Somatoform disorders and recent diagnostic controversies

The bidirectional association between chronic musculoskeletal pain and sleep-related problems: a systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis synthesizes the evidence on prospective bidirectional associations between sleep-related problems (SRP) and chronic musculoskeletal pain (CMP).

METHODS

A literature search for cohort studies available in the PubMed, Scopus, Web of Science, PsycINFO and Cochrane Library databases as of 19 July 2022 was performed. Pooled odds ratios and effect sizes were calculated through random effects meta-analysis. Subgroup and meta-regression analyses were performed to explore differences by follow-up time, proportion of each sex and mean age. The Meta-analysis Of Observational Studies in Epidemiology guidelines were strictly followed.

RESULTS

Twenty studies with a total of 208 190 adults (aged 34.4-71.7 years) were included, with 17 of them being used in the meta-analysis. Individuals with SRP at baseline had a 1.79-fold higher incidence (odds ratio [OR] = 1.79; 95% CI: 1.55, 2.08; I2 = 84.7%; P < 0.001) and a 2.04-fold higher persistence (OR = 2.04; 95% CI: 1.42, 2.94; I2 = 88.5%; P < 0.005) of CMP than those without SRP. In the subgroup analysis of the association between SRP and CMP, the longer the follow-up time of the studies, the higher the heterogeneity between them. In the corresponding meta-regression, no significant effect was observed for follow-up time, sex proportion or age. Individuals with CMP at baseline had a 2.02-fold higher incidence of SRP (OR = 2.02; 95% CI: 1.62, 2.53; I2 = 90.0%; P < 0.001) than those without CMP.

CONCLUSION

This study provides robust evidence concerning the longitudinal association between SRP and incidence-persistence of CMP in adults. In addition, the available prospective studies support the existence of a bidirectional relationship between CMP and SRP.

PROSPERO REGISTRATION NUMBER

CRD42020212360.

Mental illness rates among employees with fixed-term versus permanent employment contracts: a Danish cohort study

PURPOSE

It has been hypothesized that employment in a fixed-term instead of permanent contract position is associated with an increased risk of development of mental health problems. The present study aimed at estimating rate ratios between fixed-term and permanent employees in the Danish labor force, for use of psychotropic drugs and psychiatric hospital treatment due to mood, anxiety or stress-related disorders, respectively.

METHODS

Employment data were drawn from the Danish Labor Force Survey of 2001-2013, which is a part of the European Labor Force Survey. Full-time employed survey participants without mental illness at the baseline interview (N = 106,501) were followed in national health registers for up to 5 years. Poisson regressions were used to estimate rate ratios for redeemed prescriptions of psychotropic drugs and psychiatric hospital treatments due to mood, anxiety or stress-related disease. The analyses were controlled for age, gender, industrial sector, nighttime work, level of education, calendar year, disposable family income and social transfer payments within 1 year prior to the baseline interview.

RESULTS

The rate ratio for hospital diagnosed mood, anxiety or stress-related disorders among employees with fixed-term vs. permanent employment contracts was estimated at 1.39 (99.5% CI 1.04-1.86), while the corresponding rate ratio for redeemed prescriptions of psychotropic drugs was estimated at 1.12 (99.5% CI 1.01-1.24).

CONCLUSION

The present study supports the hypothesis that employment in a fixed-term rather than permanent contract position is associated with an increased risk of developing mental health problems.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR2-10.2196/24392.

OUP accepted manuscript

Background

Somatic syndromes are present in 30 per cent of primary healthcare populations and are associated with increased health service use and health costs. Less is known about secondary care surgical inpatient populations.

Methods

This was a prospective longitudinal cohort study (n = 465) of consecutive adult admissions with an episode of non-traumatic abdominal pain, to the Acute General Surgical Unit at a tertiary hospital in New South Wales, Australia. Somatic symptom severity (SSS) was dichotomized using the Patient Health Questionnaire (PHQ)-15 with a cut-off point of 10 or higher (medium–high SSS) and compared pre-admission and during admission. Total healthcare utilization and direct costs were stratified by a PHQ-15 score of 10 or higher. Linear regression was used to examine differences in costs, and a multivariable linear regression was used to examine the relationship of PHQ-15 scores of 10 or higher to total costs, reported as mean total costs of care and percentage difference (95 per cent confidence intervals).

Results

Fifty-two per cent (n = 242) of participants had a medium–high SSS with greater pre-admission and admission interval health service costs. Mean total direct costs of care were 25 per cent (95 per cent c.i. 8 to 44 per cent) higher in the PHQ-15 score of 10 or higher group: mean difference €1401.93 (95 per cent c.i. €512.19 to €2273.67). The multivariable model showed a significant association of PHQ-15 scores of 10 or higher (2.1 per cent; 0.2–4.1 per cent greater for each one-point increase in score) with total hospital costs, although the strongest contributions to cost were older age, operative management, and lower socioeconomic level. There was a linear relationship between PHQ scores and total healthcare costs.

Conclusions

Medium to high levels of somatic symptoms are common in surgical inpatients with abdominal pain and are independently associated with greater healthcare utilization.

Managing fibromyalgia syndrome in pregnancy no bridges between USA and EU

The first aim of this article is to analyze the risk/benefit ratio of using psychotropic drugs approved in some countries for treating fibromyalgia syndrome (FMS) during pregnancy. Assessing the effectiveness of non-pharmacological interventions is the second scope of this article, in order to help clinicians to manage FMS in pregnancy in those countries were no drugs are approved for treating the disease. Following the PRISMA guidelines for systematic reviews, a literature search was conducted on PubMed and Google Scholar. Separate literature searches were performed for the three psychotropic drugs approved in the USA for treating FMS, psychotherapy, and transcranial magnetic stimulation (TMS). Perinatal duloxetine exposure is associated with increased risk of gestational and perinatal complications. With regards pregabalin, available information suggests that the drug is not devoid of structural teratogenicity potential. No data are available for milnacipran. Duloxetine and pregabalin should be only given to pregnant women diagnosed with severe forms of FMS after carefully weighing the benefits and risks for the mother-fetus dyad. On the other hand, we have to consider that the proportion of women who discontinue psychotropic drugs during pregnancy is as high as 85.4%. This figure raises further questions about adequate alternative treatment of FMS during the perinatal period. Moreover, neither duloxetine nor milnacipran or pregabalin have been approved by the EMEA for the treatment of FMS. Unfortunately, psychological treatment of FMS in perinatal women are not yet tested and data on TMS are conflicting.

Sociodemographic Characterization and Psychiatric Symptoms of Patients With Medically Unexplained Symptoms in a Healthcare Institution in Medellin (Colombia)

INTRODUCTION

Medically unexplained symptoms are defined as physical symptoms that have been present for several weeks and that an adequate medical evaluation has not revealed any disease that explains them; when these symptoms become persistent, they lead to comprehensive clinical investigations and multiple interventions. These patients have a greater or at least comparable commitment to physical functioning, mental health, and negative health perception than patients with multiple chronic medical conditions; have significantly more stressful life events (psychological, physical and/or sexual abuse) and are more likely to meet diagnostic criteria for anxiety and depression.

OBJECTIVE

To characterize sociodemographic and psychiatric characteristics of a group of patients identified in primary care with medically unexplained symptoms.

METHODOLOGY

A descriptive, cross-sectional study with patients from 18 to 70 years old who were given PHQ-15, PHQ-9 and PHQ for anxiety, and a survey designed for the study.

RESULTS

36 patients were analysed, 94.4% women, median age 45 [RIC, 20] years-old, 33.3% married, 91.7% had children. 55% had severe functional somatic symptoms, 77.8% had one or more functional somatic disorders, and 77.7% had clinically relevant affective or anxiety symptoms. 25% of the patients reported a history of child abuse, 41.7% were mistreated by a partner, and 41.6% were victims of the Colombian armed conflict.

CONCLUSIONS

The main finding of this study was that 8 out of 10 patients met criteria for a functional somatic disorder with great symptomatic severity and three out of ten patients met criteria for two functional disorders, most of these patients without other basic medical diseases. In addition, we found a high prevalence of exposure to different types of violence that these patients have been subjected to throughout their life.

Dimensional analysis of depressive, anxious and somatic symptoms presented by primary care patients and their relationship with ICD-11 PHC proposed diagnoses

BACKGROUND

A study conducted as part of the development of the Eleventh International Classification of Mental Disorders for Primary Health Care (ICD-11 PHC) provided an opportunity to test the relationships among depressive, anxious and somatic symptoms in PHC.

METHOD

Primary care physicians participating in the ICD-11 PHC field studies in five countries selected patients who presented with somatic symptoms not explained by known physical pathology by applying a 29-item screening on somatic complaints that were under study for bodily stress disorder. Patients were interviewed using the Clinical Interview Schedule-Revised and assessed using two five-item scales that measure depressive and anxious symptoms. Structural models of anxious-depressive symptoms and somatic complaints were tested using a bi-factor approach.

RESULTS

A total of 797 patients completed the study procedures. Two bi-factor models fit the data well: Model 1 had all symptoms loaded on a general factor, along with one of three specific depression, anxiety and somatic factors [x2 (627) = 741.016, p < 0.0011, RMSEA = 0.015, CFI = 0.911, TLI = 0.9]. Model 2 had a general factor and two specific anxious depression and somatic factors [x2 (627) = 663.065, p = 0.1543, RMSEA = 0.008, CFI = 0.954, TLI = 0.948].

CONCLUSIONS

These data along with those of previous studies suggest that depressive, anxious and somatic symptoms are largely different presentations of a common latent phenomenon. This study provides support for the ICD-11 PHC conceptualization of mood disturbance, especially anxious depression, as central among patients who present multiple somatic symptoms.

The combination of health anxiety and somatic symptoms: a prospective predictor of healthcare usage in primary care

Extant research provides equivocal conclusions if the combined presentation of health anxiety with severe somatic symptoms confers risk for greater future primary care usage. The present study further examined the combination of health anxiety and somatic symptoms as a predictor of healthcare usage in primary care. Using a prospective longitudinal design, a large sample (N = 530) of patients presenting for treatment at a community health center completed self-report measures assessing health anxiety and somatic symptom severity. A medical record review at the time of questionnaire administration and 1 year following that administration was completed to assess the frequency of medical visits during the preceding and subsequent year. As expected, the interactive effect between health anxiety and somatic symptom severity predicted greater subsequent year medical visits. Covariates included preceding year medical visits, sociodemographic variables, body mass index, smoking status, and depressive symptom severity. Simple effects indicated that health anxiety predicted greater subsequent year medical visits when coupled with relatively severe, but not mild, somatic symptoms. Assessing health anxiety and somatic symptom severity in primary care settings could be important for identifying individuals at risk for future frequent healthcare visits and who may benefit from intervention.

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

The association between physical symptoms and depression among medical students in Bahrain

OBJECTIVES

To examine the association between depression and physical symptoms among medical students in Bahrain.

METHODS

  The present study employed a cross-sectional design.  A total of 160 students were recruited, 41.3% were male and 58.8% female, using a convenience sampling approach. Participants completed the validated Patients Health Questionnaires (PHQs) in which they provided information about demographics, physical symptoms, and depression. Results were considered significant if p <0.05.

RESULTS

Nearly nineteen percent of the participants have moderate to severe depression, and 42.2% has moderate to severe physical symptoms.  Participants reported different physical symptoms, sleep problems, 40%; lethargy, 31.9%; and headaches, 23.8%. The results of the logistic regression showed that there was a significant association between age and gender (χ²₍₃₎ = 32.28, p < 0.001). Sleep and gastrointestinal symptoms were the most associated with depression, respectively (χ²₍₃₎=49.77, p<0.001) and (χ²₍₃₎=49.77, p< 0.05).

CONCLUSIONS

The association between depression and physical symptoms are considerably high among medical students in Bahrain.  Medical educators should take such symptoms seriously among medical students as it may have serious consequences on the mental health of medical students. In practice, adequate awareness initiatives should be organized and provided for medical students to help them overcome their challenges they face. Additionally, incorporating screening self-screening strategies in the medical curriculum can be beneficial for early detections of mental health problems. The Implications and limitations of the study are discussed.

Somatic symptom severity among primary care patients who are obese: examining the unique contributions of anxiety sensitivity, discomfort intolerance, and health anxiety

Prior research indicates the common presentation of somatic symptoms and obesity in primary care settings, as well as links between obesity and somatic symptoms. Anxiety sensitivity, discomfort intolerance, and health anxiety are three variables relevant to somatic symptoms. How those three variables relate to somatic symptom severity among individuals who are obese and the unique variance accounted for by each variable in somatic symptom severity remains unexamined. Among a large sample of primary care patients who are obese (N = 342), anxiety sensitivity, discomfort intolerance, and health anxiety collectively accounted for 35% of variance in somatic symptom severity beyond the effects of sociodemographic variables, body mass index, medical morbidity, and depression severity. Health anxiety accounted for the largest amount of unique variance in somatic symptom severity, potentially supporting the relevance of health anxiety to the presentation of increased somatic symptoms among patients who are obese.

Frequency of somatic symptoms in the general population: Normative values for the Patient Health Questionnaire-15 (PHQ-15)

BACKGROUND

The PHQ-15 is widely used as an open access screening instrument for somatic symptoms in different health care settings. The objectives of the study were to contribute to the construct validity and to generate normative data for the PHQ-15.

METHODS

The survey was conducted in the general population in Germany from August 2011 to November 2014 (n=9250). All participants underwent an extensive core assessment including a set of questionnaires.

RESULTS

Men reported significantly less (p<0.001) physical symptoms than women (4.6 [SD=3.6] vs. 6.3 [SD=4.1]). The PHQ-15 total score was strongly correlated with the physical component of quality of life (r=-0.58), fatigue (r=0.56), anxiety (r=0.54) and sleep problems (r=0.54). While high socioeconomic status was associated with low prevalences of all complaints, obesity was associated with some of the complaints, especially shortness of breath and pain in arms, legs, and joints. Normative data for the PHQ-15 were generated for men and women.

CONCLUSIONS

This investigation confirms the burden caused by somatic symptoms in terms of impaired physical quality of life. In association with psychosocial consequences such as anxiety as well as sleep problems, future studies should also focus on the disease burden of somatic symptoms. In addition, the normative data provide a framework for the interpretation and comparison with other populations.

The combination of health anxiety and somatic symptoms: Specificity to anxiety sensitivity cognitive concerns among patients in primary care

Prior research has found that health anxiety is related to poor patient outcomes in primary care settings. Health anxiety is characterized by at least two presentations: with either severe or no/mild somatic symptoms. Preliminary data indicate that anxiety sensitivity may be important for understanding the presentation of health anxiety with severe somatic symptoms. We further examined whether the combination of health anxiety and somatic symptoms was related to anxiety sensitivity. Participants were adults presenting for treatment at a community health center (N=538). As predicted, the interactive effect between health anxiety and somatic symptoms was associated with anxiety sensitivity cognitive concerns. Health anxiety shared a stronger association with anxiety sensitivity cognitive concerns when coupled with severe, relative to mild, somatic symptoms. Contrary to predictions, the interactive effect was not associated with the other dimensions of anxiety sensitivity. We discuss the potential relevancy of anxiety sensitivity cognitive concerns to the combined presentation of health anxiety and severe somatic symptoms, as well as how this dimension of anxiety sensitivity could be treated in primary care settings.

What Does a Swiss Franc Mortgage Cost? The Tale of Polish Trust for Foreign Currency Denominated Mortgages: Implications for Well-Being and Health

It is commonly agreed that excessive household financial debts are detrimental to psychological and physical health. Research also demonstrates that housing instability, mortgage indebtedness and mortgage foreclosure negatively influence subjective well-being. In Poland at the beginning of 2015, homeowners with Swiss franc denominated mortgages suffered from an abrupt swing in the Swiss franc/Polish zloty (CHF/PLN) exchange rate, which resulted in considerable increase in the local currency value of their mortgages. These adverse financial circumstances were hypothesised to affect not only household finance but also negatively affect the psychological well-being and physical health of peoples. The 2013 and 2015 waves of the Polish representative household panel 'Social Diagnosis' were used to examine impact of the abrupt change in the CHF/PLN exchange rate in Jan. 2015 on well-being and health. Causal inference was investigated using a difference-in-differences matching estimator. Results showed that although impact of Swiss franc appreciation on the mortgage related financial burden was considerable, it did not affect well-being or health outcomes. Any manifestation of adverse effects was absent in the short term, which does not however preclude their long term existence.

The Whiteley Index-6: An Examination of Measurement Invariance Among Self-Identifying Black, Latino, and White Respondents in Primary Care

Brief measures that are comparable across disparate groups are particularly likely to be useful in primary care settings. Prior research has supported a six-item short form of the Whiteley Index (WI), a commonly used measure of health anxiety, among English-speaking respondents. This study examined the measurement invariance of the WI-6 among Black ( n = 183), Latino ( n = 173), and White ( n = 177) respondents seeking treatment at a U.S. community health center. Results supported a bifactor model of the WI-6 among the composite sample ( N = 533), suggesting the presence of a general factor and two domain-specific factors. Results supported the incremental validity of one of the domain-specific factors in accounting for unique variance in somatic symptom severity scores beyond the general factor. Multiple-groups confirmatory factor analysis supported the configural, metric, ands scalar invariance of the bifactor WI-6 model across the three groups of respondents. Results provide support for the measurement invariance of the WI-6 among Black, Latino, and White respondents. The potential use of the WI-6 in primary care, and broader, settings is discussed.

A community-based study of the relationship between somatic and psychological distress in Hong Kong

Although the predominantly somatic presentation of distress has been used to explain low rates of emotional illnesses and health service use in Chinese communities, this concept of somatization has not been examined by concurrently studying the profile of somatically and psychologically distressed Chinese individuals. A random population-based sample of 3014 adults underwent a structured telephone interview that examined their sociodemographic characteristics, somatic distress (Patient Health Questionnaire-15, PHQ-15), non-specific psychological distress (Kessler Scale-6, K6), health service use, and functional impairment. Four groups of individuals identified by PHQ-15 and K6 cut-off scores were compared. Results showed that PHQ-15 and K6 scores were positively correlated. The large majority of respondents (85.9%) reported both somatic and psychological distress. The proportions of Low Distress Group, Somatically Distressed Group, Psychologically Distressed Group, and Mixed Distress Group were 69.2%, 5.0%, 15.8%, and 10.0%, respectively. Specific age range, male gender, greater family income, higher education level, and retirement were associated with decreased odds of somatic and/or psychological distress. Although psychological distress best predicted impairment, somatic distress best predicted health service use. Mixed distress predicted most impairment and health service use. Thus, psychological distress and somatic distress commonly coexist across Chinese sociodemographic groups. This speaks against the conventional notion of somatization and is consistent with recent findings of a higher prevalence of emotional illnesses in Chinese people. That psychologically distressed individuals are more impaired but less inclined to seek help than somatically distressed individuals may partly explain low levels of help-seeking for mental disorders found in epidemiological studies.

The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey

BACKGROUND

Most knowledge of fibromyalgia comes from the clinical setting, where healthcare-seeking behavior and selection issues influence study results. The characteristics of fibromyalgia in the general population have not been studied in detail.

METHODS

We developed and tested surrogate study specific criteria for fibromyalgia in rheumatology practices using variables from the US National Health Interview Survey (NHIS) and the modification (for surveys) of the 2010 American College of Rheumatology (ACR) preliminary fibromyalgia criteria. The surrogate criteria were applied to the 2012 NHIS and identified persons who satisfied criteria from symptom data. The NHIS weighted sample of 8446 persons represents 225.7 million US adults.

RESULTS

Fibromyalgia was identified in 1.75% (95% CI 1.42, 2.07), or 3.94 million persons. However, 73% of identified cases self-reported a physician's diagnosis other than fibromyalgia. Identified cases had high levels of self-reported pain, non-pain symptoms, comorbidity, psychological distress, medical costs, Social Security and work disability. Caseness was associated with gender, education, ethnicity, citizenship and unhealthy behaviors. Demographics, behaviors, and comorbidity were predictive of case status. Examination of the surrogate polysymptomatic distress scale (PSD) of the 2010 ACR criteria found fibromyalgia symptoms extending through the full length of the scale.

CONCLUSIONS

Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. The association of fibromyalgia-like symptoms over the full length of the PSD scale with physiological as well as mental stressors suggests PSD may be a universal response variable rather than one restricted to fibromyalgia.

Mucosal-associated invariant T cell is a potential marker to distinguish fibromyalgia syndrome from arthritis

BACKGROUND

Fibromyalgia (FM) is defined as a widely distributed pain. While many rheumatologists and pain physicians have considered it to be a pain disorder, psychiatry, psychology, and general medicine have deemed it to be a syndrome (FMS) or psychosomatic disorder. The lack of concrete structural and/or pathological evidence has made patients suffer prejudice that FMS is a medically unexplained symptom, implying inauthenticity. Furthermore, FMS often exhibits comorbidity with rheumatoid arthritis (RA) or spondyloarthritis (SpA), both of which show similar indications. In this study, disease specific biomarkers were sought in blood samples from patients to facilitate objective diagnoses of FMS, and distinguish it from RA and SpA.

METHODS

Peripheral blood mononuclear cells (PBMCs) from patients and healthy donors (HD) were subjected to multicolor flow cytometric analysis. The percentage of mucosal-associated invariant T (MAIT) cells in PBMCs and the mean fluorescent intensity (MFI) of cell surface antigen expression in MAIT cells were analyzed.

RESULTS

There was a decrease in the MAIT cell population in FMS, RA, and SpA compared with HD. Among the cell surface antigens in MAIT cells, three chemokine receptors, CCR4, CCR7, and CXCR1, a natural killer (NK) receptor, NKp80, a signaling lymphocyte associated molecule (SLAM) family, CD150, a degrunulation marker, CD107a, and a coreceptor, CD8β emerged as potential biomarkers for FMS to distinguish from HD. Additionally, a memory marker, CD44 and an inflammatory chemokine receptor, CXCR1 appeared possible markers for RA, while a homeostatic chemokine receptor, CXCR4 deserved for SpA to differentiate from FMS. Furthermore, the drug treatment interruption resulted in alternation of the expression of CCR4, CCR5, CXCR4, CD27, CD28, inducible costimulatory molecule (ICOS), CD127 (IL-7 receptor α), CD94, NKp80, an activation marker, CD69, an integrin family member, CD49d, and a dipeptidase, CD26, in FMS.

CONCLUSIONS

Combined with the currently available diagnostic procedures and criteria, analysis of MAIT cells offers a more objective standard for the diagnosis of FMS, RA, and SpA, which exhibit multifaceted and confusingly similar clinical manifestations.

Somatic symptom burden and health anxiety in the population and their correlates

OBJECTIVE

Somatic symptom burden and health anxiety demonstrate overlapping clinical characteristics but their relationship in the general population is unclear. This study examined the association between these dimensions after adjustment for confounders and their respective correlation with outcome measures.

METHODS

A randomly selected population-based sample of 3014 respondents aged 15-65 was interviewed by telephone using a structured questionnaire that included the 15-item Patient Health Questionnaire (PHQ-15), Whiteley-7, Kessler-6, Sheehan Disability Scale, socio-demographic variables and items regarding health care utilization. Respondents who scored 10 or above on PHQ-15 and 4 or above on Whiteley-5 were regarded as having high somatic symptom burden and high health anxiety respectively.

RESULTS

Somatic symptom burden and health anxiety are moderately correlated after adjustment for confounders (p<.001). Both have important effects on psychological distress, functional impairment and health care utilization independent of each other (ps<.001). A considerable number of respondents (5.7%) reported both high somatic symptom burden and high health anxiety and this group showed the greatest general psychological distress, functional impairment and health care utilization.

CONCLUSION

This study demonstrates the close association of somatic symptom burden and health anxiety but also their independent association with psychological distress, functional impairment and health care utilization. The findings support the concept of the DSM-5 category of somatic symptom disorder, but also demonstrate that individuals with high somatic symptom burden or high health anxiety alone may merit separate diagnoses. More sophisticated studies of the relationship between somatic symptom burden and health anxiety are needed.

Symptoms, the nature of fibromyalgia, and diagnostic and statistical manual 5 (DSM-5) defined mental illness in patients with rheumatoid arthritis and fibromyalgia

Purpose

To describe and evaluate somatic symptoms in patients with rheumatoid arthritis (RA) and fibromyalgia, determine the relation between somatization syndromes and fibromyalgia, and evaluate symptom data in light of the Diagnostic and Statistical Manual-5 (DSM-5) criteria for somatic symptom disorder.

Methods

We administered the Patient Health Questionnaire-15 (PHQ-15), a measure of somatic symptom severity to 6,233 persons with fibromyalgia, RA, and osteoarthritis. PHQ-15 scores of 5, 10, and 15 represent low, medium, and high somatic symptom severity cut-points. A likely somatization syndrome was diagnosed when PHQ-15 score was ≥10. The intensity of fibromyalgia diagnostic symptoms was measured by the polysymptomatic distress (PSD) scale.

Results

26.4% of RA patients and 88.9% with fibromyalgia had PHQ-15 scores ≥10 compared with 9.3% in the general population. With each step-wise increase in PHQ-15 category, more abnormal mental and physical health status scores were observed. RA patients satisfying fibromyalgia criteria increased from 1.2% in the PHQ-15 low category to 88.9% in the high category. The sensitivity and specificity of PHQ-15≥10 for fibromyalgia diagnosis was 80.9% and 80.0% (correctly classified = 80.3%) compared with 84.3% and 93.7% (correctly classified = 91.7%) for the PSD scale. 51.4% of fibromyalgia patients and 14.8% with RA had fatigue, sleep or cognitive problems that were severe, continuous, and life-disturbing; and almost all fibromyalgia patients had severe impairments of function and quality of life.

Conclusions

All patients with fibromyalgia will satisfy the DSM-5 “A” criterion for distressing somatic symptoms, and most would seem to satisfy DSM-5 “B” criterion because symptom impact is life-disturbing or associated with substantial impairment of function and quality of life. But the “B” designation requires special knowledge that symptoms are “disproportionate” or “excessive,” something that is uncertain and controversial. The reliability and validity of DSM-5 criteria in this population is likely to be low.

The Combination of Health Anxiety and Somatic Symptoms: Examining Associations With Health-Related Beliefs and Gender Differences

Current diagnostic criteria suggest that some individuals experience health anxiety and severe somatic symptoms, whereas others experience health anxiety and either no or mild somatic symptoms. However, to date, our understanding of potential differences among individuals with health anxiety and varying severity of somatic symptoms remains limited. Adopting a dimensional approach, we completed this study to help fill this gap in the literature by examining whether the interactive effect between health anxiety and somatic symptoms was related to health-related beliefs among men (n = 211) and women (n = 220). Among both men and women, health anxiety was related to certain health-related beliefs, particularly anxiety sensitivity, only when coupled with severe somatic symptoms. Conceptual and therapeutic implications of these results are discussed.

Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population

OBJECTIVE

To evaluate fibromyalgia in the general population with emphasis on prevalence, dimensionality, and somatic symptom severity.

METHODS

We studied 2,445 subjects randomly selected from the German general population in 2012 using the American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia, as modified for survey research, and the polysymptomatic distress scale (PSD). Anxiety, depression, and somatic symptom severity were assessed with the Patient Health Questionnaire (PHQ) series, and measures of symptoms and quality of life were assessed with the European Organization for Research and Treatment of Cancer questionnaire.

RESULTS

The prevalence of fibromyalgia was 2.1% (95% confidence interval [95% CI] 1.6, 2.7), with 2.4% (95% CI 1.5, 3.2) in women and 1.8% (95% CI 1.1, 2.6) in men, but the difference was not statistically significant. Prevalence rose with age. Fibromyalgia subjects had markedly abnormal scores for all covariates. We found smooth, nondisordered relationships between PSD and all predictors, providing additional evidence against the hypothesis that fibromyalgia is a discrete disorder and in support of a dimensional or spectrum disorder. There was a strong correlation (r = 0.790) between the PSD and the PHQ somatic symptom severity scale; 38.5% of persons with fibromyalgia satisfied the proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for a physical symptom disorder.

CONCLUSION

The modified 2010 diagnostic criteria do not result in high levels of fibromyalgia. PSD and fibromyalgia are strongly related to somatic symptom severity. There is evidence in support of fibromyalgia as a dimensional or continuum disorder. This has important ramifications for neurobiologic and epidemiology research, and for clinical diagnosis, treatment, and ascertainment of disability.

Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population

BACKGROUND

The PHQ-15 is widely used as an open access screening instrument for somatization syndromes in different health care settings, thus far, normative data from the general population are not available. The objectives of the study were to generate normative data and to further investigate the construct validity of the PHQ-15 in the general population.

METHODS

Nationally representative face-to face household surveys were conducted in Germany between 2003 and 2008 (n=5,031). The survey questionnaires included, the 15-item somatization module from the Patient Health Questionnaire (PHQ-15), the 9-item depression module (PHQ-9), the Satisfaction With Life Scale (SWLS), the SF-12 for the measurement of health related quality of life, and demographic characteristics.

RESULTS

Normative data for the PHQ-15 were generated for both genders and different age levels including 5031 subjects (53.6% female) with a mean age (SD) of 48.9 (18.1) years. Somatization syndromes occured in 9.3% of the general population. Women had significantly higher mean (SD) scores compared with men [4.3 (4.1) vs. 3.4 (4.0)]. Intercorrelations with somatization were highest with depression, followed by the physical component summary scale of health related quality of life.

CONCLUSIONS

The normative data provide a framework for the interpretation and comparisons of somatization syndromes with other populations. Evidence supports reliability and validity of the PHQ-15 as a measure of somatization syndromes in the general population.

A cross-sectional study of somatic symptoms and the identification of depression among elderly primary care patients

OBJECTIVE

To examine the relationship between somatization and depression as rated by primary care physicians.

METHOD

This study was a cross-sectional survey of 355 older adults with and without significant depressive symptoms. Physicians' ratings of somatization and depression were obtained for 341 of the 355 patients. Patients were sorted into 4 groups on the basis of physician ratings (no depression/no somatization, somatization only, depression only, and both somatization and depression). Data were collected from 2001-2003.

RESULTS

Patients who were rated as somatizing were 4.03 (95% CI, 2.52-6.45) times as likely to be rated as depressed as well as somatizing. A comparison of the 4 groups defined by physicians' ratings found that functional status, ethnicity, number of medical conditions, depressive symptoms, and anxiety were statistically significantly different (P < .05). Primary care physicians were 3.95 (95% CI, 1.53-10.16) times more likely to identify older black patients as somatizing only versus depressed and somatizing compared to older white patients among patients above a threshold on a standard depression instrument.

CONCLUSIONS

Our study fills a gap in the literature by focusing on the primary care physician ratings of depression and somatization, and also specifically on older primary care patients. Blacks are less likely to be rated as depressed, but this may reflect the tendency of doctors to rate them as somatizing.

Psychometric properties of the Turkish version of the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms

OBJECTIVE

In this study, we examined the psychometric properties of the Turkish version of the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms (PHQ-SADS) developed by Kroenke, Spitzer, and Williams.

METHOD

This study sample consisted of 200 outpatients admitted to Erenköy Mental Health Training and Research Hospital, Erenköy Physiotherapy and Rehabilitation Hospital, and Kartal Training and Research Hospital and 240 graduate students in Karadeniz Technical University. Participants were administered the 90-item Symptoms Checklist (SCL-90R) and the 7-item Whiteley Index, along with the PHQ-SADS. A month later, the PHQ-SADS was readministered to 60 of the students. To investigate the internal consistency of the scale and its subscales, corrected item-total correlations were examined to establish the effect on the Cronbach coefficients and internal consistency of each item of the subscales. Test-retest correlations were also analyzed for reliability. Factorial structure was investigated using principal component analysis. The validity of distinguishing congruent and specific groups was also investigated for validity.

RESULTS

Total scores on the scale showed an adequate test-retest consistency (r = 0.54, 0.52, and 0.76, respectively). All items showed adequate correlations (r > 0.26) in the test-retest analysis. Cronbach α values were 0.86 (control), 0.93 (patient), and 0.92 (total) on the test of internal consistency. When the questions were analyzed individually, the item-total correlation for item 7 of the PHQ somatization subscale was found to be inadequate in the control group. Exploratory factorial analysis and varimax rotation results showed that the scale provided a 4-factor structure. In the validity analysis, a significant difference between the patient and the control group mean values was determined. The SCL-90R, 7-item Whiteley Index, and SCL-90R somatization subscales were found to be sufficiently related to the number of symptoms to establish criterion-related validity.

CONCLUSION

Findings with respect to internal consistency, test-retest consistency, item-total correlation, factorial structure, distinguishing validity for specific groups, and criterion-related validity for the PHQ-SADS show that the scale is acceptable in terms of validity and reliability for the Turkish population.

A general population study of the Chinese Whiteley-7 index in Hong Kong

OBJECTIVE

To examine the psychometric properties of the Chinese seven-item Whiteley Index (WI-7) in the general population of Hong Kong.

METHODS

A random community-based telephone survey of 3014 respondents aged 15-65 was conducted using a fully structured questionnaire that included the WI-7, 15-item Patient Health Questionnaire (PHQ-15), Sheehan Disability Scale (SDS), and items about the frequency of health service use, perceived helpfulness of doctors, level of satisfaction with doctors, and sociodemographic variables. A sub-sample of 199 respondents was re-interviewed to assess test-retest reliability.

RESULTS

The WI-7 exhibited satisfactory internal consistency (Cronbach's α=0.73) and stable one-month test-retest reliability. The most commonly endorsed item was "worrying a lot about one's health" (55.7%), followed by "worrying about getting the disease oneself if it is brought to his/her attention" (48.7%) and "bothered by many different pains and aches" (33.9%). Age, gender, and monthly family income significantly predicted WI-7 score. Confirmatory factor analysis revealed that a 2-factor structure was superior to a 1-factor structure in fitting the data. WI-7 total score was positively associated with PHQ-15 somatic distress, SDS impairment, number of healthcare visits, lower levels of perceived helpfulness of doctors and of satisfaction with doctors.

CONCLUSION

The Chinese WI-7 exhibits satisfactory reliability and internal validity in a general population. It is a promising tool for the empirical examination of health anxiety which is a common experience with a mostly typical epidemiological profile among Chinese people in Hong Kong.

Mental disorders among frequent attenders in primary care: a comparison with routine attenders

Frequent attenders account for a large proportion of primary care (PC) contacts, referrals, and prescriptions. Psychosocial and emotional distress is related to the high use of health services. Few studies have focused on the association between mental disorders assessed using structured interviews and frequent use of PC services.The aim of this study was to determine the factors associated with frequent attendance at primary healthcare units, focusing specifically on mental disorders. A two-phase screening epidemiological study comparing frequent attenders and routine attenders in five primary health care units was designed. Three hundred eighteen frequent attenders and 203 patients who attended the same units on a routine basis were compared. Sociodemographic and clinical data were obtained from statistical records and medical charts. Patients with a total score equal or higher than 7 points on the General Health Questionnaire-28 (GHQ-28) were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry. All the scores obtained on the GHQ were statistically different in the two populations. Frequency of mental disorders also differed significantly between both groups, with somatoform and affective disorders being the most prevalent ICD-10 categories among frequent attenders. The presence of depressive disorders and somatoform disorders is the most powerful predictive factor for frequent attendance. High comorbidity was found among frequent attenders with somatoform disorder. Frequent attendance at primary healthcare units is associated with depressive and somatoform disorders. Psychiatric comorbidity could be a confounder, particularly because affective and somatoform disorders often overlap in PC patients.

Classification characteristics of the Patient Health Questionnaire-15 for screening somatoform disorders in a primary care setting

BACKGROUND

This study examines how effectively the Patient Health Questionnaire-15 (PHQ-15), a self-administered screening instrument, recognizes somatoform symptoms and somatoform disorders in a German primary care setting.

METHODS

A selected sample of 308 patients (mean age 47.2 years, 71.4% women) from two regular primary care practices was screened with the PHQ-15 and additionally examined with structured interviews. Their primary care physicians rated symptoms reported in the interview as either "medically explained" or "medically unexplained."

RESULTS

Seventy-six percent of the symptoms were judged as medically unexplained. The PHQ-15 correlated significantly with the total number of symptoms as well as the number of somatoform symptoms (both r=0.63; P≤.001). A comparison between the most frequently reported symptoms in the interview and the 15 items of the PHQ-15 revealed that even though the PHQ-15 does not differentiate between medically explained and medically unexplained symptoms, it does catch many somatoform symptoms. When used to predict the diagnosis of a somatoform disorder, a cutoff of 10 points in the PHQ-15 was identified as optimal, resulting in a sensitivity of 80.2% and specificity of 58.5%. However, the cutoff has to be adjusted according to specific research or clinical purposes.

CONCLUSION

Several previous results could be confirmed, and under consideration of some limitations, the PHQ-15 seems to be a valuable tool for identifying somatoform symptoms and disorders in primary care.

Psychometric properties of the Chinese 15-item patient health questionnaire in the general population of Hong Kong

OBJECTIVE

The objective was to examine the reliability and validity of the Chinese 15-item Patient Health Questionnaire (PHQ-15) in the general population of Hong Kong.

METHODS

A random community-based sample of 3014 respondents aged 15-65 was interviewed through telephone using a structured Chinese-language questionnaire that included the PHQ-15, Sheehan Disability Scale, questions about health service use and sociodemographic variables. A random subsample of 200 respondents was reinterviewed for assessing test-retest reliability.

RESULTS

The PHQ-15 exhibited satisfactory internal consistency (Cronbach's α=0.79) and stable 1-month test-retest reliability. Being female, younger age, lower education and lower income levels were associated with higher scores. "Bothered a lot" somatic symptoms were less common than in clinical studies, but their general profile was comparable to those found in Western community studies. Pains in the limbs, trouble sleeping and feeling tired (11.2%-16.9%) were the most common, whereas fainting spells and sexual problems (0.6%-0.7%) were the least so. Using principal component analysis, we extracted four clinically meaningful factors that explained 49.7% of the variance. These factors might be termed "cardiopulmonary," "gastrointestinal," "pain" and "neurological." Somatic symptom severity was positively associated with functional impairment and health service use.

CONCLUSION

The Chinese PHQ-15 exhibits satisfactory reliability and preliminary evidence of validity in a general population. Revealing a typical profile of somatic symptom severity, it is a promising tool for the empirical examination of somatization in Chinese people.

Somatic symptoms in patients with cancer experiencing pain or depression: prevalence, disability, and health care use

BACKGROUND

The adverse impact of a high somatic symptom burden is well established for primary care and other noncancer populations with chronic medical disorders.

METHODS

This study examines the impact of somatic symptom burden on disability and health care use in patients with cancer experiencing pain, depression, or both. We performed secondary analyses of baseline data from 405 patients with cancer enrolled in a telecare management trial for pain or depression. Somatic symptom burden was measured using a 22-item scale. Multivariable models were conducted to determine the association of somatic symptom burden with the Sheehan Disability Scale (SDS) score, the number of self-reported disability days in the past 3 months, and health care use. Models were adjusted for sociodemographic characteristics, medical comorbidity, and depression and pain severity.

RESULTS

Somatic symptoms were highly prevalent, with 15 of the 22 symptoms reported by more than 50% of patients. The somatic symptom burden was similar across different types and phases of cancer. The mean SDS score (scored 0-10 [not at all disabled to unable to carry out any activities]) was 5.4, and the mean number of self-reported disability days in the past 4 weeks was 16.9. In multivariable models, somatic symptom burden was associated with SDS score (P < .001) and the likelihood of at least 14 disability days in the past 4 weeks (odds ratio, 1.51; 95% confidence interval, 1.19-1.92) but not with increased health care use.

CONCLUSIONS

The somatic symptom burden is high in patients with cancer who experience pain or depression. Given the strong association with disability and the high prevalence of many types of symptoms, recognizing and managing somatic symptoms may be important in improving quality of life and functional status regardless of type or phase of cancer. Trial Registration clinicaltrials.gov Identifier: NCT00313573.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Screening for multiple somatic complaints in a population-based survey: does excessive symptom reporting capture the concept of somatic symptom disorders? Findings from the MONICA-KORA Cohort Study

OBJECTIVE

Excessive symptom reporting (ESR) has gained a revived attention in the conceptualization of somatic symptom disorders. We aimed to explore whether ESR captures the concept of somatic symptom disorders regardless of the patient's disease status or the degree of symptom burden.

METHODS

In three independent cross-sectional population-based samples of the MONICA/KORA Study in 1985, 1990, and 1995, somatic symptom reporting and an array of somatic and mental health features were assessed in 11,895 eligible participants. After a mean 12-year follow-up, the vital status was assessed at the end of 2002. All-cause mortality was calculated as hazard risks ratios (HRs).

RESULTS

Among all participants, a total of 1238 men and 1169 women were in the sex-specific upper quintile of the somatic symptom distribution and qualified for ESR subpopulation. ESR participants were older, on a lower educational level, and more often unemployed. They suffered more often from metabolic syndrome and chronic diseases. ESR was associated with psychological distress, negative self-perceived health, and sleeping disorders. ESR was associated with twofold more ambulant and hospital medical utilization. Survival in ESR participants was significantly reduced (HR=1.33; 95% CI=1.18-1.49; P<.001). Frequency of medical ambulatory consultations and days in hospital were higher in ESR participants, even after controlling for potential confounders.

CONCLUSION

A simple approach to screen for participants with high symptom reporting in an unselected population-based sample results in the identification of a clinically meaningful target population with high burden of physical and psychological comorbidities.

Responsiveness of motor and nonmotor symptoms of Parkinson disease to dopaminergic therapy

BACKGROUND

The duration of clinical control of motor symptoms of Parkinson disease (PD) treated with levodopa/carbidopa preparations eventually starts to shorten, a phenomenon known as end-of-dose "wearing off." The involvement of core nonmotor symptoms of "wearing off" (depressed mood, pain/aching, anxiety, and cloudy/slowed thinking) is not well understood.

METHODS

A post hoc analysis from a study to validate the self-rated 9-item, Wearing-Off Questionnaire (WOQ-9), which was designed to identify motor and nonmotor symptoms of "wearing off" in PD patients, was performed to compare the frequency and sensitivity of motor and nonmotor symptoms of "wearing off" from dopaminergic therapy.

RESULTS

Analysis of responses to the WOQ-9 from 216 PD patients found that individual nonmotor symptoms were reported by 25% to 50% and motor symptoms by 55% to 80% of patients. Individual nonmotor symptoms improved following the next dose of dopaminergic therapy in 43% to 53% of the patients who presented with such symptoms, whereas motor symptoms improved in 48% to 66% of the cases, suggesting both types of symptoms respond to dopaminergic therapies.

CONCLUSION

Nonmotor symptoms of PD appear sensitive to dopaminergic treatment. These symptoms resemble those seen with depressive, anxiety, and somatoform disorders suggesting potential shared mechanisms as well as possible treatment implications.

The unbearable lightness of somatisation: a systematic review of the concept of somatisation in empirical studies of pain

Somatisation is often invoked to explain pain and suffering in patients. Lipowski [34] defined somatisation as "a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them" (p. 1359). His concept is widely accepted. This study investigated to what extent this conceptualisation is used in the empirical studies of pain. Studies were identified through searches from Web of Science, Pubmed and Psychinfo databases for the period from 1989 until 2007. Screening an initial set of 1020 articles resulted in 120 articles fulfilling inclusion criteria. One hundred and sixteen articles were retrieved and coded in terms of the conceptualisation of Lipowski [34]. All studies had a measure of somatic symptoms, most often questionnaires. Whether the symptoms were unaccounted for by pathological findings was rarely investigated. No study assessed whether the participants attributed the somatic complaints to physical illness. Most studies included patients seeking help in a clinical setting, but only one study investigated whether patients were seeking help for the somatisation complaints. In conclusion, no study fulfilled the construct criteria as defined by Lipowski [34]. Most studies focus upon the extent and diversity of somatic complaints. We recommend that researchers who use self-report instruments do not use the term "somatisation" (even if the instrument is labeled as a "somatisation" scale), but use the term "multiple physical symptoms" instead. The current operational use may unduly lead to a "psychologisation" of physical complaints.

Detecting somatoform disorders in primary care with the PHQ-15

PURPOSE

Because recognition and management of patients with somatoform disorders are difficult, we wanted to determine the specificity, sensitivity, and the test-retest reliability of the 15-symptom Patient Health Questionnaire (PHQ-15) for detection of somatoform disorders in a high-risk primary care population.

METHODS

We studied the performance of the PHQ-15 in comparison with the Structured Clinical Interview for the Diagnostic and Statistical Manual-IV Axis I disorders (SCID-I) as a reference standard. From January through September 2006, we approached patients for participation. This study was conducted in primary care settings in the Netherlands. Patients aged between 18 and 70 years were eligible if they belonged to 1 or more of the following groups: (1) patients with unexplained somatic complaints, (2) frequent attenders, and (3) patients with mental health problems. For the SCID-I interview we invited all patients with a PHQ-15 score of 6 or greater and a random sample of 30% of patients with a PHQ-15 score of less than 6. The primary study outcomes were the sensitivity and specificity for the validity and the kappa coefficient for the test-retest reliability.

RESULTS

Of 2,147 eligible patients, 906 (42%) participated (mean age 48 years, 62% female). At a cutoff level of 3 or more severe somatic symptoms during the past 4 weeks, sensitivity was 78% and specificity 71%. The test-retest reliability was 0.60.

CONCLUSIONS

The PHQ-15 is a valid and moderately reliable questionnaire for the detection of patients in a primary care setting at risk for somatoform disorders.

Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment

OBJECTIVE

To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment.

METHOD

Two thousand ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment.

RESULTS

In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment.

CONCLUSIONS

Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.