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PubMed1998

The treatment of social phobia: a critical assessment.

This article critically reviews the effects of psychological treatment (exposure, cognitive restructuring, social skills training) and pharmacological treatment (MAOIs, reversible MAOIs, anxiolytics and SSRIs) of social phobia. Only controlled studies have been included, and their outcomes were assessed for improvement in anxiety and avoidance, social functioning and clinical status. Both psychological and pharmacological treatments resulted in a significant and meaningful reduction in anxiety and, in most cases, a weakening of the tendency to avoid. Although useful, the effects were not of such a magnitude as to result in remission. Reduction in anxiety was long-lasting in patients treated by psychological methods. The lessening of anxiety did not necessarily lead to meaningfully improved social functioning. The combination of psychological and pharmacological treatments was disappointing, and did not exceed the effects of psychological treatments alone. However, the most promising medications were not tested. Subtype of social phobia and additional diagnoses did not determine the response to treatment.

Behavior Therapy↗
PubMed2000

Prospective controlled study of psychiatric out-patient non-attendance. Characteristics and outcome.

BACKGROUND: Psychiatric clinics have high non-attendance rates and failure to attend may be a sign of deteriorating mental health. AIMS: To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders. METHOD: Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained. RESULTS: Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended. CONCLUSIONS: Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.

Adolescent↗
PubMed1994

The mortality and social prognosis of hip fractures. A prospective multifactorial study.

A prospective 5-year study was carried out of 143 patients with trochanteric fractures treated by Ender nailing. A detailed proforma was used for multifactorial analysis in order to identify the prognostic indicators of social function and quality of life of the patients. Their mean age was 81 years and the female: male ratio 7:1. The mortality rate 6 months after injury was 23%, and at the end of 5 years 45.5%. The patients surviving the first 6 months had the same life expectancy as the general population. Dementia, associated disease, medical complications, total dependency and age were the most significant predictors of mortality. These factors, with pressure sores and poor rehabilitation, were also significant in determining the prognosis of social function. Deterioration of health status was seen in 36% during the first 6 months after injury and 40% showed deterioration of their social condition within this period. Later, most survivors recovered and were restored to their previous state. Postoperative geriatric care is essential to achieve this aim.

Aged↗
PubMed2001

Why do patients with rheumatoid arthritis use alternative treatments?

The aim of this study was to analyse the characteristics of patients with rheumatoid arthritis (RA) who make use of alternative or complementary medicine (CM). Two hundred and sixty-two randomly chosen patients with RA filled out self-assessment health status and pain questionnaires. Differences between the group of patients making use of both CM and conventional treatment (n = 52) and the group of patients who relied only on conventional treatment prescribed by their rheumatologists (n = 210) were explored with respect to demographic characteristics, duration of RA, levels of physical, psychological and social functioning, and pain-coping behaviour. We found that female patients used CM more often than did male patients, and those who used CM were younger than those who did not. There were no differences with respect to duration of RA, physical, psychological or social functioning or pain coping; however, the perceived impact of RA on several domains of life was higher in patients who used CM than in those who did not. Nevertheless, the patient groups did not differ in terms of medical consumption, except that those who used CM visited medical specialists for RA-related complaints less than those who relied only on conventional treatments. We concluded that the higher impact of RA, in the absence of worse disease, perceived by users of CM in several domains of life, especially psychosocial functioning, could be the reason they use CM. This suggests that CM cannot be substituted by additional conventional treatment prescribed by the rheumatologist, but rather by psychosocial intervention.

Adult↗
PubMed2002

Discontinuation symptoms: comparison of brief interruption in fluoxetine and paroxetine treatment.

Abrupt interruption or cessation of selective serotonin reuptake inhibitor (SSRI) treatment may result in discontinuation or treatment interruption symptoms. Recent reports suggested these symptoms occur more frequently with shorter half-life SSRIs. Previous studies indicated a 5-8-day treatment interruption resulted in fewer discontinuation-emergent adverse events in fluoxetine-treated patients than in paroxetine-treated patients. This study examines the effects of shorter treatment interruption (3-5 days), as would occur if patients miss just a few doses of medication. Patients successfully treated for depression with fluoxetine or paroxetine underwent treatment interruption in a double-blind fashion. Treatment interruption-emergent symptoms were assessed using the Discontinuation-Emergent Signs and Symptoms checklist. Other assessments included the Montgomery-Asberg Depression Rating Scale, Clinical Global Impressions-Severity scale and a social functioning questionnaire. Of 150 patients enrolled, 141 completed the study. Following treatment interruption, fluoxetine-treated patients experienced fewer treatment interruption-emergent events than did paroxetine-treated patients. The paroxetine treatment group also experienced significant increases in depressive symptoms, clinical global severity scores and difficulty in social functioning; the fluoxetine treatment group did not. These results are consistent with reports suggesting abrupt interruption of treatment with paroxetine is more often associated with somatic and psychological symptoms than is abrupt interruption of fluoxetine. Patients treated with fluoxetine appeared to be protected by its longer half-life.

Adult↗
PubMed2002

Schizophrenic patients without neuropsychological deficits: subgroup, disease severity or cognitive compensation?

Some schizophrenic patients do not show clinically relevant cognitive deficits. The question remains whether this represents the existence of an etiologically different subgroup, a general effect of disease severity or whether their cognitive deficits do not reach a clinical threshold due to a greater cognitive compensation ('brain reserve') capacity. A group of 23 out of 118 first onset patients was identified as cognitively normal (CN). The cognitive profile of these patients was compared with that of 45 healthy controls. Next these patients were compared with the cognitively impaired (CI) patients on obstetric complications (OCs), premorbid adjustment, age at onset, Positive and Negative Syndrome Scale ratings, social functioning and substance abuse. In addition both groups were compared on intelligence and educational level as indirect indicators of cognitive compensation capacity. There were no differences in OCs, premorbid adjustment, age at onset, psychopathology or substance abuse between the two patient groups. There was a significant difference in social functioning, which is a consequence rather than a cause of cognitive deficits. However, the CN patients scored significantly higher on measures of intelligence and educational level than the CI patients. This suggests that a difference in cognitive compensation capacity could explain the existence of a CN patient group.

Adolescent↗
PubMed1998

[Health-related quality of life. Long-term survival in patients with ARDS following extracorporeal membrane oxygenation (ECMO)].

UNLABELLED: Treatment of severe acute respiratory distress syndrome (ARDS) with extracorporeal membrane oxygenation (ECMO) can be lifesaving but requires maximal use of intensive care resources over prolonged periods of time, resulting in high costs. Little is known about the health-related quality of life (HRQL) in long-term survivors. This case-controlled retrospective study was designed to assess the health-related quality of life in long-term survivors of ARDS and ECMO-therapy. METHODS: 14 long-term survivors of ARDS (APACHE II score = 24, Lung Injury Score = 3.25, median values) treated using ECMO between 1992 and 1995 (median time interval between data collection and discharge from the ICU 16 months) and 14 ARDS-patients conventionally treated during the same period (group I) were identified and completed the SF-36 Health Status Questionnaire (Medical Outcome Trust, Boston, USA). 14 healthy subjects (group II) were drawn at random from a large data base generated to provide normal values for the SF-36 in a German population. All three groups were comparable with respect to sex and age. RESULTS: Long-term survivors of ECMO-therapy reported significant reductions in physical functioning when compared with patients treated by mechanical ventilation alone (group I, -12.5%, p < 0.05) and with healthy controls (group II, -50%, p < 0.05) and showed a higher incidence of chronic physical pain (+5% and +24%, respectively, p < 0.05). There were no differences with regard to the mental health dimensions of the SF-36 (e.g. vitality, mental health index or social functioning) between ECMO-patients and all controls. Nine patients (64.3%) from the ECMO group versus all patients treated conventionally (group I) had full-time employment (p = 0.46, Chi2 test). CONCLUSIONS: The majority of long-term survivors of ECMO-treatment show good physical and social functioning, including a high rate of employment. The more aggressive approach of ECMO-therapy and a possibly more severe underlying disease process may explain impairments in health-related quality of life outcomes after ECMO-treatment. Despite these limitations, long-term survivors of ECMO-therapy are able to reach a highly satisfactory health-related quality of life.

APACHE↗
PubMed1998

Impact of long-term care of children assisted by technology on maternal health.

This study examines the health outcomes of mothers of children assisted by technology and their associations with condition severity and family and social support. The 6-month postdischarge status of 65 mothers of children assisted by technology was compared with that of 54 mothers of children (matched for age and sex) hospitalized for acute illnesses. We measured maternal health, emotional well-being (Center for Epidemiologic Studies Depression Scale), severity of the child's condition, family functioning, social support, and sociodemographic data. Mothers in the study group reported impaired health related to pain, vitality, social functioning, and mental health and substantially more depressive symptoms than mothers in the control group (p < .001), with almost half having scores suggesting clinical depression. Family supportiveness and opportunities for recreational and cultural activities were significantly lower in families with children assisted by technology. After controlling for sociodemographic variables, high condition severity (p < .01), lack of family support (p = .05), low social support appraisal (p < .01), and high levels of receipt of social support (p < .01) were associated with more depressive symptoms of mothers in the study group. Six months after diagnosis or major hospitalization, the severity of the condition was highly associated with maternal emotional well-being, with family support and social support appraisal having moderate independent positive effects. The receipt of social support indicated need rather than support and was negatively associated with well-being. Discharge planning and support systems need to focus on both the child and the prevention of secondary social and psychological morbidity of caretakers.

Caregivers↗
PubMed2000

Autism and developmental receptive language disorder--a follow-up comparison in early adult life. II: Social, behavioural, and psychiatric outcomes.

This paper focuses on general social functioning in two groups of young men, one with autism and one with developmental receptive language disorders, who were first assessed at the ages of 7-8 years. At that time, although matched for nonverbal IQ (mean 92-93) and expressive language, the Language group showed significantly fewer social and behavioural problems. At follow-up, when aged on average, 23 to 24 years, the Autism group continued to show significantly more impairments in terms of stereotyped behaviour patterns, social relationships, jobs, and independence. However, problems in all these areas were also common in the Language group. Many still lived with their parents, few had close friends or permanent jobs, and ratings of social interaction indicated abnormalities in a number of different areas. On a composite measure of social competence only 10% of the Language group was assessed as having severe social difficulties compared to 74% of the Autism group. Nevertheless, 65% were rated as having moderate social problems and only 25% were rated as being of near/normal social functioning. Two individuals in the Language group, but none in the Autism group, had also developed a florid paranoid psychosis in late adolescence. As in the follow-up of cognitive and linguistic functioning (see Mawhood et al., 2000, this volume, pp. 547-559), discriminant function analysis, which had clearly distinguished between the groups as children, now showed much greater overlap between them. Regression analysis indicated that although early language ability appeared to be related to outcome in the Autism group, there was little association between any measures of childhood functioning and prognosis in the Language group. Theoretically, these findings have implications for our understanding of the nature of autism and other pervasive language disorders, and of the relationship between them. Practically, they demonstrate the very persistent problems experienced by individuals with developmental language disorders, and their need for much greater help and support than is presently available.

Activities of Daily Living↗
PubMed1995

Social adjustment does not predict depressive relapse during continuation fluoxetine therapy.

The purpose of this study was to assess the relationship between social adjustment and the risk of depressive relapse during continuation antidepressant treatment. The Social Adjustment Scale-Self Report Version (SAS-SR) was used to assess a broad range of social functioning before and after acute treatment in 41 outpatients with unipolar depression who responded to fluoxetine and then continued on this antidepressant. No differences were detected between those who relapsed and those who stayed well with regard to pre- and posttreatment SAS-SR total or subscale scores. These data suggest that social functioning does not affect the risk of relapse while depressed patients are taking fluoxetine continuation treatment.

Adult↗
PubMed2001

Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach.

UNLABELLED: This article reviews the efficacy of short-term psychodynamic psychotherapy (STPP) in depression compared to cognitive-behavioral therapy (CBT) or behavioral therapy (BT). In this review, only studies in which at least 13 therapy sessions were performed have been included, and a sufficient number of patients per group were treated (N > or = 20). With regard to outcome criteria, the results were reviewed for improvements in depressive symptoms, general psychiatric symptoms, and social functioning. Six studies met the inclusion criteria. RESULTS: In 58 of the 60 comparisons (97%) performed in the six studies and their follow-ups, no significant difference could be detected between STPP and CBT/BT concerning the effects in depressive symptoms, general psychiatric symptomatology, and social functioning. Furthermore, STPP and CBT/BT did not differ significantly with regard to the patients that were judged as remitted or improved. According to a meta-analytic procedure described by R. Rosenthal (1991) the studies do not differ significantly with regard to the patients that were judged as remitted or improved after treatment with STPP or CBT/BT. The mean difference between STPP and CBT/BT concerning the number of patients that were judged as remitted or improved corresponds to a small effect size (post-assessment: phi = 0.08, follow-up assessment: phi = 0.12). Thus, STPP and CBT/BT seem to be equally effective methods in the treatment of depression. However, because of the small number of studies which met the inclusion criteria, this result can only be preliminary. Furthermore, it applies only to the specific forms of STPP that were examined in the selected studies and cannot be generalized to other forms of STPP. Further studies are needed to examine the effects of specific forms of STPP in both controlled and naturalistic settings. Furthermore, there are findings indicating that 16-20 sessions of both STPP and CBT/BT are insufficient for most patients to achieve lasting remission. Future studies should address the effects of longer treatments of depression.

Adult↗
PubMed2003

Are the effects of cognitive remediation therapy (CRT) durable? Results from an exploratory trial in schizophrenia.

BACKGROUND: This paper investigates the durability of the effects of cognitive remediation therapy (CRT). In a randomised control trial, CRT was compared with a control therapy (intensive occupational therapy activities), matched for length of therapist contact. The main three cognitive outcomes, (i) number of categories achieved on the Wisconsin Card Sort Test, (ii) age-scaled score on the Digit Span subtest of the WAIS-R, and (iii) mean number of moves on the Tower of London test, were chosen because they are known to be problematic in schizophrenia. In addition, a wide variety of other outcomes (symptoms, social functioning, self-esteem and cognition) were assessed. At the end of treatment, CRT conferred a benefit to people with schizophrenia in cognition and self-esteem [Schizophr. Bull. 25 (1999) 291]. This study investigates these outcomes 6 months after the therapies were withdrawn. METHOD: Participants were assessed at baseline, posttreatment and 6-month follow-up (n=17 for the CRT group; n=16 for the control therapy group). In addition to the functioning measures, data on use of services and cost of therapy were collected. RESULTS: The effects of CRT on cognition were still apparent at follow-up, particularly in the memory domain. When these cognitive improvements reached a criterion threshold, there were also improvements in social behaviour and symptoms. The gains made in self-esteem disappeared following the withdrawal of therapy. The economic analysis showed overall reductions in the care packages of both patient groups but there was a significant increase in day-care costs for patients who have received CRT. This additional use of day care may confer further advantages to the CRT group, such as improved social functioning and quality of life. CONCLUSIONS: The overall results of this first trial of a novel CRT approach have produced encouraging results which merit further investigation.

Adolescent↗
PubMed2000

Identification of patients with headache at risk of psychological distress.

OBJECTIVE: To test the hypothesis that anxiety and depression are associated with headache frequency, severity, and disability. BACKGROUND: There is significant comorbidity between chronic headache and psychological distress. Headache associated with anxiety or depression tends to be more severe and often requires supplementary psychological treatment in addition to headache therapy. Therefore, the identification of patients with headache who are at risk of psychological distress is important. METHODS: One hundred twenty-seven consecutive patients with headache attending a university headache clinic were evaluated. Questionnaires about headache symptoms and psychological distress were completed. Comparisons were made between psychological distress and headache frequency, severity, and disability. RESULTS: Depression and anxiety were significantly greater in the subjects of this study who had frequent headache (>4 days per week) and frequent headache-associated disability (activities reduced or prohibited because of headache >3 days per week). Subjects who reported their headache severity as typically severe were no more likely to report depression or anxiety than those with mild or moderate headache severity. Quality-of-life measures of physical and social functioning, emotional distress, and general health and vitality were reduced in subjects with frequent episodes of headache-associated disability. All areas, with the exception of general health perception, were reduced in subjects with frequent headache. Severe headache was associated with reductions in role and social functioning. CONCLUSIONS: Frequent headache and frequent disability are associated with depression, anxiety, and impaired quality of life. Reports of typical headache severity are less likely to correlate with psychological distress. Therefore, patients with headache who report frequent headache or frequent periods of headache-related disability should be further evaluated for the presence of psychological disturbance.

Adult↗
PubMed1997

Outcome evaluation of a short-term mental health day treatment program.

OBJECTIVES: To determine whether a structured, 6-week mental health day treatment program was meeting its objectives and to examine the program's effectiveness with specific patient groups. METHOD: Self-report questionnaires focusing on psychiatric symptoms, assertiveness, stress management, and social functioning were completed by patients directly prior to admission (pretest), at discharge (posttest), and at 4-month follow-up. Clinician ratings, including the DSM-III-R Global Assessment of Functioning (GAF) scale, were collected. Ninety-one participants completed pre- and posttests, and 51 completed the 4-month follow-up. RESULTS: The majority of the participants displayed affective disorders or adjustment disorders. There was significant reduction in psychiatric symptoms and improvement in assertiveness, social functioning, and stress management from pretest to posttest. These gains were maintained at follow-up. All diagnostic groups responded similarly, except the bipolar disorder group. CONCLUSION: These data indicate that the program was meeting its objectives and offer strong support for the usefulness of short-term day treatment for wide range of patients. The bipolar group performed differently compared with the other subsamples. The reliability of the GAF scale and when it may be most useful are discussed.

Adjustment Disorders↗
PubMed2000

Age of onset as a discriminator between alcoholic subtypes in a treatment-seeking outpatient population.

Subtyping alcoholics may provide a more accurate guide as to the course and character of the disease. Classifications of different ages of onset of problem drinking have so far resulted in categorical inconsistencies. In the past, hospital-based alcoholics have over-represented those most severely ill, and comprehensive evaluations of psychopathology for discriminating between alcoholic subtypes have been infrequent. In a heterogeneous treatment-seeking, outpatient, alcoholic population, we tested the hypothesis that age of onset represents a continuum of disease, and that greater severity of psychopathology is associated with lower ages of onset. Using a standard questionnaire, 253 male and female treatment-seeking alcoholics were stratified according to specific ages of onset: a) < 20 years; b) 20-25 years, and c) > 25 years. These age of onset groups were compared on alcohol severity and craving, family history, childhood behavior, personality, hostility, overt aggression, mood, and social functioning. Symptom severity and age of onset were negatively correlated, and the 20-25-year onset group usually had intermediate scores. The < 20 year onset group was characterized by greater severity of alcohol-related problems, family history, childhood behavioral problems, craving, hostility, antisocial traits, mood disturbance, and poor social functioning. Alcoholics with an earlier age of onset have relatively greater psychopathology than those of later onset. While the preponderance of psychopathology among those in the < 20-year onset group could be conceptualized as a clinical "subtype," such a characterization would not define an entirely homogeneous category. Yet, this clinical characterization would be clinically important if specific age of onset levels were found to be differentially sensitive to pharmacological and/or psychological treatments.

Adult↗
PubMed1998

Reboxetine versus fluoxetine: an overview of efficacy and tolerability.

Serotonin selective reuptake inhibitors (SSRIs) are widely used to treat depression and offer the advantage of being better tolerated compared with tricyclic antidepressants, which inhibit both serotonin and norepinephrine reuptake. Against this background, 2 clinical studies were conducted comparing the efficacy and tolerability of reboxetine, a selective norepinephrine reuptake inhibitor, with fluoxetine, an SSRI. Both studies were of double-blind, randomized, parallel-group, multicenter design. One included a placebo control group. Five hundred forty-nine patients with major depression, under inpatient care or attending outpatient or day hospital clinics, received reboxetine (8-10 mg/day) or fluoxetine (20-40 mg/day) over 8 weeks. The overall efficacy of reboxetine and fluoxetine was similar, and superior to placebo, as assessed by the mean reduction in Hamilton Rating Scale for Depression total score. Reboxetine demonstrated superior efficacy compared with fluoxetine in severely ill patients and was associated with greater improvement in social functioning, especially in terms of motivation toward action and negative self-perception. Both treatments were well tolerated. In summary, reboxetine is an effective and well-tolerated antidepressant and is superior to fluoxetine in the treatment of severely ill patients and in terms of improving social functioning.

Adrenergic Uptake Inhibitors↗
PubMed2004

Residual symptoms at remission from depression: impact on long-term outcome.

BACKGROUND: Although residual symptoms after remission from depression are common and predict early relapse, little is known about the impact of residual symptoms on longer-term clinical course of depression or social functioning. METHODS: Sixty severe recurrent depressives, who remitted from an index episode of depression with residual symptoms or below residual symptomatology, were followed-up at 8-10 years. Subjects underwent detailed longitudinal interviewing on course of depression, treatment and socioecomonic functioning over follow-up. RESULTS: Long-term follow-up data was obtained on all living subjects and 55 (95%) were interviewed. The residual symptoms group spent more time with depressive symptoms over follow-up but not at full criteria for major depression and showed greater impairment in longitudinal and follow-up social adjustment. No significant differences were found between the two groups in percentage recurring long-term, mean number of recurrences, readmissions, chronic episodes or clinical global outcome criteria. LIMITATIONS: Long-term clinical and social outcomes were assessed by a single retrospective longitudinal interview. CONCLUSIONS: Patients who remit from depression with residual symptomatology continue to have more depressive symptoms and impaired social functioning long-term and may need more aggressive treatment.

Adult↗