Cognitive-behavioural therapy v. structured care for medically unexplained symptoms: randomised controlled trial.

BACKGROUND: A pilot trial in Sri Lanka among patients with medically unexplained symptoms revealed that cognitive-behavioural therapy (CBT) administered by a psychiatrist was efficacious.

AIMS: To evaluate CBT provided by primary care physicians in a comparison with structured care.

METHOD: A randomised control trial (n=75 in each arm) offered six 30 min sessions of structured care or therapy. The outcomes of the two interventions were compared at 3 months, 6 months, 9 months and 12 months.

RESULTS: In each arm, 64 patients (85%) completed the three mandatory sessions. No difference was observed between groups in mean scores on the General Health Questionnaire or the Bradford Somatic Inventory, or in number of complaints or patient-initiated consultations at 3 months. For both groups, all outcome measures improved at 3 months, and remained constant in the follow-up assessments.

CONCLUSIONS: Cognitive-behavioural therapy given by primary care physicians after a short course of training is no more efficacious than structured care. Natural remission is an unlikely explanation for improvements in people with chronic medically unexplained symptoms, but lack of a 'treatment as usual' arm limits further conclusions. Further research on enhanced structured care, medical assessment and structured care incorporating simple elements of CBT principles is worthy of consideration.