Predictors of psychiatric comorbidity in medical outpatients

Exploring Food Addiction Across Several Behavioral Addictions: Analysis of Clinical Relevance

BACKGROUND/OBJECTIVES

Recently, interest in studying food addiction (FA) in the context of behavioral addictions (BAs) has increased. However, research remains limited to determine the FA prevalence among various BAs. The current study aimed to investigate FA in a clinical sample of patients seeking treatment for gaming disorder, compulsive buying-shopping disorder (CBSD), compulsive sexual behavior disorder, and the comorbid presence of multiple BAs, as well as to determine the sociodemographic characteristics, personality traits, and general psychopathology of this clinical population. In addition, we analyzed whether FA is linked to a higher mean body mass index (BMI).

METHODS

The sample included 209 patients (135 men and 74 women) attending a specialized behavioral addiction unit. The assessment included a semi-structured clinical interview for the diagnosis of the abovementioned BAs, in addition to self-reported psychometric assessments for FA (using the Yale Food Addiction Scale 2. 0, YFAS-2), CBSD (using the Pathological Buying Screener, PBS), general psychopathology (using the Symptom Checklist-Revised, SCL-90-R), personality traits (using the Temperament and Character Inventory-Revised, TCI-R), emotional regulation (using Difficulties in Emotion Regulation Strategies, DERS), and impulsivity (using Impulsive Behavior Scale, UPPS-P). The comparison between the groups for the clinical profile was performed using logistic regression (categorical variables) and analysis of covariance (ANCOVA), adjusted based on the patients' gender. The sociodemographic profile was based on chi-square tests for categorical variables and analysis of variance (ANOVA) for quantitative measures.

RESULTS

The prevalence of FA in the total sample was 22.49%. The highest prevalence of FA was observed in CBSD (31.3%), followed by gaming disorder (24.7%), and the comorbid presence of multiple BAs (14.3%). No group differences (FA+/-) were found in relation to sociodemographic variables, but the comorbidity between FA and any BA was associated more with females as well as having greater general psychopathology, greater emotional dysregulation, higher levels of impulsivity, and a higher mean BMI.

CONCLUSIONS

The comorbidity between FA and BA is high compared to previous studies (22.49%), and it is also associated with greater severity and dysfunctionality. Emotional distress levels were high, which suggests that the group with this comorbidity may be employing FA behaviors to cope with psychological distress. However, a better understanding of the latent mechanisms that contribute to the progression of this multifaceted comorbid clinical disorder is needed. One aspect that future studies could consider is to explore the existence of FA symptoms early and routinely in patients with BAs.

Protocol for the promoting resilience in stress management (PRISM) intervention: a multi-site randomized controlled trial for adolescents and young adults with advanced cancer

BACKGROUND

Adolescents and young adults (AYAs) with cancer are at high risk of poor psychosocial outcomes, and evidence-based interventions designed to meet their psychosocial and communication needs are lacking. The main objective of this project is to test the efficacy of a new adaptation of the Promoting Resilience in Stress Management intervention for AYAs with Advanced Cancer (PRISM-AC).

METHODS/DESIGN

The PRISM-AC trial is a 2-arm, parallel, non-blinded, multisite, randomized controlled trial. 144 participants with advanced cancer will be enrolled and randomized to either usual, non-directive, supportive care without PRISM-AC ("control" arm) or with PRISM-AC ("experimental" arm). PRISM is a manualized, skills-based training program comprised of four 30-60 min, one-on-one sessions targeting AYA-endorsed resilience resources (stress-management, goal-setting, cognitive-reframing, and meaning-making). It also includes a facilitated family meeting and a fully equipped smartphone app. The current adaptation includes an embedded advance care planning module. English- or Spanish-speaking individuals 12-24 years old with advanced cancer (defined as progressive, recurrent, or refractory disease, or any diagnosis associated with < 50% survival) receiving care at 4 academic medical centers are eligible. Patients' caregivers are also eligible to participate in this study if they are able to speak and read English or Spanish, and are cognitively and physically able to participate. Participants in all groups complete surveys querying patient-reported outcomes at the time of enrollment and 3-, 6-, 9-, and 12-months post-enrollment. The primary outcome of interest is patient-reported health-related quality of life (HRQOL) and secondary outcomes of interest include patient anxiety, depression, resilience, hope and symptom burden, parent/caregiver anxiety, depression and health-related quality of life, and family palliative care activation. We will conduct intention-to-treat analysis to compare the group means of primary and secondary outcomes between PRISM-AC arm and control arm with regression models.

DISCUSSION

This study will provide methodologically rigorous data and evidence regarding a novel intervention to promote resilience and reduce distress among AYAs with advanced cancer. This research has the potential to offer a practical, skills-based curriculum designed to improve outcomes for this high-risk group.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03668223, September 12, 2018.

Protocol for The Promoting Resilience in Stress Management (PRISM) Intervention: a multi-site randomized controlled trial for adolescents and young adults with advanced cancer

Background Adolescents and young adults (AYAs) with cancer are at high risk of poor psychosocial outcomes, and evidence-based interventions designed to meet their psychosocial and communication needs are lacking. The main objective of this project is to test the efficacy of a new adaptation of the Promoting Resilience in Stress Management intervention for AYAs with Advanced Cancer (PRISM-AC). Methods/design: The PRISM-AC trial is a 2-arm, parallel, non-blinded, multisite, randomized controlled trial. 144 participants with advanced cancer will be enrolled and randomized to either usual, non-directive, supportive care without PRISM-AC ("control" arm) or with PRISM-AC ("experimental" arm). PRISM is a manualized, skills-based training program comprised of four 30-60 minute, one-on-one sessions targeting AYA-endorsed resilience resources (stress-management, goal-setting, cognitive-reframing, and meaning-making). It also includes a facilitated family meeting and a fully equipped smartphone app. The current adaptation includes an embedded advance care planning module. English- or Spanish-speaking individuals 12-24 years old with advanced cancer (defined as progressive, recurrent, or refractory disease, or any diagnosis associated with < 50% survival) receiving care at 4 academic medical centers are eligible. Patients' caregivers are also eligible to participate in this study if they are able to speak and read English or Spanish, and are cognitively and physically able to participate. Participants in all groups complete surveys querying patient-reported outcomes at the time of enrollment and 3-, 6-, 9-, and 12-months post-enrollment. The primary outcome of interest is patient-reported health-related quality of life (HRQOL) and secondary outcomes of interest include patient anxiety, depression, resilience, hope and symptom burden, parent/caregiver anxiety, depression and health-related quality of life, and family palliative care activation. We will conduct intention-to-treat analysis to compare the group means of primary and secondary outcomes between PRISM-AC arm and control arm with regression models. Discussion This study will provide methodologically rigorous data and evidence regarding a novel intervention to promote resilience and reduce distress among AYAs with advanced cancer. This research has the potential to offer a practical, skills-based curriculum designed to improve outcomes for this high-risk group. Trial registration: ClinicalTrials.gov Identifier NCT03668223, September 12, 2018.

What does low psychological distress mean in patients with no mental disorders and different pains of the musculoskeletal system?

OBJECTIVES

The aim of this study is to define the different levels of psychological distress in patients suffering from pain and functional disorders of the musculoskeletal system.

METHODS

This investigation was conducted as a retrospective study of 60 patients randomly selected of a German specialized orthopaedic hospital within the year 2016, whose therapeutic approaches are based on a non-surgical orthopaedic multimodal approach of manual therapy. All patients were suffering from pain and functional disorders of the musculoskeletal system. Two groups were formed: one without and one with additional mental disorders according to ICD-10. The impairment score (ISS) according to Schepank was determined.

RESULTS

The somatic sub score of the ISS was the highest sub score in both patient groups. The cumulative value of the ISS score of patients with both a mental disorder and pain in the musculoskeletal system was higher than for patients without concomitant mental disorder. For patients without concomitant mental disorder, the cumulative ISS exceeded the test criteria for mentally healthy individuals.

CONCLUSIONS

Patients without mental disorder but with chronic pain of the locomotoric system receive a psychological pain management program, as it is part of the billing code OPS 8-977 to the health insurance companies in Germany. However, the data show that these patients also have a substantial somatic subscore and a cumulative ISS above the level of healthy individuals. The absence of psychological disorders (according to ICD-10) in patients with pain of the musculoskeletal system should not lead to the assumption that these patients are psychologically inconspicuous. Subsyndromal mental findings (below ICD-10) can be one aspect of a mental disorder presenting with primarily somatic symptoms. In this case, patients would benefit from a psychotherapeutic program in a similar way as the patients with mental disorders according to ICD-10.

Tobacco Use Predicts Treatment Dropout and Outcome in an Acute, Transdiagnostic Psychiatric Treatment Setting

Tobacco use is consistently associated with greater levels of depression and anxiety, broadly, and preliminary evidence suggests that current tobacco use is a significant predictor of dropout from psychiatric treatment. The current study extends past work to examine the impact of tobacco use on treatment dropout and outcomes in an acute psychiatric treatment setting. Upon intake to a partial hospitalization program (PHP), patients completed a battery of measures assessing sociodemographic characteristics, current tobacco use, depression and generalized anxiety, and substance use. Patients at the PHP also completed measures assessing levels of depression and generalized anxiety again upon discharge from the program. In line with hypotheses, current tobacco use was a significant predictor of dropout from treatment at the PHP. Importantly, this relationship remained significant when statistically controlling for demographic variables and psychiatric and substance use severity (such as number of previous inpatient psychiatric hospitalizations and degree of alcohol or drug problems). Results from the current study indicate that tobacco use is a significant risk factor for treatment dropout. Further research is needed to replicate these findings and to determine the mechanism underlying this link between tobacco use and treatment dropout for people receiving intensive psychiatric care.

A Brief Assessment of Body Image Perception: Norm Values and Factorial Structure of the Short Version of the FKB-20

The Body Image Questionnaire-20 (FKB-20) is one of the most applied self-report measures in the context of body image assessment in German-speaking regions. A version of the FKB-20 capturing an ideal concept of body image is also available. A special property of the scale is its high sensitivity for individuals suffering from anorexia nervosa. The present research provided a short version of this scale (for both variants) and examined its validity in a representative sample (N = 2,347) of the German population. We utilized factor analysis methods to identify the optimal short scale of the measure, finding excellent model fit and reliability for a two-factor model (FKB-6) for both real and ideal body image. Both versions of the FKB-6 can be considered invariant across sex and age groups. Good reliability indices were shown for both versions of the FKB-6. The reliability indices were similar to those mentioned in previous studies. Our study also revealed, that large discrepancies between the real and an ideal body image are correlated with somatic and body dysmorphic symptoms. Finally, we provided norm values for comparisons of individual scores with the general population. The FKB-6 is a valid and a reliable measure that economizes assessments by clinicians and researchers.

Novel Risk Factors for Posttraumatic Stress Disorder Symptoms in Family Members of Acute Respiratory Distress Syndrome Survivors

OBJECTIVES

Family members of ICU survivors report long-term psychologic symptoms of posttraumatic stress disorder. We describe patient- and family-member risk factors for posttraumatic stress disorder symptoms among family members of survivors of acute respiratory distress syndrome.

DESIGN

Prospective cohort study of family members of acute respiratory distress syndrome survivors.

SETTING

Single tertiary care center in Seattle, Washington.

SUBJECTS

From 2010 to 2015, we assembled an inception cohort of adult acute respiratory distress syndrome survivors who identified family members involved in ICU and post-ICU care. One-hundred sixty-two family members enrolled in the study, corresponding to 120 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Family members were assessed for self-reported psychologic symptoms 6 months after patient discharge using the Posttraumatic Stress Disorder Checklist-Civilian Version, the Patient Health Questionnaire 9-item depression scale, and the Generalized Anxiety Disorder 7-item scale. The primary outcome was posttraumatic stress disorder symptoms, and secondary outcomes were symptoms of depression and anxiety. We used clustered multivariable logistic regression to identify patient- and family-member risk factors for psychologic symptoms. Posttraumatic stress disorder symptoms were present in 31% (95% CI, 24-39%) of family participants. Family member risk factors for posttraumatic stress disorder symptoms included preexisting mental health disorders (adjusted odds ratio, 3.22; 95% CI, 1.42-7.31), recent personal experience of serious physical illness (adjusted odds ratio, 3.07; 95% CI, 1.40-6.75), and female gender (adjusted odds ratio, 5.18; 95% CI, 1.74-15.4). Family members of previously healthy patients (Charlson index of zero) had higher frequency of posttraumatic stress disorder symptoms (adjusted odds ratio, 2.25; 95% CI, 1.06-4.77). Markers of patient illness severity were not associated with family posttraumatic stress disorder symptoms.

CONCLUSIONS

The prevalence of long-term posttraumatic stress disorder symptoms among family members of acute respiratory distress syndrome survivors is high. Family members with preexisting mental health disorders, recent experiences of serious physical illness, and family members of previously healthy patients are at increased risk for posttraumatic stress disorder symptoms.

Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

CONTEXT

Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values.

OBJECTIVES

To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent.

METHODS

Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states.

RESULTS

Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804).

CONCLUSION

Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.

Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial

Importance

Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication.

Objective

To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care.

Design, Setting, and Participants

Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016.

Interventions

Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care.

Main Outcomes and Measures

The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders.

Results

We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.

Conclusions and Relevance

This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study.

Trial Registration

ClinicalTrials.gov identifier: NCT01933789.

Patient reported outcome measures of quality of end-of-life care: A systematic review

End-of-life (EoL) care¹ is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients' health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided.

Burden and risk factors for gastrointestinal symptom distress in HIV patients in the modern antiretroviral era

In the modern antiretroviral (ARV) era, there is limited knowledge about the prevalence and risk factors for HIV patient-reported gastrointestinal (GI) symptoms (diarrhoea/soft stool, nausea/vomiting, bloating/painful abdomen, loss of appetite, and weight loss/wasting) and distress. We prospectively analysed data (2007-2014) on distressing GI symptoms from the Ontario HIV Treatment Network Cohort Study, which follows people attending HIV clinics. Using generalized estimating equations with a logit link, we estimated the associations of psychosocial, demographic, behavioural, and clinical factors with each GI symptoms compared to asymptomatic and non-bothersome symptoms. Among 1532 included participants, 80.4% were male, mean age was 45 years, and 64.6% reported being men who have sex with men. Most were Caucasian (56.3%), a median time since HIV diagnosis of 9.8 years (interquartile range (IQR): 4.1-16.9), and 83.1% were on ARV. More than two-thirds (68.7% (95% confidence intervals (CI): 63.1% to 69.2%)) reported one or more symptoms with a median of 1.2 (IQR: 0-1.7). The proportion remained stable over time since HIV diagnosis and ARV initiation. Risk factors varied for multivariable models. A strong association with Centre for Epidemiologic Studies Depression scale scores of ≥23 was found for all symptoms. Adjusted odds ratios (95% CI) were 1.72 (1.39-2.12), 2.95 (2.33-3.72), 2.20 (1.81-2.68), 4.97 (3.99-6.19), and 2.98 (2.52-3.82) for diarrhoea, nausea/vomiting, bloating, loss of appetite, and weight loss, respectively. With the exception of bloating, odds were significantly lower for those on ARV containing integrase inhibitors and greater for patients reporting current cannabis use. GI symptoms in the modern ARV era are highly prevalent and may arise as a common pathway of distress in response to psychosocial vulnerabilities, regardless of the stage of diagnosis. These findings support the need for integrated approaches to address psychological and physical distress in HIV disease.

Somatic symptom count scores do not identify patients with symptoms unexplained by disease: a prospective cohort study of neurology outpatients

OBJECTIVE

Somatic symptoms unexplained by disease are common in all medical settings. The process of identifying such patients requires a clinical assessment often supported by clinical tests. Such assessments are time-consuming and expensive. Consequently the observation that such patients tend to report a greater number of symptom has led to the use of self-rated somatic symptom counts as a simpler and cheaper diagnostic aid and proxy measure for epidemiological surveys. However, despite their increasing popularity there is little evidence to support their validity.

METHODS

We tested the score on a commonly used self-rated symptom questionnaire- the Patient Health Questionnaire (PHQ 15) (plus enhanced iterations including an additional 10 items on specific neurological symptoms and an additional 5 items on mental state) for diagnostic sensitivity and specificity against a medical assessment (with 18 months follow-up) in a prospective cohort study of 3781 newly attending patients at neurology clinics in Scotland, UK.

RESULTS

We found 1144/3781 new outpatients had symptoms that were unexplained by disease. The patients with symptoms unexplained by disease reported higher symptoms count scores (PHQ 15: 5.6 (95% CI 5.4 to 5.8) vs 4.2 (4.1 to 4.4) p<0.0001). However, the PHQ15 performed little better than chance in its ability to identify patients with symptoms unexplained by disease. The findings with the enhanced scales were similar.

CONCLUSIONS

Self-rated symptom count scores should not be used to identify patients with symptoms unexplained by disease.

Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial

IMPORTANCE

Communication about end-of-life care is a core clinical skill. Simulation-based training improves skill acquisition, but effects on patient-reported outcomes are unknown.

OBJECTIVE

To assess the effects of a communication skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Randomized trial conducted with 391 internal medicine and 81 nurse practitioner trainees between 2007 and 2013 at the University of Washington and Medical University of South Carolina.

INTERVENTION

Participants were randomized to an 8-session, simulation-based, communication skills intervention (N = 232) or usual education (N = 240).

MAIN OUTCOMES AND MEASURES

Primary outcome was patient-reported quality of communication (QOC; mean rating of 17 items rated from 0-10, with 0 = poor and 10 = perfect). Secondary outcomes were patient-reported quality of end-of-life care (QEOLC; mean rating of 26 items rated from 0-10) and depressive symptoms (assessed using the 8-item Personal Health Questionnaire [PHQ-8]; range, 0-24, higher scores worse) and family-reported QOC and QEOLC. Analyses were clustered by trainee.

RESULTS

There were 1866 patient ratings (44% response) and 936 family ratings (68% response). The intervention was not associated with significant changes in QOC or QEOLC. Mean values for postintervention patient QOC and QEOLC were 6.5 (95% CI, 6.2 to 6.8) and 8.3 (95% CI, 8.1 to 8.5) respectively, compared with 6.3 (95% CI, 6.2 to 6.5) and 8.3 (95% CI, 8.1 to 8.4) for control conditions. After adjustment, comparing intervention with control, there was no significant difference in the QOC score for patients (difference, 0.4 points [95% CI, -0.1 to 0.9]; P = .15) or families (difference, 0.1 [95% CI, -0.8 to 1.0]; P = .81). There was no significant difference in QEOLC score for patients (difference, 0.3 points [95% CI, -0.3 to 0.8]; P = .34) or families (difference, 0.1 [95% CI, -0.7 to 0.8]; P = .88). The intervention was associated with significantly increased depression scores among patients of postintervention trainees (mean score, 10.0 [95% CI, 9.1 to 10.8], compared with 8.8 [95% CI, 8.4 to 9.2]) for control conditions; adjusted model showed an intervention effect of 2.2 (95% CI, 0.6 to 3.8; P = .006).

CONCLUSIONS AND RELEVANCE

Among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients' depressive symptoms. These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00687349.

Specific collaborative group intervention for patients with medically unexplained symptoms in general practice: a cluster randomized controlled trial

BACKGROUND

Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention.

METHODS

We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS).

RESULTS

At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group.

CONCLUSIONS

Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care.

Specificity of psychopathology in temporal lobe epilepsy

An investigation into the specificity of psychopathology in temporal lobe epilepsy was conducted using the Minnesota Multiphase Personality Inventory second edition (MMPI-2) profiles. Consecutive series of patients with left temporal lobe epilepsy (n = 49) and those with right temporal lobe epilepsy (n = 45) were compared with patients with other forms of epilepsy (n = 46) and other heterogeneous neurological conditions (n = 69). The investigation focused on the Clinical, Content, and Subscales scales that resembled descriptions of the Interictal Dysphoric Disorder symptoms and Temporal Lobe Epilepsy Personality Traits. Patients with right temporal lobe epilepsy and those with left temporal lobe epilepsy did not have different patterns of scale elevation, nor did they have clinical elevations compared with patients with other types of epilepsy or neurological controls. The MMPI-2 scales that resemble descriptions of the Interictal Dysphoric Disorder or Temporal Lobe Epilepsy Personality Syndrome were not elevated in either group of patients with temporal lobe epilepsy compared with the group of patients with non-temporal lobe epilepsy or heterogeneous neurological controls. This study adds to the mounting body of empirical research that has used standardized measures and matched groups, but failed to detect a special affinity between psychopathology and temporal lobe epilepsy.

The role of aggressions suffered by healthcare workers as predictors of burnout

AIMS AND OBJECTIVES

To examine the prevalence of aggression against healthcare professionals and to determine the possible impact that violent episodes have on healthcare professionals in terms of loss of enthusiasm and involvement towards work. The objective was to analyse the percentage of occupational assault against professionals' aggression in different types of healthcare services, differentiating between physical and verbal aggression as a possible variable in detecting burnout in doctors and nursing professionals.

BACKGROUND

Leiter and Maslach have explored a double process model of burnout not only based on exhaustion by overload, but also based on personal and organisational value conflicts (community, rewards or values). Moreover, Whittington has obtained conclusive results about the possible relationship between violence and burnout in mental health nurses.

DESIGN

A retrospective study was performed in three hospitals and 22 primary care centres in Spain (n = 1·826).

METHODS

Through different questionnaires, we have explored the relationship between aggression suffered by healthcare workers and burnout.

RESULTS

Eleven percent of respondents had been physically assaulted on at least one occasion, whilst 34·4% had suffered threats and intimidation on at least one occasion and 36·6% had been subjected to insults. Both forms of violence, physical and non-physical aggression, showed significant correlations with symptoms of burnout (emotional exhaustion, depersonalisation and inefficacy).

CONCLUSIONS

The survey showed evidence of a double process: (1) by which excess workload helps predict burnout, and (2) by which a mismatch in the congruence of values, or interpersonal conflict, contributes in a meaningful way to each of the dimensions of burnout, adding overhead to the process of exhaustion-cynicism-lack of realisation. Relevance to clinical practice.  Studies indicate that health professionals are some of the most exposed to disorders steaming from psychosocial risks and a high comorbidity: anxiety, depression, etc. There is a clear need for accurate instruments of evaluation to detect not only the burnout but also the areas that cause it. Professional exhaustion caused by aggression or other factors can reflect a deterioration in the healthcare relationship.

[20 years of professional specialist for psychosomatic medicine and psychotherapy in Germany]

OBJECTIVE

This contribution provides an overview of the development of the professional specialty area of psychosomatic medicine and psychotherapy since its establishment by the German Parliament in 1992.

RESULTS

First, the reasons behind the decision to create this professional specialty are elucidated. Then, the three revisions of the official training regimen, the subsequent development of the number of specialists in both outpatient and inpatient sectors, and the development of hospital wards for psychosomatic disorders and rehabilitation clinics for this purpose are discussed. The creation of this specialty may be judged to have been a successful venture that has led to a better treatment of the concerned patients. The recent development of specific psychosomatic research points to the increasing emphasis on special studies of bio-psycho-social interactions, which in turn have shaped and will continue to shape the contours of this specialty.

DISCUSSION

The necessary further developments in continuing education as well as increasing cooperation with other disciplines and other pending decisions concerning treatment alternatives are discussed.

Association of somatic symptoms with depression and anxiety in clinical patients of general hospitals in Guangzhou, China

OBJECTIVES

In high-income countries, depression and anxiety are reported to be common reasons for patients visiting nonpsychiatric services. This study aimed to assess the rate of depression and anxiety, and their associations with somatic symptoms, in patients presenting to clinics of general hospitals in Guangzhou, China.

METHODS

In a hospital-based cross-sectional study of 2408 randomly selected clinical patients from 15 general hospitals, we assessed depression and anxiety via the Hospital Anxiety and Depression Scale (HADS), somatic symptoms via the Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale (PHQ-15) and patients' view of the impact of somatic symptoms on their life, job and social relationships. Multiple logistic models were used to analyze the association of somatic symptoms with depression and anxiety, the underlying physical diseases and the self-rated somatic symptoms' impact on social functions.

RESULTS

Of the participants, 454 (19.0%) reported moderate to high somatic symptoms (PHQ-15 score ≥ 10), 367 (15.2%) had depression (HADS-D score ≥ 7), 167 (6.9%) had anxiety (HADS-A score ≥ 10), and 125 (5.2%) had both depression and anxiety (HADS-D ≥ 7 and HADS-A ≥ 10). Patients with depression and anxiety had higher somatic symptoms and rated these symptoms as having a greater negative impact on their social functions. Relevant to other systemic diseases, only digestive system disease was associated with higher somatic symptoms and self-rated negative social impact, and great negative emotions. Stepwise multiple logistic analyses demonstrated that female sex and depression and anxiety were the main factors for the high somatic symptoms of the population.

CONCLUSIONS

Among patients who visit hospital clinics in Guangzhou, China, somatic complaints are highly associated with depression and anxiety, and rarely associated with their underlying medical diseases. The findings indicate the importance of recognizing and managing depression and anxiety for these patients.

[Psychological comorbidity. A challenge in acute care]

Comorbid mental disorders are common in patients with chronic conditions. It can be assumed that around 30% of all inpatients have some kind of mental disorder. Most frequent are depressive disorders, anxiety disorders, somatoform disorders, and addictive disorders. Mental disorders are not only a subjective burden for the patient, but may also lead to an unfavourable course of the disease, longer hospital stay, and increased treatment costs. However, despite its importance comorbid mental disorders are often not recognized or appropriately treated. Wherever possible, patients with psychological issues should be presented to a psychosomatic or psychiatric consultation-liaison service for further diagnosis and treatment. To treat patients with comorbid mental disorders, physicians must be well experienced in psychotherapeutic treatment and a collaborative interdisciplinary working environment must have been established.

Patients presenting with somatic complaints in general practice: depression, anxiety and somatoform disorders are frequent and associated with psychosocial stressors

Background

Mental disorders in primary care patients are frequently associated with physical complaints that can mask the disorder. There is insufficient knowledge concerning the role of anxiety, depression, and somatoform disorders in patients presenting with physical symptoms. Our primary objective was to determine the prevalence of depression, anxiety, and somatoform disorders among primary care patients with a physical complaint. We also investigated the relationship between cumulated psychosocial stressors and mental disorders.

Methods

We conducted a multicentre cross-sectional study in twenty-one private practices and in one academic primary care centre in Western Switzerland. Randomly selected patients presenting with a spontaneous physical complaint were asked to complete the self-administered Patient Health Questionnaire (PHQ) between November 2004 and July 2005. The validated French version of the PHQ allowed the diagnosis of mental disorders (DSM-IV criteria) and the analyses of exposure to psychosocial stressors.

Results

There were 917 patients exhibiting at least one physical symptom included. The rate of depression, anxiety, and somatoform disorders was 20.0% (95% confidence interval [CI] = 17.4% to 22.7%), 15.5% (95% CI = 13.2% to 18.0%), and 15.1% (95% CI = 12.8% to 17.5%), respectively. Psychosocial stressors were significantly associated with mental disorders. Patients with an accumulation of psychosocial stressors were more likely to present anxiety, depression, or somatoform disorders, with an increase of 2.2 fold (95% CI = 2.0 to 2.5) for each additional stressor.

Conclusions

The investigation of mental disorders and psychosocial stressors among patients with physical complaints is relevant in primary care. Psychosocial stressors should be explored as potential epidemiological causes of mental disorders.

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review

BACKGROUND

Depression, anxiety and somatization are the most common mental disorders in primary care as well as medical specialty populations; each is present in at least 5-10% of patients and frequently comorbid with one another. An efficient means for measuring and monitoring all three conditions would be desirable.

METHODS

Evidence regarding the psychometric and pragmatic characteristics of the Patient Health Questionnaire (PHQ)-9 depression, generalized anxiety disorder (GAD)-7 anxiety and PHQ-15 somatic symptom scales are synthesized from two sources: (1) four multisite cross-sectional studies (three conducted in primary care and one in obstetric-gynecology practices) comprising 9740 patients, and (2) key studies from the literature that have studied these scales.

RESULTS

The PHQ-9 and its abbreviated eight-item (PHQ-8) and two-item (PHQ-2) versions have good sensitivity and specificity for detecting depressive disorders. Likewise, the GAD-7 and its abbreviated two-item (GAD-2) version have good operating characteristics for detecting generalized anxiety, panic, social anxiety and post-traumatic stress disorder. The optimal cutpoint is > or = 10 on the parent scales (PHQ-9 and GAD-7) and > or = 3 on the ultra-brief versions (PHQ-2 and GAD-2). The PHQ-15 is equal or superior to other brief measures for assessing somatic symptoms and screening for somatoform disorders. Cutpoints of 5, 10 and 15 represent mild, moderate and severe symptom levels on all three scales. Sensitivity to change is well-established for the PHQ-9 and emerging albeit not yet definitive for the GAD-7 and PHQ-15.

CONCLUSIONS

The PHQ-9, GAD-7 and PHQ-15 are brief well-validated measures for detecting and monitoring depression, anxiety and somatization.

Psychobehavioral predictors of somatoform disorders in patients with suspected allergies

OBJECTIVE

To explore a combination of health-related psychobehavioral features as potential positive criteria for somatoform disorders (SFD). Currently, SFD can only be diagnosed in the absence of sufficient organic symptom explanation, resulting in low criterion validity and delay of appropriate therapy.

METHODS

Cross sectionally, we studied various psychobehavioral characteristics of 197 inpatients with suspected allergies. At the beginning of the medical work-up, patients were interviewed and completed a set of self-rating questionnaires (Illness Perception Questionnaire-Revised, Whiteley Index-7, Cognitions About Body And Health Questionnaire, Scale for the Assessment of Illness Questionnaire, Health Attitude Survey, Reassurance Questionnaire, and Patient Health Questionnaire). Organic explicability of the presenting symptoms was assessed by allergists at the end of the work-up. Forty-eight patients with SFD were compared with 149 patients without SFD, and predictive models were set up. To control for effects of the work-up situation, we also investigated 47 patients with an established diagnosis of hymenoptera venom allergy.

RESULTS

In the work-up group, various self-reported psychobehavioral features discriminated patients with SFD from patients without SFD. In logistic regression analysis, self-reported dissatisfaction with medical care, disease conviction, reduced symptom controllability, and reduced body scanning independently predicted SFD. A predictive model based on these psychobehavioral characteristics had high sensitivity and specificity (area under the curve = 0.86, 95% Confidence Interval = 0.79-0.93; p < .001), which was comparable to the Patient Health Questionnaire-15, an established SFD screening tool assessing somatization.

CONCLUSIONS

Psychobehavioral characteristics in patients with SFD cannot solely be attributed to the uncertainty of a work-up situation. Their predictive value is comparable to that of the traditional measuring of symptom number and severity; hence, they should be considered as SFD positive criteria in Diagnostic and Statistic Manual of Mental Disorders, 5th Edition.

Accuracy of specific symptoms in the diagnosis of major depressive disorder in psychiatric out-patients: data from the MIDAS project

BACKGROUND

There is uncertainty about the diagnostic significance of specific symptoms of major depressive disorder (MDD). There is also interest in using one or two specific symptoms in the development of brief scales. Our aim was to elucidate the best possible specific symptoms that would assist in ruling in or ruling out a major depressive episode in a psychiatric out-patient setting.

METHOD

A total of 1523 psychiatric out-patients were evaluated in the Methods to Improve Diagnostic Assessment and Services (MIDAS) project. The accuracy and added value of specific symptoms from a comprehensive item bank were compared against the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

The prevalence of depression in our sample was 54.4%. In this high prevalence setting the optimum specific symptoms for ruling in MDD were psychomotor retardation, diminished interest/pleasure and indecisiveness. The optimum specific symptoms for ruling out MDD were the absence of depressed mood, the absence of diminished drive and the absence of loss of energy. However, some discriminatory items were relatively uncommon. Correcting for frequency, the most clinically valuable rule-in items were depressed mood, diminished interest/pleasure and diminished drive. The most clinically valuable rule-out items were depressed mood, diminished interest/pleasure and poor concentration.

CONCLUSIONS

The study supports the use of the questions endorsed by the two-item Patient Health Questionnaire (PHQ-2) with the additional consideration of the item diminished drive as a rule-in test and poor concentration as a rule-out test. The accuracy of these questions may be different in primary care studies where prevalence differs and when they are combined into multi-question tests or algorithmic models.

Prevalence, correlates, and predictors of depersonalization experiences in the German general population

The survey aimed to investigate the prevalence of depersonalization (DP) experiences, its sociodemographic characteristics and its associations with medical conditions, illness behavior, and potential etiologic factors. A representative face-to-face household survey was conducted. The sample consists of n = 1,287 participants aged 14 to 90 years. Sociodemographic variables, medical conditions, current mental disorders, health care utilization, and childhood adversities were assessed. A total of 1.9% participants scored in the range of clinically significant DP (DP-C) and 9.7% reported at least some impairment through DP (DP-I). DP-C/DP-I were strongly associated with depression and anxiety. After adjustment for depression and anxiety, DP-C and DP-I were independently associated with hypertension, diabetes mellitus, chronic pulmonary disease, severe pain, and childhood adversities. We conclude that DP is common, it can not be reduced to a negligible variant of depression or anxiety and that more awareness about DP with respect to detection and research is urgently required.

The role of comorbidity in the detection of psychiatric disorders with checklists for mental and physical symptoms in primary care

OBJECTIVE

To examine the contribution of a mental and physical symptom count to the detection of single or comorbid anxiety, depressive and somatoform disorders.

METHOD

In primary care 1,046 consulting patients completed the Hospital Anxiety and Depression Scale (HADS) and the Physical Symptom Checklist (PSC-51). In a stratified sample of 473 patients DSM-IV psychiatric disorders were assessed using the WHO-SCAN interview. The diagnostic value of the HADS total score and the PSC-51 symptom count was examined with ROC-analyses.

RESULTS

The discriminative power of PSC-51 and HADS was highest for patients with both a somatoform disorder and an anxiety or depressive disorder, with an AUC of 0.86 (95% CI: 0.81-0.91) and 0.91 (95% CI: 0.87-0.94) respectively. Using both symptom counts together did not increase the diagnostic value for the detection of the psychiatric disorders.

CONCLUSION

Both symptom counts preferentially detected patients with comorbid disorders. When interpreting diagnostic values of screening questionnaires one should keep in mind that the validity of these values can be dependent of the presence of comorbid disorders.

Gastrointestinal symptoms in primary care: prevalence and association with depression and anxiety

OBJECTIVE

Results from general population studies suggest a relationship between gastrointestinal (GI) symptoms, depression, and anxiety. However, no primary care study has investigated this issue. This study investigates the prevalence of GI symptoms in primary care and their association with depression and anxiety.

METHOD

Within a cross-sectional survey, 2091 consecutive patients from 15 primary care clinics in the United States completed self-report questionnaires regarding GI symptoms [15-item Patient Health Questionnaire (PHQ-15)], anxiety [seven-item Generalized Anxiety Disorder Scale (GAD-7)], and depression (PHQ-8). Of those, 965 randomly selected patients additionally underwent a criterion standard diagnostic telephone interview (Structured Clinical Interview for DSM-IV) for the most common anxiety disorders.

RESULTS

A total of 380 [18% (95% CI, 16.3% to 19.3%)] patients reported to be substantially bothered by at least one GI symptom in the previous 4 weeks. The prevalence of severe levels of depression (PHQ-8 score > or =15) was nearly fivefold in patients with GI symptoms compared to patients without GI symptoms (19.1% vs. 3.9%; P<.001), and the prevalence of severe levels of anxiety (GAD-7 score > or =15) was nearly fourfold in patients with GI symptoms compared to patients without GI symptoms (19.4% vs. 5.6%; P<.001). Similarly, with each additional GI symptom, the odds for an interview-based diagnosis of specific anxiety disorders increased significantly: For example, compared to patients with no GI symptom, the odds ratio (OR) (95% CI) for generalized anxiety disorder in patients with one GI symptom was 3.7 (2.0 to 6.9); in patients with two GI symptoms, OR=6.5 (3.1 to 13.6); and in patients with three GI symptoms, OR=7.2 (2.7 to 18.8).

CONCLUSION

GI symptoms are associated significantly with depression and anxiety in primary care. It is suggested to screen as a routine for anxiety and depression in patients with GI symptoms and, if indicated, to initiate specific treatment.

Symptomchecklisten bei Patienten mit chronischen Schmerzen

Symptom checklists, in particular the SCL-90-R, are widely used in screening for psychological distress in patients with chronic pain. A detailed analysis reveals that this may lead to wrong diagnoses in many cases. The problem of using the SCL-90-R in patients with chronic pain is (a) that scale means are elevated due to items asking for pain-associated symptoms and (b) that there is a lack of specificity of the various dimensions of the SCL-90-R. Numerous short forms of the SCL-90-R are compared to the original one and analysed with respect to their applicability in patients with chronic pain. Other screening questionnaires not related to the SCL-90-R were analysed for the same purpose. As a result, the SCL-27, K9, HADS and PHQ are judged to be applicable for screening in patients with chronic pain.

Responsiveness of the PHQ-9 to Psychopharmacological Depression Treatment

This is the first study that investigates the responsiveness of the Patient Health Questionnaire-9 (PHQ-9), a standard 9-item self-report depression scale, to antidepressant medication. Authors analyzed data from 1,788 depressed outpatients (66.8% women; mean age, 50.3 years), participating in a prospective, open-label, non-interventional, observational study of sertraline. On the 0-27-point PHQ-9 scale, the total sample gained 10.3 points at 12 weeks, corresponding to a standardized effect size of -1.85. With reference to two independent criterion standards, the PHQ-9 change scores were considerably greater in therapy responders than in nonresponders. The PHQ-9 was equally responsive in men and women. Therefore, the PHQ-9 qualifies as a practical tool for gauging response to pharmacological treatment in depressed patients.

Rethinking the place of the psyche in health: toward the integration of health care systems

OBJECTIVE

To review the value provided when health care systems independently manage medical and psychiatric care.

METHOD

The authors draw on data from the world literature, their own experiences and reflections (one author as an international consultant in the coordination of physical and behavioural health care), and input from colleagues throughout the world who face similar challenges to improve outcomes for complex, high cost patients in their own health care systems.

RESULTS

Most health care systems in the world approach the administration and delivery of mental health care separately from that of general medical care. This practice is no longer supported as effective, efficient or inexpensive. Rather accumulating data indicates that concurrent and coordinated medical and psychiatric care, which can only be accomplished by integrating physical and behavioural health through infrastructure change, should replace the present system of independently provided sequential care; that is, one which provides first medical and then psychiatric treatment, or vice versa, with little communication between clinicians in the two sectors.

CONCLUSIONS

By making mental health treatment an integral part of general medical care through reorganization of the funding system, a higher percentage of those now untreated for their psychiatric disorders, both within and outside of the medical setting, can have their mental health needs addressed in coordination with their physical disorders. At the same time, the number of patients that can be treated within the same budget will be expanded.

Specific effects of depression, panic, and somatic symptoms on illness behavior

OBJECTIVE

In terms of restricted financial resources, the contribution of mental disorders to health care use and illness behavior is highly relevant. However, the specific contributions of panic disorder, depression, and somatic complaints to illness behavior in unselected samples is unclear.

METHODS

A representative sample of 2507 inhabitants of Germany was selected and grouped into people with panic disorder (30), somatic syndrome (102), major depression (24), depressive syndrome (77), and controls (2269). Assessment instruments were the complete version of the Patient Health Questionnaire (PHQ), the Scale for the Assessment of Illness Behavior (SAIB) as well as measures of health care use.

RESULTS

Although all clinical groups showed increased illness behavior, their impact was independent and specific. Subjects fulfilling the criteria of panic disorder showed the highest scores for illness behavior and health care use. People with mental disorders showed a greater increase in visits to general practitioners and medical specialists than to psychiatrists or psychologists. Regression analysis revealed that somatic complaints and depression have independent associations with illness behavior and health care use.

CONCLUSIONS

Different mental and psychosomatic disorders contribute independently to health care use and other aspects of illness behavior.

Detecting and monitoring depression with a two-item questionnaire (PHQ-2)

OBJECTIVE

This study evaluates the two-item Patient Health Questionnaire (PHQ-2) as a measure for diagnosing and monitoring depression.

METHODS

We assessed construct validity in a cross-sectional sample of 1619 medical outpatients (mean age 43+/-14 years, 64% female) by comparing the PHQ-2 to four longer self-report questionnaires. Criterion validity was established in a subsample of 520 participants with reference to the Structured Clinical Interview for DSM-IV (SCID). Sensitivity to change was investigated in a prospective study of 167 patients who completed the SCID both at baseline and the 1-year follow-up.

RESULTS

With reference to the SCID, the PHQ-2 had a sensitivity of 87% and a specificity of 78% for major depressive disorder and a sensitivity of 79% and a specificity of 86% for any depressive disorder. Its diagnostic performance was comparable with that of longer depression scales. PHQ-2 change scores accurately reflected improved, unchanged, and deteriorated depression outcomes.

CONCLUSION

The PHQ-2 performed favorably with respect to a standard diagnostic interview, as well as established depression scales and proved sensitive to change. Thus, the PHQ-2 appears promising as a brief multipurpose measure for detecting depression, grading its severity, and monitoring outcomes over time.

Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

BACKGROUND

Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care.

METHODS

This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart.

RESULTS

The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (-1.3 versus -0.9) and equivalent at 6 months (-1.3 versus -1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale.

CONCLUSIONS

Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research.

Anxiety and depression in patients with pulmonary hypertension

OBJECTIVE

This is the first study that investigates the prevalence and actual treatment of anxiety, depression, and other mental disorders in patients with pulmonary hypertension (PH). The prevalence of mental disorders in patients with PH was compared with parallel groups of primary care patients and patients with inflammatory rheumatic diseases, and the relationship between functional status and prevalence of mental disorders was determined.

METHODS

The patient group with PH (70.1% female; mean age, 47.8 +/- 12.7 years) and the two comparison groups, which were matched by age and sex, consisted of 164 patients each. Patients completed self-administered instruments, including the Patient Health Questionnaire for the diagnosis of mental disorders. New York Heart Association (NYHA) functional class was assessed in all patients with PH.

RESULTS

Thirty-five percent of the patients with PH suffered from mental disorders, with the most common being major depressive disorder (15.9%) and panic disorder (10.4%). Both panic disorder and panic attacks were significantly more prevalent in patients with PH than in either patients with inflammatory rheumatic diseases or primary care patients. The prevalence of mental disorders in patients with PH increased significantly with functional impairment, from 17.7% (NYHA class I) to 61.9% (NYHA class IV). Only 24.1% of the patients with PH with mental disorders were receiving psychopharmacological or psychotherapeutic treatment.

CONCLUSIONS

Anxiety and depression are frequent in patients with PH and increase as the severity of disease progresses. Given the fact that safe and efficacious treatments of mental disorders are available, greater importance should be attached to the diagnosis and treatment of these conditions in patients with PH.

Base rates for panic and depression according to the Brief Patient Health Questionnaire: a population-based study

BACKGROUND

Recently published studies analyzing sensitivity and specificity scores have demonstrated that the brief version of the Patient Health Questionnaire (PHQ [J. Am. Med. Assoc. 282 (1999) 1734]) is a useful tool for the detection of panic disorder and depression.

METHODS

We aimed to get normative data for the brief PHQ in a representative population-based sample. Sociodemographic data and PHQ data from 2066 subjects were included.

RESULTS

Base rates for PHQ criteria of major depression were 3.8% with the typical 1:2 ratio between males and females (frequency of minor depressive forms: 9.2%). Normative data for the depression total scores were reported. Marital status, education and family income were significantly associated with depression, even after controlling for age and sex. For panic disorder, base rates were 1.8%; age, gender, and marital status were significant predictors. Frequency for panic attacks as a less restrictively defined version were 4.5%.

CONCLUSIONS

The normative data provide a framework for the interpretation of depression and panic scores of the PHQ.

Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)“

Zusammenfassung. Ziel dieser Studie ist die Validierung der deutschen Version des “Patient Health Questionnaire (PHQ-D)“. Der PHQ wurde zum praktikablen Screening psychischer Störungen für die Primärmedizin entwickelt und erfasst direkt die diagnostischen Kriterien des DSM-IV. N = 357 allgemeinmedizinische/internistische Patienten und N = 171 psychosomatische Patienten wurden mit dem PHQ-D und dem Strukturierten Klinischen Interview für DSM-IV (SKID-I) untersucht, wobei das SKID-I als diagnostischer Goldstandard diente. Ärzte und Patienten wurden zur Akzeptanz des PHQ-D befragt. Eine ausgezeichnete Kriteriumsvalidität des PHQ-D zeigte sich insbesondere bei der Diagnose der Major Depression, wo die Sensitivität für die medizinische Stichprobe bei 95% und die Spezifität bei 86% lag. Gute teststatistische Werte ergaben sich u.a. auch für die Panikstörung. Die Anwendung des PHQ-D wurde von jeweils mehr als 90% der Patienten und Ärzte gut akzeptiert. Mit dem PHQ-D liegt ein praktikables, valides und gut akzeptiertes Instrument zur Anwendung in Forschung und klinischer Praxis vor. Sein Einsatz kann zur verbesserten Versorgung psychischer Störungen beitragen.