Depression predicts emergency care use in people with chronic obstructive pulmonary disease: a large cohort study in primary care.

Background: Depression is common in people with chronic obstructive pulmonary disease (COPD) and has been associated with a variety of poor outcomes. A large proportion of health care costs in the UK are spent on emergency care. This study examined the prospective relationship between depression and use of emergency care in patients with COPD managed in primary care. Methods: This was a twelve-month, prospective longitudinal study of 355 patients with COPD in six primary care practices in the UK. Baseline measures included demographic characteristics, depression and anxiety, severity of COPD, presence or absence of other chronic diseases, and prior use of emergency care. Outcome measures were (a) number of emergency department (ED) visits; or (b) an emergency hospital admission in the follow-up year. Results: Older age, number of comorbid physical health conditions, severity of COPD, prior use of emergency care, and depression were all independently associated with both ED attendance and an emergency hospital admission in the follow-up year. Subthreshold depression (HADS depression score 4-7) was associated with a 2.8 times increased odds of emergency hospital admission, and HADS depression >8 was associated with 4.8 times increased odds. Conclusion: Depression is a predictor of emergency care in COPD, independent of severity of disease or physical comorbidity. Even mild (subthreshold) symptoms of depression more than double the risk of using emergency care, suggesting there is a strong case to develop and deploy integrated preventive strategies in primary care that can promote mental health in people with COPD.

Identifying demographic, social and clinical predictors of biologic therapy effectiveness in psoriasis: a multicentre longitudinal cohort study.

BACKGROUND: Biologic therapies have revolutionized the treatment of moderate-to-severe psoriasis. However, for reasons largely unknown, many patients do not respond or lose response to these drugs. OBJECTIVES: To evaluate demographic, social and clinical factors that could be used to predict effectiveness and stratify response to biologic therapies in psoriasis. METHODS: Using a multicentre, observational, prospective pharmacovigilance study (BADBIR), we identified biologic-naive patients starting biologics with outcome data at 6 (n = 3079) and 12 (n = 3110) months. Associations between 31 putative predictors and outcomes were investigated in univariate and multivariable regression analyses. Potential stratifiers of treatment response were investigated with statistical interactions. RESULTS: Eight factors associated with reduced odds of achieving ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) at 6 months were identified (described as odds ratio and 95% confidence interval): demographic (female sex, 0·78, 0·66-0·93); social (unemployment, 0·67, 0·45-0·99); unemployment due to ill health (0·62, 0·48-0·82); ex- and current smoking (0·81, 0·66-0·99 and 0·79, 0·63-0·99, respectively); clinical factors (high weight, 0·99, 0·99-0·99); psoriasis of the palms and/or soles (0·75, 0·61-0·91); and presence of small plaques only compared with small and large plaques (0·78, 0·62-0·96). White ethnicity (1·48, 1·12-1·97) and higher baseline PASI (1·04, 1·03-1·04) were associated with increased odds of achieving PASI 90. The findings were largely consistent at 12 months. There was little evidence for predictors of differential treatment response. CONCLUSIONS: Psoriasis phenotype and potentially modifiable factors are associated with poor outcomes with biologics, underscoring the need for lifestyle management. Effect sizes suggest that these factors alone cannot inform treatment selection.

Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue.

OBJECTIVE: Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety. METHODS: We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms. RESULTS: Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N=93) had unexplained chronic widespread pain and 12.6% (N=125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression. DISCUSSION: This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression.

A phase-specific psychological therapy for people with problematic cannabis use following a first episode of psychosis: a randomized controlled trial.

BACKGROUND: Cannabis use is high amongst young people who have recently had their first episode of psychosis, and is associated with worse outcomes. To date, interventions to reduce cannabis consumption have been largely ineffective, and it has been suggested that longer treatment periods are required. METHOD: In a pragmatic single-blind randomized controlled trial 110 participants were randomly allocated to one of three conditions: a brief motivational interviewing and cognitive behavioural therapy (MI-CBT) intervention (up to 12 sessions over 4.5 months) with standard care from an early intervention service; a long MI-CBT intervention (up to 24 sessions over 9 months) with standard care; or standard care alone. The primary outcome was change in cannabis use as measured by Timeline Followback. RESULTS: Neither the extended nor the brief interventions conferred benefit over standard care in terms of reductions in frequency or amount of cannabis use. Also the interventions did not result in improvements in the assessed clinical outcomes, including symptoms, functioning, hospital admissions or relapse. CONCLUSIONS: Integrated MI and CBT for people with cannabis use and recent-onset psychosis does not reduce cannabis use or improve clinical outcomes. These findings are consistent with those in the published literature, and additionally demonstrate that offering a more extended intervention does not confer any advantage. Many participants were not at an action stage for change and for those not ready to reduce or quit cannabis, targeting associated problems rather than the cannabis use per se may be the best current strategy for mental health services to adopt.

Multiple somatic symptoms predict impaired health status in functional somatic syndromes.

BACKGROUND: The relationship between functional somatic syndromes and multiple somatic symptoms is unclear. PURPOSE: We assessed whether the number of somatic symptoms is a predictor of health status in three functional somatic syndromes (FSS). METHODS: In a population-based study of 990 UK adults we assessed chronic widespread pain (CWP), chronic fatigue (CF) and irritable bowel syndrome (IBS) by questionnaire and medical record data. We assessed health status (Short Form 12 and EQ-5D), number of somatic symptoms (Somatic Symptom Inventory) and anxiety/depression (Hospital Anxiety and Depression Scale) both at baseline and at follow-up 1 year later. RESULTS: The proportion of people with an FSS who also have multiple somatic symptoms (52-55 %) was similar in the three functional syndromes. The presence of multiple somatic symptoms was associated with more impaired health status both at baseline and at follow-up. This finding was not explained by severity of FSS. In the absence of multiple somatic symptoms, the health status of the FSS was fair or good. In multiple regression analysis, the number of somatic symptoms, the presence of a functional syndrome (CWP or CF) and anxiety/depression were predictors of EQ-5D thermometer at follow-up after adjustment for confounders. CONCLUSIONS: Multiple somatic symptoms in people with an FSS are associated with impaired health status and this cannot be explained by more severe functional syndrome or the presence of anxiety and depression.

A prospective study of social difficulties, acculturation and persistent depression in Pakistani women living in the UK.

BACKGROUND: The reasons for the high prevalence of depressive disorders in women of Pakistani origin living in the UK are not clear. The aim of this study was to determine the relative importance of life events, chronic social difficulties and acculturation in a population-based sample of British Pakistani women. METHOD: A cross-sectional and prospective cohort study of 18- to 65-year-old Pakistani women in UK was carried out. The Schedule for Clinical Assessment in Neuropsychiatry for diagnosis, the Life Events and Difficulties Schedule for social stress and an acculturation questionnaire were used. RESULTS: Depressive disorder at baseline was associated with older age, social isolation and marked difficulties involving health and close relationships. Depressive disorder at follow-up was associated with severity of depression at baseline, difficulties in close relationships and two aspects of acculturation, especially less acculturation in relation to use of the English language. CONCLUSIONS: Lack of acculturation, especially less familiarity with the English language, is an independent predictor of persistence of depression in Pakistani women in UK. This needs to be taken into consideration when planning treatment, which also needs to address the personal difficulties associated with persistent depression. The implication of this work is that women of Pakistani origin with depression should be encouraged to receive help in the use of English as one part of treatment that may prevent relapse.

A prospective study of psychological distress among mothers of children admitted to a nutritional rehabilitation unit in Malawi.

OBJECTIVES: Accompanying guardians (usually the mother) have a pivotal role in promoting recovery from childhood severe acute malnutrition on Nutritional Rehabilitation Units (NRUs). We describe the prevalence of maternal distress at an NRU in Malawi and identify factors associated with this. We tested the hypothesis that maternal distress during admission would be associated with reduced child weight gain over the 4-week post-discharge period. METHODS: Maternal distress was measured using the Self Reporting Questionnaire (SRQ) administered to mothers of consecutive children during NRU admission. Repeat SRQ was administered to mothers attending a follow-up clinic 4 weeks post discharge. Maternal, child and psychosocial variables were also measured. Child weight change from discharge to follow-up was compared between children of mothers scoring SRQ ≥ 8 and those scoring SRQ < 8. FINDINGS: A total of 244 mothers and their children were recruited. In total, 71% of mothers scored SRQ ≥ 8 during admission. In all, 155 of 222 mothers eligible to complete repeat SRQ did so, and 33.5% scored SRQ ≥ 8. Maternal distress at recruitment was associated with older child age, no confiding relationship with spouse, having had a previous child die, and the child having diarrhoea. Maternal distress at follow-up was associated with older child age, the child having diarrhoea or fever since discharge, and the child being HIV sero-positive. Maternal distress during admission was not associated with child weight gain at 4-week post-discharge follow-up. CONCLUSION: Levels of maternal distress are very high during child admission to an NRU. Persistent distress is associated with child health factors including HIV. Nutritional rehabilitation programmes should pay increased attention to carer psychological wellbeing using targeted evidence-based interventions.

The role of psychological distress and personality variables in the disablement process in rheumatoid arthritis.

OBJECTIVE: To test whether psychological distress and personality variables mediate or moderate physical health-related quality of life (HRQOL) in rheumatoid arthritis (RA) patients. METHODS: In 168 RA patients the following self-report instruments were administered: the Health Assessment Questionnaire (HAQ), the General Health Questionnaire (GHQ), the Defence Style Questionnaire (DSQ), the Hostility and Direction of Hostility Questionnaire (HDHQ), and the Sense of Coherence (SOC) scale. A total of 152 patients with several rheumatological disorders [56 with systemic sclerosis (SSc), 56 with systemic lupus erythematosus (SLE) and 40 with Sjögren's syndrome (SS)] served as disease controls. The outcome measure was the physical scale of the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF). We used hierarchical regression to determine whether our data were consistent with the disablement process model. RESULTS: In RA patients, sense of coherence was associated with physical HRQOL but the relationship was mediated by psychological distress. Self-sacrificing defence style moderated the relationship between pain and physical HRQOL: pain was associated with impaired physical HRQOL only in patients with predominant self-sacrificing defence style. Although psychological distress and personality variables were also associated with physical HRQOL in the disease control group, the moderating effects of personality on physical HRQOL were unique to RA. Thus, in RA, psychological distress, functional disability, and the interaction term between pain and self-sacrificing defence style were independently associated with physical HRQOL. CONCLUSIONS: In RA patients, psychological distress mediated the association of personality variables with physical HRQOL but personality moderated the effects of pain on physical HRQOL and this could be relevant to psychological interventions.

Can a brief psychological intervention prevent anxiety or depressive disorders in cancer patients? A randomised controlled trial.

BACKGROUND: We tested whether a brief psychological intervention could prevent anxiety or depressive disorders among newly diagnosed cancer patients. PATIENTS AND METHODS: Patients free of anxiety or depressive disorder were randomised to receive immediate intervention (start of cancer treatment), delayed intervention (8 weeks after starting treatment) or usual care. They were stratified according to risk of developing anxiety or depressive disorders. Primary outcome was measured using a standardised psychiatric interview to detect any anxiety or depressive disorder at 6 and 12 months following the cancer diagnosis. Analyses used conditional odds logistic regression models adjusting for age, gender, concerns and past history to compare outcome of all intervention patients with usual care. RESULTS: A total of 465 patients were recruited. In all, 313 (79%) of the 397 well enough to be interviewed completed the study. At 12 months, there was no difference between the groups receiving the intervention and usual care [odds ratio (OR) = 0.69, 95% confidence interval (CI) 0.41-1.17, P = 0.17]. In high-risk patients, those who received the intervention were less likely to develop an anxiety or depressive disorder compared with those who received usual care (OR = 0.54, 95% CI 0.29-1.00, P = 0.050). In low-risk patients, there was no difference (OR = 1.50, 95% CI 0.51-4.43, P = 0.47). CONCLUSION: A brief intervention, delivered by nonspecialists, promoted adjustment among newly diagnosed cancer patients at high risk of developing anxiety or depressive disorders.

A population-based study of irritable bowel syndrome in a non-Western population.

Previous studies have found no female predominance in irritable bowel syndrome (IBS) in non-Western countries. The aim of the study was to assess the prevalence and correlates of Rome II (IBS) in both sexes in Pakistan. A Population-based survey in a low-income inner city area using questionnaires to diagnose Rome II IBS and assess distress, disability and stressful life events. Data were collected from 880/938 (93%) randomly selected residents. 13.4% of women and 13.1% men met criteria for Rome II IBS; 34 (3.9%) had diarrhoea-predominant, 59 (6.7%) had constipation-predominant IBS and 24 (2.7%) had 'mixed IBS'. In logistic regression analysis, IBS was associated in men with high income (OR = 1.56; 95% CI: 1.05-2.3) and few years of education (OR = 2.17; 95% CI: 1.2-3.9) and in women with being married (OR = 3.6; 95% CI: 1.1-11.9) and stressful life events score (OR = 1.14; 95% CI: 1.01-1.3). Disability was associated with constipation-predominant IBS (OR = 1.99; 95% CI: 1.1-3.6), distress (OR = 1.19; 95% CI: 1.14-1.23) and stressful life events (OR = 1.19; 95% CI: 1.1-1.3). Investigations were more likely in men (54%) than in women (27%) (P = 0.003). These findings suggest that the equal sex ratio of IBS in urban Pakistan could result from a close association between marked distress and IBS in men similar to that found in women in western studies.

Life stress and depression in a tribal area of Pakistan.

BACKGROUND: Depression is common in Pakistan but no research on this subject has been reported from the North West Frontier Province (NWFP), host to numerous Afghan refugees. AIMS: To measure depressive symptoms and associated features in a population-based sample. METHOD: A Pushto translation of the Self Reporting Questionnaire (SRQ) was administered to 471 adults living in a village in one of the federally administered tribal areas. Respondents were also assessed with a life events checklist for social problems, a social support questionnaire and the Brief Disability Questionnaire. RESULTS: Sixty per cent (95/158) of women and 45% (140/313) of men scored 9 or more on the SRQ. High SRQ score was associated with few years of education, higher social problem score, less social support and greater disability. High social problem score was the strongest correlate. CONCLUSIONS: This population reports more depressive symptoms than other communities in Pakistan and this probably reflects the very high degree of social stress experienced in the NWFP, which has been affected by years of turmoilin neighbouring Afghanistan.

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.

Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction.

BACKGROUND: The extent to which depression impairs health-related quality of life (HRQoL) in the physically ill has not been clearly established. AIMS: To quantify the adverse influence of depression and anxiety, assessed at the time of first myocardial infarction and 6 months later, on the physical aspect of HRQoL 12 months after the infarction. METHOD: In all, 260 in-patients, admitted following first myocardial infarction, completed the Hospital Anxiety and Depression Scale and the Medical Outcomes Study SF-36 assessment before discharge and at 6- and 12-month follow-up. RESULTS: Depression and anxiety 6 months after myocardial infarction predicted subsequent impairment in the physical aspects of HRQoL (attributable adjusted R(2)=9%, P<0.0005). These negative effects of depression and anxiety on outcome were mediated by feelings of fatigue. Depression and anxiety present before myocardial infarction did not predict HRQoL 12 months after myocardial infarction. CONCLUSIONS: Detection and treatment of depression and anxiety following myocardial infarction improve the patient's health-related quality of life.

The risk factors for depression in first myocardial infarction patients.

BACKGROUND: Depression affects outcome following myocardial infarction but the risk factors for such depression have been little studied. This study considered whether the causes of depression occurring before and after myocardial infarction were similar to those of depression in the general population. METHOD: Consecutive patients admitted to hospital following their first myocardial infarction were interviewed with the Schedule for Clinical Assessment in Neuropsychiatry to detect psychiatric disorders and the Life Events and Difficulties Schedule to assess recent stress. Participants completed the Hospital Anxiety and Depression Scale (HADS) at entry to the study and 1 year later and the risk factors associated with a high score at both times were assessed. RESULTS: Of 314 (88% of eligible) patients who were recruited, 199 (63%) were male and 63 (20%) had depressive disorders. Logistic regression identified the following as independently associated with depressive disorder that had been present for at least I month before the myocardial infarction: younger age, female sex, past psychiatric history, social isolation, having marked non-health difficulties and lack of a close confidant. At follow-up 269/298 (90%) responded; of 189 participants not depressed at first assessment, 39 (21%) became depressed by the 1 year follow-up. Logistic regression identified frequent angina as the only significant predictor of raised HADS scores at 12 months. CONCLUSIONS: Depression developing during the year following myocardial infarction does not have the same risk factors as that which precedes myocardial infarction. Further clarification of the mechanisms linking depression to poor outcome may require separation consideration of pre- and post-myocardial infarction depression, and its risk factors.

Lack of a close confidant, but not depression, predicts further cardiac events after myocardial infarction.

OBJECTIVE: To assess the role of depression and lack of social support before myocardial infarction (MI) in determining outcome in a large representative sample of patients admitted after MI in the UK. DESIGN: Prospective cohort design. PATIENTS: 1034 consecutive patients were screened 3-4 days after MI. MAIN OUTCOME MEASURES: Mortality and further cardiac events over one year after an MI. RESULTS: At 12 months' follow up mortality and further cardiac events were assessed in 583 of 654 eligible patients (90% response); 140 of 589 for whom baseline data were collected (23.8%) were depressed before their MI. Patients who were depressed before their MI were not more likely to die (mortality 5.2% v 5.0% of non-depressed patients) or suffer further cardiac events (cardiac events rate 20.7% v 20.3% of non-depressed patients). After controlling for demographic factors and severity of MI, the absence of a close confidant predicted further cardiac events (hazard ratio 0.57, p = 0.022). CONCLUSION: Lack of a close confidant but not depression before MI was associated with adverse outcome after MI in this sample. This association may be mediated by unhealthy behaviours and lack of compliance with medical recommendations, but it is also compatible with difficulties in early life leading to heart disease.

Effect of childhood adversity on health related quality of life in patients with upper abdominal or chest pain.

BACKGROUND AND AIMS: This study assessed whether childhood and current adversities: (a) were more prevalent in patients with functional dyspepsia (FD) or non-cardiac chest pain (NCCP) than in patients with gastro-oesophageal reflux disease (GORD) or ischaemic heart disease (IHD); and (b) predicted health related quality of life in these disorders. PATIENTS: Cohort study of consecutive attenders to gastroenterology and cardiology clinics in a secondary/tertiary referral centre. METHODS: Patients were interviewed using the childhood experience of care and abuse and life events and difficulties schedules. Distress was assessed by questionnaire. Outcome was assessed using SF36 at the index clinic visit and six months later. RESULTS: A total of 133 patients were included (40 NCCP, 43 FD, 29 GORD, and 21 IHD) (67% response rate). The diagnostic groups did not differ significantly in the proportion reporting childhood adversity (30%), ongoing social stress (40%), lack of a close confidant (14%), or level of psychological distress. Reported childhood adversity was associated with poor outcome at the index visit (SF36 physical component score: 36.6 (SEM 1.8) v 42.3 (SEM 1.2) for the remainder; p = 0.014). In multiple regression analysis, childhood adversity was a significant independent predictor for patients with functional disorders (NCCP and FD) but not organic disorders (GORD or IHD). Change in SF36 score at six months was determined by age and distress score at the index visit in both groups. CONCLUSION: Childhood adversity was common among this consecutive sample but was associated directly with poor outcome only in patients with functional gastrointestinal syndromes. Distress is an important predictor of outcome in all patients. Greatest impairment occurs when lack of social support accompanies reported childhood adversity.

Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a heterogeneous condition which is diagnosed according to specific bowel symptom clusters. The aim of the present study was to identify subgroups of IBS subjects using measures of rectal sensitivity and psychological symptoms, in addition to bowel symptoms. Such groupings, which cross conventional diagnostic approaches, may provide greater understanding of the pathogenesis of the condition and its treatment. METHOD: A K means cluster analysis was used to group 107 clinic patients with IBS according to physiological, physical, and psychological parameters. All patients had severe IBS and had failed to respond to usual medical treatment. Twenty nine patients had diarrhoea predominant IBS, 26 constipation predominant, and 52 had an alternating bowel habit. RESULTS: The clusters were most clearly delineated by two variables: "rectal perceptual threshold (volume)" and "number of doctor visits". Three subgroups were formed. Group I comprised patients with low distension thresholds and high rates of psychiatric morbidity, doctor consultations, interpersonal problems, and sexual abuse. Group II also had low distension thresholds but low rates of childhood abuse and moderate levels of psychiatric disorders. Group III had high distension thresholds, constipation or alternating IBS, and low rates of medical consultations and sexual abuse. CONCLUSION: The marked differences across the three groups suggest that each may have a different pathogenesis and respond to different treatment approaches. Inclusion of psychosocial factors in the analysis enabled more clinically meaningful groups to be identified than those traditionally determined by bowel symptoms alone or rectal threshold.

Randomised controlled trial of brief psychological intervention after deliberate self poisoning.

OBJECTIVES: To determine the effects of a brief psychological intervention (brief psychodynamic interpersonal therapy) for patients after deliberate self poisoning compared with usual treatment. To compare the impact of the active intervention and usual treatment on patients' satisfaction with care. DESIGN: Randomised controlled trial. PARTICIPANTS: 119 adults who had deliberately poisoned themselves and presented to the emergency department of a teaching hospital. SETTING: Community based study. INTERVENTION: Four sessions of therapy delivered in the patient's home. Control patients received "treatment as usual," which in most cases consisted of referral back to their general practitioner. OUTCOME MEASURES: Severity of suicidal ideation six months after treatment as assessed by the Beck scale for suicidal ideation. Secondary outcome measures at six month follow up included depressive symptoms as measured by the Beck depression inventory, patient satisfaction with treatment, and self reported subsequent attempts at self harm. RESULTS: Participants randomised to the intervention had a significantly greater reduction in suicidal ideation at six month follow up compared with those in the control group (reduction in the mean (SD) Beck scale 8.0 v 1.5). They were more satisfied with their treatment and were less likely to report repeated attempts to harm themselves at follow up (proportion repeating 9% v 28% in control group; difference 19%, 95% confidence interval 9% to 30 %, P=0.009). CONCLUSION: Brief psychodynamic interpersonal therapy may be a valuable treatment after people have deliberately tried to poison themselves.

Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome.

BACKGROUND: The irritable bowel syndrome (IBS) may lead to considerable impairment of health-related quality of life and high health care costs. It is not clear whether these poor outcomes directly result from severe bowel symptoms or reflect a coexisting psychiatric disorder. OBJECTIVE: To determine whether bowel symptom severity and psychological symptoms directly influence health-related quality of life and health care costs. DESIGN: Cross-sectional survey. SETTING: Secondary and tertiary gastroenterology clinics. PATIENTS: 257 patients with severe IBS who did not respond to usual treatments and were recruited for a trial of psychological treatment. MEASUREMENTS: Predictors were abdominal pain, entries in a diary of 10 IBS symptoms, and measures of psychological symptoms. Outcomes were inability to work, health-related quality of life (measured by Medical Outcomes Survey 36-item short-form questionnaire [SF-36] physical component summary scores), and health care and productivity costs. Predictor and outcome measures were compared by using multiple regression and logistic regression analyses. RESULTS: Abdominal pain occurred on average 24 days per month and activities were restricted on 145 days of the previous 12 months. The mean (+/-SD) Hamilton depression score was 11.3 +/- 6.1. The SF-36 physical component summary score was low (37.7 +/- 10.6), and the patients had incurred high health care costs ($1743 +/- $2263) over the previous year. Global severity and somatization scores on the Symptom Checklist 90 Revised, abdominal pain, and Hamilton depression scores independently contributed to the physical component score of the SF-36 (adjusted R(2) = 35.2%), but only psychological scores were associated with disability due to ill health. These variables did not accurately predict health care or other costs (adjusted R(2) = 9.3%). History of sexual abuse was not an independent predictor of outcome. CONCLUSIONS: Both abdominal and psychological symptoms are independently associated with impaired health-related quality of life in patients with severe IBS. Optimal treatment is likely to require a holistic approach. Since health care and loss of productivity costs are not clearly associated with these symptoms, alleviation of them will not necessarily lead to reduced costs.

Face processing in schizophrenia: defining the deficit.

BACKGROUND: Abnormalities of face affect naming and face recognition occur in schizophrenia but it is not clear whether the deficits reflect wider underlying impairments of perception, memory, language or executive function. METHOD: Twenty-six patients with schizophrenia were compared with 23 healthy volunteers on neuropsychological tests and tests of face and affect processing. Face and non-face tests were compared at four levels of processing: visuo-spatial perception, recognition memory, language and naming, and executive function. We examined relationships with drug dose, duration of illness and pre-morbid and current IQ. RESULTS: Patients and controls did not differ in estimated pre-morbid IQ but current IQ was 12 points lower in patients. At each level of processing there were correlated deficits of face and non-face processing in the patients that were mostly independent of IQ decline. Impaired face and non-face visuo-spatial function and recognition performance were generally correlated with drug dose. Impairments in naming face emotions were correlated with other non-face naming tasks independently of drug dose. Patients performed less well than controls in classifying faces by emotion while ignoring identity and this was associated with poorer performance in Wisconsin Card Sorting. CONCLUSIONS: The pattern of results suggests that deficits in face processing reflect three wider neuropsychological impairments: a drug-related impairment of visual imagery, and disease-related impairments of semantic retrieval and executive function.