Screening high-risk patients and assisting in diagnosing anxiety in primary care: the Patient Health Questionnaire evaluated

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.

Comparison of the Factor Structure of the Patient Health Questionnaire for Somatic Symptoms (PHQ-15) in Germany, the Netherlands, and China. A Transcultural Structural Equation Modeling (SEM) Study

Background: Persistent somatic symptoms are associated with psychological distress, impaired function, and medical help-seeking behavior. The Patient Health Questionnaire (PHQ)-15 is used as a screening instrument for somatization and as a monitoring instrument for somatic symptom severity. A bifactorial model has been described, with one general factor and four orthogonal specific symptom factors. The objective of the present study was to assess and to clarify the factor structure of the PHQ-15 within and between different countries in Western Europe and China. Method: Cross-sectional secondary data analysis performed in three patient data samples from two Western European countries (Germany N = 2,517, the Netherlands N = 456) and from China (N = 1,329). Confirmatory factor analyses (CFA), and structural equation modeling (SEM) analysis were performed. Results: The general factor is found in every sample. However, although the outcomes of the PHQ-15 estimate severity of somatic symptoms in different facets, these subscales may have different meanings in the European and Chinese setting. Replication of the factorial structure was possible in the German and Dutch datasets but not in the dataset from China. For the Chinese dataset, a bifactorial model with a different structure for the cardiopulmonary factor is suggested. The PHQ-15 could discern somatization from anxiety and depression within the three samples. Conclusion: The PHQ-15 is a valid questionnaire that can discern somatization from anxiety and depression within different cultures like Europe or China. It can be fitted to a bifactorial model for categorical data, however, the model can only be recommended for use of the general factor. Application of the orthogonal subscales in non-European samples is not corroborated by the results. The differences cannot be ascribed to differences in health care settings or by differences in concomitant depression or anxiety but instead, a cultural factor involving concepts of disease may play a role in this as they may play a role in the translation of the questionnaire. Further research is needed to explore this, and replication studies are needed regarding the factorial structure of the PHQ-15 in China.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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