Interpretation of PROMIS Depression and Anxiety Measures Compared with DSM-5 Diagnostic Criteria in Musculoskeletal Patients

There is growing awareness among orthopaedic clinicians that mental health directly impacts clinical musculoskeletal outcomes. The Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly used for mental health screening in this context, but proper interpretation of patient scores remains unclear. The purpose of the present study was to compare musculoskeletal patients' PROMIS Depression and Anxiety scores with a board-certified clinical psychologist's assessment of their depression and/or anxiety diagnoses, as defined by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria.

Methods

In this cross-sectional analysis, existing medical records were reviewed for 50 patients who presented to an interdisciplinary program within a tertiary care orthopaedic department for the treatment of ≥1 musculoskeletal condition. All patients completed PROMIS Depression and Anxiety measures and were evaluated by a board-certified clinical psychologist. Receiver operating characteristic (ROC) curve analyses were performed to assess the diagnostic accuracy of PROMIS Depression and Anxiety scores as compared with the psychologist's diagnosis of a DSM-5 depressive or anxiety disorder.

Results

Twenty-eight patients (56%) were diagnosed by the psychologist with a DSM-5 depressive disorder, and 15 (30%) were diagnosed with a DSM-5 anxiety disorder. The ROC analysis for PROMIS Depression had an area under the curve (AUC) of 0.82. The optimal score cutoff to predict a diagnosis of a DSM-5 depressive disorder was ≥53 (sensitivity, 79% [95% CI, 63% to 94%]; specificity, 86% [72% to 100%]; positive predictive value [PPV], 88% [75% to 100%]; negative predictive value [NPV], 76% [59% to 93%]). The ROC analysis for PROMIS Anxiety had an AUC of 0.67. The optimal score cutoff to predict a diagnosis of a DSM-5 anxiety disorder was ≥59 (sensitivity, 60% [95% CI, 35% to 85%]; specificity, 74% [60% to 89%]; PPV, 50% [27% to 73%]; and NPV, 81% [68% to 95%]).

Conclusions

Modestly elevated PROMIS Depression scores were suggestive of the presence of a DSM-5 depressive disorder, whereas elevations in PROMIS Anxiety scores seemed to have less association with DSM-5 anxiety disorders. Nevertheless, neither PROMIS measure demonstrated adequate discriminant ability to definitively identify patients who met DSM-5 criteria.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain

INTRODUCTION

Factors that motivate musculoskeletal patients to pursue an intensive, lifestyle medicine based approach to care are poorly understood.

OBJECTIVE

To determine whether, compared to patients seeking musculoskeletal care through traditional pathways, patients who choose an intensive lifestyle medicine program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and/or more biopsychosocial comorbidities.

DESIGN

Cross-sectional analysis of existing medical records from 2018-2021.

SETTING

Orthopedic department of one academic medical center.

PATIENTS

Fifty consecutive patients who enrolled in an intensive lifestyle medicine program to address a musculoskeletal condition. Comparison groups were: 1.) 100 patients who presented for standard non-operative musculoskeletal care, and 2.) 100 patients who presented for operative evaluation by an orthopedic surgeon and qualified for joint arthroplasty.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Primary outcomes were age-adjusted, between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS) physical and psychological health measures. Secondary outcomes were between-group differences in sociodemographic and medical history characteristics.

RESULTS

Patients who enrolled in the intensive lifestyle medicine program were more racially diverse (non-white race: lifestyle cohort 34% versus comparison cohorts 16-18%, p≤.029) and had a higher prevalence of obesity and diabetes than both comparison groups (mean body mass index: lifestyle cohort 37.6 kg/m² versus comparison cohorts 29.3-32.0, p<.001; diabetes prevalence: lifestyle cohort 32% versus comparison cohorts 12-16%, p≤.024). Compared to standard non-operative patients, there were no clear between-group differences in PROMIS physical or psychological health scores. Compared to standard operative evaluation patients, patients in the lifestyle program reported worse anxiety but less pain interference (PROMIS Anxiety: B=3.8 points [0.1-7.4], p=.041; Pain Interference: B=-3.6 [-6.0- -1.2], p=.004).

CONCLUSIONS

Compared to musculoskeletal patients who sought care through traditional pathways, patients who chose an intensive lifestyle medicine pathway had a higher prevalence of metabolic comorbidities, but there was substantial overlap in patients' physical, psychological, and sociodemographic characteristics. This article is protected by copyright. All rights reserved.

Groundhog Day: research without old data and old references

BACKGROUND

The use of older data and references is becoming increasingly disfavored for publication. A myopic focus on newer research risks losing sight of important research questions already addressed by now-invisible older studies. This creates a 'Groundhog Day' effect as illustrated by the 1993 movie of this name in which the protagonist has to relive the same day (Groundhog Day) over and over and over within a world with no memory of it. This article examines the consequences of the recent preference for newer data and references in current publication practices and is intended to stimulate new consideration of the utility of selected older data and references for the advancement of scientific knowledge.

METHODS

Examples from the literature are used to exemplify the value of older data and older references. To illustrate the recency of references published in original medical research articles in a selected sample of recent academic medical journals, original research articles were examined in recent issues in selected psychiatry, medicine, and surgery journals.

RESULTS

The literature examined reflected this article's initial assertion that journals are emphasizing the publication of research with newer data and more recent references.

CONCLUSIONS

The current valuation of newer data above older data fails to appreciate the fact that new data eventually become old, and that old data were once new. The bias demonstrated in arbitrary policies pertaining to older data and older references can be addressed by instituting comparable treatment of older and newer data and references.

A Pilot Study Using Mixed GPS/Narrative Interview Methods to Understand Geospatial Behavior in Homeless Populations

Tracking the movements of homeless populations presents methodological difficulties, but understanding their movements in space and time is needed to inform optimal placement of services. This pilot study developed, tested, and refined methods to apply global positioning systems (GPS) technology paired with individual narratives to chronicle the movements of homeless populations. Detail of methods development and difficulties encountered and addressed, and geospatial findings are provided. A pilot sample of 29 adults was recruited from a low-demand homeless shelter in the downtown area of Fort Worth, Texas. Pre- and post-deployment interviews provided participant characteristics and planned and retrospectively-reported travels. Only one of the first eight deployments returned with sufficient usable data. Ultimately 19 participants returned the GPS device with >20 h of usable data. Protocol adjustments addressing methodological difficulties achieved 81 % of subsequent participants returning with sufficient usable data. This study established methods and demonstrated feasibility for tracking homeless population travels.

Needs Assessment of Hurricane Katrina Evacuees Residing Temporarily in Dallas

This study assessed the psychosocial needs of Hurricane Katrina evacuees temporarily residing in Dallas, TX, after sheltering but prior to their permanent resettlement. Common trauma exposures were physical exposure to flood water, seeing corpses, witnessing death, and loss of family, friends, or home. Fewer than 10 % met symptom criteria for disaster-related posttraumatic stress disorder (PTSD). More than one-fourth met major depressive disorder (MDD) symptom criteria post-disaster but only 15 % had a new (incident) MDD episode after the disaster. Specific trauma exposures and some hurricane-related stressors contributed to risk for both Katrina-related PTSD symptom criteria and incident MDD, but other hurricane-related stressors were uniquely associated with incident MDD. Referral to mental health services was associated with meeting symptom criteria for PTSD and with incident MDD, but only about one-third of these individuals received a referral. Understanding the needs of disaster-exposed population requires assessing trauma exposures and identifying pre-disaster and post-disaster psychopathology.

Alcohol use disorders and drinking among survivors of the 9/11 attacks on the World Trade Center in New York City

Research on the relationship of alcohol and disasters has yielded mixed conclusions. Some studies investigate alcohol consumption but others examine alcohol use disorders in relation to disaster. Alcohol consumption and alcohol use disorders have not be studied concurrently in relation to specific disaster trauma exposures. A volunteer sample of 379 individuals from New York City agencies affected by the September 11, 2001 (9/11) attacks on World Trade Center were assessed approximately 3years postdisaster for alcohol consumption and alcohol use disorders relative to specific disaster exposures. Increases in alcohol consumption were relatively small, eventually returning to pre-9/11 levels, with few cases of new alcohol use disorders or alcohol relapse. The findings suggest that postdisaster alcohol use has negligible clinical relevance for most of the population. Scarce disaster resources should be focused on those at identified risk of excessive alcohol use, that is, those with pre-existing alcohol or other psychiatric disorders.

A prospective study of the onset of PTSD symptoms in the first month after trauma exposure

BACKGROUND

The course of posttraumatic stress disorder (PTSD) symptoms in the month after trauma exposure has not been determined adequately. Symptom group C (avoidance/numbing) has been identified retrospectively as a marker for PTSD, but prospective studies are needed to determine whether these symptoms can provide substantially earlier identification of those who will have PTSD 1 month after trauma exposure.

METHODS

We evaluated 42 patients hospitalized for traumatic injuries over the first post-injury month to track development of posttraumatic symptoms.

RESULTS

Symptoms emerged rapidly, with group B (intrusion) and group D (hyperarousal) symptoms occurring earlier than group C symptoms. At 1 week, group C criteria accurately predicted who would develop PTSD by 1 month, and by 2 weeks, group C criteria also predicted who would not develop PTSD by 1 month.

CONCLUSIONS

The findings, if replicated, may permit earlier identification of PTSD and more timely, appropriate treatment.

Attributes of effective disaster responders: focus group discussions with key emergency response leaders

METHODS

An effective disaster response requires competent responders and leaders. The purpose of this study was to ask experts to identify attributes that distinguish effective from ineffective responders and leaders in a disaster. In this qualitative study, focus groups were held with jurisdictional medical directors for the 9-1-1 emergency medical services systems of the majority of the nation's largest cities. These sessions were recorded with audio equipment and later transcribed.

RESULTS

The researchers identified themes within the transcriptions, created categories, and coded passages into these categories. Overall interrater reliability was excellent (κ = .8). The focus group transcripts yielded 138 codable passages. Ten categories were developed from analysis of the content: Incident Command System/Disaster Training/Experience, General Training/Experience, Teamwork/Interpersonal, Communication, Cognition, Problem Solving/Decision Making, Adaptable/Flexible, Calm/Cool, Character, and Performs Role. The contents of these categories included knowledge, skills, attitudes, behaviors, and personal characteristics.

CONCLUSIONS

Experts in focus groups identified a variety of competencies for disaster responders and leaders. These competencies will require validation through further research that involves input from the disaster response community at large.