Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Understanding suicide risk and eating disorders in college student populations: Results from a National Study

OBJECTIVE

To examine suicide risk by eating disorder severity and symptom presentation in a nationwide sample of college students.

METHOD

The Healthy Minds Study is the largest mental health survey of college populations in the United States. We analyzed the most recent available data (2015-2017) with 71,712 randomly selected students from 77 campuses. We estimated associations between two measures of suicidality (ideation and attempts) and three validated measures of eating disorder symptoms (the SCOFF, weight concerns scale, and the eating disorder examination questionnaire binge and purge items). Importantly, we also controlled for co-occurring symptoms of depression and anxiety, based on validated screening tools. The large, diverse sample provided a unique opportunity to assess whether certain individual characteristics were associated with increased risk.

RESULTS

Eating disorder symptoms, even at subthreshold levels, were highly predictive of suicidality. Relative to students with no apparent eating disorder symptoms, students with the highest symptom levels (a SCOFF score of 5) had 11 times higher odds of attempting suicide, while those with subthreshold symptoms had two times higher odds. We also observed a strong association between suicide attempts and eating disorder presentations that included purging. Students from marginalized backgrounds, particularly gender and sexual minorities, were at increased risk for suicide and eating disorders.

DISCUSSION

In the largest known study to date, findings suggest that eating disorders should be a priority within broader campus suicide prevention efforts, should be assessed along a continuum of severity and symptom presentation, and should focus on reaching vulnerable students.

Male hypogonadism: a review

This article contains a systematic review of the main developments that have occurred in the area of male hypogonadism between the publication of the Endocrine Society Guidelines of 2010 and 2018 and after 2018.

Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series

BACKGROUND

Many patients with obesity and comorbid binge eating symptoms present with the desire to lose weight. Although some studies suggest that dietary restriction can exacerbate binge eating, others show dietary restriction is associated with significant reductions in binge eating. The effect of a particular type of dieting on binge eating, the ketogenic diet (a high fat, moderate protein, very low carbohydrate diet), is not known.

CASE PRESENTATIONS

We report on the feasibility of a low-carbohydrate ketogenic diet initiated by three patients (age 54, 34, and 63) with obesity (average BMI 43.5 kg/m2) with comorbid binge eating and food addiction symptoms. All patients tolerated following the ketogenic diet (macronutrient proportion 10% carbohydrate, 30% protein, and 60% fat; at least 5040 kJ) for the prescribed period (e.g., 6-7 months) and none reported any major adverse effects. Patients reported significant reductions in binge eating episodes and food addiction symptoms including cravings and lack of control as measured by the Binge-Eating Scale, Yale Food Addiction Scale, or Yale-Brown Obsessive-Compulsive Scale modified for Binge Eating, depending on the case. Additionally, the patients lost a range of 10-24% of their body weight. Participants reported maintenance of treatment gains (with respect to weight, binge eating, and food addiction symptoms) to date of up to 9-17 months after initiation and continued adherence to diet.

CONCLUSIONS

Although the absence of control cases precludes conclusions regarding the specific role of ketogenic diets versus other forms of dietary restriction, this is the first report to demonstrate the feasibility of prescribing a ketogenic diet for patients with obesity who report binge eating and food addiction symptoms. Further research should seek to reproduce the observed effects in controlled trials as well as to explore potential etiologies.

Implementing collaborative care to reduce depression for rural native American/Alaska native people

BACKGROUND

The purpose of this study was to identify the effects of Collaborative Care on rural Native American and Alaska Native (AI/AN) patients.

METHODS

Collaborative Care was implemented in three AI/AN serving clinics. Clinic staff participated in training and coaching designed to facilitate practice change. We followed clinics for 2 years to observe improvements in depression treatment and to examine treatment outcomes for enrolled patients. Collaborative Care elements included universal screening for depression, evidence-based treatment to target, use of behavioral health care managers to deliver the intervention, use of psychiatric consultants to provide caseload consultation, and quality improvement tracking to improve and maintain outcomes. We used t-tests to evaluate the main effects of Collaborative Care and used multiple linear regression to better understand the predictors of success. We also collected qualitative data from members of the Collaborative Care clinical team about their experience.

RESULTS

The clinics participated in training and practice coaching to implement Collaborative Care for depressed patients. Depression response (50% or greater reduction in depression symptoms as measured by the PHQ-9) and remission (PHQ-9 score less than 5) rates were equivalent in AI/AN patients as compared with White patients in the same clinics. Significant predictors of positive treatment outcome include only one depression treatment episodes during the study and more follow-up visits per patient. Clinicians were overall positive about their experience and the effect on patient care in their clinic.

CONCLUSIONS

This project showed that it is possible to deliver Collaborative Care to AI/AN patients via primary care settings in rural areas.

Evaluation of the Teaching Recovery Techniques community-based intervention for unaccompanied refugee youth experiencing post-traumatic stress symptoms (Swedish UnaccomPanied yOuth Refugee Trial; SUPpORT): study protocol for a randomised controlled trial

Background

In 2015, 162,877 persons sought asylum in Sweden, 35,369 of whom were unaccompanied refugee minors (URMs). Refugee children, especially URMs, have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue years after resettlement. The Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT) aims to evaluate a community-based intervention, called Teaching Recovery Techniques (TRT), for refugee youth experiencing PTSD symptoms.

Methods/design

A randomised controlled trial will be conducted in which participants will be randomly allocated to one of two possible arms: the intervention arm (n = 109) will be offered the TRT programme, and the waitlist-control arm (n = 109) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; about 8 weeks after randomisation) and follow-up (T3; about 20 weeks after randomisation).

Discussion

This study will provide knowledge about the effect and efficiency of a group intervention for URMs reporting symptoms of PTSD in Sweden.

Trial registration

ISRCTN, ISRCTN47820795. Prospectively registered on 20 December 2018.

Psychometric Properties of the Patient Health Questionnaire-9 in Elderly Chilean Primary Care Users

Background: This study aimed to assess the measurement properties (reliability, factor structure, and criterion validity) of the Patient Health Questionnaire (PHQ-9) as an instrument for screening major depressive disorder (MDD) in elderly primary care users in Chile. Method: About 582 participants aged between 65 and 80 years were enrolled from primary care centers. They completed the Composite International Diagnostic Interview (CIDI), a survey with sociodemographic characteristics and the PHQ-9. Results: The PHQ-9 revealed an acceptable internal consistency (ω = 0.79 [95% CI: 0.75-0.80] and α = 0.78 [95% CI: 0.75-0.81]); confirmatory factor analysis demonstrated a good fit for both 1- and 2-factor solutions. The chi-square difference test (χ² = 0.61, gl = 1, p = 0.43) and correlation between the somatic and the cognitive-effective latent factors were very high (r = 0.97, p < 0.001), indicating that the 1 factor model was more parsimonious. Utilizing the CIDI as the gold standard, the area under the curve (AUC) was 0.88 (SE = 0.04, 95% CI: 0.84-0.90). The optimal cut-off score of ≥ 6 yielded good sensitivity and specificity for detecting MDD (0.95 and 0.76, respectively). However, considering the clinical utility index, the cut-off score of ≥9 proved to be a more effective marker for discarding cases of MDD. Conclusion: The PHQ-9 has adequate psychometric properties for elderly primary care users. In clinical settings, it showed its greatest utility in ruling out the presence of an MDD, however, its clinical value for identifying possible cases of MDD is limited. In cases above the cut-off point, it is recommended to perform a more thorough evaluation.

Effects of Pharmacotherapy Treatment on Patient-Reported Outcomes in a Narcolepsy and Idiopathic Hypersomnia Cohort

STUDY OBJECTIVE

We aimed to evaluate the association between patient-reported outcomes (PROs) and treatment regimen/standardized dose (STD), a measure of drug burden, in patients with narcolepsy type 1 (NT1)/type 2 (NT2) and idiopathic hypersomnia (IH).

METHODS

Patients age 18 years or older with NT1/NT2 and IH with baseline and ≥ 6-month follow-up during 2008-2010 were included. Changes in PROs (Epworth Sleepiness Scale [ESS], Fatigue Severity Scale [FSS], Patient Health Questionnaire 9 [PHQ-9], total sleep time [TST]) by diagnosis, treatment regimen (monotherapy versus polytherapy, sodium oxybate [SO] use), and STD were assessed by t tests and univariable/multivariable linear regressions, adjusting for patient characteristics.

RESULTS

A total of 92 patients (26 [28.3%] NT1, 27 [29.3%] NT2, 39 [42.4%] IH) were included (age 43.8 ± 14.8 years; 66 [71.7%] female). Baseline PROs suggested excessive daytime sleepiness (ESS 14.2 ± 5.2 [74% patients > 10]), significant fatigue (FSS 47.5 ± 12.9), and mild depression (PHQ-9 9.0 [4.0, 14.0] [49.4% ≥ 10]). At follow-up, ESS and PHQ-9 improved significantly overall and within diagnostic, monotherapy/polytherapy, and SO use groups (all P < .01). FSS improved significantly overall (P = .016), but improvements were not significant for IH, monotherapy, polytherapy, and non-SO using groups. In multivariable models, PRO changes were not significantly different between groups, but baseline STD was associated with worsening PHQ-9 across PHQ-9 change models, and ESS worsened with increasing STD at follow-up (P = .056).

CONCLUSIONS

Significant improvements in sleep-related PROs were seen with pharmacotherapy use, regardless of diagnosis or treatment type, highlighting the importance of individualized prescribing decisions for this population.

Association of Night Eating with Depression and Depressive Symptoms in Korean Women

This study examined the associations of night eating with depression and depressive symptoms in Korean adults. The study used a nationally representative sample of 31,690 Korean adults (≥19 years old) from the Korea National Health and Nutrition Examination Survey from 2008 to 2013. The participants were divided into two groups based on status of night eating: night eaters (consuming ≥25% of total daily energy intake between 21:00 and 06:00) and non-night eaters. Depression was defined based on diagnosis by a doctor, whereas depressive symptoms were defined as feelings of sadness or desperation for more than two weeks in the last one year. Multivariable logistic regression analyses were performed to examine the relationship between night eating and odds of depression and depressive symptoms after controlling for age, education, income, marital status, drinking, smoking, day of recalled intake, physical activity, body mass index, menopausal status (women only), total energy intake, and sleep duration. A total of 14.3% of Korean adults were night eaters. Night eaters were more likely to be men, young, less educated, single, drinkers, current smokers, and not employed (all ps < 0.05). In women, night eaters had higher odds of depression (adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.02–1.75; p for trend = 0.0389) and depressive symptoms (AOR, 1.20; 95% CI, 1.01–1.41; p for trend = 0.0382) compared with non-night eaters. However, no associations of night eating with depression and depressive symptoms were found in men. Night eaters had higher odds of depression and depressive symptoms only in Korean women. Future studies are warranted to elucidate the underlying psychological and behavioral mechanisms that in turn may shed light on the factors influencing both night eating and odds of depression and depressive symptoms.

Antidepressant treatment with sertraline for adults with depressive symptoms in primary care: the PANDA research programme including RCT

Background

Despite a growing number of prescriptions for antidepressants (over 70 million in 2018), there is uncertainty about when people with depression might benefit from antidepressant medication and concern that antidepressants are prescribed unnecessarily.

Objectives

The main objective of the PANDA (What are the indications for Prescribing ANtiDepressAnts that will lead to a clinical benefit?) research programme was to provide more guidance about when antidepressants are likely to benefit people with depression. We aimed to estimate the minimal clinically important difference for commonly used self-administered scales for depression and anxiety, and to understand more about how patients respond to such assessments. We carried out an observational study of patients with depressive symptoms and a placebo-controlled randomised controlled trial of sertraline versus placebo to estimate the treatment effect in UK primary care. The hypothesis was that the severity and duration of symptoms were related to treatment response.

Design

The programme consisted of three phases. The first phase relied on the secondary analysis of existing data extracted from published trials. The second phase was the PANDA cohort study of patients with depressive symptoms who presented to primary care and were followed up 2, 4 and 6 weeks after a baseline assessment. Both quantitative and qualitative methods were used in the analysis. The third phase was a multicentre randomised placebo-controlled double-blind trial of sertraline versus placebo in patients presenting to primary care with depressive symptoms.

Setting

UK primary care in Bristol, London, Liverpool and York.

Participants

Patients aged 18–74 years who were experiencing depressive symptoms in primary care. Eligibility for the PANDA randomised controlled trial included that there was uncertainty about the benefits about treatment with an antidepressant.

Interventions

In the PANDA randomised controlled trial, patients were individually randomised to 100 mg daily of sertraline or an identical placebo. The PANDA cohort study was an observational study.

Main outcome measures

Depressive symptoms measured using the Patient Health Questionnaire were the primary outcome for the randomised controlled trial. Other outcomes included anxiety symptoms using the Generalised Anxiety Disorder-7; depressive symptoms using the Beck Depression Inventory, version 2; health-related quality of life; self-reported improvement; and cost-effectiveness.

Results

The secondary analysis of existing randomised controlled trials [GENetic and clinical Predictors Of treatment response in Depression (GenPod), TREAting Depression with physical activity (TREAD) and Clinical effectiveness and cost-effectiveness of cognitive Behavioural Therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care (CoBalT)] found evidence that the minimal clinically important difference increased as the initial severity of depressive symptoms rose. Our estimates of minimal clinically important difference were a 17% and 18% reduction in Beck Depression Inventory scores for GenPod and TREAD, respectively. In CoBalT, a 32% reduction corresponded to the minimal clinically important difference but the participants in this study had depression that had not responded to antidepressants. In the PANDA study cohort, and from our analyses in existing data, we found that the minimal clinically important difference varies considerably with the initial severity of depressive and anxiety symptoms. Expressing the minimal clinically important difference as a percentage reduction reduces this variation at higher scores, but at low scores the percentage reduction increased substantially. The results from the qualitative studies pointed out many limitations of the Patient Health Questionnaire-9 items in assessing change and recovery from depression. In the PANDA randomised controlled trial, there was no evidence that sertraline resulted in a reduction in depressive symptoms within 6 weeks of randomisation, but there was some evidence of a reduction by 12 weeks. However, sertraline led to a reduction in anxiety symptoms, an improvement of mental health-related quality of life and an increased likelihood of reporting improvement. The mean Patient Health Questionnaire-9 items score at 6 weeks was 7.98 (standard deviation 5.63) in the sertraline group and 8.76 (standard deviation 5.86) in the placebo group (5% relative reduction, 95% confidence interval –7% to 15%; p = 0.41). Of the secondary outcomes, there was strong evidence that sertraline reduced anxiety symptoms (Generalised Anxiety Disorder-7 score reduced by 17% (95% confidence interval 9% to 25%; p = 0.00005). Sertraline had a high probability (> 90%) of being cost-effective at 12 weeks. The PANDA randomised controlled trial found no evidence that treatment response or cost-effectiveness was related to severity or duration of depressive symptoms. The minimal clinically important difference estimates suggested that sertraline’s effect on anxiety, but not on depression, was likely to be clinically important.

Limitations

The results from the randomised controlled trial and the estimates of minimal clinically important difference were not sufficiently precise to provide specific clinical guidance for individuals. We had low power in testing whether or not initial severity and duration of depressive symptoms are related to treatment response.

Conclusions

The results of the trial support the use of sertraline and probably other selective serotonin reuptake inhibitors because of their action in reducing anxiety symptoms and the likelihood of longer-term benefit on depressive symptoms. Sertraline could be prescribed for anxiety symptoms that commonly occur with depression and many patients will experience a clinical benefit. The Patient Health Questionnaire-9 items and similar self-administered scales should not be used on their own to assess clinical outcome, but should be supplemented with further clinical assessment.

Future work

We need to examine the longer-term effects of antidepressant treatment. We need more precise estimates of the treatment effects and minimal clinically important difference at different severities to provide more specific guidance for individuals. However, the methods we have developed provide an approach towards providing such detailed guidance.

Trial registration

Current Controlled Trials ISRCTN84544741 and EudraCT number 2013-003440-22.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 10. See the NIHR Journals Library website for further project information.

Effect of Vitamin D Supplementation on Depressive Symptoms in Patients With Knee Osteoarthritis

OBJECTIVES

To determine the effect of vitamin D supplementation and maintaining sufficient serum vitamin D on depressive symptoms in patients with knee osteoarthritis (OA) and vitamin D deficiency.

DESIGN

A prespecified secondary analysis of a multicentre, randomized, double-blind, placebo-controlled trial. Participants were randomly assigned to receive oral vitamin D3 (50,000 IU, n = 209) or placebo (n = 204) monthly for 24 months. In addition, participants who completed the trial were classified into 2 groups according to their serum 25(OH)D levels at month 3 and 24 as follows: not consistently sufficient (serum 25(OH)D ≤ 50 nmol/L at month 3 and/or 24), and consistently sufficient (serum 25(OH)D > 50 nmol/L at both month 3 and 24). Multilevel mixed-effect models were used to compare differences of change in PHQ-9 scores between groups.

SETTING AND PARTICIPANTS

This clinical trial was conducted in participants with symptomatic knee OA and vitamin D deficiency from June 2010 to December 2013 in Tasmania and Victoria, Australia.

MEASURES

The primary outcome was the depressive symptoms change over 24 months, which was measured using the Patient Health Questionnaire (PHQ-9, 0-27).

RESULTS

Of 599 participants who were screened for eligibility, 413 participants were enrolled (mean age: 63.2 years; 50.3% female) and 340 participants (intervention n = 181, placebo n = 159, 82.3% retention rate) completed the study. The baseline prevalence of depression (PHQ-9 score ≥5) was 25.4%. Depressive symptoms improved more in the vitamin D supplementation group compared to the placebo group [β: -0.66, 95% confidence interval (CI): -1.22 to -0.11, P for difference = .02] and in the participants who maintained vitamin D sufficiency compared to those who did not (β: -0.73, 95% CI: -1.41 to -0.05, P for difference = .04) over 24 months.

CONCLUSIONS/IMPLICATIONS

These findings suggest that vitamin D supplementation and maintaining adequate vitamin D levels over 24 months may be beneficial for depressive symptoms in patients with knee OA.

Study protocol for the COMET study: a cluster-randomised, prospective, parallel-group, superiority trial to compare the effectiveness of a collaborative and stepped care model versus treatment as usual in patients with mental disorders in primary care

INTRODUCTION

Mental healthcare is one of the biggest challenges for healthcare systems. Comorbidities between different mental disorders are common, and patients suffer from a high burden of disease. While the effectiveness of collaborative and stepped care models has been shown for single disorders, comorbid mental disorders have rarely been addressed in such care models. The aim of the present study is to evaluate the effectiveness of a collaborative and stepped care model for depressive, anxiety, somatoform and alcohol use disorders within a multiprofessional network compared with treatment as usual.

METHODS AND ANALYSIS

In a cluster-randomised, prospective, parallel-group superiority trial, n=570 patients will be recruited from primary care practices (n=19 practices per group). The intervention is a newly developed collaborative and stepped care model in which patients will be treated using treatment options of various intensities within an integrated network of outpatient general practitioners, psychiatrists, psychotherapists and inpatient institutions. It will be compared with treatment as usual with regard to effectiveness, cost-effectiveness and feasibility, with the primary outcome being a change in mental health-related quality of life from baseline to 6 months. Patients in both groups will undergo an assessment at baseline, 3, 6 and 12 months after study inclusion.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of the Hamburg Medical Association (No. PV5595) and will be carried out in accordance with the principles of the Declaration of Helsinki. For dissemination, the results will be published in peer-reviewed journals and presented at conferences. Within the superordinate research project Hamburg Network for Health Services Research, the results will be communicated to relevant stakeholders in mental healthcare.

TRIAL REGISTRATION NUMBER

NCT03226743.

Effect of Positive Airway Pressure Therapy on Drowsy Driving in a Large Clinic-Based Obstructive Sleep Apnea Cohort

STUDY OBJECTIVES

Drowsy driving related to obstructive sleep apnea (OSA) represents an important public health problem with limited data on the effect of positive airway pressure (PAP) therapy. We hypothesize that PAP therapy will reduce self-reported drowsy driving in a large clinic-based OSA cohort.

METHODS

Drowsy driving (self-reported near-accidents/accidents) incidents from baseline to after PAP therapy (stratified by adherence) were compared in a cohort of 2,059 patients with OSA who initiated PAP therapy from January 1, 2010 to December 31, 2014. Multivariable logistic regression models evaluated the dependence of change in drowsy driving incidents on other factors, including change in Epworth Sleepiness Scale (ESS) and Patient Health Questionnaire-9 (PHQ9) scores.

RESULTS

In the entire cohort (age 56.0 ± 13.1 years, 45.4% female, 76.0% white, average follow-up 124.4 ± 67.3 days), drowsy driving incidents reduced from 14.2 to 6.9% after PAP therapy (P < .001). In subgroups, drowsy driving incidents reduced from 14% to 5.3% (P < .001) in patients who self-reported adherence to PAP therapy and 14.1% to 5.3% (P < .001) in patients objectively adherent to PAP therapy. For each one-point improvement in Epworth Sleepiness Scale score, the odds of drowsy driving decreased by about 14% (odds ratio 0.86, 95% confidence interval 0.82 to 0.90).

CONCLUSIONS

In this clinic-based cohort, drowsy driving improved after adherent PAP usage, with greater drowsy driving risk for those with greater sleep propensity. This highlights the importance of and need for routine drowsy driving assessments and careful clinical attention to PAP adherence and sleep propensity in this population. Our findings should be confirmed and may be used to provide support for initiatives to address the public health issue of drowsy driving.

PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis

OBJECTIVE

Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary rhinology practice.

SUBJECTS AND METHODS

During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22.

RESULTS

Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson's coefficient of 0.632 (P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10).

CONCLUSION

Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.

Rationale and Design of the Hamburg City Health Study

The Hamburg City Health Study (HCHS) is a large, prospective, long-term, population-based cohort study and a unique research platform and network to obtain substantial knowledge about several important risk and prognostic factors in major chronic diseases. A random sample of 45,000 participants between 45 and 74 years of age from the general population of Hamburg, Germany, are taking part in an extensive baseline assessment at one dedicated study center. Participants undergo 13 validated and 5 novel examinations primarily targeting major organ system function and structures including extensive imaging examinations. The protocol includes validate self-reports via questionnaires regarding lifestyle and environmental conditions, dietary habits, physical condition and activity, sexual dysfunction, professional life, psychosocial context and burden, quality of life, digital media use, occupational, medical and family history as well as healthcare utilization. The assessment is completed by genomic and proteomic characterization. Beyond the identification of classical risk factors for major chronic diseases and survivorship, the core intention is to gather valid prevalence and incidence, and to develop complex models predicting health outcomes based on a multitude of examination data, imaging, biomarker, psychosocial and behavioral assessments. Participants at risk for coronary artery disease, atrial fibrillation, heart failure, stroke and dementia are invited for a visit to conduct an additional MRI examination of either heart or brain. Endpoint assessment of the overall sample will be completed through repeated follow-up examinations and surveys as well as related individual routine data from involved health and pension insurances. The study is targeting the complex relationship between biologic and psychosocial risk and resilience factors, chronic disease, health care use, survivorship and health as well as favorable and bad prognosis within a unique, large-scale long-term assessment with the perspective of further examinations after 6 years in a representative European metropolitan population.

Approaching Cognitive Behavior Therapy For Generalized Anxiety Disorder From A Cognitive Process Perspective

Generalized anxiety disorder (GAD), with uncontrollable worry at its core, is a common psychological disorder with considerable individual and societal costs. Cognitive behavior therapy (CBT) is recommended as the first-line treatment for GAD; however, further investigation into its effectiveness in routine clinical care is indicated and improvement is required in treatment outcomes for worry. Improvements to CBT need to be guided by experimental research that identifies key mechanisms maintaining core aspects of the disorder. This paper summarizes how theory-driven experimental research guided selection and refinements of CBT techniques originally developed by Borkovec and Costello, to target key cognitive processes that maintain worry in GAD. Hirsch and Mathews' model specifies three key research-supported processes that maintain uncontrollable worry in GAD: implicit cognitive biases such as negative interpretation bias and attention bias, generalized verbal thinking style, and impaired ability to re-direct attentional control away from worry. Specific CBT techniques outlined in this paper aim to target these key processes. Clinical data from clients treated using our refined CBT protocol for GAD in a routine clinical care service with a special interest in anxiety disorders were collected as part of service procedures. Large pre-to-posttreatment effect sizes were obtained for anxiety (GAD-7), depression (PHQ-9), and worry (PSWQ) (d=.90-2.54), and a moderate effect size was obtained for quality of life (WASA; d=.74). Recovery was indicated for 74% of cases for anxiety, 78% for depression, and 53% for worry. These findings exceeded most previous effectiveness studies in routine care and were in-line with GAD efficacy trials. This paper also outlines the application of specific clinical techniques selected, adapted or developed to target key cognitive mechanisms which maintain worry in GAD.

The efficacy of intraoperative multimodal monitoring in pedicle subtraction osteotomies of the lumbar spine

OBJECTIVE

Iatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors' aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine.

METHODS

All patients older than 18 years who underwent lumbar PSOs at the authors' institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson's Disease Questionnaire-39 (PDQ-39) and Patient Health Questionnaire-9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined.

RESULTS

A total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively).

CONCLUSIONS

In this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

Adult Children's Migration and Well-being of Left Behind Nepalese Elderly Parents

The objective of this study is to assess whether adult children's migration is associated with overall well-being of left-behind elderly parents in Nepal. A cross-sectional house-to-house survey was conducted among 260 community-dwelling elderly residents of Krishnapur municipality, Nepal. Binary logistic regression was used to identify whether migration of adult children was associated with elderly parent's self-reported chronic diseases, depressive symptoms, perceived loneliness and social support. More than half of the study household (51.2%) had at least one adult migrant child. Compared to participants without a migrant child, participants with a migrant child had higher odds of self-reported chronic diseases (OR = 1.79, 95%CI: 0.91-3.54), presence of depressive symptoms (OR = 1.07, 95%CI: 0.64-1.77), and self-perceived loneliness (OR = 1.23, 95%CI: 1.06-1.42) but except for loneliness, the odds ratio for other indicators of well-being were not statistically significant. Although the literature posits an inverse relationship between adult children's migration and the overall well-being of the elderly parents, in our study, adult children's migration was not associated with inverse health outcomes among study participants. However, from a policy perspective, it should be understood that these observations may be transient since the family structure of Nepalese society is rapidly changing.

An Internet-Based Cognitive Behavioral Therapy Program Adapted to Patients With Cardiovascular Disease and Depression: Randomized Controlled Trial

BACKGROUND

Depression is a common cause of reduced well-being and prognosis in patients with cardiovascular disease (CVD). However, there is a lack of effective intervention strategies targeting depression.

OBJECTIVE

The study aimed to evaluate the effects of a nurse-delivered and adapted internet-based cognitive behavioral therapy (iCBT) program aimed at reducing depression in patients with CVD.

METHODS

A randomized controlled trial was conducted. A total of 144 patients with CVD with at least mild depression (Patient Health Questionnaire-9 [PHQ-9] score ≥5) were randomized 1:1 to a 9-week program of iCBT (n=72) or an active control participating in a Web-based discussion forum (online discussion forum [ODF], n=72). The iCBT program, which included 7 modules, was adapted to fit patients with CVD. Nurses with an experience of CVD care provided feedback and a short introduction to cognitive behavioral therapy. The primary outcome, depression, was measured using PHQ-9. Secondary outcomes were depression measured using the Montgomery-Åsberg Depression Rating Scale-self-rating version (MADRS-S), health-related quality of life (HRQoL) measured using Short Form 12 (SF-12) survey and EuroQol Visual Analogue Scale (EQ-VAS), and the level of adherence. An intention-to-treat analysis with multiple imputations was used. Between-group differences in the primary and secondary outcomes were determined by the analysis of covariance, and a sensitivity analysis was performed using mixed models.

RESULTS

Compared with ODF, iCBT had a significant and moderate treatment effect on the primary outcome depression (ie, PHQ-9; mean group difference=-2.34 [95% CI -3.58 to -1.10], P<.001, Cohen d=0.62). In the secondary outcomes, compared with ODF, iCBT had a significant and large effect on depression (ie, MADRS-S; P<.001, Cohen d=0.86) and a significant and moderate effect on the mental component scale of the SF-12 (P<.001, Cohen d=0.66) and the EQ-VAS (P<.001, Cohen d=0.62). Overall, 60% (n=43) of the iCBT group completed all 7 modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study owing to a high risk of suicide or deterioration in depression.

CONCLUSIONS

Nurse-delivered iCBT can reduce depression and improve HRQoL in patients with CVD, enabling treatment for depression in their own homes and at their preferred time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074.

Cognitive Development of Infants Exposed to the Zika Virus in Puerto Rico

IMPORTANCE

Existing research has established a causal link between Zika virus (ZIKV) infection and severe birth defects or consequent health impairments; however, more subtle cognitive impairments have not been explored.

OBJECTIVE

To determine whether infants of mothers with at least 1 positive ZIKV test show differences in cognitive scores at ages 3 to 6 months and ages 9 to 12 months.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study recruited infants enrolled in existing ZIKV study cohorts associated with the Maternal-Infant Studies Center and the Puerto Rico Clinical and Translational Research Consortium at the University of Puerto Rico and from the broader San Juan metropolitan area. The study took place at the Puerto Rico Clinical and Translational Research Consortium at the University of Puerto Rico. Participants were recruited through convenience sampling if their mothers underwent ZIKV testing prenatally and were at the target ages during the study period. Infants who were born preterm (<36 weeks' gestational age), with low birth weight (<2500 g), or with a known genetic disorder were excluded. Infants were tested from ages 3 to 6 months or ages 9 to 12 months from May 2018 to April 2019. Data analysis was performed from March to April 2019.

EXPOSURES

Zika virus status was measured prenatally and in the early postnatal period using real-time polymerase chain reaction or a ZIKV IgM antibody capture enzyme-linked immunosorbent assay.

MAIN OUTCOMES AND MEASURES

The infants' development was assessed using the Mullen Scales of Early Learning (translated to Spanish and adapted for Puerto Rico), and assessors were blinded to each infant's ZIKV status.

RESULTS

A total of 65 study participants were included. The mean (SD) age of the infants at the time of cognitive testing was 8.98 (3.19) months. Most of the infants were white (55 [84.6%]) and Puerto Rican (64 [98.5%]); 38 of the infants were male (58.5%). General cognitive and domain-specific scores did not differ significantly between prenatally ZIKV-positive and ZIKV-negative infants except for receptive language score (mean difference = 5.52; t = 2.10; P = .04). Exposure to ZIKV (B = -5.69; β = -0.26 [95% CI -11.01 to -0.36]; P = .04) and a measure of Hurricane Maria exposure (time without water, B = -0.05; β = -0.27 [95% CI, -0.10 to -0.01]; P = .03) were both independently and significantly associated with receptive language scores after adjusting for key confounders.

CONCLUSIONS AND RELEVANCE

Although infants exposed to ZIKV prenatally showed unaffected motor and visually mediated cognitive development, they did show deficits in receptive language scores. Receptive language skills were also associated with the degree of exposure to Hurricane Maria, with those who spent more time without water after the hurricane having lower receptive language scores.

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis

BACKGROUND

There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery.

METHODS

This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization.

RESULTS

Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured.

CONCLUSIONS

Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied.

LEVEL OF EVIDENCE

Level III, comparative study.

Association between depression and cardiovascular disease risk in general population of Korea: results from the Korea National Health and Nutrition Examination Survey, 2016

Background

Depression is considered as a risk factor for cardiovascular disease (CVD) and associated with changes in individuals' health status that might influence CVD risk. However, most studies have scrutinized this relationship on a rather narrower and specific study population. By focusing on general population of Korea, we sought to inspect the association of depression with CVD risk and cardiovascular risk factors.

Methods

The data from the first year (2016) of the 7th Korea National Health and Nutrition Examination Survey was used. Participants were classified by the Patient Health Questionnaire-9 (PHQ-9) score as such: normal group (PHQ-9 score 0–4), mild depression (MD) group (PHQ-9 score 5–9) and moderate and severe depression (MSD) group (PHQ-9 score 10–27). General linear model was used to analyze differences and the trend of mean CVD risk according to depression level. Adjusted odds ratios (AORs) were calculated by logistic regression to identify the association between depression and cardiovascular risk factors after adjusting for age.

Results

Mean CVD risk of MSD group was higher than that of normal group (p < 0.05). There was a tendency of CVD risk to increase as depression worsened (p < 0.01). Among men, MSD group was associated with current smoking (AOR, 2.97; 95% confidence interval [CI], 1.78–4.97), taking antihypertensive medications (AOR, 2.42; 95% CI, 1.26–4.66), increased fasting blood sugar (> 125 mg/dL; AOR, 2.37; 95% CI, 1.25–4.50) and taking diabetes medications (AOR, 3.08; 95% CI, 1.65–5.72). MD group was associated with current smoking (AOR, 1.60; 95% CI, 1.18–2.17). Among women, MSD group was associated with high body mass index (≥ 25 kg/m²; AOR, 1.61; 95% CI, 1.11–2.32), large waist circumference (≥ 85 cm; AOR, 1.63; 95% CI, 1.12–2.37), current smoking (AOR, 5.11; 95% CI, 3.07–8.52) and taking diabetes medications (AOR, 2.62; 95% CI, 1.68–4.08). MD group was associated with current smoking (AOR, 1.86; 95% CI, 1.18–2.93).

Conclusions

We suggest that depression is associated with increased risk for CVD occurrence in general population of Korea.

Heart Rehabilitation in patients awaiting Open heart surgery targeting to prevent Complications and to improve Quality of life (Heart-ROCQ): study protocol for a prospective, randomised, open, blinded endpoint (PROBE) trial

INTRODUCTION

The rising prevalence of modifiable risk factors (eg, obesity, hypertension and physical inactivity) is causing an increase in possible avoidable complications in patients undergoing cardiac surgery. This study aims to assess whether a combined preoperative and postoperative multidisciplinary cardiac rehabilitation (CR) programme (Heart-ROCQ programme) can improve functional status and reduce surgical complications, readmissions and major adverse cardiac events (MACE) as compared with standard care.

METHODS AND ANALYSIS

Patients (n=350) are randomised to the Heart-ROCQ programme or standard care. The Heart-ROCQ programme consists of a preoperative optimisation phase while waiting for surgery (three times per week, minimum of 3 weeks), a postoperative inpatient phase (3 weeks) and an outpatient CR phase (two times per week, 4 weeks). Patients receive multidisciplinary treatment (eg, physical therapy, dietary advice, psychological sessions and smoking cessation). Standard care consists of 6 weeks of postsurgery outpatient CR with education and physical therapy (two times per week). The primary outcome is a composite weighted score of functional status, surgical complications, readmissions and MACE, and is evaluated by a blinded endpoint committee. The secondary outcomes are length of stay, physical and psychological functioning, lifestyle risk factors, and work participation. Finally, an economic evaluation is performed. Data are collected at six time points: at baseline (start of the waiting period), the day before surgery, at discharge from the hospital, and at 3, 7 and 12 months postsurgery.

ETHICS AND DISSEMINATION

This study will be conducted according to the principles of the Declaration of Helsinki (V.8, October 2013). The protocol has been approved by the Medical Ethical Review Board of the UMCG (no 2016/464). Results of this study will be submitted to a peer-reviewed scientific journal and can be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02984449.

Caregiver Burden in Primary Congenital Glaucoma

PURPOSE

To evaluate the demographic, clinical, and socioeconomic factors associated with variation in the quality of life (QOL) in caregivers of children with primary congenital glaucoma (PCG) in south India.

DESIGN

Cross-sectional survey.

METHODS

Caregivers of children younger than 18 with diagnosed PCG were prospectively enrolled at Aravind Eye Hospital in Madurai and Coimbatore, India. Participants completed 2 questionnaires, the PHQ-9 (9-item Patient Health Questionnaire) and the CarCGQoL (Caregivers Congenital Glaucoma QOL Questionnaire). Clinical, demographic, and socioeconomic data were obtained for each child-caregiver dyad. Rasch-calibrated scores were calculated for patient-reported outcome measures. Spearman correlation and linear regression were used to analyze data to determine associations with caregiver QOL.

RESULTS

There were 70 caregivers (mean age 32.1, 77.1% female) of 70 children with PCG (mean age 7.7, 37.1% female) included in the study. In univariate and multivariable analyses, child's age (β = -0.04; 95% confidence interval, -0.08 to -0.01) and duration of disease (β = - 0.03; 95% confidence interval, -0.07 to -0.01) were the only factors associated with CarCGQoL. Survey items related to anger, self-confidence, irritability, appetite, and interest in leisure activities had the lowest scores. There was a negative correlation between CarCGQoL and PHQ-9 scores (r = -0.66, P < .01), indicating that worse caregiver QOL was significantly correlated with more depressive symptoms.

CONCLUSION

This study identified traits associated with QOL decline, as well as the QOL issues most likely to affect caregivers of children with PCG in south India. Findings from this study may be important for designing interventions to improve caregivers' QOL, thereby maximizing their ability to care for children with PCG.

Pilot study of a two-arm non-randomized controlled cluster trial of a psychosocial intervention to improve late life depression in socioeconomically deprived areas of São Paulo, Brazil (PROACTIVE): feasibility study of a psychosocial intervention for late life depression in São Paulo

BACKGROUND

Depression is a common and recurrent condition among older adults and is associated with poor quality of life and increased health care utilization and costs. The purpose of this pilot study was to assess the feasibility of delivering a psychosocial intervention targeting depression, and to develop the procedures to conduct a cluster randomized controlled trial among older adults registered with primary care clinics in poor neighbourhoods of São Paulo, Brazil.

METHODS

We conducted a pilot study of a two-arm cluster, non-randomized controlled trial. Two primary care clinics adhering to the Family Health Strategy were allocated to either the intervention or the control arm. In the control arm, patients received enhanced usual care consisting of staff training for improved recognition and management of depression. In the intervention arm, alongside the enhanced usual care, patients received a 17-week psychosocial intervention delivered by health workers assisted with an application installed in a tablet.

RESULTS

We randomly selected 579 of 2020 older adults registered in the intervention clinic to participate in the study. Among these individuals, 353 were assessed for depression and 40 (11.0%) scored at least 10 on the PHQ-9 and were therefore invited to participate. The consent rate was 33/40 (82%) with a resulting yield of 33/579 (5.7%). In the control arm, we randomly selected 320 older adults among 1482 registered in the clinic, 223 were assessed for depression and 28 (12.6%) scored 10 or above on the PHQ-9. The consent rate was 25/28 (89%), with a resulting yield of 25/320 (7.8%). Of the 33 who consented in the intervention arm, 19 (59.4%) completed all sessions. The mean PHQ-9 at follow-up (approximately 30 weeks after inclusion) were 12.3 (SD = 3.7) and 3.8 (SD = 3.9) in the control and intervention arms, respectively. Follow-up rates were 92 and 94% in control and intervention arms, respectively.

CONCLUSIONS

Identification and engagement of clinics, randomization, recruitment of individuals, measures, and baseline and follow-up assessments all proved to be feasible in primary care clinics in São Paulo, Brazil. Results support the development of a definitive cluster randomized controlled trial.

TRIAL REGISTRATION

This study was retrospectively registered with Registro Brasileiro de Ensaios Clínicos (ReBEC), number RBR-5nf6wd . Registered 06 August 2018.

A booklet self-help intervention to reduce depressive symptoms among people living with HIV in Botswana: study protocol for a randomized controlled trial

BACKGROUND

The treatment of mental health issues among people living with HIV (PLH) in Botswana is yet to be addressed. A recent study revealed that depressive symptoms are highly prevalent in a sample of PLH in Botswana. Based on empirical findings of a study that investigated intervention targets for PLH in Botswana, a self-help program with coaching in booklet format in the Setswana and English languages was developed, composed of cognitive behavioral techniques, coping skills interventions, and goal adjustment training. We will investigate the program for effectiveness in the treatment of depressive symptoms among PLH. Additionally, we will investigate treatment moderators and mediators. This paper describes the study protocol.

METHODS/DESIGN

A randomized controlled trial will be conducted to compare the booklet self-help program with coaching with an attention-only control condition, by including pre-test, post-test, and follow-up assessments. We aim to enroll 200 participants with mild to moderate depressive symptoms into the study. The self-help program contains the following main components: activation, relaxation, changing maladaptive cognitions, and the attainment of new personal goals. This content is covered over six lessons to be completed in a maximum of 8 weeks. It uses a combination of psycho-education, assignments, and exercises. The participants will work on the program 1-2 h every week for 6 weeks (maximum 8 weeks). Coaches will offer support and motivate the participants. For both groups, depressive symptoms and possible mediators will be measured three times during the intervention, and at pre-test, post-test, and follow-up.

DISCUSSION

If the intervention is found to effectively treat depressive symptoms, it will be implemented and thus help improve the psychological health of PLH in Botswana.

TRIAL REGISTRATION

Netherlands Trial Register, NTR7428 . Registered on 23 August 2018.

Making measurement-based care for addictions a reality in primary care

Three factors are important to consider when integrating measurement-based care for opioid use disorders into primary care: integration with other behavioral health and substance use disorders care, the availability of a brief, valid measure that is responsive to change, and implementation in a manner that fosters accurate reporting.

Psychometric Validation of PHQ-9 and GAD-7 in Filipino Migrant Domestic Workers in Macao (SAR), China

There are 500,000 female Filipino domestic workers worldwide. However, there are no validated instruments to assess common mental disorders in this population. The Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) are brief measures that could be effective screeners for depression and anxiety in domestic workers. This study aims to establish reliability and validity of the Filipino versions of the PHQ-9 and GAD-7. In Study 1, 131 domestic workers completed the PHQ-9, GAD-7, and other questionnaires with a test-retest interval of 10 days. Convergent validity was examined using measures of posttraumatic stress disorder, direct exposure to traumatic events, and rumination. Discriminant validity was assessed using measures of discrimination, pain, social support, and indirect exposure to traumatic events. In Study 2, criterion validity was established with another sample of domestic workers (N = 100) using clinician-administered Mini International Neuropsychiatric Interviews. Receiver operating characteristic (ROC) curve analysis was performed to evaluate diagnostic efficiency. Results showed acceptable and high internal consistency for PHQ-9 and GAD-7, respectively. Both had acceptable test-retest reliability. Convergent and discriminant validity were also established. ROC curve results demonstrated that optimal cut scores for PHQ-9 and GAD-7 are 6 and 7, respectively. The Filipino versions of PHQ-9 and GAD-7 are reliable and valid for use among Filipino domestic workers.

Examining the feasibility, acceptability, and potential utility of mobile distress screening in adult cancer patients

OBJECTIVE

A common method of distress monitoring in cancer patients relies on static and retrospective data collected in-person at the time of a health care provider appointment. Relatively little work has examined the potential usefulness of mobile distress monitoring using cancer patients' smartphones. The current study deployed longitudinal distress monitoring using secure text messaging.

METHODS

In an observational study, a total of 52 cancer patients receiving active cancer treatment (M_age  = 58, 62% female) received a text message once a week for 4 weeks. Text messages contained a secure link to complete online the Patient Health Questionnaire-4 (PHQ-4), a commonly used distress screener.

RESULTS

Cancer patients completed a distress screener 75% of the time they received a text message. On average, it took less than a minute to complete each mobile distress screener. Geolocation data indicated that cancer patients completed distress screeners across a range of locations. Analyses of model fit of distress scores indicated significant heterogeneity in variability of distress scores over time and across cancer patients (AIC = 630.5). Quantitative feedback from cancer patients at the end of the study indicated high ease of use, ease of learning, and satisfaction of completing mobile distress screeners.

CONCLUSIONS

These findings support the use of secure text messaging to monitor longitudinal, out of clinic, distress in cancer patients. Findings also highlight the importance of mobile-based approaches to distress screening in order to maximize opportunities to intervene.

A placebo-controlled pilot study of a wearable morning bright light treatment for probable PTSD

BACKGROUND

Evidence-based treatments for post-traumatic stress disorder (PTSD) have poor uptake and remission rates, suggesting that alternative treatments are needed. Morning bright light may be an effective treatment for PTSD given its established effects on mood and sleep, however, there are no published trials.

METHODS

We conducted a placebo-controlled pilot trial of a wearable light device, the Re-timer®, for individuals with probable PTSD. Individuals were randomly assigned to the active Re-timer® (n = 9) or a placebo Re-timer® dimmed with neutral density filters (n = 6). Participants self-administered the treatment at home 1 hr each morning over 4 weeks. PTSD and depression symptoms were assessed at pre- and post-treatment.

RESULTS

The Re-timer® was well tolerated and the perceived benefit was high, though treatment adherence was only moderate. Those in the active group were more likely to achieve a minimal clinically important change in PTSD and depression symptoms and had larger symptom reductions than those in the placebo group CONCLUSIONS: A wearable morning light treatment was acceptable and feasible for patients with probable PTSD. This study provides initial proof-of-concept that light treatment can improve PTSD. A larger trial is warranted to establish treatment efficacy. NCT#: 03513848.

Predictors of Seeking Psychotherapy in Primary Care Patients with High Somatic Symptom Burden

Many primary care patients with high somatic symptom burden do not initiate mental health treatment. Using a cross-sectional design, this study aimed to identify predictors of psychotherapy seeking behavior for patients with high somatic symptom burden within the last 12 months. Data from 20 primary care practices were analyzed. Patients with high somatic symptom burden were identified using the Patient Health Questionnaire, structured interviews, and information from primary care physicians (PCPs). Within the final sample of 142 patients, 54 (38.03%) had been seeking psychotherapy. More severe somatic symptoms, taking psychopharmacological medication and frequently discussing psychosocial distress with PCPs, were associated with psychotherapy seeking behavior. Depressive and anxiety symptoms, and whether PCPs had diagnosed a somatoform disorder or recommended psychotherapy, were not. The results underline the importance of patient-related factors in psychotherapy seeking behavior.

The effectiveness of depression management for improving HIV care outcomes in Malawi: protocol for a quasi-experimental study

BACKGROUND

Depression, prevalent among people living with HIV (PLWH) in Malawi, is associated with negative HIV patient outcomes and likely affects HIV medical management. Despite the high prevalence of depression, its management has not been integrated into HIV care in Malawi or most low-income countries.

METHODS

This study employs a pre-post design in two HIV clinics in Lilongwe, Malawi, to evaluate the effect of integrating depression management into routine HIV care on both mental health and HIV outcomes. Using a multiple baseline design, this study is examining mental health and HIV outcome data of adult (≥18 years) patients newly initiating ART who also have depression, comparing those entering care before and after the integration of depression screening and treatment into HIV care. The study is also collecting cost information to estimate the cost-effectiveness of the program in improving rates of depression remission and HIV treatment engagement and success.

DISCUSSION

We anticipate that the study will generate evidence on the effect of depression management on HIV outcomes and the feasibility of integrating depression management into existing HIV care clinics. The results of the study will inform practice and policy decisions on integration of depression management in HIV care clinics in Malawi and related settings, and will help design a next-step strategy to scale-up integration to a larger scale.

TRIAL REGISTRATION

ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.

Assessment of patients' expectations: development and validation of the Expectation for Treatment Scale (ETS)

OBJECTIVE

To develop a short self-report instrument for the assessment of expectations (Expectation for Treatment Scale(ETS)) using acupuncture as a case example.

DESIGN

A cross-sectional assessment with retest after 1 week.

SETTING

A web-based survey with patients suffering from pain.

METHODS

In a three-step approach, we reduced the initially collected number of items from 17 to 9 and to 5, including expectations about coping ability, vitality, physical health and reduction of patient complaints. Items were selected according to internal consistency (Cronbach's alpha); convergent and divergent validities with related constructs (optimism, pessimism, resilience, perceived sensitivity to medicines, depression and others); 1-week retest reliability (intraclass correlation coefficient (ICC)); and exploratory and confirmatory factor analysis (CFA).

RESULTS

A total of 102 patients suffering from pain were included, and 54 of these patients completed the retest assessment. The final version of the ETS consisted of five items and had an excellent Cronbach's alpha (0.90), with 72.33% variance on one single factor. Depression, pessimism and perceived sensitivity to medicines showed positive correlations with our expectation measure (r=0.23, r=0.20 and r=0.34, respectively); the correlation between the ETS and optimism was low (r=-0.07) and no correlation between the ETS and resilience was found (r=-0.07). Convergent validity was confirmed with a high correlation (r>0.90) between ETS and a treatment-specific measure of expectations. The retest ICC was 0.86, which showed high stability over 1 week. A CFA (n=439) with data from patients with low back pain confirmed the single-factor structure of the instrument.

CONCLUSION

The ETS showed strong psychometric properties and covered a distinct construct. As the next step, the ETS might be implemented in different clinical conditions and settings to investigate psychometrics and its predictive power for treatment outcomes.

A Web-Based Mental Health Platform for Individuals Seeking Specialized Mental Health Care Services: Multicenter Pragmatic Randomized Controlled Trial

BACKGROUND

Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support.

OBJECTIVE

The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care.

METHODS

A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers.

RESULTS

Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (-1.83 points, 95% CI -2.85 to -0.82) and GAD-7 score (-1.55 points, 95% CI -2.42 to -0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group.

CONCLUSIONS

The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO).

Alone, but protected? Effects of social support on mental health of unaccompanied refugee minors

Unaccompanied refugee minors (URM) are the most vulnerable group of refugees suffering from higher levels of mental health problems. Yet, there is also a group of URM with little or no symptoms or disorders. A major predictor for positive mental health outcomes is the social support network in the post-flight period which has rarely been investigated for the group of URM. The present study analyzes differences between perceived social support from family, peers, and adult mentors in URM, with subgroup analyses of peer and mentor support in URM with and without family contact. Furthermore, we investigate whether social support from each of the three sectors moderates the relationship between stressful life events (SLE) and mental health of URM with family contact. Questionnaire data were collected from 105 male URM from Syria and Afghanistan aged 14-19 years who were living in group homes of the Child Protection Services in Leipzig, Germany, in summer 2017. URM receive most social support from their families, followed by peers and adult mentors. URM without family contact received less peer and mentor support compared to URM with family contact. Lower social support from mentors increased the risk for PTSD, depression and anxiety symptoms after SLE, whereas lower social support from peers increased the association between SLE and anxiety symptoms. Mentor and peer support in the host country is relevant for the processing of SLE. URM without family contact represent a "double burden" group, as they might feel less supported by other social networks.

Posttraumatic Embitterment Disorder in Patients with Chronic Kidney Disease

Objective

Posttraumatic embitterment disorder (PTED), a subgroup of an adjustment disorder, is a feeling with anger and helplessness. Hemodialysis may be a trigger event leading to PTED. We investigated the prevalence of PTED in patients with each categorized stages of chronic kidney disease (CKD) and the association between PTED and depression and functional impairment.

Methods

Patients were categorized into three groups according to the stages of CKD (stage I–II, III–IV, and V). CKD (I–II) group was defined as estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m², CKD (III–IV) group as eGFR <60 ml/min/1.73 m², and CKD (V) group as CKD stage V including patients ongoing hemodialysis. Patients were assessed for the prevalence of PTED, depression, and decreased quality of life by using the scale of PTED, Patient Health Questionnaire-9 (PHQ-9), and EuroQol Five Dimensional Questionnaires, Visual Analogue Scale (EQ-5D-VAS), respectively.

Results

A total of 445 patients were analyzed. The number of patients in CKD (I–II) was 166, CKD (III–IV) was 172, and CKD (V) was 107. Multivariate analysis by binomial logistic regression demonstrated that CKD (V) was significantly associated with the prevalence of PTED (odds ratio, 4.13; 95% confidence interval, 1.56–15.6; p=0.006) after adjustment for age, gender, and diabetes mellitus. Also, a significant correlation existed between PTED and EQ-5D-VAS in all stages, but the correlation was nonsignificant between PTED and PHQ-9 score in group CKD (V).

Conclusion

The findings suggest that PTED is underdiagnosed in CKD patients. Acknowledgment and diagnosis of PTED in CKD patients may lead to a better quality of life.

An evaluation of large group cognitive behaviour therapy with mindfulness (CBTm) classes

BACKGROUND

Ensuring equitable and timely access to Cognitive Behaviour Therapy (CBT) is challenging within Canada's service delivery model. The current study aims to determine acceptability and effectiveness of 4-session, large, Cognitive Behaviour Therapy with Mindfulness (CBTm) classes.

METHODS

A retrospective chart review of adult outpatients (n = 523) who attended CBTm classes from 2015 to 2016. Classes were administered in a tertiary mental health clinic in Winnipeg, Canada and averaged 24 clients per session. Primary outcomes were (a) acceptability of the classes and retention rates and (b) changes in anxiety and depressive symptoms using Generalized Anxiety Disorder 7-item (GAD-7) and Patient Health Questionnaire 9-item (PHQ-9) scales.

RESULTS

Clients found classes useful and > 90% expressed a desire to attend future sessions. The dropout rate was 37.5%. A mixed-effects linear regression demonstrated classes improved anxiety symptoms (GAD-7 score change per class = - 0.52 [95%CI, - 0.74 to - 0.30], P < 0.001) and depressive symptoms (PHQ-9 score change per class = - 0.65 [95%CI, - 0.89 to - 0.40], P < 0.001). Secondary analysis found reduction in scores between baseline and follow-up to be 2.40 and 1.98 for the GAD-7 and PHQ-9, respectively. Effect sizes were small for all analyses.

CONCLUSIONS

This study offers preliminary evidence suggesting CBTm classes are an acceptable strategy to facilitate access and to engage and maintain clients' interest in pursuing CBT. Clients attending CBTm classes experienced improvements in anxiety and depressive symptoms. Symptom improvement was not clinically significant. Study limitations, such as a lack of control group, should be addressed in future research.

Which body shape dimensions and sizes predict depression?

BACKGROUND

Obesity is associated with depression, but a common measure of obesity, body mass index (BMI), combines height and weight. Consequently, which body shape dimensions and sizes are most relevant to depression is unclear.

METHOD

Data were analyzed from the National Health and Nutrition Examination Survey years 2007-2016, focusing on adults age 20 and older who were not pregnant. In this nationally-representative sample (N = 23,739), relations of depressive symptoms with body shape variables were tested, controlling for age, gender, ethnicity, and socioeconomic status.

RESULTS

Body weight and BMI, but not standing height, predicted depressive symptoms. Adults with relatively high body weight or BMI (roughly the top 30-40% of women or 10% of men) had substantively elevated depressive symptoms (d ≥ 0.20) within genders. BMI ranges predicting elevated depressive symptoms among women (BMI ≥ 30) and men (BMI ≥ 36) were higher than standard overweight and obesity definitions, respectively.

LIMITATIONS

This observational study was cross-sectional. Future longitudinal and experimental research is needed to clarify potential causal relations between body weight and depression. Other body shape variables may also predict depression.

CONCLUSIONS

Body weight but not height predicted concurrent risk for depressive symptomatology in the United States. Future research should test whether assessment focused on body weight not adjusted for height, as in BMI, improves depression prevention and treatment.

Attentional Control as a Predictor of Response to Psychological Treatment for Depression and Relapse up to 1 year After Treatment: A Pilot Cohort Study

BACKGROUND

Identifying depressed patients unlikely to reach remission and those likely to relapse after reaching remission is of great importance, but there are few pre-treatment factors that can help clinicians predict prognosis and together these explain relatively little variance in treatment outcomes. Attentional control has shown promise in studies to date, but has not been investigated prospectively in routine clinical settings with depressed patients.

AIMS

This study aimed to pilot the use of a brief self-report measure of attentional control in routine care and investigate the associations between attentional control, psychological treatment response and relapse to depression up to 1 year post-treatment.

METHOD

Depressed patients were recruited from two primary care psychological treatment (IAPT) services and completed the Attentional Control Scale (ACS) alongside routine symptom measures at every therapy session. Participants were tracked and followed up for 1 year post-treatment.

RESULTS

Baseline ACS scores were associated with remission and residual depressive symptoms post-treatment, and relapse within 12 months of ending treatment, all independent of pre-treatment depressive symptom severity, and the latter also independent of residual symptoms.

CONCLUSION

A self-report measure of attentional control can potentially be used to predict levels of depressive symptoms post-treatment and can contribute to predicting risk of relapse to depression in IAPT services, without affecting rates of therapy completion/drop-out or data completion of standard IAPT measures. However, this pilot study had a small overall sample size and a very small number of observed relapses, so replication in a larger study is needed before firm conclusions can be made.

Association Between Patient Experience With Patient-Reported Outcome Measurements and Overall Satisfaction With Care in Neurology

BACKGROUND

There has been increasing focus on both patient-reported outcome measurement (PROM) collection and patient satisfaction ratings; nevertheless, little is known about their relationship.

OBJECTIVES

To determine the association between patient experience with PROM collection and visit satisfaction and to identify characteristics of better ratings for each.

METHODS

This cross-sectional observational study included all patients seen in 15 neurological clinics who completed PROMs as well as 6 questions on the patient experience with PROMs at least once from October 1, 2015 to December 31, 2016. Visit satisfaction was evaluated using a composite measure of physician communication, overall physician rating, and the likelihood of recommending that physician as indicated on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. Predictors of PROM experience and satisfaction were identified using proportional odds and logistic regression models, respectively.

RESULTS

There were 6454 patients (average age 58 ± 15 years, 59% women) who completed PROMs and responded to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. There were significant positive associations between each PROM experience question and visit satisfaction (r = 0.11-0.19; P<.010), although factors predicting visit satisfaction differed from those predicting PROM experience. A differential effect of PROMs on visit satisfaction was identified for patients who were nonwhite, had lower income, and had more comorbidities.

CONCLUSIONS

Although there was a significant association between better PROM experience and higher visit satisfaction, relationships with clinical characteristics differed, providing insights into how PROMs may be associated with patients' visit satisfaction. Further research is necessary to confirm whether PROMs can be used to improve visit satisfaction, particularly in patients who historically have reported lower quality of care.

Effectiveness of Telephone-Administered Cognitive-Behavioral Psychotherapy for Depression With Versus Without Additional Letters: A Randomized Controlled Trial

Background: Telephone-administered cognitive-behavioral psychotherapy (T-CBT) can effectively treat patients with depressive symptoms. Introduction: We investigated whether adding letters (via postal mail) to T-CBT reduces depressive symptoms and increases response and remission. Additionally, we assessed whether T-CBT reduced all patients' symptoms in the first depression-specific T-CBT sample in German healthcare. Materials and Methods: Primary care patients were randomized to T-CBT with versus without letters. All received 1 face-to-face and 8-12 telephone-administered sessions. An intention-to-treat sample was analyzed. Between-groups differences in symptom change and the total sample's symptom change were computed using linear mixed models with group as fixed effect, referring general practice as random effect and several covariates. Differences in response and remission were assessed using logistic regressions. Results: Fifty-nine patients were referred to T-CBT and randomized. Twenty-six patients actually participated in T-CBT with letters and 21 without letters. The groups did not differ significantly regarding symptom change (Patient Health Questionnaire [PHQ-9]) from baseline to end: T-CBT without letters showed 1.05 points greater reduction (95% confidence interval: -4.72 to 2.62; p = 0.56; Cohen's d = -0.12) (adjusted mean change). The groups did not differ significantly regarding symptom change from baseline to 6-month follow-up nor odds of response or remission. The total sample's PHQ-9 showed significant adjusted mean reduction from baseline to end of T-CBT and to 6-month follow-up. Discussion: Additional letters did not lead to greater symptom reduction. Overall results for the first German T-CBT intervention for depression appear promising but require further assessment using a control condition. Conclusions: Additional letters do not appear to enhance the effectiveness of T-CBT.

Enhanced psychological care in cardiac rehabilitation services for patients with new-onset depression: the CADENCE feasibility study and pilot RCT

BACKGROUND

Around 19% of people screened by UK cardiac rehabilitation programmes report having moderate or severe symptoms of depression. These individuals are at an increased risk of cardiac mortality and morbidity, reduced quality of life and increased use of health resources compared with their non-depressed counterparts. Maximising psychological health is a goal of cardiac rehabilitation, but psychological care is patchy.

OBJECTIVE(S)

To examine the feasibility and acceptability of embedding enhanced psychological care (EPC) within cardiac rehabilitation, we tested the feasibility of developing/implementing EPC and documented the key uncertainties associated with undertaking a definitive evaluation.

DESIGN

A two-stage multimethods study; a feasibility study and a qualitative evaluation, followed by an external pilot cluster randomised controlled trial (RCT) with a nested qualitative study.

SETTING

UK comprehensive cardiac rehabilitation teams.

PARTICIPANTS

Adults eligible for cardiac rehabilitation following an acute coronary syndrome with new-onset depressive symptoms on initial nurse assessment. Patients who had received treatment for depression in the preceding 6 months were excluded.

INTERVENTIONS

The EPC intervention comprised nurse-led mental health-care co-ordination and behavioural activation within cardiac rehabilitation. The comparator was usual cardiac rehabilitation care.

MAIN OUTCOME MEASURES

Measures at baseline, and at the 5- (feasibility and pilot) and 8-month follow-ups (pilot only). Process measures related to cardiac team and patient recruitment, and participant retention. Outcomes included depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Interviews explored participant and nurses' views and experiences.

RESULTS

Between September 2014 and May 2015, five nurses from four teams recruited participants into the feasibility study. Of the 203 patients screened, 30 were eligible and nine took part (the target was 20 participants). At interview, participants and nurses gave valuable insights into the EPC intervention design and delivery. Although acceptable, the EPC delivery was challenging for nurses (e.g. the ability to allocate sufficient time within existing workloads) and the intervention was modified accordingly. Between December 2014 and February 2015, 8 out of 20 teams approached agreed to participate in the pilot RCT [five were randomised to the EPC arm and three were randomised to the usual-care (UC) arm]. Of the 614 patients screened, 55 were eligible and 29 took part (the target was 43 participants). At baseline, the trial arms were well matched for sex and ethnicity, although the EPC arm participants were younger, from more deprived areas and had higher depression scores than the UC participants. A total of 27 out of 29 participants were followed up at 5 months. Interviews with 18 participants (12 in the EPC arm and six in the UC arm) and seven nurses who delivered EPC identified that both groups acknowledged the importance of receiving psychological support embedded within routine cardiac rehabilitation. For those experiencing/delivering EPC, the intervention was broadly acceptable, albeit challenging to deliver within existing care.

LIMITATIONS

Both the feasibility and the pilot studies encountered significant challenges in recruiting patients, which limited the power of the pilot study analyses.

CONCLUSIONS

Cardiac rehabilitation nurses can be trained to deliver EPC. Although valued by both patients and nurses, organisational and workload constraints were significant barriers to implementation in participating teams, suggesting that future research may require a modified approach to intervention delivery within current service arrangements. We obtained important data informing definitive research regarding participant recruitment and retention, and optimal methods of data collection.

FUTURE RESEARCH

Consideration should be given to the delivery of EPC by dedicated mental health practitioners, working closely with cardiac rehabilitation services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN34701576.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 30. See the NIHR Journals Library website for further project information.

Gray Matter Alterations Associated With Dissociation in Female Survivors of Childhood Trauma

Objective

Across various axis-1 disorders, the severity of dissociative symptoms is significantly related to a history of childhood traumatization. Thus, the question arises if coping with childhood trauma leads to neural adaptations that enhance the frequency of dissociative processing during adulthood. The aim of the two reported studies therefore was to identify and replicate gray matter alterations associated with dissociation.

Methods and Results

In a first study, whole-brain MRI data were acquired for 22 female in-patients with trauma-spectrum disorders and a history of severe childhood trauma. Voxel-based morphometry (VBM) was carried out to test for significant correlations between dissociation (depersonalization/derealization) severity and gray matter volume. Dissociation severity was positively associated with volume in the left angular gyrus. This result was diagnosis-invariant. The replication study involved 26 female in-patients with trauma-spectrum disorders and 25 healthy controls. No significant association between dissociation severity and brain volume in a left angular gyrus region of interest located at the peak identified in study 1 was identified and no significant group difference in this region could be established.

Conclusion

The angular gyrus has previously been implicated in the processing of agency and vestibular integration as well as dissociative processing. The current attempt at a direct replication of brain volume alterations however, failed. The data thus only partially support the notion that dissociative processing is associated trans-diagnostically with structural brain alterations in the left angular gyrus and independent replication in a larger patient sample is essential.

Cost-Effectiveness of Cervical Epidural Steroid Injections: A 3-Month Pilot Study

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

There are conflicting reports on the short- and long-term quality of life (QOL) outcomes and cost-effectiveness of cervical epidural steroid injections (ESIs). The present study analyzes the cost-effectiveness analysis of ESIs versus conservative management for patients with radiculopathy or neck pain in the short term.

METHODS

Fifty patients who underwent cervical ESI and 29 patients who received physical therapy and pain medication alone for cervical radiculopathy and neck pain of <6 months duration were included. Three-month postoperative health outcomes were assessed based on EuroQol-5 Dimensions (EQ-5D; measured in quality-adjusted life years [QALYs]). Medical costs were estimated using Medicare national payment amounts. Cost/utility ratios and the incremental cost-effectiveness ratio (ICER) were calculated to assess for cost-effectiveness.

RESULTS

The ESI cohort experienced significant (P < .01) improvement in the EQ-5D score while the control cohort did not (0.13 vs 0.02 QALYs, respectively; P = .01). There were no significant differences in costs between the cohorts. The cost-utility ratio for the ESI cohort was significantly lower ($21 884/QALY gained) than that for the control cohort ($176 412/QALY gained) (P < .01). The ICER for an ESI versus conservative management was negative, indicating that ESIs provide greater improvement in QOL at a lower cost.

CONCLUSIONS

ESIs provide significant improvement in QOL within 3 months for patients with cervical radiculopathy and neck pain. ESIs are more cost-effective compared than conservative management alone in the shor -term. The durability of these results must be analyzed with longer term cost-utility analysis studies.

Somatic symptom load in men and women from middle to high age in the Gutenberg Health Study - association with psychosocial and somatic factors

The purpose of the study was (1) to determine the prevalence of somatic symptoms in men and women in the general population and (2) to identify the contributions of psychosocial factors and somatic disease on symptom reporting. A total of 7,925 participants aged 40 to 80 years underwent medical and psychological assessments, based on the PHQ-15 (Patient Health Questionnaire). We excluded 3 items in order to avoid confounding findings: 2 items overlapping with the depression measure (PHQ-9) and the menstruation complaints item which biases sex comparisons. Pain complaints (arms, legs, joints, back pain) affected the majority of men and women, and somatic symptom reporting increased with age. When confounding has been reduced, psychosocial factors (lack of social support, adverse life events, loneliness, depression, generalized anxiety, panic, social phobia) have remained the strongest predictors of somatic symptoms. As shown by the interaction between sex and depression, depression plays a smaller role for somatic symptom reporting in women vs. men. Findings highlight the complex psychosocial and somatic contributions to somatic symptom reporting.