Unexplained symptoms in primary care : an integrated physical and psychological approach

Abstract

Medically unexplained physical symptoms (MUPS) are an important health problem in primary care, with a spectrum from mild to chronic. The burden of chronic MUPS is substantial for patients, health care professionals, and society. Therefore, early identification of patients with moderate MUPS is needed in order to prevent chronicity. We developed a screening method (PRESUME) and determined its prognostic accuracy for identification of moderate MUPS. The PRESUME screening method consists of three subsequent steps based on consultation frequency, exclusion of medical/psychiatric diagnosis and identification of MUPS. Overall, the PRESUME screening method demonstrated moderate prognostic accuracy for sustained MUPS related symptoms after 1 year and low to moderate accuracy after 5 years. On average 55.5% of the moderate MUPS patients, still had MUPS related symptoms or developed chronic MUPS in 5 year follow-up. The PRESUME screening method can support timely pattern recognition by the GP. In the next step, we developed a proactive blended and integrated mental health and physical therapy intervention (PARASOL) based on a literature search and focus groups with experts (general practitioners, physical therapists, psychologists, and mental health nurses). The PARASOL intervention is a 12-week blended primary care intervention consisting of 4 face-to-face consultations with the mental health nurse and 5 physical therapy sessions, supplemented with a web-based program consisting of graded activity, exercises and information modules. We investigated the effectiveness of the PARASOL intervention on subjective symptom impact, as registered with the adequate relief question, and quality of life in patients with moderate MUPS compared with usual care in a cluster randomized clinical trial. All measurements were performed at baseline, 3, and 12 months after baseline. In total 160 participants were included. Compared to usual care (n=80), patients in the PARASOL intervention (n=80) had more adequate short-term relief (31.2% in intervention group vs. 13.7% in control group). On quality of life and secondary outcomes no significant between group differences on short- and long-term were found. Within the intervention group, almost half of the outcome measures had significantly improved on short- and long-term, compared to none in the usual care group. Not achieving the preset sample size might be an important reason why we were not able to demonstrate the effectiveness of the PARASOL intervention. Through semi-structured interviews more in-depth insights were gained into patients’ perspectives on usability of the PARASOL intervention. Patients appreciated the personal and holistic approach, recognizable information, the intervention as an incentive, and the inter-professional collaboration. Usability could be improved on the accessibility and tech support of the web-based program, the possibility to ask questions online, and tailoring the intervention to individual’ needs. Overall, patients were generally positive about the PARASOL intervention.