Life events and onset of illness.
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Abdominal Pain↗
Biomedical subjects
F Creed
Publications and source records attributed to F Creed.
Randomised controlled trial of day patient versus inpatient psychiatric treatment.
OBJECTIVE: To assess the proportion of acutely ill psychiatric patients who can be treated in a day hospital and compare the outcome of day patient and inpatient treatment. DESIGN: Prospective randomised controlled trial of day patient versus inpatient treatment after exclusion of patients precluded by severity of illness or other factors from being treated as day patients. All three groups assessed at three and 12 months. SETTING: Teaching hospital serving small socially deprived inner city area. Day hospital designed to take acute admissions because of few beds. PATIENTS: 175 Patients were considered, of whom 73 could not be allocated. Of the remaining 102 patients, 51 were allocated to each treatment setting but only 89 became established in treatment--namely, 41 day patients and 48 inpatients. 73 Of these 89 patients were reassessed at three months and 70 at one year. INTERVENTIONS: Standard day patient and inpatient treatment. MAIN OUTCOME MEASURES: Discharge from hospital and return to previous level of social functioning; reduction of psychiatric symptoms, abnormal behaviour, and burden on relatives. RESULTS: 33 Of 48 inpatients were discharged at three months compared with 17 of 41 day patients. But at one year 9 of 48 inpatients and three of 41 day patients were in hospital. 18 Of 35 day patients and 16 of 39 inpatients were at their previous level of social functioning at one year. The only significant difference at three months was a greater improvement in social role performance in the inpatients. At one year there was no significant difference between day patients and inpatients in present state examination summary scores and social role performance, burden, or behaviour. CONCLUSIONS: Roughly 40% of all acutely ill patients presenting for admission to a psychiatric unit may be treated satisfactorily in a well staffed day hospital. The outcome of treatment is similar to that of inpatient care but might possibly reduce readmissions. The hospital costs seem to be similar but further research is required to assess the costs in terms of extra demands on relatives, general practitioners, and other community resources.
Acute Disease↗
Measurement of psychiatric disorder in rheumatoid arthritis.
In a detailed physical and psychiatric assessment of 80 patients with definite or classical rheumatoid arthritis (RA) different instruments were used to measure psychiatric disorder. The prevalence of psychiatric disorder was 21% when assessed by the PSE/CATEGO programme and 24% according to RDC criteria, but these figures were nearly doubled if a lower threshold was used to define psychiatric disorder. This study demonstrates how symptoms directly attributable to arthritis may inflate the estimated prevalence of psychiatric disorder in RA and erroneously indicate a direct relationship between severity if RA and psychiatric disorder. In fact, the best prediction of psychiatric disorder resulted from using a combination of measures of social stress and severity of RA.
Activities of Daily Living↗
Somatization and illness behaviour in a neurology ward.
One hundred and thirty-three female patients admitted to a neurological ward were fully investigated for the presence of organic neurological disease, and assessed for psychiatric disorder and illness behaviour, using the Clinical Interview Schedule (CIS) and the Illness Behaviour Questionnaire (IBQ). The likelihood of the presenting symptoms being due to organic disease was expressed by the neurologists on a visual analogue scale and the psychiatrists used a similar technique to describe whether the symptoms could be the result of psychiatric disorder. Many patients either had clear organic disease or somatic presentation of psychiatric disorder 'somatization', but one-third fell between these two extremes and either had a complex mixture of the two types of illness or could not be accurately diagnosed. The IBQ scores were raised in those with psychiatric disorder but did not help to explain why some patients present to the neurologists with symptoms that are unexplained by either organic disease or psychiatric disorder. Close liaison between neurologists and psychiatrists increases the detection of psychiatric disorder but some patients would require long-term follow-up to understand the true nature of the underlying disorder.
Adolescent↗
Life events and psychological disturbance in patients with low-back pain.
To elucidate the possible contribution of psychologic factors in the pathogenesis of back pain, an assessment of life events and psychiatric symptoms was undertaken in 80 new referrals. In 57, the back pain had a definite onset recent enough to allow this to be dated accurately; these definite onset cases were divided into 26 in whom a specific organic diagnosis could be made and 31 in whom the cause of the pain was uncertain. An additional 23 patients had chronic pain, or could not date the onset of their symptoms. Unlike previous studies, events that occurred after the onset of back pain and thus could have been a consequence of the back pain were excluded. Before onset of back pain there was a significant excess of adverse life events in those with definite onset back pain of uncertain cause, compared with those with a specific diagnosis: there was no such excess in the periods before referral and attendance at the clinic. Diagnosable psychiatric illness was virtually confined to those with chronic pain. These findings indicate that stress, but not psychiatric illness, is involved in the onset of back pain. Further research is now required to ascertain whether those patients who have many psychiatric symptoms at the time of onset are those who develop chronic pain.
Adult↗
Psychiatric morbidity among mothers attending well-baby clinic: a cross-cultural comparison.
The Self Reporting Questionnaire (SRQ), a screening instrument developed for psychiatric disorders in developing countries, was administered to 149 mothers, half of whom where non-white, attending a well-baby clinic in Manchester, United Kingdom. Psychiatric interview confirmed that high scorers on the SRQ could be given DSM-III diagnoses of anxiety and depression, but the cut-off point on SRQ for being a definite psychiatric case was found to be 7/8, higher than previous validation studies. This was the same for Asians as well as white mothers. Comparison of somatic versus psychological scores between Asian and white mothers showed no significant difference across the range of total SRQ scores. Over half of the mothers who were psychiatric cases were attending their doctors and all the Asian women doing so were attending for somatic symptoms. This study suggests that when measured in a well-baby clinic, somatic and psychological symptoms are reported equally frequently by white and Asian immigrant women in the United Kingdom but somatic symptoms predominate when Asian women consult a doctor.
Adult↗
Psychological disorders in rheumatoid arthritis: a growing consensus?
Previous reviews of psychological factors in arthritis have emphasised the methodological weaknesses of many studies, especially those attempting to measure personality after years of disabling disease. To make sense of the published reports three factors need to be considered separately: previous personality, social stresses, and current mental state. Each can now be measured reliably and independently of symptoms which might be directly attributable to the arthritis. There is a growing consensus that the normal range of personality is represented among patients with early arthritis, that the prevalence of depression is similar to that of patients with other medical conditions, and that social stress is more closely related to depression than activity and the disabling effect of arthritis. Longitudinal studies are now required to examine which social stresses can be attributed to the disabling effect of arthritis. Depression and social stress often manifest themselves to the rheumatologist as excessive complaints of pain and frequent clinic attendances so appropriate psychosocial treatments may reduce this behaviour.
Anxiety Disorders↗
Psychiatric referrals within the hospital--the communication process.
This two part study examined the written communication between psychiatrists and other hospital doctors. In the first part a set of sample letters from a psychiatrist, who had seen a ward referral, was sent to 110 physicians and surgeons. Nearly half expressed a preference for a psychiatrist's letter that was one page long with main points underlined. Clarity of psychiatric diagnosis and opinion and clear treatment/follow-up arrangements were the key items of content. In the second part 100 consecutive referral letters and their replies were assessed; 20% of referral letters did not express the precise reason why psychiatric opinion was sought and many of the psychiatrists' replies did not describe adequately the follow-up arrangements and prognosis. In general the psychiatrist found the referral letters short and lacking in information whereas referring doctors found the brief replies from the psychiatrists preferable because the brief letters contained the key items mentioned in the first part of the study. In addition to these recommendations regarding written communications, this study emphasizes the need for personal discussion between psychiatrists and other hospital doctors; nearly half the doctors in the first part of the study thought this would be essential for good management of the patient.
Communication↗
Life events and the onset of mania.
Thirty manic in-patients were interviewed in hospital using the LEDS, and 24 were re-interviewed 6-12 months after discharge. Data for life events were analysed by: comparing events before onset of mania and before re-interview; and comparing these manic patients with patients in other studies which examined life events and the onset of schizophrenia and depression. No relationship was found between life events and the onset of mania in this preliminary study. Previous studies reporting a link between events and the onset of mania have serious methodological flaws, and definitive data have yet to be produced.
Adolescent↗
General practitioner referral rates to district psychiatry and psychology services.
The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.
Clinical Competence↗
The treatment of somatization: evaluation of a teaching package with general practice trainees.
A teaching package is described which aims to improve the management of somatization by general practice trainees. The package comprises a training videotape in which a model (described in the preceding paper) is demonstrated, together with material for paired role-play of new skills and small group videofeedback of consultations. Evaluation of the teaching package reveals that the skills can be effectively learned.
Education, Medical, Continuing↗
Psychological treatments of the irritable bowel syndrome: a review.
Psychological treatments are increasingly being used to help patients with the irritable bowel syndrome (IBS), but the efficacy of such treatments is still debated. This review indicates that there are three ways in which they might have been effective in published studies to date; relating bowel symptoms to stress, specific help with psychosocial problems/relationships and relaxation to decrease anxiety and tension. A close doctor-patient relationship is regarded as central to these therapeutic tasks but the time required to maximise the effectiveness of this therapeutic role means that intensive psychological treatment should be reserved for those IBS patients who do not respond to first line standard medical treatment. There are insufficient data to indicate at present which patients are best suited to each form of psychological treatment.
Colonic Diseases, Functional↗
Day-hospital and community treatment for acute psychiatric illness. A critical appraisal.
Findings on the efficacy of day-hospital and community treatment for acutely ill psychiatric patients have been contradictory. This review confirms the methodological problems previously noted, but highlights the variation in feasibility of day care: staffing levels and the attitudes of staff appear to have been responsible, along with the severity and chronicity of illness. The comparison of day and in-patient care to see which is 'superior' has been unrewarding, and further research is needed. Day-hospital treatment is unlikely to be more widely used for acutely ill patients until: (a) there is clear evidence that certain patients are best treated in this way; (b) the social and clinical characteristics of such patients are defined; (c) adequate staffing is achieved (i.e. day care is not regarded as a cheap option); and (d) day centres are available for chronic patients.
Community Mental Health Services↗
Treatment of severe psychiatric illness in a day hospital.
Severity of psychiatric illness was assessed using standardised clinical and social measures in 69 in-patients and 41 day patients admitted consecutively from the community. Day and in-patients differed little in terms of psychiatric symptoms and social disability, especially if compulsory admissions were excluded. Protection of self or others was a common reason for in-patient admission given by clinicians, who were otherwise prepared to treat seriously ill patients in the day hospital. Very few of the day patients had to be transferred to the in-patient facility, and at three months and one year the two groups showed similar improvements. It is concluded that day treatment is feasible for some seriously ill psychiatric patients, but a random-allocation study is required to assess more completely the efficacy of day treatment, and define the characteristics of those who require in-patient admission.
Adult↗
Life events and hostility in self-poisoning.
Life events in 82 self-poisoning subjects were studied using the Bedford College LEDS to see whether there was a difference between those who had a clear depressive syndrome (according to the Present State Examination) and the remainder. Equally high levels of severely threatening events were found in the depressed and non-depressed groups, but the former were older, had experienced more chronic difficulties and had been treated more often in the past for depression. Greatest numbers of life events were found in those with high levels of extrapunitiveness (recorded on the HDHQ), whereas those who had not experienced a severe life event showed predominance of intropunitiveness. Suicidal intent was not related to experience of life events, but has previously been shown to be associated with high intropunitiveness. The findings are discussed in the light of current theories linking life events, depression and parasuicide, and emphasise the need for longitudinal studies to examine these factors in relation to repeated parasuicide.
Adolescent↗
Liaison psychiatry in general practice: a comparison of the liaison-attachment scheme and shifted outpatient clinic models.
Most psychiatrists who visit health centres use the shifted outpatient clinic model, the main aim of which is to improve secondary care by providing it in the primary care setting. For five years we have employed a liaison-attachment scheme in which support and advice from the psychiatrist enables general practitioners to improve their care of patients with psychiatric and psychological problems. One of the advantages of the latter model is that the psychiatrist can contribute to the care of patients not seen by the specialist psychiatric service and also to the development of the primary care team. The scheme is cost effective as psychiatrists can advise on the care of far more patients than they could see in formal referrals, fewer patients are taken on for a course of psychiatric treatment that could be provided by general practitioners and the skills of general practitioners and their trainees are enhanced. It is hoped that more general practitioners will adopt this pattern of working so that it can be fully developed and evaluated.
Consultants↗
Life events and somatisation among students.
137 first year undergraduates presenting to the student health service were studied to assess the effect of life events, locus of control, psychiatric symptoms and illness behaviour in determining whether a psychological or physical symptom was presented to the doctor. Psychological presenters were small in number, but showed significantly more life events additional to those expected during the first year of higher education. They also showed greater external attribution for affiliation and more prominent illness behaviour. 65% of the sample showed GHQ scores indicating probable psychiatric illness. Those with a high GHQ score and physical presentation, who did not have an organic basis for their symptoms were termed 'somatisers'. Like those with a psychological presentation, the somatisers had experienced a break, or serious difficulty in a close relationship with a member of the opposite sex, or the death of a close relative or friend. This study has used a new method of assessment of life events among students and the results indicate the high prevalence of somatisation among first year college students attending the health centre.
Adult↗
Symptom complaints, psychiatric disorder and abnormal illness behaviour in patients with upper abdominal pain.
Seventy patients presenting to the gastroenterologist with upper abdominal pain were examined by a psychiatrist to establish the presence of psychiatric disorder, illness behaviour and to record in detail their symptom pattern. The 37 patients who had no organic cause for their abdominal complaints were subdivided into those with and without psychiatric disorder. The former (21 patients) demonstrated more illness behaviour, they complained of more abdominal symptoms and their pain was both more severe and more persistent than in the patients with organic disease and those with non-organic illness who did not have psychiatric disorder. The latter group reported no symptoms of 'psychoneurosis' and should probably be regarded as a separate group if the aetiology of functional abdominal pain is to be clarified. Those with non-organic abdominal complaints who had psychiatric illness could be distinguished by the presence of three symptoms, namely depression, anxiety and fatigue. Detection and treatment of their psychiatric disorder might lead to a decrease in their symptomatic complaints and illness behaviour.
Abdominal Pain↗