Group therapy for somatization disorders in primary care: maintenance of treatment goals of short cognitive-behavioural treatment one-and-a-half-year follow-up
Lidbeck J;
Commented by , 24 Jun 2003
Background
An estimated 40-60% of general practice patients have somatization disorders (SDs), representing the “high-utilizers” of medical services. Surprisingly, there is a paucity of research on the management of SDs. Most studies have been limited by short follow-up periods.
Purpose
To evaluate whether treatment effects at 6 months (reported previously; 1) are maintained at 18 months, following a group cognitive-behavioural treatment (CBT) program for SDs.
Methods
The sample consisted of patients attending a pain clinic at a Swedish university hospital. Inclusion and exclusion criteria were based on the International Classification of Health Problems in Primary Care. Patients with SDs according to Kellner’s definition of ‘functional somatic symptoms’ were included.
Patients with major mood, anxiety, psychotic or substance use disorders were excluded. 33 patients (mean age 43.8 years), 5 men and 28 women, participated in a randomized control study with a 2 x 3 repeated measures design. There were six treatment groups of 5-6 patients. Participants served as their own controls. The program consisted of eight weekly 3-hr sessions, emphasizing cognitive restructuring and relaxation techniques. Educational material and relaxation techniques were provided to take home.
The following assessments were completed at pre-post treatment, 6 and 18 months follow-up:
- Social Problem Questionnaire (SPQ)
- Illness Behaviour Questionnaire (IBQ) assessing somatization including the Whitely Index (WI) subscale assessing hypochondriasis
- Hospital Anxiety and Depression Scale (HAD)
- Sleep Disturbance Index (SDI)
- ‘drug usage questionnaire’
Statistics included analysis of variance (ANOVA) and the Wilcoxon matched pairs signed ranks test (P<0.05).
Results
ANOVA showed significant differences between the four assessments for all variables except depression. The Wilcoxon test revealed the following significant differences compared to pretreatment:
- slow reduction in the SPQ reaching significance at 18 months
- sustained reduction in the IBQ and WI post-treatment, at 6 and 18 months
- change in the HAD was not manifest until 6 months, with further improvement at 18 months
- SDI reduction was not maintained at 6 and 18 months
- medication reduction was not sustained beyond 6 months.
Discussion
The current long-term follow-up study demonstrated maintained improvements with respect to hypochondriasis, and additional reductions in anxiety, psychosocial preoccupation, somatization and depression/anxiety scores (1).
The study has several limitations. The small sample size and lack of a separate control group limits the study’s power. The generalisability is limited by the specialty population and the exclusion of patients with comorbid mood, anxiety substance use disorders common in SDs.
Furthermore, the authors relied upon self-report, largely symptomatic, data. Objective data, such as health utilization costs, would have been valuable given the potential of SDs to bankrupt the healthcare system (2). In order to stimulate health reform, more studies such as a recent report by Hiller et al (3) demonstrating the economic impact of such treatment programs are warranted.
Notwithstanding these limitations, the authors provide a valuable contribution to this emerging area of study. Of note, is the maintenance of gains following a very short and practical treatment program. Group CBT offers several advantages to individual therapy.
It is clearly more cost-effective, efficient, and can be carried out by nonphysician providers; important with such large prevalence rates. It may also be more palatable to patients with SDs as evidenced by the attendance rate above 90%, with the universality of the group experience, and application in primary care as opposed to psychiatric settings.
References
- Lidbeck J. Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model. Acta Psychiatrica Scandinavica 1997; 96:14-24
- Cummings NA, van der bos GR. The twenty years Kaiser-Permanente experience with psychotherapy and medical utilization: implications for national health policy and national health insurance. Health Policy Quarterly 1981;1:159-175
- Hiller W, Fichter MM, Rief W. A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness. Journal of Psychosomatic Research 2003;54:368-380