Collaborative stepped care for somatoform disorders: A pre–post-intervention study in primary care

Highlights

• Sofu-Net is a network for somatoform and functional disorders.

• The interdisciplinary network promotes collaborative stepped health care.

• We successfully established and evaluated Sofu-Net in a pre–post-intervention study.

• Sofu-Net improved doctor–patient-communication and prescription behavior.

• Collaborative stepped care might improve the management of somatoform disorders.

Abstract

Objective

The successful management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy, and unstructured overuse of health care. This study aimed to investigate the feasibility of establishing a collaborative stepped health care network for somatoform disorders, and its impact on the diagnostic process and treatment recommendations in primary care.

Method

The Network for Somatoform and Functional Disorders (Sofu-Net) was established to connect 41 primary care physicians (PCP), 35 psychotherapists, and 8 mental health clinics. To evaluate Sofu-Net, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire, and were assessed in detail at the patient and PCP level. Discussion of psychosocial distress in the consultations, diagnostic detection rates and treatment recommendations were compared before and 12 months after establishing the network.

Results

Out of the pre- (n = 1645) and 12-months-post Sofu-Net patient samples (n = 1756), 267 (16.2%) and 269 (15.3%) high-risk patients were identified. From these, 156 and 123 patients were interviewed and information was assessed from their PCP. Twelve months after Sofu-Net establishment, high-risk patients more frequently discussed psychosocial distress with their PCP (63.3% vs. 79.2%, p < .001). PCPs prescribed more antidepressants (3.8% vs. 25.2%, p < .001) and less benzodiazepines (21.8% vs. 6.5%, p < .001). Sofu-Net did not affect PCP's diagnostic detection rates or recommendation to initiate psychotherapy.

Conclusion

The study results indicate feasibility of an interdisciplinary network for somatoform disorders. Collaborative care networks for somatoform disorders have the potential to improve doctor–patient-communication and prescription behavior.

Introduction

Somatic symptoms are very common in the general population and are most frequently the reason why patients visit their doctor [1], [2]. Somatoform disorders are characterized by persistent or recurrent disabling bodily complaints without a sufficient organic explanation. These disorders are prevalent in 3.5% to 10% of the general population [3], and in up to 20% of patients in primary care settings [4], [5]. Medically unexplained symptoms and somatoform disorders substantially reduce patients' well-being and quality of life [1], [6]. Moreover, similarly to depressive and anxiety disorders, somatoform disorders are associated with high health care costs caused by frequent consultations, repeated diagnostic procedures and work incapacity [7], [8].

Several important barriers limit the adequate management of somatoform disorders. First, somatoform disorders remain chronically underdiagnosed [9]. Although patients often provide cues to discuss their psychological needs, primary care physicians (PCP) and patients rarely directly discuss psychosocial distress [10]. Critically, such discussion is a key determinant of the recognition of somatoform disorders in primary care. Thus, somatoform disorders are under-recognized and the detection is often limited to very severe cases [11], [12]. The lack of diagnosis could be one explanation for the large intervals between onset and treatment of 6 to 16 years [13], [14]. Other reasons might include the physicians' conservative use of this diagnostic category to avoid stigmatizing patients and overlooking somatic causes, the problematic operationalization of the diagnosis itself, and the patients' reluctance to accept a psychological symptom attribution [15], [16], [17], [18].

Second, although psychotherapy effectively reduces disability and improves functioning [19], [20], [21], only half the patients with somatoform disorders seek any help for their mental problems, and far less, about 11% of patients with current mental disorders have consulted a mental health specialist in the past 12 months [22]. Many patients are neither referred to psychotherapy by their PCPs, nor do they initiate psychotherapy themselves. The shortage of available psychotherapists and long waiting lists add to the problem [22]. Collaborative psychosomatic consultations effectively improve functioning and reduce health care use, but are rarely implemented [23].

Third, due to the ambiguous nature of somatic symptoms and—in many cases—a predominant somatic understanding of illness, patients often visit many medical specialists in search of an underlying somatic cause of their complaints. Together, these barriers result in unnecessary and uncoordinated somatic diagnostic procedures, a lack of adequate treatment, and ultimately, the chronic course of somatoform disorders [24].

According to both international and German guidelines, somatoform disorders should be managed within a collaborative stepped care approach [2], [25], [26]. The PCP should serve as the first contact person as well as the coordinator of adequate diagnostic and treatment procedures. With increasing symptom severity, psychotherapy should be part of the treatment plan. In severe or pain dominant cases, additional time-limited and low-dose antidepressant medication (but no benzodiazepines) is recommended. While there is scarce but promising evidence that collaborative stepped care might improve the management of somatoform disorders [27], [49], these approaches have rarely been implemented and evaluated in practice. This is in contrast to other mental disorders such as depression, for which collaborative care has shown to be more effective than treatment as usual in improving outcomes [28].

To our knowledge, this is the first study that aimed to establish and evaluate a collaborative stepped health care network for somatoform disorders in primary care. The network intends to improve early diagnosis, to accelerate appropriate treatment, thereby reducing unnecessary health care utilization. Since this is the first study to implement such a network in routine primary care, the main focus of this pre–post-intervention study was feasibility [29]. The evaluation focussed on changes in two outcome domains at both the PCP and patient levels, namely (a) the diagnostic process and (b) treatment recommendations. With regard to (a) the diagnostic process, we hypothesized that the discussion of psychosocial distress between patients and PCPs increases after the establishment of the health network, and the correct diagnostic detection rate for somatoform disorders by PCPs increases. With regard to (b) treatment recommendations, we hypothesized that PCPs recommend psychotherapy more often, and prescribe medication more appropriately in terms of less benzodiazepines and more antidepressants.