Somatic symptom disorders in primary care have not been extensively researched compared with other mental disorders. The few studies found didn't use standardized criteria for sensitive comparison and enhancing generalist care.4 However, the present study shows that SSD is prevalent in primary care patients in Palestine, 32.5 percent of whom have a moderate and high somatization score. This result is in the most upper range, comparable to other studies worldwide. A systemic review reported a prevalence range from 26.2–34.8% of SSD diagnosable by either DSM criteria and/or ICD-10 criteria in the PHC setting.16 Additionally, it was the most prevalent mental health morbidity among Kuwaiti primary care attendees.17 Such statistics demonstrate that SSD presents a highly significant public health concern that is not trivial, especially in the Palestinian community with its unique conflict situation, as this will carry a higher burden on health care setting in terms of health care utilization and cost compared to other economically and politically stable countries.15
A significant result is obtained in this study is the association between SSD with doctor visits, which reflects health care utilization. A finding that is consistent with a highly significant p-value (0.005) even after controlling different confounders. Literature showed a consensus that underdiagnosed SSD would result in higher health care utilization, higher morbidity, and lower health-related quality of life. 15,18,19 Patients with SSD appear to have frequent visits and contacts with their PHC physicians as they feel unhappy with their medical tests, resulting in increased use of medical resources. Patients who have mental disorders tend to be frequent visitors.20 This, in turn, will pressure the already overloaded PHC clinics in Palestine on the one hand and increasing health care costs in this low-income country on the other side. Furthermore, it is a big challenge for PHC physicians in dealing with uncertainty regarding the diagnosis in this highly-stressed clinical population with their usually somatically focused health concepts. A situation that will result in unnecessary medical treatments and referrals whereas short term psychotherapy could be the more convenient, cheaper and best choice.21
The association between SSD and the female gender is consistent with previous findings. Our results align with Alkhadhari and colleagues who reported a strong association between SSD and female gender among the Kuwaiti population 5. This could be attributed to specific cultural norms related to the Arab world and the inherent differences between males and females concerning somatic and emotional perception. Gender imbalance in the rates of abuse and violence; gender disparities in the incidence of anxiety and depressive disorders; and gender inequality may also affect these findings.22
Mechanisms linking co-morbid mental and chronic diseases are complex and bi-directional. Chronic illness can affect mental health and lead to psychological disorders, and an individual may be subjected to chronic physical disease by a psychological disorder. Other mental and physical conditions share risk factors such as chronic social stress, inactivity, overweight, smoking, alcohol use, and endocrine disorders.23 Many studies examined the association between SSD and the presence of chronic disease. They revealed a strong association, increasing in strength, with an increasing number of chronic diseases diagnosed in a single person.17,24 For example, a large population-based study found a strong association between heart attacks and the history of major surgeries and SSD. 25 SSD, on the other hand, was the most common co-morbid mental disorder associated with chronic disease and the one most implicated in poorer prognosis, increased use of health care, higher cost of health care, and more inadequate compliance with treatment.17,26,27
A statistically significant relationship between SSD and depressive disorder has been shown in several studies.6,28,29 The overlap between these disorders was also documented in various studies.5,12 As a result, screening for mental health problems in patients with unexplained symptoms could be recommended based on these results. However, this was not justified by a large longitudinal study in the United Kingdom.28 So, further studies are needed to predict anxiety and depression diagnosis among patients with multiple visits with unexplained medical symptoms.
Painful muscles and back pain are the most common somatic symptoms in our study and were significantly more frequent among clients with SDD. Similarly, back pain and tiredness were more frequently related to this condition in Turkish migrants living in Germany30. Stomach pain and painful leg and arm joints were more frequent associations among the Iranian population.6 Different symptoms may be related to SSD in different groups and cultures. Thus, PHC physicians should have a high index of suspicion to predict SSD, especially among patients with these complaints, if no underlying medical diagnosis could be reached. Moreover, a valid screening tool should be available in a PHC setting to be used by physicians in high-risk patients.
The study has many strong points, including novelty, using a standard questionnaire that has been designed specially to be used in PHC settings and the large sample size that could reduce sampling bias. However, some limitations should be taken into consideration as the study was based on self-reported data, which makes the reliability of the findings questionable. In order to ensure the reliability of participants' responses, the interviews were conducted in a place that guaranteed their privacy and was administered by trained family physicians who used a standardized procedure in data collection. Secondly, given the large sample size for this study to determine the prevalence, it is likely that the sample was not powerful enough to identify substantial differences with individual determinants. Lastly, being a cross-sectional study, not longitudinal, precludes any causal association between SSD and its risk factors.
In conclusion, SSD is prevalent in PHC settings, challenging physicians for possible diagnosis, resulting in increased utilization of healthcare resources, and increased cost. Patients with multiple visits per month could have SSD and move undiagnosed for an extended period. A high index of suspicion, improving physicians' skills in mental health disease diagnosis, and a validated screening tool are recommended at PHC to decrease the burden of this disease on patients, physicians, or the healthcare system.