INEFFECTIVE UTILIZATION, SOMATIZATION, AND UNDETECTED PSYCHIATRIC DISORDER

Perception and Cognition in DSM-III-R Hypochondriasis and Accuracy of Symptom Reporting in Patients Complaining of Palpitations1

Brigham and Women's Hospital, Department of Psychiatry

Arthur J. Barsky, M.D..,;Barsky, Arthur J.,, E. John Orav, Ph.D.,Ahern, David, David W. Bates, M.D.Antman, Elliott

The medical care utilization of patients with persistent, medically unexplained symptoms is often costly, inefficient, and ineffective. The primary aim of this study is to define certain characteristic patterns of medical care utilization which can be used to identify patients with persistent, medically unexplained symptoms, sustained high rates of medical care utilization and a high likelihood of previously undetected anxiety and depressive disorder. A secondary aim is to examine physician influences on the medical utilization of these somatizing patients.

A consecutive series of primary care patients are screened with self-report questionnaires to measure somatization and anxiety and depressive disorder. Their medical care utilization (including outpatient visits, emergency visits, days hospitalized, and laboratory and total outpatient and inpatient costs) in the preceding 12 months is then obtained from the electronic medical record. We will then test the power of several specific patterns of ineffective utilization to identify patients with high levels of somatization and to distinguish them from patients with high levels of aggregate medical morbidity. The same patients' medical utilization will then be followed prospectively in the 12 months after completion of the somatization questionnaire to determine if these patterns of ineffective utilization persist over time. Physician influences on utilization will also be studied by (1) examining the variability in utilization among comparably somatizing patients of different physicians, (2) determining the extent to which somatizing patients aggregate in the practices of a minority of the physicians, and (3) comparing physicians whose practices contain proportionately more of these patients with physicians caring for fewer such patients.

This work will permit the routine identification of patients at high risk for persistent, medically unexplained symptoms through characteristic patterns of ineffective utilization. Such a method of patient identification would then lead to specific interventions to improve their medical care, including a search for previously undetected depressive and anxiety disorders (which are prevalent in such patients, frequently undiagnosed, and eminently treatable) which may be driving their ineffective utilization.

Key words. Somatization, medical care utilization.

Grant Support. Aetna Quality Care Foundation.

Project Sites. Department of Psychiatry, Brigham and Women's Hospital.

Project Director and Principal Investigator. Arthur J. Barsky, M.D., Department of Psychiatry, Brigham and Women's Hospital, Boston, MA 02115. Tel: (617) 732-5236.

Training Opportunities. None available.

Representative Publications:

Barsky AJ, Ettner SL, Horsky J, Bates DW. Resource utilization of patients with hypochondriacal health anxiety and

somatization. Med Care 2001; 39:705-715.

Barsky AJ, Ahern DK, Bailey ED, Delamater BA. Predictors of persistent palpitations and continued medical utilization. J Fam Pract 1996; 42:465-472.

Barsky AJ, Wyshak G, Klerman GL. Medical and psychiatric determinants of outpatient medical utilization. Med Care 1986; 24:548-560.

Barsky AJ, Borus JF. Somatization and medicalization in the era of managed care. JAMA 1995; 274:1931-1934.

Barsky AJ, Wyshak G, Klerman GL. Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychiat 1992; 49:101-108.