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

Javier I. Escobar; Michael A. Gara; Angelica M. Diaz-Martinez; Alejandro Interian; Melissa Warman; Lesley A. Allen; Robert L. Woolfolk; Eric Jahn; Denise Rodgers

doi:10.1370/afm.702

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Figure 1.
Patient flow.
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Figure 2.
Percentage of patients with an improvement in physical symptoms.
Note: Improvement was defined by a rating of “very much improved” or “much improved” by blinded evaluators on the Clinical Global Impressions improvement (CGI-improvement) scale. P values were derived from logistical regression analyses wherein time and treatment condition were evaluated for their ability to predict responder status.

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Table 1.

Baseline Characteristics of the Study Patients

Characteristic	Intervention Patients (n=87)	Control Patients (n=85)	P Value
DSM IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Note: P values for age were determined by t tests. P values for all remaining variables were determined by χ² tests.
* Race/ethnicity was missing for 1 patient in the intervention group.
Age, mean±SD, y	40.97±12.72	39.58±13.37	.49
Female, No. (%)	75 (86.2)	76 (89.4)	.52
Race/ethnicity, No. (%)*
White	20 (23.0)	16 (18.8)
Hispanic	59 (67.8)	58 (68.2)
African American	3 (3.4)	2 (2.4)	.73
Asian	2 (2.3)	5 (5.9)
Other	3 (3.4)	4 (4.7)
Education, No. (%)
7th grade or less	18 (20.9)	30 (35.3)
Junior high school or some high school	17 (19.8)	11 (12.9)
High school degree	12 (14.0)	13 (15.3)	.24
Some college or a 2-year college degree	21 (24.4)	17 (20.0)
4-year college degree	9 (10.5)	10 (11.8)
Graduate college degree	9 (10.5)	4 (4.7)
Married, No. (%)	40 (46.0)	32 (37.6)	.27
Current comorbid DSM-IV Axis I disorder, No. (%)	80 (92.0)	78 (91.8)	.96

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Table 2.

Changes in Secondary Outcomes by Study Group

	Intervention Patients (n=87)		Control Patients (n=85)
Instrument	Mean (SE) [95% CI]	n	Mean (SE) [95% CI]	n	P Value, Time, Intervention vs Control	P Value, Group x Time Interaction
Note: MOS-10 denotes the physical functioning subscale from the RAND Medical Outcomes Study scale’s Short-Form Health Survey (scores range from 0 to 100; higher scores indicate better physical functioning). PHQ-15 denotes the somatic complaints module of the Patient Health Questionnaire (scores range from 0 to 30; higher scores indicate higher levels of somatic complaints in the preceding month). HAM-D denotes the 17-item Hamilton Depression Rating Scale (scores range from 0 to 48; higher scores indicate greater depression severity). HAM-A denotes the Hamilton Anxiety Rating Scale (scores range from 0 to 56; higher scores indicate greater anxiety severity). VAS denotes the visual analog scale used to assess medically unexplained symptoms (scores range from 0 to 100; higher scores represent a greater severity of symptoms).
CI = confidence interval; NS = not siginificant.
MOS-10
Baseline	63.28 (2.67) [58.00–68.55]	87	61.41 (2.71) [56.07–66.75]	85	NS	NS
End of treatment	72.19 (2.95) [66.37–78.01]	63	69.71 (2.95) [63.89–75.54]	63	NS	.92
Follow-up	73.22 (3.36) [66.60–79.85]	48	69.41 (3.45) [62.60–76.22]	44	NS	NS
PHQ-15
Baseline	14.17 (0.58) [13.03–15.32]	87	13.98 (0.59) [12.82–15.13]	85	NS	NS
End of treatment	9.32 (0.67) [8.01–10.64]	63	11.50 (0.66) [10.19–12.81]	64	.01	.03
Follow-up	9.11(0.59) [7.95–10.28]	50	10.91 (0.62) [9.69–12.12]	44	.03	NS
HAM-D
Baseline	18.25 (0.64) [16.98–19.52]	87	17.41 (0.65) [16.13–18.70]	85	NS	NS
End of treatment	12.85 (0.85) [11.17–14.52]	63	14.60 (0.84) [12.94–16.25]	65	.02	.05
Follow-up	12.88 (0.88) [11.14–14.63]	51	14.29 (0.93) [12.44–16.13]	44	.07	NS
HAM-A
Baseline	20.46 (0.75) [18.98–21.94]	87	20.99 (0.76) [19.49–22.48]	85	NS	NS
End of treatment	15.89 (1.08) [13.76–18.02]	63	18.47 (1.07) [16.36–20.57]	65	NS	.19
Follow-up	14.85 (0.94) [12.99–16.70]	51	17.58 (1.00) [15.61–19.54]	44	NS	NS
VAS
Baseline	42.34 (1.94) [38.51–46.18]	87	39.62 (1.97) [35.74–43.50]	85	NS	NS
End of treatment	23.47 (1.77) [19.97–26.96]	62	27.94 (1.75) [24.48–31.39]	64	.01	.05
Follow-up	23.72 (1.67) [20.43–27.01]	50	25.25 (1.77) [21.76–28.73]	44	.22	NS

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The Article in Brief

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

Javier I. Escobar, MD, and colleagues

Background Patients with medically unexplained physical symptoms are often seen in primary care. This study tests the effectiveness of a 10-session mental health program for primary care patients with medically unexplained symptoms that are not highly severe. The program is administered by trained psychologists and aims to reduce the patient�s physical distress and preoccupation with physical symptoms.

What This Study Found The mental health program was effective in managing an ethnically diverse sample of patients with unexplained physical symptoms in the primary care setting. About 60% of the patients who completed the treatment had significant relief of medically unexplained physical symptoms. This improvement continued months after the intervention, although the degree of improvement gradually decreased. The program also led to a decrease in depression symptoms, but this effect was less likely to continue with time.

Implications

This program may be relatively easy to implement in primary care offices in which mental health consultants are available.
Some patients may require fewer sessions or a less-intensive program while others may require more. Therefore, a staged approach to treatment should be considered.