete all items. These hospitals were excluded from the analyses for these specific items. As a consequence, the total number of patients for the analyses differs from item to item. Patients diagnosed with an SD were compared to patients with another mental disorder (OMD) and to those with no mental disorder (NMD) at psychiatric consultation. Comparisons were made for socio-demographic variables, consult characteristics, medical history, current somatic morbidity, additional diagnostic tests, hospital admission time and aftercare management. Crude numbers and percentages are given for all items. Odds ratios with 95%-confidence intervals and Pearson chi squares were used to quantify differences. Multivariate logistic-regression analysis was used to model an interaction effect between employment and age, and to adjust for potential confounding by gender. 3. Results 3.1. General consult characteristics and diagnoses A total number of 18,581 consultations were registered from 1984 to 1991, of which 13,314 (71.7%) consultations fulfilled our inclusion criteria. Characteristics of the total group were similar to the 1984 subgroup of patients that was previously described in detail by Hengeveld et al. [11]. A diagnosis of SD was made in 544 patients (4.1%). OMD were diagnosed in 10,944 patients (82,2%) and NMD was diagnosed in 1,825 patients (13,7%). The main subtypes of SD are given in Table 1 for the three large groups of medical departments. The prevalence of 39.5% conversion disorder was notably high, with an important contribution from the neurology department. | | |  | Diagnoses | Referring department | Neurology n (%) | Total n (%) | |
|---|
| Internal medicine* n (%) | Surgery** n (%) | |
|---|
| Somatoform disorders | 249 (3.5) | 130 (2.8) | 165 (11.6) | 544 (4.1) | |
| Conversion disorder | 65 (26.1) | 40 (35.2) | 110 (66.7) | 215 (39.5) | |
| Hypochondriasis† | 76 (30.5) | 34 (34.1) | 19 (11.5) | 129 (23.7) | |
| Somatoform pain disorder | 51 (20.5) | 26 (13.2) | 26 (15.8) | 107 (19.7) | |
| Somatization disorder | 57 (22.9) | 30 (17.6) | 10 (6.1) | 93 (17.1) | |
| Other mental disorders | 5,886 (81.7) | 3,927 (83.8) | 1,131 (79.5) | 10,944 (82.2) | |
| No mental disorder | 1,070 (14.8) | 628 (13.4) | 127 (8.9) | 1,825 (13.7)‡ | |
| Total n (%) | 7,205 (100) | 4,685 (100) | 1,423 (100) | 13,313 (100) | | | | |
|
*
Including Dermatology.
**
Including Ophthalmology, Neurosurgery, Ear Nose Throat, Gynaecology and Obstetrics.
†
Including body dysmorphic disorder, somatoform disorders not otherwise specified and undifferentiated somatoform disorders.
‡
one missing. |
3.2. Comparison of RT with other diagnostic groups 3.2.1. Social demographics In Table 2 working status and partner relationship are shown for SD patients as compared to those with NMD and OMD. Employment among patients with an SD decreased considerably with age. The decrease was significantly larger, as compared to patients with NMD and OMD. In a multivariate logistic regression model the significant differential decrease in employment with age in the SD group was not materially changed by including gender as potential confounder in the model. A parallel increase in claims for disability benefits was absent. Instead of employment, SD patients find their occupation in household chores. As compared to the other two groups a significantly larger proportion of patients with SD share there lives with a partner. |
*
SD: Somatoform Disorder.
**
OMD: Other Mental Disorder.
†
NMD: No Mental Disorder.
‡
Percentages are related to the total number of patients in the diagnostic categories for each age group.
§
Pearson chi square values for age groups 20–29 through 50–59. |
3.2.2. Medical history and somatic morbidity Table 3 shows the somatic history of 8,023 patients and the psychiatric history of 9,220 patients. SD patients were almost twice as likely to have three or more general hospital admissions as compared to OMD and NMD. Three or more psychiatric admissions were half as likely for SD patients when compared to OMD. One or two psychiatric admissions were significantly more prevalent only when compared to the NMD group. |
*
SD: Somatoform Disorder.
**
OMD: Other Mental Disorder.
†
NMD: No Mental Disorder.
‡
The association with SD is expressed as an odds ratio (OR) for categorical variables with 95%-confidence intervals (95%-CI). |
Somatic morbidity was coded in 481 SD, 10,016 OMD and 1,734 NMD patients according to the 17 ICD-9-CM chapters [15]. Of the SD patients 75.5% (n = 363) had a somatic diagnosis. In case of OMD and NMD this percentage was respectively 95.8% (n = 9,591) and 91.9% (n = 1,595). The somatic morbidity in SD patients was mainly of the nervous system (n = 66, 13.7%), the digestive system (n = 61, 12.7%) and the musculoskeletal system (n = 47, 9.8%). Compared to the OMD group, the percentages and odds ratios were respectively 8.3% OR=1.64 (95%-CI: 1.25–2.16), 8.4% OR=1.59 (95%-CI: 1.19–2.11) and 3.5% OR=2.98 (95%-CI: 2.14–4.15) and compared to the NMD group, respectively 5.6% OR=2.68 (95%-CI: 1.90–3.78), 6.9% OR=1.95 (95%-CI: 1.39–2.74) and 3.5% OR=2.97 (95%-CI: 1.96–4.49). The somatic morbidity in OMD and NMD patients concerned mainly neoplasms, respectively 14.5% and 19.6%, while in SD patients this was only 2.1%. 3.2.3. Diagnostic testing, additional information and medication advise For patients with an SD, significantly fewer recommendations were made for additional diagnostic testing such as somatic consultation, laboratory tests and radiology diagnostics when compared to the OMD group (OR: 0.33, 95%-CI: 0.22–0.48). There was no significant difference with the NMD group (OR: 1.06, 95%-CI: 0.68–1.63). The psychiatric consultant requested additional information for 38.2% of the SD patients compared to 36.2% of the OMD patients and 25.5% of the patients with NMD. The odds ratios were respectively 1.09 (95%-CI: 0.91–1.30) and 1.88 (95%-CI: 1.47–2.22). This concerned mainly information requested from the general practitioner. Advice concerning medication was given for 157 SD patients (28.9%). It concerned mainly recommendations for antidepressants and anxiolytics (respectively 42.0% and 45.2%). Medication advice was most frequently given for those patients diagnosed with OMD (n = 7,458, 68.1%). This advice concerned mainly recommendations for neuroleptic medication (n = 3,768, 50.5%). In the NMD group 542 (29.7%) patients received a medication advice. There was no significant difference between the three diagnostic groups for sedatives such as benzodiazepines (18.2–24.5%). What kind of advice was given remained unknown. 3.2.4. Admission time before consultation, consultation duration, follow-up, transfer and aftercare management Specifications concerning hospital admission time before consultation took place, duration of first and follow-up visits and number of follow-up visits are given in Table 4. Patients with an SD required more consultation time, both in first and follow-up visits, and called for significantly more follow-up visits in comparison with the OMD group and NMD group. A significant minority of the SD patients was transferred to (other) hospitals as compared to OMD patients (Table 5). The transfers to nonpsychiatric hospitals were mainly to nursing homes. Psychiatric transfers were mainly to the psychiatric ward of the hospital where the consultation took place. For a significant majority of the SD patients aftercare management was arranged as compared both to OMD and to NMD (Table 5). |
*
No psychiatric transfer: including nursing home, rehabilitation centre and other none-psychiatric hospitals.
**
Some hospitals systematically omitted specific items. Therefore the total number of patients on which the percentages are based differs throughout the table.
†
Psychiatric transfer: including psychiatric ward, psychiatric hospital, day treatment and psychiatric nursing home.
‡
SD: Somatoform Disorder.
§
OMD: Other Mental Disorder.
∥
NMD: No Mental Disorder.
¶
The association with SD is expressed as an odds ratio (OR) for categorical variables with 95%-confidence intervals (95%-CI). |
4. Discussion In summary, only a small proportion of patients seen in C-L psychiatry are diagnosed with an SD, of whom 40% have a diagnosis of conversion disorder. We observed a disproportionate decrease of employment figures among SD patients with age, but, contrary to expectation, we did not observe an increase in claims for disability benefits. The time interval between hospital admission and psychiatric consultation is shorter for SD patients. Consultation of an SD patient is more time-consuming. SD patients have a more extensive history of somatic admissions, but not of psychiatric admissions. Two-thirds of the SD patients are referred for aftercare management. Consult characteristics of 13,314 patients from 20 different hospitals constitute a heterogeneous population of patients and consultants. However, the integrity of the data were facilitated by the use of a registration form that was developed through consensus meetings with the NCCP-members. A similar approach was chosen in the European Consultation Liaison Workgroup (ELCW) study, where it proved to be an efficient method to reach a reliable definition of C-L service provision throughout numerous hospitals and countries [16]. The primary aim of the present study was to analyze routinely collected data of consult characteristics for patients diagnosed with an SD as compared to OMD and NMD in C-L psychiatry. In accordance with percentages specified in the literature, 544 (4.1%) patients were diagnosed with an SD [9], [10]. In primary care, the prevalence of SD is estimated between 22% and 58%, depending on the diagnostic criteria used and whether SD not otherwise specified or undifferentiated SD were included [17]. In our study almost 40% of the SD patients were diagnosed with a conversion disorder. Although little is known about the relative prevalence of the individual DSM categories of SD [18], a community survey in Florence found conversion disorder in no more than 2 out of 136 patients with SD (1,5%) [19] The high relative prevalence of 40% conversion disorders among our SD patients illustrates the highly selected nature of patients with an SD that are seen in CL-psychiatry. This selection might be based on the impressive clinical presentation of patients with a conversion disorder that could be regarded as a risk factor for admittance to a hospital and in a later phase for consulting a psychiatrist. In order to search for characteristics of SD patients in C-L psychiatry we compared them with OMD and NMD patients. Comparison of socio-demographic data on employment and disability benefits showed some interesting unexpected differences. Among the younger patients, a comparatively large proportion had a working career as compared to the NMD and OMD groups (Table 2). However, we observed a disproportionate decrease in employment among SD patients of almost 50% with each 10 years increase in age. Controlling for gender did not materially change this finding. Decrease of employment was especially high in the age category 30–39. For clinical management attention for job loss in this age category of SD patients might therefore prove beneficial [20] Surprisingly, we observed no similar increase in claims for disability benefits. Instead, patients seem to occupy themselves with household chores and up to 79% eventually live with a spouse. Non-acceptance of SD patients in disability funds might be an explanation for this phenomenon. How employment and disability figures relate to the total general hospital population (for which no psychiatric consult was requested) remained unknown. Our data on the duration of consultation show that SD patients take 10 min more time for first and follow-up consultations. This can be understood considering the complexity of SD in combination with an extensive medical history (Table 3). Whether a mean value of 10 min more time is of clinical relevance is open for debate. It would be interesting to know whether this additional time investment results in improved clinical efficacy such as shorter admission time or provision of adequate aftercare management. Initiating aftercare management is an important task of C-L psychiatrists. Two-thirds of the SD patients were referred for aftercare management, an increase of 25% compared to data from 1977 [21]. We consider this a promising development in the management of SD patients in C-L psychiatry. Again, it would also be interesting to know whether aftercare referrals lead to a reduction in admissions to a nonpsychiatric hospital and consultations with nonpsychiatric medical specialists. We are currently conducting a study into several aspects of SD patients in CL-psychiatry such as hospital admission time, medical history, compliance with aftercare management and prognosis. In conclusion, this study reports characteristics of a specific, highly selected population of SD patients as seen in C-L psychiatry, with a notable high prevalence of conversion disorders. Employment among SD patients is low but there are no excessive claims for disability benefits when compared to OMD and NMD. The increase in initiating aftercare management for SD patients is a promising development in the management of SD patients in C-L psychiatry. References [1].
[1]
Snyder S, Strain JJ.
Somatoform disorders in the general hospital inpatient setting.
Gen Hos Psychiatr. 1989;11:288–293. [2].
[2]
Fink P.
The use of hospitalization by persistent somatising patients.
Psychol Med. 1992;22:173–180. MEDLINE |
CrossRef
[3].
[3]
Ford CV.
Illness as a lifestyle. The role of somatization in medical practice.
Spine. 1992;17(10 Suppl):338–343. [4].
[4]
Samuels AH.
Somatisation disorder (a major public health issue).
Med J Australia. 1995;163:147–149. [5].
[5]
Smith R.
The course of somatisation and its effect on utilization of health care resources.
Psychosom. 1994;35:263–267. [6].
[6]
Smith R, Rost K, Kashner TM.
A trial of the effect of a standardized psychiatric consultation on health outcomes, and costs in somatizing patients.
Arch Gen Psychiatr. 1995;52:238–243. [7].
[7]
Rost KM, Akins RN, Brown FW, Smith GR.
The comorbidity of DSM-III-R personality disorders in somatization disorder.
Gen Hosp Psychiatr. 1992;14:322–326. [8].
[8]
Granet RB, Mender D.
Ability to avoid premature treatment. A skill of consultation-liaison psychiatrists.
Gen Hosp Psychiatr. 1990;12:323–328. [9].
[9]
McKegney FP, McMahon T, King J.
The use of DSM-III in a general hospital C-L service.
Gen Hosp Psychiatr. 1983;5:115–121. [10].
[10]
Larsen F.
Experience with the DSM-III in a psychiatric consultation/liaison service.
Acta Psychiatr Scand. 1986;328:57–60. [11].
[11]
Hengeveld MW, Huyse FJ, Mast van der RC, Tuinstra CL.
A proposal for standardization of psychiatric C-L data.
Gen Hosp Psychiatr. 1988;10:410–422. [12].
[12]
Huyse FJ, Herzog T, Lobo A, et al.
Consultation-Liaison psychiatric service delivery (results from a European study).
Gen Hosp Psychiatr. 2001;23:124–132. [13].
[13]
American Psychiatric Association
.
Diagnostic, and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980;. [14].
[14]
American Psychiatric Association
.
Diagnostic, and statistical manual of mental disorders. 3rd ed (Revised). Washington DC: American Psychiatric Association; 1987;. [15].
[15]
American Hospital Association. The International classification of diseases. 9th revision, clinical modification, 1980 [16].
[16]
Lobo A, Huyse FJ, Herzog T, Ulrik FM, Opmeer BC, the ELCW.
The ELCW collaborative study II (patient registration form (PRF) instrument, training, and reliability).
J Psychosom Res. 1996;40:143–156. Abstract |
Full-Text PDF (868 KB)
|
CrossRef
[17].
[17]
Fink P, Sørensen L, Engberg M, Holm M, Munk-Jørgensen P.
Somatization in primary care (prevalence, health care utilization, and general practitioner recognition).
Psychosom. 1999;40:330–338. [18].
[18]
Kellner R.
Somatization (theories, and research).
J Nerv Ment Dis. 1990;178:150–160. MEDLINE |
CrossRef
[19].
[19]
Fravelli C, Salvatori S, Galassi F, et al.
Epidemiology of somatoform disorders (a community survey in Florence).
Soc Psychiatry Epidemiol. 1997;32:24–29. [20].
[20]
Huyse FJ, Herzog T, Lobo A, et al.
European consultation-liaison services and their user populations (the European Consultation-Liaison Workgroup Collaborative Study).
Psychosom. 2000;41:330–338. [21].
[21]
Hengeveld MW, Rooymans GM, Vecht-van den Bergh R.
Psychiatric consultation in a Dutch university hospital (a report on 1814 referrals, compared with a literature review).
Gen Hosp Psychiatr. 1984;6:271–279. a Department of Psychiatry, Leiden University Medical Center, Rotterdam, The Netherlands b Department of Psychiatry, Vrije Universiteit Medical Center, Amsterdam, The Netherlands c Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands  Corresponding author. Tel.: +31-10-4633227; fax: +31-10-4633217.
PII: S0163-8343(02)00248-7 doi:10.1016/S0163-8343(02)00248-7 © 2003 Elsevier Science Inc. All rights reserved. | |
|
FULL TEXT