Athula Sumathipala

What is the Evidence for the Efficacy of Treatments for Somatoform Disorders? A Critical Review of Previous Intervention Studies

Objective: To review published literature for the highest level of evidence on the efficacy of treatment for patients with medically unexplained symptoms. Methods: A comprehensive literature search was carried out in Cochrane library, Medline (1971–2007), PsychINFO (1974–2006), and EMBASE (1980–2007) to identify pharmacological, nonpharmacological, psychological, and other interventions, using the search terms “medically unexplained symptoms,” “somatisation,” “somatization,” “somatoform disorders,” “psychological therapies,” “cognitive behavior therapy,” “pharmacological therapies,” “management,” “therapy,” “drug therapy,” and “anti-depressants” with Boolean operators AND and OR on the entire text. Searches were confined to literature in English. Results: Studies were carried out in primary, secondary, and tertiary care settings. The therapists ranged from medical specialists, psychiatrists, and psychologists to primary care physicians. Three types of interventions (antidepressant medication, cognitive behavioral therapy (CBT), and other nonspecific interventions) were supported by evidence on the efficacy of treatment for patients with medically unexplained symptoms. There is more level I evidence for CBT compared with the amount for other approaches. There was only one study reported from the developing world. Conclusions: CBT is efficacious for either symptom syndromes or for the broader category of medically unexplained symptoms, reducing physical symptoms, psychological distress, and disability. A relatively small number of studies were carried out in primary care, but the trend has been changing over the last decade. No studies have compared pharmacological and psychological treatments. Most trials assessed only short-term outcomes. Use of divergent selection procedures, interventions, outcome measures, and instruments, and other methodological differences observed in these studies hamper the ability to compare treatment effects across studies. CBT = cognitive behavioral therapy; MUS = medically unexplained symptoms; RCT = randomized controlled trial; CFS = chronic fatigue syndrome; GP = general practitioner; PPC = psychosocial primary care; NCCP = noncardiac chest pain.

Under-representation of developing countries in the research literature: ethical issues arising from a survey of five leading medical journals

BackgroundIt is widely acknowledged that there is a global divide on health care and health research known as the 10/90 divide.MethodsA retrospective survey of articles published in the BMJ, Lancet, NEJM, Annals of Internal Medicine & JAMA in a calendar year to examine the contribution of the developing world to medical literature. We categorized countries into four regions: UK, USA, Other Euro-American countries (OEAC) and (RoW). OEAC were European countries other than the UK but including Australia, New Zealand and Canada. RoW comprised all other countries.ResultsThe average contribution of the RoW to the research literature in the five journals was 6.5%. In the two British journals 7.6% of the articles were from the RoW; in the three American journals 4.8% of articles were from RoW. The highest proportion of papers from the RoW was in the Lancet (12%). An analysis of the authorship of 151 articles from RoW showed that 104 (68.9%) involved authorship with developed countries in Europe or North America. There were 15 original papers in these journals with data from RoW but without any authors from RoW.ConclusionsThere is a marked under-representation of countries in high-impact general medical journals. The ethical implications of this inequity and ways of reducing it are discussed.

Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints : a feasibility study in Sri Lanka

BACKGROUND Research on the management and the outcome of treatment of medically unexplained symptoms is very limited. Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed. METHODS A randomized controlled trial was carried out with follow-up assessments at 3 months after baseline assessments using the Short Explanatory Model Interview (SEMI), General Health Questionnaire (GHQ-30), Bradford Somatic Inventory (BSI) and patient satisfaction on a visual analogue scale. The study was carried out in a general out-patient clinic in Sri Lanka. The intervention group received six, 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months. The control group received standard clinical care. RESULTS Eighty patients out of the 110 patients referred, were eligible. Sixty-eight were randomly allocated equally to the control and treatment groups. All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions. At 3 months, 24 in the treatment and 21 in the control group completed follow-up assessments. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures (adjusted for baseline scores) between control and intervention groups respectively--complaints 6.1 and 3.8 (P = 0.001), GHQ 10.4 and 6.3 (P = 0.04), BSI score 15.6 and 132 (P < 0-01), visits 7.9 and 3.1 (P = 0.004). CONCLUSIONS Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out-patients clinic in Sri Lanka. It had a significant effective in reducing symptoms, visits and distress, and in increasing patient satisfaction.

Cognitive–behavioural therapy v. structured care for medically unexplained symptoms: randomised controlled trial

Background A pilot trial in Sri Lanka among patients with medically unexplained symptoms revealed that cognitive–behavioural therapy (CBT) administered by a psychiatrist was efficacious. Aims To evaluate CBT provided by primary care physicians in a comparison with structured care. Method A randomised control trial (n=75 in each arm) offered six 30 min sessions of structured care or therapy. The outcomes of the two interventions were compared at 3 months, 6 months, 9 months and 12 months. Results In each arm, 64 patients (85%) completed the three mandatory sessions. No difference was observed between groups in mean scores on the General Health Questionnaire or the Bradford Somatic Inventory, or in number of complaints or patient-initiated consultations at 3 months. For both groups, all outcome measures improved at 3 months, and remained constant in the follow-up assessments. Conclusions Cognitive–behavioural therapy given by primary care physicians after a short course of training is no more efficacious than structured care. Natural remission is an unlikely explanation for improvements in people with chronic medically unexplained symptoms, but lack of a ‘treatment as usual’ arm limits further conclusions. Further research on enhanced structured care, medical assessment and structured care incorporating simple elements of CBT principles is worthy of consideration.

Understanding the explanatory model of the patient on their medically unexplained symptoms and its implication on treatment development research: a Sri Lanka Study.

BackgroundPatients with medically unexplained symptoms (MUS) are often distressed, disabled and dissatisfied with the care they receive. Illness beliefs held by patients have a major influence on the decision to consult, persistence of symptoms and the degree of disability. Illness perception models consist of frameworks to organise information from multiple sources into distinct but interrelated dimensions: identity (the illness label), cause, consequences, emotional representations perceived control and timeline.Our aim was to elicit the illness perceptions of patients with MUS in Sri Lankan primary care to modify and improve a CBT intervention.MethodAn intervention study was conducted in a hospital primary care clinic in Colombo, Sri Lanka using CBT for MUS. As a part of the baseline assessment, qualitative data was collected using; the Short Explanatory Model Interview (SEMI), from 68 patients (16–65 years) with MUS. We categorised the qualitative data in to key components of the illness perception model, to refine CBT intervention for a subsequent larger trial study.ResultsThe cohort was chronically ill and 87% of the patients were ill for more than six months (range six months to 20 years) with 5 or more symptoms and 6 or more visits over preceding six months. A majority were unable to offer an explanation on identity (59%) or the cause (56%), but in the consequence domain 95% expressed significant illness worries; 37% believed their symptoms indicated moderately serious illness and 58% very serious illness. Reflecting emotional representation, 33% reported fear of death, 20% fear of paralysis, 13% fear of developing cancer and the rest unspecified incurable illness. Consequence and emotional domains were significant determinants of distress and consultations. Their repeated visits were to seek help to alleviate symptoms. Only a minority expected investigations (8.8 %) or diagnosis (8.8%). However, the doctors who had previously treated them allegedly concentrated more on identity than cause. The above information was used to develop simple techniques incorporating analogies to alter their perceptionsConclusionThe illness perception model is useful in understanding the continued distress of patients with persistent symptoms without an underlying organic cause. Hence it can make a significant contribution when developing and evaluating culturally sensitive patient friendly interventions.

Prolonged internal displacement and common mental disorders in Sri Lanka: the COMRAID study.

Background Evidence is lacking on the mental health issues of internally displaced persons, particularly where displacement is prolonged. The COMRAID study was carried out in year 2011 as a comprehensive evaluation of Muslims in North-Western Sri Lanka who had been displaced since 1990 due to conflict, to investigate the prevalence and correlates of common mental disorders. Methods A cross-sectional survey was carried out among a randomly selected sample of internally displaced people who had migrated within last 20 years or were born in displacement. The total sample consisted of 450 adults aged 18–65 years selected from 141 settlements. Common mental disorders (CMDs) and post-traumatic stress disorder (PTSD) prevalences were measured using the Patient Health Questionnaire and CIDI sub-scale respectively. Results The prevalence of any CMD was 18.8%, and prevalence for subtypes was as follows: somatoform disorder 14.0%, anxiety disorder 1.3%, major depression 5.1%, other depressive syndromes 7.3%. PTSD prevalence was 2.4%. The following factors were significantly associated with CMDs: unemployment (odds ratio 2.8, 95% confidence interval 1.6–4.9), widowed or divorced status (4.9, 2.3–10.1) and food insecurity (1.7, 1.0–2.9). Conclusions This is the first study investigating the mental health impact of prolonged forced displacement in post-conflict Sri Lanka. Findings add new insight in to mental health issues faced by internally displaced persons in Sri Lanka and globally, highlighting the need to explore broader mental health issues of vulnerable populations affected by forced displacement.

Epidemiology and symptomatology of depression in Sri Lanka: A cross-sectional population-based survey in Colombo District

Background It is important to understand the nature of depression in non-Western and lower-income countries, but little such research exists. This study aimed to examine the characteristic features of depression in Sri Lanka, and to identify environmental risk factors. Methods Depression diagnoses, symptoms and impairment were measured using the Composite International Diagnostic Interview, in a population-based sample of 6014 twins and non-twins in the Colombo region of Sri Lanka (the CoTASS sample). Socio-demographic factors and environments were assessed via questionnaires. Results Lifetime-ever depression was reported in 6.6% of participants, rising to 11.2% if the functional impairment criterion was excluded. The symptom profile of depression and its socio-demographic associations were very comparable to those in Western and more economically developed countries, whether functional impairment was included in the definition or not. Standard of living was independently associated with depression, especially among men at the more deprived end of the distribution. Specific associations were found with both financial wellbeing and material characteristics of the home environment. Limitations The observational associations identified are cross-sectional, so do not necessarily imply causal links. Conclusions Aside from a lower prevalence, depression is very similar in this predominantly urban Sri Lankan sample to higher-income, Western countries, and may be under-identified due to a relatively low cultural appropriateness of the assessment of impairment. Under Sri Lankas cultural and environmental context, certain aspects of the material environment are associated with depression among certain segments of society, perhaps because of their particular link to social status and social networks.

Association of somatoform disorders with anxiety and depression in women in low and middle income countries: A systematic review

Abstract Background: Across cultures, women are more likely than men to report somatoform disorders (SD), depression and anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible mechanisms of this relationship in women in low and middle income countries (LMIC). Methods: We reviewed two databases: MEDLINE and PsycINFO from 1994 to 2012 for studies which assessed the association between any SD and depression/ anxiety in women from LMIC. Our focus was on community and primary healthcare based studies. Both quantitative and qualitative studies were included. Results: A total of 21 studies covering eight LMICs were included in our analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from 2.5–3.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mechanisms for this association are multidimensional, and may include shared aetiologies, that both conditions are in fact variants of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a number of frameworks through which we can view these mechanisms. Conclusion: The current evidence indicates that service providers at the primary care level should be sensitized to consider SD in women as variants of CMD (Common Mental Disorders) and address both groups of disorders concurrently. Further research should explicitly seek to unpack the mechanisms of the relationship between SD and CMD.

Management of dead bodies as a component of psychosocial interventions after the tsunami: A view from Sri Lanka

Even if predicted, disasters may not be completely averted due to reasons beyond human control. There is always likely to be a degree of loss, human as well as material. Therefore, the correct strategy is to limit the damage and minimize the harm. Such damage control exercises should be mindful about the psychological costs of the disaster. Identification of dead bodies and the missing, as well as providing a dignified burial, is a crucial part of the overall management of a disaster. It will alleviate the long-term psychological as well as legal consequences. Hence, a comprehensive forensic service including modern genetic capabilities is a must for disaster response. Development of a comprehensive and efficient psychosocial intervention at community level after a disaster should recognise the importance of dead body management as an integral part of it. The guiding principles of psychosocial interventions are: to be multi-sectoral and multi-level; to include immediate, mid-term and long-term interventions; to be socially and culturally sensitive; to recognize the functionality of existing social and healthcare systems; to adopt a public mental health approach; and to be informed by evidence-based planning and implementation proven to be locally effective.

Completed suicide among Sinhalese in Sri Lanka: a psychological autopsy study.

Sri Lanka has the one of highest rates of suicide. Important factors associated with suicide were determined via the psychological autopsy approach (which had not been carried out previously in Sri Lanka). Over a 3-month period, in a catchment area, 31 suicides among Sinhalese were identified and 27 were investigated. Males were more likely to commit suicide and alcohol abuse and domestic violence were reported as contributory factors. We found it possible to use psychological autopsy methods to obtain information which can inform planned prevention measures.