Abstract 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 ≥10 on the parent scales (PHQ-9 and GAD-7) and ≥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.
IMPORTANCE Somatic symptoms are the core features of many medical diseases, and they are used to evaluate the severity and course of illness. The 8-item Somatic Symptom Scale (SSS-8) was recently ...developed as a brief, patient-reported outcome measure of somatic symptom burden, but its reliability, validity, and usefulness have not yet been tested. OBJECTIVE To investigate the reliability, validity, and severity categories as well as the reference scores of the SSS-8. DESIGN, SETTING, AND PARTICIPANTS A national, representative general-population survey was performed between June 15, 2012, and July 15, 2012, in Germany, including 2510 individuals older than 13 years. MAIN OUTCOMES AND MEASURES The SSS-8 mean (SD), item-total correlations, Cronbach α, factor structure, associations with measures of construct validity (Patient Health Questionnaire–2 depression scale, Generalized Anxiety Disorder–2 scale, visual analog scale for general health status, 12-month health care use), severity categories, and percentile rank reference scores. RESULTS The SSS-8 had excellent item characteristics and good reliability (Cronbach α = 0.81). The factor structure reflects gastrointestinal, pain, fatigue, and cardiopulmonary aspects of the general somatic symptom burden. Somatic symptom burden as measured by the SSS-8 was significantly associated with depression (r = 0.57 95% CI, 0.54 to 0.60), anxiety (r = 0.55 95% CI, 0.52 to 0.58), general health status (r = −0.24 95% CI, −0.28 to −0.20), and health care use (incidence rate ratio, 1.12 95% CI, 1.10 to 1.14). The SSS-8 severity categories were calculated in accordance with percentile ranks: no to minimal (0-3 points), low (4-7 points), medium (8-11 points), high (12-15 points), and very high (16-32 points) somatic symptom burden. For every SSS-8 severity category increase, there was a 53% (95% CI, 44% to 63%) increase in health care visits. CONCLUSIONS AND RELEVANCE The SSS-8 is a reliable and valid self-report measure of somatic symptom burden. Cutoff scores identify individuals with low, medium, high, and very high somatic symptom burden.
Abstract Objective To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment. Method Two thousand ...ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment. Results In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment. Conclusions Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.
Empirical evidence on depression and anxiety in patients with rare diseases is scarce but can help improve comprehensive treatment. The objectives of this study were to investigate the frequency of ...depression and anxiety in this heterogeneous population and to examine aspects associated with increased psychopathology.
N = 300 patients with 79 different rare diseases (female:80%, age:M = 44.3(12.8), range:16-74 years) participated in a cross-sectional online study. We determined the percentages of patients reporting elevated depression (PHQ-9) and anxiety (GAD-7) scores. We calculated two linear regressions with depression and anxiety as outcomes. Predictor variables were diagnosis-related aspects (diagnosis assigned to ICD-10 chapter, visibility of symptoms, time since diagnosis, comorbid diseases), perceived somatic-symptom-severity (PHQ-15), illness-perceptions (consequences, control, identity, concern, understanding and treatment control; B-IPQ-R), coping mechanisms (constructive attitudes, active engagement in life) and social support (heiQ). We controlled for gender, age and depression or anxiety depending on the outcome.
42% of the patients (95%CI 36.41%,47.59%) reported depression scores indicating moderately or severely elevated symptom levels. Regarding anxiety, this applies to 23% (95%CI 18.54%,28.06%). Variables significantly associated with depression were higher perceived somatic-symptom-severity (B = 0.41,p < .001), less control (B = .17,p < .05), lower levels of concern (B = -0.32,p < .01) and less constructive attitudes (B = -1.40,p < .001). No diagnosis-related variables were associated with depression. Variables significantly associated with anxiety were diseases of the circulatory system compared to congenital malformations (B = 1.88,p < .05), less consequences (B = -0.32,p < .05) and more concern (B = -0.32,p < .01).
The data reveal first insights into depression and anxiety in patients with different rare diseases. High percentages of patients showed clinically relevant symptom burden. No diagnosis-related differences were found in depression while anxiety seems to be particularly frequent in patients with rare diseases of the circulatory system. Besides perceived somatic symptom severity, cognitive appraisal seems to be linked to depression. Supporting patients in coping with their disease may help reduce psychopathology and therefore improve overall health.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Somatic symptoms are common in a wide range of medical conditions. In severe cases, they are associated with high individual and economic burden. To explore social inequalities in somatic symptom ...severity (SSS) and to identify social groups with highest SSS, we applied an intersectional research approach. Analyses are based on cross-sectional data of the adult population living in Germany (N = 2413). SSS was assessed with the Somatic Symptom Scale-8. A multiple linear regression model with three-way interaction of gender, income and history of migration and post-hoc pairwise comparison of estimated marginal means was conducted. Analyses revealed intersectional inequalities in SSS along the axis of gender, income, and history of migration. Highest SSS was found in males with low income whose parent(s) immigrated, females with low income who immigrated themselves, and females with low income and no history of migration. Intersectional approaches contribute to a more comprehensive understanding of health disparities. To reduce disparities in SSS, proportionate universal interventions combining universal screening and targeted treatment seem promising.
The aim of this study was to evaluate the validity of the seven-item Generalized Anxiety Disorder scale (GAD-7) and its two core items (GAD-2) for detecting GAD in elderly people.
A ...criterion-standard study was performed between May and December of 2010 on a general elderly population living at home. A subsample of 438 elderly persons (ages 58-82) of the large population-based German ESTHER study was included in the study. The GAD-7 was administered to participants as part of a home visit. A telephone-administered structured clinical interview was subsequently conducted by a blinded interviewer. The structured clinical (SCID) interview diagnosis of GAD constituted the criterion standard to determine sensitivity and specificity of the GAD-7 and the GAD-2 scales.
Twenty-seven participants met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for current GAD according to the SCID interview (6.2%; 95% confidence interval CI: 3.9%-8.2%). For the GAD-7, a cut point of five or greater appeared to be optimal for detecting GAD. At this cut point the sensitivity of the GAD-7 was 0.63 and the specificity was 0.9. Correspondingly, the optimal cut point for the GAD-2 was two or greater with a sensitivity of 0.67 and a specificity of 0.90. The areas under the curve were 0.88 (95% CI: 0.83-0.93) for the GAD-7 and 0.87 (95% CI: 0.80-0.94) for the GAD-2. The increased scores on both GAD scales were strongly associated with mental health related quality of life (p <0.0001).
Our results establish the validity of both the GAD-7 and the GAD-2 in elderly persons. Results of this study show that the recommended cut points of the GAD-7 and the GAD-2 for detecting GAD should be lowered for the elderly general population.
Summary Background Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study ...aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa—focal psychodynamic therapy and enhanced cognitive behaviour therapy—versus optimised treatment as usual. Methods The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org , number ISRCTN72809357. Findings Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy, 80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m2 , enhanced cognitive behaviour therapy 0·93 kg/m2 , optimised treatment as usual 0·69 kg/m2 ); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy −0·45, 95% CI −0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual −0·14, −0·68 to 0·39; enhanced cognitive behaviour therapy vs optimised treatment as usual −0·30, −0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m2 , 1·30 kg/m2 , and 1·22 kg/m2 , respectively), but no differences between groups were recorded (0·10, −0·56 to 0·76; 0·25, −0·45 to 0·95; 0·15, −0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded. Interpretation Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches. Funding German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).
Abstract Objective Many questionnaires for assessment of common somatic symptoms or functional somatic symptoms are available and their use differs greatly among studies. The prevalence and incidence ...of symptoms are partially determined by the methods used to assess them. As a result, comparison across studies is difficult. This article describes a systematic review of self-report questionnaires for somatic symptoms for use in large-scale studies and recommends two questionnaires for use in such studies. Methods A literature search was performed in the databases Medline, PsycINFO and EMBASE. Articles that reported the development, evaluation, or review of a self-report somatic symptom measure were included. Instrument evaluation was based on validity and reliability, and their fitness for purpose in large scale studies, according to the PhenX criteria. Results The literature search identified 40 questionnaires. The number of items within the questionnaires ranged from 5 to 78 items. In 70% of the questionnaires, headaches were included, followed by nausea/upset stomach (65%), shortness of breath/breathing trouble (58%), dizziness (55%), and (low) back pain/backaches (55%). Data on validity and reliability were reported and used for evaluation. Conclusion Questionnaires varied regarding usability and burden to participants, and relevance to a variety of populations and regions. Based on our criteria, the Patient Health Questionnaire-15 and the Symptom Checklist-90 somatization scale seem the most fit for purpose for use in large-scale studies. These two questionnaires have well-established psychometric properties, contain relevant symptoms, are relatively short, and are available in multiple languages.
Abstract Objectives To provide a standardized metric for the assessment of depression severity to enable comparability among results of established depression measures. Study Design and Setting A ...common metric for 11 depression questionnaires was developed applying item response theory (IRT) methods. Data of 33,844 adults were used for secondary analysis including routine assessments of 23,817 in- and outpatients with mental and/or medical conditions (46% with depressive disorders) and a general population sample of 10,027 randomly selected participants from three representative German household surveys. Results A standardized metric for depression severity was defined by 143 items, and scores were normed to a general population mean of 50 (standard deviation = 10) for easy interpretability. It covers the entire range of depression severity assessed by established instruments. The metric allows comparisons among included measures. Large differences were found in their measurement precision and range, providing a rationale for instrument selection. Published scale-specific threshold scores of depression severity showed remarkable consistencies across different questionnaires. Conclusion An IRT-based instrument-independent metric for depression severity enables direct comparisons among established measures. The "common ruler" simplifies the interpretation of depression assessment by identifying key thresholds for clinical and epidemiologic decision making and facilitates integrative psychometric research across studies, including meta-analysis.
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