Oxford University, Department of Psychiatry, Warneford Hospital, Headington, Oxford OX3 7JX, UK
Steven Reid and colleagues (2002) have introduced a welcome addition to the UK literature on somatisation with their clear demonstration that unexplained symptoms may be associated with significant use of secondary care health care resources. They emphasise a key point, repeatedly demonstrated, that somatisation is expensive for health care systems. However, their report may tell us more about the behaviour of doctors and health care systems than the behaviour of patients.
By selecting only frequently attending patients, they have controlled for the most important variable in cost of out-patient care, the cost of out-patient attendances. Their own figures show that the costs of attendances represented 74.5% and 85.9% of total out-patient care costs for somatising and non-somatising frequent attenders, respectively. They refer to a major US study (Escobar et al, 1987) which demonstrated very high rates of use of secondary care medical resources among patients with separately diagnosed somatisation. By controlling for attendance in their study design, they have almost certainly diluted the apparent impact of somatisation on secondary care use in this sample an impact they rightly emphasise.
For a significant number of these frequently attending patients, negative investigations were followed by a repeat of the cycle. Those with repeatedly unexplained symptoms were designated somatisers by the authors, implying a disorder in the patient. The medical response to these symptoms may in fact be as important in explaining continued resource use. The reasons why doctors behave in these characteristic ways are less than clear our inability to live with uncertainty, our unwillingness to go with our judgement. Recent attempts to emphasise the importance of the issue are welcome (Bass et al, 2001), but until we more clearly understand doctors' behaviour when faced with these patients, we may remain simply counting the considerable costs.
REFERENCES
Bass, C., Peveler, R. & House, A. (2001)
Somatoform disorders: severe psychiatric illnesses neglected by psychiatrists.
British Journal of Psychiatry,
179, 11-14.
Escobar, J. I., Golding, J. M., Hough, R. L., et al (1987) Somatization in the community: relationship to disability and use of services. American Journal of Public Health, 77, 837-840.[Abstract]
Reid, S., Wessely, S., Crayford, T., et al
(2002) Frequent attenders with medically unexplained
symptoms: service use and costs in secondary care. British Journal
of Psychiatry, 180,
248-253.
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