Psychometric properties of the stagnation scale in medication overuse headache patients

Major Depression in Chinese Medicine Outpatients with Stagnation Syndrome: Prevalence and the Impairments in Well-Being

Stagnation syndrome, a diagnostic entity in traditional Chinese medicine (TCM), has been long regarded as the TCM counterpart of major depression in Western medicine. The study investigated the prevalence of major depression among stagnation syndrome patients and evaluated their well-being and functioning outcomes. In total, 117 patients diagnosed with stagnation syndrome were measured using Stagnation Scale, the Patient Health Questionnaire-9 (PHQ-9), and the Body-Mind-Spirit Well-Being Inventory. Results indicate major depression among stagnation syndrome patients was characterized by a high co-occurrence rate and worse physical, mental, and functional outcomes. More than one-quarter (26.5%) of the patients met the DSM-V diagnostic criteria for major depression and over half (53%) exceeded the PHQ-9 cutoff (score above 10) for moderate/severe depression symptoms. The wellness of the stagnation syndrome patients was worse (M = 298.2, SD = 66.5) than that of the general population (M = 360.9, SD = 79.9), with a large Cohen's d value of 0.9. The “wellness outlook” of the depressed stagnation syndrome patients appeared grimmer (M = 252.3, SD = 52.2). The correlation between stagnation and depression was higher for affective symptoms than somatic symptoms. Physical distress did not mediate the relationship between stagnation and daily functioning. These might suggest that stagnation syndrome and major depression may share some similar psychological mechanisms.

A Brief Body-Mind-Spirit Group Therapy for Chinese Medicine Stagnation Syndrome: A Randomized Controlled Trial

BACKGROUND

Stagnation syndrome, a diagnostic entity in traditional Chinese medicine (TCM), is characterized by mind-body obstruction-like symptoms. Although TCM has long-established symptom-relief treatments, a comprehensive mind-body intervention was called for.

PURPOSE

The study evaluated the efficacy of a six-session body-mind-spirit (BMS) group therapy for persons with stagnation syndrome.

METHOD

A 2-arm randomized controlled trial design was adopted. The control group received a parallel general TCM instruction course. Both groups completed a pretest (T0), posttest (T1), and 2-month follow-up assessment (T2). The measures included self-report scales on stagnation, depression, anxiety, physical distress, daily functioning, and positive and negative affect; the other measure was of salivary cortisol, a biological marker of stress.

RESULTS

Data on 111 adults with stagnation syndrome were included in the analysis. Completion rates were high (over 87%) for both the intervention and control groups. Repeated-measures multivariate MANOVA revealed a significant combined effect with large effect size (eta-squared = 0.42). Repeated-measures ANOVA further revealed that the intervention group showed significant improvements in stagnation, the primary outcome, with medium effect size (eta-squared = 0.11). The intervention group also showed significant improvements in depression, physical distress, everyday functioning, and negative affect (eta-squared = 0.06 to 0.13). Post hoc analysis revealed that the intervention group showed significant improvements over the control group in cortisol level at 2-month follow-up assessment (T0 versus T2) with small effect size (eta-squared = 0.05), but not at posttest (T0 versus T1).

CONCLUSIONS

Overall, the findings indicate that our brief BMS group therapy intervention for stagnation syndrome is efficacious. Moreover, the intervention resulted in a number of substantial improvements in the physical and mental health domains.

Depression and anxiety behaviour in a rat model of chronic migraine

Background

Epidemiological and clinical studies have demonstrated comorbidity between migraine and affective disorders. However, it is unclear whether chronic migraine can lead to affective disorders in other animals.

Methods

A classical chronic migraine rat model (repeated dura mater inflammatory soup [IS] infusion) was used to evaluate depression and anxiety behaviour via weight, sucrose preference test, open field test and elevated plus maze test.

Results

We found that sucrose preference, locomotor and rearing behaviours, inner zoon distance percent, open-arm entries percent and serotonin and dopamine levels in the prefrontal cortex decreased significantly in the IS group compared with those in the control group; co-administration of low-dose amitriptyline ameliorated these deficits. However, no differences in weight, inner zone time percent, or open-arm time percent between the IS and control groups. These results were used to create new depression and anxiety scales to comprehensively assess and evaluate the degree of affective disorders in rats. Most of chronic migraine animals showed depression and anxiety like behaviors but a few didn’t.

Conclusions

Most of the chronic migraine rats were present depression and anxiety like behaviors. The new scales we created are expected to use in the future studies to find out the potential mechanism of affective disorders’ comorbidity.

The psychometric properties of the Comprehensive Headache-related Quality of life Questionnaire (CHQQ) translated to Serbian

Background

The Comprehensive Headache-related Quality of life Questionnaire (CHQQ), is a recently developed and validated instrument, intended for measuring quality of life of patients with all headache types. Currently no validated headache-specific quality of life questionnaires are available in Serbian. The aim of this study was to translate the CHQQ from Hungarian to Serbian, to make necessary cultural adaptations and to test its psychometric properties in a sample of outpatients with headache.

Methods

The CHQQ was translated and adapted according to internationally accepted guidelines, and then tested on a sample of 216 Serbian headache patients (171 females and 45 males, mean age 42.3 years/SD 13.35; range 18–75). The majority of patients suffered from episodic tension-type headache (TTH); 27 (12.5 %) had episodic migraine. We calculated the internal consistency (Cronbach’s alpha), criterion validity (correlations of individual items, dimensions and whole questionnaire with the clinical characteristics of headache), convergent validity (correlations of the abovementioned scores with results of other instruments measuring headache severity and impact), and discriminative validity (comparison of the scores in the two diagnostic groups) of the CHQQ. We used factor analysis to explore the underlying construct.

Results

The Serbian translation of CHQQ showed excellent internal consistency, both for the whole instrument (Cronbach’s alpha 0.937) and its dimensions. The validity of the instrument in all aspects (criterion, convergent and discriminative validity) was also excellent when the whole sample and the subgroup of patients with TTH were analyzed, while the results for patients with migraine were less favorable. Factor analysis suggested the existence of a single dimension in this sample.

Conclusions

The Serbian translation of CHQQ is as reliable and valid specific instrument for measuring headache-related quality of life in patients with TTH and probably in patients with migraine.

Depression and insomnia are independently associated with satisfaction and enjoyment of life in medication-overuse headache patients

Objective Medication-overuse headache is often comorbid with emotional disturbances and disordered personality traits. The aim of the present study was to determine whether depression and insomnia complaints were associated with satisfaction and enjoyment with one's own life in medication-overuse headache patients, and whether insomnia complaints were able to explain part of the variance of Quality of Life explained by depression. Methods Participants were 187 consecutive adult outpatients admitted to the Regional Referral Headache Centre of the Sant'Andrea Hospital in Rome, Italy. Patients were administered the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Depression Inventory - II, and the Athens Insomnia Scale. Results The Beck Depression Inventory was associated with all the dimensions of the Quality of Life Enjoyment and Satisfaction Questionnaire, with more severe depression being associated independently with lower satisfaction and enjoyment with one's own life. The Athens Insomnia Scale was independently and significantly associated only with physical health, such that patients with more insomnia complaints were 3.1 times ( p < 0.001) more likely to report lower physical health satisfaction. Conclusions Our findings confirmed that medication-overuse headache patients has a negative impact on quality of life and suggested that depression and insomnia were independently associated with satisfaction and enjoyment of life in medication-overuse headache patients. The early recognition and appropriate treatment of comorbid psychopathological symptoms are crucial to improve satisfaction and enjoyment of life in medication-overuse headache patients.

Headache: an important factor associated with muscle soreness/pain at the two-year follow-up point among patients with major depressive disorder

BACKGROUND

No study has compared the associations of headache, anxiety, and depression at baseline with muscle soreness or pain (MS/P) at baseline and at the two-year follow-up point among outpatients with major depressive disorder (MDD). This study aimed to investigate the above issue.

METHODS

This study enrolled 155 outpatients with MDD at baseline, and 131 attended a two-year follow-up appointment. At baseline, migraine was diagnosed based on the International Classification of Headache Disorders, 2(nd) edition. MDD and anxiety disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR. The visual analog scale was used to evaluate the intensities of headache and MS/P in the neck, shoulder, back, upper limbs, and lower limbs. Depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale. Multiple linear regressions were used to compare the associations of these factors with MS/P.

RESULTS

Compared with anxiety disorders, migraine was more strongly associated with MS/P in all areas at baseline and in the upper and lower limbs at follow-up. Headache intensity at baseline was the factor most strongly associated with MS/P in all areas at baseline and follow-up after controlling for depression and anxiety. Headache intensity at baseline predicted MS/P at baseline and follow-up.

CONCLUSIONS

Migraine and headache intensity are important factors related to MS/P at baseline and follow-up among patients with MDD. Integrating depression and headache treatment might be indicated to improve MS/P.

Impact of depression and anxiety on burden and management of episodic and chronic headaches - a cross-sectional multicentre study in eight Austrian headache centres

BACKGROUND

Recurrent and especially chronic headaches are associated with psychiatric comorbidities such as depression and anxiety. Only few studies examined the impact of depression and anxiety on episodic (EH) and chronic headache (CH), and data for Austria are missing at all. Therefore, the aim of the present study was to assess the impact of depression and anxiety on burden and management of EH and CH in patients from eight Austrian headache centres.

METHODS

We included 392 patients (84.1 % female, mean age 40.4 ± 14.0 years) who completed the Eurolight questionnaire. The treating physician recorded details about ever-before prophylactic medications. We used Hospital Anxiety and Depression Scale to assess depression and anxiety and compared patients with anxiety and/or depression to those without.

RESULTS

Depression and anxiety were more common in CH than in EH (64 % vs. 41 %, p < 0.0001). Presence compared to absence of depression and anxiety increased the prevalence of poor or very poor quality of life from 0.7 % to 13.1 % in EH and from 3.6 % to 40.3 % in CH (p = 0.001; p < 0.0001). Depression and anxiety had a statistically significant impact on employment status and on variables related to the burden of headache such as reduced earnings, being less successful in career, or feeling less understood. Neither in EH nor in CH health care use and the ever-before use of prophylactic medication was correlated with anxiety and/or depression.

CONCLUSION

Depression and anxiety have a significant impact on quality of life and increase the burden in patients with EH and CH. Improved multidimensional treatment approaches are necessary to decrease disability on the personal, social and occupational level in these patients.

Coping strategies among adolescents with chronic headache and mental health problems: a cross-sectional population-based study

To examine prevalence of mental health problems among adolescents with chronic headache and compare internal and external coping strategies in young people with chronic headaches with and without mental health problems. This study is based on a cross-sectional survey undertaken in Akershus County in Norway. A total of 19,985 adolescents were included in the study, covering lower secondary and upper secondary students, aged 13-19 years. Chronic headache was measured with a single item question based on headache frequency. Mental health was assessed by using the strengths and difficulties questionnaire (SDQ). Internal and external coping strategies were assessed through seven options for answering the question: What do you do/what happens when you are burdened by painful thoughts and feelings? Adolescents with chronic headaches showed more frequent mental health problems overall (23 %) compared to those without chronic headache (6 %). Logistic regression analyses showed that those adolescents having both chronic headaches and comorbid mental health problems more frequently used internal coping strategies, such as keeping feelings inside (OR 2.05), using abusive substances (OR 1.79) and talking oneself out of problems (OR 1.55), compared to those without mental health problems. Groups with mental health problems, especially with chronic headache, less frequently used the external strategy of talking to others about their problem than controls (OR 0.7-0.8). Factor analyses revealed significant differences in profiles of coping strategies between groups. We suggest that attention should be paid towards the high risk group that has both chronic headaches and mental health problems and their tendency to use destructive internal coping strategies.

Validation of the Patient Health Questionnaire-9 (PHQ-9) and PHQ-2 in patients with migraine

Background

Psychiatric problems have been commonly reported in patients with migraine. This study investigated the reliability and validity of the Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire-9 (PHQ-2) in patients with migraine.

Methods

Patients with migraine (with or without aura) were consecutively recruited from our headache clinic. They completed several instruments, including the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI), the PHQ-9, the Beck Depression Inventory-II (BDI-II), the Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test-6 (HIT-6), and the Migraine-Specific Quality of Life (MSQoL).

Results

Among 132 participants, 39 patients (29.5 %) had a major depressive disorder (MDD) as determined by the MINI. Cronbach’s α coefficients for the PHQ-9 and PHQ-2 were 0.894 and 0.747, respectively. At a cutoff score of 7, the PHQ-9 had a sensitivity of 79.5 %, a specificity of 81.7 %, a positive predictive value (PPV) of 64.6 %, and a negative predictive value (NPV) of 90.5 %. At a cutoff score of 2, the PHQ-2 had a sensitivity of 66.7 %, a specificity of 90.3 %, a PPV of 74.3 %, and a NPV of 86.6 %. The scores of the PHQ-9 and PHQ-2 well correlated with the BDI-II score, the MIDAS score, the HIT-6 score, and the MSQoL score.

Conclusions

The PHQ-9 and PHQ-2 are both reliable and valid screening instruments for MDD in patients with migraine.

Update on Medication-Overuse Headache and Its Treatment

OPINION STATEMENT

Medication-overuse headache-i.e., a too-frequent consumption of acute headache medications leading to increased headache frequency and reduced effectiveness of acute and preventive treatments-is a serious medical condition whose pathophysiology still remains incompletely known, which is reflected into a lack of mechanism-based treatments. The first mandatory step in the therapeutic strategy remains withdrawal of the abused drug, preferably abrupt, in concomitance with a detoxification pharmacological regimen to lessen withdrawal symptoms. Intravenous hydration, antiemetics, corticosteroids (prednisone), tranquilizers (benzodiazepine), neuroleptics, and rescue medication (another analgesic than the overused) should be delivered in various combinations, on an inpatient (hospitalization and day hospital) basis or outpatient basis, depending on the characteristics of the specific patient and type of overuse. Inpatient withdrawal should be preferred in barbiturate and opioid overuse, in concomitant depression, or, in general, in patients who have difficulty in stopping the overused medication as outpatients. In contrast, in overuse limited to simple analgesics in highly motivated patients, without high levels of depression and/or anxiety, home detoxification should be chosen. Re-prophylaxis should immediately follow detoxification, ideally with local injections of onabotulinumtoxinA every 3 months or topiramate orally for at least 3 months. Adequate information to patients about the risks of a too-frequent consumption of symptomatic headache medications is essential and should constantly parallel treatment to help preventing relapse after detoxification and re-prophylaxis.

About stagnation and the emperor's new clothes

Innamorati and colleagues (Innamorati et al., J Headache Pain 16:2, 2015) validated the “stagnation scale” and proposed to use it to screen for psychopathology. I have some critical comments to consider about the theoretical and clinical value of the instrument. First, items of the scale are not specific, and may equally well measure worry, self-worth and distress. Second, questionnaires are tools to assess the experiences of patients, but not hypothesized causal processes. The scale can thus not identify patients who repress emotions. Third, the routine use of this instrument will detract clinicians from what really is at stake in patients and what may help them.