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In cross-sectional studies, psychological distress has been associated with frequent health care utilization. However, there is a need for prospective studies to confirm these findings. This cohort study evaluated whether psychological distress predicted frequent attendance in family practice. In 1990, 185 consecutive adults who consulted their primary care physician (PCP) about an illness were rated on two psychometric scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7), and their annual number of face-to-face contacts with a family practice was followed until 1996. Frequent attenders (FAs) were defined as the top 10%. A logistic regression analysis showed a significantly increased risk of becoming an FA with an increase of 1 point (odds ratio [OR] 1.17 [1.03–1.33]) on SCL and 1.28 (1.06–1.53) on Whiteley). An association was found between score and number of years as an FA (OR 1.16 [0.99–1.36] for SCL and OR 1.31 [1.05–1.65] for Whiteley). Psychological distress involved an increased risk of future frequent attendance among adult patients consulting family practice in the daytime about an illness.

To determine the prevalence of ICD-10 mental disorders among internal medical inpatients, the relation between mental disorder, age, and gender, and the recognition and referral of the disordered patients.294 consecutive medical inpatients were examined with a two-phase design using the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) for ICD-10 psychiatric diagnoses. Information from questionnaires and interviews with patients, doctors, nurses, and from medical records.The prevalence of current mental disorders was 38.7%, being heavily increased in young patients. Main diagnoses were somatoform disorders (17.6%), phobias (12.9%), substance use disorders (10.9%), and depression (8.3%). Psychiatric consultations were very few. About 38-56% of the cases were recognized by medical doctors and nurses, and only about 20% were in mental health treatment.The prevalence of mental disorders among internal medical inpatients is high and increased in young patients and women. Detection and referral are low, and few are treated.

We investigated the complexity of medical inpatient care to learn it was associated with the presence and type of mental disorders, and with emotional distress and somatization. Six indicators of care complexity, including length of stay (LOS), were assessed for 294 consecutive medical inpatients. Patients rated their own health and physical disability, and medical consultants assessed them for chronic and life-threatening diseases. A subsample of 157 patients was assessed for ICD-10 psychiatric diagnoses by means of an extensive semi-structured interview known as Schedules for Clinical Assessment in Neuropsychiatry (SCAN). With a few exceptions, the indicators of complexity of care were not statistically significantly associated to ICD-10 mental disorders; psychological distress, measured by the SCL-8 rating scale; or somatization, measured by the Whiteley-7 rating scale. On the other hand, four of six complexity indicators were significantly associated with self-rated physical disability or health, or both, when controlling for the severity of the medical condition. In conclusion, complexity of care, including LOS, was substantially associated with the patient's own health perception but only marginally with the presence of mental illness. This is noteworthy, as previously published results concerning the same patients have shown a clear association of mental illness with utilization of admissions to nonpsychiatric departments, and with utilization of primary care resources.

The authors linked admission risk factors to a series of indicators for complex care delivery to enable detection of patients in need of care coordination at the moment of admission to the general hospital. The authors found 13 risk factors to be predictive of more than one indicator of care complexity. An admission risk screening procedure to detect patients in need of care coordination should focus on these risk factors and should include predictions made by doctors and nurses at admission and information collected from the patient and the medical chart.

Aims and objectives. The relationship between mental disturbances - anxiety and depression, somatization and alcohol abuse - on admission to internal medicine units and perceived complexity of care as indicated by the nurse at discharge was studied. The goal was to study the utility of short screeners for mental disturbances to select patients for case-management on admission. Design. The study had a cohort design: patients were included on admission and followed through their hospital stay until discharge. The study was conducted within the framework of the European Biomed 1 Risk Factor study. Research methods and instruments. In the first 3 days of admission the patients were interviewed by a trained health care professional, who scored the SCL-8D, a somatization questionnaire based on the Whiteley-7 and the CAGE. At discharge, nurses rated the complexity of the patient's care. Results. Patients with high scores on anxiety and depression (SCL-8D) and on somatization received higher ratings on perceived nursing complexity than those with low scores, with and without control for age, severity of illness and chronicity. The actual nursing intensity and medical care utilization, as measured daily by means of a checklist, could not explain these relations. No differences were found between patients with high or low scores on alcohol abuse. Conclusions. The study shows a potential use of screeners for mental disturbances to detect patients for whom nurses might need additional help. However, mental disturbance is not the sole criterion: functional status and other variables that predict medical and nursing care utilization should be included in a screening strategy for case-management programmes.

Udgivelsesdato: 2001

To study the prevalence of somatoform disorders (SDs) in primary care, a questionnaire including the modified 25-item version of the Symptom Checklist-90 was administered to 191 patients consecutively consulting their family physician. A stratified sample of the patients was interviewed with the Schedules for Clinical Assessment in Neuropsychiatry. The study showed that 22.3% (confidence interval [CI]: 95%: 16.4-28.1) of the patients fulfilled the diagnostic criteria for an International Classification of Diseases-10th Revision (ICD-10) SD, excluding SD, unspecified, and 57.5% (CI: 95%: 50.5-64.5) for DSM-IV SD. But 30.3% met the criteria (CI: 95%: 23.8- 36.9) when the DSM-IV Not Otherwise Specified (NOS) diagnostic group is excluded. The most frequent ICD-10 diagnosis was autonomous dysfunction, for which 14.1% of the patients fulfilled the criteria, whereas the prevalence of the other somatoform diagnosis was between 3.0% and 8.1%. The most frequent DSM-IV diagnoses were SD NOS and undifferentiated SD, which 29.93% and 27.3% of the interviewed patients, respectively, received, whereas the prevalence of the other diagnoses was between 1.0% and 8.1%. A high comorbidity between SDs and other mental disorders was found. The general practitioners identified between 50% and 71% of the patients with an ICD-10 SD and between 36% and 48%, according to DSM-IV criteria. Patients with SDs used more nonpsychiatric health care facilities than other patients (P = 0.01).

A total of 1281 patients were examined during consultation with their GP in a Nordic multicentre study focusing on the prevalence of psychiatric illness, hidden psychiatric morbidity, treatment and pathways to specialized care. The methodology and prevalence were reported in an accompanying paper. The present paper presents results concerning the variables hidden psychiatric morbidity, treatment and pathways to specialized care. The GPs detected 44% of the psychiatric cases compared with the result of a diagnostic interview (PSE). The distinction between psychosis and nonpsychosis did not influence the GPs' ability to detect a mental illness. According to the GPs' assessment the majority of patients suffering from a mental disorder consulted their GP about physical complaints. The GPs treated the patients themselves, and only a limited number of cases were referred to psychiatrists or psychologists.

Objective:The article seeks to provide an international perspective on the facilitating role of health services research in the treatment of psychiatric disorders in primary care. It builds on Goldberg and Huxley's model describing pathways to mental care for the psychiatrically ill in the community.Method:Seventy studies were selected for review by Medline search, sixteen studies by contacting prominent researchers in the field. All studies are discussed more or less extensively.Results:Case identification strategies including screening tools and diagnostic modules have been developed. Other strategies include educational training programs and psychiatric consultation services designed to facilitate psychopharmacological and other types of treatment of psychiatric disorders in primary care. Several models for the linkage of primary care and specialty mental health providers are discussed, and a primary care psychiatry programme is examined.Conclusion:Better psychiatric training of general practitioners (GPs), on-site consultation, and better communication between mental health professionals and GPs can improve the recognition, management, and referral of psychiatrically ill primary care patients. The further development of guidelines focusing on anxiety disorders, somatization, subthreshold disorders, and effectiveness in primary care is recommended.

Includes diagnosis, specific treatments, and appropriate communication I n all parts of our healthcare system we meet patients presenting with physical symptoms that lack an obvious organic basis. The terms used to describe such symptoms—medically unexplained symptoms or functional somatic symptoms—are purely descriptive and do not imply psychogenesis. Other names such as somatisation and somatoform disorder are also being used but imply different definitions.1–3 Patients with medically unexplained symptoms do not fit into the existing framework of a biomedical model that tends to focus on the exclusion of physical disease. However, the exclusion of relevant physical disease may not in itself cure the patient. He or she may still feel ill and seek medical care. Medically unexplained symptoms therefore represent a clinical problem that must be taken seriously.1–4 General practice has a key role in the management of this clinical problem as at least 20-30% of primary care patients have medically unexplained symptoms. Current evidence indicates that medical care of medically unexplained symptoms should include improvements in three interrelated elements—diagnosis, specific treatment strategies, and communication. The concept of medically unexplained symptoms comprises a …

The aim was to study patterns of utilization of non-psychiatric admissions over time and factors affecting the utilization. The study cohort includes all individuals born 1934–66, living in one of two Danish municipalities and admitted to a non-psychiatric department at least once in 1977 ( n = 2 686). The hospitalizations of the cohort were followed during a 5-year period by means of the Danish National Patient Register. The data were analysed using a longitudinal latent class (LC) model and a longitudinal latent Markov (LM) model. The LC model suggests that among the cases in the cohort there were 4 variants of utilization patterns. The LM model adequately described the sample in only 3 variants or classes. These classes may be interpreted as a small group of “chronically ill'' individuals (1.9% of the cohort), a major group of “healthy” individuals, with no, or only a single, random re-admission during the follow-up period (74.4% of the sample), and finally an intermediate group of “high utilizers” (23.7% of the sample). This “chronicity” variable was markedly associated with mental illness, multiple discharge diagnoses from non-psychiatric departments and total utilization of hospitalizations during the follow-up period. Conversely, gender, age and days in hospital per admission were without importance. The study implies that the analysis of patterns of hospital admissions over time can yield important insight into health service utilization and that longitudinal latent structure analyses are powerful statistical tools in this aspect. The data strongly indicated that a high utilization of admissions for physical illnesses (i.e. chronicity) does not simply depend on the severity of a physical disorder, but mental disturbances may be a more important factor.

Persistent somatization patients put a serious burden on the health care system with multiple admissions, tests, surgeries, and medications. This study reports on factors relevant to the health-seeking behavior of somatizing patients and aspects of the health care system that facilitate their overutilization of health resources. Individuals (age 17–49 years) from the general population of two danish municipalities with at least 10 general admissions during an 8-year period were studied comparing persistent somatizers with other high utilizers of medical admissions. Results are reported on geographical mobility, change in family doctors, route and distribution of admissions by time of day or week, discharges against medical advice, physical disease overlooked, and distribution of admissions to specialties. Although the health-seeking behavior of persistent somatizers may in part explain their overutilization of health care resources, such overutilization could be reduced and much suffering avoided if physicians displayed the same enthusiasm in diagnosing somatization as in ruling out organic pathology.

BACKGROUND: Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs. METHODOLOGY/PRINCIPAL FINDINGS: 1785 consecutive primary care patients aged 18-65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41-78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition. CONCLUSIONS/SIGNIFICANCE: Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.

The purpose of the study was to describe the physical complaints and symptoms of persistent somatization patients. Individuals in the general population (age 17-49 yr) with at least 10 general admissions during an 8-yr period were studied. Persistent somatizers (i.e. patients with more than six medically unexplained general admissions) were compared with patients whose admissions could be ascribed to well-defined somatic disorders. Somatizers were characterized by multiple symptoms from many organ systems, and their physical complaints simulated most types of somatic disorder. Although some symptoms were more common than others, none were infrequent, so neither 'classic' conversion symptoms nor pain symptoms were found to be especially characteristic of the persistent somatizer. Gender had no influence on number of registered symptoms, whereas the number increases with age. The finding question the use of a predefined symptom checklist in the diagnostic criteria for somatizing disorder. The major part of the somatizers present a different illness picture when admitted with medically unexplained disorders compared with admission for which no adequate medical explanation could be found. However, one fifth had, when admitted with a medically explained diagnosis, also been admitted with the diagnosis medically unexplained at another admission. One fifth of the persistent somatizers had been admitted at least once for factitious illness, but apart from the fact that they had more symptoms and admissions, they did not differ from the other persistent somatizers.

Medical records were selected from the Danish National Patient Register in order to study individuals between the ages of 17 and 49 years in the general population who, during an 8-year period, were admitted at least 10 times to a general hospital (N = 282). Fifty-six subjects (19 %) were found to be persistent somatizers, i.e. they were admitted repeatedly to general hospitals for physical symptoms without an organic basis. This corresponded to a frequency of persistent somatization in the population 0.6 per 1000 men and 3.2 per 1000 women. Seventy-five per cent of the subjects were under 25 years old at the onset of their disorder, and all were under 35. Their illnesses were long-lasting, with one-third having a hospital ‘career’ of more than 20 years. They had a lifetime median of 22 medical admissions, and had utilized 3% of the general population’s admissions to non-psychiatric departments. This investigation shows that persistent somatization is not a rare phenomenon, and that taking the heavy utilization of health-care resources into account it constitutes a considerable problem for the health-care system. The long hospital career and the relatively early start of somatization in some subjects emphasize the importance of an early identification of the condition, and of efforts to try to prevent its persistence.

Admissions to psychiatric departments and general hospitals in an 8‐year period were studied for the 17‐ to 49‐year‐old population in 2 Danish municipalities. Information was extracted from the National Patient Register and the Danish Psychiatric Register, registers containing information on all admissions to nonpsychiatric and psychiatric departments, respectively, in Denmark. Fourteen percent of the patients who had been admitted at least once to a general hospital (or 7.5% of the background population) had an indication of a mental disorder. They comprised one fourth of all general admissions of the population during the 8‐year period. Patients who had been admitted to a general hospital had a 4 times greater risk of having been admitted to a psychiatric department than the rest of the population and the risk increased markedly with number of general admissions. A pronounced association was found between the number of admissions to general hospitals and psychiatric departments; i.e., both types of admissions clustered in some individuals. The excessive general admissions of psychiatric patients were found to be correlated to all types of psychiatric diagnoses, but was less prominent in nonorganic psychoses. The implication is that there is a very close association between somatic and psychiatric morbidity and that the mentally disturbed use a great part of the nonpsychiatric health services.

The term Munchausen syndrome was introduced by Asher in 1951 for the description of patients who tell fantastic stories and deliberately seek repeated hospitalizations at different hospitals for simulated or self-induced acute illnesses. The syndrome has been repeatedly criticized and several other eponyms have been suggested. In DSM-III-R the designation chronic factitious disorder is used synonymously with Munchausen syndrome. On the basis of 3 new case reports and a statistic processing of literature case histories, this paper suggests that when using the original criteria by Asher, the syndrome constitutes a subtype of chronic factitious disorders, specially characterized by factitious illness, peregrination, pseudologia fantastica and dramatic admission circumstances. Further, most of the criticism of the syndrome may be a result of the great variability in definitions and diagnostic criteria used by different authors. Other clinical characteristics of the patients as well as psychopathologic and psychodynamic considerations are briefly discussed.

Based upon data from the Danish National Patient Register, the number of somatic admissions during the period 1977-1984 was summed up in two municipalities with an average annual population of 30,426 persons in the age group 17-49 years. 38% of the male population and 48% of the female population in this age group had been admitted at least once during the period (excl. pregnancy conditions). 1% of the population had more than nine admissions which was 18% of all admissions. 4.5% had more than four admissions which was 38% of all admissions. No difference was observed as regards sex, and age was of minor importance for the frequency of admissions. A significant statistical association was found between the number of admissions and abuse, suicidal attempts, and psychiatric illness. About half of the patients (males 56%, females 43%) with more than nine admissions were discharged with one of the "non-organic" diagnoses on at least one occasion. Patients with "non-organic" diseases had an average of 5.2 admissions during the period compared with the other diagnoses with an average of 2.7 which was 20% of all admissions. There were more males with abuse diagnoses and a majority of 30-49 year-olds among the cases of psychiatric illnesses. Apart from this, no significant differences as regards sex and age were found among these diagnostic groups.

The authors developed a screening instrument to detect patients in need of complex care coordination at admission to a general hospital. On the basis of a series of risk factors for care complexity, the authors constructed a short, care complexity prediction instrument (COMPRI) and assessed its qualities. The COMPRI is an easily administered screening instrument that detects patients at risk for complex care needs for whom care coordination is indicated. COMPRI's predictive power exceeds all currently available case-mix instruments.

BACKGROUND: Conceptualisation and classification of functional disorders appear highly inconsistent in the health-care system, particularly in primary care. Numerous terms and overlapping diagnostic criteria are prevalent of which many are considered stigmatising by general practitioners and patients. The lack of a clear concept challenges the general practitioner's decision-making when a diagnosis or a treatment approach must be selected for a patient with a functional disorder. This calls for improvements of the diagnostic categories. Intense debate has risen in connection with the release of the fifth version of the 'Diagnostic and Statistical Manual of Mental Disorders' and the current revision of the 'International Statistical Classification of Diseases and Related Health Problems'. We aim to discuss a new evidence based diagnostic proposal, bodily distress syndrome, which holds the potential to change our current approach to functional disorders in primary care. A special focus will be directed towards the validity and utility criteria recommended for diagnostic categorisation.DISCUSSION: A growing body of evidence suggests that the numerous diagnoses for functional disorders listed in the current classifications belong to one family of closely related disorders. We name the underlying phenomenon 'bodily distress'; it manifests as patterns of multiple and disturbing bodily sensations. Bodily distress syndrome is a diagnostic category with specific criteria covering this illness phenomenon. The category has been explored through empirical studies, which in combination provide a sound basis for determining a symptom profile, the diagnostic stability and the boundaries of the condition. However, as bodily distress syndrome embraces only the most common symptom patterns, patients with few but impairing symptoms are not captured. Furthermore, the current lack of treatment options may also influence the acceptance of the proposed diagnosis. Bodily distress syndrome is a diagnostic category with notable validity according to empirical studies. Nevertheless, knowledge is sparse on the utility in primary care. Future intervention studies should investigate the translation of bodily distress syndrome into clinical practice. A particular focus should be directed towards the acceptability among general practitioners and patients. Most importantly, it should be investigated whether the new category may provide the basis for better treatment and improved clinical outcome.

Kapitlet er et oversat uddrag fra bogen 'Funktionelle lidelser - udredning og behandling' og omhandler teori og evidens på området samt en konsultations- og behandlingsmodel for almen praksis (The Extended Reattribution and Management Model).