Novel Body Oriented Primary Care Treatment for MUS/SSD

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Winfred Greene
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1 Novel Body Oriented Primary Care Treatment for MUS/SSD FRANK RÖHRICHT ASSOCIATE MEDICAL DIRECTOR HONORARY PROFESSOR OF PSYCHIATRY

2 What is it about? Patients with Medically Unexplained Symptoms complain of physical symptoms that cannot be explained by organic pathology, causing distress or impair the functioning of the patient. do often not receive effective / adequate care. Ø New and innovative care models are required!

3 MUS is costly on three counts: a burden for the sufferers [patients], costly for society and difficult to treat [doctors]. (Fink & Rosendal 2008) The NHS in England is estimated to spend at least 3 billion each year attempting to diagnose and treat MUS (Bermingham et al 2010) compared with enhanced or structured care, psychological therapies generally not more effective for most of the outcomes ( Much of this expenditure currently delivers limited value to patients; at worst, it can be counterproductive or even harmful. (The Kings Fund 2016)

4 What works not so well?

5 WHY? What are the challenges? Mismatch Syndrome - Patient vs. Professional Beliefs / explanatory model: Ø It s all in the body the mind Language / terminology: Ø Unmet need Health anxiety Emphasis in therapy: Ø I am in pain We talk about pain Desired location: Ø Want to be In Out (of services)

6 The GP perspective

7 Mind and or over matter? Parity of esteem No mental health wo physical health Comorbidity Epigenetics Embodied cognition Ø Psychosomatic Medicine Ø Person-Centered Care Ø Holism

8 Does rejection hurt? An fmri Study of Social Exclusion Eisenberger et al., Science 2003 social pain is analogous in its neurocognitive function to physical pain Activations in anterior cingulate cortex / ACC (correlated with distress) It hurts to be rejected, to loose someone alerting us when we have sustained injury to our social connections allowing restorative measures to be taken

9 SDD/MUS and Embodiment? predisposing biological vulnerability, low pain threshold hyperarousal, amplifying somatic style of coping focused awareness / attention towards distressing bodily sensations (hypervigilance) Alexithymia: difficulties expressing emotions Nonverbal (somatic) communication of distress: body language, postures, gestures, movements

10 BOPT-MUS-PRINCIPLES The therapist will not aim to replace the patient s existing explanatory model The therapist will not address directly any psychological processes involved in bodily experiences, unless the patient specifically brings them up first. Body remains the main focus of the therapeutic work; diversifies negative (bodily) self images, aiming for a more inclusive understanding of symptoms as contextual The intervention targets difficulties in acknowledging and expressing emotions in the context of and whilst relating to somatic symptoms.

11 Somatoform disorder clinic service evaluation (Röhricht & Elanjithara 2014) Assessing impact of body-oriented psychological therapy (BOPT) in a small cohort of 41 patients with somatoform disorder 12 (29.3%) participated; 3 months after treatment symptoms (PHQ-15 total score) and service utilisation (A&E attendance and referrals to specialist services) significantly reduced

12 Evaluation Feasibility pilot BPT somatoform disorder LAHMANN, C., KUHN, C. RÖHRICHT, F. (IN PREPARATION)

13 Body image Vitality (DKB-35) Self acceptance 3.5 (DKB-35) Pre Post 2.5 Pre Post BPT-SD Control BPT-SD Control

14 Symptom levels Somatic Symptoms (SOMS) Depressive Symptoms (PHQ) Pre Post 8 Prä Post BPT Therapy Control group BPT therapy Control group

15 Putting the pieces of the puzzle together Addressing mismatch / The Innovation: Röhricht et al. 2017, British Journal of General Practice Open

16 How? Holistic, Body based, patient centered Identification: Specific somatic symptom algorithm Engagement strategy is empathic: Ø interest in and time for the physical complaints (how, when, where, under which circumstances ) Assessment is focused: Ø Range of in-depth somatic symptom questionnaires, health related quality of life measures Interventions are non-verbal / embodied: Ø explicitly focusing upon / engaging with bodily symptoms (MBSR / Body Oriented Psychological Interventions as SBLG )

18 Data highlights baseline Mean age 50.3 (15-92); 72 (77%) female White British/other 25.8%, Afro-Caribbean 6.5%, Black African 10.8%, Asian 53.7%. service utilisation last 6 months: number GP consultations 15.2 (0-60); contacts with specialists 2.8 (0-12) 19.2 weekly hours support from friends/ family (0-84); 2/3 receiving benefits number of non-specific drugs prescribed 4.7 (0-13; 0-7 different painkillers) SOMS-7: compared with literature very high somatic symptom levels across multiple organs

19 Outcomes The Strength of the Model: Addressing costs re - Patients - Society - Professionals

20 Cost savings 1: Patient benefits Easily embedded in PC, accessible, available 93 0ut of 145 referred patient engaged, 61 participated in group intervention Reduction in symptom levels (regardless number of session attended in intervention groups) 75% of patients BME background, high percentage had very limited English language skills

Changes in Somatic symptom levels and QOL 50 40 30 20 T=3.7 P=.001 14.9 34.4 T=2.1 P=.045 T=2.2 P=.

21 Changes in Somatic symptom levels and QOL T=3.7 P= T=2.1 P=.045 T=2.2 P= n.s. Baseline Follow-up PHQ-15 Total SF-36, QoL-PH SF-36, QoL-MH EQ5 Health

Some quotes from patients after taking part in one of the two intervention groups I am now helping my self rather than depending completely on family It made me realise I was in denial about

22 Some quotes from patients after taking part in one of the two intervention groups I am now helping my self rather than depending completely on family It made me realise I was in denial about the wider picture of my life I learned to be kind to myself.it has really turned my life around and empowered me... I started getting my tension under control and things didn't get to me no more

Cost savings 2: Service/society benefits 3.5 2.5 1.5 0.5-0.5 T=2.3 P=.002 T=2.8 P=.007 T=4.3 P=.000 n.s. Baseline Follow-up Contacts Physiotherapy Prescribed A&E visits specialists sessions medications Baseline 3.

23 Cost savings 2: Service/society benefits T=2.3 P=.002 T=2.8 P=.007 T=4.3 P=.000 n.s. Baseline Follow-up Contacts Physiotherapy Prescribed A&E visits specialists sessions medications Baseline Follow-up

2b. Changes GP contacts & support 18 16 14 14.5 16.6 15.1 12 10 8 6 9.

24 2b. Changes GP contacts & support Baseline Follow-up 4 2 T=4.9 P=.000 n.s. 0 Number contacts with GP Number hours Family support

2c. Changes in associated cost Number contacts with GP Number outpatient appointments Number A&E Atte n- dances Number Number Number Total Counselling Physiotherapy prescribed sessions medication

25 2c. Changes in associated cost Number contacts with GP Number outpatient appointments Number A&E Atte n- dances Number Number Number Total Counselling Physiotherapy prescribed sessions medication sessions Pre 14.5/ / / / / /2.5 Post 9.8/ / / / / /3.9 Unit cost Total Cost pre Total Cost post 46, = per patient = 772 per patient

26 Cost savings 3: Professionals benefits

27 Novel primary care treatment package for patients with medically unexplained symptoms: a cohort intervention study Frank Röhricht, et al BJGP Open 4 October 2017 DOI:

28 Take Home message? Nature and degree of somatic complaints in MUS should be engaged with on a somatic level across all steps of the care pathway without challenging patients explanatory beliefs. Resource-, body oriented approaches, empathic support and symptom-immanent explanations seem to be better accepted by MUS patients than talking therapies and more likely to improve outcomes. Cost per patient treated = 246 versus annual savings per patient = ; 1 invested = 2-3 saved

29 Our long term plans: Spreading grant in 2016/7: 70 therapists trained Richmond CCG early adopter (launch May 2017) Invest to save initiatives : negotiations started MUS training days for 350 HCPs in 2017 OUR AMBITION: MUS-SHINE MODEL EMBEDDED WITH ALL IAPT SERVICES IN THE NHS

30 The MUS-SHINE team Working together

This is a pre-publication version of the following article: Highfield, J.A. Lowe, K., Lewis, E.,

This is a pre-publication version of the following article: Highfield, J.A. Lowe, K., Lewis, E., Warren, R., Martin, K., Walket, E. (2016). Clinical psychologists training and supervising IAPT therapists