Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care.

OBJECTIVES: To determine whether problem solving treatment combined with antidepressant medication is more effective than either treatment alone in the management of major depression in primary care. To assess the effectiveness of problem solving treatment when given by practice nurses compared with general practitioners when both have been trained in the technique. DESIGN: Randomised controlled trial with four treatment groups. SETTING: Primary care in Oxfordshire. PARTICIPANTS: Patients aged 18-65 years with major depression on the research diagnostic criteria-a score of 13 or more on the 17 item Hamilton rating scale for depression and a minimum duration of illness of four weeks. INTERVENTIONS: Problem solving treatment by research general practitioner or research practice nurse or antidepressant medication or a combination of problem solving treatment and antidepressant medication. MAIN OUTCOME MEASURES: Hamilton rating scale for depression, Beck depression inventory, clinical interview schedule (revised), and the modified social adjustment schedule assessed at 6, 12, and 52 weeks. RESULTS: Patients in all groups showed a clear improvement over 12 weeks. The combination of problem solving treatment and antidepressant medication was no more effective than either treatment alone. There was no difference in outcome irrespective of who delivered the problem solving treatment. CONCLUSIONS: Problem solving treatment is an effective treatment for depressive disorders in primary care. The treatment can be delivered by suitably trained practice nurses or general practitioners. The combination of this treatment with antidepressant medication is no more effective than either treatment alone.

The Cardinal Needs Schedule--a modified version of the MRC Needs for Care Assessment Schedule.

This paper describes a modified version of the MRC Needs for Care Schedule (the Cardinal Needs Schedule), for measuring needs for psychiatric and social care amongst patients with severe psychiatric disorders. The modified schedule has three new features: (i) it is quick and easy to use; (ii) it takes systematic account of the views of patients and their carers; (iii) it defines and identifies need in a way that is concise and easy to interpret. The paper describes why the three new features were considered necessary, and then gives an overview of the structure of the Cardinal Needs Schedule, together with a description of how the three new features were developed. During a study of social services care management the practicality of the modified schedule was investigated and further data were obtained on the reliability and validity of the standardized approach to measuring need, in domains not previously investigated. Because of its speed and simplicity, the Cardinal Needs Schedule offers a new choice to researchers who wish to use a standardized and practical assessment of need in evaluative studies of community care. Examples of the usage of the modified schedule are given in an Appendix.

Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care.

OBJECTIVE: To determine whether, in the treatment of major depression in primary care, a brief psychological treatment (problem solving) was (a) as effective as antidepressant drugs and more effective than placebo; (b) feasible in practice; and (c) acceptable to patients. DESIGN: Randomised controlled trial of problem solving treatment, amitriptyline plus standard clinical management, and drug placebo plus standard clinical management. Each treatment was delivered in six sessions over 12 weeks. SETTING: Primary care in Oxfordshire. SUBJECTS: 91 patients in primary care who had major depression. MAIN OUTCOME MEASURES: Observer and self reported measures of severity of depression, self reported measure of social outcome, and observer measure of psychological symptoms at six and 12 weeks; self reported measure of patient satisfaction at 12 weeks. Numbers of patients recovered at six and 12 weeks. RESULTS: At six and 12 weeks the difference in score on the Hamilton rating scale for depression between problem solving and placebo treatments was significant (5.3 (95% confidence interval 1.6 to 9.0) and 4.7 (0.4 to 9.0) respectively), but the difference between problem solving and amitriptyline was not significant (1.8 (-1.8 to 5.5) and 0.9 (-3.3 to 5.2) respectively). At 12 weeks 60% (18/30) of patients given problem solving treatment had recovered on the Hamilton scale compared with 52% (16/31) given amitriptyline and 27% (8/30) given placebo. Patients were satisfied with problem solving treatment; all patients who completed treatment (28/30) rated the treatment as helpful or very helpful. The six sessions of problem solving treatment totalled a mean therapy time of 3 1/2 hours. CONCLUSIONS: As a treatment for major depression in primary care, problem solving treatment is effective, feasible, and acceptable to patients.

Emotional reactions in women attending a UK colposcopy clinic.

STUDY OBJECTIVE: To assess the emotional responses of women attending a colposcopy clinic for investigation of an abnormal cervical smear, and to elicit the women's views on the screening service and colposcopy clinic. DESIGN: Over 12 months all new attenders at a colposcopy clinic were invited to join the study. They were assessed psychiatrically four weeks before their first clinic appointment, and four weeks and 32 weeks after their first clinic appointment. SETTING: Colposcopy clinic, John Radcliffe Hospital, Oxford. PATIENTS: Of 114 women attending the colposcopy clinic for investigation of an abnormal cervical smear, 102 agreed to enter the study. MEASUREMENTS: Psychiatric symptoms were assessed with a standardised psychiatric interview, the present state examination; and with four self rated mood scales:--the general health questionnaire, the Beck depression inventory, the Leeds depression scale, and the Leeds anxiety scale. MAIN RESULTS: On all these measures, in the whole patient group, psychiatric morbidity was found to be transient and relatively minor. Thus ratings on the present state examination were not significantly higher than the rate found in a community sample of 520 women in Oxford, while on the four self rated mood scales, mean total scores were lower than the cut off value used to distinguished cases. Patient satisfaction with the colposcopy services was generally high but there was some dissatisfaction with delays. CONCLUSIONS: After an abnormal cervical smear, further investigation by colposcopy is generally associated with low levels of anxiety and depression.

Evaluation of a brief psychological treatment for emotional disorders in primary care.

A randomized trial in general practice compared: (i) a brief psychological treatment (problem-solving) given by a psychiatrist; (ii) any treatment of the GP's choice, whether psychological or pharmacological. The patients had recent onset emotional disorders of poor prognosis. Patients in the problem-solving group showed significantly greater reductions in symptoms. Problem-solving as given by a psychiatrist was feasible in primary care and acceptable to patients. Problem-solving is now being evaluated as given by general practitioners trained in the method.

The relationship between post-natal depression and mother-child interaction.

The study was based on an index group of 49 mothers who had had depressive disorders in the post-natal year, and 49 control mothers who had been free from any psychiatric disorder since delivery. Nineteen months after childbirth, the interaction between mother and child was assessed by blind assessors using defined observational methods. Compared with controls, index mother-child pairs showed a reduced quality of interaction (e.g. mothers showed less facilitation of their children, children showed less affective sharing and less initial sociability with a stranger). Similar but reduced effects were seen in a subgroup of index mothers and children where the mother had recovered from depression by 19 months. Social and marital difficulties were associated with reduced quality of mother-child interaction.

Psychological and physical determinants of premenstrual symptoms before and after hysterectomy.

The aim was to study women before and after hysterectomy (with conservation of the ovaries), in order to discover how far premenstrual symptoms are caused physically and how far psychologically. In such women both physical and psychological factors can influence premenstrual symptoms before hysterectomy; after the operation, in the absence of menstruation, only physical factors can do so. The subjects were 56 women awaiting hysterectomy for menorrhagia of benign origin. During three pre-operative months these women made daily self-ratings on a check-list in which typical premenstrual symptoms were interspersed with atypical symptoms; in this way their awareness of the premenstrual focus was minimized. Starting six months after hysterectomy, the women again kept daily check-lists for three months; over the same period their serum progesterone levels were measured to identify the premenstruum. After hysterectomy, levels of premenstrual symptoms fell significantly in the whole group, indicating that psychological factors were important determinants of such symptoms before hysterectomy.

General practice patients on long-term psychotropic drugs. A controlled investigation.

In a health centre, 3.6% of the registered patients were found to have received at least one prescription for psychotropic drugs in each quarter of a year. These patients were mainly elderly and female. Psychiatric interviews were held with randomly selected index patients, and with matched controls. Most index patients reported taking psychotropic drugs for several years, mainly anxiolytics, antidepressants and non-barbiturate hypnotics, and mainly in low dosage. Index patients had much higher levels of psychiatric morbidity, as shown by the Present State Examination, history of specialist psychiatric treatment, and previous drug overdoses. In index patients the main diagnoses were neurotic depression and phobic disorder. Index patients reported more problems with finances and with social isolation.

Psychiatric case detection in gynaecological patients.

There is a large and conflicting literature on the frequency and nature of psychiatric disorders in women with gynaecological conditions. It is difficult to interpret and compare the findings of different studies, largely because they have used non-standardised methods of case-identification. The aim of this paper is to illustrate the use of standardised methods of case detection in two gynaecological populations: women undergoing hysterectomy and those receiving elective tubal sterilisation. Three applications of case-identification techniques are described: measuring prevalence; describing features of the disorders; and testing hypotheses. Examples of each are given for the two gynaecological populations.

PIP: Examples are given of the use of case-identification techniques to measure the prevalence of psychiatric disorders, and the features of these disorders are described in 2 groups undergoing gynecological surgery, 1 group undergoing hysterectomy (mean age 42) and 1 receiving elective sterilization (mean age 35.4). 3 applications of case-identification techniques are described: measuring prevalence, describing features of the disorder, and testing hypotheses. For the technique of measuring prevalence, the Present State Examination (PSE) was administered to both groups 4 weeks before, 6 months after, and 18 months after surgery. It is shown that levels of psychiatric morbidity vary widely between the 2 groups, and in the preoperative hysterectomy groups the differences from the general population were the greatest. In the postoperative and preoperative sterilization group the proportion of cases does not differ widely from that of the general population. Using the technique of describing features of disorders, all symptoms experienced in the hysterectomy group both before and after the operation were much greater than those in the general population, especially depression, lack of energy, and general anxiety. 2 hypotheses not supported by the data were that: 1) hysterectomy and elective sterilization frequently lead to psychiatric disorder, and 2) no significant difference exists between organics and dysfunctionals, before or after surgery. 2 hypotheses proven correct were: 1) regrets at having been sterilized would be expressed by a greater proportion of women who had been psychiatric cases preoperatively, and 2) there is an association between postoperative psychiatric disorders and preoperative psychiatric status.

Teaching the doctor-patient relation to medical students. Learning experience in a behaviour therapy clinic.

The results of a 2-year trial of teaching medical students in a phobia clinic are described. This has been found a useful experience by the students, particularly as an introduction to the doctor-patient relation. The success rate and attitude of patients justified this experiment, and there might be an indication for extension to other teaching and possibly regional hospitals. The long-term benefits to the medical student are discussed.