Karl Rickels

Drug, doctor's verbal attitude and clinic setting in the symptomatic response to pharmacotherapy

Summary138 psychoneurotic outpatients manifesting anxiety were treated for 6 weeks with medication and brief, supportive interviews every 2 weeks with a psychiatric resident. The patients were divided among 12 different treatment conditions composed of 1. meprobamate 1,600 mg q.i.d. versus an identical placebo in a double-blind arrangement, 2. a doctor expressing an enthusiastic attitude toward the medication versus a doctor expressing a skeptical attitude toward the medication and 3. three different psychiatric outpatient clinics.The patients symptomatic condition was assessed at each visit by means of five ratings made by the patient before each interview and three ratings made by his doctor afterward. These ratings included an overall judgment of change, a checklist of 64 common symptoms, a score based on the patients presenting complaints and adjective checklists for registering anxiety and depression.The results at one clinic showed the expected interaction between medication and doctors expressed attitude: with the enthusiastic doctors, patients taking meprobamate improved more than patients taking placebo; whereas with the skeptical doctors, patients taking placebo tended to improve more than patients taking meprobamate. At the other two clinics, however, this interaction was absent or possibly reversed, with meprobamate tending to be superior to placebo with skeptical doctors.Some striking clinic differences among the characteristics of patients were found, particularly in social class status and the commonly associated styles of complaint and goals and expectations regarding treatment. The clinic showing the anticipated interaction between medication and doctors verbal attitude had patients with the lowest social class standing. The doctors at this clinic also came from backgrounds of lower social class than the doctors at the other two clinics. These differences suggest that the participants at this clinic may have assigned meanings to the enthusiastic and the skeptical attitudes contrasting with the meanings assigned at the other two clinics. The possible relevenace of these differences to the results is discussed.

Evaluating a household survey measure of psychic distress

This paper describes a study to assess the validity of a brief household survey measure of psychic distress (PSYDIS). The measure classifies persons according to their pattern of scores on four dimensions, including anxiety and depression. Study subjects were interviewed first as respondents from the general population in a cross-sectional household survey. Then, according to their ratings on PSYDIS, subsamples were selected for psychiatric evaluation in a clinic a few weeks later. The survey ratings of 287 persons were compared with evaluations of the same persons by experienced psychiatrists. Overall levels of concordance ranged from 76% to 80%, depending on the psychiatric criterion used. Concordance was very high for women; it was lower for men and for persons classified as High on PSYDIS. We than applied two analytic strategies for increasing agreement between the clinical judgements and the clinical ratings. Strategy number I augmented the symptom checklist data with additional survey data on the subjects history of episodes of distress. Strategy II revised procedures for constructing the PSYDIS typology by (1) using more rigorous cutting point scores on the component scales, and (2) using a non-typological method of classification. The first strategy improved agreement between the clinic and survey measures; the second did not. The paper also compares PSYDIS with other brief symptom checklist measures.

Drug effects and initial severity of symptomatology

SummaryA recurring question appearing in clinical psychopharmacological research concerns the nature of the relationship between initial severity of symptomatology and the magnitude of a drug effect. Data are presented to show that, with meprobamate and placebo in neurotic outpatients, the magnitude of the pharmacological effect remains constant across all levels of initial severity.

Is a double-blind clinical trial really double-blind? - A report of doctors' medication guesses

SummaryIn a double-blind trial of meprobamate and placebo, carried out with 138 anxious neurotic outpatients, psychiatrists performed medication guesses after 2, 4, and 6 weeks of therapy. At the same time, physician and patient independently completed several improvement measures and the physician recorded the presence or absence of side reactions as spontaneously reported by the patient.The results may be summarized as follows: a) Clinical improvement and side effects often enable the physician to make reliable medication guesses and thus break the double-blind design in drug trials. b) Clinical improvement seems to exert the most important influence in determining physician medication guesses, at least with anti-anxiety drugs in studies of only 4 to 6 weeks duration. c) The correlation between side effects and medication guesses increases with the duration of therapy.