Symptom Management in Older Primary Care Patients: Feasibility of an Experimental, Written Self-Disclosure Protocol

Somatic symptoms, in the absence of clear disease progression or a psychiatric cause, are prevalent in older primary care patients (1-4), and several studies (1-5) have identified psychological and psychosocial distress as prominent contributors to symptom manifestation in older and younger patients. Psychological interventions may be useful for reducing distress-driven symptoms in older primary care patients. The benefits of psychotherapy are numerous (6), but psychotherapy can be resource intensive and costly and may be unnecessary for patients with distress-driven symptoms in the absence of a psychiatric disorder. For these patients, the use of written self-disclosure may reduce somatic symptoms, distress, and health care utilization. Written self-disclosure involves describing the thoughts and emotions associated with a distressing life experience. In experimental protocols, people are asked to write about distressing experiences (self-disclosure) or trivial experiences (control) in a laboratory setting for 20 to 30 minutes on 3 consecutive days. Persons in the self-disclosure group are encouraged and to think about experiences involving relationships with others (including parents, spouses, children, friends, or relatives) and to think about how those experiences may have affected their past and may affect their present or future. To minimize experimental bias, detailed topics for writing are purposely not presented. The mechanism of action in written self-disclosure is largely theoretical and is believed to focus on the negative effect of inhibiting thoughts and emotions. People often inhibit negative thoughts and emotions associated with distressing events to keep them out of immediate awareness (7). This process of inhibition can increase autonomic activity (8), produce somatic symptoms, and diminish well-being (9). The presence of somatic symptoms and decreased well-being often results in visits to a physician or other health care provider. Written self-disclosure may help a person to translate distressing thoughts and emotions into the written word and organize them within the context of a narrative. To the extent that the narrative is coherent and understandable to the person doing the writing, that person gains a sense of control over the distressing thoughts and emotions. Consequently, the need to actively inhibit is diminished, and autonomic activity, somatic symptoms, and distress may be reduced. Written narratives need not be shared with or understood by other people for the benefits to occur. However, written narratives may help a person to share his or her experiences with others, and this may be beneficial. Research examining the content of writing samples created during self-disclosure studies suggests that people who incorporate increasing numbers of causal words (such as because and reason) and insight words (for example, understand and realize) into their description of the thoughts and emotions associated with a distressing experience benefit most from writing. In contrast, people who do not use causal and insight words or people whose initial written disclosure tells a coherent, resolved story are less likely to benefit from the process of writing (10). Despite our limited empirical understanding of the mechanisms of written self-disclosure, the effect of this technique has been evaluated in numerous healthy populations over the past decade. Recent meta-analytic findings (11) support an overall moderate effect of written disclosure in healthy people with respect to a variety of somatic and psychological symptoms as well as health care utilization. Unfortunately, written self-disclosure has been evaluated primarily in healthy young adults in tightly controlled experimental settings. It is not known whether this type of experimental protocol is feasible or effective as a primary carebased intervention for older patients. Therefore, we sought to develop a clinical intervention from an existing experimental protocol, evaluate the feasibility of using the intervention in primary care settings, and describe initial outcomes. Methods Participants Patients were selected from a university-based geriatric primary care clinic and an internal medicine primary clinic in Birmingham, Alabama. Patients who met the eligibility criteria and agreed to participate in the study were randomly assigned to the intervention group or the control group. Patients were included in the study if they were 66 years of age or older, did not have a current psychiatric diagnosis, had a Mini-Mental Status Examination (12) score of 24 or more or no diagnosis of dementia, had at least a fifth-grade education, could read the consent form without assistance, were physically able to write for 20 minutes on three occasions, and had transportation to and from the primary care clinics. A minimal distress level was not used as an inclusion criterion because of the difficulty in distinguishing between distress-driven and disease-driven somatic symptoms. The presence of a few somatic symptoms was not used as an inclusion criterion because previous studies showed the benefits of written self-disclosure in healthy populations (11). Measurements Feasibility Outcomes Feasibility outcomes were patient recruitment and retention, total time required to deliver the intervention, personnel requirements, and patient and provider satisfaction. Satisfaction was assessed with an adaptation of the visit-specific satisfaction questionnaire (13). Responses to nine items were evaluated on a Likert-type scale that ranged from 1 (poor) to 5 (excellent). Clinical Outcomes Somatic and distress symptoms were assessed by using the Patient Health Questionnaire (14). Diagnostic categories of this questionnaire include mood, anxiety, somatoform, and eating disorders, as well as alcohol abuse. We calculated a total distress score (range, 0 to 74) by summing the frequency and severity of all items on the Patient Health Questionnaire except those in the Somatization Scale. The Somatization Scale was used to calculate a total somatic symptom score (range, 0 to 26). The Somatization Scale comprises 13 symptoms common in the primary care setting (pain in the stomach, back, joints, head, or chest; menstrual cramps; pain during sexual intercourse; dizziness; fainting; pounding heart; shortness of breath; and two categories of gastrointestinal problems [nausea, gas, and indigestion; constipation, loose bowels, and diarrhea]). For both the somatic and distress scores, higher scores indicate more frequent and severe symptoms. Somatic and distress symptoms were assessed at baseline and 1 month after the intervention. Changes in scores from baseline to 1 month after the intervention were examined. We assessed health care utilization by using encounter data from a local managed care provider. Data were abstracted 3 months before the intervention, during the intervention, and 3 months after the intervention. Total outpatient service use was defined as the number of Physicians' Current Procedural Terminology codes for outpatient services for each time period. Total charges paid (associated costs) were defined as the total dollar amount paid by the insurance carrier. Changes in total outpatient service use and total charges paid from baseline to after the intervention were examined. Procedures To recruit patients, a checklist containing exclusion criteria (psychiatric diagnosis, Mini-Mental Status Examination score < 24, or dementia) was placed on the outside of each chart and completed by the primary care provider. Patients suitable for the study were greeted by the project manager at the completion of the office visit. They were given a brief overview of the study, and the inclusion criteria were reviewed. Before beginning the protocol, patients were escorted to a private office, where informed consent was obtained, and were randomly assigned to a study group. In both groups, the first session included completion of baseline measures and the first writing sample. Writing instructions were read aloud to minimize the possibility of misunderstanding. Briefly, patients in the treatment group were asked to write about the thoughts and feelings associated with the most distressing event of their lives. Patients in the control group were asked to write about what they did to stay healthy (see Appendix). Appendix Figure. Patient recruitment and exclusion. To promote confidentiality and increase patients' comfort with the disclosure of personal information, we informed patients that all writing samples would be anonymous. Specifically, their names would not appear on the writing samples and the samples would not be shared with the patients' physicians. Patients were asked not to share the content of their writing samples with anyone during the intervention. Patients were told that each writing sample would be reviewed briefly by the principal investigator solely for the purpose of checking that instructions had been followed in each group. It was emphasized to patients that the details of the content of the writing samples would not be evaluated or analyzed. To avoid bias, anonymity and confidentiality were emphasized to patients in both groups. Patients were then left alone to complete their writing. Each patient wrote for 20 minutes. After the first writing session, patients scheduled two times in the next 2 weeks at which to complete the second and third writing samples. Patients in both groups were given take-home instructions, paper for writing, and stamped envelopes in which to return their writing samples. Patients were telephoned 5 minutes before their scheduled times to write. They were instructed to write alone in a quiet place for 20 minutes and, when finished, to mail the writing sample to the project manager. Both groups completed follow-up questionnaires approximately 1 month after their final writing sessions. Upon receipt of completed follow-up packets, patients r