Abstract
The Somatisation Project (SP) was one of eight sub-projects of the South Australian HealthPlus Coordinated Care Trial. This trial involved the enrolment of an original cohort of 4,600 subjects. Of these, 124 subjects (89 intervention and 35 controls) suffering from GP diagnosed somatisation disorder (SD) constituted the SP cohort. One of the tasks required by the trial was to develop evidence-based, clinical protocols for systematic use at the GP level. The aims of the trial were to coordinate the care of patients suffering from chronic and complex disorders using systematic, behavioural care planning; the use of clinical care protocols and the provision of a designated care coordinator (GP), supported by a service coordinator.
Objectives: This paper aims to:
describe the development of the somatisation project
present the findings and implication from the audit of 5826 case records
describe the development of the “containment” protocol for use in GP
present some preliminary outcome data.
Results:
A Clinical Audit: A total of 5,826 casenotes were audited by the research team. Of these 1,105 or (19%) of selected patients were considered to be likely to be suffering from a psychiatric disorder which was presenting with unexplained, or poorly explained physical symptoms. Whilst a significant proportion of these patients suffered anxiety or depressive disorders the majority had a clear somatisation disorder.
A containment approach to management: The reference group evaluated the approaches advocated for somatisation in a review and recommended a theoretical model to be used in the trial. This model was then developed as a clinical algorithm and constituted the initial guidelines for management for the patients enrolled in the project. Over the next 10 months it was subjected to further review by a reference group of experienced GPs, who translated the guidelines into an algorithm.
Assessment, involvement and preliminary outcomes: Subjects were enrolled on the basis of GP diagnosis of SD. They were then assessed by means of the computerised version of the CIDI and psychometric evaluation, after which they were randomised to intervention or control groups. The intervention group received coordinated care and the controls best standard care. Outcomes were assessed by monitoring all service use and psychometric evaluation at 12 months and at the completion of the trial.
Discussion: The audit throws into question the current diagnostic criteria used for the definition of somatisation disorder and adds to the weight of the arguments presented by Escobar (1987) for a revision of these criteria.
It is also apparent that unexplained physical symptoms are potent source of health anxiety. The relationship between SD and anxiety disorders requires further study as the avoidant behaviour of these patients is very similar to that by patients suffering anxiety disorders.
The process used to develop the “containment” algorithm and its associated GP education program was an interesting example of the role for consultation–liaison psychiatry at the primary health care level. GPs found the model useful from conceptual, educational and practical perspectives.
The improvement in intervention subjects occurred whilst protocols were being developed and GPs were being educated in their use. It is likely that systematic intervention by well-trained GPs could do better.
There are important implications in this project for clinical services in general hospitals and general practice.