Hair androgen concentrations and depressive disorders in adolescents from the general population

Although the link between androgens and depression is well established in adults, the effects of cofactors on this association are less clearly understood, particularly in youth. Epidemiological cohort study of adolescents in Dresden, Germany. Analyses comprised data of 985 individuals assessed at baseline and of 512 individuals at 1-year follow-up. We investigated multivariable regression models for cross-sectional and longitudinal associations of hair testosterone, dehydroepiandrosterone (DHEA), and their cortisol ratios with 12-month diagnoses of major depressive disorder (MDD) and MDD without any anxiety disorder assessed with standardized diagnostic interview (DIA-X-5), and with dimensional depression scores (PHQ-9, PROMIS), separately for males and females. The potential moderating effect of social support was determined. Cross-sectional analyses yielded inverse associations of testosterone and DHEA with MDD and MDD without any anxiety disorders in males. In cross-sectional and longitudinal analyses, baseline ratio cortisol/DHEA was significantly, inversely associated to PROMIS-depression in males. Only cross-sectional associations for ratio cortisol/DHEA and PROMIS-depression remained significant after Bonferroni-Holm correction. No robust associations were observed in female participants. Social support exerted no consistent moderating effect on the investigated association. The present observational cohort study showed no consistent association of hair androgen concentrations with depressive disorders in adolescents. However, findings provide some support for the association between the cortisol/DHEA ratio and depression in males. Longitudinal research designs in large samples are needed to understand the interplay between androgens, depression, and developmental and social factors in youth.

Parental Sexuality Disclosure, Discrimination, and Depression Among Black Sexual Minority Men and Black Transgender Women

Racial and sexuality-based discrimination can induce depressive symptoms among Black sexual minority men and transgender women (BSMM/BTW). BSMM and BTW who disclose their sexuality to parents may be better prepared to cope with discrimination. We explored the relationship between discrimination and depression among BSMM and BTW and whether parental disclosure modified this relationship. Secondary analysis of The MARI Study was used to test the relationship between discrimination and depression modified by level of disclosure of sexuality to parents among 580 BSMM and BTW in Jackson, Mississippi, and Atlanta, Georgia. Bivariate tests and linear regression models were stratified by sexuality disclosure to parents. Discrimination was associated with greater depression, with significant dose-response modification across levels of disclosure. After adjustment, maximum discrimination scores were associated with depression scores 10.7 units higher among participants with very open disclosure (95% CI, 10.4-11.8), 15.3 units higher among participants with somewhat open disclosure (95% CI, 3.7-26.9), and 19.5 units higher among participants with no disclosure (95% CI, 10.2-26.8). Disclosure of sexuality to supportive parents can substantially benefit the mental health of BSMM and BTW. Future studies should explore intervention approaches to providing social support for BSMM and BTW in unsupportive families.

Prevalence of depressive symptoms in U.S. adults during the COVID-19 pandemic: A systematic review

The COVID-19 pandemic has led to a worsening of mental health among U.S. adults. However, no review to date has synthesized the overall prevalence of population depressive symptoms in the U.S. over the COVID-19 pandemic. We aimed to document the population prevalence of depressive symptoms and psychological distress across time since the start of the COVID-19 pandemic, both to identify patterns that emerged in the literature and to assess the data sources, methods, sampling, and measurement used to examine population mental health during the pandemic. In a systematic review of the peer review literature, we identified 49 articles reporting 88 prevalence points of depressive symptoms and related constructs in nationally representative samples of U.S. adults from March 2020 to June 2021. First, we found that the average prevalence of poor mental health across studies was 12.9% for severe depression, 26.0% for at least moderate depression, and 36.0% for at least mild depression. Second, we found that women reported significantly higher prevalence of probable depression than men in 63% of studies that reported depression levels by gender and that results on statistically significant differences between racial and ethnic groups were mixed. Third, we found that the 49 articles published were based on 12 studies; the most common sources were the Household Pulse Survey (n = 15, 31%), the AmeriSpeak panel (n = 8, 16%), the Qualtrics panel (n = 8, 16%), and the Understanding America Study (n = 5, 10%). Prevalence estimates varied based on mental health screening instruments and cutoffs used. The most commonly used instruments were the Patient Health Questionnaire (PHQ) (n = 36, 73%) and the Kessler (n = 8, 16%) series. While the prevalence of population depression varied over time depending on the survey instruments, severity, and constructs reported, the overall prevalence of depression remained high from March 2020 through June 2021 across instruments and severity. Understanding the scope of population mental health can help policymakers and providers address and prepare to meet the ongoing and future mental health needs of U.S. adults in the post-COVID-19 context and beyond.

Major depressive disorders increase the susceptibility to self-reported infections in two German cohort studies

INTRODUCTION

In several claims-based studies, major depressive disorder (MDD) has been associated with increased risk of hospitalization due to acute infections. It remains unclear if this is a causal effect, and if it generalizes to an increased susceptibility to infections.

METHODS

We used data of the BiDirect (n = 925) and the HaBIDS (n = 1007) cohort studies to estimate the effect of MDD on self-reported infections, which were assessed with identical infection susceptibility questionnaires in both studies. We used the Center for Epidemiologic Studies Depression Scale (CES-D) to examine if there was a dose-response relationship between depressive symptom severity and self-reported infections.

RESULTS

BiDirect participants with MDD diagnosis (48%) had a higher risk of lower respiratory tract infections (incidence rate ratio 1.32, 95% confidence interval [1.00-1.75]), gastrointestinal infections (1.68 [1.30-2.16]) and fever (1.48 [1.11-1.98]) after adjusting for confounders identified by a directed acyclic graph approach. There was a dose-response relationship, i.e. individuals with higher CES-D scores reported more infections. Effect sizes were similar in HaBIDS (4% individuals with MDD).

CONCLUSION

We found increased risks of mild infections in patients with MDD diagnosis and a dose-response relationship between depressive symptom severity and infection frequency. While causal immunological pathways remain unclear, the results of our study might contribute to a change in prevention strategies, e.g. by recommending vaccination against influenza and S. pneumoniae to MDD patients because observed effect sizes in our study are similar to those of patients with cardiovascular and metabolic diseases for which the respective vaccinations are recommended.

Towards standardization of measuring anxiety and depression: Differential item functioning for language and Dutch reference values of PROMIS item banks

Introduction

The outcomes anxiety and depression are measured frequently by healthcare providers to assess the impact of a disease, but with numerous instruments. PROMIS item banks provide an opportunity for standardized measurement. Cross-cultural validity of measures and the availability of reference values are prerequisites for standardized measurement.

Methods

PROMIS Anxiety and Depression item banks were completed by 1002 representative Dutch persons. To evaluate cross-cultural validity, data from US participants in PROMIS wave 1 were used and differential item functioning (DIF) was investigated, using an iterative hybrid of logistic regression and item response theory. McFadden’s pseudo R²-change of 2% was the critical threshold. The impact of any DIF on full item banks and short forms was investigated. To obtain Dutch reference values, T-scores for anxiety and depression were calculated for the complete Dutch sample, and age-group and gender subpopulations. Thresholds corresponding to normal limits, mild, moderate and severe symptoms were computed.

Results

In both item banks, two items had DIF but with minimal impact on population level T-scores for full item banks and short forms. The Dutch general population had a T-score of 49.9 for anxiety and 49.6 for depression, similar to the T-scores of 50.0 of the US general population. T-scores for age-group and gender subpopulations were also similar to T-scores of the US general population. Thresholds for mild, moderate and severe anxiety and depression were set to 55, 60 and 70, identical to US thresholds.

Conclusions

The limited number of items with DIF and its minimal impact, enables the use of standard (US) item parameters and comparisons of scores between Dutch and US populations. The Dutch reference values provide an important tool for healthcare professionals and researchers to evaluate and interpret symptoms of anxiety and depression, stimulating the uptake of PROMIS measures, and contributing to standardized outcome measurement.

Depressive Symptoms at Kidney Transplant Evaluation and Access to the Kidney Transplant Waitlist

Introduction

Depressive symptoms, even without a clinical diagnosis of depression, are common in kidney failure patients and may be a barrier to completing the complex process of kidney transplant (KT) evaluation. We assessed depressive symptom burden and association between depressive symptoms and access to KT waitlist by age.

Methods

In a prospective cohort of 3728 KT patients (aged 18–88 years), the Center for Epidemiologic Studies—Depression (CES-D) scale was used to measure depressive symptoms at evaluation. Depressive symptom severity was defined as follows: none: 0; minimal: 1 to 15; mild: 16 to 20; moderate: 21 to 25; severe: 26 to 60. Hazard ratios (HRs) of active listing within 1 year after evaluation were estimated using Cox proportional hazards models, adjusted for clinical and social factors.

Results

At evaluation, 85.8% of the patients reported at least minimal depressive symptoms; the proportion was lower among older patients: 18 to 29 years = 92.0%; 30 to 39 years = 88.3%; 40 to 49 years = 87.2%; 50 to 59 years = 87.0%; 60 to 69 years = 83.4%; and ≥70 years = 82.0%. Chance of active listing decreased with more severe depressive symptoms (log-rank, P < 0.001). After adjustment, every 5-point higher CES-D score (more depressive symptoms) was associated with a 13% lower chance of listing (HR = 0.87, 95% CI: 0.85–0.90); the strongest association was found among patients aged ≥70 years (adjusted HR [aHR] = 0.73, 95% CI: 0.62–0.86). Furthermore, minimal (HR = 0.69, 95% CI: 0.60–0.79), mild (HR = 0.57, 95% CI: 0.44–0.72), moderate (HR = 0.53, 95% CI: 0.39–0.71), and severe (HR = 0.44, 95% CI: 0.34–0.57) depressive symptoms were all associated with a lower chance of listing.

Conclusion

Older candidates were less likely to report depressive symptoms at KT evaluation. Regardless of age, candidates who did report depressive symptoms, and even minimal symptoms, had a lower chance of listing. Transplant centers should routinely screen patients for depressive symptoms and refer the affected patients to mental health services to improve access to KT.

PROMIS Provides a Broader Overview of Health-Related Quality of Life than the ESSPRI in Evaluation of Sjogren's Syndrome

Objective

Sjogren's Syndrome (SS) has significant impact on health-related quality of life (HRQL). We sought to evaluate how the Patient Reported Outcome Measurement Information System (PROMIS) domains in SS may supplement the European League Against Rheumatism (EULAR) SS Patient Reported Index (ESSPRI).

Methods

A cross-sectional evaluation was performed on consecutive adult patients during visits to a Sjogren's clinic between March 2018-February 2020. Each patient completed PROMIS short forms related to HRQL, the ESSPRI, and had a clinical assessment. Patients were either classified as SS by 2016 ACR/EULAR criteria or "sicca not otherwise specified (NOS)" and used as a comparison group. Uni- and multivariable linear regression (MVR) models were used to evaluate predictors of PROMIS fatigue, pain interference (PI), and social participation (SP).

Results

227 SS and 85 patients with sicca NOS were included and did not differ in ESSPRI domains; 26% of the SS and 20% of the sicca NOS group had concurrent autoimmune disease. In SS, PROMIS PI, fatigue, and physical function were at least ½ SD worse than US population normative values. PROMIS PI (r=0.72) and fatigue (r=0.80) highly correlated with ESSPRI pain and fatigue sub-domains. Fatigue and PI, but not dryness or mood disturbance, were the strongest predictors of SP in MVR.

Conclusion

In our SS cohort, PROMIS instruments identified a high disease burden of PI, fatigue, and physical function. Fatigue strongly predicted SP. PROMIS PI and fatigue scores correlated highly with respective ESSPRI domains. PROMIS instruments should be considered to identify relevant HQRL patterns in SS.

The relationship between depression, anxiety, and pain interference with therapy referral and utilization among patients with hand conditions

INTRODUCTION

Patients with upper extremity conditions may also experience symptoms of depression, anxiety, and pain that limit functional recovery.

PURPOSE OF THE STUDY

This study examined the impact of mental health and pain symptoms on referral rates to therapy and utilization of therapy services to achieve functional recovery among patients with common hand conditions.

STUDY DESIGN

This is a retrospective cohort study of patients from one orthopedic center.

METHODS

Data extraction provided demographics, the International Classification of Diseases, 10th revision diagnoses, therapy referral, therapy visit counts, treatment goal attainment, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression, Anxiety, and Pain Interference scores. The chi-square test, t-test, and logistic regression analyses assessed associations between baseline PROMIS depression, anxiety, and pain interference to therapy referral, the number of therapy visits, and goal attainment.

RESULTS

Forty-nine percent (172/351) of patients were referred to hand therapy. There was no relationship between three baseline PROMIS scores based on physician referral (t-test P values .32-.67) and no association between PROMIS scores and therapy utilization or goal attainment (Pearson correlation (r): 0.002 to 0.020, P > .05). Referral to therapy was most strongly associated with having a traumatic condition (P < .01). Patients with high depression, anxiety, and pain interference scores on average required one more therapy visit to achieve treatment goals (average visits: 3.7 vs 3.1; 4.1 vs 2.7; 3.4 vs 2.3, respectively). Fewer patients with high depression scores (50%) achieved their long-term goals than patients with low depression scores (69%, P = .20).

CONCLUSIONS

Patients' baseline level of depressive symptoms and anxiety do not predict referrals to hand therapy by orthopedic hand surgeons. There is some indication that patients with increased depressive symptoms, anxiety, and pain interference require more therapy with fewer achieving all goals, suggesting that mental health status may affect response to therapy. Therapists may address mental health needs in treatment plans. Future studies should examine if nonreferred patients with depressive symptoms achieve maximal functional recovery.

Prevalence, severity and distribution of depression and anxiety symptoms using observational data collected before and nine months into the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has been accompanied by substantial increases in adverse mental health, particularly among the young. However, it remains unclear to what extent increases in population scores on mental health assessments are due to changes in prevalence, rather than severity of symptoms. Further, it is not obvious that widely used assessments of aggregate symptoms retain their typical interpretation during an event that directly disrupts behavior.

METHODS

Pre-pandemic data on workers age 18-69y in the 2019 National Health Interview Survey are reweighted to match distributions of demographic characteristics of Duke University employees surveyed nine months into the pandemic. The latter population was at low risk of infection or economic insecurity. Prevalence, severity, and scores for each of nine symptoms are compared overall and by age group.

OUTCOMES

Elevated psychological distress is primarily driven by increases in prevalence of particular symptoms. Prevalence of trouble concentrating increased six-fold from 9.6% to 72.5%. Other symptoms increased by over one-third; feeling anxious, having little interest, feeling depressed, sleep problems and being irritable, while some symptoms rose only 10% or less. Severity also increased but magnitudes are small relative to prevalence changes. Escalation in prevalence and severity are greatest for the youngest.

INTERPRETATION

Some of the least prevalent symptoms pre-pandemic became the most prevalent during the pandemic, affecting interpretation of indices validated pre-pandemic. Clinical and policy interventions should focus on specific symptoms that increased including trouble concentrating and anxiety.

FUNDING

Trinity College of Arts & Sciences and Social Science Research Institute at Duke University.

Solving the Tower of Babel Problem for Patient-Reported Outcome Measures : Comments on: Linking Scores with Patient-Reported Health Outcome Instruments: A Validation Study and Comparison of Three Linking Methods

The PROsetta Stone Project, summarized in this issue by Schalet et al. (Psychometrika 86, 2021), is a major step forward in enabling comparability between different patient-reported outcomes measures. Schalet et al. clearly describe the psychometric methods used in the PROsetta Stone project and other projects from the Patient-Reported Outcomes Measurement Information System (PROMIS): linking based on unidimensional item response theory (IRT), equipercentile linking, and calibrated projection based on multidimensional IRT. Analyses in a validation data set and simulation studies provide strong support that the linking methods are robust when basic assumptions are fulfilled. The links already established will be of great value to the field, and the methodology described by Schalet et al. will hopefully inspire the next series of linking studies. Among potential improvements that should be considered by new studies are: (1) a thorough evaluation of the content of the measures to be linked to better guide the evaluation of measurement assumptions, (2) improvements in the design of linking studies such as selection of the optimal sample to provide data in the score ranges where linking precision is most critical and using counterbalanced designs to control for order effects. Finally, it may be useful to consider how the linking algorithms are used in subsequent data analyses. Analytic strategies based on plausible values or latent regression IRT models may be preferable to the simple transformation of scores from one patient at the time.

Linking Scores with Patient-Reported Health Outcome Instruments:A VALIDATION STUDY AND COMPARISON OF THREE LINKING METHODS

The psychometric process used to establish a relationship between the scores of two (or more) instruments is generically referred to as linking. When two instruments with the same content and statistical test specifications are linked, these instruments are said to be equated. Linking and equating procedures have long been used for practical benefit in educational testing. In recent years, health outcome researchers have increasingly applied linking techniques to patient-reported outcome (PRO) data. However, these applications have some noteworthy purposes and associated methodological questions. Purposes for linking health outcomes include the harmonization of data across studies or settings (enabling increased power in hypothesis testing), the aggregation of summed score data by means of score crosswalk tables, and score conversion in clinical settings where new instruments are introduced, but an interpretable connection to historical data is needed. When two PRO instruments are linked, assumptions for equating are typically not met and the extent to which those assumptions are violated becomes a decision point around how (and whether) to proceed with linking. We demonstrate multiple linking procedures-equipercentile, unidimensional IRT calibration, and calibrated projection-with the Patient-Reported Outcomes Measurement Information System Depression bank and the Patient Health Questionnaire-9. We validate this link across two samples and simulate different instrument correlation levels to provide guidance around which linking method is preferred. Finally, we discuss some remaining issues and directions for psychometric research in linking PRO instruments.

Selecting Patient-Reported Outcome Measures to Contribute to Primary Care Performance Measurement: a Mixed Methods Approach

New models of primary care include patient-reported outcome measures (PROMs) to promote patient-centered care. PROMs provide information on patient functional status and well-being, can be used to enhance care quality, and are proposed for use in assessing performance. Our objective was to identify a short list of candidate PROMs for use in primary care practice and to serve as a basis for performance measures (PMs). We used qualitative and quantitative methods to identify relevant patient-reported outcome (PRO) domains for use in performance measurement (PRO-PM) and their associated PROMs. We collected data from key informant groups: patients (n = 13; one-on-one and group interviews; concept saturation analysis), clinical thought leaders (n = 9; group discussions; thematic analysis), primary care practices representatives (n = 37; six focus groups; thematic analysis), and primary care payer representatives (n = 10; 12-question survey; frequencies of responses). We merged the key informant group information with findings from environmental literature scans. We conducted a targeted evidence review of measurement properties for candidate PROMs. We used a scoping review and key informant groups to identify PROM evaluation criteria, which were linked to the National Quality Forum measure evaluation criteria. We developed a de novo schema to score candidate PROMs against our criteria. We identified four PRO domains and 10 candidate PROMs: 3 for depressive symptoms, 2 for physical function, 3 for self-efficacy, 2 for ability to participate. Five PROMs met ≥ 70% of the evidence criteria for three PRO domains: PHQ-9 or PROMIS Depression (depression), PF-10 or PROMIS-PF (physical functioning), and PROMIS Self-Efficacy for Managing Treatments and Medications (self-efficacy). The PROMIS Ability to Participate in Social Roles and Activities met 68% of our criteria and might be considered for inclusion. Existing evidence and key informant data identified 5 candidate PROMs to use in primary care. These instruments can be used to develop PRO-PMs.

Longitudinal associations between occupational stress and depressive symptoms

Background

Most of the studies that have examined the association between the sub-factors of occupational stress and depressive symptoms have used cross-sectional data. However, our study has longitudinally measured the occupational stress and depressive symptoms of Korean workers of a semiconductor manufacturing company across six years to intending to investigate the associations between the sub-factors of occupational stress and depressive symptoms using longitudinal data.

Methods

Data collected from the workers of a semiconductor manufacturing company. Out of 1,013 recruited workers, 405 (40.0%) completed the survey questionnaires at 3 and 6-year follow-ups. Occupational stress was measured using a shorter version of the Korean Occupational Stress Scale (KOSS), whereas depressive symptoms were assessed using the Korean version of the Center for Epidemiological Studies-Depressive Symptoms Scale (CES-D). The data of male and female participants independently analyzed. Longitudinal associations were analyzed using panel data analysis with fixed effects.

Results

In panel data analysis with fixed effects, job insecurity (B = 0.048, p-value = 0.004) was associated with depressive symptoms among male workers. In female workers, inadequate social support (B = 0.080, p-value < 0.001), job insecurity (B = 0.039, p-value = 0.004), lack of reward (B = 0.059, p-value = 0.004) and discomfort in occupational climate (B = 0.074, p-value < 0.001) were associated with depressive symptoms among female workers.

Conclusions

Temporal changes in the sub-factors of occupational stress were associated with changes in depressive symptoms within the same period. There was a gender difference in occupational stress sub-factors related to depressive symptoms.

Minimally important differences and severity thresholds are estimated for the PROMIS depression scales from three randomized clinical trials

BACKGROUND

Patient Reported Outcomes Measurement Information Systems (PROMIS) scales are increasingly being used to measure symptoms in research and practice. The purpose of this study was to determine the minimally important difference (MID) and severity thresholds (cut-points) for the four fixed-length PROMIS depression scales.

METHODS

The study sample was adult participants in three randomized clinical trials (N=651). MID was estimated using multiple distribution- and anchor-based approaches including assessing correspondence between Patient Health Questionnaire (PHQ-9) and PROMIS depression scores.

RESULTS

The best MID estimate was a PROMIS depression T-score of 3.5 points with most methods producing an MID in the 3 to 4 point range across all three samples. MID estimates were similar for all four PROMIS scales. A PHQ-9 1-point change equated to a PROMIS 1.25-point T-score change. PROMIS T-scores of 55, 60, 65, and 70 appeared to be reasonable thresholds for mild, moderate, moderately severe, and severe depression, respectively.

LIMITATIONS

The study sample was predominantly male veterans with either chronic pain (2 trials) or previous stroke (1 trial). The severity of depression was mild to moderate.

CONCLUSION

A T-score of 3 to 4 points is a reasonable MID for PROMIS depression scales and can be used to assess treatment effects in both practice and research as well to calculate sample sizes for clinical trials. Severity cut-points can help interpret the meaning of scores and action thresholds for treatment decisions.

T'ai Chi for Chronic Low Back Pain in Older Adults: A Feasibility Trial

Objectives: T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC). Design: Feasibility randomized controlled trial. Settings/Location: Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility. Patients: Adults 65 years of age and older with cLBP. Interventions: Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only. Outcome Measures: Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events. Results: Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes. Conclusion: The TC intervention is feasible in this population, while the HE group requires modifications in delivery.

Photojournalism-Based Intervention Reduces Caregiver Burden and Depression in Alzheimer's Disease Family Caregivers

Purpose: Art interventions have demonstrated holistic benefits for persons living with dementia and their caregivers. In this article, we describe the results of a pilot photojournalism program for 10 unpaid caregivers of persons living with dementia, with respect to caregivers' experience in the program and their psychological well-being. Design: Caregivers participated in four sessions led by a professional photojournalist who taught principles of photography. Between the sessions, caregivers took photographs that represented what caregiving meant to them using digital cameras provided in the program. During the sessions, instruction was interspersed with discussion of caregivers' photographs. Method: Caregiver burden and depressive symptoms were measured pre- and postprogram. Qualitative exploration included sessions' observations, viewing caregivers' photographs, and recording caregivers' accompanying comments. Findings: For participants with pre- and postprogram data, caregiver burden decreased significantly (p = .037). For caregivers with pre- and postprogram data, depressive symptoms decreased nonsignificantly (p = .066). Clinically meaningful reductions in caregiver burden and depressive symptoms were attained. Qualitative findings highlighted caregivers' strong engagement with the project, the facilitator, and other participants, and reflection on multiple aspects of their experience. Conclusions: This intervention helped caregivers creatively communicate their experience and demonstrated efficacy in the improvement of caregivers' psychological well-being.

Comparison of PROMIS Anxiety and Depression, PHQ-8, and GAD-7 to screen for anxiety and depression among patients presenting for spine surgery

OBJECTIVE

In this paper, the authors demonstrate to spine surgeons the prevalence and severity of anxiety and depression among patients presenting for surgery and explore the relationships between different legacy and Patient-Reported Outcomes Measurement Information System (PROMIS) screening measures.

METHODS

A total of 512 adult spine surgery patients at a single institution completed the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), 8-item Patient Health Questionnaire (PHQ-8) depression scale, and PROMIS Anxiety and Depression computer-adaptive tests (CATs) preoperatively. Correlation coefficients were calculated between PROMIS scores and GAD-7 and PHQ-8 scores. Published reference tables were used to determine the presence of anxiety or depression using GAD-7 and PHQ-8. Sensitivity and specificity of published guidance on the PROMIS Anxiety and Depression CATs were compared. Guidance from 3 sources was compared: published GAD-7 and PHQ-8 crosswalk tables, American Psychiatric Association scales, and expert clinical consensus. Receiver operator characteristic curves were used to determine data-driven cut-points for PROMIS Anxiety and Depression. Significance was accepted as p < 0.05.

RESULTS

In 512 spine surgery patients, anxiety and depression were prevalent preoperatively (5% with any anxiety, 24% with generalized anxiety screen-positive; and 54% with any depression, 24% with probable major depression). Correlations were moderately strong between PROMIS Anxiety and GAD-7 scores (r = 0.72; p < 0.001) and between PROMIS Depression and PHQ-8 scores (r = 0.74; p < 0.001). The observed correlation of the PROMIS Depression score was greater with the PHQ-8 cognitive/affective score (r = 0.766) than with the somatic score (r = 0.601) (p < 0.001). PROMIS Anxiety and Depression CATs were able to detect the presence of generalized anxiety screen-positive (sensitivity, 86.0%; specificity, 81.6%) and of probable major depression (sensitivity, 82.3%; specificity, 81.4%). Receiver operating characteristic curve analysis demonstrated data-driven cut-points for these groups.

CONCLUSIONS

PROMIS Anxiety and Depression CATs are reliable tools for identifying generalized anxiety screen-positive spine surgery patients and those with probable major depression.

The impact of painful knee osteoarthritis on mortality: a community-based cohort study with over 24 years of follow-up

OBJECTIVE

To investigate the impact of knee osteoarthritis (OA) and/or knee pain on excess mortality.

METHOD

We analyzed data from 4,182 participants in a community-based prospective cohort study of African American and Caucasian men and women aged ≥45 years. Participants completed knee radiographs and questionnaires at baseline and at up to three follow-ups to determine knee OA (rOA), knee pain and covariate status. Mortality was determined through 2015. We used Cox proportional hazards regression with time-varying covariates (TVC) to estimate hazard ratios (HR) and 95% confidence intervals (CI). Additional analyses stratified by sex, race and age were carried out.

RESULTS

Median follow-up time was 14.6 years during which 1822 deaths occurred. Baseline knee radiographic osteoarthritis (rOA) was 27.7%, 38.8% at first follow-up, 52.6% at second follow-up and 61.9% at the third follow-up. Knee rOA with pain and knee pain alone were both associated with a >15% increase in premature all-cause mortality. In analyses stratified by sex, race and age, associations between knee pain, with or without knee rOA, and all-cause death were found among women, Caucasians, those ≤65 years of age, and those with a body mass index (BMI)≥30, with observed increased risks of death between 21% and 65%. We observed similar, somewhat attenuated, results for cardiovascular disease (CVD) deaths.

CONCLUSION

In models taking into account variables that change over time, individuals who had knee pain, alone or with knee rOA, had increased mortality. These effects were particularly strong among those obese. Effective interventions to reduce knee pain, particularly those including weight management and prevention of comorbidities, could reduce mortality.

Measuring fatigue in cancer patients: a common metric for six fatigue instruments

PURPOSE

Fatigue is one of the most disabling symptoms in cancer patients. Many instruments exist to measure fatigue. This variety impedes the comparison of data across studies or to the general population. We aimed to estimate a common metric based on six different fatigue instruments (EORTC QLQ-C30 subscale fatigue, EORTC QLQ-FA12, MFI subscale General Fatigue, BFI, Fatigue Scale, and Fatigue Diagnostic Interview Guide) to convert the patients' scores from one of the instruments to another. Additionally, we linked the common metric to the general population.

METHODS

For n = 1225 cancer patients, the common metric was estimated using the Item Response Theory framework. The linking between the common metric of the patients and the general population was estimated using linear regression.

RESULTS

The common metric was based on a model with acceptable fit (CFI = 0.94, SRMR = 0.06). Based on the standard error of measurement the reliability coefficients of the questionnaires ranged from 0.80 to 0.95. The common metric of the six questionnaires, also linked to the general population, is reported graphically and in supplementary crosswalk tables.

CONCLUSIONS

Our study enables researchers and clinicians to directly compare results across studies using different fatigue questionnaires and to assess the degree of fatigue with respect to the general population.

Psychometric properties of the PHQ-9 depression scale in people with multiple sclerosis: A systematic review

BACKGROUND

Depression affects approximately 25% of people with MS (pwMS) at any given time. It is however under recognised in clinical practice, in part due to a lack of uptake for brief assessment tools and uncertainty about their psychometric properties. The 9-item Patient Health Questionnaire (PHQ-9) is an attractive candidate for this role.

OBJECTIVE

To synthesise published findings on the psychometric properties of the 9-item Patient Health Questionnaire (PHQ-9) when applied to people with multiple sclerosis (pwMS).

DATA SOURCES

PubMed, Medline and ISI Web of Science databases, supplemented by hand-searching of references from all eligible sources.

STUDY ELIGIBILITY CRITERIA

Primary literature written in English and published following peer-review with a primary aim to evaluate the performance of the PHQ-9 in pwMS.

OUTCOME MEASURES

Psychometric performance with respect to appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility.

RESULTS

Seven relevant studies were identified, these were of high quality and included 5080 participants from all MS disease-course groups. Strong evidence was found supporting the validity of the PHQ-9 as a unidimensional measure of depression. Used as a screening tool for major depressive disorder (MDD) with a cut-point of 11, sensitivity was 95% sensitivity and specificity 88.3% (PPV 51.4%, NPV 48.6%). Alternative scoring systems that may address the issue of overlap between somatic features of depression and features of MS per se are being developed, although their utility remains unclear. However data on reliability was limited, and no specific evidence was available on test-retest reliability, responsiveness, acceptability, or feasibility.

CONCLUSIONS

The PHQ-9 represents a suitable tool to screen for MDD in pwMS. However use as a diagnostic tool cannot currently be recommended, and the potential value for monitoring depressive symptoms cannot be established without further evidence on test-retest reliability, responsiveness, acceptability, and feasibility.

REGISTRATION

PROSPERO register ID: CRD42017067814.

Scoring Depression on a Common Metric: A Comparison of EAP Estimation, Plausible Value Imputation, and Full Bayesian IRT Modeling

There are a growing number of item response theory (IRT) studies that calibrate different patient-reported outcome (PRO) measures, such as anxiety, depression, physical function, and pain, on common, instrument-independent metrics. In the case of depression, it has been reported that there are considerable mean score differences when scoring on a common metric from different, previously linked instruments. Ideally, those estimates should be the same. We investigated to what extent those differences are influenced by different scoring methods that take into account several levels of uncertainty, such as measurement error (through plausible value imputation) and item parameter uncertainty (through full Bayesian IRT modeling). Depression estimates from different instruments were more similar, and their corresponding confidence/credible intervals were larger when plausible value imputation or Bayesian modeling was used, compared to the direct use of expected a posteriori (EAP) estimates. Furthermore, we explored the use of Bayesian IRT models to update item parameters based on newly collected data.

Discriminant Ability, Concurrent Validity, and Responsiveness of PROMIS Health Domains Among Patients With Lumbar Degenerative Disease Undergoing Decompression With or Without Arthrodesis

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

The aim of this study was to investigate the ability of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains to discriminate between levels of disease severity and to determine the concurrent validity and responsiveness of PROMIS relative to "legacy" measures.

SUMMARY OF BACKGROUND DATA

PROMIS may measure recovery after lumbar spine surgery. Concurrent validity and responsiveness have not been compared with legacy measures in this population.

METHODS

We included 231 adults undergoing surgery for lumbar degenerative disease. Discriminant ability of PROMIS was estimated for adjacent categories of disease severity using the Oswestry Disability Index (ODI). Concurrent validity was determined through correlation between preoperative legacy measures and PROMIS. Responsiveness was estimated using distribution-based and anchor-based criteria (change from preoperatively to within 3 months postoperatively) anchored to treatment expectations (North American Spine Society Patient Satisfaction Index) to determine minimal important differences (MIDs). Significance was accepted at P < 0.05.

RESULTS

PROMIS discriminated between disease severity levels, with mean differences between adjacent categories of 3 to 8 points. There were strong to very strong correlations between Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, and PROMIS anxiety, depression, fatigue, and sleep disturbance; between ODI and PROMIS fatigue, pain, and physical function; between the 12-Item Short-Form Health Survey physical component and PROMIS pain and physical function; and between the Brief Pain Inventory (BPI) pain interference and PROMIS depression and pain. BPI back pain and leg pain intensity showed weak or no correlation with PROMIS. Distribution-based MIDs ranged from 3.0 to 3.5 points. After incorporating longitudinal anchor-based estimates, final PROMIS MID estimates were anxiety, -4.4; depression, -6.0; fatigue, -5.3; pain, -5.4; physical function, 5.2; satisfaction with participation in social roles, 6.0; and sleep disturbance, -6.5.

CONCLUSION

PROMIS discriminated between disease severity levels, demonstrated good concurrent validity, and was responsive to changes after lumbar spine surgery.

LEVEL OF EVIDENCE

2.

Best Practice Update: Incorporating Psychogastroenterology Into Management of Digestive Disorders

Chronic digestive diseases, including irritable bowel syndrome, gastroesophageal reflux disease, and inflammatory bowel diseases, cannot be disentangled from their psychological context-the substantial burden of these diseases is co-determined by symptom and disease severity and the ability of patients to cope with their symptoms without significant interruption to daily life. The growing field of psychogastroenterology focuses on the application of scientifically based psychological principles and techniques to the alleviation of digestive symptoms. In this Clinical Practice Update, we describe the structure and efficacy of 2 major classes of psychotherapy-cognitive behavior therapy and gut-directed hypnotherapy. We focus on the impact of these brain-gut psychotherapies on gastrointestinal symptoms, as well as their ability to facilitate improved coping, resilience, and self-regulation. The importance of the gastroenterologist in the promotion of integrated psychological care cannot be overstated, and recommendations are provided on how to address psychological issues and make an effective referral for brain-gut psychotherapy in routine practice.

Infertile women who screen positive for depression are less likely to initiate fertility treatments

STUDY QUESTION

Are infertile women who screen positive for depression less likely to initiate infertility treatments?

SUMMARY ANSWER

Infertile women who screen positive for depression are less likely to initiate treatment for infertility.

WHAT IS ALREADY KNOWN

Infertility imposes a psychological burden on many couples. Depression and anxiety have been demonstrated in ~40% of infertile women, which is twice that of fertile women. Further, the psychological burden associated with infertility treatment has been cited as a major factor for discontinuation of infertility care.

STUDY DESIGN, SIZE, DURATION

Prospective, observational study in a clinical-based cohort of 416 women who completed a questionnaire after the new patient visit, from January 2013 until December 2014 inclusive.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All new female infertility patients (n = 959) seen between January 2013 and December 2014 at University of North Carolina Fertility received an electronic questionnaire to screen for mental health disorders and to evaluate their perception of mental health disorders on infertility.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 959 surveys sent, 416 women completed the questionnaire (43%). The prevalence screening positive for depression, using the NIH PROMIS screening tool, was 41%. Sixty-two percent of all women initiated infertility treatment, and of these, 81% did so within 4 months. In multivariate analysis, women who screened positive for depression had 0.55 times the odds of initiating treatment for infertility (95% CI: 0.31-0.95). Similarly, women who screened positive for depression had 0.58 times the odds of initiating infertility treatment within 4 months (95% CI: 0.35-0.97), which was the time of censoring from the most recent patient evaluated. Women who screened positive for depression were less likely to pursue treatment with oral medications or IVF (P = 0.01 and P = 0.03, respectively), as compared to women who did not screen positive for depression.

LIMITATIONS, REASONS FOR CAUTION

Questionnaire-based evaluations may result in a lower prevalence of psychological disorder as some participants feign emotional well-being. Although we did not identify differences in women who responded to our survey and those who did not, responder bias may still be present. In addition, infertility is a couple's disease. However, this study only included psychological evaluation of the female partner. We have no information about the women's previous treatment.

WIDER IMPLICATIONS OF THE FINDINGS

Screening for depression is important in the infertility patient population, as further evaluation and psychological interventions may improve compliance with fertility treatments, quality of life, and potentially, the overall chance of pregnancy.

STUDY FUNDING/COMPETING INTERESTS

None.

Measurement properties of depression questionnaires in patients with diabetes: a systematic review

Purpose

To conduct a systematic review on measurement properties of questionnaires measuring depressive symptoms in adult patients with type 1 or type 2 diabetes.

Methods

A systematic review of the literature in MEDLINE, EMbase and PsycINFO was performed. Full text, original articles, published in any language up to October 2016 were included. Eligibility for inclusion was independently assessed by three reviewers who worked in pairs. Methodological quality of the studies was evaluated by two independent reviewers using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Quality of the questionnaires was rated per measurement property, based on the number and quality of the included studies and the reported results.

Results

Of 6286 unique hits, 21 studies met our criteria evaluating nine different questionnaires in multiple settings and languages. The methodological quality of the included studies was variable for the different measurement properties: 9/15 studies scored ‘good’ or ‘excellent’ on internal consistency, 2/5 on reliability, 0/1 on content validity, 10/10 on structural validity, 8/11 on hypothesis testing, 1/5 on cross-cultural validity, and 4/9 on criterion validity. For the CES-D, there was strong evidence for good internal consistency, structural validity, and construct validity; moderate evidence for good criterion validity; and limited evidence for good cross-cultural validity. The PHQ-9 and WHO-5 also performed well on several measurement properties. However, the evidence for structural validity of the PHQ-9 was inconclusive. The WHO-5 was less extensively researched and originally not developed to measure depression.

Conclusion

Currently, the CES-D is best supported for measuring depressive symptoms in diabetes patients.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1782-y) contains supplementary material, which is available to authorized users.

Concurrent Validity and Responsiveness of PROMIS Health Domains Among Patients Presenting for Anterior Cervical Spine Surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to determine the validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains.

SUMMARY OF BACKGROUND DATA

PROMIS health domains (anxiety, depression, fatigue, pain, physical function, satisfaction with participation in social roles, sleep disturbance) may measure quality of care and determine minimal important differences (MIDs) after spine surgery. We examined concurrent validity of PROMIS domains before and PROMIS domain MIDs after anterior cervical spine surgery.

METHODS

We included 148 adults undergoing cervical spine surgery from February 2015 through June 2016. We determined concurrent validity by correlations of preoperative PROMIS domains with legacy measures and responsiveness of PROMIS domains using distribution-based and anchor-based criteria (preoperative to postoperative change, within 6 months) anchored to treatment expectations (assessed using North American Spine Society Patient Satisfaction Index criteria). Statistical significance was accepted as P < 0.05.

RESULTS

All PROMIS domains showed moderate to strong correlations with Neck Disability Index, Short-Form Health Survey, version 2 (SF-12v2), and Brief Pain Inventory pain interference and weak correlations with intensity of arm/neck pain (except between PROMIS pain and neck pain [r = 0.45, P < 0.001] and PROMIS physical function and SF-12v2 physical [r = -0.14, P = 0.138] and mental [r = 0.39, P < 0.001] components). PROMIS domains were well correlated with Generalized Anxiety Disorder-7 and Patient Health Questionnaire-8 except PROMIS physical function (r = -0.29, P = 0.002). Distribution-based PROMIS MID estimates ranged from 2.3 to 3.9 points. Incorporating cross-sectional and longitudinal anchor-based criteria, final PROMIS MID estimates were as follows: anxiety, -5.7; depression, -4.6, fatigue, -5.8; pain, -5.2; physical function, 4.5; satisfaction with participation in social roles, 4.4; and sleep disturbance, -7.4.

CONCLUSION

PROMIS domains are a valid assessment of health in this population and were responsive to postoperative improvements in symptoms and quality of life.

LEVEL OF EVIDENCE

2.