Digital archive of theses discussed at the University of Pisa


Thesis etd-07042016-201128

Thesis type
Tesi di specializzazione (5 anni)
Thesis title
Frequent attenders in general practice: clinical features and functional impairment
Course of study
relatore Prof.ssa Dell'Osso, Liliana
  • Primary care
  • Panic-Agoraphobic Spectrum
  • MMG
  • GP
  • Frequent Attenders
  • Psychiatry
  • Somatization
  • Subthreshold
Graduation session start date
Release date
In literature, “Frequent Attenders” (FA) are defined as patients characterized by a disproportionate number of visits to General Practioner (GP).
Usually, they frequently contact GPs asking for improper diagnostic tests and several prescriptions.
This group (up to a third of the total) is responsible for a high burden of care, not always justified by the severity of the medical condition.
The aim of this study was to describe FAs by a socio-demographic and functioning point of view, pointing out their psychopathological and demographic characteristics.
Furthermore, we searched predictors of functional impairment, dividing the sample in low and high functioning.
This study was designed and performed in primary care centers of Pisa, Livorno and Lucca areas and FAs were defined as individuals who had consulted 15 times or more during 2015.
We enrolled 75 patients within the inclusion criteria (aged between 18 and 70, neither psychotic and suicidal nor affected by a extremely serious medical disease).
We assessed the sociodemographic aspects, categorical and dimensional psychopathological features (SCID-I, PHQ, PAS-SR, TEMPS-brief), global functioning (GAF), illness behavior and perceived health (IBI, SF-36), somatic comorbidity (CIRS) and clinical severity (CGI).
About sociodemographic characteristics of enrolled patients, 74.7% were female and the mean age was 55.3 years (±13.0). 67.2% were married or cohabiting and 65.3% had a low level of education (less than 8 years).
46.7% of the enrolled FAs were not part of the workforce at the time of observation.
A total of 70.3% had a current SCID diagnosis, in particular major depressive disorder (MDD – 26.7%), somatoform disorders (SFD – 17.3%) and panic disorder (PD – 16.0%) and severity of illness was mild for a third of them (34.7%).
Regarding subthreshold symptomatology, PAS-SR mean score was 35.8 (±19.9), hence greater than cut-off of 35, and the more represented temperament was the cyclotimic one.
At the enrollment, 46.7% of FAs assumed a psychopharmacological therapy, in most cases based on benzodiazepines (27.0%) and serotonin reuptake inhibitors (21.6%) that were prescribed by GP in 82.4% of cases.
One third of FAs (34.7%) was low-functioning (GAF score <70).
Musculo-skeletal (72.6%) disease was the most frequent somatic comorbidity, followed by lower gastrointestinal disease (50.0 %) and genitourinary disease (45.2%).
About health perception (SF-36), physical functioning was the better perceived (78.8±18.8) and the most compromised was vitality (44.5±20.5).
Significant predictor of low-function appeared to be stomach pain complain (PHQ1a), the present of a SCID-current diagnosis, and a depression higher score. Analyzing subclinical aspects, panic-like syndrome, phobia/hypochondriasis, anxious expectation, panic like symptoms and reassurance orientation were found to be closely associated to the lowest functioning sample.
Furthermore, also if they were not longer somatic ill than HF, LF tended to behave as sicker, claimed to be worried about their own health, and perceived themselves as more impaired also regards to the health perception and social role.
A strong predictor of LF was being under psychopharmacological treatment, and in particular benzodiazepines, currently and in the past.
The surprisingly high rate of psychopathology may allow us to classify FAs as a special population affected by a mild-moderate severity of mental illness, and treated cronically with benzodiazepine.
However, it is important to note that they are responsible of a significant impact on the quality of healthcare and economic management of primary care.
In light of these findings, educational initiatives should be undertaken aiming to increasing doctors’ and patients’ confidence in psychological support, and increasing cooperation and the referral system between general practitioners and psychiatrists.