Complexity Assessed by the INTERMED in Patients With Somatic Symptom Disorder Visiting a Specialized Outpatient Mental Health Care Setting: A Cross-sectional Study.

BACKGROUND: Somatic symptom disorders (SSD), a new classification in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition is associated with problematic diagnostic procedures and treatment that lead to complex care. In somatic health care, the INTERMED has been used to assess levels of complexity; however, in SSD this instrument has not yet been applied. OBJECTIVE: This study aims to explore complexity in patients with SSD using the INTERMED, hereby contributing to an increased comprehension of this new patient group. METHOD: In this cross-sectional study, the INTERMED was used to assess complexity in outpatients with SSD at the Clinical Centre of Excellence for Body, Mind, and Health (The Netherlands), along biologic, psychologic, social, and health care domains. This was done retrospectively with patient files from consecutive patients from 2011 until 2015. RESULTS: In the total SSD sample (N = 187), 63% was female, the mean age (standard deviation) was 42 (±12.4) years, with an average educational level. The mean INTERMED score was 23.5 indicating high overall complexity in this population. A high proportion of our sample (69%) scored as highly complex (>20). High complexity was associated with higher depression and anxiety scores, but not with a higher number of physical symptoms. CONCLUSIONS: This study demonstrates that patients with SSD form a high-complex group, with higher scores compared with literature about multiple sclerosis, rheumatoid arthritis, or patient waiting for a liver transplant. INTERMED outcomes indicate a need for extensive diagnostic procedures and integrated multidisciplinary care for patients with SSD. Attention should especially be paid to mental disorders (depression and anxiety), given their association with high complexity.

A taxonomy of threat and soothing influences in rheumatic and musculoskeletal diseases and central sensitivity syndromes.

Background: An imbalance in affect regulation, reflected by a hyperactive threat system and hypoactive soothing system, may impact physical symptoms in people with rheumatic and musculoskeletal diseases (RMD) and central sensitivity syndromes (CSS), including chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. This study aimed to identify and structure comprehensive overviews of threat and soothing influences that may worsen or alleviate physical symptoms in people with RMD or CSS. Method: A concept mapping procedure was used. An online open-question survey (N = 686, 641 [93.4%] women) yielded comprehensive sets of 40 threats and 40 soothers that were individually sorted by people with RMD or CSS (N = 115, 112 [97.4%] women). Results: Hierarchical cluster analyses generated eight threat clusters: environmental stimuli, physical symptoms, food and drugs, inactivity, demands, effort, invalidation, and emotional stress. Ten soother clusters were identified: social emotional support, rest and balance, pleasant surroundings, illness understanding, positive mindset and autonomy, spirituality, leisure activity, wellness, treatment and care, and nutrition and treats. Conclusions: Our study provided a comprehensive taxonomy of threats and soothers in people with RMD or CSS. The results can be used in experimental research to label threat and soothing stimuli and in clinical practice to screen and monitor relevant treatment targets.

Effectiveness and cost-effectiveness of transmural collaborative care with consultation letter (TCCCL) and duloxetine for major depressive disorder (MDD) and (sub)chronic pain in collaboration with primary care: design of a randomized placebo-controlled multi-Centre trial: TCC:PAINDIP.

BACKGROUND: The comorbidity of pain and depression is associated with high disease burden for patients in terms of disability, wellbeing, and use of medical care. Patients with major and minor depression often present themselves with pain to a general practitioner and recognition of depression in such cases is low, but evolving. Also, physical symptoms, including pain, in major depressive disorder, predict a poorer response to treatment. A multi-faceted, patient-tailored treatment programme, like collaborative care, is promising. However, treatment of chronic pain conditions in depressive patients has, so far, received limited attention in research. Cost effectiveness of an integrated approach of pain in depressed patients has not been studied. METHODS/DESIGN: This study is a placebo controlled double blind, three armed randomized multi centre trial. Patients with (sub)chronic pain and a depressive disorder are randomized to either a) collaborative care with duloxetine, b) collaborative care with placebo or c) duloxetine alone. 189 completers are needed to attain sufficient power to show a clinically significant effect of 0.6 SD on the primary outcome measures (PHQ-9 score). Data on depression, anxiety, mental and physical health, medication adherence, medication tolerability, quality of life, patient-doctor relationship, coping, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months. DISCUSSION: This study enables us to show the value of a closely monitored integrated treatment model above usual pharmacological treatment. Furthermore, a comparison with a placebo arm enables us to evaluate effectiveness of duloxetine in this population in a real life setting. Also, this study will provide evidence-based treatments and tools for their implementation in practice. This will facilitate generalization and implementation of results of this study. Moreover, patients included in this study are screened for pain symptoms, differentiating between nociceptive and neuropathic pain. Therefore, pain relief can be thoroughly evaluated. TRIAL REGISTRATION: NTR1089.

Individual treatment goals and factors influencing goal attainment in patients with somatic symptom disorder from the perspective of clinicians: A concept mapping study.

OBJECTIVE: Overviews of treatment goals and influencing factors may support shared decision making and optimize customized treatment to the patient with somatic symptom disorder (SSD). The aim of this study was to identify and structure comprehensive sets of treatment goals and factors influencing goal attainment in patients with SSD from the perspective of clinicians. METHODS: Using a concept mapping procedure, clinicians participated in interviews (N = 17) and card sorting tasks comprising 55 treatment goals and 55 factors influencing goal attainment (N = 38). RESULTS: We identified four overarching categories (A to D) of nine clusters (1 to 9) of treatment goals: A. empowerment (A1. personal values, A2. committed action, A3. self-esteem), B. skill improvement (B4. interpersonal skills, B5. emotion and stress regulation), C. symptom reduction (C6. dysfunctional beliefs, C7. somatic symptoms, C8. psychological symptoms), and D9. active and structured lifestyle. Also, we identified four overarching categories (A to D) of nine clusters (1 to 9) of factors influencing goal attainment: A1. therapeutic alliance, B. social and everyday context (B2. [family] system, B3. meaningful daily schedule, B4. social and economic circumstances), C. ability to change (C5. externalizing tendency, C6. reflective and psychological skills, C7. perspective and motivation), and D. psychological vulnerability (D8. vulnerable personality, D9. [psychiatric] comorbidity). CONCLUSION: The overviews of treatment goals and factors influencing goal attainment reflect different paradigmatic backgrounds of clinicians. The results can be used, in combination with the perspective of the patient, to define treatment goals, and to monitor and evaluate change in outcomes.

Childhood sexual abuse predicts treatment outcome in conversion disorder/functional neurological disorder. An observational longitudinal study.

OBJECTIVE: Explore trauma, stress, and other predictive factors for treatment outcome in conversion disorder/functional neurological disorder (CD/FND). METHODS: Prospective observational design. Clinical cohort study among consecutive outpatients with DSM-IV CD/FND in a specialized mental health institution for somatic symptom disorders and related disorders (SSRD), presented between 1 February 2010 and 31 December 2017. Patient files were assessed for early childhood trauma, childhood sexual abuse, current stress, and other predictive factors. Patient-related routine outcome monitoring (PROM) data were evaluated for treatment outcome at physical (Patient Health Questionnaire [PHQ15], Physical Symptoms Questionnaire [PSQ]) level as primary outcome, and depression (Patient Health Questionnaire [PHQ9]), anxiety (General Anxiety Disorder [GAD7]), general functioning (Short Form 36 Health Survey [SF36]), and pain (Brief Pain Inventory [BPI]) as secondary outcome. RESULTS: A total of 64 outpatients were included in the study. 70.3% of the sample reported childhood trauma and 64.1% a recent life event. Mean scores of patients proceeding to treatment improved. Sexual abuse in childhood (F(1, 28) = 30.068, ß = 0.608 p < .001) was significantly associated with worse physical (PHQ15, PSQ) treatment outcome. 42.2% reported comorbid depression, and this was significantly associated with worse concomitant depressive (PHQ9) (F[1, 39] = 11.526, ß = 0.478, p = .002) and anxiety (GAD7) (F[1,34] = 7.950, ß = 0.435, p = .008) outcome. CONCLUSION: Childhood sexual abuse is significantly associated with poor treatment outcome in CD/FND. Randomized clinical trials evaluating treatment models addressing childhood sexual abuse in CD are needed.

IL-6 and hsCRP in Somatic Symptom Disorders and related disorders.

Interleukin 6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) are biomarkers of systemic low-grade inflammation (SLI) in depression and anxiety. The question if SLI in those conditions is related to comorbid chronic medical conditions has not been resolved. DSM-5 Somatic symptom disorders and related disorders (SSRD) are conditions with serious distress related to physical symptoms as main criterion. They can occur in patients with medically unexplained symptoms (MUS) and in patients with known comorbid chronic medical conditions. Often, comorbid depression and anxiety are present. SSRDs offer the opportunity to explore the role of SLI in relation to mental distress, including trauma, MUS, chronic medical conditions and comorbid mental disorder. AIM: We hypothesized that increased IL-6 and hsCRP may be directly linked to SLI in SSRD, and that comorbid chronic medical conditions, childhood trauma, current stress and comorbid depression and anxiety may be risk factors that account for some of the variance of SLI in SSRD. METHODS: We explored these relationships in a large sample of 241 consecutive outpatients with SSRD. RESULTS: Mean hsCRP level was 3.66 â€‹mg/l, and mean IL-6 level was 3.58 â€‹pg/ml. IL-6 and hsCRP levels were associated with each other: τ â€‹= â€‹0.249, p â€‹< â€‹.001; a medium size correlation. Comorbid chronic medical conditions, adverse childhood events other than sexual trauma, and current stress levels were not associated with IL-6 or hsCRP levels. CONCLUSION: IL-6 and hsCRP are elevated in SSRD, indicating SLI in SSRD independently of comorbid chronic medical conditions. In clinical research, elevated IL-6 and hsCRP can be used as biomarkers of SLI and can indicate risk for childhood sexual abuse in SSRD. Elevated hsCRP may be a biomarker indicating risk for comorbid depression or high pain levels in SSRD as well.

Development and psychometric evaluation of the Transdiagnostic Decision Tool: matched care for patients with a mental disorder in need of highly specialised care.

BACKGROUND: Early identification of patients with mental health problems in need of highly specialised care could enhance the timely provision of appropriate care and improve the clinical and cost-effectiveness of treatment strategies. Recent research on the development and psychometric evaluation of diagnosis-specific decision-support algorithms suggested that the treatment allocation of patients to highly specialised mental healthcare settings may be guided by a core set of transdiagnostic patient factors. AIMS: To develop and psychometrically evaluate a transdiagnostic decision tool to facilitate the uniform assessment of highly specialised mental healthcare need in heterogeneous patient groups. METHOD: The Transdiagnostic Decision Tool was developed based on an analysis of transdiagnostic items of earlier developed diagnosis-specific decision tools. The Transdiagnostic Decision Tool was psychometrically evaluated in 505 patients with a somatic symptom disorder or post-traumatic stress disorder. Feasibility, interrater reliability, convergent validity and criterion validity were assessed. In order to evaluate convergent validity, the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the ICEpop CAPability measure for Adults (ICECAP-A) were administered. RESULTS: The six-item clinician-administered Transdiagnostic Decision Tool demonstrated excellent feasibility and acceptable interrater reliability. Spearman's rank correlations between the Transdiagnostic Decision Tool and ICECAP-A (-0.335), EQ-5D-5L index (-0.386) and EQ-5D-visual analogue scale (-0.348) supported convergent validity. The area under the curve was 0.81 and a cut-off value of ≥3 was found to represent the optimal cut-off value. CONCLUSIONS: The Transdiagnostic Decision Tool demonstrated solid psychometric properties and showed promise as a measure for the early detection of patients in need of highly specialised mental healthcare.

Type D Personality, Concomitant Depressive and Anxiety Disorders, and Treatment Outcomes in Somatic Symptom and Related Disorders: An Observational Longitudinal Cohort Study.

Objective: To establish the prevalence of Type D personality in patients with somatic symptoms and related disorders and to evaluate the association of Type D personality with treatment outcomes. This study explores the effect of Type D personality and its two traits, negative affectivity (NA) and social inhibition (SI). Methods: In this longitudinal observational cohort study, we assessed the prevalence of Type D in 212 patients presenting themselves at a clinic in Tilburg, the Netherlands. We explored psychological and physical treatment outcomes of a multimodal treatment tailored to patient needs in relation to Type D scores. We explored the differences with regard to physical symptoms, anxiety, and depression. We also explored the differences between patients with and without Type D personality who completed treatment with regard to the baseline scores of physical symptoms, anxiety, and depression. We explored the association between Type D personality and treatment outcome using the traditional dichotomous method and the dimensional method (with main effects of NA and SI, and the interaction of NA × SI). Results: Of the 212 patients with Somatic Symptom and Related Disorders (SSRD), those with Type D personality (181: 61.8%) had experienced significantly higher levels of depression [t = 4.404, p < .001] and anxiety [t = 3.757, p < .001]. Of the 212, 187 patients completed treatment. Mean scores improved significantly for the whole patient group after treatment with regard to depression (p < .001), anxiety (p < .001), and physical symptoms (p < .001). At baseline, patients with Type D personality had significantly higher scores in anxiety [F = 15.707, p < .001] and depression [F = 19.392] than patients without Type D personality who completed treatment. After controlling for the high baseline scores with regard to physical symptoms, anxiety, or depression, only the effect of Type D personality on remission of anxiety was significant (OR = .33, p = 0.39). Neither NA and SI nor the interaction of NA × SI was associated with the treatment outcome. Conclusions: This study shows that Type D personality occurs frequently in patients with SSRD. Type D personality only decreases the probability of remission of anxiety as a treatment outcome, and both NA and SI play a role in this. Type D personality did not decrease remission either of physical symptoms or of depression. Hence, both NA and SI factors may be expressions of anxiety mostly in type D.

Adverse Childhood Experiences (ACE) in outpatients with anxiety and depressive disorders and their association with psychiatric and somatic comorbidity and revictimization. Cross-sectional observational study.

BACKGROUND: This study aims to establish prevalence of Adverse Childhood Experiences (ACE) and their association with somatic comorbidity and adult adverse events (AAE) in outpatients with anxiety or depressive disorders. METHODS: Cross-sectional observational design. Specialty mental health outpatients classified with DSM-IV-TR anxiety or depressive disorder filled-out the ACE-IQ and the AAE-IQ. T-tests, ANOVA, logistic regressions andChi-square analyses were performed and stratified for ACE score ≥4(high) versus ACE <4(low). Gender differences were explored. RESULTS: From May 2015 -November 2016, in 298 consecutive patients 77.2% reported at least one ACE, 58.7% reported multiple ACE (mean 2.92). Scores were highest in Post-Traumatic Stress Disorder (PTSD) and in case of comorbid mental disorders. Somatic comorbidity was not associated with ACE-scores. AAE scores were significantly (t = -9.33, p < .001) higher in the high ACE-group (M = 4.09 SD = 2.42) versus the low-ACE group (M = 1.63 SD = 1.70), indicating general revictimization. An association between sexual ACE and sexual revictimization was found as well (χ2 = 86.14, p < .001).The effects did not differ for males and females. CONCLUSIONS: ACE and AAE are highly prevalent in depressive and anxiety disorders PTSD and psychiatric comorbidity are associated with higher scores, somatic comorbidity is not. Indications for general and sexual revictimization are shown. Further research is needed. LIMITATIONS: Selection bias may have influenced results on somatic comorbidity, as patients with obvious somatic comorbidity usually get referred to other health services. The generalisability of the results may be limited as non-Dutch speaking immigrants were excluded.

Illness burden and physical outcomes associated with collaborative care in patients with comorbid depressive disorder in chronic medical conditions: A systematic review and meta-analysis.

OBJECTIVE: Collaborative care (CC) improves depressive symptoms in people with comorbid depressive disorder in chronic medical conditions, but its effect on physical symptoms has not yet systematically been reviewed. This study aims to do so. METHODS: Systematic review and meta-analysis was conducted using PubMed, the Cochrane Library, and the European and US Clinical Trial Registers. Eligible studies included randomized controlled trials (RCTs) of CC compared to care as usual (CAU), in primary care and general hospital setting, reporting on physical and depressive symptoms as outcomes. Overall treatment effects were estimated for illness burden, physical outcomes and depression, respectively. RESULTS: Twenty RCTs were included, with N=4774 patients. The overall effect size of CC versus CAU for illness burden was OR 1.64 (95%CI 1.47;1.83), d=0.27 (95%CI 0.21;0.33). Best physical outcomes in CC were found for hypertension with comorbiddepression. Overall, depression outcomes were better for CC than for CAU. Moderator analyses did not yield statistically significant differences. CONCLUSIONS: CC is more effective than CAU in terms of illness burden, physical outcomes and depression, in patients with comorbid depression in chronic medical conditions. More research covering multiple medical conditions is needed. PROTOCOL REGISTRATION NUMBER: The protocol for this systematic review and meta-analysis has been registered at the International Prospective Register of Systematic Reviews (PROSPERO) on February 19th 2016: http://www.crd.york.ac.uk/PROSPERO/DisplayPDF.php?ID=CRD42016035553.

Predictors of Persistent Medically Unexplained Physical Symptoms: Findings From a General Population Study.

Objective: To explore the persistency of Medically Unexplained Symptoms (MUS) and its prognostic factors in the general adult population. Knowledge of prognostic factors of MUS may indicate possible avenues for intervention development. Methods: Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face cohort study among the Dutch general population aged 18-64 years. We selected subjects with MUS at baseline and who participated at follow-up (N = 324) and reassessed those subjects for having MUS at 3 year follow-up. Logistic regression analyses were used to determine risk factors for persistency of MUS. Results: 36.4% of the subjects had persistent MUS at follow-up. In logistic regression analyses adjusted for sex and age, persistency of MUS was predicted by the number of comorbid chronic medical disorder(s), lower education, female sex, not having a paid job, parental psychopathology as well as lower functioning. In the logistic regression analysis in which all significant variables adjusted for sex and age were entered simultaneously, three variables predicted persistent MUS: parental psychopathology, the number of comorbid chronic medical disorder(s) and physical functioning, with odds ratios of 2.01 (1.20-3.38), 1.19 (1.01-1.40), and 0.99 (0.97-1.00), respectively. Conclusion: In the adult general population, MUS were persistent in over one third of the subjects with MUS at baseline. Persistency was significantly predicted by parental psychopathology, number of comorbid chronic medical disorders, and physical functioning. These findings warrant further research into early intervention and treatment options for persons with an increased risk of persistent MUS.

Mental health care use in medically unexplained and explained physical symptoms: findings from a general population study.

OBJECTIVE: The aim of this study was to explore mental health care utilization patterns in primary and specialized mental health care of people with unexplained or explained physical symptoms. METHODS: Data were derived from the first wave of the Netherlands Mental Health Survey and Incidence Study-2, a nationally representative face-to-face cohort study among the general population aged 18-64 years. We selected subjects with medically unexplained symptoms (MUS) only (MUSonly; n=177), explained physical symptoms only (PHYonly, n=1,952), combined MUS and explained physical symptoms (MUS + PHY, n=209), and controls without physical symptoms (NONE, n=4,168). We studied entry into mental health care and the number of treatment contacts for mental problems, in both primary care and specialized mental health care. Analyses were adjusted for sociodemographic characteristics and presence of any 12-month mental disorder assessed with the Composite International Diagnostic Interview 3.0. RESULTS: At the primary care level, all three groups of subjects with physical symptoms showed entry into care for mental health problems significantly more often than controls. The adjusted odds ratios were 2.29 (1.33, 3.95) for MUSonly, 1.55 (1.13, 2.12) for PHYonly, and 2.25 (1.41, 3.57) for MUS + PHY. At the specialized mental health care level, this was the case only for MUSonly subjects (adjusted odds ratio 1.65 [1.04, 2.61]). In both the primary and specialized mental health care, there were no significant differences between the four groups in the number of treatment contacts once they entered into treatment. CONCLUSION: All sorts of physical symptoms, unexplained as well as explained, were associated with significant higher entry into primary care for mental problems. In specialized mental health care, this was true only for MUSonly. No differences were found in the number of treatment contacts. This warrants further research aimed at the content of the treatment contacts.

[Delirium on intensive care frequently missed: clinical impression alone is not enough]. / Delirium op de Intensive Care vaak gemist: klinische blik alleen is niet voldoende.

OBJECTIVE: To compare the sensitivity and specificity of a routine assessment (clinical impression) with a structured assessment which uses a validated assessment scale for the recognition of delirium on the intensive care unit (ICU). DESIGN: Observational study. METHOD: During their admission to the intensive care unit, 103 patients were assessed daily (with a maximum of 40 days) for the presence of delirium using the Confusion assessment method for the intensive care unit (CAM-ICU). Their physicians indicated whether or not they considered the patient delirious. These findings were compared. For all patients daily information was also collected about fixation and complications, such as self-extubation or self-removal of catheters. RESULTS: The patients were assessed for a period of 502 patient-days. CAM-ICU scores were positive (n = 108), negative (n = 235) or non-assessable because the patient was comatosed or deeply sedated (n = 159). The sensitivity of clinical detection by the physicians was 45% in comparison to the CAM-ICU. The specificity was high (97%). CONCLUSION: The diagnosis delirium is frequently missed on the ICU when only based on clinical impression. Routine assessment using a validated assessment scale such as the CAM-ICU might possibly improve this.