Lino Covi

The Hopkins Symptom Checklist (HSCL) ☆: Factors derived from the HSCL-90

A factor analysis of the 90-item version of the Hopkins Symptom Checklist, performed on the pretreatment self-ratings of nonpsychotic outpatients with symptoms of depression and anxiety, revealed the presence of 8 clinically meaningful factors. These eight orthogonal factors each contained at least 5 items with loadings above 0.40 and explained 4.5% or more of the matrix variance. They were labeled Somatization, Phobic-Anxiety, Retarded Depression, Agitated Depression, Obsessive-Compulsive, Interpersonal Sensitivity, Anger-Hostility and Psychoticism.

Homework compliance: An uncontrolled variable in cognitive therapy outcome research

Although patient compliance with homework assignments is considered a major component of cognitive therapy for depression, research studies have rarely investigated homework compliance as a variable potentially influencing treatment outcome. This paper reviews the literature on outcome studies of cognitive therapy for depression and describes research design problems that result from the failure to assess and control for differential homework compliance. These design problems limit the internal validity of outcome studies and make it difficult to compare studies that included allegedly similar treatments but produced different results. Recommendations for evaluating the role of homework compliance in outcome research on cognitive therapy and other treatment approaches are described. The need for adequate measures of homework compliance and quality is stressed, and potential criteria for use in cognitive therapy homework rating scales are proposed.

Symptomatic volunteers in multicenter drug trials.

1. Symptomatic volunteers were recruited at two collaborating institutions for anti-anxiety and antidepressant drug trials. Advertisements were placed for volunteers with significant symptoms of anxiety, depression, or both, and who were not currently in treatment. 2. It was possible to recruit adequate numbers of volunteers who met the numerous criteria for severity of distress; and who were not ruled out by various exclusion criteria, such as medical contraindications, etc. 3. Acceptable homogeneity across the samples at the collaborating institutions was found for demographic characteristics, level of distress, duration of symptoms, etc. 4. Attrition rates for these volunteers were lower than for the typical anxiolytic and antidepressant trials using outpatients. 5. Symptomatic volunteers appear to present a feasible alternative to the increasingly diminishing pool of outpatients.

Replication Of Symptom Distress Factors In Anxious Neurotic Outpatients.

In an attempt to replicate the factor structure of symptom distress re- ported by Mattsson et al. in their study of 404 anxious neurotic outpatients, the same 68-item pretreatment self-report Symptom Check List was administered to an independent but clinically similar sample of 1,116 patients. Using an identical factor-analytic procedure, five useful factors were extracted: Neurotic Feelings, Somatization, Performance Difficulty, Fear-Anxiety, and Depression. Four of these factors were almost identical to those reported by Mattsson e t al. while the fifth factor, Depression, seemed to represent a composite of the two small Depression factors (Anxious and Somatic) found in the earlier study. This minor discrepancy was discussed and the future research potential of these factors was indicated.

Combined pharmacotherapy and psychotherapy.

This paper summarizes controlled studies on combined pharmacotherapy (chronic dosage) and psychotherapy in the literature since 1950. Studies purportedly or actually comparing the effects of combined treatment with the effects of either treatment alone are included. Major tranquilizers, minor tranquilizers, group psychotherapy, individual psychotherapy, schizophrenic patients and psychoneurotic patients are relatively well represented, along with single studies dealing with insulin, antidepressants and depressed patients. From a practical point of view, these studies consistently suggest that combined treatment is superior to psychotherapy alone, but not to pharmacotherapy alone. From a theoretical point of view, these studies suggest that the effect of two treatment interventions combined is the same as the effect of the more effective intervention alone. Unfortunately, this point remains highly tentative because of limitations in the design and execution of the available studies. The effect of the psychotherapy offered constitutes a major question in most of the studies reviewed. They suggest that the role of psychotherapy in combined treatment may be clarified in part by including assessments of the effects of psychotherapy alone and pharmacotherapy alone in the designs of future studies. Studies of psychotherapy suggest that the role of psychotherapy in combined treatment may be further clarified by providing contrasting “dosages” of psychotherapy in terms of certain crucial indicators: the therapists level of experience; the levels of accurate empathy, nonpossessive warmth and genuineness he offers his patients; his score on the Whitehorn-Betz A-B Scale; and the extent to which his interests on the Strong Vocational Interest Blank correspond to those of a reference group of successful psychiatrists.

Drug, doctor warmth, and clinic setting in the symptomatic response to minor tranquilizers

An NIMH-PRB collaborative double-blind clinical trial, concerned with the importance of the “doctor variable” for drug treatment outcome, was conducted with 485 anxious neurotic outpatients receiving either chlordiazepoxide, meprobamate, or placebo. The participating clinics were located at the Johns Hopkins Hospital, Philadelphia General Hospital, and the Hospital of the University of Pennsylvania. The doctor variable selected for presentation was “doctor warmth”. Data on the 169 patients completing the 4 week study according to protocol were analyzed using a factorial analysis of covariance procedure, and the main findings were as follows: 1. several main “drug” effects, present only at 2 weeks, indicated chlordiazepoxide to produce significantly more improvement than either meprobamate or placebo; 2. several main “warmth” effects, present only at 4 weeks, showed patients rating their physicians at the initial visit as “warm” to improve significantly more than patients rating their physicians as “non-warm”; and 3. several significant drug X clinic interaction effects at 4 weeks reflected the fact that while hardly any drug differences were seen in 2 clinics, at Philadelphia General Hospital, patients strongly favored chlordiazepoxide. “Drug” and “warmth” effects were particularly marked in initially sicker patients, and “warmth” appeared especially important in the improvement of initially sicker placebo patients.

Effects of psychostimulants on aggression

A review of the literature on the relation between psychostimulants drugs and aggression leads to the following conclusions. 1) In laboratory animals, small and moderate acute doses of the major stimulants (as dextroamphetamine) generally either reduce or have no effect on aggression, whereas high doses and chronic moderate to high doses of these drugs increase aggression in most species. 2) In man, aggression is not produced by the major Federal Drug Administration licensed psychostinmlants, except in doses which produce a paranoid psychosis. Such doses are customarily, although not uniformly, high. The drug-intoxicated persons aggression then is characteristically a defensive response to frightening delusions. 3) Children with hyperactivity and aggressive behavior usually respond to stimulant medication with reduced fighting, defiance, and impulsiveness. The effect of the drug on aggression may be separate from its effect on hyperactivity. 4) Hyperactive, aggressive adolescents respond to stimulants with the same benefits as do hyperactive children. The available data on the human response to stimulants suggest a need to better evaluate low dose amphetamine effects on aggression in adolescents and adults.

The Precipitating Event in Depression Some Methodological Considerations

A review of the literature concerning the occurrence of significant life events and the appearance of physical, psychosomatic, and psychiatric disorders is presented. Research efforts have recently been aimed at clarifying the relationship between stressful events and depression. However, a number of methodological problems still make the results of those efforts appear doubtful, inconsistent, or confusing. Such problem areas are the representativeness of the patient sample, control groups, reporting agents, number and “meaning” of the events, and statistical methods. The relevance of this field of research is emphasized and suggestions toward a feasible research design are made. The importance of life events for different psychotherapeutic orientations is also discussed.

Diphenylhydantoin and phenobarbital in the relief of psychoneurotic symptoms - A controlled comparison

This study is a double-blind comparison of the clinical effects of diphenylhydantoin (DPH) and phenobarbital among 80 adult psychoneurotic, non-epileptic outpatients. Patients were assigned at random to eight weeks of treatment with DPH 300 mg or phenobarbital 90 mg daily. During this time, patients were followed in brief bi-weekly interviews by one of two treating psychiatrists.At each visit, the patients clinical condition was evaluated by the patients ratings of distress on a factored list of 65 common psychoneurotic symptoms, on a mood adjective checklist, on the Psychiatric Evaluation Profile and on a global scale of change, and by the doctors ratings on several global scales of change. Each criterion was analyzed with respect to initial score, medication, doctor and the medication by doctor interaction. The one doctors patients responded better than the other doctors patients.The results suggested that DPH and phenobarbital in the doses employed had similar effects on psychoneurotic symptoms. More extensive analyses of one patient rating and one doctor rating were performed to look for characteristics of the patient or the treatment situation that might affect medication responses. No useful predictors of differential response to the two medications appeared. Patients with brief illnesses, no prior psychiatric care and no previous phenothiazines or antidepressants responded better than their counterparts to both medications.Some patients who terminated prematurely reported very marked improvement—even more than most patients who completed the prescribed course of treatment. This observation challenges the usual assumption that drop-outs represent treatment failures. The equivocal results with regard to medication effects point up the potential value of studies designed to produce dose-response information.

Comparison of psychological symptoms between drug abusers seeking and not seeking treatment.

Subjects participating in nontreatment research studies have provided a great amount of information regarding the effects and complications of substance abuse. However, the validity of generalizing results from these studies to all substance abusers has not been established. Psychological test results obtained from studies conducted on subjects who have no explicit interest in treatment may differ from those obtained using individuals who are seeking treatment, limiting the generalizability of the conclusions. Results from studies (Carroll and Rounsaville, 1992; Chitwood and Morningstar, 1985; Gawin and Kleber, 1986; Graeven and Graeven, 1983; Rounsaville and Kleber, 1985; Rounsaville et al., 1991; Weiss et al., 1986) comparing the psychological status of treatment-seeking and non-treatment-seeking individuals are inconsistent. Some authors have reported that cocaine abusers seeking treatment have higher rates of psychiatric disorders (Gawin and Kleber, 1986; Rounsaville et al., 1991; Weiss et at, 1986, 1988) and more severe drug use than untreated cocaine abusers (Chitwood and Morningstar, 1985). Others (Carroll and Rounsaville, 1992) have reported that cocaine abusers seeking treatment are similar to their untreated counterparts on measures of severity and chronicity of cocaine use, use of self-control strategies to restrict cocaine use, and overall rates of current and lifetime psychiatric disorders. Studies with opiate abusers have shown less severe substance use, fewer drug-related problems, more adequate social functioning, and less psychosocial impairment among untreated drug abusers than in individuals seeking treatment (Graeven and Graeven, 1983; Rounsaville and Kleber, 1985). These data suggest that untreated opiate abusers have a greater ability to control their substance use, less prolonged use, and more chances of decreasing drug use without formal intervention. To our knowledge, there is only one prior report (Schuster and Fischman, 1985) describing the psychosocial characteristics of individuals volunteering for cocaine research studies. The present study is the first to systematically compare the current psychological status, as measured by the Symptom Checklist-90-Revised (SCL-9-R), of treatment-seeking and nontreatment-seeking substance-abusing individuals who volunteered to participate in research studies.