Intersectional inequalities in somatic symptom severity in the adult population in Germany found within the SOMA.SOC study.

Somatic symptoms are common in a wide range of medical conditions. In severe cases, they are associated with high individual and economic burden. To explore social inequalities in somatic symptom severity (SSS) and to identify social groups with highest SSS, we applied an intersectional research approach. Analyses are based on cross-sectional data of the adult population living in Germany (N = 2413). SSS was assessed with the Somatic Symptom Scale-8. A multiple linear regression model with three-way interaction of gender, income and history of migration and post-hoc pairwise comparison of estimated marginal means was conducted. Analyses revealed intersectional inequalities in SSS along the axis of gender, income, and history of migration. Highest SSS was found in males with low income whose parent(s) immigrated, females with low income who immigrated themselves, and females with low income and no history of migration. Intersectional approaches contribute to a more comprehensive understanding of health disparities. To reduce disparities in SSS, proportionate universal interventions combining universal screening and targeted treatment seem promising.

The efficacy of automated feedback after internet-based depression screening: Study protocol of the German, three-armed, randomised controlled trial DISCOVER.

BACKGROUND: Depression is one of the most disabling disorders worldwide, yet it often remains undetected. One promising approach to address both early detection and disease burden is depression screening followed by direct feedback to patients. Evidence suggests that individuals often seek information regarding mental health on the internet. Thus, internet-based screening with automated feedback has great potential to address individuals with undetected depression. OBJECTIVES: To determine whether automated feedback after internet-based depression screening reduces depression severity as compared to no feedback. METHODS: The internet-based, observer-blinded DISCOVER RCT aims to recruit a total of 1074 individuals. Participants will be screened for depression using the Patient Health Questionnaire (PHQ-9). In case of a positive screening result (PHQ-9 ≥ 10), participants with undetected depression will be randomised into one of three balanced study arms to receive either (a) no feedback (control arm), (b) standard feedback, or (c) tailored feedback on their screening result. The tailored feedback version will be adapted to participants' characteristics, i.e. symptom profile, preferences, and demographic characteristics. The primary hypothesis is that feedback reduces depression severity six months after screening compared to no feedback. The secondary hypothesis is that tailored feedback is more efficacious compared to standard feedback. Further outcomes are depression care, help-seeking behaviour, health-related quality of life, anxiety, somatic symptom severity, intervention acceptance, illness beliefs, adverse events, and a health economic evaluation. Follow-ups will be conducted one month and six months after screening by self-report questionnaires and clinical interviews. According to a statistical analysis plan, the primary outcome will be analysed on an intention-to-treat basis applying multilevel modelling. DISCUSSION: The results of the DISCOVER RCT will inform about how automated feedback after internet-based screening could improve early detection and resolution of depression. Ways of dissemination and how the trial can contribute to an understanding of help-seeking behaviour processes will be discussed. If the results show that automated feedback after internet-based depression screening can reduce depression severity, the intervention could be easily implemented and might substantially reduce the disease burden of individuals with undetected depression. ETHICAL APPROVAL: The study is approved by the Ethics Committee of the Hamburg Medical Association. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov in November 2020 (identifier: NCT04633096).

Supportive care needs of patients with rare chronic diseases: multi-method, cross-sectional study.

BACKGROUND: In the absence of a cure for the majority of rare diseases, the disease management aims to provide optimal supportive care. The goal of this study was to assess supportive care needs in patients with chronic rare diseases. METHODS: Cross-sectional mixed-method study was conducted using validated self-report scales and open-ended questions to assess supportive care needs. Participants affected by rare diseases across Germany were contacted via patient organizations and centers for rare diseases. N = 304 participants with 81 different rare diseases completed the study, 81.6% were female, mean age was 44.2 years (SD = 12.8, range 16-74). The quantitative results regarding supportive care needs were compared to a reference population of patients affected by cancer (N = 888). Main outcomes were unmet supportive care needs of patients with rare diseases, as assessed by the Supportive Care Needs Survey (SNCS-SF34) and an open-ended question on support wishes. RESULTS: Patients with rare diseases did not feel sufficiently supported with regard to psychological support, health system and information, physical and daily living, patient care and support, and sexuality needs. The unmet supportive care needs were significantly higher in the patient sample with rare diseases compared to the SCNS-SF34 reference sample of patients with cancer. 60% of patients with rare diseases did not feel sufficiently socially supported. CONCLUSIONS: Patients affected by rare diseases have high unmet support needs in all areas studied. Multidisciplinary care, including psychological support and the provision of information regarding the healthcare system, treatment options, disease course and sexuality, might help address these needs.

Development of the generic, multidimensional Treatment Expectation Questionnaire (TEX-Q) through systematic literature review, expert surveys and qualitative interviews.

OBJECTIVE: Patients' expectations-as a central mechanism of placebo and nocebo effects-are an important predictor of health outcomes. However, the lack of a way to assess expectations across different settings restricts progress in understanding the role of expectations and to quantify their importance in medical and psychological treatments. The aim of this study was to develop a theory-based, generic, multidimensional measure assessing patient expectations of medical and psychological treatments. DESIGN: The Treatment Expectation Questionnaire (TEX-Q) was developed based on the integrative model of expectations and a systematic literature review of treatment expectation scales. After creating a comprehensive item pool, the scale was further refined by use of expert ratings and patient interviews. SETTING: Patients were recruited in primary care at two hospitals in Hamburg, Germany. PARTICIPANTS: 13 scientific experts participated in the expert survey. 11 patients waiting for psychological or surgical treatments participated in the qualitative interviews. RESULTS: The 2×2×2 multidimensional structure of the TEX-Q assesses two expectation constructs (probabilistic vs value-based) across two outcome domains with two valences (direct benefits and adverse events, broader positive and negative impact), plus process and behavioural control expectations. We examined 583 items from 38 scales identified in the systematic review and developed 78 initial items. Content validity was then rated by experts according to item fit and comprehensibility. The best 53 items were further evaluated for comprehensibility, acceptability, phrasing preference and understanding by interviewing patients prior to treatment using the 'think aloud' technique. This resulted in a first 35-item version of the TEX-Q. CONCLUSIONS: The TEX-Q is a generic, multidimensional measure to assess patient expectations of medical and psychological treatments and allows comparison of the impact of multidimensional expectations across different conditions. The final TEX-Q will be available after psychometric validation.

Perceived burden in dealing with different rare diseases: a qualitative focus group study.

OBJECTIVES: There are more than 6000 heterogeneous rare diseases and little is known about shared experiences of affected individuals in everyday life and healthcare. Objective of this study was to explore perceived burden of patients with rare chronic diseases and identify commonalities and differences in the experiences of patients with four heterogeneous conditions. DESIGN: A qualitative focus group study. SETTING: In four separate and diagnostically homogeneous focus groups, we asked patients about the perceived burden of living with their rare disease. The focus groups took place at a university medical centre in Germany. PARTICIPANTS: Individuals with neurofibromatosis type 1 (n=4), primary sclerosing cholangitis (n=5), pulmonary arterial hypertension (n=4) and Marfan syndrome (n=5). RESULTS: We identified five main themes: medical problems, psychological burden, problems with the healthcare system, constraints and interpersonal problems. While medical problems differed widely between the diagnostic groups, patients with different conditions independently reported many common problems including psychological burden, constraints in professional, personal and daily life, stigmatisation and others lacking understanding. Shared problems pertaining to the healthcare system seem related to the rarity of the conditions (eg, limited access to adequate care, lack of knowledge). CONCLUSIONS: Despite clinical heterogeneity of rare diseases, affected individuals have many common experiences. Some of these experiences may resemble the burden of living with a chronic disease. However, patients reported aspects, which seem to be specific for rare chronic diseases. Generic interventions targeting shared burdens among patients with different diseases could provide adequate treatment in light of finite healthcare resources.

Assessment of perceived mental health-related stigma: The Stigma-9 Questionnaire (STIG-9).

Mental health-related stigma is common and inhibits help-seeking. It triggers fears of devaluation and can add to the burden of a mental disorder. To counter the consequences of mental health-related stigma, its sound assessment is crucial. Therefore, we developed a new measure, the Stigma-9 Questionnaire (STIG-9), and evaluated its psychometric properties and applicability in patients with mental disorders. Item development was based on the modified labelling theory, psychometric reasoning, and discussion with focus groups including patients and clinicians. Data from 919 consecutive patients from an outpatient clinic for mental disorders (69% female, mean age 41 (SD = 14) years) was used to psychometrically evaluate the measure. The STIG-9 consists of nine items assessing cognitive, behavioural and affective aspects of perceived mental health-related stigma. Higher scores indicate stronger expectations of negative societal beliefs, feelings, and behaviours towards 'mentally ill' people. Confirmatory factor analysis revealed a single factor structure. The scale showed high internal consistency. Male gender, social impairment and higher levels of psychopathology corresponded with higher STIG-9 scores. The STIG-9 is a new, theory-grounded, patient-oriented and psychometrically promising self-report measure of perceived mental health-related stigma. It is brief, comprehensive, and appears to be well accepted by patients with mental disorders.

General Population Norms for the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale.

BACKGROUND: The Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale is an internationally used validated measure. General population-based age- and sex-specific percentile norms are, however, not published to date, although these are needed as reference for the interpretation of clinical research data. OBJECTIVES: To assess the FACIT-Fatigue Scale in a large representative sample of the German general population to examine psychometric characteristics and factorial structure and to provide population-based norms. METHODS: A nationally representative face-to-face household survey was conducted in Germany using the FACIT-Fatigue Scale. Item characteristics were examined. Internal consistency was determined using the Cronbach α. Dimensionality was analyzed using confirmatory factor analysis (CFA) and bifactor analysis. Scale score differences relating to sex and age were assessed. Sex- and age-specific percentiles were computed for the entire scale range. RESULTS: Of 2426 participants, 55.7% were women, and the mean age was 49.8 ± 17.4 years. The FACIT-Fatigue Scale mean was 43.5 ± 8.3. Cronbach α was high at 0.92. Although fit indices of the CFA were below desired levels (root mean squared error of approximation = 0.144, comparative fit index = 0.846, and Tucker-Lewis index = 0.815), item loadings in the CFA and bifactor analysis confirm the scale's unidimensionality. Women were more fatigued than men, and participants who were 70 years or older showed higher fatigue scores than younger respondents. Thus, sex- and age-specific population-based percentiles were provided. CONCLUSIONS: Reliability and validity of the German translation of the FACIT-Fatigue Scale were confirmed. This study provides general population-based sex- and age-specific FACIT-Fatigue Scale percentile norms for the first time, thereby contributing to a meaningful interpretation of clinical research data.

Cost-effectiveness Analysis of a Stepped, Collaborative and Coordinated Health Care Network for Patients with Somatoform Disorders (Sofu-Net).

BACKGROUND: Somatoform disorders are highly prevalent mental disorders causing impairment and large economic burden. In order to improve the diagnosis and management of affected patients, a health care network for somatoform disorders (Sofu-Net) was implemented in primary care. AIMS OF THE STUDY: The aim of the study was to determine the cost-effectiveness of a stepped, collaborative and coordinated health care network for somatoform and functional disorders (Sofu-Net) compared with regular primary care physician (PCP) practices in German primary care from a societal perspective. METHODS: This study was part of a 6-month controlled, prospective, non-randomized, observer-blinded cluster cohort trial. Participants were recruited from 33 PCP practices in Hamburg, Germany. The health care network was a collaboration of PCPs, psychotherapists, inpatient clinics and a specialized outpatient clinic. Participants in the control group received usual care. A cost-effectiveness analysis, using treatment response as measure of effectiveness, was performed. Uncertainty in cost-effectiveness was analyzed using cost-effectiveness acceptability curves. RESULTS: In total, n=218 patients (n=119 patients in the intervention group and n=99 patients in the control group) were included in the study. At 6 months, patients within the Sofu-Net group did not differ significantly from the control group with regard to costs (533; standard error 941) and treatment response (--10.3%). For Sofu-Net, the probability of being cost-effective at a willingness-to-pay (WTP) of 10,000 per additional response to treatment was only 31%. DISCUSSION: Sofu-Net is unlikely to be cost-effective. Even for high WTP, the probability of cost-effectiveness was low. The results were robust to variation of costs included in the analysis as well as when only complete cases were included in the analysis. The most important limitations of the study were that randomization could not be established at patient level and at practice level and that the study design did not allow measurement of costs at baseline. CONCLUSION: Patients with severe somatic symptoms did not benefit from the health care network. Sofu-Net might have reduced costs in patients with moderate somatic symptoms. IMPLICATIONS FOR FURTHER RESEARCH: Owing to the limitations and due to a short follow-up of this study, further cost-effectiveness analyses with high methodological quality and a follow-up of at least one year are needed in order to produce results that are more reliable.

Duration of untreated illness in patients with somatoform disorders.

OBJECTIVE: A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders. METHODS: In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI. RESULTS: A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI. CONCLUSIONS: The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.

The change process in adult anorexia nervosa inpatient treatment: a path model.

PURPOSE: Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment. METHODS: We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model. RESULTS: The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/m2 (SD = 1.6 kg/m2). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2. CONCLUSIONS: The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory.

OBJECTIVE: The Generalized Anxiety Disorder scale (GAD-7) is one of the most frequently used diagnostic self-report scales for screening, diagnosis and severity assessment of anxiety disorder. Its psychometric properties from the view of the Item Response Theory paradigm have rarely been investigated. We aimed to close this gap by analyzing the GAD-7 within a large sample of primary care patients with respect to its psychometric properties and its implications for scoring using Item Response Theory. METHODS: Robust, nonparametric statistics were used to check unidimensionality of the GAD-7. A graded response model was fitted using a Bayesian approach. The model fit was evaluated using posterior predictive p-values, item information functions were derived and optimal predictions of anxiety were calculated. RESULTS: The sample included N = 3404 primary care patients (60% female; mean age, 52,2; standard deviation 19.2) The analysis indicated no deviations of the GAD-7 scale from unidimensionality and a decent fit of a graded response model. The commonly suggested ultra-brief measure consisting of the first two items, the GAD-2, was supported by item information analysis. The first four items discriminated better than the last three items with respect to latent anxiety. CONCLUSION: The information provided by the first four items should be weighted more heavily. Moreover, estimates corresponding to low to moderate levels of anxiety show greater variability. The psychometric validity of the GAD-2 was supported by our analysis.

Depression screening with patient-targeted feedback in cardiology: The cost-effectiveness of DEPSCREEN-INFO.

BACKGROUND: Although depression is common in patients with heart disease, screening for depression is much debated. DEPSCREEN-INFO showed that a patient-targeted feedback in addition to screening results in lower depression level six months after screening. The purpose of this analysis was to perform a cost-effectiveness analysis of DEPSCREEN-INFO. METHODS: Patients with coronary heart disease or arterial hypertension were included. Participants in both groups were screened for depression. Participants in the intervention group additionally received a patient-targeted feedback of their result and recommended treatment options. A cost-utility analysis using quality-adjusted life years (QALY) based on the EQ-5D was performed. The time horizon was 6 months. Resource utilization was assessed by a telephone interview. Multiple imputation using chained equations was used. Net-benefit regressions controlled for prognostic variables at baseline were performed to construct cost-effectiveness acceptability curves. Different sensitivity analyses were performed. RESULTS: 375 participants (intervention group: 155; control group: 220) were included at baseline. After 6 months, in the intervention group adjusted total costs were lower (-€2,098; SE: €1,717) and more QALY were gained (0.0067; SD: 0.0133); yet differences were not statistically significant. The probability of cost-effectiveness was around 80% independent of the willingness-to-pay (range: €0/QALY-€130,000/QALY). The results were robust. CONCLUSIONS: A patient-targeted feedback in addition to depression screening in cardiology is cost-effective with a high probability. This underpins the use of the patient-targeted feedbacks and the PHQ-9 that are both freely available and easy to implement in routine care.

[Improving Health Care for Patients with Somatoform and Functional Disorders: A Collaborative Stepped Care Network (Sofu-Net)]. / Verbesserte Versorgung von Patienten mit somatoformen und funktionellen Störungen: Ein koordiniertes gestuftes Netzwerk (Sofu-Net).

The management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy and overuse of health care. To address these difficulties, this study aimed to establish a collaborative stepped health care network (Sofu-Net). Sofu-Net was established among 41 primary care physicians, 35 psychotherapists and 8 mental health clinics. Baseline assessment in primary care showed elevated psychopathology and deficits in health care among patients with somatoform symptoms. Network partners provided positive evaluations of Sofu-Net.

[Review Model for the Assessment of Psychometric Instruments--Recommendations of the German College of Psychosomatic Medicine (DKPM)]. / Kriterienkatalog zur Beurteilung psychodiagnostischer Selbstbeurteilungsinstrumente--Empfehlung des Deutschen Kollegiums für Psychosomatische Medizin (DKPM).

OBJECTIVES: Psychometric instruments are commonly applied in psychotherapeutic research and care for the baseline assessment of symptoms, the planning of therapeutic interventions, the assessment of the longitudinal course of symptoms and outcomes of therapeutic interventions as well as quality management of care. Psychometric properties as well as economic aspects should be considered in the selection of specific instruments. It is assumed that users of psychometric instruments face a great variety of instruments and related information. For that reason, it seems challenging to absorb the current knowledge and to integrate it into clinical practice and research. Thus, it is likely that well-known, established and easily accessible instruments are commonly used, while new developed instruments might not be disseminated in research and healthcare. METHODS: Based on available international review models, the working group "Psychometrics and Psychodiagnostics" of the German College of Psychosomatic Medicine (DKPM) has developed and tested a review model specifically tailored for psychotherapeutic research and care. RESULTS: The different steps of development, as well as the final review model based on the consensus of the working group are presented. The review model contains 6 generic terms (reliability, validity, objectivity, reference groups and aspects of application) with 21 different criteria to be assessed with 0-3 asterisks (*). The criteria are clearly operationalized and the practical use of the review model is explained and discussed. CONCLUSIONS: With the review model for the assessment of psychometric instruments a well-defined evaluation system is made available for research and clinical practice which has been developed by an expert group. The review model facilitates systematic, transparent and comparative evaluation of psychometric instruments along clearly defined criteria. It also supports the selection of psychometric instruments in research and care. Next, the working group aims at disseminating and implementing the review model as well as the application and publication of reviews for different psychometric instruments based on the review model.

Cost-utility analyses of cognitive-behavioural therapy of depression: a systematic review.

BACKGROUND: Major depressive disorder (MDD) causes a massive disease burden worldwide. Cognitive behavioural therapy (CBT) is an important treatment approach for depression. Cost-utility analysis (CUA) is a method to support decisions on efficient allocation of resources in health policy. The objective of our study was to systematically review CUA of CBT in the treatment of patients suffering from MDD. METHODS: We conducted a systematic literature search in Medline, Embase, PsycINFO and National Health Service Economic Evaluation Database (NHS EED) to identify CUA of CBT for MDD. Cost data were inflated to the year 2011 and converted into USD using purchasing power parities (USD PPP) to ensure comparability of the data. Quality assessment of CUA was performed. RESULTS: Twenty-two studies were included in this systematic review. No study employed a time horizon of more than 5 years. In most studies, individual and group CBT as well as CBT for maintenance showed acceptable incremental cost-utility ratios (<50,000 USD PPP/quality-adjusted life year). The CUA results of CBT for children and adolescents and of computerized CBT were inconsistent. DISCUSSION: We found consistent evidence that individualized CBT is cost-effective from the perspective of a third-party payer for short-term treatment and for relapse prevention of MDD in the adult population.

Assessing somatic symptom burden: a psychometric comparison of the patient health questionnaire-15 (PHQ-15) and the somatic symptom scale-8 (SSS-8).

OBJECTIVE: The Patient Health Questionnaire-15 (PHQ-15) is a frequently used questionnaire to assess somatic symptom burden. Recently, the Somatic Symptom Scale-8 (SSS-8) has been published as a short version of the PHQ-15. This study examines whether the instruments' psychometric properties and estimates of symptom burden are comparable. METHODS: Psychosomatic outpatients (N=131) completed the PHQ-15, the SSS-8 and other questionnaires (PHQ-9, GAD-7, WI-7, SF-12). Item characteristics and measures of reliability, validity, and symptom severity were determined and compared. RESULTS: The reliabilities of the PHQ-15 and SSS-8 were α=0.80 and α=0.76, respectively and both scales were highly correlated (r=0.83). The item characteristics were comparable. Both instruments showed the same pattern of correlations with measures of depression, anxiety, health anxiety and health-related quality of life (r=0.32 to 0.61). On both scales a 1-point increase was associated with a 3% increase in health care use. The percentile distributions of the PHQ-15 and the SSS-8 were similar. Using the same thresholds for somatic symptom severity (5, 10, and 15 points), both instruments identified nearly identical subgroups of patients with respect to health related quality of life. CONCLUSION: The PHQ-15 and the SSS-8 showed similar reliability and validity but the comparability of severity classifications needs further evaluation in other populations. Until then we recommend the use of the previously established thresholds. Overall, the SSS-8 performed well as a short version of the PHQ-15 which makes it preferable for assessment in time restricted settings.

[The Somatic Symptoms Experiences Questionnaire (SSEQ): a new self-report instrument for the assessment of psychological characteristics of patients with somatoform disorder]. / Der Fragebogen zum Erleben von Körperbeschwerden (SSEQ): Ein neues Selbstbeurteilungsinstrument zur Erfassung der psychischen Merkmale somatoformer Störungen.

Psychological symptoms of somatoform disorders will be part of their new definition in DSM-5. We developed the Somatic Symptoms Experiences Questionnaire (SSEQ) as a self-report questionnaire to assess important psychological characteristics of patients with somatoform disorders. Item selection and identification of factor structure, as well as reliability and validity have been checked in a sample of N=453 psychsomatic outpatients. Results of a principal components analysis with Promax-rotation suggested 4 factors (health worries, illness experience, difficulties in interaction with doctors, impact of illness). Validity analyses confirmed associations between the SSEQ-Scores and the physical disability of patients. Although further assessments of psychometric qualities are needed, the questionnaire appears to be well-suited for future assessment of relevant psychological features of somatoform disorders.

Suicidal ideation in German primary care.

OBJECTIVE: To examine suicidal ideation in a sample of German primary care patients. METHODS: We conducted a cross-sectional study and included 1455 primary care patients who visited 1 of 41 general practitioners (GPs) working at 19 different sites. Suicidal ideation and psychopathology were assessed with the Patient Health Questionnaire (PHQ) in an anonymous screening together with health care utilization. RESULTS: One hundred seventy-one (11.8%) of 1455 patients endorsed the suicidal ideation item of the PHQ. These patients were significantly younger, more often female and unmarried, suffered more often from psychopathology and reported more health care utilization than patients without suicidal ideation. Patients with the highest frequency of suicidal ideation also talked more often routinely about psychosocial problems with their GP, used more often medication against their complaints and searched more often for a psychotherapist than other suicidal ideators. Yet, these patients were not more likely to be in psychotherapy at the time of the screening. CONCLUSION: Our data suggest that suicidal ideation is a common phenomenon in primary care, which is independently associated with psychopathology in terms of depression, anxiety and somatoform complaints. Psychosocial support from GPs and medication seem to be easier available for primary care patients with suicidal ideation than psychotherapy, independent of the severity of the suicidal ideation.

Short and precise patient self-assessment of heart failure symptoms using a computerized adaptive test.

BACKGROUND: Assessment of dyspnea, fatigue, and physical disability is fundamental to the monitoring of patients with heart failure (HF). A plethora of patient-reported measures exist, but most are too burdensome or imprecise to be useful in clinical practice. New techniques used for computer adaptive tests (CATs) may be able to address these problems. The purpose of this study was to build a CAT for patients with HF. METHODS AND RESULTS: Item banks of 74 queries ("items") were developed to assess self-reported physical disability, fatigue, and dyspnea. All queries were administered to 658 adults with HF to build 3 item banks. The resulting HF-CAT was administered to 100 patients with ancillary HF (New York Heart Association I, 11%; II, 53%; III and IV, 36%). In addition, the physical function and vitality domains of the SF-36 Health Survey questionnaire, an established shortness-of-breath scale, and the Minnesota Living with Heart Failure Questionnaire were applied. The HF-CAT assessment took 3:09±1:52 minutes to complete and score. All HF-CAT scales demonstrated good construct validity through high correlations with the corresponding SF-36 Health Survey physical function (r=-0.87), vitality (r=-0.85), and shortness-of-breath (r=0.84) scales. Simulation studies showed a more precise measurement of all HF-CAT scales over a larger range than comparable static tools. The HF-CAT scales identified significant differences between patients classified by the New York Heart Association symptom criteria, similar to the Minnesota Living with Heart Failure Questionnaire. CONCLUSIONS: A new CAT for patients with HF was built using modern psychometric methods. Initial results demonstrate its potential to increase the feasibility and precision of patient self-assessments of symptoms of HF with minimized respondent burden. CLINICAL TRIAL REGISTRATION- URL: http://www.projectreporter.nih.gov. Unique identifier: 1R43HL083622-01.

Cost-of-illness studies and cost-effectiveness analyses in eating disorders: a systematic review.

OBJECTIVE: To review cost-of-illness studies (COIs) and cost-effectiveness analyses (CEAs) of eating disorders (EDs) and to describe their methodological quality. METHOD: A systematic literature search was done. Search results passed through a selection process, included studies were classified as COIs, CEAs, or "other cost studies" (OCS). Costs were inflated and converted to 2008 US$ purchasing power parities (PPP). Quality criteria were developed and applied to each study. RESULTS: Five COI, two CEA, and eleven "OCS" were reviewed. Most studies focused on anorexia nervosa and bulimia nervosa. Annual costs per patient ranged from 1,288 to 8,042 US$-PPP. All interventions, investigated in CEA, were more effective and less costly than the alternative treatments. DISCUSSION: The number of publications investigating costs in EDs has increased recently. However, no COI provided a comprehensive estimate of costs, and the comparability of CEA was limited. Nonetheless, the results indicate that the costs arising from EDs are substantial.