Associations of chronic embitterment among NHS staff.

BACKGROUND: Chronic embitterment is commonly recognized among people seen by occupational health professionals, but its associations remain unclear. AIMS: To investigate the associations of chronic embitterment with procedural justice, the psychological work contract, depression and the Health & Safety Executive's Management Standards Indicator Tool as well as selected employment variables. METHODS: A sample of consecutive attendees at occupational health in a single NHS Trust were asked to complete a set of validated questionnaires and give further information about sickness absence and their work. RESULTS: The sample (n = 236) was representative of those attending this occupational health department. Staff showing embitterment rated procedural justice and organizational support lower than other staff and were significantly more likely to have taken sickness absence, uncertified as well as certified. Uncertified sickness absence was almost universal in embittered staff. Although depression was significantly more prevalent among embittered staff, the majority of embittered staff were not depressed. Of those who scored as embittered and depressed or anxious, 93% had had certified sickness absence in the previous 12 months. On the Management Standards Indicator Tool, embittered individuals had significantly lower scores than others on Manager and Peer Support, Role, and Change subscales. CONCLUSIONS: Although the data are cross-sectional and self-reported, they provide evidence of the burden on organizations of chronic embitterment among their staff, particularly in terms of sickness absence. Staff who are embittered perceive their organization as unsupportive of them, and as showing low levels of procedural justice.

Shared decision-making reduces drug use and psychiatric severity in substance-dependent patients.

BACKGROUND: In the last decades, shared decision-making (SDM) models have been developed to increase patient involvement in treatment decisions. The purpose of this study was to evaluate a SDM intervention (SDMI) for patients dependent on psychoactive substances in addiction health care programs. The intervention consisted of a structured procedure to reach a treatment agreement and comprised 5 sessions. METHODS: Clinicians in 3 treatment centres in the Netherlands were randomly assigned to the SDMI or a standard procedure to reach a treatment agreement. RESULTS: A total of 220 substance-dependent patients receiving inpatient treatment were randomised either to the intervention (n = 111) or control (n = 109) conditions. Reductions in primary substance use (F((1, 124)) = 248.38, p < 0.01) and addiction severity (F((8)) = 27.76, p < 0.01) were found in the total population. Significant change was found in the total population regarding patients' quality of life measured at baseline, exit and follow-up (F((2, 146)) = 5.66, p < 0.01). On the European Addiction Severity Index, SDMI showed significantly better improvements than standard decision-making regarding drug use (F((1, 164)) = 7.40, p < 0.01) and psychiatric problems (F((1, 164)) = 5.91, p = 0.02) at 3-month follow-up. CONCLUSION: SDMI showed a significant add-on effect on top of a well-established 3-month inpatient intervention. SDMI offers an effective, structured, frequent and well-balanced intervention to carry out and evaluate a treatment agreement.

Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status.

BACKGROUND: In the last decade, the clinician-patient relationship has become more of a partnership. There is growing interest in shared decision-making (SDM) in which the clinician and patient go through all phases of the decision-making process together, share treatment preferences, and reach an agreement on treatment choice. The purpose of this review is to determine the extent, quality, and consistency of the evidence about the effectiveness of SDM. METHOD: This is a systematic review of randomised controlled trials (RCTs) comparing SDM interventions with non-SDM interventions. Eleven RCTs met the required criteria, and were included in this review. RESULTS: The methodological quality of the studies included in this review was high overall. Five RCTs showed no difference between SDM and control, one RCT showed no short-term effects but showed positive longer-term effects, and five RCTs reported a positive effect of SDM on outcome measures. The two studies included of people with mental healthcare problems reported a positive effect of SDM. CONCLUSIONS: Despite the considerable interest in applying SDM clinically, little research regarding its effectiveness has been done to date. It has been argued that SDM is particularly suitable for long-term decisions, especially in the context of a chronic illness, and when the intervention contains more than one session. Our results show that under such circumstances, SDM can be an effective method of reaching a treatment agreement. Evidence for the effectiveness of SDM in the context of other types of decisions, or in general, is still inconclusive. Future studies of SDM should probably focus on long-term decisions.

Befriending patients with medication-resistant schizophrenia: can psychotic symptoms predict treatment response?

OBJECTIVES: Supportive interventions are used in schizophrenia, but little research has been conducted into whether any baseline variable predicts treatment response. The aim of this study was to establish if baseline delusions or hallucinations are associated with changes in overall symptoms in patients who received a befriending intervention. DESIGN: The sample consisted of 44 patients with schizophrenia. These patients comprised the befriending arm of a multicentre randomized controlled trial which compared the efficacy of using CBT against befriending as an adjunct to routine care for patients with medication-resistant schizophrenia. METHODS: Scores for auditory hallucinations and delusions relating to persecution or control were entered into two regression models. The dependent variables were change in overall symptoms (1) between baseline and end of the intervention, and (2) between baseline and 9 months post-intervention. RESULTS: Baseline delusions predicted a good response and auditory hallucinations predicted a poor response at 9 months. CONCLUSIONS: Baseline psychotic symptoms strongly predicted outcome in this sample. The finding that hallucinations predicted a poor outcome is consistent with previous research. These results may help to determine which patients would benefit from supportive interventions.

The half-life of polyadenylated polysomal RNA from normal and transformed cells in monolayer culture.

The small genotypic differences between normal and transformed cells are insufficient to account directly for all their wide phenotypic differences, which probably in some cases at least involve alterations in control of gene expression. To ascertain whether such alterations involved changes in mRNA stability, RNA half-lives were estimated in five monolayer cell lines, including two pairs of normal cells and their transformed counterparts. The results for the polyadenylated fractions in all cases fit with those expected from a model in which the whole fraction has a single half-life, of less than one generation time. From both the transformed/untransformed cell pairs, there is evidence that a relationship exists between cell generation time and the half-life of the polyadenylated polysomal RNA fraction, which persists even through the process of transformation. Considerable alteration in the pattern of RNA stability is therefore unlikely to be obligatory in in vitro transformation.

A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication.

BACKGROUND: Research evidence supports the efficacy of cognitive-behavioral therapy in the treatment of drug-refractory positive symptoms of schizophrenia. Although the cumulative evidence is strong, early controlled trials showed methodological limitations. METHODS: A randomized controlled design was used to compare the efficacy of manualized cognitive-behavioral therapy developed particularly for schizophrenia with that of a nonspecific befriending control intervention. Both interventions were delivered by 2 experienced nurses who received regular supervision. Patients were assessed by blind raters at baseline, after treatment (lasting up to 9 months), and at a 9-month follow-up evaluation. Patients continued to receive routine care throughout the study. An assessor blind to the patients' treatment groups rated the technical quality of audiotaped sessions chosen at random. Analysis was by intention to treat. RESULTS: Ninety patients received a mean of 19 individual treatment sessions over 9 months, with no significant between-group differences in treatment duration. Both interventions resulted in significant reductions in positive and negative symptoms and depression. At the 9-month follow-up evaluation, patients who had received cognitive therapy continued to improve, while those in the befriending group did not. These results were not attributable to changes in prescribed medication. CONCLUSION: Cognitive-behavioral therapy is effective in treating negative as well as positive symptoms in schizophrenia resistant to standard antipsychotic drugs, with its efficacy sustained over 9 months of follow-up.

A blind, randomized, controlled trial of cognitive-behavioural intervention for patients with recent onset rheumatoid arthritis: preventing psychological and physical morbidity.

This study examined the efficacy of a cognitive and behavioural intervention (CBT) for patients with recent onset, seropositive rheumatoid arthritis. Fifty-three participants with a diagnosis of classical or definite rheumatoid arthritis, who were seropositive and had less than 2 years of disease history were recruited into the trial. All participants received routine medical management during the study, although half were randomly allocated to receive an adjunctive psychological intervention. All pre- and post-treatment assessments were conducted blind to the allocation. Analyses were conducted of treatment completers and also by intention-to-treat. Significant differences were found between the groups at both post-treatment and 6-month follow-up in depressive symptoms. While the CBT group showed a reduction in depressive symptoms, the same symptoms increased in the Standard group. At outcome but not follow-up, the CBT group also showed reduction in C-reactive protein levels. However, the CBT group did show significant improvement in joint involvement at 6-month follow-up compared with the Standard group, indicating physical improvements above those achieved with standard care. These results indicate that cognitive-behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is efficacious in producing reductions in both psychological and physical morbidity

Phototherapy and its mechanisms of action in seasonal affective disorder.

Eleven depressed patients with seasonal affective disorder completed three different treatments of 1 week each given in a balanced order with a 1-week withdrawal between each week of treatment. The three treatments were photoperiod extension with bright light, or with dim light, and light augmentation with bright light without a change in photoperiod. Most patients improved on all treatments, with a trend in favour of bright light over dim. Only light augmentation was significantly better than dim light and was also superior to photoperiod extension. These findings do not replicate earlier studies and, as the most successful treatment involved no change in photoperiod, they suggest that modification of melatonin secretion may not be the mechanism of action of phototherapy.

The course of depression in recent onset rheumatoid arthritis: the predictive role of disability, illness perceptions, pain and coping.

BACKGROUND: This study aimed to investigate the course of depression for patients with recently diagnosed rheumatoid arthritis (RA) and to investigate predictors of depression. METHODS: Twenty-two patients with a history of recently diagnosed RA of less than 2 years were assessed on a variety of clinical outcome and process measures on six assessment occasions over a 21-month period. These 22 patients constituted the control group of a controlled trial and received standard outpatient clinic treatment during follow-up. RESULTS: Patients became significantly more depressed over time. A set of five factors were found to consistently predict depression at the following assessment. These were initial level of depression, disability, pain, beliefs about the consequences of arthritis and coping strategies. CONCLUSIONS: The results confirm the importance of psychological factors in early RA and their relative independence from physical findings. This is the first study to document the importance of illness perceptions in recent onset RA.

Patient determinants of mental health interventions in primary care.

BACKGROUND: A large proportion of a general practitioner's (GP's) caseload comprises patients with mental health problems. It is important to ensure that care is provided appropriately, on the basis of clinical need. It is therefore necessary to investigate the determinants of the use of mental health care in the primary care sector and, in particular, to identify any non-clinical characteristics of patients that affect the likelihood of their receiving appropriate care. AIM: To identify and compare the influence of non-clinical patient factors on GPs' acknowledgement of mental problems and on their provision of mental health care. METHOD: Cross sectional study of adults aged 16 to 65 years old (n = 802) attending one of eight practices (20 GPs in total) in inner west London. RESULTS: Multivariable analysis showed that the combination of factors that best predict GPs' acknowledgement of the presence of mental problems are general health questionnaire (GHQ) scores (odds ratio [OR] = 1.10 per unit increase in score, 95% confidence interval [CI] = 1.07 to 1.13), previous mental symptoms (OR = 7.5, 95% CI = 4.3 to 12.9), increasing age (OR = 1.03 per one-year increase, 95% CI = 1.01 to 1.04) and physical health status (OR = 0.98 per unit increase in short form-36 (SF-36) score, 95% CI = 0.96 to 1.00). Multivariable analysis showed that the combination of factors that best predict intervention (prescription for psychotropic medication; return visit to GP; referral to psychiatric inpatients/outpatients; referral to other [specified] health professionals, or social services) are previous symptoms (OR = 7.4, 95% CI = 3.8 to 14.4), white ethnic group (OR = 2.2, 95% CI 0.9 to 5.5); and not owning a property (OR = 2.1, 95% CI = 1.1 to 4.0). Life events influenced intervention only in the presence of low GHQ scores (OR = 8.1, 95% CI = 2.7 to 24.0). CONCLUSIONS: Mental problems are common in primary care and their acknowledgement is a necessary but not a sufficient condition for intervention. Our results show that GPs' decisions about mental health interventions can be influenced by non-clinical patient factors, regardless of patients' clinical needs. The results suggest that current practice may not always be equitable, and point to the need for better understanding of the basis of these potential inequalities and for focused training.

Endometriosis: associations with menorrhagia, infertility and oral contraceptives.

In a retrospective study of 163 women with endometriosis, 76% had a history of menorrhagia, a larger percentage than that which might be normally expected. Only 10% of the women complained of infertility, while 13% had used oral contraceptives regularly, a much smaller proportion than expected. These findings are discussed in terms of the pathogenesis of endometriosis and the possible prophylactic role of oral contraceptives. The authors suggest the possibility that increased sensitivity to estrogens may lead to the development of endometriosis in some women.

Referrals to psychiatrists in a general hospital--comparison of two methods of liaison psychiatry: preliminary communication.

Patients on a general medical ward were offered a liaison psychiatric service with 'unlimited' access, in which referrals were accepted from nurses, other paramedical staff and junior doctors in addition to senior medical staff. This new service (method II) was compared with the usual liaison service (method I, referrals initiated or approved by senior medical staff only) which was continued in parallel on a comparable general medical ward. Method II resulted in a threefold increase in referral rate and led to a significant alteration in the types of problem attracting referral. Despite the much higher rate of method II referrals, however, similar percentages of referrals by both methods were offered psychiatric follow up. The results do not support the commonly held belief that it is the failure of ward staff to recognize psychiatric morbidity which accounts for the low rate of referrals to many psychiatric liaison services.

Doctors' legal position in treating temporarily incompetent patients.

Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.

A simple and versatile driving appliance for upper-limb amputees.

A simple fixed-hook driving appliance is described, suitable for upper-limb amputees, and its function compared with that of the commonly available ball-and-cup device. The hook is reliable, safe and inexpensive. An attachment is also described which fits on to gear levers, allowing the use of the driving appliance to change gears manually.

Treatment goals in addiction healthcare: the perspectives of patients and clinicians.

BACKGROUND: Little is known about the perspectives of either patients or clinicians regarding treatment goals in addiction healthcare. In general, treatment goals involve abstinence or at least reduction of substance use. AIM: To examine and compare the treatment goals indicated by both patients and clinicians at baseline, interim and exit measurement. METHOD: A descriptive study was performed with multiple measurements of treatment goals. Patients (n = 111) and clinicians (n = 20) were recruited from three addiction treatment centres in the Netherlands. A Shared Decision Making Intervention (SDMI) was undertaken to promote and evaluate treatment agreement. RESULTS: Patients identified treatment goals of daytime activities and abstinence or reduced alcohol consumption as most important. Clinicians indicated psychological distress, daytime activities and substance use as most important. Differences between patients and clinicians were found for the treatment goals of physical health (patient > clinician) and psychological distress (clinician > patient). The results further showed that treatment goals of both patients and clinicians become more closely aligned during the course of treatment. CONCLUSION: SDMI provides a method to explore and discuss discrepancy between patients' and clinicians' goals of treatment which leads to convergence. Such convergence is likely to be a necessary prerequisite for positive treatment outcomes.