Digital cognitive behaviour therapy for insomnia in individuals with self-reported insomnia and chronic fatigue: A secondary analysis of a large scale randomized controlled trial.

Insomnia is associated with fatigue, but it is unclear whether response to cognitive behaviour therapy for insomnia is altered in individuals with co-occurring symptoms of insomnia and chronic fatigue. This is a secondary analysis using data from 1717 participants with self-reported insomnia in a community-based randomized controlled trial of digital cognitive behaviour therapy for insomnia compared with patient education. We employed baseline ratings of the Chalder Fatigue Questionnaire to identify participants with more or fewer symptoms of self-reported chronic fatigue (chronic fatigue, n = 592; no chronic fatigue, n = 1125). We used linear mixed models with Insomnia Severity Index, Short Form-12 mental health, Short Form-12 physical health, and the Hospital Anxiety and Depression Scale separately as outcome variables. The main covariates were main effects and interactions for time (baseline versus 9-week follow-up), intervention, and chronic fatigue. Participants with chronic fatigue reported significantly greater improvements following digital cognitive behaviour therapy for insomnia compared with patient education on the Insomnia Severity Index (Cohen's d = 1.36, p < 0.001), Short Form-12 mental health (Cohen's d = 0.19, p = 0.029), and Hospital Anxiety and Depression Scale (Cohen's d = 0.18, p = 0.010). There were no significant differences in the effectiveness of digital cognitive behaviour therapy for insomnia between chronic fatigue and no chronic fatigue participants on any outcome. We conclude that in a large community-based sample of adults with insomnia, co-occurring chronic fatigue did not moderate the effectiveness of digital cognitive behaviour therapy for insomnia on any of the tested outcomes. This may further establish digital cognitive behaviour therapy for insomnia as an adjunctive intervention in individuals with physical and mental disorders.

Who Returns to work? Exploring the Role of Interpersonal Problems in Occupational Rehabilitation.

PURPOSE: Current interventions designed to facilitate return to work (RTW) after long-term sick leave show weak effects, indicating the need for new approaches to the RTW process. The importance of social relationships in the workplace is widely recognized in existing RTW literature, but very little is known about the role of the interpersonal problems of the returning worker. Current research indicates that a subset of these - hostile-dominant interpersonal problems - give particular disadvantages in several life areas. This prospective cohort study aims to test whether higher levels of interpersonal problems predict lower likelihood of RTW when controlling for symptom levels (H1); and whether higher levels of hostile-dominant interpersonal problems specifically predict lower likelihood of RTW (H2). METHODS: 189 patients on long-term sick leave completed a 3½-week transdiagnostic RTW program. Before treatment, self-reported interpersonal problems, chronic pain, insomnia, fatigue levels, anxiety and depression were collected. RTW data for the following year were collected from the Norwegian Labour and Welfare Administration. RESULTS: A multivariable binary logistic regression analysis found that (H2) hostile-dominant interpersonal problems significantly predicted RTW (OR = 0.44, [95% CI: 0.19, 0.98], p = .045), while a corresponding analysis (H1) found that general interpersonal problems did not. CONCLUSION: Hostile-dominant interpersonal problems negatively predict RTW after long-term sick leave, suggesting an overlooked factor in the field of occupational rehabilitation. The findings could open up new avenues for research and interventions entailed to individuals in the field of occupational rehabilitation.

Digital cognitive behaviour therapy for insomnia (dCBT-I): Chronotype moderation on intervention outcomes.

Using data from 1721 participants in a community-based randomized control trial of digital cognitive behavioural therapy for insomnia compared with patient education, we employed linear mixed modelling analyses to examine whether chronotype moderated the benefits of digital cognitive behavioural therapy for insomnia on self-reported levels of insomnia severity, fatigue and psychological distress. Baseline self-ratings on the reduced version of the Horne-Östberg Morningness-Eveningness Questionnaire were used to categorize the sample into three chronotypes: morning type (n = 345; 20%); intermediate type (n = 843; 49%); and evening type (n = 524; 30%). Insomnia Severity Index, Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression Scale were assessed pre- and post-intervention (9 weeks). For individuals with self-reported morning or intermediate chronotypes, digital cognitive behavioural therapy for insomnia was superior to patient education on all ratings (Insomnia Severity Index, Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression Scale) at follow-up (p-values ≤ 0.05). For individuals with self-reported evening chronotype, digital cognitive behavioural therapy for insomnia was superior to patient education for Insomnia Severity Index and Chalder Fatigue Questionnaire, but not on the Hospital Anxiety and Depression Scale (p = 0.139). There were significant differences in the treatment effects between the three chronotypes on the Insomnia Severity Index (p = 0.023) estimated difference between evening and morning type of -1.70, 95% confidence interval: -2.96 to -0.45, p = 0.008, and estimated difference between evening and intermediate type -1.53, 95% confidence interval: -3.04 to -0.03, p = 0.046. There were no significant differences in the treatment effects between the three chronotypes on the Chalder Fatigue Questionnaire (p = 0.488) or the Hospital Anxiety and Depression Scale (p = 0.536). We conclude that self-reported chronotype moderates the effects of digital cognitive behavioural therapy for insomnia on insomnia severity, but not on psychological distress or fatigue.

Effects of Attentional Bias Modification on residual symptoms in depression: a randomized controlled trial.

BACKGROUND: Following treatment, many depressed patients have significant residual symptoms. However, large randomised controlled trials (RCT) in this population are lacking. When Attention bias modification training (ABM) leads to more positive emotional biases, associated changes in clinical symptoms have been reported. A broader and more transparent picture of the true advantage of ABM based on larger and more stringent clinical trials have been requested. The current study evaluates the early effect of two weeks ABM training on blinded clinician-rated and self-reported residual symptoms, and whether changes towards more positive attentional biases (AB) would be associated with symptom reduction. METHOD: A total of 321 patients with a history of depression were included in a preregistered randomized controlled double-blinded trial. Patients were randomised to an emotional ABM paradigm over fourteen days or a closely matched control condition. Symptoms based on the Hamilton Rating Scale for Depression (HRSD) and Beck Depression Inventory II (BDI-II) were obtained at baseline and after ABM training. RESULTS: ABM training led to significantly greater decrease in clinician-rated symptoms of depression as compared to the control condition. No differences between ABM and placebo were found for self-reported symptoms. ABM induced a change of AB towards relatively more positive stimuli for participants that also showed greater symptom reduction. CONCLUSION: The current study demonstrates that ABM produces early changes in blinded clinician-rated depressive symptoms and that changes in AB is linked to changes in symptoms. ABM may have practical potential in the treatment of residual depression. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02658682 (retrospectively registered in January 2016).

Biopsychosocial predictors and trajectories of work participation after transdiagnostic occupational rehabilitation of participants with mental and somatic disorders: a cohort study.

BACKGROUND: Group-based transdiagnostic occupational rehabilitation programs including participants with mental and somatic disorders have emerged in clinical practice. Knowledge is sparse on subsequent participation in competitive work. This study aimed to investigate trajectories for (re)entry to work for predefined subgroups in a diagnostically heterogeneous sample of sick-listed participants after completing occupational rehabilitation. METHODS: A cohort of 212 participants aged 18-69 on long-term sick leave (> 8 weeks) with chronic pain, chronic fatigue and/or common mental disorders was followed for one year after completing a 3½-week rehabilitation intervention based on Acceptance and Commitment Therapy. Self-reported, clinical and registry data were used to study the associations between predefined biopsychosocial predictors and trajectories for (re)entry to competitive work (≥ 1 day per week on average over 8 weeks). Generalized estimating equations analysis was used to investigate trajectories. RESULTS: For all biopsychosocial subgroups (re)entry to work increased over time. Baseline employment, partial sick leave and higher expectation of return to work (RTW) predicted higher probability of having (re)entered work at any given time after discharge. The odds of increasing reentry over time (statistical interaction with time) was weaker for the group receiving the benefit work assessment allowance compared with those receiving sickness benefit (OR = 0.92, p = 0.048) or for those on partial sick leave compared with full sick leave (OR 0.77, p < 0.001), but higher for those who at baseline had reported having a poor economy versus not (OR 1.16, p = 0.010) or reduced emotional functioning compared with not (OR 1.11, p = 0.012). Health factors did not differentiate substantially between trajectories. CONCLUSIONS: Work participation after completing a transdiagnostic occupational rehabilitation intervention was investigated. Individual and system factors related to work differentiated trajectories for (re)entry to work, while individual health factors did not. Having a mental disorder did not indicate a worse prognosis for (re)entry to work following the intervention. Future trials within occupational rehabilitation are recommended to pivot their focus to work-related factors, and to lesser extent target diagnostic group.

Processes in acceptance and commitment therapy and the rehabilitation of chronic fatigue.

Acceptance and commitment therapy (ACT) has never been tested for patients with chronic fatigue. We aimed to test if a 3.5-week ACT rehabilitation program for patients with chronic fatigue improved quality of life (QoL), fatigue, and psychological flexibility. Further, to test if improvements in QoL and fatigue were associated with improvement in psychological flexibility, and if psychological flexibility explained variance above and beyond maladaptive cognitions typically targeted in CBT for fatigue. Patients (n = 140) who had been on sick leave > 8 weeks due to chronic fatigue received a 3.5-week non-controlled inpatient rehabilitation program based on ACT. A physician and a psychologist examined the patients, assessing medication use and SCID-I diagnoses. Patients completed questionnaires about somatic complaints, psychological complaints, and maladaptive cognitions before and after treatment. At post-treatment, patients reported improved QoL (p < 0.001; g = 1.07) and less fatigue (p < 0.001; g = 1.08), but not increased psychological flexibility (p = 0.6). Changes in psychological flexibility was associated with improved QoL, but not fatigue, in hierarchical regression analyses. When adjusting for other cognitions, changes in fear-avoidance cognitions and all-or-nothing thoughts, but not psychological flexibility, were associated with improved QoL and fatigue. The ACT-based treatment improved QoL and reduced fatigue for patients with chronic fatigue with large effect sizes. Improvement was associated with a reduction in fear-avoidance cognitions and all-or-nothing thoughts, but not psychological flexibility.

Love Yourself as a Person, Doubt Yourself as a Therapist?

OBJECTIVE: There are reasons to suggest that the therapist effect lies at the intersection between psychotherapists' professional and personal functioning. The current study investigated if and how the interplay between therapists' (n = 70) professional self-reports (e.g., of their difficulties in practice in the form of 'professional self-doubt' and coping strategies when faced with difficulties) and presumably more global, personal self-concepts, not restricted to the professional treatment setting (i.e., the level of self-affiliation measured by the Structural Analysis of Social Behaviour (SASB) Intrex, Benjamin, ), relate to patient (n = 255) outcome in public outpatient care. METHOD: Multilevel growth curve analyses were performed on patient interpersonal and symptomatic distress rated at pre-, post- and three times during follow-up to examine whether change in patient outcome was influenced by the interaction between their therapists' level of 'professional self-doubt' and self-affiliation as well as between their therapists' use of coping when faced with difficulties, and the interaction between type of coping strategies and self-affiliation. RESULTS: A significant interaction between therapist 'professional self-doubt' (PSD) and self-affiliation on change in interpersonal distress was observed. Therapists who reported higher PSD seemed to evoke more change if they also had a self-affiliative introject. Therapists' use of coping strategies also affected therapeutic outcome, but therapists' self-affiliation was not a moderator in the interplay between therapist coping and patient outcome. CONCLUSION: A tentative take-home message from this study could be: 'Love yourself as a person, doubt yourself as a therapist'. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: The findings of this study suggest that the nature of therapists' self-concepts as a person and as a therapist influences their patients' change in psychotherapy. These self-concept states are presumably communicated through the therapists' in-session behaviour. The study noted that a combination of self-doubt as a therapist with a high degree of self-affiliation as a person is particularly fruitful, while the combination of little professional self-doubt and much positive self-affiliation is not. This finding, reflected in the study title, 'Love yourself as a person, doubt yourself as a therapist', indicates that exaggerated self-confidence does not create a healthy therapeutic attitude. Therapist way of coping with difficulties in practice seems to influence patient outcome. Constructive coping characterized by dealing actively with a clinical problem, in terms of exercising reflexive control, seeking consultation and problem-solving together with the patient seems to help patients while coping by avoiding the problem, withdrawing from therapeutic engagement or acting out one's frustrations in the therapeutic relationship is associated with less patient change.

Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial.

BACKGROUND: The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments. METHODS: A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments. RESULTS: CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group. CONCLUSIONS: CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.

The role of self-image as a predictor of psychotherapy outcome.

The present study examined the relationship between self-image and outcome in psychotherapy. Patients (n = 170) received treatment-as-usual at a university clinic, and met diagnostic criteria for mostly anxiety and depression related disorders. Self-image was measured with the Structural Analysis of Social Behavior (SASB-I) introject pre and post-treatment. Using multiple regression analyses, higher levels of Self-ignore and Self-blame pre-treatment predicted a poorer treatment outcome in terms of symptoms (SCL-90-R) and interpersonal problems (IIP-64), respectively. Increase in Self-love and decrease in Self-blame (pre to post) predicted reduced symptoms at post-treatment, whereas decrease in Self-attack and Self-control, as well as increase in Self-affirm, predicted reduced interpersonal problems. The results suggest that self-image improvement may be important in order to achieve a good outcome in psychotherapy.

Prevalence of auditory verbal hallucinations in a general population: A group comparison study.

The present study was specifically designed to investigate the prevalence of auditory verbal hallucinations (AVH) in the general population, and sought to compare similarities and differences regarding socio-demographics, mental health and severe life events between individuals who have never experienced AVH with those who had. The study also aimed to compare those who sought professional help for their experience of AVH with those who had not sought help. Through a postal questionnaire, 2,533 participants ages 18 and over from a national survey completed the Launay-Slade Hallucinations Scale and other measures examining AVH characteristics and other areas related to AVH. In total, 7.3% of the sample reported a life-time prevalence of AVH. Those with AVH were more likely to be single and unemployed, reported higher levels of depression and anxiety, and experienced a higher number of severe life events compared with those without AVH. Only 16% of those who experienced AVH in the general population sought professional help for these experiences. Compared to those who did not seek professional help, participants that had were more likely to experience AVH with a negative content, experience them on a daily basis, undergo negative reactions when experiencing AVH, and resist AVH. In conclusion, the prevalence of AVH was found to be relatively high. The results also revealed higher levels of reduced mental health for individuals who sought professional help, followed by those who did not, compared with those who had never experienced AVH.

Work stress, sleep deficiency, and predicted 10-year cardiometabolic risk in a female patient care worker population.

OBJECTIVES: The aim of this study was to investigate the longitudinal effect of work-related stress, sleep deficiency, and physical activity on 10-year cardiometabolic risk among an all-female worker population. METHODS: Data on patient care workers (n=99) was collected 2 years apart. Baseline measures included: job stress, physical activity, night work, and sleep deficiency. Biomarkers and objective measurements were used to estimate 10-year cardiometabolic risk at follow-up. Significant associations (P<0.05) from baseline analyses were used to build a multivariable linear regression model. RESULTS: The participants were mostly white nurses with a mean age of 41 years. Adjusted linear regression showed that having sleep maintenance problems, a different occupation than nurse, and/or not exercising at recommended levels at baseline increased the 10-year cardiometabolic risk at follow-up. CONCLUSIONS: In female workers prone to work-related stress and sleep deficiency, maintaining sleep and exercise patterns had a strong impact on modifiable 10-year cardiometabolic risk.

Cognitive behaviour therapy for psychotic symptoms: a randomized controlled effectiveness trial.

BACKGROUND: Cognitive behavioural therapy for psychosis (CBTp) is currently a recommended form of psychosocial treatment for persons suffering from persistent psychotic symptoms. It has been argued that effect sizes from efficacy studies cannot be generalized to real clinical settings. AIMS: Our aim was to evaluate whether the positive results from randomized controlled trials conducted by experts could be replicated in clinical setting with a heterogeneous sample of patients with psychotic disorder. METHOD: Patients referred to the study were either randomized to CBTp+TAU (the treatment group) or to a waiting-list group, only receiving TAU. The patients were assessed on different outcome measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Negative Symptoms (SANS), and the Psychotic Symptom Rating Scales (PSYRATS), at pretreatment, at posttreatment (6 months), and at 12 months follow-up. In total, 45 patients participated in the study. RESULTS: The results showed that 20 sessions of CBTp performed significantly better than the waiting list controls with respect to the global score on the BPRS, the delusional scale on the PSYRATS, and the GAF symptom score at posttreatment. At 12 months follow-up only the GAF symptom score remained significantly changed for the total sample. CONCLUSIONS: The study revealed that CBTp delivered by non-experts in routine clinical settings can produce improvements in positive psychotic symptoms, and also that some of these improvements can be maintained at one year follow-up.

Changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy mediate changes in pain intensity on disability in the treatment of chronic low back pain.

Introduction: Treatment of chronic low back pain (CLBP) based on the fear-avoidance model (FAM) has received support in randomized controlled trials, but few studies have examined treatment processes associated with treatment outcome. This study examined changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy as mediators of the relation between changes in pain intensity and disability in exposure-based treatment of CLBP. Methods: Data from a randomized controlled trial with 2 treatment arms (exposure treatment based on the FAM with/without in-session exposure) was pooled, including only participants with complete data (N = 69). Change scores (pre to booster session) were computed for all variables, and the indirect effect of change in pain intensity on change in 3 measures of disability, through change in the proposed mediators, was tested in parallel mediation analyses. Results: Decreases in pain catastrophizing and fear-avoidance beliefs, as well as increases in pain self-efficacy, mediated a unique proportion of the relation between changes in pain intensity and disability, depending on the outcome measure. The direct relation between changes in pain intensity and disability was absent when indirect effects were controlled. Conclusions: The results suggest that the way pain is interpreted (pain catastrophizing, fear-avoidance beliefs), as well as pain self-efficacy, are all more critical for reducing disability in exposure-based treatment of CLBP than symptom relief per se.

Corrigendum: Acceptance and commitment therapy preceded by attention bias modification on residual symptoms in depression: a 12-month follow-up.

[This corrects the article DOI: 10.3389/fpsyg.2019.01995.].

Dysfunctional beliefs and attitudes about sleep (DBAS) mediate outcomes in dCBT-I on psychological distress, fatigue, and insomnia severity.

OBJECTIVE/BACKGROUND: Digital cognitive behavioral therapy for insomnia (dCBT-I) improves several sleep and health outcomes in individuals with insomnia. This study investigates whether changes in Dysfunctional Beliefs and Attitudes about Sleep (DBAS) during dCBT-I mediate changes in psychological distress, fatigue, and insomnia severity. PATIENTS/METHODS: The study presents a secondary planned analysis of data from 1073 participants in a randomized control trial (Total sample = 1721) of dCBT-I compared with patient education (PE). Self-ratings with the Dysfunctional Beliefs and Attitudes about Sleep (DBAS), the Hospital Anxiety Depression Scale (HADS), the Chalder Fatigue Scale (CFQ), and the Insomnia Severity Index (ISI) were obtained at baseline and 9-week follow-up. Hayes PROCESS mediation analyses were conducted to test for mediation. RESULTS AND CONCLUSION: sDBAS scores were significantly reduced at 9-week follow-up for those randomized to dCBT-I (n = 566) compared with PE (n = 507). The estimated mean difference was -1.49 (95% CI -1.66 to -1.31, p < .001, Cohen's d. = 0.93). DBAS mediated all the effect of dCBT-I on the HADS and the CFQ, and 64% of the change on the ISI (Estimated indirect effect -3.14, 95% CI -3.60 to -2.68) at 9-week follow-up compared with PE. Changes in the DBAS fully mediated the effects of dCBT-I on psychological distress and fatigue, and the DBAS partially mediated the effects on insomnia severity. These findings may have implications for understanding how dCBT-I works and highlights the role of changing cognitions in dCBT-I.

Impact of sleep disturbance on patients in treatment for mental disorders.

BACKGROUND: In clinical practice, sleep disturbance is often regarded as an epiphenomenon of the primary mental disorder. The aim of this study was to test if sleep disturbance, independently of primary mental disorders, is associated with current clinical state and benefit from treatment in a sample representative of public mental health care clinics. METHOD: 2246 patients receiving treatment for mental disorders in eight public mental health care centers in Norway were evaluated in a cross-sectional study using patient and clinician reported measures. Patients reported quality of life, symptom severity, and benefit from treatment. Clinicians reported disorder severity, level of functioning, symptom severity and benefit from treatment. The hypothesis was tested using multiple hierarchical regression analyses. RESULTS: Sleep disturbance was, adjusted for age, gender, time in treatment, type of care, and the presence of any primary mental disorder, associated with lower quality of life, higher symptom severity, higher disorder severity, lower levels of functioning, and less benefit from treatment. CONCLUSION: Sleep disturbance ought to be considered a stand-alone therapeutic entity rather than an epiphenomenon of existing diagnoses for patients receiving treatment in mental health care.

Resilience is a good predictor of hopelessness even after accounting for stressful life events, mood and personality (NEO-PI-R).

A better understanding of the relation between protection and vulnerability may advance our understanding of mental health. Therefore the purpose of this study was to examine the incremental validity of the Resilience Scale for Adults (RSA) as a predictor for level of hopelessness. A healthy sample (N = 532) completed the Beck Hopelessness Scale, a list of Stressful Life Events (SLE), the Hopkins Symptom Checklist-25 (HSCL-25), NEO-PI-R (NEO Personality Inventory Revised) and the RSA. The relations between the variables were explored with correlations and multiple hierarchical regression analyses. The results indicated that the RSA measures important protective factors that significantly predict lower levels of hopelessness even when accounting for age, gender, SLE, HSCL-25 and NEO-PI-R. This study supports the notion that the protective resilience factors in the RSA have unique contributions over and above established constructs of stressful life events, depressive and anxiety symptoms and personality in predicting hopelessness, supporting the incremental validity of the RSA.

Corrigendum: Cognitive behavioral therapy improves physical function and fatigue in mild and moderate chronic fatigue syndrome: A consecutive randomized controlled trial of standard and short interventions.

[This corrects the article DOI: 10.3389/fpsyt.2021.580924.].

A Clinical Description of Chronic Pain in a General Population Using ICD-10 and ICD-11 (The HUNT Pain Examination Study).

The purpose was to present a total description, distribution, and ranking of chronic pain conditions in the general population. This was based on structured clinical examinations of a random sample from a population-based survey (HUNT3) with a calculated oversampling of participants with chronic pain. Supplemented with access to hospital reports, the examination was performed by experienced physicians and psychologists using a consistent definition of chronic pain as well as ICD-10- and the new ICD-11-classification. The main findings were that a higher proportion of the 551 participants had chronic pain assessed by clinical examination (399) than by self-report in a survey the same day (337). Among those with examination-verified chronic pain estimated from HUNT3 to represent 27.9% of the general population, 63% had chronic primary pain, 81% musculoskeletal pain, and 77% more than one chronic pain condition. When separating chronic primary from chronic secondary pain according to ICD-11, the weighted prevalence was 17.7% for chronic pain conditions of unknown and 10.2% of known cause. When all the participants' conditions were accounted for, the most prevalent was nonspecific low back (10.8%) and neck pain (7.6%). Participants with chronic primary pain did not have significantly more psychopathology than those with chronic secondary pain: 14.5% versus 12.5%. PERSPECTIVE: Since this study confirms the high prevalence in self-report surveys and indicates that two thirds of chronic pain conditions cannot be explained by underlying diseases, this huge health and societal problem should be solved primarily on a public health level directed toward prevention and rehabilitation.

Differences between patients' and clinicians' report of sleep disturbance: a field study in mental health care in Norway.

BACKGROUND: The aims of the study was to assess the prevalence of diagnosed insomnia and the agreement between patient- and clinician-reported sleep disturbance and use of prescribed hypnotic medication in patients in treatment for mental disorders. METHODS: We used three cross-sectional, multicenter data-sets from 2002, 2005, and 2008. Data-set 1 included diagnostic codes from 93% of all patients receiving treatment in mental health care in Norway (N = 40261). Data-sets 2 (N = 1065) and 3 (N = 1181) included diagnostic codes, patient- and clinician-reported sleep disturbance, and use of prescribed hypnotic medication from patients in 8 mental health care centers covering 10% of the Norwegian population. RESULTS: 34 patients in data-set 1 and none in data-sets 2 and 3 had a diagnosis of insomnia as a primary or comorbid diagnosis. In data-sets 2 and 3, 42% and 40% of the patients reported sleep disturbance, whereas 24% and 13% had clinician-reported sleep disturbance, and 7% and 9% used hypnotics. Patients and clinicians agreed in 29% and 15% of the cases where the patient or the clinician or both had reported sleep disturbance. Positive predictive value (PPV) of clinicians' evaluations of patient sleep disturbance was 62% and 53%. When the patient reported sleep disturbance as one of their most prominent problems PPV was 36% and 37%. Of the patients who received hypnotic medication, 23% and 29% had neither patient nor clinician-rated sleep disturbance. CONCLUSION: When patients meet the criteria for a mental disorder, insomnia is almost never diagnosed, and sleep disturbance is imprecisely recognized relative to the patients' experience of sleep disturbance.