Interrelationships between symptom burden & health functioning & health care utilization among veterans w/persistent physical symptoms, 2020, Fried

Wonderful post @rvallee, I wish the authors could read it.

I have argued that when doctors have no idea how to treat an illness they can still be useful - in helping to educate loved ones that the debility is real, or providing evidence for insurance claims, or signing an application for disabled parking, or collecting information that might contribute to a better understanding of the disease, or putting the person in touch with a peer support group. But I guess all those are things that might eventually contribute to some symptom relief.

 

So it sounds as though they started with 790 soldiers at pre-deployment. Deployments were typically about a year long. Only 422 soldiers were available for post-deployment assessment at Phase 2 - 345 could not be located. Which sounds rather careless of the army - did they just lose them somewhere on deployment? This is the army - surely if they wanted the soldiers assessed, they could find most of them? This study was done at Phase 4 - 1 year after deployment. I didn't see the number of the soldiers used for this study specifically reported anywhere in the paper but adding up numbers in tables suggests that only 319 soldiers made it to Phase 4. So, there may have been bias in the sample.

The study acknowledged the big attrition rate. But they say 'never mind, at baseline the soldiers who didn't make it to Phase 4 were no different to the ones who did. Which I would have thought was rather missing the point - it's differences in what happened to them while on deployment that is of most interest.

 

Soldiers with a range of health issues at baseline were excluded from the study. So, young, fit, healthy and primarily male.

So physical health and mental health assessed before and after deployment.

Bearing in mind the standard deviations, there's a pretty significant decrease in health given these young people were very healthy at baseline and the measurements were done only about two years later. Of course, there's an effect of aging, but I doubt that you'd see that kind of decline in non-deployed people from age 27 to age 29. Adding in the attrition rate and any bias that might have caused, it's hardly an ad for being in the army. I doubt that that kind of mean health loss would be acceptable in most employment situations.

I understand military deployment is not a walk in the park, but 'expecting a sizeable portion to develop clinically significant persistent physical symptoms' from a single one-year deployment! Perhaps you might expect that in top-level sport, but those people tend to get paid a whole lot more to put their body on the line than your typical young soldier. I wonder if the people who are expected to pay this price really know what they are signing up for.

 

This is maybe the most important finding. Contrary to the researcher's expectations, it wasn't people with bad mental health that were turning up at the doctor's office most trying to get their symptoms fixed. It was the people with physical symptoms, yes, very clearly, but they were more likely to seek medical care if they had good mental health functioning.

'Damn', you can hear the researchers saying between the lines. 'How can we say that we need to be giving these people mental health care rather than investigating their symptoms?' But fortunately, the sample is mostly male. That leaves half of the population that still might be shoehorned into a hypothesis.

Yeah, females might still be choosing to have lots of doctors' appointments without a corresponding symptom burden - 'cos, I don't know, sitting in a waiting room and then being scoffed at by a doctor is the female idea of a good time?

 

So, the authors seemed to want to differentiate physical symptoms and physical health function, so that they could conclude that there's no need to investigate the cause of symptoms or treat symptoms, but rather concentrate on improving physical health function. Which is perhaps fine if the patient has an amputated leg - the cause may be less important; it is important to get the person walking again with a prosthetic. But it's not so great if the patient has fatigue and headaches - finding the cause may be very important to working out a suitable treatment. .....Unless of course you think CBT and hardening up is the answer to anything with no obvious physical cause.

But the study found that symptom burden and physical health function were actually highly related. Who would have thought?

That's the sort of attitude that feeds conspiracy theories. If you are a person who has suddenly become so sick that you are unable to work or enjoy the activities you used to enjoy, you deserve a decent and prompt diagnostic effort. If you don't get that decent diagnostic effort, you are likely to become fodder for all sorts of quackery. There doesn't need to be an either/or when it comes to diagnostic effort and focusing on restoring health function. A doctor can fill out a form for disabled parking to make shopping more manageable for their patient while still investigating a cause.

I'm assuming the 'physical symptoms' here is a typo. Doctors find patients presenting with physical symptoms to be among the most challenging to treat? What, because patients presenting without physical symptoms are super-easy - just write 'hypochondriac' in the notes and send them off for CBT - no thinking required?

This study reeks of the data not supporting the hypothesis, but the authors pushing on heroically with their planned conclusion nonetheless.