SCREENING FOR SOMATOFORM DISORDERS AMONG ADULT PATIENTS ATTENDING PRIMARY HEALTH CARE CENTERS

Transcription

1 AL-AZHAR ASSIUT MEDICAL JOURNAL ORIGINAL ARTICLE SCREENING FOR SOMATOFORM DISORDERS AMONG ADULT PATIENTS ATTENDING PRIMARY HEALTH CARE CENTERS Family and Community Medicine Department 1, King Khalid College of Medicine, Saudi Arabia Family Physician, Directorate of Health Affairs 2, Aseer Region, Ministry of Health Saudi Arabia ABSTRACT Objectives: To screen for somatoform disorders and to identify the possible risk factors associated with these disorders among adults attending the primary health care centers in Abha City. Subjects and Methods: A cross sectional study was conducted among 400 adult attendants of three primary health care centers in Abha City. The Patient Health Questionnaire was used to assess prevalence and severity of somatoform disorders. Participants with 3 or more severe somatic symptoms were referred to as cases, and those who had fewer than 3 severe somatic symptoms were referred to as non-cases. Results: The prevalence of somatoform disorders was 60.8%. High prevalence of somatization was reported among patients in the age group years. Divorce, low education and unemployment were the most important risk factors. Conclusions: Prevalence of somatoform disorders among attendants of primary health care centers in Abha City is high. This high prevalence supports the need for a universal psychiatric screening for attendant patients. Keywords: Somatoform disorders, Screening, Risk Factors, Saudi Arabia. 34

2 INTRODUCTION Physicians are often consulted by patients who have physical symptoms for which no organic causes can be found, or whose complaints are out of proportion to the extent of an organic disease. Psychiatrists defined seventeen types of defenses, the" somatoform disorders" are one of these defense mechanisms. 1 Oyama et al. 2 stated that the somatoform disorders include somatization disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symptoms than somatization disorder), conversion disorder (voluntary motor or sensory function symptoms), pain disorder (pain with strong psychological involvement), hypochondriasis (fear of having a lifethreatening illness or condition), body dysmorphic disorder (preoccupation with a real or imagined physical defect), and somatoform disorder not otherwise specified (used when criteria are not clearly met for one of the other somatoform disorders). In the general population, and even more in medical treatment settings, the prevalence of somatoform disorders is high. Up to 50% of primary care patients present with physical symptoms that cannot be explained by a general medical condition. Some of these patients meet the criteria for somatoform disorders. 3 The severity of these functional somatic symptoms usually ranges from mild transient cases to severe and chronic somatoform disorders. 4 At least 25% of all patients continue to exhibit all somatic symptoms at a one-year follow-up visit, and symptoms are chronic or recurrent in 20% to 25% of all patients. These medically unexplained symptoms can spontaneously resolve or improve by effective management. 5 However, sometimes the complaints persist, leading to functional impairment. 6 35

3 AL-AZHAR ASSIUT MEDICAL JOURNAL Little is known about the causes of the somatoform disorders. Limited epidemiologic data suggest familial aggregation for some of the disorders. 7 These data also indicate comorbidities with other mental health disorders, such as mood disorders, anxiety disorders, personality disorders, eating disorders, and psychotic disorders. 8 Cognitive-behavioral treatment has been demonstrated to be effective in secondary care. However, the course of somatoform disorders and their need for treatment have not yet been established in primary care. 9 The unexplained symptoms of somatoform disorders often lead to general health anxiety; frequent or recurrent and excessive preoccupation with unexplained physical symptoms; inaccurate or exaggerated beliefs about somatic symptoms; difficult encounters with the health care system; disproportionate disability; displays of strong, often negative emotions toward the physician or office staff; unrealistic expectations; and, occasionally, resistance to or noncompliance with diagnostic or treatment efforts. These behaviors may result in more frequent office visits, unnecessary laboratory or imaging tests, or costly and potentially dangerous invasive procedures Somatoform disorders can be disabling for patients, they are costly for society due to sick leave, loss of working years and high health care utilization, and patients risk being exposed to iatrogenic harm in bio-medically focused health care systems. 13 Somatoform disorders are a burden for both patients and family physicians. Patients with these disorders are at risk of over-testing and receiving unnecessary medications Medically unexplained somatic symptoms may negatively influence patients by deleteriously affecting treatment outcomes of co morbid psychiatric disorders, reducing quality of life, and causing functional impairment. 16 Somatic symptoms are also an important indicator of subsequent 36

4 mood disorders, indicating the importance of appropriate and early intervention to treat these symptoms. 17 So, this study aimed to screen adult patients attending primary health care centers for somatoform disorders and to identify the associated risk factors. METHODOLOGY This study followed a cross sectional design. It was performed during 2012, in Abha City, which is the capital of Aseer Region. It lies in the southwestern part of the Kingdom of Saudi Arabia. It has 9 primary health care centers (PHCCs), which provide both preventive and curative services to a total of 214,688 persons. 18 A simple random sample was followed to select 3 primary health care centers to conduct the present study. The minimum sample size for this study has been decided according to Dahiru et al. 19, to be 384. The researcher followed a consecutive sample to interview 400 PHCC attendants from the three randomly selected PHCCs. Inclusion criteria comprised being an adult (i.e., above 18 years of age) attendant of one of the three selected PHCCs. The researchers designed a study questionnaire to collect the personal characteristics of participants. This questionnaire included patient s age, sex, nationality, occupation, educational, marital status, number of children and smoking status. Moreover, participants were screened using the 15-item version of the Patient Health Questionnaire (PHQ 15), which assesses 15 somatic symptoms or symptom clusters that account for more than 90% of all physical complaints (excluding upper respiratory tract symptoms) reported by outpatients. Each item is rated on a scale from 0 (not bothered at all) to 2 (bothered a lot). 20 The PHQ 15 has already been validated in primary-care settings in Saudi Arabia It exhibited good internal consistency and corresponded to criterion indices of physical dysfunction, disability days, clinical visits, and amount of 37

5 AL-AZHAR ASSIUT MEDICAL JOURNAL difficulty that patients attributed to their symptoms. 20 Several studies have established its diagnostic validity Scoring of results simply requires adding the numbers circled, and scores can range from 0 to 30 for women and for men from 0 to 28 (as one item pertains to menstrual problems). 20 The PHQ-15 is intended to function as a continuous measure of somatic symptom severity according to each participant score range, with minimal somatic symptoms (scores <5); low symptoms (scores 5-9); medium (scores 10-14) or high (15-30). 20 The PHQ-15 does not ascertain whether symptoms are medically explained or unexplained, although a high score is strongly associated with physicianrated somatoform disorder symptom counts. 12, 20 However, participants who complete the questionnaire and have 3 or more severe somatic symptoms are usually referred to as cases, and those who had fewer than 3 severe somatic 5, 21 symptoms were referred to as non-cases. Criteria for labeling a case as high risk for somatoform disorders: - Frequent attendee, as indicated by patient s record; - Patient has physical symptoms that the PHC physician could not categorize into a general medical condition; - A PHQ-15 of 3 or more severe somatic symptoms. Since there are separate GP clinics for female patients at the PHCCs, the researchers also trained female PHC physicians so as to assist in interviewing female patients and filling the study questionnaires. SPSS 18.0 software package was utilized for statistical analysis. Frequency distributions of responses, cross-tabulations of individual and associated factors were studied in association with reported prevalence and severity of somatoform disorders. Group differences were further analyzed by the chi-square test and level of significance was determined at p< , 21 38

6 RESULTS The study included 400 participants. Their socio-demographic characteristics are shown in Table (1). More than one third of participants aged 30 years or below (38.2%) and only 5.5% were over 60 years. Females represented 59.7% of the participants. The majority of the participants were Saudi (92.2%). Most of them were married (74.4%) with number of siblings ranging between one and five in 40.8% of participants. Their educational level was low, with 44% having less than a high-school education. Almost two-thirds of participants were not employed (67.4%). Table 1: Socio-demographic characteristics of the study participants (n=400) Variables Age (in years) Categories >60 Number (%) 153 (38.2) 125 (31.2) 69 (17.3) 31 (7.8) 22 (5.5) Gender Male Female 161 (40.3) 239 (59.7) Nationality Saudi Non-Saudi 369 (92.2) 31 (7.8) Marital status Single Married Divorced 87 (21.8) 298 (74.4) 15 (3.8) Number of siblings >5 111 (27.8) 163 (40.8) 126 (31.4) Educational level Illiterate Reading and writing Primary Intermediate Secondary Bachelor or more 63 (15.7) 36 (9.0) 29 (7.3) 48 (12.0) 90 (22.5) 134 (33.5) Occupation* Employed Not employed Retired 103 (26.2) 265 (67.4) 25 (6.4) Smoking status Smokers Nonsmokers * The occupations of 7 participants are missing 54 (13.5%) 346 (86.5%) 39

7 AL-AZHAR ASSIUT MEDICAL JOURNAL Table (2) shows that feeling tired, trouble sleeping and nausea, flatulence or indigestion were the main complaints of more than one third of participants (42.3%, 37% and 34.8% respectively). In addition, pain in arms, legs, or joints, and constipation, loose bowel or diarrhea were bothering approximately onequarter of the participants (26.5% and 26% respectively). Only 4.3% of participants had problems during sexual intercourse and fainting spells. Table (2): Somatoform symptoms severity among the respondents Health problems during the past 4Not weeks bothered at all - Stomach pain - Back pain - Pain in arms, legs, or joints - Menstrual cramps* - Headaches - Chest pain - Dizziness - Fainting spells - Feeling heart pound - Shortness of breath - Pain or problems during intercourse - Constipation, loose bowels, or diarrhea - Nausea, gas, or indigestion - Feeling tired - Trouble sleeping *For women only 185 (46.3) 145 (36.3) 133 (33.3) 80 (33.5) 122 (30.5) 228 (57.0) 219 (54.7) 300 (75.0) 201 (50.3) 242 (60.4) 327 (81.8) 186 (46.5) 137 (34.2) 107 (26.8) 148 (37.0) Bothered a little 130 (32.5) 179 (44.7) 161 (40.3) 118 (49.4) 181 (45.3) 86 (21.5) 108 (27.0) 83 (20.8) 146 (36.5) 103 (25.8) 56 (14.0) 110 (27.5) 124 (31.0) 124 (31.0) 104 (26.0) Bothered a lot 85 (21.2) 76 (19.0) 106 (26.5) 41 (17.1) 97 (14.2) 86 (21.5) 73 (18.3) 17 (4.3) 53 (13.2) 55 (13.8) 17 (4.3) 104 (26.0) 139 (34.8) 169 (42.3) 148 (37.0) Table (3) shows that prevalence of somatoform disorders, based on PHQ- 15 (i.e., having 3 or more severe somatic symptoms) was 60.8%. In almost onethird of the participants (34%), somatic symptoms were intermediate in severity while in 30.5%, it was high. Somatic symptoms were minimal and low in severity among 19% and 16.5% of the participants respectively. 40

8 Table (3): Prevalence and severity of somatic symptoms among participants according to PHQ-15 Somatoform disorders No. % Presence of somatic symptoms: - No Yes: Low severity Minimal severity Intermediate severity High severity Table (4) shows that somatic symptoms severity was high among 44.8% of participants in the age group years and 37.7% of the participants in the age group years while it was high among 16.1% and none of those in the age group years and those over 60 years respectively. These differences were statistically significant (p). Somatic symptom severity was intermediate or high among 21.1% and 39.8% of male participants compared to 42.7% and 24.3% of females. It was minimal among 26.7% of males compared to 13.8% of females. These differences were statistically significant (p). Somatic symptom severity was high among 54.8% of non-saudi participants compared to 28.5% of Saudis. This difference was statistically significant (p). Regarding participants` marital status, somatic symptom severity was high among 42.5% of singles compared to 26.8% of married patients. This difference was statistically significant (p). Among participants having no children, the somatic symptom severity was high in 37.8% of them compared to 24.6% among those having more than 5 children (p<0.05). Somatic symptom severity was highest among secondary school educated patients (53.3%) and lowest among illiterate patients (0%). However, all illiterate patients showed medium somatic symptom severity. These differences were statistically significant (p). 41

9 AL-AZHAR ASSIUT MEDICAL JOURNAL Somatic symptom severity was high among 30.1% of employed patients compared to 24% among retired patients. This differences was statistically significant (p<0.05). Smoking history of the participants was not statistically associated with somatic symptom severity. Table (4): Somatic symptoms severity according to participants' characteristics Personal characteristics Age (in years) 30 (n=153) (n=125) (n=69) (n=31) >60 (n=22) Somatic symptom severity Minimal 30 (19.6) 17 (13.6) 23 (33.3) 6 (19.4) Low 50 (32.7) 11 (8.8) 5 (22.7) Intermediate 38 (24.8) 41 (32.8) 20 (29.0) 20 (64.5) 17 (77.3) High 35 (22.9) 56 (44.8) 26 (37.7) 5 (16.1) P value Gender Male (n=161) Female (n=239) 43 (26.7) 33 (13.8) 20 (12.4) 46 (19.2) 34 (21.1) 102 (42.7) 64 (39.8) 58 (24.3) Nationality Saudi (n=369) Non-Saudi (n=31) 68 (18.4) 8 (25.8) 60 (16.3) 6 (19.4) 136 (36.9) 105 (28.5) 17 (54.8) Marital status Single (n=87) Married (n=298) Divorced (n=15) 23 (26.4) 53 (17.8) 11 (12.6) 55 (18.5) 16 (18.4) 110 (36.9) 10 (66.7) 37 (42.5) 80 (26.8) 5 (33.3) Number of children None (n=111) 1-5 (n=163) >5 (n=126) 23 (20.7) 28 (17.2) 25 (19.8) 20 (18.0) 31 (19.0) 15 (11.9) 26 (23.4) 55 (33.7) 55 (43.7) 42 (37.8) 49 (30.1) 31 (24.6) Educational level Illiterate (n=63) Read and write (n=36) Primary (n=29) Intermediate (n=48) Secondary (n=90) Bachelor or above (n=134) 6 (16.7) ) 24 (26.7) 42 (31.3) 5 (13.9) 9 (31.0) 11 (22.9) 9 (10.0) 32 (23.9) 63 (100.0) 10 (27.8) 5 (17.2) 17 (35.4) 9 (10.0) 32 (23.9) 15 (41.7) 11 (37.9) 20 (41.7) 48 (53.3) 28 (20.9) Occupation* Employed (n=103) Not employed (n=265) Retired (25) 26 (25.2) 41 (15.5) 9 (36.0) 20 (19.4) 41 (15.5) 5 (20.0) 26 (25.2) 105 (39.6) 5 (20.0) 31 (30.1) 78 (29.4) 6 (24.0) Smoking No (n=346) Yes (n=54) 63 (18.2) 13 (24.1) 60 (17.3) 6 (11.1) * The occupations of 7 participants are missing 114 (32.9) 22 (40.7) 109 (31.5) 13 (24.1)

10 Table (5) shows that prevalence of somatoform disorders was highest among patients in the age group years (80.6%) and lowest among those aged 30 years or less (51.6%). The difference was statistically significant (p=0.006). Table (5): Prevalence of somatoform disorder according to sociodemographic profile of the participants Personal characteristics Age (in years) 30 (n=153) (n=125) (n=69) (n=31) >60 (n=22) Somatoform disorder Cases 79 (51.6) 86 (68.8) 41 (59.4) 25 (80.6) 12 (54.5) Non-cases 74 (48.4) 39 (31.2) 28 (40.6) 6 (19.4) 10 (45.5) P Value Gender Male (n=161) Female (n=239) 93 (57.8) 150 (62.8) 68 (42.2) 89 (37.2) Nationality Saudi (n=369) Non-Saudi (n=31) 226 (61.2) 17 (54.8) 143 (38.6) 14 (45.2) Marital status Single (n=87) Married (n=298) Divorced (n=15) 53 (60.9) 175 (58.7) 15 (100.0) 34 (39.1) 123 (41.3) Number of children None (n=111) 1-5 (n=163) >5 (n=126) 63 (56.8) 93 (57.1) 87 (69.0) 48 (43.2) 70 (42.9) 39 (31.0) Educational level Illiterate (n=63) Read and write (n=36) Primary (n=29) Intermediate (n=48) Secondary (n=90) Bachelor or above (n=134) 58 (92.1) 20 (55.6) 16 (55.2) 26 (54.2) 57 (63.3) 66 (49.3) 5 (7.9) 16 (44.4) 13 (44.8) 22 (45.8) 33 (36.7) 68 (50.7) Occupation* Employed (n=103) Not employed (n=265) Retired (25) 58 (56.3) 172 (64.9) 6 (24.0) 45 (43.7) 93 (35.1) 19 (76.0) Smoking No (n=346) Yes (n=54) 208 (60.1) 35 (64.8) * The occupations of 7 participants are missing 138 (39.9) 19 (35.2)

11 AL-AZHAR ASSIUT MEDICAL JOURNAL Regarding participants` marital status, the prevalence of somatoform disorder was highest among divorced patients (100%) compared to 60.9% and 58.7% among single and married participants respectively. The difference was statistically significant (p=0.006). Regarding participants` educational level, the prevalence of somatoform disorder was highest among illiterate patients (92.1%) compared to 49.3% among university or above educated participants. The difference was statistically significant (p). Regarding participants` occupation, the prevalence of somatoform disorder was highest among not employed patients (64.9%) compared to 24% among retired participants. The difference was statistically significant (p). Participants` gender, nationality, number of siblings and smoking history were not significantly associated with the prevalence of somatoform disorder. 44

12 Table 1: Socio-demographic characteristics of the study participants (n=400) Variables Age (in years) Gender Nationality Marital status Number of siblings Educational level Occupation* Categories >60 Male Female Saudi Non-Saudi Single Married Divorced >5 Illiterate Reading and writing Primary Intermediate Secondary Bachelor or more Employed Not employed Retired Number (%) 153 (38.2) 125 (31.2) 69 (17.3) 31 (7.8) 22 (5.5) 161 (40.3) 239 (59.7) 369 (92.2) 31 (7.8) 87 (21.8) 298 (74.4) 15 (3.8) 111 (27.8) 163 (40.8) 126 (31.4) 63 (15.7) 36 (9.0) 29 (7.3) 48 (12.0) 90 (22.5) 134 (33.5) 103 (26.2) 265 (67.4) 25 (6.4) Smoking status Smokers Nonsmokers * The occupations of 7 participants are missing 54 (13.5%) 346 (86.5%) 45

13 AL-AZHAR ASSIUT MEDICAL JOURNAL Table (2): Somatoform symptoms severity among the respondents Health problems during the past 4 weeks - Stomach pain - Back pain - Pain in arms, legs, or joints - Menstrual cramps* - Headaches - Chest pain - Dizziness - Fainting spells - Feeling heart pound - Shortness of breath - Pain or problems during intercourse - Constipation, loose bowels, or diarrhea - Nausea, gas, or indigestion - Feeling tired - Trouble sleeping *For women only Not bothered at all 185 (46.3) 145 (36.3) 133 (33.3) 80 (33.5) 122 (30.5) 228 (57.0) 219 (54.7) 300 (75.0) 201 (50.3) 242 (60.4) 327 (81.8) 186 (46.5) 137 (34.2) 107 (26.8) 148 (37.0) Bothered a little 130 (32.5) 179 (44.7) 161 (40.3) 118 (49.4) 181 (45.3) 86 (21.5) 108 (27.0) 83 (20.8) 146 (36.5) 103 (25.8) 56 (14.0) 110 (27.5) 124 (31.0) 124 (31.0) 104 (26.0) Bothered a lot 85 (21.2) 76 (19.0) 106 (26.5) 41 (17.1) 97 (14.2) 86 (21.5) 73 (18.3) 17 (4.3) 53 (13.2) 55 (13.8) 17 (4.3) 104 (26.0) 139 (34.8) 169 (42.3) 148 (37.0) Table (3): Prevalence and severity of somatic symptoms among participants according to PHQ-15 Somatoform disorders No. % Presence of somatic symptoms: - No Yes: Low severity Minimal severity Intermediate severity High severity

14 Table (4): Somatic symptoms severity according to participants' characteristics Personal characteristics Age (in years) 30 (n=153) (n=125) (n=69) (n=31) >60 (n=22) Gender Male (n=161) Female (n=239) Nationality Saudi (n=369) Non-Saudi (n=31) Marital status Single (n=87) Married (n=298) Divorced (n=15) Number of children None (n=111) 1-5 (n=163) >5 (n=126) Educational level Illiterate (n=63) Read and write (n=36) Primary (n=29) Intermediate (n=48) Secondary (n=90) Bachelor or above (n=134) Occupation* Employed (n=103) Not employed (n=265) Retired (25) Smoking No (n=346) Yes (n=54) Minimal 30 (19.6) 17 (13.6) 23 (33.3) 6 (19.4) 43 (26.7) 33 (13.8) 68 (18.4) 8 (25.8) 23 (26.4) 53 (17.8) 23 (20.7) 28 (17.2) 25 (19.8) 6 (16.7) ) 24 (26.7) 42 (31.3) 26 (25.2) 41 (15.5) 9 (36.0) 63 (18.2) 13 (24.1) Somatic symptom severity Low 50 (32.7) 11 (8.8) 5 (22.7) 20 (12.4) 46 (19.2) 60 (16.3) 6 (19.4) 11 (12.6) 55 (18.5) 20 (18.0) 31 (19.0) 15 (11.9) 5 (13.9) 9 (31.0) 11 (22.9) 9 (10.0) 32 (23.9) 20 (19.4) 41 (15.5) 5 (20.0) 60 (17.3) 6 (11.1) * The occupations of 7 participants are missing Intermediate 38 (24.8) 41 (32.8) 20 (29.0) 20 (64.5) 17 (77.3) 34 (21.1) 102 (42.7) 136 (36.9) 16 (18.4) 110 (36.9) 10 (66.7) 26 (23.4) 55 (33.7) 55 (43.7) 63 (100.0) 10 (27.8) 5 (17.2) 17 (35.4) 9 (10.0) 32 (23.9) 26 (25.2) 105 (39.6) 5 (20.0) 114 (32.9) 22 (40.7) High 35 (22.9) 56 (44.8) 26 (37.7) 5 (16.1) 64 (39.8) 58 (24.3) 105 (28.5) 17 (54.8) 37 (42.5) 80 (26.8) 5 (33.3) 42 (37.8) 49 (30.1) 31 (24.6) 15 (41.7) 11 (37.9) 20 (41.7) 48 (53.3) 28 (20.9) 31 (30.1) 78 (29.4) 6 (24.0) 109 (31.5) 13 (24.1) P value

15 AL-AZHAR ASSIUT MEDICAL JOURNAL Table (5): Prevalence of somatoform disorder according to sociodemographic profile of the participants Personal characteristics Age (in years) 30 (n=153) (n=125) (n=69) (n=31) >60 (n=22) Somatoform disorder Cases Non-cases 79 (51.6) 86 (68.8) 41 (59.4) 25 (80.6) 12 (54.5) 74 (48.4) 39 (31.2) 28 (40.6) 6 (19.4) 10 (45.5) P Value Gender Male (n=161) Female (n=239) 93 (57.8) 150 (62.8) 68 (42.2) 89 (37.2) Nationality Saudi (n=369) Non-Saudi (n=31) 226 (61.2) 17 (54.8) 143 (38.6) 14 (45.2) Marital status Single (n=87) Married (n=298) Divorced (n=15) 53 (60.9) 175 (58.7) 15 (100.0) 34 (39.1) 123 (41.3) Number of children None (n=111) 1-5 (n=163) >5 (n=126) 63 (56.8) 93 (57.1) 87 (69.0) 48 (43.2) 70 (42.9) 39 (31.0) Educational level Illiterate (n=63) Read and write (n=36) Primary (n=29) Intermediate (n=48) Secondary (n=90) Bachelor or above (n=134) 58 (92.1) 20 (55.6) 16 (55.2) 26 (54.2) 57 (63.3) 66 (49.3) 5 (7.9) 16 (44.4) 13 (44.8) 22 (45.8) 33 (36.7) 68 (50.7) Occupation* Employed (n=103) Not employed (n=265) Retired (25) 58 (56.3) 172 (64.9) 6 (24.0) 45 (43.7) 93 (35.1) 19 (76.0) Smoking No (n=346) Yes (n=54) 208 (60.1) 35 (64.8) * The occupations of 7 participants are missing 138 (39.9) 19 (35.2)

16 DISCUSSION In this study, we used the PHQ-15 tool to screen for somatoform disorders among PHCCs attendee in Abha city. The estimated prevalence of somatoform disorders among that population was 60.8% This finding is higher than what have been reported in a very large international study conducted by the World Health Organization that found somatisation in 20% of primary care attenders. 26 Other studies have also reported similar figures. 8, 27 In Saudi Arabia. A prevalence of 19.3% has been reported by Becker. 18 In primary care settings in the Netherlands, out of 904 patients, 602 (66%) had fewer than 3 severe somatic symptoms and the other 302 (33%) had 3 or more severe somatic symptoms. 5 It is to be noted that in the Netherlands' study, they excluded the patients with known depression at baseline, a procedure that was not done in the present study. This may partly explain the relatively high prevalence of somatoform disorders in our study. Moreover, for the diagnosis of a somatoform disorder, the complaints are necessarily medically unexplained. Nevertheless, we did not conduct in this study an independent medical assessment and could not ascertain whether physical symptoms were medically unexplained. However, high somatic symptom counts do correlate with somatoform symptoms. 28 This high figure reported in our study highlights the need for screening for these problems and other mental problems in primary care. The study of Al Faris and Al Hamid 29 in Saudi Arabia estimated that the prevalence of mental disorders in primary care patients was 30 46%. They also reported that more than 90% of cases of mental disorders, later identified by a general health-screening instrument, were initially missed by primary care physicians. 49

17 AL-AZHAR ASSIUT MEDICAL JOURNAL In a population-based survey of physician practices in Saudi PHCCs, there were no psychiatric diagnoses made despite the large proportion of patients with significant mental disorders. 30 This low rate of recognition of mental disorders is not specific to Saudi Arabia. Spitzer and Williams 31 reported a 77% rate of non-recognition among physicians treating Obstetrics & Gynecology patients in the United States using the PHQ as the standard for comparison. Teaching of psychiatry at Saudi medical schools is completely hospitalbased, concentrating exclusively on patients with severe mental disorders. Consequently, communication with patients and psychiatric diagnostic skills for less severely affected patients is not addressed in medical training. Furthermore, the biomedical approach that is favored in Arab medical training focuses on physical-organic causes of illness and minimizes the important role of emotional distress in the health of patients. 30 The diagnosis of a somatoform disorder requires clinical judgment, which a questionnaire cannot provide. One might expect that patients with known physical disorders have many somatic symptoms and therefore high scores on the PHQ-15. In earlier research, however, only a weak correlation was found between the number of physical disorders and the number of somatic symptoms. 32 Total symptom counts, including unexplained and explained, have been proved to be prognostic for somatoform disorders Although there is no clear evidence to pinpoint the cause of somatization disorders, it is widely thought to be the result of a combination of stress and genetic disorders. Patients are often found with a long history of illnesses. Stress can worsen the symptoms and can lead to a negative impact on work and social relationships. 2 People with somatization disorders can also suffer from psychological problems such as personality disorders and too much dependence on others. 2 In the present work, high prevalence of somatization was reported 50

18 among patients in the age group 51-60, divorced, low educated and nonemployed. Up to our knowledge, this is the first study of somatisation in Aseer primary health care practice. The results indicating that somatisation is more prevalent than other better recognized psychiatric diagnoses. Its nature makes it difficult to recognize and to treat. As a consequence, it places an exaggerated burden on both generalist and specialist health services. Some work has been done to develop models of care that can cope with this complexity, the aim of which is, as with other chronic diseases, to cure sometimes, to relieve often, to comfort always. 35 The reduction of intrusive physical symptoms, anxiety and depression, and an increase in daily function is a realistic hope for patients who somatize. 45 For females in our Saudi conservative and restrictive culture, somatic complaints may be an accepted and traditional way of communicating hidden emotional problems resulting from the dependency and passivity that women must practice. Since females are not permitted to drive cars or to move freely in the community, there is the further problem of access to mental health care. and the primary care physician may serve as the only contact with the health care system for a woman brought to the doctor by her husband. However, in the current study there was no significant difference between males and females regarding prevalence of somatoform disorders. The expectations of the Saudi society and the medical system may be that emotional distress of patients be expressed in physical symptoms, but when practitioners fail to detect somatization, they are indirectly supporting the embarrassment that patients may feel rather than encouraging expression of emotional distress. In this milieu, the ability of psychiatric screening instruments such as the PHQ to detect psychiatric disorders is crucial as a simple and cost effective means of improving the care of patients

19 AL-AZHAR ASSIUT MEDICAL JOURNAL It is difficult to prevent somatization disorders, but with timely counseling or other psychological interventions and the right treatment, the intensity of the symptoms can be reduced to a large extent. It is also very important for the patient to maintain a good, consistent relationship with her/his doctor to enhance treatment success. In conclusion, the prevalence of somatoform disorders among primary health care patients in Abha City is very high, especially among patients who are within the age group years, divorced, low educated and nonemployed. As a consequence, it places an exaggerated burden on both generalist and specialist health services. So, psychiatric training should be supported in the continuing education of primary care physicians. Patients should be encouraged to report psychological complaints to their family physicians. There is need to change the training and practice of health professionals that strengthen the role of the family doctor in his therapeutic role, if we are to move somatoform disorders to the mainstream of primary car practice. Until improved physician detection of mental disorders and access to psychiatric care in primary care populations takes place, the use of a simple and effective screening instrument will reduce unnecessary clinical investigations and improve clinical outcomes. 52

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