Parents' experience and views on the assessment and treatment of children with OCD within the public mental health system in Iceland: a qualitative study.

PURPOSE: Obsessive-compulsive disorder (OCD) in children can lead to long-lasting symptoms and access to evidence-based evaluation and treatment is crucial for its prevention. In Iceland, the law guarantees public access to the highest quality healthcare services. To date, no study has evaluated the services available for children with OCD within the national healthcare system (NMHS). This qualitative study explored the experiences of parents navigating the Icelandic NMHS for their children with OCD. METHOD AND MATERIALS: Seven parents who had sought services within the NMHS for their children diagnosed with OCD at private clinics were interviewed using a semi-structured interview. The responses were analyzed using thematic framework analysis. RESULTS: Nineteen themes were identified, including three overarching themes and eight overarching sub-themes, and eight sub-themes within them. A prevalent theme was the giving up on the national mental healthcare system due to parents' experiences of accessing mental healthcare for their children being challenging. Other issues faced by parents included a lack of knowledge on where to seek help, inadequate evaluation of the issue, and the lack of access to psychotherapy for their children. The healthcare workers' responses and recommendations also resulted in parents seeking treatment at private clinics. CONCLUSIONS: These findings underscore the need for clearer pathways for seeking help, improved access to trained healthcare workers, and a more centralized evaluation process. These insights can potentially guide future research and policy decisions to better support families dealing with childhood OCD in Iceland.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond.

BACKGROUND: Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however. AIMS: In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment. METHOD: The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general. CONCLUSION: Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

Adults referred to a national ADHD clinic in Iceland: clinical characteristics and follow-up status.

OBJECTIVE: Evaluate adults referred to a national ADHD clinic, by comparing those diagnosed with those who were not, and those who screened negative and to evaluate changes among those diagnosed at follow-up. METHOD: Data obtained from 531 patients' medical records (49.7% males). One hundred thirty-six screened negative, 395 positive and 305 met diagnostic criteria for ADHD. Eighty-three of them were contacted by phone at follow-up. RESULTS: ADHD diagnosis was associated with lower educational status and more concerns expressed by parents and teachers during childhood. Participants not diagnosed with ADHD more often met diagnostic criteria for dysthymia, agoraphobia and generalized anxiety, and were more likely to be diagnosed with two or more comorbid disorders. At follow-up, all reported a significant reduction of ADHD symptoms, irrespective of medication, but the medicated participants reported fewer symptoms of inattention and better functioning in daily life. CONCLUSION: Adults referred to ADHD clinics may have multiple mental health problems, regardless of whether they receive ADHD diagnosis or not. This could have implications for differential diagnoses of ADHD in adults and emphasises the need to have appropriate treatment available for both groups. Psychoeducation about ADHD may be very helpful in decreasing anxiety and ADHD symptoms.

[Prevalence of persistent physical symptoms and association with depression, anxiety and health anxiety in Iceland].

INTRODUCTION: Persistent physical symptoms that are medically unexplained can result in significant functional impairment. The aim of this study was to estimate the prevalence of persistent physical symptoms among people seeking primary healthcare in Reykjavík, Iceland, how they relate to functional impairment, symptoms of depression, general anxiety and health anxiety, and estimate the proportion of people with such symptoms who would likely benefit from psychological treatment. MATERIALS AND METHODS: Questionnaires measuring persistent physical symptoms, functional impairment, and symptoms of depression, general anxiety and health anxiety were administered to 106 patients attending two primary healthcare clinics. RESULTS: The prevalence of persistent physical symptoms was 27.4% among the primary care patients and they had a strong relationship to symptoms of mental disorders. Participants with persistent physical symptoms were 8 times more likely to have clinical levels of depression and general anxiety than participants without such symptoms, 4 times more likely to have clinical levels of health anxiety and 13 times more likely to have clinical levels of functional impairment. At least two-thirds of participants with persistent physical symptoms would likely benefit from psychological treatment. CONCLUSION: The prevalence of persistent physical symptoms among health care patients in the capital area of Iceland is in line with previous studies. Similarly, the strong relationship between persistent physical symptoms and symptoms of depression and anxiety corresponds to previous studies. It is likely that at least two out of three patients with persistent physical symptoms would benefit from psychological treatment. Transdiagnostic cognitive behavioural therapy for persistent physical symptoms might be particularly useful as is focuses on the interplay between physical and mental symptoms.

Pregnancy complications, sick leave and service needs of women who experience perinatal distress, weak social support and dissatisfaction in their partner relationships.

INTRODUCTION: Although perinatal distress is acknowledged as a burdening condition for pregnant women, its effects on pregnancy are not well known. This study was conducted to increase knowledge regarding the effects of distress on pregnancy-related problems. The study also assessed women's need for sick leave and increased prenatal care due to distress, and the effects of weak social support and dissatisfaction with their partner relationships. METHODS: In total, 2523 women were screened for perinatal distress three times during pregnancy in this quantitative cohort study. Structured psychiatric interviews were conducted following the screening, with 562 of the participants. Data from participants' pregnancy records were also analysed. The study was conducted in primary healthcare centres in Iceland after receiving approval from the Icelandic National Bioethical Committee. The main outcome measures were pregnancy problems, sick leave issued and prenatal service needs. RESULTS: Data from 503 women were analysed. The perinatal distress group (PDG) was significantly more likely than was the nondistressed group (NDG) to experience fatigue, vomiting and pelvic pain after controlling for background variables. Distressed women who reported weak family support experienced symptoms of nausea and heartburn. The PDG needed more frequent prenatal care than did the NDG and was issued sick leave for up to 42 days longer. Dissatisfaction in the partner relationship and with the division of household tasks and childcare was strongly associated with distress, the development of complications and the need for sick leave. DISCUSSION: Identification of perinatal distress by midwives and other healthcare professionals is important, since distress may be linked to women's complaints of fatigue, vomiting, pelvic pain and need for prolonged sick leave, and additional prenatal care services will be needed. Perceived dissatisfaction in the partner relationship and with the division of household tasks should also form part of clinical practice and assistance provided.

Adverse life experiences and common mental health problems in pregnancy: a causal pathway analysis.

Risk factors for antenatal common mental problems include a history of depression, lack of social support and a history of both childhood and adulthood sexual and physical abuse. However, it is less clear whether pregnancy is a time of particular susceptibility to mental disorders due to prior childhood experiences. The aim of the paper was to investigate the potential pathways to antenatal mental health problems. A total of 521 women attending prenatal care attended a clinical interview and answered psychological questionnaires. Univariate analysis, sequential binary logistic regression and structural equation modelling (SEM) were used to analyse the relationships between variables. Having experienced parental maladjustment, maltreatment and serious physical illness in childhood and domestic violence, financial difficulties and serious spousal substance abuse in adulthood significantly predicted antenatal common mental health symptoms. SEM showed that history of depression and adverse experiences in adulthood had mediating effects on the relationship between adverse childhood events and symptoms of antenatal common mental disorders. Adverse childhood experiences are distal risk factors for antenatal common mental health problems, being significant indicators of history of depression and adverse experiences in adulthood. We therefore conclude that pregnancy is not a time of particular susceptibility to common mental health problems as a result of childhood abuse, but rather, these childhood experiences have increased the risk of adulthood trauma and prior mental disorders. Women at risk for antenatal common mental disorders include those with a history of depression, domestic violence, financial difficulties, spousal substance abuse and lack of social support.

Effects of a Brief Transdiagnostic Cognitive Behavioural Group Therapy on Disorder Specific Symptoms.

BACKGROUND: In recent years, cognitive behavioural group therapies (CBGT) have been increasingly deployed as a strategy to increase the efficiency and cost-effectiveness in treatment of common mental health problems. The vast majority of these therapies are disorder specific, but in the last few years there has been growing interest in transdiagnostic CBGT. AIMS: The aim of this study was twofold: to evaluate the treatment effects of transdiagnostic CBGT on disorder specific symptoms and what (if any) differences would be observed in the treatment effects with regard to general as opposed to disorder specific symptoms measured pre- and post-treatment. METHOD: The participants were 233 adult patients diagnosed with depression and/or anxiety disorders. They underwent a 6-week transdiagnostic CBGT. To compare treatment effects on general and disorder specific symptoms, raw scores on all measures were converted to standardized scores. RESULTS: Pre-post differences were significant and there was no evidence that treatment was differentially effective for general and disorder specific symptoms. Effect sizes ranged from medium to large. CONCLUSION: The 6-week transdiagnostic CBGT is feasible for a wide range of mood and anxiety disorders. The results indicate that low-intensity transdiagnostic group therapies may have similar effects on both general and disorder specific symptoms.

A randomized controlled trial reporting functional outcomes of cognitive-behavioural therapy in medication-treated adults with ADHD and comorbid psychopathology.

Studies assessing psychological treatment of attention deficit hyperactivity disorder (ADHD) in adults are increasingly reported. However, functional outcomes are often neglected in favour of symptom outcomes. We investigated functional outcomes in 95 adults with ADHD who were already treated with medication and randomized to receive treatment as usual (TAU/MED) or psychological treatment (CBT/MED) using a cognitive-behavioural programme, R&R2ADHD, which employs both group and individual modalities. RATE-S functional outcomes associated with ADHD symptoms, social functioning, emotional control and antisocial behaviour were given at baseline, end of treatment and three-month follow-up. The Total composite score of these scales is associated with life satisfaction. In addition, independent evaluator ratings of clinicians who were blind to treatment arm were obtained on the Clinical Global Impression scale at each time point. CBT/MED showed overall (combined outcome at end of treatment and 3-month follow-up) significantly greater functional improvement on all scales. Post-group treatment effects were maintained at follow-up with the exception of emotional control and the Total composite scales, which continued to improve. The largest treatment effect was for the RATE-S Total composite scale, associated with life satisfaction. CGI significantly correlated with all outcomes except for social functioning scale at follow-up. The study provides further evidence for the effectiveness of R&R2ADHD and demonstrates the importance of measuring functional outcomes. The key mechanism associated with improved functional outcomes is likely to be behavioural control.

An epidemiological study of ADHD and conduct disorder: does family conflict moderate the association?

PURPOSE: To examine the role of family conflict in the relationship between attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD). METHODS: A cross-sectional national population survey was carried out among 10,838 14-16 year old students in all secondary schools in Iceland. Three latent measures, financial status, ADHD and CD, and one observed measure, family structure, were included in the study. A structural equation model was used to evaluate direct effects between ADHD and CD for four different groups; females and males, experiencing family conflict and those not experiencing family conflict. RESULTS: ADHD was significantly and positively associated with CD for all groups. When controlling for financial status and family structure it was found that ADHD was positively and significantly associated with CD for adolescent females and males not experiencing family conflict as well as for those experiencing family conflict. The link between ADHD and CD was significantly stronger for those adolescents who had experienced family conflict compared to those who had not experienced family conflict. These results suggest that family conflict moderates the association between ADHD and CD for both girls and boys. CONCLUSIONS: The results of this study indicate that family environment and ADHD symptoms are important when predicting CD among adolescent youth. Most notably, family conflict exacerbates the effects of ADHD symptoms on CD among both females and males.

A national epidemiological study investigating risk factors for police interrogation and false confession among juveniles and young persons.

PURPOSE: The principal aims of this study are to identify risk factors associated with police arrest and false confessions and to investigate whether the severity of the ADHD condition/symptoms increases the risk. METHODS: 22,226 young persons in Iceland anonymously completed self-report questionnaires screening for conduct disorder and ADHD. In addition, they stated whether they had a diagnosis of ADHD and had received ADHD medication, and their history of offending, police interrogation and false confession. Participants were stratified into two age groups, 14-16 and 17-24 years. RESULTS: The older group was significantly more likely to have been interrogated by the police but the younger group were much more vulnerable to false confession during interrogation. Males were more likely to be at risk for both than females. The severity of the ADHD condition increased the risk of both interrogation and false confession. Negative binomial regressions showed that age, gender, conduct disorder, offending, and ADHD symptoms were all significant predictors of both interrogations and number of false confessions. Conduct disorder was the single best predictor of police interrogation, but the findings were more mixed regarding false confessions. Young people presenting with a combination of severe ADHD and comorbid conduct disorder had the worst outcome for both interrogation and false confessions. CONCLUSIONS: The findings endorse the need for support of persons with ADHD to be put in place to ensure fair due process and to prevent miscarriages of justice.

Transdiagnostic cognitive behavioural treatment and the impact of co-morbidity: An open trial in a cohort of primary care patients.

BACKGROUND: The development of initiatives to improve access to psychological therapies has been driven by the realization that untreated anxiety and depression are both very common and costly to individuals as well as society. Effective and efficient treatments, mostly in the form of cognitive behavioural therapies (CBT), can be used in ways which enhance their acceptability and accessibility. To date, numbers of group therapies have been developed to improve cost efficiency, but in spite of growing interest in transdiagnostic approaches, group therapies have so far mostly been diagnosis specific. AIMS: This study is aimed at evaluating a brief transdiagnostic cognitive behavioural group therapy (TCBGT) designed to treat both anxiety and depression among patients in primary care. METHOD: The participants were 287 adult patients in primary care with diagnoses of depression and/or anxiety disorders. They underwent a 5-week TCBGT. A mixed design ANOVA was used to evaluate differential effects of treatment according to diagnostic groups (anxiety versus depression) and number of diagnoses (co-morbidity). RESULTS: Pre-post differences were significant and the treatment was equally effective for both anxiety disorders and depression. Number of diagnoses did not affect the outcome. CONCLUSIONS: The study indicates feasibility of the brief transdiagnostic group therapy for a wide range of mood and anxiety disorders in primary care. The results indicate that low intensity, brief transdiagnostic group therapies may be a feasible way to improve access to psychological therapies for a large number of patients.

Quality of life among untreated sleep apnea patients compared with the general population and changes after treatment with positive airway pressure.

Obstructive sleep apnea leads to recurrent arousals from sleep, oxygen desaturations, daytime sleepiness and fatigue. This can have an adverse impact on quality of life. The aims of this study were to compare: (i) quality of life between the general population and untreated patients with obstructive sleep apnea; and (ii) changes of quality of life among patients with obstructive sleep apnea after 2 years of positive airway pressure treatment between adherent patients and non-users. Propensity score methodologies were used in order to minimize selection bias and strengthen causal inferences. The enrolled obstructive sleep apnea subjects (n = 822) were newly diagnosed with moderate to severe obstructive sleep apnea who were starting positive airway pressure treatment, and the general population subjects (n = 742) were randomly selected Icelanders. The Short Form 12 was used to measure quality of life. Untreated patients with obstructive sleep apnea had a worse quality of life when compared with the general population. This effect remained significant after using propensity scores to select samples, balanced with regard to age, body mass index, gender, smoking, diabetes, hypertension and cardiovascular disease. We did not find significant overall differences between full and non-users of positive airway pressure in improvement of quality of life from baseline to follow-up. However, there was a trend towards more improvement in physical quality of life for positive airway pressure-adherent patients, and the most obese subjects improved their physical quality of life more. The results suggest that co-morbidities of obstructive sleep apnea, such as obesity, insomnia and daytime sleepiness, have a great effect on life qualities and need to be taken into account and addressed with additional interventions.

Evaluation of the psychometric properties of the Icelandic version of the Clinical Outcomes in Routine Evaluation-Outcome Measure, its transdiagnostic utility and cross-cultural validation.

BACKGROUND: The development of transdiagnostic standardized measures of psychological distress have contributed to the development of practice-based evidence networks. The translation and validation of such measures cross culturally is important if such research is to be generalized across health care systems in different countries. METHOD: Translation of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) from English into Icelandic was undertaken according to recommended protocols. The resulting instrument was evaluated for reliability and validity in three groups: patients undergoing psychological treatment in general practice (n = 289), psychiatric outpatients (n = 98) and student controls (n = 207). The Mini-International Neuropsychiatric Interview was administered to the clinical participants. They also completed the CORE-OM and the Beck depression and anxiety inventories before and after treatment. The transdiagnostic relationship between CORE-OM scores and scores on those diagnostic measures was assessed. RESULTS: Good levels of validity, reliability and internal consistency were found for the CORE-OM and its domains and sensitivity to change over treatment shown. As anticipated, the risk domain had different characteristics than other domains. CORE-OM scores correlated strongly with both Beck Depression Inventory-Second edition and Beck Anxiety Inventory, particularly the problem domain. CONCLUSION: The Icelandic translation of the CORE-OM is psychometrically sound and can be applied in Icelandic mental health studies as it has been in English speaking settings. Nevertheless, the validity of the Icelandic version of the CORE-OM needs to be further investigated in larger and more diverse samples. KEY PRACTITIONER MESSAGE: The psychometric properties of the Icelandic version of the CORE-OM are comparable with the original English version. The results indicate transdiagnostic utility of the CORE-OM. The CORE-OM is a valuable instrument in outcome research on psychological treatment, specifically transdiagnostic treatment.

A psychometric evaluation of the Icelandic version of the WHO-5.

The psychometric properties of the Icelandic version of the World Health Organization five wellbeing index (WHO-5) were evaluated using two samples, a randomly selected sample (N = 3,896) from the Icelandic National Registry and a convenience sample of primary care patients (N = 126). The factor structure of the scale was tested with confirmatory factor analysis (CFA). The correlation between the WHO-5 and other measures of depression and anxiety were calculated to assess the scale's convergent and divergent validity. The discriminant validity of the WHO-5 was explored with a receiver operating analysis compared to the Mini International Neuropsychiatric Interview. The CFA indicated that the factor structure of the WHO-5 was one-dimensional and factorial invariant between groups. The internal reliability of the WHO-5 was adequate and the convergent, divergent and discriminant validity of the WHO-5 was supported. It is concluded that the psychometric properties of the Icelandic version of the WHO-5 are satisfactory.

Suicidal ideations and attempts among adolescents subjected to childhood sexual abuse and family conflict/violence: the mediating role of anger and depressed mood.

Based on a sample of 9085 16- to 19-year-old students attending all high schools in Iceland in 2004, the current study examines depressed mood and anger as potential mediators between family conflict/violence and sexual abuse, on the one hand, and suicidal ideations and suicide attempts on the other. Agnew's general strain theory provides the theoretical framework for the study. Structural equation modelling (SEM) was conducted allowing explicit modelling of both direct and mediating effects using observed and latent variables. The findings showed that both depressed mood and anger mediated the relationship between family conflict/violence and sexual abuse and suicidal attempts. However, when testing the mediating pathways between sexual abuse and family conflict/violence and suicidal ideations, only depressed mood but not anger turned out to be a significant mediator. The authors discuss how these finding may inform and facilitate the design and development of interventions to reduce the likelihood of suicide attempts among young people.

Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability.

Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.

The role of childhood adversity and prenatal mental health as psychosocial risk factors for adverse delivery and neonatal outcomes.

OBJECTIVE: Exposure to adverse childhood experiences (ACEs) is a significant predictor for physical and mental health problems later in life, especially during the perinatal period. Prenatal common mental disorders (PCMDs) are well-established as a risk for obstetric interventions but knowledge on combined effects of multiple psychosocial risk factors is sparse. We aim to examine a comprehensive model of ACEs and PCMDs as risk factors for poor delivery and neonatal outcomes. METHOD: With structural equation modeling, we examined direct and indirect pathways between psychosocial risk and delivery and neonatal outcomes in a prospective cohort from pregnancy to birth in Iceland. RESULTS: Exposure to ACEs increased risk of PCMDs [ß = 0.538, p < .001, CI: 0.195-1.154] and preterm delivery [ß = 0.768, p < .05, CI: 0.279-1.007)]. An indirect association was found between ACEs and increased risk of non-spontaneous delivery [ß = 0.054, p < .05, CI: 0.004-0.152], mediated by PCMDs. Identical findings were observed for ACEs subcategories. CONCLUSION: ACEs are strong predictors for mental health problems during pregnancy. Both ACEs and PCMDs diagnosis are associated with operative delivery interventions and neonatal outcomes. Findings underscore the importance of identifying high-risk women and interventions aimed at decreasing psychosocial risk during the prenatal period.

An epidemiological study of ADHD symptoms among young persons and the relationship with cigarette smoking, alcohol consumption and illicit drug use.

BACKGROUND: This study investigates the relationship between attention deficit hyperactivity disorder (ADHD) symptoms and cigarette smoking, alcohol use and illicit drug use. METHOD: The participants were 10,987 pupils in the final three years of their compulsory education in Iceland (ages 14-16 years). The participants completed questionnaires in class relating to anxiety, depression and antiestablishment attitudes, ADHD symptoms, smoking, alcohol consumption and illicit drug use. RESULTS: Of the total sample, 5.4% met screening criteria for ADHD. Smoking, alcohol and illicit drug use were significantly related to ADHD symptoms. In addition, the number of different illicit drugs consumed was significantly higher among the ADHD symptomatic than the nonsymptomatic participants, including the illicit use of sedatives. The main distinguishing illicit drug substances were lysergic acid diethylamide (odds ratio or OR = 8.0), cocaine (OR = 7.5), mushrooms (OR = 7.1) and amphetamines (OR = 6.5). Logistic multiple regressions showed that after controlling for gender and school grade, ADHD symptoms predicted smoking, alcohol use and illicit drug use independent of anxiety, depression and antiestablishment attitudes. In addition, poly-substance use was linearly and incrementally related to ADHD symptoms with a large effect size. CONCLUSIONS: The findings underscore the vulnerability of young persons with ADHD symptoms to smoking, alcohol and illicit drug use, possibly as a means of self-medication, and emphasize a need for early identification and treatment to reduce the risk of escalation.

Physical activity buffers the effects of family conflict on depressed mood: a study on adolescent girls and boys.

This paper investigates the relationship between physical activity and depressed mood, under conditions of family conflict. We analyze data from a representative sample of 7,232 Icelandic adolescents. Analysis of variance was carried out to test for main and interaction effects. The study shows that while family conflict increases the likelihood of depressed mood, among adolescents, physical activity decreases the likelihood of depressed mood. Furthermore, physical activity plays a more important role among those adolescents living in aversive circumstances, than other adolescents, as family conflict and physical activity interact in the effect on depressed mood for adolescents living in such circumstances. The findings highlight the role of physical activity in decreasing mental distress among adolescents, especially those living in aversive circumstances at home.

"I'm So Tired": Fatigue as a Persistent Physical Symptom among Working People Experiencing Exhaustion Disorder.

Fatigue is widespread in the population, particularly among working people. Exhaustion disorder (ED), a clinical manifestation of burnout, is common, but, after treatment, about one-third still experience fatigue and other physical symptoms. We propose that in some instances, fatigue as a persistent physical symptom (PPS) might be a more appropriate formulation of ED patients' fatigue problems, and we suggest that ED patients who meet fatigue PPS criteria will differ from other ED patients in terms of psychological distress, non-fatigue PPSs and functional impairment. Questionnaires were sent to 10,956 members of a trade union of which 2479 (22.6%) responded. Of 1090 participants who met criteria for ED, 106 (9.7%) met criteria for fatigue as a PPS. Participants who met fatigue PPS criteria scored on average higher on measures of depression, anxiety and functional impairment and were more likely to have clinically significant scores. Moreover, they had 27 times higher odds of meeting other PPS subtypes and reported more non-fatigue PPS subtypes, suggesting a more complex health problem. Specific evidence-based interventions are available for both ED and PPSs, and therefore, it is crucial to accurately formulate the fatigue problem reported by patients to provide appropriate treatment.