Dan W. Harper

The benefit of lithium carbonate adjunct in refractory depression ― fact or fiction?

Our group attempted to validate previous claims of rapid success with lithium carbonate adjunct therapy in antidepressant-resistant depression. Seven depressed patients volunteered for a study of placebo controlled, double-blind design. During their treatment on general hospital psychiatric wards, these patients received antidepressant medication for a period of at least 21 days. While continuing to receive antidepresant medication after the 21 day period, four of the patients then received lithium carbonate, and three received placebo. This combination pharmacological therapy continued for a 48 hour period. After this time, six of the seven patients showed no significant improvement. The remaining patient, who had received lithium carbonate, improved markedly over the 48 hour period. However, this patient relapsed within one week. A review of the two most extensive studies claiming significant results with the lithium carbonate adjunct therapy was performed. We feel that they, as presented, leave serious doubt as to the validity of their conclusions. We conclude that on the basis of our work up to this point in time and the analysis of previous reports claiming otherwise, no valid evidence exists for a consistent therapeutic effect of lithium carbonate adjunct in antidepressant-resistant depression. It was also found that methodologic contamination necessitated the exclusion of an additional six patients from the double-blind trial. We conclude that in order to objectively examine the rapidly expanding field of biological psychiatry, teaching of clinical staff in basic research procedure should be stressed as apart of routine ward orientation.

On Evaluating Patient Satisfaction: Methodological Issues*:

The survey of patient satisfaction with the mental health services provided is recommended but involves a methodological dilemma. Concerns include a definition problem, the delineation of a representative sample, the selection of a survey technique and the type of questions to be used. A literature review and the authors’ own experience with the process are presented. The investigation of patient satisfaction while, as yet, limited in the critical information it can provide for the evaluation of services, will help pinpoint areas where the most patient dissatisfaction exists. The process can also be useful therapeutically, but patient satisfaction, although an important outcome measure, is not systematically related to other measures of treatment success. Methodological suggestions to improve the validity of the data gathered conclude the paper.

Mental illness and the media: Part II. Content analysis of press coverage of mental health topics.

The public image of psychiatry has been tarnished in recent years. In order to determine the extent to which press coverage has contributed to negative attitudes towards psychiatry, we conducted a content analysis of a random selection of newspaper articles which appeared over a twenty-year period in two different newspapers. We found that although there had been some minor, cosmetic changes over the years, such as more appropriate headlines and more direct quotes from psychiatric experts, on the whole, content and attitudes had changed very little. An accuracy check of media reporting of forensic cases over a 20-year period revealed that when reporters have access to written material, the accuracy levels are greatly improved.

Patients' attitudes at the time of their commitment

The discussion concerning who should be committed and by whom, has dominated the psychiatric literature for many years (1). More recently, the issue of whether committal allows merely for incarceration in the least restrictive alternative or whether it also entitles patients to be treated against their will, if necessary, has also received attention (2–5). As yet, few studies have attempted to define the characteristics of the committed population (6–11). Even fewer studies have attempted to define what patients themselves thought of their committal to hospital (12–15) and for the most part, have not obtained their opinions regarding the broader issues of committal that are being debated in the professional literature. This study seeks to elicit the opinions of patients in these matters.

Mental illness and the media: an assessment of attitudes and communication.

Media coverage of psychiatric issues will reflect or influence public perceptions of the mentally ill. In order to explore the relationship between psychiatry and the media, an altitudinal questionnaire was administered to a systematic sample of 20 reporters, 20 psychiatrists, 20 medical outpatients with no psychiatric history, and 40 psychiatric inpatients. In addition, 4 psychiatric patients who had personal experience with media coverage were interviewed to determine the impact. Their stories are presented as clinical vignettes. The results of the questionnaire survey show that media reporters are no less accepting of mental illness than the other groups. A regression analysis of altitudinal predictors elicit education as more significant than age and media exposure. Yet low scores for the coverage by the media of mental illness were given by all groups with psychiatrists tending to be most critical Reasons offered by reporters included “sensationalism sells” along with cost and time factors. Recommendations for both reporters and psychiatrists groups were collated, aiming at improving communication and ensuring a more positive emphasis and greater accuracy of media coverage of mental health issues.

A study of the reliability of the clinical oral examination in psychiatry.

A study of the variability between raters in scoring an oral clinical examination in psychiatry in the format of the certification by the Royal College of Physicians and Surgeons of Canada is reported. A video-taped examination from another centre was rated independently by academic psychiatrists, nonacademic psychiatrists and residents. Considerable inter-rater differences between and within these groups were found. In particular, the averaging of the marks of pairs of raters as occurs in the actual certification resulted in the outcome depending to a considerable degree on the chance pairings of raters. These findings support a number of previous studies and emphasize the need to train examiners and to develop clearer rating criteria.

Sex role ideology among women with anorexia nervosa and bulimia

Anorexia nervosa is a complex of physical, emotional, and behavioral changes occurring in individuals who starve themselves because of an aversion to weight gain. Bulimia involves episodic binge eating, combined with an awareness that the eating pattern is abnormal. Theorists suggest that individuals with anorexia nervosa can be seen as rejecting the traditional female role, while individuals with bulimia can be seen as overidentifying with the traditional female role. The validated Sex Role Ideology Scale by Kalin and Tilby was used to determine if anorexics did in fact have a feminist perspective on womens role in society, and if bulimics had a traditional perspective. Data from the two patient groups (anorexics and bulimics) were compared to those of a control group of university students, matched for sex and age. No significant differences were found on the Sex Role Ideology Scale.

Change with time in patients' reactions to committal.

The influence of time on patients’ reactions to involuntary committal is a variable seldom considered in reports. The reactions to committal of thirty-four subjects interviewed one week/one month/three months/six months post committal are reported. Generally committal was viewed neutrally. The major changes in attitudes related to knowledge of the fact of committal and of rights of appeal. The importance of these findings for the management of committed patients is stressed.

Signal Detection Analysis of Effect of White Noise Intensity on Sensitivity to Visual Flicker

Rating scale estimates of sensitivity to visual flicker were obtained from three subjects under 10 different intensities of auditory stimulation. Results indicated reliable “sawtooch”-like changes in sensitivity as a function of increasing intensity of white noise. No systematic and reliable changes were found in estimates of response bias. Theory and future research are discussed with reference to the possible contribution of cortical arousal.

Sex‐role conflict in women with eating disorders

Sex-role conflict has been thought to influence the etiology and course of anorexia nervosa and bulimia in women. The present study used the Bern Sex-Role Inventory and a sex role satisfaction questionnaire to compare sex-role conflict among anorexic, bulimic and control groups. Conflict was defined as the discrepancy between actual and ideally perceived sex-role identity. No significant differences were found among the groups, although all three reported conflict about their sex-role identity. Anorexic and bulimic women thought their sex-role conflict was related to their illness. Support for the feminist hypothesis that bulimic women seek femininity was suggested. Anorexic women presented a much more heterogenous group such that no particular perspective was supported.