A Rasch analysis of the Hospital Anxiety and Depression Scale (HADS) among cancer survivors

The Demoralization Interview: Reliability and validity of a new brief diagnostic measure among medically ill patients

BACKGROUND

Demoralization is a state of low morale and poor coping that is being increasingly recognized in stressful circumstances, such as illness. Meta-analyses show prevalence of 30% in the medically and 50% in the mentally ill. A brief structured diagnostic interview is needed to assess for and diagnose demoralization.

METHODS

The Demoralization Interview (DI) was designed from items of the Demoralization Scale-II (DS-II) and common items used in other clinical interviews. The resultant 26 items were administered to 264 patients with serious progressive medical illnesses, together with the DS-II, measures of depression, anxiety, and quality of life. Rasch analysis was used to co-calibrate the DI against the DS-II. Sensitivity, specificity, and area under the receiver operating characteristics curve (AUROC) were assessed. Concurrent validation was conducted against measures of anxiety, depression, and quality of life.

RESULTS

A 14-item Demoralization Interview (DI) with a diagnostic threshold of 6 symptoms generated sensitivity of 78.0%, specificity of 90.9%, and AUROC of 0.84 against the DS-II. Unidimensionality was indicated, with a Cronbach's alpha of 0.81. For respondents with 6 or more symptoms on the DI, 98% recognized a current stressor and 66% described significant distress or functional impairment. Demoralized respondents carried significantly lower quality of life, higher physical disability, and higher depressive and anxiety symptoms.

CONCLUSIONS

The DI has good reliability and validity, with a threshold of 6 symptoms supporting a diagnosis of demoralization. It could be used as a stand-alone diagnosis, or as a specifier for adjustment disorder or depression.

Impact of Event Scale-6 (IES-6) for U.S. adults who experienced the COVID-19 pandemic

BACKGROUND

COVID-19 pandemic causes psychological problems such as stress. It is important to accurately identify the level of stress and establish effective intervention. The Impact of Event Scale-6 (IES-6) is widely used for post-traumatic stress disorder (PTSD) screening by measuring the level of subjective stress, but there has been no research on its psychometric properties with individuals who experienced the COVID-19 pandemic.

METHODS

A random sample of 600 participants were randomly selected from a COVID-19 survey database (n = 6391). Rasch analysis was conducted to examine item fit, rating scale structure, construct validity, differential item functioning (DIF), and precision of the IES-6.

RESULTS

The principal component analysis of Rasch residuals (54.1% of the raw variance explained) and the average of residual correlations (average r = .19) supported the unidimensionality structure in the IES-6. The rating scale was suitable, and the item difficulty hierarchy was logical. The item fit and the DIF contrast were acceptable, except for item 5. The IES-6's person reliability was .76, which was also an acceptable level.

CONCLUSIONS

This study showed that the IES-6 has acceptable item-level psychometrics for screening the stress level in adults in the United States for individuals who have experienced the COVID-19 pandemic. The findings suggested that the IES-6 would be useful for the rapid identification of the high-level stressand allow clinicians to quickly provide interventions for people with the COVID-19 related stress and their families.

Should psychological distress be listed as a surgical indication for indeterminate pulmonary nodules: protocol for a prospective cohort study in real-world settings

BACKGROUND

Pulmonary nodules (PNs) are documented in up to 30% of computed tomography (CT) reports. PNs of indeterminate nature (IPN) have been reported to be associated with increased psychological distress and deterioration of the quality of life. Despite lack of solid evidence, severe anxiety or depression has been proposed to be one of the surgical indications in expert consensus for IPN management. So far, there is no established criterion to guide the decision-making process, or to ensure evidence-based management. This study aims to evaluate whether psychological distress could be a surgical indication for IPN, and to establish an evidence-based distress threshold for necessary surgical intervention.

METHODS

This prospective observational study in real-world setting will involve an expected sample size of 1,253 IPN patients from the thoracic clinic of Guangdong Provincial People's Hospital. Web-based questionnaires powered by Wen Juan Xing (WJX) platform will be delivered to the patients for baseline data collection and psychological screening. Based on our pilot study, a total of 376 IPN patients with abnormal or borderline abnormal psychological states, as assessed by the Hospital Anxiety and Depression Scale (HADS), will be followed for 1 year before proceeding to the final analysis. The planned study period is from Jan 1, 2021, to Sept 30, 2022, and will entail two HADS assessments at baseline and follow-up. Sleep quality and indicators of healthcare-seeking behavior, such as the number of unplanned clinic visits or CT scans per year, will be used as anchors of psychological state. Patients who undergo surgical resection against the follow-up plan will be enrolled into a surgical group (expected n=94), while those who adhere to their plan will be automatically classified as a follow-up group after 1-year follow-up (expected n=282). Statistical measures such as independent-samples t-test and receiver operating characteristics (ROC) analysis will be used to assess the difference in psychological changes between the groups, and to generate an optimal threshold alerting surgical need. A Chi-square test or nonparametric test will be used to compare the baseline characteristics. Contributors to psychological burden and their effect sizes will be evaluated using general linear regression.

DISCUSSION

To date, data on the psychological benefits of surgical resection of IPN remains scanty. Evidence-based procedure of patient selection using appropriate psychological screening tools is crucial in improving the quality of care and preventing overtreatment. This protocol describes the rationale and methodology to address this unmet clinical need using real-world data, aiming to bridge the gap between clinical guidelines and real-world practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04857333. Registered April 23, 2021.

Rasch analysis of the firefighters' critical incident inventory questionnaire

BACKGROUND

The Critical Incident Inventory (CII) was developed to assess stressful exposures in firefighters and emergency service workers. The CII includes six subscales: trauma to self, victims known to fire-emergency worker, multiple casualties, incidents involving children, unusual or problematic tactical operations, and exposure to severe medical trauma.

OBJECTIVES

To examine the construct validity of all subscales of the Critical Incident Inventory (CII) by assessing the unidimensionality of the scales, and the interval properties of CII subscales by examining fit to the Rasch model and ordering of item thresholds.

METHODS

This was a secondary data analysis based on survey data collected from a sample of 390 firefighters.

RESULTS

Item 4 and Item 20 were removed with the confirmation of unacceptable fit residual. This revised version of the CII showed satisfactory fit to the Rasch model by non-significant Chi-square test and acceptable level of item fit. We rescored the CII original version and considered all items as only dichotomous response options where 0 represented the original no experience, and 1 presents the combination of experiencing 1, 2, 3 cases.

CONCLUSION

The re-appraisal of the revised version CII indicated a satisfactory level of Rasch model fit.

Rasch Analysis of the Proactive Personality Scale

The Proactive Personality Scale (PPS) is used widely to measure proactive personality. Previous research has evaluated the psychometric properties of the 6-item PPS (hereafter called PPS-6) using classical test theory. There is a need to provide further validity evidence for the PPS-6 using modern test theory. This study evaluated the psychometric properties of the PPS-6 using Rasch analysis. A total of 429 participants completed the PPS-6. Rasch rating scale model (RSM) was used to analyse the data. RSM showed that the PPS-6 fitted the Rasch model well. RSM demonstrated that the PPS-6 functioned as a unidimensional measure with good internal consistency reliability. Items on the PPS-6 did not show any noticeable differential item functioning across gender. RSM showed that the response rating scale of the PPS-6 is suitable. Results suggest that the PPS-6 is a reliable measure for the assessment of proactive personality.

A study protocol for a multicenter randomized pilot trial of a dyadic, tailored, web-based, psychosocial, and physical activity self-management program (TEMPO) for men with prostate cancer and their caregivers

Background

Prostate cancer predisposes patients and caregivers to a wide range of complex physical and psychosocial challenges, and interventions must incorporate a wide range of self-management strategies to help patients and their caregivers effectively cope with cancer challenges. To palliate this need, our team recently developed and evaluated the initial acceptability of a dyadic, Tailored, wEb-based, psychosocial, and physical activity self-Management PrOgram (TEMPO). TEMPO is a 10-week, interactive, web-based intervention consisting of five modules designed to help dyads manage their physical and psychosocial needs. It aims to teach dyads new self-management strategies and encourages them to increase their physical activity (PA) levels, mainly through walking and strength-based exercises. Initial acceptability evaluation of TEMPO revealed high user satisfaction, in addition to having a number of potential benefits for participants. After integrating suggested changes to TEMPO, the proposed pilot study aims to further test the acceptability and feasibility of TEMPO.

Methods

This study is a multicenter, stratified, parallel, two-group, pilot randomized control trial (RCT), where patient–caregiver dyads are randomized (stratified by anxiety level) to receive (a) TEMPO or (b) usual care. Participants (n goal = 40) are recruited across Canada at participating cancer centers and through self-referral (e.g., online recruitment). Patient inclusion criteria are (a) having received prostate cancer treatment within the past 2 years or scheduled to receive treatment, (b) identified a primary caregiver willing to participate in the study, and (c) has access to the Internet. Eligible caregivers are those identified by the patient as his primary source of support. Dyads complete a baseline questionnaire (T1) and another one 3 months later (T2) assessing various aspects of physical and emotional functioning (e.g., the Medical Outcomes Study (MOS) 12-item Short Form Health Survey (SF-12), the Hospital Anxiety and Depression Scale (HADS), and the Perceived Stress Scale (PSS)), self-management behaviors (e.g., the Health Education Impact Questionnaire (heiQ)), physical activity (the International Physical Activity Questionnaires (IPAQ) and the Multidimensional Self-efficacy for Exercise Scale (MSES)), and dyadic coping (the Dyadic Coping Inventory (DCI)). Dyads that used TEMPO are also asked to participate in a semi-structured exit interview exploring their overall experience with the program.

Discussion

This feasibility analysis will begin to develop the knowledge base on TEMPO’s value for men with prostate cancer and their caregivers to inform a larger trial.

Trial registration

NCT04304196

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00791-6.

Measurement properties of the Michigan hand outcomes questionnaire: Rasch analysis of responses from a traumatic hand injury population

PURPOSE

This study aimed to use Rasch analysis to test the content, scoring, and measurement properties of the Michigan Hand Outcomes Questionnaire (MHQ).

METHODS

MHQ scores from 196 patients with hand and wrist conditions were collected in an outpatient hand rehabilitation facility. Rasch analysis was conducted to assess the fit statistics of MHQ to confirm the scaling structure of disability subscales, and to identify differential item functioning.

RESULTS

The MHQ did not fit with the Rasch model (χ² = 2376.78, df = 74, p < 0.001), and most thresholds of item responses were disordered. The original scoring algorithm derived from 5-point Likert response options was adjusted to 3-point Likert (10 items) and 4-point Likert (11 items) based on the visual inspection of the thresholds map. Differential item functioning was present in the revised scale based on the age, sex, and dominant hand. Only 3 revised subscales of the MHQ including activities daily living (one hand), aesthetics, and satisfaction showed acceptable fit to the Rasch model. Unidimensionality was achieved in all revised subscales.

CONCLUSIONS

The overall MHQ had a substantial misfit from the Rasch model. Despite efforts of item reduction and rescoring, we did not reach a satisfactory solution. This calls into question the validity of the statistical evaluations performed on this scale using the traditional scoring.Implications for rehabilitationThe MHQ was designed to measure different dimensions of pain and disability but demonstrates multiple measurement problems that undermine it use in present form.It is not appropriate to sum all 37 items of the MHQ into a single score.Three subscales of activities daily living (one hand), aesthetics, and satisfaction can provide unidimensional subscales scores with interval level scaling if scored with our proposed Rasch-based revised scoring.The 27-item version of the MHQ is shown to have strong psychometric properties for administration with patients with hand injuries; however, it requires further validation.

CanDirect: Effectiveness of a Telephone-Supported Depression Self-Care Intervention for Cancer Survivors

PURPOSE

Depression in post-treatment cancer survivors is common and can impair quality of life. CanDirect is a novel, telephone-delivered depression self-care intervention for cancer survivors. We conducted a randomized controlled superiority trial to compare CanDirect with usual care (UC) in this population.

METHODS

Participants completing cancer treatment within the past 10 years who had mild-moderate depressive symptoms with or without major depression were recruited from clinical and community settings in Quebec and Ontario. Permuted block random assignment allocated participants to CanDirect plus UC or to UC alone. Assessments of depression severity (Center for Epidemiological Studies-Depression scale [CES-D]; primary outcome) and secondary outcomes health-related quality of life (Short Form Survey-12 mental and physical component summaries), anxiety symptoms (Hospital Anxiety and Depression Scale), activation (Patient Activation Measure), depression diagnosis (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV), and health services (self-report) were conducted at baseline, as well as 3 and 6 months (primary time point). Analyses of outcomes were adjusted for covariates using linear regression and missing data by inverse probability weighting.

RESULTS

Participants recruited between September 2016 and October 2018 were randomly assigned to CanDirect (n = 121) or UC (n = 124). Among 245 participants randomly assigned, 218 (89.0%) completed the primary outcome at 6 months. CanDirect participants reported less severe depressive symptoms on the CES-D than UC participants at 6 months, adjusted effect size (ES) 0.61 (95% CI, 0.33 to 0.88). CanDirect participants also had significantly greater quality of life, lower anxiety, more activation, and lower rates of depression diagnoses, compared with UC. Exploratory analysis suggested that sex was a modifier of the primary outcome (interaction term P value = .03); the intervention was less effective in men (ES, 0.12; 95% CI, -0.45 to 0.69).

CONCLUSION

The findings suggest that CanDirect is an effective method of managing mild-moderate depression symptoms in cancer survivors.

Evaluation of the Structural Validity of the Work Instability Scale Using the Rasch Model

Objective

To use Rasch analysis to examine the measurement properties of the 23-item version of the Work Instability Scale (WIS-23) in a sample of worker compensation claimants with upper extremity disorders.

Design

Secondary data analysis on the data retrieved from a cross-sectional study.

Setting

Tertiary care hospital.

Participants

Patients (N=392) attending a specialty clinic for workers with upper limb injuries at a tertiary hospital were prospectively enrolled.

Interventions

Not applicable.

Main Outcome Measures

WIS-23.

Results

The study sample contained 392 participants between the ages of 19 and 73 years (mean, 47.0±10.5y). There were 148 (37.8%) women, 182 (46.4%) men, and 62 (15.8%) participants for whom sex identification was unavailable. The initial WIS data analysis showed significant misfit from the Rasch model (item-trait interaction: χ²=293.52; P<.0001). Item removal and splitting were performed to improve the model fit, resulting in a 20-item scale that met all assumptions (χ²=160.42; P=.008), including unidimensionality, local independence of items, and the absence of differential item function based on age, sex of respondents, employment type, and affected upper extremity area across all tested factors.

Conclusion

With the application of Rasch analysis, we refined the WIS-23 to produce a 20-item WIS for work-related upper extremity disorders (WIS-WREUD). The 20-item WIS-WREUD demonstrated excellent item and person fit, unidimensionality, acceptable person separation index, and local independency. The WIS-20 may provide better measurement properties, although longitudinal psychometric evaluations are needed.

An Evaluation of the Structural Validity of the Work Limitation Questionnaire Using the Rasch Model

OBJECTIVE

To investigate the targeting, scaling, and structural validity of the Work Limitation Questionnaire (WLQ) using Rasch analysis.

DESIGN

Secondary data analysis.

SETTING

Tertiary care hospital.

PARTICIPANTS

The data were sourced from an upper limb specialty clinic of injured workers using the convenience sampling method and from a national randomized controlled trial investigating 2 surgical options for rotator cuff repair by formal, randomized selection (N=315).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Work Limitation Questionnaire 25-item version (WLQ-25). The WLQ contains 25 items measuring a client's ability to perform specific job demands on a 5-point ordinal response scale ranging from 0 (difficulty none of the time) to 4 (difficulty all the time). The average of all 25 items is used as the total score, ranging from 0 to 4, where higher index scores indicate greater difficulty performing daily work. Subscales were used to assess time management, physical demands (PD), mental-interpersonal demands, and output demands.

RESULTS

The Rasch analyses performed on the dataset included the test of fit of residuals, ordering of item thresholds, Person separation index, differential item functioning (DIF), dependency, and unidimensionality. The partial credit model was selected for the current Rasch analysis because the likelihood ratio test was significant at both the overall questionnaire and the subscale level (P<.001). The WLQ-25 did not fit with the Rasch model (χ²=1715.58; df=125; P<.001) and most of the thresholds were disordered. A series of steps were undertaken to improve the fit statistic, including item reduction (6 items) and response merging (9 items). DIF was absent in the revised scale based on sex, age, full- or part-time employment, and type of employment. Only 3 revised subscales, namely the PD, mental demands, and interpersonal demands subscales, demonstrated acceptable fit to the Rasch model.

CONCLUSIONS

The WLQ-25 demonstrated substantial misfit from the Rasch model, which could not be fully mediated. The revised PD, mental demands, and interpersonal demands subscales could be used to assess these constructs.

Nonsense on Stilts - Part 1: The ICER 2020-2023 Value Assessment Framework for Constructing Imaginary Worlds

Previous commentaries in the Formulary Evaluation section of INNOVATIONS in Pharmacy have pointed to the lack of credibility in modeled claims for cost-effectiveness and associated recommendations for pricing and access by the Institute for Clinical and Economic Review (ICER). The principal objection to ICER reports has been that their modeled claims fail the standards of normal science: they are best seen as pseudoscience. The purpose of this latest commentary is to provide a critique of the recently released ICER 2020 Value Assessment Framework (VAF). Although ICER has taken upon itself the pole position in health technology assessments and recommendations for product pricing in the US health care system, the incremental, lifetime cost-per-QALY modeling methodology should not be taken seriously. The creation of imaginary modeled worlds, built entirely from assumption, fails the demarcation test between science and pseudoscience. The ICER evidence reports are best seen as the health technology assessment equivalent of 'intelligent design' in counterpoint to 'natural selection'. It is surprising, therefore, that health care decision makers should take ICER's recommendations seriously as providing 'approximate information' for formulary decision making. What is not appreciated is that the claims made by ICER lack credibility, are impossible to evaluate and lack the ability to be replicated across treatment settings. Indeed, the models presented under the guise of a 'state of the art' value assessment were never intended to support evaluable claims. We have no idea and will never know if they are right or if they are wrong. ICER's position becomes even more untenable once the models presented are assessed in detail. Without in any way supporting the ICER methodology, it is worth noting that all too often ICER's claims for incremental QALYs in specific models are based upon what appears to be, from the limited evidence presented, a casual and ad hoc assemblage of utility scores from diverse constructs. This is a critical weakness given the role attributed by ICER to the modeled cost-per-QALY claims as central to ICERs imaginary value assessment. ICER also overlooks the fact that the utility scores it captures from the literature to populate its imaginary reference case world lack objectivity. They are ordinal rather than interval measures. To apply these manifest scores to time spent in a disease stage and then aggregate these over different disease stages is nonsensical. The critical issue is one of instrument development. The case made here is for the application of Rasch Measurement Theory (RMT) to construct a unidimensional instrument with interval properties, in this case from the needs fulfillment construct of quality of life (QoL). Unless an instrument meets RMT standards in its development, the logic of Rasch modeling to achieve fundamental measurement standards means that other scales are, by definition, ordinal. It is absurd to 'assume' they are interval. RMT is designed to create instruments to evaluate change and test hypotheses. In the absence of instruments that have RMT properties, the cost-per-QALY reference case modelling meme collapses. It is an analytical dead end. If we are to support a meaningful scientific program to discover new facts to support health care delivery and improve the lives of patients, caregivers and their families, then ICER should be put to one side.

Validation of the revised Food Neophobia Scale (FNS-R) in the Italian context

Measuring individuals' level of food neophobia, i.e., the reluctance to eat novel food, is a critical task since it negatively affects diet variety and quality. Using structural equations models, the revised Food Neophobia Scale (FNS-R) was validated with a sample of 711 Italian adults. After deleting 4 items characterized by both low face validity and a suboptimal association with the other items, and after correcting statistically for the acquiescent response-set, the resulting 6-item, fully balanced FNS-R showed a good construct validity. Moreover, it showed the expected positive correlations with General Neophobia and with Disgust Sensitivity. Finally, it resulted invariant across participants' genders, age classes, and levels of education, and across methods of administration (paper-and-pencil and on-line). Strong points and possible developments of the study are discussed.

Distress and Supportive Care Needs of Ethnically Diverse Older Adults With Advanced or Recurrent Cancer

OBJECTIVES

To assess the prevalence of supportive care needs (SCNs) and distress and to describe relationships among these and patient characteristics for ethnically diverse older adults with advanced or recurrent cancer.

SAMPLE & SETTING

Cross-sectional survey in five outpatient oncology clinics in an urban academic medical center involving 100 participants receiving cancer care in an economically challenged community.

METHODS & VARIABLES

The supportive care framework for cancer care guided this study, and participants completed the SCN Survey Short Form 34 and the Distress Thermometer. Study variables are cancer diagnosis, gender, helping to raise children, number of comorbid diseases, race or ethnicity, treatment status, and zip code.

RESULTS

Clinically meaningful distress was found in about a third of patients. Distress was not affected by race or ethnicity. Many ethnically diverse older patients with advanced or recurrent cancer report distress and SCNs; those with high distress are more likely to report multiple SCNs.

IMPLICATIONS FOR NURSING

Nursing assessment of patient SCNs and distress is integral to establishing individualized patient-centered care plans and to delivering optimal care.

Rasch analysis of the hospital anxiety and depression scale among Chinese cataract patients

Purpose

To analyze the validity of the Hospital Anxiety and Depression Scale (HADS) among Chinese cataract population.

Methods

A total of 275 participants with unilateral or bilateral cataract were recruited to complete the Chinese version of HADS. The patients' demographic and ophthalmic characteristics were documented. Rasch analysis was conducted to examine the model fit statistics, the thresholds ordering of the polytomous items, targeting, person separation index and reliability, local dependency, unidimentionality, differential item functioning (DIF) and construct validity of the HADS individual and summary measures.

Results

Rasch analysis was performed on anxiety and depression subscales as well as HADS-Total score respectively. The items of original HADS-Anxiety, HADS-Depression and HADS-Total demonstrated evidence of misfit of the Rasch model. Removing items A7 for anxiety subscale and rescoring items D14 for depression subscale significantly improved Rasch model fit. A 12-item higher order total scale with further removal of D12 was found to fit the Rasch model. The modified items had ordered response thresholds. No uniform DIF was detected, whereas notable non-uniform DIF in high-ability group was found. The revised cut-off points were given for the modified anxiety and depression subscales.

Conclusion

The modified version of HADS with HADS-A and HADS-D as subscale and HADS-T as a higher-order measure is a reliable and valid instrument that may be useful for assessing anxiety and depression states in Chinese cataract population.

The nutrition for sport knowledge questionnaire (NSKQ): development and validation using classical test theory and Rasch analysis

BACKGROUND

Appropriate dietary intake can have a significant influence on athletic performance. There is a growing consensus on sports nutrition and professionals working with athletes often provide dietary education. However, due to the limitations of existing sports nutrition knowledge questionnaires, previous reports of athletes' nutrition knowledge may be inaccurate.

METHODS

An updated questionnaire has been developed based on a recent review of sports nutrition guidelines. The tool has been validated using a robust methodology that incorporates relevant techniques from classical test theory (CTT) and Item response theory (IRT), namely, Rasch analysis.

RESULTS

The final questionnaire has 89 questions and six sub-sections (weight management, macronutrients, micronutrients, sports nutrition, supplements, and alcohol). The content and face validity of the tool have been confirmed based on feedback from expert sports dietitians and university sports students, respectively. The internal reliability of the questionnaire as a whole is high (KR = 0.88), and most sub-sections achieved an acceptable internal reliability. Construct validity has been confirmed, with an independent T-test revealing a significant (p < 0.001) difference in knowledge scores of nutrition (64 ± 16%) and non-nutrition students (51 ± 19%). Test-retest reliability has been assured, with a strong correlation (r = 0.92, p < 0.001) between individuals' scores on two attempts of the test, 10 days to 2 weeks apart. Three of the sub-sections fit the Rasch Unidimensional Model.

CONCLUSIONS

The final version of the questionnaire represents a significant improvement over previous tools. Each nutrition sub-section is unidimensional, and therefore researchers and practitioners can use these individually, as required. Use of the questionnaire will allow researchers to draw conclusions about the effectiveness of nutrition education programs, and differences in knowledge across athletes of varying ages, genders, and athletic calibres.

Treatment of Provoked Vulvodynia in a Swedish cohort using desensitization exercises and cognitive behavioral therapy

BACKGROUND

Problems related to pain during vaginal penetration are complex and the etiology is multi-factorial. It was the aim of the present study to measure whether treatment using desensitization exercises and cognitive behavioral therapy (CBT) for women with provoked vulvodynia (PVD) could increase sexual interest, sexual satisfaction and response whilst decreasing experiences of sexual pain.

METHODS AND OUTCOME MEASURES

Sixty women suffering from PVD were treated during a 10-week period with a combination of mucosal desensitization and pelvic floor exercises and CBT. The McCoy Female Sexuality Questionnaire (MFSQ) was used to measure efficacy of the treatment. The Hospital Anxiety and Depression Scale (HADS) was used to measure psychological distress. The primary outcome measurements were changes in scores for the MFSQ and changes in individual items on the MFSQ directly after treatment completion. Secondary outcome measurements were changes in the MFSQ items 6 months after treatment and changes in HADS sub-scales 6 months after treatment. Statistical comparisons of answers to the MFSQ were carried out using the Wilcoxon signed rank test (paired). Validity of the MFSQ in this study was measured by testing one global question about sexuality and total scores on MFSQ using Spearman's correlation test.

RESULTS

Study participants reported a statistically significant increase in sexual fantasies, increased sexual pleasure, excitement and vaginal lubrication after treatment was completed. PVD occurred less often which resulted in significantly less avoidance of sexual intercourse, increased frequency of masturbation and intercourse. All improvements were sustained at 6 months after treatment ended. Two questions showed no significant changes, these pertained to the individual's contentment with her partner as a lover and a friend. The anxiety sub-scale of the HADS showed a significantly decreased level of anxiety at 6 months follow-up but no change in the scores on the depression sub-scale.

CONCLUSION

Treatment for PVD using desensitization exercises and cognitive behavioral therapy significantly improved sexual interest, response and activity and decreased the experience of pain. Larger studies and RCTs are required in order to draw conclusions about treatment and long term effects should be studied. Partners should be encouraged to participate in treatment regimes.

TRIAL REGISTRATION

The study is registered with ISRCTN registry, ID ISRCTN40416405.

Identifying molecular features associated with psychoneurological symptoms in women with breast cancer using multivariate mixed models

Breast cancer (BC) is the second most common cancer among women. Research shows many women with BC experience anxiety, depression, and stress (ADS). Epigenetics has recently emerged as a potential mechanism for the development of depression.1 Although there are growing numbers of research studies indicating that epigenetic changes are associated with ADS, there is currently no evidence that this association is present in women with BC. The goal of this study was to identify high-throughput methylation sites (CpG sites) that are associated with three psychoneurological symptoms (ADS) in women with BC. Traditionally, univariate models have been used to examine the relationship between methylation sites and each psychoneurological symptom; nevertheless, ADS can be treated as a cluster of related symptoms and included together in a multivariate linear model. Hence, an overarching goal of this study is to compare and contrast univariate and multivariate models when identifying methylation sites associated with ADS in women with BC. When fitting separate linear regression models for each ADS scale, 3 among 285,173 CpG sites tested were significantly associated with depression. Two significant CpG sites are located on their respective genes FAM101A and FOXJ1, and the third site cannot be mapped to any known gene at this time. In contrast, the multivariate models identified 8,535 ADS-related CpG sites. In conclusion, when analyzing correlated psychoneurological symptom outcomes, multivariate models are more powerful and thus are recommended.

The Concerns About Recurrence Questionnaire: validation of a brief measure of fear of cancer recurrence amongst Danish and Australian breast cancer survivors

PURPOSE

Fear of cancer recurrence (FCR) is prevalent amongst survivors, and breast cancer survivors are particularly vulnerable. Currently, there are few well-validated brief measures of FCR and none specific to breast cancer. This manuscript describes the development and initial validation of a new measure of FCR for breast cancer survivors, the Concerns about Recurrence Questionnaire (CARQ), and reports its initial validation in an Australian and Danish population-based sample of breast cancer survivors.

METHODS

CTT analyses explored scale reliability and validity; Rasch analyses explored model fit statistics, item bias (DIF) and local dependency. Three-item, four-item and five-item versions were considered.

RESULTS

Two hundred eighteen Australian women aged 28-45 years diagnosed with early-stage breast cancer (stages 0-2) and 2001 Danish women diagnosed with breast cancer (stages 1-3) aged 26-70 completed the CARQ. Based on the results of both CTT and IRT analyses, the four-item English version of the scale performed best. Although the CTT analyses suggested that the CARQ-4 was reliable and valid in both samples, Rasch analyses identified item bias relative to age, and local dependence which may be remedied by further scale development.

CONCLUSIONS

The CARQ-4 English version is currently one of the most rigorously tested brief scales of FCR available.

IMPLICATIONS FOR CANCER SURVIVORS

The availability of more valid and reliable brief measures of FCR will help to promote research and screening of FCR amongst cancer survivors.

Avaliação de ansiedade e depressão em pacientes oncológicos: comparação psicométrica

Instrumentos de avaliação de ansiedade e depressão são úteis para diagnóstico e orientação do manejo clínico diante das alterações emocionais suscitadas pelas vivências do câncer. O presente estudo comparou vantagens e desvantagens psicométricas de instrumentos comumente utilizados em serviços especializados em Oncologia: Escala de Ansiedade e Depressão (HADS), Transtorno Geral de Ansiedade (GAD-7) e Questionário sobre Saúde do Paciente (PHQ-9). Participaram da pesquisa, 200 pacientes diagnosticados com câncer, em tratamento quimioterápico, sendo 30,5% homens e 69,5% mulheres, com idade entre 18 a 89 anos (M=56,8; DP=15). Os instrumentos mostraram coeficientes de fidedignidade variando entre 0,74 e 0,84. As características psicométricas estudadas indicaram valores melhores para HADS-D e GAD-7. Entretanto, HADS-A e PHQ-9 também se mostraram adequados para avaliação de ansiedade e depressão. Sugere-se a adoção desses instrumentos para triagem, diagnóstico e monitoramento de pacientes com câncer, especialmente nos domínios psicológico e social.

Cross-sectional relationships between dyadic coping and anxiety, depression, and relationship satisfaction for patients with prostate cancer and their spouses

OBJECTIVE

Dyadic coping has an impact on couples' adjustment to breast cancer; however, there is limited evidence regarding whether dyadic coping influences couples' adjustment to other types of cancer. The objective of this analysis was to further our knowledge of the relationships between dyadic coping, anxiety, depression, and relationship satisfaction among couples facing prostate cancer.

METHODS

Forty-two men recently diagnosed with prostate cancer recruited from urology clinics and their spouses completed measures of dyadic coping, anxiety, depression, and relationship satisfaction. The Actor-Partner Interdependence Model was used to examine the relationships among these concepts.

RESULTS

Relationship satisfaction was significantly associated with patients' and wives' use of positive and negative dyadic coping, and their partners' use of these strategies. Although patients' and wives' use of supportive dyadic coping was not associated with their anxiety and depression, their partner's use of this strategy was associated with anxiety and depression. Only husbands' and wives' perceptions of their partner's negative dyadic coping was associated with anxiety and depression.

CONCLUSIONS/PRACTICE IMPLICATIONS

Couples respond to a prostate cancer diagnosis as an interactional system. Future research should focus on tailoring couple-based interventions such that patients and spouses are equipped to provide the specific support their partners need.

Cross-cultural validity of the Spanish version of PHQ-9 among pregnant Peruvian women: a Rasch item response theory analysis

OBJECTIVE

We sought to evaluate the validity of the Spanish language version of the patient health questionnaire-9 (PHQ-9) depression scale in a large sample of pregnant Peruvian women using Rasch item response theory (IRT) approaches. We further sought to examine the appropriateness of the response formats, reliability and potential differential item functioning (DIF) by maternal age, educational attainment and employment status.

METHODS

This cross-sectional study was conducted among 1520 pregnant women in Lima, Peru. A structured interview was used to collect information on demographic characteristics and PHQ-9 items. Data from the PHQ-9 were fitted to the Rasch IRT model and tested for appropriate category ordering, the assumptions of unidimensionality and local independence, item fit, reliability and presence of DIF.

RESULTS

The Spanish language version of PHQ-9 demonstrated unidimensionality, local independence, and acceptable fit for the Rasch IRT model. However, we detected disordered response categories for the original four response categories. After collapsing "more than half the days" and "nearly every day", the response categories ordered properly and the PHQ-9 fit the Rasch IRT model. The PHQ-9 had moderate internal consistency (person separation index, PSI=0.72). Additionally, the items of PHQ-9 were free of DIF with regard to age, educational attainment, and employment status.

CONCLUSIONS

The Spanish language version of the PHQ-9 was shown to have item properties of an effective screening instrument. Collapsing rating scale categories and reconstructing three-point Likert scale for all items improved the fit of the instrument. Future studies are warranted to establish new cutoff scores and criterion validity of the three-point Likert scale response options for the Spanish language version of the PHQ-9.

A parallel-group, randomised controlled trial of a multimedia, self-directed, coping skills training intervention for patients with cancer and their partners: design and rationale

INTRODUCTION

Coping skills training interventions have been found to be efficacious in helping both patients and their partners manage the physical and emotional challenges they face following a cancer diagnosis. However, many of these interventions are costly and not sustainable. To overcome these issues, a self-directed format is increasingly used. The efficacy of self-directed interventions for patients has been supported; however, no study has reported on the outcomes for their partners. This study will test the efficacy of Coping-Together-a multimedia, self-directed, coping skills training intervention for patients with cancer and their partners.

METHODS AND ANALYSIS

The proposed three-group, parallel, randomised controlled trial will recruit patients diagnosed in the past 4 months with breast, prostate, colorectal cancer or melanoma through their treating clinician. Patients and their partners will be randomised to (1) a minimal ethical care (MEC) condition-selected Cancer Council New South Wales booklets and a brochure for the Cancer Council Helpline, (2) Coping-Together generic-MEC materials, the six Coping-Together booklets and DVD, the Cancer Council Queensland relaxation audio CD and login to the Coping-Together website or (3) Coping-Together tailored-MEC materials, the Coping-Together DVD, the login to the website and only those Coping-Together booklet sections that pertain to their direct concerns. Anxiety (primary outcome), distress, depression, dyadic adjustment, quality of life, illness or caregiving appraisal, self-efficacy and dyadic and individual coping will be assessed before receiving the study material (ie, baseline) and again at 3, 6 and 12 months postbaseline. Intention-to-treat and per protocol analysis will be conducted.

ETHICS AND DISSEMINATION

This study has been approved by the relevant local area health and University ethics committees. Study findings will be disseminated not only through peer-reviewed publications and conference presentations but also through educational outreach visits, publication of lay research summaries in consumer newsletters and publications targeting clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000491763 (03/05/2013).