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Original Article |

Somatization Increases Medical Utilization and Costs Independent of Psychiatric and Medical Comorbidity FREE

Arthur J. Barsky, MD; E. John Orav, PhD; David W. Bates, MD
[+] Author Affiliations

Author Affiliations: Department of Psychiatry (Dr Barsky) and Division of General Internal Medicine, Department of Medicine (Drs Orav and Bates), Brigham and Women’s Hospital and Harvard Medical School, and Department of Health Care Policy, Harvard School of Public Health (Dr Bates), Boston, Mass.


Arch Gen Psychiatry. 2005;62(8):903-910. doi:10.1001/archpsyc.62.8.903.
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Context  Somatoform disorders are an important determinant of medical care utilization, but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity.

Objectives  To assess the extent of the overlap of somatization with other psychiatric disorders; to compare the medical utilization of somatizing and nonsomatizing patients; and to determine the independent contribution of somatization alone to utilization.

Design  Patients were surveyed with self-report questionnaires assessing somatization and psychiatric disorder. Medical care utilization was obtained from automated encounter data for the year preceding the index visit. Medical morbidity was indexed with a computerized medical record audit.

Setting  Two hospital-affiliated primary care practices.

Participants  Consecutive adults making scheduled visits to their primary care physicians on randomly chosen days. In all, 2668 questionnaires were distributed, and 1914 (71.7%) were returned. Of these, 1546 (80.8%) contained complete data and met eligibility criteria.

Main Outcome Measures  Medical care utilization and costs within our hospital system in the preceding 12 months.

Results  Two hundred ninety-nine patients (20.5%) received a provisional diagnosis of somatization; 42.3% of these patients had no comorbid depressive or anxiety disorder. Somatizing patients, when compared with nonsomatizing patients, had more primary care visits (mean [SE], 4.90 [0.32] vs 3.43 [0.11]; P<.001); more specialty visits (mean [SE], 8.13 [0.55] vs 4.90 [0.21]; P<.001); more emergency department visits (mean [SE], 1.29 [0.15] vs 0.52 [0.036]; P<.001); more hospital admissions (mean [SE], 0.32 [0.051] vs 0.13 [0.014]; P<.001); higher inpatient costs (mean [SE], $3146 [$380] vs $991 [$193]; P<.001); and higher outpatient costs (mean [SE], $3208 [$180] vs $1771 [$91]; P<.001). When these results were adjusted for the presence of comorbid anxiety and depressive disorders, major medical morbidity, and sociodemographic characteristics, patients with somatoform disorder still had more primary care visits (P = .04), more specialist visits (P = .002), more emergency department visits (P<.001), more hospital admissions (P<.001), more ambulatory procedures (P<.001), higher inpatient costs (P<.001), and higher outpatient costs (P<.001). When these findings are extrapolated to the national level, an estimated $256 billion a year in medical care costs are attributable to the incremental effect of somatization alone.

Conclusions  Patients with somatization had approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of nonsomatizing patients. Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively little effect on this association.

Figures in this Article

Patients with high levels of medically unexplained symptoms, termed somatizing patients, have repeatedly been shown to have disproportionately elevated rates of medical care utilization,13 including outpatient visits,47 hospitalizations,68 and total health care costs.4,9,10 Their utilization is particularly maladaptive and suboptimal because these patients tend to “doctor shop,” consult multiple physicians for the same problem, use emergency services, and tend not to keep scheduled appointments.1013 Physicians often find them frustrating and unduly time consuming, impervious to reassurance, and irritating and aggravating to care for.7,1417 Conversely, somatizing patients are dissatisfied with their medical care, find it does not alleviate their symptoms, and remain distressed and disabled. Convinced that they are physically ill, somatizing patients characteristically deny any psychosocial influences on their symptoms,18 resist psychiatric referral,9 remain unreassured after receiving normal medical evaluation results,18 and are often refractory to palliative and supportive medical management.19,20

These patients’ symptoms are far from trivial or minor, however; they result in considerable distress, disability, and dysfunction. Severely somatizing patients have comparable or greater impairment of physical function, worse mental health, and poorer perceived general health10,2123 than patients with many chronic medical illnesses. Thus, they have high levels of role impairment10,13,19,21,2428 and spend more days in bed per month than patients with several major medical disorders,10,22,23 have elevated rates of sick leave and restricted activity days,13 and higher rates of unemployment.29 Perhaps most surprisingly, medically unexplained symptoms are also more chronic and more refractory to treatment than many symptoms with a demonstrable, organic basis.1,9,13,1921,25,30

Somatization is commonly associated with several psychiatric disorders and may also be difficult to differentiate from concurrent medical illness. Depressive and anxiety disorders are the most common psychiatric conditions found in somatizing patients,21,25,3142 though a considerable (but unknown) fraction of somatizers does not have a comorbid psychiatric disorder.32,39,4245 Since the extent of this overlap is uncertain, the unique contribution made by somatization to the variance in medical utilization remains unknown.24,28,32,4648 Medical morbidity represents a second potential confound in the association between somatization and medical utilization, since somatization may occur in patients with demonstrable medical disease and some of the somatic symptoms thought to reflect somatization may actually be caused by a medical condition.

This leads to 2 questions: To what extent does somatization occur in the absence of concurrent psychiatric or medical disorder? And to what extent does somatization itself drive medical utilization, independent of and apart from any accompanying psychiatric or medical disorder? This study had 3 objectives: to determine the degree of independence or overlap between somatization and psychiatric disorder and between somatization and major medical morbidity; to compare the medical utilization of somatizing patients with that of nonsomatizers; and to estimate the unique contribution made by somatization to medical utilization.

DESIGN AND PROCEDURES

Consecutive patients attending primary care practices at the Brigham and Women’s Hospital (Boston, Mass) on randomly chosen days completed self-report questionnaires assessing somatization, health-related anxiety, and psychiatric disorder. One third of them also completed a measure of role impairment. Utilization within our hospital system for 12 months prior to the index visit was obtained from the automated medical record, which was also used to extract a global rating of each patient’s aggregate medical morbidity. The study was conducted between July 31, 2000, and June 1, 2002. It was approved by the Brigham and Women’s Hospital Human Research Committee, and all patients gave their signed informed consent. They received $10 for participating.

SETTING AND SUBJECTS

The study was conducted in 2 primary care practices. One is located within the Brigham and Women’s Hospital, is staffed primarily by house officers, and serves a predominantly inner-city population. The other is a suburban, outpatient satellite staffed primarily by attending physicians and serving a predominately middle-class population.

All English-speaking patients older than 18 years who had been a patient in that same practice for at least 1 year were eligible. Patients were excluded if they were intoxicated or cognitively unable to complete the questionnaires.

VARIABLES AND THEIR MEASUREMENT
Somatization

Somatization was assessed with 1 categorical and 1 dimensional instrument: the somatoform disorder module of the Patient Health Questionnaire (PHQ) and the Somatic Symptom Inventory (SSI). The PHQ somatoform disorder module is a self-report instrument composed of 15 somatic symptoms, including 10 of the diagnostic symptoms of DSM-IV somatization disorder.49 The PHQ-15 somatic symptoms are rated 0 (“not bothered”), 1 (“bothered a little”), or 2 (“bothered a lot”) and are scored using a diagnostic algorithm. The PHQ-15 has high internal reliability and convergent and discriminant validity.49 To make a definitive diagnosis of a somatoform disorder, a medical evaluation must be performed to determine whether an adequate medical explanation exists for every symptom the patient endorses.50 Since we omitted this medical evaluation, we were not able to distinguish definitively between medically explained symptoms and somatoform (medically unexplained) symptoms. However, total self-reported PHQ somatic symptom counts have been shown to be highly associated with physician-rated somatoform disorder symptom counts.49,51,52 Therefore, the PHQ symptom count in this study can only be characterized as indicative of a provisional diagnosis of a somatoform disorder. Thus, in this article, patients referred to as somatizers are those with a high likelihood of being formally diagnosed with a somatoform disorder.

The dimensional measure of somatization was the SSI. This questionnaire is composed of 13 symptoms common to both the hypochondriasis subscale of the Minnesota Multiphasic Personality Inventory and the somatization subscale of the Hopkins Symptom Checklist–90.5355 The test-retest reliability, internal consistency, and convergent and external validity of the SSI have been established.56,57 The SSI is highly associated with the number of medically unexplained symptoms in the patient’s medical record, physician ratings of patient somatization, and the diagnosis of somatization disorder.7,5760 Its bivariate correlation with the PHQ somatic symptom count is 0.74.52 However, like the PHQ, the SSI is a self-report measure and, hence, without an independent medical examination, the possible medical basis of each self-reported symptom cannot be definitively ruled out.

Anxiety and Depressive Disorders

Anxiety and depressive disorders were assessed with the PHQ, which contains self-report modules covering the 8 DSM-IV disorders most commonly encountered in primary care practice. In this study, we assessed major depression, subthreshold depressive disorder, panic disorder, and other anxiety disorder. The PHQ provides provisional diagnoses only since it is entirely self-administered and definitive diagnosis requires a structured patient interview. However, the validity of these provisional diagnoses is comparable with that of the physician-administered PRIME-MD (Primary Care Evaluation of Mental Disorders) interview,43,50 and the PHQ has been shown to have acceptable criterion and construct validity.50

Role Impairment

The Functional Status Questionnaire is a valid and reliable self-report instrument developed for use in ambulatory medical populations.61,62 We used the 9 items composing the intermediate activities of daily living subscale (eg, doing errands, visiting with friends and relatives, participating in community activities, and working around the house). The Functional Status Questionnaire is scored by computer and provides ratings from 1 to 100 (maximum functional ability).

Medical Morbidity

The Charlson Comorbidity Index was used to assess serious medical comorbidity.63 This valid and reliable measure was developed empirically to index medical conditions that singly or in combination increase the short-term risk of mortality.64,65 Using International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes, a Charlson weight (from 1 to 6) is assigned to each of 17 serious medical diagnoses in the patient’s medical record, and these are then summed to derive a total score reflecting aggregate medical morbidity.

Utilization of Medical Care

Utilization for the 12 months preceding the index visit was obtained from the hospital’s computerized administrative database, which provided all patient service dates, type and location, physician identity, and costs. Outcome measures included primary care visits, specialty visits, mental health visits, emergency department visits, major ambulatory procedures, inpatient admissions, and total inpatient and outpatient costs.

DATA ANALYSIS

Participants and nonparticipant controls were compared on demographic, clinical, cost, and utilization measures using Wilcoxon rank sum tests for continuous measures, χ2 tests for multicategorical measures (race and marital status), and Fisher exact tests for binary measures. The same measures were used to compare patients who met criteria for somatoform disorder with those who did not, using the same statistical tests. The Wilcoxon test was chosen for continuous measures such as costs and visit counts because of their nonnormal distributions. However, for interpretability, continuous measures were still summarized with means. Medians were not used because the median was zero for many measures (eg, emergency department visits). The independent effect of somatoform disorder on each of our utilization end points was analyzed using linear regression models with utilization or cost as the end point and a binary marker for somatoform disorder as the primary predictor. Initial models were adjusted only for medical comorbidities using Charlson Comorbidity Index scores. Final models were adjusted simultaneously for Charlson Comorbidity Index scores, psychiatric comorbidities, and demographic descriptors. To ensure as complete adjustment as possible for confounders, no stepwise selection or other model-building processes were used. Although our results may therefore be conservative because of colinearity between somatoform disorder and the other covariates in the model, we relied on the power from our large sample size to distinguish the effect of somatoform disorder, as well as justify the inference for linear regression with nonnormal outcomes.

In all, 2668 questionnaires were distributed and 1914 (71.7%) were returned. Of these, 1546 (80.8%) provided complete data, 164 (8.6%) were from ineligible patients, 77 (4.0%) were duplicates, and 127 (6.6%) were incomplete. To assess possible sampling bias, we compared the study population with a random sample of 205 patients drawn from among all other patients attending the same practices on the same days. The study sample did not differ significantly from this random sample of nonparticipants in sociodemographic characteristics, medical morbidity, utilization, or costs, except that the study sample contained fewer Hispanic individuals (14% vs 22%; P = . 02) and had fewer primary care visits in the preceding year (mean [SD], 3.8 [4.4] vs 4.3 [4.1]; P = . 02).

In the 12 months preceding the index visit, the entire study sample averaged 0.17 (SD, 0.59) hospital admissions; 0.062 (SD, 0.32) outpatient procedures; 0.68 (SD, 1.6) emergency department visits; 0.30 (SD, 2.1) mental health visits; 3.73 (SD, 4.3) primary care visits; and 5.56 (SD, 7.9) specialist visits. The mean (SD) inpatient costs for the entire sample were $1434 ($6625), and outpatient costs were $2066 ($3162).

In the following analyses, somatizing was defined categorically as the presence or absence of a provisional diagnosis of a somatoform disorder, using the PHQ. The same analyses were performed using the SSI score as a continuous measure of somatization, and the findings did not differ to any meaningful degree in any domain. Overall, 299 patients (20.5%) received a provisional PHQ diagnosis of somatoform disorder. These patients were less likely to be married and more likely to be female, less educated, and belong to a racial or ethnic minority (Table 1). Somatizing patients were also sicker medically and had greater impairment of role function than nonsomatizing patients (Table 2).

Table Graphic Jump LocationTable 1. Sociodemographic Characteristics*
Table Graphic Jump LocationTable 2. Medical Morbidity and Role Impairment

An analysis of psychiatric comorbidity (Table 3) showed that slightly less than one third of patients with a somatoform disorder had comorbid major depression and an additional one sixth had subthreshold depression; 18.8% had panic disorder. These rates are 3 to 7 times those of nonsomatizers. Of the somatizing patients 42.3% had neither depressive nor anxiety disorder. The extent of overlap among major depression, panic disorder, and somatization is depicted in Figure 1.

Place holder to copy figure label and caption
Figure 1.

Overlap of major depression, panic disorder, and somatization, reported as a percentage of the total sample (N = 1426).

Graphic Jump Location

The medical care utilization of these groups is presented in Figure 2 and Figure 3. Somatizing patients with comorbid anxiety or depressive disorder had generally higher utilization than patients with anxiety and/or depressive disorder alone (unaccompanied by somatization). These differences assume statistical significance for hospital admissions (P<.001), emergency department visits (P = .20), inpatient costs (P<.001), and outpatient costs (P<.001).Not surprisingly, patients with both somatization and comorbid psychiatric disorder had generally higher utilization rates, except for procedures, emergency department visits, and primary care visits.

Place holder to copy figure label and caption
Figure 2.

The effects of somatization and psychiatric disorders on utilization, reported as adjusted effect estimates (from linear regression) and standard errors. Psychiatric disorders include major depression, minor depression, and anxiety and panic disorders. ED indicates emergency department; PCP, primary care physician.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

The effects of somatization and psychiatric disorder on cost, reported as adjusted effect estimates (from linear regression) and standard errors. Psychiatric disorders include major depression, minor depression, and anxiety and panic disorders.

Graphic Jump Location

Table 4 describes their medical utilization further. Column 1 presents the unadjusted comparison of patients with and without somatization. The former had 2 to 3 times as many hospitalizations, major outpatient procedures, and emergency department visits per year as those without somatization. They also averaged 1.5 times as many primary care visits and 1.7 times as many specialist visits as nonsomatizers. Their total annual medical care costs were $6354 as opposed to $2762 for nonsomatizers. Because the symptoms of somatization could result from medical disease, we repeated this analysis after adjusting the data for the Charlson Comorbidity Index score (Table 4, column 2). The differences between the 2 groups decreased only slightly, and the pattern remained consistent. It therefore appears that the utilization differences between the 2 groups were not powerfully confounded by differences in medical comorbidity. Finally, the multivariate regression analysis was repeated while taking into account the contributions of psychiatric comorbidity, as well as medical and sociodemographic characteristics (Table 4, column 3). Somatization continued to be a highly significant predictor of utilization; it was associated with hospitalizations (P<.001), ambulatory procedures (P<.001), emergency department visits (P<.001), primary care visits (P = .04), specialty visits (P = .002), inpatient costs (P<.001), and outpatient costs (P<.001). It was not related to mental health utilization. Therefore, despite the considerable overlap between somatization and depression and between somatization and anxiety disorder, somatization appears to contribute more to the variance in utilization than the other psychiatric and sociodemographic characteristics.

Table Graphic Jump LocationTable 4. The Effect of Somatization on Medical Care Utilization and Cost*

Although these data cannot be used to estimate with any precision the aggregate costs of somatization to society at large, they do hint at the order of magnitude of the problem. The adjusted, annual, total medical care cost for these somatizing patients at our institution was $5678 per patient. This is $2734 higher than that for the remaining nonsomatizing patients. This represents 16.0% of the total medical care costs of our entire sample. Thus, for every 1000 primary care patients in our setting, $561 446 of their total annual medical care costs of $3 505 446 is attributable to the incremental effect of somatization alone. The total health care expenditures in the United States were approximately $1.6 trillion in 2002. Extrapolating from our data, an estimated $256 billion a year (16.0% of this total) is then attributable to the incremental effect of somatization.

In this sample, we found that somatizing patients have approximately twice the outpatient and inpatient utilization of nonsomatizers and approximately twice the annual health care costs. Mental health care was the only form of utilization that was not significantly elevated in the somatoform group. Our findings are compatible with a large literature demonstrating that somatizing patients are frequently encountered in medical practice, use disproportionately large amounts of medical (but not mental health) services, and have elevated levels of role impairment.10,13,19,21,22,25,29 The prevalence of provisional somatoform disorder in this study is compatible with previous reports that 19% to 24% of primary care patients meet criteria for abridged somatization disorder. Because of the limitations of our study design and the generalizability of our findings, we can only speculate about the cumulative medical care costs of somatization at the national level. However, extrapolating our findings to the United States at large, we estimate that the total incremental cost of somatization is in the neighborhood of $256 billion per year. Although this is only a crude estimate, it serves to point out the magnitude of the effect. In comparison, the annual costs of diabetes mellitus in 2002 were estimated to be $132 billion.66 The existing literature does not appear to contain any precise figures on the aggregate cost of somatization; 1 observer estimated the expenditures for patients with a somatoform disorder and hypochondriasis to be 20% of total medical expenditures,67 and another speculated that 10% of all medical care is provided to patients with no serious organic disease.68

The overlap between somatization and anxiety and depressive disorders was substantial but by no means complete. Fifty-eight percent of somatizing patients had an anxiety or depressive disorder. More surprising was the finding that neither depressive nor anxiety disorder was closely associated with utilization when somatization was included in the model (though panic disorder was significantly associated with hospitalization rates and inpatient costs); somatization alone contributed more to the variance in utilization than anxiety and depressive disorders. The multivariate method we used suggests that much of the influence that depressive and anxiety disorders exert on utilization is moderated through their effect on somatization. That is, anxiety and depressive disorders lead to increased utilization primarily because of their effect on somatic symptoms. These findings are compatible with previous work. Kroenke et al32 found that somatization had an independent and additive effect on the frequency of clinic and emergency department visits, beyond the effect of comorbid depressive and anxiety disorders. Kroenke et al49 also reported that somatization was more closely associated with outpatient visits than depression and anxiety. And Miranda69 reported that having a diagnosable psychiatric disorder, apart from its relationship to somatization, was not associated with increased medical utilization. Studies of the treatment of depression in primary care settings reveal uncertainty regarding the impact of an improvement in depression on the utilization of medical care.70 Thus, improvements in the recognition and treatment of depression in primary care do not necessarily reduce utilization and health care costs.71,72 Our findings may partially explain this if somatization rather than depression per se is the more important driver of utilization.

Although somatizing patients as a group were medically sicker than nonsomatizers, this higher level of medical morbidity alone did not explain their increased medical utilization. The effect of medical morbidity on utilization only surpassed that of somatoform disorder in the more severely medically ill. Indeed, at lower levels of medical morbidity (Charlson Comorbidity Index scores <2), the effect size of somatoform disorder is comparable in magnitude with that of medical morbidity. Age had relatively little effect on utilization. Again, this may be explained by the multivariate method. Once medical morbidity has been taken into account, age alone makes little additional contribution to the variance in utilization. In other words, age apparently affects utilization primarily because longevity is accompanied by increasing medical morbidity. We also found that women had higher costs and more specialist visits and that racial and ethnic minorities used emergency services more often. Both of these findings have been widely reported before.73

This study has a number of limitations. First, there are questions of sampling bias and generalizability. A substantial fraction of the patients who were approached did not return completed questionnaires. We did find, however, that the study sample was quite comparable with a random sample of all the other clinic attendees who did not participate in the study. In addition, the findings from an academic teaching hospital may not generalize to community settings; for example, patients at our hospital may have more psychiatric and medical comorbidity than those in community practices. Furthermore, the generalizability of our findings is limited by geographic and site-specific characteristics such as insurance coverage, physician expertise and training, and institutional practice guidelines and conventions.

Second, as mentioned earlier, somatization was assessed with a self-report questionnaire and not with an individual medical evaluation to rule out a medical basis for each somatic symptom. We did index each patient’s aggregate medical morbidity with the Charlson Comorbidity Index, but this only partially addresses the problem since it emphasizes severe, life-threatening diseases more then chronic and less serious (yet very symptomatic) diseases. Thus, the possibility always remains that some of the somatic symptoms attributed to somatization could in fact have had a medical basis and that this partially explains our findings. The relationship between somatization and medical illness is especially complex because the 2 may tend to co-occur and medical illness not infrequently precipitates somatoform disorder.

Third, while we measured utilization within our hospital system, patients also sought care outside our hospital at the same time, and it is possible (even likely) that somatizing patients did so more than nonsomatizers. Previous work suggests that high users of care underestimate their use of services more than low users (ie, higher levels of medical care utilization are associated with underreporting).74 Thus, our utilization and cost estimates may be conservative.

Finally, the retrospective design does not permit conclusions about cause and effect relationships. Thus, our data are subject to the possible (though less likely) interpretation that higher utilization leads to more somatization, rather than vice versa.

Taken together, the findings emerging from this limited study underscore the importance of somatization as a driving force in medical care utilization. They point to the importance of medically unexplained symptoms in and of themselves as sources of utilization and disability and suggest that somatization symptoms are not simply nonspecific markers of other psychiatric or medical conditions. To the degree that our cost extrapolations are accurate, the costs of somatization may even exceed those of better characterized medical conditions such as diabetes mellitus. Clearly, more investigation is needed to better understand these somatizing patients and then to develop better treatments. Ultimately, if somatizing patients could be identified prospectively, it would be possible to intervene earlier in the course of their illness to improve their symptoms, decrease their maladaptive medical utilization, and reduce the costs of their care.

Correspondence: Arthur J. Barsky, MD, Department of Psychiatry, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (abarsky@partners.org).

Submitted for Publication: June 17, 2004; final revision received December 21, 2004; accepted January 13, 2005.

Funding/Support: This study was supported by a research grant from the Aetna Quality Care Research Fund Award.

Acknowledgment: We wish to acknowledge the invaluable assistance of Deborah Williams, MHA, and Julie Fiskio, BA, and of Lindsay B. Renner, BA, Jessica Payne-Murphy, BA, and Kathryn A. Griffiths, MA.

Kroenke  KMangelsdorff  AD Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86262- 266
PubMed Link to Article
Cummings  NAFollette  WT Psychiatric services and medical utilization in a prepaid health plan setting: part II. Med Care 1968;631- 41
Link to Article
Hilkevitch  A Psychiatric disturbances in outpatients of a general medical outpatient clinic. Int J Neuropsychiatry 1965;1371- 375
PubMed
deGruy  FColumbia  LDickinson  P Somatization disorder in a family practice. J Fam Pract 1987;2545- 51
PubMed
Swartz  MBlazer  DGeorge  LLanderman  R Somatization disorder in a community population. Am J Psychiatry 1986;1431403- 1408
PubMed
Zoccolillo  MSCloninger  CR Excess medical care of women with somatization disorder. South Med J 1986;79532- 535
PubMed Link to Article
Barsky  AJWyshak  GLatham  KSKlerman  GL Hypochondriacal patients, their physicians, and their medical care. J Gen Intern Med 1991;6413- 419
PubMed Link to Article
Fink  P The use of hospitalizations by persistent somatizing patients. Psychol Med 1992;22173- 180
PubMed Link to Article
Craig  TKJBoardman  APMills  KDaley-Jones  ODrake  H The South London Somatization Study I: longitudinal course and the influence of early life experiences. Br J Psychiatry 1993;163579- 588
PubMed Link to Article
Smith  GRMonson  RARay  DC Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med 1986;14669- 72
PubMed Link to Article
Simon  G Psychiatric disorders and functional somatic symptoms as predictors of health care use. Psychiatr Med 1992;1049- 59
PubMed
Beaber  RJRodney  WM Underdiagnosis of hypochondriasis in family practice. Psychosomatics 1984;2539- 46
PubMed Link to Article
Escobar  JIGolding  JMHough  RLKarno  MBurnham  MAWells  KB Somatization in the community: relationship to disability and use of services. Am J Public Health 1987;77837- 840
PubMed Link to Article
Walker  EAKaton  WJKeegan  DGardner  GSullivan  M Predictors of physician frustration in the care of patients with rheumatological complaints. Gen Hosp Psychiatry 1997;19315- 323
PubMed Link to Article
Hahn  SRThompson  KSWills  TAStern  VBudner  NS The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 1994;47647- 657
PubMed Link to Article
Quill  TE Somatization disorder: one of medicine's blind spots. JAMA 1985;2543075- 3079
PubMed Link to Article
Lin  EHKaton  WVon Korff  MBush  TLipscomb  PRusso  JWagner  E Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 1991;6241- 246
PubMed Link to Article
Benjamin  SBridges  K The special needs of chronic somatizers. Benjamin  SHouse  AJenkins  Peds.Liaison Psychiatry Defining Needs and Planning Services London, England Gaskell Press, Royal College of Psychiatrists1994;16- 23
Escobar  JIBurnham  AKarno  MForsythe  AGolding  JM Somatization in the community. Arch Gen Psychiatry 1987;44713- 718
PubMed Link to Article
Fink  P Surgery and medical treatment in persistent somatizing patients. J Psychosom Res 1992;36439- 447
PubMed Link to Article
Kroenke  KSpitzer  RLWilliams  JBWLinzer  MHahn  SRdeGruy  FV  IIIBrody  D Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994;3774- 779
PubMed Link to Article
Smith  GRRost  KKashner  TM A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52238- 243
PubMed Link to Article
Wells  KBStewart  AHays  RDBurnam  MARogers  WDaniels  MBerry  SGreenfield  SWare  J The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262914- 919
PubMed Link to Article
Katon  WLin  EVon Korff  MRusso  JLipscomb  PBush  T Somatization: a spectrum of severity. Am J Psychiatry 1991;14834- 40
PubMed
Speckens  AEMvan Hemert  AMBolk  JHRooijmans  HGMHengeveld  MW Unexplained physical symptoms: outcome, utilization of medical care and associated factors. Psychol Med 1996;26745- 752
PubMed Link to Article
Deyo  RADiehl  AK Measuring physical and psychosocial function in patients with low back pain. Spine 1983;8635- 642
PubMed Link to Article
Kroenke  KWood  DRMangelsdorff  ADMeier  NJPowell  JB Chronic fatigue in primary care: prevalence, patient characteristics, and outcome. JAMA 1988;260929- 934
PubMed Link to Article
Kroenke  KLucas  CARosenberg  MLScherokman  BJHerbers  JE Psychiatric disorders and functional impairment in patients with persistent dizziness. J Gen Intern Med 1993;8530- 535
PubMed Link to Article
Swartz  MLanderman  RGeorge  LBlazer  DGEscobar  J Somatization disorder. Robins  LNRegier  DAeds.Psychiatric Disorders in America New York, NY Free Press1991;220- 257
Kroenke  KArrington  MEMangelsdorff  AD The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990;1501685- 1690
PubMed Link to Article
Bridges  KWGoldberg  DP Somatic presentation of DSM III psychiatric disorders in primary care. J Psychosom Res 1985;29563- 569
PubMed Link to Article
Kroenke  KSpitzer  RLdeGruy  FVHahn  SRLinzer  MWilliams  JBWBrody  DDavies  M Multisomatoform disorder: an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997;54352- 358
PubMed Link to Article
Katon  WVon Korff  MLin  ELipscomb  PRusso  JWagner  EPolk  E Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12355- 362
PubMed Link to Article
Feder  AOlfson  MGameroff  MFuentes  MShea  SLantigua  RAWeissman  MM Medically unexplained symptoms in an urban general medicine practice. Psychosomatics 2001;42261- 268
PubMed Link to Article
Hamilton  JCampos  RCreed  F Anxiety, depression, and management of medically unexplained symptoms in medical clinics. J R Coll Physicians Lond 1996;3018- 20
PubMed
Brown  FWGolding  JMSmith  R Psychiatric comorbidity in primary care somatization disorder. Psychosom Med 1990;52445- 451
PubMed Link to Article
Russo  JKaton  WSullivan  MClark  MBuchwald  D Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics 1994;35546- 556
PubMed Link to Article
Katon  WRies  RKKleinman  A Part II: a prospective DSM-III study of 100 consecutive somatization patients. Compr Psychiatry 1984;25305- 314
PubMed Link to Article
Escobar  JIWaitzkin  HSilver  RCGara  MHolman  A Abridged somatization: a study in primary care. Psychosom Med 1998;60466- 472
PubMed Link to Article
Kroenke  KJackson  JLChamberlin  J Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 1997;103339- 347
PubMed Link to Article
Simon  GEVon Korff  MPiccinelli  MFullerton  COrmel  J An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;3411329- 1335
PubMed Link to Article
Simon  GEVon Korff  M Somatization and psychiatric disorder in the NIMH epidemiologic catchment area study. Am J Psychiatry 1991;1481494- 1500
PubMed
Spitzer  RLWilliams  JBKroenke  KLinzer  MdeGruy  FV  IIIHahn  SRBrody  DJohnson  JG Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;2721749- 1756
PubMed Link to Article
Peveler  RKilkenny  LKinmonth  A Medically unexplained physical symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 1997;42245- 252
PubMed Link to Article
Ormel  JVonKorff  MUstun  BPini  SKorten  AOldehinkel  T Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 1994;2721741- 1748
PubMed Link to Article
Hartz  AJNoyes  RBentler  SEDamiano  PCWillard  JCMomany  ET Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry 2000;22144- 152
PubMed Link to Article
Smith  GR The course of somatization and its effects on utilization of health care resources. Psychosomatics 1994;35263- 267
PubMed Link to Article
Hahn  SRKroenke  KSpitzer  RLBrody  DWilliams  JBWLinzer  MdeGruy  FV  III The difficult patient in primary care: prevalence, psychopathology, and impairment. J Gen Intern Med 1996;111- 8
PubMed Link to Article
Kroenke  KSpitzer  RLWilliams  JBW The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64258- 266
PubMed Link to Article
Spitzer  RLKroenke  KWilliams  JBW Validation and utility of a self-report version of PRIME-MD. JAMA 1999;2821737- 1744
PubMed Link to Article
Kisely  SGoldberg  DSimon  G A comparison between somatic symptoms with and without clear organic cause: results of an international study. Psychol Med 1997;271011- 1019
PubMed Link to Article
Kroenke  KSpitzer  RLdeGruy  FVSwindle  R A symptom checklist to screen for somatoform disorders in primary care. Psychosomatics 1998;39263- 272
PubMed Link to Article
Derogatis  LRLipman  RSRickels  KUhlenhuth  EHCovi  L The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci 1974;191- 15
PubMed Link to Article
Lipman  RSCovi  LShapiro  AK The Hopkins Symptom Checklist (HSCL): factors derived from the HSCL-90. Psychopharmacol Bull 1977;1343- 45
PubMed
Derogatis  LR The SCL-90-R: Administration, Scoring, and Procedures Manual II.  Towson, Md Clinical Psychometric Research1983;
Weinstein  MCBerwick  DMGoldman  PAMurphy  JMBarsky  AJ A comparison of three psychiatric screening tests using receiver operating characteristic (ROC) analysis. Med Care 1989;27593- 607
PubMed Link to Article
Barsky  AJWyshak  GKlerman  GL Transient hypochondriasis. Arch Gen Psychiatry 1990;47746- 752
PubMed Link to Article
Barsky  AJWyshak  GKlerman  GL Medical and psychiatric determinants of outpatient medical utilization. Med Care 1986;24548- 560
PubMed Link to Article
Barsky  AJWyshak  GKlerman  GL Hypochondriasis: an evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiatry 1986;43493- 500
PubMed Link to Article
Barsky  AJCleary  PDSarnie  MKKlerman  GL The course of transient hypochondriasis. Am J Psychiatry 1993;150484- 488
PubMed
Cleary  PDJette  AM Reliability and validity of the Functional Status Questionnaire. Qual Life Res 2001;9747- 753
Link to Article
Jette  AMDavies  ARCleary  PDCalkins  DRRubenstein  LVFink  AKosecoff  JYoung  RTBrook  RHDelbanco  TL The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med 1986;1143- 149
PubMed Link to Article
Charlson  MEPompei  PAles  KLMackenzie  CR A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40373- 383
PubMed Link to Article
Charlson  MSzatrowski  TPPerterson  JGold  J Validation of a combined comorbidity index. J Clin Epidemiol 1994;471245- 1251
PubMed Link to Article
Pompei  PCharlson  MEDouglas  RG  Jr Clinical assessments as predictors of one year survival after hospitalization: implications for prognostic stratification. J Clin Epidemiol 1988;41275- 284
PubMed Link to Article
Hogan  PDall  TNikolov  PAmerican Diabetes Association, American Diabetes Association: economic costs of diabetes in the US in 2002. Diabetes Care 2003;26917- 932
PubMed Link to Article
Kellner  R Somatization: theories and research. J Nerv Ment Dis 1990;178150- 160
PubMed Link to Article
Ford  CV The Somatizing Disorders. Illness as a Way of Life.  New York, NY Elsevier Biomedical1983;
Miranda  J Somatization, psychiatric disorder, and stress in utilization of ambulatory medical services. Health Psychol 1991;1046- 51
PubMed Link to Article
Herrman  HPatrick  DLDiehr  PMartin  MLFleck  MSimon  GEBuesching  DP Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO Study. Functional status, health service use and treatment of people with depressive symptoms. Psychol Med 2002;32889- 902
PubMed Link to Article
Sturm  RWells  KB How can care for depression become more cost-effective? JAMA 1995;27351- 58
PubMed Link to Article
Simon  GEVonKorff  MBarlow  W Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry 1995;52850- 856
PubMed Link to Article
Ladwig  KHMarten-Mittag  BFormanek  BDammann  G Gender differences of symptom reporting and medical health care utilization in the German population. Eur J Epidemiol 2000;16511- 518
PubMed Link to Article
Cleary  PDJette  AM The validity of self-reported physician utilization measures. Med Care 1984;22796- 803
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Overlap of major depression, panic disorder, and somatization, reported as a percentage of the total sample (N = 1426).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

The effects of somatization and psychiatric disorders on utilization, reported as adjusted effect estimates (from linear regression) and standard errors. Psychiatric disorders include major depression, minor depression, and anxiety and panic disorders. ED indicates emergency department; PCP, primary care physician.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

The effects of somatization and psychiatric disorder on cost, reported as adjusted effect estimates (from linear regression) and standard errors. Psychiatric disorders include major depression, minor depression, and anxiety and panic disorders.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Sociodemographic Characteristics*
Table Graphic Jump LocationTable 2. Medical Morbidity and Role Impairment
Table Graphic Jump LocationTable 4. The Effect of Somatization on Medical Care Utilization and Cost*

References

Kroenke  KMangelsdorff  AD Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86262- 266
PubMed Link to Article
Cummings  NAFollette  WT Psychiatric services and medical utilization in a prepaid health plan setting: part II. Med Care 1968;631- 41
Link to Article
Hilkevitch  A Psychiatric disturbances in outpatients of a general medical outpatient clinic. Int J Neuropsychiatry 1965;1371- 375
PubMed
deGruy  FColumbia  LDickinson  P Somatization disorder in a family practice. J Fam Pract 1987;2545- 51
PubMed
Swartz  MBlazer  DGeorge  LLanderman  R Somatization disorder in a community population. Am J Psychiatry 1986;1431403- 1408
PubMed
Zoccolillo  MSCloninger  CR Excess medical care of women with somatization disorder. South Med J 1986;79532- 535
PubMed Link to Article
Barsky  AJWyshak  GLatham  KSKlerman  GL Hypochondriacal patients, their physicians, and their medical care. J Gen Intern Med 1991;6413- 419
PubMed Link to Article
Fink  P The use of hospitalizations by persistent somatizing patients. Psychol Med 1992;22173- 180
PubMed Link to Article
Craig  TKJBoardman  APMills  KDaley-Jones  ODrake  H The South London Somatization Study I: longitudinal course and the influence of early life experiences. Br J Psychiatry 1993;163579- 588
PubMed Link to Article
Smith  GRMonson  RARay  DC Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med 1986;14669- 72
PubMed Link to Article
Simon  G Psychiatric disorders and functional somatic symptoms as predictors of health care use. Psychiatr Med 1992;1049- 59
PubMed
Beaber  RJRodney  WM Underdiagnosis of hypochondriasis in family practice. Psychosomatics 1984;2539- 46
PubMed Link to Article
Escobar  JIGolding  JMHough  RLKarno  MBurnham  MAWells  KB Somatization in the community: relationship to disability and use of services. Am J Public Health 1987;77837- 840
PubMed Link to Article
Walker  EAKaton  WJKeegan  DGardner  GSullivan  M Predictors of physician frustration in the care of patients with rheumatological complaints. Gen Hosp Psychiatry 1997;19315- 323
PubMed Link to Article
Hahn  SRThompson  KSWills  TAStern  VBudner  NS The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 1994;47647- 657
PubMed Link to Article
Quill  TE Somatization disorder: one of medicine's blind spots. JAMA 1985;2543075- 3079
PubMed Link to Article
Lin  EHKaton  WVon Korff  MBush  TLipscomb  PRusso  JWagner  E Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 1991;6241- 246
PubMed Link to Article
Benjamin  SBridges  K The special needs of chronic somatizers. Benjamin  SHouse  AJenkins  Peds.Liaison Psychiatry Defining Needs and Planning Services London, England Gaskell Press, Royal College of Psychiatrists1994;16- 23
Escobar  JIBurnham  AKarno  MForsythe  AGolding  JM Somatization in the community. Arch Gen Psychiatry 1987;44713- 718
PubMed Link to Article
Fink  P Surgery and medical treatment in persistent somatizing patients. J Psychosom Res 1992;36439- 447
PubMed Link to Article
Kroenke  KSpitzer  RLWilliams  JBWLinzer  MHahn  SRdeGruy  FV  IIIBrody  D Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994;3774- 779
PubMed Link to Article
Smith  GRRost  KKashner  TM A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52238- 243
PubMed Link to Article
Wells  KBStewart  AHays  RDBurnam  MARogers  WDaniels  MBerry  SGreenfield  SWare  J The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262914- 919
PubMed Link to Article
Katon  WLin  EVon Korff  MRusso  JLipscomb  PBush  T Somatization: a spectrum of severity. Am J Psychiatry 1991;14834- 40
PubMed
Speckens  AEMvan Hemert  AMBolk  JHRooijmans  HGMHengeveld  MW Unexplained physical symptoms: outcome, utilization of medical care and associated factors. Psychol Med 1996;26745- 752
PubMed Link to Article
Deyo  RADiehl  AK Measuring physical and psychosocial function in patients with low back pain. Spine 1983;8635- 642
PubMed Link to Article
Kroenke  KWood  DRMangelsdorff  ADMeier  NJPowell  JB Chronic fatigue in primary care: prevalence, patient characteristics, and outcome. JAMA 1988;260929- 934
PubMed Link to Article
Kroenke  KLucas  CARosenberg  MLScherokman  BJHerbers  JE Psychiatric disorders and functional impairment in patients with persistent dizziness. J Gen Intern Med 1993;8530- 535
PubMed Link to Article
Swartz  MLanderman  RGeorge  LBlazer  DGEscobar  J Somatization disorder. Robins  LNRegier  DAeds.Psychiatric Disorders in America New York, NY Free Press1991;220- 257
Kroenke  KArrington  MEMangelsdorff  AD The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990;1501685- 1690
PubMed Link to Article
Bridges  KWGoldberg  DP Somatic presentation of DSM III psychiatric disorders in primary care. J Psychosom Res 1985;29563- 569
PubMed Link to Article
Kroenke  KSpitzer  RLdeGruy  FVHahn  SRLinzer  MWilliams  JBWBrody  DDavies  M Multisomatoform disorder: an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997;54352- 358
PubMed Link to Article
Katon  WVon Korff  MLin  ELipscomb  PRusso  JWagner  EPolk  E Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12355- 362
PubMed Link to Article
Feder  AOlfson  MGameroff  MFuentes  MShea  SLantigua  RAWeissman  MM Medically unexplained symptoms in an urban general medicine practice. Psychosomatics 2001;42261- 268
PubMed Link to Article
Hamilton  JCampos  RCreed  F Anxiety, depression, and management of medically unexplained symptoms in medical clinics. J R Coll Physicians Lond 1996;3018- 20
PubMed
Brown  FWGolding  JMSmith  R Psychiatric comorbidity in primary care somatization disorder. Psychosom Med 1990;52445- 451
PubMed Link to Article
Russo  JKaton  WSullivan  MClark  MBuchwald  D Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics 1994;35546- 556
PubMed Link to Article
Katon  WRies  RKKleinman  A Part II: a prospective DSM-III study of 100 consecutive somatization patients. Compr Psychiatry 1984;25305- 314
PubMed Link to Article
Escobar  JIWaitzkin  HSilver  RCGara  MHolman  A Abridged somatization: a study in primary care. Psychosom Med 1998;60466- 472
PubMed Link to Article
Kroenke  KJackson  JLChamberlin  J Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 1997;103339- 347
PubMed Link to Article
Simon  GEVon Korff  MPiccinelli  MFullerton  COrmel  J An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;3411329- 1335
PubMed Link to Article
Simon  GEVon Korff  M Somatization and psychiatric disorder in the NIMH epidemiologic catchment area study. Am J Psychiatry 1991;1481494- 1500
PubMed
Spitzer  RLWilliams  JBKroenke  KLinzer  MdeGruy  FV  IIIHahn  SRBrody  DJohnson  JG Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;2721749- 1756
PubMed Link to Article
Peveler  RKilkenny  LKinmonth  A Medically unexplained physical symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 1997;42245- 252
PubMed Link to Article
Ormel  JVonKorff  MUstun  BPini  SKorten  AOldehinkel  T Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 1994;2721741- 1748
PubMed Link to Article
Hartz  AJNoyes  RBentler  SEDamiano  PCWillard  JCMomany  ET Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry 2000;22144- 152
PubMed Link to Article
Smith  GR The course of somatization and its effects on utilization of health care resources. Psychosomatics 1994;35263- 267
PubMed Link to Article
Hahn  SRKroenke  KSpitzer  RLBrody  DWilliams  JBWLinzer  MdeGruy  FV  III The difficult patient in primary care: prevalence, psychopathology, and impairment. J Gen Intern Med 1996;111- 8
PubMed Link to Article
Kroenke  KSpitzer  RLWilliams  JBW The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64258- 266
PubMed Link to Article
Spitzer  RLKroenke  KWilliams  JBW Validation and utility of a self-report version of PRIME-MD. JAMA 1999;2821737- 1744
PubMed Link to Article
Kisely  SGoldberg  DSimon  G A comparison between somatic symptoms with and without clear organic cause: results of an international study. Psychol Med 1997;271011- 1019
PubMed Link to Article
Kroenke  KSpitzer  RLdeGruy  FVSwindle  R A symptom checklist to screen for somatoform disorders in primary care. Psychosomatics 1998;39263- 272
PubMed Link to Article
Derogatis  LRLipman  RSRickels  KUhlenhuth  EHCovi  L The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci 1974;191- 15
PubMed Link to Article
Lipman  RSCovi  LShapiro  AK The Hopkins Symptom Checklist (HSCL): factors derived from the HSCL-90. Psychopharmacol Bull 1977;1343- 45
PubMed
Derogatis  LR The SCL-90-R: Administration, Scoring, and Procedures Manual II.  Towson, Md Clinical Psychometric Research1983;
Weinstein  MCBerwick  DMGoldman  PAMurphy  JMBarsky  AJ A comparison of three psychiatric screening tests using receiver operating characteristic (ROC) analysis. Med Care 1989;27593- 607
PubMed Link to Article
Barsky  AJWyshak  GKlerman  GL Transient hypochondriasis. Arch Gen Psychiatry 1990;47746- 752
PubMed Link to Article
Barsky  AJWyshak  GKlerman  GL Medical and psychiatric determinants of outpatient medical utilization. Med Care 1986;24548- 560
PubMed Link to Article
Barsky  AJWyshak  GKlerman  GL Hypochondriasis: an evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiatry 1986;43493- 500
PubMed Link to Article
Barsky  AJCleary  PDSarnie  MKKlerman  GL The course of transient hypochondriasis. Am J Psychiatry 1993;150484- 488
PubMed
Cleary  PDJette  AM Reliability and validity of the Functional Status Questionnaire. Qual Life Res 2001;9747- 753
Link to Article
Jette  AMDavies  ARCleary  PDCalkins  DRRubenstein  LVFink  AKosecoff  JYoung  RTBrook  RHDelbanco  TL The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med 1986;1143- 149
PubMed Link to Article
Charlson  MEPompei  PAles  KLMackenzie  CR A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40373- 383
PubMed Link to Article
Charlson  MSzatrowski  TPPerterson  JGold  J Validation of a combined comorbidity index. J Clin Epidemiol 1994;471245- 1251
PubMed Link to Article
Pompei  PCharlson  MEDouglas  RG  Jr Clinical assessments as predictors of one year survival after hospitalization: implications for prognostic stratification. J Clin Epidemiol 1988;41275- 284
PubMed Link to Article
Hogan  PDall  TNikolov  PAmerican Diabetes Association, American Diabetes Association: economic costs of diabetes in the US in 2002. Diabetes Care 2003;26917- 932
PubMed Link to Article
Kellner  R Somatization: theories and research. J Nerv Ment Dis 1990;178150- 160
PubMed Link to Article
Ford  CV The Somatizing Disorders. Illness as a Way of Life.  New York, NY Elsevier Biomedical1983;
Miranda  J Somatization, psychiatric disorder, and stress in utilization of ambulatory medical services. Health Psychol 1991;1046- 51
PubMed Link to Article
Herrman  HPatrick  DLDiehr  PMartin  MLFleck  MSimon  GEBuesching  DP Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO Study. Functional status, health service use and treatment of people with depressive symptoms. Psychol Med 2002;32889- 902
PubMed Link to Article
Sturm  RWells  KB How can care for depression become more cost-effective? JAMA 1995;27351- 58
PubMed Link to Article
Simon  GEVonKorff  MBarlow  W Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry 1995;52850- 856
PubMed Link to Article
Ladwig  KHMarten-Mittag  BFormanek  BDammann  G Gender differences of symptom reporting and medical health care utilization in the German population. Eur J Epidemiol 2000;16511- 518
PubMed Link to Article
Cleary  PDJette  AM The validity of self-reported physician utilization measures. Med Care 1984;22796- 803
PubMed Link to Article

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