Original ArticleAn international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome
Introduction
Somatoform disorders are common in primary care; 20% of patients present with medically unexplained somatic symptoms (MUS), and the proportion is higher in certain countries [1], [2], [3]. Traditional thinking regarding somatoform disorders has considered physical symptoms as either distinctly physical or distinctly psychological phenomena. Those with well-defined medical conditions are thought to have medically explained physical symptoms. Unexplained symptoms are thought to indicate a mental disorder, often anxiety or depression.
Some previous research supports this distinction between medically explained somatic symptoms (MES) and MUS. A World Health Organization (WHO) study of 15 centres reported that patients with MUS were significantly younger, had greater psychiatric morbidity, were at greater risk of harmful use of alcohol, and reported greater social disability than did those with a medical explanation for their somatic symptoms [3]. This effect was most apparent with five or more somatic symptoms. Studies in hospital settings suggest that patients with MUS have a worse outcome than do those with medically explained symptoms [5], [6]. The same international WHO study demonstrated that physical ill-health, defined by medically explained symptom count, reduced recovery from psychiatric illness 1 year later [7], [8]. However, the study also showed little difference in recovery rates between patients with medically explained and unexplained symptoms.
This study compares the effect of MES and MUS on psychiatric outcome for the entire cohort and not just those who were psychiatric cases at baseline. It also looks at differences in a wider range of outcomes including social and physical disability and health service use.
Section snippets
Baseline data collection
This research formed part of the WHO Collaborative Study of Psychological Disorders in General Health Care Settings (PPGHC). The prevalence, management, and outcome of common psychological disorders in primary care patients were investigated in 15 centres in 14 countries. Participating centres included Ankara, Athens, Bangalore, Berlin, Groningen, Ibadan, Mainz, Manchester, Nagasaki, Paris, Rio de Janeiro, Santiago, Seattle, Shanghai, and Verona in Italy. The overall study methods, including
Sociodemographic and clinical features
Three thousand two hundred one interviews were successfully completed. A further 1243 participants who were eligible for follow-up could not be interviewed. This gave a follow-up rate of 72%. Two thirds of the sample was female (n=2119). Two thousand (62%) had at least one medically explained somatic symptom and 2189 (68%) at least one medically unexplained symptom.
The patients who were lost to follow-up did not differ from participants who completed the follow-up interview in terms of the
Strengths of the study
There is a large literature on the association between MUS and psychopathology. There is also another large literature on the association between medical illness and psychopathology in terms of both increased prevalence of psychiatric disorder and poorer prognosis. However, papers have usually considered medically explained and unexplained symptoms separately as if they are distinct and unrelated. This is the first study to combine both constructs and investigate the effect of medically
Acknowledgments
This paper is based on the data and experience obtained during the WHO project on Psychological Problems in General Health Care, a project sponsored by the World Health Organization and the participating field research centres.
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