Effectiveness of a Time-Limited Cognitive Behavior Therapy–Type Intervention Among Primary Care Patients With Medically Unexplained Symptoms

First of all we would like to compliment the authors of this publication with their high-quality randomized controlled trial in primary care on a difficult subject. It must have been a great effort to complete this trial in patients with medically unexplained symptoms (MUS) in primary care in a (partly) underserved, ethnically diverse, low-income urban population.

However, we have some critical comments as well. First of all, we have some doubts about the feasibility of ten 50-minute treatment sessions of CBT in patients with MUS in primary care settings, as patients might be reluctant to undergo a time and money consuming mental health therapy while they present physical symptoms and there has been no attempt to reattribute the symptoms first. Reattribution can be a first step when treating patients with MUS effectively and we found no reference to this intervention1,2 in the article. We would be interested in the number of patients refusing participation when offered a psychological teratment ‘out of the blue’. In addition, as the researchers wrote, less than one half of the referred patients was actually enrolled in the study. Consequently, we have serious doubts on the external validity of the study. Second, the authors state that they cannot rule out nonspecific effects of increased visits and physician attention as explanation for the better outcomes in the intervention group. However, they think that nonspecific effects are not likely to play a major role in treatment success. They motivate this with the research by Rief et al. that indicates that reassurance does not provide much benefit to patients with unexplained symptoms. However, nonspecific effects include more than just reassuring patients and we think that these non-specific effects might be more important than the authors describe. In the contextual model, nonspecific factors are supposed to comprise three factors: the therapeutic bond between therapist and patient, the expectancy of the patient to have a positive outcome, and the shared goals of the therapist and the patiënt.3 Moreover, Ahn and Wampold demonstrated in their systematic review that ‘there is no evidence that the specific ingredients of psychological treatments are responsible for the beneficial outcomes of counseling and psychotherapy’.4 Third, we believe that even with proper training, the intervention does not have the desired results when this training is directed at activities solely during consultations. There is a huge gap between what physicians think about patients with MUS and what patients expect from their physician, often resulting in stressful consultations. We strongly believe that training directed at incorrect assumptions of physicians about patients with MUS is at least as important as any treatment of these patients. Fourth, we agree with the authors that a staged approach will be effective in patients with MUS. However, we would like to add something at their proposal of activities. We think that prior to the application of brief educational videos, there is room for much improvement in the patient- doctor communication. According to Epstein et al. family physicians explore patients’ feelings, cognitions and expectations far less in patients with MUS compared to patients with medically explained symptoms.5 Moreover, family physicians offer patients with MUS too many medical interventions, do not respond adequately to psychosocial utterances and do not show much empathy.6

In short, one piece of the intriguing puzzle of treating MUS patients has been added by this excellent trial. However, there are many pieces that still have to be found. Within this frame, we hope to provide you soon with the results of our symposium ‘MUS in family medicine: the state of the art’ and workshop ‘MUS in family medicine: where should we go?’ at the recent Wonca (World Organisation of National Colleges and Academies of Family Medicine) conference in Singapore. In this symposium and workshop we built a research agenda on MUS, using a nominal group technique in an audience of more than 30 nationalities from all over the world.

References

1.Blankenstein AH, van der Horst HE, Schilte AF et al. Development and feasibility of a modified reattribution model for somatising patients applied by their own general practitioners. Pat Educ Couns 2002;47:229-35

2.Kaaya S, Goldberg D, Gask L. Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners. Med Educ 1992;26:138-44

3.Hyland ME. A tale of two therapies: psychotherapy and complementary and alternative medicine (CAM) and the human effect. Clin Med 2005;5:361-7

4.Ahn H, Wampold BE. Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy. J Couns Psychother 2001;48:252-7

5.Epstein R, Shields G, Meldrum SC, Fiscella K, Carroll J, Carney PA et al. Physicians’ responses to patients’ medically unexplained symptoms. Psychosom Med 2006;68:269-76.

6.Ring A, Dowrick CF, Humphris GM, Davies, Salmon P. The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med 2005;61:1505-15.

Tim olde Hartman MD, FP Lieke Franke MD Peter Lucassen, MD, FP, PhD Evelyn van Weel-Baumgarten, MD, FP, PhD

Competing interests:   None declared