Sidney Bloch

Caring for relatives with serious mental illness: the development of the Experience of Caregiving Inventory

The aim of this study was to develop a practical, comprehensive, and valid self-report measure of the experience of caring for a relative with a serious mental illness. The notion of caregiver ‘burden’ was rejected; instead caregiving was conceptualised within a ‘stress-appraisal-coping’ framework. A 66-item version of the Experience of Caregiving Inventory (ECI) was derived from analyses of responses from 626 caregivers, and then tested on an independent sample of 63 relatives of patients with schizophrenia recently in acute care. The extent to which the ECI complied with the stress-coping model was tested, especially the degree to which it, in association with coping, predicted psychological morbidity in carers. Ten sub-scales with good internal consistency resulted from our analyses, eight negative (difficult behaviours; negative symptoms; stigma; problems with services; effects on the family; the need to provide backup; dependency; loss) and two positive (rewarding personal experiences; good aspects of the relationship with the patient). The ECI, in conjunction with coping style, predicted a large proportion of the variance in the General Health Questionnaire (GHQ). We concluded that the ECI taps salient dimensions of caregiving distinct from, although linked with, coping and psychological morbidity. It has potential as a useful outcome measure for interventions aimed at promoting caregiver well-being.

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.

Psychosocial morbidity associated with patterns of family functioning in palliative care: baseline data from the Family Focused Grief Therapy controlled trial

Family Focused Grief Therapy (FFGT) is a new model of brief intervention, which is commenced during palliative care for those families shown to be at high risk of poor adaptation, and continued preventively into bereavement with the aim of improving family functioning and reducing the morbid consequences of grief. In this paper, baseline data on 81 families (363 individuals) selected by screening from a palliative care population are explored to confirm our previously reported observation that high levels of psychosocial morbidity are positively associated with worsening family dysfunction. The Family Relationships Index (FRI) was used for screening and the Family Assessment Device (FAD) as an independent family outcome measure. The Beck Depression Inventory (BDI), Brief Symptom Inventory (BSI) and Social Adjustment Scale (SAS) were the psychosocial measures. Families were classified according to their functioning based on the FRI. To allow for correlated family data, statistical analyses employed the generalized estimating equation (GEE) method, controlling for gender and depression (BDI). Screening of 257 families (701 individuals) revealed 74 (29%) well-functioning families and 183 (71%) at some risk of morbid outcome. Of the latter, 81 (44%) gave informed consent to enter a randomized controlled trial of FFGT. Patients had a mean age of 57 years, 51% were male and they suffered from cancer, with a median length of illness from diagnosis to death of 25 months. In accordance with the FFGT model, their family types were identified as Intermediate 51%, Sullen 26% and Hostile 23%. These were significantly associated with steadily increasing levels of distress (BSI) and poor social adjustment (SAS). The FAD confirmed the concurrent accuracy of the FRI. As significantly greater levels of psychosocial morbidity were present in families whose functioning as a group was poorer, support was generated for a clinical approach that screens for families rather than individuals at high risk. The predictive validity of the FRI as a screening measure was confirmed. Overall, these baseline data point to the importance of a family-centred model of care.

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.

Diagnostic Efficiency of the Hospital Anxiety and Depression Scale in Women with Early Stage Breast Cancer

Objective: To investigate the diagnostic efficiency of the Hospital Anxiety and Depression Scale (HADS) in patients with breast cancer. Methods: Women (303) recently diagnosed with stage I or II breast cancer completed the HADS and were psychiatrically assessed. Recommended cut-off scores for Depression (D) and Anxiety (A) Scales identified probable caseness and the accuracy was compared with DSM-IV diagnoses. Cut-off scores were varied to establish optimal accuracy. Results: One hundred and eleven (36.6%) met criteria for depressive disorders and 25 (8.3%) met criteria for anxiety disorders. At the recommended cut-off score of 11 for the D scale, positive and negative predictive values were.75 and.64, respectively, while sensitivity and specificity were.05 and.99, respectively. For the A scale, positive predictive value (PPV) was.15; negative predictive value (NPV),.90; sensitivity,.08; and specificity,.87. Reducing the cut-off score to 5 produced PPV of.63, NPV of.74, sensitivity of.49 and specificity of.83 for the D scale;.14,.94,.75 and.45, respectively, for the A scale. Composite scores (cut-off of 22) had a PPV of.92, NPV of.57, sensitivity of.09 and specificity of.99. Conclusions: Recommended cut-off scores for the HADS may result in under-reporting of psychiatric morbidity among women with early stage breast cancer. These results are consistent with other recent studies of the HADS. The type of constructs measured by the scale is the likely explanation for its limited utility when screening for psychiatric morbidity in early stage breast cancer.

Screening for depression in women with metastatic breast cancer: a comparison of the Beck Depression Inventory Short Form and the Hospital Anxiety and Depression Scale

Objective: To compare two self-report questionnaires for identifying possible depression in women with metastatic breast cancer. Method: We conducted structured psychiatric interviews and administered the Beck Depression Inventory Short Form (BDI-SF) and Hospital Anxiety and Depression Scale (HADS) to 227 women with stage IV breast cancer. The accuracy for identifying DSM-IVdefined major and minor depression was examined. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated and receiver operating characteristic curves plotted. Results: Seventy-four (32.6%) patients satisfied DSM-IV criteria for a depressive disorder. With a cut-off of 4, the BDI-SF had a sensitivity of 0.84, specificity of 0.63, and PPV of 0.52. A cut-off of 11 on the HADS-Depression scale (HADS-D) resulted in sensitivity, specificity, and PPV of 0.16, 0.97, and 0.75, respectively. For major depression alone, the BDI-SF with a cut-off of 5 had excellent sensitivity but poor PPV; the HADS, with a cut-off of 7, had weak sensitivity and PPV. Conclusions: Overall, the two scales perform similarly in identifying major depression, while the BDI-SF is the more useful in screening for DSM-IV major or minor depression categories in this clinical group.

The Impact Factor: Time for Change

Objective: The Impact Factor (IF) has received virtually no attention in the psychiatric literature, despite its long-term use, expanding influence and evidence of misapplication. We examine the IFs validity as a measure of a papers scientific worth, and consider alternative ways to conduct such an appraisal. Method: We explored medical databases and websites, and conferred with acknowledged experts on the subject. Results: Irremediable problems, both conceptual and technical, make the IF a flawed measure. The notion that citations vouch for the quality of an article is questionable. Moreover, the IFs vulnerability to misuse in domains such as academic promotion and research grant assessment is a serious development. Conclusion: The IF (and all measures derived from it) should be abandoned. A ‘return to basics’ in evaluating published work is overdue. As seductive as a simple formula is to assess quality, shortcuts are unavailable and unlikely to be useful. Publishing a short-list of papers annually, judged as objectively as possible by peers to merit special attention, may be a more meaningful option. Conceivably, every psychiatric journal could participate in this cyclical exercise, leading to a ‘grand short-list’. This could be made readily available to all professionals, both researchers and clinicians, by being posted on a suitable website. Since peer review has a long-standing role in scientific publishing, our proposal is essentially an extension of that process.

Family grief therapy: a preliminary account of a new model to promote healthy family functioning during palliative care and bereavement

The family is usually the primary provider of care for the terminally ill patient with cancer or other serious progressive illness. The way in which such a family functions is a major determinant of psychological well‐being for its members. Through screening with the Family Relationships Index (FRI) (Moos and Moos, 1981), dysfunctional families and those at risk can be identified, and then helped to achieve better family functioning, thus improving psychosocial outcome of their grief. In this paper, we describe the techniques and themes involved in the application of our empirically developed model of family grief therapy, designed as a preventive intervention for use in the setting of palliative care and bereavement.

Psychological adjustment of men with prostate cancer: a review of the literature

ObjectiveProstate cancer (PCA) is the most common malignancy and a major cause of death in men but, importantly, a substantial proportion will live for several years following diagnosis. However, they face the prospect of experiencing symptoms, side-effects of treatment and diminished quality of life. The patients psychological adjustment is particularly complex, given the potential trajectory of the disease, from the point of diagnosis, with its immediate impact, to the phase of palliative care, with its attendant issue of facing mortality. Since a comprehensive review of the literature on psychological adjustment of men with PCA has not yet been done, we have documented relevant research, integrated findings and drawn conclusions, where possible, in order to map out clinical and research implications.MethodWe searched 5 databases for the period 1994 – July 2006, during which most of the work in the field has been done.ResultsWe found few studies of substance among the 60 we examined to draw conclusions about psychological adjustment to prostate cancer and its treatment. This is in marked contrast to the picture in breast cancer. While some patterns have emerged, many gaps remain to be filled.DiscussionAspects of methodology need attention, particularly longitudinal, prospective designs, incorporation of control groups and the use of valid and reliable measures. There is scope for qualitative studies as a complement to quantitative research.