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Single-item screens identified patients with elevated levels of depressive and somatization symptoms in outpatient physical therapy

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Abstract

Objective

Develop efficient and accurate screening tools to identify elevated levels of depressive or somatization symptoms, which can adversely affect functional status outcomes.

Methods

We conducted a secondary analysis of prospectively collected depressive and somatization symptoms (Symptom Checklist 90-Revised) data from 10,920 patients receiving outpatient physical therapy for a variety of neuromusculoskeletal diagnoses. Item response theory methods were used to analyze data, with particular emphasis on differential item functioning among groups of patients, and to identify potential screening items. Screening item accuracy for identifying patients with elevated symptoms was assessed with receiver-operating characteristic analyses.

Results

Seven items for depressive and 10 items for somatization symptoms represented unidimensional scales. Differential item functioning was negligible for demographic and clinical variables known to affect functional status outcomes. Items providing maximum information at the 88th percentile for depressive and 77th percentile for somatization scales accurately dichotomized patients into elevated versus not elevated symptom levels.

Conclusions

Lack of differential item functioning suggested depressive and somatization screening could be useful in routine clinical practice and allowed the development of single-item screens that accurately identified patients with elevated depressive or somatization symptoms. Item response theory-based single-item screens may facilitate evaluation and management of heterogeneous populations receiving outpatient physical therapy.

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References

  1. Dionne, C. E., Le Sage, N., Franche, R. L., Dorval, M., Bombardier, C., & Deyo, R. A. (2011). Five questions predicted long-term, severe, back-related functional limitations: Evidence from three large prospective studies. Journal of Clinical Epidemiology, 64(1), 54–66.

    Article  PubMed  Google Scholar 

  2. Pincus, T., Burton, A. K., Vogel, S., & Field, A. P. (2002). A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 27(5), E109–E120.

    Article  PubMed  Google Scholar 

  3. Deutscher, D., Horn, S. D., Dickstein, R., Hart, D. L., Smout, R. J., Gutvirtz, M., et al. (2009). Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Archives of Physical Medicine and Rehabilitation, 90, 1349–1363.

    Article  PubMed  Google Scholar 

  4. Haggman, S., Maher, C. G., & Refshauge, K. M. (2004). Screening for symptoms of depression by physical therapists managing low back pain. Physical Therapy, 84(12), 1157–1166.

    PubMed  Google Scholar 

  5. Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J. Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine (Phila Pa 1976). 2001 Apr 15;26(8):920–929.

  6. Hart, D. L., Werneke, M. W., George, S. Z., Matheson, J. W., Wang, Y. C., Cook, K. F., et al. (2009). Screening for elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient therapy. Physical Therapy, 89(8), 770–785.

    Article  PubMed  Google Scholar 

  7. Bair, M. J., Robinson, R. L., Katon, W., & Kroenke, K. (2003). Depression and pain comorbidity: A literature review. Archives of Internal Medicine, 163(20), 2433–2445.

    Article  PubMed  Google Scholar 

  8. McWilliams, L. A., Cox, B. J., & Enns, M. W. (2003). Mood and anxiety disorders associated with chronic pain: An examination in a nationally representative sample. Pain, 106(1–2), 127–133.

    Article  PubMed  Google Scholar 

  9. Hilty, D. M., Bourgeois, J. A., Chang, C. H., & Servis, M. E. (2001). Somatization disorder. Current Treatment Options in Neurology, 3(4), 305–320.

    Article  PubMed  Google Scholar 

  10. Allen, L. A., Woolfolk, R. L., Escobar, J. I., Gara, M. A., & Hamer, R. M. (2006). Cognitive-behavioral therapy for somatization disorder: A randomized controlled trial. Archives of Internal Medicine, 166(14), 1512–1518.

    Article  PubMed  Google Scholar 

  11. Janca, A., Isaac, M., & Ventouras, J. (2006). Towards better understanding and management of somatoform disorders. International Review of Psychiatry, 18(1), 5–12.

    Article  PubMed  Google Scholar 

  12. Dionne, C. E. (2005). Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings. Journal of Clinical Epidemiology, 58(7), 714–718.

    Article  PubMed  Google Scholar 

  13. Dionne, C. E., Koepsell, T. D., Von Korff, M., Deyo, R. A., Barlow, W. E., & Checkoway, H. (1997). Predicting long-term functional limitations among back pain patients in primary care settings. Journal of Clinical Epidemiology, 50(1), 31–43.

    Article  PubMed  CAS  Google Scholar 

  14. Derogatis, L. R., & Melisaratos, N. (1983). The Brief Symptom Inventory: An introductory report. Psychological Medicine, 13(3), 595–605.

    Article  PubMed  CAS  Google Scholar 

  15. Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: An outpatient psychiatric rating scale–preliminary report. Psychopharmacology Bulletin, 9(1), 13–28.

    PubMed  CAS  Google Scholar 

  16. Deutscher, D., Hart, D. L., Dickstein, R., Horn, S. D., & Gutvirtz, M. (2008). Implementing an integrated electronic outcomes and electronic health record process to create a foundation for clinical practice improvement. Physical Therapy, 88(2), 270–285.

    Article  PubMed  Google Scholar 

  17. van der Linden, W., & Hambleton, R. K. (Eds.). (1997). Handbook of modern item response theory. New York, NY: Springer.

    Google Scholar 

  18. DeSalvo, K. B., Fisher, W. P., Tran, K., Bloser, N., Merrill, W., & Peabody, J. (2006). Assessing measurement properties of two single-item general health measures. Quality of Life Research, 15(2), 191–201.

    Article  PubMed  Google Scholar 

  19. Millsap, R. E., & Everson, H. T. (1993). Methodology review: Statistical approaches for assessing measurement bias. Applied Psychological Measurement, 17, 287–334.

    Google Scholar 

  20. Lord, F. M. (1980). Applications of item response theory to practical testing problems. Hillsdale, NJ: Lawrence Erlbaum Associates.

    Google Scholar 

  21. Swinkels, I. C., Hart, D. L., Deutscher, D., van den Bosch, W. J., Dekker, J., de Bakker, D. H., et al. (2008). Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands. Cross sectional analyses of data from three clinical databases. BMC Health Services Research, 8(1), 163.

    Article  PubMed  Google Scholar 

  22. Hart, D. L., Wang, Y. C., Stratford, P. W., & Mioduski, J. E. (2008). Computerized adaptive test for patients with knee impairments produced valid and responsive measures of function. Journal of Clinical Epidemiology, 61(11), 1113–1124.

    Article  PubMed  Google Scholar 

  23. Hart, D. L., Wang, Y. C., Stratford, P. W., & Mioduski, J. E. (2008). Computerized adaptive test for patients with foot or ankle impairments produced valid and responsive measures of function. Quality of Life Research, 17(8), 1081–1091.

    Article  PubMed  Google Scholar 

  24. Hart, D. L., Werneke, M. W., Wang, Y. C., Stratford, P. W., & Mioduski, J. E. (2010). Computerized adaptive test for patients with lumbar spine impairments produced valid and responsive measures of function. Spine, 35(24), 2157–2164.

    PubMed  Google Scholar 

  25. Rossignol, M., Arsenault, B., Dionne, C. E., Poitras, S., Tousignant, M., & Truchon, M., et al. (2006). Clinic on Low-Back Pain in Interdisciplinary Practice (CLIP) Guidelines. In MPH Do (Ed.), Montreal, Canada: Agence de la sante et de services sociaux de Montreal.

  26. Derogatis, L. R., Rickels, K., & Rock, A. F. (1976). The SCL-90 and the MMPI: A step in the validation of a new self-report scale. British Journal of Psychiatry, 128, 280–289.

    Article  PubMed  CAS  Google Scholar 

  27. Hyphantis, T., Tomenson, B., Paika, V., Almyroudi, A., Pappa, C., Tsifetaki, N., et al. (2009). Somatization is associated with physical health-related quality of life independent of anxiety and depression in cancer, glaucoma and rheumatological disorders. Quality of Life Research, 18(8), 1029–1042.

    Article  PubMed  Google Scholar 

  28. Von Korff, M., Le Resche, L., & Dworkin, S. F. (1993). First onset of common pain symptoms: A prospective study of depression as a risk factor. Pain, 55(2), 251–258.

    Article  Google Scholar 

  29. Bernstein, I. H., Jaremko, M. E., & Hinkley, B. S. (1994). On the utility of the SCL-90-R with low-back pain patients. Spine (Phila Pa 1976), 19(1), 42–48.

    Article  CAS  Google Scholar 

  30. Cassisi, J. E., Sypert, G. W., Lagana, L., Friedman, E. M., & Robinson, M. E. (1993). Pain, disability, and psychological functioning in chronic low back pain subgroups: Myofascial versus herniated disc syndrome. Neurosurgery, 33(3), 379–385. (discussion 85–86).

    Article  PubMed  CAS  Google Scholar 

  31. Hambleton, R. K., Swaminathan, H., & Rogers, H. J. (1991). Fundamentals of item response theory. Newbury Park, CA: Sage.

    Google Scholar 

  32. Hays, R. D., Morales, L. S., & Reise, S. P. (2000). Item response theory and health outcomes measurement in the 21st century. Medical Care, 38(9 Suppl), II28–II42.

    PubMed  CAS  Google Scholar 

  33. Muthén, L. K., & Muthén, B. O. (2006). Mplus user’s guide (4th ed.). Los Angeles, CA: Muthén & Muthén.

    Google Scholar 

  34. Bjorner, J. B., Kosinski, M., & Ware, J. E., Jr. (2003). The feasibility of applying item response theory to measures of migraine impact: A re-analysis of three clinical studies. Quality of Life Research, 12(8), 887–902.

    Article  PubMed  Google Scholar 

  35. Fliege, H., Becker, J., Walter, O. B., Bjorner, J. B., Klapp, B. F., & Rose, M. (2005). Development of a computer-adaptive test for depression (D-CAT). Quality of Life Research, 14(10), 2277–2291.

    Article  PubMed  Google Scholar 

  36. Hu, L. T., & Bentler, P. (1999). Cutoff criteria for fit indices in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1–55.

    Article  Google Scholar 

  37. Tucker, L., & Lewis, C. (1973). A reliability coefficient for maximum likelihood factor analysis. Psychometrika, 38, 1–10.

    Article  Google Scholar 

  38. Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen & J. A. Long (Eds.), Testing structural equation models. Newbury Park, CA: Sage Publications.

    Google Scholar 

  39. Cook, K. F., Kallen, M. A., & Amtmann, D. (2009). Having a fit: Impact of number of items and distribution of data on traditional criteria for assessing IRT’s unidimensionality assumption. Quality of Life Research, 18(4), 447–460.

    Article  PubMed  Google Scholar 

  40. Samejima, F. (1969). Estimation of ability using a response pattern of graded responses. Psycometrika. Monograph 17.

  41. PARSCALE for Windows. v 4.1. Lincolnwood, IL: Scientific Software International.; 2003.

  42. Dodd, B. G., Koch, W. R., & De Ayala, R. J. (1989). Operational characteristics of adaptive testing procedures using the Graded Response Model. Applied Psychological Measurement, 13(2), 129–143.

    Article  Google Scholar 

  43. Thissen, D. (2000). Reliability and measurement precision. In H. Wainer (Ed.), Computerized adaptive testing a primer (2nd ed., pp. 159–184). Wahwah, NJ: Lawrence Erlbaum Associates.

    Google Scholar 

  44. Rose, M., Bjorner, J. B., Becker, J., Fries, J. F., & Ware, J. E. (2008). Evaluation of a preliminary physical function item bank supported the expected advantages of the Patient-Reported Outcomes Measurement Information System (PROMIS). Journal of Clinical Epidemiology, 61(1), 17–33.

    Article  PubMed  CAS  Google Scholar 

  45. Crane, P. K., Gibbons, L. E., Jolley, L., & van Belle, G. (2006). Differential item functioning analysis with ordinal logistic regression techniques. DIFdetect and difwithpar. Medical Care, 44(11 Suppl 3), S115–S123.

    Article  PubMed  Google Scholar 

  46. Deutscher, D., Hart, D. L., Crane, P. K., & Dickstein, R. (2010). Cross cultural differences in knee functional status outcomes in a polyglot society represented true disparities not biased by differential item functioning. Physical Therapy, 11(3), 288–303.

    Google Scholar 

  47. Hart, D. L., Deutscher, D., Crane, P. K., & Wang, Y. C. (2009). Differential item functioning was negligible in an adaptive test of functional status for patients with knee impairments who spoke English or Hebrew. Quality of Life Research, 18(8), 1067–1083.

    Article  PubMed  Google Scholar 

  48. Delitto, A., Erhard, R. E., & Bowling, R. W. (1995). A treatment-based classification approach to low back syndrome: Identifying and staging patients for conservative treatment. Physical Therapy, 75(6), 470–489.

    PubMed  CAS  Google Scholar 

  49. Crane, P. K., Gibbons, L. E., Ocepek-Welikson, K., Cook, K., Cella, D., Narasimhalu, K., et al. (2007). A comparison of three sets of criteria for determining the presence of differential item functioning using ordinal logistic regression. Quality of Life Research, 16 Suppl 1, 69–84.

    Article  PubMed  Google Scholar 

  50. Stata Statistical Software: Release 9.2. College Station, TX2007.

  51. Hanley, J. A., & McNeil, B. J. (1982). The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology, 143(1), 29–36.

    PubMed  CAS  Google Scholar 

  52. Choi, B. C. (1998). Slopes of a receiver operating characteristic curve and likelihood ratios for a diagnostic test. American Journal of Epidemiology, 148(11), 1127–1132.

    PubMed  CAS  Google Scholar 

  53. Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine. How to practice and teach EBM (2nd ed.). New York, NY: Churchill Livingstone.

    Google Scholar 

  54. Dujardin, B., Van den Ende, J., Van Gompel, A., Unger, J. P., & Van der Stuyft, P. (1994). Likelihood ratios: A real improvement for clinical decision making? European Journal of Epidemiology, 10(1), 29–36.

    Article  PubMed  CAS  Google Scholar 

  55. Jaeschke, R., Guyatt, G., & Sackett, D. L. (1994). Users’ guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-based medicine working group. JAMA, 271(5), 389–391.

    Article  PubMed  CAS  Google Scholar 

  56. George, S. Z., & Zeppieri, G. (2009). Physical therapy utilization of graded exposure for patients with low back pain. Journal of Orthopaedic and Sports Physical Therapy, 39(7), 496–505.

    PubMed  Google Scholar 

  57. Werneke, M. W., & Hart, D. L. (2003). Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine, 28(2), 161–166.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Consulting and Research, Focus On Therapeutic Outcomes, Inc., 551 Yopps Cove Road, White Stone, VA, 22578-2403, USA

    Dennis L. Hart

  2. Spine Rehabilitation at CentraState Medical Center, Freehold, NJ, USA

    Mark W. Werneke

  3. Department of Physical Therapy, Center for Pain Research and Behavioral Health, Brooks Center for Rehabilitation Studies, University of Florida, Gainesville, FL, USA

    Steven Z. George

  4. Director of Research & Development, Physical Therapy Service, Maccabi Healthcare Services, Tel Aviv, Israel

    Daniel Deutscher

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  1. Dennis L. Hart
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  2. Mark W. Werneke
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  3. Steven Z. George
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  4. Daniel Deutscher
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Correspondence to Dennis L. Hart.

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Hart, D.L., Werneke, M.W., George, S.Z. et al. Single-item screens identified patients with elevated levels of depressive and somatization symptoms in outpatient physical therapy. Qual Life Res 21, 257–268 (2012). https://doi.org/10.1007/s11136-011-9948-x

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