Patient preferences for acute pain treatment.

BACKGROUND: Optimal treatment for acute pain is a function of an individual's willingness to make trade-offs between treatment side effects and pain control. The objective was to investigate the degree to which patients are willing to make these trade-offs. METHODS: Fifty patients undergoing major abdominal surgery were enrolled and completed interviews before and after surgery. Measures included an experience with pain questionnaire and an adaptive conjoint analysis (ACA) interview. RESULTS: Percentage of pain relief obtained post-surgery was between 70 and 80%. Eight-two per cent reported at least one moderate or severe side effect. ACA results demonstrated that pain efficacy and side effect type/severity have almost equal 'importance' scores. Patients varied in their willingness to trade-off pain efficacy for different or milder side effects. CONCLUSIONS: We conclude that people have different relative preferences for different side effects and are willing to trade-off pain relief for less upsetting and/or less severe side effects but to different degrees. Thus, physicians should consider offering pain medications with fewer side effects than narcotics as a first choice. Our study indicates the need to balance analgesia and side effects in order for patients to achieve optimal pain control.

Research review on anger in psychotherapy.

This article selectively reviews clinically relevant research on the theory and treatment of anger. Anger is first defined, within the context of emotion theory, as the cognitive, behavioral, physiological, experiential, and social manifestations of a central nervous system process. The theories and techniques used to treat anger from several theoretical perspectives are then evaluated, making conceptual links to a basic affective model. We then review research on the treatment of anger in clinical populations (aggressive adults and children, clients with post-traumatic stress disorder, and clients with cardiovascular disease). We conclude with a discussion of anger suppression and inhibition.

HIV sexual risk behavior following bereavement in gay men.

The present study followed a group of 100 gay men up to 1 year before and 1 year after losing a partner to AIDS (University of California, San Francisco Coping Project). Following bereavement, participants were at increased risk for engaging in unprotected anal intercourse: at 4 to 6 months for HIV-negative men and at 8 to 12 months for HIV-positive men. Sociodemographic variables, HIV serostatus, substance use, depression, prebereavement relationship quality, and social support did not explain sexual risk-taking in this sample. However, men who engaged in unprotected anal intercourse were twice as likely to be involved in a new primary relationship as those who did not. The authors concluded that risk varies over time by HIV status and may involve engagement in new relationships.

Observational assessments of the interaction of implant recipients with family and peers: preliminary findings.

Two experiments were conducted to determine the feasibility of direct observational methods in the assessment of social interactions between cochlear implant recipients and their families and peers. With laboratory analogs of parent-child interactions and peer interactions, children with implants and deaf children were videotaped. These videotapes were then coded for specific patterns of behavior. The results established the feasibility of direct observational assessments of deaf children and implant recipients and identified behavioral foci that could serve as effective indexes of implant outcome. The study also suggested that the peer entry paradigm may not be suitable for deaf children under the age of 7 years.

Linguistic predictors of adaptive bereavement.

The words people use in disclosing a trauma were hypothesized to predict improvements in mental and physical health in 2 studies. The first study reanalyzed data from 6 previous experiments in which language variables served as predictors of health. Results from 177 participants in previous writing studies showed that increased use of words associated with insightful and causal thinking was linked to improved physical but not mental health. Higher use of positive relative to negative emotion words was also associated with better health. An empirical measure that was derived from these data correlated with subsequent distress ratings. The second study tested these models on interview transcripts of 30 men who had lost their partners to AIDS. Cognitive change and empirical models predicted postbereavement distress at 1 year. Implications of using computer-based text analyses in the study of narratives are discussed.

Helping clients with HIV disease navigate managed care.

AIDS: The transition of medical care from fee-for-service to managed care is having an impact on health and mental health practitioners who provide care to people with HIV and AIDS. Evidence suggests that the quality of managed care is not adequate for older patients and patients with chronic diseases. Satisfaction with a managed care plan is often linked to perception of the plan's convenience, the relationship with one's primary health care provider, and the limits on out-of-pocket expenses. Dissatisfaction is linked to inefficient service, limits on choice of provider, and substandard care. The experiences of mental health care providers and recipients in the managed care system are discussed. Advocates note enhanced communication among health care providers and opponents voice concerns about regulation. The greatest concern is that treatment decisions will be based on factors other than the client's needs and best interests. Managed care has the potential to constrain psychotherapeutic treatment, however, understanding managed care plans can result in creative treatment approaches and strategies.^ieng

Relationship between changes in EMG and respiratory sinus arrhythmia in a study of relaxation therapy for asthma.

This paper reports the relationships among changes in cardiovagal activity, surface EMG, and measures of pulmonary function in a study of relaxation therapy for asthma. Changes in FEV1/FVC were negatively correlated with those in cardiac interbeat interval, consistent with the hypothesis that relaxation-induced changes in airway function are mediated autonomically, with increased vagal tone and/or decreased sympathetic arousal producing bronchoconstriction. Contrary to Kotses's theory of a vagal-trigeminal reflex as mediator for relaxation-induced improvement in asthma, decreases in pulmonary function occurred during relaxation sessions, accompanied by increases in cardiovagal activity, and within-session changes in frontal EMG in the first session of training were positively associated with changes in a measure of pulmonary function (FEV1/FVC). However, consistent with this hypothesis, first-session frontalis EMG changes were positively associated with changes in respiratory sinus arrhythmia, and last-session changes in cardiac interbeat interval were positively associated with changes in FEV1/FVC. The results suggest that the immediate effects of generalized relaxation instruction can be associated with a parasympathetic rebound, which, in tum, may induce countertherapeutic changes in asthma. However, the effects of specific facial muscle relaxation remain unclear.

Depressive affect and survival among gay and bisexual men infected with HIV.

BACKGROUND: Although depression has been related to chronic disease processes and outcomes, studies examining the relationship between depression and disease progression in persons with human immunodeficiency virus (HIV) infection have produced inconsistent results. OBJECTIVE: To investigate whether depressive affect is associated with HIV mortality. METHODS: This was a prospective cohort study (San Francisco Men's Health Study) using a population based probability sample of single men living in areas of San Francisco, Calif, with high case rates of acquired immunodeficiency syndrome. Data collection was at 6-month intervals with up to 15 waves of follow-up. Subjects included all 402 homosexual or bisexual men who in July 1984 had serologic evidence of HIV infection and who survived a minimum of 1 wave after baseline. Depressive affect was measured at each wave with the affective subscale of the Center for Epidemiologic Studies-Depression Scale. Laboratory markers, World Health Organization staging, antiretroviral use, and hospitalizations were also used as predictor variables. The primary outcome measure was survival. RESULTS: In a Cox proportional hazards model, a time-dependent measure of depressive affect was associated with greater mortality (adjusted risk ratio, 1.67; 95% confidence interval, 1.01-2.78). CONCLUSIONS: Depressive affect was associated with mortality risk, highlighting the importance of diagnosis and treatment of depression among HIV-infected gay and bisexual men. Replication of this effect in incident cohorts with well-characterized dates of HIV infection is needed and, if replicated, an exploration of mediating pathways suggested.

Admission requirements, acceptance rates, and financial assistance in clinical psychology programs. Diversity across the practice-research continuum.

129 directors (80% response) of APA-accredited clinical psychology programs provided information pertaining to admission requirements, acceptance rates, financial assistance, and theoretical orientations. Summary data are presented and comparisons are made among 4 types of clinical programs: PsyD programs, practice-oriented PhD programs, equal-emphasis PhD programs, and research-oriented PhD programs. Clinical doctoral programs held similar expectations for undergraduate preparation in psychology, but robust differences emerged on preferred Graduate Record Examination scores, acceptance rates, and financial assistance. In the most extreme comparison (PsyD vs. research-oriented PhD programs), students were 4 times more likely to gain acceptance but 6 times less likely to receive full financial assistance in PsyD programs. Implications of these results for potential graduate students and for the future of applied psychology programs are briefly discussed.

Relaxation and music therapies for asthma among patients prestabilized on asthma medication.

One hundred six asthmatic subjects were medically prestabilized, then assigned to eight sessions of progressive relaxation, music, or a waiting-list. Seventy-two subjects completed treatment, of which 37 were evaluated in the laboratory with measures of forced expiratory flow. Relaxation-group subjects reported feeling the most deeply relaxed and produced the greatest improvement in forced expiratory flow during the last presession assessment period. All groups evidenced decreases in asthma symptoms. All groups showed decreases in pulmonary function immediately after relaxation sessions. None of the changes in pulmonary function reached levels that are accepted in drug trials to be of clinical significance, and the therapeutic changes occurred only in the situation where training was rendered. Listening to music produced greater decreases in peaks of tension than progressive relaxation, and it produced greater compliance with relaxation practice, but it did not produce any specific therapeutic effects on asthma.

Survey of current clinical and research trends in clinical psychology.

A survey of the directors of APA accredited clinical psychology programs was conducted to explore current trends in the training of clinical psychologists. Specifically, information was obtained regarding the research areas represented at each school, the types of clinical training sites available to graduate students, and the prevalence of different clinical orientations (e.g., cognitive-behavioral, systems, or psychoanalytic). Results of the survey provide a summary of the activities of faculty and students at the more than 100 fully accredited clinical psychology programs.