Guidance DDIs

International Center for Multimorbidity and Complexity

Publications providing Guidance

Selected papers that are either written by current or former members or by collaborators of the ICMC. Furthermore, we also begin to list papers that we feel might interest you and help you in everyday clinical practice. If you have a suggestion for a paper, feel free to contact one of our staff members or info@multimorbidity.org.

Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review

Authors: Milos Tatalovic, Roger Lehmann, Marcus Cheetham, Albina Nowak, Edouard Battegay

Self-developed Guidance

ICMC presents everyday operational guidance for Disease-Disease Interactions. Please feel free to download and distribute.
If you have a suggestion or would like to request guidance for a specific issue, feel free to contact info@multimorbidity.org.

Background Information: Screening for Sleep Apnea in Patients with Mental Disease or Stroke

Author(s): Edouard Battegay Published on: Sep 06, 2024

This content was generated and slightly amended by ICMC Staff Member Edouard Battegay on September 5th 2024 using ChatGPT4o with the Consensus GPT upon question by a Medical Colleague. Please let us know about potential further contents or errors or whatever: info@multimorbidity.org

Introduction

Sleep apnea encompasses both obstructive sleep apnea syndrome (OSA) and central sleep apnea syndrome (CSA). While OSA is characterized by repeated obstructions of the upper airway, central sleep apnea results from a disruption in respiratory control by the central nervous system. Both forms of sleep apnea are prevalent among patients with psychiatric disorders and stroke patients, significantly impacting health outcomes. This report reviews the available evidence and guidelines to assess whether universal screening for obstructive and central sleep apnea should be recommended for these patient populations.


Evidence from Studies on Patients with Psychiatric Disorders

1. High Prevalence of OSA and CSA in Psychiatric Disorders

Studies show a significant prevalence of OSA in patients with psychiatric disorders, particularly affective disorders such as depression and bipolar disorder. About 62% of psychiatric patients present with OSA, indicating a high risk for untreated sleep apnea [(Wichniak et al., 2023)]. Central sleep apnea is more common in patients with heart failure or neurological conditions, but psychiatric patients, especially those on medications affecting the respiratory center, may also be affected [(Vanek et al., 2022)].

2. Guideline Recommendations for Psychiatric Patients

International guidelines such as those from the American Academy of Sleep Medicine (AASM) recommend that at-risk patients for sleep apnea, including those with psychiatric disorders, be screened for both OSA and CSA. Polysomnography is recommended as the standard diagnostic method, particularly in suspected CSA cases, as home tests may not reliably detect central apneas [(Kapur et al., 2017)]. Patients with psychiatric disorders who experience insomnia, breathing pauses, or excessive daytime sleepiness should be screened for both forms of sleep apnea, especially if they are taking medications that may impair respiration.

3. Conclusion for Psychiatric Patients

Given the high prevalence of OSA and the potential risk for CSA in psychiatric patients, routine screening for both forms of sleep apnea should be considered. Guidelines should aim to standardize these tests across psychiatric clinics.


Evidence from Studies on Stroke Patients

1. OSA and CSA in Stroke Patients

About 60-80% of stroke patients suffer from OSA, which can delay neurological recovery and increase mortality. Central sleep apnea is also prevalent in stroke patients, particularly when brain damage affects respiratory centers [(Camilo et al., 2014)]. CSA is often associated with heart failure but can also occur post-stroke due to damage to the brainstem, which disrupts respiratory regulation. Early diagnosis and treatment of both forms of sleep apnea can improve functional outcomes and survival rates in stroke patients [(Rola et al., 2007)].

2. Guidelines for Stroke Patients

The American Heart Association/American Stroke Association (AHA/ASA) recommends screening for sleep-related breathing disorders (OSA and CSA) in stroke patients, as they are modifiable risk factors for worse neurological outcomes and increased mortality [(Navalkele et al., 2016)]. The Canadian Stroke Prevention Guidelines advocate for the integration of OSA and CSA screening into routine stroke care. This should be done via polysomnography or validated screening tools to detect both OSA and CSA [(King & Cuellar, 2016)].

3. Conclusion for Stroke Patients

Since OSA and CSA are prevalent in stroke patients and lead to poorer recovery and higher mortality if left untreated, all stroke patients should be routinely screened for both forms of sleep apnea.


Recommendations from International and National Guidelines

The American Academy of Sleep Medicine (AASM) recommends thorough screening of at-risk patients with psychiatric disorders or stroke for both OSA and CSA. Polysomnography is recommended for diagnosing CSA as it is the most comprehensive method to detect both obstructive and central apneas [(Kapur et al., 2017)]. The United States Preventive Services Task Force (USPSTF) emphasizes that there is insufficient evidence to recommend universal screening for OSA in asymptomatic adults, but recommends targeted testing for high-risk groups such as stroke patients and patients with severe psychiatric disorders [(Shafazand, 2017)].


Conclusion

Universal screening for OSA and CSA should be recommended for patients with psychiatric disorders and those who have had a stroke. Both forms of sleep apnea are prevalent in these groups and significantly impact health outcomes. International and national guidelines support targeted screening in high-risk patients to ensure early diagnosis and treatment.






Background Information: Sleep Apnea in Patients with PTSD: Prevalence and Guidance

Author(s): Edouard Battegay Published on: Sep 19, 2024

This content was generated and slightly amended by ICMC Staff Member Edouard Battegay on September 5th 2024 using ChatGPT4o with the Consensus GPT upon question by a Medical Colleague. Please let us know about potential further contents or errors or whatever: info@multimorbidity.org

Introduction: 

Sleep apnea, especially obstructive sleep apnea (OSA), is highly prevalent among patients with post-traumatic stress disorder (PTSD). Research indicates that sleep apnea, both central and obstructive types, is associated with exacerbation of PTSD symptoms and a potential barrier to effective treatment. The link between sleep apnea and PTSD is a growing concern, and the management of both conditions is critical to improving health outcomes.

Prevalence of Sleep Apnea in PTSD Patients:

  • A meta-analysis reported that up to 75.7% of PTSD patients may have OSA with an apnea-hypopnea index (AHI) ≥ 5. Veterans with PTSD are particularly prone to OSA, which negatively affects adherence to continuous positive airway pressure (CPAP) therapy (Ye Zhang et al., 2017).
  • Studies suggest that 60% of veterans with PTSD suffer from sleep apnea, although the reasons for this prevalence remain unclear (Brooker et al., 2023).
  • PTSD patients often report more severe symptoms when sleep apnea is present. A study of Dutch veterans found that PTSD severity correlated with the presence of OSA, potentially worsening PTSD symptoms (van Liempt et al., 2011).


Health Impacts of Sleep Apnea on PTSD Patients:

  • Untreated OSA can worsen the sleep disturbances in PTSD patients, such as nightmares and insomnia, reducing the effectiveness of trauma-focused therapies (Tamanna et al., 2014).
  • Studies also highlight that PTSD patients with OSA may have more significant daytime sleepiness, depression, and cognitive impairments, negatively impacting their overall quality of life and increasing the risk of suicidal ideation (Gupta & Jarosz, 2018).


Guidelines for Diagnosis and Management:

  1. Screening:

    • PTSD patients should be routinely screened for sleep apnea, especially if they report sleep-related symptoms such as excessive daytime sleepiness, snoring, or frequent awakenings.
    • Screening tools such as the Epworth Sleepiness Scale (ESS) or the Berlin Questionnaire can identify patients at high risk for sleep apnea (Schulz, 2019).
  2. Polysomnography (PSG):

    • A sleep study (polysomnography) should be conducted for those at high risk. This can help confirm the diagnosis of OSA and determine the severity (AHI score), which is essential for tailoring the treatment plan (Tamanna et al., 2014).
  3. Treatment:

    • CPAP Therapy: Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA. Studies have shown that CPAP reduces nightmares, improves sleep quality, and mitigates PTSD symptoms. Adherence to CPAP is critical, although PTSD patients may struggle with consistent use (Ye Zhang et al., 2017).
    • Behavioral Interventions:Weight management and sleep hygiene practices are crucial, as obesity increases the risk of OSA. Behavioral interventions to improve adherence to CPAP can also enhance treatment outcomes (Yeghiazarians et al., 2021).
  4. Follow-up and Adjustments:

    • Patients should be regularly monitored for adherence to CPAP and improvements in PTSD and sleep apnea symptoms. Sleep testing should be repeated to ensure that the treatment is effective (Schulz, 2019).


Conclusion:
Sleep apnea is highly prevalent in patients with PTSD, especially among veterans. Early screening, effective treatment with CPAP, and adherence monitoring are key to managing both OSA and PTSD symptoms. Comprehensive treatment approaches targeting both conditions can significantly improve quality of life for these patients.

Background Information: Sleep Apnea and Arterial Hypertension in Patients Without Metabolic Syndrome or Overweight

Author(s): Edouard Battegay Published on: Sep 19, 2024

This content was generated and slightly amended by ICMC Staff Member Edouard Battegay on September 5th 2024 using ChatGPT4o with the Consensus GPT upon question by a Medical Colleague. Please let us know about potential further contents or errors or whatever: info@multimorbidity.org

  1. Prevalence and Mechanism:

    • Sleep apnea, particularly obstructive sleep apnea (OSA), is linked with hypertension, even in individuals of normal weight without metabolic syndrome. This relationship is believed to be due to intermittent hypoxia, oxidative stress, and activation of the sympathetic nervous system, which increases blood pressure independent of obesity (Kono et al., 2007).
    • The association between OSA and arterial hypertension is recognized in patients without metabolic syndrome, with OSA contributing to sustained elevations in blood pressure even without metabolic risk factors (Prejbisz et al., 2014).
  2. Obstructive Sleep Apnea (OSA) as a Risk Factor:

    • Patients with OSA show a higher prevalence of hypertension than those without OSA. In normal-weight patients, OSA is an independent risk factor for hypertension due to the mechanical and inflammatory consequences of airway obstruction during sleep, which elevates blood pressure levels (Todea et al., 2013).
  3. Role of Central Sleep Apnea (CSA):

    • CSA, though less common, also contributes to fluctuations in blood pressure, typically through autonomic instability and irregularities in oxygen and CO2 levels during sleep. This can lead to both nocturnal and daytime hypertension without being linked to obesity or metabolic syndrome (Fischer & Raschke, 1995).
  4. Cardiovascular Risk:

    • The combination of OSA and hypertension, regardless of weight or metabolic factors, significantly increases cardiovascular risk. In particular, left ventricular remodeling and carotid intima-media thickness are more pronounced in non-obese OSA patients with hypertension, even when metabolic syndrome is absent (Prejbisz et al., 2014).

Guidelines and Clinical Recommendations

Current clinical guidelines primarily focus on patients with OSA and co-occurring cardiovascular risks, including hypertension, even in the absence of metabolic syndrome or obesity. Here's a summary of the recommendations and guidelines:

  1. Diagnosis and Screening:

    • Guidelines recommend screening for sleep apnea in patients with arterial hypertension, regardless of body weight, especially in cases where blood pressure is difficult to control with medication alone (Florczak et al., 2010).
    • Polysomnography is suggested to confirm the diagnosis, especially for hypertensive patients with symptoms of sleep apnea such as excessive daytime sleepiness, snoring, or nocturnal awakenings (Mineiro et al., 2017).
  2. Treatment Approaches:

    • Continuous Positive Airway Pressure (CPAP): CPAP is the primary treatment for OSA and has shown benefits in reducing blood pressure in hypertensive patients. It is especially effective in lowering nighttime blood pressure, which is a critical factor in reducing cardiovascular risks in these patients (Spannella et al., 2018).
    • In hypertensive patients without metabolic syndrome, CPAP can lead to significant improvements in both systolic and diastolic blood pressure, even in the absence of weight loss (Sharma et al., 2011).
  3. Lifestyle Modifications:

    • Lifestyle interventions, including regular physical activity and dietary changes, are also recommended for managing hypertension in OSA patients, even those who are not overweight (Choukri et al., 2022).
  4. Prognosis and Follow-Up:

    • Long-term follow-up is recommended for hypertensive patients with OSA to monitor blood pressure and cardiovascular health. Periodic reassessment with polysomnography is also advised to evaluate the effectiveness of CPAP therapy and other interventions (Prejbisz et al., 2014).


Conclusion

Patients with arterial hypertension and sleep apnea, even in the absence of metabolic syndrome or overweight, are at an increased risk of cardiovascular disease. Effective screening, diagnosis via polysomnography, and treatment with CPAP are essential interventions. CPAP therapy has been shown to improve blood pressure control and mitigate the cardiovascular risks associated with OSA in these patients.

Screening for Mental Disorders

ICMC provides a collection of validated screening questionnaires for mental health conditions. The questionnaires are designed for quick assessment and early detection. These tools support healthcare professionals and individuals in identifying symptoms of anxiety, depression, PTSD, and more. 

Screening for Anxiety

Author(s): Claudia Hackl-Zuccarella, Bianca Wahrenberger, Edouard Battegay Published on: Feb 23, 2025

Introduction to Screening for Anxiety in Individuals with Somatic Symptoms

Anxiety disorders are among the most common mental health conditions worldwide, with Generalized Anxiety Disorder (GAD) being a particularly prevalent and impairing subtype. GAD is characterized by excessive and persistent worry about everyday events, often accompanied by physical symptoms such as muscle tension, restlessness, and fatigue. Despite its high prevalence, GAD frequently goes unrecognized—especially when individuals primarily present with somatic complaints rather than emotional distress.

There is a strong and well-documented connection between anxiety and physical health. Individuals suffering from GAD commonly report a variety of somatic symptoms, including headaches, gastrointestinal disturbances, chronic pain, and cardiovascular complaints such as palpitations and chest pain (Hofmann et al., 2012). These physical manifestations can often lead patients to seek care in medical settings, where the underlying anxiety may be overlooked in favor of investigating physical causes. As a result, many people with GAD undergo unnecessary diagnostic procedures, leading to increased healthcare utilization and delayed psychological treatment (Kroenke et al., 2007).

The biological underpinnings of GAD contribute to its impact on physical health. Chronic activation of the body's stress response systems—specifically the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system—results in elevated levels of stress hormones like cortisol and adrenaline (Bystritsky et al., 2013). Over time, this physiological dysregulation can contribute to the development or worsening of conditions such as hypertension, irritable bowel syndrome (IBS), and chronic pain disorders.

In addition to biological factors, cognitive and emotional patterns associated with GAD exacerbate physical symptoms. Individuals with GAD tend to engage in catastrophic thinking and exhibit heightened sensitivity to bodily sensations. This hypervigilance often amplifies the perception of physical discomfort, creating a vicious cycle where worry and physical symptoms reinforce each other (Behar et al., 2009).

Social and behavioral consequences of GAD, such as avoidance behaviors and social withdrawal, can further impair functioning and quality of life. Isolation and reduced engagement in enjoyable activities diminish protective factors like social support and resilience, which are essential for coping with stress and managing symptoms (Cacioppo et al., 2010).

Given the profound and multifaceted impact of GAD on both mental and physical health, early detection is critical. The GAD-7 (Generalized Anxiety Disorder-7) questionnaire is a brief and validated screening tool that helps identify individuals experiencing problematic levels of anxiety. It assesses the severity of core GAD symptoms and provides a reliable basis for further clinical evaluation and treatment planning (Spitzer et al., 2006).

Incorporating routine anxiety screening, particularly in patients who frequently present with somatic complaints, allows healthcare providers to address the full spectrum of a patient’s health needs. Early intervention—whether through cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, or pharmacotherapy—can alleviate both emotional distress and physical symptoms. Ultimately, comprehensive care improves overall well-being and reduces the long-term personal and societal burden of untreated anxiety disorders.

References

  1. Behar E, DiMarco ID, Hekler EB, Mohlman J, Staples AM. Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications. J Anxiety Disord. 2009 Dec;23(8):1011-23. doi: 10.1016/j.janxdis.2009.07.006. Epub 2009 Jul 8. PMID: 19700258.
  2. Bystritsky A, Khalsa SS, Cameron ME, Schiffman J. Current diagnosis and treatment of anxiety disorders. P T. 2013 Jan;38(1):30-57. PMID: 23599668; PMCID: PMC3628173.
  3. Cacioppo JT, Cacioppo S, Capitanio JP, Cole SW. The neuroendocrinology of social isolation. Annu Rev Psychol. 2015 Jan 3;66:733-67. doi: 10.1146/annurev-psych-010814-015240. Epub 2014 Aug 22. PMID: 25148851; PMCID: PMC5130104.
  4. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res. 2012 Oct 1;36(5):427-440. doi: 10.1007/s10608-012-9476-1. Epub 2012 Jul 31. PMID: 23459093; PMCID: PMC3584580.
  5. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007 Mar 6;146(5):317-25. doi: 10.7326/0003-4819-146-5-200703060-00004. PMID: 17339617.
  6. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. doi: 10.1001/archinte.166.10.1092. PMID: 16717171.

Download:


GAD-7 Questionnaire English.pdf

GAD-7 Questionnaire German.pdf


The Generalized Anxiety Disorder (GAD-7)


Description

The Generalized Anxiety Disorder-7 (GAD-7) is a brief, self-report screening tool designed to assess symptoms of generalized anxiety disorder (GAD) and measure anxiety severity over the past two weeks. It is commonly used in primary care, mental health, and research settings to facilitate early detection and monitoring of anxiety disorders.

While originally developed for generalized anxiety disorder (GAD), research has demonstrated that the GAD-7 also effectively screens for other anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress

 

Structure and Administration

The GAD-7 consists of seven items, each assessing core symptoms of GAD based on DSM-5 criteria. Respondents indicate how often they have experienced these symptoms over the past two weeks, using a 4-point Likert scale:

Response Option

Score

Not at all

0

Several days

1

More than half the days

2

Nearly every day

3

The questionnaire is self-administered, but it can also be completed through clinician interviews or computerized assessments. It typically takes 2–3 minutes to complete.


Scoring and Interpretation

Total GAD-7 scores range from 0 to 21. Higher scores indicate greater severity of anxiety symptoms:

Score

Anxiety Severity

Clinical Interpretation

0-4

Minimal anxiety

No intervention needed

5-9

Mild anxiety

Monitor; consider follow-up

10-14

Moderate anxiety

Possible clinical diagnosis; further assessment recommended

15-21

Severe anxiety

High likelihood of an anxiety disorder; active treatment needed


Diagnostic Cut-Point for GAD

A score of ≥10 is considered optimal for detecting GAD, with high sensitivity (89%) and specificity (82%) (Spitzer et al., 2006).

Scores ≥8 may indicate clinically significant anxiety symptoms and warrant further evaluation (Podda et al., 2020).


Psychometric Properties

The GAD-7 has demonstrated strong validity and reliability across clinical and general populations, making it a robust screening tool for anxiety disorders.

Metric

Value

Sensitivity (cut-off ≥10)

0.89 (89%) (Spitzer et al., 2006)

Specificity (cut-off ≥10)

0.82 (82%) (Spitzer et al., 2006)

Positive Predictive Value (PPV)

0.75–0.85, depending on population (Löwe et al., 2008)

Negative Predictive Value (NPV)

0.97 (97%) (Löwe et al., 2008)

Internal Consistency (Cronbach’s Alpha)

0.92 (Excellent reliability) (Spitzer et al., 2006)


Key Research Findings

  • The GAD-7 score of ≥10 is highly accurate in detecting GAD, with a sensitivity of 89% and specificity of 82% (Spitzer et al., 2006).
  • The GAD-7 performs well in various populations, including primary care, general medical, and psychiatric settings, as well as among adolescents, older adults, and individuals with chronic illnesses (Löwe et al., 2008).
  • Although designed for GAD, the GAD-7 also effectively identifies other anxiety disorders, such as panic disorder, social anxiety disorder, and PTSD (Kroenke et al., 2007).


Clinical Utility & Limitations

Advantages

  • Brief and Easy to Administer: Takes 2-3 minutes to complete.
  • Highly Validated: Shows high sensitivity and specificity for GAD and other anxiety disorders.
  • Useful for Symptom Monitoring: Can track treatment progress over time.
  • Validated Across Multiple Settings: Effective in primary care, psychiatry, and community samples.


Limitations

  • Not a Standalone Diagnostic Tool: Requires further clinical assessment for formal GAD diagnosis.
  • Overlap with Other Disorders: May identify general distress rather than specific anxiety disorders.
  • Potential for False Positives: Some individuals with high scores may not meet full DSM-5 criteria for GAD.


References

  1. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. doi: 10.1001/archinte.166.10.1092. PMID: 16717171.
  2. Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, Herzberg PY. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008 Mar;46(3):266-74. doi: 10.1097/MLR.0b013e318160d093. PMID: 18388841.
  3. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007 Mar 6;146(5):317-25. doi: 10.7326/0003-4819-146-5-200703060-00004. PMID: 17339617.
  4. Podda J, Ponzio M, Messmer Uccelli M, Pedullà L, Bozzoli F, Molinari F, Monti Bragadin M, Battaglia MA, Zaratin P, Brichetto G, Tacchino A. Predictors of clinically significant anxiety in people with multiple sclerosis: A one-year follow-up study. Mult Scler Relat Disord. 2020 Oct;45:102417. doi: 10.1016/j.msard.2020.102417. Epub 2020 Jul 22. PMID: 32736214.

Screening for Depression

Author(s): Claudia Hackl-Zuccarella, Bianca Wahrenberger, Edouard Battegay Published on: Feb 23, 2025

Introduction to Screening for Depression in Individuals with Somatic Symptoms

Depression is a common yet often overlooked mental health condition that affects millions of people worldwide. While it is widely recognized for its emotional and cognitive symptoms—such as persistent sadness, loss of interest, and difficulty concentrating—depression also frequently manifests through physical, or somatic, complaints. These somatic symptoms, which include fatigue, pain, gastrointestinal discomfort, and dizziness, can obscure the underlying mental health issue and lead to underdiagnosis or misdiagnosis, particularly in primary care and medical settings.

There is a well-established, bidirectional relationship between depression and somatic disorders. Individuals experiencing chronic physical symptoms are at increased risk of developing depression, while those with depression often report more intense and numerous physical complaints (Henningsen et al., 2003). The physical burden of depression extends beyond discomfort; it can significantly impair daily functioning, reduce quality of life, and increase healthcare utilization due to frequent medical visits and diagnostic testing (Löwe et al., 2008).

The biological mechanisms that link depression and somatic symptoms are complex. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and chronic inflammation have been implicated in both depression and somatic symptom amplification (Dantzer et al., 2008). Individuals with depression may also experience altered pain perception and heightened sensitivity to bodily sensations, leading to increased reporting of physical symptoms even in the absence of a clear medical cause (Bair et al., 2003).

Social and psychological factors further complicate this relationship. Feelings of helplessness, social withdrawal, and reduced coping capacity are common in depression and can intensify the experience of somatic symptoms. Stigma surrounding mental health often leads patients to focus on physical complaints when seeking medical help, as somatic symptoms may feel more socially acceptable to report (Wangler et al., 2024).

For these reasons, early and accurate screening for depression is critical—especially in patients presenting with unexplained or chronic physical symptoms. Tools like the Somatic Symptom Scale-8 (SSS-8) offer a simple, effective way to assess the severity of somatic symptom burden, which can be an important indicator of underlying depression and other psychological distress (Gierk et al., 2014). Early identification allows for timely psychological and medical interventions, which not only improve mental health outcomes but can also alleviate physical symptom severity and enhance overall well-being.

By integrating routine screening for depression into healthcare practices—especially in settings where patients present with physical complaints—clinicians can help bridge the gap between physical and mental health care. This comprehensive approach reduces unnecessary diagnostic procedures, facilitates appropriate treatment, and ultimately improves patient outcomes.

References

  1. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003 Nov 10;163(20):2433-45. doi: 10.1001/archinte.163.20.2433. PMID: 14609780.
  2. Dantzer R, O'Connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci. 2008 Jan;9(1):46-56. doi: 10.1038/nrn2297. PMID: 18073775; PMCID: PMC2919277.
  3. Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, Löwe B. The somatic symptom scale-8 (SSS-8): a brief measure of somatic symptom burden. JAMA Intern Med. 2014 Mar;174(3):399-407. doi: 10.1001/jamainternmed.2013.12179. PMID: 24276929.
  4. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med. 2003 Jul-Aug;65(4):528-33. doi: 10.1097/01.psy.0000075977.90337.e7. PMID: 12883101.
  5. Wangler J, Jansky M. Somatoform Disorders in Primary Care-An Exploratory Mixed-Methods Study on Experiences, Challenges and Coping Strategies of General Practitioners in the Federal Republic of Germany. Int J Environ Res Public Health. 2024 Jul 10;21(7):901. doi: 10.3390/ijerph21070901. PMID: 39063478; PMCID: PMC11277205.
  6. Löwe B, Spitzer RL, Williams JB, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry. 2008 May-Jun;30(3):191-9. doi: 10.1016/j.genhosppsych.2008.01.001. PMID: 18433651.

Download PHQ-9:


PHQ-9 Questionnaire English.pdf

PHQ-9 Questionnaire German.pdf


Description

The Patient Health Questionnaire-9 (PHQ-9) is a widely used 9-item self-report screening tool for major depressive disorder (MDD) and depressive symptom severity. It aligns with the diagnostic criteria for depressionin the DSM-5 and is used in primary care, mental health, and research settings to identify and monitor depression over time.

The PHQ-9 serves two primary purposes:

  1. Screening for Major Depressive Disorder (MDD): A score-based algorithm helps detect probable MDD.
  2. Assessing Depression Severity: The total score indicates the degree of depression severity, ranging from minimal to severe depression.




Download SSS-8:


SSS-8 Questionnaire English.pdf

SSS-8 Questionnaire German.pdf


Description

The Somatic Symptom Scale-8 (SSS-8) is a brief, validated self-report instrument designed to assess the severity of somatic symptom burden. It serves as a short form of the Patient Health Questionnaire-15 (PHQ-15) and aligns with the diagnostic framework of Somatic Symptom Disorder (SSD) as defined by the DSM-5. The SSS-8 enables efficient screening of patients in primary care, mental health, and psychosomatic settings, identifying individuals with potentially disabling physical symptoms, regardless of whether a clear medical explanation exists (Gierk et al., 2014).

The scale captures the patient’s subjective experience of somatic symptoms over the previous seven days. Its simplicity makes it a useful tool for both clinical practice and research, facilitating early detection and guiding further diagnostic evaluations.


Screening for Post-traumatic Stress Disorder (PTSD)

Author(s): Claudia Hackl-Zuccarella, Bianca Wahrenberger, Edouard Battegay Published on: Feb 23, 2025

Introduction to Screening for PTSD in Somatic Disorders

Post-Traumatic Stress Disorder (PTSD) is a severe mental health condition that extends beyond psychological distress, significantly influencing physical health. One key area of concern is the relationship between PTSD and somatic disorders, particularly hypertension. Understanding the psychological mechanisms behind this connection is essential for effective screening and intervention.

Individuals with PTSD often exhibit heightened arousal and persistent hypervigilance, leading to an overactivation of the sympathetic nervous system. This chronic state of stress contributes to increased blood pressure and other cardiovascular risks. Additionally, PTSD is associated with a sense of loss of control and heightened insecurity, further exacerbating physiological stress responses. Studies indicate that individuals who feel threatened or powerless, such as refugees with PTSD, report higher blood pressure levels (Shalimova et al., 2023).

Genetic predispositions also play a role in how individuals respond to stress. Specific genetic factors, such as the ACE-I/D polymorphism, influence both psychological resilience and physiological responses, potentially making some individuals more vulnerable to hypertension under chronic stress conditions (Kong et al., 2021). Furthermore, PTSD is often accompanied by maladaptive cognitive patterns, such as catastrophizing, which perpetuate psychological distress and contribute to long-term cardiovascular complications (Farr et al., 2015 and Chu et al., 2024).

Another critical factor is the social and emotional isolation frequently experienced by individuals with PTSD. Emotional numbing and withdrawal from social interactions can diminish available support networks, exacerbating stress and further elevating blood pressure. The interplay of these psychological and physiological factors underscores the importance of early PTSD screening in individuals with somatic disorders, particularly hypertension.

Given the significant impact of PTSD on physical health, integrated screening approaches should consider both psychological symptoms and physiological indicators. Early identification of PTSD in patients with hypertension and other somatic conditions can facilitate timely psychological interventions, such as stress management strategies, security-building therapies, and hyperarousal reduction techniques. Addressing these psychological aspects not only improves mental well-being but also mitigates the risk of long-term cardiovascular complications.

References

  1. Shalimova A, Stoenoiu MS, Cubała WJ, Burnier M, Persu A, Narkiewicz K. The impact of war on the development and progression of arterial hypertension and cardiovascular disease: protocol of a prospective study among Ukrainian female refugees. Front Cardiovasc Med. 2024 Jan 11;10:1324367. doi: 10.3389/fcvm.2023.1324367. PMID: 38274316; PMCID: PMC10808621.
  2. Kong LN, Shen YL, Chen YL, Chen X, Su GM, Wang JH, Xiao GB, Guo QW, Zhang JC, Fang DZ, Lin J. Insertion/deletion polymorphism at angiotensin-converting enzyme gene in PTSD individuals and their reciprocal effects on blood pressure. Clin Exp Hypertens. 2022 Apr 3;44(3):208-214. doi: 10.1080/10641963.2021.2018598. Epub 2021 Dec 22. PMID: 34935564.
  3. Farr OM, Ko BJ, Joung KE, Zaichenko L, Usher N, Tsoukas M, Thakkar B, Davis CR, Crowell JA, Mantzoros CS. Posttraumatic stress disorder, alone or additively with early life adversity, is associated with obesity and cardiometabolic risk. Nutr Metab Cardiovasc Dis. 2015 May;25(5):479-88. doi: 10.1016/j.numecd.2015.01.007. Epub 2015 Feb 3. PMID: 25770759; PMCID: PMC4404181
  4. Chu B, Marwaha K, Sanvictores T, Awosika AO, Ayers D. Physiology, Stress Reaction. 2024 May 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 31082164.

Download:


PTSD PC-PTSD-5 Questionnaire English.pdf

PTSD PC-PTSD-5 Questionnaire German.pdf


The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) 

Description

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a brief, validated, 5-item screening tool designed to identify individuals in primary care and other medical settings who may have probable post-traumatic stress disorder (PTSD). The tool aligns with diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and is primarily used in primary care, general medical, and mental health settings to facilitate early detection and intervention for PTSD.

This screening tool is not a diagnostic instrument but rather a preliminary assessment to determine whether an individual requires further evaluation. Those screening positive should undergo a structured clinical interview, such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), for confirmation of a PTSD diagnosis.

Structure and Administration

The PC-PTSD-5 consists of an initial trauma exposure screening question followed by five dichotomous (yes/no) items assessing PTSD symptoms experienced over the past month. The five symptom-based questions are based on core PTSD symptom clusters: intrusion, avoidance, negative alterations in cognition/mood, and hyperarousal.

The measure is self-administered but can also be completed through clinical interviews or computerized administration in healthcare settings. It typically requires less than one minute to complete.

Scoring and Interpretation

Trauma Exposure Item: The screening begins with an item assessing whether the respondent has experienced a significant traumatic event at any point in their life. If the individual denies exposure, the assessment ends, and their total score remains 0.

Symptom Endorsement Items: If the individual endorses trauma exposure, they are instructed to answer five additional yes/no questions about their PTSD symptoms over the past month.

Scoring: The PC-PTSD-5 is scored by summing the number of "yes" responses, resulting in a total score between 0 and 5.


Cut-Point Recommendations

General Population & Male Veterans: A cut-off score of 4 optimally balances sensitivity and specificity, minimizing false positives and false negatives.

Female Veterans & Certain Populations: A cut-off of 4 may yield higher false negatives, and a cut-off of 3may improve sensitivity for detecting probable PTSD.

Clinical Considerations: The choice of cut-off should be tailored to the clinical setting, considering resource availability and the impact of false positives versus false negatives.


Psychometric Porperties

The PC-PTSD-5 has demonstrated strong validity and reliability in detecting probable PTSD across different populations, particularly among veterans, military personnel, and primary care patients. Key psychometric properties include:


Metric

Value

Sensitivity (cut-off = 4)

0.95 (95%) (Prins et al., 2016)

Specificity (cut-off = 4)

0.85 (85%) (Prins et al., 2016)

Positive Predictive Value (PPV)

0.63-0.72, (Bovin et al., 2021)

Negative Predictive Value (NPV)

0.98 (98%) (Bovin et al., 2021)

Internal Consistency (Cronbach’s Alpha)

0.83 (Good reliability) (Bovin et al., 2021)


Key Research Findings

  • The PC-PTSD-5 performs comparably to longer PTSD screening tools, such as the PTSD Checklist for DSM-5 (PCL-5), while being significantly shorter and more practical for routine medical settings (Prins et al., 2016).
  • The tool shows high accuracy in military and veteran populations but requires cut-point adjustments in civilian and female populationsto enhance detection (Bovin et al., 2021).


Clinical Utility & Limitations

  • Advantages
    • Brief and Efficient: Takes less than a minute to administer.
    • High Sensitivity: Accurately detects probable PTSD cases with minimal false negatives.
      Validated Across Populations: Effective in veteran, primary care, and trauma-exposed populations.
      Easily Administered: Can be used in self-report or interview formats.
  • Limitations
    • Not Diagnostic: Requires further assessment (e.g., CAPS-5) for formal PTSD diagnosis.
    • Potential False Positives: In high-risk populations, false positives may strain limited clinical resources.
    • Cut-Point Variability: May require adjustment for women and non-veteran populations.

References

  1. Prins A, Bovin MJ, Smolenski DJ, Marx BP, Kimerling R, Jenkins-Guarnieri MA, Kaloupek DG, Schnurr PP, Kaiser AP, Leyva YE, Tiet QQ. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample. J Gen Intern Med. 2016 Oct;31(10):1206-11. doi: 10.1007/s11606-016-3703-5. Epub 2016 May 11. PMID: 27170304; PMCID: PMC5023594.
  2. Bovin MJ, Kimerling R, Weathers FW, Prins A, Marx BP, Post EP, Schnurr PP. Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Among US Veterans. JAMA Netw Open. 2021 Feb 1;4(2):e2036733. doi: 10.1001/jamanetworkopen.2020.36733. PMID: 33538826; PMCID: PMC7862990.
  3. Lathan EC, Petri JM, Haynes T, Sonu SC, Mekawi Y, Michopoulos V, Powers A. Evaluating the Performance of the Primary Care Posttraumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5) in a Trauma-Exposed, Socioeconomically Vulnerable Patient Population. J Clin Psychol Med Settings. 2023 Dec;30(4):791-803. doi: 10.1007/s10880-023-09941-9. Epub 2023 Jan 30. PMID: 36715813; PMCID: PMC9885055.