Examining the optimal cutoff values of HADS, PHQ-9 and GAD-7 as screening instruments for depression and anxiety in irritable bowel syndrome.

BACKGROUND: Self-rating scales are frequently used to screen for anxiety and depression in patients with irritable bowel syndrome (IBS). Different cutoff values are recommended in literature, and guidelines have suggested the use of other screening instruments over time. The aim of this study was to assess the correlation between the most commonly used psychological screening instruments for anxiety and depression in IBS and to compare custom cutoff scores for these instruments. METHODS: Irritable bowel syndrome patients (n = 192) completed several questionnaires including the Hospital Anxiety and Depression Scale (HADS, HADS-A and HADS-D subscale), Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7). Agreement at different cutoff points, for depressive and anxiety disorder, was assessed by use of the Gwet AC1 coefficient. KEY RESULTS: Hospital Anxiety and Depression Scale (HADS)-D and PHQ-9 scores, and HADS-A and GAD-7 scores showed high correlations (rs  = 0.735 and rs  = 0.805, respectively). For depressive disorder, a Gwet AC1 value of 0.829 was found when recommended cutoff points from literature were compared (PHQ-9 cutoff ≥10, HADS-D cutoff ≥8). For anxiety disorder, a Gwet AC1 value of 0.806 was found when recommended cutoff points from literature were compared (GAD-7 cutoff ≥10, HADS-A cutoff ≥8). Even higher agreements were found when higher HADS cutoff values were chosen, with impact on sensitivity and specificity. CONCLUSIONS & INFERENCES: Custom cutoff values deem the HADS subscales (HADS-D and HADS-A) concordant to PHQ-9 and GAD-7 scores. The choice of a cutoff value has substantial impact on sensitivity/specificity and is dependent on patient population, setting, and the purpose of use.

Use of Rome criteria for the diagnosis of irritable bowel syndrome in primary care: a survey among European countries.

BACKGROUND AND OBJECTIVES: The majority of patients with irritable bowel syndrome (IBS) are diagnosed and treated in primary care. The aim of this study was to investigate the implementation of the Rome criteria in daily primary care clinical practice and adherence of general practitioners (GPs) to recommended diagnostic approaches for IBS. PATIENTS AND METHODS: A survey consisting of 18 questions was distributed across 11 European countries and was used to assess GPs' diagnostic approach of IBS, the use of Rome criteria in daily practice and GPs' perspective on the aetiology of the disorder. RESULTS: Overall, 185 GPs completed the survey. In daily clinical practice, 32% of GPs reported that they usually make a positive diagnosis on the basis of symptoms only, whereas 36% of GPs reported regular use of the Rome criteria to diagnose IBS. Furthermore, 62% of the responders reported that they applied additional diagnostics, such as blood tests, 31% found it necessary to perform endoscopy to make a positive diagnosis of IBS and 29% referred patients with IBS to a specialist. Psychological factors were the most frequently selected potential aetiological factor of IBS (88% of GPs). Overall, 52% of GPs reported systematically including questions on psychological symptoms in the assessment of history of IBS. CONCLUSION: Only about one-third of GPs regularly used the Rome criteria to diagnose IBS. In daily primary care practice, IBS largely remains a diagnosis of exclusion. This has implications in terms of GPs' specialty training and questions the applicability of IBS guidelines in daily care, which advocate an early, positive, symptom-based diagnosis.

Functional urological disorders: a sensitized defence response in the bladder-gut-brain axis.

Functional urological and gastrointestinal disorders are interrelated and characterized by a chronic course and considerable treatment resistance. Urological disorders associated with a sizeable functional effect include overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Poor treatment outcomes might be attributable to untreated underlying psychological and psychiatric disorders, as the co-occurrence of functional urological and gastrointestinal disorders with mood and anxiety disorders is common. The hypothetical bladder-gut-brain axis (BGBA) is a useful framework under which this interaction can be studied, suggesting that functional disorders represent a sensitized response to earlier threats such as childhood adversity or previous traumatic events, resulting in perceived emotional and bodily distress - the symptoms of functional disorders. Psychological and physical stress pathways might contribute to such alarm falsification, and neuroticism could be a risk factor for the co-occurrence of functional disorders and affective conditions. Additionally, physical threat - either from external sources or internal sources such as infection - might contribute to alarm falsification by influencing body-brain crosstalk on homeostasis and, therefore, affecting mood, cognition, and behaviour. Multidisciplinary research and an integrated care approach is, therefore, required to further elucidate and remediate functional urological and gastrointestinal polymorphic phenotypes.

The relationship between fiberoptic endoscopic evaluation of swallowing outcome and symptoms of anxiety and depression in dysphagic patients.

OBJECTIVES/HYPOTHESIS: Affective complaints are involved in bothersome oropharyngeal dysphagia (OD). The aim was to determine the relationship between the severity of OD and affective symptoms. STUDY DESIGN: Prospective cohort study. METHODS: One hundred seven patients underwent a standardized examination protocol including the Hospital Anxiety and Depression Scale and fiberoptic endoscopic evaluation of swallowing (FEES). Two observers independently assessed patient performance on four ordinal FEES-variables (for thin and thick liquid consistency, blindly assessed). The relationship between FEES outcome and the presence of clinically relevant symptoms of anxiety and depression was analyzed using binary logistic regression. RESULTS: Significant associations were found between clinically relevant symptoms of anxiety and two variables: piecemeal deglutition (thin liquid consistency only) (P = .026) and postswallow vallecular pooling (thick liquid consistency only) (P = .015). The probability of presenting with anxiety symptoms decreased as the severity of piecemeal deglutition and postswallow vallecular pooling increased. No significant association was found between clinically relevant symptoms of depression and any specific FEES variable. CONCLUSIONS: These data revealed few associations between anxiety symptoms and the measured FEES variables. However, the more severe the score on FEES variables, the less important the affective complaints were. Anxiety seems to play a role in OD, but no causal relationship was found, commensurate with a cross-sectional study design. The contribution of affective symptoms to the development and treatment of OD warrants longitudinal research. LEVEL OF EVIDENCE: 2b Laryngoscope, 126:E199-E207, 2016.

Decreased levels of kynurenic acid in the intestinal mucosa of IBS patients: relation to serotonin and psychological state.

OBJECTIVE: Irritable bowel syndrome (IBS) has been associated with psychiatric comorbidity and alterations in serotonergic metabolism. Tryptophan is the precursor of serotonin (5-HT), but it is mainly catabolized through the kynurenine pathway. This pathway may also be involved in the pathogenesis of IBS by virtue of deviating tryptophan from the 5-HT pathway resulting in 5-HT deficiency. We therefore aimed to ascertain the mucosal and systemic concentrations of 5-HT and kynurenic acid (KYNA), a principal kynurenine metabolite. METHODS: Duodenal mucosal biopsy specimens and platelet poor plasma samples were obtained from 15 healthy volunteers and 15 IBS patients. Psychological state was assessed using the Hospital Anxiety and Depression Scale and the Symptom Checklist-90. RESULTS: IBS patients showed significantly lower mucosal and higher systemic concentrations of both 5-HT and KYNA compared to healthy controls. Also, significant correlation between mucosal but not plasma concentrations of KYNA and 5-HT and psychological state in IBS was observed. CONCLUSION: The observation that mucosal KYNA and 5-HT are both decreased in IBS does not support the hypothesis that increased activation along the kynurenic pathway results in relative 5-HT deficiency. However, an increased release of these substances from the intestine to the systemic compartment may lead to a decrease in intestinal KYNA and 5-HT levels, resulting in disturbance of intestinal homeostasis. Thus, changes in psychological states observed in IBS patients may be secondary to alterations in gastrointestinal function, and in particular kynurenine and/or 5-HT metabolism.

Symptoms of anxiety and depression in COPD patients entering pulmonary rehabilitation.

Chronic obstructive pulmonary disease (COPD) patients may suffer from symptoms of anxiety and depression. Whether and to what extent symptoms of anxiety and depression may be present in COPD patients entering pulmonary rehabilitation and which patient characteristics are associated with psychological distress remains currently unknown. The objective of the present study is to determine the prevalence and the determinants of clinically relevant symptoms of anxiety and depression in COPD patients entering pulmonary rehabilitation. Symptoms of anxiety and depression have been assessed in 701 COPD patients entering pulmonary rehabilitation using the Hospital Anxiety and Depression Scale. Additionally, disease-specific health status, pulmonary function, body composition, exercise capacity, co-existing morbidities, smoking status, symptoms, long-term oxygen therapy and the use of antidepressant and anxiolytic drugs have been recorded. Patients had mean anxiety scores of 7.6 points and mean depression scores of 7.2 points. Anxiety scores >or=10 points were present in 225 patients (32%) and depression scores >or=10 points were present in 192 patients (27%). Patients at risk of having symptoms of anxiety were female or used antidepressant or anxiolytic drugs. Patients at risk of having symptoms of depression experienced dyspnea, had a body mass index (BMI) <21 kg/m(2) or used antidepressant or anxiolytic drugs. A considerable proportion of the COPD patients entering pulmonary rehabilitation report symptoms of anxiety and/or depression, which may significantly impair disease-specific health status. Patients at risk of having symptoms of anxiety and/or depression are female, experience dyspnea, have a low BMI or use antidepressant and/or anxiolytic drugs.

Baseline immune activation as a risk factor for the onset of depression during interferon-alpha treatment.

BACKGROUND: Major depression has been associated cross-sectionally with increased cell-mediated immune activation but causality has been difficult to establish. This study prospectively investigated the hypothesis that baseline level of immune activation predicts the development of depression during interferon-alpha (IFN-alpha) treatment. METHODS: Sixteen hepatitis C patients without psychiatric disorder underwent IFN-alpha treatment. Proinflammatory and anti-inflammatory cytokines were determined before starting treatment. Presence of a major depressive disorder (MDD) was assessed at baseline and several times during treatment. RESULTS: Baseline soluble interleukin-2 receptor (sIL-2r), interleukin-6 (IL-6), and interleukin-10 (IL-10) concentrations were significantly increased in the five subjects that developed MDD during treatment compared with those that did not, with standardized effect sizes of 1.08, 1.16, and 1.25, respectively, controlling for marijuana use, cigarette smoking, and baseline level of depressive symptoms. CONCLUSIONS: Results suggest that increased immune activation, rather than an epiphenomenon, is a causal risk factor for the development of MDD.