One third of frequent attenders to UK outpatient clinics have symptoms that are
inadequately explained by disease according to specialist opinion (medically
'unexplained'). Some of these patients are frequently referred for similar symptoms
to multiple specialties. The characteristics and treatment needs ofthese frequently
referred patients are poorly understood.
The aim was to identify and describe patients frequently referred from primary care
to hospital clinics for medically 'unexplained' symptoms (FRMUS) and compare
them with patients frequently referred with medically explained symptoms (FRMES)
and patients infrequently referred for symptoms (IRS).
Compared to FRMES and IRS patients, a greater proportion of FRMUS patients
would have anxiety or depression and this would be inadequately treated. Subsidiary
hypotheses relating to: consulting multiple doctors, health care costs, perceived
general health, satisfaction with care, and health beliefs, as well as the general
practitioners' (GPs) expressed difficulty managing the patient, were also tested.
The methodology employed for this study involved three phases as follows: (1)
Identification of cases and controls from five Edinburgh general practices using a
combination ofNational Health Service (NHS) referral data and primary care case
notes. (2) A case-control study to describe and compare FRMUS patients with the
two control patient groups. This comprised a questionnaire survey of GPs and
patients, and a lifetime case note review for a 15% random selection of FRMUS and
FRMES participants. (3) An economic analysis of the health care contacts.
FRMUS patients made up 1.1% (293/26252; CI 0.01-0.013) of the primary care
population aged 18-65 years, and nearly two thirds (218/293, 74.4%) were female.
The FRMUS patients had statistically more anxiety (67/193, 34.7%) when compared
to 37 ofthe 162 FRMES (22.8%, OR 1.8, CI 1.12-2.88) and 23 of the 152 IRS
(15.1%, OR 2.98, CI 1.75-5.09) comparison patient groups. Although there was no
statistical difference for diagnoses of depression between the FR groups, the FRMUS
patients had a significantly greater mean score for depressive symptoms than the
FRMES control patients (mean difference 2.03, CI 0.66-3.41). Of the 67 FRMUS
patients with an anxiety disorder 41(61.2%) were receiving adequate treatment, and
this was considerably more than the six of 37 FRMES (16.2%, OR 8.147, CI 2.99-
22.21) and the six of 23 IRS (26.1%, OR 4.47, CI 1.56-12.8) comparison patients
who had an anxiety disorder. Treatment for those patients with depression was also
significantly greater for FRMUS patients (43/64, 67.2%) compared with the FRMES
(10/41, 24.4%, OR 6.35, CI 2.62-15.36) and IRS (5/21, 23.8%, OR 6.56, CI 2.11-
20.32) groups. FRMUS patients were also more likely to: be female, reside in a
deprived area of Lothian, referred by multiple doctors, have problems considered to
be more difficult to help by a GP, have high health care costs, and report poor
general physical and mental health.
A third of FRMUS patients had anxiety and depression, the majority of whom were
receiving 'adequate treatment'. Factors other than undetected anxiety and depression
may better explain why these patients are repeatedly referred to outpatient clinics for