Dennis Gath

Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care.

Abstract Objective: To determine whether, in the treatment of major depression in primary care, a brief psychological treatment (problem solving) was (a) as effective as antidepressant drugs and more effective than placebo; (b) feasible in practice; and (c) acceptable to patients. Design: Randomised controlled trial of problem solving treatment, amitriptyline plus standard clinical management, and drug placebo plus standard clinical management. Each treatment was delivered in six sessions over 12 weeks. Setting: Primary care in Oxfordshire. Subjects: 91 patients in primary care who had major depression. Main outcome measures: Observer and self reported measures of severity of depression, self reported measure of social outcome, and observer measure of psychological symptoms at six and 12 weeks; self reported measure of patient satisfaction at 12 weeks. Numbers of patients recovered at six and 12 weeks. Results: At six and 12 weeks the difference in score on the Hamilton rating scale for depression between problem solving and placebo treatments was significant (5.3 (95% confidence interval 1.6 to 9.0) and 4.7 (0.4 to 9.0) respectively), but the difference between problem solving and amitriptyline was not significant (1.8 (−1.8 to 5.5) and 0.9 (−3.3 to 5.2) respectively). At 12 weeks 60% (18/30) of patients given problem solving treatment had recovered on the Hamilton scale compared with 52% (16/31) given amitriptyline and 27% (8/30) given placebo. Patients were satisfied with problem solving treatment; all patients who completed treatment (28/30) rated the treatment as helpful or very helpful. The six sessions of problem solving treatment totalled a mean therapy time of 3 1/2 hours. Conclusions: As a treatment for major depression in primary care, problem solving treatment is effective, feasible, and acceptable to patients. Key messages Key messages Patient compliance with antidepressant treatment is often poor, so there is a need for a psychological treatment This study found that problem solving is an effective psychological treatment for major depression in primary care—as effective as amitriptyline and more effective than placebo Problem solving is a feasible treatment in primary care, being effective when given over six sessions by a general practitioner Problem solving treatment is acceptable to patients

Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care

Abstract Objectives: To determine whether problem solving treatment combined with antidepressant medication is more effective than either treatment alone in the management of major depression in primary care. To assess the effectiveness of problem solving treatment when given by practice nurses compared with general practitioners when both have been trained in the technique. Design: Randomised controlled trial with four treatment groups. Setting: Primary care in Oxfordshire. Participants: Patients aged 18-65 years with major depression on the research diagnostic criteria—a score of 13 or more on the 17 item Hamilton rating scale for depression and a minimum duration of illness of four weeks. Interventions: Problem solving treatment by research general practitioner or research practice nurse or antidepressant medication or a combination of problem solving treatment and antidepressant medication. Main outcome measures: Hamilton rating scale for depression, Beck depression inventory, clinical interview schedule (revised), and the modified social adjustment schedule assessed at 6, 12, and 52 weeks. Results: Patients in all groups showed a clear improvement over 12 weeks. The combination of problem solving treatment and antidepressant medication was no more effective than either treatment alone. There was no difference in outcome irrespective of who delivered the problem solving treatment. Conclusions: Problem solving treatment is an effective treatment for depressive disorders in primary care. The treatment can be delivered by suitably trained practice nurses or general practitioners. The combination of this treatment with antidepressant medication is no more effective than either treatment alone. Key messages Problem solving treatment is an effective treatment for depressive disorders in primary care Problem solving treatment can be delivered by suitably trained practice nurses as effectively as by general practitioners The combination of problem solving treatment and antidepressant medication is no more effective than either treatment alone Problem solving treatment is most likely to benefit patients who have a depressive disorder of moderate severity and who wish to participate in an active psychological treatment

Sexual dysfunction among middle aged women in the community

In a community survey of women aged 35-59 sexual functioning was studied in the 436 women with partners. One third of these women had operationally defined sexual dysfunction: impaired sexual interest was identified in 17% of women (68/406), vaginal dryness in 17% (73/434), infrequency of orgasm in 16% (60/379), and dyspareunia in 8% (30/379). Sexual dysfunctions were statistically significantly associated with increasing age and also with psychiatric disorder, neuroticism, and marital disharmony. One in 10 women regarded themselves as having a sexual problem. These women were no older than women with sexual dysfunction who did not regard themselves as having a sexual problem. Nevertheless, they differed from the rest of the sample in having more psychiatric disorder, neuroticism, marital disharmony, and (in women still menstruating) psychological symptoms of the premenstrual syndrome. In the whole sample 16 women (4%) said that they would like help for a sexual problem. The prevalence of sexual dysfunction in this series of women suggests that general practitioners should increase their alertness to the problem in their patients.

COGNITIVE THERAPY FOR PREMENSTRUAL SYNDROME: A CONTROLLED TRIAL

The aim of this study was to evaluate the effectiveness of cognitive therapy (CT) as a psychological treatment for premenstrual syndrome (PMS), by comparison with a waitlist control group. Women meeting selection criteria for PMS were randomly allocated to one of two treatment groups: (i) an immediate treatment group, who received 12 weekly sessions of individual CT; or (ii) a waiting list group who recorded symptoms of PMS for a length of time equivalent to the duration of an individual treatment in the immediate treatment group. General practitioners and gynecologists referred women who were complaining of distressing and disabling emotional and physical symptoms in the second half of the menstrual cycle, as verified by 2 months of prospective diary recording. Assessments of the womens psychological and social functioning were made on entry to the study, 2 months later, and at the end of the treatment period. This design allows evaluation of the efficacy of CT relative to any spontaneous remission that may have occurred as a consequence of the passage of time, the keeping of menstrual diaries, interview, and self-rated assessments. Results indicated that CT was significantly more effective than assignment to the waitlist group. Diary measures and self-report questionnaires indicated an almost complete remission of psychological and somatic symptoms and of impairment of functioning. It is concluded that CT for PMS is associated with substantial improvements that cannot be attributed to the passage of time or the completion of the diary and other assessments.

Original ArticleCognitive therapy for premenstrual syndrome: A controlled trial

The aim of this study was to evaluate the effectiveness of cognitive therapy (CT) as a psychological treatment for premenstrual syndrome (PMS), by comparison with a waitlist control group. Women meeting selection criteria for PMS were randomly allocated to one of two treatment groups: (i) an immediate treatment group, who received 12 weekly sessions of individual CT; or (ii) a waiting list group who recorded symptoms of PMS for a length of time equivalent to the duration of an individual treatment in the immediate treatment group. General practitioners and gynecologists referred women who were complaining of distressing and disabling emotional and physical symptoms in the second half of the menstrual cycle, as verified by 2 months of prospective diary recording. Assessments of the womens psychological and social functioning were made on entry to the study, 2 months later, and at the end of the treatment period. This design allows evaluation of the efficacy of CT relative to any spontaneous remission that may have occurred as a consequence of the passage of time, the keeping of menstrual diaries, interview, and self-rated assessments. Results indicated that CT was significantly more effective than assignment to the waitlist group. Diary measures and self-report questionnaires indicated an almost complete remission of psychological and somatic symptoms and of impairment of functioning. It is concluded that CT for PMS is associated with substantial improvements that cannot be attributed to the passage of time or the completion of the diary and other assessments.

Psychiatric outcome of termination of pregnancy for foetal abnormality

Termination of pregnancy for foetal abnormality has become frequent with the increasing sophistication of techniques of antenatal diagnosis. The aim of this study was to obtain quantitative and qualitative information about psychiatric morbidity in women after termination of pregnancy for foetal abnormality. Two samples of women were compared. The first consisted of 71 women who had had a termination of pregnancy for foetal abnormality (FA group). The second consisted of 26 women who had experienced so-called missed abortion (MA group). Both groups had lost a pregnancy in the mid-trimester of pregnancy, but the MA group had no element of choice. Standardized psychiatric and social measures were used to assess both groups on three occasions after the termination. In both groups, 4 weeks after the termination psychiatric morbidity was high (four to five times higher than in the general population of women), and social adjustment was impaired. Six months and 12 months after the abortion, levels of psychiatric morbidity were near normal. Semi-structured interviewing was used to obtain information about the experience of grief after mid-trimester termination. For many women, symptoms of grief persisted throughout the year. These symptoms included typical features of grief as well as grief symptoms specific to pregnancy loss. The findings have implications for the counselling of women after termination for foetal abnormality or after missed abortion.

Predictors of treatment outcome for major depression in primary care

BACKGROUND A randomized controlled clinical trial compared three treatments for major depression in primary care. Ninety-one patients were randomized to receive either problem-solving, or amitriptyline with standard clinical management, or drug placebo with standard clinical management. This paper examines the possible predictive value of a range of demographic clinical and personality variables in determining outcome. METHODS To examine the interaction between treatment group and predictor variables, analyses of co-variants were carried out for two outcome measures: the Hamilton Rating Scale for Depression and the Beck Depression Inventory. Predictor variables were also entered into a stepwise forward logistic regression in which patients were categorized as recovered or not recovered. RESULTS None of the predictor variables examined interacted with treatment to predict outcome. Patients with a longer duration of illness, chronic social difficulties, or definite, as opposed to probable, major depression had a poorer outcome at the end of treatment, irrespective of treatment group. CONCLUSIONS The findings in this study do not enable clear guidelines to be given as to which patients with major depression in primary care might benefit from either a psychological or pharmacological treatment.

10 Psychological problems and uterine bleeding

Abstract Gynaecological complaints are often associated with psychiatric disorder. Women with psychiatric disorder are more likely to complain of excessive uterine bleeding than women without psychiatric disorder. When a woman complains of menorrhagia, yet also has a psychiatric disorder, it is important to establish which is the primary problem. If menorrhagia is primary, then any associated psychiatric disorder may be secondary to distress and fear caused by excessive menstruation. If the psychiatric disorder is primary, then psychological distress may lead a women to complain about her usual menstrual pattern or minor changes in it. If the complaint of excessive menstruation is secondary to psychiatric disorder, surgical or medical treatment of this complaint may not be justified. If the gynaecologist is to make the important distinction between complaints of menorrhagia which are primary and those which are secondary to psychiatric disorder, then he/she needs to be able to detect and assess psychiatric disorder in women who present with complaints of excessive uterine bleeding. Recent research has provided information about the relationship between the surgical treatment of menorrhagia and psychiatric disorder. Hysterectomy for menorrhagia seems to alleviate psychiatric disorder in many women who had psychiatric disorder before operation. The operation rarely induces psychiatric disorder in women who are psychiatrically well before surgery. There is no association between psychiatric disorder either before or after hysterectomy for menorrhagia and the presence of absence of demonstrable pelvic pathology. There is no evidence that those women who overestimate their menstrual blood loss have an increased likelihood of being psychiatrically disturbed after hysterectomy. However, an important determinant of psychiatric outcome after hysterectomy for menorrhagia is preoperative psychiatric status--for example, mental state before surgery, previous psychiatric history and neuroticism.

Psychiatric Sequelae of Pelvic Surgery and Their Management

In the management of the psychiatric sequelae of pelvic surgery, some issues apply to surgery in general, whilst others are specific to pelvic surgery. Accordingly, this chapter is in two parts. The first part deals with surgery in general, and the second with pelvic surgery.

Psychiatric Case Detection in Gynaecological Patients

There is a large and conflicting literature on the frequency and nature of psychiatric disorders in women with gynaecological conditions. It is difficult to interpret and compare the findings of different studies, largely because they have used non-standardised methods of case-identification. The aim of this paper is to illustrate the use of standardised methods of case detection in two gynaecological populations: women undergoing hysterectomy and those receiving elective tubal sterilisation. Three applications of case-identification techniques are described: measuring prevalence; describing features of the disorders; and testing hypotheses. Examples of each are given for the two gynaecological populations.