Level of Overestimation Among Dutch Recreational Skiers: Unskilled Tourists in the Mountains.

OBJECTIVE: To examine the level of overestimation (LO), associated factors, and identify the group of severe overestimators, among recreational skiers. DESIGN: Cross-sectional observational study. SETTING: An intermediate difficulty slope in an artificial snow indoor ski hall, and one in the mountains (Flachau, Austria). PARTICIPANTS: Dutch recreational skiers. INDEPENDENT VARIABLES: Participants were asked to rate themselves (SRSS, self-reported skill score). While skiing downhill they were objectively evaluated by 2 expert assessors (OSS, observed skill score). Potential associated factors and predictors for severe overestimation were assessed by a questionnaire. MAIN OUTCOME MEASURES: The LO, calculated by subtracting the OSS from the SRSS, was categorized into "no," "mild," and "severe." Potential differences between these groups were analyzed, and regression analyses were performed to identify the factors associated with severe overestimation. To construct a profile of severe overestimators, the dataset was stratified based on 3 variables. RESULTS: Overestimation was largely present (79.8%), and was severe in 32%. The LO decreased toward the more skilled skiers. Severe overestimators were mainly male, skied the least hours per day, were more avoidant, and showed the highest proportions of beginners and slightly advanced skiers. The profile of "severe overestimator" is characterized by physically unprepared males, avoidant for certain weather circumstances. CONCLUSIONS: Overestimation among recreational Dutch skiers is largely present, particularly among physically unprepared males, avoidant of certain snow and weather conditions. These features may function as a proxy to identify "severe overestimators" in comparable populations. Preventive strategies should focus to increase awareness particularly among these subjects.

Estimating skills level in recreational skiing: Development and validation of a practical multidimensional instrument.

Skiing and snowboarding are both popular recreational alpine sports, with substantial injury risk of variable severity. Although skills level has repeatedly been associated with injury risk, a validated measure to accurately estimate the actual skills level without objective assessment is missing. This study aimed to develop a practical validated instrument, to better estimate the actual skills level of recreational skiers, based on the criteria of the Dutch Skiing Federation (DSF), and covering five different skill domains. A sample of Dutch recreational skiers (n = 84) was asked to fill in a questionnaire reflecting seven, a priori chosen predictors by expert opinion, to ski downhill and to be objectively evaluated by expert assessors. The instrument was developed to have a multidimensional character and was validated according to the TRIPOD guideline (Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis). The sample reported an overall incorrect self-reported estimation of their skills, compared with the observed skill score. The instrument showed good calibration and underwent multiple validation methods. The estimated skills score showed to be closer to the observed scores, than self-reportage. Our study provides a practical, multidimensional, and validated instrument to estimate the actual skills level. It proved to better reflect the actual skills levels compared with self-reportage among recreational skiers.

A proof of principle for using adaptive testing in Routine Outcome Monitoring: the efficiency of the Mood and Anxiety Symptoms Questionnaire -Anhedonic Depression CAT.

BACKGROUND: In Routine Outcome Monitoring (ROM) there is a high demand for short assessments. Computerized Adaptive Testing (CAT) is a promising method for efficient assessment. In this article, the efficiency of a CAT version of the Mood and Anxiety Symptom Questionnaire, - Anhedonic Depression scale (MASQ-AD) for use in ROM was scrutinized in a simulation study. METHODS: The responses of a large sample of patients (N = 3,597) obtained through ROM were used. The psychometric evaluation showed that the items met the requirements for CAT. In the simulations, CATs with several measurement precision requirements were run on the item responses as if they had been collected adaptively. RESULTS: CATs employing only a small number of items gave results which, both in terms of depression measurement and criterion validity, were only marginally different from the results of a full MASQ-AD assessment. CONCLUSIONS: It was concluded that CAT improved the efficiency of the MASQ-AD questionnaire very much. The strengths and limitations of the application of CAT in ROM are discussed.

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders.

OBJECTIVE: To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting. METHODS: In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow-up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF-36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence. RESULTS: Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF-36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF-36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06-1.71). No significant differences were found within socio-demographic variables, co-morbidity and the scores on the BSI subscales between the adherence groups. CONCLUSIONS: We found that patients with low scores on the vitality subscale of the SF-36 were at the highest risk to receive low guideline-concordant care. Understanding factors that affect treatment adherence may help to prevent non-adherence and increase the quality of care as well as cost-effectiveness.

Distinguishing symptom dimensions of depression and anxiety: an integrative approach.

BACKGROUND: Clark and Watson developed the tripartite model in which a symptom dimension of 'negative affect' covers common psychological distress that is typically seen in anxious and depressed patients. The 'positive affect' and 'somatic arousal' dimensions cover more specific symptoms. Although the model has met much support, it does not cover all relevant anxiety symptoms and its negative affect dimension is rather unspecific. Therefore, we aimed to extend the tripartite model in order to describe more specific symptom patterns with unidimensional measurement scales. METHOD: 1333 outpatients provided self report data. To develop an extended factor model, exploratory factor analysis (EFA) was conducted in one part of the data (n=578). Confirmatory factor analysis (CFA) was conducted in the second part (n=755), to assess model-fit and comparison with other models. Rasch analyses were done to investigate the unidimensionality of the factors. RESULTS: EFA resulted in a 6-factor model: feelings of worthlessness, fatigue, somatic arousal, anxious apprehension, phobic fear and tension. CFA in the second sample showed that a 6-factor model with a hierarchical common severity factor fits the data better than alternative 1- and 3-factor models. Rasch analyses showed that each of the factors and the total of factors can be regarded as unidimensional measurement scales. LIMITATIONS: The model is based on a restricted symptom-pool: more dimensions are likely to exist. CONCLUSION: The extended tripartite model describes the clinical state of patients more specifically. This is relevant for both clinical practice and research.

Prevalence, demographic and clinical characteristics of body dysmorphic disorder among psychiatric outpatients with mood, anxiety or somatoform disorders.

AIMS: To describe the prevalence, demographic and clinical characteristics of body dysmorphic disorder (BDD) compared with other psychiatric outpatients with a mood, anxiety or somatoform disorder. METHOD: Outpatients referred for treatment of a mood, anxiety or somatoform disorder were routinely assessed at intake. A structured interview (MINI-Plus), observer-based and self-rating instruments were administered by an independent assessor. RESULTS: Among our sample of 3798 referred patients, 2947 patients were diagnosed with at least one DSM-IV mood, anxiety or somatoform disorder. Of these patients 1.8% (n = 54) met the diagnostic criteria for BDD. In comparison with other outpatients, patients with BDD were on average younger, less often married and were more often living alone. Highly prevalent comorbid diagnoses were major depression (in 46.3% of cases), social anxiety disorder (in 35.2% of cases) and obsessive-compulsive disorder (OCD) (in 16.7% of cases). Furthermore, patients with BDD had higher scores on the Clinical Global Impression of Severity (CGI-S) as well as lower scores on the Short Form 36 social role functioning. CONCLUSION: BDD is frequently associated with depression, social phobia and OCD. Patients with BDD have more distress and more impaired interpersonal functioning.

Prevalence and correlates of lifetime deliberate self-harm and suicidal ideation in naturalistic outpatients: the Leiden Routine Outcome Monitoring study.

BACKGROUND: Deliberate self-harm and suicidal ideation (DSHI) are common phenomena in general and mental health populations. Identifying factors associated with DSHI may contribute to the early identification, prevention and treatment of DSHI. Aims of the study are to determine the prevalence and correlates of lifetime DSHI in a naturalistic sample of psychiatric outpatients with mood, anxiety or somatoform (MAS) disorders. METHODS: Of 3798 consecutive patients from January 2004 to December 2006, 2844 (74.9%) patients were analyzed (mean age=37.5, SD=12.0; age range: 18-65; 62.7% women). Lifetime DSHI was assessed with routine outcome monitoring (ROM), including demographic parameters, DSM-IV diagnosis, depressive symptoms, symptoms of anxiety, general psychopathology and personality traits. RESULTS: Of the 2844 subjects, 55% reported lifetime DSHI. In multivariable logistic regression analysis, the most important factors associated with lifetime DSHI were being unmarried, low education, high number of psychiatric diagnoses, lower anxiety scores, higher depression scores and the personality trait of emotional dysregulation. LIMITATIONS: Deliberate self-harm may have been under-reported in self-report questionnaires; The assessment of personality traits may have been influenced by state psychopathology; traumatic events were not assessed. CONCLUSIONS: The findings suggest that DSHI is common among psychiatric outpatients with MAS disorders and that current symptoms and underlying personality vulnerabilities were independently involved in DSHI. Whether symptoms of somatic anxiety are protective should be confirmed in subsequent studies. These findings may help clinicians in identifying patients at risk for deliberate self-harm and suicide.

A randomised comparison of cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) in disaster-exposed children.

BACKGROUND: Building on previous research with disaster-exposed children and adolescents, a randomised clinical trial was performed in the treatment of trauma-related symptoms. In the current study two active treatments were compared among children in a broad age range and from a wide diversity of ethnic populations. OBJECTIVE: The primary aim was to compare the effectiveness and efficiency of Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR). DESIGN: Children (n=52, aged 4-18) were randomly allocated to either CBT (n=26) or EMDR (n=26) in a disaster mental health after-care setting after an explosion of a fireworks factory. All children received up to four individual treatment sessions over a 4-8 week period along with up to four sessions of parent guidance. Blind assessment took place pre- and post-treatment and at 3 months follow-up on a variety of parent-rated and self-report measures of post-traumatic stress disorder symptomatology, depression, anxiety, and behaviour problems. Analyses of variance (general linear model repeated measures) were conducted on the intention-to-treat sample and the completers. RESULTS: Both treatment approaches produced significant reductions on all measures and results were maintained at follow-up. Treatment gains of EMDR were reached in fewer sessions. CONCLUSION: Standardised CBT and EMDR interventions can significantly improve functioning of disaster-exposed children.

Gender differences in clinical characteristics in a naturalistic sample of depressive outpatients: the Leiden Routine Outcome Monitoring Study.

BACKGROUND: No previous large scale studies have assessed gender differences in naturalistic samples of major depressive disorder (MDD) outpatients. We therefore determined gender differences in comorbidity, symptom patterns and subjective health status in these outpatients in a mental healthcare setting. METHODS: Of 3798 consecutive adult patients (age range: 18-65), 1131 (65.1% women) fulfilled DSM-IV criteria of current MDD on the Mini-International Neuropsychiatric Interview (MINI-Plus). Patients were routinely assessed with Routine Outcome Monitoring (ROM), including the Montgomery-Asberg Depression Rating Scale (MADRS), Beck Depression Inventory (BDI-II), Brief Symptom Inventory (BSI) and Short Form-36 (SF-36). RESULTS: No gender differences were found in disease severity using the clinician-rated MADRS. However, women showed a significant higher depression severity measured with the self-report BDI-II. Also, psychopathological symptoms self-reported with the BSI were higher, and reported health status on the SF-36 was lower in women. In men with MDD, social phobia, attention deficit hyperactivity disorder, and alcohol and drug misconduct were more common comorbid disorders, while in women with MDD posttraumatic stress disorder and bulimia nervosa were more common, as well as atypical features of depression. LIMITATIONS: The use of retrospective reports of lifetime psychopathology might have led to recall bias. 20% of subjects were excluded from ROM due to language problems or logistical reasons. CONCLUSIONS: Although women self-reported higher depression severity, more severe general psychopathological symptoms and lower health status, no differences in disease severity were found on interviewer ratings. These findings could have implications for clinical decision making and treatment.

The structure and dimensionality of the Inventory of Depressive Symptomatology Self Report (IDS-SR) in patients with depressive disorders and healthy controls.

BACKGROUND: The Inventory of Depressive Symptomatology Self Report (IDS-SR) is a widely used but heterogeneous measure of depression severity. Insight in its factor structure and dimensionality could help to develop more homogeneous IDS-SR subscales. However previous factoranalytical studies have found mixed results. Therefore, the present study tested which factor structure underlies the IDS-SR and, in addition, if the factors can be used as unidimensional subscales. METHODS: Confirmatory factor analysis (CFA) was done to identify the best-fitting factor structure. The study sample consisted of 2600 individuals (mean age 40.5+/-12.1). We assessed model fit in 4 groups: 957 Major Depressive Disorder (MDD) patients, 450 remitted MDD patients, 570 patients with an anxiety disorder and 623 healthy controls to test the consistency of model fit. Rasch analyses in the full sample were used to evaluate and optimize the unidimensionality and psychometric quality of the factors. RESULTS: CFA indicated that a 3-factor model fits the IDS-SR data best and is consistent across groups, with a 'mood/cognition' factor, an 'anxiety/arousal' factor and a 'sleep' factor. In addition, Rasch analyses indicated that the 'mood/cognition' and 'anxiety/arousal' factors could be optimized to be used as unidimensional subscales. LIMITATIONS: The fit of only 4 models was tested, ranging from a 1- to 4-factor model. CONCLUSIONS: The IDS-SR is a heterogeneous instrument with a multifactorial underlying structure. It is possible to measure more homogeneous symptomatology with IDS-SR subscales, which could be useful in clinical practice and scientific research.