A systematic review of interventions to increase physical activity among South Asian adults.

OBJECTIVES: To identify interventions aimed at increasing physical activity (PA) levels among South Asian (SA) adults and identify the specific changes in the content and delivery mode of interventions designed to increase PA levels among SA people aged ≥18 years. DESIGN: A systematic review of quantitative studies. DATA SYNTHESIS: Extracted data were synthesized using a narrative approach. DATA SOURCES: ASSIA, CINHAL, EMBASE, Medline, SPORTDiscus and PsychINFO were searched. Included articles met the following criteria: (1) population: community-dwelling SA adults aged ≥18 years and (2) outcome: reporting determinants of PA, exercise, or a combination of the two, measured objectively or using self-report. The search was restricted to articles published in the English language up to 31 January 2017. RESULTS: Fifteen trials/programmes (16 articles) met the review criteria. The findings show that involving the target community in developing culturally appropriate interventions appears to be important in their acceptability, delivery and uptake. Using community-based participation in intervention planning, evaluation and research appears to produce culturally and linguistically tailored interventions that address core values, attitudes, beliefs and norms, and encourage participation in PA. Furthermore, the use of community health workers and underpinning the interventions with a psychological theory show promise in increasing PA uptake. CONCLUSIONS: This systematic review suggests that making cultural adaptations to PA interventions shows promise, but the evidence base presented is not strong. This does not mean that adopting such an approach is ineffective but that the evidence base is currently lacking.

Associations of intention to undertake physical activity among community dwelling British South Asian adults aged 60 years and over: a cross-sectional study.

OBJECTIVE: High prevalence of sedentary behaviour is seen in most immigrant groups in Western countries, particularly in those from the Indian subcontinent. The primary objective of this study was to determine the sociocognitive associations with intention to undertake physical activity (PA) among separate groups of Indian, Pakistani and Bangladeshi older adults aged ≥60 years in the North West of England, UK. STUDY DESIGN: Cross-sectional survey METHODS: Using a cross-sectional survey, informed by the Theory of Planned Behaviour (TPB), 138 of 964 South Asian (SA) older adults completed a mailed questionnaire that assessed self-reported PA and TPB variables. RESULTS: Associations were seen in beliefs about PA and the amount of PA undertaken (rho = 0.18, P = 0.04). Attitude was correlated with intention (rho = 0.29, P = 0.01) and amount of PA undertaken (rho = 0.21, P = 0.02). Subjective norm was correlated with intention to undertake PA (rho = 0.21, P = 0.02). Between-group differences were seen between (1) Indian and Pakistani group's in subjective norm; (2) all ethnicities in intention to undertake PA; and (3) in the amount and attitude to undertaking PA between men and women. Comorbidity was associated with beliefs about PA uptake. CONCLUSIONS: Subgroup differences between Indian, Pakistani and Bangladeshi older adults in subjective norm and intention to undertaking PA highlight the importance of tailoring interventions to accommodate for subgroup differences when developing culturally appropriate PA interventions aimed at increasing uptake and adherence.

Gastrointestinal dysmotility: A qualitative exploration of the journey from symptom onset to diagnosis.

BACKGROUND: Gastrointestinal dysmotility (GID) covers a spectrum of disorders disrupting enteric neuromuscular co-ordination which, when severe, causes intractable gastrointestinal symptoms and malnutrition and is a recognized cause of chronic intestinal failure. To date, no study has provided an in-depth account of the experiences of patients with severe GID and their psychosocial needs. This study aimed to explore patients' experiences from symptom onset and the process of seeking and receiving a diagnosis. It specifically explored the psychological effect of this process and the effect on relationships. METHODS: Participants (n = 20, mean age = 47.9, female n = 16, parenteral nutrition = 13) were recruited from a UK center with tertiary Neurogastroenterology and Intestinal Failure services. A qualitative exploratory design with semi-structured in-depth interviews was used. Data were analyzed using thematic analysis. KEY RESULTS: Significant delays were experienced in obtaining a diagnosis. Participants reported having their mental health questioned and felt that they had to fight to prove their symptoms had a physical basis to access appropriate treatment. Although a diagnosis helped legitimize symptoms, the condition remained poorly understood by participants themselves, relatives, and health professionals. Participants discussed the impact that "feeling delegitimized" and the "lack of coherent understanding of GID" had on their relationships and mental health. CONCLUSIONS & INFERENCES: The distressing experience of GID symptoms are compounded by a delay in validating symptoms and lack of coherent understanding. More knowledge of GID is needed by health professionals to speed up diagnosis and offer more coherent information. The psychological impact of a GID diagnosis should be acknowledged early to help facilitate adjustment.

Understanding the low uptake of bone-anchored hearing aids: a review.

BACKGROUND: Bone-anchored hearing aids improve hearing for patients for whom conventional behind-the-ear aids are problematic. However, uptake of bone-anchored hearing aids is low and it is important to understand why this is the case. METHOD: A narrative review was conducted. Studies examining why people accept or decline bone-anchored hearing aids and satisfaction levels of people with bone-anchored hearing aids were reviewed. RESULTS: Reasons for declining bone-anchored hearing aids included limited perceived benefits, concerns about surgery, aesthetic concerns and treatment cost. No studies providing in-depth analysis of the reasons for declining or accepting bone-anchored hearing aids were identified. Studies of patient satisfaction showed that most participants reported benefits with bone-anchored hearing aids. However, most studies used cross-sectional and/or retrospective designs and only included people with bone-anchored hearing aids. CONCLUSION: Important avenues for further research are in-depth qualitative research designed to fully understand the decision-making process for bone-anchored hearing aids and rigorous quantitative research comparing satisfaction of people who receive bone-anchored hearing aids with those who receive alternative (or no) treatments.

The anticipated and the lived experience of home and in-centre haemodialysis: Is there a disconnect?

This qualitative study aimed to explore home haemodialysis and in-centre haemodialysis patients' experience, to illuminate barriers and facilitators in the uptake and maintenance of home haemodialysis. Thirty-two semi-structured interviews with patients receiving home haemodialysis or in-centre haemodialysis were analysed using framework analysis. Four themes emerged: 'perceptions of self'; 'impact of haemodialysis on family'; 'perceived advantages and disadvantages of home haemodialysis and in-centre haemodialysis' and 'practical issues and negotiating haemodialysis'. The lived experience of home haemodialysis was in contrast to the lived experience of in-centre haemodialysis and to the anticipated experience of home haemodialysis, highlighting patient factors that contributed to under-usage of home haemodialysis.

"It's my business, it's my body, it's my money": experiences of smokers who are not planning to quit in the next 30 days and their views about treatment options.

BACKGROUND: Current evidence-based smoking cessation treatments in the UK are only offered to smokers ready to quit within 30 days. This study reports the experiences of smokers who are not ready to quit and explores the types of intervention approaches that might engage them. METHODS: Five focus groups were conducted with smokers who had no plans to quit within 30 days (n = 32, 44 % female). Verbatim transcripts were analyzed thematically using Nvivo 10 software. RESULTS: Participants were ambivalent towards their own smoking, but the majority indicated they would like to quit someday. Smoking was seen both to hinder and facilitate social interactions, depending on the social norms of the participant's social circle. Participants reported that, when they perceive pressure to quit smoking, they respond defensively; concurrently, existing approaches to encouraging smoking cessation were seen as unappealing. In contrast, the importance of intrinsic motivation to quit was emphasized, and interventions that were tailored, increased intrinsic motivation and kept the smoker engaged in activities incompatible with smoking were preferred. CONCLUSIONS: Despite not planning to quit in the next 30 days, the majority of participants wanted to quit smoking at some point. Even if existing services were offered to smokers not planning to quit in the next 30 days, it is unlikely that these services would meet the needs of this population. Future research should explore novel approaches to appeal specifically to smokers not planning to quit in the next 30 days, such as encouraging engagement with activities incompatible with smoking and fostering non-smoking habits.

The Burden of Cognitive Impairment in Patients With End-Stage Renal Disease and Impact on Dialysis Modality Choice.

INTRODUCTION: Kidney disease is associated with significant cognitive dysfunction. Subjective reports of cognitive ability have not been studied extensively in chronic kidney disease. We investigated the association between objective and subjective cognitive functions in predialysis patients and their association with self-care dialysis modality choice. METHODS: Cross-sectional data from the Barriers to Successful Implementation of Care in Home Haemodialysis study were used for the study of cognition in 220 predialysis patients. The data were used to ascertain the demographics, clinical, laboratory, and neuropsychometric variables. The latter includes Trail Making Tests (TMT) parts A and B, Modified Mini Mental State Examination, and metacognition questionnaire for subjective assessment of one's cognitive ability. The outcome variable was fully assisted and self-care dialysis modality choice. RESULTS: Within the study cohort, 90 patients chose fully assisted hemodialysis and 114 patients chose self-care dialysis. The median Modified Mini Mental State Examination, TMT part A, and TMT part B scores were greater for the assisted versus the self-care group. Metamemory was not significantly different between groups, but the metaconcentration score was significantly worse in the group choosing assisted dialysis. Higher (i.e., better) metaconcentration scores were significantly associated with the self-care modality choice in the univariate and hierarchical regression analyses. Adjusted and unadjusted analyses showed a significant association between perceived concentration and TMT part B scores (P < 0.01). With every 1.6-minute increase in TMT part B score, there was a 1-unit reduction in metaconcentration score, and the latter was associated with 20% lower odds of choosing self-care dialysis over a fully assisted dialysis modality. DISCUSSION: Patients' self-perception of cognitive ability is a significant predictor of self-care dialysis modality choice. Subjective report of "metaconcentration" is also strongly associated with poorer outcome on the TMT part B.

Depressive symptoms and pragmatic rehabilitation for chronic fatigue syndrome.

BACKGROUND: Previous research has suggested that depressed mood may predict outcome and moderate response to treatment in chronic fatigue syndrome, although findings have differed between studies. AIMS: To examine potential moderators of response to pragmatic rehabilitation v. general practitioner treatment as usual in a recent randomised trial for patients with chronic fatigue syndrome in primary care (IRCTN74156610). METHOD: Simple regressions, with weighting adjustments to allow for missing data, were calculated. Demographic, medical and psychological variables, and treatment arm, were entered separately and as an interaction term. The outcome variable in each case was change in Chalder Fatigue Scale scores, from baseline to 1-year follow-up, our primary outcome point. RESULTS: Longer illness durations predicted poorer outcome across the two treatment arms. For patients allocated to pragmatic rehabilitation compared with those allocated to treatment as usual, higher levels of depressive symptoms at baseline were associated with smaller improvements in fatigue (P = 0.022). CONCLUSIONS: For patients in primary care with higher levels of depressive symptoms, either more intensive or longer pragmatic rehabilitation, or cognitive-behavioural therapy, may be required in order to show a significant improvement in fatigue.

Developing a healthy living intervention for people with early psychosis using the Medical Research Council's guidelines on complex interventions: phase 1 of the HELPER - InterACT programme.

BACKGROUND: Young people with early psychosis often gain a significant amount of weight after the initiation of anti-psychotic treatment. Despite the current policy guidance to develop and evaluate 'healthy living' interventions for people with psychosis there remains a paucity of research. Our aim was to develop an acceptable, feasible, culturally sensitive and potentially effective 'healthy living' intervention, specifically for young people with early psychosis. METHODS: Using the Medical Research Council guidelines for developing and evaluating complex interventions we conducted a number of studies to devise a 'healthy living' intervention. We used a 'top down' (published evidence), bottom up (stakeholder perspectives) approach, which included updating a systematic review, identifying a theoretical basis for the intervention, exploring the perspectives of service users and health professionals, and identifying key cultural issues. The results of these studies were synthesised to determine the content and delivery of the intervention. RESULTS: The intervention developed comprised eight individual sessions to be delivered by a support time recovery worker over a 12 month period with emphasis on individualised action plans to facilitate participatory exercise and changes in diet. To optimise engagement, choice and self management a booklet and website were developed to provide participants with educational advice, healthy eating recipes and other materials. CONCLUSION: Using the Medical Research Council guidelines we have developed a potentially effective, feasible and acceptable 'healthy living' intervention for people with psychosis using early intervention services in the UK.

Attachment style and alliance in patients with diabetes and healthcare professionals.

Avoidant attachment has been found to impair attendance at appointments and treatment adherence of patients with diabetes, but the role of staff-patient relationships has not been explored. This study investigates whether attachment influences the quality of alliance between patients with diabetes and healthcare professionals. Patient avoidance was significantly associated with difficulties in therapeutic alliance. Further research is required to establish whether therapeutic alliance, underpinned by attachment, influences treatment adherence and to investigate ways of promoting collaboration.

Fatigue Intervention by Nurses Evaluation--the FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610].

BACKGROUND: Chronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP). METHODS AND DESIGN: This study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients' homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions' mechanisms of change, and also GPs' drivers and barriers towards referral.

The associations of anxiety, depression and personal illness representations with glycaemic control and health-related quality of life in patients with type 2 diabetes mellitus.

OBJECTIVE: This study examined the interrelationships of anxiety, depression and personal illness representations with glycaemic control and health-related quality of life in adults with Type 2 diabetes. METHODS: One hundred eighty-four consecutive patients with Type 2 diabetes mellitus completed the Illness Perception Questionnaire (IPQ), the Well-Being Scale (WBQ) and the Short Form 36 Health Survey Questionnaire (SF-36). Demographic characteristics, details of diabetes status (duration of diabetes, treatments and complications) and glycosylated haemoglobin (HbA1c) were recorded. RESULTS: Depression was correlated with greater perceived symptom load (r = .48, P < .01), worse anticipated consequences (r = -.41, P < .01) and perceived lack of control of diabetes (r = .28, P < .01). After controlling for demographic and illness characteristics, personal illness representations relating to symptom load and anticipated consequences were independently associated with the SF-36 physical functioning score, contributing an additional 15% to the variance. WBQ depression and anxiety scores, along with IPQ control and consequences, were independently associated with SF-36 mental function score, contributing a further 51% to the variance after controlling for demographic and illness details. Neither IPQ nor WBQ scales were associated with HbA1c after controlling for demographic and medical illness details. CONCLUSION: Anxiety, depression and negative beliefs about illness influence physical and mental functioning, but not metabolic control in patients with diabetes.

The Family Response Questionnaire: a new scale to assess the responses of family members to people with chronic fatigue syndrome.

OBJECTIVE: Family responses to patients with chronic fatigue syndrome (CFS) may influence the course of the disorder and family members themselves are likely to be adversely affected. However, the beliefs and responses of relatives of CFS patients have been under-researched. The aim of this study was to produce an easy-to-administer questionnaire to assess the responses of family members to people with CFS. METHODS: Seventy-eight people, all close relatives of (physician-diagnosed) CFS sufferers, completed the first version of the Family Response Questionnaire (FRQ). RESULTS: Examination of the correlation matrix and a cluster analysis of the items support four scales rather than the original five. The four response scales were labelled: sympathetic-empathic, active engagement, rejecting-hostile, and concern with self. Measures of test-retest and internal reliability were high. Participants found the items both comprehensible and relevant to their experiences of living with people with CFS. CONCLUSION: The new version of the FRQ will be useful in further examination of the responses of CFS on individuals and their families.

Partners' expressed emotion and the control and management of type 1 diabetes in adults.

OBJECTIVE: "Expressed emotion" (EE) refers to a set of valid and reliable measures of family emotional attitudes, which are robust predictors of illness course in several psychiatric conditions and which have recently been studied in some medical conditions. We hypothesised that high EE in partners of diabetes patients would be associated with poorer glucose control, management of and adaptation to diabetes. METHODS: Sixty adult Type 1 diabetes patients, who were attending routine clinics at a specialist diabetes centre, and their partners were interviewed separately and completed various questionnaire measures. Partners' EE was rated from a modified Camberwell Family Interview; patients were interviewed to assess self-management practices. Glycated hemoglobin (HbA(1c)) was the measure of glucose control. RESULTS: Only 10/60 (17%) partners were classified as high EE. Patients with high-EE partners had significantly worse self-management scores, more negative appraisal of diabetes, and higher depression scores than those with low-EE partners, but there was no association between EE measures and HbA(1c). CONCLUSIONS: In contrast to findings from previous research on the families of patients with psychiatric illnesses, only a minority of partners of adult patients with Type 1 diabetes are classified as high-EE. We found no evidence that partners' EE was related to patients' blood glucose control.

A review of expressed emotion research in health care.

Much research has been carried out on the impact of family relationships on the development and course of different illness. Research on Expressed Emotion (EE) developed out of studies of the impact of family members on patients with schizophrenia, and has provided us with a robust measure of relatives' emotional attitudes towards patients, which has now been applied in the study of numerous psychiatric and medical illnesses. This review outlines the history of EE research in schizophrenia, and discusses the evidence for the association between family EE and the course of schizophrenic illness. Some of the factors which might moderate the association between EE and illness course are outlined and the issues of the meaning and development of EE are discussed in the light of recent theoretical advances. The application of the EE methodology in other psychiatric and medical conditions is then reviewed and conclusions are drawn about the extent to which EE predicts illness course in conditions other than schizophrenia. Consideration is given to the ways in which the application of the paradigm to a variety of illnesses or conditions with different features can enhance our understanding of the EE construct.

Prediction of peak oxygen uptake in chronic fatigue syndrome.

OBJECTIVES: To establish a simple, valid, and acceptable method of predicting peak oxygen uptake (VO2peak) in patients with chronic fatigue syndrome (CFS), which could provide a basis for subsequent exercise prescription at an appropriate intensity as part of a clinical rehabilitation programme. METHODS: A total of 130 patients who met UK research criteria for CFS were taken from consecutive referrals for chronic fatigue to the University Department of Medicine at Withington Hospital, Manchester. VO2peak was determined using an incremental graded exercise test to exhaustion. Respiratory gas exchange, work rate, and heart rate were monitored throughout. RESULTS: In all patients, VO2peak was found to correlate strongly and significantly with peak work rate (WRpeak) during testing (r2 = 0.88, p<0.001). In patients who exercised for longer than two minutes (n = 119), regression analysis established the relation as Vo2peak = 13.1 x WRPpeak + 284, where VO2 is given in ml/min and WR in W. The mean error between the measured VO2peak and the predicted value was 10.7%. The relation between increase in work rate and oxygen uptake across the group was highly significant (r2 = 0.87, p<0.001), and given as VO2increase = 12.0 x WRincrease, this value being similar to that expected for healthy individuals. Almost all (97%) subjects reported no exacerbation of symptoms after maximal exercise testing. CONCLUSIONS: Using a simple to administer maximal exercise test on a cycle ergometer, it is possible to predict accurately the VO2peak of a patient with CFS from peak work rate alone. This value can then be used as an aid to setting appropriate exercise intensity for a rehabilitation programme. The increase in VO2 per unit increase in workload was consistent with that expected in healthy individuals, suggesting that the physiological response of the patients measured here was not abnormal. Contrary to the belief of many patients, maximal exercise testing to the point of subjective exhaustion proved to be harmless, with no subjects suffering any lasting deterioration in their condition after assessment.

The role of depression in pain, psychophysiological syndromes and medically unexplained symptoms associated with chronic fatigue syndrome.

BACKGROUND: The association between depression and pain, function, medically unexplained symptoms and psychophysiological syndromes such as irritable bowel syndrome has not been explored before in chronic fatigue syndrome. METHODS: Cross-sectional controlled study of the current prevalence of psychophysiological syndromes, pain, function and lifetime prevalence of medically unexplained symptoms in 77 out-patients with chronic fatigue syndrome (CFS) without DSM-III-R depression, 42 CFS out-patients with DSM-III-R depression and 26 out-patient with primary DSM-III-R depression. RESULTS: Both CFS groups differed significantly from the primary depression group but not each other in the prevalence of tension headaches (P < 0.001), reporting of widespread bodily pain (P < 0.001) and the number of lifetime medically unexplained symptoms (P < 0.001). The three groups did not significantly differ in the prevalence of irritable bowel syndrome or fibromyalgia. CFS patients with depression were more impaired in social function than other CFS patients. CONCLUSION: Depression is not associated with the reporting of pain, psychophysiological syndromes and medically unexplained symptoms in CFS patients. Depression is associated with decreased social function in CFS patients. LIMITATIONS: Study depended on recall of symptoms, not confirmed by medical records and current investigations. Patients with depression were taking antidepressants. CLINICAL RELEVANCE: Treating depression in chronic fatigue syndrome is unlikely to diminish reporting of pain and medically unexplained symptoms but may improve social function.

Exploring the validity of the Chalder Fatigue scale in chronic fatigue syndrome.

The Chalder fatigue scale is widely used to measure physical and mental fatigue in chronic fatigue syndrome patients, but the constructs of the scale have not been examined in this patient sample. We examined the constructs of the 14-item fatigue scale in a sample of 136 chronic fatigue syndrome patients through principal components analysis, followed by correlations with measures of subjective and objective cognitive performance, physiological measures of strength and functional work capacity, depression, anxiety, and subjective sleep difficulties. There were four factors of fatigue explaining 67% of the total variance. Factor 1 was correlated with subjective everyday cognitive difficulties, concentration difficulties, and a deficit in paired associate learning. Factor 2 was correlated with difficulties in maintaining sleep. Factor 3 was inversely correlated with grip strength, peak VO2, peak heart rate, and peak functional work capacity. Factor 4 was correlated with interview and self-rated measures of depression. The results support the validity of mental and physical fatigue subscales and the dropping of the "loss of interest" item in the 11-item version of the fatigue scale.

Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome.

BACKGROUND: The Joint Working Group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners (1996) recommended graded exercise and antidepressants for patients with chronic fatigue syndrome. We assessed efficacy and acceptability of these treatments. METHOD: Six-month prospective randomised placebo and therapist contact time controlled trial with allocation to one of four treatment cells: exercise and 20 mg fluoxetine, exercise and placebo drug, appointments only and 20 mg fluoxetine, appointments and placebo drug. Drug treatment was double blind and patients were blind to assignment to exercise or appointments. RESULTS: Ninety-six (71%) of 136 patients completed the trial. Patients were more likely to drop out of exercise than non-exercise treatment (P = 0.05). In an intention to treat analysis, exercise resulted in fewer patients with case level fatigue than appointments only at 26 weeks (12 (18%) v. 4 (6%) respectively P = 0.025) and improvement in functional work capacity at 12 (P = 0.005) and 26 weeks (P = 0.03). Fluoxetine had a significant effect on depression at week 12 only (P = 0.04). Exercise significantly improved health perception (P = 0.012) and fatigue (P = 0.028) at 28 weeks. CONCLUSIONS: Graded exercise produced improvements in functional work capacity and fatigue, while fluoxetine improved depression only.

Screening instruments for psychiatric morbidity in chronic fatigue syndrome.

Physicians require a screening instrument to detect psychiatric disorders in patients with chronic fatigue syndrome (CFS). Different threshold scores on the Hospital Anxiety and Depression scale (HAD) and the mental health scale of the Medical Outcome Survey (MOS) were compared with two gold standards for the presence or absence of psychiatric disorder, standard diagnostic criteria (DSM-III-R) and a threshold score for the number of psychiatric symptoms at a standardized psychiatric interview (Revised Clinical Interview Schedule total cut-off score of 11/12). They were compared by use of validating coefficients and receiver operating characteristics in 136 consecutive CFS medical outpatients. The HAD scale at cut-off of 9/10 was a valid and efficient screening instrument for anxiety and depression by comparison with both gold standards. The MOS mental health scale at its recommended cut-off score of 67/68 yielded too many false-positives to be recommended as a psychiatric screening instrument in CFS patients.