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Somatization Increases Medical Utilization and Costs Independent of Psychiatric and Medical Comorbidity
Arthur J. Barsky, MD;
E. John Orav, PhD;
David W. Bates, MD
Arch Gen Psychiatry. 2005;62:903-910.
Context Somatoform disorders are an important determinant of medical care utilization, but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity.
Objectives To assess the extent of the overlap of somatization with other psychiatric disorders; to compare the medical utilization of somatizing and nonsomatizing patients; and to determine the independent contribution of somatization alone to utilization.
Design Patients were surveyed with self-report questionnaires assessing somatization and psychiatric disorder. Medical care utilization was obtained from automated encounter data for the year preceding the index visit. Medical morbidity was indexed with a computerized medical record audit.
Setting Two hospital-affiliated primary care practices.
Participants Consecutive adults making scheduled visits to their primary care physicians on randomly chosen days. In all, 2668 questionnaires were distributed, and 1914 (71.7%) were returned. Of these, 1546 (80.8%) contained complete data and met eligibility criteria.
Main Outcome Measures Medical care utilization and costs within our hospital system in the preceding 12 months.
Results Two hundred ninety-nine patients (20.5%) received a provisional diagnosis of somatization; 42.3% of these patients had no comorbid depressive or anxiety disorder. Somatizing patients, when compared with nonsomatizing patients, had more primary care visits (mean [SE], 4.90 [0.32] vs 3.43 [0.11]; P<.001); more specialty visits (mean [SE], 8.13 [0.55] vs 4.90 [0.21]; P<.001); more emergency department visits (mean [SE], 1.29 [0.15] vs 0.52 [0.036]; P<.001); more hospital admissions (mean [SE], 0.32 [0.051] vs 0.13 [0.014]; P<.001); higher inpatient costs (mean [SE], $3146 [$380] vs $991 [$193]; P<.001); and higher outpatient costs (mean [SE], $3208 [$180] vs $1771 [$91]; P<.001). When these results were adjusted for the presence of comorbid anxiety and depressive disorders, major medical morbidity, and sociodemographic characteristics, patients with somatoform disorder still had more primary care visits (P = .04), more specialist visits (P = .002), more emergency department visits (P<.001), more hospital admissions (P<.001), more ambulatory procedures (P<.001), higher inpatient costs (P<.001), and higher outpatient costs (P<.001). When these findings are extrapolated to the national level, an estimated $256 billion a year in medical care costs are attributable to the incremental effect of somatization alone.
Conclusions Patients with somatization had approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of nonsomatizing patients. Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively little effect on this association.
Author Affiliations: Department of Psychiatry (Dr Barsky) and Division of General Internal Medicine, Department of Medicine (Drs Orav and Bates), Brigham and Women’s Hospital and Harvard Medical School, and Department of Health Care Policy, Harvard School of Public Health (Dr Bates), Boston, Mass.
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