The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study

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Abstract

Background

Medically unexplained physical symptoms (MUPS) are highly prevalent and are associated with frequent health care use (HCU). MUPS frequently co-occur with psychiatric disorders. With this study we examined the longitudinal association between MUPS and HCU over 2 years and the influence of depressive and anxiety disorders and personality traits on this association.

Methods

We analysed follow-up data from 2045 to 2981 participants from the Netherlands Study of Depression and Anxiety (NESDA), a multisite cohort study. The study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms for depressive and/or anxiety disorders and healthy controls. HCU, measured with the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness (TIC-P), was operationalized as the number of used medical services and the number of associated contacts. MUPS were measured with the Four Dimensional Symptoms Questionnaire, depressive and anxiety disorders with the Composite International Diagnostic Interview and personality traits with the NEO Five-Factory Inventory. Measurements were taken at baseline, 1 and 2 years follow-up. We used generalized estimating equations (GEE), using HCU at all three measurements as (multivariate) outcome. GEE also takes into account the dependency of observations within participants.

Results

MUPS were positively associated with HCU over 2 years (medical services: RR 1.020, 95 % CI 1.017–1.022; contacts: RR 1.037, 95 % CI 1.030–1.044). Neuroticism and depression had the strongest influence on the associations. After adjustment for these factors, the associations between MUPS and HCU weakened, but remained significant (services: RR 1.011, 95 % CI 1.008–1.014; contacts: RR 1.023, 95 % CI 1.015–1.032).

Conclusions

Our results show that MUPS were positively associated with HCU over 2 years, even after adjusting for depressive and anxiety disorders and personality traits.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1332-7) contains supplementary material, which is available to authorized users.

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Most cited references 35

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The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms.

Kurt Kroenke, Robert L Spitzer, Janet B W Williams (2002)

Somatization is prevalent in primary care and is associated with substantial functional impairment and healthcare utilization. However, instruments for identifying and monitoring somatic symptoms are few in number and not widely used. Therefore, we examined the validity of a brief measure of the severity of somatic symptoms. The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-15 comprises 15 somatic symptoms from the PHQ, each symptom scored from 0 ("not bothered at all") to 2 ("bothered a lot"). The PHQ-15 was administered to 6000 patients in eight general internal medicine and family practice clinics and seven obstetrics-gynecology clinics. Outcomes included functional status as assessed by the 20-item Short-Form General Health Survey (SF-20), self-reported sick days and clinic visits, and symptom-related difficulty. As PHQ-15 somatic symptom severity increased, there was a substantial stepwise decrement in functional status on all six SF-20 subscales. Also, symptom-related difficulty, sick days, and healthcare utilization increased. PHQ-15 scores of 5, 10, 15, represented cutoff points for low, medium, and high somatic symptom severity, respectively. Somatic and depressive symptom severity had differential effects on outcomes. Results were similar in the primary care and obstetrics-gynecology samples. The PHQ-15 is a brief, self-administered questionnaire that may be useful in screening for somatization and in monitoring somatic symptom severity in clinical practice and research.

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Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P)

Clazien AM Bouwmans, Kim de Jong, Reinier Timman … (2013)

Background Patient self-report allows collecting comprehensive data for the purpose of performing economic evaluations. The aim of the current study was to assess the feasibility, reliability and a part of the construct validity of a commonly applied questionnaire on healthcare utilization and productivity losses in patients with a psychiatric disorder (TiC-P). Methods Data were derived alongside two clinical trials performed in the Netherlands in patients with mental health problems. The response rate, average time of filling out the questionnaire and proportions of missing values were used as indicators of feasibility of the questionnaire. Test-retest analyses were performed including Cohen’s kappa and intra class correlation coefficients to assess reliability of the data. The construct validity was assessed by comparing patient reported data on contacts with psychotherapists and reported data on long-term absence from work with data derived from registries. Results The response rate was 72%. The mean time needed for filling out the first TiC-P was 9.4 minutes. The time needed for filling out the questionnaire was 2.3 minutes less for follow up measurements. Proportions of missing values were limited (< 2.4%) except for medication for which in 10% of the cases costs could not be calculated. Cohen’s kappa was satisfactory to almost perfect for most items related to healthcare consumption and satisfactory for items on absence from work and presenteeism. Comparable results were shown by the ICCs on variables measuring volumes of medical consumption and productivity losses indicating good reliability of the questionnaire. Absolute agreement between patient-reported data and data derived from medical registrations of the psychotherapists was satisfactory. Accepting a margin of +/− seven days, the agreement on reported and registered data on long-term absence from work was satisfactory. The validity of self-reported data using the TiC-P is promising. Conclusions The results indicate that the TiC-P is a feasible and reliable instrument for collecting data on medical consumption and productivity losses in patients with mild to moderate mental health problems. Additionally, the construct validity of questions related to contacts with psychotherapist and long-term absence from work was satisfactory.

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Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity.

Arthur J Barsky, E. Orav, David Bates (2005)

Somatoform disorders are an important determinant of medical care utilization, but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity. To assess the extent of the overlap of somatization with other psychiatric disorders; to compare the medical utilization of somatizing and nonsomatizing patients; and to determine the independent contribution of somatization alone to utilization. Patients were surveyed with self-report questionnaires assessing somatization and psychiatric disorder. Medical care utilization was obtained from automated encounter data for the year preceding the index visit. Medical morbidity was indexed with a computerized medical record audit. Two hospital-affiliated primary care practices. Consecutive adults making scheduled visits to their primary care physicians on randomly chosen days. In all, 2668 questionnaires were distributed, and 1914 (71.7%) were returned. Of these, 1546 (80.8%) contained complete data and met eligibility criteria. Medical care utilization and costs within our hospital system in the preceding 12 months. Two hundred ninety-nine patients (20.5%) received a provisional diagnosis of somatization; 42.3% of these patients had no comorbid depressive or anxiety disorder. Somatizing patients, when compared with nonsomatizing patients, had more primary care visits (mean [SE], 4.90 [0.32] vs 3.43 [0.11]; P<.001); more specialty visits (mean [SE], 8.13 [0.55] vs 4.90 [0.21]; P<.001); more emergency department visits (mean [SE], 1.29 [0.15] vs 0.52 [0.036]; P<.001); more hospital admissions (mean [SE], 0.32 [0.051] vs 0.13 [0.014]; P<.001); higher inpatient costs (mean [SE], USD 3146 [USD 380] vs USD 991 [USD 193]; P<.001); and higher outpatient costs (mean [SE], USD 3208 [USD 180] vs USD 1771 [USD 91]; P<.001). When these results were adjusted for the presence of comorbid anxiety and depressive disorders, major medical morbidity, and sociodemographic characteristics, patients with somatoform disorder still had more primary care visits (P = .04), more specialist visits (P = .002), more emergency department visits (P<.001), more hospital admissions (P<.001), more ambulatory procedures (P<.001), higher inpatient costs (P<.001), and higher outpatient costs (P<.001). When these findings are extrapolated to the national level, an estimated USD 256 billion a year in medical care costs are attributable to the incremental effect of somatization alone. Patients with somatization had approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of nonsomatizing patients. Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively little effect on this association.

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Author and article information

Contributors

Madelon den Boeft: m.denboeft@vumc.nl

Jos W. R. Twisk: jwr.twisk@vumc.nl

Berend Terluin: b.terluin@vumc.nl

Brenda W. J. H. Penninx: b.penninx@vumc.nl

Harm W. J. van Marwijk: hwj.vanmarwijk@vumc.nl

Mattijs E. Numans: m.e.numans@lumc.nl

Johannes C. van der Wouden: j.vanderwouden@vumc.nl

Henriette E. van der Horst: he.vanderhorst@vumc.nl

Journal

Journal ID (nlm-ta): BMC Health Serv Res

Journal ID (iso-abbrev): BMC Health Serv Res

Title: BMC Health Services Research

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6963

Publication date (Electronic): 22 March 2016

Publication date PMC-release: 22 March 2016

Publication date Collection: 2016

Volume: 16

Electronic Location Identifier: 100

Affiliations

[ ]Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands

[ ]Department of Epidemiology and Biostatistics, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands

[ ]Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Center, A.J. Ernststraat 1187, 1081 HL Amsterdam, The Netherlands

[ ]Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands

Article

Publisher ID: 1332

DOI: 10.1186/s12913-016-1332-7

PMC ID: 4848781

PubMed ID: 27125311

SO-VID: 6406670b-f5f1-491a-a93e-a717b2effe25

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 9 November 2015

Date accepted : 23 February 2016

Funding

Funded by: VGZ Health Insurances

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ScienceOpen disciplines: Health & Social care

Keywords: medically unexplained physical symptoms,somatisation,health care use,depressive disorders,anxiety disorders,personality traits

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ScienceOpen disciplines: Health & Social care

Keywords: medically unexplained physical symptoms, somatisation, health care use, depressive disorders, anxiety disorders, personality traits

The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study

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Most cited references 35

The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms.

Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P)

Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity.

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