Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study

A multicenter study of bodily distress syndrome in Chinese outpatient hospital care: prevalence and associations with psychosocial variables

BACKGROUND

Bodily distress syndrome (BDS) is a new, empirical-based diagnosis of functional somatic symptoms. This study aimed to explore the prevalence of BDS and its association with psychosocial variables in a Chinese clinical population.

METHODS

A multicentre cross-sectional study of 1269 patients was conducted in 9 different Chinese tertiary outpatient hospitals. The BDS was identified by trained interviewers face-to face, based on a brief version of the Schedules for Assessment in Neuropsychiatry (RIFD) and the BDS Checklist-25. Sociodemographic data and further information were characterised from psychometric questionnaires (The Patient Health Questionnaire-15, the Patient Health Questionnaire-9, the General Anxiety Disorder-7, the Whiteley scale-8) .

RESULTS

Complete data were available for 697 patients. The prevalence of BDS was 26.8% (95% confidence interval (CI): 23.5-30.1). Among the participants, 5.8% (95% CI: 4.1-7.6) fulfilled the criteria for single-organ BDS, while 20.9% (95%CI: 17.9-24.0) had multi-organ BDS. Comparison of the PHQ-15, PHQ-9, GAD-7, and WI-8 scores revealed higher scores on all dimensions for patients with BDS. In a binary logistic regression analysis, BDS was significantly associated with increased health-related anxiety (WI-8) and depression (PHQ-9). The explained variance was Nagelkerke's R² = 0.42.

CONCLUSIONS

In China, the BDS is a common clinical condition in tertiary outpatient hospital settings with high prevalence, and is associated with health anxiety and depressive symptoms. In this clinical population, the severe multi-organ subtype of BDS was the most frequent.

Trends in complementary and alternative medicine for the treatment of common mental disorders: A bibliometric analysis of two decades

OBJECTIVE

To investigate the trend of scientific production in relation to the modalities of CAM adopted for the treatment of common mental disorders (CMD), and the evolution and distribution of relevant articles.

MATERIAL AND METHODS

A bibliometric analysis of studies published between 2001 and 2020 was performed, extracted from the Scopus database, using the terms: integrative medicine, complementary therapy, common mental disorders, anxiety and depression, and synonyms. The relationship between the number of publications, and the years studied were analyzed using Pearson's correlation, followed by linear regression to estimate the number of articles along with the year. The VOSviewer software was used to analyze scientometric data. The study looked at countries with the highest number of publications and citations, co-authorships, most frequent keywords, and leading research organizations.

RESULTS

In the analysis of the two decades, we identified a high positive correlation between the number of publications and year (r = 0.945). In trend analysis, the linear regression equation predicted the growth of publications along with the year, with R² = 0.8949 explaining most of the data variability. Spirituality was the most frequent term among the modalities. The concentration of publications and the number of citations were significantly higher in developed countries.

CONCLUSION

The rise in the number of publications in the past two decades on the application of CAM among individuals with CMD suggests a growing scientific interest in Integrative practices. These bibliometric indicators suggest that new studies are warranted, as well as improvements in public health policies.

ICD-11 'mixed depressive and anxiety disorder' is clinical rather than sub-clinical and more common than anxiety and depression in the general population

Background

The new International Classification of Diseases was published in 2018 (ICD‐11; World Health Organization, 2018) and now includes ‘Mixed depressive and anxiety disorder’ (6A73: MDAD) designated as a mood disorder. This disorder is defined by symptoms of both anxiety and depression occurring more days than not, for a period of two weeks, and neither set of symptoms considered separately reaches a diagnostic threshold for either disorder. However, to date no study has examined the validity of these guidelines in a general population sample.

Methods

Using Goldberg et al.’s (2017) guidelines regarding measurement of depression and anxiety, this study used factor mixture modelling (FMM) to examine the validity of the ICD‐11 criteria of MDAD. Symptom endorsement rates are provided as well as demographic predictors and somatization outcomes.

Results

Fit indices suggested the two‐factor four‐class solution was the best balance between model complexity and model fit. The results did not support a class that is subsyndromal to both anxiety and depression. On the contrary, we suggest that there exists a ‘Comorbid’ class that represents endorsement of both anxiety and depression symptoms at a higher level when compared to both ‘anxiety’ and ‘depression’ groups. Demographic predictors, as well as somatization and functional impairment outcomes, provided support for this FMM solution.

Conclusions

The ‘Comorbid’ group was the largest symptomatic group and had the highest levels of both anxiety and depression symptoms. Importantly, this group was larger than either the ‘anxiety’ or ‘depression’ group and was associated with high levels of functional impairment and somatization.

Prevalence and overlap of somatic symptom disorder, bodily distress syndrome and fibromyalgia syndrome in the German general population: A cross sectional study

OBJECTIVE

To study the prevalence and clinical characteristics of Somatic Symptom Disorder (SSD), Bodily Distress Syndrome (BDS) and fibromyalgia syndrome (FMS) and their overlap in the general German population.

METHODS

A cross-sectional nationally representative population survey was performed. 2531 participants (mean age 48.8 ± 17.85 years, 53.3% women) completed the Somatic Symptom Scale SSS-8, the Bodily Distress Syndrome (BDS) 25 checklist, the Whiteley Index 7 (WI-7), the self-administered comorbidity questionnaire and the Michigan Body Map. Case definitions of SSD, BDS and FMS were assigned using established criteria.

RESULTS

4.5% of participants met the criteria of SSD (SSS - 8 at least one item "bothered very much" and WI- 7 total score ≥ 1). 9.6% met the criteria of single-organ BDS and 1.3% of multi-organ BDS. Prevalence of FMS according to 2016 criteria was 3.4%. 82.3% of FMS cases met any BDS criteria.28.1% of FMS cases satisfied SSD criteria. 28.8% of any BDS cases met the criteria of SSD. 75.1% of SSD cases met the criteria of any BDS. FMS cases reported the highest amount of somatic and psychological symptom burden and health anxieties. There were no differences in age and gender between any BDS and SSD cases. SSD cases reported worse general health and more fibromyalgia-related variables than any BDS cases.

CONCLUSIONS

In the general population, there is a substantial overlap between FMS and BDS, but not of FMS and SSD, and not of SSD and any BDS. Case definitions of the three disorders partially captured different groups in the general population.

Functional somatic disorders: discussion paper for a new common classification for research and clinical use

BACKGROUND

Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs.

MAIN BODY

We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum - and also within organ system-specific chapters of a classification - they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD).

CONCLUSION

We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.

The unifying diagnostic construct of bodily distress syndrome (BDS) was confirmed in the general population

OBJECTIVES

Bodily distress syndrome (BDS) has been shown to encompass a range of functional somatic syndromes (FSS) such as irritable bowel syndrome (IBS), fibromyalgia (FM), and chronic fatigue syndrome (CFS) in clinical samples. This study aimed to explore symptom clusters and test classification of individuals with illness similar to the BDS criteria in a general population sample.

METHODS

A stratified subsample of 1590 individuals from the DanFunD part two cohort was included. Symptoms were assessed with the Research Interview for Functional somatic Disorders, performed by trained physicians. In 44 symptoms pooled from criteria of IBS, FM, CFS, and BDS, symptom clusters were explored with explorative factor analysis. Confirmation of symptom clusters of BDS in the previously described 25- and 30-item BDS checklists was performed with confirmatory factor analysis. Classification of individuals into illness groups was investigated with latent class analysis.

RESULTS

Four symptom clusters (cardiopulmonary, gastrointestinal, musculoskeletal, general symptoms/fatigue) corresponding to the BDS subtypes and their corresponding FSS were identified and confirmed. A three-class model including 25 BDS items had the best fit for dividing participants into classes of illness: One class with low probability, one class with medium probability, and one class with high probability of having ≥4 symptoms in all symptom clusters.

CONCLUSION

The BDS concept was confirmed in the general population and constitutes a promising approach for improved FSS classification. It is highly clinical relevant being the only diagnostic construct defining the complex multi-organ type.

Chronic Widespread Pain in a tertiary pain clinic: classification overlap and use of a patient generated quality of life instrument

Background and aims This study has two main aims: (1) To explore the overlap between classification criteria in patients with Chronic Widespread Pain (CWP) and (2) To explore the use of the Patient Generated Index (PGI) as a quality of life (QoL) measure in this patient group. Methods Patients with Widespread Pain (ICD-11: pain in four or more out of five bodily regions, i.e. the four quadrants and axially) in a tertiary pain outpatient clinic were assessed according to classification criteria for Fibromyalgia [FM, American College of Rheumatology (ACR) criteria of 1990, 2010, 2011 and 2016], Chronic Fatigue Syndrome [CFS, Fukuda, Canada and International Consensus Criteria (ICC)] and Bodily Distress Syndrome (BDS). Furthermore, patients completed the PGI to assess QoL, and electronic questionnaires including demographic variables and standardised patient-reported outcome measures (PROMs). Results All patients (n=33) fulfilled the criteria for musculoskeletal type single-organ BDS, 81.8% met the 2016 modified criteria for FM, 30.3% met the Canada criteria for CFS and 24.2% met the criteria for multi-organ type BDS. There was substantial agreement between the 2016 and the 2011 and 2010 criteria sets for FM compared to the 1990 criteria (κ=0.766 and 0.673 compared to 0.279). Patients generally scored low on the PGI, indicating poor QoL (mean PGI 28.9, SD 19.8, range 0-100). Conclusions Our findings support the use of the term musculoskeletal type single-organ BDS to describe patients with CWP and the 2016 revision of the FM criteria. The PGI provides useful clinical information which is not captured by standardised PROMs. Implications The terminology of CWP has become less ambiguous as the new ICD-11 is closely related to the generalised pain criterion of the modified 2016 FM definition. Studies based on the 1990 classification criteria for FM should not be directly compared to studies based on later criteria set. The PGI may be a supplement to other measurements to portray patients' individual concerns in patients with complex symptom disorders.

Dimensional analysis of depressive, anxious and somatic symptoms presented by primary care patients and their relationship with ICD-11 PHC proposed diagnoses

BACKGROUND

A study conducted as part of the development of the Eleventh International Classification of Mental Disorders for Primary Health Care (ICD-11 PHC) provided an opportunity to test the relationships among depressive, anxious and somatic symptoms in PHC.

METHOD

Primary care physicians participating in the ICD-11 PHC field studies in five countries selected patients who presented with somatic symptoms not explained by known physical pathology by applying a 29-item screening on somatic complaints that were under study for bodily stress disorder. Patients were interviewed using the Clinical Interview Schedule-Revised and assessed using two five-item scales that measure depressive and anxious symptoms. Structural models of anxious-depressive symptoms and somatic complaints were tested using a bi-factor approach.

RESULTS

A total of 797 patients completed the study procedures. Two bi-factor models fit the data well: Model 1 had all symptoms loaded on a general factor, along with one of three specific depression, anxiety and somatic factors [x2 (627) = 741.016, p < 0.0011, RMSEA = 0.015, CFI = 0.911, TLI = 0.9]. Model 2 had a general factor and two specific anxious depression and somatic factors [x2 (627) = 663.065, p = 0.1543, RMSEA = 0.008, CFI = 0.954, TLI = 0.948].

CONCLUSIONS

These data along with those of previous studies suggest that depressive, anxious and somatic symptoms are largely different presentations of a common latent phenomenon. This study provides support for the ICD-11 PHC conceptualization of mood disturbance, especially anxious depression, as central among patients who present multiple somatic symptoms.

Diagnostic consequences of a new category of anxious depression and a reduced duration requirement for anxiety symptoms in the ICD-11 PHC

BACKGROUND

A new diagnosis of anxious depression (AD), characterized by both depressive and anxious symptoms at case level, has been proposed for the classification of mental disorders for primary care for ICD-11 (ICD-11 PHC). The ICD-11 PHC proposes a duration requirement for anxiety symptoms of 2 weeks, in line with the requirement for depressive symptoms. This study examined diagnostic assignment under ICD-11 PHC as compared to the previous classification, the ICD-10 PHC, and the relationship of anxiety duration to disability and suicidal ideation.

METHODS

Primary care physicians in five countries referred patients based on either perceived psychological distress or distressing somatic symptoms to a research assistant who administered a computer-guided diagnostic interview. Complete data were obtained for 2279 participants.

RESULTS

Under ICD-11 PHC 47.7% participants received a diagnosis of AD and had greater disability than other diagnostic groups. Under ICD-10 PHC, in addition to meeting requirements for depressive episode, most of these patients met requirements for either generalized anxiety disorder (41.5%) or mixed anxiety and depressive disorder (45.4%). One third of individuals diagnosed with AD had anxiety durations between 2 weeks and 3 months and presented as much disability and suicidal ideation as individuals with longer anxiety durations.

LIMITATIONS

The study was not designed to establish prevalence of these conditions.

CONCLUSION

The proposed ICD-11 PHC encourages early identification and management of significant anxiety symptoms in primary care, particularly when these co-occur with depression. This study provides support for the clinical relevance of these symptoms and the importance of early identification.

Clinical decisions and stigmatizing attitudes towards mental health problems in primary care physicians from Latin American countries

OBJECTIVE

The aim of this paper is to investigate how doctors working in primary health care in Latin American address patients with common mental disorders and to investigate how stigma can affect their clinical decisions.

METHODS

Using a cross-sectional design, we applied an online self-administered questionnaire to a sample of 550 Primary Care Physicians (PCPs) from Bolivia, Brazil, Cuba and Chile. The questionnaire collected information about sociodemographic variables, training and experience with mental health care. Clinicians' stigmatizing attitudes towards mental health were measured using the Mental Illness Clinicians' Attitudes Scale (MICA v4). The clinical decisions of PCPs were assessed through three clinical vignettes representing typical cases of depression, anxiety and somatization.

RESULTS

A total of 387 professionals completed the questionnaires (70.3% response rate). The 63.7% of the PCPs felt qualified to diagnose and treat people with common mental disorders. More than 90% of the PCPs from Bolivia, Cuba and Chile agreed to treat the patients presented in the three vignettes. We did not find significant differences between the four countries in the scores of the MICA v4 stigma levels, with a mean = 36.3 and SD = 8.3 for all four countries. Gender (p = .672), age (p = .171), training (p = .673) and years of experience (p = .28) were unrelated to stigma. In the two multivariate regression models, PCPs with high levels of stigma were more likely to refer them to a psychiatrist the patients with depression (OR = 1.03, 95% CI, 0.99 to 1.07 p<0.05) and somatoform symptoms somatoform (OR = 1.03, 95% CI, 1.00 to 1.07, p<0.05) to a psychiatrist.

DISCUSSION

The majority of PCPs in the four countries were inclined to treat patients with depression, anxiety and somatoform symptoms. PCPs with more levels of stigma were more likely to refer the patients with depression and somatoform symptoms to a psychiatrist. Stigmatizing attitudes towards mental disorders by PCPs might be important barriers for people with mental health problems to receive the treatment they need in primary care.

Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

Objective:

Disorders characterized by “distressing unexplained somatic symptoms” are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample.

Methodology:

As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed.

Results:

The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with “being a BSS” case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72).

Conclusion:

Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

Patients with somatoform disorders: More frequent attendance and higher utilization in primary Out-of-Hours care?

BACKGROUND

One significant health policy challenge in many European countries at present is developing strategies to deal with the increase in patient attendance at Out-of-Hours care (OOHC), whether this is at OOHC-Centres in primary care settings or hospital emergency departments (ED). FAs (FAs) presenting in OOHC are a known challenge and previous studies have shown that FAs present more often with psychological problems and psychiatric comorbidities rather than severe physical complaints. FAs may be also contributing to the rising workload in OOHC-Centres in primary care. The aim of this study was to determine attendance frequencies and health problem presentation patterns for patients with and without somatoform disorders (ICD-10 F45 diagnoses) in OOHC-Centres in primary care. Some of these somatoform disorders may have a psychiatric character. Moreover, we wanted to compare health care utilization patterns (pharmacotherapy and hospitalizations) between these patients groups.

METHODS

Routine OOHC data from a large German statutory health insurance company in the federal state of Baden-Wuerttemberg were evaluated. 3,813,398 health insured persons were included in the data set from 2014. The data were initially made available for our study group in order to evaluate a comprehensive evaluation programme in German primary care, the "Hausarztzentrierte Versorgung" (HZV), loosely translated as "family doctor coordinated care". We used the ICD-10 codes F45.0-F45.9 in regular care to identify patients with somatoform disorders and compared their health care utilization patterns (attendance rates, diagnoses, prescriptions, hospitalization rates) in OOHC to patients without somatoform disorders. Attendance rates were calculated with multivariable regression models in order to adjust for age, gender, comorbidities and for participation in the HZV intervention.

RESULTS

350,528 patients (9.2%) of the 3,813,398 insured persons had an F45-diagnosis. In comparison with the whole study-sample, patients with an F45-diagnosis were on average seven years older (51.7 vs. 44.0 years; p<0,0001) and the percentage of women was significantly higher (70.1% vs 53.3%; p<0,0001). In OOHC, as opposed to normal office hours, the adjusted rate of patients with an F45-diagnosis was 60.6% higher (adjusted for age, gender and co-morbidity) than in the general study-sample. Accordingly, in OOHC, prescriptions for antidepressants, hypnotics, anxiolytics but also opioids were significantly higher than in the general study population i.e. those without F45- diagnoses. However, an F45 diagnosis was only made in 3.45% of all F45 patients seen in OOHC in 2014.

CONCLUSIONS

Patients with somatoform disorders were more FAs in both regular office hours and in OOHC in primary care settings. In OOHC, they are normally not identified as such because the somatoform illness is secondary to other acutely presenting symptoms such as pain. While it is acknowledged that it is difficult to make an exact diagnosis in this complex group of somatoform disorders in an OOHC setting, it is still important to develop continuing education programmes for medical staff working in OOHC, to support effective recognition and response to the specific needs of this complex patient group.

Social Support patterns in Primary Health Care: differences between having physical diseases or mental disorders

The social support network is a health protective factor involving physical, mental and psychological aspects, providing a better quality of life, favoring better adaptation to adverse conditions, promoting resilience and mobilizing resources for a more effective coping with negative life events that can lead to illness. We aimed to analyze the association between physical diseases, common mental disorders and the social support network of patients serviced at primary care facilities in the cities of Rio de Janeiro and São Paulo through a cross-sectional study with 1,466 patients in the 18-65 years age group. We used the Social Network Index (SNI) to assess the support network through the categories of isolation and integration. The doctor/nurse completed the questionnaire to evaluate the physical disease diagnosis, while the Hospital Anxiety and Depression Scale was used to detect mental disorders. We found that the pattern of social support was different depending on the presence of physical diseases or mental disorders. Negative associations were found between diabetes and isolation; integration and anxiety; integration and depression. Positive associations were identified between isolation and anxiety and isolation and depression.

Medically unexplained syndromes: irritable bowel syndrome, fibromyalgia and chronic fatigue

This is a review of three of the more common medically unexplained syndromes that present for treatment to liaison psychiatry services in general medical hospitals: chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. The three are interrelated, extremely disabling and comorbid mood disorders are frequent. In general, treatment, whether psychological or medical, has very modest impact. The disputed classification of medically unexplained syndromes is also reviewed. There is a clear gulf between the views and experiences of patients with these syndromes and the medical establishment. In this article I summarise give the evidence for pharmacological, psychosocial and ‘alternative’ or ‘complementary’ interventions for a range of disorders, about which there is some dispute. I leave it to the reader to decide which interventions hold the most promise.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Stigmatizing attitudes of primary care professionals towards people with mental disorders: A systematic review

Objective To examine stigmatizing attitudes towards people with mental disorders among primary care professionals and to identify potential factors related to stigmatizing attitudes through a systematic review. Methods A systematic literature search was conducted in Medline, Lilacs, IBECS, Index Psicologia, CUMED, MedCarib, Sec. Est. Saúde SP, WHOLIS, Hanseníase, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex, through the Virtual Health Library portal ( http://www.bireme.br website) through to June 2017. The articles included in the review were summarized through a narrative synthesis. Results After applying eligibility criteria, 11 articles, out of 19.109 references identified, were included in the review. Primary care physicians do present stigmatizing attitudes towards patients with mental disorders and show more negative attitudes towards patients with schizophrenia than towards those with depression. Older and more experience doctors have more stigmatizing attitudes towards people with mental illness compared with younger and less-experienced doctors. Health-care providers who endorse more stigmatizing attitudes towards mental illness were likely to be more pessimistic about the patient's adherence to treatment. Conclusions Stigmatizing attitudes towards people with mental disorders are common among physicians in primary care settings, particularly among older and more experienced doctors. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need. The primary care physicians feel they need better preparation, training, and information to deal with and to treat mental illness, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.

Primary care physicians' use of the proposed classification of common mental disorders for ICD-11

BACKGROUND

The World Health Organization is revising the classification of common mental disorders in primary care for ICD-11. Major changes from the ICD-10 primary care version have been proposed for: (i) mood and anxiety disorders; and (ii) presentations of multiple somatic symptoms (bodily stress syndrome). This three-part field study explored the implementation of the revised classification by primary care physicians (PCPs) in five countries.

METHODS

Participating PCPs in Brazil, China, Mexico, Pakistan and Spain were asked to use the revised classification, first in patients that they suspected might be psychologically distressed (Part 1), and second in patients with multiple somatic symptoms causing distress or disability not wholly attributable to a known physical pathology, or with high levels of health anxiety (Part 2). Patients referred to Part 1 or Part 2 underwent a structured diagnostic interview. Part 3 consisted of feedback from PCPs regarding the classification.

RESULTS

In Part 1, anxious depression was the most common disorder among referred patients. PCPs assigned the highest severity ratings to anxious depression, and the next highest to current depression; current anxiety was rated as least severe. Considerable overlap was found between bodily stress syndrome (BSS) and health anxiety (HA). The psychiatric interview recorded higher rates of mood and anxiety disorders diagnoses among patients with BSS than did PCPs. PCPs' satisfaction with the revised classification was high.

CONCLUSIONS

Results generally supported the inclusion of the new categories of anxious depression, BSS and HA for ICD-11 PHC and suggested that PCPs could implement these categories satisfactorily.

Diagnostic barriers for somatic symptom disorders in primary care: study protocol for a mixed methods study in Germany

INTRODUCTION

Somatoform or somatic symptom disorders ((S)SD) are common and have a negative impact on the patients' health-related quality of life, healthcare use and costs. In primary care, which is central to the management of (S)SD, diagnosis and treatment tend to be delayed. There is a significant lack of evidence regarding the barriers in the diagnostic process of (S)SD in primary care and how interventions should be tailored to address them. The aim of this study is to analyse the diagnostic process in primary care that results in the diagnosis or non-diagnosis of a (S)SD.

METHODS AND ANALYSIS

This mixed methods study will investigate the topic with qualitative methods, subsequently proceeding to a quantitative phase where the initial results will be validated and/or generalised. First, focus groups will explore meanings and patterns, inconsistencies and conflicts in general practitioners' (GPs) thoughts and behaviours when diagnosing (S)SD. Second, the results of these focus groups will be used to develop interview guidelines for subsequent face-to-face interviews. Patients and their treating GPs will be interviewed separately on how they experience the history of illness, the diagnostic process and treatment. Third, based on the results of the first two study parts, a questionnaire will be derived and a nationwide survey among German GPs will be conducted, quantifying the barriers and difficulties identified before.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Hamburg Medical Association, Germany (approval number PV4763). The results of this study will be disseminated through conference presentation and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

The study is registered in the German Clinical Trial Register (DRKS), DRKS-ID DRKS00009736.

Imipramine versus placebo for multiple functional somatic syndromes (STreSS-3): a double-blind, randomised study

BACKGROUND

Functional somatic syndromes, including chronic fatigue syndrome or irritable bowel syndrome, often co-exist. Treatment guidelines supported by high quality evidence exist for most functional somatic syndromes, but are lacking for multiple comorbid functional somatic syndromes. We aimed to assess the effect of the tricyclic antidepressant, imipramine, in patients with multiple functional somatic syndromes defined by the criteria for multiorgan bodily distress syndrome, a unifying diagnosis that encompasses most functional somatic syndromes and somatoform disorders.

METHODS

In this single-centre, double-blind, randomised trial done in a Danish university hospital setting, participants were patients consecutively referred (age 20-50 years) fulfilling criteria for multiorgan bodily distress syndrome with no concurrent comorbid depression or anxiety disorder. Participants were randomly assigned (1:1) to receive either 10 weeks of low-dose imipramine or placebo (oral daily doses of 25-75 mg). The hospital pharmacy handled randomisation (computer-generated) and masking, providing sequentially numbered packs of study drug that were given serially to the participants. All others involved were masked to allocation. Primary outcome was patient-rated overall health improvement on a 5-point clinical global improvement scale. Improvement was defined as patients responding "better" or "much better" as opposed to "unchanged" and "worse" or "much worse" when rating their overall health status after 10 weeks of minimum 25 mg study drug. Analyses included patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, number NCT01518634.

FINDINGS

Between Jan 30, 2012, and Nov 24, 2014, 138 patients were randomly assigned; 70 to receive imipramine and 68 to receive placebo. The study was completed on May 1, 2015. 125 patients received at least one dose of study drug: 65 received imipramine and 60 received placebo. Treatment was terminated prematurely for eight (12%) patients receiving imipramine and seven (12%) patients receiving placebo. Data were missing for two (3%) patients receiving imipramine and three (5%) patients receiving placebo. Of the 120 patients (96%) who provided primary outcome data, 33 (53%) receiving imipramine reported their overall health status as "better" or "much better" compared with 14 patients (25%) receiving placebo. The improvement after imipramine was significantly greater than after placebo (odds ratio 3·3 [95% CI 1·6-6·8]; p=0·001). Number needed to treat was 3·6 (95% CI 2·3-8·9). Analysis of the worst-case scenario for patients with missing outcome did not change the interpretation of the results. 32 patients (49%) receiving imipramine and 10 patients (17%) receiving placebo had at least one adverse event of moderate intensity (p=0·0001); eight patients (12%) receiving imipramine and three patients (5%) receiving placebo had at least one adverse event of severe intensity (p=0·1496). One patient (1%) receiving placebo experienced a serious adverse event (a subdural haematoma sustained after an accident). Adverse events caused dropout in four patients (6%) receiving imipramine and three patients (5%) receiving placebo.

INTERPRETATION

Imipramine treatment compared with placebo significantly improved overall health in patients with multiple functional somatic syndromes when both treatments were supported by regular contacts with clinicians. Adverse events were more common in the imipramine group, but only rarely led to discontinuation of treatment.

FUNDING

The Danish Foundation, Trygfonden.

Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC

BACKGROUND

In this field study of WHO's revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings.

METHODS

The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants.

RESULTS

A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores.

LIMITATIONS

This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings.

CONCLUSIONS

The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

Long-Term Outcome of Bodily Distress Syndrome in Primary Care: A Follow-Up Study on Health Care Costs, Work Disability, and Self-Rated Health

OBJECTIVE

The upcoming International Classification of Diseases, 11th Revision for primary care use suggests inclusion of a new diagnostic construct, bodily (di)stress syndrome (BDS), for individuals with medically unexplained symptoms. We aimed to explore the long-term outcome of BDS in health care costs, work disability, and self-rated health.

METHODS

Consecutive patients consulting their family physician for a new health problem were screened for physical and mental symptoms by questionnaires (n = 1785). A stratified subsample was examined with a standardized diagnostic interview (n = 701). Patients with single-organ BDS (n = 124) and multiorgan BDS (n = 35), and a reference group with a family physician-verified medical condition (n = 880) were included. All included patients completed a questionnaire at 3, 12, and 24 months of follow-up. Register data on health care costs and work disability were obtained after 2 and 10 years of follow-up, respectively.

RESULTS

Patients with BDS displayed poorer self-rated health and higher illness worry at index consultation and throughout follow-up than the reference group (p ≤ .001). The annual health care costs were higher in the BDS groups (2270 USD and 4066 USD) than in the reference group (1392 USD) (achieved significance level (ASL) ≤ 0.001). Both BDS groups had higher risk of sick leave during the first 2 years of follow-up (RRsingle-organ BDS = 3.0; 95% confidence interval [CI] = 1.8-5.0; RRmultiorgan BDS = 3.4; 95% CI = 1.5-7.5) and substantially higher risk of newly awarded disability pension than the reference group (HRsingle-organ BDS = 4.9; 95% CI = 2.8-8.4; HRmultiorgan BDS = 8.7; 95% CI = 3.7-20.7).

CONCLUSIONS

Patients with BDS have poor long-term outcome of health care costs, work disability, and subjective suffering. These findings stress the need for adequate recognition and management of BDS.

Long-term economic evaluation of cognitive-behavioural group treatment versus enhanced usual care for functional somatic syndromes

OBJECTIVE

Patients with functional somatic syndromes (FSS) such as fibromyalgia and chronic fatigue syndrome have a poor outcome and can incur high healthcare and societal costs. We aimed to compare the medium-term (16months) cost-effectiveness and the long-term (40months) economic outcomes of a bespoke cognitive-behavioural group treatment (STreSS) with that of enhanced usual care (EUC).

METHODS

We obtained complete data on healthcare and indirect costs (i.e. labour marked-related and health-related benefits) from public registries for 120 participants from a randomised controlled trial. Costs were calculated as per capita public expenses in 2010 €. QALYs gained were estimated from the SF-6D. We conducted a medium-term cost-effectiveness analysis and a long-term cost-minimization analysis from both a healthcare (i.e. direct cost) and a societal (i.e. total cost) perspective.

RESULTS

In the medium term, the probability that STreSS was cost-effective at thresholds of 25,000 to 35,000 € per QALY was 93-95% from a healthcare perspective, but only 50-55% from a societal perspective. In the long term, however, STreSS was associated with increasing savings in indirect costs, mainly due to a greater number of patients self-supporting. When combined with stable long-term reductions in healthcare expenditures, there were total cost savings of 7184 € (95% CI 2271 to 12,096, p=0.004) during the third year after treatment.

CONCLUSION

STreSS treatment costs an average of 1545 €. This cost was more than offset by subsequent savings in direct and indirect costs. Implementation could both improve patient outcomes and reduce costs.

Association between walking, dysphoric mood and anxiety in late pregnancy: A cross-sectional study

Relationship between physical activity and mental disorders in late pregnancy is unclear. In this work, we demonstrate that there is a significant association between the time spent on walking and symptoms of depression and anxiety in antenatal period. The cross-sectional study was done on a sample of 200 healthy women in 9th month of physiological pregnancy at Health center Kraljevo, Serbia during 2015. Each participant was given a questionnaire consisting of general questions regarding physical activity, pregnancy, and other parameters. Also, each participant completed a Beck depression inventory (BDI) and Zung anxiety scale (ZAS). There was a statistically significant negative correlation (p<0.05) between the BDI score and the daily time spent on walking. There was also a strong positive connection between the daily time spent on walking and level of anxiety (p<0.01). To our knowledge this is the first study to jointly test the relationship between scores of Beck depression inventory and Zung anxiety scale, and time spent on walking as physical activity in antenatal period. The results represent the basis for further research in the field of gynecological psychology, psychiatry and behavioral physiology.

Patient characteristics and frequency of bodily distress syndrome in primary care: a cross-sectional study

Background

Bodily distress syndrome (BDS) is a newly proposed diagnosis of medically unexplained symptoms, which is based on empirical research in primary care.

Aim

To estimate the frequency of BDS in primary care and describe the characteristics of patients with BDS.

Design and setting

A cross-sectional study of primary care patients in urban and rural areas of Central Denmark Region.

Method

Data were obtained from GP one-page registration forms, patient questionnaires (including a checklist for BDS), and national registers.

Results

A total of 1356 primary care patients were included, of whom 230 patients (17.0%, 95% confidence intervals [CI] = 15.0 to 19.1) fulfilled the BDS criteria. BDS was more common among primary care patients aged 41–65 years (odds ratio [OR] = 1.9, 95% CI = 1.3 to 3.0) and was equally frequent among males and females (female sex, OR 0.9, 95% CI = 0.6 to 1.3). Patients with BDS were characterised by poor health-related quality of life (HRQOL) on the 12-item Short-Form Health Survey, that is, physical component summary scores <40 (OR 20.5, 95% CI = 12.9 to 32.4) and mental component summary scores <40 (OR 3.5, 95% CI = 2.2 to 5.6). Furthermore, patients with BDS were more likely to have high scores on the Symptom Checklist for anxiety (OR 2.2, 95% CI = 1.4 to 3.4) and depression (OR 5.1, 95% CI = 3.3 to 7.9), but regression analyses showed that mental morbidity did not account for the poor HRQOL.

Conclusion

BDS is common among primary care patients, and patients with BDS have a higher probability of poor HRQOL and mental health problems.

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings

OBJECTIVE

A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability.

METHOD

PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability.

RESULTS

Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability.

CONCLUSION

Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.

Multiple somatic symptoms in primary care patients: a cross-sectional study of consultation content, clinical management strategy and burden of encounter

Background

Consultations involving patients with multiple somatic symptoms may be considered as challenging and time-consuming by general practitioners (GPs). Yet, little is known about the possible links between consultation characteristics and GP-experienced burden of encounter. We aimed to explore consultation content, clinical management strategies, time consumption and GP-experienced burden of encounters with patients suffering from multiple somatic symptoms as defined by the concept of bodily distress syndrome (BDS).

Methods

Cross-sectional study of patient encounters in primary care from December 2008 to December 2009; 387 GPs participated (response rate: 44.4 %). Data were based on a one-page registration form completed by the GP and a patient questionnaire including the 25-item BDS checklist for somatic symptoms. Using logistic regression analyses, we compared patients who met the BDS criteria with patients who did not.

Results

A total of 1505 patients were included (response rate: 55.6 %). Health problems were less frequently reported as ‘new’ in patients with BDS (odds ratio (OR) = 0.73, 95 % confidence interval (CI): 0.54; 0.97). Medical prescriptions and referral rates were comparable in the two patient groups. Consultations focusing on mainly biomedical aspects were less frequent among patients with BDS (OR = 0.31, 95 % CI: 0.22; 0.43), whereas additional biomedical and psychosocial problems were more often discussed. GPs were more likely to ensure continuity of care in BDS patients by watchful waiting strategies (OR = 2.32, 95 % CI: 1.53; 3.52) or scheduled follow-up visits (OR = 1.61, 95 % CI: 1.09; 2.37). Patients with BDS were found to be more time-consuming (OR = 1.77, 95 % CI: 1.26; 2.48) and burdensome (OR = 2.54, 95 % CI: 1.81; 3.55) than patients without BDS. However, after adjustments for biomedical and psychosocial content of the consultation, the identified differences for time consumption and burden were no longer statistically significant.

Conclusions

Patients with BDS represent higher care complexity in terms of biomedical and psychosocial needs. GPs seem to allow space and time for discussing these issues and to aim at ensuring continuity in care through watchful waiting or scheduled follow-up consultations. However, the reported GP-experienced burden call for professional development.

Impact of anxiety symptoms on outcomes of depression: an observational study in Asian patients

OBJECTIVE

To investigate the impact of anxiety symptoms on depression outcomes in Asian patients with major depressive disorder (MDD) (n=714).

METHODS

The 17-item Hamilton Depression Scale (HAMD-17), overall severity, somatic symptoms, and quality of life (QOL) (EuroQOL Questionnaire-5 Dimensions [EQ-5D]) were assessed at baseline and 3 months. Anxiety was measured using items 10 and 11 from the HAMD-17. Linear, tobit, and logistic multiple regression models analyzed the impact of anxiety symptoms on outcomes. Baseline anxiety was related to age and the presence of pain symptoms at baseline.

RESULTS

Regression models showed that a higher level of anxiety was associated with a lower frequency of remission and lower QOL at 3 months. Patients with lower baseline anxiety symptoms had higher remission rates (odds ratio for each point of anxiety symptoms, 0.829 [95% confidence interval [CI]: 0.723-0.951]). Patients with higher levels of baseline anxiety had a lower QOL at 3 months (a decrease in EQ-5D tariff score for each point of anxiety symptoms, 0.023 [95% CI: 0.045-0.001]).

CONCLUSION

In conclusion, the presence of anxiety symptoms negatively impacts the outcomes of depression.

Bodily distress syndrome: A new diagnosis for functional disorders in primary care?

Background

Conceptualisation and classification of functional disorders appear highly inconsistent in the health-care system, particularly in primary care. Numerous terms and overlapping diagnostic criteria are prevalent of which many are considered stigmatising by general practitioners and patients. The lack of a clear concept challenges the general practitioner’s decision-making when a diagnosis or a treatment approach must be selected for a patient with a functional disorder. This calls for improvements of the diagnostic categories. Intense debate has risen in connection with the release of the fifth version of the ‘Diagnostic and Statistical Manual of Mental Disorders’ and the current revision of the ‘International Statistical Classification of Diseases and Related Health Problems’. We aim to discuss a new evidence based diagnostic proposal, bodily distress syndrome, which holds the potential to change our current approach to functional disorders in primary care. A special focus will be directed towards the validity and utility criteria recommended for diagnostic categorisation.

Discussion

A growing body of evidence suggests that the numerous diagnoses for functional disorders listed in the current classifications belong to one family of closely related disorders. We name the underlying phenomenon ‘bodily distress’; it manifests as patterns of multiple and disturbing bodily sensations. Bodily distress syndrome is a diagnostic category with specific criteria covering this illness phenomenon. The category has been explored through empirical studies, which in combination provide a sound basis for determining a symptom profile, the diagnostic stability and the boundaries of the condition. However, as bodily distress syndrome embraces only the most common symptom patterns, patients with few but impairing symptoms are not captured. Furthermore, the current lack of treatment options may also influence the acceptance of the proposed diagnosis.

Summary

Bodily distress syndrome is a diagnostic category with notable validity according to empirical studies. Nevertheless, knowledge is sparse on the utility in primary care. Future intervention studies should investigate the translation of bodily distress syndrome into clinical practice. A particular focus should be directed towards the acceptability among general practitioners and patients. Most importantly, it should be investigated whether the new category may provide the basis for better treatment and improved clinical outcome.

The prognosis of bodily distress syndrome: a cohort study in primary care

OBJECTIVE

Bodily distress syndrome (BDS) is a newly proposed diagnosis for functional disorders. The diagnosis is based on empirical research, but little is known about the course of the disease. We aimed to study the prognosis in terms of diagnosis stability over time.

METHOD

A longitudinal study of 1356 primary care patients with 2-year follow-up was conducted in the Central Denmark Region. Data were obtained from family physician registration forms, patient questionnaires (including a BDS checklist) and nationwide registries. Complete data were available for 1001 patients (73.8%).

RESULTS

Overall, 146 persons [14.6%, 95% confidence interval (CI): 12.5-16.9] fulfilled the criteria for BDS at baseline and 142 persons (14.2%, CI: 12.1-16.5) at follow-up. Among study participants with BDS at baseline, 56.8% (CI: 48.4-65.0) also had BDS at follow-up. Multiorgan BDS tended to be more persistent (81.8%, CI: 48.2-97.7) than single-organ BDS (54.8%, CI: 46.0-63.4). Patients with BDS had fewer socioeconomic resources, experienced more emotional distress, and used more opioids and medical services.

CONCLUSIONS

BDS is a common clinical condition being prone to chronicity; one in seven primary care patients met the criteria for BDS, and more than half of these patients still suffered from BDS 2 years later.

Identification and validation of mixed anxiety-depression

BACKGROUND

Mixed anxiety-depression (MAD) has been under scrutiny to determine its potential place in psychiatric nosology. The current study sought to investigate its prevalence, clinical characteristics, course and potential validators.

METHOD

Restricted latent-class analyses were fit to 12-month self-reports of depression and anxiety symptom criteria in a large population-based sample of twins. Classes were examined across an array of relevant indicators (demographics, co-morbidity, adverse life events, clinical significance and twin concordance). Longitudinal analyses investigated the stability of, and transitions between, these classes for two time periods approximately 1.5 years apart.

RESULTS

In all analyses, a class exhibiting levels of MAD symptomatology distinctly above the unaffected subjects yet having low prevalence of either major depression (MD) or generalized anxiety disorder (GAD) was identified. A restricted four-class model, constraining two classes to have no prior disorder history to distinguish residual or recurrent symptoms from new onsets in the last year, provided an interpretable classification: two groups with no prior history that were unaffected or had MAD and two with prior history having relatively low or high symptom levels. Prevalence of MAD was substantial (9-11%), and subjects with MAD differed quantitatively but not qualitatively from those with lifetime MD or GAD across the clinical validators examined.

CONCLUSIONS

Our findings suggest that MAD is a commonly occurring, identifiable syndromal subtype that warrants further study and consideration for inclusion in future nosologic systems.

New concepts for ICD-classification of common mental disorders from the perspective of general medical practice

BACKGROUND

This study aimed at obtaining views of Austrian general practitioners (GPs) regarding the appropriateness of the proposed new ICD11-PHC classifications 'anxious depression', 'bodily stress syndrome' and 'health anxiety'and on the usefulness of their diagnostic criteria in the general medical setting.

METHODS

This qualitative study used a focus group method for data collection.

RESULTS

There was general support for the additional new concept of anxious depression. When asked to choose between diagnostic criteria of bodily stress syndrome, that listed somatic symptoms in each of four bodily systems, or to use a simpler definition, most participants favoured the simpler approach. Health anxiety was thought to be a concept that overlapped with bodily stress syndrome, but several participants saw advantages in nevertheless distinguishing the two concepts.

CONCLUSIONS

The three new concepts were considered as appropriate and useful for the general medical setting, with a general view supporting the simpler definition of bodily stress syndrome.

Prevalência do uso de psicotrópicos e fatores associados na atenção primária à saúde

Objetivo Investigar a prevalência de uso de psicotrópicos e fatores associados na atenção primária à saúde com fatores sociodemográficos, farmacoterapêuticos, histórico de saúde e Transtornos Mentais Comuns. Método Estudo transversal que incluiu 430 pacientes de atenção primária à saúde. O instrumento de pesquisa foi o Self-reporting Questionnaire e prontuários. Para análise, utilizou-se teste qui-quadrado na análise univariada e regressão logística na multivariada. Resultados A prevalência de uso de psicotrópicos foi de 25,8%. Houve associação entre uso de psicofármacos e transtornos mentais comuns, uso de medicamentos não psicofármacos, número de medicamentos prescritos, número de comprimidos/dia, patologias clínicas, idade e escolaridade. Na análise multivariada os preditores para uso de psicofármacos foram: transtornos mentais comuns, patologias clínicas e escolaridade. Conclusão A prevalência de uso de psicofármacos e os fatores associados variaram conforme a análise uni ou multivariada.

Clinical effectiveness of an ultra-brief intervention for common mental health syndromes in primary care: study protocol for a cluster randomized controlled trial

BACKGROUND

Although mild to moderate mental health problems are common and often debilitating, treatment options in primary care settings in New Zealand are often severely limited for patients with these conditions. Previously, we developed an ultra-brief intervention (UBI) to address mild to moderate psychological concerns, designed to be delivered by primary care clinicians. Recent feasibility testing, including an adaptation for Māori individuals (the indigenous people of New Zealand), showed that the brief intervention was feasible and acceptable to both clinicians and their patients. This protocol describes a large pragmatic randomized controlled trial of our UBI in primary care settings across the greater Wellington region, compared with practice as usual.

METHODS/DESIGN

We are using a two-arm cluster randomized controlled trial, with primary care practices randomized to exclusively deliver either the UBI or practice as usual to all their recruited participants. The structured, guided self-help UBI is delivered in three brief general practitioner (GP) appointments over a five week period. Participants are invited into the study based on partner primary health organization access criteria (youth, people with low income, or people with Māori or Pacific Island heritage). Improvements in mental health from baseline to post-treatment will be compared between the intervention and control groups using a mixed-models application of analysis of covariance. Data analysis will be on an intention-to-treat basis, to increase the real-world relevance of UBI and to meet the study's objective of releasing UBI to primary care clinicians nationwide.

DISCUSSION

The UBI is a first-line intervention tool for GPs that models the stepped care approach advocated in New Zealand, against a background of limited access to treatments for often-overlooked patient groups. It is proposed to be accessible to clinicians and patients alike, with the potential to be relevant to primary care clinicians across New Zealand.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000041752.

A new questionnaire to identify bodily distress in primary care: The 'BDS checklist'

BACKGROUND

Functional symptoms and disorders are common in primary care. Bodily distress syndrome (BDS) is a newly proposed clinical diagnosis for functional disorders. The BDS diagnosis is based on empirical research, and the symptoms stated in the BDS criteria have been translated into a self-report questionnaire called the BDS checklist. The aim of the present study was to investigate the psychometric properties of the checklist and to test the construct of BDS.

METHOD

The 30-item BDS checklist was completed by 2480 adult primary care patients in a cross-sectional study on contact and disease patterns in Danish general practice. We performed (internal) validation analyses of the collected checklist data. We also performed factor and latent class analyses to identify both BDS symptom groups and BDS patient groups.

RESULTS

Internal validation analyses revealed acceptable and usable psychometric properties of the BDS checklist. The factor analyses identified the four distinct determining factors for BDS: cardiopulmonary, gastrointestinal, musculoskeletal and general symptoms. Results from factor and multi-trait analyses suggested a shortening of the BDS checklist (from 30 to 25 items). The latent class analyses resulted in three severity levels (no, moderate and severe BDS); the best fit index was found for a threshold of ≥4 symptoms in a symptom group.

CONCLUSION

The results provide empirical support for the previously described construct of BDS with four symptom groups and three patient groups. The BDS checklist is a self-report instrument that may be used for case finding in both clinical practice and in research.

Anxious forms of depression

Previous research has described distinctive features for anxious and nonanxious forms of major depression. The concept of "mixed anxiety depression disorder" (MADD) refers to a milder degree of the anxious form of depression, since the depressive symptoms fall short of the number required for a diagnosis of major depression. It is argued that this can be thought of as a subclinical form of anxious depression, rather than a separate disorder in its own right. In view of its substantial prevalence in general medical settings, its associated disability and its public health importance, it deserves to be recognized, and seen as being continuous with the more severe forms of anxious depression. It will therefore be included in the Field Trials of the version of the ICD-11 (where ICD is the International Classification of Disease) intended for primary care. It is argued that current anxiety, depression (without anxiety), and anxious depression would cover most of the psychologically distressed patients seen in general medical settings, using a pseudodimensional system.

Is physical disease missed in patients with medically unexplained symptoms? A long-term follow-up of 120 patients diagnosed with bodily distress syndrome

OBJECTIVE

Bodily distress syndrome (BDS) was recently introduced as an empirically based, unifying diagnosis for so-called medically unexplained symptoms and syndromes. BDS relies on a specific symptom pattern rather than on a lack of objective findings, which may increase the risk of overlooking physical disease. We investigated whether physical disease was missed in the first patients diagnosed with BDS.

METHOD

The study was a register-based follow-up study of 120 patients diagnosed with BDS at a University Clinic from 2005 to 2007. Median follow-up time was 3.7 years. We used data containing all diagnoses from inpatient, outpatient and emergency admissions supplied by systematic review of hospital records. Medical specialists evaluated all cases of suspected overlooked physical disease.

RESULTS

According to registered diagnoses, none of the 120 patients had been misdiagnosed with BDS. In five cases [4.2% (95% confidence interval: 1.4-9.5)] though, we found comorbid medical problems that had not been taken properly care of alongside BDS management. These were disc protrusion, degeneration and prolapsus, hip osteoarthritis, anemia and calcific tendinitis.

CONCLUSION

The BDS symptom pattern reliably identified patients with multiple medically unexplained symptoms referred to tertiary care. Nevertheless, differential diagnostics remains important in order to identify comorbid medical problems that require additional treatment.