Hypertension in the first blood pressure reading and the risk of cardiovascular disease mortality in the general population: findings from the prospective KORA study.

BACKGROUND: The risk of cardiovascular disease (CVD) mortality in individuals with an alerting reaction, assessed by hypertension in the first blood pressure (BP) reading but normal BP in further readings, remains unknown in the general population. METHODS AND RESULTS: In a sample of 11 146 adults (51.5% men and 48.5% women) with a mean age of 47.1 years (SD ±â€Š12.3) from a German population-based cohort, we analyzed risk factors and CVD mortality risk associated with an alerting reaction. An alerting reaction was prevalent in 10.2% of the population and associated with sociodemographic, lifestyle, and somatic CVD risk factors. Within a mean follow-up period of 22.7 years (SD ±â€Š7.05 years; max: 32 years; 253 201 person years), 1420 (12.7%) CVD mortality cases were observed. The CVD mortality rate associated with an alerting reaction was significantly higher than in normotension (64 vs. 32 cases/10 000 person-years), but lower than hypertension (118 cases/10 000 person-years). Correspondingly, the alerting reaction was associated with a 23% higher hazard ratio of CVD mortality than normal blood pressure [hazard ratio 1.23 (95% confidence interval 1.02-1.49), P  = 0.04]. However, adjustment for antihypertensive medication use attenuated this association [1.19 (0.99-1.44), P  = 0.06]. CONCLUSION: The results may warrant monitoring of an alerting reaction as a preventive measure of CVD mortality in untreated individuals with elevated first BP readings, as well as optimized treatment in treated individuals.

Health Economic Evaluation of an Online-Based Motivational Program to Reduce Problematic Media Use and Promote Treatment Motivation for Internet Use Disorder-Results of the OMPRIS Study.

Internet Use Disorders (IUD) have a relevant effect on national economies. In the randomized, controlled, multicenter, prospective, and single-blinded OMPRIS study (pre-registration number DRKS00019925; Innovation Fund of the Joint Federal Committee of Germany, grant number 01VSF18043), a four-week online program to reduce media addiction symptoms, was evaluated for cost-effectiveness. The intervention group (IG) was compared to a waiting control group (WCG) from German statutory health insurance (SHI) and a societal perspective. Resource use, namely indirect and direct (non) medical costs, was assessed by a standardized questionnaire at baseline and after the intervention. Additionally, intervention costs were calculated. Determining the Reliable Change Index (RCI) based on the primary outcome, assessed by the "Scale for the Assessment of Internet and Computer Game Addiction" (AICA-S), individuals with and without reliable change (RC) were distinguished. The incremental cost-effectiveness ratio was calculated using the difference-in-difference approach. There were 169 (IG n = 81, WCG n = 88) persons included in the analysis. The mean age was 31.9 (SD 12.1) years. A total of 75.1% were male, and 1.8% diverse. A total of 65% (IG) and 27% (WCG) had an RC. The cost per person with RC was about EUR 860 (SHI) and EUR 1110 (society). The intervention leads to an improvement of media addiction symptoms at moderate additional costs.

Efficacy of a short-term webcam-based telemedicine treatment of internet use disorders (OMPRIS): a multicentre, prospective, single-blind, randomised, clinical trial.

Background: Evidence-based treatments for internet use disorders (IUDs) are limited, and online therapy approaches are poorly studied. We investigated the efficacy of a manualised therapist-guided online intervention (OMPRIS) to reduce IUD symptoms and improve psychological well-being. Methods: In this multicentre, two-arm, single-blinded trial, individuals ≥16 years suffering from IUD symptoms were recruited in Germany from August 16, 2020, to March 11, 2022, through media advertisements and healthcare providers. Participants were randomly allocated by sequential balancing randomisation (1:1) to either the manualised webcam-based OMPRIS intervention or a waitlist control (WLC) group. OMPRIS provided strategies from motivational interviewing, behavioural therapy, and social counselling. The primary outcome at the end of treatment was a reduction in IUD symptoms as measured by the Assessment of Internet and Computer Scale (AICA-S). Follow-up assessments were conducted at 6 weeks and 6 months. Analyses were performed in the intention-to-treat population. This trial was registered (German Clinical Trial Register, DRKS00019925) and has been completed. Findings: A total of 180 individuals were randomly assigned to the OMPRIS intervention (n = 89) or WLC (n = 91) arm. After treatment, 81 (91.0%) participants in the OMPRIS intervention group and 88 (96.7%) in the WLC group completed the outcome assessment. The ANCOVA model showed that OMPRIS participants had a significantly greater reduction in AICA-S scores from baseline (mean score 12.1 [SD 4.6]) to post-treatment (6.8 [5.2]) than those in the WLC group (from 12.6 [5.1] to 11.0 [5.4]; estimated mean difference -3.9; [95% CI -5.2 to -2.6]; p < 0.0001; d = 0.92). No adverse events were reported to the trial team. Interpretation: Webcam-based OMPRIS therapy was effective and superior to waiting list conditions in reducing IUD symptoms. Webcam-based, specialised online therapy thus increases IUD treatment options. Funding: German Innovation Fund of Germany's Federal Joint Committee (G-BA), grant number 01VSF18043.

Community indicators for mental health in Europe: a scoping review.

Background: Community indicators may predict and influence individuals` mental health, and support or impede mental health management. However, there is no consensus on which indicators should be included in predictions, prognostic algorithms, or management strategies for community-based mental health promotion and prevention approaches. Therefore, this scoping review provides an overview of relevant community-level indicators for mental health in the general as well as risk populations in a European context. Methods: We conducted a scoping review in the following electronic databases: PubMed, Embase, and PsycInfo. Eligible studies focused on context factors such as either the physical or social environment, reporting at least one mental health outcome and referring to a European population. Publications between 2012 and March 8, 2022 are considered. Results: In total, the search yielded 12,200 identified records. After the removal of duplicates, 10,059 records were screened against the eligibility criteria. In total, 169 studies were included in the final analysis. Out of these included studies, 6% focused on pan-European datasets and 94% on a specific European country. Populations were either general or high-risk populations (56 vs. 44%, respectively) with depressive disorder as the main reported outcome (49%), followed by general mental health (33%) and anxiety (23%). Study designs were cross-sectional studies (59%), longitudinal (27%), and others (14%). The final set of indicators consisted of 53 indicators, which were grouped conceptually into 13 superordinate categories of community indicators. These were divided into the domains of the physical and social environment. The most commonly measured and reported categories of community indicators associated with mental health outcomes were social networks (n = 87), attitudinal factors toward vulnerable groups (n = 76), and the characteristics of the built environment (n = 56). Conclusion: This review provides an evidence base of existing and novel community-level indicators that are associated with mental health. Community factors related to the physical and social environment should be routinely recorded and considered as influencing factors or potentially underestimated confounders. The relevance should be analyzed and included in clinical outcomes, data, monitoring and surveillance as they may reveal new trends and targets for public mental health interventions.

Resting-state EEG and MEG biomarkers of pathological fatigue - A transdiagnostic systematic review.

Fatigue is a highly prevalent and disabling symptom of many disorders and syndromes, resulting from different pathomechanisms. However, whether and how different mechanisms converge and result in similar symptomatology is only partially understood, and transdiagnostic biomarkers that could further the diagnosis and treatment of fatigue are lacking. We, therefore, performed a transdiagnostic systematic review (PROSPERO: CRD42022330113) of quantitative resting-state electroencephalography (EEG) and magnetoencephalography (MEG) studies in adult patients suffering from pathological fatigue in different disorders. Studies investigating fatigue in healthy participants were excluded. The risk of bias was assessed using a modified Newcastle-Ottawa Scale. Semi-quantitative data synthesis was conducted using modified albatross plots. After searching MEDLINE, Web of Science Core Collection, and EMBASE, 26 studies were included. Cross-sectional studies revealed increased brain activity at theta frequencies and decreased activity at alpha frequencies as potential diagnostic biomarkers. However, the risk of bias was high in many studies and domains. Together, this transdiagnostic systematic review synthesizes evidence on how resting-state M/EEG might serve as a diagnostic biomarker of pathological fatigue. Beyond, this review might help to guide future M/EEG studies on the development of fatigue biomarkers.

The multicenter effectiveness study of inpatient and day hospital treatment in departments of psychosomatic medicine and psychotherapy in Germany.

Background: Reliable outcome data of psychosomatic inpatient and day hospital treatment with a focus on psychotherapy are important to strengthen ecological validity by assessing the reality of mental health care in the field. This study aims to evaluate the effectiveness of inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy in a prospective, naturalistic, multicenter design including structured assessments. Methods: Structured interviews were used to diagnose mental disorders according to ICD-10 and DSM-IV at baseline. Depression, anxiety, somatization, eating disorder and posttraumatic stress disorder (PTSD) symptoms, as well as personality functioning were assessed by means of questionnaires on admission and at discharge. Results: 2,094 patients recruited by 19 participating university hospitals consented to participation in the study. Effect sizes for each of the outcome criteria were calculated for 4-5 sub-groups per outcome domain with differing severity at baseline. Pre-post effect sizes for patients with moderate and high symptom severity at baseline ranged from d = 0.78 to d = 3.61 with symptoms of PTSD, depression, and anxiety showing the largest and somatization as well as personality functioning showing somewhat smaller effects. Conclusions: Inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy is effective under field conditions. Clinical trial registration: https://drks.de/search/de/trial/DRKS00016412, identifier: DRKS00016412.

Anomalies in the review process and interpretation of the evidence in the NICE guideline for chronic fatigue syndrome and myalgic encephalomyelitis.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability.

Post-Traumatic Distress in Adults With Congenital Heart Disease: an Under-Recognized Complication?

The stressful and potentially traumatic perception of repeated hospitalization, outpatient check-ups, and medical interventions places a high stress burden on patients with congenital heart disease (CHD). These experiences can lead to post-traumatic stress symptoms (PTSSs). This study aimed to estimate the prevalence of PTSSs in adults with CHD (ACHDs) and to identify the associated risk factors. In this cross-sectional study, 234 ACHDs were recruited from November 2021 to August 2022 at a dedicated tertiary care center. Data were collected on general health, anxiety and depression, PTSSs, and on quality of life using validated and standardized questionnaires. In addition, the reasons for PTSSs were assessed using free-text responses. Overall, 17.1% to 20.5% (mean age: 35.2 ± 10.8 [18 to 66] years, 46.6% women) of the enrolled patients met the criteria for clinically relevant PTSSs related to their CHD or treatment. The associated risk factors (p <0.05) included preexisting mental distress (odds ratio [OR] 4.86), depression (OR 5.565) and anxiety (OR 3.36,), level of perceived mental distress during the traumatic event (OR 1.46), and number of medical procedures (OR 1.17). In addition, a worse clinical state was associated with more PTSSs (p = 0.018). Using free-text responses, the various reasons for PTSSs were identified, ranging from cardiac procedures to social stigma. In conclusion, the high prevalence of PTSSs calls for increased awareness of PTSSs in ACHDs in cardiovascular care. PTSSs and their associated disorder can adversely affect the manifestation and progression of cardiac disease. Thus, it is necessary to reflect upon psychocardiac prevention and intervention as an integral part of multidisciplinary cardiac care.

Association between somatic symptom disorder and symptoms with daily life impairment after SARS-CoV-2 infection - results from a population-based cross-sectional study.

BACKGROUND: Post-COVID syndrome (PCS) is defined by symptom persistence accompanied by daily life impairment (DLI). The association of somatic symptom disorder (SSD) and symptoms with DLI after SARS-CoV-2 infection in the general population is unclear to date. The main objective of the study was to investigate the association of possible SSD, depression, anxiety, and participant-reported symptoms with DLI in a local population sample. METHODS: Anonymised cross-sectional study. A symptom questionnaire, including the scales Patient Health Questionnaire PHQ-15 (somatisation module), SSD-12 (psychological distress in SSD), PHQ-2 (depression), GAD-2 (anxiety), and FAS (fatigue assessment scale) was sent in 02/2022 to all adult residents of the district Bad Tölz-Wolfratshausen, Germany, who were registered for SARS-CoV-2-infection between 03/2020 and 11/2021 (8925 delivered). Associations between DLI, symptoms and scales were estimated using binary logistic regression models and network analysis. RESULTS: 2828 questionnaires (31.7%) were complete. 1486 (52.5%) reported persistent symptoms, and 509 (18.0%) perceived DLI. DLI was strongest associated with self-reported fatigue (OR 7.86; 95%CI 5.63-10.97), dyspnea (3.93; 2.73-5.67), impaired concentration (3.05; 2.17-4.30), SSD-12 (4.36; 2.57-7.41), and PHQ-2 (2.48; 1.57-3.92). Self-reported fatigue showed the strongest correlation (rp = 0.248) and closest proximity to DLI in network analysis. CONCLUSION: PCS appears as a complex clinical picture in which SSD might play an important role when DLI is present. The pychological burden might partly be explained by the persistent symptoms, which are difficult to treat up to now. Screening for SSD could help in differential diagnostic decision-making to ensure that patients receive appropriate psychosocial interventions for disease coping.

Functional Somatic Disorders, Their Subtypes, and Their Association With Self-Rated Health in the German General Population.

OBJECTIVE: The heterogeneous conceptualizations and classifications of persistent and troublesome physical symptoms impede their adequate clinical management. Functional somatic disorder (FSD) is a recently suggested interface concept that is etiologically neutral and allows for dysfunctional psychobehavioral characteristics as well as somatic comorbidity. However, its prevalence and impact are not yet known. METHODS: We analyzed 2379 participants (mean age = 48.3 years, 52.5% female) from a representative German community survey using operationalized FSD criteria. These criteria defined FSD types based on somatic symptom count, type, and severity assessed by the Bodily Distress Syndrome Checklist. In addition, the associations of those types with health concerns, comorbidity, psychological distress, and self-rated health were determined. RESULTS: There were four clearly demarcated groups with no relevant bothering symptoms, with one or with few bothering symptoms from one organ system, and with multiple bothering symptoms from at least two organ systems. Psychological distress, health concerns, and comorbidity steadily increased, and self-rated health decreased according to the number and severity of symptoms. Somatic symptom burden, health concerns, and comorbidity independently predicted self-rated health, with no interaction effect between the latter two. CONCLUSIONS: Our data support an FSD concept with two severity grades according to persistent and troublesome symptoms in one versus more organ systems. The delimitation of subtypes with psychobehavioral characteristics and/or with somatic comorbidity seems useful, while still allowing the demarcation of a group of participants with high symptom burden but without those additional characteristics.

Internet-Based Self-Assessment for Symptoms of Internet Use Disorder-Impact of Gender, Social Aspects, and Symptom Severity: German Cross-sectional Study.

BACKGROUND: Internet use disorder (IUD) is a new type of behavioral addiction in the digital age. At the same time, internet applications and eHealth can also provide useful support in medical treatment. OBJECTIVE: The purpose of this study is to examine if an internet-based eHealth service can reach individuals with IUD. In particular, it should be investigated whether both male and female individuals with more severe IUDs can be reached. METHODS: Data were retrieved from the OMPRIS (online-based motivational intervention to reduce problematic internet use and promote treatment motivation in internet gaming disorder and internet use disorder) project (DRKS00019925), an internet-based motivational intervention to reduce problematic internet use and promote treatment motivation in internet gaming disorder and IUD. During the recruitment process (August 2020-March 2022), a total of 3007 individuals filled out the standardized scale for the assessment of internet and computer game addiction (AICA-S). The assessment was accessible via the project homepage. There was no preselection of participants at this stage of the study; however, the offer was addressed to people with hazardous internet use and IUDs. The web-based assessment was free and could be found via search engines, but attention was also drawn to the service via newspaper articles, radio reports, and podcasts. RESULTS: Out of 3007 who participated in the web-based self-assessment, 1033 (34.4%) are female, 1740 (57.9%) are male, 67 (2.2%) are diverse individuals, and 167 (5.5%) did not disclose their gender. The IUD symptom severity score showed a wide range between the AICA-S extreme values of 0 and 27 points. On average, the total sample (mean 8.19, SD 5.47) was in the range of hazardous IUD behavior (AICA-S cutoff>7.0). Furthermore, 561 individuals (18.7% of the total sample; mean 17.42, SD 3.38) presented severe IUD (AICA-S cutoff>13.5). Focusing on female and male participants, 20.9% (363/1740) of the men and 14.9% (151/1033) of the women scored above 13.5 points, which can be considered pathological IUD behavior (χ22,2773=16.73, P<.001, effect size: Cramér V=0.078). Unemployment, being in vocational training or studying at a university, and being male were significantly associated with high IUD symptoms. CONCLUSIONS: Using a large sample, the study showed that both mildly and severely IUD-affected individuals can be reached via the internet. An internet-based eHealth offer can thus be a good way to reach patients with IUD where they are addicted-on the internet. In addition, eHealth services increase the likelihood of reaching female patients, who hardly ever come to specialized outpatient clinics and hospitals. Since social problems, especially unemployment, have a strong association with disease severity, the integration of social counseling into treatment seems advisable in terms of a multidisciplinary approach. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00019925; https://drks.de/search/de/trial/DRKS00019925.

Why do we climb mountains? An exploration of features of behavioural addiction in mountaineering and the association with stress-related psychiatric disorders.

Common knowledge implies that individuals engaging in outdoor sports and especially in regular and extreme mountaineering are exceptionally healthy and hardened. Physical activity in outdoor environments has a positive effect on physical and mental health. However, regular and/or extreme mountaineering might share similarities with behavioural addictions and could thus also have a negative impact on health. In this cross-sectional web-based questionnaire study, we collected data on exercise and mountaineering addiction (Exercise Addiction Inventory; original and adapted version for mountaineering; Exercise Dependence Scale adapted version for mountaineering). Further surveyed parameters included mountaineering habits, Risk-Taking Inventory, Sensation-Seeking/Emotion Regulation/Agency Scale (SEAS), resilience, self-perceived stress, physical activity in metabolic units and mental health. Comparisons were performed between individuals with symptoms of addiction to mountaineering (MA) and individuals without symptoms of addiction to mountaineering or sports in general (CO) using non-parametric analyses. We analysed data from 335 participants, n = 88 thereof with addiction to mountaineering (MA) and n = 247 control participants (CO). The MA group scored significantly higher with regards to self-perceived stress (p < 0.001) and included a significantly higher number of individuals affected by symptoms of depression (p < 0.001), symptoms of anxiety (p < 0.001), symptoms of eating disorders (p < 0.001), alcohol abuse or dependence (p < 0.001), illicit drug abuse (p = 0.050), or current and history of psychiatric disorders (p < 0.001). Individuals with MA showed higher values in all SEAS subscales as well as increased risk-taking (p < 0.001). Regular and extreme mountaineering can display features of a behavioural addiction and is associated with psychiatric disorders. Behavioural addiction in mountaineering is associated with higher levels of sensation-seeking, emotion regulation, and agency, as well as increased risk-taking.

What Kind of Patients Receive Inpatient and Day-Hospital Treatment in Departments of Psychosomatic Medicine and Psychotherapy in Germany?

INTRODUCTION: Germany is one of the few countries with a medical specialty of psychosomatic medicine and psychotherapy and many treatment resources of this kind. OBJECTIVE: This observational study describes the psychosomatic treatment programs as well as a large sample of day-hospital and inpatients in great detail using structured diagnostic interviews. METHODS: Mental disorders were diagnosed according to ICD-10 and DSM-IV by means of Mini-DIPS and SCID-II. In addition to the case records, a modified version of the CSSRI was employed to collect demographic data and service use. The PHQ-D was used to assess depression, anxiety, and somatization. RESULTS: 2,094 patients from 19 departments participated in the study after giving informed consent. The sample consisted of a high proportion of "complex patients" with high comorbidity of mental and somatic diseases, severe psychopathology, and considerable social and occupational dysfunction including more than 50 days of sick leave per year in half of the sample. The most frequent diagnoses were depression, somatoform and anxiety disorders, eating disorders, personality disorders, and somato-psychic conditions. CONCLUSIONS: Inpatient and day-hospital treatment in German university departments of psychosomatic medicine and psychotherapy is an intensive multimodal treatment for complex patients with high comorbidity and social as well as occupational dysfunction.

Lessons learned from applying established cut-off values of questionnaires to detect somatic symptom disorders in primary care: a cross-sectional study.

Introduction: Based on two diagnostic accuracy studies in high-prevalence settings, two distinctly different combinations of cut-off values have been recommended to identify persons at risk for somatic symptom disorder (SSD) with the combination of the Patient-Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Disorder-B Criteria Scale (SSD-12). We investigated whether the reported sensitivity and specificity of both recommended cut-off combinations are transferable to primary care. Methods: In a cross-sectional study, 420 unselected adult primary care patients completed PHQ-15 and SSD-12. Patients scoring ≥9 and ≥ 23 (recommended cut-off combination #1) or ≥ 8 and ≥ 13 (recommended cut-off combination #2) were considered test-positive for SSD, respectively. To assess the validity of the reported sensitivity and specificity in different low- to high-prevalence settings, we compared correspondingly expected proportions of test positives to the proportion observed in our sample. Results: Based on combination #1, 38 participants (9%) were found to be test positive, far fewer than expected, based on the reported values for sensitivity and specificity (expected minimum frequency 30% with a true prevalence ≥1%). This can only be explained by a lower sensitivity and higher specificity in primary care. For combination #2, 98 participants (23%) were test positive, a finding consistent with a true prevalence of SSD of 15% or lower. Discussion: Our analyzes strongly suggest that the sensitivity and specificity estimates reported for combination #1 are not applicable to unselected primary care patients and that the cut-off for the SSD (≥23) is too strict. Cut-off combination #2 seems more applicable but still needs to be tested in studies that compare screening findings by questionnaires with validated diagnostic interviews as reference standards in primary care populations.

Migraine in the context of chronic primary pain, chronic overlapping pain disorders, and functional somatic disorders: A narrative review.

OBJECTIVE: To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions. BACKGROUND: Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment. METHOD: Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders. RESULTS: Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches. CONCLUSIONS: Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

Combining the GP's assessment and the PHQ-9 questionnaire leads to more reliable and clinically relevant diagnoses in primary care.

BACKGROUND: Screening questionnaires are not sufficient to improve diagnostic quality of depression in primary care. The additional consideration of the general practitioner's (GP's) assessment could improve the accuracy of depression diagnosis. The aim of this study was to examine whether the GP rating supports a reliable depression diagnosis indicated by the PHQ-9 over a period of three months. METHODS: We performed a secondary data analysis from a previous study. PHQ-9 scores of primary care patients were collected at the time of recruitment (t1) and during a follow-up 3 months later (t2). At t1 GPs independently made a subjective assessment whether they considered the patient depressive (yes/no). Two corresponding groups with concordant and discordant PHQ-9 and GP ratings at t1 were defined. Reliability of the PHQ-9 results at t1 and t2 was assessed within these groups and within the entire sample by Cohen's Kappa, Pearson's correlation coefficient and Bland-Altman plots. RESULTS: 364 consecutive patients from 12 practices in the region of Upper Bavaria/Germany participated in this longitudinal study. 279 patients (76.6%) sent back the questionnaire at t2. Concordance of GP rating and PHQ-9 at t1 led to higher replicability of PHQ-9 results between t1 and t2. The reliability of PHQ-9 was higher in the concordant subgroup (κ = 0.507) compared to the discordant subgroup (κ = 0.211) (p = 0.064). The Bland-Altman Plot showed that the deviation of PHQ-9 scores at t1 and t2 decreased by about 15% in the concordant subgroup. Pearson's correlation coefficient between PHQ-9 scores at t1 and t2 increased significantly if the GP rating was concordant with the PHQ-9 at t1 (r = 0.671) compared to the discordant subgroup (r = 0.462) (p = 0.044). CONCLUSIONS: The combination of PHQ-9 and GP rating might improve diagnostic decision making regarding depression in general practices. PHQ-9 positive results might be more reliable and accurate, when a concordant GP rating is considered.

Gender specific somatic symptom burden and mortality risk in the general population.

Gender specific all-cause mortality risk associated with a high somatic symptom burden (SSB) in a population-based cohort was investigated. The study population included 5679 women and 5861 men aged 25-74 years from the population-based MONICA/KORA Cohort. SSB was assessed following the Somatic Symptom Scale-8 and categorized as very high (≥ 95th percentile), high (60-95th percentile), moderate (30-60th percentile), and low (≤ 30th percentile). The impact of SSB on all-cause mortality risk within a mean follow-up period of 22.6 years (SD 7.1; 267,278 person years) was estimated by gender-specific Cox regression models adjusted for sociodemographic, lifestyle, somatic and psychosocial risk factors, as well as pre-existing medical conditions. Approximately 5.7% of men and 7.3% of women had very high SSB. During follow-up, 3638 (30.6%) mortality cases were observed. Men with a very-high SSB had 48% increased relative risk of mortality in comparison to men with a low SSB after adjustment for concurrent risk factors (1.48, 95% CI 1.20-1.81, p < .0001), corresponding to 2% increased risk of mortality for each 1-point increment in SSB (1.02; 95% CI 1.01-1.03; p = 0.03). In contrast, women with a very high SSB had a 22% lower risk of mortality (0.78, 95% CI 0.61-1.00, p = 0.05) and women with high SSB had an 18% lower risk of mortality (0.82; 95% CI 0.68-0.98, p = 0.03) following adjustment for concurrent risk factors. The current findings indicate that an increasing SSB is an independent risk factor for mortality in men but not in women, pointing in the direction of critical gender differences in the management of SSB, including women's earlier health care utilization than men.