DETECTION OF ANXIETY DISORDERS IN PRIMARY CARE: A META-ANALYSIS OF ASSISTED AND UNASSISTED DIAGNOSES.

BACKGROUND: Evidence suggests that general practitioners (GPs) fail to diagnose up to half of common mental disorder cases. Yet no previous research has systematically summarized the evidence in the case of anxiety disorders. The aim of this review was to systematically assess and meta-analyze the diagnostic accuracy of GPs' assisted (i.e., using severity scales/diagnostic instruments) and unassisted (without such tools) diagnoses of anxiety disorders. METHODS: Systematic review (PROSPERO registry CRD42013006736) was conducted. Embase, Ovid Journals--Ovid SP Medline, Pubmed, PsycINFO, Scopus, Web of Science, and Science Direct were searched from January 1980 through June 2014. Seven investigators, working in pairs, evaluated studies for eligibility. The quality of included studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2). The main outcome measures were sensitivity and specificity of clinical diagnoses of any anxiety disorder. We pooled sensitivity and specificity levels from included studies using bivariate meta-analyses. RESULTS: Twenty-four studies were included in the meta-analysis with a total sample of 34,902 patients. Pooled sensitivity and specificity were estimated at 44.5% (95% CI 33.7-55.9%) and 90.8% (95% CI 87-93.5%). GPs' sensitivity was higher when diagnoses were assisted (63.6%, 95% CI 50.3-75.1%) than when unassisted (30.5%, 95% CI 20.7-42.5%) to the expense of some specificity loss (87.9%, 95% CI 81.3-92.4% vs. 91.4%, 95% CI 86.6-94.6%, respectively). Identification rates remained constant over time (P-value = .998). CONCLUSIONS: The use of diagnostic tools might improve detection of anxiety disorders in "primary care."

Health conditions and role limitation in three European Regions: a public-health perspective.

OBJECTIVE: To describe the distribution of role limitation in the European population aged 18-64 years and to examine the contribution of health conditions to role limitation using a public-health approach. METHODS: Representative samples of the adult general population (n=13,666) aged 18-64 years from 10 European countries of the World Mental Health (WMH) Surveys Initiative, grouped into three regions: Central-Western, Southern and Central-Eastern. The Composite International Diagnostic Interview (CIDI 3.0) was used to assess six mental disorders and standard checklists for seven physical conditions. Days with full and with partial role limitation in the month previous to the interview were reported (WMH-WHODAS). Population Attributable Fraction (PAFs) of full and partial role limitation were estimated. RESULTS: Health conditions explained a large proportion of full role limitation (PAF=62.6%) and somewhat less of partial role limitation (46.6%). Chronic pain was the single condition that consistently contributed to explain both disability measures in all European Regions. Mental disorders were the most important contributors to full and partial role limitation in Central-Western and Southern Europe. In Central-Eastern Europe, where mental disorders were less prevalent, physical conditions, especially cardiovascular diseases, were the highest contributors to disability. CONCLUSION: The contribution of health conditions to role limitation in the three European regions studied is high. Mental disorders are associated with the largest impact in most of the regions. There is a need for mainstreaming disability in the public health agenda to reduce the role limitation associated with health conditions. The cross-regional differences found require further investigation.

Comparison of treatment outcomes in severe personality disorder patients with or without substance use disorders: a 36-month prospective pragmatic follow-up study.

BACKGROUND: Concurrent personality disorder (PD) and substance use disorder (SUD) are common in clinical practice. However, SUD is the main criterion for study exclusion in most psychotherapeutic studies of PD. As a result, data on treatment outcomes in patients with concurrent PD/SUD are scarce. METHODS: The study sample consisted of 51 patients diagnosed with severe PD and admitted for psychotherapeutic treatment as a part of routine mental health care. All patients were diagnosed with PD according to the Structured Clinical Interview for PD. Patients were further assessed (DSM-IV diagnostic criteria) to check for the presence of concurrent SUD, with 28 patients diagnosed with both disorders (PD-SUD). These 28 cases were then compared to the 23 patients without SUD (PD-nSUD) in terms of psychiatric hospitalizations and psychiatric emergency room (ER) visits before and during the 6-month therapeutic intervention and every 6 months thereafter for a total of 36 months. RESULTS: The baseline clinical characteristics correspond to a sample of PD patients (78% met DSM-IV criteria for borderline PD) with poor general functioning and a high prevalence of suicide attempts and self-harm behaviors. Altogether, the five outcome variables - the proportion and the number of psychiatric inpatient admissions, the number of days hospitalized, and the proportion and the number of psychiatric ER visits - improved significantly during the treatment period, and this improvement was maintained throughout the follow-up period. Although PD-SUD patients had more psychiatric hospitalizations and ER visits than PD-nSUD patients during follow-up, the differences between these two groups remained stable over the study period indicating that the treatment was equally effective in both groups. CONCLUSION: Specialized psychotherapy for severe PD can be effectively applied in patients with concurrent PD-SUD under usual practice conditions. These findings suggest that exclusion of patients with dual disorders from specialized treatments is unjustified.

Partial likelihood estimation of IRT models with censored lifetime data: an application to mental disorders in the ESEMeD surveys.

Developmental studies of mental disorders based on epidemiological data are often based on cross-sectional retrospective surveys. Under such designs, observations are right-censored, causing underestimation of lifetime prevalences and correlations, and inducing bias in latent trait models on the observations. In this paper we propose a Partial Likelihood (PL) method to estimate unbiased IRT models of lifetime predisposition to develop a certain outcome. A two-step estimation procedure corrects the IRT likelihood of outcome appearance with a function depending on (a) projected outcome frequencies at the end of the risk period, and (b) outcome censoring status at the time of the observation. Simulation results showed that the PL method yielded good recovery of true frequencies and intercepts. Slopes were best estimated when events were sufficiently correlated. When PL is applied to lifetime mental health disorders (assessed in the ESEMeD project surveys), estimated univariate prevalences were, on average, 1.4 times above raw estimates, and 2.06 higher in the case of bivariate prevalences.

Differential item and test functioning methodology indicated that item response bias was not a substantial cause of country differences in mental well-being.

OBJECTIVES: Establishing the cross-cultural equivalence of the mental well-being construct, as measured with the Warwick-Edinburg Mental Well-being Scale (WEMWBS), by studying potential construct validity biases in two countries with previously reported score differences. STUDY DESIGN AND SETTING: We compared the WEMWBS total scores and item responses in Scotland (N = 779) and Catalonia (N = 1,900) general population samples. To assess whether the questionnaire spuriously favored higher scores in Catalonia, we tested for differential item functioning (DIF) by applying ordinal logistic regression on Item Response Theory scores. DIF was tested with likelihood ratio tests and standard effect measures (McFadden Pseudo R(2), >0.13; relative parameter change, >5%), and differential test functioning (DTF) was tested by plotting differences between full-test and purified (i.e., without DIF items) score estimates. RESULTS: Catalonia showed higher levels of mental well-being than Scotland (Cohen d = 0.84). Three of 14 WEMWBS items showed small amounts of DIF. DIF did not accrue to DTF, as shown by intraclass correlation coefficient (ICC, 0.999) and case-by-case differences (maximum, 0.12 SD) between total and purified scores. Population differences remained mainly constant across sociodemographics and health outcomes. CONCLUSION: The WEMWBS measures a distinct well-being construct that is stable across countries, implying that Scotland and Catalonia populations are effectively different in the distribution of mental well-being. This result adds to previous psychometric information and supports WEMWBS as a valid unbiased measures for individual and cross-cultural comparisons.

Multidimensional item response theory models yielded good fit and reliable scores for the Short Form-12 questionnaire.

OBJECTIVES: To propose a multidimensional item response theory (MIRT) scoring system for the Short Form 12 (SF-12) with good psychometric properties in terms of fit and reliability. STUDY DESIGN AND SETTINGS: Two models, indicating physical (PCS) and mental component summary (MCS) dimensions, were fitted to SF-12 data from the European Study of the Epidemiology of Mental Disorders, a representative sample from European adult general population (n=21,425; response rate=61.2%). Goodness of fit, information, reliability, and agreement of individual scores were compared with the classical SF-12 and RAND-12 algorithms. RESULTS: The bidimensional response process (BRP) model, where all items are indicators of both dimensions, yielded the best fit (root mean square error of approximation=0.057, comparative fit index=0.95, and Tucker-Lewis index=0.94), and highly agreed with PCS and MCS scores from the SF-12 (intraclass correlation coefficients of 0.92 and 0.88, respectively) and RAND-12 (0.88 and 0.95). Regarding reliability, the BRP yielded 0.75 and 0.77 (PCS and MCS, respectively), greater than SF-12 (0.65 and 0.66) and RAND-12 (0.65 and 0.67). As indicated by scale linking, MIRT scores can be interpreted similarly to the classical scores. CONCLUSION: The MIRT models showed a clear construct structure for the PCS and MCS dimensions, defined by functional and role limitation content. Results support the use of SF-12 MIRT-based scores as a valid and reliable option to assess health status.

Disability mediates the impact of common conditions on perceived health.

BACKGROUND: We examined the extent to which disability mediates the observed associations of common mental and physical conditions with perceived health. METHODS AND FINDINGS: WHO World Mental Health (WMH) Surveys carried out in 22 countries worldwide (n = 51,344 respondents, 72.0% response rate). We assessed nine common mental conditions with the WHO Composite International Diagnostic Interview (CIDI), and ten chronic physical with a checklist. A visual analog scale (VAS) score (0, worst to 100, best) measured perceived health in the previous 30 days. Disability was assessed using a modified WHO Disability Assessment Schedule (WHODAS), including: cognition, mobility, self-care, getting along, role functioning (life activities), family burden, stigma, and discrimination. Path analysis was used to estimate total effects of conditions on perceived health VAS and their separate direct and indirect (through the WHODAS dimensions) effects. Twelve-month prevalence was 14.4% for any mental and 51.4% for any physical condition. 31.7% of respondents reported difficulties in role functioning, 11.4% in mobility, 8.3% in stigma, 8.1% in family burden and 6.9% in cognition. Other difficulties were much less common. Mean VAS score was 81.0 (SD = 0.1). Decrements in VAS scores were highest for neurological conditions (9.8), depression (8.2) and bipolar disorder (8.1). Across conditions, 36.8% (IQR: 31.2-51.5%) of the total decrement in perceived health associated with the condition were mediated by WHODAS disabilities (significant for 17 of 19 conditions). Role functioning was the dominant mediator for both mental and physical conditions. Stigma and family burden were also important mediators for mental conditions, and mobility for physical conditions. CONCLUSIONS: More than a third of the decrement in perceived health associated with common conditions is mediated by disability. Although the decrement is similar for physical and mental conditions, the pattern of mediation is different. Research is needed on the benefits for perceived health of targeted interventions aimed at particular disability dimensions.