PSYCHOSOMATIC THERAPY FOR PATIENTS WITH PERSISTENT SOMATIC SYMPTOMS IN PRIMARY CARE: EFFECTIVENESS, COSTS AND WORKING MECHANISMS: effectiveness, costs and working mechanisms

Patients with PSS suffer because of their symptoms, experience functional impairment and a reduced quality of life, moreover PSS are associated with substantial costs for patients as well as society. The recommended management of PSS is an approach based on the biopsychosocial model, stepped care and is patient centered. Also, multimodal treatments are proposed, i.e., treatments that address both physical and cognitive behavioral aspects of PSS. Psychosomatic therapy delivered by specialized exercise therapists and physiotherapists in primary care in the Netherlands, is such a biopsychosocial, patient-centered, multimodal approach. A pilot randomized controlled trial (RCT) tested the systematic identification of eligible patients, acceptability and potential treatment effects of psychosomatic therapy and showed that a larger trial studying the effectiveness of psychosomatic therapy in patients with PSS in primary care is feasible and useful. The CORPUS trial, the two-armed RCT among primary care patients with PSS in the Netherlands is conducted and included 39 general practices, 34 psychosomatic therapists and 178 patients. In the usual care group (n = 85) as well as in the intervention group (n = 84), patient’s level of functioning and most secondary treatment outcomes improved but these improvements did not statistically significant differ between the two groups. Overall, it is a negative study with some interesting secondary findings. Only the group with moderate PSS seemed to benefit from the therapy compared to individuals with severe PSS. In the qualitative part of the process evaluation alongside the CORPUS trial a total of 37 patients interview transcripts, 25 therapists interview transcripts and two focus groups transcripts were included in the analysis. According to patients as well as therapists, the continuous alternation of psychosocial conversations and body-oriented exercises to provide awareness of the interaction between body and mind, is the perceived working mechanism of psychosomatic therapy. Finding common ground on the psychosomatic approach and psychosomatic explanation of patient’s symptoms are prerequisites for the success of psychosomatic therapy. In a systematic review aiming to provide an overview of the evidence regarding the cost-effectiveness of interventions for patients with PSS, and assessing the methodological quality of the identified economic evaluations we included a total of 39 studies of the 1,613 articles. In 13 cost-utility analyses the intervention conditions dominated the control conditions meaning that the interventions were (on average) cost-effective in comparison with the control condition. However, the included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes which limited comparability. A full economic evaluation with a one year time horizon was performed, alongside the CORPUS trial, from both a healthcare and societal perspective. Outcomes were costs per Quality-Adjusted Life Year (QALYs) and improvement in level of functioning. In the total group patients with PSS, psychosomatic therapy compared with usual care was cost-effective. However, in the subgroup of patients with moderate PSS, psychosomatic therapy was not cost-effective. In contrast, psychosomatic therapy was cost-effective in the subgroup of patients with severe PSS implying that psychosomatic therapy might have added value especially for these patients.