Nina Sauer

Depression, anxiety, and somatoform disorders: Vague or distinct categories in primary care? Results from a large cross-sectional study

OBJECTIVEnDepression, anxiety, and somatization are the most frequently observed mental disorders in primary health care. Our main objective was to draw on the often neglected general practitioners (GPs) perspective to investigate what characterizes these three common mental diagnoses with regard to creating more suitable categories in the DSM-V and ICD-11.nnnMETHODSnWe collected independent data from 1751 primary care patients (participation rate=77%) and their 32 treating GPs in Germany. Patients filled out validated patient self-report measures for depression (PHQ-9), somatic symptom severity (PHQ-15), and illness anxiety (Whiteley-7), and questions regarding coping and attribution of illness. GPs clinical diagnoses and associated features were assessed.nnnRESULTSnPatients diagnosed by their GPs with depression, anxiety, and/or somatoform disorders were significantly older, less educated, and more often female than the reference group not diagnosed with a mental disorder. They had visited the GP more often, had a longer duration of symptoms, and were more often under social or financial stress. Among the mental disorders diagnosed by the GPs, depression (OR=4.4; 95% CI=2.6 to 7.5) and comorbidity of somatoform, depressive, and anxiety disorders (OR=9.5; 95% CI=4.6 to 19.4) were associated with the largest degrees of impairment compared to the reference group. Patients diagnosed as having a somatoform/functional disorder only had mildly elevated impairment on all dimensions (OR=2.0; 95% CI=1.4 to 2.7). Similar results were found for the physicians attribution of psychosocial factors for cause and maintenance of the disease, difficult patient-doctor relationship, and self-assessed mental disorder.nnnCONCLUSIONnIn order to make the DSM-V and ICD-11 more suitable for primary care, we propose providing appropriate diagnostic categories for (1) the many mild forms of mental syndromes typically seen in primary care; and (2) the severe forms of comorbidity between somatoform, depressive, and/or anxiety disorder, e.g., with a dimensional approach.

Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial

BACKGROUNDnMultisomatoform disorder is characterised by severe and disabling bodily symptoms, and pain is one of the most common and impairing of these. Furthermore, these bodily symptoms cannot be explained by an underlying organic disorder. Patients with multisomatoform disorder are commonly found at all levels of healthcare and are typically difficult to treat for physicians as well as for mental health specialists.nnnAIMSnTo test whether brief psychodynamic interpersonal therapy (PIT) effectively improves the physical quality of life in patients who have had multisomatoform disorder for at least 2 years.nnnMETHODnWe recruited 211 patients (from six German academic outpatient centres) who met the criteria for multisomatoform disorder for a randomised, controlled, 12-week, parallelgroup trial from 1 July 2006 to 1 January 2009 (International Standard Randomised Controlled Trial Number ISRCTN23215121). We randomly assigned the patients to receive either 12 weekly sessions of PIT (n = 107) or three sessions of enhanced medical care (EMC, n = 104). The physical component summary of the Short Form Health Survey (SF-36) was the pre-specified primary outcome at a 9-month follow-up.nnnRESULTSnPsychodynamic interpersonal therapy improved patients physical quality of life at follow-up better than EMC (mean improvement in SF-36 score: PIT 5.3, EMC 2.2), with a small to medium between-group effect size (d = 0.42, 95% CI 0.15-0.69, P = 0.001). We also observed a significant improvement in somatisation but not in depression, health anxiety or healthcare utilisation.nnnCONCLUSIONSnThis trial documents the long-term efficacy of brief PIT for improving the physical quality of life in patients with multiple, difficult-to-treat, medically unexplained symptoms.

The impact of concomitant depression on quality of life and health service utilisation in patients with osteoarthritis

To assess the impact of concomitant depression on quality of life (QoL) and health service utilisation of patients with osteoarthritis (OA). Data were collected from 75 primary care practices in Germany. Totally, 1,250 patients were consecutively approached; 1,021 (81.7%) questionnaires were returned and analysed. Measures included sociodemographic data, the Arthritis Impact Measurement Scale (AIMS2-SF) and the Patient Health Questionnaire (PHQ-9) to assess depression. A PHQ-9 scorexa0≥xa015 was defined as reflecting depression. Patients with a depressive disorder achieved significantly (all Pxa0<xa00.001) higher scores in all AIMS2-SF dimensions. They had more contacts to general practitioners (Pxa0<xa00.01), orthopaedics (Pxa0<xa00.01) and to providers of Complementary Alternative Medicine offered e.g. by healers. Concomitant depression aggravates the burden of OA significantly. This results in increased health service utilisation. Appropriate treatment of depression would appear not only to increase QoL but also to lower costs by decreasing health service utilisation.

Trauma Exposure and Posttraumatic Stress Disorder in Primary Care Patients: Cross-Sectional Criterion Standard Study

OBJECTIVEnPosttraumatic stress disorder (PTSD) is one of the most common but least recognized anxiety disorders in primary care. This study aimed to describe the association of PTSD and trauma exposure with somatic symptoms, psychiatric comorbidity, functional impairment, and the actual treatment of PTSD in primary care.nnnMETHODnThis cross-sectional criterion standard study included 965 consecutive primary care patients from 15 civilian primary care clinics in the United States. The Structured Clinical Interview for DSM-IV (SCID) was used to establish diagnosis of PTSD and other anxiety disorders. Somatic symptoms, depression, and anxiety were measured with the Patient Health Questionnaire (PHQ), and functional impairment was measured with the Medical Outcomes Study Short-Form General Health Survey (SF-20). The study was conducted from November 2004 to June 2005.nnnRESULTSnPTSD was diagnosed in 83 patients (8.6%; 95% CI, 7.0%-10.5%), and trauma exposure without fulfilling DSM-IV criteria for PTSD was reported by 169 patients (17.5%; 15.2%-20.0%). With odds ratios ranging between 2.1 (95% CI, 1.2-3.6) for headache and 9.7 (3.8-24.8) for chest pain, PTSD patients had markedly elevated somatic symptom rates compared to the reference group of patients with no PTSD or trauma exposure. PTSD was significantly associated with elevated rates of psychiatric comorbidity, pain, and impaired functioning. Patients reporting trauma but no PTSD had rates of somatic symptoms, psychiatric comorbidity, and functional impairment that were intermediate between PTSD and reference group patients. Adjusting for depression substantially attenuated the association of PTSD and trauma with somatic symptoms, suggesting that depression may be an important mediator of the PTSD-somatic symptoms relationship.nnnCONCLUSIONSnThe high frequency of PTSD in primary care and its association with psychiatric comorbidity and functional impairment underscore the need to better detect and treat PTSD in primary care. Recognizing the frequent somatic presentation of PTSD and appreciating the salience of comorbid depression may be especially important in optimizing PTSD care.

Functional relaxation as complementary therapy in irritable bowel syndrome: a randomized, controlled clinical trial.

OBJECTIVESnIrritable bowel syndrome (IBS) is a frequently disabling and almost invariably distressing disease with a high overall prevalence. Numerous trials identified the importance of psychogenic and emotional etiological factors, and this is obvious in clinical practice. Although relaxation techniques are frequently recommended, there is still a lack of evidence for their efficacy in the management of IBS. This study therefore aims to determine the efficacy of functional relaxation (FR) in IBS.nnnSUBJECTSnThe subjects were 80 patients with IBS.nnnINTERVENTIONSnParticipants were randomly allocated either to FR or to enhanced medical care (EMC: treatment as usual plus two counseling interviews) as control intervention with 2 weekly sessions over the 5-week trial each. Thirty-nine (39) patients completed FR and 39 received EMC.nnnOUTCOME MEASURESnAn impairment-severity score (IS) was employed as the primary outcome parameter with assessment at baseline, after treatment, and again after 3-month follow-up.nnnRESULTSnFR was significantly superior to EMC with a standardized effect size of 0.85. The achieved effects through FR remained stable in terms of psychic and bodily impairment after 3-month follow-up.nnnCONCLUSIONSnThe results of our trial suggest a positive effect of FR training on subjective functional impairment in the IS, if provided in addition to treatment as usual (TAU). There appears to be a clinically relevant long-term benefit of FR as a nonpharmacological and complementary therapy approach in IBS.

Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care

OBJECTIVEn(i) To analyze general practitioners diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner.nnnMETHODSnCross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient.nnnRESULTSnOf the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented.nnnCONCLUSIONSnICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.

Effects of Functional Relaxation and Guided Imagery on Ige in Dust-mite Allergic Adult Asthmatics: A Randomized, Controlled Clinical Trial

Although relaxation and imagination techniques have repeatedly proven their effectiveness in asthma, nothing is known about the immunological effects of these complementary interventions. Therefore, the aim of this study is to investigate the effects of the brief relaxation technique of functional relaxation (FR) with guided imagery (GI) on serum IgE in adult patients with dust mite allergic asthma in a randomized, controlled trial. Sixty-four patients were treated over a 4-week period and assessed at baseline, after treatment and after 4 months for follow-up. Due to its significant role in the pathophysiology of allergic asthma, the serum IgE was employed as outcome measure in this investigation. Participation in FR, GI, and FR/GI led to decreases in serum IgE (IU/mL) of −54.7 ± 67.1, −49.5 ± 93.4, and −28.4 ± 93.9 compared with an increase of 27.7 ± 43.2 in CI. Our study confirmed a positive and clinically relevant effect of FR and GI on total serum IgE levels.

Pain and quality of life following palliative radiotherapy of bone metastases

Hintergrund und Ziel:Strahlentherapie mit palliativer Zielsetzung hat einen positiven Effekt auf Schmerz und Lebensqualität. In den meisten Studien kommt es jedoch durch den Ausschluss sehr kranker Patienten zu einer Positivselektion. Diese prospektive klinische Verlaufsstudie untersuchte die Auswirkungen von palliativer Strahlentherapie auf Schmerz und Lebensqualität bei Patienten mit Knochenmetastasen.Patienten und Methodik:Während eines 2-monatigen Bestrahlungsintervalls wurden 263 Patienten beobachtet. Zur Messung von Schmerz und Lebensqualität wurden die visuelle Analogskala (VAS) sowie der QLQ-C30 der EORTC verwendet. Um eine verzerrende Reduktion der Stichprobe zu vermeiden, wurden fehlende Werte durch die LOCF-Methode („last observation carried forward“) ersetzt.Ergebnisse:Die Bestrahlung führte zu einer Schmerzreduktion. In der Gesamtgruppe kam es zu keiner Erhöhung der Schmerzmedikation. Im Bereich Lebensqualität konnten jedoch keine positiven Veränderungen festgestellt werden. Es zeigten sich deutliche bestrahlungskorrelierte Nebenwirkungen.Schlussfolgerung:Palliative Strahlentherapie reduziert Schmerz bei Patienten mit Knochenmetastasen. Vor- und Nachteile der Behandlung müssen wegen Nebenwirkungen sorgfältig abgewogen werden.Background and Purpose:Palliative irradiation is used to provide pain relief and to increase quality of life. Most studies exclude patients with advanced cancer disease and, therefore, a positive selection results. This prospective clinical study investigates the effect of palliative radiotherapy on pain and quality of life of patients with painful bone metastases.Patients and Methods:263 patients with bone metastases due to advanced cancer were observed with respect to pain and quality of life during a 2-month course of radiotherapy. Missing data were substituted by the LOCF method (last observation carried forward) to prevent a biased reduction of data.Results:Radiotherapy resulted in pain relief. In the complete group, pain medication was not increased. Quality of life was not affected positively. Side effects of radiotherapy increased remarkably.Conclusion:Radiotherapy leads to pain relief. However, risks and benefits must be considered critically due to side effects.

Der Einfluss palliativer Strahlentherapie auf Schmerz und Lebensqualität bei Patienten mit Knochenmetastasen

Hintergrund und Ziel:Strahlentherapie mit palliativer Zielsetzung hat einen positiven Effekt auf Schmerz und Lebensqualität. In den meisten Studien kommt es jedoch durch den Ausschluss sehr kranker Patienten zu einer Positivselektion. Diese prospektive klinische Verlaufsstudie untersuchte die Auswirkungen von palliativer Strahlentherapie auf Schmerz und Lebensqualität bei Patienten mit Knochenmetastasen.Patienten und Methodik:Während eines 2-monatigen Bestrahlungsintervalls wurden 263 Patienten beobachtet. Zur Messung von Schmerz und Lebensqualität wurden die visuelle Analogskala (VAS) sowie der QLQ-C30 der EORTC verwendet. Um eine verzerrende Reduktion der Stichprobe zu vermeiden, wurden fehlende Werte durch die LOCF-Methode („last observation carried forward“) ersetzt.Ergebnisse:Die Bestrahlung führte zu einer Schmerzreduktion. In der Gesamtgruppe kam es zu keiner Erhöhung der Schmerzmedikation. Im Bereich Lebensqualität konnten jedoch keine positiven Veränderungen festgestellt werden. Es zeigten sich deutliche bestrahlungskorrelierte Nebenwirkungen.Schlussfolgerung:Palliative Strahlentherapie reduziert Schmerz bei Patienten mit Knochenmetastasen. Vor- und Nachteile der Behandlung müssen wegen Nebenwirkungen sorgfältig abgewogen werden.Background and Purpose:Palliative irradiation is used to provide pain relief and to increase quality of life. Most studies exclude patients with advanced cancer disease and, therefore, a positive selection results. This prospective clinical study investigates the effect of palliative radiotherapy on pain and quality of life of patients with painful bone metastases.Patients and Methods:263 patients with bone metastases due to advanced cancer were observed with respect to pain and quality of life during a 2-month course of radiotherapy. Missing data were substituted by the LOCF method (last observation carried forward) to prevent a biased reduction of data.Results:Radiotherapy resulted in pain relief. In the complete group, pain medication was not increased. Quality of life was not affected positively. Side effects of radiotherapy increased remarkably.Conclusion:Radiotherapy leads to pain relief. However, risks and benefits must be considered critically due to side effects.

Körperbeschwerden und Gesundheitsangst in der Primärmedizin Eine quantitative Studie bei 1751 Hausarztpatienten

Zusammenfassung. Patienten mit erhohter Gesundheitsangst verursachen erhebliche Kosten fur das Gesundheitssystem. Die durchgefuhrten medizinischen Untersuchungen und Behandlungen sind haufig unangemessen, denn in etwa der Halfte der Falle liegt den Krankheitsbefurchtungen keine organische Erkrankung zugrunde. Im Rahmen der kontrollierten cluster-randomisierten Studie FUNKTIONAL wurden in 29 Hausarztpraxen bei 1751 Patienten systematisch Gesundheitsangst (Whiteley-7), korperliche und psychische Symptome (PHQ-D) sowie die arztliche Einschatzung des Hausarztes erfasst. Es fand sich eine verstarkte psychische und globale Funktionsbeeintrachtigung bei Patienten mit erhohter Gesundheitsangst, die auf Patient- und Arztseite angegeben wird. Psychosoziale Faktoren werden vom Behandler haufiger als fur die Erkrankung relevant betrachtet, wenn Patienten erhohte Gesundheitsangst zeigen. Die Erkennung und Reduktion von Gesundheitsangst in der Allgemeinarztpraxis stellt sich also als relevanter Behandlungsaspekt dar, a...