Health Care for Persistent Somatic Symptoms Across Europe: A Qualitative Evaluation of the EURONET-SOMA Expert Discussion

Background: Persistent somatic symptoms (PSS), referred to as somatoform disorders and lately somatic symptom disorders, are frequent but often remain under-recognized and under-treated. Although European guidelines overlap, presumably, there is large diversity in their practical use and in the actual health care situation. The aim of this qualitative evaluation was to compare health care for PSS across 9 European countries, to illustrate commonalities and differences, and to discuss challenges for a pan-European research agenda.Methods: A case vignette fulfilling ICD-10 criteria of undifferentiated somatization disorder was presented to 24 experts from 9 European countries, who completed a semi-structured assessment regarding the routine management including diagnostic procedures, treatment recommendations, and country-specific health care aspects. A qualitative evaluation was conducted using the video-transcripts of the presentations. Results were validated by additional expert interviews.Results: Across all countries, primary care physicians serve as the gate keeper for further diagnostic and treatment procedures. Apart from this commonality, there is a large variability in health care routines. Experts concluded that individuals with PSS appear to be a non-identified patient group within many European health care systems. To overcome the gap between evidence-based guidelines and clinical reality needs, three key challenges were identified: (1) Defining a clinically useful, acceptable, and non-stigmatizing diagnostic term, (2) implementing guideline recommendations into routine care, (3) developing effective dissemination strategies.Conclusions: The results advocate for more research on the actual European health care situation. A systematic European research agenda with unified goals and interdisciplinary collaboration that integrates all stakeholders could answer this challenge

Response to Commentary: The Framework for Systematic Reviews on Psychological Risk Factors for Persistent Somatic Symptoms and Related Syndromes and Disorders (PSY-PSS)

Persistent somatic symptoms (PSS) are common in all fields of medicine. Current classification systems for mental disorders in this field, i.e. Somatic Symptom Disorder (SSD; DSM-5) or Bodily Distress Disorder (BDD; ICD-11), now stress the relevance of psychological features associated with the physical complaints. It is well known that psychological criteria are among the relevant risk factors for the development and/or worsening of persistent physical symptoms, however, the selected diagnostic criteria remain subject to debate. Numerous psychological concepts have been studied and discussed in the scientific field. However, empirical evidence remains scattered, individual factors have not been reviewed systematically, and longitudinal studies to allow for causal inference are scarce. In our framework for systematic reviews on psychological risk factors for persistent somatic symptoms and related syndromes and disorders (PSYPSS) (1), we summarized current knowledge regarding psychological variables relevant to the development and maintenance of persistent somatic symptoms (PSS). The framework provides two lists, one of them with 83 relevant symptoms, syndromes and disorders (list 1) and the other with 120 psychological factors, categorized into 42 subcategories and 7 main categories (list 2). Further, we invited other researchers working in the field of PSS to use and also improve our lists by adding terms and constructs which we might have missed in our initial search. Following up on our invitation, Berens and colleagues (2) rightly pointed out that so far, our list of psychological variables did not contain any factors related to personality functioning and mentalizing, although there is scientific evidence for these concepts from the field of PSS, which the authors convincingly explain in their commentary. By adding these important psychodynamic concepts, the authors helped to improve the PSY-PSS framework

Physicians’ beliefs about placebo and nocebo effects in antidepressants – an online survey among German practitioners

<div><p>Background</p><p>While substantial placebo and nocebo effects have been documented in antidepressant clinical trials, physicians’ awareness of the nonspecific effects in routine antidepressant treatment remains unclear. The study investigated physicians’ beliefs and explanatory models regarding the desired effects and undesired side effects of antidepressants, with specific emphasis on nonspecific effects accounted for by placebo and nocebo mechanisms.</p><p>Methods</p><p>An online survey was conducted among 87 physicians (40.2% psychiatrists, 25.3% neurologists, 24.1% general practitioners, 12.6% internists, 21.8% other). The survey assessed the physician’s beliefs in antidepressant effectiveness, as well as 6 explanatory models regarding antidepressant effectiveness and 8 explanatory models for the occurrence of side effects.</p><p>Results</p><p>Most physicians (89.7%) believed in the effectiveness of antidepressants while acknowledging a considerable role of the placebo effect by attributing around 40% of the total effects to nonspecific factors. For both antidepressant effectiveness and the occurrence of side effects, pharmacological effects were rated as most important (93.1% and 80.5% agreement), but physicians also attributed a substantial role to the patients’ expectations (63.2% and 58.6%) and experiences (60.9% and 56.3%). Concerning the physician’s own role in promoting nonspecific effects in antidepressant effectiveness, highest endorsements were found for the quality of the physician-patient-relationship (58.6%) and own expectations (41.4%). When asked about side effects, fewer participants agreed that informing the patient about known side effects (25.2%) or the physicians’ expectations themselves (17.2%) could induce side effects.</p><p>Conclusion</p><p>Physicians, when prescribing antidepressants, are generally open towards nonspecific treatment mechanisms. However, they consider their own influence as less important than the patient’s side, especially when it comes to the explanation of unwanted side effects. Awareness of the possible beneficial as well as malicious role of nonspecific mechanisms should be fostered as the first step towards optimizing antidepressant treatment by promoting placebo while avoiding nocebo effects.</p></div

Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory

<div><p>Objective</p><p>The Generalized Anxiety Disorder scale (GAD-7) is one of the most frequently used diagnostic self-report scales for screening, diagnosis and severity assessment of anxiety disorder. Its psychometric properties from the view of the Item Response Theory paradigm have rarely been investigated. We aimed to close this gap by analyzing the GAD-7 within a large sample of primary care patients with respect to its psychometric properties and its implications for scoring using Item Response Theory.</p><p>Methods</p><p>Robust, nonparametric statistics were used to check unidimensionality of the GAD-7. A graded response model was fitted using a Bayesian approach. The model fit was evaluated using posterior predictive p-values, item information functions were derived and optimal predictions of anxiety were calculated.</p><p>Results</p><p>The sample included N = 3404 primary care patients (60% female; mean age, 52,2; standard deviation 19.2) The analysis indicated no deviations of the GAD-7 scale from unidimensionality and a decent fit of a graded response model. The commonly suggested ultra-brief measure consisting of the first two items, the GAD-2, was supported by item information analysis. The first four items discriminated better than the last three items with respect to latent anxiety.</p><p>Conclusion</p><p>The information provided by the first four items should be weighted more heavily. Moreover, estimates corresponding to low to moderate levels of anxiety show greater variability. The psychometric validity of the GAD-2 was supported by our analysis.</p></div

Posterior predictive p-values for the pairwise item correlations of the GAD-7.

<p>Posterior predictive p-values for the pairwise item correlations of the GAD-7.</p

Physicians’ agreement to different explanatory models for antidepressant effectiveness.

<p>Depicted is the percentage of participants who agreed, disagreed or were undecided whether they agreed to the suggested mechanisms of effectiveness for antidepressants.</p

Sociodemographic characteristics and key variables of the patient health questionnaire.

<p>Sociodemographic characteristics and key variables of the patient health questionnaire.</p

Plots of the item information functions.

<p>Plots of the item information functions.</p

Physicians’ agreement to different explanatory models for the occurrence of side effects from antidepressants.

<p>Depicted is the percentage of participants that agreed, disagreed or were undecided whether to endorse the suggested reasons for the occurrence of side effects in antidepressants.</p