Phenomena associated with sick leave among primary care patients with Medically Unexplained Physical Symptoms: A systematic review

Figures & data

Figure 1. List of keywords used in the search-string.

Figure 2. Identification of studies.

Table I. Included studies: Patient-related phenomena associated with sick leave.

First author, year, country [reference]	Aim	Study design	Patient-related phenomena	Quality of paper
Harris, 2009, Boston, US [30]	A comparison of somatizing and non-somatizing patients regarding disability and role impairment, and determination of the independent contribution of somatization to this	Cross-sectional observational study with self-report questionnaires (n =467)	Somatizers reported more often psychiatric comorbidity (60% vs. 14%) and somatic co morbidity (39% vs 30%) than non-somatizers, and also more often reported work limitations (OR 3.2)	S
Muller, 2008, South Africa [34]	To evaluate the prevalence of depressive and anxiety disorders in patients with multisomatoform disorder, and to compare demographic and clinical outcomes in those with and without comorbidity	Cross-sectional observational study with structured diagnostic interview (n =51), 90% females. Among outcomes were disability and reported sick-days	4 or more psychiatric comorbid disorders were associated with significantly higher levels of overall disability, p =0. 041	M
Hoedemann, 2009, Netherlands [32]	To assess the prevalence of MUPS in sick-listed employees and its associations with depressive or anxiety disorders, health anxiety, distress, and functional impairment	Cross-sectional observational study (n =489)	A prevalence of 15.1% severe MUPS, i.e. >15 symptoms on PHQ-15, which was associated with 4–6 times more psychiatric comorbidity and impairment	S
Gureje, 1997, Australia – WHO, 14 countries [29]	To determine the frequency and correlates of somatization in primary care settings in 14 countries	Cross-sectional study with a stratified sample (n =5438). Correlates: gender, age, physical health and disability	Somatization is common across cultures and it is associated with older age, less education, worse self-reported health, psychiatric comorbidity, and more occupational disability (more than >1 day self-reported last month)	M
Gullbrandsen, Norway, 1998 [28]	To describe the prevalence of self-perceived work disability in general practice and the level of psychosocial problems among work-disabled patients.	Cross-sectional observational study (n =1058). Self-reporting questionnaire	Study identified 7 not work-related psychosocial problems of which 6 were 2–3 times more likely to occur among the work-disabled patients, indicating a correlation between greater self-reported work disability with increasing number of psychosocial problems	S
Hoedemann, 2010, Netherlands [31]	To compare patients with high levels of somatic symptom severity (HLSS) vs. lower levels. Outcomes: duration of sick leave, return to work and disability	Cross-sectional observational study with the same population as in reference [32]	Patients with HLSS had longer duration of sick leave (median 78 days longer) and remained more often disabled. Health anxiety and older age were associations for sick-leave duration among HLSS patients	S
Kroenke, US, 2002 [33]	To validate a 15-item questionnaire on mental and somatic symptoms and its association with functional status, disability days, and health-care utilization	Cross-sectional observational study (n =6000). Outcomes included functional status (SF-20), self-reported sick days and clinic visit	Greater levels of somatization severity were associated with a stepwise increase in disability days	S
Al-Windi, 2005, Sweden [27]	To examine the impact of different symptoms on health-care utilization	Cross-sectional observational study (n =1055). 7 symptoms groups: depression, tension, GI, musculoskeletal, metabolism, cardiopulmonary, and head	A linear correlation between numbers of symptom categories and days of sick leave	M
Thorslund, 2007, Sweden [25]	To determine the effect of solution-focused group therapy on RTW among MUPS^1 patients on long-term sick leave	RCT (n =30). Sick-listed for 1–5 months. Randomized to solution focus group therapy or waiting list (control)	The intervention group returned to work at a significantly higher rate and worked more days, and this difference increased at 3-month follow-up	M
Roelen, 2010, [18], Netherlands	To estimate prevalence of Subjective Health Complaints (SHC), and see if either number or type of complaints were related to sickness absence	Cross-sectional observational study (n =409). Self-reported questionnaire, linked to number of sickness absence episodes in 2003–2004	Prevalence of SHC: 78%. Positive relation between number of SHC and number of sickness absence episodes	S

Note: ¹Redefined as MUPS in this study: Diagnoses fell into two categories, D4 (depression, anxiety, stress-syndrome, and adjustment reactions) and D12 (musculoskeletal illnesses and fibromyalgia).

Table II. Included studies: GP-related phenomena associated with sick leave.

First author, year, country [reference]	Aim	Study design	GP-related phenomena	Quality of paper
Schilte, 2001, Netherlands [24]	To evaluate a disclosure intervention among somatizing patients. Sick leave was one outcome	RCT (n =161). 9 other GP offices served as an extra control-group	The intervention did not reduce the sick leave but seemed to impact negatively	S
Larisch, 2005, Germany [26]	To evaluate the cost effects of specialized psychosocial training of GPs working with somatizing patients. Sick leave was an indirect cost	RCT (n =20 GPs/73 patients in the intervention group versus 17 GPs/54 patients in the control group)	No significant difference in costs related to sick leave days.	S
Rosendal, 2007, Denmark [23]	To evaluate the effect of an educational programme (TERM) where one outcome was disability days	RCT (n =43 GPs, 911 somatizing patients)	Disability days decreased by 1.7 days in the control group and increased by 1.0 day in the intervention group, but the results were not significant (p =0.212)	S
Ringsberg, 2006, Sweden [21]	To elucidate GPs’ perception of MUS patients, focusing on stressing situations, emotional reactions, and coping strategies	Focus-group discussion, 5 groups, total of 27 GPs. Tape-recording, verbatim typewritten, phenomenographic approach	GPs issued a sickness certificate when they felt “stuck” and felt they needed a “breathing space” from the patient	S
Woivalin, 2004, Sweden [22]	To explore GPs’ perceptions and ways of managing patients with MUS	The same focus groups as Ringsberg (ref [21])	Findings of a pathological test, even subtle, eased the assessment of sick-listing the patient. They were aware of medicalization when accepting psychosocial problems as cause for sick leave as they needed to label the symptoms as a disease	M
Nilsen, Norway, 2011 [14]	To explore GPs’ considerations in decision-making regarding sick-listing of patients suffering from subjective health complaints	Focus-group discussion, 9 groups, total of 48 GPs. Tape-recording, verbatim typewritten, systematic text condensation	Factors described to ease assessment of sick leave: finding of an objective sign, seeing a clear purpose of sickness certificate, an established good therapeutic relationship based on prior knowledge, trust and sympathy	S

Harris AM, Orav EJ, Bates DW, Barsky AJ. Somatization increases disability independent of comorbidity. J Gen Intern Med 2009;24:155–61.

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Muller JE, Wentzel I, Nel DG, Stein DJ. Depression and anxiety in multisomatoform disorder: Prevalence and clinical predictors in primary care. S Afr Med J 2008;98:473–6.

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Hoedeman R, Krol B, Blankenstein N, Koopmans PC, Groothoff JW. Severe MUPS in a sick-listed population: A cross-sectional study on prevalence, recognition, psychiatric co-morbidity and impairment. BMC Public Health 2009;9:440.

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Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: A World Health Organization study in primary care. Am J Psychiatry 1997;154:989–95.

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Gulbrandsen P, Hjortdahl P, Fugelli P. Work disability and health-affecting psychosocial problems among patients in general practice. Scand J Soc Med 1998;26:96–100.

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Hoedeman R, Blankenstein AH, Krol B, Koopmans PC, Groothoff JW. The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge. J Occup Rehabil 2010;20:264–73.

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Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258–66.

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Al-Windi A. The influence of complaint symptoms on health care utilisation, medicine use, and sickness absence: A comparison between retrospective and prospective utilisation. J Psychosom Res 2005;59:139–46.

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Thorslund KW. Solution-focused group therapy for patients on long-term sick leave: A comparative outcome study. J Fam Psychother 2007:11–24.

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Roelen CA, Koopmans PC, Groothoff JW. Subjective health complaints in relation to sickness absence. Work: J Prevention, Assessment & Rehabilitation 2010;37:15–21.

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Schilte AF, Portegijs PJ, Blankenstein AH, van Der Horst HE, Latour MB, van Eijk JT, . Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. BMJ 2001;323:86.

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Larisch A, Fisch V, Fritzsche K. Cost-effectiveness of psychosocial interventions for somatising patients by the general practitioner [in German]. J Psychosom Res 2004;57:507–14.

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Rosendal M, Olesen F, Fink P, Toft T, Sokolowski I, Bro F. A randomized controlled trial of brief training in the assessment and treatment of somatization in primary care: Effects on patient outcome. Gen Hosp Psychiatry 2007;29: 364–73.

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Ringsberg KC, Krantz G. Coping with patients with medically unexplained symptoms: Work-related strategies of physicians in primary health care. J Health Psychol 2006;11:107–16.

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Woivalin T, Krantz G, Mantyranta T, Ringsberg KC. Medically unexplained symptoms: Perceptions of physicians in primary health care. Fam Pract 2004;21:199–203.

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Nilsen S, Werner EL, Maeland S, Eriksen HR, Magnussen LH. Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints. Scand J Prim Health Care 2011;29:7–12.

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