Possible interaction of zopiclone and nefazodone.

OBJECTIVE: To describe a case in which concurrent treatment with nefazodone was associated with an elevation in the plasma concentration of zopiclone, possibly resulting in enhanced hypnosedative efficacy. CASE REPORT: An 86-year-old white woman was treated with nefazodone for depression. Zopiclone was also introduced for the management of insomnia, but she subsequently experienced morning drowsiness. The concentration of zopiclone in plasma was subsequently measured eight hours after administration on two occasions, during nefazodone therapy and after its withdrawal. After discontnuation of nefazodone, the plasma concentration of the S-enantiomer of zopiclone decreased from 107 to 16.9 ng/mL, while the R-enantiomer plasma concentration decreased from 20.6 to 1.45 ng/mL. DISCUSSION: Nefazodone is a relatively potent inhibitor of CYP3A4, a hepatic isoenzyme thought to play a major role in the metabolic elimination of zopiclone. The substantial decrease in the plasma zopiclone concentrations observed after withdrawal of nefazodone likely reflects a drug interaction. Despite the normally short elimination half-life of zopiclone, the residual sedation initially observed in this case suggests that the interaction may have clinical significance. CONCLUSIONS: The features observed in this case suggest the possibility of a drug-drug interaction between nefazodone and zopiclone. Further prospective investigation is required to elucidate the nature and magnitude of this effect.

Drowning and near-drowning in Northern Territory children.

OBJECTIVE: To compare incidences of drowing for children in the Northern Territory (NT) with those in Queensland and the rest of Australia. DESIGN: Descriptive, retrospective, population-based analysis of death and hospitalisation data for drowning and near-drowning. SETTING AND PARTICIPANTS: Children aged 0-14 years resident in Australia from 1983 to 1998. MAIN OUTCOME MEASURES: Age-standardised average annual incidence of drowning (1983-1998) and near-drowning (1994-1997) in children aged 0-4 and 5-14 years in the NT, Queensland and the rest of Australia. RESULTS: The average annual incidence of drowning and near-drowning from 1994 to 1997 for children aged 0-4 years in the NT (67.82 per 100,000) was significantly higher than for Australia (24.45 per 100,000) (incident rate ratio [IRR], 2.77; 95% CI, 1.40-4.91) and for Queensland (32.55 per 100,000) (IRR, 2.13; 95% CI, 1.05-3.94). The proportion of children aged 0-4 years drowning or near-drowning in swimming pools from 1994 to 1997 was also significantly higher in the NT (83%) than Australia (64%) (difference, 0.19; 95% CI, 0.086-0.30) and Queensland (65%) (difference, 0.18; 95% Cl, 0.069-0.29). From 1983 to 1998, the incidence of drowning in NT children aged 0-4 years increased by 0.4% per year (IRR, 1.004; 95% Cl, 0.994-1.070), compared with a 5.0% reduction per year (IRR, 0.950; 95% Cl, 0.937-0.963) in Australian children. CONCLUSIONS: The incidences of drowning and near-drowning in the NT are higher than in the rest of Australia and show no significant decrease. The NT should improve its measures for prevention of childhood drowning.

Australian adolescents' attitudes and beliefs concerning pregnancy, childbirth and parenthood: the development, psychometric testing and results of a new scale.

Recent research suggests that many adolescents hold unrealistic and idealised beliefs about the likely consequences of pregnancy and parenthood. Such attitudes potentially play an important role in the aetiology of adolescent pregnancy. Disillusionment with reality may also contribute to postnatal depression, domestic violence and child abuse. This paper reports on the development of a scale to measure the prevalence of such beliefs. The scale was administered to a sample of 1546 Australian adolescents. Between one-quarter and one-third of the sample exhibited idealised beliefs, with males having higher levels of idealization. On factor analysis, the idealization construct comprised an overestimation of positive aspects and an underestimation of negative ones. Subjects reported that very few of their beliefs derived from formal educational input.

Characteristics of tranquilizer use among Australian Vietnam War veterans.

OBJECTIVE: To examine characteristics of tranquilizer use in a cohort of Australian Vietnam War veterans. DESIGN: Prospective analysis of medication use and assessment of social and clinical variables, including tranquilizer dependence. PATIENTS: Fifty-one Australian Vietnam War veterans were recruited from the department of psychiatry of an Australian teaching hospital. All subjects were men, with a mean +/- SD age of 52.2 +/- 3.3 years. MAIN OUTCOME MEASURES: A structured interview was used to obtain details of medical and psychiatric history, medication use, substance use, forensic history, and health service utilization data. Anxiety was assessed using the Hamilton Anxiety Rating Scale (Ham-A). A validated tranquilizer dependence rating scale was administered for each patient. RESULTS: Commonly used tranquilizers included diazepam (n = 19 patients) and zopiclone (26). Most patients (44) reported the use of one or more drugs for the purpose of nighttime sedation, while exclusive daytime use of tranquilizers for anxiolytic effect was uncommon. The median time spent in the hospital during the preceding year was 21.0 +/- 56.8 days. Symptoms of anxiety were prevalent, with a mean Ham-A score of 35.5 +/- 7.8. Screening criteria suggestive of tranquilizer dependence were met in 34 subjects. Health service utilization was correlated with tranquilizer intake and overall medication use. Tranquilizer dependence was independently associated with cigarette smoking (p = 0.039; odds ratio = 5.13, 95% CI 1.08 to 24.33). CONCLUSIONS: This study provides insight into the nature of tranquilizer use in an Australian population of Vietnam War veterans. The extensive use of these drugs suggests that further research and possibly intervention in this area is needed.

The assessment of depression in the postnatal period: a comparison of four self-report questionnaires.

OBJECTIVE: The objective of this study was to ascertain the degree of agreement between four self-report depression scales, with particular emphasis on whether each scale would identify the same subgroup of women as being 'most depressed'. METHOD: The questionnaires were administered to a sample of approximately 200 postnatal women at 4 weeks, 4 months and 8 months after delivery. The instruments were: the Edinburgh Postnatal Depression Scale; the depression subscale of the Hospital Anxiety Depression Scale; the Zung Self-Rating Depression Scale; and the depression subscale of the Profile of Mood States. RESULTS: Agreement between pairs of instruments, in terms of identifying the most depressed subgroup of women in the cohort, only averaged approximately 40%. Agreement between the three instruments was only about 25%. CONCLUSIONS: This poor level of agreement most likely reflects the different emphasis in item content of the questionnaires, which in turn reflects different notions of 'depression' held by the designers of the instruments. The implications of the findings for research and clinical practice are discussed.

The correlates of antenatal attachment in pregnant women.

Maternal-foetal attachment represents the earliest and most basic form of human intimacy, and has both theoretical and clinical significance. Utilizing a previously published self-report questionnaire to assess antenatal attachment, the present paper explores its correlates using 238 women in the third trimester of pregnancy. Extrapolating from studies of maternal-infant attachment, it was hypothesized that depression and a lack of social support would be detrimental to the development of maternal antenatal attachment. The findings confirmed these hypothesized effects. In particular, the subgroup of women having low attachment was characterized by high levels of depression and anxiety, low levels of social support (outside the partner relationship) and high levels of control, domination and criticism within the partner relationship. Antenatal attachment may be predictive for future maternal-infant attachment. The findings suggest that negative mood states and lack of social support during pregnancy may warrant greater attention than has previously been accorded them.

The psychological sequelae of miscarriage: a critical review of the literature.

Miscarriage, although a common event in pregnancy, has been frequently overlooked in psychological research. This paper reviews the literature on the psychological sequelae of miscarriage, including the shortcomings of that literature. Best understood against the background of psychological changes in early pregnancy, the literature reveals aspects of grief specific to miscarriage. Important components of this grief comprise high levels of guilt, the loss of part of the self and a large impact upon personal identity. The psychological sequelae impact upon other family members, including partners and surviving children. Psychiatric consequences include depression, anxiety and posttraumatic stress disorder. Given the potentially serious nature of these sequelae, it behooves the psychiatrist to inquire routinely about pregnancy loss in all female patients.

University students' subjective experiences of oral contraceptive use.

A substantial proportion of women who commence oral contraceptive discontinue usage due to unwanted side-effects. In investigations of side-effects in current users, such women are excluded, and hence such studies will tend to underestimate the prevalence of side-effects. One hundred and forty-five female university students (both former and current users) completed a questionnaire focusing on their experiences of the impact of oral contraceptives upon their psychological and physical well-being. Although, on average, over half the women reported no effect, the vast majority of those who did report a change in well-being deemed this to be negative. The only exception was pelvic pain which was reported to be improved by oral contraceptive use.

PIP: To determine the subjective experiences of the effects of oral contraceptive (OC) usage upon well-being, questionnaires were distributed to 200 female students and staff members of an Australian university. 145 completed questionnaires provided information on 1) sociodemographics (mean age of 26); 2) past (45%) and current (55%) OC usage, including discontinuation because of side effects and the reason for using OCs; 3) the difference in the subject's premenstrual psychological state when using and not using Ocs (all significant results showed perceived deterioration); 4) changes with OC use in physical premenstrual symptomatology (all were negative except for the beneficial effect on pelvic pain before and during menstruation); 5) the effect of OC use on overall physical and emotional well-being (a significantly deleterious effect was reported for these factors and for eating behavior, and duration of use did not reduce side effects); 6) whether the respondent believed the OC was damaging her body in any way (73% were concerned with longterm fertility, increased risk of cancer, had nonspecific fears, or feared cardiovascular complications); 7) any beneficial effects other than contraception attributable to OC use (83% reported such effects as reduced pain, a more regular cycle, and decreased menstrual flow); and 8) whether the women believed that medical staff had adequate knowledge of the side effects of OCs (46% believed that medical staff did not have adequate knowledge). None of these findings could be linked to type of OC used. These preliminary findings require replication in a larger study.

Investigation of the reliability and factor structure of a questionnaire for assessment of the premenstrual syndrome.

Data are presented from 696 women who completed a 35-item retrospective self-report PMS questionnaire. Item analysis resulted in the elimination of six items which predominantly reflected physical symptomatology. The resultant (29-item) questionnaire demonstrated a coefficient alpha value of 0.94 corresponding to a very high level of internal consistency and split-half reliability. It is argued that discrepancies in previous PMS research based on questionnaire data may, in part, be due to inadequate attention being devoted to achieving homogeneity of the PMS construct. A high level of internal consistency is a necessary condition for global PMS scores to be meaningful. Factor analysis of the revised questionnaire resulted in a two factor model corresponding to 'dysphoria' and 'dysfunction'. This leads to a simple four quadrant typology of PMS which may further understanding of this 'purer' PMS construct.

The assessment of antenatal emotional attachment: development of a questionnaire instrument.

The nature of the relationship which female and male expectant parents develop during pregnancy with their unborn baby has both theoretical and clinical significance. It potentially provides a framework for improved understanding of many aspects of psychosomatic obstetrics, including reactions to foetal loss. Existing instruments designed to assess this relationship inadequately differentiate between attitude to the foetus per se versus attitude to the pregnancy state or motherhood role. The present paper presents a theoretical model of the subjective experiences of human attachment. This is utilized to develop a questionnaire to assess the antenatal attachment construct. Item analysis results in a 19-item maternal and 16-item paternal questionnaire with high levels of internal consistency. Each takes approximately five minutes to complete. Finally, the factor structures of the resultant questionnaires are explored.

The premenstrual syndrome: a twin study.

Data are presented from 157 monozygotic and 143 dizygotic female twin pairs of reproductive age who completed a self-report questionnaire on the premenstrual syndrome (PMS). For global PMS scores, the correlation coefficient for the monozygotic twins (0.55) was double that of the dizygotic ones (0.28). The results are consistent with the hypothesis that aggregation for global PMS scores is determined by genetic factors acting additively over a number of loci. Two alternative explanations are suggested: that monozygotic twins share greater environmental similarities than dizygotic ones; or that PMS scores may be a reflection of some other underlying characteristic (such as neuroticism), which is itself genetically determined.

Medical litigation. The aetiological role of psychological and interpersonal factors.

The present paper focuses upon psychological factors which may cause patients to make formal complaint or embark upon legal proceedings against a doctor despite competent medical management. Although the principles involved arose from experience of liaison psychiatry in neonatal and obstetric settings, they are more broadly applicable to other areas of medical practice. The corner stone of prevention is appropriate psychological management. One of the most common forms of psychological mismanagement is a failure to share information openly with patients when it becomes available. Sometimes, despite exemplary medical and psychological management, grievance proceedings are still initiated. Often in such cases the cause lies in the patient's psychopathology. Finally, formal complaint or litigation may arise as a result of the patient's unrealistic expectations of the doctor.

The influence of parity on the experience of pregnancy: a comparison of first- and second-time expectant couples.

There is a belief prevalent in Western society that pregnancy is more stressful for first-time expectant couples. Few research studies have addressed this issue and the existing findings, on both men and women, are conflicting. The present investigation found higher psychological symptom levels in both members of second-time expectant couples in the third trimester; however, differences reached statistical significance only for men. Second-time couples tended to have lower emotional attachment to their unborn baby. The results are discussed in terms of the influence of parity on stresses arising both from the pregnancy experience and the environment.

Changes in smoking and drinking during pregnancy.

Changes in alcohol and nicotine usage during pregnancy are reported from a sample of 40 pregnant women, 28 of whom smoked prior to pregnancy and 32 of whom drank alcohol. Although most women wanted to reduce or stop their intake during pregnancy, the drinkers were far more successful in their attempt than the smokers. Thus, 85% of drinkers achieved or bettered their target behaviour (in terms of consumption), while 53% of smokers 'failed' in their attempt. Women can identify reasons which influence their smoking and drinking behaviour during pregnancy and, in particular, the amount of emotional attachment to the unborn child appears to be important. However, endorsement of a particular reason does not appear to relate in any simple way to actual consumption, and a major disparity between health beliefs and actual behaviour was apparent. Implications for primary prevention programmes and future research are discussed.

The assessment of type A behaviour pattern: results from a spouse-report approach.

Evidence is summarized suggesting that existing self-report questionnaires for the assessment of Type A behaviour pattern suffer from major methodological shortcomings. Type A individuals may be unwilling or unable to accurately self-report. The female spouse of the male patient can potentially provide a more objective, accurate 'trait' description less contaminated by 'state' variables such as diagnosis of illness or medication. The development of a spouse-report questionnaire is described and pilot data from 41 couples are presented, including comparison of the self-report and spouse-report responses on 46 questionnaire items and five scales. Unexpectedly high levels of agreement were found between self and spouse reports. Possible explanations of such agreement are critically examined.

A comparison of smoking and drinking behaviours in pregnant women: who abstains and why.

Changes in alcohol and nicotine usage during pregnancy are reported for a sample of 112 pregnant women, 35 of whom smoked cigarettes before pregnancy and 86 of whom drank alcohol before pregnancy. Striking differences were observed among the patterns of cigarette smoking compared with those of drinking. One hundred per cent of drinkers reported a reduced intake of alcohol but only 57% of the smokers reported a decrease in cigarette smoking. Forty per cent of the smokers reported that they had "tried and failed" to cut down on their cigarette consumption yet none of the drinkers reported such a failure. A reduction in drinking during pregnancy was related directly to an antenatal emotional attachment to the fetus and related inversely to feelings of irritability towards the fetus. In the case of smoking, this relationship did not emerge, and it seemed probable that a psychological and a physiological dependence on nicotine may override the effect of an emotional attachment to the fetus. Implications for the prevention of smoking are discussed.

"The battered fetus syndrome". Preliminary data on the incidence of the urge to physically abuse the unborn child.

Recently published reports of physical assault by women in late pregnancy upon their unborn children have elicited a response of incredulity in many professionals. This response is identical to that which followed the publication of the first cases of child abuse in the 1960s. The present paper attempts a preliminary exploration of the incidence of the urge to "hurt or punish" the unborn child using a sample of 112 normal pregnant women and their male partners. Eight percent of the women and 4% of the men acknowledged experiencing such an urge. The male partner appeared to be aware of the woman's aggressive feelings toward the fetus and the male's reports tend to validate the female findings. Despite some methodological shortcomings, the findings suggest that the urge to physically assault the fetus is not rare. The need for further investigation of the phenomenon is highlighted, as it may well represent the earliest precursor of later physical child abuse.

Altered cognitive functioning in pregnant women: a shift towards primary process thinking.

Psychoanalytically orientated writers have independently described an alteration in psychological functioning, which occurs in many pregnant women, and is probably best described as a shift towards a primary process mode of thinking. This literature is reviewed and an illustrative case history provided. Unlike affective changes during pregnancy, alterations in cognitive style have received little attention despite their significant diagnostic and psychotherapeutic implications. The phenomenon invites collaboration between the biological and psychoanalytic orientations within psychiatry further to investigate it.