MUS services in UK and other MUS related issues

I think this distressing article which has been posted in its own thread by Merryn Croft's sister ought to be posted here, too:

Clare Norton article about how doctors dismissed her as neurotic.

https://hystericalwomen.co.uk/2019/...ve-you-now-dismissed-as-a-neurotic-mother/amp

‘Death means we believe you now’: dismissed as a neurotic mother

...On her discharge, we were advised a referral for safeguarding had been made – the reason being FII (Factitious and Induced Illness, previously Munchausen by Proxy). I was being accused of causing Merryn’s illness...
 
I must say that a few articles published in Canada pointing at this whole IAPT thing as a model to follow are really bumming me out. This garbage is leaking everywhere and no one seems to exercise any criticism at all, magical thinking about the "pOWerS oF ThE miND" just pushes all logic out. The historical importance of British science is giving this nonsensical ideological garbage outsized importance, especially because the "gatekeepers" like Lancet, BMJ and Cochrane are embracing it in full.

I've tweeted this to Gerada, though obviously she didn't care to hear it, but your national disaster is causing an international catastrophe, dumbing down medicine (and science as a whole) in a way that could almost be described as a challenge to the germ theory of disease (or more generically a biomedical model, whatever) and replacing it with Freud, behaviorists, and, I guess, hand healing and Tarot diagnosis.

None of the ideological leaders seem to understand what they are doing and the cascading effect that it has on us because they don't want to hear anything negative. It's a field of research where everything gets a gold star and no one criticizes anyone, completely abnormal.

If there's ever been a better "too good to be true" claim that was taken to the bank without criticism I'd like to see it. Claims of 50% of "recovery" from IAPT are ludicrous to take at face value and yet the response every time seems to double down, and down again, and again because there is far too much sunk cost to stop the ship from ramming straight into the iceberg.

Independent sober analysis is badly needed here. Some parts of medicine seem to be undergoing a sort of New Age revival, embracing pseudoscience across the board.
 
rvallee said:
This garbage is leaking everywhere and no one seems to exercise any criticism at all, magical thinking about the "pOWerS oF ThE miND" just pushes all logic out.
Click to expand...

I wonder if the powers-that-be are trying to shorten life expectancy and reduce the size of the population. In doing so there is a saving on costs in national systems of healthcare, the non-rich will be forced to pay for healthcare if and when they are desperate enough and can save up enough money, and there will be yet more transfer of wealth from the non-rich to the rich who own the healthcare companies.

What I can't understand is why the medical profession is going for it in such a big way. Have they spent the last 100 years hating all their patients that much?
 
rvallee said:
I must say that a few articles published in Canada pointing at this whole IAPT thing as a model to follow are really bumming me out.
Click to expand...

Conference and Immersion Training

Monday 29th April – Thursday 2nd May 2019, University of Derby Enterprise Centre, Central Derby, UK

"Allan Abbass will elaborate and expand on the use of the graded format, working with Medically Unexplained Symptoms, and Personality Disorder."

http://www.cathexispsychotherapy.co.uk/m-conferences.html

Abbass is Canadian, and is promoting his repressed emotions theory of illness in the UK, and elsewhere.

He teaches;

"Intensive Short-Term Dynamic Psychotherapy (ISTDP) is a brief-term, emotion-focused therapy which draws on principles of psychodynamic and attachment theory."

The above quote is from the British Psychological Society, a course being presented by someone who was trained by Abbass;

https://www.bps.org.uk/events/intro...sive-short-term-dynamic-psychotherapy-istdp-0

(Whether this is directly IAPT related, I don't know.)

More about Abbass here;

https://www.s4me.info/threads/their...g-from-an-unexpected-source.7423/#post-132371

Edit: A Bristol MUS conference that quotes Abbass here;

https://www.s4me.info/threads/confe...mary-care-response-bristol-uk-july-2019.8813/
 
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https://www.devonlive.com/news/devon-news/nhs-team-replace-virgin-care-2048909

NHS team will replace Virgin Care running children's health care in Devon

27 September 2018

The seven-year contract is worth £23.8m a year

Virgin Care is set to be replaced by an NHS team to run children’s community health services in Devon after hundreds of people were involved in the process to find a new provider.

Commissioners are set to name an alliance of NHS trusts as the preferred bidder to take over the multi-million pound contract from April next year.

The seven-year contract for children’s health and wellbeing services in Devon and Torbay is worth £23.8m a year with an option to carry on for another three years.

Virgin Care won a contract in 2012 to run NHS and social care for children in the area covered by Devon County Council and Torbay. Last year it was extended by an extra 12 months to run until April 2019.

The Devon Children and Families Alliance, led by the Torbay and South Devon NHS Trust, is set to be the preferred bidder for the new contract.

In Plymouth, commissioners are to award a separate contract for children's health, wellbeing and special educational needs and disability services.

The seven-year joint contract for the NHS and Plymouth City Council is worth £12.5m a year with a three-year extension option...


...The Devon Children and Families Alliance is made up of Torbay & South Devon NHS Foundation Trust in partnership with Devon Partnership NHS Trust, Royal Devon and Exeter NHS Foundation Trust, University Hospitals Plymouth NHS Trust, Livewell Southwest, and Northern Devon Healthcare NHS Trust...



https://www.somersetlive.co.uk/news/health/virgin-care-set-lose-multi-2038196

Virgin Care set to lose multi-million pound child health service contract in Devon

24 September 2018

...If the Devon Children and Families Alliance wins the contract for children's health and wellbeing services in Devon and Torbay, it will start running them in April 2019.

The services, include:

  • Child & Adolescent Community Mental Health Services (CAMHs)
  • Learning Disability and Autism Spectrum Disorders
  • Community Children’s Nursing (incl. specialist school nursing; Palliative care)
  • Speech & Language therapy (incl. Early Years Language Consultant Torbay)
  • Occupational Therapy (NHS and Social Care),
  • Physiotherapy, Specialist Children’s Assessment Centres...
 
[Paywalled]

British Journal of General Practice

Medically unexplained symptoms: are we making progress?
Kirsti Malterud and Aase Aamland
Br J Gen Pract 2019; 69 (681): 164-165. DOI: https://doi.org/10.3399/bjgp19X701885

https://bjgp.org/content/69/681/164.short

SUBJECTIVE SYMPTOMS WITHOUT OBJECTIVE FINDINGS — STILL CHRONIC HEALTH PROBLEMS
A substantial proportion of patients in general practice consult for subjective symptoms, such as pain or fatigue, without corresponding objective findings.1–4 Some of these patients present trivial symptoms that do not indicate disease; others recover after long-lasting symptoms and disability.

Here, we shall refer to conditions with long-lasting and disabling symptoms, not trivial or passing symptoms. Such conditions are called medically unexplained symptoms (MUS). Syndromes with specific diagnostic criteria, such as fibromyalgia, chronic fatigue syndrome, or irritable bowel syndrome, are often included among MUS conditions.2

Although management of patients with MUS presents several challenges, GPs accept the responsibility for investigation, diagnosis, treatment, and follow-up.5

Biopsychosocial approaches are commonly applied in medical practice, whether the aim is full recovery or coping with symptoms and disability,1 and psychologically based interventions (especially different cognitive behavioural therapies [CBT]) have been developed for coping and symptom relief. Yet, such approaches do not substantiate MUS as a mental disorder. Lamahewa et al found, for example, that comorbidity with depression and generalised anxiety disorder occurred in only one-third of these patients.2 Studies have evaluated effects of CBT on different outcome measures, such as pain, function, work ability, or healthcare use, often presenting limited or no significant effects based on weak evidence.4

BODY–MIND DUALITY VERSUS EXPLAINABLE COMPLEX INTERACTIONS
MUS is not a clinical diagnosis but an analytical concept, unifying a diverse group of health problems where no joint cause or biomarker have been identified. Together MUS conditions dispute the idea that objective findings are needed to confirm subjective symptoms as disease. The biomedical disease model has imposed an unfortunate body–mind duality, with illness categorised as psychological when no objective findings are identified.2,4 Conceptualising MUS …

View Full Text [Paywalled]


Jump to section
 
Dx Revision Watch said:
Medically unexplained symptoms: are we making progress?
Kirsti Malterud and Aase Aamland
Click to expand...
https://sci-hub.se/https://doi.org/10.3399/bjgp19X701885

This is an editorial that seems to wander around in circles and confuse the issue. It seems to be good in parts - saying, for example that CBT doesn't seem to help much with physical symptoms, and that lack of biomed evidence doesn't mean lack of disease.

It mentions central sensitisation and HPA axis as possible 'causes'. It reminds readers that reduced GP use may not be a useful measure of success - it can mean patient has given up on GP through lack of help.

But I can't work out just what it is concluding should be done with patients with so called MUS.
 
I see from the full paper that this was a commissioned editorial.

This April edition of the British Journal of General Practice includes three MUS related papers:

https://bjgp.org/content/69/681

Table of Contents:

(...)

Research:

(...)

https://bjgp.org/content/69/681/e246

Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care

Kethakie Lamahewa, Marta Buszewicz, Kate Walters, Louise Marston and Irwin Nazareth
Br J Gen Pract 2019; 69 (681): e246-e253. DOI: https://doi.org/10.3399/bjgp19X701249

Abstract

Background Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome.

Aim To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores.

Design and setting Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013.

Method Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity.

Results Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months.

Conclusion This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes.

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https://bjgp.org/content/69/681/e254

Symptom management for medically unexplained symptoms in primary care: a qualitative study

Janna Gol, Tom Terpstra, Peter Lucassen, Juul Houwen, Sandra van Dulmen, Tim C Olde Hartman and Judith Rosmalen
Br J Gen Pract 2019; 69 (681): e254-e261. DOI: https://doi.org/10.3399/bjgp19X701849

Abstract

Background GPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS.

Aim This study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice.

Design and setting Qualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed.

Method A thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed.

Results The study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication.

Conclusion Symptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.

--------------------------------

https://bjgp.org/content/69/681/e262

CBT to reduce healthcare use for medically unexplained symptoms: systematic review and meta-analysis

Brittni Jones and Amanda C de C Williams
Br J Gen Pract 2019; 69 (681): e262-e269. DOI: https://doi.org/10.3399/bjgp19X701273

Abstract

Background Studies have reported that medically unexplained symptoms (MUS) tend to be associated with increased healthcare use, which is demanding of resources and potentially harmful to patients. This association is often used to justify the funding and study of psychological interventions for MUS, yet no systematic review has specifically examined the efficacy of psychological interventions in reducing healthcare use.

Aim To conduct a systematic review and meta-analysis to evaluate the effectiveness of cognitive behavioural therapies (CBT) for MUS in reducing healthcare use.

Design and setting Systematic review and meta-analysis.

Method The search from a previous systematic review was updated and expanded. Twenty-two randomised controlled trials reported healthcare use, of which 18 provided data for meta-analysis. Outcomes were healthcare contacts, healthcare costs, medication, and medical investigations.

Results Small reductions in healthcare contacts and medication use were found for CBT compared with active controls, treatment as usual, and waiting list controls, but not for medical investigations or healthcare costs.

Conclusion Cognitive behavioural interventions show weak benefits in reducing healthcare use in people with MUS. The imprecise use of MUS as a diagnostic label may impact on the effectiveness of interventions, and it is likely that the diversity and complexity of these difficulties may necessitate a more targeted approach.

----------------------

Edited to add:

https://sci-hub.se/https://doi.org/10.3399/bjgp19X701249

https://sci-hub.se/https://doi.org/10.3399/bjgp19X701849

https://sci-hub.se/https://doi.org/10.3399/bjgp19X701273
 
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One wonders how long researchers can maintain this output at this astonishing level of scholarship. Esppecially whenthe last conclusion seems to be that MUS is too vague to be useful.

Is this the point at which the Duke of Edinburgh Award team realise they have trekking in the wrong direction for six hours?
 
I was on Facebook messenger yesterday evening with a young woman just joined our local Facebook group. She’s very unwell but struggling to get a diagnosis from GP all that’s recorded on her medical notes is fatigue after pressing her GP she was referred to pain clinic which is now supposed to cover CFS but they wouldn’t diagnose her either. She’s worried about going back to the GP after not getting anywhere with the pain clinic as he got cross with her and asked her what she expected him to do. Bloody hell we know it is frustrating we’re the poor Bs actually having the symptoms and living with it 24/7. It is neglect there is no other word for it.
 
Jonathan Edwards said:
Yes, the whole thing needs blowing apart. There is not one iota of evidence behind any of this as far as I am aware. It will take time but MUS is such house of cards that I think it has to fall.

Maybe Jack of All Trades general practice as we know it will crumble in the same time frame, if only because nobody wants to be in that situation any more. UK general practice has survived until now because GPs thought they were self-employed independent practitioners. Almost none of them are now. They are skivvies with inadequate facilities, as opposed to skivvies in hospitals with facilities. They are just been paid to avoid or delay serious medical care to save money.
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Unfortunately to really get it to change if and when there is a sea change in understanding at the top as much effort is going to be needed into educating GPs that MUS is NOT the approved way to deal with patients as is currently being done to persuade them its the answer to all their problems
 
Dx Revision Watch said:
psychologically based interventions (especially different cognitive behavioural therapies [CBT]) have been developed for coping and symptom relief
Click to expand...
So... they have no idea that the CBT variant is actually magical thinking and brainwashing patients into ignoring their symptoms, not the standard coping (psychotherapy cannot "relieve" symptoms, that's just ridiculous)? Or they do know and choose to pretend otherwise because it's not defensible?
 
I'm wondering what it would look like to offer up something better as an alternative to MUS.

Does it all come down to money? If money were no object would Dr's be unstressed at trying various things to get at a real diagnosis?

I read this stuff and honestly I again feel deflated as it seems so huge. Isn't it enough that we are fighting for what's left of the ravages of our lives?

I think Clare Gerada is quite happy to foster disrespect and even dislike from Dr's toward their patients.
Where does this come from?
 
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