We confirmed the hypothesis that our intervention would lead to clinically significant improvement in mental function. A 4-point increase on the MCS corresponds to the mental improvement observed following a combined mitral/aortic valve replacement.9
In addition, patients' depression, satisfaction, physical disability, use of antidepressants, and non-use of controlled substances improved.
We believe the success of this study stemmed from addressing what many consider the basic problem with MUS patients, the personal dimension.1,4,23
By enhancing antidepressant use and by otherwise reducing psychological distress, MUS patients coped better with their symptoms. Patients who do best are those who cope best, not those who focus on eliminating physical symptoms.26
There were limitations. First, our results may not be representative of patients with lower utilization, with more severe co-morbid organic diseases, and with lower education. Second, the 43.7% who refused could have differed, but the baseline similarities between treatment and control groups are against this. Third, our data were not classified in such a way that we could evaluate treatment response in the various MUS syndromes such as IBS. Finally, full cost-effectiveness studies will require many more subjects,27
and utilization could not be evaluated as an outcome because the protocol prescribed a fixed number of visits for treatment patients. We do know, though, that utilization was similar in treatment and control groups (14.2 vs 12.3, respectively; P
< 0.05). But, the total amount of contact, when including telephone calls, was almost certainly greater, a useful part of the intervention itself.
With no treatment precedent in medicine for MUS patients,6
this study sought, as its main objective, to determine if a primary care method was even feasible and effective (and at what “dose”). Our data raised the following questions for future study. (1) Can using providers more skilled in primary care reduce training time? (2) With the impact of treatment occurring by 3 to 6 months, will fewer visits suffice? (3) Can outcomes be improved by selecting just the more severe MUS population? Clearly, much work remains before the field has an efficient, refined, and generalizable approach and, ultimately, effective dissemination. For the present, the study supports establishing a strong PPR, frequent visits, antidepressants, and CBT principles.6
When we controlled for satisfaction, the association of treatment with improved mental function was unchanged, indicating that satisfaction did not mediate it,25
i.e., there was no longitudinal relationship of satisfaction and mental health status.24
Importantly, though, our questionnaire addressed satisfaction only
with general communication and PPR skills (model 1), but it did not
concern the more specific informing and motivating skills we used for treatment (model 2). We hypothesize that satisfaction with specific treatment-related patient-centered skills would have to be measured to evaluate whether satisfaction with the PPR could be significantly related to mental health outcome.
When we controlled for antidepressant use, the association of treatment with an improved MCS disappeared, and, when controlling for treatment, the effect of antidepressants disappeared. While antidepressants were a key factor, they were not the only one in the multidimensional treatment that contributed to improved mental function. The nonantidepressant aspects of the treatment must be invoked to explain improvement in the 20% of treatment patients who did not take full doses of antidepressants. Further, we hypothesize that these other treatment factors led also to the tripling of antidepressant use itself, an unusual achievement in medicine.28
Further study is needed to pinpoint the key components of our multidimensional treatment package.
Like others, we found that not all MUS patients were depressed and that, instead, they seemed to exist on a spectrum of severity.3,29,30
We conceptualize MUS as the unit of interest 31
and propose that it is a general warning signal of underlying psychological distress, of which depression is an advanced manifestation.3,29
The important point for primary care is that unexplained symptoms obscure the patient's psychic distress by misdirecting providers into the organic disease realm.4,5
This creates a serious problem: high-utilizing MUS patients are one of the most common conditions in all of medicine.3
Medically unexplained symptoms also are the major mode of presentation of (co-morbid) depression.3,29