In many mental health and some somatic disorders, efficacy of therapist-guided remote CBT and in-person CBT does not differ.

SOURCE CITATION: Zandieh S, Abdollahzadeh SM, Sadeghirad B, et al. Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials. CMAJ. 2024;196:E327-E340. 38499303.

Can internal medicine specialists diagnose functional somatic disorders (FSDs)? Training and comparison with FSD specialists.

BACKGROUND: Functional somatic disorders (FSD) are a common problem across medical settings and remain challenging to diagnose and treat. Many patients with FSD undergo sequential and unnecessary extensive diagnostic work-up, which is costly for society and stressful for patients. Previous studies have shown that the empirically based FSD diagnostic entities are interrater reliable and stable over time. OBJECTIVE: The aim of this study was to investigate whether internists who have received adequate training and with sufficient time per patient could diagnose FSD. DESIGN: This was a prospective diagnostic accuracy study. The study was conducted from May 2020 to April 2022. PARTICIPANTS: The study included 27 consecutive patients referred by their general practitioner to a non-psychiatric diagnostic clinic for assessment of physical symptoms on suspicion of FSD. INTERVENTIONS: The internists received a 30-hour training course in the use of a tailored version of the SCAN interview. MAIN MEASURES: The main outcome measure was the agreement between the diagnoses of the internists and the reference diagnoses made by specialists in FSD on the basis of the full SCAN interview. KEY RESULTS: The interrater agreement between the internists and the FSD experts was substantial for any FSD (kappa = 0.63) as well as multi-organ vs. single-organ FSD (kappa = 0.73), indicating good diagnostic agreement. CONCLUSIONS: Internists with proper training and sufficient time (3-4 hours) per patient can proficiently diagnose FSD employing a tailored version of the SCAN interview for use in a non-psychiatric diagnostic setting.

[From MUPS to PSS: advancing insight]. / Van SOLK naar ALK.

Since 2021 experts advocate for the abolishment of the term Medically Unexplained Physical Symptoms (MUPS) and the use of Persistent Somatic Symptoms (PSS). This article elucidates the difference between MUPS and PSS, as well as the relation to other relevant concepts like functional syndromes and somatic symptom disorder. Because the term MUPS emphasizes that no somatic cause for the symptoms has been found, it is commonly concluded that the symptoms are 'psychological' in line with the body/mind dualism. This leads to excessive focus on psychosocial contributing factors in MUPS, and too little in PSS in the context of a known somatic disorder. With the term PSS, the question whether there is a somatic cause for the symptoms is not the key issue, but the persistence of the symptoms. This allows for personalised diagnostics and treatment according to the biopsychosocial model.

Exploring the course of functional somatic symptoms (FSS) from pre- to late adolescence and associated internalizing psychopathology - an observational cohort-study.

BACKGROUND: Functional somatic symptoms (FSS), which commonly cannot be attributed to well-defined organic pathology, often co-occur with internalizing psychopathology and fluctuate throughout different life stages. We examined FSS courses throughout adolescence, and the association between preadolescent FSS, FSS severity and internalizing psychopathology at late adolescence. METHODS: Data from the Copenhagen Child Cohort (CCC2000) were utilized from assessments at ages 11-12 years (preadolescence; T0) and 16-17 years (late adolescence; T1). Self-report questionnaire and interview data on FSS, internalizing psychopathology, chronic medical conditions, and sociodemographic data from Danish national registers were available for 1285 youths. FSS courses were categorized into persistent (high FSS at T0 & T1), remission (high FSS only at T0), incident (high FSS only at T1) or no FSS (no FSS at T0 & T1). Multiple linear and multinomial logistic regressions were conducted to investigate the FSS/psychopathology association. RESULTS: 1.8% of adolescents fell into the persistent FSS course group throughout adolescence. Higher preadolescent FSS predicted FSS (b = 0.07, p < .001), anxiety (b = 0.05, p < .001) and depression (b = 0.06, p < .001) at age 16/17, even after controlling for sex, parental education, a chronic medical condition and internalizing psychopathology in preadolescence. Persistent, incident, and remittent FSS courses were associated with significantly higher mean levels of anxiety and depression compared to the reference group (no FSS). CONCLUSIONS: FSS during pre- and late adolescence might increase and co-occur with anxiety and depression throughout adolescence, potentially due to shared underlying risk factors and processes.

Functional somatic symptoms in Emergency Department frequent presenters.

BACKGROUND: Patients with Functional Somatic Symptoms (FSS) are frequently encountered within healthcare settings such as Emergency Departments (ED). There is limited research regarding characterisation and frequency of FSS within frequent presenters to ED and no previous Australian evidence. This study aims to fill this gap. METHODS: A retrospective, single-centre study of frequent ED presenters over a 6-month period was undertaken. Patients with > 3 re-presentations/month were reviewed for the presence of FSS using Stephenson and Price's (Stephenson DT, Price JR. Medically unexplained physical symptoms in emergency medicine. Emerg Med J. 2006;23(8):595.) categorisation of FSS. Patients were divided into three groups - FSS, possible FSS (pos-FSS) and non-FSS. The characteristics of these groups were compared using descriptive statistics (chi-square tests, Welch's ANOVA). Person-time at risk during the 6-month study period was estimated for patients in each group and incidence of ED presentation for each group was then calculated. Psychological distress indicators for ED presenters with FSS, as noted by the treating clinician, were also analysed. RESULTS: 11% (71/638) of frequent ED presenters were categorised as having FSS and 72% (458/638) as having possible FSS (Pos-FSS). Mean ED presentations in the FSS group during the study period were significantly higher than in the non-FSS and Pos-FSS groups (p < 0.01). Anxiety was found to be the primary psychological distress indicator associated with ED presentations with FSS. CONCLUSION: We found that, amongst frequent ED presenters, patients with FSS presented significantly more frequently to ED than those without FSS. We propose revising the model of care for FSS in ED to promote appropriate referral to therapy services as a possible demand reduction strategy to improve patient care and efficiency in ED.

[Mental health in the workplace - What role do socioeconomic-, gender-, and migration-related inequalities play?] / Psychische Gesundheit am Arbeitsplatz ­ Welche Rolle spielen sozioökonomische, geschlechterspezifische und migrationsbedingte Ungleichheiten?

BACKGROUND: Risk factors for mental health can be found in socio-economic-, gender- and migration-specific inequalities. These factors and the extent of depression, anxiety, and somatization among employees were examined in the present study. METHODS: As part of the Early Intervention in the Workplace Study (friaa), mentally burdened employees at five locations in Germany were surveyed on socio-demographic-, work-, migration-, and health-related content. Regression analyses were used to examine the relationship between these factors and depression (Patient-Health-Questionnaire-9, PHQ-9), anxiety (Generalized Anxiety Disorder-2, GAD-2), and somatization (Somatic Symptom Scale-8, SSS-8) in the entire sample and in people with migration background (MB). For the latter, acculturation (Frankfurt Acculturation Scale, FRACC) and the perception of burden in terms of demands of immigration (Demands of Immigration Scale, DIS) were also taken into account. RESULTS: On average, the 550 employees (12% with MB) showed clinically relevant depression (M = 13.0, SD = 5.1) (PHQ-9 ≥ 10), anxiety (M = 3.5, SD = 1.7) (GAD ≥ 3) and somatization (M = 13.0, SD = 5.8) (SSS-8 ≥ 12). Female gender was associated with higher anxiety and somatization. Older age and night shift work were associated with higher somatization. DISCUSSION: The results confirm the high level of mental burden among this sample of employees in Germany. In order to maintain their mental health, support measures should be offered, especially for vulnerable groups such as women, older employees, and night shift workers.

Participatory design of bodysymptoms.org: An interactive web resource to explain multisystem functional somatic symptoms.

OBJECTIVE: There is a lack of trustworthy information about Functional Somatic Symptoms (FSS) on the internet. This means integrative bio-psycho-social explanations of FSS and related health advice are not readily available to the public. To explore and address this problem, we carried out the bodysymptoms project, with the aim to build a website which presents current widely accepted explanations for FSS and shows how different explanations are inter-connected. METHODS: Bodysymptoms was set up as a research-in-action project with a diverse range of international stakeholder-participants, combining approaches from patient and public involvement in healthcare with participatory design. 7 participants with lived experience of multi-system functional symptoms took part in the project and measures of meaningful engagement throughout the project were rated highly. This manuscript describes the methodology by which the website was developed. RESULTS: Through iterative cycles we determined the requirements for an interactive explanatory model and co-created a novel online health interactive resource with integrated actionable health advice. The target end user are young adults with persistent physical symptoms, maintained by functional mechanisms. The overall aim is to empower people at risk of developing functional disorders to seek better health outcomes. The website is intended to be used prior to or alongside engagement with healthcare. CONCLUSION: Bringing lived experience and multi-disciplinary perspectives into dialogue through participatory design can harness the power of research to create immediate shared value. This project has resulted in a usable open access website, bodysymptoms.org, which provides education about FSS for patients, healthcare professionals and members of the public looking to understand FSS.

Persistent physical symptoms: definition, genesis, and management.

Persistent physical symptoms (synonymous with persistent somatic symptoms) is an umbrella term for distressing somatic complaints that last several months or more, regardless of their cause. These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society. Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo. As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging. Multiple biological and psychosocial risk factors and mechanisms contribute to the persistence of somatic symptoms, including persistent inflammation; epigenetic profiles; immune, metabolic and microbiome dysregulation; early adverse life experiences; depression; illness-related anxiety; dysfunctional symptom expectations; symptom focusing; symptom learning; and avoidance behaviours, with many factors being common across symptoms and diagnoses. Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation. If basic care is insufficient, targeted psychological and pharmacological interventions can be beneficial. A better understanding of the multifactorial persistence of somatic symptoms should lead to more specific, personalised, and mechanism-based treatment, and a reduction in the stigma patients commonly face.

Integrated care model for patients with functional somatic symptom disorder - a co-produced stakeholder exploration with recommendations for best practice.

BACKGROUND: Functional somatic symptoms (FFS) and bodily distress disorders are highly prevalent across all medical settings. Services for these patients are dispersed across the health care system with minimal conceptual and operational integration, and patients do not currently access therapeutic offers in significant numbers due to a mismatch between their and professionals' understanding of the nature of the symptoms. New service models are urgently needed to address patients' needs and to align with advances in aetiological evidence and diagnostic classification systems to overcome the body-mind dichotomy. METHOD: A panel of clinical experts from different clinical services involved in providing aspects of health care for patients with functional symptoms reviewed the current care provision. This review and the results from a focus group exploration of patients with lived experience of functional symptoms were explored by the multidisciplinary expert group, and the conclusions are summarised as recommendations for best practice. RESULTS: The mapping exercise and multidisciplinary expert consultation revealed five themes for service improvement and pathway development: time/access, communication, barrier-free care, choice and governance. Service users identified four meta-themes for best practice recommendations: focus on healthcare professional communication and listening skills as well as professional attributes and knowledge base to help patients being both believed and understood in order to accept their condition; systemic and care pathway issues such as stronger emphasis on primary care as the first point of contact for patients, resources to reduce the length of the patient journey from initial assessment to diagnosis and treatment. CONCLUSION: We propose a novel, integrated care pathway for patients with 'functional somatic disorder', which delivers care according to and working with patients' explanatory beliefs. The therapeutic model should operate based upon an understanding of the embodied nature of patient's complaints and provide flexible access points to the care pathway.

Association of categorical diagnoses and psychopathologies with quality of life in patients with depression, anxiety, and somatic symptoms: A cross-sectional study.

OBJECTIVE: Major depressive disorder (MDD), anxiety disorders, and somatic symptom disorder (SSD) are associated with quality of life (QoL) reduction. This cross-sectional study investigated the relationship between these conditions as categorical diagnoses and related psychopathologies with QoL, recognizing their frequent overlap. METHODS: We recruited a total of 403 clinical patients and healthy individuals, administering diagnostic interviews based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. QoL and psychopathologies were assessed using the WHO Quality of Life-BREF (WHOQOL-BREF) and several self-administered questionnaires, respectively. Multiple linear regression analyses examined the associations between psychiatric diagnoses, psychopathologies, and QoL. RESULTS: SSD and MDD were independently associated with impaired global (ß = -0.318 and - 0.287) and all QoL domains (ß = -0.307, -0.150, -0.125, and - 0.133, in physical, psychological, social, and environmental domains respectively for SSD; ß = -0.278, -0.344, -0.275, and - 0.268 for MDD). The Beck Depression Inventory-II score showed pervasive associations with QoL (ß = -0.390, -0.408, -0.685, -0.463, and - 0.420, in global, physical, psychological, social, and environmental domains). The Patient Health Questionnaire-15 and Health Anxiety Questionnaire scores were associated with global (ß = -0.168 and - 0.181) and physical (ß = -0.293 and - 0.121) QoL domain, while the Cognitions About Body and Health Questionnaire score was only associated with environmental QoL domain (ß = -0.157). CONCLUSION: SSD and MDD were independently associated with QoL impairment. Depressive symptoms were associated with all QoL domains, whereas somatic symptom burden and health anxiety primarily affected the physical QoL domain. Clinicians should consider concomitant psychopathologies when managing patients with depression, anxiety, or somatic symptoms.

An integrated mental health video consultations model for patients with somatic symptom disorder in primary care: The randomized VISION pilot trial.

OBJECTIVE: Symptoms of somatic symptom disorder (SSD) are one of the most common reasons for consultations in primary care. However, specialized psychological services are mostly unavailable. This pilot trial aimed to determine the feasibility, acceptability, and safety of the integrated mental health video consultations VISION model for patients with SSD in primary care. METHODS: We conducted a parallel group, randomized controlled pilot trial involving fifty-one patients with SSD from ten primary care practices in Germany, who we randomized to the VISION model or enhanced treatment-as-usual (eTAU). The VISION model comprised five video consultations which featured diagnostic clarification, psychoeducation (acknowledging and legitimizing of symptoms), and brief psychological therapy. eTAU included training primary care practice teams on the DSM-5 concept of SSD and on current guideline recommendations for its treatment in primary care. We assessed feasibility as the primary outcome at 6-months, measuring efficiency of recruitment, intervention acceptability, and safety. RESULTS: Recruitment was efficient reflected in an overall recruitment yield (number randomized per number screened) of 55% (51/92) and a consent rate (number randomized per number eligible) of 94% (51/54). Acceptability of the intervention was high with 98% (123/125) of the video consultations conducted as planned. No serious adverse events were reported in either group. CONCLUSION: An integrated mental health video consultations VISION model for patients with SSD presenting to primary care is feasible, acceptable, and safe. Potential clinical effectiveness of the model should be evaluated in confirmatory trial implementing the multifaceted approach tailored to the individual patient with SSD directly into primary care practice. TRIAL REGISTRATION: The trial protocol was registered at German Clinical Trials Register (number: DRKS00026075, https://www.drks.de).

Factors associated with having previously received a diagnosis of fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome: A cross sectional DanFunD study.

OBJECTIVES: Fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome are highly prevalent conditions and part of the functional somatic syndromes (FSS) diagnosis, that are classified under the unifying umbrella term functional somatic disorder (FSD). Multiple factors are associated with FSD symptom development; However, few studies have explored these associations in relation to the diagnosis status. This study aims to examine associations with a previously received FSS diagnosis from a physician in participants fulfilling the FSD diagnostic criteria in a population-based sample. METHODS: This research employs a comprehensive observational approach using a cross sectional design with data from the DanFunD part two cohort. Information about received FSS diagnoses was obtained from self-reported questionnaires. Participants fulfilling the FSD diagnostic criteria were identified with both self-reported questionnaires and diagnostic interviews. Validated questionnaires were used to assess the examined factors. RESULTS: 1704 cases fulfilled the diagnostic criteria for an FSD according to questionnaires or interviews in the DanFunD study. In participants fulfilling the diagnostic criteria, having previously received an FSS diagnosis by a physician was strongly associated with female sex, negative illness perceptions and poor health-related quality of life for questionnaire and interview-based diagnoses. Less consistent associations were observed for lower socioeconomic status, anxiety, and adverse life events. CONCLUSION: Previously received FSS diagnoses showed associations with multiple factors with a particular strong association with female sex and poor health related quality of life.

Temporomandibular disorder and somatic symptoms: Relations to 'fear of missing out' and other negative emotional states.

OBJECTIVE: The association between the 'fear of missing out (FOMO)' and physical symptoms has not been widely explored. This study aimed to investigate the relationship between FOMO and other negative emotions with Temporomandibular disorder (TMD) and somatic symptoms in young adults. The correlations between the various physical and emotional variables were also established. MATERIAL AND METHODS: TMD and somatic symptoms were appraised with the Short-form Fonseca Anamnestic Index, quintessential five TMD symptoms of the Diagnostic Criteria (DC)/TMD, and Patient Health Questionnaire-15. FOMO and other negative emotional states were assessed with the FOMO Scale and Depression, Anxiety, Stress Scales-21 (DASS-21). Data were evaluated using non-parametric tests/correlation and regression analysis (α = 0.05). RESULTS: While only negative affectivity (total DASS), anxiety, and stress differed significantly between those without and with TMDs, significant variances in FOMO and all DASS-21 constructs were discerned between individuals without and with somatization.  Conclusions: Individuals with orofacial pain and more severe somatic symptoms have higher levels of negative emotions including FOMO. While somatization increased the prospect of TMDs, being female, presence of TMDs, and negative affectivity were risk factors for somatization in young adults. CLINICAL RELEVANCE: Asian young adults appear to be disposed to somatization, and TMDs may be a form of functional somatic syndromes. Recognition of somatic symptoms and emotional distress, including FOMO, is essential for person-centric TMD care.

Changes in interoceptive accuracy related to emotional interference in somatic symptom disorder.

OBJECTIVE: The somatic symptom disorder (SSD) is characterized by one or more distressing or disabling somatic symptoms accompanied by an excessive amount of time, energy and emotion related to the symptoms. These manifestations of SSD have been linked to alterations in perception and appraisal of bodily signals. We hypothesized that SSD patients would exhibit changes in interoceptive accuracy (IA), particularly when emotional processing is involved. METHODS: Twenty-three patients with SSD and 20 healthy controls were recruited. IA was assessed using the heartbeat perception task. The task was performed in the absence of stimuli as well as in the presence of emotional interference, i.e., photographs of faces with an emotional expression. IA were examined for correlation with measures related to their somatic symptoms, including resting-state heart rate variability (HRV). RESULTS: There was no significant difference in the absolute values of IA between patients with SSD and healthy controls, regardless of the condition. However, the degree of difference in IA without emotional interference and with neutral facial interference was greater in patients with SSD than in healthy controls (p = 0.039). The IA of patients with SSD also showed a significant correlation with low-frequency HRV (p = 0.004) and high-frequency HRV (p = 0.007). CONCLUSION: SSD patients showed more significant changes in IA when neutral facial interference was given. These results suggest that bodily awareness is more affected by emotionally ambiguous stimuli in SSD patients than in healthy controls.

The Association of Emotion Regulation and Somatic Symptoms.

OBJECTIVE: People with functional somatic symptoms have difficulties in various stages of the emotion regulation (ER) process. As an adaptive and flexible use of ER strategies is a core tenet of emotional health, having difficulties in this area is often assumed to be the key mechanism behind functional somatic symptoms. Following a dimensional population-based sampling approach, we investigated ER abilities across a broad range of people and tested possible associations with somatic symptom reporting, habitual ER use, and various subclinical constructs (such as alexithymia and anxiety). METHODS: In a sample of N = 254 persons, somatic symptom distress (Patient Health Questionnaire-15, Hierarchical Taxonomy of Psychopathology somatoform spectrum), trait ER facets (Emotion Regulation Questionnaire, Emotion Reactivity Scale), and the ER abilities (suppression and reappraisal) were assessed. Correlations (frequentist and Bayesian), ANOVAs, and structural equation models were used to analyze the data. RESULTS: Correlational and structural equation model analyses revealed that general symptom severity (both on the somatoform Hierarchical Taxonomy of Psychopathology and Patient Health Questionnaire-15) was not significantly associated with ER effectiveness, general arousal, or general valence. The sensory components of pain symptoms ( r = -0.708, p = .023) and health anxiety ( r = -0.443, p = .028) were significantly negatively associated with effective ER. CONCLUSIONS: ER effectiveness seems independent of general somatic symptom distress. We make recommendations for clinical interventions in light of these complex findings.

Putting the Vicious Cycle to the Test: Evidence for the Cognitive Behavioral Model of Persistent Somatic Symptoms From an Online Study.

OBJECTIVE: In clinical practice, persistent somatic symptoms are regularly explained using a cognitive-behavioral model (CBM). In the CBM, predisposing, perpetuating, and precipitating factors are assumed to interact and to cause the onset and endurance of somatic symptoms. However, these models are rarely investigated in their entirety. METHODS: We conducted an online survey during the COVID-19 pandemic. A total of 2114 participants from the general German population completed questionnaires that measured different factors of the CBM. We used state negative affectivity and neuroticism as predisposing factors, fear of a COVID-19 infection as the precipitating factor, and somatic symptoms, misinterpretation of bodily symptoms, attention allocation to bodily symptoms, and health anxiety as perpetuating factors. Moreover, we added safety and avoidance behavior as end points to the model. We conducted a psychological network analysis to exploratively study the relationships between the model's different factors and tested the assumptions of the CBM by evaluating a structural equation model (SEM) that incorporated all factors of the model. RESULTS: Network analyses revealed clustering in our data: Health anxiety and different cognitive factors are closely related, whereas somatic symptoms and state negative affectivity are strongly associated. Our SEM showed adequate fit. CONCLUSIONS: Our findings from an exploratory and a confirmatory approach give empirical support for the CBM, suggesting it as a suitable model to explain bodily symptoms in the general population and to possibly guide clinical practice. The network model additionally indicates the necessity to apply an individualized CBM for patients, depending on a preponderance of either persistent somatic symptoms or health concerns.

Somatic symptom distress is not related to cardioceptive accuracy.

OBJECTIVE: (Cardiac) interoception was long considered a key mechanism behind symptom perception in persistent somatic symptoms (PSS). In this study, we aimed to extend earlier findings to clarify this potential interoceptive mechanisms of PSS. METHODS: A cross-sectional sample of 251 participants (23.1% with self-reported functional somatic syndrome) completed a laboratory study with two cardioceptive accuracy tasks (Schandry task and a new cardiac signal detection task) and multiple questionnaires. Somatic symptom distress and associated constructs were assessed with the PHQ-15, as well as with a novel multidimensional questionnaire measure (HiTOP-SF1) derived from the somatoform spectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). Correlations (frequentist and Bayesian) and structural equation modelling (SEM) helped further investigate the interplay between these variables. RESULTS: There were no significant correlations between measures of interoception and somatic symptom distress. Self-report and behavioral cardioceptive accuracy measures did not correlate significantly. No significant covariances emerged between diagnostic tools and cardioceptive accuracy; Bayesian analyses supported the lack of association between interoception and symptom perception. CONCLUSIONS: Cardiac interoception (specifically cardioceptive accuracy) unlikely represents a key mechanism in PSS etiology. We recommend investigating other factors in PSS.

Strategies to improve implementation of collaborative care for functional disorders and persistent somatic symptoms: A qualitative study using a Research World Café design.

INTRODUCTION: Persistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD. METHODS: The Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task. RESULTS: Thirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention. CONCLUSION: We identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.