Assigning Clinical Significance and Symptom Severity Using the Zung Scales: Levels of Misclassification Arising from Confusion between Index and Raw Scores

Background. The Zung Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) are two norm-referenced scales commonly used to identify the presence of depression and anxiety in clinical research. Unfortunately, several researchers have mistakenly applied index score criteria to raw scores when assigning clinical significance and symptom severity ratings. This study examined the extent of this problem. Method. 102 papers published over the six-year period from 2010 to 2015 were used to establish two convenience samples of 60 usages of each Zung scale. Results. In those papers where cut-off scores were used (i.e., 45/60 for SDS and 40/60 for SAS), up to 51% of SDS and 45% of SAS papers involved the incorrect application of index score criteria to raw scores. Inconsistencies were also noted in the severity ranges and cut-off scores used. Conclusions. A large percentage of publications involving the Zung SDS and SAS scales are using incorrect criteria for the classification of clinically significant symptoms of depression and anxiety. The most common error—applying index score criteria to raw scores—produces a substantial elevation of the cut-off points for significance. Given the continuing usage of these scales, it is important that these inconsistencies be highlighted and resolved

Norms for Zung's Self-rating Anxiety Scale

BackgroundZung's Self-rating Anxiety Scale (SAS) is a norm-referenced scale which enjoys widespread use a screener for anxiety disorders. However, recent research (Dunstan DA and Scott N, Depress Res Treat 2018:9250972, 2018) has questioned whether the existing cut-off for identifying the presence of a disorder might be lower than ideal.MethodThe current study explored this issue by examining sensitivity and specificity figures against diagnoses made on the basis of the Patient Health Questionnaire (PHQ) in clinical and community samples. The community sample consisted of 210 participants recruited to be representative of the Australian adult population. The clinical sample consisted of a further 141 adults receiving treatment from a mental health professional for some form of anxiety disorder.ResultsMathematical formulas, including Youden's Index and the Receiver Operating Characteristics Curve, applied to positive PHQ diagnoses (presence of a disorder) from the clinical sample and negative PHQ diagnoses (absence of a disorder) from the community sample suggested that the ideal cut-off point lies between the current and original points recommended by Zung.ConclusionsConsideration of prevalence rates and of the potential costs of false negative and false positive diagnoses, suggests that, while the current cut-off of 36 might be appropriate in the context of clinical screening, the original raw score cut-off of 40 would be most appropriate when the SAS is used in research

Clarification of the cut-off score for Zung's self-rating depression scale

Background: Zung’s Self-rating Depression Scale (SDS) is an established norm-referenced screening measure used to identify the presence of depressive disorders in adults. Despite widespread usage, issues exist concerning the recommended cut-off score for a positive diagnosis. First, confusion arising from the conversion of raw scores to index scores had resulted in a considerably higher cut-off score than that recommended being used by many researchers. Second, research in China [Chin J Nervous Mental Dis. 12:267-268; 2009] and Australia [BMC Psychiatry. 17:329; 2017] had suggested that the current recommended cut-off is lower than ideal, at least in those countries. Method:To explore these matters further, sensitivity and specificity figures for alternative cut-off points were examined in positive clinical and negative community samples respectively. The positive clinical sample (n = 57) consisted of adults receiving treatment from a medical professional for some kind of depressive disorder, whose diagnosis was positively confirmed using the Patient Health Questionnaire (PHQ). The negative community sample (n = 172) was derived from a representative sample of adults whose absence of any depressive disorder was similarly confirmed by the PHQ. Results: Mathematical models, including Youden’s Index and the Receiver Operating Characteristics Curve, suggest that the recommended cut-off (a raw score of 40) is indeed too low. More detailed comparisons, including consideration of the likely numbers of false positives and negatives given prevalence rates, confirm that, ironically, the incorrect SDS cut-off score mistakenly applied by many researchers (a raw score of 50) would appear to provide far greater accuracy. Conclusions: Research in China [Chin J Nervous Mental Dis. 12:267-268; 2009] has resulted in an elevated SDS cut-off score of 42 being used in many Chinese studies. Research by Dunstan and Scott [BMC Psychiatry. 17:329; 2017] in an Australian context, suggested that a greater increase, to a raw score of 44 might be required. Based on this study, an even larger adjustment is required. Specifically, we recommend the use of an SDS raw score of 50 as the cut-off point for clinical significance

Treating Psychological Trauma in the Midst of COVID-19: The Role of Smartphone Apps

With the COVID-19 pandemic confronting health systems worldwide, medical practitioners are treating a myriad of physical symptoms that have, sadly, killed many thousands of people. There are signs that the public is also experiencing psychological trauma as they attempt to navigate their way through the COVID-19 restrictions impinging on many aspects of society. With unprecedented demand for health professionals' time, people who are unable to access face-to-face assistance are turning to smartphone apps to help them deal with symptoms of trauma. However, the evidence for smartphone apps to treat trauma is limited, and clinicians need to be aware of the limitations and unresolved issues involved in using mental health apps

Apps With Maps - Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores

Background: Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy.Objective: This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area.Methods: A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach.Results: Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy.Conclusions: The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps

Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design

Background: The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located.Objective: The aim of this study is to examine the effectiveness of 5 apps (Destressify, MoodMission, Smiling Mind, MindShift, and SuperBetter) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy.Methods: A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention.Results: Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021.Conclusions: If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment.International Registered Report Identifier (IRRID): PRR1-10.2196/1715

Lactobacillus rhamnosus HN001 Attenuates Allergy Development in a Pig Model

HN001 (HN001) supplementation decreased the prevalence of eczema and IgE associated eczema. However, the influence of HN001 on the incidence of wheeze, asthma, and/or other allergic manifestations has yet to be reported.This study was conducted to determine the effects of the probiotic HN001 on the development of allergic lung disease in a pig model. allergen (ASA) during a six week time frame in post-weanling pigs supplemented daily with HN001, or without supplementation. One week following final sensitization intradermal skin tests and respiratory challenges were conducted.In response to intradermal and respiratory challenges, ASA-sensitized pigs fed HN001 had less severe skin flare reactions, smaller increases in pleural pressure, and trends towards lower changes in arterial oxygen and carbon dioxide partial pressure levels compared to control pigs. The frequency of ASA-specific IFN-γ-secreting peripheral blood mononuclear cells, as well as the amount of IL-10 produced by ASA-specific cells, was of greater magnitude in probiotic-fed pigs compared to control animals. These observations suggest that differences in clinical responses to the allergen challenges may be related to probiotic-induced modulation of Th1 (IFN-γ) and regulatory (IL-10) cytokine expression.Probiotic supplementation decreased the severity of allergic skin and lung responses in allergen-sensitized pigs with a corresponding increase in IFN-γ expression. A similar correlation between certain allergic responses and increased IFN-γ expression has been reported in human clinical studies of allergy; this pig model of allergy may be indicative of potential probiotic modulation of allergic lung disease in humans

Barriers to Psychologists' Adherence to Evidence-Based Practice Guidelines for Treating Musculoskeletal Injuries Within the State Insurance Regulatory Authority Compensation Schemes

Objectives: The use of evidence-based practice (EBP) guidelines by psychologists working within the State Insurance Regulatory Authority (SIRA) compensation schemes for treating musculoskeletal injuries has been found to vary. The aim of this study was to qualitatively explore psychologists’ perceived barriers to adhering with EBP guidelines implemented by the New South Wales (NSW) SIRA. Methods: Registered psychologists (n = 20) working within the NSW SIRA compensation schemes participated in four focus groups conducted face-to-face (F2F) and online. Participants’ responses were audiotaped, transcribed verbatim and entered into NVivo 11 software. Text data were analysed to identify recurrent themes within and across groups (metropolitan, regional and rural). Results: Thematic analysis revealed three key issues: (a) a lack of trust in the validity of the recommended EBP guidelines; (b) lack of knowledge of the psychologist’s role in this context and insufficient skills to fully apply the guidelines, protocols and procedures; and (c) a poor fit between EBP guidelines, client presentations and circumstances, and the SIRA compensation schemes. Conclusion: The findings showed that both individual practitioner variables and contextual barriers influenced adherence to EBP. Practical implications for future research include generating recommendations to overcome the identified barriers using a collaborative approach between policymakers, researchers and practitioners

Can a rural community-based work-related activity program make a difference for chronic pain-disabled injured workers?

Objective: To assess the effectiveness of a clinical guidelines-informed multidisciplinary work-related activity program, and to improve the physical, psychological and occupational functioning of chronic pain-disabled injured workers. Design: An uncontrolled, repeated-measures, pilot study was conducted. Setting: The intervention was delivered in a community setting in regional New South Wales. Participants: Participants (n = 30), mean age of 41 years, had a compensable musculoskeletal injury: 60% were male, 63% had back injuries; the mean time off work was 13 months. Intervention: A cognitive-behavioural, interdisciplinary intervention was delivered using a multi-contributor provider model (a clinical psychologist and physiotherapist from separate practices, working in liaison with the participant's occupational rehabilitation provider and treating doctor). Groups of six participants attended for one half day per week for six weeks. Main outcome measures: The outcome measures included: physical functioning, pain intensity and psychological variables, which were assessed pre- and post-program; and medical certification and work participation, which was recorded pre-program and at six-month follow up. Results: Significant gains were made in pain intensity, physical and psychological functioning, and medical certification. The mean effect size of the intervention was medium to large ( d = 0.70). There was no significant change in employment status at six-month follow up. Conclusions: The results of this pilot study suggest that independent, rural or community-based practitioners, working collaboratively using an integrated treatment program, can produce positive outcomes for pain-disabled injured workers, and achieve results similar to those reported by metropolitan-based pain clinics

The Assessment and Treatment of Long-Standing Disruptive Behavior Problems in a 10-Year-Old Boy

A 10-year-old boy was referred for ongoing behavioral problems. These problems were reported as having occurred at home since preschool years and had become increasingly problematic outside of the home in latter years, resulting in frequent suspensions from school. A range of diagnoses had been made in the years prior to referral, including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, and pervasive developmental disorder - not otherwise specified (PDD-NOS). The central intervention since age 6 had been pharmacotherapy, with intermittent support at school in the form of school counseling and teachers' aids. However, the situation appeared to only be worsening, and the need for a more integrated, multimodal approach was recognized. In addition to individual therapy for the client and his mother, the intervention also included engagement of the father, collaboration with other educational and professional service providers, and the development of an integrated plan with shared objectives and strategies. The case explores limitations inherent in taking a medical model diagnostic approach to child behavioral problems and highlights the need to utilize an idiographic approach taking a range of individual psychosocial circumstances into account, rather than taking a more nomothetic treatment approach based mainly on diagnostic assessment