MUS, SERVICES AND OBSTACLES

Dr David Porteous

GP, Fishponds Family Practice, Bristol

Dr Thanos Tsapas

Consultant Psychiatrist in Psychotherapy, Avon and Wiltshire Partnership NHS Trust

OVERVIEW

• Primary care

• MUS

• Need for new understandings

• Obstacles and context

• What can be useful?

• Primary Care Assessment and Consultation service

• Evolution

WHY PRIMARY CARE?

• GP is usually the first health professional to whom people turn when they develop symptoms (joint report Royal College of Psychiatrists & Royal College of General Practitioners, 2009)

• Primary care patients: complex, chronic and severe

• Curious mix of not quite knowing who will present with what problem(s) at the next consultation and GPs know patients very well, being involved at key points in their

lives (crisis), working with family members and community resources over a long time

span

• Estimated consultations per year per typical practice in 2008 equalled 34,200 (Hippisley Cox J, 2009)

MEDICALLY UNEXPLAINED SYMPTOMS

• Estimated 15–30% of all primary care consultations (Kirmayer et al, 2004)

• In secondary care 50% outpatients fulfil criteria for MUS

• Patients receive large amounts of symptomatic investigation and treatment (Barsky & Borus, 1999)

• Incremental healthcare cost: £3 billion; 10% of total NHS expenditure for the working-age population in 2008–2009 (of which 1158 million Primary Care; Cost of sickness absence and decreased quality of life: over £14 billion (Bermingham et. al, 2010)

• Most patients with medically unexplained symptoms in primary care allow doctors the opportunity to address their psychological needs (Salmon et al, 2004; Ring et al, 2005)

• The main reason GPs instigate investigation and treatment is to end a consultation in which the patient is elaborating at length on their symptoms (Salmon et al, 2006)

MEDICALLY UNEXPLAINED SYMPTOMS

• Psychological therapies can lead to decreased utilisation, improved wellbeing and between 9% and 53% reduction in costs, especially when

implemented at the primary care level (Kathol RG, 2009)

• Even one session of psychological therapy may help reduce the number of primary care visits and somatisation severity in MUS patients (Martin et al, 2007)

COMPLEXITY

• Patients’ complexity appears as a multiplicity of mental health diagnoses, as a combination of mental and physical health problems, often coupled with a background of social difficulties, neglect and trauma. Primary care patients fall primarily in this category (Gask, Klinkman, Fortes and Dowrick 2008)

• The greater mass of human mental pain is hidden below the diagnostic waterline (RCGP, 2005)

• Patients reduce the complexities of their lives to one particular condition (physical), they feel comfortable to seek help from their GPs who, in turn, are trained to diagnose and treat clearly defined conditions using the reductionist medical model.

• Addressing the issue of patient complexity could be done either by developing interventions of matching complexity or by using interventions, which, by virtue of the psychotherapeutic principles on which they are based, are well placed to explore this complexity

COMPLEXITY

MUS cannot be easily ascribed to recognised physical

diseases

They might be caused by physiological disturbance, emotional or social problems, or pathological conditions which have not yet been diagnosed

WHY IS IT HARD TO MANAGE PATIENTS WITH MUS?

Cultural Obstacles

• Mind - Body Split• Stigma of non-organic cause for symptoms• Medical model

Managing Risk

• Fear of missing organic disease• Patients complaints• Blame culture

Lack of time

NEW UNDERSTANDINGS

• Embodied symptoms

• “Since thought derives from a tissue that is not yet thought and extends its branches into social relations that may no longer constitute thought.” (P. Marty)

• Human existence is embodied and defined by perceptual experience -inseparable

mind and body (thinking and perceiving) (M. Merleau-Ponty)

• Transparency of the healthy body - “the body passes us by in silence” (J-P Sartre)

• Disruption of harmony between biological and lived (experienced) body

• The habitual body meets the resistance of the biological body

• The betrayal and alienation of the ill body

• New world of illness: no spontaneity, limitations, fear, negotiations, avoidance, helplessness (H. Carel)

THE CONTEXT

• Every individual redefined in a permanent condition of vulnerability to mental illness

• Awareness campaigns: invoking the risk of mental health within the general population, screenings and early interventions at schools

• High levels of self- labelling

• Self-help culture: the values of self-improvement, striving to be more positive and happy in life....promoting a model of deficit focused entirely

on the individual (Ehrenreich 2009)

THE CONTEXT

• Shift from collective virtue of equality and solidarity to individual value of competition and consumerism

• Individual: site of responsibility, transformation and wellbeing - “identity disorder”

• Recovery as personal responsibility and failure

• Link of mental illness with productivity and underperformance

THE CONTEXT

• Social determinants of health and the realities that produce people’s psychological

distress are ignored (Kuznetsova, 2012; Kings Fund, 2013)

• Negative impact of the recession on mental health (Katikireddi et al, 2012; Vizard and

Obolenskaya, 2015; Barnes et al, 2017)

• North of England:

increased rates of poor mental health combined with increased self harm (Barnes et

al, 2016) and suicide rates (Hawton et al, 2016)

antidepressant prescribing is higher comparing to other areas in the South of

England (Spence, 2014)

• Strong evidence for the link between those increased rates and material

deprivation, low income and socioeconomic status (Williams, 2002; Melzer et al, 2009)

• Clear link between prescribing and to deprivation in the North and East of England; in Blackpool (the only district in England) more than two

prescriptions per person per year were given out by GPs

• The lowest prescribing is in Greater London, half the number of antidepressants compared to the rest of the country

https://www.exasol.com/en/company/newsroom/news-and-press/2017-04-13-over-64-million-

prescriptions-of-antidepressants-dispensed-per-year-in-england/

https://www.exasol.com/en/company/newsroom/news-and-press/2017-04-13-over-64-million-prescriptions-of-antidepressants-dispensed-per-year-in-england/

• Far too many instances in which Universal Credit is being implemented in ways that negatively

impact many claimants’ mental health, finances, and work prospects

• Cuts are being made without either measuring or accounting for their broader impact, such as

increasing the need for crisis support and mental health services

• 14 million people, a fifth of the population, live in poverty

• 2.8 million people living in poverty in families where all adults work full time

• Various sources predict child poverty rates of as high as 40%

• The Equality and Human Rights Commission forecasts that another 1.5 million more children will fall

into poverty between 2010 and 2021/22 as a result of the changes to benefits and taxes, a 10%

increase from 31% to 41%

• For almost one in every two children to be poor in twenty-first century Britain is not just a

disgrace, but a social calamity and an economic disaster, all rolled into one

• The overall social safety net is being systematically dismantled

• In England, homelessness is up 60% since 2010, rough sleeping is up 134%

• Food bank use is up almost four-fold since 2012, and there are now about 2,000 food banks in the

UK, up from just 29 at the height of the financial crisis

https://www.ohchr.org/Documents/Issues/Poverty/EOM_GB_16Nov2018.pdf

https://www.ohchr.org/Documents/Issues/Poverty/EOM_GB_16Nov2018.pdf

“Groups with a low socio-economic background, ethnic minorities, and young

people are increasingly exposed to traumatic and stressful events with

corresponding health trajectories” (Hatch and Dohrenwend, 2007)

“Cumulative inequality interacts with one’s ability to mobilise social, economic,

and psychological resources, together with human agency (i.e. the ability to

change one’s environment), in shaping the individual’s mode and level of

functioning throughout the course of life” (Ferraro & Shippee, 2009)

https://www.kingsfund.org.uk/projects/time-think-differently/trends-broader-determinants-health

https://www.kingsfund.org.uk/projects/time-think-differently/trends-broader-determinants-health

LIMITATIONS OF PHARMACOLOGY

Advantage of SSRIs over placebo

is small (Kirsch, 2008)

and possibly meaningless (Moncrieff, 2011)

90% of published trials

are sponsored

by the pharmaceuticals (Goldacre, 2012)

MRS SH AGED 50

• Attended GP –’I think I have a UTI’; but minimal symptoms• UTI excluded during consultation and further discussion re symptoms• Low mood poor sleep etc• Son died from drugs OD 3 years ago, unhappy marriage; not much

social support.

• Working long hours. Financial problems. Husband disabled from cva and not able to work. Facing eviction.

• Depressive symptoms treated – good recovery

MS NM AGED 25

• Chronic pain• Headaches back pain leg pain neck pain joint pains• Numerous investigations – all normal• Single mum with 3 children. 10 month old baby.• Lots of ill health in family• Poverty, inadequate housing, poor social and community support.• Several consultations to discuss symptoms and their relation to her

overall circumstances really helped.

• But a lack of access to services hinders her recovery

WHAT CAN BE USEFUL?

• Identify MUS – but don’t use it as a label / diagnosis

• Treat the treatable bits, including anxiety / depression

• Use helpful consultation techniques - EMPATHISE

• When considering referrals or investigation, discuss beforehand likelihood of negative results

• Be clear in referral letters of your expectation of MUS

• AND remember investigation / referral may not be best approach

WHAT DOESN’T HELP

• Focussing exclusively on diagnosis - instead focus on symptoms and their effect on functioning

• Claiming symptoms are normal without taking notice of patients concerns• Investigating without explaining likelihood of negative result• Assume you know what patients want• Ignore or miss psychological clues• Force the idea of psychosocial cause for symptoms - this may just lead

to defensiveness

CAUTION

By highlighting MUS, doctors may use it as a diagnosis – this is best avoided; it is better to focus on the symptoms, the consequences

and the functioning, not the name.

MEDICALLY UNEXPLAINED SYMPTOMS:WHOSE JOB IS IT ANYWAY?

Doctor - patient relationship

Clinicians should trust, far more than they do, their own

psychological abilities and the therapeutic alliance with their

patients

This would help achieve better concordance between addressing

the patients’ fears and managing their own anxiety and

uncertainty

WHAT ELSE CAN HELP?

• More supportive

• More educational

• More micro-work

• Active reparation of ruptures

• Structural disorder not analysed as having meanings

• Flexibility

• Collaborative work with other agencies – confidentiality

• From cure to care

• Health within illness

• Creativity of adaptation

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

• History• Service model • Exclusion criteria

Working with:

• Medically unexplained symptoms• Personality difficulties • Difficulties that stand in the way of engaging with services• People with chronic mental health problems who do not meet referral threshold for

secondary services or have been discharged

• Difficulties that result in high GP service usage• People with life limiting and long term physical conditions• Carers of all the above clients

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

• A named medical psychotherapist or psychotherapist linked to each practice to discuss all referrals and provide regular feedback

• Assessments / consultations to patients by a medical psychotherapist or psychotherapist who is experienced in working with patients with complex mental

health difficulties

• All assessments / consultations took place in the patient’s own GP practice• Case discussion of complex cases with GPs• Joint assessments with GPs to patients with complex needs• A detailed formulation of the patient’s difficulties following each assessment and a

written summary of the assessment with suggested recommendations

• Art psychotherapy in a group setting for people with psychosomatic difficulties and medically unexplained symptoms for 10 weeks

• Identification of appropriate care pathways for the referred patients and advise on referrals to other services if needed

• Balint groups offered to GPs in their Practice on a regular basis

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

Evaluation

• Number of patients referred (18 months): 321• Number of patient accepted: 319• GP practices included: 8• Number of GPs who referred: 52• Previous contact with BWT: 107 (33%) (not available data for 67 - 21%)• Average waiting time from referral to first offered appointment: 18.9 days• Average staying in the service from referral to discharge: 38.5 days

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

Patient characteristics

• DiagnosisChronic or Severe Mental Illness: 68%, MUS: 13%, CSMI +MUS: 13%

• Gender Male: 60%, Female: 40%

• Age36-55: 43%, 18-35: 39%, 56+: 17%

• Ethnicity: White British 78%• Employment

Employed 35%, Unemployed 42%, Retired 10%

Severity of difficulties (CORE)

Severe: 32%, Moderate to severe: 31%

AQP therapies: Didn’t engage: 37% (mostly MUS and Hx of trauma), 16sessions: 32%

• WBT: disengaged after 1 session: 28%, >16 sessions: 5%

• Art psychotherapy group 10 weeks: Mean reduction of 20 points on CORE

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

Patient feedback• Assessments met expectations: 91%• How helpful: Very 67%, Moderately: 18%• How satisfied: Very 62%, satisfied: 23%

Patients’ verbatim comments:“For the first time I felt I was listened to by someone who understood everything I tried to say. I

feel I will now get the help I desperately need.”

“Very worried about coming and having an assessment but thought it was really helpful and

would like to see where it can take me. Thanks.”

“They say it’s good to talk and by having this meeting I am able to back track my life and

understand why some things now add up. I wish I had this years ago when first asked. Can see

a small light of hope now.”

BRISTOL PRIMARY CARE ASSESSMENT AND CONSULTATION SERVICE (PCACS)

GP feedback• Service met your expectations: 91%• Service met your patient’s needs: All: 50%, Most: 39%• How do you feel now about dealing with patient’s problems?Able to support patients: 44%, Encouraged by their ability to help: 43%

Net promoter score: 9.6/10 (All GPs would recommend the Service to a colleague)

GPs’ verbatim comments• “This has been the best service in the mental health field for years. We have valued it greatly and feel it has

helped us understand and manage complex patients in a truly therapeutic way, and I am sure has reduced the

use of secondary care by many of these patients.”

• "I feel much more equipped to deal with patients with complex mental health problems. I am able to explore the impact their mental health has on their lives. Prior to this service I did not feel I had an appropriate service

to offer them.”

• “This service is unique - flexible approach - supportive - addresses an existing gap in services. GPs have no psychotherapy training - joint working extremely useful.”

• “This is an excellent service. I hope it will continue, I have seen patients have better insight and are self managing. Many thanks.”

EVOLUTION AND WAYS FORWARD

Service pathway covering journey

from GP to General hospital (Liaison psychiatry)

incl. Psychological help

• 78 referrals for patents with MUS within a year

• 4/5 assessment

• 2/3 of assessed patients: relationally focused psychotherapy (20 sessions)

• 1/10 Art psychotherapy group

• Savings: £296,634 from secondary service usage

• Costing: £81,180