Elspeth Guthrie

Psychological stress and burnout in medical students: a five-year prospective longitudinal study:

The aim of this study was to assess psychological morbidity and symptoms of burnout in medical students during their undergraduate training, and to identify baseline factors that predict psychological morbidity in students in the final year of the course. It was a 5-year prospective longitudinal cohort study. Students were assessed in years 1, 4 and 5 of their medical undergraduate training by means of the GHQ-12 and the Maslach Burnout Inventory. 172 (84.3%), 157 (77.0%) and 155 (75.9%) students out of an original group of 204 completed assessments in years 1, 4 and 5, respectively. 18 students were above threshold on the GHQ-12 on all three occasions, 25 on two occasions and 43 on one occasion; 69 students were never a ‘case’. Students who were cases on two or more occasions were more likely to find the medical course stressful during the first year, but not subsequent years. There was no significant difference between the percentages of men and women who scored as cases on the GHQ-12 in any of the years. The best predictor of psychological morbidity in the final year of the course was the GHQ-12 score in year 1. This study suggests that a small group of students repeatedly experience psychological distress during their medical training.

Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn's disease

OBJECTIVE:The determinants of health-related quality of life in inflammatory bowel disease are not completely understood. The present study aimed to assess two factors in patients with inflammatory bowel disease: a) whether health-related quality of life is independently associated with both bowel disease severity and psychological disorder, and b) whether Crohns disease is associated with more marked psychological disorder than ulcerative colitis.METHODS:116/170 (68%) consecutive patients with inflammatory bowel disease attending a GI clinic (37 patients with ulcerative colitis, 75 patients with Crohns disease, and four unspecified) completed the following self-report questionnaires: demographic details, a modified disease activity index, a total severity measure, the Hospital Anxiety and Depression Scale, and the Short Form-36.RESULTS:Thirty patients (25.9%) scored 11 or more on either the depression or anxiety subscales of the Hospital Anxiety and Depression Scale indicating probable psychological disorder; 55% (47.4%) scored over 8 indicating possible psychological disorder. Stepwise multiple regression analyses showed that both psychological symptoms and disease severity or activity contributed independently to impaired health-related quality of life. After severity of disease was taken into account, there were no significant differences between Crohns disease and ulcerative colitis in terms of depression scores and health-related quality of life.CONCLUSIONS:The presence of psychological disorder in inflammatory bowel disease contributes to poor health-related quality of life, regardless of the severity of the condition. Detection and treatment of psychological disorder in inflammatory bowel disease carries the potential to improve health-related quality of life for these patients.

Embarking upon a medical career: psychological morbidity in first year medical students

This study was undertaken to measure the prevalence of psychological morbidity, and the nature and source of stress, in first year medical students. Two hundred and four first year medical students at a university in the north of England were sent a postal, self‐report questionnaire. They were asked to complete the General Health Questionnaire (GHQ), the Stress Incident Record and to give details of their alcohol consumption. A total of 172 students (84·3%) replied. Thirty‐six per cent of the students scored above the threshold of the GHQ, indicating probable psychological disturbance. There was no difference between men and women. Approximately half of the students described a stressful incident, the majority of which were related to medical training rather than to personal problems. Male students reported drinking significantly more alcohol than female students, but there was no relationship between levels of alcohol consumption and either psychological disturbance or reporting of stress.

Is there a better term than "medically unexplained symptoms"?

The European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP) is preparing a document aimed at improving the quality of care received by patients who have “medically unexplained symptoms” or “somatisation” [1]. Part of this document identifies barriers to improved care and it has become apparent that the term “medically unexplained symptoms” is itself a barrier to improved care. This is because the term is not acceptable to some patients and doctors. It defines the patients symptoms by what they are not, rather than by what they are, and it reflects dualistic thinking – regarding symptoms as either “organic” or “non-organic”/“psychological”. The authors of this paper met in Manchester in May 2009 to review thoroughly this problem of terminology and make recommendations for a better term.. The deliberations of the group form the basis of this paper. Our discussion concerned terminology applicable to the more severe and persistent common symptoms of unknown aetiology, so often seen in primary care, and the recognised disorders, which present with symptoms that escape orthodox medical or surgical disease explanations. The latter include the disorders currently listed in the Somatoform disorders chapters of the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the WHO International Classification of Diseases (ICD). Our priority was to identify a term or terms that would facilitate management – that is it would encourage joint medical psychiatric/psychological assessment and treatment and be acceptable to physicians, patients, psychiatrists and psychologists. In the first step, we reviewed why the term “medically unexplained symptoms” is so often unhelpful. In the second step we established a set of criteria which may be used to judge any alternative term. In the third step we applied these criteria to the various terms which have been used to describe this group of complaints.

Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: A comparison with routine attenders

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8--18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3--47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5--2959.0), and more GP visits (95% CI for difference=-10.2 to -5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.

A long-term follow-up study of patients with ischaemic heart disease versus patients with nonspecific chest pain

Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.

How QOF is shaping primary care review consultations: a longitudinal qualitative study

BackgroundLong-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management.MethodsA longitudinal qualitative study. We audio-recorded consultations of primary care practitioners with patients with LTCs. We then interviewed both patients and practitioners using tape-assisted recall. Patient participants were followed for three months during which the research team made weekly contact and invited them to complete weekly logs about their health service use. A second interview at three months was conducted with patients. Analysis of the data sets used an integrative framework approach.ResultsPractitioners view consultations as a means of ‘surveillance’ of patients. Patients present themselves, often passively, to the practitioner for scrutiny, but leave the consultation with unmet biomedical, informational and emotional needs. Patients perceived review consultations as insignificant and irrelevant to the daily management of their LTC and future healthcare needs. Two deviant cases, where the requirements of the ‘review’ were subsumed to meet the patient’s needs, focused on cancer and bereavement.ConclusionsRoutine review consultations in primary care focus on the biomedical agenda set by QOF where the practitioner is the expert, and the patient agenda unheard. Review consultations shape patients’ expectations of future care and socialize patients into becoming passive subjects of ‘surveillance’. Patient needs outside the narrow protocol of the review are made invisible by the process of review except in extreme cases such as anticipating death and bereavement. We suggest how these constraints might be overcome.

Changes in tolerance to rectal distension correlate with changes in psychological state in patients with severe irritable bowel syndrome.

Objective: Reduced tolerance to rectal distension has been regarded as a biological marker for irritable bowel syndrome (IBS), but longitudinal studies are few. This study determined whether change in tolerance to rectal distension after psychological treatments was associated with: 1) change in abdominal pain; 2) change in psychological symptoms; 3) a reported history of sexual abuse. Methods: Participants completed a visual analogue scale of abdominal pain, SCL-90 and Hamilton rating scale of depression; discomfort threshold to rectal distension was determined using a double random staircase protocol. These were measured at entry to a trial of psychotherapy or paroxetine (selective serotonin reuptake inhibitor antidepressant) and 3 months later (N = 52). Analysis of change scores were adjusted for treatment group and baseline values. Results: Increased tolerance to distension after treatment was associated with reduction in depression (r = − 0.37, p = .008) but not abdominal pain. Patients who reported prior sexual abuse showed greater increase in tolerance than the remainder (changes in volume threshold: −24.7 ml [SEM = 12.1] vs. 3.6 ml [SEM = 6.2], adjusted p = .045; changes in pressure threshold: −4.7 [SEM = 1.7] mm Hg vs. 0.96 [SEM=0.9], adjusted p = .005). Multiple regression indicated that reduction in depression score and a reported history of sexual abuse were independently associated with improved tolerance to distension. Conclusions: In patients with severe IBS, increased tolerance to rectal distension after psychological treatment is significantly associated with improved depression and reported sexual abuse. These results suggest that in some patients with severe IBS psychological rather than biological processes are primarily responsible for reduced tolerance to rectal distension.

The relationship between somatisation and outcome in patients with severe irritable bowel syndrome

OBJECTIVE This study aimed to assess the relationship between somatisation and outcome in patients with severe irritable bowel syndrome (IBS). METHOD Two hundred fifty-seven patients with severe IBS included in a randomised controlled trial were assessed at baseline and divided into four quartiles on the basis of their somatisation score. The patients were randomised to receive the following over 3 months: brief interpersonal psychotherapy, 20 mg daily of the SSRI antidepressant paroxetine, or treatment as usual. Outcome 1 year after treatment was assessed using the Short Form-36 physical component summary (PCS) score and total costs for posttreatment year. RESULTS The patients in the quartile with the highest baseline somatisation score had the most severe IBS, the most concurrent psychiatric disorders, and the highest total costs for the year prior to baseline. At 1 year after the end of treatment, however, the patients with marked somatisation, who received psychotherapy or antidepressant, had improved health status compared to those who received usual care: mean (S.E.) PCS scores at 15 months were 36.6 (2.2), 35.5 (1.9), and 26.4 (2.7) for psychotherapy, antidepressant, and treatment-as-usual groups, respectively (adjusted P=.014). Corresponding data for total costs over the year following the trial, adjusted for baseline costs, were pound 1092 (487), pound 1394 (443), and pound 2949 (593) (adjusted P=.050). CONCLUSIONS Patients with severe IBS who have marked somatisation improve with treatment like other IBS patients and show a greater reduction of costs. Antidepressants and psychotherapy are cost-effective treatments in severe IBS accompanied by marked somatisation.

Outpatients with irritable bowel syndrome: a comparison of first time and chronic attenders.

Fifty two chronic clinic attenders with irritable bowel syndrome were compared with 97 newly referred patients in respect of physical symptoms and psychiatric status. Profound differences between the two groups emerged. Many abdominal and non-colonic symptoms were perceived as much more severe in chronic attenders compared with first time attenders (p less than 0.0001 for abdominal pain and abdominal distension). Chronic attenders were much more likely to complain of constant symptoms (p less than 0.05), and the social consequences of their illness were much more striking (p less than 0.0001). There was, however, no difference in the prevalence of psychiatric morbidity in the two groups. Clinical trials and other investigations of the irritable bowel syndrome are usually conducted on hospital outpatient populations. The results of this study indicate that the patient populations used for these purposes need to be carefully defined.