Practice Approach 2

Conservative diagnostic testing. Clinicians are often aware at the time of initial history and physical that diagnostic testing offers a low yield or that anxiety or depression are important exacerbating factors. Most evidence suggests that ordering medically unnecessary tests to reassure patients does not work (Kidd et al. 1993; McDonald et al. 1996). It may also promote a passive patient mindset (e.g., “the doctor's in charge” and will “find it and fix it”) that is counter to behavioral activation goals and the shifting of responsibility for wellness to the patient. One alternative to running new tests is for doctor and patient to carefully review past testing together, an approach that promotes clinician-patient collaboration and patient understanding. It is important, however, that both the clinician and the patient recognize that MUPs is not a diagnosis and that they continue to explore, without excessive testing at each visit, the possibility that new evidence indicates the emergence of a specific disease entity.

Judicious medication use. Medications are no substitute for person-centered care that addresses patient concerns and disability. Central nervous system depressants such as sedative-hypnotics, “muscle relaxers,” and anxiolytics are usually inappropriate unless insomnia is acute, related to a clearly identifiable stressor, and expected to abate within a short time. These medications and narcotic analgesics usually do more harm than good, since they typically slow cognition, cause sedation, and reduce overall functioning and levels of physical activity.

In contrast, antidepressants may reduce MUPS among patients with chronic pain, panic disorder, dysthymic disorder, and major depressive disorder and can result in improved activity levels among depressed or anxious patients. It is important to carefully explain the rationale for psychotropic medications prescribed for MUPS or else patients may assume “the doctor thinks that the symptoms are in my head.” All patients with MUPS should receive a complete and careful explanation of medication side effects, so that if they occur the clinician's credibility is enhanced and the chance of continued adherence is maximized.

Reassurance strategies. Comforting patients with MUPS often entails reassurance. This means more than simply telling them that their symptoms are not serious, a strategy that many patients will experience as

² The section is taken from a report prepared for the committee by Charles C. Engel, Jr., M.D., M.P.H., and Wayne J. Katon, M.D.