Depression screening in patients with coronary heart disease : A narrative review of the current evidence.

In view of the large and sometimes conflicting body of research, this narrative review summarizes the current evidence on depression screening in patients with coronary heart disease. Depression is a risk factor for development and progression of coronary heart disease. Consequently, many international cardiac guidelines recommend screening for depression in patients with coronary heart disease. However, the efficacy and implementation of these guidelines are debated due to the lack of empirical evidence supporting the benefits of routine depression screening. Studies conducted in cardiac routine care support this assumption: Patients with positive depression screens do not receive adequate follow-up care, which highlights gaps in the detection-to-treatment pathway. Barriers to effective screening and treatment include system-level factors, such as insufficient integration of mental health resources in cardiology, and patient-related factors like stigma and low acceptance of mental health treatment. Innovative interventions that address these barriers and involve patients as active partners in depression care should be developed through a theory-driven, transparent, multistage process involving key stakeholders such as patients, nurses, and cardiologists. A sound methodological evaluation of such multilevel interventions could answer the question of whether early detection of depression in patients with coronary heart disease would lead to health benefits.

Public and patient involvement in the development of an internet-based guide for persistent somatic symptoms (GUIDE.PSS): A qualitative study on the needs of those affected.

BACKGROUND: Persistent somatic symptoms (PSS) frequently remain under-treated in health care settings. Evidence-based services that lead affected individuals to early guideline-based care are currently missing. This study aimed to identify the needs of those affected concerning an internet-based guide. The second aim was to evaluate public and patient involvement (PPI). METHODS: Participants experiencing PSS for at least 6 months were recruited via hospitals, psychotherapeutic practices and self-help organizations. Qualitative data were gathered via ideation discussions and prioritization tasks. Thematic analysis was conducted to gain insight on the needs of people with lived experiences. PPI was quantitatively evaluated with the Public and Patient Engagement Evaluation Tool. RESULTS: A total of 12 individuals participated (eight females, ages 22-66 years, duration of symptoms 1-43 years). Participants wanted to feel more supported, validated, in control and engaged with managing their health. Content-related preferences included education, self-help, social support and contact addresses. The majority of participants (>90%) experienced their involvement as worthwhile. CONCLUSIONS: To the best of our knowledge, this is one of the first studies describing PPI in intervention development for PSS. The involvement was perceived as a valuable contribution to the development process. PATIENT OR PUBLIC CONTRIBUTION: Adults with lived experiences were involved at the level of collaboration through the establishment of a participatory research team (PRT) and at the level of consultation through a workshop series, including one of the coauthors. They were involved in developing and validating intervention material and checking data interpretation.

Somatic symptom disorder: a scoping review on the empirical evidence of a new diagnosis.

BACKGROUND: In 2013, the diagnosis of somatic symptom disorder (SSD) was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This review aims to comprehensively synthesize contemporary evidence related to SSD. METHODS: A scoping review was conducted using PubMed, PsycINFO, and Cochrane Library. The main inclusion criteria were SSD and publication in the English language between 01/2009 and 05/2020. Systematic search terms also included subheadings for the DSM-5 text sections; i.e., diagnostic features, prevalence, development and course, risk and prognostic factors, culture, gender, suicide risk, functional consequences, differential diagnosis, and comorbidity. RESULTS: Eight hundred and eighty-two articles were identified, of which 59 full texts were included for analysis. Empirical evidence supports the reliability, validity, and clinical utility of SSD diagnostic criteria, but the further specification of the psychological SSD B-criteria criteria seems necessary. General population studies using self-report questionnaires reported mean frequencies for SSD of 12.9% [95% confidence interval (CI) 12.5-13.3%], while prevalence studies based on criterion standard interviews are lacking. SSD was associated with increased functional impairment, decreased quality of life, and high comorbidity with anxiety and depressive disorders. Relevant research gaps remain regarding developmental aspects, risk and prognostic factors, suicide risk as well as culture- and gender-associated issues. CONCLUSIONS: Strengths of the SSD diagnosis are its good reliability, validity, and clinical utility, which substantially improved on its predecessors. SSD characterizes a specific patient population that is significantly impaired both physically and psychologically. However, substantial research gaps exist, e.g., regarding SSD prevalence assessed with criterion standard diagnostic interviews.

Excessiveness in Symptom-Related Thoughts, Feelings, and Behaviors: An Investigation of Somatic Symptom Disorders in the General Population.

OBJECTIVE: The diagnostic criteria of somatic symptom disorder (SSD) emphasize that somatic symptoms receive disease value once they are accompanied by excessive thoughts, feelings, or behaviors. The main objective of this study was to examine what constitutes excessiveness in psychological reactions to somatic complaints and how excessive symptom-related behavior influences self-reported health status and health care utilization. METHODS: A national, representative general population survey was performed between January and March 2016 in Germany, including 2395 individuals older than 13 years. Self-report questionnaires (Somatic Symptom Scale-8, Somatic Symptom Disorder-B Criteria Scale) were used to operationalize the SSD criteria. Group differences in the daily amount of time dedicated to physical complaints were analyzed between individuals with and without SSD. Stepwise linear regression analyses were performed to predict general mental and physical health status, and health care utilization. RESULTS: There was a significant effect of group (SSD yes/no) in daily time spent on symptoms, after controlling for age, sex, depression, and anxiety (F(1,2336) = 447.53, p < .001). The SSD group (n = 213) reported an average of 4 hours, whereas individuals without SSD reported 30 minutes. Results of the regression analyses showed that the combination of somatic symptoms and symptom-related psychological features is predictive of worsened self-reported physical and mental health status, and increased health care utilization. CONCLUSIONS: A range of 3 to 4 hours per day spent on dealing with physical complaints seems indicative of excessiveness. If, during a clinical consultation, a patient reports such a large amount of time, a more comprehensive clinical examination of SSD should follow.

GPs' views on the use of depression screening and GP-targeted feedback: a qualitative study.

PURPOSE: The first aim of this qualitative study was to identify general practitioners' (GPs') views on depression screening combined with GP-targeted feedback in primary care. The second aim was to determine the needs and preferences of GPs with respect to GP-targeted feedback to enhance the efficacy of depression screening. METHODS: A semistructured qualitative interview was conducted with officially registered GPs in Hamburg (Germany). Interviews were audio recorded and transcribed verbatim. An inductive approach was used to code the transcripts. RESULTS: Nine GPs (27 to 70 years; 5 male) from Hamburg, Germany, participated. Regarding depression screening combined with GP-targeted feedback, five thematic groups were identified: application of screening; screening and patient-physician relationships; GPs' attitudes towards screening; benefits and concerns related to screening; and GPs' needs and preferences regarding feedback. While the negative aspects of screening can be described in rather general terms (e.g., screening determines the mental health competence, screening threatens the doctor-patient relationship, revealing questions harm the patients), its advantages were very specific (e.g., promoting the identification of undetected cases, relief of the daily workload, wider communication channel to reach more patients). Standardized GP-targeted feedback of the screening results was perceived as helpful and purposeful. GPs preferred feedback materials that eased their clinical workload (e.g., short text with visuals, pictures, or images). CONCLUSION: Addressing GPs' needs is essential when implementing depression screening tools in clinical practice. To overcome prejudices and enhance the efficacy of screening, further education for GPs on the purpose and application on depression screening may be needed. Standardized GP-targeted feedback in combination with depression screening could be the missing link to improve the detection of depression in primary care.

Patient involvement in developing a patient-targeted feedback intervention after depression screening in primary care within the randomized controlled trial GET.FEEDBACK.GP.

BACKGROUND: Patient and public involvement (PPI) is increasingly required in mental health services research. To empower patients to actively address depression, the GET.FEEDBACK.GP study evaluates a patient-targeted feedback intervention after depression screening using the Patient Health Questionnaire (PHQ-9). OBJECTIVE: To refine the patient-targeted feedback from a previous study within a participatory research team (PRT) by conducting workshops to investigate patients' needs and preferences for feedback. To evaluate the process and outcome of PPI. DESIGN: Patient and public involvement was carried out on the levels of collaboration and consultation. A PRT of patient partners and researchers planned and conducted three workshops with patients. Patients' needs were investigated using a focus group. Participants prioritized needs, discussed feedback drafts and evaluated two drafts using cognitive debriefings. Researchers of the PRT communicated the results at project level. PPI was evaluated using the Public and Patient Engagement Evaluation Tools (PPEET). SETTING AND PARTICIPANTS: A purposeful sampling of N = 12 patients with experiences of depression participated in at least one workshop. RESULTS: Relevant content-related needs about feedback (eg no distinction between severe and moderate symptoms), recommendations for action and patient-relevant information were considered. Needs for comprehensible, valuing, nonstigmatizing language and design elements (eg dimensional bar) were implemented. Workshops and PRT were positively evaluated. DISCUSSION AND CONCLUSIONS: Patient and public involvement influenced the content, wording and design of the feedback. Strengths include two levels of PPI, methodical diversity and purposeful sampling. Limitations include the lack of inclusion of patients who are unaware of their depression. The evaluated PPI concept can be useful for future studies.

[Screening for mental comorbidities in dermatology : Successful implementation of a screening for mental comorbidities in the field of inpatient dermatological treatment]. / Screening auf psychische Komorbiditäten in der Dermatologie : Erfolgreiche Implementierung eines Screenings auf psychische Komorbiditäten im Bereich der stationären dermatologischen Versorgung.

BACKGROUND: Anxiety and depression are common in the field of inpatient somatic treatment. Especially in dermatology in which the treatment of chronic diseases is very common and the risk of stigmatization by society is particularly high, mental disorders appear in every third patient. Dermatological diseases and mental disorders often negatively interact with each other leading to increased morbidity. Dermatological guidelines recommend early detection, but this is often not adequately done in practice. MATERIALS AND METHODS: We present the implementation of an easy screening for mental comorbidities in the field of inpatient dermatological treatment by using a short questionnaire. This so-called Patient Health Questionnaire­4 (PHQ-4) consists of four questions regarding anxiety disorders and depression. Upon reaching a certain number of points, a psychosomatic consult is automatically requested. As a result the patient's stress is relieved and the necessary holistic treatment becomes possible. RESULTS: In 2019, 83% of inpatients in our clinic were screened using the PHQ­4; 98 psychosomatic consults were performed. CONCLUSION: Our findings so far have shown the benefit of the screening with a minimal investment of time. We recommend its comprehensive use in the field of inpatient dermatological treatment.

[Early Detection of Psychological Comorbidity in Patients Admitted to Dermatological and Internal Medicine Wards: A New Care Model for Psychosomatic Consultation Service]. / Früherkennung von psychischer Komorbidität in der stationären dermatologischen und internistischen Versorgung: Darstellung eines neuen Versorgungskonzeptes.

This article explains the development and implementation of a psychosomatic screening and consultation service for inpatient somatic care. Approximately one in six somatic inpatients has a mental disorder. It is estimated that only half of these cases are properly identified. Consequently, a large proportion of patients remains untreated. To address this gap in care, a psychosomatic early detection programme was developed by an interdisciplinary working group. This programme is based on the Patient Health Questionnaire-4 (PHQ-4), a psychometrically very well evaluated ultra-short screening questionnaire for the detection of depressive and anxiety disorders. For implementation in routine inpatient care, the PHQ-4 was programmed as a form in the electronic medical record and administered by nursing staff during the admission interview. If the PHQ-4 screening result indicates the presence of a mental comorbidity and the patient expresses a wish for assessment of this disorder, a psychosomatic consultation is automatically ordered. The PHQ-4 was implemented into the clinical routine in four internal medicine and three dermatology wards of the University Medical Center Hamburg-Eppendorf. Documentation of the early diagnosis in the electronic patient record is a minimally costly, less time-consuming and practicable method of providing patients with holistic care through rapid interdisciplinary referral. An evaluation of cost-effectiveness, clinical efficiency, and acceptance is still pending.

Detecting DSM-5 somatic symptom disorder: criterion validity of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12).

BACKGROUND: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced somatic symptom and related disorders (SSD) to improve the diagnosis of somatoform disorders. It is unclear whether existing questionnaires are useful to identify patients with SSD. Our study investigates the diagnostic accuracy of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12). METHODS: For this cross-sectional study, participants were recruited from a psychosomatic outpatient clinic. PHQ-15, SSS-8, and SSD-12 were administered and compared with SSD criteria from a diagnostic interview. Sensitivity and specificity were calculated for optimal individual and combined cutpoints. Receiver operator curves were created and area under the curve (AUC) analyses assessed. RESULTS: Data of n = 372 patients [31.2% male, mean age: 39.3 years (s.d. = 13.6)] were analyzed. A total of 56.2% fulfilled the SSD criteria. Diagnostic accuracy was moderate for each questionnaire (PHQ-15: AUC = 0.70; 95% CI = 0.65-0.76; SSS-8: AUC = 0.71; 95% CI = 0.66-0.77; SSD-12: AUC = 0.74; 95% CI = 0.69-0.80). Combining questionnaires improved diagnostic accuracy (PHQ-15 + SSD-12: AUC = 0.77; 95% CI = 0.72-0.82; SSS-8 + SSD-12: AUC = 0.79; 95% CI = 0.74-0.84). Optimal combined cutpoints were ⩾9 for the PHQ-15 or SSS-8, and ⩾23 for the SSD-12 (sensitivity and specificity = 69% and 70%). CONCLUSIONS: The combination of the PHQ-15 or SSS-8 with the SSD-12 provides an easy-to-use and time- and cost-efficient opportunity to identify persons at risk for SSD. If systematically applied in routine care, effective screening and subsequent treatment might help to improve quality of life and reduce health care excess costs.

Severity of somatic symptoms in outpatients with anorexia and bulimia nervosa.

OBJECTIVE: Prior studies investigated objective somatic consequences of eating disorders whereas research on subjective somatic symptom severity, that is, profiles of subjective burden of somatic symptoms in patients with anorexia (AN) and bulimia nervosa (BN), is sparse. METHODS: Somatic symptom severity (Patient Health Questionnaire-15) was investigated in a cross-sectional consecutive sample of outpatients with AN or BN. Using regression and mediation analyses, effects of somatic symptom severity on days of sick leave during the last 2 weeks and quality of life were examined. RESULTS: Compared with AN-outpatients (n = 90, MBMI  = 17.2, Mage  = 27.9 years, 95% female), BN-outpatients (n = 63, MBMI  = 21.8, Mage  = 29.0 years, 93% female) reported a significantly higher somatic symptom severity (p = 0.016). Increased somatic symptom severity predicted days of sick leave during the last 2 weeks (p = 0.036) and physical quality of life (p = <0.001). However, after controlling for depression and anxiety as mediators, somatic symptom severity did no longer predict psychological quality of life (p = n.s.). CONCLUSIONS: Somatic symptom severity is high in both eating disorders. As it is associated with increased sick leave during the last 2 weeks and decreased quality of life, it adds to the psychological burden of AN and BN. Future research should investigate predictors of subjective somatic symptom severity and whether direct somatic symptom management enhances treatment of AN and BN.

Illness beliefs about depression among patients seeking depression care and patients seeking cardiac care: an exploratory analysis using a mixed method design.

BACKGROUND: Treatment of depression in cardiac patients is difficult. Patients' illness beliefs regarding depression are associated with outcomes. The aim of the mixed-methods study was to test whether patients in routine care for depression differ from patients with depression in routine care for cardiac diseases regarding illness beliefs about depression. METHODS: A consecutive sample of n = 217 patients with depressive disorder was recruited from routine care for depression (N = 148) and routine care for cardiac diseases (N = 69). Beliefs about depression were measured by the Brief-Illness Perception Questionnaire. Causal beliefs were categorized using qualitative methods. To investigate differences regarding other illness beliefs, we performed an ANCOVA controlling for sociodemographic and clinical differences by propensity score matching. RESULTS: Patients in routine care for cardiac diseases attributed their depression more often to physical illnesses (48% vs. 16%) and less often to their self (30% vs. 47%), problems at work (25% vs. 35%), childhood (25% vs. 30%), and negative life events (19% vs. 25%) in contrast to patients in routine care for depression. Patients in routine care for cardiac diseases reported beliefs of lower disability, burden, and treatment-control and of higher self-control in contrast to patients in routine care for depression. CONCLUSIONS: Illness beliefs especially causal beliefs differ between patients in routine care for cardiac diseases and routine care for depression. Future research should investigate effects of these illness beliefs. We recommend exploring patients' illness beliefs about depression in routine care for cardiac diseases and routine care for depression.

Suicidal ideation in patients with coronary heart disease and hypertension: Baseline results from the DEPSCREEN-INFO clinical trial.

BACKGROUND: A high proportion of cardiac patients suffers from depression, which is an antecedent for suicidal ideation. This study identifies clinical vulnerabilities for suicidal ideation in cardiac patients. METHODS: The primary outcome of the study was severity of suicidal ideation as measured with the Patient Health Questionnaire (PHQ-9) item No. 9. Covariates were demographics, cardiac characteristics (i.e., Canadian Cardiovascular Society angina rating of chest pain and New York Heart Association rating of shortness of breath), depression (PHQ-8,i.e., PHQ-9 minus item No. 9), anxiety (Generalized Anxiety Disorder-7, GAD-7), somatic symptoms (PHQ-15), illness perception (Brief-Illness Perception Questionnaire), and health-related quality of life (EuroQol-5D, EQ 5D). RESULTS: Data from 1,976 patients were analysed. At least 14% (95% CI [12%, 16%]) of patients indicated suicidal ideations within the last 2 weeks. Bivariate analyses yielded associations between suicidal ideation and higher levels of depression severity, anxiety severity, somatic symptom burden, chest pain, shortness of breath, negative illness perceptions, reduced health-related quality of life, and a higher probability of living alone (all p < 0.001). A multivariable ordinal regression revealed depression severity and anxiety severity to show the highest associations with suicidal ideation (ORPHQ-8  = 1.22, p < 0.001; ORGAD-7  = 1.09, p < 0.001). Having a defibrillator implant was associated with a lower probability of suicidal ideation (OR = 0.27, p = 0.017). CONCLUSIONS: This study identified several clinical vulnerabilities of suicidal ideation. The results stress the importance of screening for suicidal ideation in clinical practice.

Depression screening with patient-targeted feedback in cardiology: DEPSCREEN-INFO randomised clinical trial.

BACKGROUND: International guidelines advocate depression screening in patients with coronary heart disease (CHD) and other chronic illnesses, but evidence is lacking. AIMS: To test the differential efficacy of written patient-targeted feedback v. no written patient feedback after depression screening. METHOD: Patients with CHD or hypertension from three cardiology settings were randomised and screened for depression (ClinicalTrials.gov Identifier: NCT01879111). Compared with the control group, where only cardiologists received written feedback, in the intervention group both cardiologists and patients received written feedback regarding depression status. Depression severity was measured 1 month (primary outcome) and 6 months after screening. RESULTS: The control group (n = 220) and the patient-feedback group (n = 155) did not differ in depression severity 1 month after screening. Six months after screening, the patient-feedback group showed significantly greater improvements in depression severity and was twice as likely to seek information about depression compared with the control group. CONCLUSIONS: Patient-targeted feedback in addition to screening has a significant but small effect on depression severity after 6 months and may encourage patients to take an active role in the self-management of depression.

Expressive Suppression of Emotions and Overeating in Individuals with Overweight and Obesity.

Emotions have a considerable impact on eating behaviour; however, research addressing emotion regulation in obesity is rare. The present study is the first to investigate the association between emotional suppression and overeating in individuals with overweight. In total, 314 participants including 190 individuals with obesity filled in a cross-sectional online survey, which assessed emotional suppression, eating behaviour and psychopathology. A hierarchical linear regression analysis was conducted to identify factors associated with overeating. Individuals with obesity reported more frequent overeating compared with individuals without obesity. The habitual use of emotional suppression was associated with more overeating; however, this link was moderated by increased body mass index (BMI). The results suggest that suppression of emotional expression contributes to overeating and is maladaptive especially in individuals with obesity. Further research should longitudinally investigate the predictive value of emotional suppression on overweight, as the training of emotion regulation could contribute to treating obesity. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Somatic symptom disorder symptoms in individuals at risk for heart failure: A cluster analysis with cross-sectional data from a population-based cohort study.

OBJECTIVE: Identifying whether experienced symptom burden in individuals with medical predisposition indicates somatic symptom disorder (SSD) is challenging, given the high overlap in the phenomenology of symptoms within this group. This study aimed to enhance understanding SSD in individuals at risk for heart failure. SUBJECTS AND METHODS: Cross-sectional data from the Hamburg City Health Study was analyzed including randomly selected individuals from the general population of Hamburg, Germany recruited from February 2016 to November 2018. SSD symptoms assessed with the Somatic Symptom Scale-8 and the Somatic Symptom Disorder-12 scale were categorized by applying cluster analysis including 412 individuals having at least 5% risk for heart failure-related hospitalization within the next ten years. Clusters were compared for biomedical and psychological factors using ANOVA and chi-square tests. Linear regressions, adjusting for sociodemographic, biomedical, and psychological factors, explored associations between clusters with general practitioner visits and quality of life. RESULTS: Three clusters emerged: none (n = 215; 43% female), moderate (n = 151; 48% female), and severe (n = 46; 54% female) SSD symptom burden. The SSS-8 mean sum scores were 3.4 (SD = 2.7) for no, 6.4 (SD = 3.4) for moderate, and 12.4 (SD = 3.7) for severe SSD symptom burden. The SSD-12 mean sum scores were 3.1 (SD = 2.6) for no, 12.2 (SD = 4.2) for moderate, and 23.5 (SD = 6.7) for severe SSD symptom burden. Higher SSD symptom burden correlated with biomedical factors (having diabetes: p = .005 and dyspnea: p ≤ .001) and increased psychological burden (depression severity: p ≤ .001; anxiety severity: p ≤ .001), irrespective of heart failure risk (p = .202). Increased SSD symptoms were associated with more general practitioner visits (ß = 0.172; p = .002) and decreased physical quality of life (ß = -0.417; p ≤ .001). CONCLUSION: Biomedical factors appear relevant in characterizing individuals at risk for heart failure, while psychological factors affect SSD symptom experience. Understanding SSD symptom diversity and addressing subgroup needs could prove beneficial.

Patient-centered evaluation of an expectation-focused intervention for patients undergoing heart valve surgery: a qualitative study.

Objective: Randomized controlled trials demonstrate the effectiveness of expectation-focused interventions in improving recovery outcomes following cardiac surgery. For dissemination in routine health care, it is important to capture the perspective of affected individuals. This qualitative study explores the perceived benefits and intervention-specific needs of patients who received expectation-focused intervention in the context of heart valve surgery. In addition, it explores potential barriers and adverse effects. Methods: As part of an Enhanced Recovery After Surgery (ERAS) program within a multicentered randomized controlled trial, patients undergoing minimally invasive heart valve surgery received an intervention focused on their expectations. Six weeks after the intervention, semi-structured interviews were conducted with 18 patients to assess its feasibility, acceptance, barriers, benefits, and side effects. The transcribed interviews were analyzed using qualitative content analysis. Results: The results indicate that both the intervention and the role of the patient and psychologist are key aspects in evaluating the expectation-focused intervention. Five key themes emerged from the patients' perspective: personal needs, expectations and emotions, relationship, communication, and individuality. Patients valued the preparation for surgery and recovery and the space for emotions. Establishing a trustful relationship and addressing stigmatization were identified as primary challenges within the intervention. Conclusion: Overall, patients experienced the expectation-focused intervention as helpful and no adverse effects were reported. Perceived benefits included enhanced personal control throughout the surgery and recovery, while the potential barrier of stigmatization towards a psychologist may complicate establishing a trustful relationship. Addressing personal needs, as a relevant topic to the patients, could be achieved through additional research to identify the specific needs of different patient subgroups. Enhancing the expectation-focused intervention could involve the implementation of a modular concept to address individual needs better.

The efficacy of automated feedback after internet-based depression screening (DISCOVER): an observer-masked, three-armed, randomised controlled trial in Germany.

BACKGROUND: Despite the availability of effective treatments, most depressive disorders remain undetected and untreated. Internet-based depression screening combined with automated feedback of screening results could reach people with depression and lead to evidence-based care. We aimed to test the efficacy of two versions of automated feedback after internet-based screening on depression severity compared with no feedback. METHODS: DISCOVER was an observer-masked, three-armed, randomised controlled trial in Germany. We recruited individuals (aged ≥18 years) who were undiagnosed with depression and screened positive for depression on an internet-based self-report depression rating scale (Patient Health Questionnaire-9 [PHQ-9] ≥10 points). Participants were randomly assigned 1:1:1 to automatically receive no feedback, non-tailored feedback, or tailored feedback on the depression screening result. Randomisation was stratified by depression severity (moderate: PHQ-9 score 10-14 points; severe: PHQ-9 score ≥15 points). Participants could not be masked but were kept unaware of trial hypotheses to minimise expectancy bias. The non-tailored feedback included the depression screening result, a recommendation to seek professional diagnostic advice, and brief general information about depression and its treatment. The tailored feedback included the same basic information but individually framed according to the participants' symptom profiles, treatment preferences, causal symptom attributions, health insurance, and local residence. Research staff were masked to group allocation and outcome assessment as these were done using online questionnaires. The primary outcome was change in depression severity, defined as change in PHQ-9 score 6 months after random assignment. Analyses were conducted following the intention-to-treat principle for participants with at least one follow-up visit. This trial was registered at ClinicalTrials.gov, NCT04633096. FINDINGS: Between Jan 12, 2021, and Jan 31, 2022, 4878 individuals completed the internet-based screening. Of these, 1178 (24%) screened positive for depression (mean age 37·1 [SD 14·2] years; 824 [70%] woman, 344 [29%] men, and 10 [1%] other gender identity). 6 months after random assignment, depression severity decreased by 3·4 PHQ-9 points in the no feedback group (95% CI 2·9-4·0; within-group d 0·67; 325 participants), by 3·5 points in the non-tailored feedback group (3·0-4·0; within-group d 0·74; 319 participants), and by 3·7 points in the tailored feedback group (3·2-4·3; within-group d 0·71; 321 participants), with no significant differences among the three groups (p=0·72). The number of participants seeking help for depression or initiating psychotherapy or antidepressant treatment did not differ among study groups. The results remained consistent when adjusted for fulfilling the DSM-5-based criteria for major depressive disorder or subjective belief of having a depressive disorder. Negative effects were reported by less than 1% of the total sample 6 months after random assignment. INTERPRETATION: Automated feedback following internet-based depression screening did not reduce depression severity or prompt sufficient depression care in individuals previously undiagnosed with but affected by depression. FUNDING: German Research Foundation.

Healthcare needs in elderly patients with chronic heart failure in view of a personalized blended collaborative care intervention: a cross sectional study.

Introduction: Few studies explored healthcare needs of elderly heart failure (HF) patients with comorbidities in view of a personalized intervention conducted by Care Managers (CM) in the framework of Blended Collaborative Care (BCC). The aims of the present study were to: (1) identify perceived healthcare needs/preferences in elderly patients with HF prior to a CM intervention; (2) investigate possible associations between healthcare needs/preferences, sociodemographic variables (age; sex) and number of comorbidities. Method: Patients aged 65 years or more affected by HF with at least 2 medical comorbidities were enrolled in the study. They were assessed by structured interviewing with colored cue cards that represented six main topics including education, individual tailoring of treatment, monitoring, support, coordination, and communication, related to healthcare needs and preferences. Results: Thirty-three patients (Italy = 21, Denmark = 7, Germany = 5; mean age = 75.2 ± 7.7 years; males 63.6%) were enrolled from June 2021 to February 2022. Major identified needs included: HF information (education), patients' involvement in treatment-related management (individual tailoring of treatment), regular checks of HF symptoms (monitoring), general practitioner update by a CM about progression of symptoms and health behaviors (coordination), and telephone contacts with the CM (communication). Regarding communication modalities with a CM, males preferred phone calls (χ2 = 6.291, p = 0.043) and mobile messaging services (χ2 = 9.647, p = 0.008), whereas females preferred in-person meetings and a patient dashboard. No differences in needs and preferences according to age and number of comorbidities were found. Discussion: The findings highlight specific healthcare needs and preferences in older HF multimorbid patients, allowing a more personalized intervention delivered by CM in the framework of BCC.

Clinical effectiveness of patient-targeted feedback following depression screening in general practice (GET.FEEDBACK.GP): an investigator-initiated, prospective, multicentre, three-arm, observer-blinded, randomised controlled trial in Germany.

BACKGROUND: Screening for depression in primary care alone is not sufficient to improve clinical outcomes. However, targeted feedback of the screening results to patients might result in beneficial effects. The GET.FEEDBACK.GP trial investigated whether targeted feedback of the depression screening result to patients, in addition to feedback to general practitioners (GPs), leads to greater reductions in depression severity than GP feedback alone or no feedback. METHODS: The GET.FEEDBACK.GP trial was an investigator-initiated, multicentre, three-arm, observer-blinded, randomised controlled trial. Depression screening was conducted electronically using the Patient Health Questionnaire-9 (PHQ-9) in 64 GP practices across five regions in Germany while patients were waiting to see their GP. Currently undiagnosed patients (aged ≥18 years) who screened positive for depression (PHQ-9 score ≥10), were proficient in the German language, and had a personal consultation with a GP were randomly assigned (1:1:1) into a group that received no feedback on their depression screening result, a group in which only the GP received feedback, or a group in which both GP and patient received feedback. Randomisation was stratified by treating GP and PHQ-9 depression severity. Trial staff were masked to patient enrolment and study group allocation and GPs were masked to the feedback recieved by the patient. Written feedback, including the screening result and information on depression, was provided to the relevant groups before the consultation. The primary outcome was PHQ-9-measured depression severity at 6 months after randomisation. An intention-to-treat analysis was conducted for patients who had at least one follow-up visit. This study is registered at ClinicalTrials.gov (NCT03988985) and is complete. FINDINGS: Between July 17, 2019, and Jan 31, 2022, 25 279 patients were approached for eligibility screening, 17 150 were excluded, and 8129 patients completed screening, of whom 1030 (12·7%) screened positive for depression. 344 patients were randomly assigned to receive no feedback, 344 were assigned to receive GP-targeted feedback, and 339 were assigned to receive GP-targeted plus patient-targeted feedback. 252 (73%) patients in the no feedback group, 252 (73%) in the GP-targeted feedback group, and 256 (76%) in the GP-targeted and patient-targeted feedback group were included in the analysis of the primary outcome at 6 months, which reflected a follow-up rate of 74%. Gender was reported as female by 637 (62·1%) of 1025 participants, male by 384 (37·5%), and diverse by four (0·4%). 169 (16%) of 1026 patients with available migration data had a migration background. Mean age was 39·5 years (SD 15·2). PHQ-9 scores improved for each group between baseline and 6 months by -4·15 (95% CI -4·99 to -3·30) in the no feedback group, -4·19 (-5·04 to -3·33) in the GP feedback group, and -4·91 (-5·76 to -4·07) in the GP plus patient feedback group, with no significant difference between the three groups (global p=0·13). The difference in PHQ-9 scores when comparing the GP plus patient feedback group with the no feedback group was -0·77 (-1·60 to 0·07, d=-0·16) and when comparing with the GP-only feedback group was -0·73 (-1·56 to 0·11, d=-0·15). No increase in suicidality was observed as an adverse event in either group. INTERPRETATION: Providing targeted feedback to patients and GPs after depression screening does not significantly reduce depression severity compared with GP feedback alone or no feedback. Further research is required to investigate the potential specific effectiveness of depression screening with systematic feedback for selected subgroups. FUNDING: German Innovation Fund. TRANSLATION: For the German translation of the abstract see Supplementary Materials section.

How adults with suspected depressive disorder experience online depression screening: A qualitative interview study.

Background: While evidence on the effects and mechanisms of online depression screening is inconclusive, publicly available 'online depression tests' are already frequently used. To further a comprehensive understanding of online depression screening and evince the perspectives of those affected, we aimed to qualitatively explore how adults with undiagnosed but suspected depressive disorder experience the screening process. Methods: This study is a qualitative follow-up of a German-wide, 3-arm, randomised controlled trial on feedback after online depression screening conducted between Jan 2021 and Sep 2022. A subsample of 26 participants with undiagnosed but suspected depressive disorder (Patient Health Questionnaire-9 ≥ 10; no depression diagnosis/treatment within the last year) were purposefully selected based on maximum variation in gender, age, and study arm. In-depth semi-structured telephone interviews (mean = 37 min) were conducted approximately six months after screening. Data were analysed within a contextualist theoretical framework using inductive reflexive thematic analysis. Results: Participants were balanced in terms of gender (female/male, n = 15/11), age (range = 22 to 61 years), and study arm (no feedback/standard feedback/tailored feedback, n = 7/11/8). Reported experiences of online depression screening can be described as a two-step process: Step 1 is the initial reaction to the screening procedure and comprises the theme recognition of depressive symptoms: from denial to awareness. Step 2 describes a subsequent self-explorative process encompassing the themes cognitive positioning: rejection vs. acceptance, emotional reaction: between overload and empowerment, and personal activation: from reflection to action. Conclusions: Findings indicate that online depression screening with and without feedback of results is experienced as a two-step process promoting symptom recognition and subsequent self-exploration. While few participants reported negative effects, the majority described the screening process as insightful, empowering, and activating. Future research should determine to what extent online depression screening may pose a standalone form of low-threshold support for individuals with undiagnosed depressive disorder, while focusing as well on potential negative effects.