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The Depressing Truth about Depression Scales for People with Chronic Invisible Illness

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Abstract

Background: Depression screening instruments are commonly used in research and the clinic. Aim: This study seeks to determine whether several common depression scales might be contaminated by somatic symptoms, thus overestimating depression in people with chronic invisible illness. Method: 685 chronically ill women with postural orthostatic tachycardia syndrome, chronic fatigue syndrome/myalgic encephalomyelitis, mast cell activation syndrome, Ehlers-Danlos syndrome and/or fibromyalgia took the Beck Depression Inventory-II (BDI-II). For a broader look at major self-report scales that assess depression in adults, we also investigated seven additional instruments listed on the American Psychological Association webpage. Results: In this sample, 38.5% appeared to have major depression as measured by the BDI-II, but this number decreased to 8% when somatic symptoms were removed. Further, there was a 31.2% increase in the number of participants in the minimal depression category of the BDI-II-Mood. Finally, 75% of the adult depression scales that we assessed had at least 40% of the score related to somatic symptoms. Conclusion: Care must be taken when assessing depression in people with chronic invisible illnesses to prevent artificial over-inflation of scores based on somatic complaints.
DOI: 10.0000/JHSE.1000223 J Health Sci Educ Vol 6(1): 1-6
The Depressing Truth about Depression Scales for People with
Chronic Invisible Illness
Pederson CL1,* , Wagner BM2
1Department of Biology, Wittenberg University, Springfield, Ohio, USA
2Department of Sociology, Wittenberg University, Springfield, Ohio, USA
Introduction
Obtaining an accurate measure of depression in people
with chronic invisible illnesses like postural orthostatic
tachycardia syndrome (POTS), chronic fatigue
syndrome/myalgic encephalomyelitis (CFS/ME), Ehlers-
Danlos syndrome (EDS), mast cell activation syndrome
(MCAS), and fibromyalgia is complicated. Most current self-
report depression instruments use a combination of questions
that assess somatic complaints in addition to those describing
depressive mood. While many physically healthy individuals
have somatic symptoms accompanying depression [1], in
chronically ill individuals it is often difficult to separate
physical manifestations of their disorder from the somatic
symptoms of clinical depression [2].
These self-report depression scales, often used in
research and the clinic, could cause the over-diagnosis of
depression in this population with two possible ramifications.
First, the majority of people with these chronic invisible
illnesses are first diagnosed with depression and/or anxiety or
told that their symptoms are “all in their head” [3]. When
depression instruments weigh somatic symptoms heavily, it is
possible that the practitioner will not look past depression for
another possible diagnosis, and therefore the physical illness
may not be diagnosed. Second, for those with chronic illness
and depression, the level of depression may be over-estimated
by these instruments. In this case, people might be overly
medicated for depression or have freedoms removed (placed
on suicide watch) when their depression scores on these
instruments have been inflated by the physical symptoms of
POTS, CFS/ME, EDS, MCAS, fibromyalgia or other chronic
invisible illnesses.
Objectives
First, one self-report depression scale was assessed to
determine the potential for over-diagnosis of depression in
women with chronic invisible illnesses. Second, several well-
known and often used self-report measures of depression were
evaluated for contamination with somatic symptoms.
Hypothesis
We hypothesize that chronically ill women will be
overrepresented in the moderate and major depression
categories due to their somatic symptoms. We further
hypothesize that many self-report depression instruments
utilize multiple somatic symptoms as markers for depression.
Method
This project utilizes a mixed-methodological approach.
First, we explore the impact of somatic symptoms on one’s
likelihood to be categorized as depressed in a sample of
women with chronic illness. In the second part of this
research, we conduct a content analysis to explore the
Abstract
Background: Depression screening instruments are commonly used in research and the clinic. Aim: This study seeks
to determine whether several common depression scales might be contaminated by somatic symptoms, thus overestimating
depression in people with chronic invisible illness. Method: 685 chronically ill women with postural orthostatic tachycardia
syndrome, chronic fatigue syndrome/myalgic encephalomyelitis, mast cell activation syndrome, Ehlers-Danlos syndrome
and/or fibromyalgia took the Beck Depression Inventory-II (BDI-II). For a broader look at major self-report scales that assess
depression in adults, we also investigated seven additional instruments listed on the American Psychological Association
webpage. Results: In this sample, 38.5% appeared to have major depression as measured by the BDI-II, but this number
decreased to 8% when somatic symptoms were removed. Further, there was a 31.2% increase in the number of participants in
the minimal depression category of the BDI-II-Mood. Finally, 75% of the adult depression scales that we assessed had at least
40% of the score related to somatic symptoms. Conclusion: Care must be taken when assessing depression in people with
chronic invisible illnesses to prevent artificial over-inflation of scores based on somatic complaints.
Keywords: Chronic invisible illness; Depression; Somatic symptoms; Postural orthostatic tachycardia syndrome (POTS);
Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME); Fibromyalgia
Pederson CL, Wagner BM (2022) The Depressing Truth about Depression Scales for People with Chronic Invisible
Illness. J Health Sci Educ 6: 223.
DOI: 10.0000/JHSE.1000223 J Health Sci Educ Vol 6(1): 1-6
frequency of somatic symptoms in commonly used self-report
adult depression instruments.
Participants
Participants in this study were females who were at
least 18 years old and reported a physician diagnosis of
POTS, CFS/ME, EDS, MCAS, fibromyalgia or another
chronic invisible illness.
Procedure
All data were collected electronically via the
StandingUptoPOTS.org website. Participants became aware
of the online survey through the Standing Up to POTS®
social media accounts and online support groups. Participants
were prompted to complete the electronically signed informed
consent form before beginning the survey, which was both
voluntary and confidential. Participants completed several
demographic questions and the Beck Depression Inventory-II.
A debriefing statement was provided at the end of the survey
that included contact information for the National Suicide
Prevention Lifeline (phone) and HOPELINE (text). The study
protocol was approved by the Wittenberg University
Institutional Review Board.
Variables
The survey included demographic questions on gender,
age, years chronically ill, and physician diagnoses of chronic
invisible illnesses. Because multiple diagnoses are typical for
this population, the respondents were instructed to check “all
that apply” to the diagnosis question. Respondent’s age,
number of years with chronic illness, and total number of
diagnoses were measured as continuous variables.
Instruments
Beck Depression Inventory-II [BDI-II; 4]. This 21-
item survey has a series of titles with four possible responses
(scored 0-3). The sum of all scores gives the total score, with
a possible range from 0-63. Higher scores reflect higher levels
of depression, with minimal depression 0-13, mild depression
14-19, moderate depression 20-28, and major depression 29-
63 on the BDI-II. The BDI-II was found to be reliable when
tested for internal consistency (Cronbach’s α = 0.89).
Beck Depression Inventory-II Mood (BDI-II-Mood).
While the BDI-II is a 21-item inventory used to assess
depression, seven health indicators used in the scale measure
common physical changes experienced by those with chronic
illness [Agitation, Appetite, Concentration, Energy, Fatigue,
Irritability, and Sleep; 5] were removed to create the BDI-II-
Mood. This new scale assessed how somatic symptoms
impact the likelihood that a person with chronic invisible
illness is mislabeled with higher levels of depression. The
BDI-II-Mood was found to be reliable when tested for internal
consistency (Cronbach’s α = 0.88).
Removing the seven items reduced the total score
available for participants on the BDI-II-Mood (from 63 to 42)
and the score range for each depression category (minimal,
mild, moderate, and major). We did not readjust the score
range for each depression category used in the BDI-II because
our goal is to compare results on each instrument to better
understand if and how somatic symptoms impact one’s score
on the BDI-II. It is not our intent to suggest that the BDI-II-
Mood should replace the BDI-II as an instrument.
Analysis Plan
The data were analyzed with jamovi 1.6.23 (Sydney,
Australia) after excluding male, nonbinary, and transgender
participants to ensure only females were included in the
sample (n=685). Descriptive statistics and frequencies were
calculated for age, years ill, total number of diagnoses, and
primary and other diagnoses. Two scales were created in
jamovi for this analysis, BDI-II and the BDI-II-Mood. Using
the depression categories associated with the BDI-II, we
found the percentage of respondents within each depression
category (minimal, mild, moderate, and major as labeled by
the BDI-II) on the BDI-II scale as well as our modified BDI-
II-Mood scale.
Following this, we completed a content analysis
reviewing seven additional adult depression scales listed on
the American Psychological Association page
(https://www.apa.org/depression-guideline/assessment) to
better understand the frequency and use of somatic symptoms
in assessing depression more broadly. These scales were
assessed for composition of questions, with each question
placed into one of three symptom categories: somatic,
depressive, and other. Somatic symptoms were defined as
bodily symptoms that could be explained by a physical
chronic invisible illness like POTS, CFS/ME, EDS, MCAS or
fibromyalgia, and included questions regarding appetite,
weight change, heart palpitations/tachycardia, energy, fatigue,
slowness of movement, mental clarity, concentration,
agitation, irritability and hypochondria. Depressive symptoms
were defined as assessing depressed mood and included
questions about sadness, happiness, loneliness, enjoyment and
hopefulness. Questions that did not fall into either somatic or
depressive were placed in the other category.
Results
On average, participants were 36.9 years old, had been
ill for 12.7 years, and reported 2.5 diagnoses (Table 1). These
women had been diagnosed with a variety of chronic invisible
illnesses by a physician (Table 2), including POTS (81%),
EDS (29%), fibromyalgia (28%), CFS/ME (26%), and MCAS
(23%).
Assessing Depression in Chronic Invisible Illness Using the
BDI-II
As expected, the mean of the BDI-II was nine points
higher than the BDI-II-Mood, indicating that somatic
symptoms associated with chronic illness can potentially
increase one’s likelihood of being mislabeled as depressed
(Table 1).
Pederson CL, Wagner BM (2022) The Depressing Truth about Depression Scales for People with Chronic Invisible
Illness. J Health Sci Educ 6: 223.
DOI: 10.0000/JHSE.1000223 J Health Sci Educ Vol 6(1): 1-6
Independent Measures
Median
Mean
Mode
Age (18-76)
36
36.9
22
Years Ill (1-34)
9
12.7
3
Total Diagnoses (1-6)
2
2.5
1
BDI-II (21 Items)
26
25.0
21
BDI-II-Mood (14 Items)
15
15.7
17
Note: Removal of 7 questions for the BDI-II-Mood could drop BDI-II scores between 0 and 21 points.
Table 1: Descriptive statistics for continuous variables & self-report scales (n=685).
Diagnosis
Primary Diagnosis
N (%)
Postural orthostatic tachycardia syndrome
405 (59.1)
Ehlers-Danlos syndrome
105 (15.3)
Chronic fatigue syndrome/myalgic encephalomyelitis
41 (6.0)
Mast cell activation disorder
23 (3.4)
Vasovagal syncope/neurocardiogenic syncope
19 (2.8)
Fibromyalgia
16 (2.3)
Lupus
9 (1.3)
Sjogren’s syndrome
3 (0.4)
Lyme disease
3 (0.4)
Orthostatic hypotension
2 (0.3)
Chiari malformation
2 (0.3)
Addison’s disease
1 (0.1)
Multiple sclerosis
1 (0.1)
Mitochondrial disease
---
Crohn’s disease
---
Ulcerative colitis
---
Other
55 (8.0)
Note: Sum of diagnoses > 685 because many participants reported multiple diagnoses.
Table 2: frequency & percentages of primary & other diagnoses (n=685).
Most participants scored in the major depression
category of the BDI-II, but interestingly, most were in the
minimal depression category of the BDI-II-Mood (Table 3).
Results indicate an overrepresentation of participants in the
moderate and major depression categories as a result of their
somatic symptoms. For example, 38.5% of participants
appeared to have major depression as measured by the BDI-II.
After removing somatic symptoms, this number decreased to
8.0% on the BDI-II-Mood, a 30.5% decrease that may be
attributed to physical symptoms of their chronic illness. On
the other end of the scale, 13.9% of participants appeared to
have minimal depression on the BDI-II, but this number
increased to 45.1% in the BDI-II-Mood once somatic
symptoms were removed.
BDI-II Depression Category
BDI-II (%)
BDI-II-Mood (%)
Percent Difference
Minimal (0-13)
13.9
45.1
+31.2
Mild (14-19)
17.4
24.4
+7.0
Moderate (20-28)
30.2
22.5
-7.7
Major (29-63)
38.5
8.0
-30.5
Note. Removal of 7 questions for the BDI-II-Mood could drop BDI-II scores between 0 and 21 points.
Table 3: Comparison of percent of participants within categories of the BDI-II and BDI-II-Mood.
Pederson CL, Wagner BM (2022) The Depressing Truth about Depression Scales for People with Chronic Invisible
Illness. J Health Sci Educ 6: 223.
DOI: 10.0000/JHSE.1000223 J Health Sci Educ Vol 6(1): 1-6
Prevalence of Somatic Symptoms on Common Depression
Instruments
To better understand the impact of somatic symptoms
on depression scores more broadly, we reviewed seven
additional adult depression instruments listed on the American
Psychological Association website (Table 4). We examined
all 130 items, or indicators, used in these instruments to
measure depression. The publication year ranged from 1965
(Zung Self-Rating Depression Scale) to 2016 (Clinically
Useful Depression Outcome Scale). The number of items on
each scale varied from 9 (Patient Health Questionnaire, 2001)
to 21 (BDI-II, 1996), with a mean of 16 questions.
Instrument
Year
Total Items
Somatic
Depressive
Other
Center for Epidemiological Studies Depression Scale
1977
20
4 (20%)
15 (75%)
1 (5%)
Beck Depression Inventory II
1996
21
7 (33%)
13 (62%)
1 (5%)
Montgomery-Asberg Depression Rating Scale
1978
10
4 (40%)
6 (60%)
0
Clinically Useful Depression Outcome Scale
2016
18
8 (44%)
9 (50%)
1 (6%)
Zung Self-Rating Depression Scale
1965
20
10 (50%)
4 (20%)
6 (30%)
Hamilton Depression Rating Scale
1980
17
9 (53%)
6 (35%)
2 (12%)
Patient Health Questionnaire
2001
9
5 (55%)
4 (45%)
0
Quick Inventory of Depressive Symptomology-Self-
Report
2008
16
12 (75%)
4 (25%)
0
Note. Somatic symptoms included questions on appetite, weight change, energy, fatigue, slowness of movement, agitation, irritability, heartbeat, mental
clarity, concentration, and hypochondria that could be related to diagnosed physical illness rather than depression. Depressive symptoms were defined as
assessing depressed mood and included questions about sadness, happiness, loneliness, enjoyment and hopefulness. Questions that did not fall into either
the somatic or depressive category were placed in the other category. Organized from least to most inclusion of somatic symptoms within the instrument.
Table 4: Common depression scales used clinically and in research.
All instruments examined used somatic symptoms as a
measure of depression. Somatic symptoms were defined as
bodily symptoms that could be explained by a physical
chronic invisible illness like POTS, CFS/ME, EDS, MCAS or
fibromyalgia, and included questions regarding appetite,
weight change, heart palpitations/tachycardia, energy, fatigue,
slowness of movement, mental clarity, concentration,
agitation, irritability, and hypochondria. The Center for
Epidemiological Studies Depression Scale (1977) used only
four somatic questions (20%), the smallest proportion in this
sample. In comparison, the Quick Inventory of Depressive
Symptomology Self-Report used 12 somatic items (75%), the
largest proportion in this sample. The BDI-II used 7 items
reflecting somatic symptoms (33%). Of the 130 items
examined for this analysis, 45.4% measured somatic
symptoms.
All the depression instruments we analyzed included
items measuring symptoms related to a depressed mood. This
included questions about sadness, happiness, loneliness,
enjoyment and hopefulness. The number of depressive items
used in each scale varied across the sample. Only four of the
instruments utilized depressive items for a majority of the
questionnaire (Table 4). The Center for Epidemiological
Studies Depression Scale (1977) used the most items
measuring depressive mood, with 15 questions (75%). In
comparison, the Quick Inventory of Depressive
Symptomology Self-Report used only four depressive mood
items (25%). The BDI-II used 13 items (62%) reflecting a
depressive mood. Of the 130 items examined for this analysis,
only 47.0% reflected depressive mood.
In our sample, five scales (out of eight) included at
least one question we coded as other because it did not easily
fall into either the somatic or depressive category. For
example, the Zung Self-Rating Depression Scale (1965) had
the most other items with 6 questions (30%). Examples of
other items measured in the Zung scale include “morning is
when I feel best” and “I find it easy to make decisions.” The
BDI-II had one question we categorized as other which asked
about one’s interest in sex. The Hamilton Depression Rating
Scale (1980) similarly used sex as an item asking if the person
experienced menstrual disturbances or lack of libido. Of the
130 items examined for this analysis, 7.6% were judged to not
be directly related to either somatic symptoms or depressed
mood.
Discussion
In this study, 68.7% of participants with chronic
invisible illnesses including POTS, CFS/ME, EDS, MCAS
and fibromyalgia were diagnosed with moderate to major
depression using the BDI-II. When somatic symptoms were
removed, 38.2% of those participants scores dropped
significantly. This demonstrates that somatic symptoms,
commonly associated with POTS and other chronic illnesses,
impact scoring on the BDI-II, increasing the likelihood that
participants with these symptoms will be categorized as
having depression. This indicates that in this population,
depression is likely being overestimated using standard adult
depression scales due to the prevalence of somatic questions.
Unfortunately, when we surveyed other commonly used
depression screening instruments, the BDI-II was one of the
better scales with 33% of their questions related to somatic
symptoms (range 20-75%). Sadly, many of these tools may
misidentify people with chronic invisible illness as depressed
based primarily on their somatic symptoms.
Pederson CL, Wagner BM (2022) The Depressing Truth about Depression Scales for People with Chronic Invisible
Illness. J Health Sci Educ 6: 223.
DOI: 10.0000/JHSE.1000223 J Health Sci Educ Vol 6(1): 1-6
Somatic symptoms of depression significantly overlap
with those of several chronic invisible illnesses. Using POTS
as an example, increased heart rate (upon standing) and
palpitations are common in POTS but also occur with
depression. POTS also commonly present with fatigue, sleep
disturbance, gastrointestinal issues, and pain syndromes [6],
all of which are common somatic symptoms assessed on
many depression scales. In addition, POTS can affect mental
clarity, alertness, attention and concentration [7] and patients
often have a low body mass index [8], perhaps indicating a
decrease in appetite or issues in digesting or absorbing
nutrients that might account for changes in weight. Again,
these somatic symptoms are common both for POTS patients
and assessed on many depression scales. Finally, people in the
chronic invisible illness community are often accused of being
hypochondriacs or having psychological issues before being
properly diagnosed, especially when blood, urine, and other
testing is normal.
While people with these physical chronic illnesses can
certainly suffer from depression, we believe that many in this
community are over diagnosed with depression based on the
symptoms of their physical illness. One large study found that
77% of POTS patients were initially told by a physician that
their symptoms were likely due to a psychiatric or
psychological problem, while after a POTS diagnosis only
37% continued to have a diagnosis of depression or anxiety
[3]. It’s likely that the somatic symptoms of these chronic
invisible illnesses, including appetite, weight change, sleep
disturbances, and fatigue, etc., inflate depression scores when
screenings are conducted. In people with MCAS, depression
scores were elevated as the symptoms of their illness
increasingly affected activities of daily living [9], indicating
that these somatic symptoms may inflate depression scores.
Further, 13-63% of people with fibromyalgia are diagnosed as
depressed [10] with those having more major physical
symptoms and functional limitations showing higher
depression scores [11]. In contrast, a large study of people
with neurological disorders including stroke, amyotrophic
lateral sclerosis, migraine, and Parkinson’s disease found very
little impact of somatic symptoms on depression scores for
most individuals [12]. It is possible that the somatic symptoms
of these disorders do not match those on the depression
screening scales as closely as the illnesses that we are
discussing, although clearly these disorders have significant
somatic symptoms.
There are a wide variety of depression instruments
available that are regularly used both in research and clinical
practice. We assessed the questions for eight common
depression scales used in young and middle-aged adults and
found that 75% of the screening tools had at least 40% of their
total questions asking about somatic symptoms. These
symptoms, including gastrointestinal issues, fatigue and
musculoskeletal pain, were linked with increased depression
scores on the Patient Health Questionnaire in a large
community sample in Japan [13]. In the multiple sclerosis
community, elevating the cutoff for depression on the Patient
Health Questionnaire from 5 to 10 points accounted for bias
due to somatic symptoms [14]. While we understand that
somatic symptoms can be indicators of depression in the
general population, it is problematic when trying to assess
depression in people with these chronic invisible illnesses.
Limitations of the Study
There are many limitations to this study. We used an
online survey to assess depression using the BDI-II without
access to medical records for diagnosis of depression or the
chronic illnesses our participants reported. Our data may be
skewed toward women with more severe symptoms of POTS
and other chronic invisible illnesses who might be more likely
to join online support groups or follow Standing Up to
POTS® on social media. Our participants only took the BDI-
II, so while we assessed questions on the other seven adult
depression screening tools, we did not directly assess
participant responses on these other scales. These depression
screening tools were assessed using three loosely described
categories: somatic, depressive, and other. For a few items,
evaluators might categorize questions differently. We did not
assess pediatric or geriatric depression scales.
Conclusions
People with chronic invisible illnesses like POTS,
CFS/ME, EDS, MCAS, and fibromyalgia have numerous and
often severe somatic symptoms related to their illness that
may over-inflate their depression scores on many common
screening instruments. This leads to the possible over-
diagnosis of depression in this community, further hindering
individuals with chronic invisible illness when seeking
treatment.
Recommendations
Our study demonstrates the need for better depression
instruments for those with chronic illness. Practitioners using
self-report depression scales should be cautious when using
these instruments with chronically ill populations and when
possible choose an instrument with minimal weight given to
somatic symptoms. In addition, focusing on questions related
to mood will provide a more accurate overall measure of
depression. When developing instruments to measure
depression, researchers should consider the needs of patients
with somatic symptoms from underlying issues like chronic
invisible illness and adjust the instrument and/or its scoring to
better meet the needs of this group.
Ethical Standards
The study protocol was approved by the Wittenberg
University Institutional Review Board and has been
performed in accordance with the ethical standards described
in the 1964 Declaration of Helsinki. All participants gave
informed consent prior to their inclusion in this research
study.
Pederson CL, Wagner BM (2022) The Depressing Truth about Depression Scales for People with Chronic Invisible
Illness. J Health Sci Educ 6: 223.
DOI: 10.0000/JHSE.1000223 J Health Sci Educ Vol 6(1): 1-6
Conflict of Interest
The authors state that there is no conflict of interest.
This research did not receive any specific grant from funding
agencies in public, commercial, or not-for-profit sectors.
Sources of Support
None.
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*Corresponding author: Cathy L Pederson, Ph.D,
Department of Biology, Wittenberg University, P.O. Box 720,
Springfield, Ohio USA 45501, Tel: 937-327-6481; e-mail:
cpederson@wittenberg.edu
Received date: June 08, 2022; Accepted date: June 09,
2022; Published date: July 11, 2022
Citation: Pederson CL, Wagner BM (2022) The Depressing
Truth about Depression Scales for People with Chronic
Invisible Illness. J Health Sci Educ 6(1): 223.
Copyright: Pederson CL, Wagner BM (2022) The
Depressing Truth about Depression Scales for People with
Chronic Invisible Illness. J Health Sci Educ 6(1): 223.
... All participants completed the Beck Depression Inventory (BDI-II), which contains 21 multiple-choice questions and results in a score between 0 and 63, with higher scores indicating more depressive symptoms [5]. To control for questions asking for somatic symptoms that overlap with symptoms of POTS, we created a second "POTS-aware" scoring of the BDI-II, which eliminated 5 questions (#15 loss of energy, #16 change in sleep, #18 change in appetite, #19 concentration difficulty, #20 fatigue), for a possible total score of 0-48 points [6]. ...
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Background: Depression continues to be under-diagnosed in primary care settings. One factor that influences physicians’ likelihood of diagnosing depression is patients’ presentation style. Patients who initially present with somatic symptoms are diagnosed at a lower rate and with greater delay than patients who present with psychosocial complaints. Objectives: To identify the barriers preventing depression diagnosis in somatically presenting patients in an Eastern European primary care setting. Methods: Thematic analysis of semi-structured interviews with 16 family physicians (FPs) in Latvia. FPs were sampled using a maximum variation strategy, varying on patient load, urban/rural setting, FP gender, presence/absence of on-site mental health specialists, and FP years of practice. Results: FPs observed that a large subgroup of depression patients presented with solely somatic complaints. FPs often did not recognize depression in somatically presenting patients until several consultations had passed without resolution of the somatic complaint. When FPs had psychosocial information about the somatically presenting patient, they recognized depression more quickly. Use of depression screening questionnaires was rare. Barriers to diagnosis continued beyond recognition. Faced with equivocal symptoms that undermined clinical certainty, FPs postponed investigating their clinical suspicion that the patient had depression and pursued physical examinations that delayed depression diagnosis. FPs also used negative physical examination results to convince reluctant patients of a depression diagnosis. Conclusion: Delayed recognition, the need to rule out physical illness, and the use of negative physical examination results to discuss depression with patients all slowed the path to depression diagnosis for somatically presenting patients in Latvian primary care.
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Background There is concern that the Patient Health Questionnaire‐9 (PHQ‐9) depression scale may be impacted by the presence of somatic symptoms (differential item functioning (DIF)) in patients with neurological conditions. We evaluated the PHQ‐9 for the presence and impact of DIF in large clinical samples of neurological patients. Methods We conducted a cross‐sectional study of patients seen at the Cleveland Clinic Cerebrovascular, Headache, Movement Disorder, and Neuromuscular clinics who completed the PHQ‐9 and patient‐reported disease severity measures as part of standard care between 7/29/2008‐2/21/2013. We evaluated PHQ‐9 items for DIF with respect to disease‐specific severity for each condition. Salient DIF impact was characterized as a difference between DIF‐adjusted and unadjusted PHQ‐9 scores. Results Included in the study were 2,112 patients with stroke, 8,221 with migraine, 440 with amyotrophic lateral sclerosis (ALS), and 5,022 with Parkinson’s disease (PD). Several PHQ‐9 items demonstrated DIF with respect to disease‐specific severity, although salient DIF was present in very few patients (stroke (n=0); migraine (n=1); ALS (n=13); PD (n=1)). Conclusions PHQ‐9 items function consistently across disease severity, with salient levels of DIF impact found only for a very small proportion of people. These results suggest that the PHQ‐9 provides a consistent measure of depression severity among people with neurological conditions associated with somatic symptoms that overlap with depression.
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Lin J, Zhao H, Ma L, Jiao F. Body mass index is decreased in children and adolescents with postural tachycardia syndrome. Turk J Pediatr 2019; 61: 52-58. Our intent was to explore the predictive value of body mass index (BMI) in differentiating between vasovagal syncope (VVS) and postural tachycardia syndrome (POTS) in children and adolescents. A total of 111 children and adolescents with POTS and 154 children and adolescents with VVS were included in our study. The control group included 82 healthy children and adolescents. Height and weight were measured in all participants. The headup tilt test was performed in participants in all groups (POTS, VVS, and control). BMI was significantly lower in children and adolescents with POTS (18.3±3.4) than in children and adolescents with VVS (20.3±4.2) and the control group (20.5±2.9). The receiver operating characteristic curve was performed to determine the predictive value of BMI differentiation between POTS and VVS and showed that a BMI of 19.30 was the cutoff value for the probability of distinction. However, the results (BMI of 19.30) produced unsatisfactory sensitivity (57.1%) and specificity (28.8%) rates of correctly discriminating between patients with POTS and patients with VVS. Children and adolescents with POTS have a lower BMI compared with healthy peers or children and adolescents with VVS.
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Background: People with multiple sclerosis (MS) are at increased risk for depression and anxiety. The symptoms of MS are often similar to the somatic or physical symptoms of depression and anxiety (fatigue, trouble concentrating). This study examined whether MS symptoms and effects biased the assessment of somatic symptoms of anxiety and depression. Methods: People with MS (n = 513) completed a survey about MS symptoms, treatments, and distress. The Patient Health Questionnaire-9 assessed depression, and the patient-report version of the Primary Care Evaluation of Mental Disorders assessed anxiety. Participants were grouped into low versus high MS symptoms based on self-reported symptoms and as high versus low disability by the Expanded Disability Status Scale (EDSS). Groups were compared using differential item functioning analysis. Results: No bias was found on somatic symptoms of depression comparing high versus low MS symptom groups (P > .15) or comparing groups based on EDSS scores (P > .29). Two anxiety symptoms (fatigue and muscle tension) showed bias comparing high versus low MS symptom groups (P < .01) and comparing high versus low groups based on EDSS scores (P ≤ .01). Intraclass correlations suggested a small effect due to bias in the somatic symptoms of anxiety. Conclusions: Somatic symptoms of depression are unlikely to be biased by MS symptoms. However, the use of certain somatic symptoms to assess anxiety may be biased for those with high MS symptoms.