Estimating probability of sustained recovery from mild to moderate depression in primary care: evidence from the THREAD study.

BACKGROUND: It is important for doctors and patients to know what factors help recovery from depression. Our objectives were to predict the probability of sustained recovery for patients presenting with mild to moderate depression in primary care and to devise a means of estimating this probability on an individual basis. METHOD: Participants in a randomized controlled trial were identified through general practitioners (GPs) around three academic centres in England. Participants were aged >18 years, with Hamilton Depression Rating Scale (HAMD) scores 12-19 inclusive, and at least one physical symptom on the Bradford Somatic Inventory (BSI). Baseline assessments included demographics, treatment preference, life events and difficulties and health and social care use. The outcome was sustained recovery, defined as HAMD score <8 at both 12 and 26 week follow-up. We produced a predictive model of outcome using logistic regression clustered by GP and created a probability tree to demonstrate estimated probability of recovery at the individual level. RESULTS: Of 220 participants, 74% provided HAMD scores at 12 and 26 weeks. A total of 39 (24%) achieved sustained recovery, associated with being female, married/cohabiting, having a low BSI score and receiving preferred treatment. A linear predictor gives individual probabilities for sustained recovery given specific characteristics and probability trees illustrate the range of probabilities and their uncertainties for some important combinations of factors. CONCLUSIONS: Sustained recovery from mild to moderate depression in primary care appears more likely for women, people who are married or cohabiting, have few somatic symptoms and receive their preferred treatment.

The relationship between depression and diabetes mellitus: findings from the Hertfordshire Cohort Study.

AIMS: To assess the relationship between depression scores and diabetes, glucose and insulin in a cross-sectional population-based study. METHODS: One thousand, five hundred and seventy-nine men and 1418 women from the Hertfordshire Cohort Study were assessed for diabetes. Plasma glucose and insulin concentrations were measured at 0, 30 and 120 min during a standard 75-g oral glucose tolerance test. Depressive and anxiety symptoms were measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Overall, 431 (14.6%) were diagnosed with diabetes [232 men (14.9%) and 199 women (14.3%)]. One hundred and eight (47%) men and 74 (37%) women had known diabetes. The remainder were previously undiagnosed. Fifty-nine (3.7%) men and 65 (4.6%) women had possible depression (HAD-D scores 8-10) and 17 (1.1%) men and 20 (1.4%) women had probable depression (HAD-D scores > or = 11). Probable depression was associated with an adjusted odds ratio for diabetes of 3.89 [95% confidence interval (CI) 1.28-11.88] in men and 1.51 (95% CI 0.47-4.84) in women. In men without previously diagnosed diabetes, fasting insulin (P = 0.035), 2-h glucose concentrations (P = 0.028) and insulin resistance (P = 0.032) were significantly associated with HAD-D scores. With the exception of 2-h glucose concentrations (P = 0.034), the associations were not significant in women. CONCLUSIONS: These data support the hypothesis that depression may increase the risk for diabetes. The relationship between depression score and metabolic variables extends across the whole population and is not confined to those with either diagnosed depression or diabetes. This relationship should lead clinicians to consider screening for diabetes in those with depression and vice versa.

The effect of concurrent pain on the management of patients with depression: an analysis of NHS healthcare resource utilisation using the GPRD database.

INTRODUCTION: Patients with depression frequently report painful physical symptoms. However, there are scant data from the UK concerning differences in primary and secondary care resource use between depressed patients with and without pain treated in general practice. METHODS: Patients with depression codes were identified from the General Practice Research Database (GPRD) excluding those with psychoses. The observation period was 1st January 2000-31st December 2006. Patients were further categorised into three groups: (i) no painful physical symptom codes ever in the observation period (NO PAIN); (ii) patients with no other diagnostic or test codes 30 days either side of a pain code (PAIN MINUS DIAGNOSIS) and (iii) patients with pain codes and other diagnostic codes (PAIN PLUS DIAGNOSIS). Rates of general practitioner (GP) visits, antidepressant and concomitant prescribing and switching, secondary care referrals and diagnostic tests were reported per group with 95% confidence limits (CI). RESULTS: A total of 145,784 patients with depression aged 18-50 years were selected. Of these, 48,615 (33.3%) were classed as NO PAIN, the remaining 66.6% having pain. PAIN MINUS DIAGNOSIS patients constituted 5654 (5.8%) of those with pain. PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS had a significantly higher rate of GP visits than NO PAIN patients, 10.37 (95% CI 10.23, 10.52); 11.15 (11.11,11.20) and 7.04 (7.00, 7.08) respectively. Inter and intraclass drug switching was high with 13% of PAIN MINUS DIAGNOSIS and 14% of PAIN PLUS DIAGNOSIS patients having three or more switches compared with 7% of NO PAIN patients. Referral rates to secondary care were significantly higher in both pain groups compared with patients with no pain. Diagnostic testing was significantly greater in PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS groups than NO PAIN patients for all test types, with X-rays being the most common test; 3.85 (3.69,4.00); 2.77 (2.74,2.80); 0.91 (0.89, 0.94) respectively. CONCLUSION: Patients in general practice diagnosed with depression and concurrent painful physical symptoms have higher resource use in primary and secondary care.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines.

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia.

People with schizophrenia are at greater risk of obesity, Type 2 diabetes, dyslipidaemia and hypertension than the general population. This results in an increased incidence of cardiovascular disease (CVD) and reduced life expectancy, over and above that imposed by their mental illness through suicide. Several levels of evidence from data linkage analyses to clinical trials demonstrate that treatment-related metabolic disturbances are commonplace in this patient group, and that the use of certain second-generation antipsychotics may compound the risk of developing the metabolic syndrome and CVD. In addition, smoking, poor diet, reduced physical activity and alcohol or drug abuse are prevalent in people with schizophrenia and contribute to the overall CVD risk. Management and minimization of metabolic risk factors are pertinent when providing optimal care to patients with schizophrenia. This review recommends a framework for the assessment, monitoring and management of patients with schizophrenia in the UK clinical setting.

Adherence to treatment in patients with epilepsy: associations with seizure control and illness beliefs.

OBJECTIVE: This study investigated non-adherence to antiepileptic drug treatment amongst patients with epilepsy in secondary care. The associations between adherence and seizure control, perceptions of illness and medication, anxiety and depression were also examined. METHODS: A cross-sectional study of fifty-four patients with epilepsy were recruited from a hospital epilepsy clinic. RESULTS: Fifty-nine percent were estimated to be non-adherent to medication. There was a negative correlation between adherence and frequency of seizures. Patients with poorly controlled epilepsy were more anxious, and expected a longer duration of their epilepsy. CONCLUSION: Assessment of adherence should be a routine part of management of epilepsy. Further recognition and support should be given to patients who have poor seizure control since they are more likely to be more anxious and have unhelpful illness and treatment beliefs.

The association of depression and painful physical symptoms--a review of the European literature.

OBJECTIVE: The presence of painful physical symptoms may confound the diagnosis of major depressive disorder and may worsen patient prognosis. Epidemiological literature was reviewed to investigate the association between depression and painful physical symptoms. METHOD: MEDLINE and EMBASE database searches were conducted. Studies where a definable organic basis for pain was given were excluded. The search was unrestricted by language but limited to European studies and countries. After filters were applied, 70 eligible studies were reviewed. RESULTS: The majority of studies reviewed showed an association between depression and painful physical symptoms. Over 40% of all studies examining the association between pain and depression were carried out in pain clinics in secondary care. Very few studies were conducted in psychiatric settings. CONCLUSION: The findings of this review suggest that painful physical symptoms may be an important part of the depressive syndrome. Although the relationship between depression and painful physical symptoms is not yet fully understood, findings suggest that diagnosis and treatment of depression should involve investigating and treating the full spectrum of symptoms (emotional and physical). Further research in psychiatric and generalist settings is needed to elucidate the relationship between depression and painful physical symptoms as experienced by patients and at the clinical level.

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine.

OBJECTIVE: To determine the relative cost-effectiveness of three classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the modified TCA lofepramine, as first choice treatments for depression in primary care. DESIGN: Open, pragmatic, controlled trial with three randomised arms and one preference arm. Patients were followed up for 12 months. SETTING: UK primary care: 73 practices in urban and rural areas in England. PARTICIPANTS: Patients with a new episode of depressive illness according to GP diagnosis. INTERVENTIONS: Patients were randomised to receive a TCA (amitriptyline, dothiepin or imipramine), an SSRI (fluoxetine, sertraline or paroxetine) or lofepramine. Patients or GPs were able to choose an alternative treatment if preferred. MAIN OUTCOME MEASURES: At baseline the Clinical Interview Schedule, Revised (CIS-R PROQSY computerised version) was administered to establish symptom profiles. Outcome measures over the 12-month follow-up included the Hospital Anxiety and Depression Scale self-rating of depression (HAD-D), CIS-R, EuroQol (EQ-5D) for quality of life, Short Form (SF-36) for generic health status, and patient and practice records of use of health and social services. The primary effectiveness outcome was the number of depression-free weeks (HAD-D less than 8, with interpolation of intervening values) and the primary cost outcome total direct NHS costs. Quality-adjusted life-years (QALYs) were used as the outcome measure in a secondary analysis. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were computed. Estimates were bootstrapped with 5000 replications. RESULTS: In total, 327 patients were randomised. Follow-up rates were 68% at 3 months and 52% at 1 year. Linear regression analysis revealed no significant differences between groups in number of depression-free weeks when adjusted for baseline HAD-D. A higher proportion of patients randomised to TCAs entered the preference arm than those allocated to the other choices. Switching to another class of antidepressant in the first few weeks of treatment occurred significantly more often in the lofepramine arm and less in the preference arm. There were no significant differences between arms in mean cost per depression-free week. For values placed on an additional QALY of over 5000 pounds, treatment with SSRIs was likely to be the most cost-effective strategy. TCAs were the least likely to be cost-effective as first choice of antidepressant for most values of a depression-free week or QALY respectively, but these differences were relatively modest. CONCLUSIONS: When comparing the different treatment options, no significant differences were found in outcomes or costs within the sample, but when outcomes and costs were analysed together, the resulting cost-effectiveness acceptability curves suggested that SSRIs were likely to be the most cost-effective option, although the probability of this did not rise above 0.6. Choosing lofepramine is likely to lead to a greater proportion of patients switching treatment in the first few weeks. Further research is still needed on the management of depressive illness in primary care. This should address areas such as the optimum severity threshold at which medication should be used; the feasibility and effectiveness of adopting structured depression management programmes in the UK context; the importance of factors such as physical co-morbidity and recent life events in GPs' prescribing decisions; alternative ways of collecting data; and the factors that give rise to many patients being reluctant to accept medication and discontinue treatment early.

Psychotherapy and bulimia nervosa. Longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy.

OBJECTIVE: To determine whether cognitive behavior therapy (CBT) for bulimia nervosa has a specific therapeutic effect and determine whether a simplified behavioral treatment (BT) of CBT is as effective as the full treatment. DESIGN: Randomized controlled trial involving three psychological treatments. Two planned comparisons, CBT with interpersonal psychotherapy (IPT), and CBT with BT. Closed 12-month follow-up period. Independent assessors. SETTING: Secondary referral center. PATIENTS: Seventy-five consecutively referred patients with bulimia nervosa. Patients with concurrent anorexia nervosa were excluded. INTERVENTIONS: Cognitive behavior therapy, IPT, BT conducted on an individual outpatient basis. There were nineteen sessions over 18 weeks. Six experienced therapists administered all three treatments. There was no concurrent treatment. MAIN OUTCOME MEASURE: Frequency of binge eating and purging. RESULTS: High rate (48%) of attrition and withdrawal among the patients who received BT. Over follow-up, few patients undergoing BT met criteria for a good outcome (cessation of all forms of binge eating and purging). Patients in the CBT and IPT treatments made equivalent, substantial, and lasting changes across all areas of symptoms, although there were clear temporal differences in the pattern of response, with IPT taking longer to achieve its effects. CONCLUSIONS: Bulimia nervosa may be treated successfully without focusing directly on the patient's eating habits and attitudes to shape and weight. Cognitive behavior therapy and IPT achieved equivalent effects through the operation of apparently different mediating mechanisms. A further comparison of CBT and IPT is warranted. The behavioral version of CBT was markedly less effective than the full treatment.

Three psychological treatments for bulimia nervosa. A comparative trial.

The specificity and magnitude of the effects of cognitive behavior therapy in the treatment of bulimia nervosa were evaluated. Seventy-five patients who met strict diagnostic criteria were treated with either cognitive behavior therapy, a simplified behavioral version of this treatment, or interpersonal psychotherapy. Assessment was by interview and self-report questionnaire, and many aspects of functioning were evaluated. All three treatments resulted in an improvement in the measures of the psychopathology. Cognitive behavior therapy was more effective than interpersonal psychotherapy in modifying the disturbed attitudes to shape and weight, extreme attempts to diet, and self-induced vomiting. Cognitive behavior therapy was more effective than behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting, but it was equivalent in other respects. The findings suggest that cognitive behavior therapy, when applied to patients with bulimia nervosa, operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy.

A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments.

BACKGROUND: Little is known about the longer-term outcome of bulimia nervosa and the distal effects of treatment. METHODS: Prospective follow-up of subjects from two randomized controlled trials, involving a comparison of cognitive behavior therapy, behavior therapy, and focal interpersonal therapy. RESULTS: Ninety percent (89/99) underwent reassessment by interview (mean [+/- SD] length of follow-up, 5.8 +/- 2.0 years). Almost half (46%) had a DSM-IV eating disorder; 19%, bulimia nervosa; 3%, anorexia nervosa; and 24%, eating disorder not otherwise specified. There was a low rate of other psychiatric disorders. Premorbid and paternal obesity predicted a poor outcome. While the three treatments did not differ with respect to the proportion of subjects with anorexia nervosa or bulimia nervosa at follow-up, they did differ once all forms of DSM-IV eating disorder were considered together. Those who had received cognitive behavior therapy or focal interpersonal therapy were doing markedly better than those who had received behavior therapy. CONCLUSIONS: The longer-term outcome of bulimia nervosa depends on the nature of the treatment received. Patients who receive a treatment such as behavior therapy, which only has a short-lived effect, tend to do badly, whereas those who receive treatments such as cognitive behavior therapy or focal interpersonal therapy have a better prognosis.

Eating disorders in adolescents with IDDM. A controlled study.

OBJECTIVE: To determine the prevalence of clinical eating disorders and lesser degrees of disturbed eating in adolescents with IDDM and a matched sample of nondiabetic control subjects. RESEARCH DESIGN AND METHODS: A cross-sectional survey of eating habits and attitudes conducted in 76 adolescents with IDDM, and age- and sex-matched nondiabetic control subjects. Eating disorder features were assessed by standardized research interview adapted for use with patients with diabetes (EDE). Glycemic control was assessed by GHb assay. RESULTS: Adolescent girls with IDDM were heavier than nondiabetic female control subjects and were dieting more intensively to control their shape and weight. However, clinical eating disorders were no more common among adolescent girls with IDDM than among nondiabetic control subjects. Nine percent of the IDDM girls met diagnostic criteria for an operational version of "Eating disorder not otherwise specified." Fifteen percent had omitted or reduced their dose of insulin to influence their shape and weight. Eating disorder features and insulin misuse for shape and weight control were not found in IDDM or nondiabetic boys, and these two groups did not differ in their body weight. CONCLUSIONS: Adolescent girls with IDDM are heavier than their nondiabetic counterparts and diet more intensively to control their shape and weight. Disordered eating habits and weight control behavior are common, but no more so in IDDM than in nondiabetic subjects. Insulin misuse for the purpose of shape and weight control is not restricted to subjects with a clinical eating disorder. Disordered eating is associated with impaired glycemic control.

Clinical and psychological course of diabetes from adolescence to young adulthood: a longitudinal cohort study.

OBJECTIVE: To determine the clinical and psychological course of diabetes through adolescence and the relationship with glycemic control in young adulthood. RESEARCH DESIGN AND METHODS: A longitudinal cohort study of adolescents recruited from the register of the outpatient pediatric diabetes clinic. A total of 76 individuals (43 male patients, 33 female patients) aged 11-18 years completed baseline assessments, and 65 individuals (86%) were reinterviewed as young adults (20-28 years of age). Longitudinal assessments were made of glycemic control (HbA(1c)), weight gain (BMI), and development of complications. Adolescents completed self-report questionnaires to assess emotional and behavioral problems as well as self-esteem. As young adults, psychological state was assessed by the Revised Clinical Interview Schedule and the self-report Brief Symptom Inventory. RESULTS: Mean HbA(1c) levels peaked in late adolescence and were worse in female participants (average 11.1% at 18-19 years of age). The proportion of individuals who were overweight (BMI >25.0 kg/m(2)) increased during the 8-year period from 21 to 54% in female patients and from 2 to 28% in male patients. Serious diabetes-related events included death in one patient and cognitive impairment in two patients. Individuals in whom diabetic complications developed (25% of male patients and 38% of female patients) had significantly higher mean HbA(1c) levels than those without complications (difference 1.9%, 95% CI 1.1-2.7, P < 0.0001). Behavioral problems at baseline were related to higher mean HbA(1c) during the subsequent 8 years (beta = 0.15, SEM (beta) 0.04, P < 0.001, 95% CI 0.07-0.24). CONCLUSIONS: The outcome for this cohort was generally poor. Behavioral problems in adolescence seem to be important in influencing later glycemic control.

Eating habits, body weight, and insulin misuse. A longitudinal study of teenagers and young adults with type 1 diabetes.

OBJECTIVE: To examine disordered eating, insulin misuse, weight change, and their relationships with glycemic control and diabetic complications in adolescents with type 1 diabetes followed up over eight years. RESEARCH DESIGN AND METHODS: Of 76 adolescents (43 male, 33 female) with type 1 diabetes aged 11-18 years at the first assessment, 65 were interviewed as young adults (aged 20-28 years). Eating habits were assessed using a standardized Eating Disorder Examination. Height and weight were determined and BMI calculated. Three consecutive urine specimens were collected for measurement of albumin/creatinine ratio and other significant diabetic complications were recorded. Glycemic control was assessed by glycated hemoglobin. RESULTS: Weight and BMI increased from adolescence to young adulthood. Females were overweight as adolescents and both sexes were overweight as young adults. Concern over weight and shape increased significantly for both sexes from adolescence to young adulthood. This increase in concern was reflected in increased levels of dietary restraint. Features of disordered eating were apparent in females at both assessments, but no patients met the criteria for anorexia nervosa or bulimia nervosa at either assessment. A total of 10 (30%) females, but none of the males admitted underusing insulin to control weight. Five (45%) females with microvascular complications had intentionally misused insulin to prevent weight gain. CONCLUSIONS: An increase in BMI from adolescence to adulthood was associated with higher levels of concern over shape and weight and more intense dietary restraint, especially among females. Overt eating disorders were no more prevalent in these patients than in the general population, but milder forms of disordered eating were common and had implications for diabetes management. Insulin omission for weight control was frequent among females and may contribute to poor glycemic control and to risk of complications.

Compliance with antidepressant medication in the treatment of major depressive disorder in primary care: a randomized comparison of fluoxetine and a tricyclic antidepressant.

OBJECTIVE: Many claims have been made for superior compliance with selective serotonin reuptake inhibitors (SSRIs) compared with tricyclic antidepressants, but to date meta-analyses have not confirmed reduced dropouts in randomized controlled trials. The authors used a randomized study design to evaluate differential compliance with antidepressant medications in a primary care setting. METHOD: A total of 152 patients treated in 10 primary care practices in the United Kingdom were included in a randomized, open-label, parallel-group study of fluoxetine and dothiepin at therapeutic doses for 12 weeks. Compliance was assessed by using pill count, patient questionnaires, and the Medication Event Monitoring System. RESULTS: The level of compliance with fluoxetine was numerically higher than the level of compliance with dothiepin on all three primary outcome measures, although the differences were not significant. In a secondary analysis using data from the Medication Event Monitoring System, both a survival analysis for length of time without a gap in medicine taking and a derived compliance index showed a significant advantage to fluoxetine. Patients in the fluoxetine group reported superior response on the health transition scale of the 36-item Short-Form Health Survey Questionnaire and numerically greater improvement on the Hamilton Depression Rating Scale. In both treatment arms patients with a superior compliance index were more likely to have improved in Hamilton depression scale scores by the last study visit. CONCLUSIONS: This study supports recent meta-analyses of SSRIs versus tricyclic antidepressants in finding no significant differences in crude indices of compliance between fluoxetine and dothiepin, despite marked differences in side effect profile and dose regimen. However, both a survival analysis and a new measure that takes account of prolonged periods of noncompliance distinguished between the treatments and was associated with improvement in both groups.

Predictors of successful smoking cessation following advice from nurses in general practice.

At follow-up of 751 subjects receiving a brief nurse-administered anti-smoking intervention in general practice, 135 subjects (18%) reported stopping smoking, of whom 44 (6%) reported sustained cessation for one year. The demographic, social and attitudinal characteristics of these subjects were compared with 616 subjects who continued to smoke. The most important predictors of cessation were intention to stop (OR 5.1, 95% CI 2.1-12.0), personal rating of likelihood of cessation (OR 4.9, 95% CI 2.8-8.5), nurse rating of likelihood of cessation (OR 4.0, 95% CI 2.2-7.4), and smoking habit of partner (1.9, 95% CI 1.3-2.9). As practice nurses are able to distinguish likely quitters from those who are not motivated and less likely to succeed, it is important to decide whether it is more cost effective to target support at the motivated or to spend more time encouraging less motivated. The most challenging, but possibly the most rewarding, task is to try to reduce the high proportion of new ex-smokers who relapse. Although 41.1% (95% CI 28.1, 58.0) of those expressing a definite intention to stop smoking gave up, only 17.9% (95% CI 8.9, 30.4) achieved sustained cessation. However, as sustained cessation is strongly predicted by social variables, such as marital status and time spent in the company of smokers, preventing relapse may not be easy to achieve through medical intervention alone.

Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to shape and weight.

Seventy-five patients with bulimia nervosa were treated with 1 of 3 short-term psychological treatments and were then entered into a closed 1-year period of follow-up. Pretreatment predictors of 3 measures of outcome were sought. Only 2 variables were significantly associated with outcome: attitudes toward shape and weight, and self-esteem. The nature of the relation between attitudinal disturbance and outcome was complex and unexpected. The data set was also used to test the major prediction of the cognitive view of bulimia nervosa, namely that among patients who have responded to treatment, the residual level of attitudinal disturbance will predict subsequent outcome. This prediction was confirmed.

Psychiatric complications of 'Ecstasy' use.

Two case reports are presented of significant psychiatric disorders associated with ingestion of 'Ecstasy' (3,4-methylenedioxymethamphetamine), a recreational drug whose use appears to be increasing. In one case, the patient developed a brief paranoid psychosis which recurred and persisted for at least a month after he took a second dose of the drug. In the other, the patient experienced persistent symptoms of anxiety and depression for > 8 weeks after taking the drug.

The psychological treatment of patients with functional somatic symptoms: a practical guide.

Functional somatic symptoms (FSS) are bodily sensations which do not result from physical disease, but which the patient responds to as if they did. Such symptoms are common and usually transient. In some patients they become persistent and associated with distress and disability. In such cases specific treatment is indicated. A cognitive-behavioural model of the aetiology of FSS and a psychological treatment approach based on the model, are outlined. The practical details of treatment are described.

Psychosocial factors and chronic pelvic pain: a comparison of women with endometriosis and with unexplained pain.

Chronic pelvic pain is a common clinical problem, and physical investigation often fails to reveal its cause. For this reason, it has been argued that psychological and social factors contribute to such "unexplained" pain. Few studies to date using well-validated psychometric measures and adequate sample sizes have compared patients with unexplained pain and those with identified physical disease. The present study compared pain severity, mood symptoms, personality characteristics and social adjustment in women with unexplained pain and women with endometriosis. Women with endometriosis were more likely to come from upper socioeconomic groups. No differences in mood symptoms or personality characteristics were identified, but women with endometriosis had somewhat more severe pain and greater social dysfunction than those with unexplained pain. Mood disorder and social dysfunction appear to be at least as important in patients with proven endometriosis as in those with unexplained pain.