Graeme C. Smith

Effect of Cognitive-Existential Group Therapy on Survival in Early-Stage Breast Cancer

PURPOSE Cognitive-existential group therapy (CEGT) was developed to improve mood and mental attitude toward cancer in women with early-stage breast cancer receiving adjuvant chemotherapy. Given the debate about group therapys association with increased survival in women with metastatic breast cancer, we were curious to check its effect at a much earlier stage in the cancer journey. PATIENTS AND METHODS We randomly assigned 303 women with early-stage breast cancer who were receiving adjuvant chemotherapy to either 20 sessions of weekly group therapy plus three relaxation classes (n = 154) or to a control condition of three relaxation classes alone (n = 149). The primary outcome was survival. RESULTS CEGT did not extend survival; the median survival time was 81.9 months (95% CI, 64.8 to 99.0 months) in the group-therapy women and 85.5 months (95% CI, 67.5 to 103.6 months) in the control arm. The hazard ratio for death was 1.35 (95% CI, 0.76 to 2.39; P = .31). In contrast, histology and axillary lymph node status were significant predictors of survival. Low-grade histology yielded a hazard ratio of 0.342 (95% CI, 0.17 to 0.69), and axillary lymph node-negative status yielded a hazard ratio of 0.397 (95% CI, 0.20 to 0.78). CONCLUSION CEGT does not prolong survival in women with early-stage breast cancer.

Psychological morbidity and quality of life in women with advanced breast cancer : a cross-sectional survey

OBJECTIVE Our purpose was to determine the frequency of psychiatric morbidity and to assess the quality of life of women with advanced breast cancer. METHODS The 227 women in the sample were recruited in Melbourne, Australia, and were interviewed (prior to intervention) for a randomized controlled trial of supportive-expressive group therapy. The main outcome measures were DSM-IV psychiatric diagnoses plus quality of life data based on the EORTC QLQ-C30 (core) and QLQ-BR23 (breast module) instruments. RESULTS Forty-two percent of the women (97/227) had a psychiatric disorder; 35.7% (81) of these had depression or anxiety or both. Specific diagnoses were minor depression in 58 women (25.6%), major depression in 16 (7%), anxiety disorder in 14 (6.2%), and phobic disorder in 9 (4%). Seventeen (7.5%) women had more than one disorder. In terms of quality of life, one-third felt less attractive, one-quarter were dissatisfied with their body image, and, in most, sexual interest had waned. Menopausal symptoms such as hot flashes affected less than one-third, whereas symptoms of lymphedema were experienced by 26 (11.5%). SIGNIFICANCE Women with advanced breast cancer have high rates of psychiatric and psychological disturbance. Quality of life is substantially affected. Clinicians need to be vigilant in monitoring psychological adjustment as part of a comprehensive biopsychosocial approach.

Cognitive-existential group therapy for patients with primary breast cancer--techniques and themes.

We describe a model of cognitive‐existential group therapy designed to be integrated over 6 months with regimens of adjuvant chemotherapy given as conventional medical treatment to breast cancer patients with stage 1 and 2 disease. Our broad therapy goals are for members to develop a supportive network, work through grief over losses, improve problem solving and develop cognitive strategies to maximise coping, enhance a sense of mastery over life and re‐evaluate priorities for the future. Specific group themes include death anxiety, fear of recurrence, living with uncertainty, understanding treatment with chemotherapy, radiotherapy and hormone regimens, the collaborative doctor‐patient relationship, body and self image, sexuality, relationships with partner, friends and family, surgical reconstruction, life style effects and future goals. Active coping skills are developed through teaching formal problem solving and cognitive restructuring of automatic negative thoughts. Technical aspects of the therapy are discussed.

Rituximab Purging and/or Maintenance in Patients Undergoing Autologous Transplantation for Relapsed Follicular Lymphoma: A Prospective Randomized Trial From the Lymphoma Working Party of the European Group for Blood and Marrow Transplantation

PURPOSE The objective of this randomized trial was to assess the efficacy and safety of rituximab as in vivo purging before transplantation and as maintenance treatment immediately after high-dose chemotherapy and autologous stem-cell transplantation (HDC-ASCT) in patients with relapsed follicular lymphoma (FL). PATIENTS AND METHODS Patients with relapsed FL who achieved either complete or very good partial remission with salvage chemotherapy were randomly assigned using a factorial design to rituximab purging (P+; 375 mg/m(2) once per week for 4 weeks) or observation (NP) before HDC-ASCT and to maintenance rituximab (M+; 375 mg/m(2) once every 2 months for four infusions) or observation (NM). RESULTS From October 1999 to April 2006, 280 patients were enrolled. The median age was 51 years (range, 26 to 70 years), and baseline characteristics were well balanced between groups. On average, patients were 44 months (range, 3 to 464 months) from diagnosis, with 79% having received two lines and 15% three lines of prior therapy. Median follow-up was 8.3 years. In contrast to purging, 10-year progression-free survival (PFS) was 48% for P+ and 42% for NP groups (hazard ratio [HR], 0.80; 95% CI, 0.58 to 1.11; P = .18); maintenance had a significant effect on PFS (10-year PFS, 54% for M+ and 37% for NM; HR, 0.66; 95% CI, 0.47 to 0.91; P = .012). Overall survival (OS) was not improved by either rituximab purging or maintenance. CONCLUSION Rituximab maintenance after HDC-ASCT is safe and significantly prolongs PFS but not OS in patients undergoing transplantation for relapsed FL. Pretransplantation rituximab in vivo purging, even in rituximab-naive patients, failed to improve PFS or OS.

A Comparative Study of Screening Instruments for Mental Disorders in General Hospital Patients

Objective: Self-administered questionnaires are frequently used in studies of hospitalized physically ill patients to identify and measure psychiatric morbidity. This study examines the validity of some commonly used questionnaires in this context. Method: One hundred and seventy-nine patients in a general hospital completed the GHQ, HAD, BDI and STAI and were interviewed using the SCID-R. The findings were evaluated against DSM-III-R diagnoses using the QROC curve. Results: Thirty-eight percent of patients obtained one or more DSM-III-R diagnoses; 25 percent mood disorder, 12 percent anxiety disorder, 11 percent drug abuse or dependence, 2 percent a somatic syndrome. Eleven percent had more than one diagnosis. As screening instruments for general psychiatric morbidity there were no statistically significant differences between versions of the GHQ and the HAD. With respect to identifying depression, the GHQ tended to perform better than the other instruments. Conclusions: The questionnaires identified general morbidity and depression satisfactorily but anxiety and drug abuse and dependence syndromes poorly. The results also support the notion that the DSM-III-R classification has a number of deficiencies when used in this population.

Ventricular, paraventricular and circumventricular structures involved in peptide-induced satiety

Cholecystokinin, bombesin or gastrin (2 microliter of 50 ng/microliter) was injected stereotaxically into the paraventricular nucleus of the hypothalamus, the arcuate/ventromedial area, the subfornical organ, the area postrema and the cerebral aqueduct of Sprague-Dawley rats and the effects of these injections on food and water intake were studied. While the injection of cholecystokinin reduced food intake when it was injected into both hypothalamic loci, food and water intake were most severely affected by the injection of this peptide into the cerebral aqueduct. Bombesin reduced food intake after its injection into all areas except the subfornical organ and reliable reductions in water intake were seen after injection of this peptide into all areas except the paraventricular nucleus. Minor reductions in food intake were seen following gastrin injection into the paraventricular nucleus while increased water consumption was observed after this peptide was injected into the paraventricular nucleus and cerebral aqueduct. In a second study 6-hydroxydopamine injections (2 microliter of 8 micrograms/microliter were made into the five areas studied 10 days before animals were injected with 100 micrograms/kg of cholecystokinin (i.p.). All 6-hydroxydopamine-injected animals reduced their food and water intake in response to the cholecystokinin challenge as did intact controls. These results indicate that while the changes in food and water intake produced by the central injection of cholecystokinin, bombesin or gastrin may involve central catecholamine systems, those occurring after its systemic administration do not. Therefore, if the release of gastrointestinal peptides during natural feeding is part of a homeostatic mechanism regulating hunger and satiety, this mechanism may operate without directly involving central catecholamine systems.

Prospective psychosocial monitoring of living kidney donors using the SF-36 health survey.

Background. Psychosocial assessment and monitoring of living kidney donors is not yet standard practice, despite calls for it in the literature. Methods. Psychosocial assessment of living kidney donors was performed preoperatively and 4 months postoperatively, using the SF-36 Health Survey, the Patient Health Questionnaire psychiatric assessment, and semistructured interview. Results. Assessment was acceptable to the majority of donors; 92% (44) of 48 consecutive donors completed both assessments. Preoperatively, both physical function (SF-36 Physical Component Score [PCS]) and psychosocial function (SF-36 Mental Component Score [MCS]) were significantly higher than community (state of Victoria) norms. Postoperatively, PCS and MCS fell significantly, but not below the Victorian norm. Seven donors (16%) developed adjustment disorder or anxiety disorder; their MCS were significantly lower than those without psychiatric disorder. Conclusions. It is concluded that routine psychosocial assessment performed by a psychiatrist, including the use of questionnaires, is acceptable to donors and identifies those impaired. Potential donors need to be well prepared for such assessment and well educated about the extent of physical and psychosocial impairment that might occur in the postoperative period.

An empirically derived taxonomy of common distress syndromes in the medically ill

OBJECTIVE Contemporary psychiatric classifications have not proved to be useful in the understanding and care of people with physical illness. Distress syndromes are common, but classifications fail to differentiate syndromes relevantly. We sought to take a fresh look at the common distress syndromes in the medically ill. METHODS 312 medical inpatients were interviewed using a structured psychiatric interview [the Monash Interview for Liaison Psychiatry (MILP)] to elicit the presence of mood, anxiety and somatoform symptoms. A previously reported examination of these data using latent trait analysis revealed the dimensions of demoralization, anhedonia, autonomic anxiety, somatoform symptoms and grief. Patients were scored on these dimensions and, on the basis of these, subjected to cluster analysis. Derived classes were compared on a range of demographic and clinical data including psychiatric diagnosis. RESULTS Six classes were found, distinguished by general levels of distress (measured by demoralization, autonomic anxiety and somatoform symptoms), anhedonia and grief. The most distressed groups were Demoralization and Demoralized Grief. Anhedonic Depression showed moderate levels of distress but the highest level of social dysfunction. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) categories of mood disorders did not follow any particular pattern other than reflecting severity of distress. The classes of high distress (Demoralization and Demoralized Grief) were significantly associated with younger age, past history of psychiatric treatment, low Global Assessment of Functioning (GAF) scores over the previous 12 months and DSM-IV somatoform disorders. Patients with Demoralized Grief tended to acknowledge their illness as a significant and relevant stressor. Patients with Demoralization identified other stressors as significant. CONCLUSION Concepts of demoralization, anhedonia and grief differentiate between important clinical syndromes and have informed the development of a taxonomy of common distress syndromes in the medically ill. Research is required to further explore the validity and utility of these concepts.

Consultation-liaison psychiatry in general medical units

The activities of a consultation-liaison psychiatry service to general medical units in a university affiliated suburban teaching hospital are described, with a report from the MICRO-CARES clinical database on 165 consecutive referrals over a 12 month period. The referral rate was 4.2% of admissions. The data confirm the association of psychiatric referral and prolonged length of hospital stay (mean of 18 days for referred patients, 9 days for non-referred patients). The most common reasons for referral were depression, suicide risk evaluation, organic brain syndrome and suspected psychological component to illness. The most common psychiatric diagnoses were Mood Disorders (55%), Organic Mental Disorders (35%), Adjustment Disorders (19%), Somatoform and other Somatic Disorders (16%) and Personality Disorders (15%). Although 67% of patients received at least one confirmed diagnosis, 39% of all diagnoses remained “differential”, or unconfirmed, at discharge. Concordance with drug recommendations was 97% and with non-drug recommendations 95%. Two groups of patients were prominent among the referrals: the young self-poisoning patient, and the older patient living alone. The issues involved in providing a liaison psychiatry service to general medical units with these characteristics are described.

Establishing a consultation-liaison psychiatry clinical database in an Australian general hospital

This paper describes the institution of a clinical database in the consultation-liaison psychiatry service of an Australian general hospital psychiatry unit. One of the problems faced was that many researchers and clinicians in Australia use the ICD-9 rather than the DSM-III-R classification system. Nevertheless, it was possible to use the DSM-III-R-based MICRO-CARES clinical database management system in this project. The data obtained during the first 12 months of its use are presented. Despite differences in the patient demographic characteristics, the data obtained are within the ranges described for North American and European sites. The local benefits of such a clinical database are described, and it is argued that such a database is also necessary for interhospital and international collaborative studies and comparisons.