Outcome measurement in functional somatic syndromes: SF-36 summary scores and some scales were not valid

Efficacy of patient education and duloxetine, alone and in combination, for patients with multisystem functional somatic disorder: Study protocol for the EDULOX trial

BACKGROUND

Multisystem functional somatic disorder is characterized by specific patterns of persistent physical symptoms with a complex biopsychosocial etiology. The disorder can lead to disability and personal suffering. Current treatment options require specialized settings, therefore patients often wait a long time to receive specific treatment. Patient education is considered important in most treatment programs, but has only been investigated sparsely as a stand-alone treatment. Pharmacological treatment is limited to tricyclic antidepressants in low doses with no antidepressant properties. Duloxetine has been found effective in single organ functional disorders. As a treatment for multisystem functional somatic disorder, duloxetine could reduce symptoms and treat comorbid anxiety and depression. It may furthermore enhance the effect of patient education through a hypothesized effect on cognitive functioning. The purpose of the EDULOX trial is to study psycho-EDUcation and duLOXetine alone and in combination.

METHODS

This is a nested study design. The parent trial "EDULOX1" (n = 424) will compare a patient education program with enhanced usual care in an open-labelled, randomized controlled trial. In addition to this, eligible participants will furthermore receive either duloxetine or active placebo in the nested, double-blinded, randomized controlled trial, "EDULOX2" (n = 212). Patient and clinician reported outcomes will be collected through questionnaires.

CONCLUSION

The EDULOX trial may establish evidence for treatments applicable for the majority of patients with multisystem functional somatic disorder. If effective, duloxetine would be a more tolerable pharmacological treatment option that can target comorbid depression and anxiety, and potentially boost the effect of patient education. Trial registration number The study is registered at www.

CLINICALTRIALS

gov (NCT06232473) and the internal list of research projects at the Region of Central Denmark (Case number 1-16-02-305-23). Approval from the Danish Medical Research Ethics Committees (Case number: 2212291) and the Danish Medicines Agency was obtained under EudraCT Number: 2022-002780-30 and Sponsor's Protocol Code Number: 9515.

Internet-delivered treatment for patients suffering from severe functional somatic disorders: Protocol for a randomized controlled trial

Background

Functional somatic disorders (FSDs) with symptoms from multiple organs, i.e., multi-system type, are common in the general population and may lead to disability and reduced quality of life. Evidence for efficient treatment programs has been established, however, there is a need for making treatments accessible to a larger group of patients. Internet-delivered therapy has become prevalent and has proven as effective as face-to-face therapy, while providing a flexible and easily accessible treatment alternative. The aim of the current study is to compare the efficacy of the therapist-assisted internet-delivered treatment program One step at a time (OneStep) with the internet-delivered self-help program Get started (GetStarted).

Methods

A total of 166 participants aged 18-60 years diagnosed with multi-system FSD will be assessed and randomized to either 1) OneStep: a 14-week program consisting of 11 treatment modules based on principles from cognitive behavioural therapy or 2) GetStarted consisting of 1 module on psychoeducation. The primary outcome is physical health, assessed by a Short Form Health Survey (SF-36) aggregate score of the subscales vitality, physical functioning, and bodily pain 3 months after end-of-treatment and self-reported improvement assessed by the Clinical Global Improvement Scale. Secondary outcomes include symptom load, depression, anxiety, and illness worry. Process measures include emotional distress, illness perception, illness behaviour, and symptom interference.

Conclusions

This study is the first study to test an internet-delivered treatment program for FSD, multi-system type and has the potential to show the importance of making evidence-based internet-delivered treatment for FSD more accessible.

Are study populations in trials of antidepressants and psychotherapy comparable? A retrospective case study of two parallel running trials for multi- organ functional somatic disorder

This study retrospectively compares two previous parallel running, randomized, controlled trials of pharmacotherapy (imipramine) and psychotherapy (acceptance and commitment therapy) for multi-organ functional somatic disorder (FSD). Differences in demographics, psychiatric comorbidity, illness severity, and illness duration associated with eligibility for the two trials and patients' willingness to participate are explored using linear or binary regression models. 418 patients with multi-organ FSD was included. We found that 377 (95%) were eligible for psychotherapy and 257 patients (61%) for pharmacotherapy. Patients eligible for pharmacotherapy were less severely impaired, less often received disability pension, reported shorter illness duration and experienced less psychological distress than patients eligible for psychotherapy. Whilst exclusion criteria for both trials differed markedly, it was not possible to clearly identify patient or illness characteristics associated with patients' willingness to participate. The study showed that trial-specific exclusion criteria led to the selection of less complex and less severely impaired patients in the pharmacological trial in this sample of multi-organ FSD. Our findings have important implications for the interpretation and comparability of RCT results of different treatments in multi-organ FSD and may point to some common flaws in study design and interpretation of pharmacological vs. psychotherapeutic intervention trials in psychiatry.

Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology

Purpose: The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) is a screening tool that incorporates many important psychosocial domains into one questionnaire to reduce the burden of completing multiple questionnaires. The objectives of this study were to examine the reliability and validity of the 10-item version of the OSPRO-YF with patients with shoulder conditions. Method: The study group consisted of injured workers with an active compensation claim for a shoulder injury. The control group consisted of patients with a complaint of shoulder pain but without a work-related shoulder injury. We examined reliability (internal consistency, test-retest) and validity (factorial, convergent, known groups). The Hospital Anxiety and Depression Scale; the Quick Disabilities of Arm, Shoulder and Hand; and the short Örebro Musculoskeletal Pain Screening Questionnaire were used for comparison. Results: Eighty patients had an active compensation claim, and 160 were in the control group. The intra-class correlation coefficient values for two observations of the domain scores varied from 0.91 to 0.94. The test-retest reliability of the dichotomous constructs was moderate to perfect for 8 of 11 constructs. The 10-item OSPRO-YF questionnaire had three distinct domains, as conceptualized by the developers: mood, fear avoidance, and positive affect-coping. The Cronbach's a coefficients for these domains were 0.88, 0.94, and 0.94, respectively. The associations between the psychological constructs and domains and the similar theoretically derived scales were moderate to high and in the expected direction. Of the 11 constructs of the OSPRO-YF, 10 differentiated between patients with and without a work-related injury (p-values ranging from 0.028 to < 0.001). Conclusions: The 10-item OSPRO-YF reduces the burden of using multiple questionnaires and has acceptable test-retest and internal consistency reliability and factorial, convergent, and known-groups validity.

The BDS checklist as measure of illness severity: a cross-sectional cohort study in the Danish general population, primary care and specialised setting

OBJECTIVE

The bodily distress syndrome (BDS) checklist has proven to be useful in the diagnostic categorisation and as screening tool for functional somatic disorders (FSD). This study aims to investigate whether the BDS checklist total sum score (0-100) can be used as a measure of physical symptom burden and FSD illness severity.

DESIGN

Cross-sectional.

SETTING

Danish general population, primary care and specialised clinical setting.

PARTICIPANTS

A general population cohort (n=9656), a primary care cohort (n=2480) and a cohort of patients with multiorgan BDS from specialised clinical setting (n=492).

OUTCOME MEASURES

All data were self-reported. Physical symptoms were measured with the 25-item BDS checklist. Overall self-perceived health was measured with one item from the 36-item Short-Form Health Survey (SF-36). Physical functioning was measured with an aggregate score of four items from the SF-36/SF-12 scales 'physical functioning', 'bodily pain' and 'vitality'. Emotional distress was measured with the mental distress subscale (SCL-8) from the Danish version of the Hopkins Symptom Checklist-90. Illness worry was measured with the six-item Whiteley Index.

RESULTS

For all cohorts, bifactor models established that despite some multidimensionality the total sum score of the BDS checklist adequately reflected physical symptom burden and illness severity. The BDS checklist had acceptable convergent validity with measures of overall health (r=0.25-0.58), physical functioning (r=0.22-0.58), emotional distress (r=0.47-0.62) and illness worry (r=0.36-0.55). Acceptability was good with a low number of missing responses to items (<3%). Internal consistency was high (α ≥0.879). BDS score means varied and reflected symptom burden across cohorts (13.03-46.15). We provide normative data for the Danish general population.

CONCLUSIONS

The BDS checklist total sum score can be used as a measure of symptom burden and FSD illness severity across settings. These findings establish the usefulness of the BDS checklist in clinics and in research, both as a diagnostic screening tool and as an instrument to assess illness severity.

Composite outcome measurement in clinical research: the triumph of illusion over reality?

Composite measures that combine different types of indicators are widely used in medical research; to evaluate health systems, as outcomes in clinical trials and patient-reported outcome measurement. The potential advantages of such indices are clear. They are used to summarise complex data and to overcome the problem of evaluating new interventions when the most important outcome is rare or likely to occur far in the future. However, many scientists question the value of composite measures, primarily due to inadequate development methodology, lack of transparency or the likelihood of producing misleading results. It is argued that the real problems with composite measurement are related to their failure to take account of measurement theory and the absence of coherent theoretical models that justify the addition of the individual indicators that are combined into the composite index. All outcome measures must be unidimensional if they are to provide meaningful data. They should also have dimensional homogeneity. Ideally, a specification equation should be developed that can predict accurately how organisations or individuals will score on an index, based on their scores on the individual indicators that make up the measure. The article concludes that composite measures should not be used as they fail to apply measurement theory and, consequently, produce invalid and misleading scores.

Feasibility of group-based acceptance and commitment therapy for adolescents (AHEAD) with multiple functional somatic syndromes: a pilot study

BACKGROUND

Recurrent and impairing functional somatic syndromes (FSS) are common in adolescents. Despite a high need for care, empirically supported treatments are lacking for youth. The aim of this uncontrolled pilot study was to assess feasibility and treatment potential of a new intervention with group-based Acceptance and Commitment Therapy (ACT) in a generic treatment approach for adolescents with multiple FSS.

METHODS

Twenty-one patients received 'ACT for Health in Adolescents' (AHEAD) (30 h), specifically developed for adolescents (aged 15-19 years) with moderate to severe FSS. Close relatives attended an information meeting to facilitate support of the patients throughout treatment. Treatment satisfaction was evaluated by means of self-report and relatives' impressions. Self-reported physical health at 3 months follow-up (FU) after end of treatment was the primary outcome whereas secondary outcomes included symptom burden, limitation due to symptoms, illness worry, emotional distress and physical and emotional symptoms. Treatment targets were assessed by measures on illness behaviour, illness perception and psychological inflexibility.

RESULTS

Nineteen patients (90.5%) completed the treatment with a high overall attendance rate of 93%. All would recommend the treatment to a friend with similar problems. Close relatives rated it valuable to participate in an information meeting. Patients' physical health improved significantly from assessment to FU with a clinically relevant mean change of 8.9 points (95% CI [5.4; 12.4]; SRM 0.91 [0.26;1.57]). Improvement was also seen on all secondary outcome measures, from assessment to FU. Maladaptive illness behaviours and perceptions as well as psychological inflexibility showed a significant decline from assessment to FU.

CONCLUSION

AHEAD was feasible and potentially efficacious and warrants testing in a larger clinical trial.

TRIAL REGISTRATION

Clinical Trials gov NCT04464447 , registration date July 9th, 2020. Retrospectively registered.

Substantial clinical benefit, responsiveness, and sensitivity to change of three common outcome measures following shoulder arthroplasty

Objectives:

It is important for clinicians involved in the care of patients with advanced glenohumeral osteoarthritis to determine clinically significant change when using outcome measures. There is little information on the amount of substantial clinical benefit in shoulder outcomes after shoulder arthroplasty. The purpose of this study was twofold: (1) to quantify substantial clinical benefit for the American Shoulder and Elbow Surgery score, the Constant Murley Score, and the Western Ontario Osteoarthritis of the Shoulder index and (2) to provide estimates of responsiveness and sensitivity to change for these measures following shoulder arthroplasty.

Methods:

The study involved a secondary analysis of previously collected data. The substantial clinical benefit and responsiveness of the measures were calculated based on external anchors related to change in pain, range of motion, and ability to carry out activities of daily living. The areas under curve and standardized response mean represented responsiveness and sensitivity to change.

Results:

The data of 159 and 131 patients with complete follow-up at 6 months and 2 years were reviewed. The amount of substantial clinical benefit was dependent on the outcome measure and the external anchor and increased for all measures from 6 months to 2 years. Responsiveness was high (areas under curve > 0.80) at 6 months and further improved at 2 years (areas under curve > 0.88). The standardized response mean values of both time points were over 2.00, indicating high effect sizes. The standardized response means of the Constant Murley Score were statistically significantly higher than the standardized response means of the American Shoulder and Elbow Surgery and Western Ontario Osteoarthritis of the Shoulder.

Conclusion:

Amount of substantial clinical improvement in pain, range of motion, and activities of daily living following shoulder arthroplasty depends on the type of outcome measure used. All three measures, the American Shoulder and Elbow Surgery, absolute and relative Constant Murley Score, and Western Ontario Osteoarthritis of the Shoulder, demonstrated good to excellent accuracy and optimal standardized response means.

Level of evidence:

Level III, Retrospective Cohort study

Sense of coherence and physical health-related quality of life in Italian chronic patients: the mediating role of the mental component

OBJECTIVE

To examine the relationship between sense of coherence (SOC) and physical health-related quality of life in patients with chronic illnesses by focusing on the mediating role of the mental component of quality of life.

DESIGN

Cross-sectional survey design.

SETTING

Secondary care; three departments of an Italian university hospital.

METHODS

The participants (n=209) in the study were adult (≥18 years) outpatients with a chronic pathology (eg, diabetes, thyroid disorders or cancer) at any phase in the care trajectory (eg, pre-treatment, undergoing treatment, follow-up care). They agreed to participate in the study after providing their informed consent. Data were collected using a structured self-reporting questionnaire. Data analysis was carried out using SPSS, and mediation analysis was performed via PROCESS macro.

RESULTS

The SOC score of the study sample was equivalent to that of the general population (mean difference=-2.50, 95% CI -4.57 to 0.00). Correlation analysis showed that SOC was mainly correlated to the mental component (MCS) (r=0.51, p<0.01) of quality of life and then to the physical component (PCS) (r=0.35, p<0.01). Mediation analysis showed that SOC was directly related to MCS (p<0.001, 95% CI 0.62 to 0.99) but not to PCS (p=0.42, 95% CI -0.27 to 0.12). In turn, MCS was directly related to PCS (p<0.001, 95% CI 0.76 to 1.01). The indirect effect of SOC on PCS through MCS was significant (0.71, p<0.001, bootstrap 95% CI 0.54 to 0.91), thus supporting the mediating role of the mental component of quality of life.

CONCLUSION

The indirect effect suggests that SOC is a marker of quality of life, especially of the mental component. The findings show that SOC is a psychological process that impacts patients' mental health status, which in turn affects physical health. Better knowledge of a person's SOC and how it affects his/her quality of life may help to plan tailoring interventions to strengthen SOC and improve health-related quality of life.

Psychometric Evaluation of the Brunei-Malay SF-36 version 2 Health Survey

Objectives: To culturally adapt the Short Form Health-36 version 2 (SF-36v2) into the Brunei-Malay context and determine its reliability and validity for measuring health-related quality of life (HRQOL) in healthy individuals and patients with chronic kidney disease in Brunei Darussalam. Methods: An iterative multistep strategy involving setting up a bilingual expert panel, pretesting, text revision and back translation was used to prepare the Brunei-Malay SF-36v2 as an adaptation from the Malaysian-Malay SF-36v2. The Brunei-Malay SF-36v2 was then self-administered to a sample of healthy individuals (n=95) and predialysis chronic kidney disease outpatients (n=95) resident in Brunei. The mean (SD) age of the participants was 46.6 (17.8) years. Results: Data completion rate was 100% with minimal floor effects (≤0.21) in all the 8 domains and >15% ceiling effects in 3 of the 8 domain scales. Cronbach’s alpha was >0.70 for all the 8 domain scales. Scaling success was 100% for convergent validity, with 100% item discriminant validity for all domain scales except Social Functioning (94%), Mental Health (85%) and General Health (85%). Principal component analysis of the two-factor dimension explained 68% overall variance and accounted for 81% reliable variance, but the exact SF-36 two-factor summary constructs in the standard algorithm were not replicated in the Bruneian population. Conclusions: The Brunei-Malay SF-36v2 is a valid and reliable instrument for measuring HRQOL in healthy individuals and patients with chronic kidney disease in Brunei. The summary scales should, however, be interpreted with caution. Further studies should be carried out to assess additional psychometric properties of the Brunei-Malay SF-36v2.

Physical comorbidity in patients with multiple functional somatic syndromes. A register-based case-control study

BACKGROUND

Patients with multiple functional somatic syndromes show markedly reduced functioning and numerous somatic symptoms that cannot be explained by conventionally-defined physical disease. Whilst the comorbidity of functional somatic syndromes with mental disorders is well-known, knowledge about physical comorbidity and mortality is scarce.

AIM

To compare number of physical diseases between patients with multiple functional somatic syndromes (operationalized as multi-organ bodily distress syndrome) and the general population with regard to: 1) All conventionally-defined physical diseases, and 2) Severe mortality-associated physical diseases.

MATERIALS AND METHODS

Patients with multiple functional somatic syndromes (n=239) were compared with age- and gender-matched population-based controls (n=5975). The number of physical diseases during a four-year period was estimated by means of registered ICD-10 codes in relation to hospital admissions and ambulatory care. We counted individual diagnoses indicating conventionally-defined physical disease based on a previously developed diagnosis sorting algorithm and an additional clinical evaluation, excluding unspecific (symptom) diagnoses and functional somatic syndromes. An updated version of Charlson Comorbidity Index (CCI₁₂) was used to estimate severe, mortality-associated physical diseases.

RESULTS

Patients with multiple functional somatic syndromes had an increased number of conventionally-defined physical disease compared to controls (Ratio: 2.17, 95% CI: 1.96-2.41). Groups were similar as regards CCI₁₂ (P=0.55).

CONCLUSIONS

Patients with multiple functional somatic syndromes showed substantial physical comorbidity. Their burden of severe, mortality-associated physical diseases was comparable to the general population. Further research is needed to clarify the nature, clinical significance, and long-term consequences of the comorbid physical diseases.

Is psychotherapy for functional somatic syndromes harmful? A mixed methods study on negative effects

INTRODUCTION

Concern for negative effects of psychotherapy for functional somatic syndromes (FSS) has been expressed by clinicians and some patient associations, which may prevent patients from seeking treatment. Therefore, we sought to explore the occurrence and characteristics of negative effects from group-based psychotherapy as experienced by patients with severe or multiple FSS.

METHODS

An adapted version of the explanatory sequential mixed methods design was applied. We used data from an on-going pilot study on Acceptance and Commitment Therapy and Mindfulness-Based Stress Reduction. Negative effects were measured by Inventory for the assessment of Negative Effects of Psychotherapy (INEP). In addition, telephone interviews were conducted with randomly chosen patients and patients who reported negative effects. The latter were asked to elaborate on their INEP response. Quantitative data were analysed descriptively while interview transcripts were explored by thematic analysis.

RESULTS

Eighty patients responded to the questionnaire (89%). Negative effects to different extent (from 'slightly agree' to 'fully agree') were reported by 25 (31%). The most frequent negative effects were dependence on the therapist (12%), feeling down after therapy (6%) and insurance problems (7%). By exploring 27 participants' experiences of negative effects 3 main themes were identified: relations in therapy, outcome and transition from therapy to everyday life.

CONCLUSION

Patients with FSS reported a few specific negative effects, all with low frequency. Generally, therapy was well-received. Some patients did however express negative effects both within and outside the therapeutic context. It is important to inform patients about potential negative effects prior to psychotherapy.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

The Danish Foundation, Trygfonden.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparing group-based acceptance and commitment therapy (ACT) with enhanced usual care for adolescents with functional somatic syndromes: a study protocol for a randomised trial

INTRODUCTION

Functional somatic syndromes (FSS) are common in adolescents, characterised by severe disability and reduced quality of life. Behavioural treatments such as acceptance and commitment therapy (ACT) has shown promising results in children and adolescents with FSS, but has focused on specific syndromes such as functional pain. The current study will compare the efficacy of group-based ACT with that of enhanced usual care (EUC) in adolescents with a range of FSS operationalised by the unifying construct of multiorgan bodily distress syndrome (BDS).

METHODS AND ANALYSIS

A total of 120 adolescents aged 15-19 and diagnosed with multiorgan BDS, of at least 12 months duration, will be assessed and randomised to either: (1) EUC: a manualised consultation with a child and adolescent psychiatrist and individualised treatment plan or (2) manualised ACT-based group therapy plus EUC. The ACT programme consists of 9 modules (ie, 27 hours) and 1 follow-up meeting (3 hours). The primary outcome is physical health, assessed by an Short Form Health Survey (SF-36) aggregate score 12 months after randomisation. Secondary outcomes include self-reported symptom severity, symptom interference, depression and anxiety, illness worry, perceived stress and global improvement; as well as objective physical activity and bodily stress response measured by heart rate variability, hair cortisol and inflammatory biomarkers. Process measures are illness perception, illness-related behaviour and psychological flexibility.

ETHICS AND DISSEMINATION

The study is conducted in accordance with Helsinki Declaration II. Approval has been obtained from the Science Ethics Committee of the Central Denmark Region and the Danish Data Protection. The results will be sought to be published according to the CONSORT statement in peer-reviewed journals.

DISCUSSION

This is one of the first larger randomised clinical trials evaluating the effect of a group-based intervention for adolescents with a range of severe FSS.

TRIAL REGISTRATION NUMBER

NCT02346071; Pre-results.

B-Lymphocyte Depletion in Myalgic Encephalopathy/ Chronic Fatigue Syndrome. An Open-Label Phase II Study with Rituximab Maintenance Treatment

Background

Myalgic Encephalopathy/Chronic Fatigue Syndrome (ME/CFS) is a disease of unknown etiology. We previously reported a pilot case series followed by a small, randomized, placebo-controlled phase II study, suggesting that B-cell depletion using the monoclonal anti-CD20 antibody rituximab can yield clinical benefit in ME/CFS.

Methods

In this single-center, open-label, one-armed phase II study (NCT01156909), 29 patients were included for treatment with rituximab (500 mg/m²) two infusions two weeks apart, followed by maintenance rituximab infusions after 3, 6, 10 and 15 months, and with follow-up for 36 months.

Findings

Major or moderate responses, predefined as lasting improvements in self-reported Fatigue score, were detected in 18 out of 29 patients (intention to treat). Clinically significant responses were seen in 18 out of 28 patients (64%) receiving rituximab maintenance treatment. For these 18 patients, the mean response durations within the 156 weeks study period were 105 weeks in 14 major responders, and 69 weeks in four moderate responders. At end of follow-up (36 months), 11 out of 18 responding patients were still in ongoing clinical remission. For major responders, the mean lag time from first rituximab infusion until start of clinical response was 23 weeks (range 8–66). Among the nine patients from the placebo group in the previous randomized study with no significant improvement during 12 months follow-up after saline infusions, six achieved a clinical response before 12 months after rituximab maintenance infusions in the present study. Two patients had an allergic reaction to rituximab and two had an episode of uncomplicated late-onset neutropenia. Eight patients experienced one or more transient symptom flares after rituximab infusions. There was no unexpected toxicity.

Conclusion

In a subgroup of ME/CFS patients, prolonged B-cell depletion with rituximab maintenance infusions was associated with sustained clinical responses. The observed patterns of delayed responses and relapse after B-cell depletion and regeneration, a three times higher disease prevalence in women than in men, and a previously demonstrated increase in B-cell lymphoma risk for elderly ME/CFS patients, suggest that ME/CFS may be a variant of an autoimmune disease.

Trial registration

ClinicalTrials.gov NCT01156909

Changes in illness perceptions mediated the effect of cognitive behavioural therapy in severe functional somatic syndromes

OBJECTIVE

Although there is substantial evidence that cognitive behavioural therapy alleviates symptoms in functional somatic syndromes, the mechanisms of change are less investigated. This study examined whether changes in illness perceptions mediated the effect of cognitive behavioural therapy.

METHODS

We analysed additional data from a randomised controlled trial comparing completers of cognitive behavioural group therapy (46 patients) to an enhanced usual care group (66 patients). Proposed mediators (illness perceptions) and primary (physical health) and secondary (somatic symptoms and illness worry) outcomes were assessed by means of questionnaires at referral, baseline, end of treatment, and 10 and 16 months after randomisation. Multiple mediation analysis determined whether (1) changes in specific illness perceptions during treatment mediated the effect of cognitive behavioural therapy (primary analysis), and (2) whether changes in illness perceptions during the whole trial period were associated with improved outcome (secondary analysis).

RESULTS

Improvements in illness perceptions during treatment partially mediated the effect of cognitive behavioural therapy on physical health one year after treatment (sum of indirect effects 1.556, BCa 95% CI (0.006; 3.620)). Improving perceived control was particularly important. Changes in illness perceptions from baseline to 16 months after randomisation were associated with clinically meaningful improvements in physical health, somatic symptoms and illness worry during the same period.

CONCLUSION

Our results suggest that changing patients' illness perceptions is an important process in cognitive behavioural therapy for functional somatic syndromes. Challenging patients' own understanding of their illness may hence be a key element of successful treatment.

Anxiety and depression mediate the health-related quality of life differently in patients with cardiovascular disease and stroke-preliminary report of the Yilan study: a population-based community health survey

BACKGROUND

Cardiovascular disease and stroke have emerged as substantial and growing health challenges to populations around the world. Besides for the survival and medical prognosis, how to improve the health-related quality of life (HRQoL) might also become one of the goals of treatment programs. There are multiple factors that influence HRQol, including comorbidity, mental function and lifestyle. However, substantial research and investigation have still not clarified these underlying pathways, which merit further attention. The purpose of this study was to determine how psychological factors affect the link between cardiovascular disease and stroke with HRQoL.

METHODS AND RESULT

A total of 1,285 elder subjects at least 65 years of age (47.2% male) were enrolled. The mental function and HRQol of each patient was then measured using the Hospital Anxiety and Depression Scale and Short Form-12. After multiple regression analysis, anxiety, depression, cardiovascular disease, stroke, education level and age were shown to be associated with both mental component score (MCS) and physical component score (PCS). In the mediation analysis using the SPSS macro provided by Preacher and Hayes, cardiovascular disease and stroke affected HRQoL via anxiety and depression, respectively.

CONCLUSIONS

These results suggest that cardiovascular disease and stroke have negative impacts on patient MCS and PCS through different underlying pathways. Cardiovascular disease influences the HRQoL both directly and indirectly with the mediation of anxiety, and stroke influences the HRQoL by way of depression. These findings support the proposition that different combinations of both physical and psychological support are necessary to best manage these diseases.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Enhanced care by generalists for functional somatic symptoms and disorders in primary care

BACKGROUND

Patients with medically unexplained or functional somatic symptoms are common in primary care. Previous reviews have reported benefit from specialised interventions such as cognitive behavioural therapy and consultation letters, but there is a need for treatment models which can be applied within the primary care setting. Primary care studies of enhanced care, which includes techniques of reattribution or cognitive behavioural therapy, or both, have shown changes in healthcare professionals' attitudes and behaviour. However, studies of patient outcome have shown variable results and the value of enhanced care on patient outcome remains unclear.

OBJECTIVES

We aimed to assess the clinical effectiveness of enhanced care interventions for adults with functional somatic symptoms in primary care. The intervention should be delivered by professionals providing first contact care and be compared to treatment as usual. The review focused on patient outcomes only.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR-Studies and CCDANCTR-References) (all years to August 2012), together with Ovid searches (to September 2012) on MEDLINE (1950 - ), EMBASE (1980 - ) and PsycINFO (1806 - ). Earlier searches of the Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL, PSYNDEX, SIGLE, and LILACS were conducted in April 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2009. No language restrictions were applied. Electronic searches were supplemented by handsearches of relevant conference proceedings (2004 to 2012), reference lists (2011) and contact with authors of included studies and experts in the field (2011).

SELECTION CRITERIA

We limited our literature search to randomised controlled trials (RCTs), primary care, and adults with functional somatic symptoms. Subsequently we selected studies including all of the following: 1) a trial arm with treatment as usual; 2) an intervention using a structured treatment model which draws on explanations for symptoms in broad bio-psycho-social terms or encourages patients to develop additional strategies for dealing with their physical symptoms, or both; 3) delivery of the intervention by primary care professionals providing first contact care; and 4) assessment of patient outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently screened identified study abstracts. Disagreements about trial selections were resolved by a third review author. Data from selected publications were independently extracted and risk of bias assessed by two of three authors, avoiding investigators reviewing their own studies. We contacted authors from included studies to obtain missing information. We used continuous outcomes converted to standardised mean differences (SMDs) and based analyses on changes from baseline to follow-up, adjusted for clustering.

MAIN RESULTS

We included seven studies from the literature search, but only six provided sufficient data for analyses. Included studies were European, cluster RCTs with adult participants seeing their usual doctor (in total 233 general practitioners and 1787 participants). Methodological quality was only moderate as studies had no blinding of healthcare professionals and several studies had a risk of recruitment and attrition bias. Studies were heterogeneous with regard to selection of patient populations and intensity of interventions. Outcomes relating to physical or general health (physical symptoms, quality of life) showed substantial heterogeneity between studies (I(2) > 70%) and post hoc analysis suggested that benefit was confined to more intensive interventions; thus we did not calculate a pooled effect. Outcomes relating to mental health showed less heterogeneity and we conducted meta-analyses, which found non-significant overall effect sizes with SMDs for changes at 6 to 24 months follow-up: mental health (3 studies) SMD -0.04 (95% CI -0.18 to 0.10), illness worry (3 studies) SMD 0.09 (95% CI -0.04 to 0.22), depression (4 studies) SMD 0.07 (95% CI -0.05 to 0.20) and anxiety (2 studies) SMD -0.07 (95% CI -0.38 to 0.25). Effects on sick leave could not be estimated. Three studies of patient satisfaction with care all showed positive but non-significant effects, and measures were too heterogeneous to allow meta-analysis. Results on healthcare utilisation were inconclusive. We analysed study discontinuation and found that both short term and long term discontinuation occurred more often in patients allocated to the intervention group, RR of 1.25 (95% CI 1.08 to 1.46) at 12 to 24 months.

AUTHORS' CONCLUSIONS

Current evidence does not answer the question whether enhanced care delivered by front line primary care professionals has an effect or not on the outcome of patients with functional somatic symptoms. Enhanced care may have an effect when delivered per protocol to well-defined groups of patients with functional disorders, but this needs further investigation. Attention should be paid to difficulties including limited consultation time, lack of skills, the need for a degree of diagnostic openness, and patient resistance towards psychosomatic attributions. There is some indication from this and other reviews that more intensive interventions are more successful in changing patient outcomes.

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.

Performance of the Dutch SF-36 version 2 as a measure of health-related quality of life in patients with rheumatoid arthritis

Background

The aim of this study was to examine the measurement properties of the Dutch SF-36 version 2 (SF-36v2) health survey in patients with rheumatoid arthritis (RA).

Methods

Scaling assumptions, internal reliability, and internal construct validity were examined using available data from 1884 RA patients included in the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry. External construct validity and responsiveness to change were examined using baseline and 6-month follow-up data from a subset of 387 early RA patients participating in the DREAM remission induction cohort.

Results

The individual items of the SF-36v2 adequately met scaling assumptions, although four items correlated too highly with items from different scales. Internal consistency was high for all eight scales and the physical and mental health components underlying the scales were replicated, supporting the use of the standard scoring algorithms. The SF-36v2 scales demonstrated minimal floor effects and ceiling effects were noteworthy only for the role-physical, social functioning, and role-emotional scales. Correlations with other core measures were as expected and the SF-36v2 showed excellent known-groups validity in distinguishing between patients with low or moderate-high disease activity. All scales related to physical health showed moderate to large responsiveness to change in patients that achieved low disease activity at six months.

Conclusion

The SF-36v2 appears to be a psychometrically sound tool for the assessment of health-related quality of life of Dutch patients with RA.

Cognitive-behavioural group treatment for a range of functional somatic syndromes: randomised trial

BACKGROUND

Many specialty-specific functional somatic syndrome diagnoses exist to describe people who are experiencing so-called medically unexplained symptoms. Although cognitive-behavioural therapy can be effective in the management of such syndromes, it is rarely available. A cognitive-behavioural therapy suitable for group treatment of people with different functional somatic syndromes could address this problem.

AIMS

To test the efficacy of a cognitive-behavioural therapy (Specialised Treatment for Severe Bodily Distress Syndromes, STreSS) designed for patients with a range of severe functional somatic syndromes.

METHOD

A randomised controlled trial (clinicaltrials.gov, NCT00132197) compared STreSS (nine 3.5 h sessions over 4 months, n = 54) with enhanced usual care (management by primary care physician or medical specialist, n = 66). The primary outcome was improvement in aggregate score on subscales of the 36-item Short Form Health Survey (physical functioning, bodily pain and vitality) at 16 months.

RESULTS

Participants receiving STreSS had a greater improvement on the primary outcome (adjusted mean difference 4.0, 95% CI 1.4-6.6, P = 0.002) and on most secondary outcomes.

CONCLUSIONS

In the management of functional somatic syndromes, a cognitive-behavioural group treatment was more effective than enhanced usual care.

Validation of a Finnish version of the Fibromyalgia Impact Questionnaire (Finn-FIQ)

Background and purpose Fibromyalgia (FM) is a chronic pain syndrome, which affects up to 5% of the general population. The aetiology of FM is unclear. The lack of specific diagnostic laboratory tests or imaging options combined with the severe burden on both patients and society caused by the FM syndrome demands the development of valid instruments able to measure the current health status of the FM patients. The Fibromyalgia Impact Questionnaire (FIQ) is the most widely used of these instruments. Our objective was to translate the Fibromyalgia Impact Questionnaire (FIQ) into Finnish and evaluate its validity in Finnish speaking FM patients. Methods FIQ was translated by two bilingual researchers into the Finnish version (Finn-FIQ) and linked to the categories of International Classification of Functioning, Disability and Health (ICF). Finn-FIQ was administered to 162 patients who had prior fibromyalgia diagnoses M79.0 according to ICD-10 year 2006 version. They also filled in the Health Assessment Questionnaire (HAQ), the Rand 36-item Health Survey (RAND-36), the Beck Depression Inventory IA (BDIIA), the Chronic Pain Acceptance Questionnaire (CPAQ), the International Physical Activity Questionnaire Short Form (IPAQ), and they assessed their general well-being on a 0-100 mm visual analogue scale while attending a clinical check-up visit. Internal consistency was estimated according to Cronbach's alpha internal consistency. An exploratory factor analysis was performed to identify related items and to show construct validity. Correlation coefficients were calculated by the Spearman method. Results From the 162 participants 153 were female and 9 male, 119 (73%) had an active job or were students, 21 (13%) were unemployed, 16 (10%) were retired and 6 (4%) were on sick leave. The mean age was 47 years. The internal consistency value (95% CI) was 0.90 for the overall Finn-FIQ. The factor analysis performed for construct analysis showed that Finn-FIQ was loaded on 4 factors. These factors were loaded on components of ICF and explained 69% of total variance. Significant correlations were obtained between patients own assessments of general well-being and Finn-FIQ total score (r = 0.64 [95% CI 0.53-0.73]) and also between Finn-FIQ total score and HAQ total score (r = 0.56 [95% CI 0.44-0.66]). Finn-FIQ questions had significant correlations with RAND-36 domains. Conclusion Finn-FIQ is a valid and feasible instrument to mirror the functioning of FM patients according to its internal consistency, correlation to general well-being, convergent validity and response rate. It covers the main components of the ICF framework hence reflecting the whole spectrum of functioning. Implications In our study Finn-FIQ was proven as a valid instrument with Finnish speaking FM patients. Original FIQ and other validated translations have already confirmed their place in fibromyalgia research. After this study Finnish fibromyalgia research can be included in those using the best-known instrument in validated form and native language. Current study showed also Finn-FIQ's ability to measure functioning of the FM patients, and it had good applicability among Finnish speaking patients. Therefore it can be recommended also for monitoring individual FM patients and their functioning for example during different treatment trials.