Raymond Prince

Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction

BACKGROUND Increases in life stress have been linked to poor prognosis, after myocardial infarction (MI). Previous research suggested that a programme of monthly screening for psychological distress, combined with supportive and educational home nursing interventions for distressed patients, may improve post-MI survival among men. Our study assessed this approach for both men and women. We aimed to find out whether the programme would reduce 1-year cardiac mortality for women and men. METHODS We carried out a randomised, controlled trial of 1376 post-MI patients (903 men, 473 women) assigned to the intervention programme (n = 692) or usual care (n = 684) for 1 year. All patients completed a baseline interview that included assessment of depression and anxiety. Survivors were also interviewed at 1 year. FINDINGS The programme had no overall survival impact. Preplanned analyses showed higher cardiac (9.4 vs 5.0%, p = 0.064) and all-cause mortality (10.3 vs 5.4%, p = 0.051) among women in the intervention group. There was no evidence of either benefit or harm among men (cardiac mortality 2.4 vs 2.5%, p = 0.94; all-cause mortality 3.1 vs 3.1%, p = 0.93). The programmes impact on depression and anxiety among survivors was small. INTERPRETATION Our results do not warrant the routine implementation of programmes that involve psychological-distress screening and home nursing intervention for patients recovering from MI. The poorer overall outcome for women, and the possible harmful impact of the intervention on women, underline the need for further research and the inclusion of adequate numbers of women in future post-MI trials.

Long-term follow-up of the ischemic heart disease life stress monitoring program

&NA; This study examines patient outcomes up to seven years after a one‐year, post‐myocardial infarction (MI) stress monitoring and management program. A previous randomized controlled trial involving 461 male patients demonstrated that the program lowered stress scores and reduced one‐year cardiac deaths by almost 50%, but made no difference in readmission rates or durations. The present study used medical records to assess the durability of these outcomes. Results indicated that the difference in cardiac deaths was primarily due to out‐of‐hospital deaths (that is, those that were more likely to have been sudden deaths) and persisted for six months beyond the end of the program, after which the mortality curves began to approach one another. In addition, although during the program year MI recurrences occurred at the same rate in the two groups, during the years after the program there were fewer MI recurrences among the treated patients. Over the full follow‐up period the group difference in MI recurrences was statistically significant (p = 0.043). Results are considered in terms of methodological limitations of the study, including the timing of randomization, sample selection requirements, and group differences on baseline variables. Findings are also discussed in relation to the outcomes of other programs producing long‐term reductions in recurrences or deaths from ischemic heart disease. It is suggested that, regardless of their approach, all such programs may share a common therapeutic mechanism: the provision of emotional support during a period of high vulnerability to stress.

Culture-bound syndromes and international disease classifications

An important endeavor in the world psychiatric community is the development of an international classification of psychiatric disorders that will be more culture-free than either the current DSM-III or ICD-9. This classification should be clinically useful and relevant to psychiatric experience in all countries of the world. A major problem in this endeavor is the existence of the so-called culture-bound syndromes syndromes (CBSs) which reflect cultural influences on disease patterns and render them difficult to place in disease classifications which have their origins in Western cultures. Literally dozens of disorders have been labelled CBSs around the world, and considerable looseness has developed in the use of the CBS rubric. Recently it has been proposed that all illnesses (both physical and psychiatric) are in fact culture bound. In reaction to this drift towards meaninglessness, a new definition for CBSs is proposed - a collection of signs and symptoms (excluding notions of cause) which is restricted to a limited number of cultures primarily by reason of certain of their psychosocial features. In this definition, notions of etiology and illness labels are excluded because these are highly variable and change over time. On the other hand, collections of signs and symptoms (i.e., syndromes), insofar as they are reasonably complete descriptions of nature, remain constant over time and are verifiable by all investigators. Using two CBSs from the Pacific basin area - taijin-kyofu-sho and latah - as examples, the following conclusions are drawn: CBS status should not be assigned on the basis of differential distribution of illnesses because of accidents of geography or on the basis of local labels or notions of cause; epidemiological features of diseases such as global prevalence or age/sex differentials of those affected should not be used as basis of CBS status; the meaning of illness, both for individuals and for cultures, is an important area of study in its own right but such meanings should not be confused with syndrome descriptions or used as criteria for an international disease classification; a truly international classification of diseases is close to realization through relatively minor alterations in the Axis I designations and descriptions of DSM-III. Few entirely new categories would be required.

A Technique for Improving Linguistic Equivalence in Cross-Cultural Surveys

AN increasing amount of cross-cultural research involves the translation of research instruments from the language in which they were developed into a second language. It is clear that such research becomes significant only insofar as the translation approaches the precise meaning of the original. It is only then that response differences can be attributed to cultural differences and not to inaccurately translated instruments.

The ischemic heart disease life stress monitoring program: Possible therapeutic mechanisms

Abstract This paper attempts to identify the therapeutic components responsible for the mortality-reducing impact of the Ischemic Heart Disease Life Stress Monitoring Program. Designed to break the link between stress and illness, this one-year intervention program for patients recovering from myocardial infarctions included monthly telephone monitoring of psychological symptoms of stress and home nursing visits for high stress patients. Nursing interventions were individually tailored for each patient and involved a combination of teaching, support and referral strategies. A randomized controlled trial of the program. involving 453 male patients showed that it reduced stress symptoms and cut one-year mortality rates by 50%. These results are considered in the context of the approaches and outcomes of other educational and support programs for cardiac patients. In addition to sample size two factors appear to differentiate the program from other less successful therapies: patient selection for treatment o...

Separated and divorced women compared with married controls: Selected life satisfaction, stress and health indices from a community survey

A stratified sample of 31 French-Canadian and 33 English-Canadian separated or divorced (S/D) mothers and matched married controls were identified by telephone in four high-income census tracts of Montreal. The 128 women were home-interviewed by questionnaire which included extensive sections on health, stress and life satisfaction. It was predicted that modern S/D women with children would be better off as regards satisfaction, stress and health than pre-womens liberation era women, and that they would be as well or better off than the married controls. These hypotheses were supported only in part. The S/D were significantly worse off than the married in four areas (general life satisfaction, sexual satisfaction, self-esteem and use of professional therapists) and on almost all other health-stress measures, there were trends favouring the married. There were no significant differences or no trends favouring the S/D. Nonetheless, the S/D did appear to be considerably better off when compared with the picture of the S/D in the earlier literature. The greater frequency of depressions and greater use of therapists by the English-Canadian women was thought to reflect their weaker network of supportive relatives as well as the impact of recent political changes in Quebec.

Transcultural psychiatry: personal experiences and Canadian perspectives.

In the mid-1950s, a unique section of transcultural psychiatric studies was established within the McGill Department of Psychiatry. These personal recollections describe the backgrounds, methods, and motivations of those most involved and suggest why such a specialized study should have emerged in Canada and at McGill. Some of the major controversies and developments in the field are explored, focusing on the question of culture-bound syndromes and their occasional biological underpinnings. The relevance of transcultural psychiatry to psychiatric practice is discussed. La psychiatrie transculturelle: experiences vécues et perspectives canadiennes

Life stress, denial and outcome in ischemic heart disease patients

Goldbergs 20-item General Health Questionnaire was administered to 320 male ischemic heart disease patients prior to discharge from hospital. The relationship between GHQ scores and rehospitalization/death rates for the subsequent year was examined. Surprisingly, a curvilinear relationship emerged with both low and high scorers having better outcomes than patients scoring in the middle ranges. This relationship held regardless of physical risk factors reflecting severity of disease, and demographic factors failed to explain the curve. It was suggested that denial and compliance accounted for the good outcomes of the low and high scorers respectively, whereas the medium scoring patients were neither adequate deniers nor sufficiently enthusiastic about entering the sick role.

Report: conference on key issues in post-graduate psychiatric education in Canada.

At a national conference in 1985, the Royal College guidelines for post-graduate training in psychiatry in Canada were reviewed. The topics considered included geriatrics, consultation-liaison, chronic care, out-patient, and psychotherapy training, as well as pre-licensure requirements and examinations. The recommendations will be used by the Royal College in reformulating its requirements for pychiatric residency programs.

Middle income, divorced female heads of families: their lifestyles, health and stress levels.

Forty-five, French-Canadian female heads of families with adequate incomes and high educational levels were identified through newspaper ads. At time of interview, the subjects had been separated or divorced for from one to three years. Interviews showed that, unlike previous reports of divorced women and female heads of families, this group enjoyed relatively good health and normal stress levels, and were generally positive about being head of the family. Among the positive changes, the majority emphasized their greater autonomy, freedom, and sense of selfhood. Some mentioned improved relations with their children. On the negative side, loneliness, absence of the father (particularly for their sons), and limited social lives were most often mentioned. It was concluded that the role of head of family is perfectly acceptable for many economically viable women, though not necessarily ideal.