L. von Knorring

Long‐term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression

In 1983‐1984 the Swedish Committee for the Prevention and Treatment of Depression offered an educational program on diagnosis and treatment of depressive disorders to all general practitioners on the island of Gotland. The program has been carefully evaluated; 1982 was used as the baseline and the main evaluation was carried out in 1985. After the educational programs, the frequency of sick leave for depressive disorders decreased, the frequency of inpatient care for depressive disorders decreased to 30% of that at the baseline; the prescription of antidepressants increased, but prescription of major tranquilizers, sedatives and hypnotics decreased. The frequency of suicide on the island decreased significantly. This study describes the long‐term effects. In 1988, 3 years after the project ended, the inpatient care for depressive disorders increased, the suicidal rate returned almost to baseline values and the prescription of antidepressants stabilized. Thus, the effects were strictly related in time to the educational programs, indicating that the effects were real and not only a coincidence with local trends on Gotland. Furthermore, the results indicate that educational programs that can have pronounced effects on the health care system have to be repeated approximately every 2 years if long‐term effects are to be expected.

Frequency of suicide on Gotland after systematic postgraduate education of general practitioners

In 1983–1984 the Swedish Committee for Prevention and Treatment of Depression (PTD Committee) introduced an educational program for all general practitioners (GPs) on the Swedish island of Gotland. The primary goal was to increase knowledge about diagnosis and treatment of patients with affective disorders. The effects of the educational programs were evaluated in detail; GPs identified more patients with depressive disorders and treated them more accurately. The suicide rate on Gotland was followed, primarily to ensure that the new treatment strategies did not include a risk for the individual patients. However, it was also hoped that increased awareness of patients with affective disorders and better treatment routines could reduce the suicide rale. The suicide rate dropped the year after the educational programs were introduced. This was a statistically significant deviation both from the long‐term trend on Gotland and from the trends in Sweden as a whole. Programs aiming at giving GPs increased capacity and responsibility to treat patients with affective disorders do not increase the frequency of suicide. Better primary treatment of patients with depressive disorders may reduce the suicide rate in a given area.

SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R

A modified version of the SCID Screen questionnaire covering 103 criteria by means of 124 questions was compared with SCID II interviews in 69 psychiatric patients. The correlation between the number of criteria fulfilled in the SCID II interviews or the questionnaires was 0.84. In the SCID interviews, 54% of the patients had a personality disorder. When the SCID Screen questionnaire was used, 73% had a personality disorder. When the cut‐off level for diagnosis was adjusted, the frequency found by means of the SCID screen questionnaire or the interviews was roughly the same, 58% and 54%, respectively. The overall kappa for agreement between the SCID II interviews and questionnaire with adjusted cut‐off was 0.78.

Pain as a symptom in depressive disorders: I. Relationship to diagnostic subgroup and depressive symptomatology.

Abstract The incidence of pain as a symptom in depressive disorders has been studied in a series of 161 depressed patients admitted to the Department of Psychiatry, Umeå University. 57% of the patients reported pain as a symptom. Female patients reported pain significantly more often than male patients and the patients with pain were found to be significantly older than those without. Despite the fact that patients with neurotic reactive depressions were significantly younger than the patients in the other diagnostic subgroups, they reported pain significantly more often than patients with other depressive disorders. Patients with pain were found to have significantly more muscular tension and more autonomic disturbances while no significant differences were found in items measuring sadness or inhibition‐retardation.

The impact of life events in female patients with fibromyalgia and in female healthy controls

The aim was to investigate if female fibromyalgia patients (FMS) had experienced more negative life events than healthy women. Furthermore, the life events experienced in relation to onset of the FMS were evaluated. Another important area was to investigate the impact of the events experienced in the patients compared to healthy women. A new inventory was constructed to assess life events during childhood, adolescence and in adulthood as well as life events experienced in relation to the onset of the disorder. Forty female FMS patients and 38 healthy age-matched women participated in the study. During childhood or adolescence 51% of the patients had experienced very negative life events as compared to 28% of the controls. Conflict with parents was the most common life event. Before onset, 65% of the patients experienced some negative life event. Economic problems and conflicts with husband/partner were common. During the last year, 51% of the patients had life events which they experienced as very negative, compared to 24.5% of the controls (P < 0.01). Stressful life events in childhood/adolescence and in adulthood seem to be very common in FMS. Furthermore, the life events were experienced as more negative than the life events experienced by healthy controls.

Biochemistry of the Augmenting-Reducing Response in Visual Evoked Potentials

The augmenting-reducing response in visual evoked potentials (VEP) has between shown to be a useful tool in psychiatric research. A series of studies has been devoted to the search for the biochemical basis of this phenomenon. An augmenter response in VEP is shown to be clearly related to low levels of endorphins, 5-HIAA and homovanillic acid in CSF and to low serum-dopamine-beta-hydroxylase activity, while no significant relationship was found with 4-hydroxy-3-methoxyphenylethylene glycol or tryptophan in CSF or MAO in thrombocytes. The results indicate that an augmenter response in VEP is related to low activity in the serotoninergic, dopaminergic and endophinergic pathways in CNS.

The Experience of Pain in Depressed Patients

An experience of pain according to Merskey’s definition was found in 24 out of 40 consecutive patients with depressive disorders. No age or sex differences were found between patients with and those without an experience of pain. In a comparison of ratings using the Cronholm-Ottosson depression rating scale, patients with an experience of pain were found to have a more severe type of depression, more psychic and vegetative anxiety, more motoric restlessness, more local tension, more thoughts of suicide, more hypochondriacal ideas, more sleep disturbances and a higher total depression score. On the other hand, no difference was found as regards depressive ideas, intellectual, conative or emotional inhibition or psychomotoric retardation. In the experimental part of the study, 30 patients – 18 with an experience of pain – were investigated with pain measures and visual averaged evoked responses. No differences were found in pain measures between patients with and those without an experience of pain. Out of 18 patients with an experience of pain, 15 were found to be augmenters as measured by visual averaged evoked responses. In the group of patients without pain only 4 out of 12 patients were augmenters.

A double-blind multicenter trial comparing sertraline and citalopram in patients with major depression treated in general practice.

The purpose of this double-blind, multicenter trial was to compare the efficacy and safety of sertraline (50–150 ing/day) with those of citalopram (20–60 mg/day) in patients with major depression in general practice during 24 weeks of treatment. The patients were assessed using the Montgomery-Åsberg Depression Rating Scale and the Clinical Global Impressions of severity and improvement scales. Observed and spontaneously reported adverse events were recorded and side-effects were assessed by means of the UKU Side-Effect Scale. Altogether 400 patients were randomized into the study. A total of 308 patients completed the 24-week study in accordance with the protocol. A significant reduction in the total Montgomery-Åsberg Depression Rating Scale scores was observed in both treatment groups as early as 2 weeks, with no statistically significant differences between the drugs. In the intention to treat-lust observation carried forward analysis 76% responded to treatment in the sertraline and 81% in the citalopram group. The final mean doses were 82 mg/day (64% higher than baseline) in the sertraline group and 34 mg/day (70% higher than baseline) in the citalopram group. The response rate in completers in accordance with protocol was 90% in the sertraline group and 93% in the citalopram group. The side-effects were those usually seen, and both sertraline and citalopram were considered to be well tolerated. It was concluded that patients with major depression in general practice respond well to 24 weeks of treatment with sertraline or citalopram. With regard to efficacy, no statistically significant differences were found between the drugs.

Substance P in CSF of patients with chronic pain syndromes

&NA; Immunoreactive substance P was determined in lumbar CSF of 35 healthy volunteers and 60 patients with chronic pain syndromes of at least 6 months duration. No significant relationships were found between substance P levels and age, sex or body height. Substance P levels were lower in chronic pain patients, with either neurogenic (n = 23) or idiopathic pain (n = 37) syndromes, than in the healthy volunteers. Substance P levels were especially low in patients with neurogenic pain with lesions involving the extremities and in those with polyneuropathy, while patients with central pain or pain of the head or face had higher values. Substance P levels were related to depressive symptomatology as determined by means of visual analogue scales and to stable personality traits as determined by means of the Karolinska Scales of Personality (KSP). The most consistent (and inverse) relationship was found between substance P levels and the symptom ‘inner tension’ and between substance P levels and the personality trait ‘psychic anxiety.’

DSM-IV and ICD-10 personality disorders: a comparison of a self-report questionnaire (DIP-Q) with a structured interview.

OBJECTIVE Diagnosing personality disorders according to structured expert interviews is time-consuming and costly. For epidemiological studies, self-report instruments have several advantages. The DSM-IV and ICD-10 personality questionnaire (DIP-Q) is a selfreport questionnaire constructed to identify personality disorder according to DSM-IV and ICD-10. METHOD The DIP-Q is validated vs a structured expert interview in a clinical sample of 138 individuals. In addition, prevalence rates yielded by DIP-Q among 136 healthy volunteers are assessed and compared to expected prevalence. RESULTS For DSM-IV the agreement for any personality disorder as measured by Cohens Kappa was 0.61 and 0.56 for ICD-10. Overall sensitivity for any personality disorder was for DSM-IV 0.84 and for ICD-10 0.85. However, specificity was lower: 0.77 and 0.70, respectively. When dimensional scores between self-report and interview for each personality disorder were compared, the intraclass correlation for the DSMIV entities was 0.37-0.87 and for the ICD-10 entities 0.33-0.73. Among healthy volunteers the base rate of personality disorders was found to be 14%. CONCLUSION DIP-Q can be used as a screening instrument for personality disorders according to DSM-IV and ICD-10. Self-report questionnaires such as DIP-Q will probably play an increasingly important role in future epidemiological studies.