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March 1995, Vol 52, No. 3 >
Article | March 1995

A Trial of the Effect of a Standardized Psychiatric Consultation on Health Outcomes and Costs in Somatizing Patients

G. Richard Smith, Jr, MD; Kathryn Rost, PhD; T. Michael Kashner, PhD
Arch Gen Psychiatry. 1995;52(3):238-243. doi:10.1001/archpsyc.1995.03950150070012
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Background:  Patients who somatize but who do not meet criteria for somatization disorder are common in the community. Virtually no research has been conducted to determine how to treat these patients.

Methods:  We conducted a randomized controlled clinical trial of a psychiatric consultation intervention we had previously shown to improve the management of somatization disorder. The study population included 51 physicians treating 56 somatizing patients who had a history of seeking help for six to 12 lifetime unexplained physical symptoms. At the onset of the experiment, physicians randomized to the treatment condition received a consultation letter recommending a specific management approach; physicians randomized to the control/crossover condition received the consultation letter after 12 months. Data on health outcomes and charges were collected every 4 months for 2 years after randomization for 96% of subjects who entered the study.

Results:  Patients of physicians who received the intervention reported significantly increased physical functioning, an improvement that remained stable during the year after the intervention. The intervention reduced annual medical care charges by $289 (95% confidence interval, $40 to $464) in 1990 constant dollars, which equates to a 32.9% reduction in the annual median cost of their medical care.

Conclusions:  Somatizing patients with a lifetime history of six to 12 unexplained physical symptoms reported better physical functioning after their primary care physician was provided appropriate treatment recommendations via a psychiatric consultation. Such a consultation is cost-effective because it reduces subsequent charges for medical care, while improving health outcomes in a chronically impaired population.

REFERENCES

1 +
Kellner R.  Functional somatic symptoms in hypochondriasis . Arch Gen Psychiatry . 1985;;42:821-833.
2 +
Kellner R.  Neurosis in general practice . Br J Clin Practice . 1965;;19:681-682.
3 +
Mayou R.  Chest pain in the cardiac clinic . J Psychosom Res . 1978;;17:353-357.
4 +
Mayou R.  The nature of bodily symptoms . Br J Psychiatry . 1976;;129:55-60.
5 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
6 +
Swartz M, Landerman R, George L, Blazer D, Escobar J.  Somatization disorder . In: Robins LN, Regier D, eds. Psychiatric Disorders in America . New York, NY: Free Press; 1990;:228.
7 +
Escobar JI, Burnham A, Karno M, Forsythe A, Golding JM.  Somatization in the community . Arch Gen Psychiatry . 1987;;44:713-718.
8 +
Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA. Wells KB.  Somatization in the community: relationship to disability and use of services . Am J Public Health . 1987;;77:837-840.
9 +
Escobar JI, Rubio-Stipec M, Canino G, Karno M.  Somatic symptom index (SSI): a new and abridged somatization construct . J Nerv Ment Dis . 1989;;177:140-146.
10 +
Simon GE. VonKorff M.  Somatization and psychiatric disorder in the NIMH epidemiologic catchment area study . Am J Psychiatry . 1991;;148:1494-1500.
11 +
Rost KM, Smith GR, Kashner TM. Clinical differentiation between somatization disorder patients and somatizers: a test of two hypotheses. Presented at the Fourth Annual NIMH International Conference on the Classification and Treatment of Mental Disorders in General Medical Settings, Washington, DC, June 13, 1990.
12 +
Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T.  Somatization: a spectrum of severity . Am J Psychiatry . 1991;;148:34-40.
13 +
Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, Berry S, Greenfield S, Ware J.  The functioning and well-being of depressed patients: results from the medical outcomes study . JAMA . 1989;;262:914-919.
14 +
Lefkowitz D, Monheit AC. National Medical Expenditure Research Findings: Health Insurance, Use of Health Services, and Health Care Expenditures . Rockville, Md: Center for General Health Services Intramural Research, Agency for Health Care Policy and Research; 1991;.
15 +
Smith GR Jr, Monson RA, Ray DC.  Psychiatric consultation in somatization disorder: a randomized, controlled study . N Engl J Med . 1986;;314:1407-1413.
16 +
Rost K, Kashner TM, Smith GR Jr.  Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs . Gen Hosp Psychiatry . 1994;;16:381-387.
17 +
Kashner TM, Rost K, Smith GR, Lewis S.  An analysis of panel data: the impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder . Med Care . 1992;;30:811-821.
18 +
Coryell W.  Diagnosis-specific mortality . Arch Gen Psychiatry . 1981;;38:939-942.
19 +
Brook RH, Ware JE Jr, Davies-Avery A, Stewart AL, Donald CA, Rogers WH, Williams KN, Johnston SA. Conceptualization and Measurement of Health for Adults in the Health Insurance Study, Vol VII: Overview . Santa Monica, Calif: RAND Corp; 1979;.
20 +
Kmenta J. Elements of Econometrics . New York, NY: Macmillan Publishing Co Inc: 1971;.
21 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: history, characteristics, and validity . Arch Gen Psychiatry . 1981;;38:381-389.
22 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition . Washington, DC: American Psychiatric Association; 1980;.
23 +
Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, McGlynn EA, Ware JE.  Functional status and well-being of patients with chronic conditions: results from the medical outcomes study . JAMA . 1989;;262:907-913.
24 +
Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide . Boston, Mass: Health Institute, New England Medical Center; 1993;.
25 +
Robins LN, Barrett JE. The Validity of Psychiatric Diagnosis . New York, NY: Raven Press; 1989;.
26 +
Kashner TM, Rost K, Cohen B, Anderson M, Smith GR.  Enhancing the health of somatization disorder patients: the cost effectiveness of short term group therapy . Psychosomatics . In press.
27 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;.
28 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA . 1990;;264:2524-2528.

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1 +
Kellner R.  Functional somatic symptoms in hypochondriasis . Arch Gen Psychiatry . 1985;;42:821-833.
2 +
Kellner R.  Neurosis in general practice . Br J Clin Practice . 1965;;19:681-682.
3 +
Mayou R.  Chest pain in the cardiac clinic . J Psychosom Res . 1978;;17:353-357.
4 +
Mayou R.  The nature of bodily symptoms . Br J Psychiatry . 1976;;129:55-60.
5 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
6 +
Swartz M, Landerman R, George L, Blazer D, Escobar J.  Somatization disorder . In: Robins LN, Regier D, eds. Psychiatric Disorders in America . New York, NY: Free Press; 1990;:228.
7 +
Escobar JI, Burnham A, Karno M, Forsythe A, Golding JM.  Somatization in the community . Arch Gen Psychiatry . 1987;;44:713-718.
8 +
Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA. Wells KB.  Somatization in the community: relationship to disability and use of services . Am J Public Health . 1987;;77:837-840.
9 +
Escobar JI, Rubio-Stipec M, Canino G, Karno M.  Somatic symptom index (SSI): a new and abridged somatization construct . J Nerv Ment Dis . 1989;;177:140-146.
10 +
Simon GE. VonKorff M.  Somatization and psychiatric disorder in the NIMH epidemiologic catchment area study . Am J Psychiatry . 1991;;148:1494-1500.
11 +
Rost KM, Smith GR, Kashner TM. Clinical differentiation between somatization disorder patients and somatizers: a test of two hypotheses. Presented at the Fourth Annual NIMH International Conference on the Classification and Treatment of Mental Disorders in General Medical Settings, Washington, DC, June 13, 1990.
12 +
Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T.  Somatization: a spectrum of severity . Am J Psychiatry . 1991;;148:34-40.
13 +
Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, Berry S, Greenfield S, Ware J.  The functioning and well-being of depressed patients: results from the medical outcomes study . JAMA . 1989;;262:914-919.
14 +
Lefkowitz D, Monheit AC. National Medical Expenditure Research Findings: Health Insurance, Use of Health Services, and Health Care Expenditures . Rockville, Md: Center for General Health Services Intramural Research, Agency for Health Care Policy and Research; 1991;.
15 +
Smith GR Jr, Monson RA, Ray DC.  Psychiatric consultation in somatization disorder: a randomized, controlled study . N Engl J Med . 1986;;314:1407-1413.
16 +
Rost K, Kashner TM, Smith GR Jr.  Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs . Gen Hosp Psychiatry . 1994;;16:381-387.
17 +
Kashner TM, Rost K, Smith GR, Lewis S.  An analysis of panel data: the impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder . Med Care . 1992;;30:811-821.
18 +
Coryell W.  Diagnosis-specific mortality . Arch Gen Psychiatry . 1981;;38:939-942.
19 +
Brook RH, Ware JE Jr, Davies-Avery A, Stewart AL, Donald CA, Rogers WH, Williams KN, Johnston SA. Conceptualization and Measurement of Health for Adults in the Health Insurance Study, Vol VII: Overview . Santa Monica, Calif: RAND Corp; 1979;.
20 +
Kmenta J. Elements of Econometrics . New York, NY: Macmillan Publishing Co Inc: 1971;.
21 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: history, characteristics, and validity . Arch Gen Psychiatry . 1981;;38:381-389.
22 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition . Washington, DC: American Psychiatric Association; 1980;.
23 +
Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, McGlynn EA, Ware JE.  Functional status and well-being of patients with chronic conditions: results from the medical outcomes study . JAMA . 1989;;262:907-913.
24 +
Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide . Boston, Mass: Health Institute, New England Medical Center; 1993;.
25 +
Robins LN, Barrett JE. The Validity of Psychiatric Diagnosis . New York, NY: Raven Press; 1989;.
26 +
Kashner TM, Rost K, Cohen B, Anderson M, Smith GR.  Enhancing the health of somatization disorder patients: the cost effectiveness of short term group therapy . Psychosomatics . In press.
27 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;.
28 +
Broadhead WE, Blazer DG, George LK, Tse CK.  Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA . 1990;;264:2524-2528.

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