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Henrik Schou Pedersen,1,2 Kaj Sparle Christensen,1,2 Anders Prior1,2 1Research Unit for General Practice, Aarhus, Denmark; 2Department of Public Health, Aarhus University, Aarhus, DenmarkCorrespondence: Henrik Schou Pedersen, Research Unit for General Practice, Bartholins Allé 2, Aarhus, 8000, Denmark, Email henrikp@ph.au.dkObjective: Most mental disorders are diagnosed and treated in general practice. Psychometric tests may help the general practitioner diagnose and treat mental disorders like dementia, anxiety, and depression. However, little is known about the use of psychometric tests in general practice and their impact on further treatment. We aimed to assess the use of psychometric tests in Danish general practice and to estimate whether variation in use is associated with the provided treatment and death by suicide in patients.Methods: This nationwide cohort study included registry data on all psychometric tests performed in Danish general practice in 2007– 2018. We used Poisson regression models adjusted for sex, age, and calendar time to assess predictors of use. We used fully adjusted models to estimate the standardized utilization rates for all general practices.Results: A total of 2,768,893 psychometric tests were used in the study period. Considerable variations were observed among general practices. A positive association was seen between a general practitioner’s propensity to use psychometric testing and talk therapy. Patients listed with a general practitioner with low use had an increased rate of redeemed prescriptions for anxiolytics [incidence rate ratio (95% confidence interval):1.39 (1.23;1.57)]. General practitioners with high use had an increased rate of prescriptions for antidementia drugs [1.25 (1.05;1.49)] and first-time antidepressants [1.09 (1.01;1.19)]. High test use was seen for females [1.58 (1.55; 1.62)] and patients with comorbid diseases. Low use was seen for populations with high income [0.49 (0.47; 0.51)] and high educational level [0.78 (0.75; 0.81)].Conclusion: Psychometric tests were used mostly for women, individuals with a low socioeconomic status, and individuals with comorbid conditions. The use of psychometric tests depends on general practice and is associated with talk therapy, redemptions for anxiolytics, antidementia drugs, and antidepressants. No association was found between general practice rates and other treatment outcomes.Keywords: psychometric tests, registries, general practice, mental disorders, treatment variation

BACKGROUND: The assessment of psychological well-being and euthymia represents an emerging issue in clinical psychology and psychiatry. Rating scales and indices such as the 5-item version of the World Health Organization Well-Being Index (WHO-5) and the Euthymia Scale (ES) were developed but insufficient attention has been devoted to the evaluation of their cross-cultural validity. This is the first study using Clinimetric Patient-Reported Outcome Measures (CLIPROM) criteria to assess cross-cultural validity and sensitivity of five different versions of the WHO-5 and ES.METHODS: A multicenter cross-sectional study involving a total of 3762 adult participants from different European (i.e., Italy, Poland, Denmark) and non-European (i.e., China, Japan) countries was conducted. Item Response Theory models (Mokken and Rasch analyses) were applied.RESULTS: Mokken coefficients of scalability were found to range from 0.42 to 0.84. The majority of the versions of the WHO-5 fitted the Rasch model expectations. Paired t-tests revealed that the Italian and Danish WHO-5 versions were unidimensional. Person Separation Reliability indices showed that the Polish, Danish, and Japanese ES versions could reliably discriminate between subjects with different levels of euthymia.LIMITATIONS: A convenience sampling was used, thus limiting the generalizability of study findings. In addition, no measures of negative mental health were administered.CONCLUSIONS: WHO-5 can be used in international studies for cross-cultural comparisons since it covers transcultural components of subjective well-being. Findings also suggest that the ES can be used as a cross-cultural screening tool since it entailed the clinimetric property of sensitivity.

PURPOSE: The purpose of this study is to describe the prevalence of anxiety disorders in a general population and the association to socioeconomic position (SEP), which has not been described in a Danish context before.MATERIAL AND METHODS: We present data on anxiety symptoms from respondents in the rural-provincial Lolland-Falster population Health Study (LOFUS). Analyses of the questionnaire responses to the Anxiety Symptom Scale were done by descriptive statistics and logistic regression analyses adjusted for sex and age.RESULTS: 14,834 LOFUS respondents who completed the Anxiety Symptom Scale were included; According to the original algorithm 371 (2.5%) had an anxiety disorder. The adjusted odds ratios (aOR) for anxiety disorder were strongly associated to SEP. We found aOR for anxiety to be: 3.8 (confidence interval (CI 95%) 2.54 - 5.92) for respondents with no postsecondary education compared to those with 3+ years of postsecondary education; 11.9 (CI 8.89 - 16.01) for respondents temporarily out of a job compared to those working; 9.4 (CI 6.06 - 14.51) for those experiencing constant financial strain compared to those not experiencing financial strain. Relaxing the criteria for anxiety to item 10 > 1, the prevalence raised to 3.9%. The association was unchanged related to education; however, the aOR dropped to 9 and 8 respectively, for being temporally out of job, or in financial strain every month- when doing same comparisons.CONCLUSIONS: The 14-day prevalence of anxiety disorder seems low but strongly associated to SEP especially for individuals temporarily out of a job or experiencing financial strain.

OBJECTIVE: The Patient Health Questionnaire (PHQ-9) and the Major Depression Inventory (MDI) are psychometric instruments frequently used for depression diagnosis and monitoring in primary care settings. The goal of this study was to assess and compare the construct validity of the PHQ-9 and the MDI using Rasch analysis.METHODS: The PHQ-9 and the MDI were distributed in random ordering (first or last) to a waiting room sample of Danish primary care patients. Analysis of fit to the Rasch model, ordering of response categories, dimensionality-testing, test for differential item functioning, test for local dependency, and calculation of reliability indices were used to evaluate the psychometric characteristics of the instruments.RESULTS: A sample of 281 persons (18-87 years, 72 % females) responded to both instruments. Reliability was acceptable for PHQ-9 (PSI 0.80) and excellent for MDI (PSI 0.88). Both instruments demonstrated fit to the Rasch model after rescoring of all items. Dimensionality testing supports that both instruments are unidimensional. Indication of local dependency was observed for PHQ-9 item 2&6 and MDI item 1&4. No indication of differential item functioning regarding age, gender or ordering of instruments was found.CONCLUSION: The PHQ-9 and the MDI both demonstrate measurement problems. Modifying individual items and reducing the number of response categories in both instruments could potentially improve their measurement capabilities. Study findings do not provide a conclusive indication of which instrument has superior operating characteristics.

OBJECTIVE: To examine the concurrent validity of the Anxiety Symptom-scale against two well-being scales, the Cantril Ladder (CL) and World Health Organization Well-Being Index (WHO-5), to test the algorithm defining anxiety against these scales, and identify cut-off points for the Anxiety Symptom-scale sum score.SUBJECTS: 14,405 adult respondents completing all psychometric questions in the Lolland Falster Health Study.METHOD: Receiver operating characteristic analyses comparing Anxiety Symptom-scale WHO-5 and CL.RESULTS: 2.5% of respondents had an anxiety disorder (3% female and 2% male) according to the Anxiety Symptom-scale algorithm. The area under the curve (AUC) was 0.87 for CL and 0.90 for WHO-5 (using inverse scores), indicating high concordance with anxiety disorder as identified by the scale. A score solely ≥2 on item 10 is a relevant cut off to low wellbeing. Anxiety disorder covers a broad range on the scale's sum score, with 3 to 4 indicating low well-being in this population sample and a sensitivity of 0.85 - 0.99 against CL and WHO-5.CONCLUSION: The Anxiety Symptom-scale is a sensitive and valid instrument for the identification of patients in low well-being with symptoms of anxiety. A score ≥2 on the functional impact (Item 10) of all symptoms is a relevant indicator of anxiety associated with low well-being in this sample. A higher Anxiety Symptom-scale sum score is coherent with lower well-being, though without specific cut-off points. Further validation of the Anxiety Symptom-scale in a clinical setting is recommended.

BACKGROUND: We aimed to assess the psychometric properties of the ten-item Anxiety Symptom Scale (ASS) using Rasch analysis. Data from the Lolland-Falster Health Study (LOFUS) were used including ASS data for 16,137 persons aged 18-90 years.METHODS: Fit to the Rasch model, ordering of response categories, dimensionality testing, test for differential item functioning, test for local dependency of items, and calculation of reliability were used to evaluate the psychometric characteristics of the ASS.RESULTS: Ordered response categories were achieved for nine of ten items after modifying the original six-point scoring system into a five-point system. After adjustment of the sample size to 500 persons, the ASS fitted the Rasch Model (p=0.051). Dimensionality testing supported combining the ten items into a total score. No significant differential item functioning was observed for sex, age group, and educational level. Items 1 and 9 and items 4 and 5 demonstrated indication of local dependency. Combining these two item pairs improved the fit of the ASS to the Rasch model.LIMITATIONS: The total ASS was poorly targeted for the LOFUS population as the majority of persons were located at the lower end of the construct. This poor alignment could explain the low reliability (PSI 0.49). Analyzing a balanced random sample of responders with high and low ASS scores demonstrated a sufficient PSI (0.81).CONCLUSIONS: Despite problems with the measurement structure, the ASS seems to be a promising instrument for measuring anxiety. However, it may prove more reliable for use in clinical samples of respondents.

OBJECTIVES: Mental disorders have caused increasing sickness absence and related benefit claims in the OECD countries. This study investigates the association between antidepressant treatment initiation and public sick leave compensation (PLSC) in the following year in Denmark.METHODS: The study was designed as a register-based prospective cohort study. We included 39,401 adults (aged 18-65 years) with at least 12 consecutive months of full-time labour market attachment who had initiated first-time antidepressant monotherapy for depression or anxiety between 1 January 2015 and 31 December 2018. PLSC was estimated for the year following the incident prescription of various antidepressants for depression or anxiety disorders.RESULTS: The most frequently prescribed antidepressant medication was SSRIs (66.8%), with sertraline being the leading choice. Compared with sertraline, mirtazapine and mianserin were associated with the highest risks of PSLC in the year following initiation, with IRRs of 2.74 (95% CI: 2.63 to 2.86) and 5.79 (95% CI: 5.18 to 6.47), respectively. Compared with sertraline, citalopram (IRR 1.22, 95%CI 1.17-1.28), venlafaxine (IRR 1.34, 95%CI 1.23-1.45) and duloxetine (IRR 1.48, 95%CI 1.35-1.62) were all associated with increased PSLC. In contrast, paroxetine (IRR 0.85, 95% CI 0.74-0.98), fluoxetine (IRR 0.51, 95%CI 0.42-0.62) and vortioxetine (IRR 0.78, 95% CI 0.63-0.97) were all associated with a significantly lower risk of PSLC compared with sertraline.CONCLUSIONS: Antidepressant treatment initiation was associated with PLSC. The highest risk of PLSC was seen for antidepressants with sedative side effects. Some types of antidepressants were associated with a lower risk of PLSC in the year following treatment initiation.

Objective: This is the first study applying Clinimetric Patient-Reported Outcome Measures (CLIPROM) criteria to evaluate the construct validity, sensitivity, and clinical utility of the SCL-90-R in patients with Parkinson’s disease (PD). Methods: A Rasch analysis was conducted using a sample of 488 PD outpatients. Results: Testing for dimensionality revealed that less than 5% of t-tests were significant, indicating that the SCL-90-R subscales entailed the property of construct validity. As to the total score, a Person Separation Reliability Index of .96 was found. Conclusions: The SCL-90-R total score is a sensitive screening measure that can be used not only to differentiate healthy stress reactions from symptoms of psychological distress but also to detect PD patients with an increased risk for psychiatric complications. As to the subscales, the brief versions that did not include misfitting items should be used to assess the severity of specific symptoms of psychological distress affecting PD patients.

BACKGROUND: Euthymia has been described as a transdiagnostic construct characterized by the absence of mood disturbances and the presence of an integration of psychic forces, such as coping strategy and well-being. A multidimensional measure, the Euthymia Scale (ES), has been proposed to assess it. We investigated construct and concurrent validity of the ES.METHODS: Construct validity was studied via Rasch and Mokken analyses and compared with that of the 11-item Resilience Scale (RS-11) and 9-item Positive Mental Health Scale (PMH-Scale). A total of 951 participants were recruited (77.5% women; 24.86 ± 5.62 years).RESULTS: The ES, RS and PMH demonstrated similar sensitivity and construct validity. Findings indicate minor needs for adjustments only. As expected the ES demonstrated a strong negative correlation with neuroticism.LIMITATIONS: The convenience sample of subjects recruited primarily from female Italian university students and a community-based data collection limit the generalizability of the present findings. The cross-sectional design precludes the assessment of test-retest reliability, predictive and incremental validity. Only self-report measures and a Likert version of the ES were used.CONCLUSIONS: ES is the most comprehensive measure of euthymia. The RS-11 is a valid measure of a specific component of euthymia, namely subjective ability to cope with stress and empower well-being in face of life adversities. The PMH-Scale is a valid measure of overall positive mental health.

OBJECTIVES: Off-label prescriptions of antidepressants may be of special concern in older-adults. We aimed to study the potential off-label use of antidepressants among adults ≥65 years by describing the patterns, trends, and factors associated with missing and unspecified treatment indications.METHODS: We used registry data to describe indications of all antidepressant prescriptions (N = 13.8 million) redeemed by older-adults in 2006-2019. We investigated factors associated with off-label use by considering prescriptions with missing and unspecified indications of the first antidepressant prescription using a multinomial logistic regression with the 'depression' indication as a reference category and reported odds ratios (ORs) with 95% confidence intervals (CI).RESULTS: Overall, 18.1% of all antidepressant prescriptions had missing indications, and 9.9% had unspecified indications. The proportion of potential off-label use based on missing and unspecified prescriptions remained mostly consistent during 2006-2019. We identified similar associations in user characteristics whether considering missing or unspecified first prescription. ORs with 95% CI were raised in non-western ethnicity (vs. Danish, 1.12 (0.99-1.26) for missing indication and 1.28 (1.11-1.48) for unspecified indication) and female sex (vs. male, 1.05 (1.02-1.07) and 1.05 (1.02-1.07) respectively). ORs were reduced for shorter educational attainment (vs. long, 0.90 (0.87-0.94) and 0.92 (0.88-0.96)), older age (≥81 vs. 67-70 years, 0.66 (0.65-0.71) and 0.73 (0.70-0.76)) and hospital psychiatric diagnosis (per diagnosis 0.76 (0.73-0.78) and 0.88 (0.86-0.91)).CONCLUSIONS: Nearly one-third of all antidepressant prescriptions redeemed by older-adults in Denmark had either missing or unspecified treatment indications. Whether these prescriptions were actual off-label use needs to be validated. Clinicians should pay special attention to patients' characteristics linking missing and unspecified indications and maintain adequate documentation while prescribing medication.

Background Methods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral. Methods This study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups. Results Fifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78–0.88) and 0.93 (95% CI 0.89–0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs. Conclusions In this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression. Trial registration The trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845.

Background The time interval from first symptom and sign until a cancer diagnosis significantly affects the prognosis. Therefore, recognising and acting on signs of cancer, such as anaemia, is essential. Evidence is sparse on the overall risk of cancer and the risk of specific cancer types in persons with new-onset anaemia detected in an unselected general practice population. We aimed to assess the risk of cancer in persons with new-onset anaemia detected in general practice, both overall and for selected cancer types. Methods This observational population-based cohort study used individually linked electronic data from laboratory information systems and nationwide healthcare registries in Denmark. We included persons aged 40–90 years without a prior history of cancer and with new-onset anaemia (no anaemia during the previous 15 months) detected in general practice in 2014–2018. We measured the incidence proportion and standardised incidence ratios of a new cancer diagnosis (all cancers except for non-melanoma skin cancers) during 12 months follow-up. Results A total of 48,925 persons (median [interquartile interval] age, 69 [55–78] years; 55.5% men) were included in the study. In total, 7.9% (95% confidence interval (CI): 7.6 to 8.2) of men and 5.2% (CI: 4.9 to 5.5) of women were diagnosed with cancer during 12 months. Across selected anaemia types, the highest cancer incidence proportion was seen in women with ‘anaemia of inflammation’ (15.3%, CI: 13.1 to 17.5) (ferritin > 100 ng/mL and increased C-reactive protein (CRP)) and in men with ‘combined inflammatory iron deficiency anaemia’ (19.3%, CI: 14.5 to 24.1) (ferritin Conclusions Persons with new-onset anaemia detected in general practice have a high cancer risk; and markedly high for ‘combined inflammatory iron deficiency anaemia’ and ‘anaemia of inflammation’. Anaemia is a sign of cancer that calls for increased awareness and action. There is a need for research on how to improve the initial pathway for new-onset anaemia in general practice.

Background A number of patient-reported outcomes (PROs) have been developed but insufficient attention has been devoted to the assessment of their clinimetric properties. Clinimetrics, the science of clinical measurements, has been considered an emerging approach for evaluating reliability and validity of PROs. This is the first study using clinimetric principles to compare the construct and criterion validity of the Major Depression Inventory (MDI), the Beck Depression Inventory-II (BDI-II), the World Health Organization Well-Being Index (WHO-5), three of the most widely used PROs for the assessment of depression. Methods Construct validity was evaluated via Item Response Theory (IRT) models (i.e., combining Rasch and Mokken analyses). Using the ICD-10 diagnostic algorithm for any depression as the gold standard, Receiver Operating Characteristic (ROC) curves were performed to examine the criterion validity of PROs. Results One hundred healthy subjects (73% females, 32.6 ± 10.5 years) participated in the study, giving a response rate of 90.1%. When using IRT analyses, MDI and WHO-5 were found to be reliable and unidimensional, while BDI-II showed lack of unidimensionality. ROC analyses supported the diagnostic accuracy of MDI and the screening properties of WHO-5. Limitations The main limitations of the present study are that healthy subjects were assessed only via only self-reported measures and a cross-sectional design was used. Conclusions WHO-5 and MDI outperformed BDI-II in terms of construct and criterion validity. WHO-5 should be considered when screening for depression, while MDI should be used as a valid diagnostic instrument and as a unidimensional measure to assess depression severity.

Patient-reported outcome measures (PROMs) are self-rated scales and indices developed to improve the detection of the patients’ subjective experience. Given that a considerable number of PROMs are available, it is important to evaluate their validity and usefulness in a specific research or clinical setting. Published guidelines, based on psychometric criteria, do not fit in with the complexity of clinical challenges, because of their quest for homogeneity of components and inadequate attention to sensitivity. Psychometric theory has stifled the field and led to the routine use of scales widely accepted yet with a history of poor performance. Clinimetrics, the science of clinical measurements, may provide a more suitable conceptual and methodological framework. The aims of this paper are to outline the major limitations of the psychometric model and to provide criteria for clinimetric patient-reported outcome measures (CLIPROMs). The characteristics related to reliability, sensitivity, validity, and clinical utility of instruments are critically reviewed, with particular reference to the differences between clinimetric and psychometric approaches. Of note is the fact that PROMs, rating scales, and indices developed according to psychometric criteria may display relevant clinimetric properties. The present paper underpins the importance of the clini­metric methodology in choosing the appropriate PROMs. CLIPROM criteria may also guide the development of new indices and the validation of existing PROMs to be employed in clinical settings.

BackgroundMaternal depression has been linked to adverse outcomes in the offspring. Existing literature is mainly based on parental reports, which can be an unreliable source when the parent has depression.AimTo explore if maternal depression was associated with daily health complaints and low self-assessed health (SAH) in the offspring.Design and settingParticipants were 45 727 children from the Danish National Birth Cohort recruited between 1996 and 2002. At 11-year follow-up, mothers and their children were invited to complete a questionnaire. Maternal depression was categorised into: no depression, first-time treatment, continued treatment, post-treatment, and relapse.MethodBinomial regression was used to estimate the adjusted prevalence proportion ratio (aPPR) of frequent health complaints and low SAH in children of mothers with depression compared to children of mothers without depression.ResultsThe prevalence of any daily health complaint was 11.4%, daily somatic complaints 4.1%, daily mental complaints 8.9%, both daily mental and somatic complaints 1.5%, and low SAH 5.3%. Children of mothers with depression (any category) were more likely to report a daily health complaint: first-time treatment aPPR 1.35 (95% confidence interval [CI] = 0.96 to 1.85), continued treatment aPPR 1.59 (95% CI = 1.37 to 1.85), post-treatment aPPR 1.30 (95% CI = 1.20 to 1.41), and relapse aPPR 1.56 (95% CI = 1.35 to 1.79). Children of mothers with depression were also more likely to report low SAH: first-time treatment aPPR 1.58 (95% CI = 0.99 to 2.54), continued treatment aPPR 1.86 (95% CI = 1.51 to 2.28), post-treatment aPPR 1.34 (95% CI = 1.19 to 1.50), and relapse aPPR 1.56 (95% CI = 1.26 to 1.93). Girls had a higher prevalence of mental and somatic health complaints and more often reported low SAH compared to boys.ConclusionTreatment of maternal depression was associated with higher prevalence of daily health complaints and low SAH in the offspring at age 11 years. The association was strongest for children of mothers with continued depression or relapse.

Many studies have been conducted on psychological distress but the question of how to conceptualize and assess this phenomenon still remains a controversial issue. Clinimetrics, the science of clinical measurements, may pave the ground for a substantial revision of the clinical conceptualization and assessment of this construct. A Rasch analysis was performed to evaluate whether the Symptom Checklist-90-Revised (SCL-90-R) and its subscales were valid indices of underlying dimensions of psychological distress. Based on the clinimetric validation of the SCL-90-R, as well as on a critical review of the available literature, a concept analysis of psychological distress was performed. The SCL-90-R total score misfitted the Rasch model but it was found to have a Person Separation Reliability Index of 0.94. Model fit was achieved after the exclusion of six misfitting items. Paired t tests indicated that all the subscales of the SCL-90-R were unidimensional. Psychological distress was defined as a subjective, unifying, dimensional, and transdiagnostic construct consisting in a unique experience of discomfort, which may involve a sense of demoralization, the experience of feeling broken or mental pain, a sense of anguish, symptoms of somatization and attention deficit hyperactivity disorder (ADHD), feelings of anger, self-perceived lack of control, and self-criticism. Our findings also showed that the SCL-90-R could reliably differentiate healthy stress from psychological distress, and identify individuals at risk of psychiatric disorders. The total score of the 84-itemversion of the SCL-90-Rmay be used as an overall indicator of psychological distress.

BACKGROUND: Anaemia is associated with adverse outcomes, including increased morbidity and all-cause mortality. Diagnostic workup of patients with anaemia is essential to detect underlying disease, especially undiagnosed malignancy.OBJECTIVE: To describe the cancer-relevant diagnostic workup in patients with new-onset anaemia detected in general practice. An additional aim was to analyse associations between patient characteristics and the diagnostic workup.DESIGN: Observational population-based cohort study using electronic laboratory and register data.SETTING: Danish general practice.SUBJECTS: Patients aged 40-90 years with new-onset anaemia (no anaemia in the preceding 15 months) detected in general practice. Patients were identified in Danish laboratory information systems and nationwide registries in 2014-2018.MAIN OUTCOME MEASURES: We measured the proportion of patients receiving predefined diagnostic investigations, that is, cancer patient pathway, colonoscopy, gastroscopy, computerised tomography (CT) scan, faecal test for haemoglobin, and bone marrow examination within three months of the anaemia index date.RESULTS: We included 59,993 patients, and around half of the patients with 'iron deficiency anaemia', 'anaemia of inflammation', or 'combined inflammatory iron deficiency anaemia' had no cancer-relevant diagnostic investigations performed. Patients aged 60-79 years and patients with severe anaemia were more likely to have investigations performed, while patients with comorbidity were less likely to have investigations performed.CONCLUSION: Around half of the patients with anaemia subtypes that may indicate underlying cancer had no cancer-relevant diagnostic investigations performed. This may represent missed diagnostic opportunities. Future interventions are needed to improve the diagnostic workup of cancer in patients with anaemia, for example, laboratory alert systems and clinical decision support.KEY POINTSThe general practitioners are often the first to detect anaemia and its underlying disease (e.g. undiagnosed malignancy).Large-scale studies are needed on the diagnostic workup of patients with anaemia in general practice in relation to an underlying malignancy.This study shows that the majority of patients with anaemia had no cancer-relevant diagnostic investigations performed, which may cause diagnostic delay.Interventions seems needed to improve the diagnostic workup of cancer in these patients to ensure timely diagnosis.

Anaemia can be a pointer of underlying severe disease, including undiagnosed malignancy. Subsequent blood tests are essential to classify the anaemia into subtypes and to facilitate targeted diagnostic investigation to ensure timely diagnosis of underlying disease. We aimed to describe and classify anaemia based on laboratory tests from patients with new-onset anaemia detected in general practice. An additional aim was to analyse associations between patient characteristics and unclassified anaemia (not classifiable according to an algorithm). Population-based cross-sectional study. Danish general practice. A total of 62,731 patients (age: 40–90 years) with new-onset anaemia were identified in Danish laboratory information systems and nationwide registries, and data were obtained for 2014–2018. We measured the proportion of patients classified into subtypes of anaemia based on blood tests requested by general practitioners within 31 days of the anaemia index date. Of the 62,731 patients with new-onset anaemia, we identified unclassified anaemia in 78.9% (95% confidence interval (CI): 77.3–80.5) of men and 65.1% (CI: 63.4–66.9) of women. The likelihood of unclassified anaemia increased with age, increasing comorbidity and decreasing severity of anaemia. The majority of patients with new-onset anaemia could not be classified through a simple algorithm due to missing blood tests, which highlights a potential missed opportunity for diagnosis. Standardised laboratory testing of patients with anaemia is warranted to ensure adequate follow-up and early detection of underlying severe disease.KEY POINTSAnaemia can be a sign of malignancy, and anaemia classification is an important step in the diagnosis of underlying disorders.The majority of patients with anaemia could not be classified according to a simple algorithm due to missing blood tests.Some patient characteristics were associated with a high risk of unclassified anaemia: high age, high comorbidity, and severe anaemia.Standardised laboratory testing in patients with anaemia is needed to inform targeted diagnostic investigation to ensure timely diagnosis. Anaemia can be a sign of malignancy, and anaemia classification is an important step in the diagnosis of underlying disorders. The majority of patients with anaemia could not be classified according to a simple algorithm due to missing blood tests. Some patient characteristics were associated with a high risk of unclassified anaemia: high age, high comorbidity, and severe anaemia. Standardised laboratory testing in patients with anaemia is needed to inform targeted diagnostic investigation to ensure timely diagnosis.

Smoking abstinence expectancies are beliefs about negative and positive short-term psychological and physiological consequences of not smoking. The Smoking Abstinence Expectancies Questionnaire (SAEQ) is a widely used Patient-Reported Outcome Measure (PROM) to assess smoking abstinence expectancies. It has four subscales: negative mood, somatic symptoms, harmful consequences, positive consequences. Although studied from a psychometric perspective, the SAEQ needs further evaluation. Clinimetrics, and its Clinimetric Criteria for Patient-Reported Outcome Measures (CLIPROM), offers a robust method to evaluate the SAEQ. We verified construct validity and sensitivity of the Italian version of the SAEQ applying CLIPROM criteria. A total of 293 adult Italian smokers were consecutively enrolled at two smoking cessation clinics and assessed via the SAEQ. Item Response Theory models (i.e., combining Rasch and Mokken analyses) were used to test construct validity and sensitivity. The total score of the SAEQ was not found to be unidimensional but each SAEQ subscale score was. PSI (0.90) indicated that the total score of the SAEQ could reliably discriminate between respondents with different levels of the trait under assessment, whereas SAEQ subscales on negative mood and harmful consequences could reliably distinguish between different groups but not between different subjects (PSI ranging from 0.77 and 0.78). Overall, the total score of the SAEQ is a sensitive screening PROM and can be used at smoking cessation clinics to discriminate between subjects with different levels of smoking abstinence expectancies. SAEQ subscales should be used to detect severity and subjective burden of a wide range of expected effects of nicotine abstinence.

A number of rating scales evaluating symptoms of nicotine withdrawal have been developed over the years but insufficient attention has been devoted to the assessment of their clinimetric properties. Clinimetrics, the science of clinical measurements, is an innovative approach, particularly useful for assessing the validity of rating scales. This is the first study using clinimetric principles to test the construct validity of the Smoker Complaint Scale (SCS), a self-rating scale specifically developed to assess acute symptoms of nicotine withdrawal. Construct validity was evaluated via Item Response Theory (IRT) models (i.e., combining Rasch and Mokken analyses). A total of 366 subjects (mean age = 34.0, SD = 11.3 years) participated in the study. IRT analyses showed that SCS was a multidimensional measure of symptoms of nicotine withdrawal, including unidimensional subscales, particularly a four-item subscale (the SCS4), which was found to entail the clinimetric property of construct validity. IRT analyses also revealed that affective symptoms of nicotine withdrawal preceded cognitive ones. The SCS should be considered as an item bank, including a particularly valid subscale, the SCS4 that can be used as a screening or outcome measure to evaluate the severity of cognitive and affective symptoms of nicotine withdrawal. SCS4 is a sensitive clinimetric index which differentiates “ceiling symptoms” of nicotine withdrawal (e.g., “feeling slowed down”) from “floor symptoms” of nicotine withdrawal (e.g., “feeling lightheaded”) that emerge in the severe form of nicotine withdrawal.

Aims To assess the association between different stages of maternal depression and injury risk in offspring aged 0–10 years. Methods Population‐based cohort study of all live‐born children in Denmark from 1 January 1997 until 31 December 2013 (n = 1,064,387). Main outcome measure was emergency department contacts with a main diagnosis of injury coded as DS00‐DT98 (chapter XIX) according to the ICD‐10. All information was obtained from Danish national registries. Results Maternal depression was associated with higher injury hazard in the offspring throughout childhood compared to offspring of mothers with no history of depression. The strongest association was seen for the first year of life. First‐time maternal depression was most strongly associated with injury in the child, especially in the first year of life (aHR = 1.70, 95% CI: 1.48–1.96). Children of mothers with relapse depression had 1.57 higher hazard of injury in the first year of life (aHR: 1.57, 95% CI: 1.44–1.70). Children of mothers with previously treated depression (postdepression) had 1.13 higher hazard of injury in the first year of life (aHR: 1.13, 95% CI: 1.09–1.17). Continuous treatment for depression was associated with a nonsignificant higher hazard of injuries in the first year of life (aHR: 1.06, 95% CI: 0.91–1.23). Conclusions Maternal depression was associated with higher injury risk in the offspring, particularly in early childhood. The association persisted in children of mothers with relapse depression. Our results suggest that children of mothers with depression are vulnerable several years after depression onset and treatment cessation., This study adds to the field results from an entire nation on the association between maternal depression and offspring injury risk. Follow‐up is, to the best of our knowledge, one of the longest, and we show significant and interesting results.

BackgroundFamily caregivers to patients who are severely ill have high use of primary health care and psychotropic medication. However, it remains sparsely investigated whether healthcare services target the most vulnerable caregivers.AimThis study aimed to examine associations between family caregivers’ grief trajectories of persistent high-grief symptom level (high-grief trajectory) versus persistent low-grief symptom level (low-grief trajectory), as well as early contacts with GPs or psychologists and the use of psychotropic medication.Design & settingA population-based cohort study of family caregivers (n = 1735) in Denmark was undertaken.MethodThe Prolonged Grief-13 (PG-13) scale measured family caregivers’ grief symptoms at inclusion (during the patient's terminal illness), 6 months after bereavement, and 3 years after bereavement. Multinomial regression was used to analyse register-based information on GP consultations, psychologist sessions, and psychotropic medication prescriptions in the 6 months before inclusion.ResultsA total of 1447 (83.4%) family caregivers contacted their GP, and 91.6% of participants in the high-grief trajectory had GP contact. Compared with family caregivers in the low-grief trajectory, family caregivers in the high-grief trajectory had ≥4 face-to-face GP consultations (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.3 to 5.0), more GP talk therapy (OR =4.4; 95% CI = 1.9 to 10.0), and more psychotropic medication, but not significantly more psychologist sessions (OR = 1.7; 95% CI = 0.5 to 6.6).ConclusionFamily caregivers in the high-grief trajectory had more contact with their GP, but their persisting grief symptoms suggest that primary care interventions for family caregivers should be optimised. Future research is warranted in such interventions and in the referral patterns to specialised mental health care.

BackgroundMeta-analyses suggest that collaborative care (CC) improves symptoms of depression and anxiety. In CC, a care manager collaborates with a general practitioner (GP) to provide evidence-based care. Most CC research is from the US, focusing on depression. As research results may not transfer to other settings, we developed and tested a Danish CC-model (the Collabri-model) for depression, panic disorder, generalized anxiety disorder, and social anxiety disorder in general practice.MethodsFour cluster-randomized superiority trials evaluated the effects of CC. The overall aim was to explore if CC significantly improved depression and anxiety symptoms compared to treatment-as-usual at 6-months’ follow-up. The Collabri-model was founded on a multi-professional collaboration between a team of mental-health specialists (psychiatrists and care managers) and GPs. In collaboration with GPs, care managers provided treatment according to a structured plan, including regular reassessments and follow-up. Treatment modalities (cognitive behavioral therapy, psychoeducation, and medication) were offered based on stepped care algorithms. Face-to-face meetings between GPs and care managers took place regularly, and a psychiatrist provided supervision. The control group received treatment-as-usual. Primary outcomes were symptoms of depression (BDI-II) and anxiety (BAI) at 6-months’ follow-up. The incremental cost-effectiveness ratio (ICER) was estimated based on 6-months’ follow-up.ResultsDespite various attempts to improve inclusion rates, the necessary number of participants was not recruited. Seven hundred thirty-one participants were included: 325 in the depression trial and 406 in the anxiety trials. The Collabri-model was implemented, demonstrating good fidelity to core model elements. In favor of CC, we found a statistically significant difference between depression scores at 6-months’ follow-up in the depression trial. The difference was not significant at 15-months’ follow-up. The anxiety trials were pooled for data analysis due to inadequate sample sizes. At 6- and 15-months’ follow-up, there was a difference in anxiety symptoms favoring CC. These differences were not statistically significant. The ICER was 58,280 Euro per QALY.ConclusionsAt 6 months, a significant difference between groups was found in the depression trial, but not in the pooled anxiety trial. However, these results should be cautiously interpreted as there is a risk of selection bias and lacking statistical power.Trial registrationClinicalTrials.gov, ID:NCT02678624andNCT02678845. Retrospectively registered on 7 February 2016.

Mental distress is an independent risk factor for illness related impairment. Awareness of mental health (MH) allows prevention, but early detection is not routinely performed in primary care. This cohort study incorporated MH assessment in a health promoting programme. We described the level of poor MH among health check participants, explored the potential for early intervention, and the potential for reducing social inequality in MH. The study was based on 9767 randomly selected citizens aged 30–49 years invited to a health check in Denmark in 2012–14. A total of 4871 (50%) were included; 49% were men. Poor MH was defined as a mental component summary score of ≤ 35.76 in the SF-12 Health Survey. Data was obtained from national health registers and health check. Participants with poor MH (9%) were more socioeconomic disadvantaged and had poorer health than those with better MH. Two thirds of men (64%) and half of women (50%) with poor MH had not received MH care one year before the health check. Among those with (presumably) unrecognized MH problems, the proportion of participants with disadvantaged socioeconomic characteristics was high (43–55%). Four out of five of those with apparently unacknowledged poor MH had seen their GP only once or not at all during the one year before the health check. In conclusion, MH assessment in health check may help identify yet undiscovered MH problems., Highlights • Nine % of health check participants were identified with poor mental health (MH). • Poor MH was associated with lower socioeconomic status and worse health. • Only 45% of persons with poor MH had received MH care. • High proportion of low socioeconomic status among those who had not received MH care • MH assessment in health checks may help identify yet undiscovered MH problems.

Marie Germund Nielsen,1 Eva Ørnbøl,2 Per Bech,3 Mogens Vestergaard,1,4 Kaj Sparle Christensen1 1Research Unit for General Practice, Department of Public Health, Aarhus University, 2Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, 3Psychiatric Research Unit, Psychiatric Centre North Zealand, University Hospital of Copenhagen, Hillerød, 4Section forGeneral Medical Practice, Department of Public Health, AarhusUniversity, Aarhus, Denmark Background: The Major Depression Inventory (MDI) is widely used in Danish general practice as a screening tool to assess depression in symptomatic patients. Nevertheless, no validation studies of the MDI have been performed. The aim of this study was to validate the web-based version of the MDI against a fully structured telephone interview in a population selected on clinical suspicion of depression (ie, presence of two or three core symptoms of depression) in general practice.Materials and methods: General practitioners (GPs) invited consecutive persons suspected of depression to complete the web-based MDI in a primary care setting. The validation was based on the Munich-Composite International Diagnostic Interview (M-CIDI) by phone. GPs in the 22 practices in our study included 132 persons suspected of depression. Depression was rated as yes/no according to the MDI and M-CIDI. Sensitivity, specificity, and positive predictive value of the International Classification of Diseases, Tenth Revision (ICD-10) algorithms of the MDI were examined.Results: According to the M-CIDI interview, 87.9% of the included population was depressed and 64.4% was severely depressed. According to the MDI scale, 59.1% of the population was depressed and 31.8% was severely depressed. The sensitivity of the MDI for depression was 62.1% (95% confidence interval [95% CI]: 52.6–70.9) and the specificity was 62.5% (95% CI: 35.4–84.8). The sensitivity for severe depression was 42.2% (95% CI: 30.6–52.4) and the specificity was 85.1% (95% CI: 71.7–93.8). The receiver operating curve showed an area under the curve of 0.66 (95% CI: 0.52–0.81) for any depression and of 0.72 (95% CI: 0.63–0.81) for severe depression.Conclusion: The MDI is a conservative instrument for diagnosing ICD-10 depression in a clinical setting compared to the M-CIDI interview. Only a few false-positive diagnoses were identified when the MDI was used on clinical suspicion of depression. Keywords: Major Depression Inventory, depression, criterion validity, M-CIDI interview, diagnosing

BackgroundDepression is a common mental illness worldwide. The offspring of a mother with depression has higher risk of developing mental and physical illness.AimThis study aimed to investigate the association between the timing of maternal depression and the use of primary health care for the offspring.Design and settingA population-based birth cohort study in Danish primary care using Danish national registers.MethodAll Danish children born between 1 January 2000 and 31 December 2013 (n = 869 140 children) were included in the study. The primary outcome was number and type of annual contacts with the GP. The secondary outcome was specific services used by the GP to assess inflammatory and infectious disease in the children. Exposure was maternal depression of four categories: non-depressed, recent, previous, and past depression. The association was expressed as adjusted incidence rate ratios (IRR) with 95% confidence intervals (CI).ResultsMaternal depression was associated with a higher use of primary health care for all three categories of depression. The strongest association was found for children of a mother with recent depression; they had 16% more contacts than children of a non-depressed mother (adjusted IRR = 1.16, 95% CI = 1.15 to 1.17), and 19–24% more positive infectious-related tests were found in this group.ConclusionExposure to maternal depression was associated with a significantly higher use of primary health care for the offspring for all exposure categories. These findings reveal that healthcare use is higher for the offspring exposed to maternal depression, even several years after expected remission. The higher ratio of positive tests indicates that exposed children are ill with infectious disease more often.

Background: Depression constitutes a significant part of the global burden of diseases. General practice plays a central role in diagnosing and monitoring depression. A telemedicine solution comprising a web-based psychometric tool may reduce number of visits to general practice and increase patient empowerment. However, the current use of telemedicine solutions in the field of general practice is limited. This study aims to explore barriers and facilitators to using a web-based version of the Major Depression Inventory (eMDI) for psychometric testing of potentially depressive patients in general practice. Methods: Semi-structured individual interviews were conducted with nine general practitioners (GPs) from eight general practices in the Central Denmark Region. All interviewees had previous experience in using the eMDI in general practice. Determinants for using the eMDI were identified in relation to the GPs' capability, opportunity and motivation to change clinical behaviour (the COM-B system). Results: Our results indicate that the main barriers for using the eMDI are related to limitations in the GPs' opportunity in regards to having the time it takes to introduce change. Further, the use of the eMDI seems to be hampered by the time-consuming login process. Facilitating factors included behavioural aspects of capability, opportunity and motivation. The implementation of the eMDI was facilitated by the interviewees' previous familiarity with the paper-based version of the tool. Continued use of the eMDI was facilitated by a time-saving documentation process and motivational factors associated with clinical core values. These factors included perceptions of improved consultation quality and services for patients, improved possibilities for GPs to prioritise their patients and improved possibilities for disease monitoring. Furthermore, the flexible nature of the eMDI allowed the GPs to use the paper-based MDI for patients whom the eMDI was not considered appropriate. Conclusions: Implementation of a telemedicine intervention in general practice can be facilitated by resemblance between the intervention and already existing tools as well as the perception among GPs that the intervention is time-saving and improves quality of care for the patients.