Biomedical subjects
M Hotopf
Publications and source records attributed to M Hotopf.
Stability of recall of military hazards over time. Evidence from the Persian Gulf War of 1991.
BACKGROUND: War time traumatic events are related to subsequent psychological and physical health, but quantifying the association is problematic. Memory changes over time and is influenced by psychological status. AIMS: To use a large, two-stage cohort study of members of the UK armed forces to study changes in recall of both traumatic and 'toxic' hazards. METHOD: A questionnaire-based follow-up study assessed 2370 UK military personnel, repeating earlier questions about exposure to military hazards. RESULTS: The k statistics for reporting of hazards were good for some exposures, but very low for others. Gulf veterans reported more exposures over time (no significant rise in the Bosnia cohort). In the Gulf cohort only, reporting new exposures was associated with worsening health perception, and forgetting previously reported exposures with improved perception. We found no association between physical health, psychological morbidity or post-traumatic stress disorder symptoms and endorsement or non-endorsement of exposures. CONCLUSIONS: Reporting of military hazards after a conflict is not static, and is associated with current self-rated perception of health. Self-report of exposures associated with media publicity needs to be treated with caution.
Systematic review and meta-analysis of interventions for postoperative fatigue.
BACKGROUND: Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques. METHODS: Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed. RESULTS: Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom. CONCLUSION: While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive-behavioural, sleep and activity-based interventions also needs to be addressed.
Reported chemical sensitivities in a health survey of United Kingdom military personnel.
OBJECTIVE: To report the prevalence of self reported chemical sensitivities in three cohorts of United Kingdom service personnel. METHOD: Cross sectional postal survey of three cohorts of United Kingdom military personnel comprising Gulf veterans (n=3531), those who had served in Bosnia (n=2050), and those serving during the Gulf war but not deployed there (Era cohort, n=2614). RESULTS: Sensitivity to at least one everyday chemical was reported by a considerable proportion of all three cohorts, and particularly by veterans of the Gulf war (Era: 14%; Bosnia: 13%; Gulf: 28%). CONCLUSION: Reported chemical sensitivities were common in all three military cohorts. Our understanding of chemical sensitivities remains limited and objective evidence for a causal link between low level exposures to chemicals and reported symptoms is lacking. Given their frequency in the population, further work in this area is necessary.
Depression in advanced disease: a systematic review Part 1. Prevalence and case finding.
OBJECTIVE: To identify all literature regarding depression in patients with advanced cancer and among mixed hospice populations, and to summarise the prevalence of depression according to different definitions. METHODS: A systematic review was performed using extensive electronic and hand searches. All studies with quantitative data on prevalence of depression were included and categorised according to their definition of depression. RESULTS: We identified 46 eligible studies giving information on the prevalence of depression, and a further four which gave information on case finding. The most widely used assessment of depression was the Hospital Anxiety and Depression Scale (HADS), which gave a median prevalence of 'definite depression' (i.e., a score on the depression subscale of > 10) of 29%, (interquartile range, IQR, 19.50-34.25%). Studies that used psychiatric interviews indicated a prevalence of major depressive disorder ranging from 5% to 26%, with a median of 15%. Studies were generally small (median sample size 88.5, IQR 50-108), had high numbers of nonresponders, and rarely gave confidence intervals for estimates of prevalence. CONCLUSIONS: Depression is a common problem in palliative care settings. The quality of much of the available research is poor, based on small samples of patients with very high nonparticipation rates. The clinical importance of depression is described in subsequent papers.
Prevalence of Gulf war veterans who believe they have Gulf war syndrome: questionnaire study.
OBJECTIVES: To determine how many veterans in a random sample of British veterans who served in the Gulf war believe they have "Gulf war syndrome," to examine factors associated with the presence of this belief, and to compare the health status of those who believe they have Gulf war syndrome with those who do not. DESIGN: Questionnaire study asking British Gulf war veterans whether they believe they have Gulf war syndrome and about symptoms, fatigue, psychological distress, post-traumatic stress, physical functioning, and their perception of health. PARTICIPANTS: 2961 respondents to questionnaires sent out to a random sample of 4250 Gulf war veterans (69.7%). MAIN OUTCOME MEASURE: The proportion of veterans who believe they have Gulf war syndrome. RESULTS: Overall, 17.3% (95% confidence interval 15.9 to 18.7) of the respondents believed they had Gulf war syndrome. The belief was associated with the veteran having poor health, not serving in the army when responding to the questionnaire, and having received a high number of vaccinations before deployment to the Gulf. The strongest association was knowing another person who also thought they had Gulf war syndrome. CONCLUSIONS: Substantial numbers of British Gulf war veterans believe they have Gulf war syndrome, which is associated with psychological distress, a high number of symptoms, and some reduction in activity levels. A combination of biological, psychological, and sociological factors are associated with the belief, and these factors should be addressed in clinical practice.
Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study.
OBJECTIVE: To elucidate the associations between frequent headache and psychosocial factors in childhood and to determine whether such children are at an increased risk of headache, multiple physical symptoms, and psychiatric symptoms in adulthood. DESIGN: Population based birth cohort study. SETTING: General population. PARTICIPANTS: People participating in the national child development study, a population based birth cohort study established in 1958. MAIN OUTCOME MEASURES: Headache, multiple physical symptoms, and psychiatric morbidity at age 33. RESULTS: Headache in childhood was associated with several psychosocial factors. Prospectively, children with frequent headache had an increased risk in adulthood of headache (odds ratio 2.22, 95% confidence interval 1.62 to 3.06), multiple physical symptoms (1.75, 1.46 to 2.10), and psychiatric morbidity (1.41, 1.20 to 1.66). The outcomes of headache and multiple physical symptoms were not accounted for by psychiatric morbidity. CONCLUSION: Children with headache are at an increased risk of recurring headache in adulthood and may complain of other physical and psychiatric symptoms. Strategies for coping with psychosocial adversity in childhood may improve the prognosis in adulthood.
Are some public-health problems better neglected?
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Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study.
OBJECTIVE: To estimate the prevalence of medically unexplained symptoms in patients who most frequently attend outpatient services. DESIGN: Retrospective cohort study over three years with review of case notes. SETTING: Secondary care services in the South Thames (West) NHS region. PARTICIPANTS: Outpatient attenders with new appointments in 1993. MAIN OUTCOME MEASURES: Number of outpatient appointments, and number of consultation episodes for medically unexplained conditions. RESULTS: Medical records of 361 of 400 sampled frequent attenders were examined, and 971 consultation episodes were recorded. Ninety seven (27%) had one or more consultation episodes in which the condition was medically unexplained; 208 (21%) of the 971 consultation episodes were medically unexplained. Abdominal pain, chest pain, headache, and back pain were commonly found to be medically unexplained. CONCLUSIONS: Medically unexplained symptoms present in most hospital specialties and account for a considerable proportion of consultations by frequent attenders in secondary care.
Multiple chemical sensitivity and chronic fatigue syndrome in British Gulf War veterans.
The objective of this study was to measure the prevalence of multiple chemical sensitivity (MCS) and chronic fatigue syndrome (CFS) in British Gulf War veterans and to investigate their association with reported exposures and psychologic morbidity. In 1997--1998, the authors undertook a cross-sectional survey of three cohorts of British military personnel comprising Gulf veterans (n = 3,531), those who had served in Bosnia (n = 2,050), and those serving during the Gulf War but not deployed there (Era cohort, n = 2,614). MCS and CFS were defined according to operational criteria. The prevalence of MCS in the Gulf, Bosnia, and Era cohorts was 1.3%, 0.3%, and 0.2%, respectively. For CFS, the prevalence was 2.1% (Gulf cohort), 0.7% (Bosnia cohort), and 1.8% (Era cohort). In Gulf veterans, MCS was strongly associated with exposure to pesticides (adjusted odds ratio = 12.3, 95% confidence interval: 5.1, 30.0). Both syndromes were associated with high levels of psychologic morbidity. These findings suggest that CFS and MCS account for some of the medically unexplained illnesses reported by veterans after deployment to the Gulf. MCS was particularly associated with Gulf deployment and self-reported exposure to pesticides, findings that merit further exploration given the controversial status of this diagnosis and the potential for recall bias in a questionnaire survey.
Is "somatisation" a defense against the acknowledgment of psychiatric disorder?
OBJECTIVE: To determine whether experiencing physical symptoms is associated with a denial of psychological distress in individuals with probable psychiatric disorder. METHODS: A nested case-control study was performed using data from a national birth cohort study. All subjects who scored above threshold on a case-finding questionnaire of psychiatric disorder were identified. Those who in a separate question endorsed the presence of psychiatric disorder ("acknowledgers") were compared with those who did not. RESULTS: Acknowledgers were more likely to be female, better educated and have more severe current and past psychiatric disorder. They were also more likely to report multiple physical symptoms, even when potential confounders and severity of psychiatric disorder were controlled. CONCLUSION: There is no evidence that experiencing multiple physical symptoms helps the individual deny the presence of psychiatric disorder.
Medically unexplained symptoms: an epidemiological study in seven specialities.
OBJECTIVES: This study aimed to estimate the prevalence and risk factors for medically unexplained symptoms across a variety of specialities. METHODS: A cross-sectional survey was conducted at two general hospitals in southeast London between 1995 and 1997. Eight hundred and ninety consecutive new patients from seven outpatient clinics were included. Demographic and clinical characteristic variables were assessed. RESULTS: Five hundred eighty-two (65%) of the subjects surveyed returned completed questionnaires. A final diagnosis was available in 550 (62%). Two hundred twenty-eight (52%) fulfilled criteria for medically unexplained symptoms. The highest prevalence was in the gynecology clinic (66%). After adjustment for confounders, medically unexplained symptoms were associated with being female, younger, and currently employed. Psychiatric morbidity per se was not associated with the presence of medically unexplained symptoms, but was more likely in those complaining of multiple symptoms. Those with medically unexplained symptoms were less disabled, but more likely to use alternative treatment in comparison with those whose symptoms were medically explained. Patients with medically unexplained symptoms were more likely to attribute their illness to physical causes as opposed to lifestyle factors. CONCLUSIONS: Medically unexplained symptoms are common across general/internal medicine and represent the most common diagnosis in some specialities. Medical behavior, training, and management need to take this into account.
How many functional somatic syndromes?
OBJECTIVE: Patients with medically unexplained symptoms are given diagnoses dependent upon the particular medical specialty consulted--irritable bowel syndrome in gastroenterology, fibromyalgia in rheumatology and others. The purpose of this paper is to establish whether these 13 different syndromes are discrete entities. METHODS: Consecutive new patients in seven outpatient clinics at two general hospitals were recruited. Patients completed questionnaires measuring symptoms and demographic data. Case notes were reviewed to ascertain whether the presenting symptoms were medically explained 3 months after the initial visit. RESULTS: Complete data were available for 550 subjects. With 37 unexplained symptoms included in the model, 30% of the total variance could be explained by one factor using unrotated principal component analysis. When the 13 identified functional syndromes were included, it was evident that functional syndromes could not be assumed to be independent. A two-factor model was the best fit for the present data after rotation. CONCLUSIONS: This study suggests that the existence of distinct functional somatic syndromes (FSSynd) as defined clinically in medicine should be reconsidered.
Forty years of antidepressant drug trials.
OBJECTIVE: This study was conducted to investigate whether the quality of antidepressant drug trials has improved during the last 40 years. METHOD: A sample of 314 randomized clinical trials published between 1962 and 1998 was analysed. RESULTS: From 1962 to 1970 the median number of patients per trial was 56 (range 24-137), from 1971 to 1980 was 50 (10-211) and from 1981 to 1990 was 51 (20-314). In the last 8 years the median sample size increased to 100 patients (20-1002). Trials had a median duration of 4 weeks in the first two decades of publication, and a median duration of 6 weeks in the following two decades. Patient selection criteria have become increasingly sophisticated and the median number of efficacy measures increased in the last 4 decades from 1 to 4. CONCLUSION: Stringent selection criteria and sophisticated outcome assessment tend to exclude typical patients from randomized controlled trials and made it more difficult to follow many patients in the long term.
Medically unexplained symptoms--GPs' attitudes towards their cause and management.
BACKGROUND: Medically unexplained physical symptoms present one of the most common problems in modern medical practice but often prove difficult to manage. The central position of the GP in the care of patients with medically unexplained symptoms has been emphasized repeatedly, but little is known about the attitudes of GPs to this role. Understanding how GPs view these patients may inform the development of effective strategies for management. OBJECTIVE: Our aim was to survey the attitudes of UK GPs towards medically unexplained symptoms (MUS) and somatization. METHODS: A random sample of 400 GPs in the South Thames (West) region were surveyed using a postal questionnaire. Respondents' attitudes toward the cause and management of MUS were recorded. RESULTS: A total of 284 completed questionnaires were returned (22 returned incomplete), giving an adjusted response rate of 75%. Although it was broadly felt that patients with MUS are difficult to manage, most GPs felt that patients with MUS should be managed in primary care. Providing reassurance, counselling and acting as a 'gatekeeper' to prevent inappropriate investigations were considered important roles for GP management. A majority felt that patients with MUS have personality problems or psychiatric illness. Fewer than half of the respondents felt that there are effective treatments available for somatization. CONCLUSION: GPs consider the management of patients with MUS to be an important part of their workload, but there is a perception that effective management strategies are lacking. Psychiatrists need to offer greater support and training for GPs in this area of health care.
Liaison psychiatry and occupational health.
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Effectiveness of involuntary outpatient commitment.
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Amitriptyline v. the rest: still the leading antidepressant after 40 years of randomised controlled trials.
BACKGROUND: Tricyclic antidepressants have similar efficacy and slightly lower tolerability than selective serotonin reuptake inhibitors (SSRIs). However, there are no systematic reviews assessing amitriptyline, the reference tricyclic drug, v. other tricyclics and SSRIs directly. AIMS: To review the tolerability and efficacy of amitriptyline in the management of depression. METHOD: A systematic review of randomised controlled trials (RCTs) comparing amitriptyline with other tricyclics/heterocyclics or with an SSRI. RESULTS: We reviewed 186 RCTs. The overall estimate of the efficacy of amitriptyline revealed a standardised mean difference of 0.147 (95% CI 0.05-0.243), significantly favouring amitriptyline. The overall OR for dropping out was 0.99 (95% CI 0.91-1.08) and that for side-effects was 0.62 (95% CI 0.54-0.70), favouring the control drugs. With drop-outs included as treatment failures, the estimate of the effectiveness of amitriptyline v. tricyclics/heterocyclics and SSRIs showed a 2.5% difference in the proportion of responders in favour of amitriptyline (number needed to treat 40, CI 21-694; OR 1.12 (95% CI 1.01-1.24)). CONCLUSIONS: Amitriptyline is less well tolerated than tricyclics/heterocyclics and SSRIs, but slightly more patients treated on it recover than on alternative antidepressants.