A brief case-finding questionnaire for common mental disorders: the CMDQ

Emotional Demands at Work and the Risk of Clinical Depression: A Longitudinal Study in the Danish Public Sector

OBJECTIVE

This study is a 2-year follow-up study of different dimensions of work-related emotional demands as a predictor for clinical depression.

METHODS

In a two-wave study, 3224 (72%) public employees from 474 work-units participated twice by filling in questionnaires. Sixty-two cases of clinical depression were diagnosed. Emotional demands were examined as perceived and content-related emotional demands, individually reported and work-unit based. Support, meaningful work, and enrichment were considered as potential effect modifiers.

RESULTS

Individually reported perceived emotional demands predicted depression (odds ratio: 1.40; 95% confidence intervals: 1.02 to 1.92). The work-unit based odds ratio was in the same direction, though not significant. Content-related emotional demands did not predict depression. Support, meaningful work, and enrichment did not modify the results.

CONCLUSIONS

The personal perception of emotional demands was a risk factor for clinical depression but specific emotionally demanding work tasks were not.

Pilot-RCT of an integrative group therapy for patients with refractory irritable bowel syndrome (ISRCTN02977330)

OBJECTIVE

Different forms of psychotherapeutic treatments have been proven effective in irritable bowel syndrome (IBS), but disorder-oriented and integrative concepts are still rare. Therefore, we implemented and evaluated an integrative group therapeutic concept within an interdisciplinary tertiary care clinic for functional gastrointestinal disorders (FGIDs).

AIMS

present our integrative group concept, assess feasibility issues, and evaluate efficacy.

METHODS

A pilot-RCT with a randomized controlled wait-listed group design was conducted. The treatment concept was a disorder-oriented multicomponent group therapy (12 90-min weekly sessions) integrating interactive psychoeducation, gut-directed hypnotherapy, and open group phases. All patients received enhanced medical care and completed a short online diary as an active wait-listed control condition.

INCLUSION CRITERIA

refractory IBS diagnosed as somatoform autonomic dysfunction of the lower gastrointestinal tract (SAD).

PRIMARY OUTCOME

IBS symptom severity (IBS-SSS).

RESULTS

Of 294 patients, 220 had IBS (ROME III), 144 were diagnosed as SAD (ICD-10), 51 were eligible regarding inclusion/exclusion criteria, and 30 consented to participate (group intervention: n=16, wait-listed control condition: n=14). Only 1 patient dropped out. Intention-to-treat-analysis with repeated-measures mixed ANOVA showed that the group intervention was not significantly superior to the wait-listed control condition. Nevertheless, the calculated effect size for the between-group difference in IBS-SSS at the end of treatment (post) was moderate (d=0.539).

CONCLUSION

Our disorder-oriented integrative group intervention for IBS proved to be acceptable and feasible in an interdisciplinary tertiary care setting. There is promise in this intervention, but a larger RCT may be needed to investigate efficacy.

"It Was the Best of Times, It Was the Worst of Times": A Qualitative Investigation of Perfectionism and Drinking Narratives in Undergraduate Students

Perfectionism is a transdiagnostic risk factor for mental health and interpersonal difficulties, but research on perfectionism and alcohol use in emerging adults remains equivocal. Qualitative research methods are underutilized in this area, and inductive analysis of drinking narratives in undergraduate perfectionists may help clarify conflicting results and support novel approaches to quantitative inquiry in this area. We interviewed 20 undergraduates high in perfectionism (6 adaptive perfectionists and 14 maladaptive perfectionists) using a narrative interview, with analyses focusing on a situation involving alcohol use. We coded interviews for emergent themes using thematic analysis. Five themes emerged as follows: (1) drinking as a social experience, (2) suffering consequences, (3) learning from alcohol, (4) alcohol use as escapism, and (5) reluctance and moderation. Our results add to existing literature by highlighting the interpersonal conflict in perfectionistic people's experience in relation to alcohol use during emerging adulthood. Results also suggest perfectionistic people may use alcohol and intoxication as a way to facilitate a "release" from unpleasant situations or emotions. Perfectionists reported both positive and negative experiences, which lends support for using a narrative perspective to help overcome preexisting assumptions about adaptive and maladaptive qualities of perfectionism.

The psychometric properties of depression screening tools in primary healthcare settings: A systematic review

BACKGROUND

Consensus on a tool for depression screening among adults in primary healthcare (PHC) settings is lacking. This systematic review aimed to explore the psychometric properties of depression screening tools.

METHODS

A systematic literature search composed of four terms (screening AND psychometric AND depression AND primary healthcare) was conducted in PubMed, EMBASE, PsycINFO and MEDLINE, between January 1995 through October 2015. Studies that aimed to psychometrically test a depression screening tool among the general adult population in a PHC setting were included. Studies exploring the diagnostic properties of depression screening tools among specific populations were excluded.

RESULTS

Sixty publications, evaluating the psychometric properties of 55 tools or adaptations, were included. Studies were conducted in 24 countries and 18 languages on 48234 adults. The Patient Health Questionnaire-9 was the most evaluated tool with 14 studies evaluating its psychometric properties. Fifty-four studies reported on at least one measure of receiver operating characteristics. Sensitivity and specificity values ranged from 28% to 100% and 43% to 100%, respectively. Cronbach alpha values ranged from 0.56 to 0.94. Other forms of reliability and validity testing were less consistently and commonly reported.

LIMITATIONS

The inclusion of studies regardless of methodological quality or design may have limited generalizability, but allowed for a comprehensive and detailed overview of the current literature.

CONCLUSIONS

Depression screening tools vary in their psychometric properties. The PHQ-9 was the most extensively psychometrically tested tool. This systematic review may aid PHC professionals in choosing a depression screening tool for universal use as it provides a comprehensive overview of their psychometric properties.

Comparing multidisciplinary and brief intervention in employees with different job relations on sick leave due to low back pain: protocol of a randomised controlled trial

BACKGROUND

Low back pain (LBP) is a common problem that affects the lives of many individuals and is a frequent cause of sickness absence. To help this group of individuals resume work, several interventions have been studied. However, not all individuals may profit from the same intervention and the effect of a given intervention on return to work (RTW) may depend on their work situation. The aim of this study is to evaluate whether employees on sick leave due to LBP and with poor job relations will benefit more from a multidisciplinary intervention, while patients with strong job relations will benefit more from a brief intervention.

METHODS

The study is designed as a randomised controlled trial with up to five years of follow-up comparing brief intervention with brief intervention plus multidisciplinary intervention. Employees, aged 18-60 years, are included in the study from March 2011 to August 2016 if they have been on sick leave for 4-12 weeks due to LBP with or without radiculopathy. They are divided into two groups, a group with poor job relations and a group with strong job relations based on their answers in the baseline questionnaire. Each group is randomised 1:1 to receive the brief intervention or brief intervention plus multidisciplinary intervention. The brief intervention comprises a clinical examination and advice offered by a rheumatologist and a physiotherapist, whereas the supplementary multidisciplinary intervention comprises the assignment of a case manager who draws up a rehabilitation plan in collaboration with the participant and the multidisciplinary team. The primary outcome is duration of sickness absence measured by register data. Secondary outcomes include sustainable RTW and questionnaire-based measures of functional capacity. Outcomes will be assessed at one, two and five years of follow-up.

DISCUSSION

This trial will evaluate the effect of brief and multidisciplinary intervention on RTW and functional capacity among employees on sick leave due to LBP with poor or strong job relations. This will indicate whether work-related characteristics should be considered when providing treatment of LBP patients in the health care sector.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14136384 . Registered 4 August 2015.

Systematic review of measurement properties of questionnaires measuring somatization in primary care patients

OBJECTIVE

The aim of this review is to critically appraise the evidence on measurement properties of self-report questionnaires measuring somatization in adult primary care patients and to provide recommendations about which questionnaires are most useful for this purpose.

METHODS

We assessed the methodological quality of included studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. To draw overall conclusions about the quality of the questionnaires, we conducted an evidence synthesis using predefined criteria for judging the measurement properties.

RESULTS

We found 24 articles on 9 questionnaires. Studies on the Patient Health Questionnaire-15 (PHQ-15) and the Four-Dimensional Symptom Questionnaire (4DSQ) somatization subscale prevailed and covered the broadest range of measurement properties. These questionnaires had the best internal consistency, test-retest reliability, structural validity, and construct validity. The PHQ-15 also had good criterion validity, whereas the 4DSQ somatization subscale was validated in several languages. The Bodily Distress Syndrome (BDS) checklist had good internal consistency and structural validity. Some evidence was found for good construct validity and criterion validity of the Physical Symptom Checklist (PSC-51) and good construct validity of the Symptom Check-List (SCL-90-R) somatization subscale. However, these three questionnaires were only studied in a small number of primary care studies.

CONCLUSION

Based on our findings, we recommend the use of either the PHQ-15 or 4DSQ somatization subscale for somatization in primary care. Other questionnaires, such as the BDS checklist, PSC-51 and the SCL-90-R somatization subscale show promising results but have not been studied extensively in primary care.

Collaborative care for panic disorder, generalised anxiety disorder and social phobia in general practice: study protocol for three cluster-randomised, superiority trials

Background

People with anxiety disorders represent a significant part of a general practitioner’s patient population. However, there are organisational obstacles for optimal treatment, such as a lack of coordination of illness management and limited access to evidence-based treatment such as cognitive behavioral therapy. A limited number of studies suggest that collaborative care has a positive effect on symptoms for people with anxiety disorders. However, most studies are carried out in the USA and none have reported results for social phobia or generalised anxiety disorder separately. Thus, there is a need for studies carried out in different settings for specific anxiety populations.

A Danish model for collaborative care (the Collabri model) has been developed for people diagnosed with depression or anxiety disorders. The model is evaluated through four trials, of which three will be outlined in this protocol and focus on panic disorder, generalised anxiety disorder and social phobia. The aim is to investigate whether treatment according to the Collabri model has a better effect than usual treatment on symptoms when provided to people with anxiety disorders.

Methods

Three cluster-randomised, clinical superiority trials are set up to investigate treatment according to the Collabri model for collaborative care compared to treatment-as-usual for 364 patients diagnosed with panic disorder, generalised anxiety disorder and social phobia, respectively (total n = 1092). Patients are recruited from general practices located in the Capital Region of Denmark. For all trials, the primary outcome is anxiety symptoms (Beck Anxiety Inventory (BAI)) 6 months after baseline. Secondary outcomes include BAI after 15 months, depression symptoms (Beck Depression Inventory) after 6 months, level of psychosocial functioning (Global Assessment of Functioning) and general psychological symptoms (Symptom Checklist-90-R) after 6 and 15 months.

Discussion

Results will add to the limited pool of information about collaborative care for patients with anxiety disorders. To our knowledge, these will be the first carried out in a Danish context and the first to report results for generalised anxiety and social phobia separately. If the trials show positive results, they could contribute to the improvement of future treatment of anxiety disorders.

Trial registration

ClinicalTrials.gov, ID: NCT02678624. Retrospectively registered 7 February 2016; last updated 15 August 2016,

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2120-3) contains supplementary material, which is available to authorized users.

The effect of a lay-led, group-based self-management program for patients with chronic pain: a randomized controlled trial of the Danish version of the Chronic Pain Self-Management Programme

The Stanford Chronic Pain Self-Management Programme (CPSMP) consists of 6 2½-hour weekly workshops focusing on how to manage pain in daily life. The workshops are facilitated by 2 workshop leaders of whom at least 1 must suffer from a long-term pain condition. The program is highly structured and manualized. Only few controlled trials testing the effect of CPSMP exist. Enrolled in the study were 424 adults from 19 Danish municipalities, (72% women; age: 25-93 years) with pain of any etiology and great variation in pain history (0-50 yrs). Of these, 216 were randomized to a lay-led version of the CPSMP. The primary outcome was pain-related disability. Secondary outcomes were pain, pain catastrophizing, self-efficacy, emotional distress, physical symptoms, and illness worry. Outcomes were measured before randomization, immediately after the CPSMP (response rate: 94%), and at 3-month follow-up (response rate: 92%). National register data on health expenditure were obtained to examine effects on health care use. ClinicalTrials.gov Identifier: NCT01306747. The CPSMP had no effect on the primary outcome pain-related disability or on health expenditure during intervention and follow-up period. Small positive effects on emotional distress and illness worry 3 months after CPSMP were observed. Lay-led CPSMP is not recommended as treatment for chronic pain-related disability. This heterogeneous group of patients with pain did not benefit from the CPSMP except for a small, but clinically insignificant improvement in psychological well-being.

Reasons for using workplace wellness services: Cross-sectional study among 6000 employees

AIMS

While workplace wellness services are proactively established to improve well-being and reduce sickness absence, knowledge of reasons for using these services remains sparse. This study investigates which factors determine use of an in-house wellness service at a large organization (the Danish Police) with several departments in different geographical locations.

METHODS

All potential users of the Wellness service ( n = 15,284) were invited to respond to a cross-sectional questionnaire. Of 6060 eligible respondents, 58% had used the service at least once (any use) and 17% had used the service at least three times (frequent users). Two items assessed the frequency of statements of justifications for using or not using the Wellness service. Associations between 32 demographic and psychosocial variables and use of the Wellness service were evaluated with unadjusted bivariate logistic regression analyses.

RESULTS

The two primary justifications for using the Wellness service were: to get a blood pressure assessment (37%) and to rehabilitate injury (26%). The two most common justifications for not using the Wellness service were: no perceived need (44%) and already physically active (34%). Of the 32 demographical and psychosocial variables included, 28 were associated with any use and 24 with frequent use.

CONCLUSIONS

Use of the Wellness service appears to be driven by a complex configuration of factors that resist easy translation into practical advice. Non-participation was accounted for in terms of both positive and negative barriers. Use of the service for purposes of primary prevention and health promotion was, relatively speaking, lagging behind.

A decline in self-defining memories following a diagnosis of schizophrenia

PURPOSE

Receiving a diagnosis of schizophrenia can be a profound life transition that often has a negative influence on the patient's sense of self. The present study is the first to examine how self-defining memories are temporally distributed around age at diagnosis of schizophrenia.

METHOD

25 patients and 25 matched control participants identified 3 self-defining memories from their lives. In addition, participants were assessed with standardized interviews and questionnaires on negative and positive symptoms as well as tests of cognitive function.

RESULTS

Patients' self-defining memories increased in the years leading up to diagnosis and declined abruptly in the years immediately following diagnosis. The pre-diagnosis increase in self-defining memories was not attributable primarily to a rise in disease-related recollections.

CONCLUSION

The sharp post-diagnosis memory decline suggests that patients find it difficult to establish new or evolve existing definitions of self. Implications for models of schizophrenia and for clinical practice are discussed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Screening instruments for predicting return to work in long-term sickness absence

Background

Multiple somatic symptoms are common and may cause prolonged sickness absence (SA) and unsuccessful return to work (RTW).

Aims

To compare three instruments and their predictive and discriminative abilities regarding RTW.

Methods

A longitudinal cohort study of participants recruited from two municipal job centres, with at least 8 weeks of SA. The instruments used were the Symptom Check List of somatic distress (SCL-SOM) (score 0-48 points), the Bodily Distress Syndrome Questionnaire (BDSQ) (0-120 points) and the one-item self-rated health (SRH) (1-5 points). The instruments' predictive value was explored in a time-to-event analysis. Different cut-points were analysed to find the highest number of correctly classified RTW cases, identified in a register on public transfer payments.

Results

The study involved 305 subjects. The adjusted relative risk regarding prediction of RTW was 0.89 [95% confidence interval (CI) 0.83-0.95], 0.89 (95% CI 0.83-0.95) and 0.78 (95% CI 0.70-0.86) per 5-, 10- and 1-point increase in the SCL-SOM, BDSQ and SRH, respectively. After mutual adjustment for the three instruments, only the prediction of RTW from SRH remained statistically significant 0.81 (95% CI 0.72-0.92). The highest sensitivity (86%) was found by SRH at the cut-point ≤5, at which 62% were correctly classified.

Conclusions

All three instruments predicted RTW, but only SRH remained a significant predictor after adjustment for the SCL-SOM and BDSQ. The SRH provides an efficient alternative to more time-consuming instruments such as SCL-SOM or BDSQ for estimating the chances of RTW among sickness absentees.

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

Background

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

Aim

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

Design and setting

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

Method

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

Results

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

Conclusion

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

Effects of a randomized controlled intervention trial on return to work and health care utilization after long-term sickness absence

Background

The aim of the RCT study was to investigate if the effect of a multidisciplinary intervention on return to work (RTW) and health care utilization differed by participants’ self-reported health status at baseline, defined by a) level of somatic symptoms, b) health anxiety and c) self-reported general health.

Methods

A total of 443 individuals were randomized to the intervention (n = 301) or the control group (n = 142) and responded to a questionnaire measuring health status at baseline. Participants were followed in registries measuring RTW and health care utilization. Relative risk (RR) and odds ratio (OR) were used as measures of associations. Results were adjusted for gender, age, educational level, work ability and previous sick leave.

Results

Among all responders we found no effect of the intervention on RTW. Among participants with low health anxiety, the one-year probability of RTW was lower in the intervention than in the control group (RR = 0.79 95 % CI 0.68-0.93), but for those with high health anxiety there was no difference between the groups (RR = 1.15 95 % CI 0.84-1.57). Neither general health nor somatic symptoms modified the effect of the intervention on RTW. The intervention had no effect on health care utilization.

Conclusions

The multidisciplinary intervention did not facilitate RTW or decrease health care utilization compared to ordinary case management in subgroups with multiple somatic symptoms, health anxiety or low self-rated health. However, the intervention resulted in a reduced chance of RTW among participants with low health anxiety levels.

Trial registration

ISRCTN43004323, and ISRCTN51445682

Cost-utility of a specific collaborative group intervention for patients with functional somatic syndromes

BACKGROUND

Collaborative group intervention (CGI) in patients with functional somatic syndromes (FSS) has been shown to improve mental quality of life.

OBJECTIVE

To analyse incremental cost-utility of CGI compared to enhanced medical care in patients with FSS.

METHODS

An economic evaluation alongside a cluster-randomised controlled trial was performed. 35 general practitioners (GPs) recruited 300 FSS patients. Patients in the CGI arm were offered 10 group sessions within 3months and 2 booster sessions 6 and 12months after baseline. Costs were assessed via questionnaire. Quality adjusted life years (QALYs) were calculated using the SF-6D index, derived from the 36-item short-form health survey (SF-36). We calculated patients' net-monetary-benefit (NMB), estimated the treatment effect via regression, and generated cost-effectiveness acceptability curves.

RESULTS

Using intention-to-treat analysis, total costs during the 12-month study period were 5777EUR in the intervention, and 6858EUR in the control group. Controlling for possible confounders, we found a small, but significant positive intervention effect on QALYs (+0.017; p=0.019) and an insignificant cost saving resulting from a cost-increase in the control group (-10.5%; p=0.278). NMB regression showed that the probability of CGI to be cost-effective was 69% for a willingness to pay (WTP) of 0EUR/QALY, increased to 92% for a WTP of 50,000EUR/QALY and reached the level of 95% at a WTP of 70,375EUR/QALY. Subgroup analyses yielded that CGI was only cost-effective in severe somatic symptom severity (PHQ-15≥15).

CONCLUSION

CGI has a high probability to be a cost-effective treatment for FSS, in particular for patients with severe somatic symptom severity.

A scoping review of the literature on benefits and challenges of participating in patient education programs aimed at promoting self-management for people living with chronic illness

OBJECTIVE

To give a comprehensive overview of benefits and challenges from participating in group based patient education programs that are carried out by health care professionals and lay participants, aimed at promoting self-management for people living with chronic illness.

METHODS

We searched 8 literature databases. Full text articles meeting the inclusion criteria were retrieved and reviewed. Arksey and O'Malley's framework for scoping studies guided the review process and thematic analysis was undertaken to synthesize extracted data.

RESULTS

Of the 5935 titles identified, 47 articles were included in this review. The participants experienced the programs as beneficial according to less symptom distress and greater awareness of their own health, improved self-management strategies, peer support, learning and hope.

CONCLUSION

A substantial evidence base supports the conclusion that group based self-management patient education programs in different ways have been experienced as beneficial, but more research is needed.

PRACTICE IMPLICATIONS

The insights gained from this review can enable researchers, health care professionals, and participants to understand the complexity in evaluating self-management patient education programs, and constitute a basis for a more standardized and systematic evaluation. The results may also encourage health care professionals in planning and carrying out programs in cooperation with lay participants.

Emotional Intimacy Among Coupled Heterosexual and Gay/Bisexual Croatian Men: Assessing the Role of Minority Stress

Emotional intimacy cuts across contexts as diverse as sexual motivation and satisfaction, psychological and physical health, and relational well-being. Although the experience of intimacy and its effects on sex life may be gender and sexual orientation-specific, the role of intimacy in personal and sexual relationships has been studied mostly among heterosexual individuals and couples. Using the minority stress framework (Meyer, 2003) to address this gap in knowledge, the present study comparatively explored levels and predictors/correlates of emotional intimacy, and its association with sexual satisfaction among coupled heterosexual and gay/bisexual men sampled online in a predominantly homonegative country (Croatia). Heterosexual participants (n = 860; M age = 36.4, SD = 9.09) were recruited in 2011 and gay/bisexual participants (n = 250; M age = 29.4, SD = 7.13) in 2013. Controlling for age and relationship duration, gay/bisexual men reported higher levels of emotional intimacy than heterosexual men. Suggesting that the role of emotional intimacy in sexual satisfaction is not sexual orientation-specific, the strength of the association between these two constructs was similar in both samples. However, internalized homonegativity, which was negatively associated with emotional intimacy in this study, remains a challenge to creating and maintaining intimacy in male same-sex relationships.

The role of poor sleep in the relation between workplace bullying/unwanted sexual attention and long-term sickness absence

PURPOSE

While exposure to bullying and unwanted sexual attention was previously found to increase the risk of sickness absence, the underlying mechanisms are largely unknown. Poor sleep can be a consequence of stressful exposures and a cause of poor health, and poor sleep is also a determinant of insufficient recovery. Therefore, the present study investigated whether poor sleep mediates and/or moderates the association between bullying and unwanted sexual attention, on the one hand, and long-term sickness absence (LTSA), on the other hand.

METHODS

We used questionnaire data from 7650 individuals contributing with 15,040 2-year observation periods. Workplace bullying, unwanted sexual attention, disturbed sleep, and difficulties awakening were measured at three time points, and participants were followed in registers to measure the occurrence of LTSA, defined as ≥30 consecutive days of sickness absence during the subsequent 2 years.

RESULTS

The odds of LTSA were significantly increased by workplace bullying (OR 1.77; 95 % CI 1.50-2.12) and unwanted sexual attention (OR 1.55; 95 % CI 1.06-2.29). Together, disturbed sleep and difficulties awakening mediated 12.8 % (95 % CI 8.1-19.8) of the association between bullying and long-term sickness absence, and 8.5 % (95 % CI -0.45 to 37.1) of the association between unwanted sexual attention and long-term sickness absence in the fully adjusted model. Neither disturbed sleep nor difficulties awakening moderated these associations.

CONCLUSION

As expected, bullying and unwanted sexual attention were prospectively associated with long-term sickness absence. Only a small part of this association was mediated by poor sleep.

Web-based cognitive training for breast cancer survivors with cognitive complaints-a randomized controlled trial

Background

Cognitive complaints are common amongst breast cancer survivors, and no standard treatment exists. The present study evaluates whether web‐based cognitive training can alleviate subjectively reported and objectively assessed cognitive complaints in a sample of breast cancer survivors. The primary and secondary outcomes were an objective measure of working memory and a measure of perceived cognitive functioning. Additional outcomes were neuropsychological tests of memory, executive function, working memory and questionnaire‐based assessment of anxiety, depression and somatization.

Methods

A total of 157 female breast cancer survivors were recruited from an existing cohort and through announcements in open access cancer‐related Internet fora and randomly allocated to either web‐based cognitive training (eCogT) with telephone support (n = 94) or a waitlist control (WLC) condition (n = 63). eCogT encompassed 30 training sessions over 6 weeks. Neuropsychological assessments were undertaken over the telephone, and questionnaire data was collected online. Data was collected at baseline, post‐intervention and at 5‐month follow‐up.

Results

Mixed linear models revealed no statistically significant change in primary or secondary outcome at follow‐up in either group. Statistically significant improvements (p 0.040–0.043) were found in the eCogT group for verbal learning and on a working memory test.

Conclusions

Web‐based cognitive training did not result in improvements of the primary or secondary outcome. Improved performance was observed on verbal learning and working memory. These effects were observed at 5‐month follow‐up, indicating long‐term effects of training. The intervention may be applied in a clinical setting at low cost and without risk of adverse effects.© 2016 The Authors Psycho‐Oncology Published by John Wiley & Sons Ltd.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Exposure to workplace bullying and risk of depression

OBJECTIVE

We examined the prospective association between self-labeled and witness-reported bullying and the risk of newly onset of depression.

METHODS

Employees were recruited from two cohorts of 3196 and 2002 employees, respectively. Participants received a questionnaire at baseline in 2006 to 2007 with follow-up in 2008 to 2009 and 2011. New cases of depression were diagnosed in the follow-up using Schedules for Clinical Assessment in Neuropsychiatry interviews and the Major Depression Inventory questionnaire.

RESULTS

We identified 147 new cases of depression. The odds ratio for newly onset depression among participants reporting bullying occasionally was 2.17 (95% confidence interval [CI]: 1.11 to 4.23) and among frequently bullied 9.63 (95% CI: 3.42 to 27.1). There was no association between percentage witnessing bullying and newly onset depression.

CONCLUSIONS

Frequent self-labeled bullying predicts development of depression but a work environment with high proportion of employees witnessing bullying does not.

DETECTION OF ANXIETY DISORDERS IN PRIMARY CARE: A META-ANALYSIS OF ASSISTED AND UNASSISTED DIAGNOSES

BACKGROUND

Evidence suggests that general practitioners (GPs) fail to diagnose up to half of common mental disorder cases. Yet no previous research has systematically summarized the evidence in the case of anxiety disorders. The aim of this review was to systematically assess and meta-analyze the diagnostic accuracy of GPs' assisted (i.e., using severity scales/diagnostic instruments) and unassisted (without such tools) diagnoses of anxiety disorders.

METHODS

Systematic review (PROSPERO registry CRD42013006736) was conducted. Embase, Ovid Journals--Ovid SP Medline, Pubmed, PsycINFO, Scopus, Web of Science, and Science Direct were searched from January 1980 through June 2014. Seven investigators, working in pairs, evaluated studies for eligibility. The quality of included studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2). The main outcome measures were sensitivity and specificity of clinical diagnoses of any anxiety disorder. We pooled sensitivity and specificity levels from included studies using bivariate meta-analyses.

RESULTS

Twenty-four studies were included in the meta-analysis with a total sample of 34,902 patients. Pooled sensitivity and specificity were estimated at 44.5% (95% CI 33.7-55.9%) and 90.8% (95% CI 87-93.5%). GPs' sensitivity was higher when diagnoses were assisted (63.6%, 95% CI 50.3-75.1%) than when unassisted (30.5%, 95% CI 20.7-42.5%) to the expense of some specificity loss (87.9%, 95% CI 81.3-92.4% vs. 91.4%, 95% CI 86.6-94.6%, respectively). Identification rates remained constant over time (P-value = .998).

CONCLUSIONS

The use of diagnostic tools might improve detection of anxiety disorders in "primary care."

Diagnosis of depressed young people--criterion validity of WHO-5 and HSCL-6 in Denmark and Norway

BACKGROUND

According to the World Health Organization, depression ranks as a major contributor to the global burden of disease. A large proportion of adult depressions had their first appearance in adolescence. Brief and reliable rating scales are needed for early detection.

OBJECTIVE

The aim of this study is to validate the WHO-5 and the HSCL-6 for detection of depression among adolescents.

METHODS

The project is a GP multicentre study conducted in Denmark and Norway. A total of 294 adolescents (14-16 years) responded by answering a paper- or web-based questionnaire and later completed a Composite International Diagnostic Interview, which was used as the gold standard. Depression was defined by ICD-10 criteria. Criterion validity was examined, the likelihood ratios measured and cut-offs for depression were calculated using the Youden index.

RESULTS

The prevalence of depression was 11.8% in our sample. The optimal cut-off point was 11 for the WHO-5 test and 9 for the HSCL-6 test. There were no gender differences. For the WHO-5 and the HSCL-6, respectively, the sensitivity was 0.88 [95% confidence interval (CI): 0.74-0.96] and 0.85 (95% CI: 0.70-0.94), the specificity was 0.80 (95% CI: 0.75-0.85) and 0.79 (95% CI: 0.74-0.84) and the likelihood ratio was 4.5 and 3.8 (P = 0.39). We observed no statistically significant diagnostic differences with respect to nationality or administration procedure.

CONCLUSIONS

The WHO-5 and the HSCL-6 may both serve as valid case finding instruments for depression in young people in primary care.

A prospective evaluation of the Chronic Pain Self-Management Programme in a Danish population of chronic pain patients

OBJECTIVE

This study evaluates the feasibility and changes in pain, pain cognition, and distress during a patient education course and a 5-month follow-up period. The Chronic Pain Self-Management Programme (CPSMP) is a lay-led patient education consisting of six manualized sessions.

METHODS

A Danish adaptation of the CPSMP was tested in four municipalities. The sample consisted of 74 women and 13 men between 26 and 80 years with a long pain history (+10 years). Participants completed questionnaires before the CPSMP, immediately after and 5 months after the program.

RESULTS

The study showed that the Danish version of the CPSMP was feasible. The sample was heterogeneous with respect to age, education, duration and causes of pain but all participants reported serious pain and most experienced high levels of distress and disability. Participants evaluated the CPSMP as satisfying and more than 75% would recommend the program to other patients. Participants showed significant improvements on pain, disability, catastrophizing, depression, anxiety, and health worry, and changes were stable through the follow-up period.

CONCLUSION

A consistent pattern of stable improvements in pain, pain cognition and distress was observed but the scope of changes was modest.

PRACTICE IMPLICATIONS

The Danish version of the CPSMP is feasible.

Estudos psicométricos de instrumentos breves de rastreio para múltiplos transtornos mentais

Objetivo Realizar uma revisão sistemática sobre as características psicométricas de instrumentos breves para rastreamento de múltiplos transtornos mentais em cuidados primários de saúde. Métodos Revisão sistemática da literatura nas bases de dados PubMed, Lilacs, SciELO e ISI, de artigos publicados até abril de 2014, utilizando descritores sobre rastreamento breve de múltiplos transtornos mentais em cuidados primários de saúde. Resultados Foram obtidos 277 estudos e selecionados 15 após a aplicação dos critérios de inclusão e exclusão. Oito estudos analisaram confiabilidade e/ou consistência interna e os resultados mostraram índices bastante satisfatórios. Nos artigos selecionados, estavam presentes as análises das validades preditiva, concorrente e discriminante. Conclusão As escalas de rastreamento são úteis para a triagem de pacientes com possíveis transtornos mentais, e o uso desses instrumentos melhoraria a capacidade de detecção desses transtornos em cuidados primários de saúde.

Test-retest reliability of Common Mental Disorders Questionnaire (CMDQ) in patients with total hip replacement (THR)

Background

The Common Mental Disorders Questionnaire (CMDQ) is used to assess patients’ mental health. It has previously been shown to provide a sensitive and specific instrument for general practitioner setting but has so far not been tested in hospital setting or for changes over time (test-retest). The aim of this study is, by means of a test-retest method, to investigate the reliability of the instrument over time with total hip replacement (THR) patients.

Methods

Forty-nine hip osteoarthritis patients who had undergone THR answered the questionnaire twelve months after their operation. Fourteen days later they completed it again. Covering emotional disorder, anxiety, depression, concern, somatoform disorder and alcohol abuse, the questionnaire consists of 38 items with six subscales, each of which has between 4 to 12 items. A five-point Likert scale (from 0–4) is used.

Results

For each of the 38 questions, a quadratic-weighted Kappa coefficient of 0.42 (0.68 – 0.16) to 0.98 (1.00 – 0.70) was found. A Cronbach’s alpha of 0.94 for all the questions indicated high internal consistency.

Conclusion

The results showed a moderate to almost perfect reliability of CMDQ of this specific population.

Trial registration

Current Controlled Trials: NCT01205295

Sick leave and work disability in primary care patients with recent-onset multiple medically unexplained symptoms and persistent somatoform disorders: a 10-year follow-up of the FIP study

OBJECTIVE

The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD).

METHOD

Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained.

RESULTS

At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave.

CONCLUSIONS

Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.

Multiple somatic symptoms in employees participating in a randomized controlled trial associated with sickness absence because of nonspecific low back pain

BACKGROUND CONTEXT

The prevalence of multiple somatic symptoms is high in primary and hospital outpatient populations. Multiple somatic symptoms may be present in patients sick-listed because of low back pain (LBP) and may be associated with increased risk of not returning to work (RTW).

PURPOSE

To explore whether multiple somatic symptoms in a subset of patients with nonspecific LBP was associated with RTW, sickness absence (SA), or other social benefits.

STUDY DESIGN

The study was a cohort study based on a randomized clinical trial with a prospective 2-year follow-up period. Patients were referred from general practices to the Spine Center, Regional Hospital Silkeborg, Denmark.

PATIENT SAMPLE

Patients were 285 sick-listed employees (4-12 weeks), with nonspecific LBP as their prime reason for SA. Exclusion criteria were unemployment, radiculopathy, LBP surgery within the past year, previous lumbar fusion, suspected cauda equina syndrome, progressive paresis or other serious back disease, pregnancy, known substance abuse, or primary psychiatric diagnosis.

OUTCOME MEASURES

Self-reported health was assessed by the LBP rating scale and questions about pain and health in general. Disabilities were measured by the Roland Morris Questionnaire, the Short Form-36, and the Fear-Avoidance Beliefs Questionnaire. Work-related questions comprised expectations about RTW and risk of losing job because of SA. The Common Mental Disorder Questionnaire (subscale SCL-SOM) was used to assess multiple somatic symptoms (12 items). We categorized multiple somatic symptoms into four groups based on the SCL-SOM sum score: <6, 6 to 12, 13 to 18 and >18. Status of SA (>2 weeks) and RTW were gathered from a national database (DREAM).

METHODS

The patients (N=285) were randomized into either multidisciplinary or brief intervention at the Spine Center (2004-2008). Both interventions comprised clinical examination and advice by a physiotherapist and a rheumatologist. Data were collected from questionnaires at baseline (inclusion) and 1 year after inclusion. Data on SA benefits were gathered from the DREAM database that contains data on all social transfer payments (such as sick leave benefits and other disability benefits) registered on a weekly basis.

RESULTS

All health factors, female gender, and poor work ability were significantly associated with a higher level of multiple somatic symptoms. The percentage of persons with SA increased significantly with the symptom score after 1 year, and the duration of SA remained significantly longer after 2 years of follow-up between the multiple somatic symptoms groups. The percentages with RTW after 1 and 2 years were negatively associated with a higher level of multiple somatic symptoms at baseline. We found no difference between the intervention groups.

CONCLUSIONS

A higher level of multiple somatic symptoms was significantly associated with poor health and work ability at baseline and with longer duration of SA and unsuccessful RTW through a 2-year follow-up period.

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

BACKGROUND CONTEXT

It is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.

PURPOSE

To study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.

STUDY DESIGN

Prospective nested cohort study based on a randomized controlled trial.

PATIENT SAMPLE

Out of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study.

OUTCOME MEASURES

Degenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW).

METHODS

By using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW.

RESULTS

Clinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.

CONCLUSIONS

The only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.

Distressing Sexual Difficulties in Heterosexual and Non-Heterosexual Croatian Men: Assessing the Role of Minority Stress

Although research has shown a connection between minority stressors and internalizing mental health problems, the role of minority stress has mainly been neglected in the assessment of sexual problems among non-heterosexual men. Using online samples of heterosexual (n = 933) and non-heterosexual participants (n = 561) aged 18 to 50 years, this study aimed to comparatively assess sexual difficulties and problems and explore the role of minority stress in non-heterosexual men's sexual problems. Although the age-adjusted odds of reporting rapid ejaculation, delayed ejaculation, and sex-related anxiousness significantly differed between the two groups, the overall prevalence of sexual difficulties and the associated levels of distress did not significantly differ between the samples. In multivariate assessment, anxiety and depression significantly increased the odds of reporting distressing sexual difficulties among both heterosexual and non-heterosexual participants. In the non-heterosexual sample, positive body image significantly decreased the odds of experiencing sexual problems. Pointing to a role of minority stress, highest levels of victimization related to sexual orientation increased the risk of sexual problems. This association was partially mediated by negative emotions. Our findings offer some support for a recent call to include sexual orientation among the social determinants of health recognized by the World Health Organization.

Salivary cortisol and depression in public sector employees: cross-sectional and short term follow-up findings

INTRODUCTION

Increased cortisol levels have been suggested to play a role in the development of depression. An association has been shown in some studies but not consistently. The timing of an association is uncertain, and long-term follow-up studies may miss associations in narrower time windows. In the present study, we examined the association of several cortisol measures and depression in a repeated cross-sectional and short-term follow-up design. Depression was assessed by both self-reported symptoms of depression and clinical interviews.

METHOD

In 2007, 10,036 public sector employees received a questionnaire along with salivary cortisol test tubes for home administration. Morning (30min after awakening) and evening (2000h) salivary samples were collected. Questionnaires and valid saliva samples were returned from 3536 employees. Approximately 3.6 months later a subsample of the participants collected three morning saliva samples (at awakening, 20min and 40min after awakening) plus an evening sample (2000h); participants with high baseline scores of self-reported depressive symptoms, burnout and perceived stress were invited to a standardized interview (SCAN) to detect clinical depression; and the symptom questionnaire was repeated for subsample participants. The study was repeated in 2009 with questionnaires and salivary test tubes (n=2408). In four cross-sectional and two short-term follow-up analyses odds ratios of depressive symptoms and of clinical depression were estimated by logistic regression for morning, evening, mean and the difference between morning and evening cortisol (slope). For the subsample, awakening response (CAR) and area under the curve (AUC) cortisol measures were calculated. We adjusted for sex, age, income, education, family history of depression, physical activity and alcohol consumption.

RESULTS

None except one of the measures of salivary cortisol were associated with self-reported depressive symptoms or clinical depression, neither in the four cross-sectional analyses nor in the two short term follow-up analyses. E.g. in 2007, the adjusted odds ratios (OR) of depressive symptoms by a one unit increase in morning and evening cortisol (ln(nmol/litre saliva)) were 1.01 (95% CI: 0.88-1.17) and 1.05 (0.93-1.18), respectively. The one exception was significant at p=0.04 and was considered as due to chance.

CONCLUSION

In this large study, salivary cortisol was not associated with self-reported symptoms of depression or with clinical depression.

Neuroanatomical correlates of Klinefelter syndrome studied in relation to the neuropsychological profile

Brain imaging in Klinefelter syndrome (47, XXY) (KS), a genetic disorder characterized by the presence of an extra X chromosome, may contribute to understanding the relationship between gene expression, brain structure, and subsequent cognitive disabilities and psychiatric disorders. We conducted the largest to date voxel-based morphometry study of 65 KS subjects and 65 controls matched for age and education and correlated these data to neuropsychological test scores. The KS patients had significantly smaller total brain volume (TBV), total gray matter volume (GMV) and total white matter volume (WMV) compared to controls, whereas no volumetric difference in cerebral spinal fluid (CSF) was found. There were no differences in TBV, GMV, WMV or CSF between testosterone treated KS (T-KS) and untreated KS (U-KS) patients. Compared to controls, KS patients had significantly decreased GMV bilaterally in insula, putamen, caudate, hippocampus, amygdala, temporal pole and frontal inferior orbita. Additionally, the right parahippocampal region and cerebellar volumes were reduced in KS patients. KS patients had significantly larger volumes in right postcentral gyrus, precuneus and parietal regions. Multivariate classification analysis discriminated KS patients from controls with 96.9% (p < 0.001) accuracy. Regression analyses, however, revealed no significant association between GMV differences and cognitive and psychological factors within the KS patients and controls or the groups combined. These results show that although gene dosage effect of having and extra X-chromosome may lead to large scale alterations of brain morphometry and extended cognitive disabilities no simple correspondence links these measures.

A two-year follow-up study of salivary cortisol concentration and the risk of depression

Stress is a suspected cause of depression. High cortisol concentration, a biomarker of an activated stress response, has been found in depressed patients. The aim of this study was to determine if a high level of salivary cortisol is a risk factor of depression. In 2007, we enrolled 4467 public employees. Morning and evening salivary cortisol concentration were measured for each participant. Participants reporting high levels of depressive, burnout, or stress symptoms, assessed by questionnaires were assigned to a psychiatric interview. In this interview 98 participants were diagnosed with depression and subsequently excluded. Two years later in 2009, 2920 participants who had provided at least one valid saliva cortisol measurement at baseline participated at follow up. The psychiatric interviews were repeated and 62 cases of newly onset depression were diagnosed. Odds ratios of depression were estimated for every 1.0nmol/l increase in morning, evening, and daily mean cortisol concentration, as well as for the difference between morning and evening cortisol concentration. The risk of depression decreased by increasing daily mean cortisol concentration and by increasing difference between morning and evening concentrations, while morning and evening cortisol concentrations were not significantly associated with depression. The adjusted odds ratios for 1.0nmol/l increase in morning, evening, and daily mean cortisol concentration were 0.69 (95% CI: 0.45, 1.05), 0.87 (95% CI: 0.59, 1.28), and 0.53 (95% CI: 0.32, 0.90), respectively. The adjusted odds ratio for 1.0nmol/l increase in difference between morning and evening concentration were 0.64 (95% CI: 0.45, 0.90). This study did not support the hypothesis that high salivary cortisol concentration is a risk factor of depression, but indicate that low mean salivary cortisol concentration and a small difference between morning and evening cortisol concentration may be risk factors of depression.

Association of costs with somatic symptom severity in patients with medically unexplained symptoms

OBJECTIVE

To analyse the association of direct and indirect costs in patients with medically unexplained symptoms (MUS) with somatic symptom severity (SSS).

METHODS

A cross-sectional cost analysis for retrospective 6 months was conducted in 294 primary care patients with MUS. Health care utilisation and loss of productivity were measured by questionnaires. SSS was measured using the "Patient Health Questionnaire 15" (PHQ-15). Direct and indirect costs and the association of costs with SSS were analysed via multiple linear regression analysis.

RESULTS

Patients with MUS had average 6-month direct costs of 1098 EUR and indirect costs of 7645 EUR. For direct costs, outpatient physician visits were the most expensive single cost category (36%), followed by pharmaceuticals (25%) and hospital stays (19%). Indirect costs were predominantly caused by productivity reduction at work (56%) followed by early retirement (29%) and acute sickness absence (14%). As compared to mild SSS, moderate SSS was not significantly associated with direct, but with indirect costs (+2948 EUR; p<.001); severe SSS was associated with increased direct cost (+658 EUR; p=.001) and increased indirect costs (+4630 EUR; p<.001). Age was positively associated with direct cost (+15 EUR for each additional year; p=.015) as well as indirect cost (+104 EUR for each additional year; p<.001).

CONCLUSIONS

MUS are associated with relevant direct and even much higher indirect costs that strongly depend on SSS.

Exercise as Treatment for Alcohol Dependence

Objective The clinical management of alcohol dependence involves evidence-based knowledge on medical treatment, physical training, and psychological management. This pilot study investigates the effect of physical exercise on cardio-respiratory fitness and socio-psychological outcomes. Design: 10 alcohol patients are included to 12 times moderate intensity exercise in groups. Methods: Aerobic power, anxiety, and depression are measured at baseline and post intervention. Observations of the instructor are described. Results: No significant change of aerobic power, but decreased subjective exhaustion. A trend is shown of decreased depression and less concern. Clinical observations showed the testing environment as obstacle and found the communicative role of the instructor crucial. Conclusion: Future research with regard of adherence has to concentrate on the social and contextual aspects of physical activity as treatment.

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.

[Fibromyalgia syndrome as a psychosomatic disorder - diagnosis and therapy according to current evidence-based guidelines]

OBJECTIVES

The classification and therapy of patients with chronic widespread pain without evidence of somatic factors as an explanation is currently a matter of debate. The diagnostic label "fibromyalgia syndrome"(FMS) has been rejected by some representatives of general and psychosomatic medicine.

METHODS

A summary is given of the main recommendations from current evidence-based guidelines on FMS and nonspecific/functional/somatoform bodily complaints.

RESULTS

The criteria of FMS and of persistent somatoform pain disorder or chronic pain disorder with somatic and psychological factors partly overlap. They include differential clinical characteristics of persons with chronic widespread pain but without sufficiently explaining somatic factors. Not all patients diagnosed with FMS meet the criteria of a persistent somatoform pain disorder. FMS is a functional disorder, in which in most patients psychosocial factors play an important role in both the etiology and course of illness. FMS can be diagnosed by looking at the history of a typical symptom cluster and excluding somatic differential diagnoses (without a tender point examination) using the modified 2010 diagnostic criteria of the American College of Rheumatology. Various levels of severity of FMS can be distinguished from a psychosomatic point of view, ranging from slight (single functional syndrome) to severe (meeting the criteria of multiple functional syndromes) forms of chronic pain disorder with somatic and psychological factors, of persistent somatoform pain disorder or of a somatization disorder. The diagnosis of FMS as a functional syndrome/stress-associated disorder should be explicitly communicated to the patient. A therapy within collaborative care adapted to the severity should be provided. For long-term management, nonpharmacological therapies such as aerobic exercise are recommended. In more severe cases, psychotherapy of comorbid mental disorders should be conducted.

CONCLUSIONS

The coordinated recommendations of both guidelines can synthesize general medical, somatic, and psychosocial perspectives, and can promote graduated care of patients diagnosed with FMS.

Prediction model for unsuccessful return to work after hospital-based intervention in low back pain patients

Background

Many studies on low back pain (LBP) have identified prognostic factors, but prediction models for use in secondary health care are not available. The purpose of this cohort study, based on a randomised clinical study, was to identify risk factors for unsuccessful return to work (U-RTW) in sick-listed LBP patients with or without radiculopathy and to validate a prediction model for U-RTW.

Methods

325 sick-listed LBP patients with or without radiculopathy were included in an intervention study and followed for one year. Afterwards, 117 other LBP patients were recruited similarly, included in a validation study and also followed for one year. All patients were subjected to identical procedures and interventions and received a brief intervention by the same rehabilitation doctor and physiotherapist. Half of them received case manager guidance within a multidisciplinary setting. At baseline, they completed a questionnaire and went through a clinical low-back examination. Sciatica was investigated by magnetic resonance imaging (MRI). U-RTW was registered in a national database both initially and at 1-year.

Results

Neither initial U-RTW (24.0%) nor one-year U-RTW (38.2%) were statistically significantly different in the two intervention groups nor in patients with and without radiculopathy. Multivariate logistic regression analysis identified two clinical and five psychosocial baseline predictors for one-year U-RTW (primary outcome). The clinical predictors included pain score (back+leg pain) and side-flexion. The five psychosocial predictors included ‘bodily distress’ ‘low expectations of RTW’, ‘blaming the work for pain’, ‘no home ownership’ and ‘drinking alcohol less than once/month’. These predictors were not statistically significantly different in patients with and without radiculopathy, and they also predicted initial U-RTW (secondary outcome). Obesity and older age were only supplementary predictors in patients with radiculopathy. A prediction model was established and tested in the validation study group. The model predicted one-year U-RWT in patients with intermediate and high risk, but only partially in patients with low risk. The model predicted all three risk categories in initial U-RTW.

Conclusions

A prediction model combining baseline clinical and psychosocial risk factors predicted patients with low, intermediate and high risk for unsuccessful return to work, both initially and at 1-year.

Work-unit measures of organisational justice and risk of depression--a 2-year cohort study

OBJECTIVES

The aim of this study is to analyse if low justice at work, analysed as aggregated workplace means, increases the risk of depression.

METHODS

A total of 4237 non-depressed Danish public employees within 378 different work units were enrolled in 2007. Mean levels of procedural and relational justice were computed for each work unit to obtain exposure measures that were robust to reporting bias related to depression. Two years later in 2009, 3047 (72%) participated at follow-up. Those reporting high levels of depressive, burn-out or stress symptoms were assigned to a psychiatric diagnostic interview. In the interview 58 cases of new onset depression were identified. Depression ORs by work unit level of procedural and relational justice were estimated by multivariable logistic regression accounting for established risk factors for depression.

RESULTS

Working in a work unit with low procedural justice (adjusted ORs of 2.50, 95% CI 1.06 to 5.88) and low relational justice (3.14, 95% CI 1.37 to 7.19) predicted onset of depression.

CONCLUSIONS

Our results indicate that a work environment characterised by low levels of justice is a risk factor for depression.

Efficacy of 'Tailored Physical Activity' or 'Chronic Pain Self-Management Program' on return to work for sick-listed citizens: design of a randomised controlled trial

Background

Pain affects quality of life and can result in absence from work. Treatment and/or prevention strategies for musculoskeletal pain-related long-term sick leave are currently undertaken in several health sectors. Moreover, there are few evidence-based guidelines for such treatment and prevention. The aim of this study is to evaluate the efficacy of ‘Tailored Physical Activity’ or ‘Chronic Pain Self-Management Program’ for sick-listed citizens with pain in the back and/or the upper body.

Methods

This protocol describes the design of a parallel randomised controlled trial on the efficacy of ‘Tailored Physical Activity’ or a ‘Chronic Pain Self-management Program’ versus a reference group for sick-listed citizens with complaints of pain in the back or upper body. Participants will have been absent from work due to sick-listing for 3 to 9 weeks at the time of recruitment. All interventions will be performed at the ‘Health Care Center’ in the Sonderborg Municipality, and a minimum of 138 participants will be randomised into one of the three groups.

All participants will receive ‘Health Guidance’, a (1.5-hour) individualised dialogue focusing on improving ways of living, based on assessments of risk behavior, motivation for change, level of self-care and personal resources. In addition, the experimental groups will receive either ‘Tailored Physical Activity’ (three 50-minute sessions/week over 10 weeks) or ‘Chronic Pain Self-Management Program’ (2.5-hours per week over 6 weeks). The reference group will receive only ‘Health Guidance’.

The primary outcome is the participants’ sick-listed status at 3 and 12 months after baseline. The co-primary outcome is the time it takes to return to work. In addition, secondary outcomes include anthropometric measurements, functional capacity and self-reported number of sick days, musculoskeletal symptoms, general health, work ability, physical capacity, kinesiophobia, physical functional status, interpersonal problems and mental disorders.

Discussion

There are few evidence-based interventions for rehabilitation programmes assisting people with musculoskeletal pain-related work absence. This study will compare outcomes of interventions on return to work in order to increase the knowledge of evidence-based rehabilitation of sick-listed citizens to prevent long-term sick-leave and facilitate return to work.

Trial registration

The trial is registered in the ClinicalTrials.gov, number NCT01356784.

Validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with somatoform disorders

BACKGROUND

The EQ-5D is a generic questionnaire providing a preference-based index score applicable to cost-utility analysis. This is the first study to validate the EQ-5D in patients with somatoform disorders.

METHODS

Data of the EQ-5D descriptive system, the British and the German EQ-5D index and the EQ Visual Analogue Scale, the Patient Health Questionnaire 15, the Patient Health Questionnaire 9, the Whiteley Index 7 and the Short Form 36 were collected from 294 patients at baseline, 244 at 6 months and 256 at 12 months after baseline. The discriminative ability of the EQ-5D was evaluated by comparison with a general population sample and by the ability to distinguish between different symptom severities. Convergent validity was analysed by assessing associations between the EQ-5D and the other instruments. Responsiveness was evaluated by analysing the effects on scores between two measurements in groups of patients reporting worse, same or better health. The Bonferroni correction was employed.

RESULTS

For all items of the EQ-5D except 'self-care', patients with somatoform disorders reported more problems than the general population. The EQ-5D showed discriminative ability in patients with different symptom severities. For nearly all reference instruments there were significant differences in mean scores between respondents with and without problems in the various EQ-5D items and strong correlations with the EQ Visual Analogue Scale and the EQ-5D index scores. Evidence for the responsiveness of the EQ-5D could only be found for patients with better health; effects were medium at the utmost.

CONCLUSIONS

The EQ-5D showed a considerable validity and a limited responsiveness in patients with somatoform disorders.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55280791.

Modern health worries and visits to the general practitioner in a general population sample: an 18month follow-up study

OBJECTIVE

Modern health worries (MHW) are concerns about health risks from features of modern life (e.g. additives in food, contaminated water supply, drug resistant bacteria, etc.). We investigated the role of MHW for care seeking for all purposes at the general practitioner (GP) and studied the role of neuroticism, symptoms of anxiety and somatization, other health anxiety, self-rated health, age, education and gender on the association between MHW and care-seeking.

METHODS

A representative sample from eight GPs (n=5068) completed a baseline questionnaire on MHW, symptoms of health and personality, and was followed for visits to the GP for the next 18months in the registers from the GP.

RESULTS

Modern health worries were common, and higher levels were seen among women and in higher age. Care seeking at the GP was associated with MHW, and this association was maintained after adjusting for age, gender, neurotic traits, symptoms of anxiety, somatization, other health anxieties and self-rated health.

CONCLUSION

Over and beyond health related factors and personality, MHW had an independent role for future visits to the GP in the magnitude of 20% more visits among the participants in the highest quartile of the MHW-scale.

Patient anxiety and concern as predictors for the perceived quality of treatment and patient reported outcome (PRO) in orthopaedic surgery

BACKGROUND

Previous studies have shown that patients' anxiety and dissatisfaction are predictors for increased postoperative pain and reduced efficacy of pain treatment. However, it remains to be shown whether patient anxiety and concern are predictors for the perceived quality of treatment and patient reported outcome (PRO).The aim of this study is to investigate whether there is a correlation between preoperative anxiety and concern, and the perceived quality of postoperative treatment and outcome. The hypothesis is that anxious and concerned patients are less satisfied with treatment and have a poorer outcome.

METHODS/DESIGN

This study is designed as a prospective follow-up study and has the aim of investigating the correlation between patient anxiety and concern, patients' perceived quality of treatment and outcome. This correlation will be detected using five questionnaires: CMD-SQ (Common Mental Disorders Screening Questionnaire), EuroQol 5 Dimensions (EQ-5D), Short form 12 (SF-12), "What is your evaluation of the patient progress in the Department of Orthopaedic Surgery?" (HVOK), Questionnaire for patients who have had hip surgery (RCS) and Oxford Hip Score (OHS) or Oxford Shoulder Score (OSS). The patients will complete the above mentioned questionnaires preoperatively in the outpatient department, and postoperatively just before discharge from the inpatient department, and 12 and 52 weeks after the operation. The study includes a reliability test of CMD-SQ regarding this specific population and tested by means of a Kappa. A total of 500 hip- and shoulder-patients will be included from October 2010 till October 2011.

DISCUSSION

If a correlation between patient anxiety and concern, patients' perceived quality of treatment and patient reported outcome is found, it will be recommended to screen all hip- and shoulder-patients for anxiety and concern preoperatively. Besides, it would be relevant to carry out investigations of possible interventions towards anxious and concerned patients.

TRIAL REGISTRATION

Current Controlled Trials: NCT01205295.