Esther12
Senior Member
- Messages
- 13,774
Just posting this as it's now off-line, and it might be nice to have a searchable copy on the forum.
It includes bits from Aylward, Sharpe and Robb (Unum's guy) which may be of interest.
(In two parts)
http://web.archive.org/web/20060830...ome/AccessiblePDF/CMOReport2002.htm?UPCC=True
Trends in Health and Disability 2002
Contents
Peter joined UnumProvident in July 2000 having spent 16 years with the Department of Social Security. He qualified in medicine in 1977 and became a member of the Royal College of Physicians, working in general internal medicine before joining the DSS. Within the DSS he has held a number of claims assessment, managerial and policy roles. He is a recognised expert in the developing discipline of Disability Assessment Medicine. He has been instrumental in the setting up of the diploma of Disability Assessment Medicine of the Faculty of Occupational Medicine of the Royal College of Physicians. He continues to work as an examiner for that diploma.
Chief Medical Officer’s Report 2002
Peter Dewis BSc MB ChB DDAM MRC
The need for a thorough understanding of medical issues is essential if UnumProvident is to maintain its position as the UK’s leading provider of income protection insurance. Whilst we frequently emphasise the fact that a medical diagnosis does not equate to a certain level of disability, it is nevertheless true that a knowledge of the range of effects which can arise from a particular medical condition is an essential starting point for us in the way we deal with individuals, whether as applicants for insurance cover in the Underwriting arena, or as claimants for income protection benefits.
Medical research is advancing rapidly on a number of fronts and thus the expectations we may form on how a person might be affected by a particular disease and condition today, in a number of areas might be considerably different to what they were a few years ago. This however has to be set against the fact that the media will frequently highlight particular areas of medical research and raise public expectations of cures and advances which are way in excess of what can be permitted from a detailed knowledge of what the research actually shows.
It is against this background that we need to be in a position to understand where medical advances are taking us and to be able to form a balanced view on what the implications are for us as an insurer over the years to come. To this end, I have commissioned a number of papers from leaders within the medical profession whose disciplines are particularly relevant to those people we see most frequently making claims for benefit, or whose claims most frequently pose us difficulties in their management.
Each contributor was asked to highlight the most recent developments in their particular discipline and to speculate on how things are likely to develop over the next few years. Some of the contributors have worked closely with us in either underwriting, claims or appeals over the last year or so and have been able to concentrate on issues, which are likely to be of greatest importance to us.
Mental health issues have been of particular importance to us recently and thus Maurice Lipsedge who until very recently was consultant psychiatrist at Guy’s Hospital, has reviewed the range of developments within psychiatry in general. Complementing this, is a paper from Michael Sharpe, consultant in liaison psychiatry from Edinburgh who has reviewed the developments, not only in chronic fatigue syndrome, but also the range of disorders where the symptoms experienced by individual patients appear to be out of proportion with the physical findings or objective evidence of disease in its traditional sense.Our other large area of work involves musculo-skeletal disorders. Tony Clarke who is Medical Director of the National Rheumatic Diseases Hospital in Bath, has chosen to concentrate on the issue of chronic back pain, upper limb disorders and inappropriate pain. His paper therefore has many points of similarity with those from the psychiatric field.
Charles Pumphrey, Consultant Cardiologist from St George’s Hospital in London, has highlighted many of the exciting recent developments within cardiology. Many of these have also been picked up by Geoffrey Robb who has been associated with UnumProvident for a number of years and fully understands how medical issues and insurance interact. He has also described a number of other relevant developments from the field of general medicine.
Finally, Mansel Aylward who is Chief Medical Advisor to the Department of Work and Pensions has set out the current trends in government strategy relating to both health and social security. Clearly any organisation working in this area needs to set its activities in a context of government policy both in the short and long term.
Hopefully, each of these papers speaks for itself. I would however like to draw out a few specific points both in terms highlighting the technical advances, but also describing those areas which are likely to present us with the greatest challenges as we move forward. My intention would be for this report to be repeated on an annual basis and so become an authoritative and informative document on the current state of medical thinking on those issues which are of greatest importance to us.
Medical Genetics
Before moving on to discuss the detail of the individual papers, I need to make some reference to the field of medical genetics. I have not commissioned a paper on this particular subject which may appear to be an omission in light of the publicity which has surrounded the subject over the past year and which has culminated in the ABI announcement of the moratorium on the use of genetics testing for insurance purposes.
The field of medical genetics is one in which I believe the media is portraying a future which is currently way beyond the current ability of medical technology to meet the expectations being put forward. Clearly some fundamental advances have been made in medical research in this area, but it will still be some time before the benefits will be seen for the majority of people.
The insurance industry developments in this field have centred around the ability of DNA testing to detect those who are at risk of developing inherited diseases. For most diseases seen commonly, genetics usually plays only a part in determining who will develop the disease. Genetics testing currently is only of real relevance to those suffering from what are known as single gene disorders. These are usually relatively uncommon disorders whose incidence can be predicted accurately from their pattern of inheritance. Many also have their manifestations in childhood so that by the time these people are making applications for insurance, we already know whether or not they are going to develop the disease. All of this means that even before the recently announced moratorium, the only genetic test which had been approved for use by the government’s Genetics and Insurance Advisory Committee, was that for Huntington’s disease for life insurance purposes.
From a practical day to day point of view, the issue of genetics testing does not pose the sorts of significant problems as have been highlighted in the papers commissioned. We are more often in a position to use the results of a genetics test favourably to an applicant that to exclude them from cover and will continue to do this. This does not mean that I am dismissing this issue, since it will undoubtedly assume greater practical importance as medical research continues to develop. We need to play our full part in helping the industry establish its position during the course of the five year moratorium. Almost certainly there will be scope for an expert paper specifically on this subject in subsequent editions of the CMO report.
Technical Advances
Both Dr Robb and Dr Pumphrey have referred to the changes which have taken place in the diagnosis of heart attack (myocardial infarction) through the discovery of a new very sensitive biochemical marker of heart muscle damage known as Tropinin T. This has changed the criteria for the diagnosis of heart attacks in the clinical setting, to the extent that a diagnosis of a heart attack may well be made now in people whose episodes of chest pain might have remained undiagnosed. Moreover, this has important implications since the life expectancy of such people may well not be impaired in the way that is traditionally the case for people who have had heart attacks and indeed for some might in fact be enhanced. Dr Robb, however urges caution in the wholesale adoption of these new diagnostic criteria within the critical illness arena and this has been reflected in the definitions for heart attack (both major and minor) adopted for the new individual critical illness product. This is an area which will need to be kept under active review in discussion with our re-insurers. The overall prognosis of people with coronary artery disease has also been referred to, especially in relation to the more widespread use of the lipid lowering drugs known as the statins. Dr Robb has also identified the fact that with greater attention to detail in control of blood sugar, the prognosis for people with diabetes mellitus can be much better than has previously been the case. I will, in discussion with the Chief Medical Underwriter, be looking critically at our underwriting policies in these particular areas over the coming year.
Dr Pumphrey has identified the improvements which have taken place in the surgical treatment of established coronary artery disease, which should lead us to expect an increasing trend in people being able to return to and remain in work. This is important information for benefits claims managers in forming their expectations on individual cases. The increasing use of Percutaneous Coronary Intervention (coronary angioplasty) should also cause them to expect that this will be used more and more routinely so that uncontrolled ischaemic chest pain will become less and less common.
Within the musculo-skeletal field, the advances Dr Clarke describes relate more to those of understanding of the nature of chronic painful conditions rather than to any particular technical breakthrough. Most such conditions do not have a serious underlying pathological basis. Stemming from this is the increasing realisation of the need for people to remain active and for clinicians to intervene early in the process to ensure that optimum recovery and rehabilitation is achieved. Much of what Dr Clarke has described has been mirrored by Dr Sharpe in his description of the apparent rise in the prevalence of conditions for which no underlying disease process can be identified.
Dr Lipsedge has referred to a number of developments in the way in which imaging techniques are starting to delineate the neurological basis for a number of psychiatric disorders. However, many of these currently are at a purely academic level and he points out that the treatment of depression has not improved significantly since the first discovery of antidepressant drugs.
Ongoing Challenges
The fact that there have been few advances in the treatment of depression represents a challenge. This is particularly so since all the authors have identified this as being of significance in their own particular field. Dr Lipsedge for example, has highlighted the importance of symptoms which fall short of producing a definite depressive illness, but which may well have an influence on overall disability. Its impact in the field of cardiology and general medicine has been particularly identified by Dr Robb. This presents us with a particular challenge in being able to identify those claimants where depression may be having a significant impact at an early stage of their incapacity and where possible being able to influence their treatment since it is clear that these issues are not always being adequately addressed within the constraints of primary care.
Dr Lipsedge, Dr Sharpe and Dr Clarke have identified the importance of cognitive behaviour therapy of influencing the outcome in depression, chronic fatigue syndrome and chronic pain. This again represents a challenge in ensuring that people are directed towards this approach. This can be particularly difficult in relation to the availability of such services under the NHS. All of this needs to be considered in relation to the other common theme, which has been emphasised particularly by Dr Sharpe and which relates to the need to intervene early in the course of a disability to achieve a positive outcome.
Message for UnumProvident
Although contributions were sought from specialists across a wide variety of disciplines, when looking at those areas which are likely to pose particular challenges, the importance of psychological factors in determining long term disability emerges. In addition, in such people there will frequently be a predominance of subjective complaints with little in the way objective findings to support these. All the findings presented by Dr Aylward on the trends in social security statistics show that these are also major issues for the public sector. Dr Aylward’s data also supports strongly the view that early intervention appears to be the only way of influencing this situation. He has also identified a number of government initiatives, such as the New Deal for Disabled People and NHS Plus, which signify the government’s intention of addressing these issues. Clearly however, there is a tremendous amount of work that needs to be done to make these a reality.
Within UnumProvident, I believe that we need specifically to continue to develop in two particular areas and that the information presented by the experts contributing to this report, support this view.
Maurice Lipsedge
Maurice Lipsedge is Emeritus Consultant Psychiatrist to the South London and Maudslay NHS Trust. He is also Honary Senior Lecturer in the Department of Psychological Medicine within Guy’s, King’s and St Thomas’s school of medicine. His special interests include the fitness for work in patients with mental health problems. He has made a significant contribution as an author, to a number of standard reference works in the fields of occupational and insurance medicine, including “Fitness for Work”, “Life and Disability Underwriting” and “Medical Selection of Life Risks”. He is a former member of the Home Office Parole Board and of the Nolan Committee: Review on Child Protection in the Catholic Church in England and Wales.
Recent Developments in Psychiatry
Maurice Lipsedge M.Phil FRCP
Introduction
In this brief review of recent developments in psychiatry, I have drawn on both the American and the British psychiatric journals published over the past couple of years. The basis of selection has been developments in research which have potential implications for long term or recurrent occupational disability arising from psychiatric disorders.
Given the current emphasis on neurological research, the bulk of the literature deals with those disorders, which have a basis in cerebral dysfunction, especially schizophrenia, the affective disorders and dementia. Although the clinical onset of Alzheimer’s disease can be prior to the age of sixty it is, of course, typically a disorder of old age. The first phase of Alzheimer’s disease, which can last for two to three years, is characterised by failing memory, muddled inefficiency over everyday tasks and spatial disorientation. Moreover, because disturbance of mood can be prominent and since a degree of depressive pseudodementia is not uncommon, presenile dementia has to be considered as a differential diagnosis in the occupational setting in all people who are referred for a psychiatric assessment after the onset of middle age.
For this reason consideration of recent developments in the cause and potential treatment of Alzheimer’s disease merit inclusion in a review such as this. In view of the increasing prevalence of schizophrenia and the established high level of affective disorders in the community, these “non-organic” disorders require no such justification. The 1990s were designated the “Decade of the Brain” by Time Magazine and significant advances were made during that period in the basic sciences of neurobiology and genetics. So far, however, these developments have had virtually no impact on psychiatric clinical activity. Thus, in the field of depressive illnesses, which have a wide prevalence, the efficacy and speed to onset of response to antidepressants has changed little since the serendipitous discovery of the MAOI’s (monoamise oxidase inhibitors) over forty years ago.
Neuroimaging
The neurochemical pathology of the major psychiatric disorders has been elucidated recently by the use of functional brain imaging techniques namely Positron Emission Tomography (PET), Magnetic Resonance Spectroscopy (MRS), Functional Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT).
Early Detection of Alzheimer’s Disease
Recent studies on the functional neuroanatomy of depression using SPECT and PET imaging techniques have compared the effects of pharmacotherapy with a form of psychotherapy. Surprisingly, both the administration of antidepressant drugs and the psychosocial intervention were associated with increased blood flow to the left temporal or right basal ganglia regions. Furthermore, both the interpersonal psychotherapy and the antidepressant treatment normalised metabolism in the prefrontal cortex and left anterior cingular gyrus.
Although these results have emerged only from preliminary studies and some methodological reservations have been expressed, the tangible cerebral effects apparently brought about by psychotherapy are an interesting sequel to the earlier work on the changes induced in the brain by the cognitive-behaviour therapy of obsessional compulsive disorder.
Working forwards conceptually from psychological trauma to neurobiological changes, recent MRI studies have demonstrated hippocampal atrophy in post traumatic stress disorder. In functional terms, this reduction in hippocampal volume is associated with explicit memory deficits. The same picture has already been demonstrated in depression. It is still not clearly established whether the hippocampal atrophy arises from the clinical disorder or precedes it and whether a disturbance of glucocorticoids is the underlying cause.
Recent studies of longitudinal changes in cognitive performance during the preclinical phase of Alzheimer’s disease show that in the near future it may be possible to identify people at risk of developing this type of dementia and to administer prophylactic treatments in order to delay or stop the progression of this disease. The possibility of identifying people at risk of developing Alzheimer’s disease carries implications for potential therapeutic interventions. A number of recent studies have attempted to identify the cognitive markers of preclinical Alzheimer’s disease and it has been found that people who later developed Alzheimer’s disease experienced greater changes across multiple cognitive domains compared with those who did not develop dementia. The most prominent changes were an accelerated decline in episodic memory and in executive functioning.
By carrying out multiple measures longitudinally, it is possible to identify changes in cognitive performance when people are still regarded as free of dementia and recent research shows that cross sectional deficits in cognitive performance can appear years before the actual diagnosis of
Alzheimer’s disease. It is likely that individuals at risk of Alzheimer’s disease will be more precisely identified before the clinical onset of the disorder by combining longitudinal studies of cognitive performance with genetic and neuroimaging techniques, since more individuals who go on to develop Alzheimer’s disease show prediagnostic changes in neuroanatomy. These changes have been demonstrated both in neuropathological studies as well as magnetic resonance imaging which has demonstrated changes in the hippocampus and entorhinal cortex.
Prevention of Relapse in Residual Depression by Cognitive – Therapy
It is known that marked morbidity and disability occurs as a result of the significant rates of relapse and recurrence in major depression and that depression is a risk factor for the onset of both physical and psychosocial
disability while the effective treatment of depression improves functional outcomes. The rate of relapse and recurrence can be reduced by patients continuing to take antidepressants. It is recognised that many patients still achieve only a partial remission and have persistent residual symptoms. Residual depression can occur in about a third of patients suffering from major depression who have been treated with appropriate doses of antidepressants for an adequate trial period. A recent meta-analysis of the drug treatment of depression found response rates to be no better than 50 per cent for active treatment by comparison to 32 per cent for placebo (Agency for
Healthcare Policy Research, 1999). Furthermore, patients with residual depression are particularly prone to relapse. It has now been shown that cognitive therapy is highly effective in reducing relapse rates in cases of severe residual depressive symptoms, despite antidepressant treatment. Cognitive therapy is a cost effective form of treatment for depression requiring less than 20 weekly sessions. In this study, cognitive therapy was added to antidepressants and this psychological intervention was shown to prevent relapse into a further episode of major depression.
Long-Term Disability Associated with Depression
A prospective study of psychosocial disability in relation to the severity of depressive symptoms was conducted over a ten year period. The results show a progressive gradient of psychosocial impairment, which parallels the severity of depressive symptoms. It was found that there is a significant stepwise increment in psychosocial disability as one progresses from subthreshold depressive symptoms through dysthymia to unipolar major depressive disorder. This common-sense relationship between the severity of depression and occupational impairment (ie, the synchrony of change in depression and disability) shows that effective treatment of depression will improve functional outcome.
This synchrony may be predictable, but an unexpected recent finding was the link between depression and the course of coronary artery disease. Recent studies have shown that there is an increased risk of ischaemic heart disease among depressed patients. Furthermore, patients with depression following a myocardial infarction are over three times more likely to die than non-depressed patients. It has been suggested that association between depression and coronary artery disease might be based on changes in the autonomic nervous system or in a disturbance of platelet function. It has also been shown that major depression is a significant risk factor for the development of stroke.
Assessing and Measuring Psychiatric Disability
There is an important and challenging contribution to the literature on the assessment of disability in a recent communication in the American Journal of Psychiatry (Janca, 2001). Janca has critically evaluated the disability axis of the Multi-Axial Presentation of ICD-10 for Use in Adult Psychiatry which is an instrument comparable in purpose to the
DSM-IV Axis V scales, ie The Global Assessment of Functioning Scale, The Global Assessment of Relationing Scale and The Social and Occupational Assessment Scale.
In contrast to the impressively high levels of inter-rater reliability found with the DSM-IV Axis V scales, Janca found a very low inter-rater reliability when the World Health Organisation’s Short Disability Assessment Schedule was subjected to trials by 274 clinicians from 21 different countries.
The question is therefore asked as to whether DSM-IV Axis V scales have a “true” inter-rater reliability or whether the claimed satisfactory psychometric properties are merely a reflection of “extensive instrument administration training and high motivation of the clinicians”? (I must say that I have some sympathy for Janca’s sceptical view since the operational guidelines supplied by DSM-IV for the determination of disability are difficult to apply with any degree of confidence, eg on the SOFAS one would allocate a score of 41-50 – “serious impairment in ....occupational....functioning” on the basis of the example “unable to keep a job”, when the alleged inability to keep a job might arise from a “genuine” disability but completely fails to take into account motivational and “illness behaviour” factors).
In assessing disability we tend to set the boundary at ICD-10 or preferably DSM-IV defined conditions, relying on clinical significance criteria. Dysthymic disorder which was first introduced as a separate diagnostic category in DSM-IV-R, is found in about 5 per cent of the population. This chronic low grade depressive condition is generally punctuated by episodes of major depression and the condition tends to become more severe with increasing age. The level of functional impairment in dysthymic disorder equals or exceeds that in major depressive disorder.
A prospective 5 year follow-up study has shown that the course and outcome of dysthymic disorder are rendered unfavourable by a family history of psychiatric disorder, adversity in childhood, chronic stress and an avoidant, dependent or obsessive-compulsive personality disorder. Interestingly a family history of bipolar disorder is associated with a higher probability of recovery.
Although dysthymic disorder has achieved the status of a DSM-IV recognised category, there has been a proliferation of substhreshold disorders over the past few years. Synonyms include “minor depression”, “subsyndromal symptomatic depression” etc. some of these subthreshold conditions lack validity as formal psychiatric disorders and they are often difficult to distinguish from common-or-garden unhappiness. It has been suggested that these subthreshold conditions should be more precisely defined and studied on a longitudinal basis, but it is also recognised that providing formal identifying criteria and quantifying these symptoms might exacerbate the current tendency to pathologise conditions that may be within the normal spectrum. Grief would be a case in point.
Antidepressants of all types cause an increase in the release of presynaptic monoamines, which activate a range of post-synaptic receptors. These are coupled to second messenger signal transduction factors that control gene expression. This knowledge has been derived from recent research with animal models, providing new perspectives on the pathophysiology of depressive disorder, the biology of stress and the mode of action of antidepressant drugs.
In summary, antidepressants of different classes all appear to increase the expression of neuroprotective proteins which are important for the function and growth of neurones.
Cost-Effective Psychological Treatment of Common Psychiatric Disorders
The past few years has seen the consolidation of the role of psychological treatment methods in both depression and the anxiety-based disorders. Cognitive-behavioural therapy now has an established track record in terms of cost effectiveness and its methods can be applied either in conjunction with medication or without concurrent pharmacological treatment. Post-traumatic stress disorder and chronic fatigue syndromes provide examples of common and often disabling conditions in which the optimal treatment might be cognitive-behaviour therapy administered by a nurse therapist or clinical psychologist backed up by antidepressant medication prescribed by a general practitioner or psychiatrist. Cognitive therapy has also, perhaps surprisingly, become recognised as an effective way of helping patients with refractory schizophrenia and chronic paranoid psychoses to learn effective strategies for challenging delusional ideas and for dealing with distressing hallucinations.
Schizophrenia
The recent application of quantitive methods in schizophrenia research has been a first step in identifying an anatomical substrate for schizophrenia. Stereological analysis of the prefrontal cortex has shown
the presence of increased density of neurones in patients with schizophrenia. This is now known to be due to a reduction in the elements of neural connectivity rather than the actual destruction of nerve cells. This deficit appears to occur in a specific area of the prefrontal cortex in patients with schizophrenia suggesting that the large pyramidal cells in that particular area (layer 3c) receive fewer synapses from modulatory dopaminergic and exitatory afferent inputs.
Since the pathology in the prefrontal cortex of patients with schizophrenia appears to be confined to neuronal processes and synaptic connections
rather than actual loss of neurones, it is hoped that highly targeted pharmacological treatments can be developed which will have a selective action on specific neuronal cells and connections.
Top
Michael Sharpe
Michael Sharpe is Reader in Psychological Medicine at the University of Edinburgh and is an Honorary Consultant Psychiatrist to the Edinburgh Hospitals. His interests have focused on the interface between psychiatry and medicine. He is particularly interested in the role of depression in physical illness, in poorly understood syndromes, such as chronic pain and chronic fatigue and in how biological and psychological factors interact to cause symptoms and disability. He is currently chair of the Scottish Liaison Psychiatry Group, Director of Psychological Medicine Research and Teaching at the University of Edinburgh and provides a consultation service to the Department of Neurology at the Western General Hospital in Edinburgh.
Functional Symptoms and Syndromes
Michael Sharpe MA MD MRCP MRCPsych Reader in Psychological Medicine University of Edinburgh
The Nature and Size of the Problem
It is becoming increasingly clear that the problem of patients who have illness that is defined only subjectively and not clearly explained by disease is a large one. Recent research has shown that such presentations are extremely common in general practice in a range of countries and cultures. They also account for a quarter to a half of all new medical hospital outpatient consultations. The most common symptoms are pain in various sites (back pain, head pain, chest pain and generalised pain) and fatigue. Other common symptoms are tingling, dizziness, weakness, breathlessness, bowel disturbance and palpitations. Although not due to any recognised disease these symptoms may nonetheless be associated with severe and persistent disability.
Terminology and Classification
Terminology
There is a great deal of confusion about what to call such illness. A wide range of general terms has been used including “hysteria”, “abnormal illness behaviour”, “somatisation”, and “somatoform disorders”. Recently the terms “medically unexplained symptoms (MUS)” and “functional” symptoms have become popular amongst researchers, as they do not assume any particular aetiology.
Classification
Classification is also confusing as there are parallel medical and psychiatric classifications. The medical classification defines “functional syndromes” such as tension headache, irritable bowel, and so on based on the bodily system or part apparently most affected. Hence, patients attending gastroenterology with functional symptoms tend to receive the label of irritable bowel syndrome, those attending rheumatology be diagnosed as having fibromyalgia, those attending infectious disease as having (post viral) fatigue syndrome and so on (see Table 1).
Table 1: Common medically defined functional syndromes listed
Gastroenterology Irritable bowel syndrome (IBS), non-ulcer dyspepsia (NUD)
Gynaecology Pre-menstrual syndrome (PMS), chronic pelvic pain (CPP)
Rheumatology Fibromyalgia (FMG)
Cardiology Atypical or non-cardiac chest pain; benign palpitation.
Respiratory medicine Hyperventilation syndrome (HVS)
Infectious diseases (Post-viral) fatigue syndrome (CFS)
Neurology Tension headache
Dentistry Temporal-mandibular joint dysfunction,atypical facial pain
ENT Globus syndrome
Allergy Multiple chemical sensitivity
There has recently been increased awareness that these individual “functional syndromes” are not as separate as they seem. There is not only overlap in the symptoms patients report but also in associated
characteristics and response to treatment (see below). It has therefore been proposed that these conditions be considered together as a “general functional somatic syndrome”. Whilst this may be too extreme a view, substantial commonality between them is now generally accepted.
The psychiatric classifications provide alternative diagnoses for the same patients (See Table 2). The majority, but not all patients will meet criteria for depressive or anxiety disorders and most of the remainder of those for the so-called somatoform disorders of which hypochondriasis (severe anxiety about disease) and somatisation disorder (a long term tendency to present repeatedly with a range of medically unexplained symptoms) have most clinical utility.
Table 2 : DSM-IV and ICD-10 categories for medically unexplained syndromes
DSMIV ICD-10
Somatoform disorders Somatoform disorders
Somatisation disorder Somatisation disorder
Undifferentiated somatoform disorder Undifferentiated somatoform disorder
Conversion disorder
Pain disorder Persistent somatoform pain disorder
Hypochondriasis Hypochondriacal disorder
Body dysmorphic disorder
Somatoform disorder NOS Somatoform autonomic dysfunction
Other somatoform disorders
Somatoform disorder unspecified
Dissociative (conversion) disorders
Disorders of movement and sensation
Other neurotic disorders
Neurasthenia
Depressive disorders Depressive disorders
Anxiety disorders Anxiety disorders
Neither classification is ideal. However, the psychiatric classification has important treatment implications. Because patients present somatically (and may not want a psychiatric diagnosis) this may be missed. Hence, patients may become chronically disabled because of a treatable but untreated psychiatric disorder. This is not an uncommon finding both in clinical practice and in IMEs. We need better classifications – in the meantime, the best practice is to always seek evidence for and record diagnoses from both medical and psychiatric systems for example “irritable bowel syndrome with anxiety”.
The Aetiology of Functional Syndromes
The best ways of understanding such syndromes is to consider a range of biological, psychological and social factors. Table 3 illustrates such an approach to chronic fatigue syndrome.
Table 3: Possible causal factors in chronic fatigue syndrome
PredisposingPrecipitatingPerpetuating
Biological Genetic Previous depression virus HPA axis disturbanceinactivity
Psychological Personality (perfectionism) response to stress disease attribution, avoidant coping style
Social stresses life conflicts, iatrogenic factors
Biological factors
Recent research using functional brain imaging (PET and fMRI) has started to identify altered brain functioning in patients who have functional syndromes (as well as in those with depression and anxiety). This does not mean the patients have brain disease, but that their experience of symptoms has a neurophysiological correlate. On the one hand this is merely evidence of mind-brain identity, on the other hand it does remind us that these symptoms are not purely psychological phenomena but that they have a biological reality, albeit a potentially reversible one.
Psychological factors
Whatever their biological basis, there is strong evidence that symptoms and disability are shaped by psychological factors. Especially important are the patients’ beliefs and fears about their symptoms. Research in several functional syndromes has found that a strong belief and preoccupation that one has a “medical disease” and a helpless and passive attitude to coping is associated with persistent disability (as it is in recovery from acute medical condition such as myocardial infarction). The presence of depression is similarly associated with greater disability and worse outcome. Some persons appear to exaggerate symptoms but this is often hard to prove.
Although harder to research, social factors are almost certainly of great importance in shaping functional illness. Relevant factors include the information patients receive about the symptoms and how to cope with them. This information may be helpful or may stress the chronicity of the illness and promote helplessness. Such unhelpful information is found in “self-help” (!) books and increasingly on the Internet (see for example www.meassociation.org.uk). Unfortunately, doctors and especially “specialist private doctors” and complementary therapists may be as bad. Other social factors that perpetuate illness are anger with the person or organisation the illness is attributed to, or toward the insurer for not believing them. It has been pointed out that: “ if you have to prove you are ill you can’t get well”. Both State and private insurers pay people to remain ill. Litigation for poorly understood and functional illness appears to be on the increase and a recent large study from Canada provided evidence that it does increase the duration of so-called whiplash symptoms.
Treatment
Evidence based treatment
Recent systematic reviews of randomised controlled trials have confirmed that psychologically informed rehabilitative treatments (often called cognitive behaviour therapy or CBT) and “antidepressant” drugs have some effectiveness in treating most functional syndromes. There is however a great shortage of skilled providers of CBT in particular and rehabilitative facilities in general.
Obstacles to recovery
In practice, even if treatment is available, there may be obstacles to recovery. Over time, the patient’s beliefs may be become entrenched and be driven by anger and the need to explain continuing disability. The current system of state benefits, insurance payments and litigation remain potentially major obstacles to effective rehabilitation. It is often unrealistic to expect medical treatment alone to overcome these. Furthermore patient groups who champion the interest of individuals with functional complaints (particularly for chronic fatigue and fibromyalgia) are increasingly influential; they are extremely effective in lobbying politicians and have even been threatening towards individuals and organisations who question the validity and permanence of the illness they champion. Again the ME lobby is the best example.
What can be done?
Generally
It will be imperative that health and social policy addresses this problem. Benefits and medical services need to be more rehabilitation orientated. This will not be easy. However, there are glimmers of progress.
An example is recent developments in the politics of CFS. After a failure of patient organisations to accept a report on the condition produced by the Royal Colleges, the previous CMO for England set up a working party that included both patient advocates and professionals. The meetings were difficult and there was a failure to agree the final report. Nonetheless, the current Chief Medical Officer released the report early in 2002 (www.doh.gov.uk/cmo/cfsmereport). It is “mixed”, in terms of the relationship of its contents to the research evidence as opposed to advocacy – but does accept the increasingly strong evidence for rehabilitation. Furthermore, one of the major patient charities (Action for ME) is aligning itself with a more evidence-based approach. These are early days but if this convergence of rehabilitation oriented clinicians and a patient advocacy group is successful, there could be very positive implications for patients and for insurers.
There is a major need for effective rehabilitation for treatable patients. Existing pain and rehabilitation services would provide a useful basis. However, their capacity and skills are currently far too limited. Funding of rehabilitation by commercial bodies has begun in the UK (with organisations such as PRISMA) and is likely to continue. As long as the economy remains strong and skilled workers are sought after, it will be in employers’ interests to rehabilitate sick but valued employees.
By the insurance industry
From the insurance point of view, efforts need to be made to minimise the risk of their policyholders getting ill and to minimise the obstacles to their recovery. There are implications for pre-acceptance medical assessment and for the work practices of employers. When policyholders do fall sick with a functional syndrome it is likely to help if both insurer and employer maintain a positive relationship with the claimant. An early but positively planned return to work (even in a very limited capacity) is desirable. If the claimant becomes hostile toward employer or insurer the position is likely to be difficult to retrieve.
Much could be gained from having an early biopsychosocial assessments of patients that ensured the identification of psychiatric as well as medical diagnoses. There is also a need to minimise iatrogenic harm both from family doctors who misguidedly encourage the patients to “take time off ” at the insurer’s expense and from certain “specialists”.
For those with established disability an increased availability of rehabilitative treatment facilities is highly desirable. The NHS is not likely to pay for these.
Summary
The problem of medically unexplained or functional illness is a large one. It is not going to go away and it is likely to get bigger. Social factors are more likely to influence the trends in the prevalence, presentation and cost than are medical developments. Both health services and insurers now need to take a more positive approach. To those who say that this will cost money I would reply – how much is it costing you doing nothing?
Top
It includes bits from Aylward, Sharpe and Robb (Unum's guy) which may be of interest.
(In two parts)
http://web.archive.org/web/20060830...ome/AccessiblePDF/CMOReport2002.htm?UPCC=True
Trends in Health and Disability 2002
Contents
- Chief Medical Officer’s Report 2002 – Dr P Dewis
- Recent Developments in Psychiatry – Dr M Lipsedge
- Functional Symptoms and Syndromes – Dr M Sharpe
- “Doctor, I have a pain” – Dr A K Clarke
- Recent Advances in General Medicine – Dr G H Robb
- Recent Developments in Cardiology – Dr C W Pumphrey
- Health and Welfare – Prof M Aylward
Chief Medical Officer’s Report 2002
Peter Dewis BSc MB ChB DDAM MRC
The need for a thorough understanding of medical issues is essential if UnumProvident is to maintain its position as the UK’s leading provider of income protection insurance. Whilst we frequently emphasise the fact that a medical diagnosis does not equate to a certain level of disability, it is nevertheless true that a knowledge of the range of effects which can arise from a particular medical condition is an essential starting point for us in the way we deal with individuals, whether as applicants for insurance cover in the Underwriting arena, or as claimants for income protection benefits.
Medical research is advancing rapidly on a number of fronts and thus the expectations we may form on how a person might be affected by a particular disease and condition today, in a number of areas might be considerably different to what they were a few years ago. This however has to be set against the fact that the media will frequently highlight particular areas of medical research and raise public expectations of cures and advances which are way in excess of what can be permitted from a detailed knowledge of what the research actually shows.
It is against this background that we need to be in a position to understand where medical advances are taking us and to be able to form a balanced view on what the implications are for us as an insurer over the years to come. To this end, I have commissioned a number of papers from leaders within the medical profession whose disciplines are particularly relevant to those people we see most frequently making claims for benefit, or whose claims most frequently pose us difficulties in their management.
Each contributor was asked to highlight the most recent developments in their particular discipline and to speculate on how things are likely to develop over the next few years. Some of the contributors have worked closely with us in either underwriting, claims or appeals over the last year or so and have been able to concentrate on issues, which are likely to be of greatest importance to us.
Mental health issues have been of particular importance to us recently and thus Maurice Lipsedge who until very recently was consultant psychiatrist at Guy’s Hospital, has reviewed the range of developments within psychiatry in general. Complementing this, is a paper from Michael Sharpe, consultant in liaison psychiatry from Edinburgh who has reviewed the developments, not only in chronic fatigue syndrome, but also the range of disorders where the symptoms experienced by individual patients appear to be out of proportion with the physical findings or objective evidence of disease in its traditional sense.Our other large area of work involves musculo-skeletal disorders. Tony Clarke who is Medical Director of the National Rheumatic Diseases Hospital in Bath, has chosen to concentrate on the issue of chronic back pain, upper limb disorders and inappropriate pain. His paper therefore has many points of similarity with those from the psychiatric field.
Charles Pumphrey, Consultant Cardiologist from St George’s Hospital in London, has highlighted many of the exciting recent developments within cardiology. Many of these have also been picked up by Geoffrey Robb who has been associated with UnumProvident for a number of years and fully understands how medical issues and insurance interact. He has also described a number of other relevant developments from the field of general medicine.
Finally, Mansel Aylward who is Chief Medical Advisor to the Department of Work and Pensions has set out the current trends in government strategy relating to both health and social security. Clearly any organisation working in this area needs to set its activities in a context of government policy both in the short and long term.
Hopefully, each of these papers speaks for itself. I would however like to draw out a few specific points both in terms highlighting the technical advances, but also describing those areas which are likely to present us with the greatest challenges as we move forward. My intention would be for this report to be repeated on an annual basis and so become an authoritative and informative document on the current state of medical thinking on those issues which are of greatest importance to us.
Medical Genetics
Before moving on to discuss the detail of the individual papers, I need to make some reference to the field of medical genetics. I have not commissioned a paper on this particular subject which may appear to be an omission in light of the publicity which has surrounded the subject over the past year and which has culminated in the ABI announcement of the moratorium on the use of genetics testing for insurance purposes.
The field of medical genetics is one in which I believe the media is portraying a future which is currently way beyond the current ability of medical technology to meet the expectations being put forward. Clearly some fundamental advances have been made in medical research in this area, but it will still be some time before the benefits will be seen for the majority of people.
The insurance industry developments in this field have centred around the ability of DNA testing to detect those who are at risk of developing inherited diseases. For most diseases seen commonly, genetics usually plays only a part in determining who will develop the disease. Genetics testing currently is only of real relevance to those suffering from what are known as single gene disorders. These are usually relatively uncommon disorders whose incidence can be predicted accurately from their pattern of inheritance. Many also have their manifestations in childhood so that by the time these people are making applications for insurance, we already know whether or not they are going to develop the disease. All of this means that even before the recently announced moratorium, the only genetic test which had been approved for use by the government’s Genetics and Insurance Advisory Committee, was that for Huntington’s disease for life insurance purposes.
From a practical day to day point of view, the issue of genetics testing does not pose the sorts of significant problems as have been highlighted in the papers commissioned. We are more often in a position to use the results of a genetics test favourably to an applicant that to exclude them from cover and will continue to do this. This does not mean that I am dismissing this issue, since it will undoubtedly assume greater practical importance as medical research continues to develop. We need to play our full part in helping the industry establish its position during the course of the five year moratorium. Almost certainly there will be scope for an expert paper specifically on this subject in subsequent editions of the CMO report.
Technical Advances
Both Dr Robb and Dr Pumphrey have referred to the changes which have taken place in the diagnosis of heart attack (myocardial infarction) through the discovery of a new very sensitive biochemical marker of heart muscle damage known as Tropinin T. This has changed the criteria for the diagnosis of heart attacks in the clinical setting, to the extent that a diagnosis of a heart attack may well be made now in people whose episodes of chest pain might have remained undiagnosed. Moreover, this has important implications since the life expectancy of such people may well not be impaired in the way that is traditionally the case for people who have had heart attacks and indeed for some might in fact be enhanced. Dr Robb, however urges caution in the wholesale adoption of these new diagnostic criteria within the critical illness arena and this has been reflected in the definitions for heart attack (both major and minor) adopted for the new individual critical illness product. This is an area which will need to be kept under active review in discussion with our re-insurers. The overall prognosis of people with coronary artery disease has also been referred to, especially in relation to the more widespread use of the lipid lowering drugs known as the statins. Dr Robb has also identified the fact that with greater attention to detail in control of blood sugar, the prognosis for people with diabetes mellitus can be much better than has previously been the case. I will, in discussion with the Chief Medical Underwriter, be looking critically at our underwriting policies in these particular areas over the coming year.
Dr Pumphrey has identified the improvements which have taken place in the surgical treatment of established coronary artery disease, which should lead us to expect an increasing trend in people being able to return to and remain in work. This is important information for benefits claims managers in forming their expectations on individual cases. The increasing use of Percutaneous Coronary Intervention (coronary angioplasty) should also cause them to expect that this will be used more and more routinely so that uncontrolled ischaemic chest pain will become less and less common.
Within the musculo-skeletal field, the advances Dr Clarke describes relate more to those of understanding of the nature of chronic painful conditions rather than to any particular technical breakthrough. Most such conditions do not have a serious underlying pathological basis. Stemming from this is the increasing realisation of the need for people to remain active and for clinicians to intervene early in the process to ensure that optimum recovery and rehabilitation is achieved. Much of what Dr Clarke has described has been mirrored by Dr Sharpe in his description of the apparent rise in the prevalence of conditions for which no underlying disease process can be identified.
Dr Lipsedge has referred to a number of developments in the way in which imaging techniques are starting to delineate the neurological basis for a number of psychiatric disorders. However, many of these currently are at a purely academic level and he points out that the treatment of depression has not improved significantly since the first discovery of antidepressant drugs.
Ongoing Challenges
The fact that there have been few advances in the treatment of depression represents a challenge. This is particularly so since all the authors have identified this as being of significance in their own particular field. Dr Lipsedge for example, has highlighted the importance of symptoms which fall short of producing a definite depressive illness, but which may well have an influence on overall disability. Its impact in the field of cardiology and general medicine has been particularly identified by Dr Robb. This presents us with a particular challenge in being able to identify those claimants where depression may be having a significant impact at an early stage of their incapacity and where possible being able to influence their treatment since it is clear that these issues are not always being adequately addressed within the constraints of primary care.
Dr Lipsedge, Dr Sharpe and Dr Clarke have identified the importance of cognitive behaviour therapy of influencing the outcome in depression, chronic fatigue syndrome and chronic pain. This again represents a challenge in ensuring that people are directed towards this approach. This can be particularly difficult in relation to the availability of such services under the NHS. All of this needs to be considered in relation to the other common theme, which has been emphasised particularly by Dr Sharpe and which relates to the need to intervene early in the course of a disability to achieve a positive outcome.
Message for UnumProvident
Although contributions were sought from specialists across a wide variety of disciplines, when looking at those areas which are likely to pose particular challenges, the importance of psychological factors in determining long term disability emerges. In addition, in such people there will frequently be a predominance of subjective complaints with little in the way objective findings to support these. All the findings presented by Dr Aylward on the trends in social security statistics show that these are also major issues for the public sector. Dr Aylward’s data also supports strongly the view that early intervention appears to be the only way of influencing this situation. He has also identified a number of government initiatives, such as the New Deal for Disabled People and NHS Plus, which signify the government’s intention of addressing these issues. Clearly however, there is a tremendous amount of work that needs to be done to make these a reality.
Within UnumProvident, I believe that we need specifically to continue to develop in two particular areas and that the information presented by the experts contributing to this report, support this view.
- We need to continue to develop our capability within Medical Services and Rehabilitation Services to be able to intervene earlier in the course of any disability. This means increasing our ability to have an integrated approach within UnumProvident and to be able to engage with employers as well as individual disabled people.
- We need to continue to develop the disciplined thinking required to assess fairly those claims from people, which are based entirely on subjective factors.
Maurice Lipsedge
Recent Developments in Psychiatry
Maurice Lipsedge M.Phil FRCP
Introduction
In this brief review of recent developments in psychiatry, I have drawn on both the American and the British psychiatric journals published over the past couple of years. The basis of selection has been developments in research which have potential implications for long term or recurrent occupational disability arising from psychiatric disorders.
Given the current emphasis on neurological research, the bulk of the literature deals with those disorders, which have a basis in cerebral dysfunction, especially schizophrenia, the affective disorders and dementia. Although the clinical onset of Alzheimer’s disease can be prior to the age of sixty it is, of course, typically a disorder of old age. The first phase of Alzheimer’s disease, which can last for two to three years, is characterised by failing memory, muddled inefficiency over everyday tasks and spatial disorientation. Moreover, because disturbance of mood can be prominent and since a degree of depressive pseudodementia is not uncommon, presenile dementia has to be considered as a differential diagnosis in the occupational setting in all people who are referred for a psychiatric assessment after the onset of middle age.
For this reason consideration of recent developments in the cause and potential treatment of Alzheimer’s disease merit inclusion in a review such as this. In view of the increasing prevalence of schizophrenia and the established high level of affective disorders in the community, these “non-organic” disorders require no such justification. The 1990s were designated the “Decade of the Brain” by Time Magazine and significant advances were made during that period in the basic sciences of neurobiology and genetics. So far, however, these developments have had virtually no impact on psychiatric clinical activity. Thus, in the field of depressive illnesses, which have a wide prevalence, the efficacy and speed to onset of response to antidepressants has changed little since the serendipitous discovery of the MAOI’s (monoamise oxidase inhibitors) over forty years ago.
Neuroimaging
The neurochemical pathology of the major psychiatric disorders has been elucidated recently by the use of functional brain imaging techniques namely Positron Emission Tomography (PET), Magnetic Resonance Spectroscopy (MRS), Functional Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT).
Early Detection of Alzheimer’s Disease
Recent studies on the functional neuroanatomy of depression using SPECT and PET imaging techniques have compared the effects of pharmacotherapy with a form of psychotherapy. Surprisingly, both the administration of antidepressant drugs and the psychosocial intervention were associated with increased blood flow to the left temporal or right basal ganglia regions. Furthermore, both the interpersonal psychotherapy and the antidepressant treatment normalised metabolism in the prefrontal cortex and left anterior cingular gyrus.
Although these results have emerged only from preliminary studies and some methodological reservations have been expressed, the tangible cerebral effects apparently brought about by psychotherapy are an interesting sequel to the earlier work on the changes induced in the brain by the cognitive-behaviour therapy of obsessional compulsive disorder.
Working forwards conceptually from psychological trauma to neurobiological changes, recent MRI studies have demonstrated hippocampal atrophy in post traumatic stress disorder. In functional terms, this reduction in hippocampal volume is associated with explicit memory deficits. The same picture has already been demonstrated in depression. It is still not clearly established whether the hippocampal atrophy arises from the clinical disorder or precedes it and whether a disturbance of glucocorticoids is the underlying cause.
Recent studies of longitudinal changes in cognitive performance during the preclinical phase of Alzheimer’s disease show that in the near future it may be possible to identify people at risk of developing this type of dementia and to administer prophylactic treatments in order to delay or stop the progression of this disease. The possibility of identifying people at risk of developing Alzheimer’s disease carries implications for potential therapeutic interventions. A number of recent studies have attempted to identify the cognitive markers of preclinical Alzheimer’s disease and it has been found that people who later developed Alzheimer’s disease experienced greater changes across multiple cognitive domains compared with those who did not develop dementia. The most prominent changes were an accelerated decline in episodic memory and in executive functioning.
By carrying out multiple measures longitudinally, it is possible to identify changes in cognitive performance when people are still regarded as free of dementia and recent research shows that cross sectional deficits in cognitive performance can appear years before the actual diagnosis of
Alzheimer’s disease. It is likely that individuals at risk of Alzheimer’s disease will be more precisely identified before the clinical onset of the disorder by combining longitudinal studies of cognitive performance with genetic and neuroimaging techniques, since more individuals who go on to develop Alzheimer’s disease show prediagnostic changes in neuroanatomy. These changes have been demonstrated both in neuropathological studies as well as magnetic resonance imaging which has demonstrated changes in the hippocampus and entorhinal cortex.
Prevention of Relapse in Residual Depression by Cognitive – Therapy
It is known that marked morbidity and disability occurs as a result of the significant rates of relapse and recurrence in major depression and that depression is a risk factor for the onset of both physical and psychosocial
disability while the effective treatment of depression improves functional outcomes. The rate of relapse and recurrence can be reduced by patients continuing to take antidepressants. It is recognised that many patients still achieve only a partial remission and have persistent residual symptoms. Residual depression can occur in about a third of patients suffering from major depression who have been treated with appropriate doses of antidepressants for an adequate trial period. A recent meta-analysis of the drug treatment of depression found response rates to be no better than 50 per cent for active treatment by comparison to 32 per cent for placebo (Agency for
Healthcare Policy Research, 1999). Furthermore, patients with residual depression are particularly prone to relapse. It has now been shown that cognitive therapy is highly effective in reducing relapse rates in cases of severe residual depressive symptoms, despite antidepressant treatment. Cognitive therapy is a cost effective form of treatment for depression requiring less than 20 weekly sessions. In this study, cognitive therapy was added to antidepressants and this psychological intervention was shown to prevent relapse into a further episode of major depression.
Long-Term Disability Associated with Depression
A prospective study of psychosocial disability in relation to the severity of depressive symptoms was conducted over a ten year period. The results show a progressive gradient of psychosocial impairment, which parallels the severity of depressive symptoms. It was found that there is a significant stepwise increment in psychosocial disability as one progresses from subthreshold depressive symptoms through dysthymia to unipolar major depressive disorder. This common-sense relationship between the severity of depression and occupational impairment (ie, the synchrony of change in depression and disability) shows that effective treatment of depression will improve functional outcome.
This synchrony may be predictable, but an unexpected recent finding was the link between depression and the course of coronary artery disease. Recent studies have shown that there is an increased risk of ischaemic heart disease among depressed patients. Furthermore, patients with depression following a myocardial infarction are over three times more likely to die than non-depressed patients. It has been suggested that association between depression and coronary artery disease might be based on changes in the autonomic nervous system or in a disturbance of platelet function. It has also been shown that major depression is a significant risk factor for the development of stroke.
Assessing and Measuring Psychiatric Disability
There is an important and challenging contribution to the literature on the assessment of disability in a recent communication in the American Journal of Psychiatry (Janca, 2001). Janca has critically evaluated the disability axis of the Multi-Axial Presentation of ICD-10 for Use in Adult Psychiatry which is an instrument comparable in purpose to the
DSM-IV Axis V scales, ie The Global Assessment of Functioning Scale, The Global Assessment of Relationing Scale and The Social and Occupational Assessment Scale.
In contrast to the impressively high levels of inter-rater reliability found with the DSM-IV Axis V scales, Janca found a very low inter-rater reliability when the World Health Organisation’s Short Disability Assessment Schedule was subjected to trials by 274 clinicians from 21 different countries.
The question is therefore asked as to whether DSM-IV Axis V scales have a “true” inter-rater reliability or whether the claimed satisfactory psychometric properties are merely a reflection of “extensive instrument administration training and high motivation of the clinicians”? (I must say that I have some sympathy for Janca’s sceptical view since the operational guidelines supplied by DSM-IV for the determination of disability are difficult to apply with any degree of confidence, eg on the SOFAS one would allocate a score of 41-50 – “serious impairment in ....occupational....functioning” on the basis of the example “unable to keep a job”, when the alleged inability to keep a job might arise from a “genuine” disability but completely fails to take into account motivational and “illness behaviour” factors).
In assessing disability we tend to set the boundary at ICD-10 or preferably DSM-IV defined conditions, relying on clinical significance criteria. Dysthymic disorder which was first introduced as a separate diagnostic category in DSM-IV-R, is found in about 5 per cent of the population. This chronic low grade depressive condition is generally punctuated by episodes of major depression and the condition tends to become more severe with increasing age. The level of functional impairment in dysthymic disorder equals or exceeds that in major depressive disorder.
A prospective 5 year follow-up study has shown that the course and outcome of dysthymic disorder are rendered unfavourable by a family history of psychiatric disorder, adversity in childhood, chronic stress and an avoidant, dependent or obsessive-compulsive personality disorder. Interestingly a family history of bipolar disorder is associated with a higher probability of recovery.
Although dysthymic disorder has achieved the status of a DSM-IV recognised category, there has been a proliferation of substhreshold disorders over the past few years. Synonyms include “minor depression”, “subsyndromal symptomatic depression” etc. some of these subthreshold conditions lack validity as formal psychiatric disorders and they are often difficult to distinguish from common-or-garden unhappiness. It has been suggested that these subthreshold conditions should be more precisely defined and studied on a longitudinal basis, but it is also recognised that providing formal identifying criteria and quantifying these symptoms might exacerbate the current tendency to pathologise conditions that may be within the normal spectrum. Grief would be a case in point.
Antidepressants of all types cause an increase in the release of presynaptic monoamines, which activate a range of post-synaptic receptors. These are coupled to second messenger signal transduction factors that control gene expression. This knowledge has been derived from recent research with animal models, providing new perspectives on the pathophysiology of depressive disorder, the biology of stress and the mode of action of antidepressant drugs.
In summary, antidepressants of different classes all appear to increase the expression of neuroprotective proteins which are important for the function and growth of neurones.
Cost-Effective Psychological Treatment of Common Psychiatric Disorders
The past few years has seen the consolidation of the role of psychological treatment methods in both depression and the anxiety-based disorders. Cognitive-behavioural therapy now has an established track record in terms of cost effectiveness and its methods can be applied either in conjunction with medication or without concurrent pharmacological treatment. Post-traumatic stress disorder and chronic fatigue syndromes provide examples of common and often disabling conditions in which the optimal treatment might be cognitive-behaviour therapy administered by a nurse therapist or clinical psychologist backed up by antidepressant medication prescribed by a general practitioner or psychiatrist. Cognitive therapy has also, perhaps surprisingly, become recognised as an effective way of helping patients with refractory schizophrenia and chronic paranoid psychoses to learn effective strategies for challenging delusional ideas and for dealing with distressing hallucinations.
Schizophrenia
The recent application of quantitive methods in schizophrenia research has been a first step in identifying an anatomical substrate for schizophrenia. Stereological analysis of the prefrontal cortex has shown
the presence of increased density of neurones in patients with schizophrenia. This is now known to be due to a reduction in the elements of neural connectivity rather than the actual destruction of nerve cells. This deficit appears to occur in a specific area of the prefrontal cortex in patients with schizophrenia suggesting that the large pyramidal cells in that particular area (layer 3c) receive fewer synapses from modulatory dopaminergic and exitatory afferent inputs.
Since the pathology in the prefrontal cortex of patients with schizophrenia appears to be confined to neuronal processes and synaptic connections
rather than actual loss of neurones, it is hoped that highly targeted pharmacological treatments can be developed which will have a selective action on specific neuronal cells and connections.
Top
Michael Sharpe
Functional Symptoms and Syndromes
Michael Sharpe MA MD MRCP MRCPsych Reader in Psychological Medicine University of Edinburgh
The Nature and Size of the Problem
It is becoming increasingly clear that the problem of patients who have illness that is defined only subjectively and not clearly explained by disease is a large one. Recent research has shown that such presentations are extremely common in general practice in a range of countries and cultures. They also account for a quarter to a half of all new medical hospital outpatient consultations. The most common symptoms are pain in various sites (back pain, head pain, chest pain and generalised pain) and fatigue. Other common symptoms are tingling, dizziness, weakness, breathlessness, bowel disturbance and palpitations. Although not due to any recognised disease these symptoms may nonetheless be associated with severe and persistent disability.
Terminology and Classification
Terminology
There is a great deal of confusion about what to call such illness. A wide range of general terms has been used including “hysteria”, “abnormal illness behaviour”, “somatisation”, and “somatoform disorders”. Recently the terms “medically unexplained symptoms (MUS)” and “functional” symptoms have become popular amongst researchers, as they do not assume any particular aetiology.
Classification
Classification is also confusing as there are parallel medical and psychiatric classifications. The medical classification defines “functional syndromes” such as tension headache, irritable bowel, and so on based on the bodily system or part apparently most affected. Hence, patients attending gastroenterology with functional symptoms tend to receive the label of irritable bowel syndrome, those attending rheumatology be diagnosed as having fibromyalgia, those attending infectious disease as having (post viral) fatigue syndrome and so on (see Table 1).
Table 1: Common medically defined functional syndromes listed
Gastroenterology Irritable bowel syndrome (IBS), non-ulcer dyspepsia (NUD)
Gynaecology Pre-menstrual syndrome (PMS), chronic pelvic pain (CPP)
Rheumatology Fibromyalgia (FMG)
Cardiology Atypical or non-cardiac chest pain; benign palpitation.
Respiratory medicine Hyperventilation syndrome (HVS)
Infectious diseases (Post-viral) fatigue syndrome (CFS)
Neurology Tension headache
Dentistry Temporal-mandibular joint dysfunction,atypical facial pain
ENT Globus syndrome
Allergy Multiple chemical sensitivity
There has recently been increased awareness that these individual “functional syndromes” are not as separate as they seem. There is not only overlap in the symptoms patients report but also in associated
characteristics and response to treatment (see below). It has therefore been proposed that these conditions be considered together as a “general functional somatic syndrome”. Whilst this may be too extreme a view, substantial commonality between them is now generally accepted.
The psychiatric classifications provide alternative diagnoses for the same patients (See Table 2). The majority, but not all patients will meet criteria for depressive or anxiety disorders and most of the remainder of those for the so-called somatoform disorders of which hypochondriasis (severe anxiety about disease) and somatisation disorder (a long term tendency to present repeatedly with a range of medically unexplained symptoms) have most clinical utility.
Table 2 : DSM-IV and ICD-10 categories for medically unexplained syndromes
DSMIV ICD-10
Somatoform disorders Somatoform disorders
Somatisation disorder Somatisation disorder
Undifferentiated somatoform disorder Undifferentiated somatoform disorder
Conversion disorder
Pain disorder Persistent somatoform pain disorder
Hypochondriasis Hypochondriacal disorder
Body dysmorphic disorder
Somatoform disorder NOS Somatoform autonomic dysfunction
Other somatoform disorders
Somatoform disorder unspecified
Dissociative (conversion) disorders
Disorders of movement and sensation
Other neurotic disorders
Neurasthenia
Depressive disorders Depressive disorders
Anxiety disorders Anxiety disorders
Neither classification is ideal. However, the psychiatric classification has important treatment implications. Because patients present somatically (and may not want a psychiatric diagnosis) this may be missed. Hence, patients may become chronically disabled because of a treatable but untreated psychiatric disorder. This is not an uncommon finding both in clinical practice and in IMEs. We need better classifications – in the meantime, the best practice is to always seek evidence for and record diagnoses from both medical and psychiatric systems for example “irritable bowel syndrome with anxiety”.
The Aetiology of Functional Syndromes
The best ways of understanding such syndromes is to consider a range of biological, psychological and social factors. Table 3 illustrates such an approach to chronic fatigue syndrome.
Table 3: Possible causal factors in chronic fatigue syndrome
PredisposingPrecipitatingPerpetuating
Biological Genetic Previous depression virus HPA axis disturbanceinactivity
Psychological Personality (perfectionism) response to stress disease attribution, avoidant coping style
Social stresses life conflicts, iatrogenic factors
Biological factors
Recent research using functional brain imaging (PET and fMRI) has started to identify altered brain functioning in patients who have functional syndromes (as well as in those with depression and anxiety). This does not mean the patients have brain disease, but that their experience of symptoms has a neurophysiological correlate. On the one hand this is merely evidence of mind-brain identity, on the other hand it does remind us that these symptoms are not purely psychological phenomena but that they have a biological reality, albeit a potentially reversible one.
Psychological factors
Whatever their biological basis, there is strong evidence that symptoms and disability are shaped by psychological factors. Especially important are the patients’ beliefs and fears about their symptoms. Research in several functional syndromes has found that a strong belief and preoccupation that one has a “medical disease” and a helpless and passive attitude to coping is associated with persistent disability (as it is in recovery from acute medical condition such as myocardial infarction). The presence of depression is similarly associated with greater disability and worse outcome. Some persons appear to exaggerate symptoms but this is often hard to prove.
Although harder to research, social factors are almost certainly of great importance in shaping functional illness. Relevant factors include the information patients receive about the symptoms and how to cope with them. This information may be helpful or may stress the chronicity of the illness and promote helplessness. Such unhelpful information is found in “self-help” (!) books and increasingly on the Internet (see for example www.meassociation.org.uk). Unfortunately, doctors and especially “specialist private doctors” and complementary therapists may be as bad. Other social factors that perpetuate illness are anger with the person or organisation the illness is attributed to, or toward the insurer for not believing them. It has been pointed out that: “ if you have to prove you are ill you can’t get well”. Both State and private insurers pay people to remain ill. Litigation for poorly understood and functional illness appears to be on the increase and a recent large study from Canada provided evidence that it does increase the duration of so-called whiplash symptoms.
Treatment
Evidence based treatment
Recent systematic reviews of randomised controlled trials have confirmed that psychologically informed rehabilitative treatments (often called cognitive behaviour therapy or CBT) and “antidepressant” drugs have some effectiveness in treating most functional syndromes. There is however a great shortage of skilled providers of CBT in particular and rehabilitative facilities in general.
Obstacles to recovery
In practice, even if treatment is available, there may be obstacles to recovery. Over time, the patient’s beliefs may be become entrenched and be driven by anger and the need to explain continuing disability. The current system of state benefits, insurance payments and litigation remain potentially major obstacles to effective rehabilitation. It is often unrealistic to expect medical treatment alone to overcome these. Furthermore patient groups who champion the interest of individuals with functional complaints (particularly for chronic fatigue and fibromyalgia) are increasingly influential; they are extremely effective in lobbying politicians and have even been threatening towards individuals and organisations who question the validity and permanence of the illness they champion. Again the ME lobby is the best example.
What can be done?
Generally
It will be imperative that health and social policy addresses this problem. Benefits and medical services need to be more rehabilitation orientated. This will not be easy. However, there are glimmers of progress.
An example is recent developments in the politics of CFS. After a failure of patient organisations to accept a report on the condition produced by the Royal Colleges, the previous CMO for England set up a working party that included both patient advocates and professionals. The meetings were difficult and there was a failure to agree the final report. Nonetheless, the current Chief Medical Officer released the report early in 2002 (www.doh.gov.uk/cmo/cfsmereport). It is “mixed”, in terms of the relationship of its contents to the research evidence as opposed to advocacy – but does accept the increasingly strong evidence for rehabilitation. Furthermore, one of the major patient charities (Action for ME) is aligning itself with a more evidence-based approach. These are early days but if this convergence of rehabilitation oriented clinicians and a patient advocacy group is successful, there could be very positive implications for patients and for insurers.
There is a major need for effective rehabilitation for treatable patients. Existing pain and rehabilitation services would provide a useful basis. However, their capacity and skills are currently far too limited. Funding of rehabilitation by commercial bodies has begun in the UK (with organisations such as PRISMA) and is likely to continue. As long as the economy remains strong and skilled workers are sought after, it will be in employers’ interests to rehabilitate sick but valued employees.
By the insurance industry
From the insurance point of view, efforts need to be made to minimise the risk of their policyholders getting ill and to minimise the obstacles to their recovery. There are implications for pre-acceptance medical assessment and for the work practices of employers. When policyholders do fall sick with a functional syndrome it is likely to help if both insurer and employer maintain a positive relationship with the claimant. An early but positively planned return to work (even in a very limited capacity) is desirable. If the claimant becomes hostile toward employer or insurer the position is likely to be difficult to retrieve.
Much could be gained from having an early biopsychosocial assessments of patients that ensured the identification of psychiatric as well as medical diagnoses. There is also a need to minimise iatrogenic harm both from family doctors who misguidedly encourage the patients to “take time off ” at the insurer’s expense and from certain “specialists”.
For those with established disability an increased availability of rehabilitative treatment facilities is highly desirable. The NHS is not likely to pay for these.
Summary
The problem of medically unexplained or functional illness is a large one. It is not going to go away and it is likely to get bigger. Social factors are more likely to influence the trends in the prevalence, presentation and cost than are medical developments. Both health services and insurers now need to take a more positive approach. To those who say that this will cost money I would reply – how much is it costing you doing nothing?
Top
