Culturally-adapted cognitive behavioural therapy based intervention for maternal depression: a mixed-methods feasibility study.

BACKGROUND: British Pakistanis are one of the largest ethnic minority groups living in the UK, with high rates of maternal depression being reported in this population. Evidence suggests that culturally-adapted Cognitive Behavioural Therapy (CBT)-based interventions for depression, may improve clinical outcomes and patient satisfaction. This study was conducted to develop and test the feasibility and acceptability of a culturally-adapted, CBT-based, manual-assisted intervention in British Pakistani mothers experiencing maternal depression. METHODS: A mixed-method feasibility study that included qualitative interviews followed by the development of a CBT-based intervention for mothers with mild to moderate depression. Following the qualitative interviews, a CBT-based intervention called the Positive Health Program (PHP) was developed and delivered consisting of 12-weekly sessions. A before and after design was used to explore the feasibility and acceptability of the Positive Health Programme. RESULTS: A culturally-adapted CBT-based group intervention (PHP) was acceptable to this group and improvements were reported in depression and health-related quality of life. The women's understanding of 'depression' as a general consensus was in physical terms, but with an onset triggered by psychosocial causes. The most commonly reported factors contributing to depression were marital disharmony, lack of social support, and financial difficulties. Past help offered was primarily antidepressants, which were not welcomed by most of the women. A lack of availability of culturally sensitive interventions and the limited cultural sensitivity of NHS staff was also reported. CONCLUSION: This study provides preliminary evidence for the feasibility and acceptability of a CBT-based culturally-adapted group psychological intervention for British Pakistani mothers. TRIAL REGISTRATION: Study ethics registration number: 10/H1005/62 (University of Manchester).

Associations between antenatal depression and neonatal outcomes in Malawi.

Studies from several low- and middle-income countries have shown that antenatal depression may be a risk factor for poor neonatal outcomes. However, those studies conducted in sub-Saharan Africa have not consistently demonstrated this association. We set out to investigate whether antenatal depression is associated with shorter duration of pregnancy and reduced newborn size in rural Malawi. Pregnant women recruited from four antenatal clinics to the International Lipid-Based Nutrient Supplements Project-DYAD-Malawi (iLiNS-DYAD-M) randomised controlled trial of nutrient supplementation were screened for antenatal depression in the second or third trimester using a locally validated version of the Self Reporting Questionnaire (SRQ). Outcomes were duration of pregnancy, birthweight, newborn length for age z-score (LAZ), head circumference z-score, and mid-upper arm circumference (MUAC). Other potential confounding factors and predictors of birth outcome were measured and adjusted for in the analysis. 1,391 women were enrolled to the trial. 1,006/1,391 (72.3%) of these women completed an SRQ and gave birth to a singleton infant whose weight was measured within 2 weeks of birth. 143/1,006 (14.2%) scored SRQ ≥ 8, indicating likely depression. Antenatal depression was not associated with birth weight, duration of pregnancy, newborn LAZ, or head-circumference Z-score. There was an inverse association with newborn MUAC (adjusted mean difference - 0.2 cm (95% CI -0.4 to 0, p = 0.021) the significance of which is unclear. The study was conducted within a randomised controlled trial of nutritional supplementation and there was a high proportion of missing data in some enrolment sites; this may have affected the validity of our findings.

The impact of maternal diet fortification with lipid-based nutrient supplements on postpartum depression in rural Malawi: a randomised-controlled trial.

Perinatal depression is highly prevalent in low-and-middle-income countries and has been linked to poor child health. Suboptimal maternal nutrition may be a risk factor for perinatal depression. In this randomised-controlled trial conducted in rural Malawi, we set out to test the hypothesis that women taking a fatty acid-rich lipid-based nutrient supplement (LNS) would have fewer depressive symptoms postpartum than those taking iron-folate (IFA) or multiple-micronutrient (MMN) capsules. Women were recruited from antenatal clinics and randomised to receive LNS or MMN during pregnancy and for 6 months postpartum, or IFA during pregnancy only. Maternal depressive symptoms were measured using validated translations of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS), antenatally (SRQ only) and at 6 months postpartum (SRQ and EPDS). Analysis was by modified intention to treat. One thousand three hundred and ninety one women were randomised (LNS = 462, MMN = 466, IFA = 463). The groups were similar across a range of baseline variables. At 6 months postpartum, 1078 (77.5%) had SRQ completed; mean (SD) scores were LNS 1.76(2.73), MMN 1.92(2.75), IFA 1.71(2.66), P = 0.541. One thousand and fifty seven (76.0%) had EPDS completed; mean (SD) scores were LNS 5.77(5.53), MMN 5.43(4.97), IFA 5.52(5.18), P = 0.676. There were no statistically significant differences between the groups on SRQ or EPDS scores (continuous or dichotomised) in unadjusted or adjusted models. In conclusion, fortification of maternal diet with LNS compared with MMN or IFA did not reduce postnatal depressive symptoms in this study.

Double RASS cutpoint accurately diagnosed suicidal risk in females with long-term conditions attending the emergency department compared to their male counterparts.

BACKGROUND: Suicidal risk is often unrecognized in emergency department (ED). We aimed to assess its prevalence in patients with long-term conditions (LTCs) attending an ED and to test whether gender differences influence suicidal risk assessment, using the diagnostic accuracy properties of the Risk Assessment Suicidality Scale (RASS). METHODS: The RASS was administered to 349 patients with diabetes, COPD and rheumatic diseases visiting an ED. The MINI interview was used as the criterion standard. ROC curve analysis was performed to determine the optimal RASS cutpoint for suicidal risk separately for males and females. Somatic (PHQ-15) and depressive (PHQ-9) symptoms were also assessed and factors associated with suicidal risk across gender were determined in hierarchical regression models. RESULTS: The prevalence of suicidal risk according to the MINI was 22.9%; 16.6% of patients were at low, 5.1% at moderate, and 0.9% at high risk. At an optimal cutpoint of 270, RASS had 81.3% sensitivity and 81.8% specificity. The optimal RASS cutpoint for females (340) was double the cutpoint for males (175). Somatic symptom burden was associated with suicidal risk in both sexes but it became non-significant after depressive symptoms were taken into account; suicidal risk was also associated with history of depression in females and lower income in males. CONCLUSION: There is a high prevalence of suicidal risk in patients with LTCs attending the ED. As the optimal RASS cutpoint for females was double the cutpoint for males, clinicians should bear in mind gender differences when assessing for suicidal risk in the ED.

The impact of perinatal depression on exclusive breastfeeding: a cohort study.

Perinatal depression is associated with infant undernutrition. We hypothesised that perinatal depression was associated with early cessation of exclusive breastfeeding and reduced quantity of breast milk in rural Pakistan. We used a prospective cohort design to study a population-based sample of 132 depressed and 147 non-depressed women from the third trimester of pregnancy to 6 months post-natal. Current major depressive episode was measured in the third trimester and 6 months post-natal using the Structured Clinical Interview for DSM-IV Diagnosis. In a convenience sample of 24 depressed and 31 non-depressed exclusively breastfeeding mothers, breast milk quantity was assessed (mL kg(-1) infant weight per 24 h) at 4 months using the dose-to-mother deuterium dilution method. We administered also the Perception of Insufficient Milk questionnaire at 6 months post-natal. Depression was associated with fewer days of exclusive breastfeeding (91.8 (SD = 47.1) vs. 108.7 days (SD = 54.3) (95% CI: 3.4 to 30.3 P = 0.014). Women with persistent depression ceased exclusive breastfeed earliest. There was no difference in the quantity of breast milk produced by depressed and non-depressed mothers: 89.3 (SD = 38.1) vs. 83.9 (29.0) ml/kg infant wt/24 hours, P = 0.57. Depressed mothers were significantly more likely to report insufficient milk: PIM scores were 34.4 (SD = 14.3) for depressed and 39.7 (SD = 10.4) for non-depressed women (P = 0.004). In Cox regression PIM score mediated the association between depression and early cessation of breastfeeding. In this area of rural Pakistan, perinatal depression is associated with early cessation of exclusive breastfeeding and this is associated with mothers' perceptions of insufficiency of breast milk but not reduced milk production.

Psychological distress in mothers of children admitted to a nutritional rehabilitation unit in Malawi - a comparison with other paediatric wards.

In a previous study we found a very high prevalence of psychological distress in mothers of children admitted to a nutritional rehabilitation unit (NRU) in Malawi, Africa. The objective of this study was to compare the prevalence and severity of maternal distress within the NRU with that in other paediatric wards. Given the known association between poor maternal psychological well-being and child undernutrition in low- and middle-income countries, we hypothesised that distress would be higher among NRU mothers. Mothers of consecutive paediatric inpatients in a NRU, a high-dependency (and research) unit and an oncology ward were assessed for psychological distress using the Self-Reporting Questionnaire (SRQ). Two hundred sixty-eight mothers were interviewed (90.3% of eligible). The prevalence of SRQ score ≥8 was 35/150 {23.3% [95% confidence interval (CI) 16.8- 30.9%]} on the NRU, 13/84 [15.5% (95% CI 8.5-25.0%)] on the high-dependency unit and 7/34 [20.6% (95% CI 8.7-37.9%)] on the oncology ward (χ(2) = 2.04, P = 0.36). In linear regression analysis, the correlates of higher SRQ score were child diarrhoea on admission, child diagnosed with tuberculosis, and maternal experience of abuse by partner; child height-for-age z-score fell only just outside significance (P = 0.05). In summary, we found no evidence of greater maternal distress among the mothers of severely malnourished children within the NRU compared with mothers of paediatric inpatients with other severe illnesses. However, in support of previous research findings, we found some evidence that poor maternal psychological well-being is associated with child stunting and diarrhoea.

Brief psychological intervention after self-harm: randomised controlled trial from Pakistan.

BACKGROUND: Self-harm is a major risk factor for completed suicide. AIMS: To determine the efficacy of a brief psychological intervention - culturally adapted manual-assisted problem-solving training (C-MAP) - delivered following an episode of self-harm compared with treatment as usual (TAU). METHOD: The study was a randomised controlled assessor-masked clinical trial (trial registration: ClinicalTrials.gov NCT01308151). All patients admitted after an episode of self-harm during the previous 7 days to the participating medical units of three university hospitals in Karachi, Pakistan, were included in the study. A total of 250 patients were screened and 221 were randomly allocated to C-MAP plus treatment as usual (TAU) or to TAU alone. All patients were assessed at baseline, at 3 months (end of intervention) and at 6 months after baseline. The primary outcome measure was reduction in suicidal ideation at 3 months. The secondary outcome measures included hopelessness, depression, coping resources and healthcare utilisation. RESULTS: A total of 108 patients were randomised to the C-MAP group and 113 to the TAU group. Patients in the C-MAP group showed statistically significant improvement on the Beck Scale for Suicide Ideation and Beck Hopelessness Inventory, which was sustained at 3 months after the completion of C-MAP. There was also a significant reduction in symptoms of depression compared with patients receiving TAU. CONCLUSIONS: The positive outcomes of this brief psychological intervention in patients attempting self-harm are promising and suggest that C-MAP may have a role in suicide prevention.

Validation of the multi-dimensional scale of perceived social support (MSPSS) and the relationship between social support, intimate partner violence and antenatal depression in Malawi.

BACKGROUND: Lack of social support is an important risk factor for antenatal depression and anxiety in low- and middle-income countries. We translated, adapted and validated the Multi-dimensional Scale of Perceived Social Support (MSPSS) in order to study the relationship between perceived social support, intimate partner violence and antenatal depression in Malawi. METHODS: The MSPSS was translated and adapted into Chichewa and Chiyao. Five hundred and eighty-three women attending an antenatal clinic were administered the MSPSS, depression screening measures, and a risk factor questionnaire including questions about intimate partner violence. A sub-sample of participants (n = 196) were interviewed using the Structured Clinical Interview for DSM-IV to diagnose major depressive episode. Validity of the MSPSS was evaluated by assessment of internal consistency, factor structure, and correlation with Self Reporting Questionnaire (SRQ) score and major depressive episode. We investigated associations between perception of support from different sources (significant other, family, and friends) and major depressive episode, and whether intimate partner violence was a moderator of these associations. RESULTS: In both Chichewa and Chiyao, the MSPSS had high internal consistency for the full scale and significant other, family, and friends subscales. MSPSS full scale and subscale scores were inversely associated with SRQ score and major depression diagnosis. Using principal components analysis, the MSPSS had the expected 3-factor structure in analysis of the whole sample. On confirmatory factor analysis, goodness-of-fit indices were better for a 3-factor model than for a 2-factor model, and met standard criteria when correlation between items was allowed. Lack of support from a significant other was the only MSPSS subscale that showed a significant association with depression on multivariate analysis, and this association was moderated by experience of intimate partner violence. CONCLUSIONS: The MSPSS is a valid measure of perceived social support in Malawi. Lack of support by a significant other is associated with depression in pregnant women who have experienced intimate partner violence in this setting.

Validity of the Greek version of the PHQ 15-item Somatic Symptom Severity Scale in patients with chronic medical conditions and correlations with emergency department use and illness perceptions.

BACKGROUND: The PHQ-15 is a brief measure assessing the severity of somatic symptoms and is widely used in different health care settings. We aimed to assess the psychometric properties of its Greek version in patients with chronic physical illnesses seeking urgent or unscheduled care in the Accident and Emergency Department (AED). METHODS: The PHQ-15 was translated into Greek using back-translation, and it was administered to 303 patients with diabetes, COPD and rheumatic diseases visiting our AED during a one-year period. Patients were interviewed with the MINI. Depressive (PHQ-9) and somatization symptoms (SCL-12), illness perceptions (B-IPQ) and health-related quality of life (WHOQOL-BREF) were also assessed to test criterion and concurrent validity. RESULTS: The Greek version of the PHQ-15 showed acceptable internal consistency. Convergent validity was established by the strong associations observed between PHQ-15 scores and functional status, depressive symptom severity and AED visits during the previous year. PHQ-15 scores were also associated with the patients' concerns about personal and treatment illness's control and their beliefs regarding the number of bodily symptoms attributed to their illness (illness identity). The highly acceptable convergent and discriminant validity of the five individual bodily symptoms assessed by both the PHQ-15 and SCL-12 is a further construct validity indicator. CONCLUSIONS: The present findings support the applicability of the Greek version of PHQ-15 in assessing common somatic symptoms either medically explained or unexplained in patients seeking care in the AED, further confirming that it can be considered suitable for use in a broad range of populations in clinical research.

A cross-sectional study of antenatal depression and associated factors in Malawi.

Depression, and disabling levels of mixed depressive, anxious and somatic symptoms, termed common mental disorder, occurring in the perinatal period are an important health problem in low- and middle-income countries. In this cross-sectional study, pregnant women were recruited from a district hospital antenatal clinic in Malawi. Symptoms of depression and anxiety, and non-specific somatic symptoms commonly associated with distress, were measured using validated local versions of the Self Reporting Questionnaire (SRQ). In a sub-sample, Diagnostic Statistical Manual (DSM)-IV diagnoses of major and minor depressive disorders were made using the Structured Clinical Interview for DSM-IV. Maternal socio-demographic and health variables were measured, and associations with SRQ score and depression diagnosis were determined. Of 599 eligible women, 583 were included in the analysis. The adjusted weighted prevalence of current major depressive episode and current major or minor depressive episode were 10.7 % (95 % CI 6.9-14.5 %) and 21.1 % (95 % CI 15.5-26.6 %), respectively. On multivariate analysis, SRQ score was significantly associated with lower perceived social support, experience of intimate partner violence, having had a complication in a previous delivery, higher maternal mid-upper arm circumference and more years of schooling. Major depressive episode was associated with lower perceived social support and experience of intimate partner violence. This study demonstrates that antenatal depression/CMD is common in Malawi and is associated with factors that may be amenable to psychosocial interventions.

Antidepressant and group psychosocial treatment for depression: a rater blind exploratory RCT from a low income country.

BACKGROUND: Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. AIM: To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. METHOD: This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. RESULTS: More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. CONCLUSION: Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

Total somatic symptom score as a predictor of health outcome in somatic symptom disorders.

BACKGROUND: The diagnosis of somatisation disorder in DSM-IV was based on 'medically unexplained' symptoms, which is unsatisfactory. AIMS: To determine the value of a total somatic symptom score as a predictor of health status and healthcare use after adjustment for anxiety, depression and general medical illness. METHOD: Data from nine population-based studies (total n = 28 377) were analysed. RESULTS: In all cross-sectional analyses total somatic symptom score was associated with health status and healthcare use after adjustment for confounders. In two prospective studies total somatic symptom score predicted subsequent health status. This association appeared stronger than that for medically unexplained symptoms. CONCLUSIONS: Total somatic symptom score provides a predictor of health status and healthcare use over and above the effects of anxiety, depression and general medical illnesses.

Exploratory RCT of a group psychological intervention for postnatal depression in British mothers of South Asian origin - ROSHNI-D.

BACKGROUND: Postnatal depression (PND) is a global public health problem. There is a high prevalence of PND amongst ethnic minority women and major ethnic inequalities in mental health care in the U.K. Language and cultural barriers pose a significant challenge for access to timely treatment and interventions for British South Asian (BSA) women with PND. METHODS: The study, carried out in Manchester and Lancashire, England, was a two-arm single-blind exploratory randomised controlled trial. BSA women (N = 83) having a baby <12 months were randomised either to the group receiving the culturally adapted Positive Health Programme (PHP) (n = 42) or to the group receiving treatment as usual (TAU) (n = 41). Follow-up assessments were at 3 months (end of intervention) and 6 months after randomisation. RESULTS: Using an intention to treat analysis, there was no significant difference between PHP intervention and TAU groups in depression measured using Hamilton Depression Rating Scale both at 3 and 6 months follow up. Using modified intention to treat analysis, women who attended four or more sessions showed significant reduction in depression in the PHP group compared to the TAU group and the greater number of sessions attended was associated with greater reductions in depression scores. LIMITATIONS: The sample was relatively small and the study was conducted in one geographical area in Northwest England; hence, these results may not be generalizable to other regions and populations. CONCLUSION: The recruitment and trial retention figures highlighted the ability of the research team to engage with BSA women, having implications in planning services for this group. TRIAL REGISTRATION: Clinicaltrials.govNCT01838889.

Somatization and health anxiety as predictors of health care use.

OBJECTIVE: To assess whether the number of somatic symptoms and health anxiety are independent predictors of future health care use after adjusting for confounders. METHODS: In a random sample of the adult UK population, questionnaires assessed the number of somatic symptoms (Somatic Symptom Inventory), health anxiety (Whiteley Index), anxiety/depression (Hospital Anxiety and Depression Scale), the number of physical illnesses and demographic variables. The number of consultations in primary care was obtained from medical records for 1 year before and after questionnaire assessment, and negative binomial regression analyses identified predictors of consultation rate. RESULTS: The sample included 961 participants (58.0% response) with complete medical record data for 609 participants. After adjustment for consultation rate in the prior year, the predictors of subsequent consultation rate in primary care were the number of physical illnesses, off work through illness, Whiteley Index (incidence rate ratio [IRR] = 1.22, 95% confidence interval [CI] = 1.09-1.35), and the Whiteley Index-by-Somatic Symptom Inventory interaction term. Reported physical abuse predicted an increased consultation rate in women (IRR = 2.30, 95% CI = 1.08-4.90) but a reduced rate in men (IRR = 0.43, 95% CI = 0.22-0.84), interaction p = 0.003. CONCLUSIONS: These data raise the possibility that both increased health anxiety and number of bothersome somatic symptoms predict frequent medical consultations. A more complex model of predicting future health care use is needed than has been studied previously, which is potentially relevant to the current discussions of the proposed DSM-V and International Classification of Diseases, 11th Revision, diagnostic guidelines regarding complex somatic symptom disorders.

Effective treatment of perinatal depression for women in debt and lacking financial empowerment in a low-income country.

BACKGROUND: Poverty may moderate the effect of treatment of depression in low-income countries. AIMS: To assess poverty and lack of empowerment as moderators of a cognitive-behavioural therapy (CBT)-based intervention for perinatal depression in rural Pakistan. METHOD: Using secondary analysis of data from a randomised controlled trial (trial registration: ISRCTN65316374) we identified predictors of depression at 1-year follow-up and moderators of the intervention (n = 791). RESULTS: Predictors of follow-up depression included household debt, the participant not being empowered to manage household finance and the interaction terms for these variables with the trial arm. Effect sizes for women with and without household debt were 0.80 and 0.55 respectively. The effect size for women in debt and not empowered financially was 0.94 compared with 0.50 for women with neither of these factors. CONCLUSIONS: Our findings demonstrate the importance of household debt and lack of financial empowerment of women as important maintaining factors of depression in low-income countries and our locally developed intervention tackled these problems successfully.

Prevalence and psychosocial correlates of perinatal depression: a cohort study from urban Pakistan.

Depression around childbirth is common in low income countries. The aim of this study was to examine the factors associated with persistence of depression from the antenatal to the postnatal period in urban Pakistan. A total of 1,357 pregnant women in their third trimester attending the antenatal clinic were included in the study. From these, 763 mothers who delivered at the study maternity home were reassessed after 3 months of childbirth. Edinburgh Postnatal Depression Scale (EPDS) was administered to measure depression in both the antenatal and the postnatal periods. Psychological distress, disability and life events experienced by mothers were also measured by using the Self-Reporting Questionnaire (SRQ-20), Brief Disability Questionnaire (BDQ), and Life Events Checklist, respectively. We found 25.8% prevalence rate of antenatal depression and 38.3% persistent depression in a private clinic. Persistently depressed mothers had significantly high psychological distress, more disability, and experienced more stressful life events than the resolved group. Our findings confirm the high rates of depression during pregnancy but we found low rates of persistent depression in this urban population as compared to the previous report. There is a need for further investigation of factors associated with persistent depression in order to develop appropriate interventions.

Depressive disorder and social stress in Pakistan compared to people of Pakistani origin in the UK.

PURPOSE: Depressive disorder is more common in low to middle than high-income countries, but the reasons for this have not been explicitly defined. METHOD: We compared the results of two population-based studies of people of Pakistani origin: one living in rural Pakistan and one in UK. Both samples were screened with the self-reporting questionnaire followed by research interview to determine depressive disorders and social stress. RESULTS: Logistic regression was used to compare the prevalence of depressive disorder in the two countries after adjustment for socio-demographic characteristics and social stress. The estimated prevalence of depression for men was 35.8% (95% CI 16.1-55.5) in Pakistan and 9% (5.0-13.0) in Manchester (p<0.001). Corresponding figures for women were 50.2% (40.8-59.6) and 31.1% (24.1-38.0) in Mandra and Manchester, respectively (p=0.006). The differences remained significant after adjustment for socio-demographic characteristics until we adjusted for either years of education (women only) or severe social stress (both sexes). 35% of women in Pakistan and 71% of those in UK had received 8 years or more of education. Extremely poor housing and marked poverty were experienced by 36.1% of women in Pakistan and 0.6% of those in Manchester. In Pakistan, housing and poverty predominated as correlates of depression, whereas in Manchester it was marked difficulties in physical health and close relationships. CONCLUSION: The results suggest that the higher rate of depressive disorder amongst women in Pakistan compared to UK can be attributed to less education and frequent severe social difficulties. These differences have implications for treatment.

Social intervention for British Pakistani women with depression: randomised controlled trial.

BACKGROUND: British Pakistani women have a high prevalence of depression. There are no reported psychosocial interventions for depression in ethnic minorities in the UK. AIMS: To determine the efficacy of a social group intervention compared with antidepressants, and whether the combination of the two is more efficacious than either alone. METHOD: A total of 123 women with depression participated in the primary care-based cluster randomised controlled trial (ISRCTN19172148). Outcome measures were severity of depression (Hamilton Rating Scale for Depression), social functioning and satisfaction at 3 and 9 months. RESULTS: Greater improvement in depression in the social intervention group and the combined treatment group compared with those receiving antidepressants alone fell short of significance. There was significantly greater improvement in social functioning in the social intervention and combined treatment groups than in the antidepressant group at both 3 and 9 months. CONCLUSIONS: Pakistani women with depression found the social groups acceptable and their social function and satisfaction improved if they received social treatment compared with the receipt of antidepressants alone.

Personality variables are associated with colorectal cancer patients' quality of life independent of psychological distress and disease severity.

OBJECTIVE: The aim of the present study was to test whether psychological distress and personality variables are independently associated with health-related quality of life (HRQOL) in colorectal cancer patients, after adjusting for age, gender, education and disease severity. METHODS: In a cross-sectional study of 162 colorectal cancer patients (response rate 65.6%), the following self-report instruments were administered: the Symptom Distress Checklist-90-R, the Sense of Coherence scale, the Life Style Index and the Hostility and Direction of Hostility Questionnaire. The outcome measures were the four components of the WHO Quality of Life Instrument, Short Form. We used hierarchical regressions to determine whether psychological distress mediates the relationship of personality and disease parameters with HRQOL. RESULTS: The overall proportion of the variance in the four components of HRQOL explained by our regression models ranged from 28.1 to 44.4%. Psychological distress was an independent correlate of HRQOL, associated with physical (p<0005), mental (p<0.05) and social relationships HRQOL (p<0.02). Personality variables were associated with HRQOL independent of psychological distress and disease severity. Sense of coherence and denial defense were positively associated with all aspects of HRQOL independent of psychological distress and disease parameters (p-values ranging from p<0.05 to p<0.0005). Hostility (p<0.01) and repression defense (p=0.024) were also independently but negatively associated with physical HRQOL. CONCLUSIONS: In colorectal cancer patients, psychological distress is associated with HRQOL independent of disease parameters but personality variables are also associated with HRQOL independent of disease severity and psychological distress, and this could be relevant to psychological interventions.

Psychological distress, somatization, and defense mechanisms associated with quality of life in inflammatory bowel disease patients.

BACKGROUND: Clinical parameters predict health-related quality of life (HRQOL) in inflammatory bowel disease (IBD), but some patients have impaired HRQOL despite being in clinical remission. OBJECTIVE: To identify personality and psychological distress variables associated with HRQOL in IBD. METHOD: In a cross-sectional study of 185 IBD patients, the General Health Questionnaire, the Hopkins' Symptoms Distress Checklist, the Defense Style Questionnaire and the Life Style Index were administered. The Inflammatory Bowel Disease Questionnaire was used for the assessment of HRQOL. RESULTS: Psychological distress was associated with impaired HRQOL in a dose-response fashion. Somatization mediated the relationships of anxiety and depression with HRQOL. Few years of education, more extensive use of the reaction-formation defense mechanism and higher rates of somatization were the variables most closely and independently associated with impaired HRQOL. CONCLUSIONS: Somatization and reaction-formation are independent correlates of disease-specific HRQOL in IBD patients, and this could be relevant to psychological interventions.