Clinical relevance of findings in trials of CBT for depression.

Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression - Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant clinical response. The non-specific or placebo effect of being in a psychotherapy trial was a 29% reduction of HAMD.

Individualisation in crisis planning for people with psychotic disorders.

Background. In England, people with a serious mental illness are offered a standardized care plan under the Care Programme Approach (CPA). A crisis plan is a mandatory part of this standard; however, the quality and in particular the level of individualisation of these crisis plans are unknown. In this context, the aim of this study was to assess the quality of crisis planning and the impact of exposure to a specialized crisis planning intervention. Method. The crisis plans of 424 participants were assessed, before and after exposure to the Joint Crisis Plan (JCP) intervention, for 'individualisation' (i.e., at least one item of specific and identifiable information about an individual). Associations of individualisation were investigated. Results. A total of 15% of crisis plans were individualised at baseline. There was little or no improvement following exposure to the JCP. Individualised crisis plans were not associated with a history of prior crises or incidences of harm to self and others. Conclusions. Routine crisis planning for individuals with serious mental illness is not influenced by clinical risk profiles. 'Top down' implementation of the policy is unlikely to generate the best practice and compliance if clinicians do not perceive the clinical value in the process.

Psychological treatments for depression and anxiety disorders in low- and middle- income countries: a meta-analysis.

OBJECTIVE: The objective of this meta-analysis was to determine the efficacy of psychological treatments for depression and anxiety disorders in low- and middle- income countries (LAMIC). METHOD: Meta-analysis of randomized controlled trials on psychological treatment of depression and anxiety disorders in low-and middle income countries using an existing database (www.evidencebasedpsychotherapies.org), PubMed, Embase, Psychinfo, Dissertation Abstracts International and the Cochrane Central Register of Controlled Trials were searched for studies published in all languages. Additional studies were identified from reference lists of found studies. Randomized controlled trials in which a psychological intervention for anxiety or depression was compared to a control condition (care-as-usual, waiting list, placebo, or another control group) were included. The randomized controlled trials needed to be conducted in a LAMI country (classification of LAMI countries according to the World Bank's list of economies) to be eligible for inclusion in the meta-analysis. Psychological treatments were defined as interventions in which the core element of treatment consisted of verbal communication between a therapist and a patient. RESULTS: Seventeen studies met our inclusion criteria, with a total of 3,010 participants. The mean standardized difference between the treatment and control groups at post-test was 1.02 (95% CI: 0.76∼1.28) which corresponds well with the effects found in high-income countries. CONCLUSION: These results indicate that psychological treatments of depression and anxiety disorders are also effective in LAMI countries, and may encourage global dissemination of these interventions.

MR imaging of psychosurgery: rostral atrophy following stereotacic subcaudate tractotomy.

There are few reports of MR imaging findings following psychosurgery. Here, we report the findings of 3T MR imaging of the sequelae of stereotactic subcaudate tractotomy (SST). Rostral atrophy is noted on conventional imaging. Diffusion tensor (DT) tractography demonstrated no communicating white matter tracts between the inferior frontal lobes, which appeared normally as thick fibre bundles in age-matched controls. DT tractography provides a unique tool for the evaluation of sequelae of ablative psychosurgical procedures.

The validation of personal health questionnaire amongst people of Pakistani family origin living in the United Kingdom.

BACKGROUND: The Personal Health Questionnaire (PHQ) was developed to screen for depressive disorder in an English speaking population. Its validity in Urdu speaking people of Pakistani family origin living in UK is yet to be established. METHODS: The PHQ was used to screen for depression in a two phase primary care based study of depressive disorder in people of Pakistani family origin residing in Manchester, UK. A proportion of high scorers (PHQ> or =7) and a random selection of low scorers (PHQ 0-6) were interviewed with the Psychiatric Assessment Schedule (PAS) to confirm caseness (ID> or =5). A receiver operator characteristic curve (ROC) analysis was carried out to confirm the optimum threshold value. RESULTS: The PHQ was used to screen 218 subjects with cut off of PHQ> or =7. 46 high scorers and 31 low scorers were interviewed in second stage using PAS. At this threshold PHQ has a sensitivity of 70.4% and specificity of 89.3%. CONCLUSIONS: Findings of this study confirm high sensitivity and specificity of PHQ amongst people of Pakistani family origin. It can be used as a screening instrument to detect depression in Urdu speaking population in UK.

Management strategies in geriatric depression by primary care physicians and factors associated with the use of psychiatric services: a naturalistic study.

Approximately 10% of elderly patients in primary care have depression yet it is often under-diagnosed and under-treated. It is unclear exactly how patients are being managed in primary care or what factors are associated with referral to psychiatric services. This study aimed to establish in a naturalistic setting how older depressed patients are managed in primary care; to determine which patients are referred to psychiatric services and the differences between patients referred and those not; in terms of primary care consultation rate and degree of co-morbid illness. Computerised records and referral letters were read for 1089 elderly patients in a large practice in central Manchester, UK. Of the 9% identified as depressed, 90% were managed in primary care alone, a third without antidepressants. More than half of those prescribed antidepressants received tricyclic antidepressants. Suicidal ideation and treatment failure were the principle reasons for referral. Patients referred had a greater psychiatric co-morbidity and had consulted their GP more frequently in the past year. Management of depression in the elderly may be conservative and older antidepressants may be over-prescribed. Increased primary care consultation rate and a greater psychiatric co-morbidity may be associated with referral to psychiatric services.

Self-harm in British South Asian women: psychosocial correlates and strategies for prevention.

OBJECTIVE: To review the rates of self-harm in British South Asian women, look into the factors that contribute to these high rates of self-harm and discuss possible strategies for prevention and provision of culturally sensitive service for South Asian women who harm themselves. METHOD: Review. RESULTS: South Asian women are significantly more likely to self harm between ages 16-24 years than white women. Across all age groups the rates of self harm are lower in South Asian men as compared to South Asian women. These women are generally younger, likely to be married and less likely to be unemployed or use alcohol or other drugs. They report more relationship problems within the family. South Asian women are less likely to attend the ER with repeat episode since they hold the view that mainstream services do not meet their needs. CONCLUSION: South Asian women are at an increased risk of self harm. Their demographic characteristics, precipitating factors and clinical management are different than whites. There is an urgent need for all those concerned with the mental health services for ethnic minorities to take positive action and eradicate the barriers that prevent British South Asians from seeking help. There is a need to move away from stereotypes and overgeneralisations and start from the user's frame of reference, taking into account family dynamics, belief systems and cultural constraints.

Peripheral neuropathies in Waldenström's macroglobulinaemia.

OBJECTIVE: We sought to determine the prevalence, clinical features, and laboratory characteristics of polyneuropathies in Waldenström's macroglobulinaemia (WM), a malignant bone marrow disorder with lymphocytes that produce monoclonal IgM. METHODS: We prospectively studied 119 patients with WM and 58 controls. Medical history was taken, and neurological examinations, electrodiagnostic tests, and serum studies were performed by different examiners who were blinded to results except the diagnosis of WM. RESULTS: Polyneuropathy symptoms, including discomfort and sensory loss in the legs, occurred more frequently (p<0.001) in patients with WM (47%) than in controls (9%). Patients with WM had 35% lower quantitative vibration scores, and more frequent pin loss (3.4 times) and gait disorders (5.5 times) than controls (all p<0.001). Patients with IgM binding to sulphatide (5% of WM) had sensory axon loss; those with IgM binding to myelin associated glycoprotein (MAG) (4% of WM) had sensorimotor axon loss and demyelination. Patients with WM with IgM binding to sulphatide (p<0.005) or MAG (p<0.001) had more severe sensory axon loss than other patients with WM. Demyelination occurred in 4% of patients with WM with no IgM binding to MAG. Age related reductions in vibration sense and sural SNAP amplitudes were similar ( approximately 30%) in WM and controls. CONCLUSIONS: Peripheral nerve symptoms and signs occur more frequently in patients with WM than controls, involve sensory modalities, and are often associated with gait disorders. IgM binding to MAG or sulphatide is associated with a further increase in the frequency and severity of peripheral nerve involvement. Age related changes, similar to those in controls, add to the degree of reduced nerve function in patients with WM.

Sensory exam with a quantitative tuning fork: rapid, sensitive and predictive of SNAP amplitude.

BACKGROUND: In the standard neurologic examination, outcome measures of sensation testing are typically qualitative and subjective. The authors compared the outcome of vibratory sense evaluation using a quantitative Rydel-Seiffer 64 Hz tuning fork with qualitative vibration testing, and two other features of the neurologic evaluation, deep tendon reflexes and sensory nerve conduction studies. METHODS: The authors studied 184 subjects, including 126 with Waldenström's macroglobulinemia and 58 controls, over the course of a weekend. Standard neurologic examinations and quantitative vibratory testing were performed. Sensory nerve action potentials (SNAP) were tested as a measure of sensory nerve function. Tests were carried out by different examiners who were blinded to the results of other testing and to clinical information other than the diagnosis of Waldenström's macroglobulinemia. RESULTS: Quantitative vibration measurements in all body regions correlated with sural SNAP amplitudes. Quantitative vibration outcomes were more strongly related to sural SNAP results than qualitative evaluations of vibration. Quantitative vibration testing also detected a loss of sensation with increased age in all body regions tested. CONCLUSIONS: Quantitative vibratory evaluation with Rydel-Seiffer tuning fork is rapid, has high inter- and intrarater reliability, and provides measures for evaluating changes in sensory function over time. Examinations with the quantitative tuning fork are also more sensitive and specific than qualitative vibration testing for detecting changes in sensory nerve function. Use of the quantitative tuning fork takes no more time, provides more objective information, and should replace the qualitative vibratory testing method that is now commonly used in the standard neurologic examination.

Translation and cultural adaptation of health questionnaires.

BACKGROUND: Health research in Pakistan often requires questionnaires in English language developed in the West to be translated into the local language. Many of the factors measured by these questionnaires are complex and apply to a different culture. Simple translations may lead to problems of validity and reliability in the Pakistani setting. This paper describes the strategies adopted for the translation and cross-cultural adaptation of the Self-Reporting Questionnaire (SRQ), a screening questionnaire for mental health developed by the World Health Organisation. METHODS: A general protocol was developed for translation of questionnaires into Urdu, describing each step in the translation procedure. Key informant interviews were carried out to obtain better cultural understanding of difficult concepts. The translation was tested and disputed items discussed in a focus group in a structured manner. RESULTS: Modifications were made to the questionnaire in light of the target population's culture and language. CONCLUSION: Simple translations are often insufficient for complex questionnaires. Key informant interviews and focus groups are useful to address conceptual and construct issues in such questionnaires.